Resolution Of Apical Periodontitis Research Articles

Well-being, postoperative pain and outcome after clinical application of a novel root canal irrigation fluid-RISA-in teeth with apical periodontitis: A first-in-human study.

The aim of the study was to assess the tolerance to the new root canal irrigation fluid RISA after root canal treatment (RCT) by evaluating the subject's postoperative well-being, postoperative pain (PP) and treatment outcome. A single-arm prospective study with 16 subjects (17 teeth) diagnosed with asymptomatic apical periodontitis. Endodontic treatment in one session performed using RISA for root canal irrigation. Well-being was assessed on the same day and after 24 h by telephone. For pain intensity, a visual analogue scale was used at 0-5 days. Clinical and radiographic evaluations were performed at ≥12 months. Well-being, occurrence of PP and outcome were qualitatively reported. Friedman test for paired samples and Spearman correlation coefficient were used. Significance was set at p < .05. At the same day and after 24 h, 14/16 subjects felt 'good'. 9/16 presented intra- or extra-oral swelling. The frequency of PP ≥36 (weak) was 82.4%. On the same day, 1 and 2 days postoperatively, there was more pain compared with preoperative pain p < .05. At Day 3, PP equalled preoperative pain (p > .05). 62.5% of subjects needed analgesics Day 0-2. The recall rate was 94.1%, and resolution of apical periodontitis was observed in 87.5%. The well-being of subjects was good, and the overall PP intensity was low. However, postoperative intra- and extra-oral swelling occurred often. At the recall visit, the effectiveness of the RCT with RISA appeared high (87.5%). The encouraging outcome results plus the fact that RISA has a broader action range than NaOCl in vitro, justify further work on the RISA solution. To reduce postoperative swelling, it is advised to further investigate the optimal way of application of RISA in the laboratory before clinical application is recommended.

The Effect of Unintentional AH-Plus Sealer Extrusion on Resolution of Apical Periodontitis After Root Canal Treatment and Retreatment—A Retrospective Case-control Study

IntroductionThis study aimed to investigate the effect of unintentional AH Plus sealer extrusion on the outcome of nonsurgical root canal treatment and retreatment in teeth with apical periodontitis (AP) compared to teeth with AP and no sealer extrusion at the 1-year follow-up. MethodsIn a retrospective case-control study conducted from September 2016 to September 2021, teeth presenting clinical and radiographic signs of AP prior to treatment were included. The study comprised 2 groups: AH Plus sealer extrusion group (n = 60): initial root canal treatment or nonsurgical retreatment with unintentional apical extrusion of AH Plus sealer; and no AH Plus sealer extrusion group (n = 60): underwent the same treatment types without sealer extrusion. Additional factors, including sex, age, tooth type, tooth location, and treatment type, were recorded as potential outcome predictors. At 1-year follow-up, teeth were evaluated clinically and radiographically, and outcomes were classified as favorable (healed/healing) or unfavorable (uncertain/non-healing). Statistical analyses, such as the χ2 test, logistic regression, and Mann-Whitney U test, were employed for data analysis. ResultsA favorable outcome was observed in 88.4% and 85% of the cases of the AH Plus sealer extrusion and no AH Plus sealer extrusion groups, respectively. There was no statistically significant difference between the groups in terms of outcomes (P > .05) when analyzed categorically or ordinally. Of independent variables, nonsurgical retreatment showed lower healing of AP in both groups. ConclusionsUnintentional AH Plus sealer extrusion did not affect the healing of AP. However, initial root canal treatment showed better healing of AP than nonsurgical retreatment in the presence of AH Plus sealer extrusion. The analyzed outcome predictors had no effect on treatment outcome.

Effectiveness of root canal treatment for vital pulps compared with necrotic pulps in the presence or absence of signs of periradicular pathosis: A systematic review and meta-analysis.

Preoperative pulpal status may influence the outcomes of root canal treatment (RCTx) according to various measures used. To compare the effectiveness of RCTx of teeth with a vital pulp versus a necrotic pulp, using a range of clinical and patient-related outcomes proposed for the development of S3-level clinical practice guidelines. A search was conducted in the PubMed-MEDLINE, Scopus, EMBASE, Google scholar databases and available repositories, followed by hand searches, until 29 March 2022. Clinical studies published in the English language comparing the stipulated outcomes of RCTx of teeth with vital versus necrotic pulp were included. The Newcastle-Ottawa Scale was adapted to assess study quality. Effects of pulpal status were estimated and expressed as risk ratio (RR) using fixed- and random-effect meta-analyses. The quality of evidence was assessed through the Grading of Recommendations Assessment, Development and Evaluation tool. Twenty-eight studies published between 1961 and 2021 were included. Five studies have investigated the "tooth survival" outcome, four reported pulpal status was not a significant predictor, consistent with meta-analysis findings (RR: 1.00; 95% CI: 1.00, 1.00; n=3). Seven studies reported pulpal status had no significant influence on postoperative pain, regardless of duration after treatment. Sixteen studies have analysed "periapical health," and 11 revealed pulpal status had no significant influence. Meta-analyses revealed the influence was not significant if preoperative periapical radiolucency was absent (RR: 0.95; 95% CI: 0.90, 1.00; n=9) but significant if it was present (RR: 1.12; 95% CI: 1.05, 1.19; n=11). Most studies were classified as "some concerns" (n=17) to "low" (n=9) risk of bias RoB. Evidence is limited and only available for three outcomes when comparing the effectiveness of RCTx in permanent teeth with vital pulp versus pulp necrosis. Nevertheless, the quality of available evidence was moderate to high. The "periapical health" data heterogeneity could be explained by preoperative radiolucency, thus RCTx was found more effective for prevention than the resolution of apical periodontitis. There was no significant difference in the "tooth survival," "postoperative pain" and "evidence of apical radiolucency" outcomes of RCTx in teeth with vital or necrotic pulps. PROSPERO database (CRD42021260280).

REVASCULARIZATION IN MATURE PERMANENT TEETH WITH NECROTIC PULP AND APICAL PERIODONTITIS: CASE SERIES

INTRODUCTION: Revascularization procedures have been limited to immature teeth but application to mature teeth should be clinically investigated as an alternative to conventional root canal treatment. The translation of regenerative endodontic procedures into treating mature teeth is challenging and depends on efficient root canal disinfection, proper size of the apical foramen, the availability and delivery of stem cells into the root canal system. OBJECTIVES: Evaluation of revascularization in mature teeth after enlargement of the apical foramen to size 35 K-file. MATERIALS AND METHODS: Three necrotic incisors with mature roots and apical periodontitis in three patients ranging from 20–30 years old were treated by revascularization procedures. Access opening was performed. The canal was mechanically instrumented to the radiographic apex. The apical foramen was enlarged with a size 35 K-file. Triple antibiotic paste (0.1 mg/ml) was applied in the canal using a syringe. After three weeks, the medication was removed with 20 ml of 1.5% sodium hypochlorite followed by final irrigation with 20 ml of 17% EDTA. Bleeding was induced in the root canal and mineral trioxide aggregate (MTA) was placed approximately 3-4 mm below the CEJ. The tooth was restored with a layer of glass ionomer followed by composite resin. The patient was scheduled for follow up and evaluation of healing after 3 months, 6 months and 9 months. Resolution of apical periodontitis and regression of clinical signs and symptoms were observed during the follow up periods. RESULTS: After a follow-up period of 9 months, the three teeth demonstrated radiographic evidence of periapical healing with absence of clinical signs and symptoms. CONCLUSIONS: The present cases demonstrated a favorable outcome of the revascularization procedure in mature necrotic incisors with chronic apical periodontitis

Revascularization-associated Intracanal Calcification: Assessment of Prevalence and Contributing Factors

IntroductionIntracanal calcifications have been reported in endodontic cases after revascularization. The purpose of the current study was to determine the incidence of intracanal calcification and potential contributing factors in retrospective revascularization cases. MethodsAmong 37 patients who had undergone revascularization between 2010 and 2014, 29 cases were assessed with average follow-up period of 24.9 months. Clinical and radiographic examinations were performed to evaluate the treatment outcomes, eg, resolution of apical periodontitis (AP), root development, and occurrence of intracanal calcification. Radiographic assessment revealed varied calcification patterns, which were classified into calcific barrier or canal obliteration, collectively referred to as revascularization-associated intracanal calcification (RAIC). ResultsAll 29 cases demonstrated resolution of AP, whereas continued root development with apical closure occurred in 23 of 29 cases (79.3%). RAIC was noted in 18 of 29 cases (62.1%), among which 5 of 18 cases (27.8%) were classified as calcific barrier and 13 of 18 cases as canal obliteration (72.2%). Higher frequency of RAIC was noted in the cases with induced bleeding (16 of 23 cases, 69.6%), whereas the 6 cases without induced bleeding showed RAIC at 33.4%. Also, RAIC occurred more frequently in cases medicated with Ca(OH)2 (10 of 13 cases, 76.9%) than in those medicated with antibiotic pastes (6 of 13 cases, 46.2%). ConclusionsThis study indicated that RAIC is common (62.1%) among cases treated with revascularization. Multiple contributing factors may include the type of medicaments and induction of intracanal bleeding. Although RAIC does not interfere with resolution of AP, some cases may progress to complete obliteration of root canals and would impede normal function of dental pulp tissues.

Regeneration and Repair in Endodontics-A Special Issue of the Regenerative Endodontics-A New Era in Clinical Endodontics.

Caries is the most common cause of pulp-periapical disease. When the pulp tissue involved in caries becomes irreversibly inflamed and progresses to necrosis, the treatment option is root canal therapy because the infected or non-infected necrotic pulp tissue in the root canal system is not accessible to the host's innate and adaptive immune defense mechanisms and antimicrobial agents. Therefore, the infected or non-infected necrotic pulp tissue must be removed from the canal space by pulpectomy. As our knowledge in pulp biology advances, the concept of treatment of pulpal and periapical disease also changes. Endodontists have been looking for biologically based treatment procedures, which could promote regeneration or repair of the dentin-pulp complex destroyed by infection or trauma for several decades. After a long, extensive search in in vitro laboratory and in vivo preclinical animal experiments, the dental stem cells capable of regenerating the dentin-pulp complex were discovered. Consequently, the biological concept of ‘regenerative endodontics’ emerged and has highlighted the paradigm shift in the treatment of immature permanent teeth with necrotic pulps in clinical endodontics. Regenerative endodontics is defined as biologically based procedures designed to physiologically replace damaged tooth structures, including dentin and root structures, as well as the pulp-dentin complex. According to the American Association of Endodontists’ Clinical Considerations for a Regenerative Procedure, the primary goal of the regenerative procedure is the elimination of clinical symptoms and the resolution of apical periodontitis. Thickening of canal walls and continued root maturation is the secondary goal. Therefore, the primary goal of regenerative endodontics and traditional non-surgical root canal therapy is the same. The difference between non-surgical root canal therapy and regenerative endodontic therapy is that the disinfected root canals in the former therapy are filled with biocompatible foreign materials and the root canals in the latter therapy are filled with the host's own vital tissue. The purpose of this article is to review the potential of using regenerative endodontic therapy for human immature and mature permanent teeth with necrotic pulps and/or apical periodontitis, teeth with persistent apical periodontitis after root canal therapy, traumatized teeth with external inflammatory root resorption, and avulsed teeth in terms of elimination of clinical symptoms and resolution of apical periodontitis.

Treatment of Mature Permanent Teeth with Necrotic Pulps and Apical Periodontitis Using Regenerative Endodontic Procedures: A Case Series

IntroductionRegenerative endodontic procedures (REPs) are usually used to treat human immature permanent teeth with necrotic pulps and/or apical periodontitis. Successful REPs result in the elimination of clinical signs/symptoms, the resolution of apical periodontitis, and, in some cases, thickening of the canal walls and/or continued root development with or without apical closure. REPs can restore the vitality of tissue in the canals of immature permanent teeth previously destroyed by infection or trauma. Vital tissue is inherited with immune defense mechanisms to protect itself from foreign invaders. Recently, REPs have also been used to successfully treat human mature permanent teeth with necrotic pulps and apical periodontitis. The purpose of this case series was to present the potential of using REPs for mature permanent teeth with necrotic pulps and apical periodontitis. MethodsThis case series consisted of 6 patients, 4 females and 2 males. The patients' ages ranged from 8–21 years old. Seven permanent teeth, 4 anterior and 3 molar teeth, with necrotic pulps and apical periodontitis were treated using REP. Radiographically, the root development of all teeth was almost completed except the apices of 2 molars, which showed slightly open. Complete chemomechanical debridement of the canals of the teeth was performed, and the canals were dressed with Metapaste (Meta Biomed Co, Ltd, Chungbuk, Korea) during treatment visits. Periapical bleeding into the canals was induced at the last treatment visit by placing a hand #20 or #25 K-file with the tip slightly bent through the apical foramina into the periapical tissues. A 3-mm thickness of mineral trioxide aggregate was placed into the coronal canals over semicoagulated blood. The access cavities were restored with either composite resin or amalgam. ResultsFollow-ups of the 7 teeth ranged from 8 to 26 months. The periapical lesions of 2 teeth were considered healed, and 5 teeth revealed healing. Clinical signs/symptoms were absent in all teeth at follow-up visits at different time points. None of the treated teeth responded to cold and electric pulp tests. ConclusionsThis case series shows the potential of using REPs for mature teeth with necrotic pulp and apical periodontitis.

Management of Teeth with Persistent Apical Periodontitis after Root Canal Treatment Using Regenerative Endodontic Therapy

Regenerative endodontic therapy (RET) is currently used to treat immature teeth with necrotic pulp and/or apical periodontitis. However, recently RET has been used to treat mature teeth with necrotic pulp and/or apical periodontitis and resulted in regression of clinical signs and/or symptoms and resolution of apical periodontitis. The purpose of this case report was to describe the potential of using RET to treat 2 mature teeth with persistent apical periodontitis after root canal therapy using RET. Two male patients, one 26-year old and another 12-year old, presented for retreatment of persistent apical periodontitis after root canal treatment of 2 mature teeth (#9 and #19). The gutta-percha fillings in the canals of teeth #9 and #19 were removed with Carvene gutta-percha solvent (Prevest DenPro, Jammu, India) and ProTaper Universal rotary retreatment files (Dentsply Maillefer, Ballaigues, Switzerland). The canals of both teeth were further chemomechanically debrided with rotary retreatment files and copious amounts of sodium hypochlorite irrigation and dressed with Metapaste (Meta Biomed, Chungbuk, Korea). RET was performed on teeth #9 and #19. Periapical bleeding was provoked into the disinfected root canals. The blood clots were covered with mineral trioxide aggregate plugs, and the access cavities were restored with intermediate restorative material. Teeth #9 and #19 showed regression of clinical signs and/or symptoms and healing of apical periodontitis after 13-month and 14-month follow-ups, respectively. Tooth #9 revealed narrowing of the canal space and apical closure by deposition of hard tissue. RET has the potential to be used to retreat teeth with persistent apical periodontitis after root canal therapy.

Treatment of a Large Cystlike Inflammatory Periapical Lesion Associated with Mature Necrotic Teeth Using Regenerative Endodontic Therapy

IntroductionRegenerative endodontic therapy is currently used to treat immature permanent teeth with necrotic pulp and/or apical periodontitis. However, mature teeth with necrotic pulp and apical periodontitis have also been treated using regenerative endodontic therapy. The treatment resulted in resolution of apical periodontitis, regression of clinical signs and symptoms but no apparent thickening of the canal walls, and/or continued root development. A recent study in an animal model showed that the tissues formed in the canals of mature teeth with apical periodontitis after regenerative endodontic therapy were cementumlike, bonelike, and periodontal ligament–like tissue with numerous blood vessels. These tissues are similar to the tissues observed in immature permanent teeth with apical periodontitis after regenerative endodontic therapy. MethodsA 23-year-old woman had a history of traumatic injury to her upper anterior teeth when she was 8 years old. Subsequently, #8 developed pulp necrosis and an acute apical abscess and #7 symptomatic apical periodontitis. The apex of #8 was slightly open, and the apex of #7 was completely formed. Instead of nonsurgical root canal therapy, regenerative endodontic therapy was attempted, including complete chemomechanical debridement on #8 and #7. This was based on the premise that filling of disinfected root canals with the host's biological vital tissue might be better than filling with foreign materials. ResultsAfter regenerative endodontic therapy of #8 and #7, there was radiographic evidence of periapical osseous healing and regression of clinical signs and symptoms. The pulp cavity of #8 decreased in size, and the apex closed. The pulp cavity of #7 appeared to be obliterated by mineralized tissue. These indicated ingrowth of new vital tissue into the chemomechanically debrided canals. ConclusionsRegenerative endodontic therapy of mature teeth with apical periodontitis and apical abscess can result in the regression of clinical signs and/or symptoms and healing of apical periodontitis but no apparent thickening of the canal walls or continued root development. Filling of the disinfected canals with the host's vital tissue may be better than with foreign materials because vital tissue has innate and adaptive immune defense mechanisms.

Histological Findings of Revascularized/Revitalized Immature Permanent Molar with Apical Periodontitis Using Platelet-rich Plasma

IntroductionAn immature mandibular right first molar (#30) with apical periodontitis of a 9-year-old boy was treated with a revascularization/revitalization procedure using either a mixture of platelet-rich plasma (PRP) and a blood clot or a blood clot alone on the same tooth. MethodsTooth #30 fractured 2 years and 1 month after the revascularization/revitalization procedure and could not be saved. The tooth was extracted and processed for histologic examination to determine the nature of the tissues that formed in the canals. ResultsClinically, the endodontic treatment of the case was successful based on the resolution of apical periodontitis and the absence of clinical signs and symptoms. Histologically, the tissues formed in the distal and mesial canals were mineralized tissue similar to cementoid/osteoid tissue and uninflamed fibrous connective tissue regardless of PRP or no PRP treatment. No pulp-like tissue characterized by the presence of odontoblast-like cells polarized along the dentin-like mineralized tissue was observed. ConclusionsThe tissues formed in the canals were mineralized tissue and some fibrous connective tissue. No pulp-like tissue characterized by the presence of odontoblast-like cells was observed lining the dentin-like mineralized tissue.

Regenerative endodontics – biologically‐based treatment for immature permanent teeth: a case report and review of the literature

A paradigm shift in the treatment of immature, necrotic teeth has occurred with biologically-based principles and regenerative endodontic protocols replacing traditional 'apexification' procedures. Preliminary research suggests that stem and progenitor cells from the pulp and/or periodontium contribute to continued root development when regenerative procedures are followed. A mandibular premolar tooth with a chronic periapical abscess was irrigated with sodium hypochlorite with minimal instrumentation and then dressed with tri-antibiotic paste consisting of ciprofloxacin, metronidazole and amoxicillin. At a subsequent visit a blood clot was evoked in the canal by irritating periapical tissues and the canal sealed with mineral trioxide aggregate, glass ionomer cement and composite resin. Resolution of apical periodontitis and the draining sinus, continued root maturation and apical closure occurred over an 18-month period. The tooth became responsive to pulp sensibility testing. It is important that dentists recognize the potential of regenerative endodontics in the treatment of necrotic, immature teeth. Initial management should involve irrigation with sodium hypochlorite only. Intra-canal medicaments, such as calcium hydroxide, are contraindicated as they inhibit further root growth. This report uses a variation of the tri-antibiotic paste currently recommended for regenerative procedures that avoided the discolouration of the crown associated with current protocols. Regenerative endodontics with continued root growth may reduce the risk of fracture and premature tooth loss associated with traditional 'apexification' procedures where the root remains thin and weak.

Evaluation of Chlorhexidine Toxicity Injected in the Paw of Mice and Added to Cultured L929 Fibroblasts

Because chlorhexidine (CHX) has been recommended as either an endodontic irrigant or root canal dressing, this study aimed to characterize, in vivo, the lesion induced by injections of CHX in the paw of mice at selected time intervals (24 and 48 hours and 7 and 14 days) and, in vitro, the mode of cell death, necrosis and/or apoptosis, and the cellular stress caused by exposition of cultured L929 fibroblasts to ascending concentrations of CHX for 24 hours. CHX injected in the subplantar space of the hind paw of mice induced severe toxic effects, as evidenced by necrotic changes in the epidermis, dermis, and subcutaneous tissue in association with reactive inflammatory response, particularly at higher concentrations. In addition, in cultured fibroblasts, CHX induced apoptosis at lower concentrations and necrosis at higher concentrations and increased expression of heat-shock protein 70, an indicator of cellular stress. Taken together, these findings suggest that CHX may have an unfavorable effect on the resolution of apical periodontitis.