Guía de práctica médica patología pulpar y periapical en dentición permanente / Pulp and periapical pathology medical practice guide in permanent dentition

Generar recomendaciones basadas en la mejor evidencia disponible acerca del manejo de personas con diagnóstico de patologías pulpares o periapicales en dentición permanente. Personas con diagnóstico de patología pulpar o periapical en diente permanente que reciben atención en el nivel primario de salud en el sector público y privado de salud.

Inhibition of Nuclear Factor Kappa B Prevents the Development of Experimental Periapical Lesions.

INTRODUCTION: Nuclear factor kappa B (NF-κB) is an important transcriptional regulator of angiogenesis involving B-cell lymphoma 2 (Bcl-2) and Bcl-2-associated X protein (Bax) signaling pathways. Thus, inhibition of NF-κB may suppress the development of periapical lesions via blockage of angiogenesis. Accordingly, we examined the effects of NF-κB decoy oligodeoxynucleotide (ODN) treatment on experimentally induced periapical lesions. METHODS: Periapical lesions were induced in the mandibular first molars of 5-week-old male Wistar rats by the application of lipopolysaccharide to the pulp. NF-κB decoy ODN or NF-κB decoy scramble (control) was injected intraperitoneally every 7 days, starting 1 day before pulp exposure. After 28 days, the samples were retrieved, and digital radiographs were taken for radiomorphometry. Samples were processed for (1) immunohistochemistry of CD31, Bcl-2, and Bax; (2) laser capture microdissection to analyze Bcl-2, Bax, chemokine (C-X-C motif) ligand 1 (CXCL1), CXC receptor 2 (CXCR2), and vascular endothelial cell growth factor receptor 2 (VEGFR2) messenger RNA (mRNA) expression in CD31+ endothelial cells; (3) enzyme-linked immunosorbent assay to determine NF-κB/p65 activity; and (4) Western blotting for vascular endothelial growth factor expression. RESULTS: NF-κB decoy ODN treatment significantly reduced lesion size, NF-κB/p65 activity, and the density of CD31+ endothelial cells in the lesion. NF-κB decoy ODNs also down-regulated CXCL1, CXCR2, and VEGFR2 mRNAs and up-regulated Bax mRNA in endothelial cells but did not affect Bcl2 mRNA in endothelial cells. Vascular endothelial growth factor protein expression in the lesions was significantly decreased. CONCLUSIONS: The inhibition of NF-κB activity by decoy ODN treatment suppressed the development of experimentally induced periapical lesions with a concomitant reduction in angiogenic responses in endothelial cells.

Comportamiento de urgencias estomatológicas, Hospital Faustino Pérez, 2009 / Stomatologic emergencies behavior, Hospital Faustino Pérez, 2009

Introducción: las urgencias dentales, además de causar signos y síntomas, producen complicaciones que afectan la salud general de los pacientes, por lo que se requiere de atención priorizada, apoyo psicológico y maniobras no traumáticas. Objetivo: determinar el comportamiento de las urgencias estomatológicas. Materiales y métodos: se realizó un estudio observacional, descriptivo y transversal en la consulta de Estomatología del Hospital “Faustino Pérez” de Matanzas en el periodo marzo-diciembre del 2009. El universo estuvo constituido por 533 pacientes que asistieron a la consulta de Estomatología y que presentaron diferentes tipos de urgencias estomatológicas, los cuales se caracterizaron, según variables sociodemográficas y clínicas. Se realizó un interrogatorio minucioso y un examen bucal a cada paciente en el sillón dental y se confeccionó la historia clínica individual de Estomatología. Los datos se recopilaron de forma manual. Para su análisis se emplearon medidas de frecuencias absolutas y relativas. Se tuvo en cuenta el consentimiento informado. Resultados: el 59,5 por ciento de los pacientes con urgencias estomatológicas correspondió al sexo masculino y fue el más representado, los pacientes de 35 a 59 años constituyeron el 32,5 por ciento y predominaron los trabajadores. Conclusiones: el absceso dentoalveolar agudo fue la forma clínica más frecuente dentro de los trastornos pulpares y periapicales en el grupo de edad de 35 a 59 años y en el sexo femenino(AU)

Background: stomatologic emergencies, in addition to causing signs and symptoms, produce complications affecting the patients general health status, so they require prioritized care, psychological support and no-traumatic actions. Aim: to determine the stomatologic emergencies behavior. Material and methods: we carried out a cross-sectional, descriptive, observational study in the Stomatologic consultation of the Hospital “Faustino Perez” of Matanzas in the period March-December 2009. The universe was formed by 533 patients who attended the Stomatologic consultation having different kinds of stomatologic emergencies that were characterized according to clinical and social variables. Each patient was carefully questioned; a buccal examination was carried out to each of them and the Stomatologic individual historical record was filled out. Data were compiled manually. For their analysis we used absolute and relative frequency measures. The informed consent was taken into account.Results: 59,5 percent of the patients with stomatologic emergencies were male, the most represented gender. The patients aged 35-59 years were 32,5 percent, and workers predominated. Conclusions: the acute dental alveolar abscess was the most frequent clinical form among the pulp and periapical disorders in the 35-59 years age group and in the female gender(AU)

The FiCTION dental trial protocol - filling children's teeth: indicated or not?

BACKGROUND: There is a lack of evidence for effective management of dental caries (decay) in children's primary (baby) teeth and an apparent failure of conventional dental restorations (fillings) to prevent dental pain and infection for UK children in Primary Care. UK dental schools' teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed. However, the evidence base for this is limited in volume and quality, and comes from studies conducted in either secondary care or specialist practices. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been questioned. The FiCTION trial addresses the Health Technology Assessment (HTA) Programme's commissioning brief and research question "What is the clinical and cost effectiveness of restoration caries in primary teeth, compared to no treatment?" It compares conventional restorations with an intermediate treatment strategy based on the biological (sealing-in) management of caries and with no restorations. METHODS/DESIGN: This is a Primary Care-based multi-centre, three-arm, parallel group, patient-randomised controlled trial. Practitioners are recruiting 1461 children, (3-7 years) with at least one primary molar tooth where caries extends into dentine. Children are randomized and treated according to one of three treatment approaches; conventional caries management with best practice prevention, biological management of caries with best practice prevention or best practice prevention alone. Baseline measures and outcome data (at review/treatment during three year follow-up) are assessed through direct reporting, clinical examination including blinded radiograph assessment, and child/parent questionnaires. The primary outcome measure is the incidence of either pain or infection related to dental caries. Secondary outcomes are; incidence of caries in primary and permanent teeth, patient quality of life, cost-effectiveness, acceptability of treatment strategies to patients and parents and their experiences, and dentists' preferences. DISCUSSION: FiCTION will provide evidence for the most clinically-effective and cost-effective approach to managing caries in children's primary teeth in Primary Care. This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth. The trial is currently recruiting patients. TRIAL REGISTRATION: Protocol ID: NCTU: ISRCTN77044005.

Inhibiting periapical lesions through AAV-RNAi silencing of cathepsin K.

Dental caries, one of the most prevalent infectious diseases worldwide, affects approximately 80% of children and the majority of adults. Dental caries may result in endodontic disease, leading to dental pulp necrosis, periapical inflammation and bone resorption, severe pain, and tooth loss. Periapical inflammation may also increase inflammation in other parts of the body. Although many studies have attempted to develop therapies for this disease, there is still an urgent need for effective treatments. In this study, we applied a novel gene therapeutic approach using recombinant adeno-associated virus (AAV)-mediated RNAi knockdown of Cathepsin K (Ctsk) gene expression, to target osteoclasts and periapical bone resorption in a mouse model. We found that AAV-sh-Cathepsin K (AAV-sh-Ctsk) impaired osteoclast function in vivo and furthermore reduced bacterial infection-stimulated bone resorption by 88%. Reduced periapical lesion size was accompanied by decreases in mononuclear leukocyte infiltration and inflammatory cytokine expression. Our study shows that AAV-RNAi silencing of Cathepsin K in periapical tissues can significantly reduce endodontic disease development, bone destruction, and inflammation in the periapical lesion. This is the first demonstration that AAV-mediated RNAi knockdown gene therapy may significantly reduce the severity of endodontic disease.

Impact of the quality of coronal restoration versus the quality of root canal fillings on success of root canal treatment: a systematic review and meta-analysis.

INTRODUCTION: Thorough cleaning and shaping of root canals are essential for periapical healing. Restoration of endodontically treated teeth is also required for them to function and prevent coronal leakage. This study compared the impact of the quality of root canal treatment versus the quality of coronal restoration in treatment outcomes. METHODS: Literature search was conducted using the search terms "coronal restoration," "root canal," "periapical status," and "quality." Articles that evaluated the effect of the quality of root filling and coronal restoration or both on the success of root canal treatment were selected. Nine articles were identified and were reviewed by 3 investigators. Data were collected based on predetermined criteria. Percentages of teeth without apical periodontitis were recorded for each category: adequate root canal treatment (AE), inadequate root canal treatment (IE), adequate restoration (AR), and inadequate restoration (IR). Data were analyzed using meta-analysis for odds ratios (ORs). RESULTS: After adjusting for significant covariates to reduce heterogeneity, the results were combined to obtain pooled estimates of the common OR for the comparison of AR/AE versus AR/IE (OR = 2.734; 95% confidence interval [CI], 2.61-2.88; P < .001) and AR/AE versus IR/AE (OR = 2.808; 95% CI, 2.64-2.97; P < .001). CONCLUSIONS: On the basis of the current best available evidence, the odds for healing of apical periodontitis increase with both adequate root canal treatment and adequate restorative treatment. Although poorer clinical outcomes may be expected with adequate root filling-inadequate coronal restoration and inadequate root filling-adequate coronal restoration, there is no significant difference in the odds of healing between these 2 combinations.

Clinical recommendations for avoiding and managing surgical complications associated with implant dentistry: a review.

Proposing to place endosseous implants is an integral facet of dental treatment plans. Their insertion is usually associated with a low incidence of untoward events. However, despite careful planning, surgical complications can arise: infection, intraoral hemorrhage, wound dehiscence, postoperative pain, lack of primary implant stability, inadvertent penetration into the maxillary sinus or nasal fossa, sinus lift sequelae, neurosensory disturbances, injuries to adjacent teeth, tissue emphysema, and aspiration, or ingestion of surgical instruments. This article addresses some surgical complications associated with dental implant placement and discusses how to avoid and manage them when they occur.

Management and prevention of retrograde peri-implant infection from retained root tips: two case reports.

Fracture of root tips in the maxillary premolar region is not an uncommon finding because of the high incidence of bifid and root dilacerations. Therefore, a retained root tip may serve as a nidus of infection when a dental implant is placed. The likely result is the development of an implant periapical lesion. This case report shows the successful management of a rapidly developing implant periapical lesion caused by an undetected retained root tip. Initially, systemic antibiotics failed to subdue the infection. A retained root fragment was retrieved surgically, together with the implant, and a new wide-body implant was engaged with DFDBA mixed with tetracycline. A 5-month follow-up showed increased radiographic density, and clinical reentry revealed the formation of bone with a hard consistency. The second case demonstrates the management of a retained root tip via a guided bone regeneration technique when it is detected prior to or during implant placement. Finally, a systematic therapeutic approach is proposed based on 17 case reports on implant periapical lesion management.

Effects of cyclosporin-A-induced immunosuppression on periapical lesions in rats.

Cyclosporin A (CsA) might induce immune response alterations in periapical lesions and modify bone remodeling. This study determined the changes that occur in the periapical lesions of rats during CsA administration and after CsA withdrawal. After the induction of periapical lesions, the animals were treated with CsA (0-20 mg/kg/day) for 4 wks. Lesion volumes were measured by computed tomography. Histological observations and immunohistochemical evaluations were performed with anti-CD3 and anti-CD25 antibodies. CsA administration reduced lesion volumes, and the lesions significantly expanded after CsA withdrawal. CsA inhibited the proliferation and activation of T-cells at lesion sites. The effects of CsA on T-cells were dose-dependent up to 10 mg/kg/day, after which no significant difference was evident. These results suggest that CsA inhibits periapical destruction by interfering with T-cell function in periapical lesions.

Avaliação em radiografias panorâmicas e periapicais do diâmetro mesio-distal de terceiros molares retidos / Evaluation of the mesio-distal diameter of retained third molars through panaromic and periapical radiograhs

A maioria dos métodos radiográficos que dispomos, possuem uma distorção que nos impedem de obter maior precisão de medidas ósseas ou dentárias durante a prática clínica. As radiografias periapicais são mais precisas e simples de serem feitas, porém não englobam grandes regiões como as tomadas panorâmicas, cujo detalhamento da imagem não é seu melhor requisito. Por isso, em alguns procedimentos temos que lançar mão da tomada intra e extra-bucal para buscar um diagnóstico mais fiel e seguro. Para reduzirmos os índices de erros devido a distorção das radiografias panorâmicas na região de terceiros molares, dispusemo-nos em calcular o valor real destes dentes, que apresentavam-se retidos e posteriormente foram extraídos. Para tanto, utilizamo-nos de radiografias panorâmicas e periapicais, na qual foram estabelecidas equações, devidamente separadas pelo sexo e arco. Comparando os resultados das equações com as medidas dos 3º molares que foram extraídos, pudemos constatar que estas se mostraram altamente significativas, viabilizando o uso deste método

Sequential expressions of MMP-1, TIMP-1, IL-6, and COX-2 genes in induced periapical lesions in rats.

To elucidate the pathogenesis of periapical lesion-associated bone resorption, a disease model of Wistar rat molar was employed. After lesion induction, the mRNAs encoding for matrix metalloproteinase-1 (MMP-1), tissue inhibitor of metalloproteinase-1 (TIMP-1), interleukin-6 (IL-6), and cyclooxygenase-2 (COX-2) in the developing lesions were detected by in situ hybridization at day 5, 10, 15 and 20, respectively. At day 5, MMP-1, IL-6 and COX-2 mRNAs appeared predominantly in macrophages. During day 15 to day 20, increased expressions of these mediators were also found in osteoblasts but to a lesser extent compared with those in macrophages. MMP-1 mRNA was also detected in osteoclasts. In contrast, expression of the TIMP-1 gene was noted primarily in osteoblasts and was less pronounced compared with that of MMP-1. The mediator-expressing cells aggregated in the vicinity of bone resorption areas and their numbers increased with time. These data suggest that macrophages and osteoblasts are involved in the development of periapical lesions, and that they promote bone resorption by producing MMP-1, IL-6 and COX-2. In addition, administration of a specific COX-2 inhibitor, meloxicam, reduced the extent of periapical bone resorption by 43% and simultaneously diminished the numbers of cells synthesizing MMP-1 and IL-6 mRNAs. These results further elucidate the significance of COX-2 in disease progression of periapical lesions as it modulates indirectly the production of MMP-1 and IL-6.

Endodontic failure caused by inadequate restorative procedures: review and treatment recommendations.

A review of the literature was performed to determine whether prompt placement of coronal restorations, including sealing and placement of posts and cores, can positively influence the long-term prognosis of teeth after root canal therapy. Both hand and MEDLINE searches were employed to identify peer-reviewed articles on radicular apical integrity after coronal restorations, especially where root canal space was used for post and core fabrication. A total of 41 articles published between 1969 and 1999 (the majority from the 1990s) were reviewed. The literature suggests that the prognosis of root canal-treated teeth can be improved by sealing the canal and minimizing the leakage of oral fluids and bacteria into the periradicular areas as soon as possible after the completion of root canal therapy.

Discuss that the coronal seal is more important than the apical seal for endodontic success.

One of the main principles for successful root canal treatment is the prevention of microorganisms and toxins from the oral flora penetrating through the root canal system into the periapical tissues (1). This is achieved by obturating the root canal system completely, including the coronal and apical ends. Inadequate obturation of the root canal system has been found to be the most frequent cause of failure after endodontic treatment (2). A number of studies have indicated that leakage, whether from a coronal or apical direction, adversely affects the success of root canal treatment (3-7). The significance of the coronal seal has been increasingly recognized in the dental literature (4, 5, 8, 9) and in more recent times, it has been suggested that apical leakage may not be the most important factor leading to the failure of endodontic treatment--but that coronal leakage is far more likely to be the major determinant of clinical success or failure (10). This paper will discuss aspects of: endodontic success and failure; the use of leakage studies to assess the quality of the seal; the significance of both apical and coronal leakage; followed by a review of the literature.

Surgical repositioning of unerupted anterior teeth.

The result of surgical repositioning of 12 unerupted anterior teeth was studied. The unerupted teeth were gently exposed, gradually repositioned by shifting them bodily toward the occlusal plane without disturbing the periodontal ligament, and splinted for 3 wk. Root canal therapy was performed at the end of the second week following repositioning. Obturation was done at the end of the third week just before splint removal. Clinical and radiographic examination (follow-up period: 6 months to 3.5 yr) revealed no root resorption with satisfactory apical healing and healthy supporting tissues.

The implant periapical lesion: etiology, prevention, and treatment.

A classification of implant periapical lesions that separates them into inactive and infected has been suggested. The inactive form is likely to be an apical scar, resulting from a residual bone cavity created by placing an implant that was shorter than the prepared drill site. The infected focus probably occurs when an implant apex is placed in proximity to an existing infection or when a contaminated implant is placed. Bone necrosis caused by overheating during preparation may also be a causative factor. Suggested preventions of implant periapical lesions include careful management of contaminants and heat generation during implant surgery. Treatment varies according to the type of lesion. The inactive type is observed and monitored. The infected type requires surgical intervention, elimination of the infection, and an implant apical resection or implant removal depending on the extent of the infection and the stability of the implant.

Acute pulpal-alveolar cellulitis syndrome. V. Apical closure of immature teeth by infection control: the importance of an endodontic seal with therapeutic factors. Part 2.

During orthodontic treatment to promote eruption of maxillary and mandibular second bicuspids, a young male patient had a severe endodontic cellulitis of a mandibular bicuspid. Apexogenesis and resolution of the periapical lesion was achieved by infection control with nonspecific intracanal medication without calcium hydroxide, as stated by Das. A mild periodontal cellulitis occurred shortly thereafter and rapidly resolved. A second endodontic cellulitis, after apexogenesis without an endodontic seal, occurred shortly after completion of orthodontic treatment. This also quickly resolved, and the canal was effectively sealed. This case indicates the importance of an effective endodontic seal shortly after apexogenesis is induced by infection control. This report and others on the subject indicate that apexogenesis of nonvital permanent immature teeth by infection control is a predictable endodontic treatment procedure.

Prophylactic use of penicillin V in teeth with necrotic pulps and asymptomatic periapical radiolucencies.

As a result of (1) clinical experience with flare-ups occurring in teeth with necrotic pulps and asymptomatic periapical radiolucencies and (2) on apparent reduction to the incidence of such flare-ups by the administration of penicillin V at the first sign of swelling, this study on the prophylactic administration of penicillin V in similar cases was undertaken. The subjects were 100 consecutive clinic patients whose teeth had necrotic pulps and asymptomatic periapical radiolucencies. At the initial visit, all teeth were instrumented completely to the radiographic apex, with 0.5% to 2.54% sodium hypochlorite as the irrigant. Sterile, dry cotton pellets and ZOE restorations were used. Alternate patients were given 250 mg of penicillin V and an identical-appearing placebo with instructions to take two tablets every 6 hours for the first 24 hours, followed by one tablet every 6 hours until all tablets were taken. Pain and swelling were graded by the patients on five-point scales, and flare-ups were scored when either pain and/or swelling necessitated an unscheduled emergency visit. Fifteen patients developed flare-ups, with significantly more flare-ups in the placebo group (p less than 0.05). The findings indicate that, in selected cases, prophylactic penicillin can be used to prevent flare-ups.