healing of apical tissues after root canal...

Healing of apical tissues after root

canal treatment

Domenico Ricucci MD, DDS

Dansk EndodontiforeningHindsgavl Slot d. 8. -9. januar 2016

•Schilder H. Filling root canals in three dimensions. Dent Clin North Am. Philadelphia and

London; WB Saunders Co. p. 723. 1967.

•Schilder H. Canal debridement and disinfection. In: Cohen S, Burns RC, Pathways of the pulp,

2nd edn. St. Louis, U.S.A.: C.V. Mosby. p. 111. 1976.

•Langeland K. The histopathologic basis in endodontic treatment. Dental Clinics of North

America; Philadelphia and London: WB Saunders Co, pp. 491-520; 1967.

•Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part II. A

histological study. Int Endod J 31:394-409; 1998.

Vital pulp tissue Necrotic pulp tissue

(partial)

Necrotic pulp tissue

(total)

Vital pulp tissue

“To leave the apical and foraminal part of the pulp tissue and to retain

its vitality will play a decisive role for the success in the treatment of

the vital pulp.” “In cases where the pulp is vital before treatment, no

matter whether the diagnosis be clinically intact pulp, acute or chronic

pulpitis, partial extirpation seems to give the most favourable

prognosis. By appropriate treatment, in the majority of cases, the

vitality of the residual pulp may be conserved, the result being a

normal apical periodontal ligament and fibrous connective tissue in

the apical portion of the root canal.”

NYGAARD-ØSTBY B (1944) Om vevsforandringer i det apikale

paradentium hos mennesket ved rotbehandling. Nye kliniske,

røntgenologiske og histopatologiske studier. Det Norske

Videnskaps-Akademi. 2, 57; Oslo.

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Vital pulp

Instrum. 2 mm short of radiographic apex

Irrigation 1% NaOCl

Ca(OH)2 medication

Biopsy after 82 days

Patency??? Patency???

Histopathologic status of the tissue in LC/AR

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In vital cases where the filling material was not seen

within lateral canals, the tissue therein usually

remained vital and there was no significant influence

on the outcome.

Ricucci D, Siqueira JF Jr. Fate of the tissue in lateral canals and

apical ramifications in response to pathological conditions and

treatment procedures. J Endod 2010; 36:1-15.

9yr 5mo

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100x25x Apical collar

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1yr 3mo 1yr 8mo

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Apical

constriction

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Sealer: Apexit

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400xSealer: Apexit

13yr 5mo

25x 100xPalatal root apex

18yr 7mo9yr 3mo

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Kronfeld R. Histopathology of the teeth and their surrounding

structures. 2nd ed. Lea & Febiger, Philadelphia, 1943, p. 228.

“Most roots are slightly underfilled…and containing fibrous

connective tissue, which may be either a remnant of the original

pulp tissue or periodontal connective tissue that proliferated into

the open apical portion of the root canal. The connective tissue has

a tendency to form cementum, which is deposited in layers on the

wall of the pulp canal.”

Kronfeld R. Histopathology of the teeth and their surrounding

structures. 2nd ed. Lea & Febiger, Philadelphia, 1943, p. 228.

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Ricucci D, Siqueira JF Jr, Loghin S, Lin LM.

Repair of extensive apical root resorption associated with apical periodontitis. Radiographic and

histologic observations after 25 years. Report of a case.

J Endod 2014; 40:268-74.

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Brynolf I. A histological and roentgenological study of the periapical region

of human upper incisors. Odont Revy 18 (supp. 11):1-176; 1967.

Only 6% of root filled teeth could be considered histologically healthy.

Green TL, Walton RE, Yaylor JK, Merrel P. Radiographic and histologic

periapical findings of root canal treated teeth in cadaver. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod 83:707-711; 1997.

Barthel CR, Zimmer S, Trope M. Relationship of radiologic and histologic

signs of inflammation in human root-filled teeth. J Endod 30:75-79; 2004.

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2

Can overfilling impair treatment outcome?

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Spångberg LSW, Haapasalo M. Rationale and efficacy of root canal

medicaments and root filling materials with emphasis on treatment

outcome. Endodontic Topics 2:35-58; 2002.

“The majority of root canal filling materials are relatively inert after

setting...No commonly used material, however, can by itself cause a

progressively growing bone lesion. Therefore, it is logical to

question the wisdom of the negative effect observed on treatment

outcome of excess filling material. It appears that the increased rate

of failures associated with excess of materials also has some

association with failure to obtain a completely disinfected pulp

space before obturation.”

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Ricucci D, Lin LM, Spångberg LSW. Wound healing of apical tissues after root

canal therapy: A long-term clinical, radiographic, and histopathologic observation

study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108:609-621; 2009.

51 human teeth

Observation periods ranged from 2 years to 22 years and 4 months

(mean 10 years 3 months).

Various sealers were used in a random fashion during this study. Most

commercially available sealers become practically inert after some

time. As the observation periods in this study was very long it is very

unlikely that any material toxicity would be discernible as tissue

changes. No clinical association with outcome could be observed

when comparing the long term treatment results of the sealer used

here.

Ricucci D, Rôças IN, Alves FRF, Loghin S, Siqueira JF Jr.

Apically extruded sealers: fate and influence on treatment outcome.

Journal of Endodontics 2016. In press.

105 teeth treated by a single operator (75 of which showing apical

periodontitis lesions) and exhibiting overfillings in the postobturation

radiograph were included in the study.

Sealer included:

Pulp Canal Sealer (PCS), PCS Extended Working Time-EWT, Tubli-

Seal, Endomethasone, AH Plus, and Apexit.

Sealer Baseline 1-yr follow-up 2-yr follow-up >4-yr follow-up

N Present Absent Present Absent Present Absent Absent %

AH Plus 20 13 1 16 1 17 3 15

Apexit 15 7 2 8 0 10 5 33

Endomethasone 15 7 2 4 5 2 13 87

PCS 28 8 6 8 8 5 23 82

PCS EWT 21 9 5 9 10 6 15 71

Tubli-Seal 6 0 3 0 4 0 6 100

Table 1. Fate of different sealers after unintentional extrusion to the periradicular tissues over different follow-up periods

4yr 7yr

PCS EWT

3yr 6moPCS EWT

5yr

6yr 10mo AH Plus

1yr 9yr 5mo

AH Plus

4yr 9mo

Apexit

16yr

Table 2. Outcome of the endodontic treatment of teeth without apical periodontitis

after unintentional extrusion of different sealers to the periradicular tissues


N Healed Diseased Healed Diseased Healed Diseased Healed %

AH Plus 2 2 0 1 0 2 0 100

Apexit 4 1 0 1 0 4 0 100

Endomethasone 6 3 0 3 0 6 0 100

PCS 7 5 0 5 0 7 0 100

PCS EWT 10 8 0 10 0 10 0 100

Tubli-Seal 1 1 0 1 0 1 0 100

Table 3. Outcome of the endodontic treatment of teeth with apical periodontitis

after unintentional extrusion of different sealers to the periradicular tissues


N Healed Healing Not healed Healed Healing Not healed Healed Not healed Healed %

AH Plus 18 4 6 1 11 3 2 14 4 78

Apexit 11 5 2 1 4 2 1 9 2 82

Endomethasone 9 2 2 2 2 3 1 8 1 89

PCS 21 4 1 4 5 2 4 14 7 67

PCS EWT 11 3 2 1 7 1 1 10 1 91

Tubli-Seal 5 2 1 0 2 1 0 4 1 80

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“14 of the 17 roots with late signs of periapical healing had been

filled with surpluss material extruding into the periapical area in

necrotic cases. These cases can, therefore, be explained as healing

processes disturbed by a foreign-body reaction.”

Molven O, Halse A, Fristad L, MacDonald-Jankowski D. Periapical changes

following root-canal treatment observed 20-27 years postoperatively. Int Endod J

35:784-790; 2002.

Fristad L, Molven O, Halse A. Nonsurgically retreated root-filled teeth –

radiographic findings after 20-27 years. Int Endod J 37:12-18; 2004.

Thank you

for your attention

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healing of apical tissues after root canal...

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