Clinical-radiographic follow-up studies of endodontic treatment: expectations and limitations We all strive for excellence, but how well do we do?

Clinical-radiographic follow-up studies of endodontic treatment: expectations and limitations We all strive for excellence, but how well do we do? How can we monitor improvement?

Clinical-radiographic follow-up studies of endodontic treatment: expectations and limitations We all strive for excellence, but how well do we do? How can we monitor improvement? Where do we seek information to support/adjust treatment?

Design of follow-up studies: RCTs, cohort studies, case controls, case series, retro- and prospective, Critical issues in endodontic clinical research: Tooth survival, case selection, criteria and harmonization - examples The fundamental difference between prevention and treatment When will we ever learn? Can we cure chronic apical periodontitis? Histology, experiments, Ricucci, Brynolf, Wu & Wesselink A change in concept from qualitative to quantitative microbial control The futility of personal experience A journey through a hypothetical practice situation Precision in design Stiches in embroidery Clinical-radiographic follow-up studies of endodontic treatment: expectations and limitations

1 Design of follow-up studies

What do we know? Technical performance Length is important in cases of AP Width is controversial at best(worst), of no consequence at worst (best) Cultivable bacteria left in the canal at the time of filling are associated with outcome, measured in teeth with AP mainly Biological and clinical factors tbd

Clinical-radiographic follow-up studies of endodontic treatment: expectations and limitations Design of follow-up studies: RCTs (prosp) Cohort studies (r&p) Case controls (r&p) {Matched pairs} Case series (r&p) Case collection (r&p) Retro- and prospective drop-outs!

Cumulative PAI Scores AHKPPS TIME: 0 to 4 years rstavik et al., 1986

The single case report: A valuable contribution to the scientific literature G ould 3xO September 2001 editorial I wish to advocate for the validity and value of the single case report. I believe that the case report with appropriate content remains an important contribution to the body of clinical and diagnostic information for oral health care providers and researchers.

2 Critical issues in endodontic clinical research

Different situations of radiographic follow-up methods Case-by-case monitoring for healing or emergence of apical periodontitis: everyday practice, quality assurance Particular clinical situations: eg, perforations, apexification,cyst size reduction: practice and case reports very difficult to produce high-quality data Feasibility studies: case series: New materials Scientific clinical studies: influence of specific clinical/biological/technical variables; need a homogenous baseline

Clinical Studies: Final and Surrogate Endpoints Clinical outcome Disease: Local: presence of AP disseminated Pain During treatment epidemiology Retention of teeth/restorations Biological outcome Microbiological status of tissues much done, more attention? Tissue status Healing of lesion Nerves, vessels, cells Biological markers Technical outcome Time spent Operators experience

Tooth retention Caplan DJ, Weintraub JA. Factors related to loss of root canal filled teeth. J Public Health Dent. 1997 Winter;57(1):31-9. ParameterOdds Ratio95 CI Number of proximal contacts (two=O, zero or one=l)2,71,4-5,1 Age (continuous, from 50 years, per 10-year increase)1,41,1-1,9 History of facial injury (no=O, yes=l)3,61,2-10,5 Number of missing nonwisdom teeth1,51,0-2,1 Plaque (none or light=0, moderate=l, heavy=2)1,71,0-2,6

Factors related to loss of root canal filled teeth. Caplan DJ, Weintraub JA. J Public Health Dent. 1997 Winter;57(1):31-9. The results suggest that variables at the tooth level (number of proximal contacts), mouth level (number of missing teeth, plaque), and patient level (age, history of facial injury) are associated with loss of RCF teeth, implying that loss of a particular tooth is influenced by more than tooth-specific features. The findings also suggest that variables ascertainable at the time of treatment planning are related more strongly to subsequent loss of an RCF tooth than are endodontic or postobturation restorative factors.

Tooth survival: Endo-Perio Periodontal Practices Today. 2008;5:15 - 20 Survival of endodontically treated teeth with severe periodontal involvement Saetervold, Heidi / Bruseth, Ane Marthe / Orstavik, Dag / Preus, Hans R

Tooth survival: Endo-Perio Periodontal Practices Today. 2008;5:15 - 20 Survival of endodontically treated teeth with severe periodontal involvement Saetervold, Heidi / Bruseth, Ane Marthe / Orstavik, Dag / Preus, Hans R Tooth survival is of interest when several end diagnoses are possible, eg, perio, caries, restorative considerations, in addition to endodontic. Here, the control group has a 100% survival, but that does not mean it has no AP.

VariablesCategoryAdjusted OR95% CI (P) Age20-29 (n = 111)1.00- 30-39 (n = 153)1.820.80-4.12 (0.15) 40-49 (n = 169)1.240.54-2.86 (0.61) 50-59 (n = 144)2.380.97-5.85 (0.59) 60+ (n = 36)1.800.40-8.39 (0.43) SmokingNo (n = 325)1.00- Yes (n = 250)1.641.00-2.84 (0.05) Number of services from the dentist 0 (n = 82)3.981.87-8.46 (0.00) 1-5 (n = 309)1.00- 6-9 (n = 127)0.890.47-1.67 (0.70) 10-19 (n = 56)0.990.39-2.47 (0.90) 20+ (n = 12)12.630.79-200.07 (0.07) Adjusted odds ratio (OR) with 95% confidence intervals (CI) and P-values. Community Dent Oral Epidemiol. 2003 Feb;31(1):59-67 Risk indicators for apical periodontitis Lise-Lotte Kirkevang and Ann Wenzel

VariablesCategoryAdjusted OR95% CI (P) Number of teeth1-18 (n = 22)1.00- 19-27 (n = 280)0.660.18-2.49 (0.54) 28 (n = 311)0.340.09-1.34 (0.12) Number of secondary caries 0 (n = 403)1.00- 1 (n = 141)0.950.51-1.79 (0.88) 2 (n = 69)2.631.01-6.87 (0.05) Number of inadequate coronal fillings 0-2 (n = 474)1.00- 3 (n = 134)2.441.17-5.07 (0.02) Number of root fillings0 (n = 295)1.00- 1 (n = 140)11.185.99-20.85 (0.00) 2 (n = 178)80.0738.19-167.87 (0.00) Adjusted odds ratio (OR) with 95% confidence intervals (CI) and P-values.

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, Jimnez-Pinzn 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. Adapted from: Harald Eriksen 2008 in: rstavik & Pitt Ford, Essential Endodontology a d e fg h i b c

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, Jimnez-Pinzn 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. Segura-Egea JJ, Jimnez-Pinzn A, Ros-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.

Endodontics is: Prevention or treatment of apical periodontitis which in practice means Protection against or elimination (?) of root canal infection Diagnostics, choice of treatment method, irrigation, medication and root filling are all means towards this end rstavik 1988

Endodontics is: Prevention or treatment of apical periodontitis which in practice means Protection against or elimination (?) of root canal infection How to monitor this disease? rstavik 1988

Success/failure criteria (Strindberg 1956) success when a, the contours, width and structure of the periodontal margin were normal b, the periodontal contours were widened mainly around the excess filling failure when there was a) a decrease in the periradicular rarefaction b) an unchanged periradicular rarefaction c) an appearance of new rarefaction or an increase in the initial uncertain when a) there were ambiguous or technically unsatisfactory control radiographs which could not for some reason be repeated b) the tooth was extracted prior to the 3-year follow-up owing to the unsuccessful treatment of another root of the tooth

Probability assessments Definitively no disease1 Probably no disease2 Uncertain3 Probably disease4 Definitively disease5 An attempt to systematize the clinical assessment situation

Scoring Systems in Clinical Dentistry Caries: limited progress until DMF index was established (1938) Gingivitis & marginal periodontitis: confusion until indices were applied (1950-60) Apical periodontitis: Calibrated indices? X- ray digitized measurements? Quantification by (CB)CT?

The PAI Scoring System Apical periodontitis: A calibrated index rstavik et al. 1986: The periapical index: a scoring system for tradiographic assessment of apical periodontitis

Brynolf 1967: A histological and radiological study of the periapical region of human upper central incisors 300 teeth with histology and radiographs. (Note in passing: very few 7% - without some inflammatory reactions)

Brynolf 1967: A histological and radiological study of the periapical region of human upper central incisors rstavik et al. 1986: The periapical index: a scoring system for tradiographic assessment of apical periodontitis Seven histologic/radiographic groups Five radiographic categories on an ordinal scale of severity

*The PAI scoring system is a radiographic interpretation on a 5 point scale from 1-5 in order of absence to presence and increasing severity of disease. *It uses a reference set of radiographs with corresponding line drawings and their associated score on a photographic print or computer screen. *The scores are based on a correlation with inflammatory periapical status confirmed by histology.

Nine radiographs from Brynolfs selection were taken as representatives of the five categories, unwillingly verbally described as: 1 - Normal apical periodontium 2 Structural changes in periapical bone 3 Structural changes with mineral loss 4 Overt radiolucency 5 Structural changes peripheral to radiolucency

Find the reference radiograph where the periapical area most closely resembles the periapical area you are studying. Assign the corresponding score to the observed root. When in doubt, assign a higher score. For multirooted teeth, use the highest of the scores given to the individual roots. All teeth must be given a score.

Calibration Material: Reference scale Set of written instructions for scoring Set of 100 radiographs, one tooth in each is scored. The true scores have been determined by consensus of two endodontists involved with the development of the system. Excel file for computation of essential statistical parameters. 20 calibrated scorers world wide kappa values from 0.62 to 0.80

Usage 16 countries, 50+ publications Retrospective clinical follow-ups Epidemiological studies Prospective and experimentalstudies

The ridit statistic Parametric statistics

Periapical improvement with time PAI 3-5 at start Trope et al 1999 TIME, weeks

Change of PAI in cases with bacteria absent or present at the second appointment. Single visit cases are not included. From: Waltimo et al: J Endod, Volume 31(12).December 2005.863-866 PAI difference over time: Parametric statistics

Post Placement

Weaknesses of the PAI system Front tooth reference only Moderate specifity

Cone beam CT The potential applications of cone beam computed tomography in the management of endodontic problems Patel & al. 2007 Increased sensitivity = better disease detection Periapical radiographs are still current best or adequate practice

3 The fundamental difference between prevention and treatment

Prognosis for Pulpectomy: Prevention of Apical Periodontitis Strindberg 195694 Kerekes & Tronstad 197997 rstavik et al 1986(2004)94 Sjgren et al 199097 Marquis et al 200693 This is probably a reflection of an almost complete success failures are iatrogenic, via contamination, and avoidable

Prognosis for Root Canal Infection: Treatment of Apical Periodontitis Strindberg 195688 Kerekes & Tronstad 197991 rstavik et al 1986(2004)79 Sjgren et al 199086 Marquis et al 200680 Zmener & Pamejer 200489 This is probably a reflection of persistent infection failures are due to inadequate disinfection (+ the contaminants from the previous slide)

Results of endodontic treatment based on the presence of apical periodontitis associated with root-filled teeth evaluated from radiographs. Reference Avg ageSuccFail Eriksen and Bjertness 1991 (Norway)5064 36 desj et al. 1990 (Sweden)45 75 25 Imfeld 1991 (Switzerland)66 69 31 de Cleen et al. 1993 (the Netherlands)38 6139 Buckley and Spngberg 1995 (USA)456931 Ray and Trope 1995 (USA)6139 Saunders et al. 1997 (Scotland) (20-60+) 4258 Weiger et al. 1997 (Germany) 3961 Marques MD et al. 1998 (Portugal) 357822 Georgopoulou MK et al. 2005 (Greece)484060 Mean value456337 Success range:39-78 % From: Harald Eriksen 2008 In: rstavik & Pitt Ford, Essential Endodontology

Factors known to affect the prognosis of endodontic treatment Cotton TP, Schindler WG, Schwartz SA, Watson WR, Hargreaves KM. A retrospective study comparing clinical outcomes after obturation with Resilon/Epiphany or Gutta-Percha/Kerr sealer. (endodontist, recalled at 225 months) J Endod. 2008 Jul;34(7):789-97. Epub 2008 May 12.

Factors known to affect the prognosis of endodontic treatment Cotton TP, Schindler WG, Schwartz SA, Watson WR, Hargreaves KM. A retrospective study comparing clinical outcomes after obturation with Resilon/Epiphany or Gutta-Percha/Kerr sealer. J Endod. 2008 Jul;34(7):789-97. Epub 2008 May 12. HealedNonhealedTotal p Value Obturation material, n (%) 1 Resilon42 (79.2)11 (20.8)43 (100) Gutta-percha39 (78.0)11 (22.0)50 (100) Total (some w no pulp Dx)8122103

Factors known to affect the prognosis of endodontic treatment Cotton TP, Schindler WG, Schwartz SA, Watson WR, Hargreaves KM. A retrospective study comparing clinical outcomes after obturation with Resilon/Epiphany or Gutta-Percha/Kerr sealer. J Endod. 2008 Jul;34(7):789-97. Epub 2008 May 12. HealedNonhealedTotal p Value Preoperative lesion, n (%)

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Clinical-radiographic follow-up studies of endodontic treatment: expectations and limitations We all strive for excellence, but how well do we do?