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Human teeth with periapical pathosis after

overinstrumentation and overfilling of the root


canals: a scanning electron microscopic study

J. H. GutieÂrrez1, C. Brizuela* & E. Villota*


1
Faculty of Dentistry, Department of Restorative Dentistry, Endodontics Section, University of ConcepcioÂn, ConcepcioÂn, Chile

Abstract Results Bacteria were detected on the flute of the files


and mostly at the root apices around the main foramen,
GutieÂrrez JH, Brizuela C, Villota E. Human teeth
remaining firmly attached to resorptive lacunae despite
with periapical pathosis after overinstrumentation and
the fact that the apices had undergone great changes,
overfilling of the root canals: a scanning electron microscopic
including fracture or zipping. A control group consisting
study. International Endodontic Journal, 32, 40±48, 1999.
of 10 human teeth root canals containing vital pulps
Aim The aim of this study was to determine whether were also overinstrumented and overfilled. No bacteria
overinstrumentation followed by immediate overfilling were detected on the flutes of the files, at the apices or on
could be a potential risk in the treatment of infected the extruded master cone overfilling these samples.
root canals. Conclusions The high percentage of bacteria
adhering to the resorptive lacunae or in the flutes of
Methodology Thirty-five human teeth with infected
files used in overinstrumented human teeth with
root canals were overinstrumented and overfilled ap-
infected root canals carry a potential risk for postopera-
proximately 45min after their extraction. The experi-
tive pain, clinical discomfort and flare-ups. The hazards
mental teeth were enlarged up to size 40 and the
observed in these circumstances do not support the
overinstrumentation and overfilling were checked with
one-visit treatment of teeth having acute or chronic
the aid of a magnifying glass. The specimens were fixed
periapical abscesses.
in glutaraldehyde plus sodium cacodylate solution and
prepared for scanning electron microscope Keywords: overfilling, overinstrumentation, periapical
examination. pathosis, pulpless teeth.

Introduction preparing the root canal mechanically and subse-


quently obliterating the space occupied primarily by
The root canal treatment of both vital and infected teeth
the dental pulp. Many authors have demonstrated that
root canals is performed in one or more visits. The
the main foramen can be located at distances ranging
mechanical preparation of root canals is part of a
from 0.20 to 3.00 mm or more from the anatomical
process, one goal of which is establishing a convenient
apex (Burch & Hulen 1972; Pineda & Kuttler 1972;
form, thereby facilitating efficient root canal obturation
Laurichesse et al. 1977; Stein & Corcoran 1990;
(Ingle et al, 1990, 1985).
Blaskovic-Subat et al. 1992; Moris et al. 1994). The
Since foraminal openings are not at the anatomical
clinical significance of these anatomical features is
apex, obtaining the real working length of a tooth is
that, by chance, many root canals can be inadvertently
only the estimation of the place where the cemento-
prepared beyond the apical foramen, which can be
dentinal junction could be located, with the purpose of
deleterious to the periapical tissues in teeth with
infected root canals. In a previous paper, GutieÂrrez
Correspondence: Juan Hugo GutieÂrrez, San Martin 515.18,
Concepcion, Chile et al. (1996), using scanning electron microscopy,
*C. Brizuela and E. Villota are in private practice. found that overinstrumentation of root canals of

40 International Endodontic Journal, 32, 40±48, 1999 q 1999 Blackwell Science Ltd
GutieÂrrez et al. Overinstrumentation and overfilling

human teeth provoked a variety of apical changes, (Duralay; Kerr Mfg. Co, Romulus, MI, USA). When
consisting of different types of apical cementum per- the Duralay was cured, the roots were cut 10 mm
forations and/or the production of zipping. These from the apex with carborundum disks mounted in a
changes were named according to their particular straight handpiece, keeping the teeth with the
microscopic appearance. crowns directed downwards, to avoid contamination
The aim of this study was to determine if overinstru- of the roots with dentinal chips. The apical portion of
mentation followed by immediate overfilling could be a the root with the file in the canal was then placed in
potential risk in the treatment of infected root canals, flasks containing 4% glutaraldehyde solution plus
considering that the mechanical trauma of breaking 1 mol L-1 sodium cacodylate solution at pH 7.2.±7.4.
apical cementum is added to the bacterial contamina- All these procedures were done during the 45 min
tion if present. immediately after extraction, using sterile gloves and
sterile instruments to prevent cross contamination.
After a minimum of 48 h of fixation, the samples
Materials and methods
were washed throughly with distilled water, and
The material consisted of 35 human teeth with dried in an electric stove at 37C for 56 h. The ex-
infected root canals which had acute and/or chronic perimental roots were then sputtered-coated with
apical abscesses. The root canals were prepared me- pure gold, and examined under a scanning electron
chanically immediately after extraction. In addition, 10 microscope (AutoScan; ETEC Corp, San Francisco,
teeth with vital pulps were overinstrumented and CA, USA), with magnifications up to 8000.
overfilled and used as controls. The samples were
separated into three groups as follows:
Group B
This group consisted of 15 anterior and/or posterior
Group A
human teeth with root canals which were both
This group consisted of 20 anterior and posterior overinstrumented and overfilled, simulating a clinical
human teeth with infected root canals, which were one-visit treatment. This was completed within 45 min
intentionally instrumented beyond their apices. The of extraction. These experimental teeth were
teeth were washed out with sterile saline until no mechanically prepared in the same manner as those in
blood was seen on the surface of the roots. Periodontal group A. When preparation was completed, a master
fibres were removed from the roots with a scalpel, gutta-percha point which fitted to the apical third of
except the apical 5 mm. Negotiation of the root canal the root was selected, ensuring that the tip extruded
was performed with files up to size 40 as a maximum, slightly through the apex, checking such extrusion
checking to ensure the appearance of the tip of the file with a magnifying glass. The root canals were filled by
penetrated beyond the main foramen using a the cold lateral condensation technique using Tubli-
magnifying glass. Seal as a sealer (Kerr Mfg. Co, Romulus, MI, USA). No
The mechanical preparation was done under more than three accessory gutta-percha cones were
alternate irrigation with 0.5 mL 5.25% NaOCl placed in the root canal. As in group A, each root was
solution + 0.5 mL 10% hydrogen peroxide + cut with carborundum disks 10 mm from the apex and
0.25 mL 5.25% NaOCL solution. The irrigants were placed in flasks containing 4% of glutaraldehyde plus
carried to the pulp chamber using syringes, and the 1 mol L-1 sodium cacodylate solution at pH 7.2±7.4,
chemicals moved with a file by applying a pumping until preparation for scanning electron microscopic
motion into the root canals. From time to time, the examination.
root canal contents were aspirated and then, the
canal moistened again as indicated. Each tooth was
Group C
maintained horizontally during the cleaning and
enlargement of the canal, avoiding overflow onto the This group consisted of 10 human teeth with vital pulp
external surface of the roots. Once the overinstru- root canals which served as controls, five of which
mentation was confirmed, the root canal was dried were overinstrumented and the other five,
with small pieces of cotton rolled over the flutes of a overinstrumented and overfilled, within 45 min of
reamer, and the extruded files fixed in place inside extraction. All the preparation and obturation of the
the root canals with polymethylacrylate resin samples were the same as those performed for group B.

q 1999 Blackwell Science Ltd International Endodontic Journal, 32, 40±48, 1999 41
Overinstrumentation and overfilling GutieÂrrez et al.

The teeth were prepared for and examined by scanning to facilitate their identification on the flutes of the
electron microscopy, as described previously. files or on the resorption lacunae found at the
apices.
Table 1 shows that 7 out of 20 (35%) overinstru-
Results
mented teeth with infected root canals which exhibited
Results based on the analysis of 270 SEM photomi- the file well through the apex (more than 1 mm) had
crographs are presented in Tables 1 and 2. Figs 1±4 suffered severe apical damage which could be designed
correspond to black and white photomicrographs as neat, crater, eggshell, banana skin, Chinese hat,
which were scanned and digitally coloured. Cocci and/or zip (GutieÂrrez et al. 1996). Neat was the name
were arbitrarily coloured in blue, and rods in pink for the perforation of the apex like a pinhole; crater,

Table 1 Bacteria detected on the files' tips and/or the apices of 20 human infected root canals intentionally overinstrumented
Tooth Root Location of the tip Apical change Appearance of Presence of bacteria Other findings
number canal of the file the apical on the file on the apex
cementum

27 mb Well through the Eggshell Resorptive Cocci Cocci, rods, ±


apex lacunae Filiforms
27 db Slightly through Eggshell ± Cocci, Cocci, ±
the apex Filiforms Filiforms
27 P Well through the Zip Resorptive Diplococci Diplococci Dentinal chips on
apex lacunae the apex
27 db Well through the Eggshell ± ± ± Detritus on the
apex flutes
27 P Well through the Banana skin ± ± ± Dentinal chips on
apex the apex
28 P Slightly through Neat ± Diplococci ± Detritus on the
the apex Filiforms flutes
28 P Slightly through Zip ± Cocci, ± Detritus on the
the apex Filiforms flutes
14 Slightly through Crater-like Resorptive ± Cocci, rods Detritus on the
the apex lacunae tip's file
22 Slightly through Neat ± Diplococci ± File covered with
the apex detritus
12 Slightly through Neat Resorptive ± ± ±
the apex lacunae
24 P Slightly through Neat ± ± Cocci Cocci around the
the apex foramen
17 P Slightly through Neat ± ± ± Detritus on the
the apex file, infiltrate of
lymphocytes
12 Slightly through Banana skin Resorptive Diplococci, rods Cocci, rods Detritus on the
the apex lacunae file
27 P Slightly through Crater-like Resorptive Rods, crystals Cocci, rods Apical
the apex lacunae cementum
remnants
16 P Well through the Zip ± ± Diplococci, rods Dentinal chips on
apex the apex
14 Slightly through Crater-like ± ± ± Dentinal chips.
the apex Periodontal fibre
remnants
27 P Well through the Zip ± Cocci, filiforms ± Periodontal
apex remnants
16 P Well through the Zip ± Cocci, Filiforms ± Periodontal
apex remnants
27 P Slightly through Crater-like Resorptive Diplococci, rods ± Periodontal
the apex lacunae remnants

42 International Endodontic Journal, 32, 40±48, 1999 q 1999 Blackwell Science Ltd
GutieÂrrez et al. Overinstrumentation and overfilling

Table 2 Bacteria detected on the master cone's tips and/or the apices of 15 human infected teeth root canals intentionally
overinstrumented and overfilled
Tooth Root Location of the tip's Apical change Appearance of the Presence of Other findings
number canal master cone apical cementum bacteria on the
apex

28 P Slightly through the Neat Resorptive lacunae Diplococci, rods Periodontal


apex remnants Crystals
on the gutta-percha
master point
47 m Well through the Zip Resorptive lacunae Cocci, rods Crystals on the
apex gutta-percha
master cone
47 d Apical perforation Zip Resorptive lacunae Cocci, rods Two gutta-percha
cones, one of them
filling the root's
perforation
28 P Slightly through the Neat Resorptive lacunae Streptococci
apex diplococci
28 P Slightly through the Crater-like Resorptive lacunae Cocci, rods Crystals on the
apex gutta-percha cone
47 d Slightly through the Crater-like Covered with Diplococci, rods Periodontal
apex periodontal remnants
remnants contaminated with
blood and yeast-
like cells
17 P Slightly through the Neat Resorptive lacunae ± ±
apex
15 Slightly through the Neat Resorptive lacunae Diplococci Root canal on the
apex master cone and
the apex
37 d Well through the Zip Covered with Cocci and rods on Root canal sealer
apex periodontal the periodontal on the master cone
remnants remnants
17 P Well through the Zip Resorptive lacunae Cocci Crystals and root
apex canal sealer on the
master cone
47 m Well through the Zip Periodontal Diplococci, Dentinal chips on
apex remnants filiforms master cone and
apex
47 m Well through the Zip Resorptive lacunae Diplococci, ±
apex filiforms
31 Two cones well Zip ± Cocci, filiforms Root canal sealer
through the apex around the master
cone and the
accessory gutta-
percha point
43 Slightly through the Neat ± Diplococci Root canal sealer
apex on the master cone
47 d Slightly through the Neat Resorptive lacunae Diplococci and Root canal sealer
apex large rods on the master cone

the disruption of the apex with loss of part of the apical became attached to the tip of the file; and, finally, zip
cementum; eggshell, the fracture of the cementum was the name for the deformation of the foramen
leaving an irregular edge-line; banana skin was the across and to one side of the foramen which had been
name given to a fracture, with vertical cracks, of the described by GutieÂrrez & GarcõÂa (1968) as hourglass.
apical cementum around the main foramen; Chinese Five out of 20 (25%) root canals whose files were
hat was where the tip of the apex was removed and slightly through the main foramen (less than 0.5 mm)

q 1999 Blackwell Science Ltd International Endodontic Journal, 32, 40±48, 1999 43
Overinstrumentation and overfilling GutieÂrrez et al.

Discussion
It is difficult to conceive that the apical fracture seen in
teeth instrumented by hand and intentionally overin-
strumented could not produce any discomfort
clinically. Unsuspected overinstrumention must be
common in clinical endodontics. Unexplained pain in
teeth showing faultless root canal filling, radiographi-
cally ending at an appropriate apical level occurs occa-
sionally. Since, clinically, there is no possibility of
establishing with certainty where the cemento-dentinal
junction is located (Dummer et al. 1984), slight overin-
strumentation as well as overfilling, which may not be
detected radiographically, may contribute to
subsequent failure. Furthermore, if bacteria and
dentinal chips on the flutes of the file are pushed out of
the main foramen, they may be lost, and lodged into
the periapical tissues when the instrument is
withdrawn from the root canal. This could induce a
Figure 1 Maxillary lateral incisor. White arrows pointing
out a banana skin pattern of cementum fracture, as a
flare-up or postoperative pain.
consequence of penetrating the main foramen with a size 15 In the present study, when the file was grossly over-
file. Note the flat point of the file. extended, there were different appearances microscopi-
cally compared with files that were less overextended.
In fact, a close relationship was found between apical
showed neat apical perforations. Six out of 20 (30%) resorption and the ease of overextension of the file,
root canals whose files were also slightly through the probably due to the alteration or to the lack of
foramen corresponded to roots which were either cementum, as compared with teeth with sound apices
curved or had thin apices where the apical changes and vital pulps which were used as controls, having
were eggshell, crater, banana skin, or zipping. Of the round cementum.
teeth which exhibited acute alveolar abscesses or The absence of bacterial cells on the surface of the
recent flare-ups, root resorption was found in 40% of extruded gutta-percha master points can be explained
the cases. by the drying of the root canals before their filling,
Table 2 shows that in six out of 15 (40%) overin- which could contribute to eradication, or they might
strumented and overfilled roots, the master cone was be included in the layer of Tubli-Seal which remained
slightly through the main foramen (less than 0.5 mm) firmly adhered to the root canal dentine or both.
whilst in another 6 out of 15 (40%) there was gross On the specimens belonging to the control group,
overextension of the master cone (more than 1 mm) periodontal fibre remnants were found frequently, as
and all the cases exhibited zips. Two out of 15 well as crystals deposited on the extruded tip of the
(13.33%) corresponded to master cones slightly master points, the latter associated with the
through the apices of a palatal root of a third maxillary components of the Tubli-Seal root canal cement.
molar, and to a distal root of a second mandibular Cocci, diplococci, yeast-like cells, rods of different
molar, and both teeth had straight roots. In this group, sizes, and filiforms were the types of bacteria found on
10 out of 15 experimental roots (66.66%) presented the resorptive lacunae seen on the apices and on the
apices with resorptive lacunae containing microorgan- flutes of the files, in the specimens with infected root
isms. However, no bacterial cells were observed on the canals. Bacteria must have been pushed out of the
extruded master gutta-percha cones. foramen whenever a file penetrated the apex of an
All the samples in group C (control) had no bacterial infected root canal. Bacteria were seen attached firmly
cells on the flutes, or the tips of the files, nor on the on the dimples of the resorptive lacunae, which
extruded master gutta-percha cones. As in groups A correspond to inflammatory resorption of the root
and B, different patterns of apical perforations and zip (Tronstad et al. 1981, Andreasen 1985). Simon et al.
were detected. (1981) found that in single-rooted human teeth with

44 International Endodontic Journal, 32, 40±48, 1999 q 1999 Blackwell Science Ltd
GutieÂrrez et al. Overinstrumentation and overfilling

Figure 2 Maxillary right first premolar.


(1) Area of resorptive lacunae;
magnification:  315. (2) rp, resorptive
lacunae;  750. (3)  2250, (4)  2850,
(5)  2850, and (6)  3000, Cocci and
rods (arrowed).

necrotic pulps, cemental resorption was a consistent Microorganisms identified in the apices of infected
observation. Delzangles (1989) who studied apical and teeth or their surrounding structures have been
intracanal resorption with scanning electron mostly anaerobic. Sundqvist et al. (1989) recovered
microscopy, observed in teeth with granulomas, apical black-pigmented bacteria in 30% of 72 single-rooted
resorption centred on the main foramina, whereas the teeth with necrotic pulps and apical periodontitis,
hard tissue underlying a cyst showed little or no and confirmed the association of this type of bacteria
resorption. Intracanal resorption was severe in all the and apical abscess. They believe that bacteria are
samples showing chronic lesions, always marked in the pushed out apically by the pumping movements of
apical third and more scattered in the middle and the file and may cause the development of post-
cervical third. The resorption disrupted the anatomical treatment abscesses, when the root canal contains
structures. Microorganisms can infiltrate dentinal black-pigmented Bacteroides. Sundqvist (1994)
tubules in heavily infected teeth as reported by reported a cause and effect relationship between
Armitage et al. (1983) who found bacteria up to specific bacteria and symptoms, finding a 100%
halfway to the cemento-dentinal junction. correlation of pain with the presence of P. melanino-

q 1999 Blackwell Science Ltd International Endodontic Journal, 32, 40±48, 1999 45
Overinstrumentation and overfilling GutieÂrrez et al.

Figure 3 Maxillary left third molar. (1)


fp. flat point file with debris at its tip;
 420. (2)  2250, (3)  3000, debris
covering part of the flute's surface (fs).
(4), (5) and (6): apical cementum
exhibiting rods (arrowed).

genica. Yoshida et al. (1987) suggested that, in 10 years after treatment. Six of the nine biopsies
addition to P. melaninogenica, an important role in revealed the presence of microorganisms in the apical
the development of clinical symptoms is associated root canal, of which four contained one or more
with Peptostreptococcus, both strict anaerobic microor- species of bacteria and two revealed yeasts. These
ganisms. The movement of endotoxin into the authors suggest that in the majority of root-filled
periapical tissues may also result in painful human teeth with therapy-resistant periapical lesions,
symptoms (Horiba et al. 1991) bacteria may persist, playing a significant role in
Nair et al. (1990), in a long-term light and electron endodontic treatment failures, and that in certain
microscopic follow-up study, analyzed nine therapy- instances such lesions may also be sustained by foreign
resistant and asymptomatic human periapical lesions, body giant cells. Nair et al. (1996) removed in toto 256
which were removed as block biopsies during surgical periapical lesions, 15% of which were classified as
treatment of the affected teeth. These cases revealed periapical cysts, 35% as periapical abscesses, and 50%
periapical lesions when they were examined 4± as granulomas.

46 International Endodontic Journal, 32, 40±48, 1999 q 1999 Blackwell Science Ltd
GutieÂrrez et al. Overinstrumentation and overfilling

Figure 4 Maxillary left third molar,


palatal root. (1) Master gutta-percha
point protruding slightly through main
foramen;  30. (2), (3), (4) and (5),
arrows pointing out rods;  3000. (6)
arrows pointing out diplocci and a large
rod. No bacterial cells were seen on the
tip of the master gutta-percha point;
 3000.

The high incidence of contaminated resorpted carry a potential risk for postoperative pain, clinical
lacunae found in the present study; the identification discomfort and flare-ups.
of strict anaerobes in infected root canals with acute or Overinstrumentation of the apices of teeth enlarged
chronical pathosis (Sundqvist, 1994; Yoshida et al. by hand in vitro produced different patterns of apical
1987); the presence of bacteria in root-filled teeth with fracture, in some instances with loose pieces of
therapy-resistant periapical lesions (Nair et al. 1990); cementum, which undoubtedly favoured overfilling of
and the possibility of damaging the periapical tissues the root canals.
when over-enlarging infected root canals either inad- The contamination hazards and apical damage
vertently or intentionally, as described in the present observed in these circumstances do not support the
study, do not support the proposal of one-visit therapy clinical one-visit treatment of teeth having acute or
for the acute periapical abscesses (Southard & Rooney chronic periapical abscesses.
1984).

Acknowledgements
Conclusions
This investigation was supported by institutional
The high percentage of bacteria adhered to the grant no. 94.102.09.01 from the DireccioÂn de Inves-
resorptive lacunae or in the flutes of the files of overin- tigacioÂn, awarded through the University of
strumented human teeth with infected root canals ConcepcioÂn-Chile.

q 1999 Blackwell Science Ltd International Endodontic Journal, 32, 40±48, 1999 47
Overinstrumentation and overfilling GutieÂrrez et al.

Our gratitude to Mr J. R. GutieÂrrez, Civil Mechanical Laurichesse JM, Chapelle PP, Griveau B (1977) Lanatomie
Engineer who improved the outlines of the photomicro- canalaire et son intrepreÂtation radiographique. ActualiteÂs
graphs, and digitally coloured the images, facilitating Odonto-Stomatologiques 117, 97±134.
the view of bacteria on the samples. Moris A, Sylaras SN, Georgopolou M, Kernani M, Prountzos F
(1994) Study of the apices of human permanent teeth with
the use of a scanning electron microscope. Oral Surgery, Oral
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