Atypical facial pain related to apical fenestration and overfilling

Correlation between Tooth Position Parameters and Apical Fenestration: A Cone-Beam Computed Tomography Study

This study aimed to assess the relationship between apical fenestration-a defect in the alveolar bone involving the root apex-and tooth position in all tooth groups, excluding the third molars, utilizing cone-beam computed tomography (CBCT) images. A total of 800 CBCT scans (400 maxillary and 400 mandibular) from patients undergoing various treatments were examined by a single professional (radiologist and endodontist). Statistical analyses, including the chi-square test or Fisher's exact test, were conducted using R software 2.7.3 (R Foundation, Vienna, Austria). Results indicated a significant association (p ≤ 0.05) between apical fenestration and tooth position. In the upper teeth, apical fenestrations were notably present in the mesio-buccal (17.17%) and disto-buccal (11.07%) roots of the first molars. Conversely, apical fenestrations in the lower teeth were relatively less frequent. The study revealed a negative correlation between apical fenestration and mesial inclination, rotation, and extrusion in the upper teeth. However, a positive correlation was observed between apical fenestration and lingual inclination in the upper teeth. In conclusion, this study illuminates the distribution of apical fenestration and its correlation with tooth positions, offering insights into factors influencing this defect in dental anatomy. The findings enhance our understanding of nuanced relationships between tooth position and apical fenestration in the upper and lower dental arches.

Retrospective Evaluation of Periradicular Biopsies: An 18-Year Study

INTRODUCTION

Radiographic findings in periradicular areas are repeatedly associated with infected root canal systems. Although non-odontogenic lesions in teeth are reported to be low, they often mimic periapical pathoses, and consequently, histopathologic examinations after surgical revisions are nurtured.

METHODS

Biopsies submitted to the College of Dentistry between 2003 and 2021 were reviewed. Clinicopathologic characteristics were collected, including age, sex, medical history, location, sensibility tests, and clinic impressions from each specimen. Histopathologic diagnosis and gross description were also part of our database.

RESULTS

A total of 72,055 pathology reports were reviewed, of which 10,031 lesions (13.9%) met the criterion of being intraosseous lesions at the periradicular area. Among those 10,031 lesions, 7.94% (n = 796) were of non-endodontic origin, 7153 were documented as non-vital, and 2.36% (n = 169) of these non-vital teeth were diagnosed with a non-endodontic origin. A total of 5707 lesions were obtained from surgeries within the periapical tissues, primarily performed by endodontists (94.02%). Non-endodontic lesions were reported in 1.09% of the cases. Odontogenic keratocyst was the most common non-endodontic diagnosis, followed by nasopalatine duct cyst and benign fibro-osseous lesion, respectively.

CONCLUSIONS

Pathologic findings of the periradicular tissues are not always from endodontic origin. The probability of encountering non-endodontic lesions is almost 8%. Even in clinically reported teeth with pulp necrosis, 1%-3% of biopsies were confirmed as non-endodontic lesions.

Evaluation of the correlation between oral infections and systemic complications in kidney transplant patients: a retrospective pilot study

BACKGROUND

Data regarding the efficacy of the dental clearance required prior to kidney transplantation (KT) for preventing post-transplant complications is controversial. The aim of this retrospective study was to investigate a possible correlation between any untreated oral infectious foci and the onset of systemic complications in KT patients.

METHODS

Patients scheduled for regular check-ups during the post-transplant period were visited at the C.I.R. Dental School in Turin, Italy. Patients were asked to bring orthopantomography (OPT) acquired prior to transplantation to compare the possible presence of untreated infectious foci at the time of transplantation with the time of their post-transplant visit. Patients were then divided, according to the evaluation of the OPT obtained prior to the transplantation, into two groups according to their dental status prior to the transplant. "Group Infected" was comprised of patients with no dental clearance, and "Group Clear" included patients with dental clearance. The medical records were then retrospectively reviewed for the evaluation of any systemic complications that occurred after transplantation. The following medical complications were considered: fever, pneumonia, urinary tract infections, systemic infections, kidney rejection, and death. Complications were divided in two groups: early complications, which occurred within 100 days of transplantation, and late complications, which occurred more than 100 days after transplantation.

RESULTS

A total of 77 patients were enrolled in the study. Group Infected was composed of 19 subjects (25%), while Group Clear was composed of 58 patients (75%). In Group Infected, 13 (68%) patients developed complications within 100 days of transplantation, and 11 (58%) did so after 100 days. In Group Clear, 31 (53%) patients had complications within 100 days of the transplant, and 23 (40%) did after 100 days. Patients in Group Infected had a statistically significant increase in episodes of fever (p = 0.03), compared to Group Clear, with a higher relative risk (RR) of 3.66 in the first 100 days after transplantation.

CONCLUSION

Within the limitations of the present retrospective pilot study, and based on the results, a correlation between the absence of dental clearance prior to KT and a higher RR of developing a fever within the first 100 days post transplantation was highlighted. The present results encourage doctors to continue research on the topic, which remains controversial. Further prospective studies are required to confirm the results of the present study.

Assessment of the Proximity of the Inferior Alveolar Canal with the Mandibular Root Apices and Cortical Plates-A Retrospective Cone Beam Computed Tomographic Analysis

Various endodontic interventions often lead to iatrogenic damage to the inferior alveolar nerve present in the inferior alveolar canal (IAC). The purpose of the present study was to analyze the relationships of IAC with the root apices of mandibular teeth and with the mandibular cortical plates.

MATERIALS

116 cone beam computed tomography (CBCT) scans were examined and the shortest distance of IAC with the root apices of mandibular canines, premolars and molars, and with cortical plates was analyzed. The data were statistically analyzed using SPSS.

RESULTS

The shortest mean distance between IAC and lingual cortical plate (LCP) was found in the third molar area, and between IAC and buccal cortical plate (BCP) in the second premolar area. A high incidence of 60% direct communication (DC) was present in mandibular second molars; 38% in mandibular third molars; 13% in mandibular second premolars; 12% in mandibular first molars; and 1% in mandibular first premolars.

CONCLUSION

Anteriorly, IAC was found to be significantly present in close approximation to the roots of mandibular canines. Posteriorly, IAC was found to be in significant proximity to the distal roots of mandibular second molars.

Clinical outcome of bioceramic sealer iRoot SP extrusion in root canal treatment: a retrospective analysis

Background

During the obturation procedure, sealer extrusion occurs in some cases. iRoot SP is a kind of bioceramic sealer with superior physicochemical and biological properties. This article reports the outcome of iRoot SP extrusion in root canal treatment and the potential factors associated with the outcome.

Methods

Ninety-nine patients and one hundred and eighty-five teeth treated between 2014 and 2020 were included in this retrospective study. All of the cases were filled with a single-cone technique and the iRoot SP sealer. The minimum follow-up visit period was 1 year. The outcome was evaluated by clinical examination and radiographic examination at recall and was classified as healed, healing (success), or not healed (failure).

Results

The overall success rate of all teeth was 96.8%. The success rate of adequately filled teeth was 97.3%, while that of iRoot SP extrusion was 95.8%; the difference was not statistically significant. Factors such as gender, age, tooth position, follow-up visit period, size of periapical lesion, treatment type and extruding sealer amount had no influence on the outcome of iRoot SP extruded teeth.

Conclusions

The results suggested that iRoot SP extrusion has no adverse effect on the outcome of root canal treatment, which may contribute to the endodontic treatment.

Micro-Computed Tomography Evaluation of Minimally Invasive Shaping Systems in Mandibular First Molars

The aim of this study was to compare the shaping ability of a modified ProTaper Next technique (PTNm) with that of TruNatomy (TN) in lower molars mesial curved canals using micro-computed tomography (Micro-CT). Sixty mesial canals of first mandibular molars were randomly assigned between two groups (n = 30). After canal scouting with K-File #10, glide path and shaping were carried out with TN or PTNm systems. The PTNm sequence consists of ProGlider, followed by ProTaper Next X1 and apical finishing with NiTiFlex #25 up to working length (WL) to ensure adequate apical cleaning. Samples were scanned using micro-CT and pre- and post-shaping volumes were matched to analyse geometric parameters: the volume of removed dentin; the difference of canal surface; centroid shift, minimum and maximum root canal diameters; cross-sectional areas; the ratio of diameter ratios (RDR) and the ratio of cross-sectional areas (RA). Measurements were assessed 2 mm from the apex and in relation to the middle and coronal root canal thirds. Data were analysed using ANOVA (p < 0.05). No statistically significant differences were found between the groups for any parameter at each level of analysis, except for RA at the coronal level (p = 0.037). The PTNm system showed the tendency to enlarge more in the coronal portion with a lower centroid shift at apical level compared with TN sequence (p > 0.05). Both PTNm and TN sequences demonstrated similar maintenance of original anatomy during the shaping of lower molar mesial curved canals.

Diagnosis and Management of Apical Fenestrations Associated with Endodontic Diseases: A Literature Review

Apical fenestration describes a window-like opening of the alveolar bone that involves the root apex of the associated tooth. Mucosal fenestration is a similar defect of the overlying mucosa and, when presented with a concomitant apical fenestration, may expose the root apex to the oral environment. A fenestration may arise from physiological and pathological processes. Although its presence does not necessitate treatment per se, these lesions have significant clinical implications when associated with endodontic diseases. Apical fenestrations associated with endodontic infections are relatively uncommon and can easily be overlooked or misdiagnosed. A thorough understanding of these lesions is key for timely diagnosis and successful management. The aim of this study was to review the epidemiology, aetiological factors, characteristics, management methods and potential outcomes of apical fenestrations associated with endodontic diseases. A search of online databases for relevant studies was conducted. With the inclusion of hand searched articles, 20 articles, consisting of case reports and series, were identified, and the key characteristics of each case were summarised. Apical fenestrations were found to be most commonly associated with maxillary teeth and almost always occur on the buccal aspect of the alveolar bone. Clinicians may consider the possibility of an apical fenestration with concurrent endodontic pathology when patients present with non-healing sinus tracts, exposed tooth apices and/or persistent pain after endodontic treatment, particularly on palpation and mastication. Clinical signs and symptoms can vary, hence cone-beam computed tomography is an important tool for diagnosis. The management involves surgically restoring a favourable anatomical configuration of the root apex in relation to the alveolar bony housing and may be combined with guided tissue regeneration and/or grafting procedures. Sloughing, reopening and infection are potential complications. The literature on apical fenestrations associated with endodontic diseases is limited, thus further research is needed to develop evidence-based guidelines for the diagnosis and management of these lesions.

Management of Root Fenestration Using Buccal Decortication and Guided Tissue Regeneration: A Case Report and 3-dimensional Analysis

The management of patients with apical fenestration and clinical symptoms has always been limited to apical root resection and placement of the root tip within the bony crypt. This result would often present resolution of clinical symptoms based on a few case studies. In this case report, we present a case in which apical resection alone did not resolve the patient's discomfort; on the contrary, it resulted in further bone loss and persistence of clinical symptoms. A corrective surgery was performed with the use of guided bone regeneration in conjunction with decortication of the cortical plate to induce bleeding. The patient symptoms resolved within a few weeks after the surgery, and the follow-up scan showed apical root coverage. Three-dimensional analysis was performed to compare the bony changes between the 2 surgeries and showed a significant amount of bone gain of around 200 mm³ and a 2-mm linear bone gain opposite the distobuccal root. The case presents a conservative approach to manage root fenestration of the buccal plate without further compromising the root apex.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part II: other clinical applications and complications

Mineral trioxide aggregate (MTA) is a dental material used extensively for vital pulp therapies (VPT), protecting scaffolds during regenerative endodontic procedures, apical barriers in teeth with necrotic pulps and open apices, perforation repairs as well as root canal filling and root-end filling during surgical endodontics. A number of bioactive endodontic cements (BECs) have recently been introduced to the market. Most of these materials have calcium and silicate in their compositions; however, bioactivity is a common property of these cements. These materials include the following: BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, Neo MTA Plus, Ortho MTA, Quick-Set, Retro MTA, Tech Biosealer, and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA but without the drawbacks. In Part I of this review, the available information on the chemical composition of the materials listed above was reviewed and their applications for VPT was discussed. In this article, the clinical applications of MTA and other BECs will be reviewed for apexification, regenerative endodontics, perforation repair, root canal filling, root-end filling, restorative procedures, periodontal defects and treatment of vertical and horizontal root fractures. In addition, the literature regarding the possible drawbacks of these materials following their clinical applications is reviewed. These drawbacks include their discolouration potential, systemic effects and retreatability following use as a root filling material. Based on selected keywords, all publications were searched regarding the use of MTA as well as BECs for the relevant clinical applications. Numerous publications were found regarding the use of BECs for various endodontic applications. The majority of these investigations compared BECs with MTA. Despite promising results for some materials, the number of publications using BECs for various clinical applications was limited. Furthermore, most studies had several methodological shortcomings and low levels of evidence.

Impact of a sodium carbonate spray combined with professional oral hygiene procedures in patients with Sjögren's syndrome: an explorative study

OBJECTIVES

The aim of this study was to make an initial estimation on the effects of a sodium bicarbonate and xylitol spray (Cariex^® ), associated with non-surgical periodontal therapy, in participants with primary Sjögren's syndrome.

BACKGROUND

Sjögren's syndrome (SS) is a multisystem autoimmune disease that predominantly involves salivary and lachrymal glands, with the clinical effect of dry eyes and mouth.

MATERIALS AND METHODS

A prospective cohort of 22 women and two men has been evaluated. They were randomized into three groups (eight patients each): Group A) those treated once with non-surgical periodontal therapy, education and motivation to oral hygiene, associated with the use of Cariex^® ; Group B) treated only with Cariex^® ; Group C) treated only with non-surgical periodontal therapy, education and motivation to oral hygiene. Clinical variables described after treatment were unstimulated whole salivary flow, stimulated whole salivary flow, salivary pH, reported pain (using Visual Analogue Scale) and the Periodontal Screening and Recording index.

RESULTS

Salivary flow rate improved in all groups, but the difference was statistically significant only in those treated with Cariex^® , alone or in combination with periodontal therapy. Gingival status improved in participants who underwent periodontal non-surgical therapy while remained unchanged in those only treated with Cariex^® . Reported pain decreased in all groups, showing the best result in participants treated with periodontal therapy together with Cariex^® .

CONCLUSIONS

We propose a practical approach for improving gingival conditions and alleviating oral symptoms in patients with SS. Future randomized and controlled trials are however required to confirm these results as well as larger population, and also assessing other parameters due to oral dryness, possible oral infections and more comprehensive periodontal indices.

Maxillary Sinus Impaction of a Core Carrier Causing Sustained Apical Periodontitis, Sinusitis, and Nasal Stenosis: A 3-year Follow-up

INTRODUCTION

The aim was to present a case report of a full-length extrusion of an obturator's core carrier into the maxillary sinus, causing clinical symptoms from the nose region with differential diagnostics aspects, which, in turn, led to several surgical treatments of the nostrils before diagnosis and correct endodontic retreatment of a maxillary right first molar. A 36-year-old man presented in 2012 with complaints from the right nostril region. Medical treatment with antibiotics and surgical procedures because of nasal stenosis resulted only in partial improvement. Five years earlier, a root canal treatment was performed on the maxillary right first molar. Intraoral radiographs revealed 10-mm overfilling of root filling material into the maxillary sinus from the palatal root of tooth #3.

METHODS

Before surgical removal of the excess root filling material, orthograde revision was performed. Cone-beam computed tomographic imaging was used to localize the position of the root filling material, which protruded through the maxillary sinus and reached the inferior nasal wall.

RESULTS

Surgical removal from the palatal aspect revealed that the root filling material was a core carrier of an obturator. Scanning electron microscopy and transmission electron microscopy showed evidence of microbial biofilm on the core carrier as well as remnants of sinus mucosa. At the long-term follow-ups, the tooth had healed apically, and symptoms of nasal stenosis were markedly reduced.

CONCLUSIONS

This case report represents a challenging differential diagnostic topic urging the importance of a medical and dental interdisciplinary dialogue. The use of cone-beam computed tomographic imaging was crucial for the surgical retreatment.

The psychosomatic disorders pertaining to dental practice with revised working type classification

Psychosomatic disorders are defined as disorders characterized by physiological changes that originate partially from emotional factors. This article aims to discuss the psychosomatic disorders of the oral cavity with a revised working type classification. The author has added one more subset to the existing classification, i.e., disorders caused by altered perception of dentofacial form and function, which include body dysmorphic disorder. The author has also inserted delusional halitosis under the miscellaneous disorders classification of psychosomatic disorders and revised the already existing classification proposed for the psychosomatic disorders pertaining to dental practice. After the inclusion of the subset (disorders caused by altered perception of dentofacial form and function), the terminology "psychosomatic disorders of the oral cavity" is modified to "psychosomatic disorders pertaining to dental practice".

Retrieval of extensive gutta-percha extruded into the maxillary sinus: use of 3-dimensional cone-beam computed tomography

INTRODUCTION

Close proximity of the maxillary sinus to the roots of maxillary teeth can predispose to the inadvertent deposition of endodontic products into the maxillary sinus. One such material is thermoplasticized injectable gutta-percha, which has gained popularity of late. As a consequence of overfilling, some patients warrant surgical retrieval.

METHODS

A case report of extreme overextension of gutta-percha within the maxillary sinus after endodontic retreatment on tooth #14 was provided. The distobuccal and palatal canals had been obturated with gutta-percha master cones and backfilled with thermoplasticized injectable warm gutta-percha. The mesiobuccal canal had only been filled with thermoplasticized injectable warm gutta-percha, the origin of the extrusion. Imagery with 3-dimensional cone-beam computed tomography was performed for localization of the gutta-percha.

RESULTS

The patient underwent a Caldwell-Luc approach for removal of the extruded material. The gutta-percha was successfully removed intact, and the patient had an unremarkable postoperative course. However, the patient continues to have mild tenderness in the sinus region.

CONCLUSIONS

The featured case exemplified the consequence of overinstrumentation and ensuing inadequate apical stop. In these situations, the obturation of a maxillary tooth with thermoplasticized injectable gutta-percha, without master cones, can potentially result in overfilling and deposition into the antrum. Use of 3-dimensional cone-beam computed tomography could enhance endodontic diagnosis, serve as an aid for visualization of foreign materials within the sinus and contiguous soft tissue structures, and improve clinical outcome.