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The influence of endodontic treatment upon periodontal wound healing.

The interrelationship between periodontal and endodontic disease has aroused much speculation, confusion, and controversy. Pulpal and periodontal problems are responsible for more than 50% of tooth mortality today. Diagnosis is often difficult since these diseases have been studied primarily as separate entities. The toxic substances of the pulp may initiate periodontal defects through canal ramifications and patent dentinal tubules, thus impairing wound healing in regenerative procedures. Although no studies exist addressing the direct effect of pulpal infection on the outcome of guided tissue regeneration (GTR) procedures, several studies do indicate that pulpal status may play a significant role toward the end results of GTR. This review article discusses the potential influence of endodontic treatment on the long-term outcomes of GTR. Potential pathways between the pulp and periodontal ligament, which may be responsible for the failure of the regeneration of new periodontal attachment apparatus, are explored. Examination and review of the clinical and research findings in the literature relating to perio-endo lesions are made to demonstrate that a negative influence may exist between GTR outcomes and the status of the pulp.

Bacterial Infections↗

[Pain after cementation of cast restorations].

Some patients experience pain after cementation of a cast restoration on a vital tooth. Limited data are available on the prevalence of this pain. In many cases the pain disappears within two weeks. The major cause of the pain might be attributed to more permeability of the dentine after preparation. Consequently, bacteria have free access towards the pulp. With respect to the cement, it is more likely that microleakage after cementation will be the cause of pulpal problems than toxicity of the cement. In order to prevent pain, the use of a desensitizer (a primer or a bonding) can be considered. However, use of a desensitizer in combination with some cements, can reduce the retention of a cast restoration. More important than the use of a desensitizer seem precautions during the procedures of preparing the restoration, like using sufficient cooling water and preventing a tooth from dehydration.

Cementation↗

Effect of intermittent long-lasting electrical tooth stimulation on pulpal blood flow and immunocompetent cells: a hemodynamic and immunohistochemical study in young rat molars.

Release of sensory neuropeptides after stimulation of afferent nerve fibers has previously been shown to induce vasodilation and increased vascular permeability in the dental pulp, a condition recognized as neurogenic inflammation. In the present study a possible role for the sensory neuropeptides in transendothelial migration of immunocompetent cells was investigated. The dental pulp is an isolated tissue densely innervated with sensory fibers containing neuropeptides, and following electrical stimulation of the crown, the effect on pulpal blood flow and immunocompetent cells can be studied in a noninvasive model. A laser Doppler flowmeter was used to measure relative changes in pulpal blood flow during long-lasting intermittent stimulation of innervated and denervated rat first molars. In the innervated teeth, stimulation promptly increased pulpal blood flow by on average 45% at the start of the experiment, whereas almost no blood flow increase was recorded after 4 to 5 h stimulation. Surgical sectioning of the inferior alveolar nerve abolished blood flow increase upon stimulation. After stimulation, a quantitative analysis of CD43+, CD4+, CD11+, and I-A antigen-expressing cells was performed, and the effect of stimulation on calcitonin gene-related peptide (CGRP)-immunoreactive and substance P (SP)-immunoreactive (IR) nerve fibers was studied. Immunohistochemistry was performed by the avidin-biotin peroxidase method. Stimulation resulted in an almost complete depletion of CGRP- and SP-IR nerve fibers in the first molar pulp, whereas nerve fibers in the gingiva and neighboring teeth were unaffected. A significant increase in the number of CD43+ cells was found in the innervated tooth after stimulation compared to the stimulated denervated (P < 0.01) and unstimulated control (P < 0.05) first molars. For I-A antigen-expressing cells a significant increase (P < 0.05) was found between the innervated stimulated and unstimulated control, but not between the innervated and denervated stimulated first molars. Hence, from the present experiment it is concluded that the pulpal nerves participate in and facilitate transendothelial migration of CD43+ cells during acute neurogenic inflammation.

Afferent Pathways↗

The permeability of human cementum in vitro measured by electron paramagnetic resonance.

The structure and permeability of cementum are changed during the course of periodontal disease. In this study, the transport of water-soluble, spin-labelled molecules through cementum was studied by electron paramagnetic resonance (EPR). Cementum samples cut from different parts of the root were classified into four different groups: (A) samples exposed to the oral environment, (B) samples exposed to the periodontal-pocket environment; (C) samples cut from periodontally involved teeth but not exposed to saliva or periodontal pocket and (D) samples from sound young teeth extracted for orthodontic reasons. In order to obtain undamaged cementum, a dentine layer was left on each sample. Two methods were used to measure the diffusion coefficients of spin-labelled molecules in cementum dentine samples. First, the method of one-dimensional EPR imaging (EPRI) was used to evaluate the penetration of spin-labelled molecules into the cementum/dentine structure. Second, the diaphragm-cell method was used to determine the diffusion coefficients of the labelled molecules through the cementum under steady-state conditions. The results indicate that the interface between cementum and dentine is a barrier to diffusion. A set of diffusion (D) and partition (K) coefficients to describe the molecular transport in cementum, barrier and dentine was generated from the experimental data of both methods. For cementum (c), the barrier (b) and dentine (d) these coefficients were: Dc= 10(-8)cm2/s, Db= 10(-10)cm2/s, Dd= 10(-6)cm2/s and K=0.1. For the particular periodontally involved and uninvolved teeth the value of the rate-limiting barrier was DbA= 0.3 +/- 0.03 x 10(-10)cm2/s, DbB= 1 +/-0.3 x 10(-10)cm2/s, DbC= 0.3 +/- 0.03 x 10(-10)cm2/s, DbD= 0.4 +/- 0.05 x 10(-10)cm2/s. The largest diffusion flux across the dental hard tissue was found in the samples that had been exposed to the pocket environment (3.1 +/- 0.2) x 10(-9)cm2/s (p < 0.01), which coincided with the permeability calculated from the data evaluated by EPRI. The transport of the labelled molecules into and through the cementum dentine samples depends on the structure of the dental hard tissues, which changes during the course of periodontal disease. Knowledge of molecular diffusion across the tooth cementum/dentine structure is likely to be important for planning new treatments for periodontal disease.

Adolescent↗

Vascular permeability in the rat gingiva. A model of vessel response in chronic inflammation.

The vascular permeability of the vessels of clinically normal gingiva of rats was studied using the colloidal carbon technique. The connective tissue situated underneath the keratinised epithelium was normal, but that subjacent to the non-keratinised epithelium showed some degree of chronic inflammation and as a rule the vessels of the area exhibited increased vascular permeability. In the buccal gingiva the vessels labelled with carbon form loops situated 200 micrometers below the marginal gingiva, while in the interdental gingiva the altered vessels are just below the superficial epithelium. On electron microscopy the vessels in the inflamed areas showed many open endothelial junctions, and also pseudo-fenestration, and endoplasmic vesicles full of carbon. Little is known about vascular changes in chronic inflammation, and the rat gingiva seems to be a suitable model for their study.

Animals↗

The density and branching of dentinal tubules in human teeth.

Detailed knowledge of dentine structure, and especially that of the dentinal tubules, is essential in order to understand dentine permeability and to interpret data from investigations on dentine adhesive materials. The aim here was to examine the density and branching of dentinal tubules in human teeth by light and scanning electron microscopy. Stained and unstained demineralized sections and undemineralized fractured specimens were studied. Statistically significant differences in the density of tubules were found depending on location. Differences in density of tubules between the peripheral and inner aspects were more marked in the crown than in root. The mean number of dentinal tubules in the middle part of the root was significantly lower than in the middle part of the crown. The density of the tubules in the outer dentine at the cusp location was also significantly different from that subjacent to the occlusal fissure. The number of branches of dentinal tubules was particularly abundant in locations where the density of tubules was low. The branching patterns revealed an intricate and profuse canalicular, anastomosing system, criss-crossing the intertubular dentine. Three types of branches, major, fine and microbranches, were identified on the basis of size, direction and location. Major branches, 0.5-1.0 micron dia., were the typical delta branchings found peripherally. Fine branches, 300-700 nm dia., forked off at 45 degrees and were abundant in areas such as in the root where the density of the tubules was relatively low. Microbranches, 25-200 nm dia., extended at right angles from the tubules in all parts of the dentine. The findings emphasize the need for detailed characterization of dentine substrates for adhesive testing and of samples used in permeability studies.

Adolescent↗

Resin bonding to cervical sclerotic dentin: a review.

Several reports have indicated that resin bond strengths to noncarious sclerotic cervical dentine are lower than bonds made to normal dentine. This is thought to be due to tubule occlusion by mineral salts, preventing resin tag formation. The purpose of this review was to critically examine what is known about the structure of this type of dentine. Recent transmission electron microscopy revealed that in addition to occlusion of the tubules by mineral crystals, many parts of wedge-shaped cervical lesions contain a hypermineralised surface that resists the etching action of both self-etching primers and phosphoric acid. This layer prevents hybridisation of the underlying sclerotic dentine. In addition, bacteria are often detected on top of the hypermineralised layer. Sometimes the bacteria were embedded in a partially mineralised matrix. Acidic conditioners and resins penetrate variable distances into these multilayered structures. Examination of both sides of the failed bonds revealed a wide variation in fracture patterns that involved all of these structures. Microtensile bond strengths to the occlusal, gingival and deepest portions of these wedge-shaped lesions were significantly lower than similar areas artificially prepared in normal teeth. When resin bonds to sclerotic dentine are extended to include peripheral sound dentine, their bond strengths are probably high enough to permit retention of class V restorations by adhesion, without additional retention.

Acid Etching, Dental↗

Dentin demineralization: effects of dentin depth, pH and different acids.

OBJECTIVES: This investigation sought to determine: 1) if dentin demineralization rates are proportional to acid concentration for demineralization in phosphoric acid (10% or 1.76 M, 0.025 M, 0.0001 M, with pH = 0.95, 2.0, 4.0 respectively); 2) if the etching characteristics are independent of dentin depth; and 3) if the etching characteristics for phosphoric acid were comparable to those for citric acid over a similar pH range. METHODS: Highly polished dentin disks from freshly extracted, non-carious, third molars were prepared with a reference layer. Samples were prepared from either superficial or deep coronal dentin. The samples were etched for periods of up to 30 min using phosphoric acid solutions (pH = 0.95, 2.0, 4.0) in a wet cell of an atomic force microscope (AFM). Depth changes with respect to the reference layer were determined for the intertubular and peritubular dentin to quantify structural changes. The results were compared with similar studies using citric acid (pH = 1.0, 2.15 or 3.4). Etching characteristics were statistically compared using 2-way repeated measures ANOVA at p < 0.05 and the Tukey's multiple comparison test. RESULTS: The relation between time and recession for peritubular dentin was initially linear. The intertubular dentin recession started rapidly but then reached a plateau within a very short interval for etching solutions at pH = 2.0 and 4.0. At the highest concentration, the recession decreased with time, but a clear plateau was not established. There was no statistical difference between peritubular etching rates of superficial and deep dentin surfaces with phosphoric acid at any concentration. There was also no difference in the intertubular dentin recession at the location of the plateau that depended on dentin depth. Etching rates increased dramatically with decreased pH for both phosphoric and citric acids, but were higher for citric acid than for phosphoric acid. SIGNIFICANCE: The AFM allowed quantification of changes during etching of wet dentin. Peritubular dentin etching rates increased with decreasing pH, as expected, but changes were not linear and were different for the two acids studied over a similar pH range. Intertubular dentin surface recession was small and plateaued for low concentrations. The peritubular etching rate and intertubular dentin recession did not depend on dentin depth.

Acid Etching, Dental↗

Immunoglobulin G in cystic lesions of rat enamel organ following fluoride intoxication.

Fluoride given as a high single dose to young rats with developing molars has earlier been shown to cause subameloblastic cysts with disorganized ameloblasts in the cystic wall and an irregular mineralization pattern of the underlying enamel. In the present study immunohistochemistry has been employed to determine if an increased permeability of the enamel organ occurred at the areas of cell disturbances. For this purpose 5-day-old rats were injected with 60 mg sodium fluoride per kg body weight. They were decapitated after 24 h, the maxilla prepared histologically and paraffin sections incubated for the demonstration of IgG according to the avidin-biotin-peroxidase complex method. Staining for IgG was present in the cystic lumina and in areas of disorganized ameloblasts. No reaction was observed in areas of unaffected ameloblasts. It was suggested that the fluoride-induced cell injury increased the permeability of the ameloblastic cell layer. Diffusion of IgG and most likely other substances as well, through the ameloblastic layer may have contributed to cyst formation and to the irregular mineral deposits that have been found in the ameloblastic layer and at the enamel surface.

Ameloblasts↗

An in vitro model to measure the effect of a silver fluoride and potassium iodide treatment on the permeability of demineralized dentine to Streptococcus mutans.

BACKGROUND: Diamine silver fluoride (Ag(NH3)2F), referred to as AgF, has been used to reduce the incidence of caries in primary dentitions but has been limited by the associated staining of both teeth and restorative materials. The application of potassium iodide (KI), following AgF prevents staining but its effects on the ability of AgF to reduce caries are not known. The aim of this study was to develop an in vitro model that would provide an indication of the permeability of demineralized dentine to Streptococcus mutans after treatment of the dentine with AgF followed by KI. METHODS: Forty dentine discs were bonded to the base of forty 5mL polycarbonate screw top vials (that had had their bases removed), filled with nutrient medium, sterilized and placed into a continuous culture of S. mutans. Samples were divided into four groups as follows: 10 samples of demineralized dentine as a control, 10 samples of demineralized dentine treated with AgF/KI, 10 samples of demineralized dentine treated with KI and 10 samples of demineralized dentine treated with AgF. After two weeks the optical density of the growth medium chambers was measured to determine bacterial penetration and growth. Cultures were plated out to determine migration through the discs by S. mutans. RESULTS: S. mutans migrated through all dentine discs. However, the samples treated with AgF and AgF/KI had significantly lower optical densities than the corresponding controls. The range of optical densities was least amongst demineralized samples treated with AgF/KI. CONCLUSIONS: Under the conditions of this study, treatment of demineralized dentine discs with AgF followed by KI allowed the penetration of S. mutans. Based on optical density measurements, the treatment resulted in significantly fewer microorganisms being present subjacent to the discs treated with AgF and KI than the control discs at the end of the experimental period.

Bacteriological Techniques↗

Time-dependent decrease and seasonal variation of the porosity of recently erupted sound dental enamel in vivo.

Recently erupted teeth are more sensitive to dental caries than teeth that have remained free from caries lesions for a few years after eruption. It has been hypothesized that this may be ascribed to differences in enamel porosity. The objective of the present work was to assess the time-dependence of electrical conductance, as an indication of porosity, of occlusal enamel in recently erupted permanent molar teeth. Fifty children aged 5-15 years of age, receiving regular dental care at six-month intervals, participated in the study when their first molar teeth (in 5- to 6-year-olds) or their second molar teeth (in 11- to 15-year-olds) had not been exposed to the oral environment for more than six months. On the first semi-annual check-up after eruption of a first or second molar, baseline diagnostic measurements, i.e., visual inspection and electrical conductance measurements (ECMs), were made at three or four pre-defined sites in the fissures. Subsequently, data collection was repeated every six months for three years. Sites were excluded from ECMs when a caries lesion was observed at a site by visual inspection. After 36 months, there were 257 sites in teeth considered sound upon visual examination. The ECM values of these sound sites showed a clear decrease with time after the first examination. The conductance decreased on average from 0.13 (Momega)(-1) to 0.059 (Momega)(-1). Since the conductance is assumed to be proportional to the porosity of the enamel, the latter decreased by a factor of 2.2 over the 36-month period. The results furthermore indicated a higher conductance for maxillary than for mandibular enamel. Almost all sites in that sample appeared to be in teeth that were observed for the first time during the months September to December. Electrical conductance, and therefore enamel porosity, of the sites showed a periodic variation with season of observation: In the fall, the conductance was higher than in the spring. This implies that a dentist should be more prudent in the fall than in the spring when indicating restorative treatment of an incipient caries lesion.

Adolescent↗

Evaluation of the permeability of the furcation area of deciduous molars conditioned with Er:YAG laser and cyanoacrylate.

The purpose of this study was to evaluate in vitro the dentin permeability of the deciduous pulp chamber floor after employing 2-octyl cyanoacrylate and Er:YAG laser. Twenty four deciduous molars were used, divided into four groups. After chemical-surgical preparation each group received a different treatment: Group 1 - control, without treatment; Group 2 - the floor of the pulp chamber was covered with a fine layer of 2-octyl cyanoacrylate; Group 3 - the floor of the pulp chamber was irradiated with Er:YAG laser (250 mJ, 10 Hz for 30 seconds, 80 J of energy and 320 pulses), and covered with a fine layer of 2-octyl cyanoacrylate; and Group 4 - the floor of the pulp chamber was irradiated with Er:YAG laser set at the parameters already described. After that the specimens received application of 0.5% methylene blue, for 15 minutes. The teeth were cut, photographed, and the digitalized images were analyzed using the ImageLab program. The results obtained were submitted to statistical analysis. Group 4 (Er:YAG) presented the largest averages in percentage of dye penetration area (19.5%), followed by Group 1 (11.1%), Group 3 (1.4%) and Group 2 (0.2%). The experimental model allowed to conclude that the specimens conditioned with 2-octyl cyanoacrylate (Group 2) and Er:YAG laser associated to 2-octyl cyanoacrylate (Group 3) presented a decrease in permeability, and the specimens treated with Er:YAG laser (Group 4) presented an increase in permeability of the analyzed area.

Cyanoacrylates↗

Durability of FTLA treatment as a medicament for dentin hypersensitivity--abrasion resistance and profiles of fluoride release.

The purpose of this study was to evaluate the durability of tubules occluded with FTLA treatment by toothbrush abrasion test on the applied surface and by measuring fluoride release from the FTLA components. Dentin specimens with simulated hypersensitive surfaces were treated with APF containing tannic acid. After which, the specimens received lanthanum-chloride-with-powdered-fluoroapatite-glass-ceramics treatment. The specimens were subjected to toothbrush abrasion test up to 6,000 strokes. SEM observation revealed that dentinal tubules of the FTLA treated specimens were completely occluded with fine deposits even after toothbrush abrasion of 6,000 strokes. EPMA analysis revealed that fluoride, lanthanum, and aluminum were the main FTLA components on the dentin surface after 6,000-stroke abrasion. To measure fluoride release from the FTLA components, a slurry was enclosed in a cellulose tube and suspended in deionized water at 37 degrees C. After fluoride was dialyzed against deionized water, a high concentration of fluoride was found to be released from FTLA the components, indicating FTLA treatment's prominent durability. These results suggested that FTLA treatment has a superior resistance against toothbrush abrasion and a high fluoride-releasing performance. These characteristics lend much weight to showing that the FTLA method is an effective and durable medicament for dentin hypersensitivity.

Acidulated Phosphate Fluoride↗

Effect of endodontic smear layer and various solvents on the calcium ion diffusion through radicular dentin--an in vitro study.

External root resorption and ankylosis remains the major cause of failure of replanted teeth. This study was conducted to explore the different ways to increase the pH of periradicular area in order to overcome the problem of root resorption and ankylosis. 60 freshly extracted permanent anteriors were used after removing the crown at CEJ. After biomechanical preparation Ca (OH)2 was injected and assays were done using EDTA, Citric and tannic acid Assays were repeated. Calcium diffusion and pH in the root exterior was measured using spectrophotometer. Results showed that dentin is permeable to calcium & hydroxyl ions and placement of Ca (OH)2 in the canal resulted in its increased recovery and alkaline pH periradicularly. Smear layer removal did not result in significant increase in Ca++ recovery or alkaline pH however combination of EDTA & NaOCl was found best than the other two.

Calcium↗

Treating hypersensitivity with fluoride varnish.

Dentinal hypersensitivity results when stimulation causes the fluid in open dentinal tubules to undergo pressure changes, which activates mechanoreceptor nerves and results in pain. Treatment with fluoride varnish forms a protective layer of calcium fluoride that prevents this fluid flow, thereby reducing dentinal sensitivity.

Calcium Fluoride↗

Dentin permeability and eugenol diffusion after full crown preparation.

PURPOSE: To compare teeth prepared to receive a metallic versus a metal-ceramic crown with respect to (1) in vitro dentin permeability before and after using a desensitizing agent and (2) pulpal eugenol concentration after sealing a temporary crown with a zinc oxide-eugenol based cement. MATERIALS AND METHODS: The roots of 20 human mandibular molars were separated and the crowns were prepared to receive a metallic crown. The hydraulic conductance was recorded before and after using Protect dentin desensitizer. The crowns were then further reduced to receive a metal-ceramic crown and the hydraulic conductance was recorded under the same conditions, on deeper dentin, before and after using the desensitizing agent. Twenty additional teeth were prepared: 10 to receive a metallic crown and 10 teeth to receive a metal-ceramic crown. A tube filled with 1 mL phosphate buffered saline (PBS) was sealed to the cementoenamel junction. A temporary crown was sealed onto the preparation with Temp Bond. The amount of eugenol that diffused across dentin into PBS was spectrofluorimetrically measured at Day 1 and Day 7. The crown preparations were vertically sectioned and the dentin remaining thickness was recorded. RESULTS: The hydraulic conductance of teeth prepared for a metal-ceramic crown was twice as high as teeth prepared for a metallic crown (P < 0.001). The desensitizing agent reduced the hydraulic conductance in both groups (P< 0.001). The two groups showed the same hydraulic conductance after using Protect (ns). No significant difference was found in the amount of eugenol diffusion between the two groups of teeth although eugenol diffusion decreased with time (P < 0.01). No correlation was found between eugenol diffusion and remaining dentin thickness.

Analysis of Variance↗

Adhesive interface between resin and etched dentin of cervical erosion/abrasion lesions.

The interfacial structure between an adhesive composite resin and the dentinal walls of cervical erosion/abrasion lesions etched with 37% phosphoric acid gel for 60 seconds was investigated. Almost all dentinal tubules were occluded with rod-like structural depositions that remained undissolved even after acid conditioning. The hybrid layer between the adhesive resin and surface-demineralized dentin was found to be 0.3 to 3 microns, much thinner than that routinely found in either normal dentin or cariously affected dentin. The hybrid layer was thinnest at the occlusal walls of the cavity where the dentinal tubules run parallel to the cavity surface. The bond strength of adhesive resin to these areas may differ from that to intact normal dentin.

Acid Etching, Dental↗