Five-year longitudinal assessment of the prognosis of apical microsurgery

Apical surgery is an important treatment option for teeth with post-treatment apical periodontitis. Knowledge of the long-term prognosis is necessary when weighing apical surgery against alternative treatments. This study assessed the 5-year outcome of apical surgery and its predictors in a cohort for which the 1-year outcome was previously reported.

Treatment decisions in 330 cases referred for apical surgery

INTRODUCTION Apical surgery is an important treatment option for teeth with postendodontic apical periodontitis. However, little information is available regarding treatment planning in cases referred for apical surgery. This study evaluated the decisions made in such cases and analyzed the variables influencing the decision-making process. METHODS The study retrospectively assessed clinical and radiographic data of 330 teeth that had been referred to a specialist in apical surgery with regard to the treatment decisions made in those teeth. The clinical and radiographic variables were divided into subcategories to analyze which factors influenced the decision-making process. RESULTS The treatment decisions included apical surgery (59.1%), tooth extraction (25.8%), no treatment (9.1%), and nonsurgical endodontic retreatment (6.1%). Variables that showed statistically significant differences comparing treatment decisions among subcategories included probing depth (P = .001), clinical attachment level (P = .0001), tooth mobility (P = .012), pain (P = .014), clinical signs (P = .0001), length (P = .041) and quality (P = .026) of the root canal filling, and size (P = .0001) and location (P = .0001) of the periapical lesion. CONCLUSIONS This study shows that apical surgery was the most frequently made treatment decision in teeth referred to a specialist in apical surgery, but every fourth tooth was considered nonretainable and was scheduled for extraction. The data showed that the most common variables that influenced the decision to extract teeth were teeth with an increased probing depth and tooth mobility and teeth presenting with lesions not located at the apex.

Periapical surgery and the maxillary sinus: radiographic parameters for clinical outcome

OBJECTIVE: To find out whether conventional periapical radiographs can be used to determine the risk of creating an oroantral communication (OAC) while performing periapical surgery on maxillary premolars and molars. STUDY DESIGN: One hundred thirteen periapical radiographs of maxillary premolars and molars with periapical radiolucencies indicating chronic apical periodontitis were retrospectively analyzed and classified. The surgery reports were evaluated for occurrence of perforation of the maxillary sinus and postoperative complications. RESULTS: Perforation of the sinus membrane (also referred to as the Schneiderian membrane) occurred in 12 cases (9.6%). Exposure of the membrane without rupture occurred in 15 cases (12%). It was found that the distance between the apex or the periapical lesion and the sinus floor did not serve as a predictor of a possible sinus membrane rupture. On the other hand, if the radiograph showed a distinct distance between the lesion and the sinus floor, there was an 82.5% probability that OAC would not occur. Additionally, a blurred radiographic outline of the periapical lesion did not indicate an increased risk of sinus membrane rupture. CONCLUSION: Conventional periapical radiographs cannot be used as predictors for perforation of the maxillary sinus during periapical surgery. However, radiographs with a specific distance between the periapical lesion and the sinus floor point toward a very low risk of accidental sinus perforation during periapical surgery.

Loss of pulp sensitivity and pain as the first symptoms of a Ewing's sarcoma in the right maxillary sinus and alveolar process: report of a case

This case report describes the diagnosis and treatment of a Ewing's sarcoma in the right maxillary sinus and alveolar bone of a 19-year-old female patient. The first clinical symptoms were a loss of sensitivity of the premolars and first molar in the right maxilla and acute pain located in the area of these teeth. Initially, the referring dentist had treated these findings as an acute apical periodontitis with root canal medication. Because swellings on the palatal and buccal aspects of the teeth occurred and could not be treated with incision and drainage, the dentist referred the patient. Cone-beam computed tomography revealed a proliferation of soft tissue in the right maxillary sinus, with a radiopaque material at the tip of the mesiobuccal root of the first molar and resorptive signs of the mesiobuccal and distobuccal roots of the first molar. The palatal cortical bone of the right alveolar process seemed to be intact. After explorative surgery with biopsies from the buccal, palatal, and sinus proliferation areas, the pathologist diagnosed the lesion as a Ewing's sarcoma. Treatment of the patient consisted of initial chemotherapy, hemimaxillectomy, and postsurgical chemoradiotherapy.

Clinical results with two different methods of root-end preparation and filling in apical surgery: mineral trioxide aggregate and adhesive resin composite

INTRODUCTION: The aim of apical surgery is to hermetically seal the root canal system after root-end resection, thereby enabling periradicular healing. The objective of this nonrandomized prospective clinical study was to report results of 2 different root-end preparation and filling methods, ie, mineral trioxide aggregate (MTA) and an adhesive resin composite (Retroplast). METHODS: The study included 353 consecutive cases with endodontic lesions limited to the periapical area. Root-end cavities were prepared with sonic microtips and filled with MTA (n = 178), or alternatively, a shallow concavity was prepared in the cut root face, with subsequent placement of an adhesive resin composite (Retroplast) (n = 175). Patients were recalled after 1 year. Cases were defined as healed when no clinical signs or symptoms were present and radiographs demonstrated complete or incomplete (scar tissue) healing of previous radiolucencies. RESULTS: The overall rate of healed cases was 85.5%. MTA-treated teeth demonstrated a significantly (P = .003) higher rate of healed cases (91.3%) compared with Retroplast-treated teeth (79.5%). Within the MTA group, 89.5%-100% of cases were classified as healed, depending on the type of treated tooth. In contrast, more variable rates ranging from 66.7%-100% were found in the Retroplast group. In particular, mandibular premolars and molars demonstrated considerably lower rates of healed cases when treated with Retroplast. CONCLUSIONS: MTA can be recommended for root-end filling in apical surgery, irrespective of the type of treated tooth. Retroplast should be used with caution for root-end sealing in apical surgery of mandibular premolars and molars.

Complication and failure rates in patients treated for chronic periodontitis and restored with single crowns on teeth and/or implants

Objectives: To assess the biological and technical complication rates of single crowns on vital teeth (SC-V), endodontically treated teeth without post and core (SC-E), with a cast post and core (SC-PC) and on implants (SC-I). Material and methods: From 392 patients with chronic periodontitis treated and documented by graduate students during the period from 1978 to 2002, 199 were reexamined during 2005 for this retrospective cohort study, and 64 of these patients were treated with SCs. Statistical analysis included Kaplan–Meier survival functions and event rates per 100 years of object-time. Poisson regression was used to compare the four groups of crowns with respect to the incidence rate ratio of failures, and failures and complications combined over 10 years and the entire observation period. Results: Forty-one (64%) female and 23 (36%) male patients participated in the reexamination. At the time of seating the crowns, the mean patient age was 46.8 (range 24–66.3) years. One hundred and sixty-eight single unit crowns were incorporated. Their mean follow-up time was 11.8 (range 0.8–26.4) years. During the time of observation, 22 biological and 11 technical complications occurred; 19 SC were lost. The chance for SC-V (56) to remain free of any failure or complication was 89.3% (95% confidence interval [CI] 76.1–95.4) after 10 years, 85.8% (95% CI 66–94.5) for SC-E (34), 75.9% for SC-PC (39), (95% CI 58.8–86.7) and 66.2% (95% CI 45.1–80.7) for SC-I (39). Over 10 years, 95% of SC-I remained free of failure and demonstrated a cumulative incidence of failure or complication of 34%. Compared with SC-E, SC-I were 3.5 times more likely to yield failures or complications and SC-PC failed 1.7 times more frequently than did SC-E. SC-V had the lowest rate of failures or complications over the 10 years. Conclusions: While SCs on vital teeth have the best prognosis, those on endodontically treated teeth have a slightly poorer prognosis over 10 years. Crowns on teeth with post and cores and implant-supported SCs displayed the highest incidence of failures and complications.

Significance of Periodontal Risk Assessment in the recurrence of periodontitis and tooth loss

Aim: To investigate the association of the Periodontal Risk Assessment (PRA) model categories with periodontitis recurrence and tooth loss during supportive periodontal therapy (SPT) and to explore the role of patient compliance. Material and Methods: In a retrospective cohort, PRA was performed for 160 patients after active periodontal therapy (APT) and after 9.5 ± 4.5 years of SPT. The recurrence of periodontitis and tooth loss were analysed according to the patient's risk profile (low, moderate or high) after APT and compliance with SPT. The association of risk factors with tooth loss and recurrence of periodontitis was investigated using logistic regression analysis. Results: In 18.2% of patients with a low-risk profile, in 42.2% of patients with a moderate-risk profile and in 49.2% of patients with a high-risk profile after APT, periodontitis recurred. During SPT, 1.61 ± 2.8 teeth/patient were lost. High-risk profile patients lost significantly more teeth (2.59 ± 3.9) than patients with moderate- (1.02 ± 1.8) or low-risk profiles (1.18 ± 1.9) (Kruskal–Wallis test, p=0.0229). Patients with erratic compliance lost significantly (Kruskal–Wallis test, p=0.0067) more teeth (3.11 ± 4.5) than patients compliant with SPT (1.07 ± 1.6). Conclusions: In multivariate logistic regression analysis, a high-risk patient profile according to the PRA model at the end of APT was associated with recurrence of periodontitis. Another significant factor for recurrence of periodontitis was an SPT duration of more than 10 years.

Haemostatic effect and tissue reactions of methods and agents used for haemorrhage control in apical surgery

To compare the haemostatic effect and tissue reactions of different agents and methods used for haemorrhage control in apical surgery.

Periodontitis: a future risk of acute coronary syndrome? A follow-up study over 3 years

BACKGROUND: Periodontitis has been associated with cardiovascular disease. We assess if the recurrence of acute coronary syndrome (ACS) could be predicted by preceding medical and periodontal conditions. METHODS: A total of 165 consecutive subjects with ACS and 159 medically healthy, matched control subjects were examined and followed for 3 years. Periodontitis was defined by alveolar bone loss. Subgingival microbial samples were studied by the checkerboard DNA-DNA hybridization method. RESULTS: The recurrence of ACS was found in 66 of 165 (40.0%) subjects, and a first ACS event was found in seven of 159 (4.4%) subjects among baseline control subjects. Subjects who later had a second ACS event were older (P <0.001). Significantly higher serum levels of high-density lipoprotein (P <0.05), creatinine (P <0.01), and white blood cell (WBC) counts (P <0.001) were found in subjects with future ACS. Periodontitis was associated with a first event of ACS (crude odds ratio [OR]: 10.3:1; 95% confidence interval [CI]: 6.1 to 17.4; P <0.001) and the recurrence of ACS (crude OR: 3.6:1; 95% CI: 2.0 to 6.6; P <0.001). General linear modeling multivariate analysis, controlling for age and the prediction of a future ACS event, identified that WBC counts (F = 20.6; P <0.001), periodontitis (F = 17.6; P <0.001), and serum creatinine counts (F = 4.5; P <0.05) were explanatory of a future ACS event. CONCLUSIONS: The results of this study indicate that recurrent ACS events are predicted by serum WBC counts, serum creatinine levels, and a diagnosis of periodontitis. Significantly higher counts of putative pathogens are found in subjects with ACS, but these counts do not predict future ACS events.

Prediction of hip and hand fractures in older persons with or without a diagnosis of periodontitis

Purpose: In a prospective study, we assessed if a diagnosis of osteoporosis and periodontitis could predict hip and hand fractures in older persons. Materials and methods: Bone density was assessed by a Densitometer. Periodontitis was defined by evidence of alveolar bone loss. Results: 788 Caucasians (52.4% women, overall mean age: 76 years, S.D. +/- 9.0, range: 62 to 96) were enrolled and 7.4% had a hip/hand fracture in 3 years. Calcaneus PIXI T-values < - 1.6 identified osteoporosis in 28.2% of the older persons predicting a hip/hand fracture with an odds ratio of 3.3:1 (95% CI: 1.9, 5.7, p < 0.001). Older persons with osteoporosis had more severe periodontitis (p < 0.01). Periodontitis defined by >= 30% of sites with >= 5 mm distance between the cemento-enamel junction (CEJ) and bone level (ABL) was found in 18.7% of the older persons predicting a hip/hand fracture with an odds ratio of 1.8:1 (95% CI: 1.0, 3.3, p < 0.05). Adjusted for age, the odds ratio of a hip/hand fracture in older persons with osteoporosis (PIXI T-value <-2.5) and periodontitis was 12.2:1 (95% CI: 3.5, 42.3, p < 0.001). Conclusions: Older persons with osteoporosis and periodontitis have an increased risk for hip/hand fractures

Apical surgery of a maxillary molar creating a maxillary sinus window using ultrasonics: a clinical case

AIM: To describe a method of carrying out apical surgery of a maxillary molar using ultrasonics to create a lateral sinus window into the maxillary sinus and an endoscope to enhance visibility during surgery. SUMMARY: A 37-year-old female patient presented with tenderness to percussion of the maxillary second right molar. Root canal treatment had been undertaken, and the tooth restored with a metal-ceramic crown. Radiological examination revealed an apical radiolucency in close proximity to the maxillary sinus. Apical surgery of the molar was performed through the maxillary sinus, using ultrasonics for the osteotomy, creating a window in the lateral wall of the maxillary sinus. During surgery, the lining of the sinus was exposed and elevated without perforation. The root-end was resected using a round tungsten carbide drill, and the root-end cavity was prepared with ultrasonic retrotips. Root-end filling was accomplished with MTA(®) . An endoscope was used to examine the cut root face, the prepared cavity and the root-end filling. No intraoperative or postoperative complications were observed. At the 12-month follow-up, the tooth had no clinical signs or symptoms, and the radiograph demonstrated progressing resolution of the radiolucency. KEY LEARNING POINTS: When conventional root canal retreatment cannot be performed or has failed, apical surgery may be considered, even in maxillary molars with roots in close proximity to the maxillary sinus. Ultrasonic sinus window preparation allows more control and can minimize perforation of the sinus membrane when compared with conventional rotary drilling techniques. The endoscope enhances visibility during endodontic surgery, thus improving the quality of the case.

Prognostic factors in apical surgery with root-end filling: a meta-analysis

INTRODUCTION: Apical surgery has seen continuous development with regard to equipment and surgical technique. However, there is still a shortage of evidence-based information regarding healing determinants. The objective of this meta-analysis was to review clinical articles on apical surgery with root-end filling in order to assess potential prognostic factors. METHODS: An electronic search of PubMed and Cochrane databases was performed in 2008. Only studies with clearly defined healing criteria were included, and data for at least two categories per prognostic factor had to be reported. Prognostic factors were divided into patient-related, tooth-related, or treatment-related factors. The reported percentages of healed teeth ("the healed rate") were pooled per category. The statistical method of Mantel-Haenszel was applied to estimate the odds ratios and their 95% confidence intervals. RESULTS: With regard to tooth-related factors, the following categories were significantly associated with higher healed rates: cases without preoperative pain or signs, cases with good density of root canal filling, and cases with absence or size < or = 5 mm of periapical lesion. With regard to treatment-related factors, cases treated with the use of an endoscope tended to have higher healed rates than cases without the use of an endoscope. CONCLUSIONS: Although the clinician may be able to control treatment-related factors (by choosing a certain technique), patient- and tooth-related factors are usually beyond the surgeon's power. Nevertheless, patient- and tooth-related factors should be considered as important prognostic determinants when planning or weighing apical surgery against treatment alternatives.

Substrate characterization and catheter ablation for monomorphic ventricular tachycardia in patients with apical hypertrophic cardiomyopathy

VT Ablation in Apical Hypertrophic Cardiomyopathy.

Expansive nasopalatine duct cysts with nasal involvement mimicking apical lesions of endodontic origin: a report of two cases

The nasopalatine duct cyst (NPDC) is the most frequent nonodontogenic cyst of the jaws and can be misinterpreted as an apical lesion of endodontic origin.