Received: 20.04.2021 Revision: 30.04.2021 Accepted: 10.05.2021 Published: 20.05.2021
Gabriel Henrique de Oliveira Queiroz, Paulo Maurício Reis, Guilherme Marinho, Júlia Damasceno Pompílio, Sandra Maria Alves Sayão and Luciano Barreto Silva
Faculdade de Odontologia do Recife
Abstract: Pulp necrosis is a common finding in Endodontics. It is responsible for many of the chronic and acute inflammation that affect the apices of the teeth. Chronic apical abscesses are often detectable through fistulas that appear in the gingival region of many patients. In such cases, tracking the fistulous pathway is essential to detect which tooth, or teeth, are responsible for the infectious process caused by dental pulp deterioration, due mainly to bacterial invasion. in this way, the introduction of the gutta-percha points at the opening of the fistula can easily track the fistulous path and bring light to a proper diagnosis. It can be easily accomplished and may be easily carried out by dental professionals, when facing endodontic routine clinical procedures. Thus, the aim of this study was to describe two cases of patients who underwent this simple and highly effective examination
Dental caries in Brazil is a multifactorial public health problem responsible for the existence of most pathological problems related to dental pulp and periapical pathologies. In this context, apical abscesses appear in most cases as a result of this primary pathology. Before the formation of apical abscesses, some changes occur, along with carelessness, with the caries disease itself, which in turn invaded the vital space of the pulp, causing it to unleash an inflammatory process and thereafter die and start retaining bacteria that will produce purulent secretion until abscesses are formed.
Apical abscesses are didactically divided between acute and chronic apical abscesses. The former like any other acute condition, is fast evolving and painful in nature, while the latter is shows mild symptoms that may last for years and sometimes for a lifetime. In this way, an acute condition may evolve to chronification, and vice versa. In the context of chronic apical abscesses, there is an infectious, purulent condition, contained in the dental apice, which may be altered by diminished immunological response by the host organism, causing the process to worsen. The appearance of fistulas may be resumed as nothing more than the organism itself looking for a way to secrete all that purulent secretion out of inflammatory site, so that this infectious process may be drained, causing clinical relief, and is easily found in routine endodontic clinical examination, by the visual detection of the parulis, which is a mass of inflammatory granulation tissue in the fistula region and which is not innervated.
Diagnosis in Endodontics
Like any other science in health area, diagnosis plays a fundamental role in the sense that, if accomplished incompletely or wrongly, the course of the pathology will be cause serious damages to the patients.
According to Lopes and Siqueira (2010), periapical radiographs are the most appropriate to show the details of the mineralized structures of the teeth involved, and also the periodontal framework, allowing the visualization of its width, length and radius of root curvature. Paradoxically, Sewell et al., (1999) features that the use of panoramic radiographs for diagnosis in endodontics has been neglected for a more accurate examination of the dental organ, especially in cases of more extensive pathologies, in which the size limit of the periapical radiography is unviable for the full visualization of lesions.
Santos et al., (2011) claims that the percussion tests evaluate the commitment degree of the periapical tissues and the presence of inflammation in it. Torres et al., (2013) added that positive vertical percussion will be associated with inflammation of endodontic origin, and positive horizontal percussion is usually related to periodontal alterations. However, in practical terms, such maneuvers may respond with pain depending on the virulence of the causative agent associated with the host's capacity for effective immune response.
Santos et al., (2011) also addresses that as for what regards the mobility tests, its increase indicates the impairment of periodontal insertion, which can be the result of physical, chronic or acute trauma; occlusal trauma; parafunctional habits; periodontal disease and extension of an inflammatory process in the gingival tissue or in the periradicular region.
Fagundes et al., (2017) explains that the probing test aims to establish the diagnosis and prognosis of endoperiodontal lesions, since in the detection of deep periodontal pockets and in the absence of periodontal diseases, an injury of endodontic origin may be indicated.
According to Lopes and Siqueira (2010) the anesthesia test is indicated when pain is diffuse or reflexive, not allowing the patient to identify exactly which tooth is causing it. In this way, the suspect tooth is anesthetized. If the pain ceases, it can be interpreted that such tooth actually has got some pulp involvement, requiring other supplemented tests and exams for a possible endodontic treatment.
According to Paulo and Torres (2020), endodontic treatment of teeth with chronic periapical lesion requires a series of precautions, such as stimulating apical repair and decontamination. For reaching success of these cases, There is an alternative to use the iodoformed paste associated with the modeling and hermetic sealing of the root canal.
Anyhow, the correct diagnosis is the basis of any and all treatments of the different pathologies, in the difficult art of identifying the causative agent and its repercussion in the living organism.
Estrela et al., (2008) classify chronic periapical abscesses as an area of circumscribed suppuration, asymptomatic, of slow evolution and, occasionally, detected by routine radiographic examination. According to Sousa (2003), microorganisms are one of the main etiological factors in the development and maintenance of pulp and periapical pathologies. In this sense, the endodontic treatment has, as its major objectives, to combat such microorganisms, by neutralizing and removing their bacterial by-products and substrates from the root canal.
Takahashi (1998) claimed that, although the inflammatory reaction is unleashed to defend the organism, the persistence of the injuriant agents for a relatively long time may cause greater tissue destruction, causing apical abscesses. According to Cohen and Burns (2000), the acute inflammatory process is an exudative reaction that counts on the presence of neutrophils and macrophages, whereas the chronic process is a proliferative reaction. Microscopically, the chronic process is characterized by the proliferation of fibroblasts, vascular elements and the infiltration of macrophages and lymphocytes. In addition to the chronic inflammatory reaction, macrophages function as antigen presenting cells, whose proteins are digested and expressed in the T cell receptors on their membrane. Thus, this interaction with T lymphocytes stimulates a complex immune response that intersects the two types of immunity: the innate and the adaptive.
Nobuhara and Del Rio (2013) explain that in cases of abscesses, the presence of a fistula is indicative of a chronic abscess. However, there may be cases where there is no fistula, with only purulent exudate within the tissues adjacent to the tooth involved.
Fistulography is a diagnostic maneuver to identify a specific tooth responsible for an infectious process, named chronic apical abscess. The technique is painless and may be performed with no discomfort to the patient (Figure 1)
Figure Image is available at PDF file
Figure 1. Fistulography in tooth 12 for the localization of purulent collection
Cipriani (2013) explained that in fistulography, the gutta-percha cone is carefully inserted through the fistulous path, from the path exit (parulid), until resistance is found in the apical surroundings. Subsequently, a periapical radiograph is taken, through which a point of the gutta-percha will be detected in the lesion causing the fistula, along with the entire fistulous path, and the infection causing the pathology may be of endodontic or periodontal origin.
Slutzky-Goldberg et al.,., (2009) determined the prevalence, location and distribution of intra and extra-oral fistulas in patients referred for endodontic treatment. After clinical and radiographic examination, from the overall 1119 evaluated teeth, 108 showed fistulas. On clinical examination, the location, signs and symptoms present in each patient were recorded.
Guimarães (1980) explained that, from a clinical point of view, fistulas can be noticed with the presence of a nodular or papular lesion composed of granulation tissue. Mortensen and Winter (1970) approached that from the histological point of view, the walls of the fistulous path are covered by stratified ciliated squamous epithelium, while Harrison and Larson (1976) explained that the path may be covered by inflamed epithelium or connective tissue, which may cause painful sensitivity. The authors added that in this fistulous path there is no formation of nervous threads, allowing it to be penetrated by gutta-percha points painlessly. The fistulous path can be observed in figure 2.
Figure Image is available at PDF file
Figure 2. Tortuous fistulous path indicating the tooth responsible for infection
Fistulography is an easy doing diagnostic maneuver that can be accomplished by dental students easily. Nevertheless, students must be aware as for what concerns the choice of the gutta-percha point to be inserted in the fistulous path. If can neither be too soft and no too hard. Usually, a #25 gutta-percha point may be thick enough to penetrate all the way withing the path until it reaches the tooth, or teeth, responsible for the abscess. Some patients, however, report feeling some sort of light discomfort during the penetration of the point, but it is usually painless.
Care must be taken when the location of the fistula is in the palatal site, especially when it reaches the third molar region. Some patients feel nausea when the gutta-point touches the uvula region in some cases. In such situation anesthesia may be useful. Other than this, the process may be conduct easily and painlessly. It is important to mention that the parulis may disappear for some time, usually when the immune response is more active, and reappear afterward in the opposite situation. Chronic apical abscesses may also exist without the evidence of fistulas. Radiographically, it may appear as an increased radiolucent lesion in the apice of the teeth, usually very discrete. Increased radiolucent lesions are usually older ones, long enough to resorb bone and dental hard structures.
Fistulography is an easy doing procedure that may help clinical dental practioners and endodontists detect the presence of chronic apical abscess. It causes no painful discomfort in the patients and is accomplished with the aid of periapical radiographs.
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