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.

IMMUNE MODULATION OF THE MYCOBACTERIUM TUBERCULOSIS GRANULOMATOUS RESPONSE

Tuberculosis (TB) remains a major public health burden. The immunocompetant host responds to Mycobacterium tuberculosis (MTB) infection by the formation of granulomas, which initially prevent uncontrolled bacterial proliferation and dissemination. However, increasing evidence suggests that granuloma formation promotes persistence of the organism by physically separating infected cells from effector lymphocytes and by inducing a state of non-replicating persistence in the bacilli, making them resistant to the action of antibiotics. Additionally, immune-mediated tissue destruction likely facilitates disease transmission. The granulomatous response is in part due to mycobacterial glycolipid antigens. Therefore, studies were first undertaken to determine the innate mechanisms of mycobacterial cord factor trehalose-6’6-dimycolate (TDM) on granuloma formation. Investigations using knock-out mice suggest that TNF-a is involved in the initiation of the granulomatous response, complement factor C5a generates granuloma cohesiveness, and IL-6 is necessary for maintenance of an established granulomatous responses. Studies were next performed to determine the ability of lactoferrin to modulate the immune response and pathology to mycobacterial cord factor. Lactoferrin is an iron-binding glycoprotein with immunomodulatory properties that decrease tissue damage and promote Th1 responses. Mice challenged with TDM and treated with lactoferrin had decreased size and numbers of granulomas at the peak of the granulomatous response, accompanied by increased IL-10 and TGF-b production. Finally, the ability of lactoferrin to serve as a novel therapeutic for the treatment of TB was performed by aerosol challenging mice with MTB and treating them with lactoferrin added to the drinking water. Mice given tap water had lung log10 CFUs of 7.5 ± 0.3 at week 3 post-infection. Lung CFUs were significantly decreased in mice given lactoferrin starting the day of infection (6.4 ± 0.7) and mice started therapeutically on lactoferrin at day 7 after established infection (6.5 ± 0.4). Total lung inflammation in lactoferrin treated mice was significantly decreased, with fewer areas of macrophages, increased total lymphocytes, and increased numbers of CD4+ and CD8+ cells. The lungs of lactoferrin treated mice had increased CD4+ IFN-g+ cells and IL-17 producing cells on ELISpot analysis. It is hypothesized that lactoferrin decreases bacterial burden during MTB infection by early induction of Th1 responses.

Reactivated Moraxella osteitis presenting as granulomatous disease.

Granulomatous infections are commonly associated with mycobacteria, brucellosis, actinomycosis, nocardiosis, spirochetes, and fungi. Rarely, granuloma formation is a host response to other bacterial infection. Osteomyelitis and osteitis that reactivate many years after the primary episode is a known phenomenon. A reactivation that presents as a granulomatous disease is rare. We present a case of reactivated osteitis due to Moraxella osloensis with consecutive granuloma formation.

Use of nitinol self-expandable stents in 26 dogs with tracheal collapse

A study was designed to describe a novel approach to the treatment of tracheal collapse (TC) in dogs using self-expandable nitinol stents. Medical records were reviewed retrospectively for 26 client owned dogs in which nitinol stents were deployed. The entire length of trachea was supported independently of the extent of TC. Two overlapping stents were used instead of one in cases where one stent was not spanning the entire trachea adequately. The diameter of the cranial radiolucent portion of trachea, just behind the cricoid cartilage, was measured as a specific landmark to select the appropriate size of the stent. Two self-expandable nitinol stents were inserted in 9 of 26 dogs; the trachea in the rest of the cases was supported with only one stent. A follow up tracheoscopy was performed in 10 of 26 cases with recurrent clinical signs. Secondary tracheal stenosis in these cases was caused by stent fracture, granuloma or excessive stent shortening. Additional stents were placed successfully to expand the stenotic lumen. A support of the entire trachea may decrease risk of nitinol fracture at the end of the implant. Long term clinical improvement (25 of 26 dogs, 96 %) is comparable with the results of other studies.

SADMFR Guidelines for the Use of Cone-Beam Computed Tomography/Digital Volume Tomography

In 2011, the first consensus conference on guidelines for the use of cone-beam computed tomography (CBCT) was convened by the Swiss Society of Dentomaxillofacial Radiology (SGDMFR). This conference covered topics of oral and maxillofacial surgery, temporomandibular joint dysfunctions and disorders, and orthodontics. In 2014, a second consensus conference was convened on guidelines for the use of CBCT in endodontics, periodontology, reconstructive dentistry and pediatric dentistry. The guidelines are intended for all dentists in order to facilitate the decision as to when the use of CBCT is justified. As a rule, the use of CBCT is considered restrictive, since radiation protection reasons do not allow its routine use. CBCT should therefore be reserved for complex cases where its application can be expected to provide further information that is relevant to the choice of therapy. In periodontology, sufficient information is usually available from clinical examination and periapical radiographs; in endodontics alternative methods can often be used instead of CBCT; and for implant patients undergoing reconstructive dentistry, CT is of interest for the workflow from implant planning to the superstructure. For pediatric dentistry no application of CBCT is seen for caries diagnosis.

Evaluation of New Cone-beam Computed Tomographic Criteria for Radiographic Healing Evaluation after Apical Surgery: Assessment of Repeatability and Reproducibility.

INTRODUCTION Conventional 2-dimensional radiography uses defined criteria for outcome assessment of apical surgery. However, these radiographic healing criteria are not applicable for 3-dimensional radiography. The present study evaluated the repeatability and reproducibility of new cone-beam computed tomographic (CBCT)-based healing criteria for the judgment of periapical healing 1 year after apical surgery. METHODS CBCT scans taken 1 year after apical surgery (61 roots of 54 teeth in 54 patients, mean age = 54.4 years) were evaluated by 3 blinded and calibrated observers using 4 different indices. Reformatted buccolingual CBCT sections through the longitudinal axis of the treated roots were analyzed. Radiographic healing was assessed at the resection plane (R index), within the apical area (A index), of the cortical plate (C index), and regarding a combined apical-cortical area (B index). All readings were performed twice to calculate the intraobserver agreement (repeatability). Second-time readings were used for analyzing the interobserver agreement (reproducibility). Various statistical tests (Cohen, kappa, Fisher, and Spearman) were performed to measure the intra- and interobserver concurrence, the variability of score ratios, and the correlation of indices. RESULTS For all indices, the rates of identical first- and second-time scores were always higher than 80% (intraobserver Cohen κ values ranging from 0.793 to 0.963). The B index (94.0%) showed the highest intraobserver agreement. Regarding interobserver agreement, the highest rate was found for the B index (72.1%). The Fleiss' κ values for R and B indices exhibited substantial agreement (0.626 and 0.717, respectively), whereas the values for A and C indices showed moderate agreement (0.561 and 0.573, respectively). The Spearman correlation coefficients for R, A, C, and B indices all exhibited a moderate to very strong correlation with the highest correlation found between C and B indices (rs = 0.8069). CONCLUSIONS All indices showed an excellent intraobserver agreement (repeatability). With regard to interobserver agreement (reproducibility), the B index (healing of apical and cortical defects combined) and the R index (healing on the resection plane) showed substantial congruence and thus are to be recommended in future studies when using buccolingual CBCT sections for radiographic outcome assessment of apical surgery.

Cone beam computed tomography (CBCT) for diagnosis and treatment planning in periodontology: A systematic review.

OBJECTIVE The improvement in diagnostic accuracy and optimization of treatment planning in periodontology through the use of three-dimensional imaging with cone beam computed tomography (CBCT) is discussed controversially in the literature. The objective was to identify the best available external evidence for the indications of CBCT for periodontal diagnosis and treatment planning in specific clinical situations. DATA SOURCES A systematic literature search was performed for articles published by 2 March 2015 using electronic databases and hand search. Two reviewers performed the study selection, data collection, and validity assessment. PICO and PRISMA criteria were applied. From the combined search, seven studies were finally included. CONCLUSION The case series were published from the years 2009 to 2014. Five of the included publications refer to maxillary and/or mandibular molars and two to aspects related to vertical bony defects. Two studies show a high accuracy of CBCT in detecting intrabony defect morphology when compared to periapical radiographs. Particularly, in maxillary molars, CBCT provides high accuracy for detecting furcation involvement and morphology of surrounding periodontal tissues. CBCT has demonstrated advantages, when more invasive treatment approaches were considered in terms of decision making and cost benefit. Within their limits, the available data suggest that CBCT may improve diagnostic accuracy and optimize treatment planning in periodontal defects, particularly in maxillary molars with furcation involvement, and that the higher irradiation doses and cost-benefit ratio should be carefully analyzed before using CBCT for periodontal diagnosis and treatment planning.

Assessment of the nonoperated root after apical surgery of the other root in mandibular molars: a 5-year follow-up study

INTRODUCTION If a surgical approach is chosen to treat a multirooted tooth affected by persistent periapical pathosis, usually only the affected roots are operated on. The present study assessed the periapical status of the nonoperated root 5 years after apical surgery of the other root in mandibular molars. METHODS Patients treated with apical surgery of mandibular molars with a follow-up of 5 years were selected. Patient-related and clinical parameters (sex, age, smoking, symptoms, and signs of infection) before surgery were recorded. Preoperative intraoral periapical radiographs and radiographs 5 years after surgery were examined. The following data were collected: tooth, operated root, type and quality of the coronal restoration, marginal bone level, length and homogeneity of the root canal filling, presence of a post/screw, periapical index (PAI) of each root, and radiographic healing of the operated root. The presence of apical pathosis of the nonoperated root was analyzed statistically in relation to the recorded variables. RESULTS Thirty-seven patients fulfilled the inclusion criteria. Signs of periapical pathosis in the nonoperated root 5 years after surgery (PAI ≥ 3) could be observed in only 3 cases (8.1%). Therefore, statistical analysis in relation to the variables was not possible. The PAI of the nonoperated root before surgery had a weak correlation with signs of apical pathosis 5 years after surgery. CONCLUSIONS Nonoperated roots rarely developed signs of new apical pathosis 5 years after apical surgery of the other root in mandibular molars. It appears reasonable to resect and fill only roots with a radiographically evident periapical lesion.

Hypersensitive granulomatous response to mycobacterial glycolipid trehalose 6,6'-dimycolate

Protection against Mycobacterium tuberculosis infection requires an effective cell mediated immune response leading to granuloma formation and organism containment. Trehalose 6,6'-dimycolate (TDM), a glycolipid present on the mycobacterial cell wall, has been implicated as a key component in establishment of the granulomatous response. TDM has potent immunoregulatory and inflammatory properties; the acute response to TDM produces pathology resembling early Mycobacterium tuberculosis infection. We have further developed this model to study TDM-specific cell mediated immune responses that may play a role in the later stages of infection and pathology. Lungs from mice immunized with TDM in the form of a water-oil-water (w/o/w) emulsion demonstrate heightened histological damage, inflammation, lymphocytic infiltration, and vascular endothelial cell damage upon subsequent challenge with TDM. This exacerbated response can be adoptively transferred to naïve mice via transfer of non-adherent lymphocytes from TDM immunized mice. To identify the cell phenotype(s) regulating this response, purified non-adherent cell populations (CD4+ and CD8+ T cells; CD19 + B cells) were isolated from TDM immunized mice, adoptively transferred into naive mice, and subsequently challenged with TDM. Lung histopathology and cytokine production identified CD4+ cells as the critical cell phenotype regulating the TDM-specific hypersensitive response. The role of CD1d in presentation of TDM was examined. CD1d, a molecule known to present lipids to T cells, was identified as critical in development of the hypersensitive response. CD4+ cells were isolated from TDM-immunized CD1d -/- mice and adoptively transferred into naive wild type mice, followed by TDM challenge. These mice were deficient in development of the hypersensitive granulomatous response, signifying the importance of CD1d in the generation of TDM-specific CD4+ cells. The experiments presented in this dissertation provide further evidence for involvement of TDM-specific cell mediated immune response in elicitation of pathological damage during Mycobacterium tuberculosis infection. ^

11beta-hydroxysteroid dehydrogenases as regulators of pulmonary corticosterone during the granulomatous response to trehalose 6,6'-dimycolate

Protection against Mycobacterium tuberculosis requires development and maintenance of granulomatous lesions, a feature considered to be the pathological hallmark of Tuberculosis (TB) disease. Upon encountering Mtb or mycobacterial antigens, specifically trehalose 6,6'-dimycolate (TDM), a strong local pro-inflammatory response is initiated. Systemic production of anti-inflammatory glucocorticoids (GCs) is also induced. Emergence of these antagonists at the inflammatory foci is counterproductive to development of the granulomatous structure and detrimental to host protection against TB. Therefore, it was hypothesized that local enzymatic regulation of GCs occurs locally at the site of granulomatous inflammation. The experiments described here strongly suggest that 11β-hydroxysteroid dehydrogenases (11βHSDs) shuttle GCs between active and inert forms during the acute granulomatous response, supporting the net reduction of corticosterone. The patterns of GC and 11βHSD regulation were specific to the lung (the site of inflammation) and were not observed in other tissues. Furthermore, 11βHSD2, which decreases corticosterone concentrations, was not expressed in models of dysregulated granulomatous inflammation. These findings suggest that cellular exposure to local active GC concentrations is restricted via 11βHSDs as a mechanism to initiate and maintain granuloma formation. The information derived from the experiments outlined in this dissertation provides a better understanding of the events required for establishment and maintenance of the protective granulomatous response. As a practical consequence, exploiting 11βHSD2 modulation of GCs at the site of Mtb infection may lead to improvement of Tuberculosis treatment strategies.^

Restauración de incisivo inferior fracturado mediante procedimientos de invasión mínima : reporte de un caso clínico

La odontología está inmersa en un nuevo paradigma: no se puede pensar en ninguna técnica restauradora sin que participen fenómenos de adhesión. El desarrollo de pernos de fibra de vidrio, sumado a los procedimientos de restauraciones adhesivas puede utilizarse como uno de los tantos recursos de la odontología de invasión mínima. Los pernos de fibra de vidrio ofrecen varias ventajas: comportamiento anisótropo, módulo de elasticidad bajo, buena resistencia mecánica, el lecho que aloja al perno de fibra requiere de una mínima preparación y se cementan con cementos adhesivos con carga, permitiendo de esta manera obtener una superficie homogénea que se interpone entre el perno de fibra y los tejidos dentales, conectándolo a los tejidos del conducto y sustituyendo mecánicamente la dentina. El caso clínico que se reporta se presentó para su resolución en la Clínica Integrada III F. O. UNCuyo durante el año lectivo 2009. El paciente presentaba una fractura amelodentinaria desde hacía cuatro años, con compromiso de la vitalidad y un proceso periapical. Durante los procedimientos endodónticos se realizó una perforación de la pared del conducto que se selló mediante la colocación de hidróxido de calcio y la obturación del mismo con conos de gutapercha. Se efectuó el seguimiento clínico y radiográfico del caso en donde se constató la reparación del proceso apical y luego se procedió a la restauración del elemento dentario con resinas compuestas con la ayuda de un poste de fibra de vidrio cementado con cemento resinoso. Dadas las características del tratamiento endodóntico realizado, se decidió dejar más porción del cono de gutapercha a pesar de lo aconsejado por numerosos autores, ya que de esta manera se aseguró el sellado de la perforación radicular para evitar de esta manera la nanofiltración hacia el interior del elemento dentario.

INFLUÊNCIA DO LASER DE BAIXA INTENSIDADE NA VELOCIDADE DA MOVIMENTAÇÃO ORTODÔNTICA

Este estudo investigou os efeitos do laser de baixa intensidade na velocidade da movimentação ortodôntica de caninos submetidos à retração inicial. A amostra constou de 26 caninos superiores e inferiores, submetidos à retração inicial realizada com mola Niti, com força de 150g. Um dos caninos foi irradiado com laser de diodo, seguindo o protocolo de aplicação: 780nm/20mW/5Jcm2/0,2J por ponto/Et=2J, nos dias 0, 3 e 7 pós-ativação, sendo que o contralateral foi considerado placebo. A retração durou em média 4 meses, num total de 9 aplicações de laser. Os modelos de cada mês foram escaneados com scanner 3D (3Shape) e as imagens tridimensionais foram analisadas por meio do Software Geomagic Studio 5, para a mensuração da quantidade de movimentação dos caninos retraídos. Foi empregada a Análise de Variância a três critérios, seguida pelo teste de Tukey (p<0,05). Para verificação da integridade tecidual, foram efetuadas radiografias periapicais iniciais e finais dos caninos retraídos e dos molares, nas quais foram avaliados uma possível reabsorção na crista alveolar, por meio da distância da crista óssea alveolar até a junção cemento-esmalte e os níveis de reabsorção radicular, por meio do índice de Levander e Malmgreen, sendo este último avaliado somente nos caninos retraídos. Para isto, foi empregado o teste não paramétrico de Wilcoxon (p<0,05). Os resultados indicaram que houve um aumento estatisticamente significante na velocidade da movimentação dos caninos irradiados comparados ao seu contralateral, em todos os tempos avaliados, como também a preservação da integridade tecidual. Com isso, concluiu-se que o laser de diodo pode acelerar a movimentação ortodôntica, podendo contribuir para a diminuição do tempo de tratamento.(AU)

INFLUÊNCIA DO LASER DE BAIXA INTENSIDADE NA VELOCIDADE DA MOVIMENTAÇÃO ORTODÔNTICA

Este estudo investigou os efeitos do laser de baixa intensidade na velocidade da movimentação ortodôntica de caninos submetidos à retração inicial. A amostra constou de 26 caninos superiores e inferiores, submetidos à retração inicial realizada com mola Niti, com força de 150g. Um dos caninos foi irradiado com laser de diodo, seguindo o protocolo de aplicação: 780nm/20mW/5Jcm2/0,2J por ponto/Et=2J, nos dias 0, 3 e 7 pós-ativação, sendo que o contralateral foi considerado placebo. A retração durou em média 4 meses, num total de 9 aplicações de laser. Os modelos de cada mês foram escaneados com scanner 3D (3Shape) e as imagens tridimensionais foram analisadas por meio do Software Geomagic Studio 5, para a mensuração da quantidade de movimentação dos caninos retraídos. Foi empregada a Análise de Variância a três critérios, seguida pelo teste de Tukey (p<0,05). Para verificação da integridade tecidual, foram efetuadas radiografias periapicais iniciais e finais dos caninos retraídos e dos molares, nas quais foram avaliados uma possível reabsorção na crista alveolar, por meio da distância da crista óssea alveolar até a junção cemento-esmalte e os níveis de reabsorção radicular, por meio do índice de Levander e Malmgreen, sendo este último avaliado somente nos caninos retraídos. Para isto, foi empregado o teste não paramétrico de Wilcoxon (p<0,05). Os resultados indicaram que houve um aumento estatisticamente significante na velocidade da movimentação dos caninos irradiados comparados ao seu contralateral, em todos os tempos avaliados, como também a preservação da integridade tecidual. Com isso, concluiu-se que o laser de diodo pode acelerar a movimentação ortodôntica, podendo contribuir para a diminuição do tempo de tratamento.(AU)