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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 100-104

Bone regeneration on chronic apical abscess after root canal treatment on left mandibular first molar: A case report


Department of Conservative Dentistry, Faculty of Dentistry, Trisakti University, West Jakarta, Indonesia

Date of Submission26-Jun-2019
Date of Decision13-Aug-2019
Date of Acceptance01-Sep-2019
Date of Web Publication14-Oct-2019

Correspondence Address:
Dr. le Elline Istanto
Department of Conservative Dentistry, Faculty of Dentistry, Trisakti University, West Jakarta
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SDJ.SDJ_17_19

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  Abstract 


Background: A chronic apical abscess is defined as an inflammatory response to pulp infection and necrosis. It is identified by a step-wise onset, almost no discomfort, and the discontinuous release of pus through a related sinus tract. Radiographically, there are regular indications of bone destruction, such as radiolucency. The source of the infection in the root canal should be eradicated by root canal treatment. The main purpose of endodontic treatment is the finished debridement of the pulp tissue from the canal combined with the shaping and sufficient obstruction of the root canal system. This case report was written to show the proper management of a tooth with a chronic apical abscess and to reveal self-bone regeneration after treatment. Case Report: A 27-year-old woman complained of a cavity on her left lower back tooth, and she wanted it to be filled. There was a history of a fistula that appeared frequently in the gums near the decayed tooth. The radiographic examination showed that the caries had reached the pulp, along with a periapical lesion and bone destruction. The canals were prepared using a file instrument and irrigation with 5.25% sodium hypochlorite, 17% ethylenediaminetetraacetic acid, and 2% chlorhexidine gluconate. Calcium hydroxide paste was used as an intracanal medicament, and the canals were obturated using a continuous wave compaction technique. At the 4-month follow-up, healing of the periapical lesion and bone regeneration was evident. Conclusion: Adequate root canal treatment can result in the healing of periapical lesions and bone regeneration in chronic apical abscesses.

Keywords: Bone destruction, bone regeneration, endodontic treatment, periapical lesion


How to cite this article:
Indah DP, Fibryanto E, Istanto lE. Bone regeneration on chronic apical abscess after root canal treatment on left mandibular first molar: A case report. Sci Dent J 2019;3:100-4

How to cite this URL:
Indah DP, Fibryanto E, Istanto lE. Bone regeneration on chronic apical abscess after root canal treatment on left mandibular first molar: A case report. Sci Dent J [serial online] 2019 [cited 2019 Dec 6];3:100-4. Available from: http://www.scidentj.com/text.asp?2019/3/3/100/268998




  Background Top


Periapical lesions are some of the most common pathological conditions affecting periradicular tissues.[1] These lesions (>90%) can be categorized as dental granulomas, radicular cysts, or abscesses.[2] The occurrence of abscesses ranges between 28.7% and 70.07%,[3] and periapical abscesses can be categorized as acute or chronic. A chronic apical abscess is an inflammatory response to a pulpal infection and necrosis as identified by a stepwise onset, almost no discomfort, and the discontinuous release of pus through a related sinus tract. Radiographically, there are regular indications of bone destruction, such as radiolucency.[4] In general, the presence of a sinus tract in the oral mucosa indicates underlying necrosis of the dental pulp, periapical suppuration, or the periodontal destruction of a tooth or teeth. This leads to the resorption of the apical bone or the buccal or lingual cortical plate and the mucoperiosteum, with the sinus tract reaching the mucosal surface for drainage.[5] Apical periodontitis is induced by microorganisms in the root canal system, which can lead to apical inflammation. This may cause local inflammation, hard-tissue resorption, or the destruction of other periapical tissues.[6]

It is important to eradicate microorganisms in the root canal system. The purpose of root canal treatment is to eliminate vital or necrotic pulp tissue and irritants from the root canal system, and thus improve healing. Therefore, optimum root canal cleaning and disinfection are important to induce quicker healing of the periradicular tissue.[7] The main purpose of endodontic treatment is the finished debridement of the pulp tissue from the root canal, combined with shaping and the sufficient obstruction of the root canal system.

This case report was written to show the proper management of a tooth with chronic apical abscesses and to reveal self-bone regeneration after the treatment.


  Case Report Top


A 27-year-old woman presented to the Department of Conservative Dentistry, Faculty of Dentistry, Trisakti University, with a complaint regarding tooth number 36. The tooth had never been treated, before experienced spontaneous pain 1 year previously. There was a history of a sinus tract appearing frequently in the gums near the decayed tooth. The extraoral examination revealed no signs or symptoms. However, the intraoral examination revealed the presence of a deep disto-occlusal carious lesion approaching the pulp, and there was a sinus tract in the gingiva near the filled tooth [Figure 1]. The vitality tests using a cold thermal test, and an electric pulp tester provided negative responses, and there was no tenderness on percussion or palpation. The radiographic examination showed that caries had reached the pulp with a periapical lesion and the bone destruction of tooth 36 [Figure 2]. The diagnosis of tooth 36 was a chronic apical abscess with causal pulp necrosis.
Figure 1: Preoperative photo

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Figure 2: Preoperative radiograph

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Root canal treatment was performed on tooth 36. First, the tooth was isolated with a rubber dam. An artificial wall was built, with access cavity preparation, and three canals (mesiobuccal, mesiolingual, and distal) were found on tooth 36. On exploration, the canals were negotiated to the apex using #8, #10, and irrigated K-files. The working length was determined using an electronic apex locator (Root ZX; J. Morita Corp., Osaka, Japan), and it was radiographically confirmed. An apical glide path was established using a ProGliderfile (Dentsply Sirona, Charlotte, NC, USA).

The biomechanical preparation of the root canals was conducted with the ProTaper next rotary system (Dentsply Sirona) using the single length technique. The canals were irrigated with 5.25% sodium hypochlorite (NaOCl) between the instrumentations. Then, the mesiobuccal and mesiolingual canals were shaped with an X2 file, and the distal canal was shaped using an X3 file. Finally, the root canals were irrigated using 5.25% NaOCl, 17% ethylenediaminetetraacetic acid (EDTA), and 2% chlorhexidine gluconate agitated using EndoActivator tip #25 (Dentsply Sirona). They were dried using Paper Points [Figure 3]. Calcium hydroxide (UltraCal; Ultradent Products, Inc., South Jordan, UT, USA) was used as an intracanal medicament, and the patient was recalled after 1 week.
Figure 3: After biomechanical preparation

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The 1-week follow-up extraoral examination revealed no signs, and the intraoral examination revealed that the sinus tract had disappeared. The percussion and palpation tests provided negative responses. The tooth was isolated with a rubber dam, and the root canals were cleaned with 5.25% NaOCl. Radiographic evaluation to confirm the fitness of root canal filling material showed that Gutta-percha X2 was fitted into the mesiobuccal canal and the mesiolingual canal, while Gutta-percha X3 was fitted into the distal canal [Figure 4]. Final irrigation was conducted using 5.25% NaOCl, 17% EDTA, 2% chlorhexidine gluconate, and saline. The irrigating solution was activated using the EndoActivator tip #25 for the final irrigation. The canals were then dried using Paper Points. Next, the canals were obturated using a continuous wave compaction technique and sealer (Sealapex; SybronEndo, Orange, CA, USA), Gutta-percha cutting up to 2 mm below the orifice and compacting it [Figure 5]a and [Figure 5]b. The orifice barrier was formed using glass ionomer cement, and temporary fillings were placed.
Figure 4: Master point Gutta-percha trial radiograph

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Figure 5: (a) Obturation. (b) Obturation radiograph

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At the 1-week follow-up, the extraoral and intraoral examinations revealed no symptoms or signs. The final restoration was performed using a fiber postcore and porcelain fused to metal a crown [Figure 6]a and [Figure 6]b. At the 4-month follow-up, healing of the periapical lesion and bone regeneration were evident [Figure 7]a and [Figure 7]b. The patient received all of the proper patient consent forms. This patient signed a form providing her consent for her pictures and other clinical data to be presented in the journal.
Figure 6: (a) Fiber postcementation. (b) One-weeks follow-up, sinus tract disappeared

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Figure 7: (a) Four-month follow-up. (b) Four-month follow-up radiograph

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  Discussion Top


A chronic apical abscess is a type of apical periodontitis caused by a root canal infection that creates abscesses to the surface.[8] This condition is generally described by periapical radiolucency related to the intraoral sinus tract and drainage pathway abscesses that pass through the bone, periosteum, and mucosa.[9]

Bacteria and their products located in the root canal system are the main causes of the beginning and persistence of periapical inflammatory lesions. Initially, the pulp becomes infected and necrotic. Due to the interrelationship between the pulp and the periradicular tissues, the pulpal inflammation causes changes in the periodontal area, which results in periodontal lesions. The bacterial invasion and infection of the root canal systems play a decisive role in the initiation and progression of periapical lesions. Host defenses are not equipped to destroy an infection established in the necrotic pulp due to a lack of circulation. The immune response of the periapical tissues includes both innate and adaptive responses to the irritants,[1] the body does not have the ability to destroy the bacteria that live deep in the necrotic root canal, which is beyond the body's immune system. Therefore, the main purpose of the root canal treatment is to eliminate biofilms and bacteria and their products.[10]

The biomechanical preparation of the root canals in this case was done using the ProTaper next rotary system (Dentsply Sirona). The ProTaper Next is made using M-wire NiTi alloys, and it has the advantages of increased flexibility, resistance to cyclic fatigue, and the reduced potential for broken instruments.[11] In addition, the advantages of this file include having an off-centered rectangular cross-sectional shape in the middle and only two points of contact on the root canal wall. The rectangular cross-sectional shape provides more space for increased cutting, loading, auguring, and reducing the contact between the file and the dentin to maximize the debris removal toward the corona.[12] Root canal treatment with mechanical preparation and antibacterial irrigation can reduce 40%–60% of the Gram-negative bacteria.[13]

In this case, a calcium hydroxide intracanal medicament was used. It plays a role in triggering periapical tissue repair due to the following characteristics: antimicrobial action and anti-inflammatory activity, destroying necrotic material, decreasing matrix metalloproteinases, supporting tissue mineralization through alkaline phosphatase activation and collagen synthesis, increasing the extracellular calcium levels through calcium ions, and causing the differentiation of periodontal ligament cells.[14] Calcium hydroxide has a high pH (12.5–12.8), and it is divided into calcium and hydroxyl ions. The hydroxyl ions are highly alkaline. Bacteria are not able to live in a highly alkaline environment, such as the pH level of 12.5 provided by Ca(OH)2, because the hydroxyl ions can damage the bacterial cytoplasmic membrane and DNA and alter the proteins.[15] Broon et al. reported that the success rate was 94% in cases of endodontic treatment with periapical lesions using calcium hydroxide paste for an intracanal medicament.[16]

The process of periapical healing after root canal treatment will direct the regeneration of soft and hard tissue.[17] The new formation of bone and cementum has been found after a decrease in the apical inflammatory process.[16] During the periapical healing process, the osteoprogenitor (OPG) cells or mesenchymal cells in the bone marrow can go through proliferation and differentiation into osteoblasts and produce bone matrix.[17] OPG cells are stimulated by bone morphogenetic proteins (BMPs) to become OPG cells. OPG cells chemotactically attract certain growth factors, including the epidermal growth factor, insulin-like growth factor, transforming growth factor-beta, and platelet-derived growth factor, and cause them to proliferate. BMPs cause the last differentiation of the OPG cells into cuboidal, metabolically active osteoblasts that line the bone surface and produce osteoid that will later mineralize and transform into bone.[18]


  Conclusion Top


Adequate root canal treatment can result in the healing of periapical lesions and bone regeneration in teeth with chronic apical abscesses.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images, and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Karunakaran JV, Abraham CS, Karthik AK, Jayaprakash N. Successful nonsurgical management of periapical lesions of endodontic origin: A Conservative orthograde approach. J Pharm Bioallied Sci 2017;9:S246-51.  Back to cited text no. 1
    
2.
Lalonde ER, Luebke RG. The frequency and distribution of periapical cysts and granulomas. An evaluation of 800 specimens. Oral Surg Oral Med Oral Pathol 1968;25:861-8.  Back to cited text no. 2
    
3.
Schulz M, von Arx T, Altermatt HJ, Bosshardt D. Histology of periapical lesions obtained during apical surgery. J Endod 2009;35:634-42.  Back to cited text no. 3
    
4.
Berman LH, Rotstein I. Diagnosis. In: Hargreaves KM, Berman LH, Rotstein I editors. Cohen's Pathways of the Pulp. 11th ed. Missouri: Elsevier; 2016. p. 2-30.  Back to cited text no. 4
    
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Tai TF, Huang SH, Lin CP, Tsai YL, Jeng JH. Sinus tracts from proximal roots with infected root canals cases report. J Dent Sci 2006;1:202-6.  Back to cited text no. 5
    
6.
Croitoru IC, CrăiṬoiu Ş, Petcu CM, Mihăilescu OA, Pascu RM, Bobic AG, et al. Clinical, imagistic and histopathological study of chronic apical periodontitis. Rom J Morphol Embryol 2016;57:719-28.  Back to cited text no. 6
    
7.
Sigurdsson A, Garland RW, Le KT, Woo SM 12-month healing rates after endodontic therapy using the novel gentleWave system: A Prospective multicenter clinical study. J Endod 2016;42:1040-8.  Back to cited text no. 7
    
8.
Gupta R, Hasselgren G. Prevalence of odontogenic sinus tracts in patients referred for endodontic therapy. J Endod 2003;29:798-800.  Back to cited text no. 8
    
9.
Ricucci D, Loghin S, Gonçalves LS, Rôças IN, Siqueira JF Jr., Histobacteriologic conditions of the apical root canal system and periapical tissues in teeth associated with sinus tracts. J Endod 2018;44:405-13.  Back to cited text no. 9
    
10.
Cohenca N, Amaro AM. Root canal infection and endodontic disease. In: Cohenca N. editor. Disinfection of Root Canal Systems: The Treatment of Apical Periodontitis. Oxford: Wiley Blackwell; 2014. p. 3-12.  Back to cited text no. 10
    
11.
Chandrasekhar P, Shetty RU, Adlakha T, Shende S, Podar R. A comparison of two NiTi rotary systems, protaper next and silk for root canal cleaning ability (An in vitro study). Indian J Conserv endod 2016;1:21-3.  Back to cited text no. 11
    
12.
Ruddle CJ, Machtou P, West JD. The shaping movement: Fifth-generation technology. Dent Today 2013;32:94, 96-9.  Back to cited text no. 12
    
13.
Sathorn C, Parashos P, Messer HH. Effectiveness of single- versus multiple-visit endodontic treatment of teeth with apical periodontitis: A systematic review and meta-analysis. Int Endod J 2005;38:347-55.  Back to cited text no. 13
    
14.
Bezerra da Silva LA, Bezerra da Silva RA, Nelson-Filho P, Cohenca N. Intracanal medication in root canal disinfection. In: Nestor Cohenca, editor. Disinfection of Root Canal Systems: The Treatment of Apical Periodontitis. Oxford: Wiley Blackwell; 2014. p. 252-3.  Back to cited text no. 14
    
15.
Kim D, Kim E. Antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: A literature review – part II.In vivo studies. Restor Dent Endod 2015;40:97-103.  Back to cited text no. 15
    
16.
Broon NJ, Bortoluzzi EA, Bramante CM. Repair of large periapical radiolucent lesions of endodontic origin without surgical treatment. Aust Endod J 2007;33:36-41.  Back to cited text no. 16
    
17.
Lin ML, Huang GT. Pathobiology of apical periodontitis. In: Hargreaves KM, Berman LH, Rotstein I editors. Cohen's Pathways of the Pulp. 11th ed. Missouri: Elsevier; 2016. p. 652-5.  Back to cited text no. 17
    
18.
Metzger Z, Kfir A. Healing of apical lesions: How do they heal, why does the healing take so long, and why do some lesions fail to heal? In: Cohenca N, editor. Disinfection of Root Canal Systems: The Treatment of Apical Periodontitis. Oxford: Wiley Blackwell; 2014. p. 303-5.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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