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Seltzer and Benders Dental Pulp 2012 3.Pdf Pu/pal Infections, Including Caries Persistent and secondary infections are for the most part clinically indistinguishable. Exceptions include infectious complications (such as an apical abscess) arising after the treatment of noninfected vital pulps or cases in which apical periodontitis was absent at the time of treatment but present in the follow-up radiograph. Both situations are typical examples of secondary infections (secorld­ ary to intervention). Both persistent and secondary infections can be responsible for several clinical problems, including persistent exudation, persistent Fig 10-23 Persistence of an apical periodontitis lesion in an endodonti­ symptoms, interappointment flare-ups, and failure of cally treated tooth. Persistent or secondary intraradicular infections are the main causative agents of endodontic treatment failure. the endodontic treatment, characterized by a post­ treatment apical periodontitis lesion. Treatment failure Persistent or secondary intraradicular infections are the major causes of endodontic treatment failures been hypothesized that human cytomegalovirus and (Fig 10-23). This statement is supported by two strong Epstein-Barr virus may be implicated in the patho­ evidence-based arguments. First, it has been dem­ genesis of apical periodontitis as a direct result of onstrated that there is an increased risk of adverse virus infection and replication or as a result of virally treatment outcome when bacteria are present in the induced impairment of local host defenses, which canal at the time of filling.17s...1so Second, most (if not might give rise to overgrowth of pathogenic bacteria all) endodontically treated teeth presenting with per­ in the very apical part of the root canal.169 sistent apical periodontitis lesions have been dem­ onstrated to harbor an intraradicular infection.181-185 Secondary and persistent endodontic infections Based on these arguments, studies have attempted Secondary intraradicular infections are caused by to identify the microorganisms found at the root canal microorganisms that were not present in the primary filling stage, which have the potential to put the treat­ infection but that gained entry into the root canal ment outcome at risk, and the microorganisms in system at some time after professional intervention. endodontically treated teeth with apical periodontitis, The moment can be during treatment, between which can be participating in the already established appointments, or even after root canal filling. In treatment failure. any circumstance, if penetrating microorganisms succeed in adapting themselves to the new envi­ Bacteria at the root canal filling stage ronment, surviving and colonizing the root canal, a Diligent antimicrobial treatment may fail to promote secondary infection is established. Species involved total eradication of bacteria from root canals. Persis­ can be oral or nonoral microorganisms, depending tent bacteria are either resistant or inaccessible to on the cause of infection. treatment procedures. Whatever the cause of per­ Persistent intraradicular infections are caused sistence, bacterial diversity and density are substan­ by microorganisms that can resist intracanal antimi­ tially reduced after treatment. Root canal samples crobial procedures and endure periods of nutrient positive for bacterial growth after chemomechanical deprivation in a prepared canal. Involved microor­ procedures, whether followed by intracanal medica­ ganisms are remnants of a primary or secondary tion or not, have been shown to harbor an average infection. The microbiota associated with persistent of one to five bacterial species per case. The num­ infections is usually composed of fewer species than ber of bacterial cells usually varies from 102 to 105 primary infections, and gram-positive facultative or per sample1 35•179•187-189 (see Fig 10-1 ?b and Box 10-1 ). anaerobic bacteria are predominant. Fungi can also No single species has been significantly found to be found in frequencies significantly higher than in persist after treatment procedures. Gram-negative primary infections.176·177 bacteria, which are common members of primary 232 www.shayanNemodar.com Endodontic Infections and Apical Periodontitis infections, are usually eliminated. Exceptions may canals.184-186·197 The number of bacterial cells varies include some anaerobic rods, such as F nucleatum, from 103 to 107 (see Fig 10-17 c and Box 10-1 ).193·198 Prevotella species, and Campy/obacter rectus, which Irrespective of the identification method used, are among the species found in postinstrumenta­ E faeca/is has been reported to be the most prev­ tion samples.135·179·187·189-192 However, most studies on alent species in endodontically treated teeth, with this subject have clearly revealed that gram-positive prevalence values reaching up to 90% of the cases.18:>- bacteria are most frequently present. Gram-positive 186·198-201 Endodontically treated teeth are about 9 facultatives or anaerobes often detected in post­ times more likely to harbor E faeca/is than are primary treatment samples include streptococci (5 mitis, S infections.201 This suggests that this species can be gordonii, S anginosus, S sanguinis, and S ora/is), P inhibited by other members of a mixed bacterial con­ micra, Actinomyces species (A israe/ii and A odon­ sortium commonly present in primary infections and tolyticus), Propionibacterium species (P acnes and P that the bleak environmental conditions within filled propionicum), P a/acto/yticus, lactobacilli (Lactobaci/­ root canals do not prevent its survival. /us paracasei and Lactobaci//us acidophi/us), Ente­ The fact that E faeca/is is the most commonly rococcus faeca/is, and O/sene//a u/i.135,179,187-191,193-195 encountered species in treated canals and the attri­ These findings support the notion that gram-positive butes of this species that help it to survive under bacteria can be more resistant to antimicrobial treat­ unfavorable environmental conditions have prompt­ ment measures and have the ability to adapt to the ed many authors to nominate E faecalis as the main harsh environmental conditions in instrumented (and pathogen involved in treatment failures. The con­ medicated) canals. Of the taxa found in posttreat­ sequence of this has been an avalanche of in vitro ment samples, 42% have been shown to be as-yet­ papers focusing on this species.202 However, findings uncultivated bacteria.135 from recent studies carried out in independent labo­ For residual bacteria to be the cause of persistent ratories have questioned the role of E faeca/is as the apical periodontitis lesions, they have to: (1) adapt to main causative agent of endodontic failures. Some the environment drastically modified by treatment, studies have not detected enterococci in endodon­ acquiring nutrients and surviving the antimicrobial tically treated teeth with lesions 149 or have demon­ effects of root canal filling materials; (2) reach critical strated that E faeca/is is not the dominant species numbers and exhibit virulence attributes sufficient in most retreatment cases.197 Recent reports have to sustain or induce periradicular inflammation; (3) demonstrated that E faecalis is no more prevalent have unrestrained access to the periradicular tis­ in endodontically treated teeth with lesions than in sues to exert their pathogenicity; and (4) induce host teeth with no lesions.200.203 responses (see chapter 12). This helps to explain All these findings apparently put into question why some apical periodontitis lesions can heal even the status of E faecalis as the main species causing when bacteria are present in the canals at the root treatment failure. However, other related factors 7 canal filling stage.178·1 9 However, the fact that there still must be clarified before this assumption turns is an increased risk of adverse treatment outcome into certainty. Further studies addressing this issue when bacteria are present in the canal at the time should include a precise diagnosis of apical peri­ of obturation178-180 indicates that, in many cases, odontitis (circumventing radiographic biases), pro­ residual bacteria succeed in fulfilling the requisites vide quantitative results (bacterial counts), test the to survive, thrive, and maintain an apical periodonti­ association of specific clonal types with disease, and tis lesion. evaluate the different patterns of host response to infection.200 Microbiota in endodontically treated teeth Other microorganisms found in endodontically The microbiota in endodontically treated teeth with treated teeth with apical periodontitis include strep­ persistent apical periodontitis lesions also exhibits tococci, C albicans, and some fastidious anaerobic less diversity than that in primary infections. Canals bacterial species: P alactolyticus, P propionicum, that are apparently well treated can harbor 1 to 5 Filifactor alocis, Dialister pneumosintes, and Dialister species, while the number of species in canals with invisus.134·183-186· 197·199 As-yet-uncultivated phylotypes inadequate treatment can reach up to 30 species, correspond to 55% of the taxa detected in treated a number very similar to that found in untreated canals.204 In fact, the bacterial community profiles in 233 www.shayanNemodar.com Pu/pal Infections, Including Caries these cases can vary from individual to individual, died by periradicular surgery. The high success rate suggesting that many distinct bacterial combina­ reported for endodontic treatment and retreatment tions can play a role in
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