Healing of Periapical Lesions of Pulpless Teeth After tic Treatment With Controlled Asepsi

8/3/2019 Healing of Periapical Lesions of Pulpless Teeth After tic Treatment With Controlled Asepsi

1/7

o f p e r i a p i c a l l e s i o n s o f p u l p l e s s t e e t ht e r e n d o d o n t i c t r e a t m e n t w i t h c o n t r o l l e dons of pulpless teeth after endod ontic treatm ent with58-63.

Actinomyces or Arachnia. In another case

pical tissue. In these sites, the bacteria are inaccessible to conven-ional endodontic treatment.

A n d e r s B y s t r o m \ R i s t o - P e k k a H a p -p o n e n ^ U i f S j o g r e n ' a n d G o r a nS u n d q v i s t ' ^'Department of Endodontics, University of UmSweden, ^Deparfment of Medical MicrobiologyLaborafory of Electron Microscopy, University Turku, Finland, and 'Department of Oral Microbiology, University of Umea, Sweden

Key words: root canal infection, endodontic trment, bacteriological control, periapical healinDr. Anders Bystrom, Department of EndodontFaculty of Odontology, University of Umea, S87 Umea, SwedenAccepted for publication 1 September 1986.

Bacteria in dental root canals play a decisive rolein the development of periapical lesions (1-4). Thismeans th at the elimination of bacteria from the rootcanals is the ultimate aim of endodontic treatment.The elimination of bacteria is achieved by a combi-nation of measures such as mechanical cleansing,irrigation with various medicaments and the depo-sition of antibacterial dressings in the canals. How-ever, this treatment may fail, even in cases wherethe bacteriological technique has not been able toreveal any bacteria in the root canals (5-9). It istherefore possible that the bacteriological tech-niques used in these studies did not detect all bac-teria present in the root canals. In particular, oxy-gen-sensitive bacteria may have been missed (10).The aim of the present study was to evaluatethe efficacy ofthe endodontic treatment of pulplessinfected teeth. The various steps during treatmentwere monitored by an advanced anaerobic bacterio-logical techniq ue, and the canal was not root filled

M a t e r i a i a n d m e t h o d sT e e t hThe material initially consisted of 140 single-roonon-vital teeth with periapical lesions. The trment of these teeth has been reported in earstudies (11-14). Seventy-nine ofthe teeth werecluded in the present study. Two to 5 yr had elapafter they were root-filled. Thirty-nine of the twere not included in the present study beeause thad been treated within the last 2 yr. Seventteeth could not be followed up, because the patihad moved to other parts of the country or not answer the recall request. Four teeth were reviewed because the patients were seriously ill, 1 tooth had been extracted for prosthetic reasThe 79 teeth in the present study had been treain three different ways:Group I. Eleven teeth had been instrumented


2/7

Bacteriologicaliy controlied endodontic treatmenttreatment were root-filled without use of antibac-terial solutions or dressings. Seven root canals inwhich the bacteria persisted after this treatmentwere dressed with calcium hydroxide paste (Cala-sept, Scania Dental AB, Sweden) for 1 to 2 months.Before the root canals were filled, a bacteriologicalsample was taken (11).

Group II . Forty-two root canals had been instru-mented and irrigated with sodium hypochlorite so-lutions (0.5% and 5%) or sodium hypochlorite incombination with EDTA solution (15%). No anti-bacterial dressings were used between appoint-me nts. Bacteria were eliminated from 32 root canalsby this treatment; 7 of the 32 canals had been rootfilled without the use of antibacterial dressings, and25 had been dressed with calcium hydroxide pastefor 1 mo nth. Ten root canals in which bacteriapersisted were dressed with calcium hydroxide pastefor 1 to 2 mo nths . The reafter, a bacteriolog icalsam ple was taken and the root canals were filled(12, 13).

Group III. Twenty-six root canals had been instru-mented and irrigated with sodium hypochlorite so-lutions (0.5% and 5%) and dressed with calciumhydroxide paste at the first appointment. At thesecond appo intm ent, 1 mon th later, the antibac-terial dressing was removed and a sample for bac-teriological examina tion was collected from the rootcanal. Thereafter, the canals were dried and sealedwith zinc oxide eugenol cement without dressing.At the third appointment, after 2 to 4 d, anotherbacteriological sample was taken. The canals werethen dressed with calcium hydroxide paste andsealed w ith zinc oxide eugenol cem ent. W hen it wasestablished that no bacteria could be recovered fromthe samples taken at the third appointment, theroot canals were filled (14).All teeth were bacteriologicaliy m onitored as pre-viously reported (11, 13, 14) and all root canalsv^'ere filled using the lateral condensation technique.The master cone was adapted to the canal by dip-ping it in rosin chloroform, and then multiple acces-sory cones were laterally condensed using rosinchloroform as a sealing agent.

Clinical and radiographic examinationAt the clinical examination, pain, swelling, tender-ness to apical and gingival palpation, and tender-ness to percussion w ere recorded. R adiogr aphs wereobtained before and during the treatment, 6 and 12months after the root canals were filled, and oncea year thereafter. Radiographic examination wasperformed using a long-cone technique (Oralix 65,Philips) with K odak Ultraspeed film (24 x 36 mm)in a film holder (15). In order to obtain optimaldiagnostic quality of the radiographs, a standard-ized exposure and processing procedure was used.The same X-ray unit was used for all examinationsand the radiographs were processed by hand bythe same person. All teeth exhibited radiographicevidence of periapical lesions before treatment(Table 1). The apical level ofthe root filling wasalso recorded from the post-operative radiographs.In the evaluation of treatment results, the radio-graphs were studied separately by 2 oral radiologistsand 3 endodontists, using a viewer with a magnify-ing glass (16). The radiographs were eoded prior toevaluation by the examiners. In the radiographicevaluation the examiners determined the size of thelesion on each radiograph by measuring the largestextent ofth e lesion using a ruler. The interpretationof the treatment results was then based on thechange in size of the lesions as determined on theentire series of recall radiographs. If there was dis-agreement between the evaluations of the 5 exam-iners the median value for each radiograph wasused. The criterion for complete healing was thatthe radiographic width ofthe periodontal space wasnormal or slightly widened (


3/7

et a l .oi^ Actinomyces israelii, Actinomyces naes-a n d Arachnia propionica was done according to

GA. The substitution controls were2 rabbits.

ize ofthe periapical lesion and the nu m be r of

1 and 12 mm

Of the 79 lesions, 67 healed completely. The

6 mm)

-|- 2 standardIn 7 cases the size of the lesions also decreased,ut the healing was not complete within a 2-yrobservation period (Fig. 3). In 3 of these cases thehealing pattern was similar to those that healedcompletely (Fig. 2), and in 1 case (LL12) there wasa slower decrease in the size of the lesion. The

Table 2. The initial size of the periapical lesions and the number of bacterialcells in the initial samples from the root canals

Number of bacterial cellsSize of lesions

1 2 3 4 OBSERVATION PERIOD (YEARS)

Fig. 1. The decrease in size during the observadon perioeach of the 67 completely healed lesions.

remaining 3 cases in Fig. 3 (LL31, LL41 and Lwere treated by surgery. They were all involvea large confiuent lesion in the mandibular antregion, and histological examination of the tremoved at surgery showed scar tissue whichalmost free of infiammatory cells.In 5 cases there was no or only an insignifdecrease in the size ofthe lesions (Fig. 4). Of cases, OD belonged to group III, and JW, ABand LB to group II. These 4 cases in group IIbeen treated with sodium hypochlorite irrigabut when this treatment was finished, there persistent infections in ABg and IL, exudatiothe canal of LB and acute exacerbation inThese root canals were dressed with calciumdrox ide pa ste for 12 m onths . After bac terio locontrol the root canals were filled.When healing failed to occur, the cases IL,ABg, and LB (Fig. 4) were treated by surgerytissue samples from IL, JW, and ABg were hlogically examined. Gase IL was operated oearly as 6 mo nths after the root can al was


4/7

Bactarioiogicaiiy controiied endodontic treatme

E

O

I"N

OBSERVATION PERIOD(YEARS)Fig. 2. The decrease in size during tlie iirst 2 yr Ibliowing treat-ment for completely healed lesions; grouped according to initialsizes. The number of cases in each group is given in the flgtire.Sizes given as mean+ 2 standard deviations.

LL12

1 2 3 4OBSERVATION PERIOD (YEARS)

Fig. 3. The decrease in size for 7 incompletely healed lesions.

In case ABg there was a radicular cyst with chipsof dentin in the tissue. There was uneventful healingwith complete bone repair within 1 yr for the oper-ated lesions LL 41, 42, 31 (Fig. 3) and JW. Gases

the operation. It has not been possible to check casIL since the operation.Twelve cases had acute apical abscesses at thbeginning of the treatment, and 9 cases developeacute exacerbations during the treatment (Table 1Nineteen of these 21 cases healed completely. Threma ining 2 cases were J W and ABg (Fig. 4).The apical level of the root filling did not influence the outcome of the endodontic treatmen(Table 3). None of the cases in which overfillinoccurred had material extending more than 2 mmfrom the apex o fthe root. All root fillings appeareradiographically to be well-filled.

DiscussionAll the teeth in the present study had infected roocanals and periapical lesions. After the treatmenthe majority of the lesions healed completely odecreased in size in such a way that they could bexpected to heal.When comparing the results of the present studywith those of various other studies there are somdifficulties because of variations in criteria for theevaluation of the periapical healing (19-23), thelength of the postoperative observation period(24-26), and the type of teeth treated (24, 25, 2728). The teeth in the present study were single-

- ' . f ^ '': , - ' ^

1211

; 109

8 7

654

2 3W) 2

1

- JW

! , i , i i . [ , , K i

AB g

- O D- LB

1, 2 3OBSERVATION PERIOD (YEARS)


5/7

et al.and periapical lesions,has been reported to have the least(24, 25, 27, 29). StrindbergGrahnen & Hansson (25) and Adenubi &(26) have presented material that is compar-to ours. These studies report complete healing4 yr after root filling in 74%, 69% and 77%

In the study by Ade nubi &(26) an additional 5% of the lesions healedthe observation period was ex-4 yr to 7 yr, and Strindberg (24) foundto increase from 74% at the 4-to 93% when the same teeth were10 yr.Our results indicate that as long as there is adecrease in the size ofa lesion followingtreatment, there is no reason to judge a case aThe lesions LL41, 42, 31 were operated on

efore this became app are nt (Fig. 3). T he histologi-cal examination of these lesions showed dense fi-brous tissue mostly free ofinflammation, and it islikely that these lesions would have healed withoutsurgical intervention. Only 5ofthe 79 lesions in thepresent study showed little or no decrease in sizeafter they were root-filled (Fig. 4). It is probablethat these lesions would not have healed withoutsurgical treatment.There may be several reasons for a periapicallesion not healing. The endodontic treatment maynot have eliminated all the bacteria from the rootcanal. Bacteria may also persist on the root surfacein exposed dentinal tubules, in lacunae of the cellu-lar cementum, or in apical foramina (30-32). Fur-thermore, some bacteria of the genera Actinomycesan d Arachnia may prevent normal healing due totheir capacity to survive in the periapical tissue(33). These infections might be the reason for thelack ofhealing in 2 ofour cases (JW, IL). Anotherreason for delay or prevention of healing may bethat infected dentin and cementum chips are forcedout into the periapical tissue during meehaniealinstrumentation (34, 35). Histological examinationrevealed dentin chips in the lesion of case ABg. Untilrecently, only bacteria of the species Actinomyces andArachnia have been shown to have the ability toestablish themselves and survive in the periapical

Table 3.The apical level of thetreatment

root filling and the outcome of the

NumberCompletely

healedor healing

endodontic

Nothealed

tissue outside the root canals (33, 36). HowevTronstad et al . (37)claim that other anaerobic bteria establish themselves in apical tissue, inaccsible to conventional endodontic treatment. Svival ofbacteria outside the root canal could be reason for the lack of healing not only in the caJ W and IL, where Actinomyces and Arachniademonstrated, but also in the cases OD , LB and A(Fig. 4).Bacteriological analysis of tissue specimfrom periapical lesions refractory to conventioendodontic therapy may reveal why some lesido not heal. Such an analysis may be a very dilfitask, but could be achieved by combining bacterlogical, histological and immunological techniquR e f e r e n c e s ^

1. KAKEHASI S, STANLEY HR, FITZGERALD RJ. The elTecsnrgical exposures ofdental pulps in germ-free and contional laboratory rats. Oral Surg Oral Med Oral Path20 : 340-9.2. SuNDiivisT G. Bacteriological studies of necrotic depulps. Umea University Odontological Dissertation nUme4: University of Umea, 1976.3. DAHLEN G, BERGENHOLTZ G. Endotoxic activity in twith necrotic pulps. J Dent Res 1980; 59 : 1033-40.

4. MoLLER AJR, FABRICIUS L, DAHLEN G, OHMAN AE, HDEN G. Influence on periapical tissues of indigenous bacteria and necrotic pulp tissue. An experimental studmonkeys. .Scand J Dent Res 1981; 89 : 475-84.5. ZELDOW BJ, INGLE J I. Correlation o fthe j^osilive culturthe prognosis of endodontically treated teeth: a cli

study. J Am Dent Assoc 1963; 66 : 9-13.6. ENGSTROM B, HARD AF, SEGERSTAD L, RAMSTROM G,FSTELL G. Gorrelation of positive cultures with the prognfor root canal treatment. Odontol Revy 1964; 15 : 257-77. ENGSTROM B , LUNDBERG M . The eorrelation between tive culture and the prognosis of root canal therapy pulpectomy. Odontol Revy 1965; 16 : 194-203.8. OLIET S, SORIN SM. Evaluation of clinical results bupon culturing root canals. J Br Endod Soc 1969; 3: 39. HELING B, SHAPIRA J. Roentgenologic and clinical evation ofendodontically treated teeth, with or without ntive culture. Quintessence Int 1978; // ; 79-84.

10. CARLSSON J , FROLANDER F, SUNDQ^VIST G. Oxygen toleof anaerobic bacteria isolated from necrotic denial pActa Odontol Scand 1977; 35 : 1 3 9 ^ 5 .11. BYSTROM A, SUNDQVIST G. Bacteriologic evaluation oefficacy of mechanical root canal instrumentation in edontie therapy. Scand J Dent Res 1981; 89 : 321-8.

12. BvsTROM A, SUNDQVIST G. Bacteriologic evaluation oeffect of 0.5 percent sodium hypochlorite in endodontic apy. Oral Surg Oral Med Oral Pathol 1983; 55 : 307-13. BYSTROM A, SUND^VIST G. The antibacterial aetion odium hypoehlorite and EDTA in 60 cases of endodtherapy, hitEndod J 1985; 18 : 35-40.14. BYSTROM A, GLAESSON R, SUNDQ^VIST G. The antibacteffect of camp horated paramon ochlorophen ol, c amp horphenol and calcium hydroxide in the treatment of infroot canals. Endod Dent Traumalol 1985; /. 170 5.15. EGGEN S. Rontgcnografiske tannmalinger i daglig praSwedDentJ 1974; 66 : 10-2.


6/7

of Actinomyces species and Arachnia propionica in periapicalinfections. J Oral Pathol 1985; 14 : 405-13.18. Hsu S-M, RAINE L. Protein A, avidin and biotin in immuno-histochemistry. J Histochem Cytochem 1981; 29 : 1349-53.19. BRYNOLF I. Ahistologieal and roentgenological study oftheperiapical region ofhuman upper incisors. Odontol Revy 1967;18 : Suppl 11.20. SELTZER S, BENDER IB, SMITH J, EREEDMAN I, NAZIMOV H.Endo dontic failures - an analysis based onclinical, roentgen-ographic, and histologic findings. Oral Surg Oral Med OralPathol 1967; 23 : 500-30.21. GOLDMAN M, PEARSON AH, DARZENTA N. Endodontic suc-cess - who's reading tbe radiograph? Oral Surg Orai MedOral Pathol 1972; 33 : 432-7.22. GOLDMAN M, PEARSON AH, DARZENTA N. Reliability ofradiographic interpretations. Oral Surg Oral Med Oral Pathol1974;'55.- 287-93.23. ZAKARIASEN KL, SCOTT DA, JENSEN JR. Endodontic recallradiographs: how reliable is our interpretation of endodonticsuccess or failure and what factors affect our reliability? OralSurg Oral Med Oral Pathol 1984; 57 : 343-7.24. STRINDBERG LZ .The dependence of the results of pulptherapy ofcertain factors. An analytic study based on radio-graphic and clinical follow-up examinations. Acta OdontolScand 1956; 14 : Suppl 21.25. GRAHNEN H, HANSSON L. The prognosis of pulp and rootcanal therapy. Aclinical and radiographic follow-up exam-ination. Odontol Revy 1961; 12 : 146-65.26. ADENUBI JO , RULE DC. Success rate for root fillings inyoungpatients. Aretrospective analysis of treated cases. Br Dent J1976; 141: 237-41.27. BoYSEN H, GI0RTZ-CARLSEN E,ANERUD A. Rodkanal terapi.

B a c t e r io l o g i c a i fy c o n t r o l l e d e n d o d o n t i c t r e a t m e nEn rentgenologisk cfterkontrol. Tandlaegebladet 1972;425-37.

28. KEREKES K, TRONSTAD L. Long-term results of endodontictreatment performed with a standardized technique. J Endo1979; 5.-83-90.29. STORMS JL. Factors that influence the success of endodontitreatment. J C an Dent Assoc 1969; 35 : 83-97.30. BLOCK RM, BUSHELL A, RODRIDGUES H, LANGELAND K. Ahistopathologic, histobactcriologic, and radiographic studyof periapical endodontic surgical specimens. Oral Surg OM ed Oral Pathol 1976; 42 : 656-78.31. PITT-FORD TR. The effects on the periapical tissues of bacterial contamination of the filled root canal, hit Endod1982; 15 : 16-22.32. BERGENHOLTZ G, LEKHOLM U, LILJENBERG B, LINDHE JMorphometric analysis ofchronic inflammatory periapicalesions in root-filled teeth. Oral Surg Oral Med Oral Pa1983; 55 : 295-301.33. HAPPONEN R-P. Periapical actinomycosis: a follow-up studyof 16 surgically treated eases. Endod Dent Traumatol 1986205-9.34. YusuE H. The significance ofthe prcsenee of foreign niaterialpcriapically asa cause of failure of root treatment. Oral SurOral Med Oral Pathol 1982; 54 : 566-74.35. MALOOLEY J , PATTERSON SS, KAFRAWY A. Response ofperiapical pathosis to endodontic treatment in monkeysOral Surg Oral Med Oral Pathol 1979; 47 : 545-54.36. WEIR JC, BUCK W H. Periapical actinomycosis. Oral SurOral Med Oral Pathol 1982; 54 : 336-40.37. TRONSTAD L, BARNETT F, FLAX M, SLOTS J. Anaerobic bac-teria in periapical lesions of human teeth. J Dent Res 19865: 231.


7/7

Documents

Healing of Periapical Lesions of Pulpless Teeth After tic Treatment With Controlled Asepsi