disease, prognosis, retention

Disease, Prognosis, Retention

Prognosis of Endodontic Therapy: Controlling Disease and Retaining Teeth

Prognosis

• is the prospect of recovery as anticipated from the usual course of disease or peculiarities of the case

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Prospect of Recovery

• From disease to health– from pulpitis to freedom from

pain and infection – by regeneration or replacement

– from apical periodontitis to normal apical periodontium – by regeneration

Prognosis - Outcome

• Outcome studies may also address

the function and survival of the treated tooth

Caplan & Weintraub, 1997

Treatment of apical periodontitis

Prevention of apical periodontitis

Common purpose: No root canal infection; no apical periodontitis.

This is what we usually think of when we say “prognosis of endodontic treatment”

Pulpitis

• .. is tissue reactions to trauma and/or infections of the pulp-dentin organ

• .. includes acute and chronic phases, abscesses, but may be reversible

Effective prevention is possible only when you know the etiology and pathogenesis of the disease in question, so..

Vital Pulp Treatment

The prognosis of endodontic treatment of teeth with initially vital pulps or uninfected necrotic pulps is unrelated to the pulp; it is a matter of preventing apical periodontitis

What is Apical Periodontitis?

Apical Periodontitis

• .. is tissue reactions to trauma and/or infection of the root canal system

• .. includes acute and chronic phases, abscesses and radicular cysts

• ..that persists is a sign of infection of the root canal system

Why Apical Periodontitis?• A defense

mechanism developed for the protection of the body interior from life-threatening infections

• Transition from continuously shedding to permanent teeth with pulps


20081200


How well do we do? What is the status of apical periodontitis in the population at large? We need to respond to such issues.

When treating individual patients, epidemiology is of little concern, and prognosis of interest only in predicting the fate of that particular tooth.

But as a profession, we will be judged by how well we can control and eliminate the disease.

Fig. 6. The prevalence of apical periodontitis in different populations. a, Dugas et al 2003; b, Marques et al 1998; c, Frisk & Hakeberg 2005; d, Loftus et al 2005; e, Buckley & Spangberg 1995; f, DeCleen et al 1993; g, Eriksen et al 1991; h, Dugas et al 2003; i, Kirkevang et al 1991; j, Frisk & Hakeberg 2005; k, Chen et al 2007; l, Jiménez-Pinzón et al 2004; n, De Moor et al 2000; o, Saunders et al 1997; p, Sidaravicius et al 1999; q, Tsuneishi et al 2005; r, Kabak & Abbott 2005; s, Segura-Egea et al 2005.

a bc d

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20

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100

Ind

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AP

, %

Adapted from: Harald Eriksen 2008 in: Ørstavik & Pitt Ford, Essential Endodontology

Epidemiology Prevalence of apical periodontitis %, selected countries, age 35-45 years

0

10

20

30

40

50

60

70

80

%

Portugal

Norway

Lithuania

From Eriksen et al., 2002

Many extractions;moderate quality

Few extractions;moderate quality

Few extractions;poor technical quality

Harald Eriksen 2008 in: Ørstavik & Pitt Ford, Essential Endodontology

Maintaining a high number of retained teeth into old age is a goal common to all of dentistry;

Endodontology deals with bringing down the prevalence of apical periodontitis

Reasons for Extraction

• In a survey of 31 investigations dealing with reasons for extraction of permanent teeth, in only three was apical periodontitis mentioned explicitly as the reason for extraction. One of them was an investigation performed by Brekhus as early as 1929. An interesting observation was that some additional investigations mentioned “failed endodontic treatment” and “pain” as reasons for extraction without explicitly defining pulpitis or apical periodontitits. It can therefore be concluded that apical periodontitis has not been appreciated as a “disease” compared to, for instance, marginal periodontitis, but rather considered as a sequel to dental caries.

Harald Eriksen in: Ørstavik & Pitt Ford, Essential Endodontology 2008


Caries

Pulp/AP Perio

0

4

8

12

16

20

Per cent

Brennan DS, Spencer AJ, Szuster FS. Provision of extractions by main diagnoses. Int Dent J. 2001 Feb;51(1):1-6. Australia: Practitioners completed service logs over one to two typical clinical days.


CariesPulp/AP

Perio Caries

Pulp/AP

Perio

1

3

5

7

Odds ratio

18-44 år 45+

Brennan DS, Spencer AJ, Szuster FS. Provision of extractions by main diagnoses. Int Dent J. 2001 Feb;51(1):1-6. Australia: Practitioners completed service logs over one to two typical clinical days.

”On the road to damnation”

”On the road to salvation”


Caries

Pulp/APPerio Pulp/AP

PerioPulp/AP

Perio

0

10

20

30

40

50

Per cent

overall urban rural

Spalj S, Plancak D, Jurić H, Pavelić B, Bosnjak A. Reasons for extraction of permanent teeth in urban and rural populations of Croatia. Coll Antropol. 2004 Dec;28(2):833-9. Survey among practitioners.

Reasons for Extraction of Endodontically Treated Teeth

Caplan DJ, Weintraub JA. Factors related to loss of root canal filled teeth. J Public Health Dent. 1997 Winter;57(1):31-9.

No. of approximal contacts .000

Age .000

No. of missing teeth .000

Anxiety .002

Bridge abutment .006

Medication .007

Diabetes .022

Denture/partial .037

Poor hygiene .039

Fig. 6. The prevalence of apical periodontitis in different populations. a, Dugas et al 2003; b, Marques et al 1998; c, Frisk & Hakeberg 2005; d, Loftus et al 2005; e, Buckley & Spangberg 1995; f, DeCleen et al 1993; g, Eriksen et al 1991; h, Dugas et al 2003; i, Kirkevang et al 1991; j, Frisk & Hakeberg 2005; k, Chen et al 2007; l, Jiménez-Pinzón et al 2004; n, De Moor et al 2000; o, Saunders et al 1997; p, Sidaravicius et al 1999; q, Tsuneishi et al 2005; r, Kabak & Abbott 2005; s, Segura-Egea et al 2005.

a bc d

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Segura-Egea JJ, Jiménez-Pinzón A, Ríos-Santos JV, Velasco-Ortega E, Cisneros-Cabello R, Poyato-Ferrera M. Int Endod J. 2005 Aug;38(8):564-9. High prevalence of apical periodontitis amongst type 2 diabetic patients. Department of Stomatology, School of Dentistry, University of Seville, Seville, Spain.

RESULTS: Apical periodontitis in at least one tooth was found in 81.3% of diabetic patients and in 58% of control subjects (P = 0.040; OR = 3.2; 95% CI = 1.1-9.4). Amongst diabetic patients 7% of the teeth had AP, whereas in the control subjects 4% of teeth were affected (P = 0.007; OR = 1.8; 95% CI = 1.2-2.8). CONCLUSIONS: Type 2 diabetes mellitus is significantly associated with an increased prevalence of AP.


Caplan DJ, Weintraub JA. Factors related to loss of root canal filled teeth. J Public Health Dent. 1997 Winter;57(1):31-9.

Periodontal disease .066

History of trauma .075

Cuspal coverage .096

Loss of Endodontically Treated Teeth

Caplan DJ, Cai J, Yin G, White BA. Root canal filled versus non-root canal filled teeth: a retrospective comparison of survival times. J

Public Health Dent. 2005;65(2):90-6.


Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod.

2004 Dec;30(12):846-50.

…treatment done in 1,462,936 teeth of 1,126,288 patients from 50 states across the USA was assessed over a period of 8 yr. …….

Overall, 97% of teeth were retained in the oral cavity 8 yr after initial nonsurgical endodontic treatment.



2004 Dec;30(12):846-50.

Analysis of the extracted teeth revealed that 85% had no full coronal coverage. A significant difference was found between covered and noncovered teeth for all tooth groups tested (p < 0.001).



2004 Dec;30(12):846-50.

The combined incidence of untoward events such as retreatments, apical surgeries, and extractions was 3% and occurred mostly within 3 yr from completion of treatment.

Loss of Endodontically Treated Teeth: Primary Teeth

Rocha MJ, Cardoso M. Survival analysis of endodontically treated traumatized primary teeth. Dent Traumatol. 2007 Dec;23(6):340-7.

51 teeth, 10-60 months of age 0

10

20

30

40

50

60

70

80

90

100

0–6

7–12

13–1

8

19–2

4

25–3

0

31–3

6

37–4

2

43–4

8

Time from treatment, months

Per

cen

t o

f tr

eate

d t

eeth

Failure (%) Cumulative success %


Wegner PK, Freitag S, Kern M. Survival rate of endodontically treated teeth with posts after prosthetic restoration. J Endod. 2006 Oct;32(10):928-31.

Usual Course of Disease

• Prognosis assessment is impossible without knowing the ”natural history” of AP:

• The infectious process

• The inflammatory response

• Variations and deviations from case to case

The Infectious Process• Sources of infection

– Caries – diminishing importance

– Physical exposure – filling margins, previous pulp/dentin trauma

– Traumatic fractures – special concerns

– Anachoresis – questionable occurrence

• Relative importance? – few/no data– Public health perspective: adequate conservative

treatment is the best prevention of apical periodontitis

The Infectious Process

• Sites of established infection– Main pulp canal space and walls

– Accessory canals and apical delta

– Dentinal tubules

– Cementum surface

– Extraradicular colonizations

• Relative importance? – few data, but the root canal infection is of course paramount– Brynolf 1966, Langeland et al. 1977

The Infectious Process

Pulpitis NecrosisCanalinfection

Apicalperiodontitis

Time

Spread toapex

Increasing infectious load;increasingly difficult to treat

Further course of disease:Sequels to the initial events

Severity

Incidence Adielsson et al 1999

The Inflammatory Response

• Acute and chronic– Acute AP

– Chronic AP: primary, persistent, secondary

– Exacerbating AP: Phoenix abscess

– Acute periapical abscess

– Chronic periapical abscess with sinus tract

– Radicular cyst: detached or pocket cyst

Time-Course of Apical Peridontitis

• Dynamics of pulpal infection

• Bacterial succession and variations in virulence and pathogenicity

• Host factors modulating inflammation and spread of the infection

• Ultimate consequences of root canal infection

Percentage of teeth at risk of developing apical periodontitis

Ørstavik 1994

0

2

4

6

8

0 1 2 3 4

TIME, years

RO

OT

S,

pe

r c

en

t

AP % of at risk General risk* Risk for RF teeth* Risk for noRF teeth*

0

2

4

6

8

0 1 2 3 4

TIME, years

RO

OT

S,

pe

r c

en

t

AP % of at risk General risk* Risk for RF teeth* Risk for noRF teeth*

Time-Course of Apical Peridontitis

• Bacterial succession and variations in virulence and pathogenicity

– Primary infection – self-explanatory

– Persistent infection – original flora, no cure

– Recurrent infection – residuals reemerging

– Secondary infection – new infection through leaking root filling

Natural Course of the Disease:Pain

• Varying in intensity and severity

– Pain sometimes accompanies pulpitis and apical periodontitis

• Unpredictable if untreated

– Pulpitis and acute apical periodontitis dominate as sources for acute dental pain in children and adults (Zeng et al 1994, Lygidakis et at 1998) which may be debilitating to the patient and lead to absence from work and involvement of costly health services. (Ørstavik, 2009)

Natural Course of the Disease:Pain


– While we know that emergency dental services are in great demand in most countries, in urban as well as rural areas, there is very scant information on the actual incidence and prevalence of acute pulpal and apical periodontal disease. Therefore, one can only speculate that there is still, even in communities with well-developed dental services, a significant impact on the general well-being by acute pulpal and periodontal conditions (Sindet-Pedersen et al 1985, Richardsson 2005). (Ørstavik 2009)

End-Points of Root Canal Infections

• Immediate abscess and sinus tract formation: incidence?

• Chronic, stable encapsulation: prevalence known

• Chronic cyst formation: prevalence known

• Exacerbation of chronic lesion: incidence (5% per year?)

• Sinus tract formation: incidence?

– Any available surface, sinus, nose, mucosa, skin

• Spreading oral infection: incidence?

– Submandibular, sublingual, local fascies

– Eyes, brain, mediastinum

20-70%}

Natural Course of the Disease:Conclusions


• It does not heal

• Potentially very painful

• Serious complications/sequelae are rare

Pulpitis ->Necrosis->Apical Perio->Acute phases->Local spread->Systemic spread

Filling therapy Endodontics Extraction

disease, prognosis, retention

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