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Biologic Aspects of Endodontics
Biologic Aspects of Endodontics
Biologic Aspects of Endodontics
Copyright © 2004 by The American Association of Endodontists VOL. 30, NO. 7, JULY 2004
In previous reports we have described the normal anatomic and teeth, as determined by roentgenographic visualization with instru-
morphologic variations of the root apex and surrounding structures ments in the root canals. In fifteen teeth, after pulp extirpation, the
of the teeth of human beings and of Macaca rhesus monkeys (11) canals were instrumented several millimeters beyond the morpho-
as well as the reactions of those tissues to vital pulp extirpation logic apices of the teeth, as confirmed by roentgenograms with
(12). We found that in the human periapical tissues inflammation files or reamers in the root canals. In both groups, following
persisted for at least one year after pulp extirpation, except where instrumentation, the canals were irrigated with physiologic saline
the root canals had been narrowed by prior reparative dentine solution and dried with sterile paper absorbent points. The coronal
formation or where denticles were present in the root canal near the orifices were then closed with an amalgam restoration placed over
apical foramen. In the animal tissues, the apical pulp stumps either a zinc oxide-eugenol base.
recovered completely or became necrotic with accompanying peri- After specific time intervals (Table 1), the root apices and
apical inflammation. We concluded that periapical inflammation surrounding bone were block resected. The extirpated pulps and
was likely to persist unless subsequent endodontic procedures were the resected tissues were fixed, decalcified, and processed in the
employed. usual manner. Most of the sections were stained with hematoxylin
The present report deals with the reactions of the apical and and eosin. Some sections were stained with Masson’s stain and
periapical tissues around the teeth of Macaca rhesus monkeys and some by the Papanicolaou method.
human patients following pulp extirpation plus reaming and filing Endodontic procedures were performed on twenty-four noncari-
of the root canals. In this investigation, comparisons have been ous teeth of the Macaca rhesus monkey, utilizing standard aseptic
made between the reactions of the periapical tissues following root procedures under the rubber dam. The root canals of twelve teeth
canal instrumentation (reaming and filing) short of the apices of the were instrumented short of the morphologic apices, and the root
teeth and those reactions which followed instrumentation beyond canals of the other twelve teeth were instrumented beyond the
the apices of the teeth into the periodontal ligament and alveolar
bone. The purposes of this investigation, which was conducted
under controlled conditions, were (1) to discover the reactions of TABLE 1. Number of human teeth resected at various time
the apical pulp and periapical tissues to root canal instrumentation, intervals following root canal instrumentation
(2) to document the sequence of reactions of the apical-periapical Interval between instrumentation
Number of teeth
tissue complex over a time span of 1 year, and (3) to discover and resection
whether there were differences in tissue reactions between teeth Canals instrumented short of apex
with canals instrumented short of the root apices and those teeth in Immediately 1
which the canals were instrumented beyond the root apices. 14 days 2
As a result of these continuing investigations, we hope to 28 to 42 days 3
uncover which endodontic procedures are least likely to produce 77 to 90 days 2
periapical inflammation in teeth with no prior periapical pathologic 180 days 1
involvement and, eventually, to discover those endodontic proce- 250 days 2
360 days 1
dures or techniques which are most likely to promote repair of
Canals instrumented beyond apex
previously diseased periapical tissues. Immediately 2
4 to 7 days 2
35 to 42 days 4
PROCEDURE 90 days 1
120 days 1
Twenty-seven noncarious human teeth were studied. In twelve 180 days 2
teeth, the pulps were extirpated and the root canals were instru- 210 to 270 days 2
360 days 1
mented from 2 to 10 mm. short of the morphologic apices of the
491
492 Seltzer et al. Journal of Endodontics
FIG. 1. Composite photomicrograph of root apex of upper central incisor. Pulp has been extirpated and instrumentation of root canal (RC) has
been performed short of apex. Dentine filings (DF) are packed against remaining pulp stump (P). D, dentine; AB, alveolar bone; PL, periodontal
ligament. (Magnification, ⫻54.)
apices. The teeth were treated at such intervals that, at the time of sacrifice. The root canals of half of the teeth in each time category
sacrifice, six teeth had been treated 6 months previously and six presumably had been instrumented short of the apices, and in the
teeth had been treated 3 months, 1 month, and 1 week prior to other half the root canals had been instrumented beyond the apices.
Vol. 30, No. 7, July 2004 Biologic Aspects of Endodontics 493
FINDINGS
FIG. 3. Composite photomicrograph of root apex of upper incisor. Pulp was extirpated and canal was instrumented short of apex 5 weeks
previously. Remaining pulp (P) stump appears to be intact, and periodontal ligament (PL) is free of inflammation. D, Dentine; C, cementum; AB,
alveolar bone. (Magnification, ⫻54.)
Tooth Canal wall appearance Canal content External root surface Periapical tissue
Lower left first Apical third resorbed Apical third, normal Resorption and repair Normal
premolar and repaired with pulp tissue;
secondary cementum coronally, dentine
filings
Lower left first Distal root resorption Dentine filings with No change Normal
molar and repair in apical normal pulp in
third with cementum apical portion
Lower right Resorption and Dentine filings No change Small
second funneling of root granuloma
incisor apex
Lower right No change Mesial canal, normal Distal root, resorption Normal
first pulp tissue, due to pressure of
premolar apically; distal adjacent tooth
canal, connective
tissue ingrowth
collagen fibers were separated by edema. A small amount of with the granulation tissue surrounding the root apex. Dense col-
granulation tissue was detected in the periapical tissues. lagen fiber formation had resulted in encapsulation of the granu-
In another specimen, a tooth with a large silicate restoration, the loma. The cementum and dentine of the root apex had been
periapical tissue had a normal appearance (Fig. 3). resorbed. The lesion was a typical periapical granuloma.
In a third human specimen which had no previous caries or Apical-periapical tissue changes in the animal teeth generally
restoration (42 days after instrumentation), a large area of rarefac- were mild (Table 3).
tion had developed, as seen in the roentgenogram. The apical Seventy-seven to 90 days following instrumentation, a periapi-
foramen was filled with granulation tissue which was confluent cal area of rarefaction was detected in the roentgenograms of both
Vol. 30, No. 7, July 2004 Biologic Aspects of Endodontics 495
Canal wall
Tooth Canal content External root surface Periapical tissue
appearance
Lower left first Secondary Dentine filings and chronic Secondary cementum Slight chronic
incisor cementum inflammatory cells deposited inflammatory cell
deposited accumulation
Lower left No change Dentine filings in mesial and Some resorption of Mesial and distal
second distal roots cementum and roots, normal
premolar dentine with repair by tissue
secondary cementum;
apical opening almost
sealed
Lower right No change Distal root, normal tissue; No change Slight accumulation
second molar mesial root, chronic of chronic
inflammation inflammatory cells
FIG. 4. Root apex and surrounding tissue of lower left central incisor
of monkey. Pulp was extirpated and canal (RC) instrumented short
of apex 3 months previously. Slight chronic inflammatory infiltrate
(INF) is present in periodontal ligament (PL), opposite apical fora-
men. AB, Alveolar bone. (Magnification, ⫻54.)
FIG. 6. Composite photomicrograph of upper central incisor. Pulp had been extirpated and canal reamed short of apex 6 months previously.
Remaining pulp stump (P) is intact but slightly inflamed. Regions of resorption of dentine and cementum of root (arrows) have been repaired
by secondary cementum (Ce). Periodontal ligament (PL) is slightly inflamed. AB, Alveolar bone. (Magnification, ⫻54.)
pushed into the pulp tissue. Secondary cementum had been hence, the results were deleted from consideration. In the 270-day
deposited profusely on the walls of the root canal and around the human specimen, complete repair had occurred. The apical pulp
apex of the tooth, repairing the previously resorbed regions. The stump was intact and uninflamed. New cementum had been elab-
root canal had become narrowed by the cemental deposition. orated, both within the root canal and around the apex of the tooth.
The periapical tissues were slightly distended by edema, and The periapical tissues were free of inflammation.
scattered inflammatory cells and erythrocytes were present. At the end of 360 days, the root apex had been resorbed and
New bone trabeculae had been elaborated, indicative of alveolar granulomatous tissue was present periapically. The granuloma was
bone regeneration (Fig. 6). encapsulated by dense collagen fiber bundles. Chronic inflamma-
Periapical tissue inflammation was present in all of the animal tory cells were scattered throughout the collagen fibers. Although
specimens 6 months postoperatively (Table 5). In two of the teeth, the tissue was processed poorly, some new bone formation was
the root canals contained necrotic debris. Periapically, granuloma- evident around the periphery of the lesion (Fig. 9).
tous lesions were present (Fig. 7). In a third tooth, chronically However, examination of the roentgenograms of the 360-day
inflamed pulp tissue was present in the apical third of the root canal specimen tended to cast doubt that the canal had been instrumented
(Fig. 8, A). Periapically, the tissue was relatively normal (Fig. 8, short of the apex. In the roentgenogram with the instrument in
B). Inflammatory reactions were observed on the lateral aspects of position, it appeared as if the instrument might have been extended
the root, however, and some epithelial proliferation had occurred slightly beyond the apex of the tooth.
within the inflamed lesion (Fig. 8, C and D). (This article will be concluded in the next issue of the Journal.
In the 250-day human specimen, a large periapical granuloma References for the entire article will appear at that time.)
which contained some proliferated epithelium had developed.
This investigation was supported by United States Public Health Service Grant DE
However, a restoration had become dislodged from the coronal 01930 from the National Institute of Dental Research, United States Public Health
portion of the tooth sometime between the endodontic procedure Service, Bethesda, Md.
School of Dental Medicine, University of Pennsylvania
and the resection. The presence of the periapical inflammation Reprinted from Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology &
could not be divorced from the influence of the persistent leakage; Endodontics Vol. 25(4):534 –546, Copyright 1968, with permission from Elsevier..
Vol. 30, No. 7, July 2004 Biologic Aspects of Endodontics 497
FIG. 7. Mesial root apex of upper right first premolar of monkey. Root canal (RC) had been instrumented short of apex 6 months previously.
Moderate-sized granuloma (G) is present around apex. Some epithelial proliferation (E) has occurred within granuloma. AB, Alveolar bone.
(Magnification, ⫻54.)
498 Seltzer et al. Journal of Endodontics
FIG. 8. Mesiobuccal root of upper right second molar of monkey. Six months prior to sacrifice, pulp had been extirpated and canal was reamed
short of apex. A, Chronically inflamed pulp tissue (P) is present in apical third of root. D, Dentine; C, cementum. B, Level of same root showing
apical foramen (AF). Cementum has been elaborated on walls of root canal (RC). Periodontal ligament (PL) is infiltrated slightly by inflammatory
cells. C, Composite photomicrograph of same root at another level. Opposite root canal (RC) in apical third of root are chronic inflammatory
infiltrates, each with some epithelial proliferation (E). Inflammation (INF) is also present periapically. (Magnification, ⫻54.). D, Higher magnifi-
cation of epithelial mass seen at arrow in upper left-hand portion of photomicrograph C. Epithelium is infiltrated with polymorphonuclear
leukocytes (P), a sign of proliferation. (Magnification, ⫻540.)
Vol. 30, No. 7, July 2004 Biologic Aspects of Endodontics 499
FIG. 9. Composite photomicrograph of root apex of upper incisor. Canals had been reamed out, presumably short of apex, 1 year previously.
However, instrumentation may have been beyond apex. Root canal (RC) contains necrotic cells and some granulation tissue. Surrounding apex
is granulomatous tissue (G). Poor processing has resulted in artifacts (A). (Magnification, ⫻54.)