The influence of cone-beam computed tomography and periapical radiographic evaluation on the assessment of periapical bone destruction in dog`s teeth

Objective. The aim of this study was to determine the influence of periapical radiographs, cone beam computed tomography (CBCT) sections, and cone beam volumetric data on the determination of periapical bone destruction in endodontically treated distal root canals of premolar canine teeth. Nontreated mesial roots were used as controls. Study design. Enterococcus faecalis strain (ATCC 29212) was inoculated into 30 root canals of 2 mongrel dogs to induce apical periodontitis. After 60 days, the root canals of the distal roots of the 11 mandibular and 4 maxillary premolars were endodontically treated (n = 15). The mesial root canals were used as controls (no treatment). The bone destruction was evaluated after 6 months by 5 evaluators using periapical radiographs and by CBCT (coronal and sagittal sections). After the experimental period, the area of the lesions in periapical radiographs and CBCT sections were measured in mm(2) using the ImageTool software. A single evaluator measured the volumetric data using the OsiriX software. The comparison between the diagnosis methods in treated root canals and controls was performed using parametric and nonparametric criteria. The Pearson correlation coefficient was computed between radiographic values and CBCT volumetric data in treated root canals and controls. Results. The results showed the presence of chronic apical periodontitis in every inoculated tooth. After 6 months, periapical radiographs, coronal CBCT sections, and volumetric data showed lower bone destruction in endodontically treated teeth in comparison with the control group (P < .05). The 5 evaluators found no differences between the apical periodontitis area of treated teeth and controls when CBCT sagittal sections were used (P > .05). No correlation was found between x-ray and CBCT volumetric values in treated root canals. Conclusions. Although selected CBCT sagittal sections showed similar values of bone destruction in endodontically and nontreated root canals, volumetric CBCT data showed that periapical lesions of endodontically treated root canals had half of the volume of periapical lesions in nontreated root canals. No relationship could be found between the periapical values of bone destruction and volumetric data found in CBCT of treated rood canals. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112: 272-279)

Expression analysis of matrix metalloproteinase-9 in epithelialized and nonepithelialized apical periodontitis lesions

Objective. The objective of this study was to determine the expression of matrix metalloproteinase-9 (MMP-9) in apical periodontitis lesions. Study design. Nineteen epithelialized and 18 nonepithelialized apical periodontitis lesions were collected after periapical surgery. After histological processing, serial sectioning, H&E staining, and microscopic analysis, 10 epithelialized and 10 nonepithelialized lesions were selected for immunohistochemical analysis for MMP-9 and CD 68. At least one third of each specimen collected was frozen at -70 degrees C for further mRNA isolation and reverse transcription into cDNA for real-time-PCR procedures. Geometric averaging of multiple housekeeping genes normalized MMP-9 mRNA expression level. Results. Polymorphonuclear neutrophils, macrophages and lymphocytes presented MMP-9 positive immunostaining in both types of lesions. When present, epithelial cells were also stained. The number and the ratio of MMP-9(+)/total cells were greater in nonepithelialized than epithelialized lesions (P = .0001) presenting a positive correlation to CD68(+)/total cells (P = .045). Both types of lesions presented increased MMP-9 expression (P < .0001) when compared to healthy periapical ligaments. However, no significant differences were observed for MMP-9 mRNA expression between ephithelized and nonephithelized lesions. Conclusion. The present data suggest the participation of several inflammatory cells, mainly CD68(+) cells, in the MMP-9 expression in apical periodontitis lesions. MMP-9 could be actively enrolled in the extracellular matrix degradation in apical periodontitis lesions. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 107: 127-132)

A New Periapical Index Based on Cone Beam Computed Tomography

The purpose of this study was to evaluate a new periapical index based on cone beam computed tomography (CBCT) for identification of apical periodontitis (AP). The periapical index proposed in this study (CBCTPAI) was developed on the basis of criteria established from measurements corresponding to periapical radiolucency interpreted on CBCT scans. Radiolucent images suggestive of periapical lesions were measured by using the working tools of Planimp software on CBCT scans in 3 dimensions: buccopalatal, mesiodistal, and diagonal. The CBCTPAI was determined by the largest lesion extension. A 6-point (0-5) scoring system was used with 2 additional variables, expansion of cortical bone and destruction of cortical bone. A total of 1014 images (periapical radiographs and CBCT scans) originally taken from 596 patients were evaluated by 3 observers by using the CBCTPAI criteria. AP was identified in 39.5% and 60.9% of cases by radiography and CBCT, respectively (P<.01). The CBCTPAI offers an accurate diagnostic method for use with high-resolution images, which can reduce the incidence of false-negative diagnosis, minimize observer interference, and increase the reliability of epidemiologic studies, especially those referring to AP prevalence and severity. (J Endod 2008;34:1325-1331)

Diabetes mellitus, periapical inflammation and endodontic treatment outcome

The possible connection between chronic oral inflammatory processes, such as apical periodontitis and periodontal disease (PD), and systemic health is one of the most interesting aspects faced by the medical and dental scientific community. Chronic apical periodontitis shares important characteristics with PD: 1) both are chronic infections of the oral cavity, 2) the Gram-negative anaerobic microbiota found in both diseases is comparable, and 3) in both infectious processes increased local levels of inflammatory mediators may have an impact on systemic levels. One of the systemic disorders linked to PD is diabetes mellitus (DM); is therefore plausible to assume that chronic apical periodontitis and endodontic treatment are also associated with DM. The status of knowledge regarding the relationship between DM and endodontics is reviewed. Upon review, we conclude that there are data in the literature that associate DM with a higher prevalence of periapical lesions, greater size of the osteolityc lesions, greater likelihood of asymptomatic infections and worse prognosis for root filled teeth. The results of some studies suggest that periapical disease may contribute to diabetic metabolic dyscontrol

Revascularization and periapical repair after endodontic treatment using apical negative pressure irrigation versus conventional irrigation plus triantibiotic intracanal dressing in dogs` teeth with apical periodontitis

Objective. The objective of this study was to evaluate in vivo the revascularization and the apical and periapical repair after endodontic treatment using 2 techniques for root canal disinfection (apical negative pressure irrigation versus apical positive pressure irrigation plus triantibiotic intracanal dressing) in immature dogs` teeth with apical periodontitis. Study design. Two test groups of canals with experimentally induced apical periodontitis were evaluated according to the disinfection technique: Group 1, apical negative pressure irrigation (EndoVac system), and Group 2, apical positive pressure irrigation (conventional irrigation) plus triantibiotic intracanal dressing. In Group 3 (positive control), periapical lesions were induced, but no endodontic treatment was done. Group 4 (negative control) was composed of sound teeth. The animals were killed after 90 days and the maxillas and mandibles were subjected to histological processing. The sections were stained with hematoxylin and eosin and Mallory Trichrome and examined under light microscopy. A description of the apical and periapical features was done and scores were attributed to the following histopathological parameters: newly formed mineralized apical tissue, periapical inflammatory infiltrate, apical periodontal ligament thickness, dentin resorption, and bone tissue resorption. Intergroup comparisons were done by the Kruskal-Wallis and Dunn`s tests (alpha = 0.05). Results. Although statistically significant difference was found only for the inflammatory infiltrate (P < .05), Group 1 presented more exuberant mineralized formations, more structured apical and periapical connective tissue, and a more advanced repair process than Group 2. Conclusion. From the histological observations, sodium hypochlorite irrigation with the EndoVac system can be considered as a promising disinfection protocol in immature teeth with apical periodontitis, suggesting that the use of intracanal antibiotics might not be necessary. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109: 779-787)

Cone-beam computerized tomographic, radiographic, and histologic evaluation of periapical repair in dogs` post-endodontic treatment

Objective. To evaluate the periapical repair after root canal treatment in the teeth of dogs using CT and conventional radiography and to compare these findings with the gold standard microscopic evaluation. Study design. The animals were divided into three groups according to endodontic treatment performed: Group 1, single-visit endodontic treatment in teeth without apical periodontitis; Group 2, single-visit endodontic treatment in teeth with apical periodontitis; and Group 3, endodontic treatment in teeth with apical periodontitis using calcium hydroxide as a root canal dressing. Group 4 consisted of teeth with apical periodontitis not submitted to root canal treatment and Group 5 consisted of healthy teeth without periapical disease. Radiographic, tomographic, and microscopic evaluations were performed by blind examiners. At 180 days experimental time, CT and radiographic measurements of periapical disease were compared with the gold standard microscopic measurement using intraclass correlation coefficient. Intergroup comparisons considering different methods of periapical lesions measurement or different clinical protocols of root canal treatment were performed by Kruskal Wallis test followed by Dunn. Integrity of lamina dura, presence of radiolucent areas, and presence of root resorption were analyzed by Fisher`s exact test. Results. There was discontinuity of the lamina dura and CPD in all teeth from Groups 2, 3, and 4 evaluated by tomography and radiography 45 days after CPD induction. Radiographically, 180 days after root canal treatment, there was no periapical lesion in teeth from Groups 1 and 3, different from groups 2 and 4 (p < .05). The highest reduction in the CPD size was observed on Group 3 (p < .05). According to the tomographic results, there was decrease of the size of the CPD on Group 3 but not on Groups 2 or 4. However, in all groups the periapical lesions presented larger mesio-distal extension if compared with radiography, both 45 days after CPD induction and 180 days after root canal treatment. At 180 days, CT measurements were closely related to microscopic results (ICC = 0.95) differently from radiographic evaluation (ICC = 0.86). Conclusion. CT Scan evaluation of periapical repair following root canal treatment provided similar information than that obtained by microscopic analysis, whereas radiographic evaluation underestimated the size do periapical lesion. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108:796-805)

Outcome of Root Canal Treatment in Dogs Determined by Periapical Radiography and Cone-Beam Computed Tomography Scans

The purpose of this study was to compare the favorable outcome of root canal treatment determined by periapical radiographs (PRs) and cone beam computed tomography (CBCT) scans. Ninety-six roots of dogs` teeth were used to form four groups (n = 24). In group 1, root canal treatments were performed in healthy teeth. Root canals in groups 2 through 4 were infected until apical periodontitis (AP) was radiographically confirmed. Roots with AP were treated by one-visit therapy in group 2, by two-visit therapy in group 3, and left untreated in group 4. The radiolucent area in the PRs and the volume of CBCT-scanned periapical lesions were measured before and 6 months after the treatment. In groups 1, 2, and 3, a favorable outcome (lesions absent or reduced) was shown in 57 (79%) roots using PRs but only in 25 (35%) roots using CBCT scans (p = 0.0001). Unfavorable outcomes occurred more frequently after one-visit therapy than two-visit therapy when determined by CBCT scans (p = 0.023). (J Endod 2009; 35:723-726)

Detection of periapical lesion development by conventional radiography or computed tomography

Objective. The aim of this study was to detect the development of experimentally induced periapical lesions using conventional radiography and computed tomography.Study design. The root canals of dogs' teeth were exposed to the oral environment for 7 days for contamination and then sealed for 7 days (GI), 15 days (GII), 30 days (GIII), and 60 days (GIV). Immediately after each experimental period, radiographs and tomograms were taken in order to detect the occurrence of periapical bone resorption. The periapical radiographs were digitized and areas of bone resorption were measured using the VIXWIN 2000 software. Scores were assigned to the tomograms based on the progression of periapical bone resorption. The specimens were evaluated by calibrated examiners who were blinded to the groups. The radiographic results were analyzed by ANOVA and Tukey's test (P <.05) and the tomographic results were analyzed by Kruskal-Wallis and Dunn's tests (P <.05).Results. The radiographic evaluation did not reveal periapical lesions at the 7-day control. Lesions were radiographically visible at 15 and 30 days (47.4% and 77.8% of the cases, respectively) and presented similar dimensions (P <.05). At 60 days, lesions were detected in all specimens, presenting larger dimensions than those of the earlier evaluation periods (P <.05). The tomographic evaluation detected lesions at 7 and 15 days (32.5% and 83.3% of the cases, respectively). Lesions were detected in all specimens at the 30- and 60-day periods, when the greatest values of bone resorption were observed (P <.05).Conclusions. Tomography was able to detect periapical lesion development in its initial stages, even when the lesions were undetectable radiographically.

Comparative radiographic and histological analyses of periapical lesion development

Objective. The present study evaluated the dynamics of the development of periapical lesions.Study design. Root canals from dogs' teeth were exposed to the oral environment, and then sealed for 7 days (Group A), 15 days (Group B), 30 days (Group C), and 60 days (Group D). After each experimental period, radiographs were taken to detect periapical bone resorption. In addition, histological sections from the periapical region were prepared. The radiographic and histological results were analyzed by ANOVA and Tukey's, Wilcoxon, and Pearson's tests. Significance level was set at 5%.Results. Lesions were radiographically visible at 15 and 30 days, and had similar size at these periods (P > .05). At 60 days, lesions were larger than in the other periods (P < .05). Bone resorption was detected histologically at 7 days. The greatest values of bone resorption were observed at the 30- and 60-day periods (P < .05). The results of the methods of evaluation were similar only at the 30-day period. There was no correlation between the radiographic and histological results.Conclusions. Periapical radiography did not provide detection of periapical lesion in its initial stages. The periapical lesions became more evident radiographically when the bone resorption area increased. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:442-447)

Evaluation of periapical changes following endodontic therapy: digital subtraction technique compared with computerized morphometric analysis

Objectives: The aim of this study was to compare two methods for the evaluation of periapical lesion changes following endodontic therapy (digital subtraction technique and morphometric analysis) by outlining the radiolucent area.Methods: 13 human anterior teeth with pulp necrosis and chronic periapical lesions were used. Periapical radiographs were taken immediately after endodontic therapy (0) and then 2 months, 4 months and 6 months post treatment, using an intraoral radiographic film holder stabilized with impression material. The films were processed in a standard manner and the digitized images were submitted to digital subtraction using Adobe Photoshop 6.0. New bone formation or bone resorption areas were then measured. In the morphometric analysis, the periapical lesions were outlined using VixWin 2000 and the area (in square millimetres) was recorded. The obtained data were submitted to agreement analysis for comparison of the two techniques.Results: There was no correlation between the areas of radiographic changes detected by digital subtraction and periapical lesion outline (r=0.02-0.45). The new bone formation areas observed by digital subtraction presented higher values, with bone changes being especially evident in the 2 month follow-up radiographs, which suggests a higher sensitivity for this method.Conclusions: Both methods are suitable for the evaluation of periapical lesion changes, but the digital subtraction technique is more sensitive for detecting radiographic periapical changes. Dentomaxillofacial Radiology (2009) 38, 438-444. doi: 10.1259/dmfr/53304677

Effect of a calcium hydroxide-based root canal dressing on periapical repair in dogs: a histological study

Objective. To compare the periapical repair of teeth with periapical lesion following root canal treatment by using a calcium hydroxide-based intracanal dressing for several time periods or filling in a single visit.Study design. After induction of periapical lesions in 4 dogs, the root canals were prepared using 5.25% sodium hypochlorite for irrigation, and animals were separated into 4 experimental groups; in group I, root canals were filled in a single session; in groups II, III, and IV, a calcium hydroxide-based dressing was kept in place for 15, 30, or 180 days, respectively. Root canals from groups I, II, and III were filled with gutta-percha cones and AH Plus sealer. After 180 days, animals were killed and histological sections were stained with hematoxylin-eosin to evaluate periapical repair.Results. Periapical repair was better in groups II, III, and IV (intracanal dressing) compared with group I (single session; P <.05).Conclusion. The use of a calcium hydroxide-based intracanal dressing was important for periapical repair in teeth with periapical lesion. Dressing with calcium hydroxide paste results in better periapical repair than when the root canal is filled in a single-session treatment.

Radiographic and microbiologic evaluation of posttreatment apical and periapical repair of root canals of dogs' teeth with experimentally induced chronic lesion

The objective of the present study was to evaluate radiographically and bacteriologically apical and periapical repair in dogs' teeth with induced chronic periapical lesions with the use of two different operative techniques (techniques 1 and 2). The study was conducted on 40 root canals of upper and lower premolars from two dogs aged approximately 12 months. Periapical lesions were induced by leaving the root canals exposed to the oral environment for 5 days and then sealing them with zinc oxide-eugenol for 45 days. After this period, radiographic examination revealed the occurrence of a radiolucent lesion and endodontic treatment was started. The two techniques did not differ in terms of chemomechanical preparation, final filling, or type of cement, but differed in terms of irrigating solution and the presence of an antibacterial dressing. Thus 4% to 6% hypochlorite and hydrogen peroxide (10 volumes) were used in technique 1 during chemomechanical preparation and an antibacterial dressing based on calcium hydroxide was applied between sessions, whereas Dakin's fluid (0.5% sodium hypochlorite solution) and a final filling with no antibacterial dressing were used in technique 2. After chemomechanical preparation, the root canals were filled with gutta-percha cones and Sealapex (Sealapex-Sybron, Kerr, Sao Paulo, Brazil), and the animals were killed 270 days after the final filling. Blocks were cut into 6-μm sections and stained by the Brown and Brenn method. Radiographic, histomicrobiologic and statistical analysis permitted us to conclude the following: radiographically there was a marked reduction or even the disappearance of the radiolucent area present before treatment with greater success in the group treated with technique 1 (group I) than in the group treated with technique 2 (group II); the extent of bacterial invasion of dentinal tubules was greater and more intense in group II than in group I; and the amount of microorganisms detected in the ramifications of the apical delta and in the lumen of the root canal was intense in group II and mild or absent in group I. © 1994.

Calcium hydroxide root canal dressing. Histopathological evaluation of periapical repair at different time periods.

The objective of this study was to evaluate periapical and apical repair using calcium hydroxide root canal dressings for different lengths of times in teeth with induced chronic periapical lesions. A total of 61 root canals of maxillary and mandibular premolars from 4 dogs were used. After mechanical preparation of the root canals using the crown-down technique, and 5.25% NaOCl as irrigating solution, the apical foramen was enlarged in all cases. A calcium hydroxide root canal dressing was applied. The control group did not receive a root canal dressing. The animals were killed at 7, 15 or 30 days. After histological preparation, serial sections were stained with hematoxylin-eosin and Mallory's trichrome. The best histopathological results occurred at 15 and 30 days, and the worst results occurred at 7 days and in the control group.

Associação do hidróxido de cálcio e metronidazol no tratamento de dentes de cães com lesão periapical crônica

One of the primary objectives of endodontic treatment of teeth with pulp necrosis is the elimination of microorganisms from the root canal system, as effectively as possible, especially in cases with chronic periapical lesions. AIM: The purpose of this study was to analyze the response of the periapical tissue of dogs' teeth with chronic periapical lesions to endodontic treatment performed with utilization of metronidazole, calcium hydroxide, and an association of both as root canal dressings. METHODOLOGY: Forty root canals were submitted to pulpectomy and the root canals were kept exposed to the oral environment for 6 months. Then, they were submitted to biomechanical preparation and divided into 4 study groups with 10 specimens: group I - no root canal dressing; group II - calcium hydroxide; group III - metronidazole; group IV - calcium hydroxide associated to metronidazole. After 15 days, the root canals were filled with Fill Canal sealer. After 90 days, the animals were killed and the especimens processed for histological analysis. RESULTS: Calcium hydroxide dressing provided a significantly better outcome compared to other experimental groups (α = 0.01). Also, the results of the association of metronidazole and calcium hydroxide were similar to those observed for the metronidazole group. The worst results were obtained by the no root canal dressing group. CONCLUSION: The use of metronidazole alone or associated with Calcium hydroxide, did not improve periapical healing when compared to Calcium hydroxide dressing.

Microbial distribution in the root canal system after periapical lesion induction using different methods

The aim of this study was to evaluate the microbial distribution in the root canal system after periapical lesion induction in dogs' teeth using different methods. Fifty-two root canals were assigned to 4 groups (n=13). Groups I and II: root canals were exposed to the oral cavity for 180 days; groups III and IV: root canals were exposed for 7 days and then the coronal openings were sealed for 53 days. The root apices of groups I and III were perforated, while those of groups II and IV remained intact. After the experimental periods, the animals were euthanized and the anatomic pieces containing the roots were processed and stained with the Brown & Brenn method to assess the presence and distribution of microorganisms. The incidence of microorganisms at different sites of the roots and periapical lesions was analyzed statistically by the chi-square test at 5% significance level. All groups presented microorganisms in the entire root canal system. A larger number of microorganisms was observed on the root canal walls, apical delta and dentinal tubules (p<0.05), followed by cementum and cemental resorption areas. In spite of the different periods of exposure to the oral environment, the methods used for induction of periapical periodontitis yielded similar distribution of microorganisms in the root canal system.