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Apical infection spreading to adjacent teeth: a case report
Apical infection spreading to adjacent teeth: a case report Takashi Komabayashi, DDS, MDentSc, PhD,a Jin Jiang, DDS, PhD,b and Qiang Zhu, DDS, PhD,c Dallas, TX, Farmington, CT BAYLOR COLLEGE OF DENTISTRY AND UNIVERSITY OF CONNECTICUT
This case report describes apical infection on tooth number 24 that spread to adjacent teeth, resulting in devitalized teeth numbers 23 and 25. The 25-year-old Caucasian female patient was referred to the endodontic resident clinic because of uncontrolled apical infection. Root-end surgery and root-end filling of teeth numbers 23, 24, and 25 were performed. The histopathological diagnosis was a periapical cyst; however, the clinical surgical finding of a purulence-filled bone cavity also revealed a periapical abscess. After root-end surgery and regenerative therapy using Mineral Trioxide Aggregate, Bio-Oss xenograft material, and Bio-Gide resorbable collagen membrane, the patient had no symptoms. Radiographs showed the apical lesion had healed satisfactorily at the 6-month, 1-year, and 2-year follow-ups. The clinical implication of this rare case suggests the importance of standard endodontic diagnostic procedures for pulpal and apical diagnosis, prevention of apical periodontitis exacerbation by reducing bacterial factors, and the effectiveness of healing large bone defects using regenerative materials. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:e15-e20)
Pulp necrosis and apical lesion deployment occur only when oral microbiota exist; they do not occur when there is no oral microbiota in the root canals of pulpless teeth.1,2 Nonsurgical root canal treatment has a very high success rate in teeth with apical periodontitis3,4; therefore, a necrotic tooth with apical periodontitis is generally treated by nonsurgical root canal treatment alone. However, in this case, the apical periodontitis did not respond to root canal treatment; instead, the apical infection spread to the adjacent teeth. Without apparent caries or mechanical damage, the pulp status of the adjacent teeth changed from vital to necrotic. Similar case reports involving devitalized neighboring teeth or damaged adjacent vital structures are scarce.5-8 Therefore, this case is extremely rare because it is most likely caused by exacerbating infection that spread to neighboring teeth. The purpose of this case report is to describe apical infection that spread to adjacent teeth and the manage-
a
Assistant Professor, Department of Endodontics, Texas A&M Health Science Center, Baylor College of Dentistry. b Assistant Professor, Division of Endodontology, Department of Oral Health and Diagnostic Sciences, School of Dental Medicine, University of Connecticut. c Associate Professor, Division of Endodontology, Department of Oral Health and Diagnostic Sciences, School of Dental Medicine, University of Connecticut. Received for publication Sep 22, 2010; returned for revision Dec 14, 2010; accepted for publication Jan 6, 2011. 1079-2104/$ - see front matter Published by Mosby, Inc. doi:10.1016/j.tripleo.2011.01.008
ment of this case using root-end surgery and regenerative therapy. CASE REPORT Root canal treatment on tooth number 24 A 25-year-old Caucasian female visited a student provider at the University of Connecticut predoctoral clinic for comprehensive dental care. The patient’s medical history was noncontributory, and she presented with no symptoms. The patient had large caries on the distal of tooth number 24, and a radiographic evaluation indicated a well-defined 7 ⫻ 7-mm circumscribed radiolucency at the apex of tooth number 24. Endodontic examination and tests, such as percussion, palpation, cold tests (Hygenic Endo-Ice, Coltene Whaledent), and electric pulp test (EPT, Analytical Technology) were conducted. The results of these objective endodontic examinations are summarized in Table I, section A. The pulp diagnosis of tooth number 24 was pulp necrosis, and the apical diagnosis was asymptomatic apical periodontitis. Notably, the pulp diagnosis of teeth numbers 23 and 25 were normal (vital pulp), and the apical diagnosis was normal apical tissues by summarizing all of the information, such as symptoms, clinical findings, radiograph, and objective endodontic examinations. The root canal therapy of tooth number 24 was completed in 2 visits by the student provider. The final radiograph showed that the root filling of tooth number 24 was 1.5 mm short of the apex (Fig. 1).
Root canal treatment of teeth numbers 23 and 25 Four months after completion of the root canal therapy of tooth number 24, the patient presented with pain in her lower front teeth. A second student provider conducted the objective endodontic examinations summarized in Table I, section B. The apical radiolucency had enlarged to approximately 17 ⫻ 10 mm (Fig. 2). The pulp diagnosis of teeth numbers 23 and 25 was pulp necrosis, and the apical diagnosis was
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Table I. Clinical diagnostic summary Tooth no. A. Initial presentation Percussion Palpation Endo-ice EPT B. 4 mo after root canal filling of tooth number 24 Percussion Palpation Endo-ice EPT C. 1 wk after root canal filling of teeth numbers 23 and 25 Percussion Palpation Endo-ice EPT
22
23
24
25
26
27
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫺ ⫺
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
Mild Mild ⫺ ⫺
Moderate Mild N/A N/A
Moderate Mild ⫺ ⫺
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
Mild Mild N/A N/A
Mild Mild N/A N/A
Mild Mild N/A N/A
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫹, response; ⫺, no response; Mild, mild pain; Moderate, moderate pain; N/A, not applicable.
Fig. 1. Radiograph after root canal filling of tooth number 24.
Fig. 2. Radiograph 4 months after root canal filling of tooth number 24.
symptomatic apical periodontitis. The treatment plan was root canal treatment on teeth numbers 23 and 25 and retreatment of number 24. Root-end surgery was possible owing to the size of the lesion but in this instance, root canal therapy was started by the second student provider on teeth numbers 23 and 25. After access preparation, the pulp was found necrotic with no bleeding, which confirmed the diagnosis and the vitality test findings. Two visits for endodontic treatment using calcium hydroxide as an interappointment canal medicament were conducted on teeth numbers 23 and 25. On follow-up, the patient reported some relief from the symp-
toms. Then, the root canal treatment was completed by her second student provider. The final radiograph (Fig. 3) showed the presence of a large ill-defined periradicular radiolucency (approximately 20 ⫻ 12 mm in diameter) associated with broken lamina dura at the apices of teeth numbers 23, 24, and 25. Sealer extrusion was seen at the apex of tooth number 25.
Patient referral to endodontic resident clinic because of uncontrolled apical infection One week after the completion of the root canal treatment on teeth numbers 23 and 25, the patient complained of feeling
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Fig. 3. Radiograph after root canal filling of teeth numbers 23 and 25.
Komabayashi et al. e17 discomfort and pressure, especially when she pushed on her chin area. She was then referred to the resident clinic for further evaluation and treatment. There was no history of trauma to this area. Clinical examination revealed submandibular lymphadenopathy. The patient felt discomfort when the chin area was palpated. During the intraoral examination, teeth numbers 23, 24, and 25 exhibited mild tenderness to palpation in the labial vestibule. The endodontic evaluations are summarized in Table I, section C. Based on the clinical and radiographic information, the pulp diagnosis of teeth numbers 23, 24, and 25 was previously treated, and the apical diagnosis was symptomatic apical periodontitis. The patient was informed that the continuous enlargement of the periradicular radiolucency with illdefined borders suggested that the periradicular infection had not been controlled despite the root canal therapy. A treatment plan was presented to the patient that included the retreatment of tooth number 24 and root-end surgery of teeth numbers 23, 24, and 25. However, the patient did not want to have tooth number 24 retreated because of her experience with root canal therapy in the previous several months. She was very concerned with the continuous growth of the apical
Fig. 4. Root-end surgery on teeth numbers 23, 24, and 25. A, Purulent exudate was seen as the flap was being reflected near the apical area of teeth numbers 23, 24, and 25. B, Inflamed periosteum. C, Periradicular lesion. D, Removed tissue attached to the apex of tooth number 24 for biopsy. E, Root-end preparation. F, Root-end filling with white MTA. G, Bio-Oss was placed into the bony crypt. H, Bio-Gide membrane was placed.
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Postoperative evaluation The postsurgery follow-up found that the soft tissue was healing well, and the patient’s symptoms had improved. During the 6-month (Fig. 5, B), 1-year (Fig. 5, C), and 2-year (Fig. 5, D) follow-ups, the patient had no symptoms, and the radiographs showed the apical lesion had healed completely.
Pathology report The pathology report revealed a well-delineated cyst lined partially by a somewhat hyperplastic, but nonkeratinized, stratified squamous epithelium. The wall was slightly thickened and fibrotic and contained a mild-to-moderate mixed inflammatory response (Fig. 6, A and B). The histopathological diagnosis was periapical cyst; however, the clinical surgical finding of a purulence-filled bone cavity also revealed periapical abscess.
Fig. 5. A, Radiograph immediately after root-end filling with MTA. B, Six-month follow-up. C, One-year follow-up. D, Two-year follow-up.
lesion and wanted to proceed with the surgical endodontic therapy as soon as possible.
Root-end surgery on teeth numbers 23, 24, and 25 Root-end surgery was performed 1 week after consultation. As the flap was being reflected near the apical area of teeth numbers 23, 24, and 25, significant purulent exudate was evident (Fig. 4, A). An inflamed periosteum overlaid the purulence-filled bone cavity (Fig. 4, B). Dehiscence of the buccal cortical bone was noticed (Fig. 4, C). Inside the bone crypt, tissue of 10 ⫻ 8 ⫻ 4 mm was attached to the apex of tooth number 24. The tissue was removed and submitted for biopsy (Fig. 4, D). A root-end cavity was prepared (Fig. 4, E) and filled with White ProRoot Mineral Trioxide Aggregate (MTA) (Dentsply, Tulsa Dental, Johnson City, TN) (Fig. 4, F). Bio-Oss (Osteohealth, Shirley, NY) (0.75 mg) was used to fill the bony defect (Fig. 4, G). Then, a Bio-Gide (Osteohealth) resorbable collagen membrane was placed to cover the bony defect (Fig. 4, H). The flap was sutured and a radiograph taken (Fig. 5, A). Postoperative instructions to take antibiotics and pain medication were given to the patient.
DISCUSSION At the beginning stages of this case, tooth number 24 had necrotic pulp with apical periodontitis, whereas teeth numbers 23 and 25 had vital pulp with normal apical tissue. However, 4 months after nonsurgical treatment on tooth number 24, teeth numbers 23 and 25 developed necrotic pulp. During this period, no caries, trauma, or fracture was observed on these teeth. Accordingly, the authors speculated the following about this case. After tooth number 24 underwent nonsurgical root canal treatment, the apical lesion worsened. The infection grew and affected adjacent teeth numbers 23 and 25. One of the reasons that tooth number 24 did not respond to treatment may have been because of insufficient cleaning and shaping at the apical area, which resulted in an insufficient filling. Growing bacteria in an unfilled root canal can increase significantly, gain access to the apical lesion, and continue to inflame and infect the apical tissues.9 Stashenko et al.10 reported that apical infections may spread and produce symptoms when the bacteria becomes stronger than the host’s defense systems. Also the anatomic complexities of the apical area may limit treatment success.11 Another reason for the lack of response from tooth number 24 to treatment was the cystic lesion. The lesion of tooth number 24 expanded laterally to teeth numbers 23 and 25 owing to the thickness of the cortical bone and the thin anatomical structure in the anterior teeth area of mandible. According to Skaug,12 fluid pressure in odontogenic jaw cysts is higher than the atmospheric pressure. It has been speculated that increased intracystic fluid pressure might activate the growth of odontogenic jaw cysts.13,14 Large cystic and periapical lesions are difficult to heal using only nonsurgical root canal treatment.15,16 The clinical findings in this case indicated that the lesion may be a pocket cyst. The radiograph (Fig. 1) shows a well-defined
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Fig. 6. Histologic slides of the biopsy tissue revealed a cyst lined by nonkeratinized stratified squamous epithelium. The wall contains mild to moderate inflammatory response. A, Original magnification ⫻10. B, Original magnification ⫻40.
circumscribed radiolucency with a well-defined cortical border, which was interrupted by the apex of tooth number 24. During surgery, tissue was found attached to the apex of tooth number 24 and needed to be separated for the biopsy. The pulp infection of teeth numbers 23 and 25 presents bacteria that could spread extraradicularly to neighboring teeth. Anachoresis has been investigated to explain the presence of microorganisms in unexposed dental pulps.17,18 Bacteria introduced into the gingival sulcus or bloodstream were recovered in teeth with pulp inflammation.17-19 It was attributed to the destruction of the pulp vessels and the increased vascular permeability resulting from inflammation.19 As teeth numbers 23 and 25 were heavily restored, a level of inflammation may have existed that possibly led to the ingress of bacteria retrograde from the acute apical abscess of tooth number 24. Because the apical infection was not properly controlled despite the root canal therapy on teeth numbers 23, 24, and 25, root-end surgery and root-end filling of these teeth were performed. Root-end surgery is needed for large apical cystic lesion healing20; the success rate of root-end surgery is approximately 90%.21-24 In a previous case report regarding the periapical lesion involvement from 1 tooth to adjacent teeth, 2 collagen membranes were placed around the bony defect and stabilized using titanium pins.5 In our case, Bio-Oss xenograft material was used to fill the large bony defect to effectively maintain space and promote revascularization and clot stabilization. Bio-Gide resorbable collagen membrane was used to cover the bony defect. This membrane serves as the matrix for soft tissue support and inhibits soft tissue ingrowth into the underlying bone defect. A 2-year follow-up showed that the outcome was excellent; both the graft material and membrane appeared to have facilitated large apical lesion healing.
In summary, this rare case shows that apical infection from 1 tooth may spread to the adjacent teeth. Large apical cysts may be difficult to heal and regenerative materials may be useful in healing large bone defects. The authors thank Ms Jeanne Santa Cruz (Texas A&M Health Science Center, Baylor College of Dentistry) for the critical editing. REFERENCES 1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340-9. 2. Sundqvist G. Bacteriological studies of necrotic dental pulps. Umea: University of Umea; 1976. 3. Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990; 16:498-504. 4. Marquis VL, Dao T, Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: The Toronto Study. Phase III: initial treatment. J Endod 2006;32:299-306. 5. Chaniotis AM, Tzanetakis GN, Kontakiotis EG, Tosios KI. Combined endodontic and surgical management of a mandibular lateral incisor with a rare type of dens invaginatus. J Endod 2008;34:1255-60. 6. Wong M. Surgical fenestration of large periapical lesions. J Endod 1991;17:516-21. 7. Enislidis G, Fock N, Sulzbacher I, Ewers R. Conservative treatment of large cystic lesions of the mandible: a prospective study of the effect of decompression. Br J Oral Maxillofac Surg 2004;42:546-50. 8. Sakkas N, Schoen R, Schulze D, Otten JE, Schmelzeisen R. Obturator after marsupialization of a recurrence of a radicular cyst of the mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e16-8. 9. Siqueira JF. Aetiology of root canal treatment failure: why welltreated teeth can fail. Int Endod J 2001;34:1-10. 10. Stashenko P, Wang C-Y, Tani-Ishii N, Yu SM. Pathogenesis of induced rat periapical lesions. Oral Surg Oral Med Oral Pathol 1994;78:494-502. 11. Ricucci D, Siqueira JF Jr. Anatomic and microbiologic challenges to achieving success with endodontic treatment: a case report. J Endod 2008;34:1249-54.
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12. Skaug N. Intracystic fluid pressure in non-keratinizing jaw cysts. Int J Oral Surg 1976;5:59-65. 13. Kubota Y, Yamashiro T, Oka S, Ninomiya T, Ogata S, Shirasuna K. Relation between size of odontogenic jaw cysts and the pressure of fluid within. Br J Oral Maxillofac Surg 2004;42: 391-5. 14. Oka S, Kubota Y, Yamashiro T, Ogata S, Ninomiya T, Ito S, et al. Effects of positive pressure in odontogenic keratocysts. J Dent Res 2005;84:913-8. 15. Nair PN. New perspectives on radicular cysts: do they heal? Int Endod J 1998;31:155-60. 16. Nair PN, Sjogren U, Schumacher E, Sundqvist G. Radicular cyst affecting a root-filled human tooth: a long-term post-treatment follow-up. Int Endod J 1993;26:225-33. 17. Grossman LI. Origin of microorganisms in traumatized, pulpless, sound teeth. J Dent Res 1967;46:551-3. 18. Gier RE, Mitchell DF. Anachoretic effect of pulpitis. J Dent Res 1968;47:564-70. 19. Tziafas D. Experimental bacterial anachoresis in dog dental pulps capped with calcium hydroxide. J Endod 1989;15:591-5. 20. Lin LM, Ricucci D, Lin J, Rosenberg PA. Nonsurgical root canal therapy of large cyst-like inflammatory periapical lesions and inflammatory apical cysts. J Endod 2009;35:607-15.
21. Gagliani MM, Gorni FGM, Strohmenger L. Periapical resurgery versus periapical surgery: a 5-year longitudinal comparison. Int Endod J 2005;38:320-7. 22. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod 2002;28: 378-83. 23. Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in periradicular surgery: A clinical prospective study. Int Endod J 2000;33: 91-8. 24. Grung B, Molven O, Halse A. Periapical surgery in a Norwegian county hospital: follow-up findings of 477 teeth. J Endod 1990;16:411-7. Reprint requests: Takashi Komabayashi, DDS, MDentSc, PhD Assistant Professor Department of Endodontics Texas A&M Health Science Center Baylor College of Dentistry 3302 Gaston Avenue Dallas, TX 75246 [email protected]
This case report describes apical infection on tooth number 24 that spread to adjacent teeth, resulting in devitalized teeth numbers 23 and 25. The 25-year-old Caucasian female patient was referred to the endodontic resident clinic because of uncontrolled apical infection. Root-end surgery and root-end filling of teeth numbers 23, 24, and 25 were performed. The histopathological diagnosis was a periapical cyst; however, the clinical surgical finding of a purulence-filled bone cavity also revealed a periapical abscess. After root-end surgery and regenerative therapy using Mineral Trioxide Aggregate, Bio-Oss xenograft material, and Bio-Gide resorbable collagen membrane, the patient had no symptoms. Radiographs showed the apical lesion had healed satisfactorily at the 6-month, 1-year, and 2-year follow-ups. The clinical implication of this rare case suggests the importance of standard endodontic diagnostic procedures for pulpal and apical diagnosis, prevention of apical periodontitis exacerbation by reducing bacterial factors, and the effectiveness of healing large bone defects using regenerative materials. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:e15-e20)
Pulp necrosis and apical lesion deployment occur only when oral microbiota exist; they do not occur when there is no oral microbiota in the root canals of pulpless teeth.1,2 Nonsurgical root canal treatment has a very high success rate in teeth with apical periodontitis3,4; therefore, a necrotic tooth with apical periodontitis is generally treated by nonsurgical root canal treatment alone. However, in this case, the apical periodontitis did not respond to root canal treatment; instead, the apical infection spread to the adjacent teeth. Without apparent caries or mechanical damage, the pulp status of the adjacent teeth changed from vital to necrotic. Similar case reports involving devitalized neighboring teeth or damaged adjacent vital structures are scarce.5-8 Therefore, this case is extremely rare because it is most likely caused by exacerbating infection that spread to neighboring teeth. The purpose of this case report is to describe apical infection that spread to adjacent teeth and the manage-
a
Assistant Professor, Department of Endodontics, Texas A&M Health Science Center, Baylor College of Dentistry. b Assistant Professor, Division of Endodontology, Department of Oral Health and Diagnostic Sciences, School of Dental Medicine, University of Connecticut. c Associate Professor, Division of Endodontology, Department of Oral Health and Diagnostic Sciences, School of Dental Medicine, University of Connecticut. Received for publication Sep 22, 2010; returned for revision Dec 14, 2010; accepted for publication Jan 6, 2011. 1079-2104/$ - see front matter Published by Mosby, Inc. doi:10.1016/j.tripleo.2011.01.008
ment of this case using root-end surgery and regenerative therapy. CASE REPORT Root canal treatment on tooth number 24 A 25-year-old Caucasian female visited a student provider at the University of Connecticut predoctoral clinic for comprehensive dental care. The patient’s medical history was noncontributory, and she presented with no symptoms. The patient had large caries on the distal of tooth number 24, and a radiographic evaluation indicated a well-defined 7 ⫻ 7-mm circumscribed radiolucency at the apex of tooth number 24. Endodontic examination and tests, such as percussion, palpation, cold tests (Hygenic Endo-Ice, Coltene Whaledent), and electric pulp test (EPT, Analytical Technology) were conducted. The results of these objective endodontic examinations are summarized in Table I, section A. The pulp diagnosis of tooth number 24 was pulp necrosis, and the apical diagnosis was asymptomatic apical periodontitis. Notably, the pulp diagnosis of teeth numbers 23 and 25 were normal (vital pulp), and the apical diagnosis was normal apical tissues by summarizing all of the information, such as symptoms, clinical findings, radiograph, and objective endodontic examinations. The root canal therapy of tooth number 24 was completed in 2 visits by the student provider. The final radiograph showed that the root filling of tooth number 24 was 1.5 mm short of the apex (Fig. 1).
Root canal treatment of teeth numbers 23 and 25 Four months after completion of the root canal therapy of tooth number 24, the patient presented with pain in her lower front teeth. A second student provider conducted the objective endodontic examinations summarized in Table I, section B. The apical radiolucency had enlarged to approximately 17 ⫻ 10 mm (Fig. 2). The pulp diagnosis of teeth numbers 23 and 25 was pulp necrosis, and the apical diagnosis was
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Table I. Clinical diagnostic summary Tooth no. A. Initial presentation Percussion Palpation Endo-ice EPT B. 4 mo after root canal filling of tooth number 24 Percussion Palpation Endo-ice EPT C. 1 wk after root canal filling of teeth numbers 23 and 25 Percussion Palpation Endo-ice EPT
22
23
24
25
26
27
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫺ ⫺
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
Mild Mild ⫺ ⫺
Moderate Mild N/A N/A
Moderate Mild ⫺ ⫺
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
Mild Mild N/A N/A
Mild Mild N/A N/A
Mild Mild N/A N/A
⫺ ⫺ ⫹ ⫹
⫺ ⫺ ⫹ ⫹
⫹, response; ⫺, no response; Mild, mild pain; Moderate, moderate pain; N/A, not applicable.
Fig. 1. Radiograph after root canal filling of tooth number 24.
Fig. 2. Radiograph 4 months after root canal filling of tooth number 24.
symptomatic apical periodontitis. The treatment plan was root canal treatment on teeth numbers 23 and 25 and retreatment of number 24. Root-end surgery was possible owing to the size of the lesion but in this instance, root canal therapy was started by the second student provider on teeth numbers 23 and 25. After access preparation, the pulp was found necrotic with no bleeding, which confirmed the diagnosis and the vitality test findings. Two visits for endodontic treatment using calcium hydroxide as an interappointment canal medicament were conducted on teeth numbers 23 and 25. On follow-up, the patient reported some relief from the symp-
toms. Then, the root canal treatment was completed by her second student provider. The final radiograph (Fig. 3) showed the presence of a large ill-defined periradicular radiolucency (approximately 20 ⫻ 12 mm in diameter) associated with broken lamina dura at the apices of teeth numbers 23, 24, and 25. Sealer extrusion was seen at the apex of tooth number 25.
Patient referral to endodontic resident clinic because of uncontrolled apical infection One week after the completion of the root canal treatment on teeth numbers 23 and 25, the patient complained of feeling
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Fig. 3. Radiograph after root canal filling of teeth numbers 23 and 25.
Komabayashi et al. e17 discomfort and pressure, especially when she pushed on her chin area. She was then referred to the resident clinic for further evaluation and treatment. There was no history of trauma to this area. Clinical examination revealed submandibular lymphadenopathy. The patient felt discomfort when the chin area was palpated. During the intraoral examination, teeth numbers 23, 24, and 25 exhibited mild tenderness to palpation in the labial vestibule. The endodontic evaluations are summarized in Table I, section C. Based on the clinical and radiographic information, the pulp diagnosis of teeth numbers 23, 24, and 25 was previously treated, and the apical diagnosis was symptomatic apical periodontitis. The patient was informed that the continuous enlargement of the periradicular radiolucency with illdefined borders suggested that the periradicular infection had not been controlled despite the root canal therapy. A treatment plan was presented to the patient that included the retreatment of tooth number 24 and root-end surgery of teeth numbers 23, 24, and 25. However, the patient did not want to have tooth number 24 retreated because of her experience with root canal therapy in the previous several months. She was very concerned with the continuous growth of the apical
Fig. 4. Root-end surgery on teeth numbers 23, 24, and 25. A, Purulent exudate was seen as the flap was being reflected near the apical area of teeth numbers 23, 24, and 25. B, Inflamed periosteum. C, Periradicular lesion. D, Removed tissue attached to the apex of tooth number 24 for biopsy. E, Root-end preparation. F, Root-end filling with white MTA. G, Bio-Oss was placed into the bony crypt. H, Bio-Gide membrane was placed.
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Postoperative evaluation The postsurgery follow-up found that the soft tissue was healing well, and the patient’s symptoms had improved. During the 6-month (Fig. 5, B), 1-year (Fig. 5, C), and 2-year (Fig. 5, D) follow-ups, the patient had no symptoms, and the radiographs showed the apical lesion had healed completely.
Pathology report The pathology report revealed a well-delineated cyst lined partially by a somewhat hyperplastic, but nonkeratinized, stratified squamous epithelium. The wall was slightly thickened and fibrotic and contained a mild-to-moderate mixed inflammatory response (Fig. 6, A and B). The histopathological diagnosis was periapical cyst; however, the clinical surgical finding of a purulence-filled bone cavity also revealed periapical abscess.
Fig. 5. A, Radiograph immediately after root-end filling with MTA. B, Six-month follow-up. C, One-year follow-up. D, Two-year follow-up.
lesion and wanted to proceed with the surgical endodontic therapy as soon as possible.
Root-end surgery on teeth numbers 23, 24, and 25 Root-end surgery was performed 1 week after consultation. As the flap was being reflected near the apical area of teeth numbers 23, 24, and 25, significant purulent exudate was evident (Fig. 4, A). An inflamed periosteum overlaid the purulence-filled bone cavity (Fig. 4, B). Dehiscence of the buccal cortical bone was noticed (Fig. 4, C). Inside the bone crypt, tissue of 10 ⫻ 8 ⫻ 4 mm was attached to the apex of tooth number 24. The tissue was removed and submitted for biopsy (Fig. 4, D). A root-end cavity was prepared (Fig. 4, E) and filled with White ProRoot Mineral Trioxide Aggregate (MTA) (Dentsply, Tulsa Dental, Johnson City, TN) (Fig. 4, F). Bio-Oss (Osteohealth, Shirley, NY) (0.75 mg) was used to fill the bony defect (Fig. 4, G). Then, a Bio-Gide (Osteohealth) resorbable collagen membrane was placed to cover the bony defect (Fig. 4, H). The flap was sutured and a radiograph taken (Fig. 5, A). Postoperative instructions to take antibiotics and pain medication were given to the patient.
DISCUSSION At the beginning stages of this case, tooth number 24 had necrotic pulp with apical periodontitis, whereas teeth numbers 23 and 25 had vital pulp with normal apical tissue. However, 4 months after nonsurgical treatment on tooth number 24, teeth numbers 23 and 25 developed necrotic pulp. During this period, no caries, trauma, or fracture was observed on these teeth. Accordingly, the authors speculated the following about this case. After tooth number 24 underwent nonsurgical root canal treatment, the apical lesion worsened. The infection grew and affected adjacent teeth numbers 23 and 25. One of the reasons that tooth number 24 did not respond to treatment may have been because of insufficient cleaning and shaping at the apical area, which resulted in an insufficient filling. Growing bacteria in an unfilled root canal can increase significantly, gain access to the apical lesion, and continue to inflame and infect the apical tissues.9 Stashenko et al.10 reported that apical infections may spread and produce symptoms when the bacteria becomes stronger than the host’s defense systems. Also the anatomic complexities of the apical area may limit treatment success.11 Another reason for the lack of response from tooth number 24 to treatment was the cystic lesion. The lesion of tooth number 24 expanded laterally to teeth numbers 23 and 25 owing to the thickness of the cortical bone and the thin anatomical structure in the anterior teeth area of mandible. According to Skaug,12 fluid pressure in odontogenic jaw cysts is higher than the atmospheric pressure. It has been speculated that increased intracystic fluid pressure might activate the growth of odontogenic jaw cysts.13,14 Large cystic and periapical lesions are difficult to heal using only nonsurgical root canal treatment.15,16 The clinical findings in this case indicated that the lesion may be a pocket cyst. The radiograph (Fig. 1) shows a well-defined
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Fig. 6. Histologic slides of the biopsy tissue revealed a cyst lined by nonkeratinized stratified squamous epithelium. The wall contains mild to moderate inflammatory response. A, Original magnification ⫻10. B, Original magnification ⫻40.
circumscribed radiolucency with a well-defined cortical border, which was interrupted by the apex of tooth number 24. During surgery, tissue was found attached to the apex of tooth number 24 and needed to be separated for the biopsy. The pulp infection of teeth numbers 23 and 25 presents bacteria that could spread extraradicularly to neighboring teeth. Anachoresis has been investigated to explain the presence of microorganisms in unexposed dental pulps.17,18 Bacteria introduced into the gingival sulcus or bloodstream were recovered in teeth with pulp inflammation.17-19 It was attributed to the destruction of the pulp vessels and the increased vascular permeability resulting from inflammation.19 As teeth numbers 23 and 25 were heavily restored, a level of inflammation may have existed that possibly led to the ingress of bacteria retrograde from the acute apical abscess of tooth number 24. Because the apical infection was not properly controlled despite the root canal therapy on teeth numbers 23, 24, and 25, root-end surgery and root-end filling of these teeth were performed. Root-end surgery is needed for large apical cystic lesion healing20; the success rate of root-end surgery is approximately 90%.21-24 In a previous case report regarding the periapical lesion involvement from 1 tooth to adjacent teeth, 2 collagen membranes were placed around the bony defect and stabilized using titanium pins.5 In our case, Bio-Oss xenograft material was used to fill the large bony defect to effectively maintain space and promote revascularization and clot stabilization. Bio-Gide resorbable collagen membrane was used to cover the bony defect. This membrane serves as the matrix for soft tissue support and inhibits soft tissue ingrowth into the underlying bone defect. A 2-year follow-up showed that the outcome was excellent; both the graft material and membrane appeared to have facilitated large apical lesion healing.
In summary, this rare case shows that apical infection from 1 tooth may spread to the adjacent teeth. Large apical cysts may be difficult to heal and regenerative materials may be useful in healing large bone defects. The authors thank Ms Jeanne Santa Cruz (Texas A&M Health Science Center, Baylor College of Dentistry) for the critical editing. REFERENCES 1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340-9. 2. Sundqvist G. Bacteriological studies of necrotic dental pulps. Umea: University of Umea; 1976. 3. Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 1990; 16:498-504. 4. Marquis VL, Dao T, Farzaneh M, Abitbol S, Friedman S. Treatment outcome in endodontics: The Toronto Study. Phase III: initial treatment. J Endod 2006;32:299-306. 5. Chaniotis AM, Tzanetakis GN, Kontakiotis EG, Tosios KI. Combined endodontic and surgical management of a mandibular lateral incisor with a rare type of dens invaginatus. J Endod 2008;34:1255-60. 6. Wong M. Surgical fenestration of large periapical lesions. J Endod 1991;17:516-21. 7. Enislidis G, Fock N, Sulzbacher I, Ewers R. Conservative treatment of large cystic lesions of the mandible: a prospective study of the effect of decompression. Br J Oral Maxillofac Surg 2004;42:546-50. 8. Sakkas N, Schoen R, Schulze D, Otten JE, Schmelzeisen R. Obturator after marsupialization of a recurrence of a radicular cyst of the mandible. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e16-8. 9. Siqueira JF. Aetiology of root canal treatment failure: why welltreated teeth can fail. Int Endod J 2001;34:1-10. 10. Stashenko P, Wang C-Y, Tani-Ishii N, Yu SM. Pathogenesis of induced rat periapical lesions. Oral Surg Oral Med Oral Pathol 1994;78:494-502. 11. Ricucci D, Siqueira JF Jr. Anatomic and microbiologic challenges to achieving success with endodontic treatment: a case report. J Endod 2008;34:1249-54.
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21. Gagliani MM, Gorni FGM, Strohmenger L. Periapical resurgery versus periapical surgery: a 5-year longitudinal comparison. Int Endod J 2005;38:320-7. 22. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod 2002;28: 378-83. 23. Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in periradicular surgery: A clinical prospective study. Int Endod J 2000;33: 91-8. 24. Grung B, Molven O, Halse A. Periapical surgery in a Norwegian county hospital: follow-up findings of 477 teeth. J Endod 1990;16:411-7. Reprint requests: Takashi Komabayashi, DDS, MDentSc, PhD Assistant Professor Department of Endodontics Texas A&M Health Science Center Baylor College of Dentistry 3302 Gaston Avenue Dallas, TX 75246 [email protected]