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Periapical repair after conservative treatment of a cariously involved first molar
0099-2399/99/2501-0060503.00/0 JOURNAL OF ENDODONTICS Copyright © 1999 by The American Association of Endodontists
Printed in U.S.A.
VOL. 25, No. 1, JANUARY1999
CASE REPORT Periapical Repair after Conservative Treatment of a Cariously Involved First Molar Christen John Nielsen, DMD, MS
A case is presented wherein existing periapical pathology, including both bone and root resorption, was successfully treated and pulp vitality maintained by restoration of a deep carious lesion in a mandibular first molar. A review of the literature demonstrates that under certain conditions such success may be expected, but all cases reported to date have involved pulpotomies or indirect/direct pulp capping procedures. Successful treatment seems to depend on a tooth being relatively young, asymptomatic, and having normal responses to vitality testing.
CASE REPORT In the present case, a 23-yr-old male with a nonremarkable medical history presented for endodontic treatment of a carious mandibular right first molar with "apical involvement." Upon examination, it was noted that this tooth had been asymptomatic in the past, and currently demonstrated normal responses to thermal and electric vitality testing and percussion. The tooth had been restored with mesioocclusal and buccal amalgam restorations some time in the past. Distal caries was evident clinically. A periapical radiograph showed a large restoration with distal caries in close proximity to the pulp (Fig. 1). Caries was also noted on both adjacent teeth. Distinct apical radiolucencies were noted on the blunted distal root and mesial root of the first molar along with condensing osteitis. Based primarily on the radiographic evidence, a diagnosis of probable irreversible pulpitis with chronic apical periodontitis was made. Because the patient was eager to avoid endodontic therapy in the absence of clinical symptoms, the decision was made to temporarily restore the tooth (after no carious exposure was noted during caries excavation), then evaluate and
It is a widely held belief that once pulpally induced periapical pathology has progressed to the point that distinct radiographic evidence of bone destruction has occurred, endodontic therapy (or extraction) is the recommended course of treatment. Several reports in the literature, however, cite instances where conventional endodontics is not necessary in restoring periapical health. Moore (t) was the first to report successful restitution of periapical health by use of both indirect and direct pulp-capping procedures. His protocol included treating deep caries with calcium hydroxide, then at a subsequent appointment, removing all remaining carious dentin and restoring. Sapone (2) reported two cases of cariously involved teeth with periapical lesions successfully treated with direct pulp capping. Finally, Jordan et al. (3), using a protocol in which subsequent removal of remaining caries was not done after initial indirect pulp capping, was able to show resolution of periapical pathosis with preservation of pulp vitality in 11 cases. In all reports, cage selection and diagnosis were considered critical to success in so far as only young patients ( < 2 4 yr old) with what was considered to be a reversible pulpal condition were seen to benefit from the treatment rendered. Clinical success depended on a tooth demonstrating vitality to thermal and electrical stimulation and an absence of spontaneous pain.
FIG 1. Note caries on second premolar, first and second molars, and radiolucency with condensing osteitis on resorbed distal root of the first molar with widening of apical periodontal ligament of mesial root. 60
Voh 25, No. 1, January 1999
FIG 2. Amalgam restoration of first molar 7 wk after initial temporization.
Periapical Repair after Caries Restoration
61
FiG 4. Eleven months after initial temporization. Good osseous healing of both mesial and distal root apices.
DISCUSSION
FIG 3. Eight months after initial temporization. Good osseous healing of both mesial and distal root apices.
permanently restore at a future date if symptoms did not subsequently arise. Initial treatment consisted of complete caries removal in all three teeth. An Intermediate Restorative Material (IRM) restoration was placed in the first molar, whereas the other teeth received amalgam restorations. Seven weeks later, the patient returned for an amalgam restoration in which the IRM was left in the deepest portion of the preparation as a base. A periapical radiograph confirmed the existence of periapical radiolucencies on both roots, but the tooth continued to be asymptomatic (Fig. 2). The patient was seen 8 wk later (15 wk after initial temporization with IRM), at which time the tooth was reported to be asymptomatic. A periapical radiograph indicated apparent bone deposition within the previously lucent areas at both the mesial and distal root apices (Fig. 3). The patient was seen twice more, at 8 and 11 months, after the initial treatment. Radiographs taken at both times revealed excellent osseous healing with diminished osteitis (Fig. 4). The tooth had remained asymptomatic and tested normally to percussion, thermal tests, and the electric pulp test at the final appointment. Further evaluation could not be done because the patient left the area.
The resolution of periapical pathology white maintaining pulpal viability has been well documented in the case of pulpotomies (4-6), but such treatments are generally followed by conventional endodontics after circumstances leading to the choice of pulpotomy have changed (e.g. a patient becomes more cooperative, financing becomes available, or root development has progressed to where endodontics is considered more feasible). Long-term maintenance of complete pulp viability in the presence of periapical pathology has been rarely reported in the literature. In all cases, treatment consisted of either direct pulp capping (2) or indirect pulp capping (1, 3). In the present case neither procedure was found to be necessary, and initial treatment, consisting of a simple zinc oxide-eugenol-based temporary restoration followed by an amalgam restoration, resulted in a successful outcome. The other distinguishing characteristic of this case was the distal root resorption. In no other reported case was it evident that such a condition existed preoperatively. The ability of a pulp to remain viable in conditions such as described in this case and in other references cited apparently may depend on several factors. Because no report has ever shown success in patients over the age of 24, it has been suggested that a young pulp is better able to withstand the onslaught of carious insult, in part due to its richer blood supply and natural defenses (7). In addition, it would seem critical that absence of symptoms and a normal response to vitality testing be present to ensure the pulp's presumed viability at the commencement of treatment. It may nevertheless be difficult for the clinician to come to grips with the idea that a pulp can retain health in the presence of periapical pathology. Historically, a lesion characteristic of chronic apical periodontitis dictates endodontic therapy once a pulpal etiology is established. The assumption by most clinicians is that, in the presence of bone destruction, either the pulp is totally inflamed (and hence irreversibly damaged) or, in fact, necrotic. However, such does not have to be the case, because both Bender et al. (8) and Langeland et al. (9) have demonstrated uninflamed radicular pulp between inflammation of both coronal pulp and periapical tissue. Seltzer et al. (10) speculated that fibrous collagen bundles of radicular pulp were responsible for limiting progression of the infammatory infiltrate into the root portion of the pulp, whereas chronic inflammatory cells were still found in the periapical area. Langeland et al. (9) attributed the appearance of periapical inflam-
62
Journal of Endodontics
Nielsen
mation in the presence of relatively unaltered radicular pulp tissue to the presence of lymph vessels carrying tissue breakdown products and bacterial toxins past the radicular portion into the periapical area. These considerations give histological credence to the concept that young pulp tissue can--in an asymptomatic, normally responsive tooth--maintain its integrity even in the presence of periapical inflammation with bone destruction. This case report demonstrates a case in which pulpal and periapical health were maintained after initial radiographic evidence of osseous destruction, and root resorption was noted in conjunction with deep caries without pulp exposure. A review of the literature indicates that similar cases involving direct and indirect pulp capping may succeed if case selection (young, asymptomatic patient) and diagnosis (evidence of initial pulp vitality) are considered.
Dr, Nielsen is assistant professor, section head, Endodontics, Department of Applied Dental Medicine, University of Southern Illinois, School of Dental Medicine, Carbondale, IL. Address requests for reprints to Dr. Christen J. Nielsen, 108 Kingsbrooke Boulevard, Glen Carbon, IL 62034.
References 1. Moore DL. Conservative treatment of teeth with vital pulps and periapical lesions: a preliminary report. J Prosthet Dent 1967;18:476-81. 2. Sapone J. Vital pulp therapy. In: Cohen S, Burns RC. Pathways of the pulp. 1st ed. St. Louis: CV Mosby Co., 1976:580-1. 3. Jordan RE, Suzuki M, Skinner DH. Indirect pulp-capping of carious teeth with periapical lesions. J Am Dent Assoc 1976;97:37-43. 4. Caliskan MK. Pulpotomy of carious vital teeth with periapical involvement. tnt Endod J 1995;28:172-6. 5. Russo MDEC, Holland R, deSouza V. Radiographic and histological evaluation of the treatment of inflamed dental pulp. Int Endod J 1982;15:13742. 6. Moule JA, Oswald JR. Resolution of periapical radiolucency following pulpotomy. J Endodon 1983;9:388-9. 7. Kim S, Trowbridge HO. Pulpal reaction to caries and dental procedures. In: Cohen S, Burns RC. Pathways of the pulp. 4th ed. St. Louis: CV Mosby Co., 1987:444. 8. Bender IB, Seltzer S, Soltanoff W. Endodontic success--a reappraisal of criteria. Oral Surg Oral Med Oral Pathol 1966;22:790-802. 9. Langeland K, Block R, Grossman L. A histopathologic and histobacteriologic study of 35 periapical endodontic surgical specimens. J Endodon 1977;3:8-12. 10. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correJations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:846-71.
A Happy Thought Falsification of medical research data is to be universally deplored. However, one can feel sympathy for the suggestion that data be published to show a direct causative relation between teenage smoking and the development of severe ache. That would change behavior! William Cornelius
Printed in U.S.A.
VOL. 25, No. 1, JANUARY1999
CASE REPORT Periapical Repair after Conservative Treatment of a Cariously Involved First Molar Christen John Nielsen, DMD, MS
A case is presented wherein existing periapical pathology, including both bone and root resorption, was successfully treated and pulp vitality maintained by restoration of a deep carious lesion in a mandibular first molar. A review of the literature demonstrates that under certain conditions such success may be expected, but all cases reported to date have involved pulpotomies or indirect/direct pulp capping procedures. Successful treatment seems to depend on a tooth being relatively young, asymptomatic, and having normal responses to vitality testing.
CASE REPORT In the present case, a 23-yr-old male with a nonremarkable medical history presented for endodontic treatment of a carious mandibular right first molar with "apical involvement." Upon examination, it was noted that this tooth had been asymptomatic in the past, and currently demonstrated normal responses to thermal and electric vitality testing and percussion. The tooth had been restored with mesioocclusal and buccal amalgam restorations some time in the past. Distal caries was evident clinically. A periapical radiograph showed a large restoration with distal caries in close proximity to the pulp (Fig. 1). Caries was also noted on both adjacent teeth. Distinct apical radiolucencies were noted on the blunted distal root and mesial root of the first molar along with condensing osteitis. Based primarily on the radiographic evidence, a diagnosis of probable irreversible pulpitis with chronic apical periodontitis was made. Because the patient was eager to avoid endodontic therapy in the absence of clinical symptoms, the decision was made to temporarily restore the tooth (after no carious exposure was noted during caries excavation), then evaluate and
It is a widely held belief that once pulpally induced periapical pathology has progressed to the point that distinct radiographic evidence of bone destruction has occurred, endodontic therapy (or extraction) is the recommended course of treatment. Several reports in the literature, however, cite instances where conventional endodontics is not necessary in restoring periapical health. Moore (t) was the first to report successful restitution of periapical health by use of both indirect and direct pulp-capping procedures. His protocol included treating deep caries with calcium hydroxide, then at a subsequent appointment, removing all remaining carious dentin and restoring. Sapone (2) reported two cases of cariously involved teeth with periapical lesions successfully treated with direct pulp capping. Finally, Jordan et al. (3), using a protocol in which subsequent removal of remaining caries was not done after initial indirect pulp capping, was able to show resolution of periapical pathosis with preservation of pulp vitality in 11 cases. In all reports, cage selection and diagnosis were considered critical to success in so far as only young patients ( < 2 4 yr old) with what was considered to be a reversible pulpal condition were seen to benefit from the treatment rendered. Clinical success depended on a tooth demonstrating vitality to thermal and electrical stimulation and an absence of spontaneous pain.
FIG 1. Note caries on second premolar, first and second molars, and radiolucency with condensing osteitis on resorbed distal root of the first molar with widening of apical periodontal ligament of mesial root. 60
Voh 25, No. 1, January 1999
FIG 2. Amalgam restoration of first molar 7 wk after initial temporization.
Periapical Repair after Caries Restoration
61
FiG 4. Eleven months after initial temporization. Good osseous healing of both mesial and distal root apices.
DISCUSSION
FIG 3. Eight months after initial temporization. Good osseous healing of both mesial and distal root apices.
permanently restore at a future date if symptoms did not subsequently arise. Initial treatment consisted of complete caries removal in all three teeth. An Intermediate Restorative Material (IRM) restoration was placed in the first molar, whereas the other teeth received amalgam restorations. Seven weeks later, the patient returned for an amalgam restoration in which the IRM was left in the deepest portion of the preparation as a base. A periapical radiograph confirmed the existence of periapical radiolucencies on both roots, but the tooth continued to be asymptomatic (Fig. 2). The patient was seen 8 wk later (15 wk after initial temporization with IRM), at which time the tooth was reported to be asymptomatic. A periapical radiograph indicated apparent bone deposition within the previously lucent areas at both the mesial and distal root apices (Fig. 3). The patient was seen twice more, at 8 and 11 months, after the initial treatment. Radiographs taken at both times revealed excellent osseous healing with diminished osteitis (Fig. 4). The tooth had remained asymptomatic and tested normally to percussion, thermal tests, and the electric pulp test at the final appointment. Further evaluation could not be done because the patient left the area.
The resolution of periapical pathology white maintaining pulpal viability has been well documented in the case of pulpotomies (4-6), but such treatments are generally followed by conventional endodontics after circumstances leading to the choice of pulpotomy have changed (e.g. a patient becomes more cooperative, financing becomes available, or root development has progressed to where endodontics is considered more feasible). Long-term maintenance of complete pulp viability in the presence of periapical pathology has been rarely reported in the literature. In all cases, treatment consisted of either direct pulp capping (2) or indirect pulp capping (1, 3). In the present case neither procedure was found to be necessary, and initial treatment, consisting of a simple zinc oxide-eugenol-based temporary restoration followed by an amalgam restoration, resulted in a successful outcome. The other distinguishing characteristic of this case was the distal root resorption. In no other reported case was it evident that such a condition existed preoperatively. The ability of a pulp to remain viable in conditions such as described in this case and in other references cited apparently may depend on several factors. Because no report has ever shown success in patients over the age of 24, it has been suggested that a young pulp is better able to withstand the onslaught of carious insult, in part due to its richer blood supply and natural defenses (7). In addition, it would seem critical that absence of symptoms and a normal response to vitality testing be present to ensure the pulp's presumed viability at the commencement of treatment. It may nevertheless be difficult for the clinician to come to grips with the idea that a pulp can retain health in the presence of periapical pathology. Historically, a lesion characteristic of chronic apical periodontitis dictates endodontic therapy once a pulpal etiology is established. The assumption by most clinicians is that, in the presence of bone destruction, either the pulp is totally inflamed (and hence irreversibly damaged) or, in fact, necrotic. However, such does not have to be the case, because both Bender et al. (8) and Langeland et al. (9) have demonstrated uninflamed radicular pulp between inflammation of both coronal pulp and periapical tissue. Seltzer et al. (10) speculated that fibrous collagen bundles of radicular pulp were responsible for limiting progression of the infammatory infiltrate into the root portion of the pulp, whereas chronic inflammatory cells were still found in the periapical area. Langeland et al. (9) attributed the appearance of periapical inflam-
62
Journal of Endodontics
Nielsen
mation in the presence of relatively unaltered radicular pulp tissue to the presence of lymph vessels carrying tissue breakdown products and bacterial toxins past the radicular portion into the periapical area. These considerations give histological credence to the concept that young pulp tissue can--in an asymptomatic, normally responsive tooth--maintain its integrity even in the presence of periapical inflammation with bone destruction. This case report demonstrates a case in which pulpal and periapical health were maintained after initial radiographic evidence of osseous destruction, and root resorption was noted in conjunction with deep caries without pulp exposure. A review of the literature indicates that similar cases involving direct and indirect pulp capping may succeed if case selection (young, asymptomatic patient) and diagnosis (evidence of initial pulp vitality) are considered.
Dr, Nielsen is assistant professor, section head, Endodontics, Department of Applied Dental Medicine, University of Southern Illinois, School of Dental Medicine, Carbondale, IL. Address requests for reprints to Dr. Christen J. Nielsen, 108 Kingsbrooke Boulevard, Glen Carbon, IL 62034.
References 1. Moore DL. Conservative treatment of teeth with vital pulps and periapical lesions: a preliminary report. J Prosthet Dent 1967;18:476-81. 2. Sapone J. Vital pulp therapy. In: Cohen S, Burns RC. Pathways of the pulp. 1st ed. St. Louis: CV Mosby Co., 1976:580-1. 3. Jordan RE, Suzuki M, Skinner DH. Indirect pulp-capping of carious teeth with periapical lesions. J Am Dent Assoc 1976;97:37-43. 4. Caliskan MK. Pulpotomy of carious vital teeth with periapical involvement. tnt Endod J 1995;28:172-6. 5. Russo MDEC, Holland R, deSouza V. Radiographic and histological evaluation of the treatment of inflamed dental pulp. Int Endod J 1982;15:13742. 6. Moule JA, Oswald JR. Resolution of periapical radiolucency following pulpotomy. J Endodon 1983;9:388-9. 7. Kim S, Trowbridge HO. Pulpal reaction to caries and dental procedures. In: Cohen S, Burns RC. Pathways of the pulp. 4th ed. St. Louis: CV Mosby Co., 1987:444. 8. Bender IB, Seltzer S, Soltanoff W. Endodontic success--a reappraisal of criteria. Oral Surg Oral Med Oral Pathol 1966;22:790-802. 9. Langeland K, Block R, Grossman L. A histopathologic and histobacteriologic study of 35 periapical endodontic surgical specimens. J Endodon 1977;3:8-12. 10. Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correJations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:846-71.
A Happy Thought Falsification of medical research data is to be universally deplored. However, one can feel sympathy for the suggestion that data be published to show a direct causative relation between teenage smoking and the development of severe ache. That would change behavior! William Cornelius