Comparison of Healing of Apical Periodontitis in Periodontally Diseased and Healthy Patients.
Condition: Apical Periodontitis
MeSH terms: Periodontitis; Periapical Periodontitis
Study type: Interventional

Summary: 
      Periodontal health may jeopardize the success of endodontic treatment.Intraorifice barrier
      apart from enhancing probability of success of endodontic treatment may also augment
      periodontal therapy as intra pulpal infection is known to contribute in worsening of
      periodontal health by promoting marginal bone loss and pocket formation.This study compared
      the apical healing in healthy and periodontally compromised teeth and evaluated the effect of
      intra orifice barrier and base in the healing of apical periodontitis.
    

Detailed description: 
      Endodontic treatment comprises bio-mechanical preparation of root canal system, chemical
      debridement and obturation with inert material. Various prognostic factors like adequacy of
      root filling, pre-operative size of periapical lesion on radiograph, type and location of
      teeth, periodontal status of the teeth and coronal restoration may play role in the success
      of endodontic treatment.

      In the presence of defective coronal seal percolation of saliva and microbes may take place
      causing treatment failure. This assumption has acquired support mainly from various in-vitro
      studies which has demonstrated penetration of dye /microbe / radioactive tracer along root
      filling. Marshall and Massler in an in-vitro study using radioisotopes were first to
      highlight effect of coronal leakage and later Swanson and Madison in a study involving 70
      extracted single rooted human teeth showed complete dye penetration throughout obturation
      material and along the canal walls. Since then there has been a renewed interest in the
      endodontic community in exploring relation of coronal seal with prognosis of endodontic
      treatment.

      In a retrospective study Ray and Trope concluded that coronal restoration has greater impact
      on success of endodontic therapy rather than quality of root filling. However, various other
      epidemiological studies failed to replicate this result. A recent meta-analysis stated that
      problem of coronal leakage may not be of that clinical significance as demonstrated in
      various in-vitro studies, though importance of good coronal restoration and good root filling
      in the success of endodontic treatment can't be denied.

      Placing an additional protective barrier in the coronal portion of the root canal has been
      recommended to minimize microleakage and facilitate healing of apical periodontitis.
      Intraorifice barrier apart from enhancing probability of success of endodontic treatment may
      also augment periodontal therapy as intra pulpal infection may also contribute in worsening
      of periodontal health by promoting marginal bone loss and pocket formation. Similarity
      between microflora of periodontium and root canal has led to a view that the communication
      between the two exists, and can potentially affect status of one another. The observations on
      this issue have been conflicting in nature with some authors reporting pulpal necrosis due to
      periodontal disease, and others reporting normal teeth regardless of severity of periodontal
      disease (Zehnder). Stassen et al. in a retrospective study observed more signs of apical
      periodontitis in teeth with reduced marginal support. They also reported significant
      influence of coronal extent of obturation on outcome of endodontic treatment in periodontally
      compromised patients. Significantly less incidence of apical periodontitis was seen where
      gutta percha was apical to marginal bone as compared to gutta percha being coronal to
      marginal bone. It is evident that the interrelationship between root canal and periodontium
      is complicated, and still not fully understood on account of lack of studies exploring the
      topic So far no prospective clinical trial has investigated the effect of periodontal status
      on healing of apical periodontitis. Also in absence of a clinical study substantial amount of
      doubt still persists whether intraorifice barrier can emerge as an effective mean to prevent
      microleakage in furcation and root canals of a multirooted tooth which because of its
      anatomical aberrations poses stiff challenge for clinicians. Therefore aim of this study was
      to determine effect of the periodontal status on periapical healing and to determine effect
      of intracanal glass ionomer restoration as intraorifice barrier on treatment outcome of
      apical periodontitis.

      Clinical procedure:

      After initial periodontal therapy, Standard root canal treatment was done using standard
      protocol. The canals were prepared with Revo S instrument according to manufacturer
      instructions and obturation was done using gutta percha. First of all, local anesthesia was
      administered using 2% lignocaine hydrochloride with epinephrine 1:80,000 (ICPA Health
      Products Ltd, Ankleshwar, India) and tooth was isolated under rubber dam. Caries excavation
      was done and access cavity was prepared using carbide burs in high speed hand-piece with
      copious irrigation. The pulp chamber was debrided and all canal orifices were identified and
      coronally enlarged with low speed Gates Glidden drills (Mani Inc, Utsunomiya, Tochigi,
      Japan). Working length was determined using Root ZX apex locator (J. Morita, Irvine, CA) and
      verified radiographically. After creating glide path with #15 k-file, Revo-S (Micro Mega,
      Besancon, France) instruments were used in sequence as suggested by manufacturer with a
      rotational speed of 350 rpm at torque setting of 2.5 Ncm in gentle in-out motion. Irrigation
      was carried out using 5 mL of a 5.25% Sodium hypochlorite (NaOCl; PrevestDenpro Ltd, Jammu,
      India) solution between files with 26 gauge side vented needle (Neelkanth Healthcare Pvt.
      Ltd, Jodhpur, Rajasthan, India). After preparation, the root canals were irrigated with 5 mL
      17% EDTA (Canallarge, Ammdent, Mohali, India) for 1 minute to remove smear layer, followed by
      final irrigation with 5 mL 5.25% NaOCl. The root canal was then dried using paper points and
      filled with laterally condensed gutta-percha (Meta Biomed Co Ltd, Korea) and zinc oxide
      eugenol sealer (Dental Products of India Ltd, New Delhi, India). Gutta-percha was cut with a
      heated instrument and vertically condensed right at the orifice opening of the canals.

      The teeth were then randomly sub-divided into 3 experimental groups IOB, Base and Control. In
      IOB group gutta-percha was removed 3 mm from the coronal portion of the canal with heated
      plugger, while it was left at the level of orifice in base and control groups. Thereafter,
      coronal restoration of composite resin was done in all groups. In IOB group orifice was
      sealed with GIC and base of GIC was applied in both IOB and base group before composite
      restoration
    

Intervention name(s): Intra orifice barrier; Base; Control
Intervention type(s): Procedure; Procedure; Procedure
Intervention description(s): After primary root canal treatment, Glass Ionomer Cement (KetacTM Molar, 3M ESPE) applied as intraorifice barrier 3mm inside canal from root canal orifice in first group, as 2mm base on floor of pulp chamber in second group and direct composite restoration in 3rd group without Intraorifice barrier or base.3mm GP in the orifice was removed and intraorifice barrier and 2mm thick base was given of GIC.; After primary root canal treatment, Glass Ionomer Cement (KetacTM Molar, 3M ESPE) applied as intraorifice barrier 3mm inside canal from root canal orifice in first group, as 2mm base on floor of pulp chamber in second group and direct composite restoration in 3rd group without Intraorifice barrier or base.2mm thick Base of GIC was applied over the orifice before composite restoration; After primary root canal treatment, Glass Ionomer Cement (KetacTM Molar, 3M ESPE) applied as intraorifice barrier 3mm inside canal from root canal orifice in first group, as 2mm base on floor of pulp chamber in second group and direct composite restoration in 3rd group without Intraorifice barrier or base.coronal accees upto orifice was restored with composite resin
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Root canal treatment, intraorifice barrier.