Periapical cemento-osseous dysplasia in maxillary teeth suggesting apical periodontitis: case report

This article describes the case of a 34-year-old woman whose prosthodontist had referred her for root canal treatment of tooth No. 10, due to an initial diagnosis of apical periodontitis. Although periapical radiolucencies were present, teeth No. 10 and 11 responded positively to pulp vitality tests. A series of periapical radiographs revealed circumscribed periapical radiolucencies on teeth No. 21 and 28, while teeth No. 23, 24, and 27 were associated with mixed radiolucent/radiopaque periapical lesions. All teeth responded to cold stimulus. Based on the clinical and radiographic findings, a diagnosis of periapical cemento-osseous dysplasia was suggested. A re-evaluation 12 months later confirmed this diagnosis. Tooth No. 10 was restored and the patient was scheduled to return for clinical and radiographic follow-up after one year and three years.

Inflammatory implant periapical lesion: etiology, diagnosis, and treatment--presentation of 7 cases

PURPOSE

To investigate implant periapical lesions, and to describe their treatment. The hypothesis of this evaluation is that implant periapical lesions are disorders of the area surrounding the apex of a dental implant, and that their etiology can be multifactorial (ie, vascular impairment, vascular ischemia, overheating of bone during drilling, and implant surface contamination). The diagnosis is based on the clinical manifestations and x-ray findings. The x-ray findings usually involve a periapical radiotransparency.

MATERIALS AND METHODS

Seven patients with implant periapical lesions (3 in the upper jaw, and 4 in the mandible) after implant placement are described. All patients reported pain, and 3 suffered from inflammation. Upon percussion, the 3 nonsubmerged implants produced a dull sound, with no mobility. A panoramic x-ray study showed periapical transparencies around 5 implants, whereas in 1 case, computed tomography showed a maxillary sinus reaction. The diagnosis was acute apical peri-implantitis (nonsuppurative in 2 cases, and suppurative in 5 cases).

RESULTS

The clinical manifestations did not subside with antibiotics. In all cases, treatment consisted of implant periapical surgery, after which the symptoms disappeared. The radiotransparencies showed progressive resolution.

CONCLUSION

The possibility of implant periapical lesions must be taken into account. A rapid diagnosis should be established to treat the lesions at an early stage, hence preventing the need for implant extraction.

Use of dental radiography among Lithuanian general dentists

OBJECTIVE

To gather information about the radiographic facilities and techniques used by Lithuanian general dentists.

MATERIALS AND METHODS

Questionnaires were sent to all 2879 Lithuanian dental practitioners registered on the Lithuanian Dental Chamber licence registry data list. The questionnaire was made with multiple-choice answers. Respondents were invited to choose the only one category of answer that best fitted their clinical attitude. Questions included in the present survey concerned general and specific information regarding peculiarities of radiographic imaging. Only answers of respondents who are licensed as general dentists were included in this study.

RESULTS

From the 2850 questionnaires mailed 1532 were returned. The response rate was 53.8%. Of the total responses 1431 questionnaires were received from licensed general dentists. Of total 956 dentists practiced in urban and 576 dentists in rural areas. 61.6% of respondents had access to an intra-oral radiographic unit in their practice and 91.5% of them used dental radiography always or often as the diagnostic tool. To support the film packet in the patient's mouth alternatively film holder or patient's finger was used by 48% of respondents, while film holder was used only by 19.3% of dentists.

CONCLUSION

Recently graduated dental practitioners more common used diagnostic radiography in endodontic pathology than dentists with a longer time from graduation. Film holder was not a popular device among general dental practitioners to perform periapical radioraphs. It is important to improve the existing dental curriculum to ensure the necessary competency when using dental radiography and film holders routinely in clinical practice.

Florid cemento-osseous dysplasia mimicking multiple periapical pathology--an endodontic dilemma

A case of florid cemento-osseous dysplasia (COD) mimicking periapical pathology is presented. The fact that the patient's lesion failed to resolve three years after root canal therapy, in addition to the presence of a mixed radiolucency with discreet radiopacities, mandated a biopsy which (along with radiographic co-relation) confirmed the diagnosis of cemento-osseous dysplasia. This case report illustrates the point that periapical radiolucencies may represent benign fibro-osseous lesions that may be overlooked or result in unnecessary endodontic treatment.

Replacement of teeth exhibiting periapical pathology by immediate implants. A prospective, controlled clinical trial

OBJECTIVES

The aim of the present study was to test whether or not immediate implantation leads to more biological complications, when performed at extraction sockets of teeth exhibiting periapical pathology compared with teeth not exhibiting periapical pathology.

MATERIALS AND METHODS

In 17 consecutively admitted patients, immediate implant placement was planned in order to replace single teeth exhibiting periapical pathology (test group). These teeth demonstrated pain, periapical radiolucency, fistula, suppuration or a combination of these findings. Another 17 consecutively admitted patients in need of single tooth replacement in the absence of periapical pathology served as the control group. Implant placement and accompanying bone regeneration were performed according to standard clinical procedures. Implants were loaded after a healing period of 3 months. Clinical and radiographical parameters were assessed at the time of implant placement (baseline) and at 12 months thereafter.

RESULTS

Out of the 34 patients, four test and one control patient had to be withdrawn from the study due to the inability to obtain primary implant stability. The residual 29 implants revealed a survival rate of 100% 1 year after placement. Clinical and radiographical differences between 12 months and baseline comparing test and control groups showed no statistical significances for any of the parameters assessed. Within test and control groups there was a statistically significant loss of vertical bone height at the adjacent teeth (mesial test=0.4+/-0.6 mm, control=0.4+/-0.5 mm; distal test=0.3+/-0.2 mm, control=0.7+/-0.8 mm) as well as at the implant site (mesial test=1.9+/-1.4 mm, control=1.8+/-1.1 mm; distal test=1.7+/-1.4 mm, control=1.6+/-1.1 mm) and of buccal keratinized mucosa (test=-2.2+/-1.2 mm; control=-1.3+/-1.6 mm) between baseline and 12 months. During the first 13 weeks of healing, two sites of the test and one site of the control group showed signs of infection, which required intervention. Neither the incident of early exit nor of signs of infection was statistically significantly different between the test and the control group (Mann-Whitney U test).

CONCLUSION

It is concluded that for those implants where primary stability was achieved, the immediate implant placement performed at extraction sockets exhibiting periapical pathology did not lead to an increased rate of complications and rendered an equally favorable type of tissue integration of the implants in both groups. Implant placement into such sites can, therefore, be successfully performed.

Ultrasonic root-end preparation in apical surgery: a prospective randomized study

OBJECTIVE

The purpose of this study was to evaluate the potential benefit of an ultrasonic device in apical surgery on the outcome of treatment.

STUDY DESIGN

A randomized prospective design was used in a standardized treatment protocol. Patients were allocated to treatment with an ultrasonic device (P-Max Newtron) or treatment with a bur in an otherwise similar protocol. One year after treatment the results were evaluated by 2 oral and maxillofacial surgeons who were blinded for the therapy.

RESULTS

Out of a total group of 399 patients who were included in the study, adequate follow-up could be obtained in 290 patients. The overall success rate in the ultrasonic group was 80.5% and in the group treated with a bur 70.9% (P = .056). In molars, the difference in success rate was significant (P = .02).

CONCLUSION

The use of an ultrasonic device in apical surgery improved the outcome of treatment. In molars this effect was significant.

A systematic review on the outcome of surgical vs non-surgical procedure for the retreatment of periapical lesions

The most common therapeutical options for the retreatment of teeth with periapical pathosis are orthograde treatment and periapical surgery. The aim of this review was to evaluate the outcomes of surgical versus non-surgical retreatment, in order to provide clinicians with evidence-based information for decision making process. Articles were retrieved by electronic search strategy and traditional searching. Articles were selected based on strict inclusion criteria. The first criterion was the success of retreatment, as determined by clinical and radiographic criteria. The outcomes were further dichotomized according to functionality criteria. Two randomized trials (RCTs) were found. One hundred and twenty-six teeth were followed up after one year, and 82 after 4 years. The success rate for surgical treatment after one year was slightly better than non-surgical: 90.7% vs 80.6%, respectively, according to functional criteria. At the four-year evaluation (40 surgically treated and 42 non-surgically treated cases from 1 RCT) the outcomes were similar. A higher early post-operative discomfort was reported for surgically treated cases. There is no apparent advantage of using a surgical or non-surgical approach for the retreatment of periapical lesions in terms of long-term outcome. The choice between the two procedures should rely upon factors other than the mere treatment outcome, such as patient's initial clinical situation, patient's preference, operator's experience and skill, complication risk, technical feasibility, and overall treatment cost. More well-designed RCTs should be performed with a large sample size and at least 4 years follow-up, using modern instrumentation and materials, to detect a true difference in the long term between the outcomes of the two alternative treatments, if any exists.

Interleukin-17 plays a role in exacerbation of inflammation within chronic periapical lesions

Interleukin (IL)-17 plays an important role in inflammation and certain autoimmune diseases. However, its role in the pathogenesis of chronic dental periapical lesions has not been studied. Periapical lesion mononuclear cells (PL-MNC) were isolated from inflammatory cells and phenotypically analyzed by immunocytochemistry. The cells were cultured in vitro and IL-17 and IL-8 were measured in the culture supernatants. Controls were peripheral blood (PB) MNC. The level of IL-17 and the proportion of neutrophils were significantly higher in symptomatic lesions. In addition, the production of IL-17 was higher in culture supernatants of PL-MNC isolated from lesions with a predominance of T cells, and the IL-17 concentration correlated with the proportion of CD3+ and CD4+ cells. There was a positive correlation between the levels of IL-17 and IL-8 in the group of symptomatic lesions. The relationship between these cytokines was additionally confirmed on the basis of augmented production of IL-8 by both PL-MNC and PB-MNC treated with IL-17. Our results suggest that IL-17, by stimulating the production of IL-8, may play a role in exacerbating inflammation within chronic periapical lesions.

Relationship of periapical lesion radiologic size, apical resection, and retrograde filling with the prognosis of periapical surgery

PURPOSE

Periapical surgery eliminates the periradicular inflammatory tissue and seals the apical foramen. The present study relates the radiologic size of the periapical lesion, apical resection, and retrograde filling to the middle- and long-term success of periapical surgery.

MATERIALS AND METHODS

In a prospective study, 235 patients and 333 teeth were subjected to ultrasound instrumentation and retrograde filling with silver amalgam. Radiographic measurements were made of the maximum and minimum diameters of 320 periapical lesions before surgery. In the 384 apicoectomized roots, calculations were made of the eliminated apical portion, and in 526 root canals the magnitude of retrograde filling was determined. The patients were subjected to a minimum follow-up period of 12 months, with a mean of 27.8 months (range 12 months to 10 years).

RESULTS

Global evaluation showed a success rate of 73.9% after 12 months. The mean periapical area before surgery was 37 mm(2) (maximum diameter, 7.4 mm; minimum diameter, 5 mm). The mean apical resection was 6.48 mm(2) (height, 2.7 mm; base, 2.4 mm). The mean area of the retrograde cavities was 3.05 mm(2) (long side, 2.25 mm; short side, 1.1 mm). A positive correlation was observed between the dimensions of the lesion and apical resection with the treatment failure. None of the dimensions of the filling cavity was related to treatment failure.

CONCLUSION

The prognosis of periapical surgery improves with decreasing periapical lesion size and lesser apical resection, and is not dependent on the magnitude of retrograde filling.

Progressive dental development in regional odontodysplasia

Regional odontodysplasia (RO), also known as ghost teeth, is an unusual nonhereditary developmental anomaly of tooth formation that characteristically affects enamel and dentin formation of the primary and/or permanent dentition. In the present paper, we report a case of RO affecting a 7-year-old boy, with 9 years of follow-up. During this time, progressive development of dental tissue was observed, including complete root formation. However, delayed dental eruption was evident. In view of these findings, we discuss the clinical presentation, pathogenesis, differential diagnosis, and treatment of RO.

Maintaining a high level of suspicion for recurrent malignant disease: report of a case with periapical involvement

AIM

To report the unusual endodontic presentation and radiographic features of a subgroup of pleomorphic adenoma called carcinoma ex pleomorphic adenoma and to stress the importance of maintaining a high level of suspicion in cases where primary or recurrent neoplasia is included in the differential diagnosis.

SUMMARY

This paper describes a case in which a patient with a previous history of malignant neoplasm presented with signs and symptoms similar to a dental infection. The pathology report however confirmed recurrence of the previous tumour in a malignant fashion. The importance of maintaining a high level of suspicion in early management of such disease is highlighted.

KEY LEARNING POINTS

*Pleomorphic adenomas, also known as benign mixed tumours, are common salivary gland tumours, which infrequently undergo malignant transformation, with potentially devastating consequences. *Malignant salivary gland tumours can present as dental swelling, dental pain and sudden loss of vitality of teeth so both general practitioners and specialists have the responsibility to evaluate such patients with a broad vision. *Radiographic differential diagnosis of periapical radiolucency should also include malignant salivary gland tumours. *This case highlights the need of vigilance at all times and emphasizes the benefits of biopsy and histological examination in the diagnosis of recurrent malignant salivary gland tumours.

Evaluation of chronic periapical lesions by digital subtraction radiography by using Adobe Photoshop CS: a technical report

The purpose of this study was to describe a new technique by using Adobe Photoshop CS (San Jose, CA) image-analysis software to evaluate the radiographic changes of chronic periapical lesions after root canal treatment by digital subtraction radiography. Thirteen upper anterior human teeth with pulp necrosis and radiographic image of chronic periapical lesion were endodontically treated and radiographed 0, 2, 4, and 6 months after root canal treatment by using a film holder. The radiographic films were automatically developed and digitized. The radiographic images taken 0, 2, 4, and 6 months after root canal therapy were submitted to digital subtraction in pairs (0 and 2 months, 2 and 4 months, and 4 and 6 months) choosing "image," "calculation," "subtract," and "new document" tools from Adobe Photoshop CS image-analysis software toolbar. The resulting images showed areas of periapical healing in all cases. According to this methodology, the healing or expansion of periapical lesions can be evaluated by means of digital subtraction radiography by using Adobe Photoshop CS software.

[Root canal treatments in a patient with florid cemento-osseous dysplasia]

This article follows the comprehensive dental treatment of a patient who presented with multi periapical radiolucencies on a complete set of periapical radiographs. All the affected teeth were treated and root canal fillings were performed. None of the periapical radiolucencies showed any evidence of a healing process. On a later stage, the lesions have been diagnosed as florid cemento-osseous dysplasia. (In this article the correct diagnosis and treatment will be discussed).

Radiological assessment of periapical status using the periapical index: comparison of periapical radiography and digital panoramic radiography

AIM

To compare the use of periapical radiographs and digital panoramic images displayed on monitor and glossy paper in the assessment of the periapical status of the teeth using the periapical index (PAI).

METHODOLOGY

A total of 86 subjects were examined. All participants underwent a full-mouth radiographic survey (14 periapical radiographs) and a panoramic radiography. The periapical status, using the PAI score, of all appraised teeth was assessed.

RESULTS

Periapical radiographs allowed the assessment of the periapical status of 87% of teeth using the PAI. On the contrary, digital radiography had a significantly reduced potential to allow assessment of the periapical status (P<0.01). Only 57.6% and 34.1% of teeth could be appraised using digital panoramic images displayed on monitor and glossy paper respectively (P<0.01). The total percentage of teeth with periapical pathosis was five fold higher when assessed with digital panoramic images displayed on glossy paper compared with periapical radiographs (P<0.01).

CONCLUSIONS

Teeth were best viewed on periapical radiographs except maxillary second and third molars, which were better viewed in orthopantomograms. Orthopantomograms on screen were scorable more often than when on printed images. Apical periodontitis was scored more often on paper than on screen, and more often on screen than in periapical radiographs.

Nonsurgical treatment of periapical lesions using intracanal calcium hydroxide medicament--a report of 2 cases

Periapical pathology is the most common sequelae of pulpal necrosis due to traumatic injury. For the success of endodontic treatment, healing of periapical pathology is necessary and can be achieved by maintaining a sterile root canal system. Calcium hydroxide has the potential to maintain a sterile root canal by its antibacterial and tissue-dissolving property. Two case reports of periapical pathology that healed within a period of 3 to 6 months after intracanal calcium hydroxide dressing are presented.

Clinical, radiographic, and histopathologic evaluation of Nd:YAG laser pulpotomy on human primary teeth

The purpose of this study was to compare clinical, radiographic, and histopathologic effects of Nd:YAG laser pulpotomy to formocresol pulpotomy on human primary teeth. Patients with at least two vital primary molar teeth that required pulpotomy, because of pulpal exposure to caries, were selected for this study. After hemorrhage control, complete hemostasis into the canal orifice was achieved by exposure to Nd:YAG laser (1064 nm) and an He-Ne laser (the aiming beam of the Nd:YAG laser) in noncontact mode at 2 W, 20 Hz, 100 mJ, or was achieved by applying 1:5 dilution of formocresol. Forty-two teeth in two groups were to be followed up clinically and radiographic at 1, 3, 6, 9, and 12 months. Eighteen teeth planned for serial extractions were selected for histopathologic study. The teeth were extracted at 7 and 60 days. The teeth in the laser group had a clinical success rate of 85.71% and a radiographic success rate 71.42% at 12 months. The teeth in the formocresol group had a clinical and radiographic success rate of 90.47% at 12 months. There were no statistically significant differences between laser and formocresol group with regard to both clinical and radiographic success rates. There was a statistically significant difference between 7- and 60-day laser groups with regard to inflammatory cell response criteria. Dentin bridge was absent in all samples. No stained bacteria were observed in any of these samples. In conclusion, Nd:YAG laser may be considered as an alternative to formocresol for pulpotomies in primary teeth.

A clinical classification of the status of the pulp and the root canal system

Many different classification systems have been advocated for pulp diseases. However, most of them are based on histopathological findings rather than clinical findings which leads to confusion since there is little correlation between them. Most classifications mix clinical and histological terms resulting in misleading terminology and diagnoses. This in turn leads to further confusion and uncertainty in clinical practice when a rational treatment plan needs to be established in order to manage a specific pathological entity. A simple, yet practical classification of pulp diseases which uses terminology related to clinical findings is proposed. This classification will help clinicians understand the progressive nature of the pulp disease processes and direct them to the most appropriate and conservative treatment strategy for each condition. With a comprehensive knowledge of the pathophysiology of pain and inflammation in the pulp tissues, clinicians may accomplish this task with confidence.

Diagnostic accuracy ofin vitropanoramic radiographs depending on the exposure

OBJECTIVES

The aim was to evaluate the effect of dose reduction on diagnostic accuracy in panoramic radiographs with increased tube potential and reduced milliampere settings.

METHODS

Panoramic radiographs of 12 dried human skulls prepared with lesions in the bone, teeth and peri-implant bone in ascending size were taken. Medium and regular film--screen combinations and a storage phosphor system were used for imaging. All systems were exposed at a low and a high tube potential level. To compare the dose at different tube potential settings, dose length product was measured at the secondary collimator. Five observers assessed the presence (response: 1) or absence (response: 0) of lesions. Sensitivity, specificity and diagnostic accuracy were evaluated and 36 000 ratings were made in all. All settings were repeated once. Intrarater agreement was expressed by Cohen's kappa coefficient.

RESULTS

There was no significant difference in diagnostic accuracy between a medium and a regular film--screen combination at a low tube potential level (70 kV; 0.935 and 0.930) and the medium film--screen system at a high tube potential level (85 kV; 0.926). Compared with this group, the regular film-screen combinations at high tube potential level (85 kV, 0.906) and all digital radiographs were significantly different (0.886 and 0.866), irrespective of the tube potential level. The digital panoramic radiograph was only comparable with the best film--screen combinations with an exposure for a medium film-screen system and at a low tube potential level. Sensitivity was 89.9% and specificity 93.7%. The kappa coefficient for intrarater agreement was high (0.81).

CONCLUSIONS

The medium intensifying screen can be used at high tube potential settings instead of low tube potential settings, or the regular intensifying screen can be used at low tube potential settings with the same diagnostic value. A dose reduction of about 40% is possible. The storage phosphor plates should be exposed at least like a regular film-screen system and at a low tube potential level.

Endodontic treatment of dens in dente associated with a chronic periapical lesion using an apical plug of mineral trioxide aggregate

Dens in dente is a developmental anomaly that predisposes the tooth to develop caries and pulp periapical pathologies. A chronic lesion can develop without any clinical symptoms of the pathology. The purpose of this case report is to describe the endodontic treatment of dens in dente associated with a periapical lesion using a mineral trioxide aggregate apical plug.

Clinical and radiological course in apicoectomies with the Erbium:YAG laser

OBJECTIVE

A study is made of the efficacy of the Erbium:YAG laser in granulomatous periapical lesions, based on clinical and radiographic controls.

MATERIAL AND METHODS

The study comprised a series of 45 patients amenable to periapical surgical treatment of incisors, canines and premolars. A conventional surgical technique was used, with silver amalgam retrograde filling and irradiation of the bone defect and remnant root cement with the Erbium:YAG laser. Clinical and radiographic controls were made during 24 months, assessing the absence of symptoms and the presence of pain, swelling or fistula and ossification of the lesions, respectively.

RESULTS

The clinical course proved asymptomatic in 95.5% of the cases. As regards remodeling of the bone cavity, 77.7% had completed ossification after 24 months, 13.3% were in an advanced stage of ossification and 4.5% in an intermediate stage, while 4.5% showed treatment failure.

CONCLUSIONS

The combination of silver amalgam and irradiation with the Erbium:YAG laser in periapical surgery showed a very high clinical success rate, with a 77.7% bone cavity remodeling rate after 24 months.

Accuracy of cone beam dental CT, intraoral digital and conventional film radiography for the detection of periapical lesions. An ex vivo study in pig jaws

To compare the accuracy of cone beam CT scanning (NewTom 3G) with intraoral periapical radiography (Dixi2, Planmeca CCD sensor and Insight film) for the detection of periapical bone defects. Ten frozen pig mandibles were used. All soft tissues were removed and the jaws were sagittally sectioned to obtain three blocks from each side of the jaw containing the premolars and the molars with surrounding jaw bone. All teeth with intact roots were then "extracted". First, 15 blocks were used to define defect size and exposure parameters; then, the remaining 45 blocks were divided into three equal groups. In one group, cylindrical defects of 1 x 1 mm were prepared beyond the apices of the extraction sockets, in another group defects of 2 x 2 mm were similarly prepared, while no defects were prepared in the last group. The teeth were replaced into their sockets and digital and conventional radiographs of all blocks were taken under reproducible conditions. In addition, all blocks were CT scanned with the same volumetric data and then reconstructed to provide sagittal and coronal 2-D sections. Masked evaluation of the images (defect present vs no defect) was performed by four calibrated examiners. Statistical analysis was performed with ANOVA and the significance level was set to P < 0.05. NewTom 3G was statistically significantly better in terms of sensitivity (54%), positive (82.6%) and negative (44.5%) predictive values, and diagnostic accuracy (61%) when compared with digital radiographs (23%, 60%, 31%, 39%), and with conventional ones (28%, 70%, 35%, 44%)-except in the positive predictive value. Specificity was similar for all three methods. No difference was observed between the two periapical (digital vs conventional) radiographs. NewTom 3G may be useful in cases of immediate implants intended to replace teeth with suspicion for possible existing endodontic pathology, or in candidate implant sites neighboring such teeth.