Relación entre diabetes mellitus y periodontitis apical de origen endodóntico. Revisión narrativa / Relationship between diabetes mellitus and apical periodontitis of endodontic origin. Narrative review

La diabetes mellitus es una enfermedad metabólica que se caracteriza por tener un aumento en los niveles de glucemia, causando un estado inflamatorio sistémico que puede afectar la cicatrización de las lesiones periapicales presentes en la periodontitis apical, una enfermedad inflamatoria crónica causada por una infección endodóntica cuyo desarrollo está regulado por la respuesta inmunitaria del huésped. La diabetes podría interactuar con la periodontitis apical al desencadenar la modulación inmunitaria, pudiendo afectar la respuesta clínica de las lesiones periapicales e interferir con la cicatrización después del tratamiento endodóntico. El objetivo de esta revisión de la literatura es analizar la evidencia respecto a la relación entre la diabetes mellitus y la presencia y severidad de la periodontitis apical de origen endodóntico. Se recopilaron artículos de las bases de datos PubMed, Scopus y Web of Science entre los años 2016 y 2021. Se eligieron 31 artículos pertinentes para el estudio. En el 41,6% de los estudios se encontró una mayor presencia de periodontitis apical en pacientes con diabetes asociada a una lesión apical más compleja y comprometida. Un 25% de los estudios encontró que los pacientes diabéticos mal controlados presentan mayor presencia de periodontitis apical. Un 25% de los estudios encontró que niveles altos de HbA1c se asocian a la presencia de periodontitis apical. Se encontró una relación entre la diabetes y la periodontitis apical, por lo que la diabetes debe ser considerada como un factor preoperatorio importante en el desarrollo y severidad de la periodontitis apical, sin embargo, se deben realizar estudios experimentales más estandarizados para poder determinar con mayor exactitud esta relación, además de poder indagar la bidireccionalidad entre ambos.(AU)

Diabetes mellitus is a metabolic disease that is characterized by an increase in blood glucose levels, causing a systemic inflammatory state that can affect the healing of periapical lesions present in apical periodontitis, a chronic inflammatory disease caused by an endodontic infection whose development is regulated by the host's immune response. Diabetes could interact with apical periodontitis by triggering immune modulation, being able to affect the clinical outcome of periapical lesions and interfering with healing after endodontic treatment. The objective of this literature review is to analyze the evidence regarding the relationship between diabetes mellitus and the presence and severity of apical periodontitis of endodontic origin. Articles were collected from the PubMed, Scopus and Web of Science databases between the years 2016 and 2021. 31 relevant articles were included for this study. In 41.6% of the studies a greater presence of apical periodontitis was found in patients with diabetes associated with a more complex and compromised apical lesion. 25% of the studies reported that poorly controlled diabetic patients had a greater presence of apical periodontitis. 25% of the studies reported high levels of HbA1c in association with apical periodontitis. A relationship was found between diabetes and apical periodontitis, which means diabetes should be considered as an important preoperative factor in the development and severity of apical periodontitis; however, more standardized experimental studies should be carried out to determine this relationship more accurately, in addition to being able to investigate a bidirectionality between the two.(AU)

Evaluation of Serum Levels of Cytokines in Acute Apical Abscess: A Longitudinal Observational Study.

INTRODUCTION: Cytokine levels are related to the aethiopathogenia of acute apical abscesses (AAA); however, the specific cytokine profiles in these cases are unclear. This study aimed to investigate the changes in systemic cytokine levels in patients with AAA and trismus onset, postantibiotic treatment, and postroot canal disinfection. METHODS: In total, 46 AAA patients with trismus and 32 control subjects were included. After seven days of antibiotic therapy, root canal disinfection was performed in the AAA patients. The serum levels of cytokines were evaluated at basal, seven, and 14 days after endodontic treatment. Quantification of cytokines from T helper (Th) 1, Th2, Th17, and regulatory T cells profiles was determined using the BioPlex MagPix system, and the obtained data were analyzed using SPSS statistical software (P < .05). RESULTS: AAA patients showed higher tumor necrosis factor-alpha (TNF-α), interleukin (IL) -6, and IL-10 levels than control subjects, at basal measurement (P < .05); there were similar levels of interferon gamma, IL-1ß, IL-4, and IL-17 between groups (P > .05). IL-6 and IL-10 levels decreased after antibiotic treatment (P < .05), which was also associated with clinical improvement in patients with AAA and trismus. Patients with AAA had a positive correlation with higher serum levels of IL-6 and IL-10. In addition, TNF-α levels decreased only after antibiotic and endodontic treatment. CONCLUSIONS: In conclusion, patients with AAA had increased systemic serum levels of TNF-α, IL-6, and IL-10. Moreover, increased levels of IL-6 and IL-10 are associated with acute inflammatory symptoms. However, IL-6 and IL-10 levels decreased after antibiotic treatment, while TNF-α levels decreased after antibiotic and endodontic treatment.

TNFSF13B rs9514828 gene polymorphism and soluble B cell activating factor levels: Association with apical periodontitis.

AIM: The aim of this case-control study was to evaluate the association between the TNFSF13B rs9514828 (-871 C > T) polymorphism and soluble BAFF (sBAFF) in apical periodontitis (AP) patients. METHODOLOGY: Two hundred and sixty one healthy subjects (HS) and 158 patients with AP classified as: 46 acute apical abscess (AAA), 81 primary AP (pAP) and 31 secondary AP (sAP) patients were included. Genomic DNA (gDNA) was extracted from peripheral blood cells according to the salting out method. The TNFSF13B rs9514828 (NC_000013.11:g.108269025C > T) were identified using polymerase chain reaction (PCR) followed by restriction fragment length polymorphisms (RFLP). Serum sBAFF levels were measured by ELISA test. The chi-squared or Fisher's exact test was performed. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated to evaluate the risk of AP associated with the rs9514828. The Mann-Whitney U test and Kruskal-Wallis analysis were used for non-normally distributed data. Differences were considered significant with a p-value <.05. RESULTS: No differences in the genotype/allele frequencies were shown between HS and patients with AAA. However, the TT genotype (OR = 2.68, 95% CI: 1.10-6.53; p = .025) and T allele (OR = 1.46, 95% CI: 1.00-2.12; p = .045) were associated with increased risk of pAP. In contrast, the minor allele T significantly decreased the risk of sAP (OR = 0.49, 95% CI: 0.024-0.99; p = .043). sBAFF serum levels were increased in AAA and pAP compared with HS (p < .01 and p = .021, respectively). The AAA patients had higher sBAFF serum levels than pAP (p = .034) and sAP (p < .01). CONCLUSIONS: These results suggest that the TNFSF13B rs9514828 (-871 C > T) polymorphism is associated with pAP susceptibility and that BAFF is a cytokine that might be involved in acute and chronic AP. The future exploration of the rs9514828 polymorphism in other AP cohorts is recommended.

Comparative analysis of bacterial content, levels of lipopolysaccharides and lipoteichoic acid in symptomatic and asymptomatic endodontic infections at different stages of endodontic treatment.

OBJECTIVES: This study aimed to detect the presence of specific bacteria and to evaluate the levels of lipopolysaccharides (LPS) and lipoteichoic acid (LTA) in symptomatic necrotic root canals associated with acute apical abscess (symptomatic group - GI). It also aimed to compare the findings with those presented by asymptomatic necrotic root canals (asymptomatic group - GII) in the different stages of the endodontic treatment. MATERIALS AND METHODS: Microbiological samples were collected from 20 root canals, including purulent collection from acute apical abscesses, before and after chemo-mechanical preparation (CMP) preparation (CMP) with chlorhexidine gel 2% and after 30 days of intracanal medication (ICM) with (Ca[OH]2) + chlorhexidine. The culture method was used to evaluate the efficacy of CMP and ICM. Nested PCR was used to detect the presence of 17 specific bacteria. Levels of LPS were measured by using limulus amebocyte lysate, whereas enzyme-linked immunosorbent assay was used for the quantification of LTA. RESULTS: CMP was effective in reducing the microbial load in both groups (P < 0.05). LPS levels were higher in GI than in GII (P < 0.05). There was a significant reduction in the LPS levels after CMP and ICM (P < 0.05) in GI and GII. LTA levels were significantly reduced in GI after ICM and in GII after CMP and ICM (both P < 0.05). Fusobacterium nucleatum and Enterococcus faecalis were frequently identified in both groups, alone or in combination with each other. CONCLUSION: Different species were detected in all stages of the endodontic treatment. CMP was able to reduce bacterial content and the levels of LPS, but not of LTA in the symptomatic group. High levels of LPS were correlated with spontaneous pain and pain to percussion in the symptomatic group. CLINICAL RELEVANCE: This clinical study showed that chemo-mechanical preparation was able to reduce bacterial load and levels of LPS, but not of LTA in the symptomatic group. Elevated levels of LPS were correlated with the presence of symptomatology.

Clinical and radiographic outcome of the root canal treatment of infected teeth with associated sinus tract: A retrospective study.

This retrospective study evaluated the outcome of the endodontic treatment/retreatment of teeth with intraoral sinus tracts. Seventy-two teeth from 70 individuals were included. One operator treated all teeth over about 20 years. Time for the sinus tract to heal was recorded. Treatment outcome was evaluated after at least 1 year and classified as healed, healing or diseased. The overall healed rate of periradicular lesions was 73.6% (74.1% for treatment and 72.2% for retreatment). In 6 (8.3%) teeth, lesions were healing. Thirteen teeth (18.1%) exhibited persistent disease. In 68/72 (94.4%) cases, the sinus tract healed in less than 1 month. No preoperative/intraoperative variable affected the outcome (P > 0.05). Missing restorations had a negative impact (P < 0.05). Healing of both the sinus tract quickly after treatment and the periradicular lesion later were usually achieved. Closure of the sinus tract in the first month was a good predictor of lesion healing.

12-year follow-up of regenerative endodontic treatment of immature permanent upper incisors with acute abscess

Abstract This case report discusses the endodontic treatment of a 7-year-old girl who suffered trauma (intrusion) to the immature upper central incisors secondary to a fall from a bicycle. Thirty days after the accident the patient was brought by her mother for clinical and radiographic assessment with a chief complaint of swelling and tenderness to percussion and palpation. Acute apical abscess associated with immature teeth were diagnosed. A decision was made to perform regenerative endodontic treatment. Access cavities were made and the root canals were disinfected by irrigation with 2.5% sodium hypochlorite. Final irrigation was performed with 17% EDTA. Due to pain and presence of secretions, 2% chlorhexidine gel was applied as an intracanal medicament. Seven days later, at the second visit, the root canals were once again disinfected and the canals of the right and left permanent upper central incisors were filled with double antibiotic paste (metronidazole/ciprofloxacin) and calcium hydroxide paste, respectively. Zinc oxide was mixed in both pastes. At the third visit, after 21 more days, the pastes were removed and the periapical areas were stimulated with a #80 K-file to encourage clot formation within the pulp cavities. A mineral trioxide aggregate (MTA) paste cervical plug was placed and the teeth were restored with glass ionomer cement. Radiographs and CBCT scans demonstrated complete root formations. The patient has been followed for 12 years, with evidence of clinical success throughout.

Resumo Este relato de caso discute o tratamento endodôntico de uma menina de 7 anos que sofreu trauma nos incisivos centrais superiores imaturos, após queda de bicicleta. Trinta dias após o acidente, a paciente foi levada pela mãe para avaliação clínica e radiográfica com queixa principal de inchaço e sensibilidade à percussão e palpação. Foram diagnosticados abscessos apicais agudos em ambos os dentes. Foi decidido por realizar o tratamento endodôntico regenerativo. Após acessos coronários, os canais radiculares foram submetidos à protocolos de antissepsia com auxílio de irrigação com hipoclorito de sódio a 2,5% e EDTA 17%. Devido à dor e presença de secreções, foi utilizada medicação intracanal com clorexidina gel 2% por 7 dias. Na segunda sessão, os canais radiculares foram novamente submetidos aos procedimentos de antissepsia e os canais dos incisivos centrais superiores permanentes direito e esquerdo foram preenchidos com pasta antibiótica dupla (Metronidazol / Ciprofloxacina) e pasta de hidróxido de cálcio, respectivamente. Em ambas as pastas foi adicionado o óxido de zinco. Na terceira sessão, após mais 21 dias, as pastas foram removidas e as regiões periapicais foram estimuladas com lima K nº 80 para incentivar a formação de coágulos sanguíneos no interior das cavidades pulpares. Tampões cervicais de MTA foram adaptados e os dentes restaurados com cimento de ionômero de vidro resinoso. Radiografias e tomografias computadorizadas demonstraram formações radiculares completas. A paciente é acompanhada há 12 anos, com evidências clínicas e radiográficas de sucesso.

Treatment of an Acute Apical Abscess in a Patient With Autoimmune Hepatitis Taking Alendronate: A Case Report.

INTRODUCTION: The aim of this study was to report a patient's clinical case who was diagnosed with severe apical abscess and with autoimmune hepatitis (AIH) using immunosuppressive drugs and bisphosphonate. METHODS: A 32-year-old man of black African descent urgently sought dental surgery because of an increase in volume in the right genic region and a nuisance in the region of the lower right second premolar when chewing. After intraoral and radiographic clinical examination, the patient was diagnosed with pulp necrosis and an acute apical abscess. Because he had AIH and was taking corticosteroids and bisphosphonate (alendronate), he was submitted to endodontic therapy as a minimally invasive treatment, considering his systemic state. RESULTS: After 3 years of follow-up treatment with periapical and tomographic radiographic control, bone repair of the periapical region of the tooth was observed. CONCLUSIONS: Through this report, we can infer that it is possible to reverse the condition of a periapical lesion in a tooth with an acute apical abscess and necrotic pulp in an AIH patient who is using alendronate without the need for more invasive procedures and that would put at risk the patient's general and oral condition in the postoperative period.

Human Exoproteome in Acute Apical Abscesses.

INTRODUCTION: An acute apical abscess is a severe response of the host to massive invasion of the periapical tissues by bacteria from infected root canals. Although many studies have investigated the microbiota involved in the process, information on the host factors released during abscess formation is scarce. The purpose of this study was to describe the human exoproteome in samples from acute apical abscesses. METHODS: Fourteen pus samples were obtained by aspiration from patients with an acute apical abscess. Samples were subjected to protein digestion, and the tryptic peptides were analyzed using a mass spectrometer and ion trap instrument. The human proteins identified in this analysis were classified into different functional categories. RESULTS: A total of 303 proteins were identified. Most of these proteins were involved in cellular and metabolic processes. Immune system proteins were also very frequent and included immunoglobulins, S100 proteins, complement proteins, and heat shock proteins. Polymorphonuclear neutrophil proteins were also commonly detected, including myeloperoxidases, defensins, elastases, and gelatinases. Iron-sequestering proteins including transferrin and lactoferrin/lactotransferrin were found in many samples. CONCLUSIONS: The human exoproteome included a wide variety of proteins related to cellular processes, metabolism, and immune response. Proteins involved in different mechanisms against infection, tissue damage, and protection against tissue damage were identified. Knowledge of the presence and function of these proteins using proteomics provides an insight into the complex host-pathogen relationship, the host antimicrobial strategies to fight infections, and the disease pathogenesis.

Histologic study of a human immature permanent premolar with chronic apical abscess after revascularization/revitalization.

INTRODUCTION: Histologic studies of teeth from animal models of revascularization/revitalization are available; however, specimens from human studies are lacking. The nature of tissues formed in the canal of human revascularized/revitalized teeth was not well established. METHODS: An immature mandibular premolar with infected necrotic pulp and a chronic apical abscess was treated with revascularization/revitalization procedures. At both the 18-month and 2-year follow-up visits, radiographic examination showed complete resolution of the periapical lesion, narrowing of the root apex without root lengthening, and minimal thickening of the canal walls. The revascularized/revitalized tooth was removed because of orthodontic treatment and processed for histologic examination. RESULTS: The large canal space of revascularized/revitalized tooth was not empty and filled with fibrous connective tissue. The apical closure was caused by cementum deposition without dentin. Some cementum-like tissue was formed on the canal dentin walls. Inflammatory cells were observed in the coronal and middle third of revascularized/revitalized tissue. CONCLUSIONS: In the present case, the tissue formed in the canal of a human revascularized/revitalized tooth was soft connective tissue similar to that in the periodontal ligament and cementum-like or bone-like hard tissue, which is comparable with the histology observed in the canals of teeth from animal models of revascularization/revitalization.

Detection of antibiotic resistance genes in samples from acute and chronic endodontic infections and after treatment.

OBJECTIVE: The purpose of this study was twofold: survey samples from acute and chronic endodontic infections for the presence of genes encoding resistance to beta-lactams, tetracycline and erythromycin, and evaluate the ability of treatment to eliminate these genes from root canals. DESIGN: DNA extracts from samples of abscess aspirates (n=25) and root canals of teeth with asymptomatic apical periodontitis (n=24) were used as template for direct detection of the genes blaTEM, cfxA, tetM, tetQ, tetW, and ermC using real-time polymerase chain reaction (PCR). Bacterial presence was determined using PCR with universal bacterial primers. Root canals of the asymptomatic cases were also sampled and evaluated after chemomechanical procedures using NiTi instruments with 2.5% NaOCl irrigation. RESULTS: All abscess and initial root canal samples were positive for bacteria. At least one of the target resistance genes was found in 36% of the abscess samples and 67% of the asymptomatic cases. The most prevalent genes in abscesses were blaTEM (24%) and ermC (24%), while tetM (42%) and tetW (29%) prevailed in asymptomatic cases. The blaTEM gene was significantly associated with acute cases (p=0.02). Conversely, tetM was significantly more prevalent in asymptomatic cases (p=0.008). Treatment eliminated resistance genes from most cases. CONCLUSIONS: Acute and chronic endodontic infections harboured resistance genes for 3 classes of widely used antibiotics. In most cases, treatment was effective in eliminating these genes, but there were a few cases in which they persisted. The implications of persistence are unknown. Direct detection of resistance genes in abscesses may be a potential method for rapid diagnosis and establishment of proactive antimicrobial therapy.

Searching for Helicobacter pylori and Chlamydia pneumoniae in primary endodontic infections.

OBJECTIVES: The purpose of this study was to search samples from primary endodontic infections for the presence of two common human bacterial pathogens - Helicobacter pylori and Chlamydia pneumoniae. METHODS: Genomic DNA isolated from samples taken from 25 root canals of teeth with asymptomatic (chronic) apical periodontitis and 25 aspirates from acute apical abscess was initially amplified by the multiple displacement amplification approach and then used as template in species-specific polymerase chain reaction (PCR) for detection of H. pylori and C. pneumoniae. RESULTS: All clinical samples were positive for the presence of bacterial DNA. However, no clinical sample was positive for either H. pylori or C. pneumoniae. CONCLUSIONS: Neither H. pylori nor C. pneumoniae were found in samples from primary endodontic infections. These findings suggest that these species are not candidate endodontic pathogens and that the necrotic root canal does not serve as a reservoir for these human pathogens in healthy patients.

Tratamiento de conductos de un densinvaginatus: reporte de un caso / Root Canal Therapy of a Dens Invaginatus: A Case Report

El diente invaginado es una malformación que resulta probablemente de un desdoblamientode la papila dental durante el desarrollo dentario. Los dens invaginatus son dientes clínicamentesignificativos, debido a la gran facilidad de afección de la pulpa. La profundidaddel defecto estructural varía de una leve ampliación del cíngulo a una invaginación quese extiende al ápice. El presente artículo relata el caso de una mujer de veintitrés años deedad, quien refiere una fístula de diez años de evolución en la mucosa en el fondo de sacoa la altura del diente lateral superior izquierdo (diente 22). Luego de la exploración clínica yradiográfica se diagnostica un dens in dente unilateral con necrosis pulpar y absceso apicalcrónico, para lo cual se realizó terapia de conductos y cirugía apical con éxito radiográficode dos años de evolución...

Invaginated tooth is a malformation likely resulting from a splitting of dental papilla duringtooth development. Dens invaginatus are clinically important teeth due to the easy affectionof the dental pulp. Invagination depth varies from a slight enlargement of the cingulum untoan extended invagination to the apex. This article reports the case of a female patient aged23, who referred fistula with ten years of evolution in tooth 22. The clinical and radiographicdiagnosis was dens in dent with necrosis and chronic suppurative periapical periodontitis.The root canal therapy and apical surgery were performed showing successfully radiographicevolution within a two-year follow-up period...

Distinctive features of the microbiota associated with different forms of apical periodontitis.

Microorganisms infecting the dental root canal system play an unequivocal role as causative agents of apical periodontitis. Although fungi, archaea, and viruses have been found in association with some forms of apical periodontitis, bacteria are the main microbial etiologic agents of this disease. Bacteria colonizing the root canal are usually organized in communities similar to biofilm structures. Culture and molecular biology technologies have demonstrated that the endodontic bacterial communities vary in species richness and abundance depending on the different types of infection and different forms of apical periodontitis. This review paper highlights the distinctive features of the endodontic microbiota associated with diverse clinical conditions.