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 m-w.com

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

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”

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

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..

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

Apical Periodontitis 1200 2008

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.

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.

Epidemiology Prevalence of apical periodontitis %, selected countries, age 35-45 years Few extractions; poor technical quality Few extractions; moderate quality Many extractions; moderate quality From Eriksen et al., 2002

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

Reasons for Extraction 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.

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. 2001 Feb;51(1):1-6. Australia: Practitioners completed service logs over one to two typical clinical days.

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. 2004 Dec;28(2):833-9. Survey among practitioners.

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. 1997 Winter;57(1):31-9.

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. 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.

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. 1997 Winter;57(1):31-9.

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.

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

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

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

Loss of Endodontically Treated Teeth: Primary Teeth 51 teeth, 10-60 months of age Rocha MJ, Cardoso M. Survival analysis of endodontically treated traumatized primary teeth. Dent Traumatol. 2007 Dec;23(6):340-7.

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

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

Percentage of teeth at risk of developing apical periodontitis Ørstavik 1994

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 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)

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 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