Clinical management of infected root canal dentin

Several hundred different species of bacteria are present in the human intraoral environment. Bacterial penetration of root canal dentin occurs when bacteria invade the root canal system. These bacteria may constitute a reservoir from which root canal reinfection may occur during or after endodontic treatment. The learning objective of this article is to review endodontic microbiology, update readers on the role of bacteria in pulp and periapical disease, and discuss the principles of management of infected root canal dentin. Complete debridement, removal of microorganisms and affected dentin, and chemomechanical cleansing of the root canal are suggested as being the cornerstones of successful endodontic therapy, followed by intracanal medication to remove residual bacteria, when required.

Associations of endodontic symptoms and signs with particular combinations of specific bacteria

Significant associations have been reported between (a) specific bacterial species isolated from root canals and (b) between individual bacterial species and endodontic symptoms and signs. The prime objective of this study was to determine whether particular combinations of specific bacteria are associated with individual endodontic symptoms and signs. Seventy root canals were investigated microbiologically taking care to maintain the viability of obligate anaerobes, which accounted for 64% of the total species isolated, including Peptostreptococcus micros, Prevotella melaninogenica, Prevotella oralis, Eubacterium aerofaciens, Eubacterium lentum, Fusobacterium nucleatum, Prevotella buccae and Prevotella intermedia. Significant associations were found between individual clinical features and the following pairs of species: (a) pain (37 cases) and Peptostreptococcus spp./Prevotella spp., Peptostreptococcus spp./Prevotella melaninogenica, Pstr. micros/Prev. melaninogenica (all P < 0.01); (b) swelling (23 cases) and Pstr. micros/Prevotella spp. (P < 0.01); (c) 'Wet' canal (57 cases) and Prevotella spp./Eubacterium spp. (P < 0.01), Peptostreptococcus spp./Eubacterium spp. (P < 0.05). Thus data from this investigation suggests that statistically significant associations exist between individual endodontic symptoms and signs and particular combinations of specific bacteria.

Clinical significance of dental root canal microflora

OBJECTIVES

Previous work by this group has shown that a significant association exists between pain and the presence of either Prevotella or Peptostreptococcus spp. in dental root canals. The aim of this study was to examine a more extensive series of canals microbiologically, to determine whether any other particular endodontic symptoms or clinical signs showed specific associations with individual bacterial species.

METHODS

Seventy root canals were examined microbiologically and clinical data collected to investigate in detail such associations.

RESULTS

Of the canals studied, 37 were associated with pain, 49 with tenderness to percussion, 23 with swelling, six with purulent exudate and 57 presented with wet root canals. Anaerobes were isolated from 70.3% of painful canals and from 29.7% of pain-free canals. Significant associations were found between (a) pain and either Prevotella spp. or peptostreptococci, both with P < 0.01; (b) tenderness to percussion and Prevotella spp. (P < 0.01) or anaerobes (P < 0.05); (c) swelling and Eubacterium spp. (P < 0.01), or with Prevotella spp. or Pstr. micros, both with P < 0.05; (d) purulent exudate and any one of F. necrophorum (P < 0.01), Prev. loescheii, Streptoccoccus constellatus or Bacteroides spp. (each P < 0.05); (e) wet canal and facultative anaerobes (P < 0.01), and any one of the genera of Eubacterium, Peptostreptococcus, Prevotella or Propionibacterium (each P < 0.05).

CONCLUSION

It was concluded that several different endodontic clinical signs and symptoms are significantly associated with specific bacterial species.

A microbiological and immunological study of endodontic-periodontic lesions

The microflora and humoral immune response in tissue from the periodontal pockets and root canals of five teeth with endodontic-periodontic lesions were examined. We found more microbes in the periodontal pockets than in the root canals. The flora in the periodontal pockets was dominated by rods and motile organisms, whereas that in the root canals was largely rods and cocci. We detected no spirochetes in the root canals. The cultivable microflora in the periodontal pockets comprised a high number of different species of bacteria, whereas those in the root canals included only a small number of species. There was no correlation between microbial isolates and antibody titer in the apical tissues or periodontal pockets. We conclude from these studies that the microflora of infected root canals is simple and limited, and that the local humoral immune response does not seem to affect the pathogenesis of disease directly.

The influence of endodontic infection on progression of marginal bone loss in periodontitis

The purpose of the present investigation was to determine magnitude and rate of proximal radiographic attachment loss in relation to endodontic infection in periodontally involved teeth. The investigation was conducted as a retrospective longitudinal study on a periodontitis-prone randomly selected referral population, including 175 single-rooted, root-filled teeth in 133 patients. An observation period of at least 3 years was required. Periapical conditions of the selected sample at baseline and re-examination were evaluated on radiographs, independently by 3 investigators. Each single-rooted, root-filled tooth of the sample was given a score according to the combined registrations. Radiographic attachment level was measured as the distance between the most coronal point of the alveolar bone and the apex at the mesial and distal sides of the tooth, and expressed as relative radiographic attachment level (RRAL) (radiographic attachment level at baseline/root length) at proximal sites for every tooth. Multiple regression analysis was used to study change in RRAL over time. Teeth in periodontitis-prone patients with progressing periapical pathology indicating a continuous root canal infection were found to lose comparatively more radiographic attachment than teeth with no signs of periapical pathology or teeth with an established periapical destruction which subsided during the observation period. An approximate 3-fold amplification of the rate of marginal proximal radiographic bone loss by endodontic infection in periodontitis-prone patients was found with an average 0.19 mm/year, while 0.06 mm/year was lost for teeth without endodontic infection or subsiding endodontic involvement.

Endodontic pathogens in periodontal disease augmentation

Periapical pathology indicating endodontic infection, when present in periodontitis-affected teeth, has recently been shown to be correlated to marginal periodontal breakdown. This has been associated with patency of dentinal tubules in the tooth cervix, an area normally devoid of cementum following periodontal therapy. These studies are, however hampered by that only circumstantial evidence such as presence of periapical destruction have been applied as criteria of endodontic infection. The aim of the present investigation was to assess the effects of endodontic pathogens on marginal periodontal wound healing on root surfaces devoid of cementum but surrounded by healthy periodontal membrane. Significant differences between infected and non-infected teeth were found with respect to pathological pocket and connective tissue: The experimental defects were covered by approximately 20% more pocket epithelium in infected teeth while defects in non-infected teeth showed approximately 10% more connective tissue coverage. It was concluded, that an intra-canal infection of endodontic pathogens stimulates epithelial downgrowth along denuded dentin surfaces with marginal communication. Extrapolated to the clinical situation, endodontic infections in periodontitis-prone patients may augment periodontitis propagation.

Endodontic cellulitis 'flare-up'. Case report

Endodontic cellulitis involves facial swelling which can vary from mild to severe and can occur as a primary case or a flare-up following initial treatment of asymptomatic teeth with periapical lesions. The microbial spectrum in primary cases involves a significant mixture of anaerobic and facultative aerobic microbes, chiefly streptococci. In a previous study, cultures from flare-up cases, utilizing the same anaerobic techniques as in primary cases, revealed an absence of obligate anaerobes and an 80 per cent incidence of facultative aerobic streptococci. These cases also revealed a significant time lapse from onset of symptoms to the cellulitis phase. No sex or age factors were noted in the primary or flare-up cases. The purpose of this case report is to restate a traditional theory, namely, the alteration of the oxidation/reduction potential (Eh), as a major factor for endodontic cellulitis flare-ups; to confirm the pathogenic potential of oral facultative streptococci; and that asymptomatic endodontic lesions tend to exist with mixed aerobic/anaerobic microbial flora.

Observation of bacteria and fungi in infected root canals and dentinal tubules by SEM

The aim of this study was to observe the root canal flora and possible penetration of microorganisms into dentinal tubules in teeth with necrotic pulps. Ten infected maxillary and mandibular molars with periapical lesions were extracted and fixed in 2.5% phosphate-buffered glutaraldehyde solution for nine days. After separation from the crowns, longitudinal grooves were cut in the roots, and they were split into two halves. The specimens were prepared for SEM. The root canals and the dentinal tubules of the fractured dentin were scanned systematically from the cervical to the apical area of the root. Cocci and rods were seen in 6 specimens. Penetration of bacteria into the dentinal tubules ranged from 10 to 150 microns. In 4 specimens, the root canals were heavily invaded by yeasts. The antimicrobial effect of routinely used endodontic disinfectants also on yeasts may be considered in persistent root canal infections.

Slime production by coagulase-negative staphylococci in the infected pulps

In this study; slime factor which is produced by coagulase negative Staphylococci was investigated in infected pulps of 145 primary and permanent teeth. Staphylococci were isolated in 27% of the cultures and all of the isolated Staphylococci were coagulase negative (CNS) in permanent teeth whereas 75% of isolated Staphylococci were coagulase negative in primary teeth. Slime production rate was the same for both groups and 22% of CNS were found slime positive. It is thought that slime production is important not only in endodontic microbiology, but also in other fields of dentistry for the explanation of the pathogenesis of infection.

Microbiologic factors in endodontology

The role of microorganisms in the cause of endodontic lesions has been intensively investigated. Bacterial components such as endotoxin and other cell wall components are implicated in the development of pulpal and periapical inflammation. Newer anaerobic microbiologic techniques have facilitated accurate and reproducible identification of endodontic pathogens, some of which have been reclassified. This article reviews and correlates newer microbiologic findings with clinical symptoms.

Associations of specific bacteria with some endodontic signs and symptoms

Although a wide range of bacterial species has been isolated from infected dental root canals it remains necessary to determine whether any particular group of such bacteria is associated with specific endodontic symptoms and clinical signs. In this study 30 root canals were examined microbiologically; of these, 14 were associated with pain, 20 with tenderness to percussion, 23 presented with wet root canals, seven with swelling, five with purulent exudate and four with a sinus. Clinical and microbiological correlation was observed particularly with regard to pain where anaerobes were isolated from 93% of painful canals and only from 53% of painfree canals. The former yielded means of 2.5 anaerobic species and 1.6 facultative species per canal, compared with 1.5 and 2.4 in painfree canals. Prevotella spp. were isolated from 64.2% of painful canals and 12.5% of painless canals (P < 0.01) similarly, peptostreptococci were isolated from 71.4% of painful and 31.3% of painless canals (P < 0.05). It was concluded that a significant association exists between pain and the presence of Prevotella and Peptostreptococcus spp. in dental root canals.

Changes in root canal microbiota during the development of rat periapical lesions

Periapical lesions are reproducibly induced in rats by pulp exposure and infection from the oral cavity. Lesions expand rapidly between day 7 and day 15-20 (active phase), with slowed expansion thereafter. In the present study we characterized the root canal microbiota present during the active phase of lesion development in this system. The mandibular first molars of Sprague-Dawley rats were exposed on day 0. The teeth were extracted after 7 days (n = 10 animals) and 15 days (n = 10), and the microbiota present in roots was isolated and characterized. The number of colonies isolated per tooth was similar on day 7 (1.53 +/- 0.64 colony-forming units x 10(3)) and day 15 (1.49 +/- 0.37 colony-forming units x 10(3)). No colonies were isolated from unexposed control teeth. Anaerobic bacteria increased significantly between day 7 (24.3 +/- 5.7%) and day 15 (47.3 +/- 7.5%), and the proportion of gram-negative organisms increased from day 7 (24.3 +/- 6.1) to day 15 (46.9 +/- 6.8). The predominant bacteria included, on day 7: Streptococcus and Bacteroides species; on day 15: species of Streptococcus, Bacteroides, Prevotella, Neisseria and Peptostreptococcus. Streptococcus oralis, Streptococcus mitis, Streptococcus rattus, Bacteroides pneumosintes and Bacteroides ureolyticus were frequently isolated at both points. Although approximately the same mean number of different species (approximately 3.5) was isolated per tooth on both day 7 and 15, the overall diversity of the isolates increased on day 15.(ABSTRACT TRUNCATED AT 250 WORDS)

Spirochaetes in oral infections

Oral spirochaetes, which are small-, medium- or large-sized, include species of the genus Treponema, many of which have not yet been cultured. They are found in root canal infections, pericoronitis, gingivitis and periodontitis, constituting up to 10% of the flora in endodontic abscesses, 30% in acute necrotizing ulcerative gingivitis, and 56% in advanced marginal periodontitis. The strong proteolytic activity of these organisms probably make them causes of infection rather than consequences. Being able to penetrate tissue, they bring their enzymes, metabolic products, and endotoxins, in direct contact with target cells. This may perturb essential functions of host cells and immunoglobulins. Enzyme activities may also help fulfil the complex growth requirements of spirochaetes in vivo. Reaction between infected periodontal tissue and monoclonal antibodies to Treponema pallidum has suggested that uncharacterized pathogen-related oral spirochaetes have surface structures and functions analogue to this well recognized pathogen. This warrants a more intensified search for the role of spirochaetes in oral infections.

In vitro antimicrobial susceptibility to combinations of drugs on bacteria from carious and endodontic lesions of human deciduous teeth

The purpose of this study was to clarify the antibacterial efficacy of mixed antibacterial drugs on bacteria of carious and endodontic lesions of human deciduous teeth in vitro. The antibacterial drugs used in this study were mixtures of ciprofloxacin, metronidazole, plus a third antibiotic: amoxicillin, cefaclor, cefroxadine, fosfomycin or rokitamycin. Samples taken from carious dentin (17 cases) and infected pulpal tissues (14 cases) were cultured on control plates and plates containing the mixed drugs. No bacteria were recovered in the presence of any combination of the mixture of the drugs (100 micrograms each/ml), and the bacterial growth occurred on control plates (10(1) to 10(7) colony-forming units), indicating that the mixed drugs inhibit the growth of bacteria in the samples. When carious and endodontic lesions on split surfaces of freshly extracted teeth were covered overnight with alpha-tricalcium phosphate cement containing a mixture of ciprofloxacin, metronidazole and cefaclor (1% each; 5 cases), no bacteria were recovered from the lesions. No bacteria were recovered from carious and endodontic lesions when these lesions were immersed in a solution of the mixture (200 micrograms each/ml; 5 cases). These findings indicate that carious and endodontic lesions can be sterilized by the mixed drugs in situ.

Migration of a Streptococcus sanguis strain through the root dentinal tubules

The persistent presence of bacteria in the root canal system often leads to the failure of treatment. The aim of this study was to study the in vitro penetration of root dentinal tubules by bacteria. Bovine dentin was inoculated with a strain of Streptococcus sanguis, NCTC 7863; samples were taken at 10, 20, and 28 days, and bacterial penetration of the tubules was demonstrated using two techniques, scanning electron microscopy and light microscopy after Brown and Brenn staining. The results showed that S. sanguis can penetrate deep inside the tubules (792 microns). The maturity of the dentin blocks seems to be a major factor in tubule penetration.

Endodontic infection and calcium hydroxide-treatment. Effects on periodontal healing in mature and immature replanted monkey teeth

Large experimental defects with marginal communication, and small isolated experimental defects were created on the root surfaces of extracted monkey lateral incisors with either open or closed apices. The pulp tissue was either infected or removed, and calcium hydroxide placed in the root canal. The teeth were then replanted and the healing pattern evaluated histomorphometrically after 20 weeks. From the results, it was concluded that (1) an intrapulpal infection promotes marginal epithelial down-growth on a denuded dentin surface irrespective of tooth developmental stage, and that (2) the periodontal healing potential after calcium hydroxide-treatment appears to be higher in teeth with open apices compared with teeth with closed apices, where ankylosis was promoted as opposed to teeth with open apices where significantly more reparative cementum was found.

Porphyromonas (Bacteroides) endodontalis: its role in endodontal infections

Porphyromonas endodontalis (formerly Bacteroides endodontalis) is a black-pigmented anaerobic Gram-negative rod which is associated with endodontal infections. It has been isolated from infected dental root canals and submucous abscesses of endodontal origin. The presence of P. endodontalis in infected dental root canals has been correlated with symptoms of an acute infection. It is occasionally found on oral mucous membranes and periodontal pockets. P. endodontalis has shown relatively low virulence in experimental monoinfections. In anaerobic mixed infections it can play an essential role. Differences in virulence between strains have been related to capsular material. On the basis of different types of capsules, three serotypes have been described. P. endodontalis is sensitive to a wide range of antibiotics, including the penicillins, the tetracyclines, and metronidazole.

Bacteriological investigation of infected root canals in Benin City, Nigeria

Possible viable bacteria were isolated and determined through culture based on paper point inoculation from infected root canals of 50 patients who presented for endodontic therapy at the school of Dentistry, University of Benin Teaching Hospital and Central Hospital, Benin City. Eighty-one strains of bacteria were isolated from 50 patients. The bacterial isolates were Streptococcus species, (51), Klebsiella species (17), E. coll (5), Staphylococcus aureus (3), Micrococcus species (2), Neisseria spp. (2) and Lactobacillus. The isolation of Klebsiella spp from the study is particularly interesting, constituting 21% of all the isolated bacteria. The implications of these findings in root canal infections are presented.

Serum IgG reactive with oral anaerobic microorganisms associated with infections of endodontic origin

Numerous species of bacteria have been implicated with infections of endodontic origin. The purpose of this study was to compare the levels of serum IgG antibodies reactive with a panel of 10 oral anaerobic microorganisms implicated in infections of endodontic origin. Serum samples were collected from 4 patient groups that included healthy patients without endodontic or periodontal disease, patients with chronic adult periodontal disease, patients with endodontic disease and patients with combined endodontic-periodontal disease. When Prevotella intermedia was allowed to react with sera from the 4 patient groups, significant pairwise differences were shown between the healthy group and each of the other 3 groups. In addition, there was a significant difference between the periodontal disease group and the combined endodontic-periodontal disease group. When Porphyromonas gingivalis was allowed to react with sera from the 4 patient groups, significant pairwise differences were shown between the healthy group and the periodontal disease group, the healthy group and the combined endodontic-periodontal disease group, the endodontic disease group and the periodontal disease group and the endodontic disease group and the combined endodontic-periodontal disease group. The results of this investigation support other studies that associate P. intermedia with both endodontic disease and chronic adult periodontal disease. The results also support studies that implicate P. gingivalis as a periodontopathogen.

Antibodies in normal and diseased pulps reactive with microorganisms isolated from deep caries

Immunoglobulin molecules in the supernatant fluids (SF) from pulpal explant cultures have been observed to react with microorganisms implicated in infections of root canals. In this study, the reactivity of immunoglobulin molecules in the SF from normal and irreversible pulpitis pulps to six strains of predominant microorganisms isolated from the immediate layer of carious lesions above the pulps used for explant cultures was investigated using an enzyme-linked immunosorbent assay. Two ATCC strains of Eubacterium were also included in this assay. Specific antibodies to Lactobacillus casei subsp. casei, Lactobacillus casei subsp. rhamnosus, Lactobacillus acidophilus (I), (II), Streptococcus mutans, Bacteroides intermedius, Eubacterium brachy, and Eubacterium alactolyticum in the SF from the normal and irreversible pulpitis tissues were observed with a large variation of antibody levels in both groups. Immunodiffusion assays of the SF revealed that IgG was the major class of immunoglobulin in the normal as well as the irreversible groups. The presence of natural antibodies in the normal pulps suggested a possible protective role of antibodies during the invasive process of caries.