Keywords

Abscess; Cysts; Granuloma; Periapical Lesion; Periapical Radiolucency.

Introduction

The success of any endodontic treatment depends on a wide range of factors, including proper diagnosis, proper access cavity, correct determination of working length, achieving good apical sealing, preparing the root canal using hand and rotary instruments in order to obtain mechanical preparation [1, 2]. Diagnostic aids like the pulp vitality tests are the valuable diagnostic tools that help in accurate diagnosis and appropriate treatment planning [3]. CBCT has been routinely used to achieve proper diagnosis and treatment planning [4]. Root canal treatment depends primarily on the removal of microorganism through chemo-mechanical instrumentation. Shaping and cleaning technique of a root canal system along with the preservation of the surrounding periodontal tissues are the principal goal of an endodontic treatment [5] During endodontic treatment, root canal irrigants include the cleaning and lubrication of the root canal system by dissolution of inorganic and organic substances. The major hurdle in root canal disinfection is the removal of the bacterial biofilm that can be achieved through proper irrigation protocol and final irrigant activation and complete sealing of root canal space.Use of an effective intracanal medicament has also aided in disinfection of the root canal system, reduced inflammation and thereby reducing postoperative pain.

Inadequate seal of the root canal system can result in contamination and entry of microbes into the periapical tissues which can further lead to the development of periapical diseases. Quality of the coronal restoration also plays an important role in achieving an adequate seal and preventing coronal microleakage. Thus, root canal fillings and coronal restorations of the tooth should resume its functions within the oral cavity and the previous periapical lesions should be repaired, and this normality should be maintained for a long time. However, no endodontic treatment protocol ensures 100% clinical and radiographic success. Thus, deficient root canal instrumentation would lead to failure and continuity of periapical lesion [6, 7]. Coronal-sealing disruption favors microbial recolonization in the root canal and leads to endodontic treatment failure [8]. The aim of this retrospective study was to evaluate clinical protocol to manage teeth with periapical lesion reporting dental hospital in chennai.

Material and Methods

The type of research was a cross sectional analytic study. All dependent variables here were mainly assessed. The data collection was retrospective in nature. Case records of around 86,000 patients availing treatment at our dental hospital between june 1 2019 to march 31 2020 were analyzed and the required data was extracted. Inclusion criteria included all patients aged 18 years of age and above, who presented with symptomatic or asymptomatic apical periodontitis having periapical lesions. Patients below 18 years of age, periodontal disease were excluded from the study. The data was first extracted and then all data was transferred to an MS Excel sheet and tabulated. SPSS software was used for performing statistical analysis. Chi square test was done along with other tests to determine correlation between the dependent and the independent variables. Since most of the variables were parametric in nature. Graphs and charts were obtained for all the data and analysed. Results were displayed as percentages. The ethical clearance for the study was obtained from the institutional research SDCC/SIHEC/2020/DIASDATA/0619-0320. Patient personal information was kept confidential in exception to the examiners.

Result and Discussion

In the present study, on assessing the association between age and the periapical lesions, periapical lesion size 1-3mm and 3-5mm were more observed in 18- 30 years age group when compared to other age groups, but it was not statistically significant (p >0.05) [Figure 1]. On assessing the association between gender and the periapical lesion, more number of periapical lesions were present in males with the lesion size of 1-3mm and 3-5mm when compared to females but it was not statistically significant (p >0.05)[ Figure 2]. On comparing the association between teeth and periapical lesion, maximum number of periapical lesions was found in the upper left quadrant ( 21.58%) with the lesion size of 1-3mm as compared to other teeth but it was not statistically significant (p >0.05) [Figure 3]. On assessing the association between cleaning and shaping technique and periapical lesions, majority of cases rotary files were used in periapical lesion size of 1-3mm and 3-5mm but it was not statistically significant (p >0.05)[Figure 4]. Associations between the irrigants and periapical lesions, majority of cases NaOCL, EDTA and saline were used for irrigation in patients with periapical lesion size of 1-3 mm and 3-5 mm but it was not statistically significant (p >0.05) [Figure 5]. On comparing the association between obturation technique and periapical lesions, majority of cases lateral compaction was used in patients with periapical lesion size of 1-3mm as compared to other techniques but it was not statistically significant (p >0.05) [Figure 6] and also it was observed that on comparing the association between intracanal medicaments and periapical lesions, majority of cases calcium hydroxide was used as an intracanal medicaments in patients with periapical lesion size of 1-3mm and 3-5mm but it was not statistically significant (p >0.05) [Figure 7].

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The complete elimination of microbial flora from the root canal system promotes periapical healing. Periapical tissue have a rich blood supply, lymphatic drainage and number of undifferentiated mesenchymal cells which promote good healing potential through treatment procedures aiming at removal of the etiologic factors. Microbial flora plays a very important role in the development of apical periodontitis and subsequent periapical lesions [9]. Necrotic pulp provides a very good nutritional environment for the development of pathogenic bacteria which in turn multiples and release various toxins into the periapical area,thereby initiating an inflammatory reaction and development of periapical lesion. Immuno-pathologic mechanism also play a key role in the initiation of periapical lesions. During endodontic treatment, complete elimination of bacteria by instrumentation alone is impossible. Previously we have worked on Laminates and Veneers, restorative materials for cervical abrasion, management of avulsed teeth, Calcified canal and its negotiation, remineralizing agents, [10-15] In the present research we wanted to analyse factors related to management of periapical pathology. Proper irrigation and intracanal medication protocol should be followed for the complete three dimensional cleaning and disinfection of the root canal environment. Root canal instrumentation 0.5-1 mm short of the apex is indicated to avoid additional trauma and for reducing microbial load, meticulous debridement using irrigant such as sodium hypochlorite as an irrigant and calcium hydroxide as an intra canal medicament is essential [16-18]. The antimicrobial activity of calcium hydroxide is due to its dissociation into calcium and hydroxyl ions in a high pH environment which inhibits enzymatic activities such as metabolism,growth and cellular division which are essential for microbial growth. It exhibits anti-inflammatory action,anticlastic property by inhibition of phospholipase, activation of alkaline phosphatase and destruction of cystic epithelium and thus allowing connective tissue to invaginate into the lesion [19]. The antibacterial component of calcium hydroxide based root canal sealer also prevents regrowth of residual bacteria and reduce bacterial re -entry into the root canal after endodontic treatment. Clinical signs and symptoms and radiographic signs such as change in density within the lesion, trabecular reformation and lamina dura reformation should be checked during followup visits through radiographs especially in asymptomatic teeth and healthy soft tissues. Thus, complete periapical healing was observed by thorough cleaning & shaping technique, prolonged disinfecting procedures using calcium hydroxide as an intracanal medicament and root canal sealer during obturation. Coronal restorations also play major role in maintaining integrity of tooth in the arch [20]. The result of the study showed that maxillary teeth were more involved with periapical lesion when compared to mandibular teeth. When the periapical lesions were evident, nonsurgical approach was achieved through complete cleaning and shaping technique by using rotary files with proper debridement, disinfection and three-dimensional obturation of root canal system. Healing of periapical lesion is effectively achieved through calcium hydroxide dressing as an intracanal medicament.

Conclusion

Within the limitations of the study, it was found that patients in the age group of 18-30 years had the maximum number of periapical lesions and was more common in males. Periapical lesions were managed by using rotary files and combination of various irrigants and calcium hydroxide was the choice of intracanal medicament. Although it is necessary to observe and monitor the prognosis of periapical lesions. These protocols were followed but long term follow up is required.

Acknowledgement

The authors would like to acknowledge all the faculties of the Department of Conservative Dentistry and Endodontics for their help with data collection for this study.