\r\n\tEqually important are the consequences deriving from the extraordinary nature of the present times. The COVID-19 pandemic and the restrictive measures to contain the infection (lockdown and "physical distancing" in primis) have revolutionized the lives, and a distortion/modification of habits, rhythms, arrangements will continue to be necessary.
\r\n\tGovernments have implemented a series of actions to mitigate the spread of infections and alleviate the consequent pressure on the hospital system. On the other hand, the Covid-19 pandemic has caused a series of other cascading effects that will probably be much more difficult to mitigate and which expose to complex consequences. The past two years have brought many challenges, particularly for healthcare professionals, students, family members of COVID-19 patients, people with mental disorders, the frail, the elderly, and more generally those in disadvantaged socio-economic conditions, and workers whose livelihoods have been threatened. Indeed, the substantial economic impact of the pandemic may hinder progress towards economic growth as well as progress towards social inclusion and mental well-being.
\r\n\t
\r\n\tAlthough in all countries the knowledge on the impact of the pandemic on mental health is still limited and mostly derived from experiences only partially comparable to the current epidemic, such as those referring to the SARS or Ebola epidemics, it is likely that the demand for intervention it will increase significantly in the coming months and years. The extraordinary growth of scientific research in the field of neuroscience now offers the possibility of a new perspective on the relationship between mind and brain and generates new scenarios in understanding the long wave of the pandemic and in the prospects for treatment. Moreover, the pandemic also has led to opportunities to implement remote monitoring and management interventions.
\r\n\t
\r\n\tOverall this volume will address the complex relationship existing between COVID-19, mental health, acquired knowledge, and possible interventions taking a highly multidisciplinary approach; from physiological and psychobiological mechanisms, and neuromodulation through medical treatment, psychosocial interventions, and self-management.
Carbon nanotube (CNT) is a unique material with fantastic electrical, thermal, and mechanical properties, and since its discovery by Iijima in 1991 [1], global attention attracted toward it, and many researchers have evaluated the extraordinary properties of CNTs toward development of nanocomposites and sheets holding highly oriented CNTs with enhanced electrical and mechanical properties [2, 3, 4, 5, 6, 7].
Alignment of CNTs within the matrix can boost their properties in various fields include electrical and mechanical properties [2, 3, 4, 5, 6, 7]. What is more, alignment of CNTs can be achieved via various methods such as electrical field [2, 3, 4, 7, 8], magnetic field [9], shear flow [10, 11], mechanical force [12, 13], and electrospinning [14, 15], which electrical field–induced alignment is the simplest and most manageable method for alignment of CNTs within the matrix.
Besides, exert of electrical field to a matrix containing CNTs can lead to expansion of a highly oriented network from the negative electrode toward the positive electrode, which acting as a pathway for transferring current from the negative electrode toward the positive electrode. In this case, interruption of applied current can lead to collapse of developed network which known as relaxation mechanism [16].
In this chapter, first the alignment mechanism of CNTs within the matrix was evaluated, and thence, useful techniques for justification of CNT alignment in the content of matrix were presented. Afterward, effective techniques for fabrication of nanocomposites containing highly and randomly oriented CNTs were discussed, and effect of alignment on various properties of nanocomposites was examined.
Alignment mechanism of CNTs consisted from four stages [16]. In the first stage, due to the application of electric field, a dipole moment induced at the edges of CNTs resulted in their rotation to a certain angle and thence aligned in the direction of electric field. In the second stage, polarized CNTs attract each other, and head-to-head contact occurs, forming an aggregating in a chain-like structure. In the third stage, CNTs migrate toward and attach to the negative electrode, respectively. When CNTs are close enough to the electrode in order to transfer the charge, they discharge and aggregate onto the electrodes. Attached CNTs to the electrode become sources of high field strength and primary locations for absorption of other CNTs. In the fourth stage, following the connection of the first CNT bundle to the negative electrode, other CNT bundles attached the first bundle, and thence aligned CNT network spans negative-positive electrode spacing. In fact, CNTs form a pathway for transferring the current from the negative electrode toward the positive electrode and if the electric field interrupted during the alignment process, highly oriented network breaks down and CNTs return to their primary locations, this phenomenon is known as relaxation mechanism [16, 17]. Likewise, the translational motion of CNTs toward the negative electrode, justifying the presence of a negative surface charge, is governed by the electrophoretic mobility of charged CNTs. In case of relaxation mechanism, the Brownain diffusion is relevant to the motion and tends to fade of the aligned network, till it returns to the primary randomly distribution situation [18]. In Figure 1, alignment process of CNTs within matrix can be seen.
Alignment behavior of CNTs under application of electric field, (1) rotation, (2) head-to-head contact, (3) migration toward the negative electrode and (4) formation of aligned network between electrodes.
There are several effective techniques for evaluation of CNT alignment within the matrix. In this case, the most common technique is via micro Raman spectroscopy. Raman spectrum of CNT/polymer nanocomposites features two characteristic peaks, namely D-band and G-band. The band at 1350 cm−1 is known as D-band and corresponds to overall amount of defects in carbon atom bonds in curved graphene sheets. Therefore, the structural defects including heteroatoms, vacancies, impurities, as well as pentagon-heptagon pairs in helical structures of CNTs can activate the D-band feature. The other strong band observed at 1590 cm−1, called G-band, corresponds to the graphitization/crystallization degree of CNTs. G-band is believed to derive from the stretching of sp2-hybridized carbon atom bonds along the surface of graphitic CNTs [19, 20, 21]. Alignment of CNTs within the polymer matrix has significant effect on both D-band and G-band peaks [22, 23, 24]; this introduces Raman spectroscopy as a complementary technique to verify the alignment of SWCNTs within the polymer matrix.
For this purpose, D (G) band intensities obtained parallel and perpendicular to CNT alignment direction are denoted as D∥ (G∥) and D⊥ (G⊥), respectively. Enhancement of D∥/D⊥ and G∥/G⊥ values corresponds to improvement of CNT alignment within the matrix, due to higher surface area of aligned CNT projected to applied laser light in parallel direction than perpendicular direction. Abbasi et al. [19] and Arjmand et al. [20, 25, 26] used this technique in order to examine the alignment degree for compression-molded and injection-molded multi-walled carbon nanotube (MWCNT)/polymer nanocomposites. Their obtained results revealed that alignment of MWCNT via injection molding method had higher D∥/D⊥ and G∥/G⊥ values compared to the compression-molded samples, which contain randomly distributed CNTs. They also found out that D-band is more sensitive to MWCNT alignment than G-band; thus, higher values of D∥/D⊥ than G∥/G⊥ are expected for the aligned nanocomposites compared to unaligned nanocomposites.
The higher the ratio of G∥/G⊥ the better the quality of aligned CNT network [27]. In a study by Chapkin et al. [28], they have developed a technique, which has utilized polarized Raman spectroscopy for evaluation of CNT alignment within the polymer matrix under applied electric field. In this case, the effect of electric field strength between range 200 and 1100 V/cm on the degree of alignment and required time for achieving highly oriented CNT network was examined. The Raman scattering intensity is proportional to falling CNTs within the excitation volume of the laser. Increase in the concentration of CNTs within the matrix not only can increase the likelihood of multiple scattering events but also can increase the opacity of the mixture, which can lead to decrease in the penetration depth of the laser. Comparison between intensities of Raman spectra provided by orthogonally polarized incident light in nanocomposites containing well-aligned CNTs is an evaluation method for alignment characterization. Electrostatically aligned network of CNTs can lead to increase in the G-band intensity for parallel polarization direction and decrease for perpendicular direction in comparison to unaligned network. The G∥/G⊥ ratio indicating the degree of CNT alignment, which increases in this ratio, is the sign of better alignment within the matrix. In an unaligned specimen, this ratio is approximately 1. By applying the electric field between electrodes and alignment of CNTs between them, the intensities related to Raman peaks in the CNT spectrum begin to rise. In this case, the intensity of G-band was increased for the parallel polarization and decreased for the perpendicular polarization than unaligned specimens. Besides, by interruption of electric field, a considerable drop in the normalized G-band intensity was observed which is known as relaxation mechanism [16]. Decrease in the G-band intensity due to interruption of electric field indicating the loss of CNT alignment and collapse of aligned network. Furthermore, viscosity of matrix can highly affect the alignment behavior of CNTs. In this regard, a rapid loss in CNT alignment on the order of tens of milliseconds observed for low viscosity systems by interruption of the electric field [29, 30]. However, it has been observed that the alignment degree of CNTs in a matrix with high viscosity is higher than in a matrix with lower viscosity [31]. Increase in the electric field strength can either improve the G∥/G⊥ ratio or degree of alignment within the matrix. On the other hand, the polarization of a CNT highly depends on its conductivity [32, 33] and aspect ratio [32]. Conductivity of a CNT is based on its charity and behavior, which could be metallic or semiconducting. It has been proved that metallic CNTs presenting a greater degree of alignment via applied electric field than semiconducting CNTs [28]. Khan et al. [3] and Chen et al [4] have used micro Raman spectroscopy for determining the degree of CNT alignment via applied DC and AC electric fields, respectively.
In addition, Monti et al. [16] and Martin et al. [17] have measured the electrical current during the exertion of electric field as an indicator for formation of a highly oriented network in the area between two opposite electrodes. In fact, when highly oriented CNT network completed, the negative surface charge on the surface of the suspension has become constant, which shows highly oriented network has completed. Moreover, this network is a conductive path for transferring the current toward the positive electrode under electrophoresis, which verifying the presence of negative surface charge on CNT surfaces [17]. In Figure 2, a view of various justification methods for CNT alignment can be seen.
(a–c) Justification of CNT alignment via micro Raman spectroscopy [
Many effective factors involved in case of CNT alignment, which evaluation of their effects on aligned network is very essential. Homogenous dispersion of pristine CNT in the matrix is difficult to achieve, which is due to the poor interfacial interaction between CNTs and matrix [34, 35]. What is more, functionalization of CNTs can improve their dispersion within the matrix and enhance the align network. The alignment of CNTs within the matrix has significant effect on overall properties of developed nanocomposites, which are mainly dependent on the degree of CNT dispersion, type of matrix, and interfacial bonds between the matrix and fillers [3]. On the other hand, functionalization of CNTs can improve their dispersion and thus alignment of CNTs within the matrix due to the better interaction with matrix. In fact, functionalization of CNT can change its nature from hydrophobic to hydrophilic [36]. But functionalization of CNTs can increase their resistivity and examination of nanocomposites containing aligned CNTs revealed that highly oriented network consisted form pristine CNTs presenting higher electrical conductivity than functionalized CNTs [8]. A view of aligned CNTs networks containing pristine and functionalized CNTs can be seen in Figure 3. As can be seen in this figure, pristine CNTs have formed agglomerated bundles, while functionalized CNTs formed approximately homogenous aligned network.
Comparison between performance of pristine and functionalized CNTs for formation of aligned network under application of AC electric field [
Furthermore, alignment of CNTs within the matrix can be achieved via both AC and DC electric fields, while behavior of CNTs highly depends on the type of employed electric field and surface charge on the surface of suspension [17, 37]. In regard of DC electric field, migration of CNTs toward the negative electrode is governed by their electrophoretic mobility, which highly depends on the surface charge, while the electrophoretic mobility for AC electric field is zero. This specification of AC electric field can lead to creation of homogenous aligned network within the matrix due to their dielectrophoretic behavior. Likewise, usage of AC electric field found to be more effective compared with DC electric field [4, 17]. Moreover, increase in the electric field voltage can enhance the degree of CNT alignment, while for both AC and DC electric fields, increase in the electric field voltage can increase the aggregation rate, which highlights the requirement for optimization of voltage level [3, 8]. It was revealed that increase in the frequency of AC electric field can enhance the alignment degree and increase the transvers connections between aligned CNT bundles in the direction of electric field [8]. On the other hand, AC electric field presented both better dispersion and alignment within the matrix compared with DC electric field [4]. In Figure 4, effect of CNT weight percentage and DC electric field exerting time and strength on the quality of final aligned network can be seen. As can be seen in this figure, increase in CNT weight percentage and voltage can lead to increase in agglomeration rate and creation of robe-like CNT bundles which can be seen in Figure 4(g). Moreover, a view of aligned CNT network in fully cured samples can be seen in Figure 5.
Optical images from aligned CNT networks with respect to their concentration, size and duration which DC electric field was applied between electrodes, (a–f) 100 V/cm for 30 min and (g) 200 V/cm for 30 min [
Optical micrographs of suspension containing (a) randomly distributed SWCNTs before the field application, (b) alignment of SWCNTs after 180 s of field application, (c) alignment of SWCNTs after 15 min of field application, (d) a view of relaxation mechanism 10 min after switching the electric field off [
In addition, applied voltage and viscosity of matrix can highly affect the alignment process. Increase in the voltage and decrease in the viscosity of matrix can decrease the alignment time. However, unnecessary increase in the electric field voltage can improve the aggregation rate of CNTs and lead to creation of rope-like thick CNT bundles. On the other hand, due to high aspect ratio of CNTs, longitudinal polarization overcomes the transverse polarization. It is worth noting that after completion of the longitudinal polarization, CNTs start to attach each other in the transverse direction, forming transverse crosslinking [3, 16]. In Figure 6(a–c), effect of viscosity and electric field strength on required times for rotation, formation of chain-like structure, and migration can be seen, respectively. Besides, in Figure 6(d), comparison between total alignment time and required time for CNT migration toward negative electrode can be seen.
Effect of electric field strength and viscosity of matrix on the required time for (a) rotation, (b) head to head contact and (c) migration, (d) shows comparison between required time for alignment of CNTs within the matrix and migration of CNTs toward negative electrode [
In order to achieve a nanocomposite containing highly oriented CNT network with homogenous distribution, development of a practical procedure which has considered all of effective factors in matter of CNT alignment and nanocomposites preparation is essential. In this case, Ma et al. [4] synthesized MWCNTs using chemical vapor deposition (CVD) technique and thence functionalized fabricated MWCNTs using acidic method. In this regard, a mixture of H2SO4 and HNO3 acid (1:1 volume ratio) was prepared, and thereon, MWCNTs were added to the previous solution and heated up to 150°C for 30 min. Then, MWCNTs were rinsed with deionized water till they become chemically neutral. FTIR examination revealed that these MWCNTs have hydroxyl (─OH) and carboxyl (─COOH) functional groups, which can improve their dispersion within the matrix. Thence, MWCNT/poly methyl meth acrylate (PMMA) composites fabricated using in situ polymerization technique. In this regard, 0.1 wt% 2,2-azobisisobutylonitrile (AIBN) was dissolved in liquid methyl methacrylate (MMA) monomer. Then, desirable weight percentage of MWCNTs added to the MMA/AIBN solution and ultrasonicated for 15 min. In the next step, in order to align MWCNTs in the matrix, AC voltage of 300 Vp-p (peak to peak) at 500 Hz was maintained across the copper electrodes. The resulting nanocomposite was allowed to cure under the AC electric field for 2 h at 70°C.
Zhu et al [7] developed nanocomposites containing aligned MWCNTs within the epoxy resin. In this regard, MWCNTs were synthesized with mean diameter and average length of 20 nm and 10 μm, respectively. Afterward, they have developed two different kinds of MWCNT. For the first MWCNT type, MWCNTs were purified with hydrofluoric acid for 24 h in order to remove impurities and residual catalyst from synthesized MWCNTs. Thence, purified MWCNTs were placed in an oven at 100°C for 24 h, thereby resulting in production of pristine MWCNT. For development of second type of MWCNTs, pristine MWCNTs were added into a solution of H2SO4 and HNO3 (volume ratio 1:1) and resulting suspension heated up to 150°C for 30 min. Thereon, MWCNTs were filtered and rinsed continuously with deionized water in order to make it chemically neutral. This procedure can lead to production of functionalized MWCNTs with carboxyl (–COOH) and hydroxyl (–OH) functional groups. the oxidized MWCNTs were thence refluxed in thionyl chloride at 80°C for 1 h, and residual suspension was distilled and added into a mixture of methylene dichloride, 1,2-ethylenediamine, and triethylamine. Resulting suspension was stirred for 1 h at room temperature. Eventually, MWCNTs were filtrated out, rinsed with deionized water till become chemically neutral, and then dried at 100°C for 24 h to gain amine functionalized MWCNT. In case of matrix, they have used an epoxy resin which could be cured via emission of UV beams and while irradiated by 265-nm UV light, it was fast polymerized within several minutes. In the next stage, specific amount of prepared MWCNTs was poured in the epoxy resin and ultrasonicated for 20 min. Then, 2 mL of the resulting suspension poured into the related mold, and thence, an AC voltage of 2000 Vp-p (peak to peak) at 200 Hz was applied to the suspension for approximately 10 min. Then, UV light was emitted to the suspension for 10 min, which resulted in fast polymerize (cure) of the suspension. A view of their fabrication procedure can be seen in Figure 7(a).
Production procedures presented by (a) Zhu et al. [
Khan et al. [3] used CVD fabricated MWCNTs for development of nanocomposites containing highly oriented CNTs. For this regard, first MWCNTs were subjected to ultra-violet/ozone (UV-O3) treatment for 30 min used equipment consisted from a low-pressure mercury vapor grid lamp, which could irradiate UV radiation of 28 W/cm2 to samples placed 20 mm far from it. This step can change the nature of CNTs from hydrophobic to hydrophilic due to the creation of oxygen-based functional groups on CNT surface, thereby enhancing the interaction between matrix and CNTs. Functionalized MWCNTs sonicated in acetone and Tritone x-100. Thence, epoxy resin was added to the previous suspension and sonicated for further 1 h. Thereon, CNT/epoxy mixture was placed in the vacuum oven for 2 h in order to evaporate acetone from the suspension. For further degassing, suspension was passed through a three-roller mill for six times. Resulting mixture was then degassed for further 20 min to eliminate trapped air bubbles, and thereupon, curing agent triethylenetetramine was added to the epoxy resin with ratio 12:100. MWCNTs aligned due to application of DC electric field in a place between two aluminum electrodes with 50 mm distance. In this case, 100 or 200 V/cm electric field was applied to the mixture depend on the concentration of MWCNTs. An elevated temperature of 100°C was applied to the mixture after completion of alignment, which resulted in the rapid cure of the mixture. Primary cured composite was then postcured at 120°C for 2 h. A view of their production technique can be seen in Figure 7(b).
On the other hand, despite the fabrication process, which is very important in development of nanocomposites containing aligned CNTs in the direction of electric field, destructive factors such as bubble based voids can also significantly affect the overall properties of nanocomposites includes mechanical and electrical properties [38, 39, 40, 41, 42, 43]. Formation of bubble-based voids in the thermoset resins, such as epoxy resin, can highly affect their structural properties and lead creation of stress concentration areas. Bubbles are created due to various factors; diffusion of air into the polymer matrix and amalgamation of small bubbles have the main role in the creation of large bubbles. After completion of matrix-curing steps, the bubbles transform to voids and due to higher internal pressure than pressure in border with matrix and matrix itself, thereby resulting in growth of cracks in radial direction around the void [39, 42, 44]. For this regard, researchers have developed various kind of techniques to minimize the overall amount of bubble based voids, including molecular dispersion of bubbles in the polymer matrix [39], simultaneous usage of vacuum and vibration [45], and vacuum shock technique [42].
Moreover, addition of curing agent to the epoxy resin can lead to generation of a great amount of bubbles throughout the matrix, which is due to the reaction between the resin and the curing agent and can be removed via vacuum shock technique before completion of the first curing step. For instance, the presence of bubble-based voids throughout the epoxy resin with 1.0 wt% randomly oriented single-walled carbon nanotube (SWCNTS) can lead to 63% decrease in EMI shielding (X-band) and significant reduction in the electrical conductivity compared with nanocomposites holding small amount of bubble-based voids (less than 2%) [42]. What is more, creation of moisture throughout the dielectric nanocomposites can lead to significant decrease in both dielectric constant and dielectric loss [46]. Absorbed moisture not only can lead to decrease in the electrical performance but also can deteriorate the reliability of the dielectric materials [47]. Thus, removal of moisture and bubbles from nanocomposites has high level of importance.
Alignment of CNTs within the matrix can lead to obvious anisotropy in different directions. In this regard, aligned network presented significant enhancement in mechanical and electrical properties for parallel direction compared to perpendicular direction and randomly distribution of CNTs within the matrix [2, 3, 4, 6, 7, 8, 13, 20, 35]. Khan et al. [3] achieved remarkably low percolation threshold and significant improvement in mechanical properties of nanocomposites containing aligned MWCNTs. In this case, low percolation threshold of 0.0031 vol% was obtained for parallel direction of CNT alignment, which is one order higher than 0.034 vol% corresponding to the randomly oriented CNTs or that measured in transverse direction of CNT alignment. It is worth noting that the conductivity of developed nanocomposites increased by about four orders of magnitude due to increase in CNT weight percentage from 0.001 to 0.01 wt%, which shows a percolation behavior at even very low weight percentage of CNTs. Figure 8(a) shows the effect of CNT alignment on the electrical conductivity of developed nanocomposites containing aligned MWCNTs. As can be seen, alignment of CNTs within the matrix can lead to significant enhancement in the electrical conductivity, which is due to the increase in the interface of CNT bundles that enhanced the contact resistance [27, 48]. This trend for parallel direction is significantly higher than perpendicular direction and randomly distributed CNTs. On application of electric field between electrodes, CNTs immediately align in the direction of electric field to form interconnected bundles even at a very low CNT content, which can lead to achievement of percolation in the direction of CNT alignment, while the similar trend is not occurred for perpendicular direction of CNT alignment at the same content [3]. Despite CNT content, there are some other effective factors which are also responsible for the anisotropy in percolation include applied voltage, polymerization time (cure time), applied temperature, and viscosity of the matrix [8]. Moreover, it should be mentioned that transverse migration and connection starts once the alignment in the longitudinal direction (parallel direction) completed. In this case, increase in CNT weight percentage can enhance the rate of transverse direction and thus minimize the differences between parallel and perpendicular directions. On the other hand, the same as electrical conductivity, alignment of CNTs within the matrix shows significant improvement in the mechanical properties of nanocomposites include tensile strength, storage modulus, and quasi-static fracture toughness, which indicating the string reinforcing effect of high-modulus CNTs. In this regard, alignment of MWCNTs within the matrix led to 40% and 15% improvement in the Young’s modulus for nanocomposites containing 0.3 wt% aligned and unaligned MWCNT, respectively. However, it was observed that by further increase in the CNT concentration beyond 0.3 wt%, overall mechanical properties of developed nanocomposites containing aligned MWCNTs decreased, which is due to the reduction in the degree of alignment at high CNT concentration. In fact, increase in the CNT concentration can lead to significant increase in the viscosity of matrix as well as fillers packing, which can lead to higher resistance and less available free spaces for CNTs in order to move and align in the direction of electric field. In Figure 8(b−d), effect of CNT alignment on storage modulus, Young’s modulus, and quasi-static fracture toughness of nanocomposites can be seen [3].
Effect of MWCNT alignment within the epoxy resin on (a) electrical conductivity, (b) storage modulus, (c) Young’s modulus, and (d) quasi-static fracture toughness of developed nanocomposites [
On the other hand, present gaps and pores inside the aligned network due to low-weight percentage of CNTs can increase the contact resistance and thus reduce the electrical conductivity [49, 50]. Alignment of CNTs can lead to significant drop in obtained resistivity for a percolation threshold [51]. Moreover, alignment of CNTs can avoid the entanglement among CNTs in a certain degree, which can avoid creation of the conductive path [31]. It was also reported that alignment of CNTs within the matrix can lead increase in the volume resistivity and thus decrease in the conductivity of matrix [52]. In a work by Gupta et al. [2], they have aligned CNTs with current-assisted technique, which was led to the formation of shortest, continuous path for the flow of electrons, and thus formation of a highly anisotropic conductive path. Obtained results showed that current passage assisted alignment of CNTs can lead to significant 360% improvement in the conductivity for parallel direction than random distribution. However, lower conductivity in transverse direction than randomly distributed structure has been seen, which shows the efficiency of alignment. Despite of that, CNTs are forming a liner path with minimal distance between the electrodes in order to assisting current directly pass through. Electric field–induced alignment recorded 28% increase in the conductivity for parallel direction than randomly distribution, while the transverse direction showed 58% decrease in the electrical conductivity. In fact, current-induced alignment resulted in creation of continuous channels of aligned CNT, where CNTs are contacted end to end with each other and formed and uninterrupted conductive pathway. In this case, electrons will get direct path of flow, which can lead to fantastic enhancement in the electrical conductivity.
Zhu et al. [7] reported that alignment of MWCNTs via AC electric field can lead to significant improvement in the storage modulus and electrical conductivity of developed nanocomposites. Their obtained results revealed that increase in concentration of MWCNTs as well as their alignment can lead significant enhancement in the storage modulus of developed nanocomposites. Furthermore, nanocomposites containing amine functionalized MWCNTs (a-MWCNT) have shown higher storage modulus compared to pristine MWCNTs (p-MWCNT), which is due to the better compatibility and interaction between the matrix and a-MWCNTs. Moreover, measured storage modulus of aligned CNTs in parallel direction was greater than perpendicular direction and their randomly distribution within the matrix. On the other hand, nanocomposites containing p-MWCNT were presented higher electrical conductivity compared to a-MWCNT by about two orders of magnitude, which could be due to the decrease in length of a-MWCNT during chemical functionalization and increase in the a-MWCNT resistance. Figure 9(a) and (b) illustrated the effect of MWCNT alignment within the epoxy resin on storage modulus and electrical conductivity, respectively.
Effect of MWCNT alignment on (a) storage modulus and (b) electrical conductivity of developed nanocomposites [
CNTs presenting extraordinary mechanical, thermal, and electrical properties, which have reinforcement of nanocomposites with various kinds of CNT, can lead to significant improvement in their overall properties. In this case, application of electric field to the suspension containing CNT at different filler loadings can lead their alignment within the matrix and obvious anisotropy in different directions. In fact, CNTs act as path for transferring current from negative to positive electrode. This phenomenon can boost both electrical and mechanical properties of developed nanocomposites at same filler content. On the other hand, achieved results revealed that the overall properties of nanocomposites include mechanical and electrical properties are higher for parallel direction than perpendicular direction and random distribution of CNTs within the matrix, which is due to the desire of CNTs in formation of longitudinal connections than transverse connections.
Eventually, by alignment of CNTs within the matrix, significant improvement in overall properties of nanocomposites at same filler loadings compared with randomly distribution can be achieved, which is very essential for aerospace and aviation industries that encounter with serious limits in matter of structures’ weight.
The close inter-relationship between the periodontium and root canal systems has resulted in concomitant lesions from both entities, leading to periodontal-endodontic (perio-endo) infections that, to date, remain a challenge for the dental professional to both diagnose and manage. An in-depth understanding of the anatomy and disease pathogenesis is of utmost importance in assisting clinicians to establish a prognosis, derive a rational treatment plan and troubleshoot complicated cases grounded on sound biological and clinical bases. In this chapter, evidence-based and contemporary approaches to managing periodontal and/or endodontic lesions will be discussed collectively.
\nPeriodontal disease is an inflammatory disease of the tooth supporting structures initiated by bacteria that form a biofilm on the tooth/root surfaces [1]. Root canal infections (i.e. apical periodontitis) are multi-microbial, biofilm-associated diseases [2, 3]. Apical ramifications, lateral canals, and isthmuses connecting main root canals may harbor biofilm-like microbial structures [2]. The communications between the pulp and the periodontium occur primarily through: exposed dentinal tubules, small portal of exits - e.g. accessory canals and lateral canals - and via the apical foramen [4, 5]. As such, it is unsurprising that pathogens infecting the periodontium and root canal systems are highly similar, indicative of an inseparable relationship between the root canal system and the periodontium [6].
\nIn chronic apical abscesses caused by endodontic infections, a localized collection of pus with a draining sinus may track through the periodontium, forming a deep, narrow and isolated periodontal pocket, adjacent to, or alongside, the gingival sulcus. For molars or multi-rooted teeth, radiographic examination may reveal a radiolucent area at the furcation of an infected tooth, indicating presence of accessory canals which drain into the furcation area [4].
\nJansson et al. [7] reported that teeth in periodontitis-prone patients lost more attachment when a continuous root canal infection was present compared to teeth with no periapical lesions. Such findings were also observed by Ehnevid et al. [8] who concluded that a root-canal infection, if left untreated, may impair periodontal healing following non-surgical periodontal therapy. When the pulp is the source of infection, considerations should be given towards treating the endodontic infections prior to periodontal treatment [5, 9]. Such an approach is aimed at eliminating the source of pulpal infection prior to periodontal therapy, as root instrumentation may remove the protective cementum layer [10] and communicate residual infection through exposed dentinal tubules or accessory canals [11, 12].
\nAn inflamed periodontium resulting from a periodontal infection may affect the vitality of the pulp. Seltzer and Bender [13], reported that periodontal lesions could potentially infect the pulp through numerous lateral and accessory canals in the furcation area. The authors found that 79% of periodontally involved teeth, without caries and restorations, exhibited histological evidence of pulpal pathology. In periodontal disease affected teeth, localized pulpal necrosis adjacent to accessory canals was found [13].
\nLangeland et al. [14] reported that the effect of periodontal disease on the pulp was degenerative in nature, resulting in pulpal inflammation, calcifications and resorption. Such insults from periodontal disease to the pulp were cumulative over time [14]. Similarly, Wan et al. [15] reported that the severity of periodontitis had substantial effect on pulpal health. They speculated that denuded root surfaces could induce more pathological changes within the pulp [15]. Root surfaces may be denuded of the protective cementum layer as a result of periodontal treatment [16], developmental defects [17] or even due to direct bacterial invasion [18]. Denuded surfaces are thought to allow passage of microorganisms between the pulp and periodontal tissues through patent dentinal tubules, lateral or accessory canals [18]. Furthermore, if the microvasculature of the apical foramen remains intact, the pulp may maintain its vitality [14].
\nThe dental pulp and periodontium are closely related both anatomically and functionally, through three different channels of communication – as discussed below.
\nThe root canal system is a complicated system with the apical foramen as the principal route of communication between the pulp and the periodontium. A single apical foramen is the exception rather than the rule. Multiple foramina, fins, deltas, loops, and furcations are usually present at the apical end of the root canal [19]. Bacteria, bacterial toxins, inflammatory by-products and mediators pass readily through the apical foramen into the root canal eliciting inflammation of the pulp and subsequently pulpal necrosis [20].
\nIf periodontal disease reaches the apical foramen, such inflammatory reactions may spread both ways leading to perio-endo pathologies. Similarly, infection from an infected pulp may exit the apical foramen, track through the periodontium, eliciting tissue destruction and formation of what registers clinically as a periodontal pocket.
\nAccessory or lateral canals from the dental pulp may be formed during formation of the root sheath. A break develops in the continuity of the sheath, producing a small gap, which results in a small “accessory” canal between the dental sac and the pulp. Accessory and lateral canals can be seen anywhere along the root, creating a potential perio-endo pathway of communication [21]. Studies have reported that nerve fiber and blood vessels are commonly present in these lateral canals. They are found to traverse the periodontal ligament, course through the portal on cementum wall, root dentin and connect to the main root canal system [22]. Approximately 17% of teeth may present with multiple canal systems in the apical third of the root, about 9% in the middle third and fewer than 2% in the coronal third [23]. It has been reported that debridement at molar furcation areas may increase the risk of bacterial contamination of the pulp by 39% through exposed dentin or furcation canals [24].
\nAs periodontitis gradually destroys the periodontal ligament between the cementum and bone, cementum becomes exposed to the oral environment via periodontal pockets and through gingiva recession. Destruction of Sharpey’s fibers leaves a sieve-like surface on the cementum, full of canals which may be contaminated by bacteria and their toxins that may transverse the protective cemental layer into the patent dentinal tubules [10]. Furthermore, iatrogenic removal of cementum during periodontal treatment, various developmental fissures, grooves and incomplete calcifications on cementum may all permit penetration by bacteria into the underlying dentinal tubules [10].
\nDentin is highly permeable with dentinal tubules as the major channels for diffusion of material across dentin. Bergenholtz and Lindhe [25] reported that the application of soluble material from bacterial plaque readily caused pulpal inflammation, suggesting there was a pathway of communication between the dentinal tubules, periodontium and the pulp. Such findings were again confirmed by Bergenholtz [26], who found that bacterial products applied to exposed dentin initiated inflammatory reactions in the dental pulp whilst occlusion of such exposed dentin had a protective effect with respect to the pulp.
\nThe source of perio-endo infection is no doubt from within the mouth yet there is no comprehensive report on the microbiota involved compare with periodontal or endodontic infection occurring independently. More than 460 bacterial, almost 10 fungal and 1 archaeal taxa [27] plus predominantly herpesviruses detectable at periradicular lesions [28] were reported associated with endodontic infection. Such observations were rather similar to microbiology of periodontitis [29]. Microbiology of failed endodontic treatment [30] and persisting periradicular endodontic infection (i.e. L-phase bacteria) [28], however exhibit unique microbiology. Taking that into consideration, the exact microbiological nature of perio-endo lesion remained to be elucidated.
\nThe primary aim of endodontic treatment is to disinfect the root canal system through chemo-mechanical debridement and cleaning so that the canal space can be freed of infected organic materials and obturated with an inert material [31]. Endodontic failures are caused by inadequate disinfection of the root canal system or reinfection of the root canal system due to failure to obtain a hermetic seal [32]. Endodontic infection may spread to the periodontium leading to perio-endo pathologies.
\nEndodontic failure may be caused by various biological and procedural factors e.g. (i) persistence intra- and extra-canal infection; (ii) inadequate or poorly condensed filling of the canal; (iii) overextensions of root filling materials; (iv) leakage due to inadequate coronal seal; (v) missed and thus undebrided canals; (vi) iatrogenic procedural errors such as poor access cavity design; and (vii) improper instrumentation (inadequate chemo-mechanical cleaning, ledges, perforations, or separated instruments). As it stands, proper access cavity design, thorough chemo-mechanical debridement and complete sealing of the root canal system to obliterate infection and prevent reinfection are key in prevention of endodontic failure.
\nPoor restorations can be a major culprit for periodontal conditions and endodontic failure. Poor contours due to overhanging restorations, which impinge upon and thus violate the biological width, can contribute to localized periodontal defects [33, 34].
\nPoorly adapted restorations predispose to coronal leakage, allowing for recontamination of the root canal system and subsequent endodontic failure [35, 36]. Ray and Trope [36] reported that defective restorations with adequate root fillings had a higher failure rate in comparison to teeth with inadequate root fillings but with adequate restoration [36]. Similarly, a systematic review by Gillen et al. [35] reported that adequate root canal treatment (RCT) and good coronal seal increased the odds for healing of periapical lesions. In cases with adequate root filling-inadequate coronal restoration and inadequate root filling-adequate coronal restoration, poorer resolution of periapical infections are to be expected [35].
\nIn short, sufficient disinfection and filling of the root canal system and a well-adapted coronal restoration which respects the biological width are paramount in ensuring long-term endodontic success and maintenance of a healthy periodontium around the treated tooth.
\nRoot perforation is a mechanical or pathological, communication between the root canal system and the external tooth surface [37]. Misalignment of instruments during endodontic access, negotiation and preparation of the root canals, and preparation of post space can cause iatrogenic perforations. Pathological root perforation, on the other hand, is caused by root resorption and/or caries.
\nIn perforations, bacterial infections emanating from either the root canal or periodontal tissues, or both, could prevent healing and bring about inflammation. Down-growth of the gingival epithelium to the perforation site can follow, resulting in accelerated periodontal breakdown [38]. Ideally, any perforation should be repaired immediately. Treatment outcomes of endodontic perforations at the apical part of roots have been reported to be more successful than those located more coronally [39, 40]. Mineral trioxide aggregate (MTA) is often used for perforation repair [41] as it can stimulate hard tissue deposition [42], is biocompatible [43], provides excellent seal [44] and sets in the presence of moisture [45].
\nDevelopmental malformations both affect the periodontium and complicate conventional RCT. One of the most common dental malformations seen is the palatal-radicular groove, which has a reported prevalence of 4.6% appearing in maxillary incisors [46]. Its presence is a locus of plaque accumulation and provides potential pathway for microorganisms to penetrate into deeper parts of the periodontium, causing local inflammation and subsequent periodontal breakdown. Attachment loss may extend apically until it adversely affects the viability of the pulp, which is typical of the pathogenesis of a primary periodontal lesion with secondary endodontic involvement. RCT may be needed first if the patient complains of toothache. This may then be followed by periodontal surgical debridement or regenerative periodontal therapy when indicated [47].
\nCemental tear is a rare periodontal condition characterized by partial or total separation of the cementum. The detachment normally happens at the cementum-dentin junction predisposing the tooth to plaque-induced periodontitis. Clinically, a cemental tear may present as a localized deep periodontal pocket, with or without other symptoms such as a sinus tract or pain. Probing at the affected site may detect root surface roughness or an obstruction, different to the expected typical tactile sense of calculus [48]. Treatment of cemental tear includes conventional periodontal therapy, combined periodontal and endodontic treatment when pulpal status of the affected tooth is compromised and/or surgery to remove the tear.
\nCervical enamel projections and enamel pearls are development anomalies presenting as ectopic globules of enamel on the root surface. Enamel projections are small continuous or discontinuous extensions of enamel that occur in the molar furcations while enamel pearls are larger masses of enamel that have a predilection for molars [49]. It has been reported that 82.5% of molars with furcation attachment loss exhibited cervical enamel projections [50]. Enamel pearls are a rarity and occur mostly on permanent molars with an incidence rate of 1.1–9.7% [51]. Cervical enamel projections and enamel pearls predispose to periodontitis because Sharpey’s fiber insertion is not developmentally possible, allowing only a hemi-desmosomal attachment, which may be less resistant to periodontal breakdown. Both entities may also prevent effective oral hygiene procedures when exposed to the oral environment and may serve as a nidus for periodonto-pathogenic bacteria to grow and populate their surface [49]. In longstanding conditions, down-growth of epithelial attachment may cause a perio-endo lesion, especially if exposed accessory canals in the furcation area allow bacteria invasion into the pulp [24]. A combination of treatments may be warranted, such as RCT if pulpal symptoms are present, followed by periodontal surgery to recontour locally the affected root to allow for root debridement and to facilitate proper oral hygiene measures and periodontal maintenance measures.
\nDental resorption is the loss of dental hard tissues as a result of resorptive activities by clastic cells (aptly known as odontoclasts) [52]. Root resorption may occur as a physiologic or pathologic phenomenon. Root resorption is classified into two types, external and internal.
\nExternal inflammatory resorption (EIR) is often a result of root avulsion injuries [53]. Traumatic dental injuries (e.g., intrusion, lateral luxation, and avulsion) and subsequent replantation often result in contusion injuries to the periodontal ligament (PDL). Damage to the pre-cementum, with a resultant breach in its integrity, is the precipitating factor in all types of external resorption [53]. In the wound healing process that follows, necrotic PDL tissues, damaged cementum and even root dentin may be actively removed by macrophages and osteoclasts, although the underlining mechanism is still unclear [52].
\nThe diagnosis of EIR in clinical situations is often based on radiographic findings [54]. However, in two-dimentional radiographic imaging EIR may be obscured by overlapping images, or may not detectably show early signs of EIR, resulting in late diagnosis of EIR. Chronic inflammation seen in periodontal disease has been regarded as a cause for root resorption [55, 56], and such resorptive processes are associated with the severity of periodontitis [55]. The exact mechanism of periodontal disease-associated resorption is not known, but such a process may be a sequela of tooth mobility due to attachment loss [55]. When mobile teeth are subjected to occlusal forces, traumatic assault of the radicular surface may ensue, causing formation of cemental tears or lesions which may become colonized by odontoclastic cells or even periodontal pathogens that may resorb the root [55].
\nTreatment of EIR is based on effective removal of the cause, which is to institute a RCT with removal of the infected necrotic pulpal tissue [57]. Although the treatment of such lesions in periodontal disease is inconclusive, conventional mechanical debridement [56] may suppress inflammation and arrest the resorptive process. The earlier EIR is diagnosed and treated, the better the prognosis is for the affected tooth [58].
\nExternal cervical resorption (ECR) is a form of root resorption that originates on the external root surface but may invade root dentin in any direction and to varying degrees. ECR generally develops immediately apical to the epithelial attachment to the tooth. However, in teeth that have developed gingival recession and lost periodontal support and/or have developed a long junctional epithelium, the resorptive defect may arise at a more apical location [59]. The difference between EIR and ECR is that the pulp remains vital in ECR lesions unless the lesion is extensive and erodes into the pulpal space, while EIR always presents with necrotic pulp with or without any periapical lesion.
\nThe exact etiology and pathogenesis of ECR have not been fully elucidated but may be regarded as the same for EIR. Infected or denuded cementum surfaces allow binding of multinucleated clastic cells which perpetuate the resorptive process [52]. Orthodontic treatment, dental trauma, oral surgery, periodontal therapy, bruxism, delayed eruption, and dental developmental defects were all identified as potential predisposing factors to ECR [60, 61]. In patients with periodontal disease, ECR may occur if the root-protective junctional epithelium (JE) did not develop. In such instances periodonto-pathogen initiated inflammation and dietary acid may extend into the root surfaces to cause ECR [56]. Although not fully understood, such a situation may explain why resorption occurs only in the cervical region, where JE is absent and dietary acid easily gains access and may accumulate over a long period.
\nThe clinical features of ECR may vary depending on etiology. However, the process is very often quiescent and asymptomatic initially. Its diagnosis is commonly made from a chance radiographic finding. A pink or red discoloration may later develop at the cervical region due to fibrovascular granulation tissue occupying the resorptive defect [59]. Inflammatory periodontal destruction may occur in the region of the resorption, resulting in a periodontal pocket that bleeds profusely on probing.
\nIn recent years, CBCT has allowed three-dimensional assessment of the nature, position, and extent of resorptive defects, eliminating diagnostic confusion and providing essential information about the restorability and subsequent management of affected teeth [62, 63, 64]. A CBCT scan (at the smallest voxel size – 0.2 mm) provides a more site-focused and clearer radiographic image [65], thus reducing the need for exploratory treatment (usually surgical exploration), allowing timely intervention and reduced patient morbidity.
\nThe fundamental treatment objectives in ECR are to access and excavate the resorptive defect (usually by raising a mucoperiosteal flap), halt the resorptive process (through application of 90% trichloroacetic acid), restore the hard tissue defect [66], and regular monitoring of the affected tooth for ECR recurrence, and the same for all other teeth which may be predisposed to the same resorptive event. This is especially true for ECRs related to periodontal diseases as multiple ECRs may occur in the same patient [56]. In cases where perforation of the root canal wall has occurred, RCT should be carried out as soon as possible to avoid pain. In periodontal disease-associated ECR, treatment was primarily aimed at suppressing periodontal pathogens through mechanical debridement, oral hygiene instruction and systemic antibiotics. This was supplemented with diet counseling and monitoring to lower the patients daily acid intake. High acidic intake may have contributed to the initiation of the resorptive process by retarding the proliferative capacity of the protective junctional epithelium [56].
\nA vertical root fracture (VRF) is a longitudinally oriented complete or incomplete fracture initiated in the root at any level and is usually directed buccolingually [67]. The diagnosis of a VRF is somehow difficult in the early phase with patients complaining of dull pain, tooth sensitivity and discomfort while chewing. Early detection of VRF is unlikely radiographically due to various obstructions and overlapping structures, making proper diagnosis difficult. In of long-standing VRFs, a sinus tract may develop at a location more coronal than a sinus tract associated with chronic apical abscess [68]. This hints that the source of infection is not likely from an apical lesion [69, 70]. A deep, narrow, isolated periodontal pocket may be present, which is usually pathognomonic of a VRF. Radiographically, a typical J-shaped or halo radiolucency, with bone loss seen apically and extends alongside the involved root is highly indicative of VRF [71].
\nOver time, the pocket along the fracture line, which was initially tight and narrow, may become wider and easier to detect. When the fracture line propagates coronally, extending to the cervical root area, bacteria may penetrate and biofilm can attach along the fracture line, triggering local host immune response which destroys the local periodontium. The fracture line allows the leakage of oral bacteria into the clean and previously sealed root canal system causing contamination. As reported by Tamse et al. [68], a typical VRF pocket could be observed in 67% of the cases. In periodontitis patients, vertical root fractures and cracks may serve to communicate the dental pulp with the periodontium. If the periodontium is infected or inflamed, pulp necrosis may ensue due to bacterial and bacterial product dissemination through such crevices [72].
\nTreatment for VRF differs greatly. VRF does not usually respond to non-surgical RCT or retreatment or to periodontal treatments instituted. In most cases, extraction of the tooth, especially for single-rooted teeth, is required. As for multi-rooted teeth, a root-resective approach may sometimes be considered.
\nUntreated periodontal disease may progress and cause extensive damage to the tooth supporting structures. As the disease extends along the root surface, infection and/or inflammation can spread through the various communications between the pulp and the periodontium [28] until periodontal disease progression reaches the apical foramen leading to a primary periodontal lesion with secondary endodontic involvement [4]. Classification and management of such lesions will be discussed in the segments below.
\nMany classifications for perio-endo lesions have been suggested [4, 72, 73, 74]. However, the proposed classification by Simon et al. [4] is still espoused by many, despite more rational later classifications, for many cases of perio-endo infections, and shall form the framework for the following discussion below.
\nA necrotic pulp with its infected root canal system elicits inflammation of the adjacent periodontium through leaking of bacteria and bacterial by-products through the apical foramen and/or lateral canals causing tooth-supporting bone destruction [4, 72]. In multi-rooted teeth, infection from the apical foramen or the numerous accessory canals located in the molar bifurcation area, may track into the bifurcation area giving a radiographic and often clinical appearance of periodontal furcation involvement [21]. To consider solely endodontic lesions as having a component attributable to periodontitis is a diagnostic and conceptual error.
\nAs such, when differentiating endodontic or periodontal lesions, one should be suspicious of a pulpally/endodontically induced lesion when the crestal bone levels on the mesial and distal aspects of the offending tooth appear relatively normal radiographically, despite a radiographically evident furcation radiolucency, and when clinical attachment loss is localized. Moreover, when the pulp is non-responsive to sensibility testing, it is likely that a necrotic pulp may be the infectious source. Adequate RCT with adequate coronal restoration should usually resolve a primary endodontic lesion without any periodontal therapy, for such lesions are solely endodontic in origin. If solely affected by pulpal pathology, such teeth are only endodontically involved, and the so-called “primary endodontic lesion” is solely an endodontic lesion, and thus really should not be a component of any perio-endo classification. Figure 1 illustrates a pure endodontic lesion managed by endodontic retreatment alone.
\nEndodontic lesion managed by endodontic retreatment. (A) Periapical radiograph of previously root treated tooth 31 exhibiting a large periapical lesion and infection draining through buccal gingival sulcus; (B) retreatment of 31 and RCT of a non-vital 32 completed; (C) radiograph of 31 and 32 showing bone fill 6 months post treatment.
Over time, an untreated primary endodontic lesion may result in secondary consequential periodontal breakdown, which, if this reaches the gingival sulcus or a periodontal pocket, may become infected by periodonto-pathogens which subsequently trigger further periodontitis-associated periodontal tissue destruction, pocket formation, crestal bone loss and plaque (and calculus) contamination of root surfaces.
\nA tooth so affected requires both endodontic and periodontal treatments. In general, healing of tissues damaged by infection from the pulp can be anticipated after adequate RCT. The prognosis of the tooth will then largely depend on the outcome of periodontal therapy [4].
\nPure periodontal lesions are bacterial-induced inflammatory destructions of the tooth supporting apparatus due to periodonto-pathogens [75]. Diagnosis is based on periodontal examination such as probing pocket depths at 6 sites of each tooth, plaque accumulation and gingival bleeding scores [75, 76], on teeth having normal pulpal sensibility test outcomes. Teeth affected by solely periodontitis, which should respond to adequate periodontal therapy alone, are not endodontically involved.
\nIn periodontitis, probing usually reveals plaque and calculus of varying quantity and quality along the root surface. In periodontitis many teeth are usually. The pulp typically responds positively to endodontic sensibility tests unless periodontitis has progressed towards the root apex. Prognosis of purely periodontally affected teeth depends largely upon the amount of bony destruction, the overall management of the patient, including non-surgical and surgical periodontal therapy, practice of adequate oral hygiene measures and adherence to supportive periodontal care [76, 77]. Once more, if a tooth is affected by only periodontitis which would respond to adequate periodontal treatment alone, then it is free from any endodontic involvement, and as such the so-called “primary periodontal lesion” should not form any part of a classification of perio-endo lesions.
\nIf periodontitis progresses apically along the root surface, bacterial infiltrates from the periodontium may penetrate the pulp through exposed accessory and lateral canals, canaliculi of the furcation area, and eventually the apical foramen [72]. Pulpal necrosis can also result from periodontal procedures where the blood supply, through an accessory canal or the apex is severed during instrumentation. Lateral canals and dentinal tubules may be exposed to the oral environment during periodontal treatment allowing microorganism to pass freely to, or be pushed into, the pulpal tissue space [4].
\nPrimary periodontal lesions with secondary endodontic involvement differ from primary endodontic lesion with secondary periodontal involvement only by the temporal sequence of the disease processes. Regardless of the primary cause of disease, RCT should precede periodontal therapy to prevent excessive removal of the protective root cementum and to alleviate any pulpal pain [5, 9, 22]. The tooth prognosis depends on adequate endodontic therapy, adequate coronal restoration and continuing periodontal care subsequent to endodontic therapy. The sequencing of treatment for both primary endodontic with secondary periodontal lesions and primary periodontal with secondary endodontic lesions is basically the same, so there is not a therapeutic distinction to be drawn from the differentiation between these two types of both periodontal and endodontic lesions affecting a tooth.
\nTrue combined lesions occur where a primary endodontic lesion exists on a tooth that is also affected by periodontitis. These lesions are created when an infected periodontal pocket progresses apically to join with the endodontic lesion progressing coronally. Once the endodontic and periodontal lesions coalesce, they may be clinically and radiographically indistinguishable. The degree of attachment loss is usually quite substantial and the prognosis of such lesion is often very guarded [4].
\nIn most cases, apical healing is often evident following successful endodontic treatment. The periodontal lesion, however, should respond well to adequate periodontal treatment and the prognosis may well depend on the severity of the periodontitis-induced periodontal attachment loss and the extent and pattern of alveolar bony destruction. The radiographic appearance of combined endodontic–periodontal disease may be similar to that of a VRF [4, 78].
\nThe primary endodontic lesion and the primary periodontal lesion are solely endodontic or periodontal in origin and should not be confused as perio-endo lesions where both entities are assumed to be associated with one another. To clarify such relationships, Abbott and Salgado [11] proposed a classification that limits the diagnosis of perio-endo lesions to teeth that have both endodontic and periodontal diseases occurring simultaneously. They proposed that such teeth should be classified into:
Al-Fouzan [72] in their discussion on perio-endo lesions agreed largely with the classification by Simon et al. [4] but proposed a modification to the primary endodontic lesion. They classified an endodontic lesion with a deep narrow probing defect as “retrograde periodontal disease”, with two subdivisions:
Al-Fouzan [72] also added an additional classification termed “iatrogenic periodontal lesions” which included: root perforation, coronal leakage, dental injuries or trauma, damage from chemicals used in dentistry and vertical root fractures. Although such lesions are not exactly periodontal lesions, such a classification allowed separate definition of perio-endo pathologies associated with trauma or iatrogenic injuries to the root surface itself. This was important as extensive damage to the root greatly diminishes a tooth’s long-term prognosis. This distinction may aid clinicians in identifying perio-endo lesions with direct and extensive damage to the root surface as opposed to lesions initiated by root canal infections and/or periodontal infections. Perio-endo lesions arising from root canal and/or periodontal infections are basically inflammatory lesions initiated by a wide array of microbiota such as bacteria, viruses or fungi. These are usually presented clinically without detectable damage to the root itself. Such lesions are treated differently from those with significant root damage and will be discussed below.
\nEvidently, various opinions and controversies have emerged over the classification of perio-endo lesions. Future research or discussion may bring about a more comprehensive classification for such lesions that can clearly define the etiology of such pathologies and serve as a guide to adequately treat them.
\nCombined perio-endo lesions are a challenge to manage. RCT, or at least its initiation with mechanical and chemical cleaning of the pulp canal spaces, and effective intra-canal medication, is usually advocated as the first step in treatment of teeth with combined perio-endo lesions presenting with increased PPD and for teeth are unresponsive to pulp sensibility testing. Non-surgical periodontal therapy can proceed. Once RCT has been completed, adequate time for healing of the endodontic lesion should be given before further advanced periodontal therapy is considered [9]. Treatment modalities aimed at removal of bacterial irritants result in tooth prognosis which has been shown to improve over time [47]. This section summarized the treatment sequence for perio-endo lesions (Figure 2).
\nFlow chart summarizing treatment sequence for perio-endo lesions.
In the management of perio-endo lesions, it is important to recall that infected or necrotic pulps may lead to a narrow sinus tract undistinguishable clinically from a periodontal pocket. Because the primary cause of such lesions is pulpal in origin, the indicated treatment is solely RCT followed by adequate coronal seal, with long-term follow-up and monitoring to assess healing.
\nSimilarly, if a vital tooth affected by solely periodontal disease develops mild pulpal symptoms, periodontal treatment should be the only intervention, followed by long-term follow-up. This will allow the mild and usually reversible inflammatory reaction of the pulp (which may transiently increase after periodontal therapy) to resolve as the vital pulp resists the spread of inflammation from the periodontal lesion [12].
\nWith regards to concurrent perio-endo infections, although these separate entities may not be communicating, RCT should be carried out, or at least initiated, first to eliminate pulpal infection and relieve pain. This may then be followed by root surface debridement. Such a treatment sequence will allow removal of infectious source from the pulp and control of any possible communication between the infected root canal system and the adjacent periodontium. With this, even if the protective cementum layer is removed during root surface debridement, there should be no pulpal infection that can spread towards the periodontium through open dentinal tubules or accessory canals [11, 12]. Such a treatment philosophy is applied to true perio-endo lesions as well, to allow the affected tooth to undergo infection control in its entirety, sequentially and as effectively as possible [12].
\nIndeed, in any patient with periodontal disease, management should include plaque control, non-surgical scaling and root debridement; periodontal surgery (with or with regenerative periodontal therapies) when indicated; and subsequent supportive periodontal care (SPC) [76, 79]. SPC should allow any teeth with pathologies, periodontal, endodontic or combined, to be well maintained within the oral cavity in the long term.
\nConventional non-surgical periodontal and endodontic therapy may be predictably used to treat mild to moderate bony defects caused by perio-endo lesions. However, these non-surgical therapies alone might be inadequate for the treatment of lesions characterized by deep pockets, or wide circumferential apical defects caused by non-healing endodontic lesions, previous endodontic surgery [80], or those with substantial root surface damage such as root fracture of resorption. An endodontic lesion may be considered non-healing if the periapical lesion increases in size or remains unchanged after RCT. A decision to provide alternative treatment modalities will depend largely on the signs and symptoms experienced by the patient and judgment of the treating clinician, as periapical lesions can take up to four years [32] or longer [81] to heal. Surgical options for perio-endo lesions can be divided into surgical debridement, periodontal- or root- resective, or regenerative, approaches. The extent of periodontal tissue destruction or the failure of adequately delivered treatment to resolve the lesions, or any component thereof, may leave tooth extraction as the only practical treatment option.
\nRoot resection is the removal of a root (or roots, or root with coronal tooth structure) along with accompanying odontoplasty, before or preferably after endodontic treatment. Such tooth respective modalities are advocated to treat specific non-furcation and furcation defects that unlikely to be managed by non-surgical or surgical debridement alone [82]. The indications for root resection include root fracture, perforation, root caries, dehiscence, fenestration, external root resorption involving one root, incomplete endodontic treatment of a particular root, severe periodontitis affecting only one or two roots with at least one good sized root with proper/sufficient periodontal support to remain [83], or and severe grade II or grade III furcation involvement of multi-rooted teeth in the treatment of which clinicians attempt to create ‘single rooted’ situations to remove affect root(s) and to facilitate oral hygiene and SPC measures [84, 85].
\nFactors such as occlusal forces, tooth restorability, residual periodontal support and strategic value of the remaining root(s) should be taken into consideration during the planning stage before treatment. Proper reshaping of the occlusal table and appropriate restoration of the clinical crown are essential [83]. Additionally, the root surface at the site of the amputation must be recontoured after removal of the root stump to allow reestablishment of soft and hard tissue morphology favorable for oral hygiene measures by the patient and SPC measures by treating clinicians [86].
\nHemisection is the surgical separation of a multirooted tooth. This is usually only a treatment option for mandibular molars with severe furcation involvement and periodontal attachment loss having affected one root more severely than the other (Figure 3). The tooth was sectioned through the furcation, and the respective root and associated portion of the crown may be removed while another moiety is retained [87]. In most instances, an elective RCT should be performed before or as soon as possible after the hemisection to avoid any future pulpal complications. Hemisection allows retention of natural tooth structure, especially the root, which helps preserve surrounding alveolar bone, and may facilitate the placement of fixed prostheses [87].
\nManagement of a mandibular left first molar with severe furcation involvement and periodontal attachment loss. (A) Radiographic bone loss observable at distal root of a non-vital 36; (B) RCT was completed and 36 was hemisected distally; (C) 36 was subsequently crowned to coronally seal the treated root canal, re-establish occlusion and prevent further mesial drift of the second molar.
The restorative aspects of the tooth to be so treated must be carefully assessed and integrated into the anticipated surgical procedure to ensure proper positioning of restorative margins relative to the osseous crest, and also to manage the anticipated changes in occlusal relationships and masticatory forces. In certain occasions, splinting of a resected tooth to neighboring teeth or the use of such teeth as abutments for fixed partial dentures may confer some reinforcement towards its long-term survival [83]. Although factors such as older age at time of resection, grade II mobility or above, and reduced pre-operative radiographic bone heights around roots seem to reduce the survival of resected teeth, the major cause of failure of resective procedures is often due to endodontic failure or vertical root fractures [88]. This is especially true if periodontal treatment had been properly carried out and the patient adheres to strict SPC [83, 88]. In most situations, the residual periodontal support of the treated tooth dictates the prognosis of the tooth. However, teeth with reduced periodontal support may still be maintained if proper SPC is provided [76, 89].
\nRegenerative therapy has been shown to yield greater attachment gain and re-establish more favorable tissue morphology for oral hygiene measures compared to conventional periodontal therapy [90]. Pre-surgical assessment includes assessment of the pulp status and the severity of periodontal destruction. Once the therapeutic prognosis for the periodontal regenerative procedure is determined to be favorable, endodontic therapy is provided and the endodontic lesion is allowed to heal. Unsatisfactory healing after RCT might be further addressed with a surgical endodontic therapy approach (apicectomy) [78]. After a successful RCT, tooth mobility is reassessed to determine the necessity for splinting, as tooth mobility may reduce the success of regenerative therapy [91]. The intrasurgical assessment includes morphology of the periodontal defect, material of choice to manage the defect, control of patient’s oral hygiene, wound and tooth stabilization [78]. The defect, patient, and surgery-specific factors associated with favorable periodontal regeneration are [80]:
Defect considerations: Deep (≥4 mm), narrow (<45 degrees), vertical, two to three wall defects with no/minimal furcation involvement, adequate soft tissue thickness (>1.1 mm) and keratinization (2 mm).
Patient considerations: Good oral hygiene, compliance towards periodontal care, abstinence from smoking/non-smoking and good systematic health/properly controlled systemic conditions.
Surgical considerations: Atraumatic incisions and flap elevation, primary closure, passive wound tension, uncontaminated wound during surgery (and post-surgical healing) and no occlusal trauma
In perio-endo lesions, regenerative periodontal therapies, such as use of biologically active products or guided tissue regeneration (GTR), may be used to promote periodontal regeneration and crestal intra-osseous defect bone-fill after endodontic treatment. In GTR, a barrier membrane is used to prevent contact of connective tissue with the osseous walls of an intra-osseous defect, to protect the underlying blood clot and to encourage growth of key tissues, while excluding unwanted cells such as epithelial cells [80]. When the intra-osseous defect is large, bone substitutes may be placed in the defect to support the overlying membrane and to maintain a space in which healing may occur [80]. Sometimes both root-resective and regenerative treatment may be carried out simultaneously to retain a tooth in function. Figure 4 shows treatment of an upper first molar with a root fracture.
\nPeriodontal surgical management of an upper left first molar with a root fracture. (A) Radiograph of root treated 26 with suspected mesio-buccal root fracture; (B) intra-operative view of 26 confirming initial diagnosis; (C) 26 MB root was resected and the defect regenerated with xenograft and a collagen barrier membrane. Radiograph taken at 6 months post treatment.
An in-depth understanding of the biology underlying perio-endo inter-relationships guides a clinician in diagnosing and subsequently deriving a sensible and timely treatment plan. Conventional endodontic and periodontal therapy have been shown to be successful in managing such lesions [47] with endodontic therapy, or at least its initiation, being the first line of treatment in most cases [9]. The use of regenerative approaches to manage perio-endo lesions has advantages especially in terms of enhanced attachment gain and better long-term outcome of treated teeth. Various other treatment modalities for managing the periodontal component of perio-endo lesions, such as the application of enamel matrix derivatives [92] or platelet-rich fibrins [93] may offer good results. However, more research is warranted in this field with hope that retention of perio-endo involved teeth may become more predictable in the near future.
\nThe work described in this chapter was substantially supported by the Young Researcher’s Incentive Grants (GGPM-2016-062 and GGPM-2017-109), The National University of Malaysia, and the Research Grants Council of the Hong Kong Special Administrative Region, China (HKU 772110 M).
\nThe authors declare no conflict of interest.
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