Presentation on theme: "Disease, Prognosis, Retention"— Presentation transcript:
1Disease, Prognosis, Retention Prognosis of Endodontic Therapy: Controlling Disease and Retaining Teeth
2Prognosisis the prospect of recovery as anticipated from the usual course of disease or peculiarities of the case m-w.com
3Prospect of Recovery From disease to health from pulpitis to freedom from pain and infection – by regeneration or replacementfrom apical periodontitis to normal apical periodontium – by regeneration
4Prognosis - OutcomeOutcome studies may also address the function and survival of the treated tooth Caplan & Weintraub, 1997
5Prevention of apical periodontitis Treatment of apical periodontitisCommon purpose: No root canal infection; no apical periodontitis. This is what we usually think of when we say “prognosis of endodontic treatment”
6Pulpitis.. is tissue reactions to trauma and/or infections of the pulp-dentin organ.. includes acute and chronic phases, abscesses, but may be reversible
7Vital Pulp TreatmentThe 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 periodontitisEffective prevention is possible only when you know the etiology and pathogenesis of the disease in question, so..
9Apical 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
10Why Apical Periodontitis? A defense mechanism developed for the protection of the body interior from life-threatening infectionsTransition from continuously shedding to permanent teeth with pulps
12Apical PeriodontitisWhen 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.How well do we do? What is the status of apical periodontitis in the population at large? We need to respond to such issues.
13Adapted from: Harald Eriksen 2008 in: Ørstavik & Pitt Ford, Essential Endodontology 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.
14EpidemiologyPrevalence of apical periodontitis %, selected countries, age yearsFew extractions; poor technical qualityFew extractions; moderate qualityMany extractions; moderate qualityFrom Eriksen et al., 2002
15Harald 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
16Reasons 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 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
17Reasons for Extraction Brennan DS, Spencer AJ, Szuster FS. Provision of extractions by main diagnoses. Int Dent J Feb;51(1):1-6. Australia: Practitioners completed service logs over one to two typical clinical days.
18Reasons for Extraction ”On the road to damnation””On the road to salvation”Brennan DS, Spencer AJ, Szuster FS. Provision of extractions by main diagnoses. Int Dent J Feb;51(1):1-6. Australia: Practitioners completed service logs over one to two typical clinical days.
19Reasons for Extraction 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 Dec;28(2): Survey among practitioners.
20Reasons for Extraction of Endodontically Treated Teeth No. of approximal contacts.000AgeNo. of missing teethAnxiety.002Bridge abutment.006Medication.007Diabetes.022Denture/partial.037Poor hygiene.039Caplan DJ, Weintraub JA. Factors related to loss of root canal filled teeth. J Public Health Dent Winter;57(1):31-9.
21Segura-Egea JJ, Jiménez-Pinzón A, Ríos-Santos JV, Velasco-Ortega E, Cisneros-Cabello R, Poyato-Ferrera M. Int Endod J Aug;38(8): 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 = ). 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 = ). CONCLUSIONS: Type 2 diabetes mellitus is significantly associated with an increased prevalence of AP.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.
22Reasons for Extraction of Endodontically Treated Teeth Periodontal disease.066History of trauma.075Cuspal coverage.096Caplan DJ, Weintraub JA. Factors related to loss of root canal filled teeth. J Public Health Dent Winter;57(1):31-9.
23Loss 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.
24Loss of Endodontically Treated Teeth …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.Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod Dec;30(12):
25Loss of Endodontically Treated Teeth 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).Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod Dec;30(12):
26Loss of Endodontically Treated Teeth 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.Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod Dec;30(12):
27Loss of Endodontically Treated Teeth: Primary Teeth 51 teeth, months of ageRocha MJ, Cardoso M. Survival analysis of endodontically treated traumatized primary teeth. Dent Traumatol Dec;23(6):340-7.
28Reasons for Extraction of Endodontically Treated Teeth Wegner PK, Freitag S, Kern M. Survival rate of endodontically treated teeth with posts after prosthetic restoration. J Endod Oct;32(10):
29Usual Course of Disease Prognosis assessment is impossible without knowing the ”natural history” of AP:The infectious processThe inflammatory responseVariations and deviations from case to case
30The Infectious Process Sources of infectionCaries – diminishing importancePhysical exposure – filling margins, previous pulp/dentin traumaTraumatic fractures – special concernsAnachoresis – questionable occurrenceRelative importance? – few/no dataPublic health perspective: adequate conservative treatment is the best prevention of apical periodontitis
31The Infectious Process Sites of established infectionMain pulp canal space and wallsAccessory canals and apical deltaDentinal tubulesCementum surfaceExtraradicular colonizationsRelative importance? – few data, but the root canal infection is of course paramountBrynolf 1966, Langeland et al. 1977
32The Infectious Process Apical periodontitisSpread to apexCanal infectionNecrosisPulpitisIncreasing infectious load; increasingly difficult to treatTime
33Further course of disease: Sequels to the initial events
36The Inflammatory Response Acute and chronicAcute APChronic AP: primary, persistent, secondaryExacerbating AP: Phoenix abscessAcute periapical abscessChronic periapical abscess with sinus tractRadicular cyst: detached or pocket cyst
37Time-Course of Apical Peridontitis Dynamics of pulpal infectionBacterial succession and variations in virulence and pathogenicityHost factors modulating inflammation and spread of the infectionUltimate consequences of root canal infection
38Percentage of teeth at risk of developing apical periodontitis Ørstavik 1994
39Percentage of teeth at risk of developing apical periodontitis Ørstavik 1994
40Time-Course of Apical Peridontitis Bacterial succession and variations in virulence and pathogenicityPrimary infection – self-explanatoryPersistent infection – original flora, no cureRecurrent infection – residuals reemergingSecondary infection – new infection through leaking root filling
41Natural Course of the Disease: Pain Varying in intensity and severityPain sometimes accompanies pulpitis and apical periodontitisUnpredictable if untreatedPulpitis 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)
42Natural Course of the Disease: Pain Unpredictable if untreatedWhile 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)
43End-Points of Root Canal Infections Immediate abscess and sinus tract formation: incidence?Chronic, stable encapsulation: prevalence knownChronic cyst formation: prevalence knownExacerbation of chronic lesion: incidence (5% per year?)Sinus tract formation: incidence?Any available surface, sinus, nose, mucosa, skinSpreading oral infection: incidence?Submandibular, sublingual, local fasciesEyes, brain, mediastinum}20-70%
44Natural Course of the Disease: Conclusions Unpredictable if untreatedIt does not healPotentially very painfulSerious complications/sequelae are rareFilling therapy Endodontics ExtractionPulpitis ->Necrosis->Apical Perio->Acute phases->Local spread->Systemic spread