Endoscopic management of a lateral root lesion. A case report

The aim of this study was to obtain periradicular tissue healing of a lateral root lesion using a microsurgical technique. The case report concerns a 52-year-old female patient, in general good health (ASA1), presented with the left maxillary canine (2.3) exhibiting acute, specific symptoms. A radiographic examination revealed the presence of a circumscribed radiolucent lesion associated with the mesial mid-root area of the 2.3 and the distal mid-root area of 2.2, both endodontically treated. Using an endoscope as a magnification device a surgical inspection of the middle-third of the root of 2.2 and 2.3 was made. A pathway between the periodontium and root-canal system was detected with an endodontic file on the middle-third of 2.3 root wall. A root-lateral cavity was prepared using retro-tips. An EBA cement was used as the root-end filling material. Following clinical and radiographic assessment at 36 months post-surgery, the case was classified as successful. This case report showed the utility of using an endoscope and micro-surgical instruments for diagnosis and surgical treatment of micro-anatomical root structures.

Vitamin-D-resistant rickets: report of a case

A case is presented of a child from rural New Zealand with vitamin-D-resistant rickets. He underwent extensive treatment and is now partially dentate. The child may have received substantially different care if appropriate dental specialists had practised locally, although, in the long term, his outcome may not have been different. Early medical diagnosis of rickets and prompt preventive dental care may be useful in reducing spontaneous pulp death in either the primary or permanent dentitions.

Multiple sinus tracts as a result of root fracture: a case report

Sinus tracts are a consequence of chronic apical disease or vertical root fractures. They are usually diagnosed upon routine clinical examination or in response to patient complaints of swelling and occasional pus secretion. An unusual case report of a maxillary canine with multiple orifices of sinus tracts is presented. Vertical root fracture was confirmed after removal of the root canal filling under an operating microscope. Clinicians should suspect vertical root fracture when multiple sinus tracts originating from the same tooth are observed.

[Diagnostic image (342). A woman with a fistula at the edge of the jaw]

A 17-year-old girl had a persistent ulcerating external submandibular fistula which radiographically originated from a periapical abscess of the left lower second molar.

Surgical intervention of complex endo-perio lesions

Complex endo-perio lesions are infrequent, but pose treatment dilemmas. The lesions are complex with bone loss involving adjacent teeth that are not part of the initial endodontic lesion. The aggressive bone loss is not clearly understood and apparently has some differences from the usual apical periodontitis.

Persistent endodontic lesion due to complex cementodentinal tears in a maxillary central incisor—a case report

The cementodentinal tear is rarely detected by noninvasive procedures owing to its clinical picture simulating a root fracture or a periodontal or endodontic lesion. We present a case of complex cementodentinal tears in a 79-year-old woman who presented a repeated swelling at the labial mucosa of the left maxillary central incisor for 6 months. Periapical radiographs demonstrated a vertical radiolucent fracture line extending from the root apex along the mesial aspect of the root to near the middle portion of the root of the left maxillary central incisor. Because endodontic re-treatment failed to cure the disease, periapical surgery was performed, and 2 fractured U-shaped root fragments around the apical root surface were removed. Histologic examination showed that the 2 fractured root fragments were composed mainly of the dentin covered by a thin layer of the cementum and overlying periodontal ligament tissue, suggesting cementodentinal tears. A swelling recurred 8 months after the initial operation. Therefore, a second periapical surgery was performed. Although no obvious fracture line was observed around the root surface, the second surgery did not cure the disease, either. A persistent small swelling was noted at the alveolar mucosa of the affected tooth during the follow-up. We conclude that although a cementodentinal tear can be detected by a careful radiographic examination, its clinical outcome is not predictable by surgical removal only.

Persistent sinus tract formation 1 year following cast post-and-core replacements: a case report

Sinus tracts are paths of drainage for abscesses and can occur both intraorally and extraorally. It is a fact that sinus tracts can heal with proper endodontic therapy. However, there are those types that are persistent and will not respond to any treatment. In these perplexing cases, it may be necessary to elevate a surgical flap to unveil the real etiologic factor. In this article, a case is presented in which 2 persistent and nonhealing sinus tracts were observed around the maxillary left incisor area of a 53-year-old female patient. A difficult cast post-and-core removal had been accomplished to the compromised tooth 1 year previously. A surgical flap had to be reflected, and the cause of the persistent inflammation was determined to be 2 separate root perforations. The granulation tissue was removed, the perforations were sealed with mineral trioxide aggregate, and bone graft was packed in the resorptive bone areas. The symptoms subsided by the time of the 2-week recall. No complaints were noted from the patient during the 4-month follow-up period. This case is a good example that demonstrates the possible complications of post preparation and the necessity of explorative surgery for unveiling the etiologic factor of persistent sinus tract formation.

Prevalence and pathogenesis of dental and periodontal lesions in children with X-linked hypophosphatemic rickets

AIM

To assess the prevalence and to investigate the pathogenetic mechanisms of dental and periodontal lesions in children with X-linked hypophosphatemic rickets (XLH) examined at diagnosis or during treatment.

METHODS

Nine children with XLH (age 7.2 +/- 3.3 years) were enrolled in the study (at diagnosis, n = 2; during treatment with oral inorganic phosphate salts combined with 1,25-dihydroxyvitamin D3, n = 7). Oral examination was performed according to the evidence of carious and gingival lesions. Decayed or filled teeth (dft) index for primary teeth, and the decayed, missing, or filled teeth (DMFT) index for permanent teeth was assessed. All patients with a history of spontaneous dental abscesses underwent orthopantomography examination.

RESULTS

d/D ranged from 0 to 9 and f/F from 0 to 3. DMFT/dft index was 0 in the three youngest patients. One patient had enamel hypoplasia and two had enamel dyschromic alterations. Six out of nine patients (67%) had a history of spontaneous fistulae as a consequence of periapical abscesses occurring in the absence of dental decay or history of injury. In these patients, orthopantomographies showed enlarged pulp chambers associated with prominent pulp horns extending up to the dentino-enamel junction in both primary and permanent dentition.

CONCLUSION

XLH patients show some peculiar dentinal abnormalities. Treatment prevents only in part dental and periodontal lesions. Genetic mechanisms have a main role in causing defective dentin mineralisation.

Diagnosis and treatment of a large periapical implant lesion associated with adjacent natural tooth: a case report

A possible cause for dental implant failure is the periapical implant lesion (PIL). In this case report we describe an apical periodontitis on a tooth adjacent to a dental implant that may have communicated with the apical region of the dental implant, and causing retrograde peri-implantitis. To our knowledge this is the first report demonstrating the concomitant successful treatment of the periapical implant pathology and the adjacent natural tooth without the removal of the implant. The presence of large bony defect at the apical region of the natural tooth and the implant, resulting in a sinus tract and a deep periodontal pocket, was also confirmed with computerized tomography. The treatment procedure included root canal treatment followed by the debridement of the apical bone lesion, and guided bone regeneration. An uneventful healing with acceptable esthetic was observed.

Three-dimensional visualization of a mandibular first molar with three distal roots using computer-aided rapid prototyping

Nonsurgical endodontic therapy of a right mandibular first molar with 3 distal roots was successfully performed with the aid of magnification. 3D data (DICOM format) of the tooth were obtained from a CT HighSpeed Advantage and a Denta Scan program produced by GE Medical Systems. The CT protocol used for this procedure involved a slit thickness of 1 mm. The 3D digital data obtained were fed into a visualization program (V-works; Cybermed Co) and then exported to the rapid prototyping machine for fabrication of the actual-sized tooth model. The material for the model-making process was starch. The 3D digital visualization and the computer-aided rapid prototyping (CARP) model clearly showed 3 separate distal roots (distobuccal, distolingual, and middle distal). The CARP technique seems to be a useful imaging technology to document unusual root anatomy in clinical dentistry.

Endodontic management of a maxillary first molar with a single root and a single canal diagnosed with the aid of spiral CT: a case report

The aim of this article is to present an endodontically managed maxillary first molar with an unusual morphology of a single root and a single canal, which has not been reported in the literature so far. An accurate assessment of this unusual morphology was made with the help of a Spiral computed tomography. This report extends the range of known possible anatomical variations to include teeth with lesser number of roots and canals. This report also highlights the role of Spiral computed tomography as an objective method to confirm the three-dimensional anatomy of teeth.

An investigation of the relationship between untreated decayed teeth and dental sepsis in 5-year-old children

OBJECTIVES

To investigate the prevalence of dental sepsis in 5-year-old children in Scotland and the relationship between sepsis, treated and untreated decayed teeth, oral cleanliness (visible plaque on anterior teeth) and socio-economic deprivation.

SUBJECTS AND METHODS

Six thousand, nine hundred and ninety-four children of mean age 5.3 years were examined as part of a survey conducted under the Scottish Health Board's Dental Epidemiological Programme. The presence of dental sepsis was recorded, in addition to caries status, and presence of plaque. Postal code information was used to obtain a measure of material deprivation. Relationships between sepsis and its possible contributory factors were explored using stepwise logistic regression.

MAIN RESULTS

In the whole sample, 4.8% of children examined had dental sepsis, ranging from 2% in the most affluent areas to 11% in the most deprived. Children with sepsis had much higher caries experience (mean dmft 6.30) than those without sepsis (mean dmft 2.36). However, when these factors and the presence of plaque were entered into a logistic regression model to predict presence or absence of dental sepsis, the most important factor was not deprivation, but untreated decay.

CONCLUSIONS

The proportion of children with sepsis increases markedly with caries experience. This disadvantage can be mitigated if more of the caries experience is treated. These findings would not support a policy of non-intervention for deciduous caries if oral sepsis is to be minimised.

Retrospective clinical and radiologic evaluation of nonsurgical endodontic treatment in human immunodeficiency virus (HIV) infection

PURPOSE

This retrospective study evaluated the clinical and radiographic status of nonsurgical endodontic treatment (ET) of anterior and posterior teeth in HIV-seropositive patients.

METHODS

ET was analyzed in 26 anterior and 34 posterior teeth from 54 consecutive HIV patients (gender ratio 3 Male : 1 Female, mean age 40.2 years, mean CD4 240, CD4<500 in 88%, 12 with AIDS) over a six year period with a minimum of six months follow-up. ET was evaluated as successful, questionable, or failure based upon clinical factors (palpation, mobility, sinus tract, percussion, function, infection/swelling, occlusion, symptoms) and radiographic factors (periodontal ligament space, rarefaction, lamina dura, root resorption, obturation) during post-treatment examinations with a mean follow up of 26 months.

RESULTS

Clinical evaluation at follow up found ET outcome was successful in 88%, questionable in 10% (tenderness with percussion, mobility, widened ligament), and a failure in 2% (developed lesion after ET). Periapical lesions were present in 37% of cases (mean lesion size 6.2 mm). Following ET, mean lesion size (1.8 mm) had decreased by 71%. Obturation was evaluated as optimal or acceptable in 68%. Radiographic evaluation was considered successful in 80%, no change in 15%, and a failure in 5%.

CONCLUSIONS

Despite obturation deficiencies and the immunocompromised state of the patients, endodontic therapy has a relatively high degree of success in the majority of HIV/AIDS patients. HIV infection and AIDS should not be considered as a contraindication to endodontic therapy in this patient population.

Cutaneous draining sinus tract of odontogenic origin: unusual presentation of a challenging diagnosis

A 44-year-old woman presented with a chronically draining lesion on her cheek just lateral to the nasofacial sulcus. The lesion was refractory to treatment with oral antibiotics. Physical examination revealed poor dentition, and a panoramic radiograph demonstrated periapical abscesses in the maxillary right lateral incisor and canine. A diagnosis of cutaneous fistula of odontogenic origin was made, and the patient was treated with tooth extraction. The cutaneous fistula subsequently resolved. Intraoral examinations and radiographs are critical for making the diagnosis of cutaneous draining sinus tract of odontogenic origin. Many patients undergo unnecessary surgical therapies before having the correct diagnosis made, but root canal therapy or surgical extraction is the treatment of choice. A dental origin must be considered for any chronically draining sinus of the face or neck.

The clinical significance and management of apical accessory canals in maxillary central incisors

BACKGROUND

The maxillary central incisor is considered to be the least difficult subject for a clinical endodontic experience. However, the internal anatomy of maxillary central incisors can present a number of variations, including multiple accessory canals.

CASE DESCRIPTION

This article highlights the clinical significance and management of accessory canals located in the apical one-third of maxillary central incisors. The authors present two case reports in which failure to detect the accessory canals led to root canal failure and subsequent surgical intervention. Another two case reports present the serendipitous discovery and nonsurgical management of accessory canals during the initial treatment of maxillary incisors.

CONCLUSIONS AND CLINICAL IMPLICATIONS

It is important for the clinician to be able to detect the signs suggesting the presence of accessory canals in maxillary central incisors. Failure to do so may lead to a less-than-optimal endodontic treatment outcome.

Periapical actinomycosis: a review

Actinomycosis has increasingly been recognized as a cause of persistent or recurrent periapical disease associated with endodontically treated teeth. This case report shows the classic clinical picture of periapical actinomycosis: persistent periapical disease with recurrent sinus tracts. Although there was no pain or swelling after clinically acceptable initial endodontic treatment, a periapical lesion developed. After retreatment, the periapical lesion persisted, and a sinus tract developed. The sinus tract healed with antibiotic therapy but recurred within a few months. This cycle of sinus tract to antibiotic therapy to recurrence of the sinus tract repeated several times over a period of 5 years. Upon biopsy, periapical actinomycosis was diagnosed, where classic "sulfur granules" were demonstrated in the histologic examination of the periapical lesion. Antibiotic therapy for a period of 6 weeks was prescribed subsequent to the histologic diagnosis because of the possibility of spread of the actinomycotic infection into the maxillary sinus. Considerable healing was evident within 5 months of surgical and antibiotic treatment.

Federal University of Santa Catarina endodontic treatment of traumatized primary teeth - part 2

This research sought to evaluate periapical repair in 28 traumatized deciduous teeth that had suffered endodontic intervention due to the presence of internal or external inflammatory resorption or replacement root resorption. After obtaining endodontic access, work length and biomechanical preparation, the root canals were filled with calcium hydroxide and propylene glycol under the form of a dense slurry, during 12 months. Replacement of the intracanal dressing was performed when monthly radiographic examinations showed its absence. After 12 months the teeth were obturated with zinc oxide and eugenol cement. Halting of the inflammatory and replacement root resorption (64.3%; n = 28) occurred 9 months after the use of calcium hydroxide dressings, in a total of 18 successful cases. Fisher's test was applied to relate success with the type of trauma, work length time, child's age and pulpal condition. The test did not present statistical significance (P < 0.05). However, in the qualitative analysis, failure was observed in those cases (35.7%) where replacement resorption was already present at the moment of treatment (up to two-thirds) associated with severe trauma cases. The authors concluded that endodontic treatment must be initiated at an early stage, and must be coincident with the radiographic signs of resorption. Success of the treatment is directly related to the seriousness of the sequelae at the moment of the first examination or the endodontic treatment.

Clinical management of a maxillary lateral incisor with vital pulp and type 3 dens invaginatus: a case report

A maxillary right lateral incisor with a type 3 dens invaginatus and a large periapical lesion with vital pulp in a separate root canal was treated both nonsurgically and surgically. Care was taken not to expose or devitalize the vital pulp in the main root canal system during the treatment. The signs and symptoms ceased after the treatment, and 4-month recall showed complete bone healing with pulp vitality maintained.

Periosteal grafts as barriers in periradicular surgery: report of two cases

AIM

To describe the usefulness of periosteal grafts as barriers for bone regeneration in periradicular surgery when advanced periodontal breakdown occurs.

SUMMARY

The treatment of advanced periodontal breakdown as a result of an associated endodontic lesion constitutes a multifaceted challenge to the clinician. If the source of the irritation cannot be removed by orthograde endodontic treatment, nonsurgical and surgical endodontic/periodontal intervention may be required. Two cases with suppurative chronic apical periodontitis with apicomarginal communication are described. Clinical and radiological evaluations were completed immediately prior to surgery, a week later and every 2 months after surgery for 10 months. Both patients were treated using split-thickness flaps and lateral displacement of the periosteum prior to suturing, in order to close the communication between the oral and the periapical surroundings. A remission of the clinical signs and symptoms, and successful healing in the short-term were achieved in these cases.

KEY LEARNING POINTS

Periapical and periodontal lesions are closely related through pathways of communication. Disruption of the cortical plate and the presence of dentoalveolar sinus tracts can have a deleterious effect on the regeneration process after periradicular surgery. The adoption of supplementary periodontal surgical techniques may help to solve some of the difficulties in the healing process in periradicular surgery. Periosteal grafts have been shown to have the potential to stimulate bone formation when used as a graft material.