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A study of some periapical roentgenolucencies and their significance
ORAL
ROENTGENOLOGY
American
Academy
Arthur H. Wuehrmann,
*
l
e
l
.*
of Oral Roentgenology Editor
l
.*
l
.*..***
A STUDY OF SOME PERIAPICAL
l
l
ROENTGENOLUCENCIES
l
.*..
AND THEIR
SIGNIFIGANCE:g
Tufts
Unicersity
Sckool
of l3cntnl
Medicine
I
has been demonstrated that some agent capable of causing periapical irritation is generated during pulpal infection. The agent reaches its site of action by passing through the apical foramen. 1 When the irritant has been eliminated, healing will occur.” The reaction of tissue to irritants-either bacterial, physical, or chemicalhas the same basic response, whether the reaction be within the tooth or not. These irritants, when introduced into the tissue, may elicit a response commensurat‘e with their destructive potency. The response may produce a slight tissue reaction if the stimulus is mild. When the stimulus increases, the response reaches a stage where the resistance of the tissue cannot localize and contain the action. This will result in tissue breakdown and in the formation of pus. The reaction of the host to the irritant is determined by the contact of the organism with the tissue, the amount, of toxic material emanating from the nidus, and the host’s susceptibilit,y to these irritants. 3 It is the delicate balance of action and counteraction that usually maintains or attempts to maintain the status quo. This study was undertaken to determine the incidence of positive cultures obtained from periapical tissues. Granula.tion tissue is healing tissue ; therefore. its removal only delays repair. Surgical removal of involved periapical tissue is logical only if periapicnl tissue is infected. T
TWX
OF
STUDY
AND
METHOD
The scope of this study was limited to determining whet,her or not apical granulation tissue harbors bacteria. No identification of the types of microorganisms was planned. **Associate
Professor. 10.57
SHINDELL
O.S., O.M. & O.P. September,
1961
As lloted in the r&urn6 of the literature, many investigators have developed experimental techniques designed to determine the bacterial content of both the root canal and the periapical granulation tissue. Cramer and Rcith,” Boyle,” and Hardnt7 used extracted teeth. BulleidS used three types of spccimcns in his bacteriologic st,udy of perinpical infections. These included (1) extracted teeth, (2 j specimens obtained by cutting through alveolar plate, and (3) apical granuloma attached to the tooth after extraction. Grossman and Prinz! used a trochar and cannula and drilled through the alveolar plate for the culture. Burket,“’ who used teeth from autopsy specimens, also cut through the alveolat~ plate for his culture after sterilizing the superficial tissue. In a recent study 1~~7Hedman, I1 the teeth were studied in situ. Ksing cannulas and stylets, Hedmall took cultnrcs of the residual periapical areas. The initial procedure was that of culturing the content of the canal. After dilbridcmerit by osidativc layage, the eannula was inserted to the apex. Cultures of the apical granulomat~ous arca uxw Ohtili?ld by pnssin, 0 a stplet through the tooth apex. All of these studies were made for bacteriologic evaluation. :1lthongh the procedures were varied, the basic bacteriologic techniques were similar as far as procedure and culture media were concerned. The conclusions drawn s110w diffuse and inconsistent results. Most early bacteriologic studies of the apical areas were carried out follo\ving extractions. Although there wew various attempts at, aseptic tcwhniqucs, ii is nevertheless possible that t,he positiyc results were due to contaminants. Hardnt,‘” using extracted teeth, found that all solid grannlomas are sterile. Ilc studied the granulomas histobacteriologically and found that bacteria were ne\-(‘1‘ in or among the cells of the grannloma. ~1ny bacteria found on the outer surface of the capsule were contaminants from the cstraction process. Fish and ;\Z;w Lean,l: using a similar procedure, concurwd and claimed that living tissues aw invariably sterile. Streptococci, ~11~~1~t’ountl, arc lwnallg confinc~l lo acute 01’ chronic abscess areas. ( )sgood,14 in a roentgenographic evaluation, found that grannlomas occur in young adults whose rcsistancc is high. Chronic abscesses tend to occur in patients with lowered resistance. Bronfeld,15 in a histobactcriologic study of pulpless teeth in situ, always found bacteria in t,he canal, but granulation tissue attached to the apices of the teeth was often Srce of miwoorganisms. He determined that granulomas and cysts are sterile in a large pcrcentage of the cases. ITc stated that granulomas destroy bacteria, for this tissucl is “ one of healing. ’ ’ Conversely, Cramer and Reith,“’ reporting a study of extracted teeth, stated t,hat “ (1) granulomas arc invariably infected, (2) apical areas about x-ray positive teeth are probably infected, (3) teeth with slight periapical change are infected to a lesser degree than those with more pronounced pathology-, (4) 1wt.11 definitely s-ray negative are infected only occasionally. ” Gilmer,‘? who studied extracted teeth from forty CRSCS, Found ntrobir as well as anaerobic organisms in the periapical tissues. In addition to extracted t,eeth, Burkct’” studied teeth at, autopsy 1)). cutting through the alwolar plate. He stated tha.t granulomas
_-__---.~
I_
80 5%
60 40 20
PERIAPICALLY
POSITIVE
ijqh NEGATIVE PERIAPICALLY %f:!i: ,,RE Af,,D POST-REAMING lIz!l Ia
AND POSITIVE
NEGATIVE PERIAPICALLY AND POSITIVE PR;‘R;;$MING AND NEGATIVE POSTWK. 1
Oi’ the sist>.-three casts stuclied, three sliowd posit ire cultures i’or tlrv pcrial)ical tissnc. h”ixtJ5 caws Ivcrc nrgati\-c. On(~ of tlrc three positiw c~nses hat1 ncgatiw pl’c- illId postreatiiin g cnltnrcs, the s~wnid caw hat1 posit ivc proant1 postreaming cnltnrw, and Ihe third case was Iwsitiw tll wngho~rt. oi’ t11v remaining sixty- caws forty-one vwe initially positirc l)~it had ncgativc~ poslreaming and pcriapicirl cultures. LXinctccn were positi\rv hth hforc illl(l ;I t’lci reaming and ncgativc pwiapically ; tlwrc is a stat istieally siylificatlt tlifYcwnc*c~ (cl&squaw = X.3) hetwecn tlic incidcncc of postwiiniiiig posit ivc c*rllt1lrc3 iln(l the incidence of apical positive culturcx
I)Iscc,s8Iox
The important finding ol*igGiat~ittg from Iltis work is the IOU- inciderw 01’ This result scrws t,o altcirpositiw cultures obtainahlc from periapical lesions. In\-asion of the pc?Yiilpical tissue 1)y tnicroor~anour roriccpts in scvwal ways. isms from the tooth canal is not an cwsy ~~rocws ; this inwsion docks not owii I*, or it does not, occur rapidly enough for the rtlic!.r.oo~~anisnls to gain a foot hold. 1’1-1~
Is there any evidcncc of bacteria in periapical ~IWS prior to 111ccom~)lctiorr of root canal therapy? This question was inrwtigatrcl 1,~ making cultures 01’ .\ modified Tlctlman trchniqnc was samples obtained from the apical awas. used. The canals WPI’C cleaned hot.h nrcc~harlicall~~ ant1 c~hc~nGcal1~ I)riot’ to insertion of the cannula and St)-let irito the ap(ls. LAlthough nineteen 01’ t,hc Iwstrcaming cultures ux’r*c positivcl. or11;. orrv 01’ The change in t whnical these gacc a positive eultlli*c for the IWrial’icill arca. methods is aswmrd to have nclarl). (11iminatwl the J)ushin,rr of cw~taminants ~hro~~~h to the apes. The sixty of the sixty-thwe casrs which were pcriapicall> Onr east was l)osit,i\e thwn~hoL~t arId negative wthstantiatecl this conntrntion. might i)c considered a contaminant. 1n the SCcorld f’asf’. tllfJ pwrcarning ilIlt pcriapical cultnres were Iwsitivc, whcwas the Iwstrcairlin, 0 cnltiirc was nf~gxtivv. ‘I’hc third ca.se was ncgati\o both 1)~ and Iwstrcamin g anti positive l,c~r’ial)ic~all~‘.
Thwe results lead one to the wricIiision that most of thv poriapiral arcas :IIY’ and that the -few vast‘s that contain hac*ic~*i;~iIt’(’ oi’ little statistiwl sixnificance. sterile
My appreciation and acknowlcdgemcnt to Arthur 11. I’earwn, I).hl.I)., Profrwr)r dontics, Chairman of the Tjepartment, Tufts University School of lhwt,al Mwlivinr. assistance in the organization and dewlopmcnt. of this study.
Hoyle, Paul E.: Kronfeld’s Histopathology of the ‘I’cseth ant1 Thc,ir Smrtrunding cvl. 3, Philadelphia, 1949, I,en & Feljigcr, p. 219. 2. Menkin, Valey: Biochemical Mechanisms in Inflammation, rd. 2, Springfield, Charles C Thomas. 3. E’ish, E. I$‘. : Bone Infection. .J. .\m. I)ent. A. 26: 691-X?, 1939. 1953, IAL 1. Boyd, William: A Text,hook of Pathology, ed. 6, Philadelphia, 1.
101,
112.
01’ F:rldo for
1~i.q
St twtuvx lllinoiy,
&z E’csbigvr,
19,X.
pp.
5. Cramer, H. C., and Reith, Allan l-‘. : Quantitative Bacteriologic Study of Pulplrss ‘I’wt II Correlated With Dental Roentgcnograms, J. Am. Dent. A. 19: 976-982, 1932. 6. Boyle, Paul E.: Kronfeld’s Histopa&ology of the Treth and Their Surrounding Structurlis. Philadelphia, 1955, Lea & Febiger, p. 167. 7. Hardnt, Ewald: Histo-bakteriologische Untersuchungen der erkrankten Zahnpulpa, Deutscli. Zahn-, Mund-, u. Kirferh. 5: 85101, 1938. 8. Bulleid, Art,hur: Bacteriological Studiw of Apical Infection, Brit. I). J. 52: 65-72, 105114, 145-151, 197405, 1931. 9. Grossman, L. I., and Print, II.: Bacteriologic Control of Periapical Tissue by the Cloriell Trocar Method, Dental Cosmos 73: 219, 1931.
IO. I I. 12. 13. 11. 13. 16. I’;. IX. 19. 20.
ROENTGENOLOGY
American
Academy
Arthur H. Wuehrmann,
*
l
e
l
.*
of Oral Roentgenology Editor
l
.*
l
.*..***
A STUDY OF SOME PERIAPICAL
l
l
ROENTGENOLUCENCIES
l
.*..
AND THEIR
SIGNIFIGANCE:g
Tufts
Unicersity
Sckool
of l3cntnl
Medicine
I
has been demonstrated that some agent capable of causing periapical irritation is generated during pulpal infection. The agent reaches its site of action by passing through the apical foramen. 1 When the irritant has been eliminated, healing will occur.” The reaction of tissue to irritants-either bacterial, physical, or chemicalhas the same basic response, whether the reaction be within the tooth or not. These irritants, when introduced into the tissue, may elicit a response commensurat‘e with their destructive potency. The response may produce a slight tissue reaction if the stimulus is mild. When the stimulus increases, the response reaches a stage where the resistance of the tissue cannot localize and contain the action. This will result in tissue breakdown and in the formation of pus. The reaction of the host to the irritant is determined by the contact of the organism with the tissue, the amount, of toxic material emanating from the nidus, and the host’s susceptibilit,y to these irritants. 3 It is the delicate balance of action and counteraction that usually maintains or attempts to maintain the status quo. This study was undertaken to determine the incidence of positive cultures obtained from periapical tissues. Granula.tion tissue is healing tissue ; therefore. its removal only delays repair. Surgical removal of involved periapical tissue is logical only if periapicnl tissue is infected. T
TWX
OF
STUDY
AND
METHOD
The scope of this study was limited to determining whet,her or not apical granulation tissue harbors bacteria. No identification of the types of microorganisms was planned. **Associate
Professor. 10.57
SHINDELL
O.S., O.M. & O.P. September,
1961
As lloted in the r&urn6 of the literature, many investigators have developed experimental techniques designed to determine the bacterial content of both the root canal and the periapical granulation tissue. Cramer and Rcith,” Boyle,” and Hardnt7 used extracted teeth. BulleidS used three types of spccimcns in his bacteriologic st,udy of perinpical infections. These included (1) extracted teeth, (2 j specimens obtained by cutting through alveolar plate, and (3) apical granuloma attached to the tooth after extraction. Grossman and Prinz! used a trochar and cannula and drilled through the alveolar plate for the culture. Burket,“’ who used teeth from autopsy specimens, also cut through the alveolat~ plate for his culture after sterilizing the superficial tissue. In a recent study 1~~7Hedman, I1 the teeth were studied in situ. Ksing cannulas and stylets, Hedmall took cultnrcs of the residual periapical areas. The initial procedure was that of culturing the content of the canal. After dilbridcmerit by osidativc layage, the eannula was inserted to the apex. Cultures of the apical granulomat~ous arca uxw Ohtili?ld by pnssin, 0 a stplet through the tooth apex. All of these studies were made for bacteriologic evaluation. :1lthongh the procedures were varied, the basic bacteriologic techniques were similar as far as procedure and culture media were concerned. The conclusions drawn s110w diffuse and inconsistent results. Most early bacteriologic studies of the apical areas were carried out follo\ving extractions. Although there wew various attempts at, aseptic tcwhniqucs, ii is nevertheless possible that t,he positiyc results were due to contaminants. Hardnt,‘” using extracted teeth, found that all solid grannlomas are sterile. Ilc studied the granulomas histobacteriologically and found that bacteria were ne\-(‘1‘ in or among the cells of the grannloma. ~1ny bacteria found on the outer surface of the capsule were contaminants from the cstraction process. Fish and ;\Z;w Lean,l: using a similar procedure, concurwd and claimed that living tissues aw invariably sterile. Streptococci, ~11~~1~t’ountl, arc lwnallg confinc~l lo acute 01’ chronic abscess areas. ( )sgood,14 in a roentgenographic evaluation, found that grannlomas occur in young adults whose rcsistancc is high. Chronic abscesses tend to occur in patients with lowered resistance. Bronfeld,15 in a histobactcriologic study of pulpless teeth in situ, always found bacteria in t,he canal, but granulation tissue attached to the apices of the teeth was often Srce of miwoorganisms. He determined that granulomas and cysts are sterile in a large pcrcentage of the cases. ITc stated that granulomas destroy bacteria, for this tissucl is “ one of healing. ’ ’ Conversely, Cramer and Reith,“’ reporting a study of extracted teeth, stated t,hat “ (1) granulomas arc invariably infected, (2) apical areas about x-ray positive teeth are probably infected, (3) teeth with slight periapical change are infected to a lesser degree than those with more pronounced pathology-, (4) 1wt.11 definitely s-ray negative are infected only occasionally. ” Gilmer,‘? who studied extracted teeth from forty CRSCS, Found ntrobir as well as anaerobic organisms in the periapical tissues. In addition to extracted t,eeth, Burkct’” studied teeth at, autopsy 1)). cutting through the alwolar plate. He stated tha.t granulomas
_-__---.~
I_
80 5%
60 40 20
PERIAPICALLY
POSITIVE
ijqh NEGATIVE PERIAPICALLY %f:!i: ,,RE Af,,D POST-REAMING lIz!l Ia
AND POSITIVE
NEGATIVE PERIAPICALLY AND POSITIVE PR;‘R;;$MING AND NEGATIVE POSTWK. 1
Oi’ the sist>.-three casts stuclied, three sliowd posit ire cultures i’or tlrv pcrial)ical tissnc. h”ixtJ5 caws Ivcrc nrgati\-c. On(~ of tlrc three positiw c~nses hat1 ncgatiw pl’c- illId postreatiiin g cnltnrcs, the s~wnid caw hat1 posit ivc proant1 postreaming cnltnrw, and Ihe third case was Iwsitiw tll wngho~rt. oi’ t11v remaining sixty- caws forty-one vwe initially positirc l)~it had ncgativc~ poslreaming and pcriapicirl cultures. LXinctccn were positi\rv hth hforc illl(l ;I t’lci reaming and ncgativc pwiapically ; tlwrc is a stat istieally siylificatlt tlifYcwnc*c~ (cl&squaw = X.3) hetwecn tlic incidcncc of postwiiniiiig posit ivc c*rllt1lrc3 iln(l the incidence of apical positive culturcx
I)Iscc,s8Iox
The important finding ol*igGiat~ittg from Iltis work is the IOU- inciderw 01’ This result scrws t,o altcirpositiw cultures obtainahlc from periapical lesions. In\-asion of the pc?Yiilpical tissue 1)y tnicroor~anour roriccpts in scvwal ways. isms from the tooth canal is not an cwsy ~~rocws ; this inwsion docks not owii I*, or it does not, occur rapidly enough for the rtlic!.r.oo~~anisnls to gain a foot hold. 1’1-1~
Is there any evidcncc of bacteria in periapical ~IWS prior to 111ccom~)lctiorr of root canal therapy? This question was inrwtigatrcl 1,~ making cultures 01’ .\ modified Tlctlman trchniqnc was samples obtained from the apical awas. used. The canals WPI’C cleaned hot.h nrcc~harlicall~~ ant1 c~hc~nGcal1~ I)riot’ to insertion of the cannula and St)-let irito the ap(ls. LAlthough nineteen 01’ t,hc Iwstrcaming cultures ux’r*c positivcl. or11;. orrv 01’ The change in t whnical these gacc a positive eultlli*c for the IWrial’icill arca. methods is aswmrd to have nclarl). (11iminatwl the J)ushin,rr of cw~taminants ~hro~~~h to the apes. The sixty of the sixty-thwe casrs which were pcriapicall> Onr east was l)osit,i\e thwn~hoL~t arId negative wthstantiatecl this conntrntion. might i)c considered a contaminant. 1n the SCcorld f’asf’. tllfJ pwrcarning ilIlt pcriapical cultnres were Iwsitivc, whcwas the Iwstrcairlin, 0 cnltiirc was nf~gxtivv. ‘I’hc third ca.se was ncgati\o both 1)~ and Iwstrcamin g anti positive l,c~r’ial)ic~all~‘.
Thwe results lead one to the wricIiision that most of thv poriapiral arcas :IIY’ and that the -few vast‘s that contain hac*ic~*i;~iIt’(’ oi’ little statistiwl sixnificance. sterile
My appreciation and acknowlcdgemcnt to Arthur 11. I’earwn, I).hl.I)., Profrwr)r dontics, Chairman of the Tjepartment, Tufts University School of lhwt,al Mwlivinr. assistance in the organization and dewlopmcnt. of this study.
Hoyle, Paul E.: Kronfeld’s Histopathology of the ‘I’cseth ant1 Thc,ir Smrtrunding cvl. 3, Philadelphia, 1949, I,en & Feljigcr, p. 219. 2. Menkin, Valey: Biochemical Mechanisms in Inflammation, rd. 2, Springfield, Charles C Thomas. 3. E’ish, E. I$‘. : Bone Infection. .J. .\m. I)ent. A. 26: 691-X?, 1939. 1953, IAL 1. Boyd, William: A Text,hook of Pathology, ed. 6, Philadelphia, 1.
101,
112.
01’ F:rldo for
1~i.q
St twtuvx lllinoiy,
&z E’csbigvr,
19,X.
pp.
5. Cramer, H. C., and Reith, Allan l-‘. : Quantitative Bacteriologic Study of Pulplrss ‘I’wt II Correlated With Dental Roentgcnograms, J. Am. Dent. A. 19: 976-982, 1932. 6. Boyle, Paul E.: Kronfeld’s Histopa&ology of the Treth and Their Surrounding Structurlis. Philadelphia, 1955, Lea & Febiger, p. 167. 7. Hardnt, Ewald: Histo-bakteriologische Untersuchungen der erkrankten Zahnpulpa, Deutscli. Zahn-, Mund-, u. Kirferh. 5: 85101, 1938. 8. Bulleid, Art,hur: Bacteriological Studiw of Apical Infection, Brit. I). J. 52: 65-72, 105114, 145-151, 197405, 1931. 9. Grossman, L. I., and Print, II.: Bacteriologic Control of Periapical Tissue by the Cloriell Trocar Method, Dental Cosmos 73: 219, 1931.
IO. I I. 12. 13. 11. 13. 16. I’;. IX. 19. 20.