1. Disease, Prognosis, Retention
Prognosis of Endodontic Therapy: Controlling Disease and Retaining Teeth

2. Prognosis
is the prospect of recovery as anticipated from the usual course of disease or peculiarities of the case m-w.com

3. 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

4. Prognosis - Outcome
Outcome studies may also address the function and survival of the treated tooth Caplan & Weintraub, 1997

5. Prevention of apical periodontitis
Treatment 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”

6. Pulpitis
.. is tissue reactions to trauma and/or infections of the pulp-dentin organ
.. includes acute and chronic phases, abscesses, but may be reversible

7. 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
Effective prevention is possible only when you know the etiology and pathogenesis of the disease in question, so..

8. What is Apical Periodontitis?

9. 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

10. 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

11. Apical Periodontitis
1200
2008

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

13. Adapted 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.

14. Epidemiology
Prevalence of apical periodontitis %, selected countries, age years
Few extractions; poor technical quality
Few extractions; moderate quality
Many extractions; moderate quality
From Eriksen et al., 2002

15. 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

16. 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 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

17. Reasons 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.

18. Reasons 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.

19. Reasons 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.

20. Reasons for Extraction of Endodontically Treated Teeth
No. of approximal contacts
.000
Age
No. of missing teeth
Anxiety
.002
Bridge abutment
.006
Medication
.007
Diabetes
.022
Denture/partial
.037
Poor hygiene
.039
Caplan DJ, Weintraub JA. Factors related to loss of root canal filled teeth. J Public Health Dent Winter;57(1):31-9.

21. Segura-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.

22. Reasons for Extraction of Endodontically Treated Teeth
Periodontal disease
.066
History of trauma
.075
Cuspal coverage
.096
Caplan DJ, Weintraub JA. Factors related to loss of root canal filled teeth. J Public Health Dent Winter;57(1):31-9.

23. 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.

24. Loss 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):

25. Loss 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):

26. Loss 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):

27. Loss of Endodontically Treated Teeth: Primary Teeth
51 teeth, months of age
Rocha MJ, Cardoso M. Survival analysis of endodontically treated traumatized primary teeth. Dent Traumatol Dec;23(6):340-7.

28. Reasons 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):

29. 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

30. 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

31. 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

32. The Infectious Process
Apical periodontitis
Spread to apex
Canal infection
Necrosis
Pulpitis
Increasing infectious load; increasingly difficult to treat
Time

33. Further course of disease: Sequels to the initial events

35. Severity
Incidence
Adielsson et al 1999

36. 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

37. 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

38. Percentage of teeth at risk of developing apical periodontitis
Ørstavik 1994

39. Percentage of teeth at risk of developing apical periodontitis
Ørstavik 1994

40. 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

41. 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)

42. Natural Course of the Disease: Pain
Unpredictable if untreated
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)

43. 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%

44. Natural Course of the Disease: Conclusions
Unpredictable if untreated
It does not heal
Potentially very painful
Serious complications/sequelae are rare
Filling therapy Endodontics Extraction
Pulpitis ->Necrosis->Apical Perio->Acute phases->Local spread->Systemic spread