Histological changes within dental pulps in teeth with moderate-to-severe chronic periodontitis

Type 2 diabetes aggravates periodontitis-induced pathological changes in the dental pulp

OBJECTIVES

The inner mechanism of how diabetes affects dental pulp of patients with periodontitis has seldom been reported. We collected clinical samples and explored the influence of diabetes and periodontitis on the pathological change of dental pulp.

METHODS

Dental pulp from healthy individuals and patients with periodontitis with or without diabetes were collected based on strict inclusion and exclusion criteria. Dental pulp was morphologically observed; advanced glycation end products (AGEs) and lectin-like oxidized low-density lipoprotein receptor-1 (LOX1) were examined. Oxidative stress (OS), inflammatory indices, and apoptotic levels were assessed.

RESULTS

Morphologically, fibrous structure in the dental pulp of patients with diabetic periodontitis (DP) group was sparse and disordered, and the blood vessel wall was thickened. Diabetes related indexes as AGEs and LOX1 were upregulated. Superoxide dismutase 2 expression was decreased, and OS level was increased. Matrix metalloproteinase 3 and other relevant proinflammatory cytokines levels were increased. The elevated OS and inflammation contributed to upregulation of apoptotic levels in DP group.

CONCLUSIONS

Diabetes aggravates the pathological changes in the dental pulp of periodontitis patients possibly due to upregulated AGEs and LOX1. Our results highlight the importance of early oral intervention in patients with DP.

Incidence and influential factors in pulp necrosis and periapical pathosis following indirect restorations: a systematic review and meta-analysis

BACKGROUND

Restoring vital teeth with indirect restorations may threaten dental pulp integrity. However, the incidence of and influential factors on pulp necrosis and periapical pathosis in such teeth are still unknown. Therefore, this systematic review and meta-analysis aimed to investigate the incidence of and influential factors on pulp necrosis and periapical pathosis of vital teeth following indirect restorations.

METHODS

The search was conducted in five databases, using MEDLINE via PubMed, Web of Science, EMBASE, CINAHL, and Cochrane Library. Eligible clinical trials and cohort studies were included. The risk of bias was assessed using Joanna Briggs Institute's critical appraisal tool and Newcastle-Ottawa Scale. The overall incidences of pulp necrosis and periapical pathosis following indirect restorations were calculated using a random effects model. Subgroup meta-analyses were also performed to determine the potential influencing factors for pulp necrosis and periapical pathosis. The certainty of the evidence was assessed using the GRADE tool.

RESULTS

A total of 5,814 studies were identified, of which 37 were included in the meta-analysis. The overall incidences of pulp necrosis and periapical pathosis following indirect restorations were determined to be 5.02% and 3.63%, respectively. All studies were assessed as having a moderate-low risk of bias. The incidence of pulp necrosis following indirect restorations increased when the pulp status was objectively assessed (thermal/electrical testing). The presence of pre-operative caries or restorations, treatment of anterior teeth, temporization for more than two weeks, and cementation with eugenol-free temporary cement, all increased this incidence. Final impression with polyether and permanent cementation with glass ionomer cement both increased the incidence of pulp necrosis. Longer follow-up periods (> 10 years) and treatment provided by undergraduate students or general practitioners were also factors that increased this incidence. On the other hand, the incidence of periapical pathosis increased when teeth were restored with fixed partial dentures, the bone level was < 35%, and the follow-up was > 10 years. The certainty of the evidence overall was assessed as low.

CONCLUSIONS

Although the incidences of pulp necrosis and periapical pathosis following indirect restorations remain low, many factors affect these incidences that should thus be considered when planning indirect restorations on vital teeth.

DATABASE REGISTRATION

PROSPERO (CRD42020218378).

Apical periodontitis and associated factors in a rural population of southern Brazil: a multilevel analysis

OBJECTIVES

This study aims to evaluate the association between apical periodontitis (AP) and sociodemographic/clinical factors in a probability sample of individuals living in a rural area of southern Brazilian.

MATERIALS AND METHODS

A cross-sectional study was conducted involving 584 non-edentulous adult individuals who had undergone a full-mouth radiographic survey. Periapical status was analysed using the periapical index (PAI). Endodontic status was evaluated considering the occurrence of voids in the filling material and the root filling length. Crown status was classified based on the presence of caries, restorations, and prosthetic crowns. Sociodemographic variables, frequency of dental care, and periodontal disease were also registered. The data were analysed using hierarchical multilevel Poisson regression analysis. The multilevel structure was composed of three models: sociodemographic variables, clinical variables, and clinical variables adjusted by sociodemographic variables (α = 5%).

RESULTS

The prevalence of AP in the sample was 60.45%. AP was significantly associated with age, skin colour, schooling, periodontal disease, and frequency of dental care (P < 0.005). Among the 10,396 teeth evaluated, 868 (8.35%) had AP, which was significantly associated with tooth group, dental arch, crown status, and endodontic treatment (P < 0.005).

CONCLUSIONS

The prevalence of AP was high in the population studied. An older age, black/brown skin colour, low level of schooling, infrequent dental care, severe periodontal disease, mandibular teeth, posterior teeth, inadequate crown status, and having undergone endodontic treatment were significantly associated with the outcome. Clinical relevance This study about a rural probability sample reinforces that AP is still a recurrent oral health problem.

Assessment of Pulp Vitality in Multirooted Teeth With Advanced Periodontal Disease: A Clinical and Histological Study

BACKGROUND/PURPOSE

The relationship between endodontic and periodontal lesions remains a controversy. Their diagnosis is often difficult and requires an interdisciplinary approach to rule out the cause and provide appropriate treatment. Periodontitis as an etiology of pulpal necrosis and irreversible pulpitis has been a hypothetical concept. Thus, the aim of this study was to assess the non-carious teeth extracted due to periodontitis both clinically and histologically to understand the possible association between periodontitis and its effect on pulp vitality.

MATERIALS AND METHODS

The study consisted of 60 teeth, of which 20 were extracted due to orthodontic requirements (control group) and 40 were extracted due to periodontitis (test group), which was further subclassified based on the presence or absence of gingival recession. Clinically, the teeth were categorized as non-vital after testing them with the electronic pulp tester (EPT). Later, these teeth were sectioned, and histopathological analysis was done to detect the presence of lateral or accessory canals.

RESULTS

The results showed that there were mild to moderate deteriorative changes in the pulp in the periodontitis group without a gingival recession and moderate to severe changes in the pulp in the periodontitis group with a gingival recession.

CONCLUSION

There exists a possible deteriorative effect on pulp vitality as a consequence of periodontitis, even when the vitality of the pulp remains unaffected by dental caries.

Analysis of oral microbiota in non-vital teeth and clinically intact external surface from patients with severe periodontitis using Nanopore sequencing: a case study

Periodontal diseases include a wide range of pathological conditions, damaging the supporting structures of the teeth. Origin and propagation of periodontal disease is believed to be caused by dysbiosis of the commensal oral microbiota. The aim of this study was to evaluate the presence of bacteria in the pulp cavity of teeth with severe periodontal disease with clinically intact external surface. Periodontal (P) and endodontic (E) tissue samples of root canals from six intact teeth of three patients were sampled for analysis of microbial population using Nanopore technology. Streptococcus was the predominant genus in E samples. Porphyromonas (33.4%, p = 0.047), Tannerella (41.7%, p = 0.042), and Treponema (50.0%, p = 0.0064) were significantly more present in P than in E samples. Some samples (E6 and E1) exhibited a remarkable difference in terms of microbial composition, whilst Streptococcus was a common signature in samples E2 to E5, all which were obtained from the same patient. In conclusion, bacteria were identified on both the root surface and the root canal system, thus demonstrating the possibility of bacteria to spread directly from the periodontal pocket to the root canal system even in the absence of crown's loss of integrity.

Histological characteristics of dental pulp in teeth with periodontal problems and healthy teeth

Background

Chronic periodontitis is the most common type of periodontitis, which is associated with calculus and plaque accumulation. Several studies have indicated that uncured periodontitis can affect the dental pulp. However, this relationship is controversial. This study aimed to compare histopathological results obtained from the dental pulp in teeth with periodontal problems and healthy teeth.

Methods

In this study, 23 teeth with periodontal problems and 23 healthy teeth were extracted. After cutting off 2 mm from the root apex, the teeth were sectioned into apical, middle, and coronal thirds. Then, the specimens were evaluated in both groups based on histopathological features.

Results

According to the evaluations, in the middle third, the amount of inflammation was only statistically significant in the group that consisted of teeth with periodontal problems (P=0.014). There was no significant difference in fibrosis and blood vessel diameter between the two groups. Necrosis in the middle (P=0.002) and coronal thirds (P=0.004) of teeth with periodontal problems was more than the healthy teeth. The lack of odontoblastic integrity in all the sections of teeth with periodontal problems was more than that in healthy teeth (P=0.0001).

Conclusion

Inflammation of the periodontium in chronic periodontitis can lead to histological changes in the pulp, including an increase in inflammation, necrosis, and loss of odontoblastic integrity.

Pulpal and periapical disease in crowned vital teeth: A prospective matched cohort study

This study aimed to determine the incidence and contributing factors to pulpal and periapical disease in crowned vital teeth. Seventy-three pairs of healthy teeth were included and divided into two groups; 'crowned' and 'untreated' groups. The crowned group was prepared for full coverage crown and no treatment was carried out on the untreated group. Both groups were subjected to clinical and radiographic examination to detect endodontic signs and symptoms pre-operatively and one-week after crown cementation. Electric pulp test was also subjected to both groups, pre-operatively, after tooth preparation and before crown cementation. The incidence of pulpal and periapical disease was 6.8% and 1.4%, respectively, after tooth preparation. Factors associated with pulpal and periapical disease were exposed pulp during tooth preparation and pre-operative bone level <35%. Despite the low incidence, the occurrence of pulpal and periapical disease within a short period is noteworthy.

Histopathological Investigation of Dental Pulp Reactions Related to Periodontitis

OBJECTIVE

Since the 1960s, there has been contradictory evidence regarding the association between periodontal pathology and the status of the pulp. The purpose of this study was to evaluate the histopathological changes of pulp tissue with severe periodontal disease, including vertical bone loss involving the major apical foramen, and compared them with the histological pulpal status of teeth with healthy periodontium.

METHODS

This case-controlled study included 35 intact teeth with severe periodontitis of hopeless prognosis (test group) and 35 teeth without periodontitis extracted for orthodontic reasons (control group). For each tooth, periodontal and endodontic parameters such as probing depth and pulpal vitality were recorded, and the pulp tissue was evaluated histologically. The data were analysed with a significance level of 0.05.

RESULTS

Vital pulp was observed in all specimens of both groups (P=1). Pulpal inflammation in the apical portion was observed in 81.71% of the severe periodontitis group, whereas all teeth in the control group demonstrated no signs of pulpal inflammation. Dystrophic calcification and pulp stones were observed in 7.5% of the periodontitis group and 5.7% of the healthy group (P>0.05). Pulp fibrosis was observed in 22.8% of the periodontitis group and 2.8% of the control group (P=0.012). Pulpal necrosis was not noted in either group. In the periodontitis group, internal resorption was present in 22.8% of cases (P=0.005) and external resorption was present in 80% of cases (P<0.001). In the control group, no internal or external resorption was observed in any of the specimens. No differences were noted in the study patients with regard to sex or age.

CONCLUSION

Periodontal disease does not significantly affect pulp vitality and pulpal calcifications. However internal and/or external resorption was significantly different between the two groups as well as apical inflammation and pulp fibrosis.

Contrast-enhanced nano-CT reveals soft dental tissues and cellular layers

AIM

To introduce a methodology designed to simultaneously visualize dental ultrastructures, including cellular and soft tissue components, by utilizing phosphotungstic acid (PTA) as a contrast-enhancement agent.

METHODOLOGY

Sound third molars were collected from healthy human adults and fixed in 4% buffered paraformaldehyde. To evaluate the impact of PTA in concentrations of 0.3%, 0.7% and 1% on dental soft and hard tissues for CT imaging, cementum and dentine-pulp sections were cut, dehydrated and stained with immersion periods of 12, 24 h, 2 days or 5 days. The samples were scanned in a high-resolution nano-CT device using pixel sizes down to 0.5 µm to examine both the cementum and pulpal regions.

RESULTS

Dental cementum and periodontium as well as odontoblasts and predentine were made visible through PTA staining in high-resolution three-dimensional nano-CT scans. Different segments of the tooth required different staining protocols. The thickness of the cementum could be computed over the length of the tooth once it was made visible by the PTA-enhanced contrast, and the attached soft tissue components of the interior of the tooth could be shown on the dentine-pulp interface in greater detail. Three-dimensional illustrations allowed a histology-like visualization of the sections in all orientations with a single scan and easy sample preparation. The segmentation of the sigmoidal dentinal tubules and the surrounding dentine allowed a three-dimensional investigation and quantitative of the dentine composition, such as the tubular lumen or the ratio of the tubular lumen area to the dentinal surface.

CONCLUSION

The staining protocol made it possible to visualize hard tissues along with cellular layers and soft tissues in teeth using a laboratory-based nano-CT technique. The protocol depended on both tissue type and size. This methodology offers enhanced possibilities for the concomitant visualization of soft and hard dental tissues.

Pulp Response to Periodontal Disease: Novel Observations Help Clarify the Processes of Tissue Breakdown and Infection

INTRODUCTION

This study evaluated the pulp response to periodontal disease of increasing severity.

METHODS

The material comprised human teeth affected by moderate (n = 16) to severe (n = 48) periodontal disease and no clinically identified caries lesions. Specimens were obtained by extraction and were processed for histopathologic and histobacteriologic methods.

RESULTS

In 13 of 16 teeth with moderate periodontal disease and vital pulp, no frank accumulations of inflammatory cells were observed. In 22 of 32 teeth with severe periodontal disease and vital pulps, no distinct inflammatory cell accumulations were observed in any portion of the pulp when there was an intact or minimally damaged cementum layer in the corresponding areas. Intravascular bacterial aggregations were detected in pulp blood vessels in 6 teeth with symptomatic pulpitis and severe periodontal disease, which had not reached the root apex in 4 of them. Focal areas of infection and varying accumulations of acute and chronic inflammatory cells were observed throughout the pulp tissue and surrounding these infected blood vessels. When the periodontal pocket reached the apex of single-rooted teeth, the entire canal space was necrotic and colonized by bacteria, often forming biofilms. In multirooted teeth, the pulp response varied according to the root(s) affected. Intrapulpal calcifications were observed in 91% of the teeth. The pulp and cementum of the control teeth showed no pathologic changes or bacteria.

CONCLUSIONS

The pulp showed a significantly detectable response when the cementum coverage was lost or when the periodontal pocket reached the root apex. In the former condition, the pulp response was usually discrete, whereas in the latter, severe reactions usually developed. In some teeth, vessels with a compromised blood flow may serve as avenues for bacteria to invade the pulp via apical or lateral foramina. This indicates that in some teeth the pulp may undergo severe inflammation and necrosis even before the periodontal disease reaches the apical root segment.

Effect of scaling on the invasion of oral microorganisms into dentinal tubules including the response of pulpal cells-an in vitro study

Objectives

To investigate how scaling affects the penetration of microorganisms into dentinal tubules, how pulpal cells seeded into the pulp cavity respond to bacterial challenge, and how penetration and inflammatory response may depend on the bacterial composition.

Materials and methods

Root canals of 102 extracted human teeth underwent shaping and cleaning. Half of the teeth were subjected to scaling and root planing, the other half remained untreated. Teeth were exposed to either Streptococcus gordonii and Actinomyces oris or S. gordonii and Porphyromonas gingivalis for 10 weeks. Bacterial invasion was assessed in a depth of 1 mm to the root surface. Human pulpal cells were seeded into the cavities to assess the expression of interleukin-8 (IL-8), monocyte chemoattractant protein-1 (MCP-1), and matrix metalloproteinase-3 (MMP-3) by real-time polymerase chain reaction and immunoassay.

Results

The percentage of teeth with bacteria detected in dentine was higher when teeth received scaling than when they were untreated: 66.6% versus 44.4% when exposed to A. oris/S. gordonii, and 50% versus 25% when exposed to P. gingivalis/S. gordonii (p = 0.043). Scaling had no impact on IL-8 and MMP-3 expression in pulpal cells. P. gingivalis/S. gordonii caused higher levels of IL-8, MCP-1, and MMP-3 than A. oris/S. gordonii (p = 0.003, p = 0.011, p = 0.037).

Conclusion

Scaling supports the penetration of bacteria into the dentine of extracted human teeth. P. gingivalis may affect the immune response in pulpal cells.

Clinical relevance

Root surface debridement with hand instruments may facilitate bacterial penetration. Other kinds of mechanical instrumentation in this experimental setting should be investigated.

Successful management of a tooth with endodontic-periodontal lesion: A case report

BACKGROUND

Endodontic-periodontal lesion is a commonly encountered dental condition. However, the prognosis of the condition varies from good to poor. Some cases are associated with a poor prognosis that requires tooth extraction. This report presents a case of an endodontic-periodontal lesion in a tooth that was successfully treated by root canal treatment.

CASE SUMMARY

A 51-year-old female patient with no medical history complained about persistent pain and discomfort in her left mandibular first molar. Clinical examination showed the left mandibular first molar with poor restoration. It was also associated with underlying necrotic pulp and periodontal involvement. Radiographic examination revealed visible bone defects in the apical and periodontal areas. Based on the findings, the patient was diagnosed with a primary endodontic lesion. A root canal treatment for the endodontic lesion was performed. The patient received a coronal all-ceramic endocrown restoration. A follow-up was arranged to check the prognosis. At the 3 mo follow-up, the clinical and radiography evaluations showed complete disappearance of signs and symptoms and an increase in the radiopacity of the root area.

CONCLUSION

Despite the poor prognosis associated with many endodontic lesions, this case report highlights that a good prognosis is still possible for an endodontic lesion with apical and periodontal bone loss. In this case, it was achieved via successful root canal treatment without the need for periodontal or surgical intervention.

High levels of HIF-1ɑ in hypoxic dental pulps associated with teeth with severe periodontitis

In this study we investigated the expression of HIF-1ɑ in dental pulps of the teeth with severe periodontitis. The expression of HIF-1ɑ in dental pulps of the teeth with severe periodontitis was detected by immunohistochemistry, immunofluorescence and real-time PCR. Bone marrow macrophages (BMMs) were cultured under hypoxia in vitro. HIF-1ɑ, osteoclast-specific factors (NFATc1, CTSK and c-fos) and RANKL-induced osteoclastogenesis were evaluated by immunofluorescence, TRAP staining and western blotting. High levels of HIF-1ɑ protein were detected in dental pulps of teeth with severe periodontitis, whereas few positive HIF-1ɑ expressions were detected in healthy dental pulps. Hypoxia occurred in the dental pulps in response to heavy periodontitis. Many HIF-1ɑ-positive infiltratory inflammatory cells were observed around blood vessels. Tooth internal resorption was found in some teeth with severe periodontitis. The HIF-1ɑ levels were upregulated in BMMs under hypoxia, which also promoted osteoclast formation and resorption by NFATc1, CTSK and c-fos. Teeth with severe periodontitis show hypoxic dental pulps and increased potential of osteoclastic differentiation.

Role of dental pulp in age estimation: A quantitative and morphometric study

Context:

This study was designed to characterize the role of the dental pulp (DP) in age estimation.

Aim:

The analysis of age-related quantifiable changes in DP components such as odontoblasts, collagen fibers, and blood vessels.

Subjects and Methods:

One hundred and twenty extracted teeth from six age groups (20–30 years, 31–40 years, 41–50 years, 51–60 years, 61–70 years, and 71–80 years) were subjected to decalcification and routine histopathological processing followed by Hematoxylin and Eosin and Picrosirius Red staining. Evaluation of the number of odontoblasts, mean vessel area (MVA), mean vessel diameter (MVD), and collagen fiber thickness were done.

Statistical Analysis Used:

ANOVA test, Fisher's test, and Regression Analysis.

Results:

Reduction in the number of odontoblasts/mm of pulp-dentinal border, MVA, and MVD were seen with advancing age. Rise in collagen fiber thickness was noted with increasing age. All parameters showed strongly statistically significant differences between age groups with P < 0.001 (ANOVA test).

Conclusions:

Regression formulae derived for age estimation based on data collected demonstrated linear correlation with age. Collagen fiber thickness had the highest accuracy followed by odontoblast numbers and MVA. MVD was the least accurate among the factors considered. However, the highest accuracy of 90.9% was seen when all parameters were incorporated together in a single equation.

Presence of root canal treatment has no influence on periodontal bone loss

AIM

The aim of this study was to compare the interproximal bone level at root canal-filled teeth and non-root canal-filled teeth.

MATERIALS AND METHODS

The records of patients from the department were consecutively screened from January 2009 to October 2011. The distance between the coronal reference point to the alveolar bone crest (AC) was assessed at the mesial and distal aspects of root canal-filled teeth (RCF+) and their contralateral non-root canal-filled teeth (RCF-) on periapical radiographs. Generalised linear mixed-effects models were applied.

RESULTS

The sample consisted of 128 pairs of teeth comprising data from 72 patients. The results for AC revealed a median distance of 3.2 mm for RCF+ and 3.4 mm for RCF- (p = 0.61). Using the maximal distance on either the distal or the mesial tooth surface, a median distance of 3.6 mm was detected for RCF+ and 3.8 mm for RCF-, respectively (p = 0.42). Even after taking several tooth- and subject-specific variables into account, the differences between AC on RCF+ and RCF- were statistically not significant (p > 0.05).

CONCLUSION

The interproximal bone loss did not differ statistically significant between root canal-filled teeth and non-root canal-filled teeth.

CLINICAL RELEVANCE

Existence of appropriately done root canal fillings in periodontitis patients has no effect on the prognosis of periodontal disease.