Periapical Pathosis Research Articles

Fraudulent management of digital endodontic images.

To present examples of radiographic image reconstructions in endodontic treatment, to discuss the potential problems arising from the use of image processing software and to mention some current methods to prevent such counterfeit utilization of digital endodontic radiographs. Conventional Ultra-Speed periapical films of root canal treatment were digitized with flatbed scanner (Umax Powerlook II, Umax Technologies, Inc., Taiwan). Digital images were altered with PHOTOSHOP 6.0 software (Adobe Corporation, San Jose, CA, USA). Carious lesions, periapical pathoses, fake root canals and artificial fillings were created, and inadequate treatment was corrected by application of various image manipulation functions of the software. Digital endodontic images can be altered with image processing software. The use of digital radiographic data inevitably raises concerns about security, reliability and the potential for fraud.

Antibacterial Activity of 2% Chlorhexidine Gluconate and 5.25% Sodium Hypochlorite in Infected Root Canal: In Vivo Study

In this study, the antibacterial activity of the different antibacterial solutions using as root canal irrigant was compared in the teeth with pulpal necrosis and with periapical pathosis. Thirty root canals of incisors and premolars of 20 patients were used. Before and after the root canal preparation, two canal samples were obtained by a harvesting method using a sterile paper point in the first appointment. During the biomechanical preparation, both irrigant solutions were used for each tooth which were randomly divided into two groups. Last samples were also obtained before the root filling procedure. Samples obtained from the root canals were subjected to microbiologic processing, including anaerobic incubation on trypticase soy agar for 5 to 7 days. After counting of CFU on the plates, we concluded that both chlorhexidine gluconate and sodium hypochlorite were significantly effective to reduce the microorganisms in the teeth with necrotic pulp, periapical pathologies, or both, and could be used successfully as an irrigant solution.

Herpesviral-bacterial Coinfection in Periapical Pathosis

Two members of the herpesvirus family, human cytomegalovirus (HCMV) and Epstein-Barr virus (EBV), seem to be important putative pathogens of human periodontitis and symptomatic periapical lesions, causing pathosis either by inducing immunosuppression with a subsequent risk of aggressive bacterial infections or by infecting of periodontal cells directly. This study aimed to relate periapical occurrence of HCMV, EBV, and herpes simplex virus active infections to clinical characteristics of periapical lesions and periapical bacterial flora. Microbial samples were collected from 34 periapical lesions in conjunction with periapical surgery. Part of the periapical specimen was frozen for virologic examination, and another part was transferred to anaerobic transport medium for bacteriologic examination. RNA was isolated by means of a guanidinium isothiocyanate-acid phenol procedure, and cDNA was produced using herpesvirus-specific primers and reverse-transcription polymerase chain reaction amplification. Bacteriologic examination was performed according to established anaerobic culture methods. Of the 34 periapical lesions studied, 20 showed both HCMV and EBV, seven showed only HCMV, one showed only EBV, and six showed neither HCMV nor EBV. Herpes simplex virus was detected in two lesions. Higher occurrence of herpesvirus was detected in large versus small periapical lesions (p < 0.001) and in symptomatic versus asymptomatic periapical lesions (p < 0.001). A total of 18 microbial groups and an average of 2.1 to 3.0 bacterial groups were isolated from various categories of periapical lesions. The important finding of this study was that most teeth with necrotic pulp and periapical lesions harbored herpesviruses in periapical granulomatous tissue. Herpesvirus species in cooperation with endodontopathic bacteria may play major roles in the etiopathogenesis of aggressive types of periapical pathosis in humans.

Herpesviruses in periapical pathosis: an etiopathogenic relationship?

Much remains to be learned about the etiopathogenesis of periapical pathosis, especially about the molecular events preceding and causing disease onset. Human cytomegalovirus and Epstein-Barr virus, 2 herpesviruses, are discussed in this review as they relate to apical periodontitis in humans. Cytomegalovirus or Epstein-Barr virus active infections are detected in more than 90% of granulomas of symptomatic and large periapical lesions. Dual infection with cytomegalovirus and Epstein-Barr virus is closely associated with symptomatic lesions. Herpes simplex virus active infection has no apparent relationship to periapical disease. The available evidence suggests the involvement of active cytomegalovirus and Epstein-Barr infections in the etiopathogenesis of apical periodontitis. In periapical pathosis, herpesviruses may cause the release of tissue-destructive cytokines, the overgrowth of pathogenic bacteria, and the initiation of cytotoxic or immunopathologic events. Immune impairment resulting from herpesvirus infection may aid bacteria at several stages of the pathogenesis of periapical lesions, including growth in the periapical environment, possible invasion of tissue, and direct damage to tissue. Unraveling the etiology and pathogenesis of periapical pathosis may require a broadening of our experimental approaches to include studies on interactions among herpesviruses, bacteria, and host immune reactions. Understanding the significance of herpesviruses in the development of periapical lesions may aid in the diagnosis, prevention, and treatment of the diseases.

Endodontic infection: some biologic and treatment factors associated with outcome.

We sought to investigate the simultaneous effect of apical periodontitis, instrumentation level, and density of root canal filling on endodontic treatment outcome. For this study, 200 endodontically treated teeth with 441 roots were used. A follow-up examination was conducted 4 +/- 0.5 years postoperatively. Data were subjected to univariate and multivariate analysis. Periapical pathosis had the strongest effect on treatment outcome (P <.0001). The instrumentation level (mean +/- SEM of the working length) for successfully treated teeth/roots with normal preoperative pulp and periapex was farther away from the radiographic apex (1.23 +/- 0.13 mm) than for teeth/roots with an unsuccessful outcome (0.20 +/- 0.09 mm; P <.005). However, successfully treated teeth/roots with pulp necrosis and apical periodontitis had working length levels closer to the radiographic apex (0.55 +/- 0.12 mm) than did teeth/roots with unsuccessful outcomes (1.73 +/- 0.30 mm; P<.001). In teeth/roots with apical periodontitis, a millimeter loss in working length increased the chance of treatment failure by 14%. The risk of failure was higher for a fair/poor density of obturation than for a good density for all diagnoses of periradicular status. Diseased periapex, level of working length relative to the radiographic apex, and fair/poor density all affect the outcome of endodontic treatment.

Cytomegalovirus and Epstein-Barr Virus Active Infection in Periapical Lesions of Teeth with Intact Crowns

Herpesviruses seem to play an important role in the pathogenesis of aggressive periodontitis and may also contribute to periapical pathosis. This study determined the presence of human cytomegalovirus, Epstein-Barr virus, and herpes simplex virus productive infection in five symptomatic periapical lesions of teeth having intact crowns and calcified necrotic pulps. Periapical samples were collected in conjunction with periapical surgery and kept frozen until virological examination. Reverse transcription-polymerase chain reaction was used in herpesviral identification. RNA was isolated from periapical tissue by a guanidinium isothiocyanate-acid phenol procedure. cDNAs were generated from highly conserved regions of the test viruses using a preamplification kit. Sensitivity and validity of the PCR-primers were determined according to established methods. Amplification products were identified using gel electrophoresis. Human cytomegalovirus and Epstein-Barr virus dual transcription was detected in all five periapical lesions studied. Herpes simplex virus transcript was not identified in any lesion. The present data suggest that human cytomegalovirus or Epstein-Barr virus activation participate in the pathogenesis of symptomatic periapical lesions. We hypothesize that periapical active herpesvirus infection impairs local defenses, thereby inducing overgrowth of endodontopathic bacteria and the clinical flare-up of inflammation.

Apicoectomy using Er:YAG laser—a clinical study

Surgical endodontics was performed using an Er:YAG laser on 23 patients (4 males, 19 females) exhibiting periapical pathosis. After mucoperiosteal flap reflection, osteotomy was performed over the lesion using a low-speed dental engine with a round bur (#6–8). Root-end resection was then performed using an Er:YAG laser (100 mJ, 10 pps) with copious saline coolant. The root apex cavity for the retrograde root canal filling was prepared using either an ultrasonic device or Er:YAG laser. The clinical condition of the patients was evaluated at 1 week, 1 month, and 3 months after surgery. The mean irradiation time (±S.D.) for apicoectomy using the Er:YAG laser was 123.9±113.2 s. No adverse reactions were seen during the laser irradiation procedure, and no harmful sequelae were observed during the follow-up periods. It is concluded that apicoectomy using the Er:YAG laser would be both safe and practical. However, improvement of the laser device to limit the operation time would offer considerable advantages.

Cytomegalovirus and Epstein-Barr virus DNA transcription in endodontic symptomatic lesions.

Productive Herpesviridae infections are implicated in the etio-pathogenesis of aggressive periodontitis. However, virtually nothing is known about a possible role of herpesviruses in pulpal and periapical pathosis. This study employed a cDNA analysis to determine transcription of human cytomegalovirus (HCMV), Epstein-Barr virus (EBV) and herpes simplex virus (HSV) in 14 recalcitrant periapical lesions and in 2 periapical healthy control sites. Periapical samples were collected in conjunction with periapical surgery and kept frozen until virologic examination. RNA was isolated from periapical tissue by using a guanidinium isothiocyanate-acid phenol procedure (TRIZOL LS Reagent, GIBCO BRL, Rockville, MD). cDNAs were amplified by means of oligonucleotides targeting highly conserved regions of the test viruses and the RT-PCR-100 amplification kit (Sigma-Aldrich, St Louis, MO). Standardization of PCR primer sensitivity and validation was carried out according to established methods. Amplification products were identified by agarose gel electrophoresis. HCMV transcript was detected in 12 of 13 symptomatic and in 1 asymptomatic periapical lesion. EBV transcript was demonstrated in 8 of the 13 symptomatic lesions but not in the asymptomatic periapical lesion. HCMV and EBV dual transcription occurred at higher frequency in periapical lesions showing radiographic bone destruction of 5 mm x 7 mm or larger than in smaller size lesions (P = 0.03; Chi-squared test). No HCMV or EBV transcription was identified in the 2 healthy control sites. HSV transcript was not detected in any study site. The present data suggest that HCMV or EBV infections participate in the pathogenesis of periapical symptomatic lesions. Herpesviruses may produce periapical pathosis as a direct result of viral infection and replication, or as a consequence of virally induced impairment of the host defense and subsequent increased virulence of resident bacterial pathogens.

PENATALAKSANAAN KASUS KEGAGALAN PERAWATAN MUMIFIKASI (LAPORAN KASUS)

The management of failure case resulting from mummification treatment. Signs of successful treatment following mummification are the absence of clinical complaints, the formation of secondary cement, and no periapical pathosis present. Treatment about amputation the infected pulp, which has been devitalized in the pulp chamber and leaving the necrotic pulp tissues in root canal is no longer in accordance with treatment tenet nowadays. The remaining necrotic tissues is a focus of infection capable of disturbing biologic healing of tissues. Three cases of root canal treatment following pulp mummification which has been done causes complaints from discomfort to severe pain and the infections spread to periapical tissue in 2, 10, and 22 years afterwards. The results of the treatment are good and periapical radiolucency showing signs of diminution and disappearance. Evaluation on such case was done in 3 months, 6 months, and 2 years after the root canal treatment.

Radiological aspects of apical periodontitis

The diagnosis and management of periapical pathosis requires a thorough clinical and radiographic examination. As chronic apical periodontitis often develops without subjective symptoms, the radiological diagnosis is particularly important. However, radiography is not a perfect diagnostic tool, partly because radiographs are two‐dimensional representations of three‐dimensional structures, and partly because particular clinical and biological features may not be reflected in radiographic changes. The presence of a lesion may not be directly evident and its real extent and the spatial relationships to important anatomical landmarks are not always easily visualized. This paper reviews the usefulness and limitations of the radiological examination in periapical diagnosis.

A prognostic model for assessment of the outcome of endodontic treatment: Effect of biologic and diagnostic variables

Objective: Many biological variables, endodontic treatment factors, and restorative considerations have been suggested in the literature to affect the outcome of endodontic treatment. However, few attempts have been made recently to study these variables further. The purpose of this study was to identify the biologic and endodontic treatment-associated variables that are most predictive of treatment outcome for conventional endodontic therapy and to determine the magnitude of risk these variables pose on the outcome. Study Design: The population of this historical prospective cohort study comprised a total of 200 teeth with 441 root canals. Diagnostic and treatment information was abstracted from the original patient records. An endodontic follow-up examination was conducted 4 ± 0.5 years after obturation. Each tooth/root was analyzed according to 3 indices of periradicular status at 2 time points. The main outcome measure was the presence of apical periodontitis. The criteria used for evaluation of the outcome were modified from Strindberg. Data were subjected to univariate and multivariate analysis. Logistic regression models were fit by using various clinical measures to determine which combination of biologic and treatment-associated factors best predicted treatment outcome. Results: The preoperative pulp diagnosis, the periapical diagnosis, the preoperative periapical radiolucency size, and the sex of the patients were revealed, by means of univariate analysis, to exert a significant influence on endodontic treatment outcome (P < .05). In the logistic regression model, the strongest effect on postoperative healing was the presence and magnitude of preoperative apical periodontitis. In the presence of this variable, no other factor contributed value to the prediction. The correct prediction of this model was 74.7% (P < .05). Conclusion: The major biologic factors influencing the outcome of endodontic treatment appear to be the extent of microbiological insult to the pulp and periapical tissue, as reflected by the periapical diagnosis and the magnitude of periapical pathosis.(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:342-52)

Case 10

This very challenging case demonstrates how two teeth with similar endodontic treatments can produce a multiplicity of factors that complicates treatment planning and prognosis. Although both teeth are failing silver cone root canal treatments, the causes for failure of each could be different. Tooth #18 may have had coronal leakage prior to the new crown construction. This could have led to endodontic failure despite adequate technical treatment. Tooth #19 may have failed because of inadequate technical treatment. The distal root of tooth #19 could be fractured, thus causing the deep periodontal pocket. Corrosion of the silver cone obturating material could also contribute to periapical pathosis. Therefore, it may be impossible to separate all of the potential influences in order to establish a clear diagnosis and prognosis. However, the probability of improving the current situation with treatment is good.

Tumor necrosis factor-alpha and transforming growth factor-beta1 in chronic periapical lesions.

Proinflammatory cytokines are involved in the pathogenesis of periapical lesions. The purpose of this study was to evaluate the presence of the cytokines tumor necrosis factor-alpha (TNF-alpha) and transforming growth factor-beta(1) (TGF-beta(1)) in periapical pathosis and to determine their relationship to the size of the lesions. One tooth from each of 25 patients was root-end resected, and the periapical lesion was collected. The amounts of TNF-alpha and TGF-beta(1) were assessed by enzyme-linked immunosorbent assay. TGF-beta(1) was detected in 21 of 25 lesions. In samples with scar tissue, no TGF-beta(1) activity was detected. A statistically significant correlation was found between TGF-beta(1) per milligram of tissue and the diameter of the lesions. TNF-alpha was detected in only 2 samples. TGF-beta(1) was present in periapical granulomas and cysts but not in lesions with scar tissue. The correlation between the amount of TGF-beta(1) per milligram of tissue and the size of the lesion was significant.

The influence of viewing conditions on radiological diagnosis of periapical inflammation.

To determine the effect of viewing conditions upon diagnosis of early periapical inflammatory pathosis on intra-oral radiographs, and to examine the effect of observer experience upon diagnostic performance in this task. 50 observers examined 18 periapical radiographs using three different viewing conditions (room lighting; viewing box; viewing box with x2 magnification and masking). Their diagnoses were compared with an 'expert' diagnosis provided by repeated viewings of the films by two dental radiologists. Sensitivities and specificities were determined. When 'ideal' viewing conditions were used, optimal sensitivity (78%) and specificity (78%) were obtained. Use of a viewing box was associated with significantly higher specificity than the use of room lighting (P = 0.0016). Use of masking and x2 magnification was associated with significantly higher sensitivity than a viewing box alone (P = 0.004). There were few significant differences in diagnostic performance between observers, but qualified dental staff had significantly higher specificities than 4th year (P = 0.01) and 5th year (P = 0.01) students when a viewing box was used alone. This study on early periapical inflammatory pathosis gives support to guidelines which recommend the use of a viewing box, x2 magnification and masking for interpreting intra-oral radiographs. It also suggests that observer experience may influence interpretation of early periapical pathosis.

Can we improve radiological diagnosis of periapical inflammation?

Objectives To determine the effect of viewing conditions upon diagnosis of early periapical inflammatory pathosis on intra-oral radiographs, and to examine the effect of observer experience upon diagnostic performance in this task. Methods 50 observers examined 18 periapical radiographs using three different viewing conditions (room lighting; viewing box; viewing box with x2 magnification and masking). Their diagnoses were compared with an 'expert' diagnosis provided by repeated viewings of the films by two dental radiologists. Sensitivities and specificities were determined. Results When 'ideal' viewing conditions were used, optimal sensitivity (78%) and specificity (78%) were obtained. Use of a viewing box was associated with significantly higher specificity than the use of room lighting (P = 0.0016). Use of masking and x2 magnification was associated with significantly higher sensitivity than a viewing box alone (P = 0.004). There were few significant differences in diagnostic performance between observers, but qualified dental staff had significantly higher specificities than 4th year (P = 0.01) and 5th year (P = 0.01) students when a viewing box was used alone. Conclusions This study on early periapical inflammatory pathosis gives support to guidelines which recommend the use of a viewing box, x2 magnification and masking for interpreting intra-oral radiographs. It also suggests that observer experience may influence interpretation of early periapical pathosis.

TREATING INTERNAL RESORPTION USING A SYRINGEABLE COMPOSITE RESIN

Internal resorption is a pathological process initiated within the pulp space with the loss of dentin. It often is described as an oval shaped enlargement of the root canal space and usually is asymptomatic and detectable by routine radiographs. Treatment of internal resorption has included several materials--gutta-percha, zinc oxide eugenol and amalgam alloy. These materials do not provide strength to the tooth structure. A 29-year-old woman was referred to a dental clinic for treatment of a large internal resorptive defect in the coronal and middle one-third of the maxillary left central incisor root with no apparent periapical pathosis, as well as a large periapical radiolucency at the apex of the maxillary left lateral incisor that was associated with a necrotic pulp. The authors used a dual-cure syringable composite resin in conjunction with a bonding agent within the defect to treat it. This technique seals the dentinal tubules and strengthens the remaining tooth structure. It also improves the outcome of resorptive defects and reduces operators' chair time.

POTENTIAL FOR FRAUDULENT USE OF DIGITAL RADIOGRAPHY

Digital radiographic images can be manipulated using personal computers. To test the potential for fraudulent use, the authors altered a series of dental radiographs, printed them to simulate duplicated films and submitted them for authorization of proposed treatment. The authors obtained periapical radiographs of teeth that contained small restorations or were unrestored from the files of three dental patients at a private dental practice. The authors used a flatbed scanner to digitize and import the radiographs into a computer. Then they added dental caries, large restorations, fractures and periapical pathosis to the radiographs. The authors proposed to the insurance companies that the teeth in question be restored using expensive treatment, such as root-canal therapy and full-coverage crowns. In each case, the insurance companies authorized the proposed treatment based on the appearance of the teeth on the radiographs. The altered images illustrated an apparent need for dental treatment that was not required and that could have led to payment for treatment that was not actually performed. This study illustrates the potential for the fraudulent use of manipulated digital radiographic images. Dentistry should be aware of the implications of the potential for such abuse and should develop measures both to prevent it from occurring and to facilitate its detection.

Focal cemento-osseous dysplasia in the maxilla mimicking periapical granuloma

A case of focal cemento-osseous dysplasia of the maxilla in a 19-year-old man is reported. Clinically, the lesion resembled periapical pathosis of odontogenic origin. The clinical and histopathologic features of cemento-osseous dysplasia are reviewed. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88: 87-9)

Osteomyelitis of the maxilla

The present patient, a healthy 48-yearold male, was referred to our university dental hospital for evaluation of a swelling of the left palatal region. The patient had noticed a swelling and a pulsing pain in the anterior region of the left palate two weeks before his first visit to our hospital. Ten days before this first visit, he had undergone the removal of cuspids of the left maxi l lary first molar and incision of the swelling. Intra-oral examination revealed a swelling, which fluctuated on palpation, of the left palate in the region of the left maxi l lary canine to the second premolar. The mucosal surface of the swelling appeared normal in color and texture. Percussion pain was noted in all erupted teeth of the maxilla. A panoramic radiograph revealed diffuse osteolyses in the region from the left maxillary canine to the left first molar on (Fig. 1, ar row heads). All teeth in the affected area, except the left maxi l lary molars, were free from carious lesions and periodontal diseases (Fig. 2). CT images revealed an extensive osteolysis perforating the cortical plate of the palatal in the region of the left maxi l lary canine (Fig. 3, arrow). These radiographic features are very similar to those of malignant lymphoma of the bone I~, which made it difficult to determine if the lesion was a benign reactive process or a malignant one or some interaction of the two. A purulent discharge was released upon incision of the swelling of the palatal aspect of the left maxi l lary canine. The patient 's prognosis has been uneventful for the past three years and the osteolytic areas caused by the osteomyelitis has been completely filled in with new bone trabeculae. In the present case, the extensive osteolysis of the lesion by itself may not be enough to d e t e r m i n e w h e t h e r it is osteomyelitis from malignant lymphoma. Periapical pathosis of the left maxi l lary first molar and fluctuation of the swelling suggested that the lesion migh t r a t he r be osteomyelitis than malignant lymphoma of the bone. However, the rar i ty of maxil lary osteomyelitis made it more difficult to determine w h e t h e r the p r e s e n t case is osteomyelitis or malignant lymphoma. In such cases as this, it is necessary to check for signs and/or causes of inflammatory conditions. Where no such conditions exist, a biopsy of the lesion should be taken.

Optimum dental radiography in bone marrow transplant patients

Objective. The purpose of this study was to establish an optimum radiographic examination regimen for patients undergoing bone marrow transplantation. Two radiographic examinations were compared: the panoramic radiograph and the full mouth series of radiographs. Study Design. A prospective analysis of 65 consecutive patients undergoing bone marrow transplantation was undertaken. All patients were examined through use of both panoramic and full mouth series intraoral radiographs, including bitewings. Significant findings were recorded and compared by means of paired t test analysis for parametric data, such as caries, periapical inflammation and subgingival calculus, and by means of McNemar’s test for nonparametric data, such as the presence or absence of severe periodontal disease. Results. Acquired findings, such as caries, periodontal disease, and clinically significant faulty restorations, were detected more frequently from the full mouth series ( P < .05). There was no significant difference in the detection of periapical pathosis. In 8 of 65 patients, clinically significant information, such as evidence of impacted wisdom teeth, neoplasms, and multiple myeloma, was better detected from the panoramic radiographs. Conclusions. The results suggest a combination of both modalities as the optimum means of radiologic survey in this “high-risk” patient population.( Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:375-9)