The periapical space--a dynamic interface

Pioneering Periapical Healing: The Novel Synergy of Mineral Trioxide Aggregate and Injectable Platelet-Rich Fibrin

This case report presents a novel non-surgical approach for managing a substantial periapical lesion associated with tooth 12 using a combination of injectable platelet-rich fibrin (i-PRF) and mineral trioxide aggregate (MTA). A 28-year-old male patient presented with pus discharge and intermittent swelling following a history of dental trauma. Clinical and radiographic assessments confirmed a large periapical cyst associated with tooth 12. The treatment involved root canal therapy with calcium hydroxide medication, leading to symptom relief. Subsequently, i-PRF combined with MTA was used as a regenerative material for periapical healing. Follow-up examinations at three, six, and nine months showed complete resolution of symptoms and radiographic evidence of lesion healing. This innovative technique demonstrates the potential of i-PRF and MTA synergy in the non-surgical management of periapical lesions, avoiding the risks associated with surgical interventions and promoting effective tissue healing.

Plasma Rich in Growth Factors in the Treatment of Endodontic Periapical Lesions in Adult Patients: A Narrative Review

Platelet concentrates have been widely used in regenerative medicine, including endodontics. The aim of this manuscript was to assess critically the efficacy of PRF in the treatment of endodontic periapical lesions in adult patients on the basis of the literature. The PICO approach was used to properly develop literature search strategies. The PubMed database was analyzed with the keywords: "((PRP) OR (PRF) OR (PRGF) OR (CGF)) AND (endodontic) AND ((treatment) OR (therapy))". After screening of 155 results, 14 articles were included in this review. Different types of platelet concentrates are able to stimulate the processes of proliferation and differentiation of mesenchymal stem cells. Platelet rich fibrin (PRF) releases growth factors for at least 7 days at the application site. Growth factors and released cytokines stimulate the activity of osteoblasts. Moreover, the release of growth factors accelerates tissue regeneration by increasing the migration of fibroblasts. It was not possible to assess the efficacy of PRF supplementation in the treatment of endodontic periapical lesions in permanent, mature teeth with closed apexes, due to the lack of well-designed scientific research. Further studies are needed to analyze the effect of PRF on the healing processes in the periapical region.

Chronic inflammatory periapical diseases: a Brazilian multicenter study of 10,381 cases and literature review

The aim of this study was to investigate the epidemiological and clinical characteristics of chronic inflammatory periapical diseases in different regions of Brazil and to compare with data from the literature. A multicenter study was carried out in four Brazilian referral centers in oral diagnosis. Histopathological records were reviewed, and all cases diagnosed microscopically as periapical granuloma, radicular cyst, and periapical abscess were included. Demographic and clinical data were collected. Descriptive statistics and Pearson's chi-square test were performed. A total of 10,381 cases of chronic inflammatory periapical diseases were found (13.8% of 74,931 archived specimens) over a period of 65 years. Radicular cysts were the most common lesion (59.9%). Women (56.1%) with a mean age of 37.01 years old (range 13 to 100 ± 14.42) and people of white skin color (59.2%) were the most affected individuals by chronic inflammatory periapical diseases. The lesions were generally asymptomatic (28.1%), located in the maxilla (60.1%), and posterior region (49.8%). The radicular cysts were larger when compared to periapical granulomas (p < 0.001). The disagreement between the clinical and histopathological diagnoses was higher when the final diagnosis was a periapical granuloma (p < 0.001). Chronic inflammatory periapical diseases continue to be common lesions affecting mainly adults. This should be a consequence of the burden of untreated caries in permanent teeth. Women are more affected and radicular cyst was the most common lesion.

The effectiveness of ultrasound examination to assess the healing process of bone lesions of the jaws: a systematic review

OBJECTIVE

To assess the potential of ultrasound examination (USE) as an adjunctive method to conventional radiology to evaluate the healing processes occurring after the treatment of bone lesions of the jaws. The research question was: what is the effectiveness of USE to evaluate the healing of intra-osseous bone lesions when compared to radiological or clinical examination?

MATERIALS AND METHODS

Six databases (PubMed, the Web of Science, Scopus, Embase, the Cochrane Library, and Best Evidence) were searched from their inception (PROSPERO CRD42019134482). A quality assessment was performed combining the Downs and Black tool and the Newcastle-Ottawa scale. The risk of bias was calculated using the Cochrane collaboration tool to assess the risk of bias.

RESULTS

A total of 4404 records were screened, and 7 studies meeting the inclusion criteria were included in the systematic review. USE allowed to evaluate the healing of jaw bone lesions by assessing their reduction in size, the increase in echogenicity of the affected area, and the progressive decrease\disappearance of the vascular flow signal within the lesions.

CONCLUSIONS

USE implemented with color power Doppler is an advanced imaging technique feasible to monitor the early and long-term response of the intra-osseous lesions of the jaws to both surgical and nonsurgical treatment.

CLINICAL RELEVANCE

This systematic review brought evidence that USE can constitute a safe alternative imaging technique in the dental clinical practice for the management of central lesions of the maxillary bones.

Healing of Periapical Lesions After Surgical Endodontic Retreatment: A Systematic Review

Background: Surgical root canal retreatment is required when peri-radicular pathosis associated with endodontically treated teeth cannot be treated by non-surgical root canal therapy (retreatment), or when retreatment was ineffective, not feasible or contraindicated. Endodontic failures maybe happen when irritants remain within the confines of the root canal, or when an extra-radicular infection cannot be eradicated by orthograde root canal treatment. Following enhanced microsurgical techniques in the last years, the success rates of surgical root canal retreatment have improved considerably.

Objective: The aim of this systematic review is to gather updated data in regard to the surgical root canal (retrograde) retreatment to heal the periapical lesions.

Materials and methods: The electronic databases PubMed and Google Scholar were searched in this review using specific inclusion and exclusion criteria. The search was performed in June 2019 and updated in November 2019. Among 3900 studies, 10 studies satisfied the eligibility criteria and were included in the review to be analyzed.

Results: The 10 studies showed the importance of surgical root canal retreatment as a treatment option in removing infections within the root canal system and its efficiency in periapical tissue healing. These studies investigated different aspects of healing of periapical lesion after surgical (retrograde) retreatment including success rates, follow-up duration, and updated studies in surgical (retrograde) retreatment.

Conclusions: Surgical root canal (retrograde) retreatment demonstrates its efficiency in reducing the period needed for healing of the periapical lesions in short-term follow-up compared to conventional orthograde retreatment.

Anatomical analysis of the resected roots of mandibular first molars after failed non-surgical retreatment

Objectives

Understanding the reason for an unsuccessful non-surgical endodontic treatment outcome, as well as the complex anatomy of the root canal system, is very important. This study examined the cross-sectional root canal structure of mandibular first molars confirmed to have failed non-surgical root canal treatment using digital images obtained during intentional replantation surgery, as well as the causative factors of the failed conventional endodontic treatments.

Materials and Methods

This study evaluated 115 mandibular first molars. Digital photographic images of the resected surface were taken at the apical 3 mm level and examined. The discolored dentin area around the root canal was investigated by measuring the total surface area, the treated areas as determined by the endodontic filling material, and the discolored dentin area.

Results

Forty 2-rooted teeth showed discolored root dentin in both the mesial and distal roots. Compared to the original filled area, significant expansion of root dentin discoloration was observed. Moreover, the mesial roots were significantly more discolored than the distal roots. Of the 115 molars, 92 had 2 roots. Among the mesial roots of the 2-rooted teeth, 95.7% of the roots had 2 canals and 79.4% had partial/complete isthmuses and/or accessory canals.

Conclusions

Dentin discoloration that was not visible on periapical radiographs and cone-beam computed tomography was frequently found in mandibular first molars that failed endodontic treatment. The complex anatomy of the mesial roots of the mandibular first molars is another reason for the failure of conventional endodontic treatment.

The effect of micro-electric current and other activation techniques on dissolution abilities of sodium hypochlorite in bovine tissues

Background

The aim of the study was to evaluate the effects of micro-electric current on sodium hypochlorite’s (NaOCl’s) tissue-dissolution abilities, compared with other activation methods, including sonic, ultrasonic, pipetting, and temperature.

Methods

Bovine muscle tissues (n = 154) with standard sizes and weights were prepared and divided into two temperature groups: room temperature and 45 °C. Each temperature group was divided into seven sub-groups by activation methods: D = distilled water (−control); NaOCl = 5.25 % passive NaOCl (+ control); P = 5.25 % NaOCl with pipetting; SA = 5.25 % NaOCl with sonic activation; UA = 5.25 % NaOCl with ultrasonic activation; E-NaOCl = 5.25 % NaOCl with micro-electric current; and E-NaOCl + P = 5.25 % NaOCl with micro-electric current and pipetting. Specimens were weighed before and after treatment. Average, standard deviation, minimum, maximum, and median were calculated for each group. Resulting data were analyzed statistically using multi-way ANOVA and Tukey HSD tests. The level of the alpha-type error was set at < 0.05.

Results

At room temperature, the E-NaOCl + P group dissolved the highest amount of tissue (p < 0.05), and the UA, SA, and P groups dissolved significantly higher amounts of tissue than did the positive control or E-NaOCl groups (p < 0.05). At 45 °C, there was no significant difference between the SA and E-NaOCl groups (p > 0.05), and the E-NaOCl + P group dissolved a higher amount of tissue than any other group (p < 0.05).

Conclusions

Using NaOCl with micro-electric current can improve the tissue-dissolving ability of the solution. In addition, this method can be combined with additional techniques, such as heating and/or pipetting, to achieve a synergistic effect of NaOCl on tissue dissolution.

Pulp tissue dissolution capacity of QMix 2in1 irrigation solution

OBJECTIVE

The aim of this study was to evaluate the tissue dissolution efficacy of four root canal irrigation solutions (sodium hypochlorite [NaOCl], chlorhexidine gluconate [CHX], Octenidine [OCT], and QMix 2in1) on bovine pulp tissue.

MATERIALS AND METHODS

Fifty bovine pulp tissue samples, each weighing 6.55 mg, were prepared and randomly divided into four experimental groups and one control group (n = 10) according to the dissolution irrigants used: (1) 5.25% NaOCl group; (2) 2% CHX group; (3) OCT group; (4) QMix 2in1 group; and (5) control group (saline solution). These samples were then placed into special bovine dentin reservoir models and immersed for 1 h with each test solution (0.1 mL of each) at room temperature. The pulp samples were then blotted dry and weighed again. The percentage of weight loss was calculated. Statistically analyzed with one-way analysis of variance and post-hoc Tukey tests (P = 0.05).

RESULTS

Saline solution did not dissolve the bovine pulp tissue. All groups, except OCT, dissolved pulp samples more effectively than the control group (P < 0.05). The highest tissue dissolution was observed in 5.25% NaOCl group (P < 0.05). No statistically significant difference was found between the tissue-dissolving effect between QMix 2in1 and those of 2% CHX.

CONCLUSIONS

Within the limitations of this in vitro study, NaOCl exhibited the best tissue-dissolving effect out of all solutions tested. CHX and QMix 2in1 were able to dissolve pulp tissue but less than NaOCl. OCT and saline solutions could not exhibit significantly tissue-dissolving effectiveness. This study shown that QMix 2in1 has little capacity to dissolve pulp tissue therefore used alone is not sufficient for this purpose.

Nonsurgical management of an extensive endodontic lesion in an orthodontic patient by calcium-enriched mixture apical plug

Periapical lesion is a general term used to describe the periapical inflammatory process that occurs in response to the invasion of micro-organisms in the root canal system as well as inflamed vital pulp. This phenomenon necessitates endodontic intervention and if the necrosis has occurred prior to tooth maturation, wide patency of the apical foramen requires some treatment modalities such as apexification or apical plug. Orthodontic treatment, on the other hand, is cautiously done for previously traumatized teeth due to increased risk for necrosis of the compromised tooth. This article tends to review the successful treatment process with calcium-enriched mixture (CEM) cement apical plug for an immature previously traumatized incisor tooth with an extensive periapical lesion, which was under orthodontic treatment as well.

Healing of an extensive periradicular lesion subsequent to a proper endodontic treatment of a mandibular first premolar with complex anatomy

Long-term success of endodontic treatment is strictly dependent on proper shaping and cleaning of the root canal system followed by obturation of entire prepared space. Anatomical variations should be considered during radiographic and clinical evaluation as parts of endodontic treatment. A mandibular premolar with three canals is quite rare and such a tooth requires special canal preparation and obturation techniques. An astute clinician should identify different canal configurations and treat them endodontically well, because presence of an untreated canal could be a reason for failure of endodontic treatment. This paper describes the conventional orthograde endodontic therapy on an unusual mandibular first premolar with three root canals.

Technical quality of root canal fillings done in a Nigerian general dental clinic

Background

Previous reports indicate that worldwide, the technical quality of root canal fillings is poor. There are few reports from sub-Saharan Africa and none yet from Nigeria where most patients access treatment from non-specialists especially at general dental clinics. The aim of this study was to evaluate the technical quality of root canal fillings done in a general dental clinic with emphasis on the effects of professional experience of the operator, whether tooth was anterior or posterior and whether it was a maxillary or mandibular tooth.

Methods

Retrospective study of case notes and periapical radiographs of patients with completed root canal fillings seen between 2008 and 2011. Inclusion criteria included cases of primary treatment with available case notes, good quality pre-operative and post-operative periapical radiographs. Technical quality that was assessed was root canal length and homogeneity. Root canal fillings were classified either as Good Quality Endodontic Work (GQEW) or Non- Good Quality Endodontic Work (NGQEW).

Results

Fifty-one patients aged between 8 and 54 years (mean 28) fulfilled the inclusion criteria for this study. From these, there were 62 root filled teeth giving a ratio of 1.2 root canal filled teeth per person. There were acceptable length of root canal fillings in 71% of teeth, 58.1% were homogeneous while 53.2% were GQEW. There was no statistically significant difference in whether tooth was root filled by junior or senior dentist (p = 0.43), anterior or posterior (p = 0.11). There was significant association between GQEW and maxillary teeth (p = 0.03).

Conclusion

This study showed that the overall technical quality of root canal fillings done by non-specialists was better than earlier reports but lower than that done by endodontists. Since many patients receive treatment from non-specialists in developing countries, it is necessary to improve technical quality of root canal fillings done in general dental clinics. These could be through improvement in the quality of undergraduate training and more post graduate continuing education courses for skills update.

Prevalence of apical periodontitis and endodontic treatment in a Kosovar adult population

Background

Despite numerous studies on the prevalence of apical periodontitis (AP) and endodontic treatment in diverse geographical populations, there are currently no data on the prevalence of these conditions in populations of adults native to Kosovo. Therefore, little is known about how widespread these conditions are, and whether there is any correlation between root canal treatment and AP. The purpose of our research was to address this anomaly by investigating AP and endodontic treatment in an adult Kosovar population based on radiographic examination.

Methods

The sample used for this study consisted of randomly selected individuals referred to the University Dentistry Clinical Center of Kosovo in the years 2006-2007. Orthopantomographs of 193 patients were evaluated. The periapical status of all teeth (with the exception of third molars) was examined according to Ørstavik's Periapical Index. The quality of the root canal filling was rated as 'adequate' or 'inadequate' based on whether all canals were filled, the depth of fill relative to the radiographic apex and the quality of compaction (absence/presence of voids). Data were analyzed statistically using the Chi-square test and calculation of odds ratios.

Results

Out of 4131 examined teeth, the prevalence of apical periodontitis (AP) and endodontic treatment was 12.3% and 2.3%, respectively. Of 95 endodontically-treated teeth, 46.3% were associated with AP. The prevalence of AP increased with age. The prevalence in subjects aged over 60 years old (20.2%) was higher than in other age groups. A statistically significant difference was found for the frequency of endodontically-treated teeth associated with AP in the 40-49 year age group (P < 0.001). Of some concern was the discovery that only 30.5% of the endodontically-treated teeth examined met the criteria of an acceptable root canal filling. Inadequately root-filled teeth were associated with an increased AP risk.

Conclusions

The prevalence of AP and the frequency of endodontically-treated teeth with AP in this Kosovar population are higher than those found in other countries. Inadequate root canal fillings were associated with an increased prevalence of AP.

External invasive resorption in a three-rooted lower first molar*

Several pathoses can be present concurrently in one tooth, and if that tooth has an unusual anatomical variation, the diagnosis and treatment can be further complicated. This case stresses the importance of accurate assessment and diagnosis prior to intervention and their role in identifying cases for referral to a specialist in today's increasingly litigious environment.

Diagnosis and treatment planning are essential prior to commencing endodontic treatment: discuss this statement as it relates to clinical endodontic management

Diagnosis and treatment planning are essential to the practice of endodontics. Diagnosis aims to determine whether pathological involvement of the dental pulp has or is occurring. Treatment planning meanwhile, involves appropriately selecting cases, determining how difficult the treatment may be to perform on a specific individual and sequencing treatment procedures to achieve a healthy and functional dentition. In endodontic management, this may involve establishing whether the tooth is restorable and periodontally sound, the patient is able to tolerate the treatments and the clinician has the skills to perform the required treatment procedures. Careful consideration of these issues must be given prior to commencing treatment.