JOURNAL OF ENDODONTICS Printed in U.S.A.

Copyright © 2004 by The American Association of Endodontists VOL. 30, NO. 7, JULY 2004

Biologic Aspects of Endodontics

Part III. Periapical Tissue Reactions to Root Canal
Instrumentation
Samuel Seltzer, D.D.S., Walter Soltanoff, D.D.S., Irving Sinai, D.D.S., Arthur Goldenberg, D.D.S., and
I. B. Bender, D.D.S.

In previous reports we have described the normal anatomic and teeth, as determined by roentgenographic visualization with instru-
morphologic variations of the root apex and surrounding structures ments in the root canals. In fifteen teeth, after pulp extirpation, the
of the teeth of human beings and of Macaca rhesus monkeys (11) canals were instrumented several millimeters beyond the morpho-
as well as the reactions of those tissues to vital pulp extirpation logic apices of the teeth, as confirmed by roentgenograms with
(12). We found that in the human periapical tissues inflammation files or reamers in the root canals. In both groups, following
persisted for at least one year after pulp extirpation, except where instrumentation, the canals were irrigated with physiologic saline
the root canals had been narrowed by prior reparative dentine solution and dried with sterile paper absorbent points. The coronal
formation or where denticles were present in the root canal near the orifices were then closed with an amalgam restoration placed over
apical foramen. In the animal tissues, the apical pulp stumps either a zinc oxide-eugenol base.
recovered completely or became necrotic with accompanying peri- After specific time intervals (Table 1), the root apices and
apical inflammation. We concluded that periapical inflammation surrounding bone were block resected. The extirpated pulps and
was likely to persist unless subsequent endodontic procedures were the resected tissues were fixed, decalcified, and processed in the
employed. usual manner. Most of the sections were stained with hematoxylin
The present report deals with the reactions of the apical and and eosin. Some sections were stained with Masson’s stain and
periapical tissues around the teeth of Macaca rhesus monkeys and some by the Papanicolaou method.
human patients following pulp extirpation plus reaming and filing Endodontic procedures were performed on twenty-four noncari-
of the root canals. In this investigation, comparisons have been ous teeth of the Macaca rhesus monkey, utilizing standard aseptic
made between the reactions of the periapical tissues following root procedures under the rubber dam. The root canals of twelve teeth
canal instrumentation (reaming and filing) short of the apices of the were instrumented short of the morphologic apices, and the root
teeth and those reactions which followed instrumentation beyond canals of the other twelve teeth were instrumented beyond the
the apices of the teeth into the periodontal ligament and alveolar
bone. The purposes of this investigation, which was conducted
under controlled conditions, were (1) to discover the reactions of TABLE 1. Number of human teeth resected at various time
the apical pulp and periapical tissues to root canal instrumentation, intervals following root canal instrumentation
(2) to document the sequence of reactions of the apical-periapical Interval between instrumentation
Number of teeth
tissue complex over a time span of 1 year, and (3) to discover and resection
whether there were differences in tissue reactions between teeth Canals instrumented short of apex
with canals instrumented short of the root apices and those teeth in Immediately 1
which the canals were instrumented beyond the root apices. 14 days 2
As a result of these continuing investigations, we hope to 28 to 42 days 3
uncover which endodontic procedures are least likely to produce 77 to 90 days 2
periapical inflammation in teeth with no prior periapical pathologic 180 days 1
involvement and, eventually, to discover those endodontic proce- 250 days 2
360 days 1
dures or techniques which are most likely to promote repair of
Canals instrumented beyond apex
previously diseased periapical tissues. Immediately 2
4 to 7 days 2
35 to 42 days 4
PROCEDURE 90 days 1
120 days 1
Twenty-seven noncarious human teeth were studied. In twelve 180 days 2
teeth, the pulps were extirpated and the root canals were instru- 210 to 270 days 2
360 days 1
mented from 2 to 10 mm. short of the morphologic apices of the

491
492 Seltzer et al. Journal of Endodontics

FIG. 1. Composite photomicrograph of root apex of upper central incisor. Pulp has been extirpated and instrumentation of root canal (RC) has
been performed short of apex. Dentine filings (DF) are packed against remaining pulp stump (P). D, dentine; AB, alveolar bone; PL, periodontal
ligament. (Magnification, ⫻54.)

TABLE 2. Canals instrumented short of apex, 1-week animal series

Canal wall External root

Tooth Canal content Periapical tissue
appearance surface
Upper right second incisor No change Dentine filings; necrotic No change Slight accumulation of
pulp tissue with polymorphonuclear
some inflammatory cells leukocytes
Upper right second premolar, No change Dentine filings; necrotic No change Uninflamed
mesiobuccal root only pulp tissue with
inflammatory cells
Upper left third molar, mesiobuccal No change Dentine filings No change Slight accumulation of
root only polymorphonuclear
leukocytes

apices. The teeth were treated at such intervals that, at the time of sacrifice. The root canals of half of the teeth in each time category
sacrifice, six teeth had been treated 6 months previously and six presumably had been instrumented short of the apices, and in the
teeth had been treated 3 months, 1 month, and 1 week prior to other half the root canals had been instrumented beyond the apices.
Vol. 30, No. 7, July 2004
FIG. 2. Mesial root apex of upper left second premolar of monkey.
Pulp was extirpated and canal reamed short of apex 1 week prior to
sacrifice. Top: Apical foramen (AF) is located at side of root. P, pulp;
D, dentine; C, cementum (Magnification, ⫻54.) Middle: Higher mag-
nification of root canal shown in rectangle in top photomicrograph.
Resorption (R) of dentine (D) has occurred. Slight inflammatory
infiltrate (INF) is visible. (Magnification, ⫻270.) Bottom: Higher mag-
nification of region of resorption outlined by rectangle in middle
photomicrograph. Osteoclasts (O) are visible, as well as polymor-
phonuclear leukocytes (P) and fibroblasts (f). D, dentine. (Magnifi-
cation, ⫻540.)
Biologic Aspects of Endodontics 493
However, subsequent histologic examinations revealed that, inad-
vertently, some canals which were to have been instrumented
beyond the apex were actually reamed short of the apex; hence,
those teeth were reclassified into the appropriate category.
Following the endodontic procedures, the root canals were
sealed with an amalgam restoration over a zinc oxide-eugenol
base. After the animals had been killed by perfusion with fixatives,
the maxillae and mandibles were dissected and jaw quadrants with
teeth in situ were decalcified and sectioned. The sections were
made serially and stained with hematoxylin and eosin for micro-
scopic study.
FINDINGS
On histologic examination, all of the extirpated pulps were
found to be free of inflammation. In general, the findings relating
to the apical-periapical tissues, described below, were common to
both the human and animal tissues.
For the sake of brevity, and to avoid needless repetition, the
findings from the human specimens will be described where they
and the animal tissue findings were similar. However, where
differences between the human and animal tissues were found,
those differences will be described.
Instrumentation short of the apices of the teeth
In the human teeth immediately following instrumentation, den-
tine filings were found packed against the walls of the root canal
and within the apical pulp stump. The remaining pulp tissue was
compressed and appeared to encapsulate the dentine chips. The
presence of extravasated erythrocytes and fibrin indicated that
hemorrhage had occurred and that a blood clot had formed. The
apical blood vessels were dilated, but they and the apical nerves
were structurally intact. (Fig. 1).
No human teeth were studied, one week after underinstrumen-
tation. In 3 animal teeth, dentine filings were found packed into the
apical portion of the root canal (Table 2). Resorption of the dentine
in the apical third of the root canal had occurred. A slight infil-
tration of polymorphonuclear leukocytes was present in the peri-
apical periodontal ligament in two of the three teeth (Fig. 2). The
periapical tissues of the third tooth contained no such inflammatory
exudate.
In two human specimens, 2 weeks following instrumentation
short of the apex, a blood clot was present on the surface of the
pulp stump. Dentine filings, erythrocytes, and polymorphonuclear
leukocytes were detected in the coronal portions of the pulp
stumps. Edema and hemorrhage were visible in the periapical
periodontal ligaments. The blood vessels in the periodontal liga-
ments were dilated and engorged with red blood cells. The peria-
pical tissues were composed of granulation tissue. Osteoelastic
activity was detected in the bone marrow spaces at some distance
from the apices of the teeth. Resorption of the root apices was
evident. In one section, several cell rests of Malassez had begun to
proliferate.
Twenty-eight to 42 days later, in one human specimen which
had no prior restoration, the remaining pulp stump was infiltrated
with polymorphonuclear leukocytes, lymphocytes, and macro-
phages, and the blood vessels were dilated and engorged with red
blood cells. The periodontal ligament space was widened, and its
494 Seltzer et al. Journal of Endodontics

FIG. 3. Composite photomicrograph of root apex of upper incisor. Pulp was extirpated and canal was instrumented short of apex 5 weeks
previously. Remaining pulp (P) stump appears to be intact, and periodontal ligament (PL) is free of inflammation. D, Dentine; C, cementum; AB,
alveolar bone. (Magnification, ⫻54.)

TABLE 3. Canals instrumented short of apex, 1-month animal series

Tooth Canal wall appearance Canal content External root surface Periapical tissue
Lower left first Apical third resorbed Apical third, normal Resorption and repair Normal
premolar and repaired with pulp tissue;
secondary cementum coronally, dentine
filings
Lower left first Distal root resorption Dentine filings with No change Normal
molar and repair in apical normal pulp in
third with cementum apical portion
Lower right Resorption and Dentine filings No change Small
second funneling of root granuloma
incisor apex
Lower right No change Mesial canal, normal Distal root, resorption Normal
first pulp tissue, due to pressure of
premolar apically; distal adjacent tooth
canal, connective
tissue ingrowth

collagen fibers were separated by edema. A small amount of
granulation tissue was detected in the periapical tissues.
In another specimen, a tooth with a large silicate restoration, the
periapical tissue had a normal appearance (Fig. 3).
In a third human specimen which had no previous caries or
restoration (42 days after instrumentation), a large area of rarefac-
tion had developed, as seen in the roentgenogram. The apical
foramen was filled with granulation tissue which was confluent
with the granulation tissue surrounding the root apex. Dense col-
lagen fiber formation had resulted in encapsulation of the granu-
loma. The cementum and dentine of the root apex had been
resorbed. The lesion was a typical periapical granuloma.
Apical-periapical tissue changes in the animal teeth generally
were mild (Table 3).
Seventy-seven to 90 days following instrumentation, a periapi-
cal area of rarefaction was detected in the roentgenograms of both
Vol. 30, No. 7, July 2004 Biologic Aspects of Endodontics 495

TABLE 4. Canals instrumented short of apex, 3-month animal series

Canal wall
Tooth Canal content External root surface Periapical tissue
appearance
Lower left first Secondary Dentine filings and chronic Secondary cementum Slight chronic
incisor cementum inflammatory cells deposited inflammatory cell
deposited accumulation
Lower left No change Dentine filings in mesial and Some resorption of Mesial and distal
second distal roots cementum and roots, normal
premolar dentine with repair by tissue
secondary cementum;
apical opening almost
sealed
Lower right No change Distal root, normal tissue; No change Slight accumulation
second molar mesial root, chronic of chronic
inflammation inflammatory cells

FIG. 4. Root apex and surrounding tissue of lower left central incisor
of monkey. Pulp was extirpated and canal (RC) instrumented short
of apex 3 months previously. Slight chronic inflammatory infiltrate
(INF) is present in periodontal ligament (PL), opposite apical fora-
men. AB, Alveolar bone. (Magnification, ⫻54.)

human specimens. In one specimen, the remaining pulp stump had

become necrotic. The apical foramen had become widened by
resorption of the cementum and dentine, and a granuloma was
present periapically. In the second specimen, the pulp stump had
retained its vitality but was chronically inflamed. Secondary ce-
mentum had been elaborated profusely and had lined the walls of
the root canal, repairing previous resorptions.
In the animal specimens, either normal pulp and periapical
tissues or mild chronic inflammatory responses were noted in the
apical pulp stumps and periapically in all the teeth (Table 4 and
Fig. 4). In one tooth, dentine filings had been packed against the
apical foramen and resorption of the cementum and dentine of the
root apex had occurred, but these resorptions had been repaired by
secondary cementum. The apical foramen was almost obliterated
by cementum; a biologic “seal” had formed. During the examina-
tion of serial sections, however, a small opening containing peri-
FIG. 5. Mesial root apex of lower left second premolar of monkey.
Canal had been instrumented short of apex 3 months prior to
sacrifice. Top: Dentine chips (DC) have been packed into apical part
of root canal. Secondary cementum (C) has been elaborated, ap-
parently sealing off apical foramen. PL, Periodontal ligament; AB,
alveolar bone. Bottom: Same root apex viewed at another level.
Here it can be seen that apical foramen (AF) is not completely
obliterated by cementum. (Magnification, ⫻54.)
odontal tissue was observed. The periapical tissues were free of
inflammation (Fig. 5).
At the end of 180 days, the remaining pulp stump in the
human specimen was structurally intact but mildly infiltrated
with chronic inflammatory cells. Some dentine filings had been
496 Seltzer et al. Journal of Endodontics

FIG. 6. Composite photomicrograph of upper central incisor. Pulp had been extirpated and canal reamed short of apex 6 months previously.
Remaining pulp stump (P) is intact but slightly inflamed. Regions of resorption of dentine and cementum of root (arrows) have been repaired
by secondary cementum (Ce). Periodontal ligament (PL) is slightly inflamed. AB, Alveolar bone. (Magnification, ⫻54.)

pushed into the pulp tissue. Secondary cementum had been
deposited profusely on the walls of the root canal and around the
apex of the tooth, repairing the previously resorbed regions. The
root canal had become narrowed by the cemental deposition.
The periapical tissues were slightly distended by edema, and
scattered inflammatory cells and erythrocytes were present.
New bone trabeculae had been elaborated, indicative of alveolar
bone regeneration (Fig. 6).
Periapical tissue inflammation was present in all of the animal
specimens 6 months postoperatively (Table 5). In two of the teeth,
the root canals contained necrotic debris. Periapically, granuloma-
tous lesions were present (Fig. 7). In a third tooth, chronically
inflamed pulp tissue was present in the apical third of the root canal
(Fig. 8, A). Periapically, the tissue was relatively normal (Fig. 8,
B). Inflammatory reactions were observed on the lateral aspects of
the root, however, and some epithelial proliferation had occurred
within the inflamed lesion (Fig. 8, C and D).
In the 250-day human specimen, a large periapical granuloma
which contained some proliferated epithelium had developed.
However, a restoration had become dislodged from the coronal
portion of the tooth sometime between the endodontic procedure
and the resection. The presence of the periapical inflammation
could not be divorced from the influence of the persistent leakage;
hence, the results were deleted from consideration. In the 270-day
human specimen, complete repair had occurred. The apical pulp
stump was intact and uninflamed. New cementum had been elab-
orated, both within the root canal and around the apex of the tooth.
The periapical tissues were free of inflammation.
At the end of 360 days, the root apex had been resorbed and
granulomatous tissue was present periapically. The granuloma was
encapsulated by dense collagen fiber bundles. Chronic inflamma-
tory cells were scattered throughout the collagen fibers. Although
the tissue was processed poorly, some new bone formation was
evident around the periphery of the lesion (Fig. 9).
However, examination of the roentgenograms of the 360-day
specimen tended to cast doubt that the canal had been instrumented
short of the apex. In the roentgenogram with the instrument in
position, it appeared as if the instrument might have been extended
slightly beyond the apex of the tooth.
(This article will be concluded in the next issue of the Journal.
References for the entire article will appear at that time.)
This investigation was supported by United States Public Health Service Grant DE
01930 from the National Institute of Dental Research, United States Public Health
Service, Bethesda, Md.
School of Dental Medicine, University of Pennsylvania
Reprinted from Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology &
Endodontics Vol. 25(4):534 –546, Copyright 1968, with permission from Elsevier..
Vol. 30, No. 7, July 2004 Biologic Aspects of Endodontics 497

TABLE 5. Canals instrumented short of apex, 6-month animal series

Canal wall External root

Tooth Canal content Periapical tissue
appearance surface
Upper right No change Necrotic debris External resorption Granuloma with
first and repair, epithelial proliferation
premolar mesiobuccal root
Upper right Reparative cementum Chronic inflammatory No change Palatal and distobuccal
second deposited in tissue in apical portion roots, large
molar mesiobuccal root of mesiobuccal root; granuloma with
debris in distobuccal liquefaction necrosis;
and palatal roots mesiobuccal root,
slight chronic
inflammatory cells,
granuloma on lateral
surface with
epithelial proliferation
adjacent to lateral
canal
Upper left No change Debris and chronic No change Granuloma with
first incisor inflammatory cells liquefaction necrosis,
(granulation tissue) chronic inflammatory
cells; no sign of
repair; slight amount
of epithelial
proliferation

FIG. 7. Mesial root apex of upper right first premolar of monkey. Root canal (RC) had been instrumented short of apex 6 months previously.
Moderate-sized granuloma (G) is present around apex. Some epithelial proliferation (E) has occurred within granuloma. AB, Alveolar bone.
(Magnification, ⫻54.)
498 Seltzer et al. Journal of Endodontics

FIG. 8. Mesiobuccal root of upper right second molar of monkey. Six months prior to sacrifice, pulp had been extirpated and canal was reamed
short of apex. A, Chronically inflamed pulp tissue (P) is present in apical third of root. D, Dentine; C, cementum. B, Level of same root showing
apical foramen (AF). Cementum has been elaborated on walls of root canal (RC). Periodontal ligament (PL) is infiltrated slightly by inflammatory
cells. C, Composite photomicrograph of same root at another level. Opposite root canal (RC) in apical third of root are chronic inflammatory
infiltrates, each with some epithelial proliferation (E). Inflammation (INF) is also present periapically. (Magnification, ⫻54.). D, Higher magnifi-
cation of epithelial mass seen at arrow in upper left-hand portion of photomicrograph C. Epithelium is infiltrated with polymorphonuclear
leukocytes (P), a sign of proliferation. (Magnification, ⫻540.)
Vol. 30, No. 7, July 2004 Biologic Aspects of Endodontics 499

FIG. 9. Composite photomicrograph of root apex of upper incisor. Canals had been reamed out, presumably short of apex, 1 year previously.
However, instrumentation may have been beyond apex. Root canal (RC) contains necrotic cells and some granulation tissue. Surrounding apex
is granulomatous tissue (G). Poor processing has resulted in artifacts (A). (Magnification, ⫻54.)