Ulf Sjögren

Factors affecting the long-term results of endodontic treatment

The influence of various factors that may affect the outcome of root canal therapy was evaluated in 356 patients 8 to 10 yr after the treatment. The results of treatment were directly dependent on the preoperative status of the pulp and periapical tissues. The rate of success for cases with vital or nonvital pulps but having no periapical radiolucency exceeded 96%, whereas only 86% of the cases with pulp necrosis and periapical radiolucency showed apical healing. The possibility of instrumenting the root canal to its full length and the level of root filling significantly affected the outcome of treatment. Of all of the periapical lesions present on previously root-filled teeth, only 62% healed after retreatment. The predictability from clinical and radiographic signs of the treatment-outcome in individual cases with preoperative periapical lesions cases was found to be low. Thus, factors which were not measured or identified may be critical to the outcome of endodontic treatment.

Microbiologic analysis of teeth with failed endodontic treatment and the outcome of conservative re-treatment

OBJECTIVE The purposes of this study were to determine what microbial flora were present in teeth after failed root canal therapy and to establish the outcome of conservative re-treatment. STUDY DESIGN Fifty-four root-filled teeth with persisting periapical lesions were selected for re-treatment. After removal of the root filling, canals were sampled by means of advanced microbiologic techniques. The teeth were then re-treated and followed for up to 5 years. RESULTS The microbial flora was mainly single species of predominantly gram-positive organisms. The isolates most commonly recovered were bacteria of the species Enterococcus faecalis. The overall success rate of re-treatment was 74%. CONCLUSIONS The microbial flora in canals after failed endodontic therapy differed markedly from the flora in untreated teeth. Infection at the time of root filling and size of the periapical lesion were factors that had a negative influence on the prognosis. Three of four endodontic failures were successfully managed by re-treatment.

Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: A long-term light and electron microscopic follow-up study

Light and electron microscopy were used to analyze nine therapy-resistant and asymptomatic human periapical lesions, which were removed as block biopsies during surgical treatment of the affected teeth. The cases that required surgery represented about 10% of all of the cases which received endodontic treatment and root fillings during the period 1977 to 1984. These cases revealed periapical lesions when they were examined 4 to 10 yr after treatment. The biopsies were processed for correlated light and electron microscopy. Six of the nine biopsies revealed the presence of microorganisms in the apical root canal. Four contained one or more species of bacteria and two revealed yeasts. Of the four cases in which bacteria were found, only in one biopsy could they be found by light microscope. In the other three specimens, the bacterial presence could be confirmed only after repeated electron microscopic examination of the apical root canal by serial step-cutting technique. Among the three cases in which no microorganisms could be encountered, one showed histopathological features of a foreign body giant cell granuloma. These findings suggest that in the majority of root-filled human teeth with therapy-resistant periapical lesions, microorganisms may persist and may play a significant role in endodontic treatment failures. In certain instances such lesions may also be sustained by foreign body giant cell type of tissue responses at the periapex of root-filled teeth.

Prevalence of black-pigmented bacteroides species in root canal infections

The prevalence of black-pigmented Bacteroides species in the root canals of 72 teeth with apical periodontitis was evaluated. Twenty-two of the canals contained one or more species of black-pigmented Bacteroides. Bacteroides intermedius (14 strains) and Bacteroides endodontalis (5 strains) were most common. Of the species Bacteroides gingivalis, Bacteroides loeschei, and Bacteroides denticola, 2, 3, and 1 strains, respectively, were isolated. The median number of bacterial cells recovered from the root canals containing black-pigmented Bacteroides was 2.8 x 10(5) and from the other canals 3.0 x 10(3). The mean number of strains was 7.9 and 3.3, respectively. Sixteen of the 22 root canals containing black-pigmented Bacteroides species were associated with acute apical abscesses and purulent drainage through the root canal. The other six teeth with black-pigmented Bacteroides were asymptomatic. One additional abscess was present among the 72 cases. This root canal contained Actinomyces israelii and Actinomyces naeslundii.

Therapy-resistant foreign body giant cell granuloma at the periapex of a root-filled human tooth

Although the primary etiological factor of periapical lesions is microbial, there are other independent factors that can adversely affect the outcome of endodontic treatment. In this communication, we present morphological evidence in support of the role of a foreign body reaction of periapical tissue to root-filling materials. The specimen consisted of a surgical biopsy of an asymptomatic periapical lesion which persisted after a decade of postendodontic follow-up. The biopsy was processed for correlated light and electron microscopy and was analyzed by various microtechniques. The unique feature of the lesion was the presence of vast numbers of large multinucleated cells and their cytoplasmic inclusion bodies. Morphologically, these multinucleated cells resembled foreign body giant cells. They contained characteristic birefringent cytoplasmic inclusions which on electron-probe X-ray microanalysis consistently revealed the presence of magnesium and silicon. The magnesium and silicon are presumably the remnants of a root-filling excess which protruded into the periapex and had been resorbed during the follow-up period. These observations strongly suggest that in the absence of microbial factors, root-filling materials which contain irritating substances can evoke a foreign body reaction at the periapex, leading to the development of asymptomatic periapical lesions that may remain refractory to endodontic therapy for long periods of time.

Bacteriologic evaluation of ultrasonic root canal instrumentation

The antibacterial effect of ultrasonic instrumentation in the treatment of infected root canals was clinically evaluated. Sodium hypochlorite solution (0.5%) was used as an irrigant, but no antibacterial intracanal dressing was used between the appointments. The ultrasonic technique eliminated the bacteria from the canals more efficiently than hand instrumentation alone. Even though ultrasonication definitely improves the procedure of root canal disinfection, the use of an antibacterial dressing between appointments is necessary to achieve as complete a reduction in bacterial levels as possible.

DNA binding to hydroxyapatite: a potential mechanism for preservation of microbial DNA.

INTRODUCTION Molecular methods are increasingly being deployed for analysis of the microbial flora in the root canal. Such methods are based on the assumption that recovered DNA is associated with the active endodontic infection, yet paleomicrobiology research is based on the recovery of ancient DNA from centuries-old tooth and bone samples, which points to considerable longevity of the DNA molecule in these tissues. The main component of dentin and bone is the mineral hydroxyapatite. This study assessed DNA binding to hydroxyapatite and whether this binding affinity stabilizes the DNA molecule in various media. METHODS DNA was extracted from Fusobacterium nucleatum and added to ceramic hydroxyapatite for 90 minutes. The DNA-bound hydroxyapatite was incubated in different media (ie, water, sera, and DNase I) for up to 3 months. At predetermined intervals, the recovery of detectable DNA was assessed by releasing the DNA from the hydroxyapatite using EDTA and evaluating the presence of DNA by gel electrophoresis and polymerase chain reaction (PCR) amplification. RESULTS When incubated with hydroxyapatite, nonamplified DNA was detectable after 3 months in water, sera, and DNase I. In contrast, DNA incubated in the same media (without hydroxyapatite) decomposed to levels below the detection level of PCR within 3 weeks, with the exception of DNA in sera in which PCR revealed a weak positive amplification product. CONCLUSIONS These results confirm a specific binding affinity of hydroxyapatite for DNA. Hydroxyapatite-bound DNA is more resistant to decay and less susceptible to degradation by serum and nucleases, which may account for the long-term persistence of DNA in bone and tooth.

Persistence of dead-cell bacterial DNA in ex vivo root canals and influence of nucleases on DNA decay in vitro

OBJECTIVE The fate of DNA from bacteria that do not survive in the root canal is uncertain, yet DNA longevity may confound recovery of authentic etiologic participants in the disease process. This study assessed the recovery of PCR-detectable DNA in ex vivo human root canals and some environmental factors on the decay of microbial DNA. STUDY DESIGN Heat-killed Enterococcus faecalis cells were inoculated into instrumented human root canals ex vivo, and samples were taken at intervals over 2 years and analyzed by polymerase chain reaction. In an in vitro assay, heat-killed E. faecalis cells and extracted E. faecalis DNA were inoculated into various media, DNase, and culture of a DNase-producing species, Prevotella intermedia. Recovery of DNA was assessed by gel electrophoresis. RESULTS In ex vivo human teeth, amplifiable DNA was recovered after 1 and 2 years (in 14/15 and 21/25 teeth, respectively). In vitro experiments showed that extracted DNA incubated in different media (water, 10%-50% sera, and DNase) progressively decomposed to levels below the detection limit. In corresponding assays, cell-bound DNA was more resistant to decay. CONCLUSION Amplifiable DNA is preserved after cell death, but the critical determinant is the form of DNA. Free DNA undergoes spontaneous and enzymatic decomposition, whereas cell-bound E. faecalis DNA persists for long periods.

Starvation response and growth in serum of Fusobacterium nucleatum, Peptostreptococcus anaerobius, Prevotella intermedia, and Pseudoramibacter alactolyticus

The microbiota inhabiting the untreated root canal differ markedly from those found in post-treatment disease, yet there is limited information on the microbial characteristics distinguishing the different infections. We hypothesized that starvation survival is a key microbial property in species selection. This study analyzed starvation-survival behavior over 60 days of species representative of the untreated root canal infection: Fusobacterium nucleatum, Peptostreptococcus anaerobius, Prevotella intermedia and Pseudoramibacter alactolyticus. All species did not survive 1 day in water. In 1% serum, the 4 species could not survive beyond 2-3 weeks. They required a high initial cell density and >or=10% serum to survive the observation period. The results highlight a poor starvation-survival capacity of these 4 species compared with species prevalent in post-treatment infection, which are well equipped to endure starvation and survive in low numbers on minimal serum. These findings point to starvation-survival capacity as a selection factor for microbial participation in post-treatment disease.

Building biofilms in vital host tissues: a survival strategy of Actinomyces radicidentis

OBJECTIVE To investigate the ability of Actinomyces radicidentis to survive and establish in soft connective tissue that grew into subcutaneously implanted tissue cages in Sprague-Dawley rats. STUDY DESIGN Known concentrations of A. radicidentis suspension, grown on blood agar and broth cultures, were inoculated into tissue cages in rats. The cage contents were retrieved after 7, 14, and 28 days for culturing and correlative light and transmission electron microscopy. RESULTS Cell suspensions harvested from both types of cultures showed substantial decline in numbers in tissue cages during the observation period. However, correlative light and transmission electron microscopy revealed numerous aggregates of coccoid bacteria already by 7 days of observation compared with the formation of well established colonies with characteristic actinomycotic features by 14 days after inoculation. CONCLUSIONS These results suggest that the pathogenicity of A. radicidentis is due to its ability to form large aggregates of cells held together by embedding themselves in an extracellular matrix in vital host tissues. Thus, A. radicidentis, like other pathogenic Actinomyces, existing in the protected biofilm-environment can collectively evade destruction and elimination by host defenses, including phagocytosis.