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

Pulp and periapical disease as a risk factor for osteonecrosis of the jaw: a national cohort-based study in Korea

PURPOSE

This longitudinal cohort study aimed to evaluate the relationship between osteonecrosis of the jaw and pulp and periapical disease in patients who were administered bisphosphonates.

METHODS

Using data from a nationwide cohort, we examined the association among dental caries, pulp and periapical disease, and osteonecrosis of the jaw in women aged >50 years who received bisphosphonates for more than 1 year between 2002 and 2015. Because of ambiguities in the diagnosis of osteonecrosis of the jaw in population-based data, we operationally defined and categorized the condition into established and potential osteonecrosis of the jaw.

RESULTS

Pulp and periapical disease significantly increased the development of both established and potential osteonecrosis of the jaw (hazard ratio, 2.21; 95% confidence interval, 1.40-3.48; and hazard ratio, 2.22; 95% confidence interval, 1.65-2.98, respectively). Root canal treatment did not have any influence on the development of osteonecrosis of the jaw.

CONCLUSIONS

Pulp and periapical disease may be a major risk factor for osteonecrosis of the jaw. The study findings suggest that patients should undergo regular dental examinations to detect pulp and periapical disease before or during the administration of bisphosphonates and that root canal treatment should be considered to decrease the risk of osteonecrosis of the jaw.

Comparison of the biomechanical differences in the occlusal movement of wild-type and BMP9 knockout mice with apical periodontitis

Apical periodontitis is a common clinical disease caused by bacteria; bacterial metabolites can cause an imbalance in bone homeostasis, bone mass reduction, and tooth loss. Bone resorption in apical periodontitis causes a concentration of stress in the tooth and periodontal tissues during occlusion, which aggravates the disease. Emerging evidence indicates that bone morphogenetic protein 9 (BMP9), also known as growth differentiation factor 2(Gdf2), may play an important role in tooth and dentoalveolar development. Herein, we investigated the role of BMP9 in the development of apical periodontitis and its effects on the biomechanics of dentoalveolar bone. Apical periodontitis models were established in five BMP9 knockout (KO) mice and five C57BL/6 WT (wild-type) mice. At baseline and 14, 28, and 42 days after modeling, in vivo micro-computed tomography analysis and three-dimensional (3D) reconstruction were performed to evaluate the apical lesion in each mouse, and confirm that the animal models were successfully established. Finite element analysis (FEA) was performed to study the stress and strain at the alveolar fossa of each mouse under the same vertical and lateral stress. FEA revealed that the stress and strain at the alveolar fossa of each mouse gradually concentrated on the tooth cervix. The stress and strain at the tooth cervix gradually increased with time but were decreased at day 42. Under the same lingual loading, the maximum differences of the stress and strain at the tooth root in KO mice were greater than those in WT mice. Thus, these findings demonstrate that BMP9 could affect the biomechanical response of the alveolar fossa at the tooth root in mice with apical periodontitis. Moreover, the effects of BMP9 on the biomechanical response of the alveolar bone may be site-dependent. Overall, this work contributes to an improved understanding of the pathogenesis of apical periodontitis and may inform the development of new treatment strategies for apical periodontitis.

Endo-perio lesions prevalence in non-molar and molar teeth: a pilot study

Abstract Introduction Pulp and periodontal tissues may communicate and, in pathological situations, combined endodontic-periodontal lesions may be established. Objective The aim of this study was to evaluate the prevalence of endo-perio lesions in non-molar and molar teeth referred for endodontic treatment. Material and method The sample consisted of 104 teeth evaluated in 79 consecutive patients in a cross-sectional design. Visible plaque, probing depth, and bleeding on probing were evaluated. Endodontic evaluation included the presence or absence of caries, fistulas, pain, and pulp sensitivity. The presence/absence of periapical lesion, bone loss in the furcation region, and proximal area were evaluated. Result The results showed that pain was the main reason for seeking dental care in 63.3% of patients. The molar teeth demonstrated higher presence of probing depth (PD) ≥ 7 mm (38.3%) and higher PD mean (6.17 mm) than non-molar teeth (P<0.05). It was verified that 65.4% of the teeth were diagnosed with a primary endodontic lesion and that the periodontal component was present in 34.6% of the teeth, either in a primary (10.6%), secondary (11.5%), or combined form (12.5%). True combined endodontic-periodontal lesion occurred significantly in molar teeth compared to non-molar teeth (p<0.05). Conclusion The primary endodontic lesion was found in a greater proportion in teeth referred for endodontic treatment; however, approximately 1/3 of the sample had periodontal involvement, which demonstrates the importance of the periodontal examination together with the general clinical examination.

Factors affecting decision making at reassessment of periodontitis. Part 1: history and examination at reassessment

Periodontal therapy aims to arrest the disease while maintaining function and aesthetics. Reassessment allows an opportunity to assess the periodontal status and need for further treatment. This is distinct from initial assessment in that the patient's response to initial therapy will be apparent and many treatment options other than non-surgical therapy require consideration. This series of papers outlines the processes to undergo at periodontal reassessment in order to assess viable treatment options and decide on a plan. This first article focuses on the information that should be gathered at the reassessment appointment in order to allow a full view of a case to aid decision-making. Subsequent papers in this series discuss the systemic and local factors that can account for residual probing depths, assessment of prognosis and treatment planning. Reassessment should be undertaken in a detailed manner to establish the reasons for any residual periodontal probing depths which will lead to the appropriate treatment option.

Multidisciplinary prognostic transition of a molar tooth for long-term survival

Patients with periodontitis may have one or few teeth with hopeless prognosis, which would have to be extracted before initiation of orthodontic therapy. Periodontal therapy aims to prolong the lifespan of dentition, as preserving natural dentition is always the best treatment option. The decision to retain a tooth is always based on the probability of long-term success of one or more treatment modality. A 17-year-old female patient seeking fixed orthodontic treatment presented with the left mandibular first molar tooth (36) having hopeless periodontal prognosis with advanced primary periodontal and secondary endodontic lesion, grade III mobility, and grade II furcation involvement. Root canal treatment followed by periodontal surgery using a combination of bone graft (allograft) and platelet-rich fibrin membrane resulted in a clinical and radiographic indication of periodontal healing. The tooth (36) was even used for orthodontic anchorage 3-month postsurgically and was maintained for 2 years. Appropriate diagnosis and meticulous multidisciplinary treatment approach can lead to the restoration of health and function of the teeth with severe loss of attachment and bone loss and can even be used for orthodontic anchorage.

Development of Periapical Lesions in Endodontically Treated Teeth with and without Periodontal Involvement: A Retrospective Cohort Study

INTRODUCTION

The purpose of this study was to investigate the incidence of apical periodontitis (AP) in endodontically treated teeth with and without periodontal involvement.

METHODS

The records of 602 patients with 775 root canal-treated teeth were initially examined. Only teeth with adequate root canal filling, adequate coronal restoration, and no AP (periapical index = 1) were selected for further investigation. A total of 194 teeth were included in this cohort study. Age, sex, history of diabetes mellitus, smoking, hypertension, and immunodeficiency disorders were recorded. Two groups were made according to the periodontal status of the patients. The control group included periodontally healthy patients and the periodontal group patients with periodontal disease receiving nonsurgical periodontal treatment. After an observation period of at least 2 years, the incidence of AP was scored using the periapical index. The relationship between patients' variables and AP was conducted using the Cohen kappa test, the chi-square test, odds ratio (OR), and logistic regression analysis.

RESULTS

Newly emerged AP was found in 14% of periodontally involved teeth and in 3% of nonperiodontal involved teeth (P < .05, OR = 5.19, 95% confidence interval). The periodontal condition and hypertension were the only significant factors associated with the presence of AP in the follow-up after univariate logistic regression. Adjusting for hypertension, multivariate logistic regressions showed that periodontal status remained significant (OR = 5.25, 95% CI, P < .05).

CONCLUSIONS

The risk of developing AP in endodontically treated teeth is 5.19 times higher for patients with periodontal disease compared with patients without periodontal disease.

Factors Affecting the Periapical Status of Root-Filled Canals: A Cross-Sectional Study at the Undergraduate Level

OBJECTIVE

The aim was to evaluate the influence of multiple factors on the periapical status of endodontically treated (ET) teeth.

METHODS

The patients were clinically and radiographically reevaluated after root canal therapy. The quality of the root-filled canals, coronal restorations, intraradicular posts, dental caries, and periodontal parameters were associated with the teeth's periapical status.

RESULTS

The 122 patients provided 154 ET teeth; 97.4% teeth were asymptomatic, and 75.5% had a normal periapical status. The percentage of perfect, satisfactory, and deficient root-filled canals was of the order of 41.6%, 46.1%, and 12.3%, respectively. The percentage of adequate and inadequate coronal restorations was 31.2% and 68.8%, respectively. A total of 14.9% teeth had intraradicular posts, and 29.2% had cavitated carious lesions in the dentin. Gingival bleeding was observed in 31.8% of teeth, and dental biofilm was visible in 58.4%. A total of 11.7% showed pathologic tooth mobility, and 22.1% teeth were diagnosed with periodontal disease.

CONCLUSIONS

Carious lesions, gingival bleeding, and tooth mobility were significantly associated with the occurrence of periapical lesions in root-filled canals.

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.

Endodontic status and retention of molars in periodontally treated patients: results after 10 or more years of supportive periodontal therapy

OBJECTIVES

To assess the influence of endodontic status on retention of molars in patients under supportive periodontal treatment (SPT).

MATERIAL & METHODS

A total of 136 subjects with 1015 molars at baseline were examined retrospectively, including 188 endodontically treated molars in 90 patients. Multilevel Cox regression analysis identified factors contributing to loss of molars.

RESULTS

Root canal treatments contributed significantly to loss of molars during on average 13.2 years of SPT (Hazard ratio: 2.98, 95% CI: 1.74-5.1, p < 0.001). Endodontic treatment was more frequently present in first molars (p < 0.001) and in the maxilla (p = 0.01). In endodontically treated molars, degree III furcation involvement could be detected more often compared to molars without root canal treatment (p < 0.001). Among the root canal-treated molars, several patient and tooth-related factors showed an impact on tooth retention, but only molars with a periapical index of 4 and 5 (labelled "diseased") were significantly more often lost.

CONCLUSION

The retention of molars in periodontally compromised patients after periodontal treatment is influenced by periodontal as well as endodontal factors. On a long-term basis, it is feasible to retain these teeth via active periodontal treatment and SPT for more than 10 years.

Survival of Restored Endodontically Treated Teeth in Relation to Periodontal Status

Abstract The aim of the present study was to investigate the success and survival of restored endodontically treated teeth (ETT) in a general practice environment related to periodontal parameters. Data from 360 restored ETT treated between 2000 and 2011 were collected. Dates of interventions like restorations, repairs, replacements and extractions were recorded. Additionally, general information about patients and dentitions as well as periodontal status was recorded. Success was analyzed using Kaplan-Meier statistics and a multivariate Cox regression analysis was performed to assess variables influencing success and survival. After a mean observation time of 4.34 years (range 0.6 - 11.6 years), 19 teeth were extracted and 27 restorations needed repair or replacement. According to the Cox regression, increasing maximum pocket depth of the tooth resulted in a higher risk for failure (p=0.012). In conclusion, periodontal pocket depth was found to be a significant factor in the survival of restored ETT.

A root canal filling per se does not have a significant negative effect on the marginal periodontium

AIM

To evaluate the periodontal status of single-rooted endodontically treated teeth (ET), correcting for patient- and tooth-related factors.

METHODS

Clinical parameters (BoP,PD,CAL) of 240 ET and 240 contralateral vital teeth (VT), before and after non-surgical periodontal treatment, were extracted retrospectively from the journals of 175 patients. Possible patient-related (age, gender, smoking status) and tooth-related (interproximal restoration, root canal filling's extent, post, tooth type) confounders were tested.

RESULTS

At baseline, frequency of BoP at an interproximal site at ET versus VT was 70.4% versus 65.0%, respectively. The frequency of teeth with interproximal PD ≥ 5 mm and CAL ≥ 5 mm was 47.9% versus 42.9% and 54.6% versus 49.6% at ET and VT, respectively. Interproximal PD and CAL at ET versus VT were 3.86 versus 3.61 mm and 4.11 versus 3.95 mm. After correcting for tooth-related factors, no significant differences were observed between ET and VT. An improper restoration had a significant (p < 0.001) negative effect on BoP [OR 3.49 (95%CI: 1.95-6.27)], PD [36.81% (95%CI: 18.52-57.92)] and CAL [27.01% (95%CI: 12.67-43.18)]. No significant differences between ET and VT were observed regarding clinical outcome of non-surgical periodontal therapy.

CONCLUSIONS

Presence of a root canal filling per se does not have a significant negative influence on the marginal periodontium, when correcting for the quality of the interproximal restoration.

Effect of Time Lapse between Endodontic and Periodontal Therapies on the Healing of Concurrent Endodontic-Periodontal Lesions without Communication: A Prospective Randomized Clinical Trial

INTRODUCTION

The aim of this prospective randomized clinical trial was to evaluate the effect of a time lapse between endodontic treatment and nonsurgical periodontal treatment on periodontal healing of concurrent endodontic-periodontal lesions without communication.

METHODS

Thirty-one patients were randomly divided into 2 groups: group 1: endodontic treatment and scaling and root planning (SRP) were performed simultaneously and group 2: SRP was performed 3 months after endodontic treatment. Both groups were followed for 3 and 6 months after SRP. Primary outcome variables were the probing depth, clinical attachment level, and periapical index score.

RESULTS

Both the groups showed a significant improvement in all the clinical parameters evaluated after the completion of endodontic and periodontal treatment (P < .05). No statistically significant difference in improvement was observed between the 2 groups at 3 and 6 months after SRP (P > .05). Periodontal healing responses were comparable in the 2 groups, with no apparent detriment resulting from simultaneous treatment. Improvements in periodontal parameters that were achieved in 6 months in group 2 were achieved only in 3 months in group 1 (P > .05).

CONCLUSIONS

Nonsurgical periodontal treatment may be performed simultaneously with endodontic treatment in the management of concurrent endodontic-periodontal lesions without communication, and an observation period after endodontic treatment may not be required.

Relationship between apical periodontitis and marginal bone loss at individual level from a general population

AIM

To study the relationship between the presence of apical periodontitis in root-filled teeth and marginal bone loss (MBL) in individual subjects from a general population.

MATERIALS AND METHODS

The study was conducted on a sample of 1,152 dentate individuals (participants in an epdemiological investigation) who were subjected to clinical and radiographic investigations. The presence of root fillings and apical periodontitis were registered. MBL was measured mesially and distally at all roots. The MBL index of the subject was defined as the mean MBL value at all measurable points in the same individual. Multiple regression analysis was adopted to calculate the influence of the presence of apical periodontitis and potential confounders on the dependent variable, MBL index.

RESULTS

There was a significant correlation between MBL and the percentage of root-filled teeth and the percentage of root-filled teeth with apical periodontitis. The results of the multiple regression analysis showed that the relative frequency of root-filled teeth with apical periodontitis was significantly higher in subjects with more MBL, irrespective of age, number of remaining teeth, relative frequency of root-filled teeth and smoking habits.

CONCLUSIONS

A significant association between the presence of apical and marginal periodontitis in individual subjects was found. The mechanisms behind the associations between these diseases are unknown and this cross-sectional observational study did not permit distinction between cause and effect. It is hoped that future cohort studies may provide more knowledge about the biological actions behind the relationship between apical and marginal disease.

Assessment of oxygen saturation in dental pulp of permanent teeth with periodontal disease

INTRODUCTION

In individuals with periodontal disease, dental pulp status should be determined before a treatment plan is made. Pulse oximeters are promising diagnostic tools to evaluate pulp vascularization. This study used pulse oximetry to determine the level of oxygen saturation in dental pulp of intact permanent teeth with periodontal attachment loss (PAL) and gingival recession (GR) and to evaluate the correlation between periodontal disease and level of oxygen saturation in the pulp.

METHODS

This study included 67 anterior teeth of 35 patients; all teeth showed intact crowns, PAL, a periodontal pocket (PP), and GR. The teeth underwent periodontal examination, cold and electric pulp testing, and pulse oximetry measurements. The Pearson correlation coefficient and a linear regression coefficient were calculated to evaluate the degree of correlation between periodontal disease markers (PAL, PP, and GR) and the level of oxygen saturation in dental pulp. These tests also evaluated possible associations between oxygen saturation and cold and electric pulp testing.

RESULTS

PAL, PP, and GR had negative correlations with oxygen saturation in dental pulp. Conversely, no statistically significant association was found between oxygen saturation in dental pulp and the response to electric sensibility testing.

CONCLUSIONS

Oxygen saturation was lower in the pulp of permanent teeth with PAL, PP, and GR, indicating that periodontal disease correlates with the level of oxygen saturation in the pulp.

Evaluation of efficacy of chlorhexidine intracanal medicament on the periodontal healing of concomitant endodontic-periodontal lesions without communication: an interventional study

BACKGROUND

Treatment of concomitant endodontic-periodontal lesions remains a challenge in clinical practice and requires effective endodontic and regenerative periodontal therapy. Among other factors, cross seeding and recolonization of flora may affect the outcome of periodontal therapy. Intracanal medicaments have been shown to exert antimicrobial activity on the external root surface, and local delivery of antimicrobials has been suggested to be a complementary approach in the management of periodontitis. Therefore, the objective of this study is to determine the influence of chlorhexidine (CHX) intracanal medicament on the clinical outcomes of therapy.

METHODS

Thirty-one patients were divided into two treatment groups: 1) open flap debridement (OFD) in endodontically treated teeth (control); and 2) OFD in endodontically treated teeth with CHX placed in the coronal space (test). The clinical variables evaluated were probing depth (PD), clinical attachment level (CAL), and percentage of sites with PD ≥5 mm. Reevaluation was performed at 3 and 6 months post-surgery.

RESULTS

Both treatments resulted in improvement in all the clinical variables evaluated. Postoperative measurements from test and control groups showed reductions in mean PD of 2.22 ± 1.27 and 0.91 ± 0.81 mm, mean CAL gains of 2.16 ± 1.12 and 0.60 ± 0.93 mm, and 43.33% ± 31.37% and 17.71% ± 14.23% reduction in sites with PD ≥5 mm. Significantly more PD reduction, CAL gain, and percentage reduction in sites with PD ≥5 mm were observed in the test group at 6 months (P <0.05).

CONCLUSION

CHX may be used as an effective intracanal medicament for promoting periodontal healing in concomitant endodontic-periodontal lesions.

Guided tissue regeneration in communicating periodontal and endodontic lesions - A hope for the hopeless!

The use of guided tissue regeneration (GTR) has become a standard of care in Periodontology. GTR using membrane barriers and/or bone grafting materials has also been used in periapical surgery. However, the application of the GTR principle, particularly in communicating endodontic-periodontal lesions with loss of the buccal cortical plate, is a very challenging task, with very few reported human clinical studies. An interdisciplinary approach, combining endodontic and periodontal (surgical) procedures can save a tooth in the long run that has been defined as hopeless at the preliminary stage of treatment.

Histopathological features of dental pulp in teeth with different levels of chronic periodontitis severity

Purpose. To evaluate the histopathological condition of the pulp in teeth with different levels of chronic periodontitis in humans. Methods. Twenty-five single-root nondecayed teeth were divided into three groups as follows: group 1, clinical attachment level (CAL) 3 to 4 mm and alveolar bone loss (BL) from 4 to 6 mm without reaching the tooth apex; group 2, CAL ≥ 5 mm and BL > 6 mm without reaching the tooth apex; group 3, CAL ≥ 5 mm and BL > 6 mm up to the tooth apex. Histological analyses were accomplished after laboratorial processing. Results. The mean of CAL was 3.2 ± 0.7 mm in group 1, 7.6 ± 2.0 mm in group 2, and 12.1 ± 2.8 mm in group 3, while for BL it was 4.8 ± 0.9 mm, 7.6 ± 2.2 mm, and 11.9 ± 2.1 mm, respectively. Histopathological data in the pulpal chambers were similar among the three groups showing normal aspects, and, the radicular pulps showed variable levels of reactive dentin, fibrosis, dystrophic mineralizations, atrophy, and mononuclear inflammatory infiltrate. Conclusions. Gradual progression of the chronic periodontitis led to changes in the histopathological aspects of the radicular pulp with progressive involvement.

Prediction of future marginal bone level: a radiographic study

AIM

The aim of the study was to predict the marginal bone level at a 5-year follow-up based on the information available from an initial radiographic examination and to evaluate the precision of the prediction by comparing the predicted bone levels with those actually observed at the follow-up.

MATERIALS AND METHODS

In 1997, 616 randomly selected dentate individuals underwent a full-mouth radiographic survey. In 2003, 473 of those individuals (77%) participated in a second radiographic examination. Marginal bone level, caries lesions, fillings, crowns, root fillings and periapical status were recorded on all teeth. On the basis of data available from the first examination, a linear mixed model regression analysis with the tooth as the unit of analysis was used to predict the marginal bone level 5 years later.

RESULTS

Number of teeth, smoking, and also presence of apical periodontitis and crowns were associated with bone loss and could be used as predictors of future marginal bone level.

CONCLUSION

The analysis of all teeth showed that the number of tooth- and person-specific factors at the first examination influenced the prediction of the marginal bone level at the 5-year follow-up examination. However, the performance of the combined prediction model was less satisfactory.

Five-year changes in periodontal parameters after apical surgery

INTRODUCTION

Most clinical studies on the outcome of apical surgery concentrate on periapical healing based on radiographic and clinical characteristics (signs and symptoms). This study focuses on long-term changes in periodontal parameters after apical surgery.

METHODS

Periodontal parameters (ie, probing depth [PD], level of gingival margin [GM], and calculated clinical attachment level [CAL]) were collected at baseline and at 1 and 5 years after apical surgery. Changes in PD, GM, and CAL were calculated over time and were also evaluated in relation to patient-, tooth-, and treatment-related covariables.

RESULTS

One hundred eighty-six of 242 initially identified teeth could be evaluated. Significant changes in GM and CAL were observed at facial sites during the first year after surgery (mean recession of GM was 0.29 mm, mean CAL loss was 0.20 mm), but none of the periodontal parameters significantly changed between 1 and 5 years after apical surgery. With regard to covariables, the type of incision technique was found to be the major factor affecting changes in GM and CAL between baseline and 1 year after surgery. Age, smoking, and type of periapical healing were the variables influencing the periodontal parameters over the longer observation period of up to 5 years.

CONCLUSIONS

Patients should be informed about possible changes in periodontal parameters (gingival recession and loss of attachment) after apical surgery. The surgery itself appears to account for changes observed during the first year, whereas patient- and healing-related factors seem to affect periodontal changes seen thereafter.

Strategies for the endodontic management of concurrent endodontic and periodontal diseases

Endodontic and periodontal diseases can provide many diagnostic and management challenges to clinicians, particularly when they occur concurrently. As with all diseases, a thorough history combined with comprehensive clinical and radiographic examinations are all required so an accurate diagnosis can be made. This is essential since the diagnosis will determine the type and sequence of treatment required. This paper reviews the relevant literature and proposes a new classification for concurrent endodontic and periodontal diseases. This classification is a simple one that will help clinicians to formulate management plans for when these diseases occur concurrently. The key aspects are to determine whether both types of diseases are present, rather than just having manifestations of one disease in the alternate tissue. Once it is established that both diseases are present and that they are as a result of infections of each tissue, then the clinician must determine whether the two diseases communicate via the periodontal pocket so that appropriate management can be provided using the guidelines outlined. In general, if the root canal system is infected, endodontic treatment should be commenced prior to any periodontal therapy in order to remove the intracanal infection before any cementum is removed. This avoids several complications and provides a more favourable environment for periodontal repair. The endodontic treatment can be completed before periodontal treatment is provided when there is no communication between the disease processes. However, when there is communication between the two disease processes, then the root canals should be medicated until the periodontal treatment has been completed and the overall prognosis of the tooth has been reassessed as being favourable. The use of non-toxic intracanal therapeutic medicaments is essential to destroy bacteria and to help encourage tissue repair.

Patterns of bone loss around teeth restored with endodontic posts

OBJECTIVES

This retrospective study described the pattern of bone loss around teeth with endodontic posts in periodontitis patients, and compared it with contra-lateral teeth without posts.

MATERIAL AND METHODS

From full-mouth radiographic surveys of 146 periodontitis patients (> or =35 years), 194 roots with endodontic posts and contra-laterals without posts were selected. Upper molars, pre-molars with two posts and roots of lower molars with two posts were excluded. Technical parameters of the post space preparation, endodontic and restorative status were evaluated. The level of alveolar bone measured in millimetre from the cemento-enamel junction (CEJ)/restoration margin and the pattern of bone loss (angular/horizontal) were evaluated on both mesial and distal aspects of roots with posts and contra-laterals, but not on the furcal areas of lower molars.

RESULTS

The distance from the bone level to the CEJ/restoration margin was similar for teeth with posts and contra-laterals. However, teeth with posts had more angular defects mesially (18.8%versus 7.3%) as compared with their contra-laterals without posts. The defects around teeth with posts appeared to be typical in the sense that their apical level approximated the tip of the endodontic post.

CONCLUSION

In periodontitis patients, teeth restored by an endodontic post had angular bony defects on the mesial aspect more frequently in comparison with their contra-laterals.

Bone level around endodontically treated teeth in periodontitis patients

OBJECTIVES

This retrospective study compared the marginal bone level of teeth with root canal fillings with contra-lateral teeth without.

METHODS

Of 286 consecutive patients (> or =35 years), referred to practice for periodontology in the Netherlands, 67 full sets of radiographs contained > or =1 endodontically treated tooth and its contra-lateral tooth without root canal treatment. Bone level at the mesial and distal of these teeth was scored from the CEJ. In multi-rooted teeth, the presence of interradicular radiolucency was assessed. The presence of posts, and periapical radiolucencies was assessed. Analysis for differences between treated teeth and contra-laterals was controlled for tooth surface, presence of a post and tooth type.

RESULTS

The mean distance from the root filling to the apex was 2.6 mm. Periapical radiolucencies were found in 14%. The mean bone level was at 4.3 mm for endodontically treated teeth and at 3.7 mm for contra-laterals. Significantly more bone loss (0.6 mm) was found at the endodontically treated teeth. No difference was found between mesial and distal, teeth without and with posts and different tooth types. The presence of interradicular radiolucency was more frequent in endodontically treated teeth (OR 2.1, p(McNemar test)=0.039).

CONCLUSION

In periodontitis patients, teeth with endodontic treatment had more bone loss as compared with untreated contralaterals.

The relation between apical periodontitis and root-filled teeth in patients with periodontal treatment need

AIM

To investigate a number of clinical and treatment variables that might have influenced the prevalence of apical periodontitis in root-filled teeth in a population of periodontally compromised patients.

METHODOLOGY

This investigation was a retrospective cross-sectional study on data collected from periodontal charts in addition to intra-oral full-mouth radiographs from patients attending the Department of Periodontology of the Dental School of the Ghent University Hospital. Periodontal parameters (clinical attachment loss and the lowest marginal bone level, the history of periodontal treatment), endodontic treatment (length, homogeneity and overall quality of the root filling) and the quality of coronal restorations were related to the prevalence of apical periodontitis. A total of 272 root-filled teeth in 94 patients were evaluated.

RESULTS

The periapical condition was significantly influenced by the quality of the root filling and the coronal filling (P < 0.05). More apical periodontitis was seen when the coronal level of the root filling exceeded the marginal bone level (P < 0.005). The marginal periodontal condition seemed to influence the periapical status. Teeth with apical periodontitis were associated with significantly more extended marginal bone loss (P < 0.001). Significantly less apical periodontitis was seen in patients that had received marginal periodontal treatment (P < 0.005), compared with untreated periodontal patients.

CONCLUSIONS

Signs of periodontal disease, as reflected by marginal bone loss, are of importance for the periapical condition of root-filled teeth. Efforts should be taken in preventing spread of infection through the periodontal-endodontic pathway by periodontal infection control and a high quality of root filling and coronal filling. Care should also be taken to seal the coronal cavity up to the level of the root filling, where it is advisable to reduce the coronal level of the root filling below or at least at the level of the surrounding marginal bone.

Alveolar bone loss in adults as assessed on panoramic radiographs. (II) Multilevel models

The aim of this study was to delineate factors influencing the severity of bone loss in randomly selected orthopantomograms of adult patients seeking treatment by the dental service of the German Armed Forces. A total of 240 panoramic exposures was available for analysis, 60 in each of the age groups <30, 30-39, 40-49, and >or=50. For each tooth, distances between the coronal landmark (CL) cemento-enamel junction or margin of restoration, and alveolar crest (AC), and bone level (BL) were measured with a calliper to the nearest 0.1 mm. Multilevel models revealed that bone levels decreased by 0.05 mm each year of life, on average. Bone loss was more pronounced in the maxilla, especially at molars. Infrabony lesions were strongly associated with deficient restorations and periapical lesions. Periapical pathology was also associated with radiographic evidence for furcation involvement. In this predominantly male population, periodontal bone loss gradually increased with age, but prevalence of infrabony defects was very low. Multilevel modelling indicated strong associations between infrabony defects and insufficient restorations and periapical pathology.

Intra-oral pattern of tooth and periodontal bone loss between the age of 50 and 60 years. A longitudinal prospective study

OBJECTIVE

In a 10-year prospective study we analyzed (i) the intra-oral pattern of and (ii) potential risk factors for tooth and periodontal bone loss in 50-year-old individuals.

METHODS

A randomized subject sample of 50-year-old inhabitants in the County of Varmland, Sweden, was examined at baseline and after 10 years. Data from full-mouth clinical and radiographic examinations and questionnaire surveys of 309 (72%) of the individuals who were dentate at baseline were available for analysis. Non-parametric tests and binary logistic multiple regression models were used for statistical analysis of the data.

RESULTS

4.1% of the 7,101 teeth present at baseline, distributed among 39% of the subjects, were lost during the 10-year interval. The incidence of tooth loss was highest among mandibular molars (7.5%) and lowest among canines (1.8%). The relative risk (RR) for tooth loss for endodontically compromised teeth was 4.1 and for furcation-involved molars 2.4-6.5, depending on tooth position. Logistic regression analysis identified baseline alveolar bone level (ABL), endodontic conditions, CPITN score (Community Periodontal Index of Treatment Needs), tooth position, caries, and educational level as risk factors for tooth loss. The overall mean 10-year ABL change was -0.54 mm (S.E. 0.01). On a tooth level the ABL change varied between -0.35 mm (mandibular molars) and -0.79 mm (mandibular incisors). Smokers experienced a greater (20-131% depending on tooth type) mean bone loss than non-smokers. The logistic regression model revealed that tooth position, smoking, and probing pocket depth > or =4 mm were risk factors for bone loss of >1 mm. No pertinent differences were observed with respect to risk factors for ABL change in the subgroup of non-smokers compared to the results of the analysis based on the entire subject sample.

CONCLUSION

Tooth loss was more common in the molar than in the anterior tooth regions, while periodontal bone loss had a random distribution in the dentition. The predominant risk factors identified with regard to further radiographic bone loss were "probing pocket depth > or =6 mm" and "smoking".

A multivariate analysis of the outcome of endodontic treatment

In the present study, multivariate analyses were performed on clinical and treatment variables that may influence the outcome of endodontic treatment. Data collected in a previous clinical-radiographic follow-up study were used. Of 810 treated, 675 roots in 498 teeth were followed for 6 months to 4 yr. Of these, 192 (the CAP group) had pre-existing, chronic apical periodontitis and 483 (the NAP group) had not. Root canal treatment followed a standard procedure with one of three sealers chosen at random. Demographic, clinical and radiographic variables were recorded at the start of, and during treatment. The periapical index (PAI) score was used to record the outcome of treatment, and applied in two different endpoint modes (END1 and END2) as the dependent variable for multivariate statistical analyses using logistic regression and the general model. The modes reflected increasing PAI scores (END1) and conventional success/failure assessment (END2). Dropouts were largely similar to the cases followed up. A total of 10 preoperative and peroperative variables were found to be significantly associated with treatment outcome by the multivariate analyses of either the total material or the NAP or CAP subgroups. Several of these were not significant in univariate analyses (e.g. the effect of sealer). Conventional success/failure analyses (END2) identified fewer of the influential variables and had low explanatory power, whereas PAI scores on an ordinal scale (END1) were most sensitive in identifying variables of influence on the treatment outcome.

Systemic disorders in patients with periodontal disease

BACKGROUND, AIMS

Over the past 10 years several studies have been published pointing towards a relationship between periodontal disease and various systemic disorders or diseases. The purpose of this retrospective study was to investigate the occurrence of self-reported systemic disorders in patients referred to a specialist clinic for periodontal treatment and to explore possible relationships between general health and periodontal disease severity in this population.

MATERIAL AND METHODS

Data were collected from the dental records and the health questionnaires of 1006 subjects. Stepwise multiple linear regression analyses were adopted to calculate correlations between systemic disorders as independent variables and number of remaining teeth and the relative frequency of periodontal pockets of 5 mm or more, respectively, as the dependent variable.

RESULTS

The number of remaining teeth was significantly and positively correlated to the presence of cardiovascular disease, diabetes and rheumatoid disease after adjustment for age, sex and smoking. The relative frequency of diseased sites, however, was not significantly correlated to any one of the investigated systemic health disorders.

CONCLUSION

No significant associations between investigated systemic disorders and periodontal disease severity were found if the relative frequency of deep periodontal pockets was used as the clinical parameter for periodontal disease severity. However, cardiovascular disease, diabetes and rheumatoid disease were found to be significantly correlated to number of lost teeth, which may represent one aspect of periodontal health. This result held true in nonsmokers only.

Evaluation of the effect of tooth vitality on regenerative outcomes in infrabony defects

BACKGROUND, AIMS

This investigation was designed to evaluate the null hypothesis of no differences in GTR outcomes in intrabony defects at vital and successfully root-canal-treated teeth.

METHOD

208 consecutive patients with one intrabony defect each were enrolled. Based on tooth vitality, the treated population was divided at baseline into 2 groups: one with 41 non-vital teeth and the other with 167 vital teeth. The 2 groups were similar in terms of patient and defect characteristics.

RESULTS

A slight unbalance in terms of depth of the intrabony component was observed in the non-vital group compared to the vital group (6.9+/-2.1 mm versus 6.2+/-2.3 mm, p=0.08). All defects were treated with GTR therapy. At 1 year, the non-vital and the vital groups showed a clinical attachment level (CAL) gain of 4.9+/-2.2 mm and of 4.2+/-2 mm, respectively. The difference was statistically significant (p=0.03). To correct for the baseline unbalance in defect depth, data were expressed as a % of clinical attachment level gains with respect to the original intrabony depth of the defect. % CAL gains were 72.8+/-42.2% and 73+/-26.4% for vital and non-vital teeth, respectively: the difference was not statistically significant (p=0.48). Average residual pocket depths were 2.8+/-1 mm in the vital and 2.8+/-0.9 mm in the non-vital group. Tooth vitality was assessed at baseline, at 1-year and at follow-up (5.4+/-2.8 years after surgery): all teeth vital at baseline were still vital at follow-up with the exception of 2 teeth that received endodontic treatment for reconstructive reasons and for caries. At follow-up visit, the difference in CAL with respect to 1-year measurements was -0.9+/-0.8 mm in the vital group and -0.7+/-0.8 mm in the non-vital group, indicating stability of the regenerated attachment at the majority of sites.

CONCLUSIONS

Data from this study demonstrate that root canal treatment does not negatively affect the healing response of deep intrabony defects treated with GTR therapy; furthermore GTR therapy in deep intrabony defects does not negatively influence tooth vitality.

The influence of endodontic infection on periodontal status in mandibular molars

The purpose of the study was to investigate the influence of an endodontic infection on periodontal probing depth and presence of furcation involvement in periodontally-involved mandibular molars. All first and second mandibular molars in 100 patients were selected if at least one was root-filled or had a possible periapical radiolucency. The sample consisted of patients from a referral population at a periodontal clinic which represented an adult population with a mean age between 50 and 60 years. For mandibular molars with periapical destruction at both roots, mean periodontal probing depth was significantly greater compared to teeth without periapical destruction. Horizontal furcation depths > or =3 mm were significantly more frequent at mandibular molars with periapical destruction. It is suggested that a root canal infection in periodontitis-involved molars may potentiate periodontitis progression by spreading of endodontic pathogens through patent accessory canals and dentinal tubules. In conclusion, an endodontic infection in mandibular molars was found to be associated with additional attachment loss in the furcation area, and may thus be considered to be one of several risk factors influencing the prognosis of molars in periodontitis-prone patients.

Chlorhexidine as a root canal medicament for treating inflammatory lesions in the periodontal space

The purpose of the present study was to investigate the therapeutic effect of intra-canal application of chlorhexidine on inflammatory root resorption. Dental pulps from monkey incisors were infected and resealed prior to extraction of the teeth. Root dentin was mechanically exposed and the teeth were replanted under aseptic conditions. After 4 weeks, the experimental teeth were dressed with chlorhexidine gel and resealed. Animals were sacrificed 4 weeks later, and their jaws prepared for histologic examination. Results showed that both marginal and apical periodontal inflammation and resorption were reduced in the chlorhexidine-treated teeth. It was concluded that the use of intra-canal chlorhexidine may be a useful adjunct in the treatment of inflammatory root resorption, but further human trials need to be undertaken before its clinical use can be recommended.

Impact of endodontic conditions on marginal bone loss

This study was undertaken to examine the extent to which the marginal alveolar bone may be influenced by the condition of the dental pulp. A total of 115 pairs of contralateral teeth were observed in 87 patients (25 to 45 years old) in which the test tooth, but not the control tooth, was either endodontically treated or not treated but with a periapical radiolucency. The distance from the cemento-enamel junction to the marginal bone level was measured using intraoral radiographs. The condition of the endodontic filling, the periapical status, and the presence of root canal post were also assessed. With clinical parameters similar between teeth in the two groups in terms of visible plaque, bleeding on probing, probing depth, and attachment level, the results showed a somewhat (mean value 0.1 mm; SD 0.7) larger reduction of the alveolar bone support in test than control teeth. This difference was not statistically significant on a patient level. Hence, this study failed to demonstrate a correlation between a reduced marginal bone support and endodontic status.

The endodontic-periodontal continuum revisited: new insights into etiology, diagnosis and treatment

For many decades, investigators have conducted studies of the interrelationship between endodontics and periodontics. This review article examines previously held concepts regarding the endodontic-periodontal continuum in light of new research and explores promising advances in understanding etiology and in diagnosis and treatment.

Relationship between apical and marginal healing in periradicular surgery

OBJECTIVE

The purpose of the present study was to evaluate the relationship between apical and marginal periodontal healing after periapical surgery.

STUDY DESIGN

The investigation was conducted on 59 patients referred for periradicular surgery. A radiographic examination as well as assessments of periodontal attachment and pocket depth of teeth undergoing surgery and control teeth were performed at the time of surgery and 1 year after surgery. The radiographic periapical healing pattern was evaluated.

RESULTS

After an observation time of 1 year, 85% of the healing patterns were classified as successful or uncertain. Teeth within the surgical area showed a significant loss of clinical attachment during the observation period. The mean clinical attachment loss in teeth with an unsuccessful healing was 0.85 mm and differed significantly from successfully healed cases (mean, 0.15 mm).

CONCLUSIONS

A persisting endodontic infection may be regarded as a contributing risk factor for a progressing marginal attachment loss.

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.