Download Apical Periodontitis

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.
Individuals with AP, %
100
Adapted from: Harald Eriksen 2008
in: Ørstavik & Pitt Ford, Essential
Endodontology
80
l
60
40
a b
e
c d
f g h i j
n
r s
o p q
k
20
0
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
80
Few extractions;
poor technical quality
70
Portugal
60
%
50
40
30
Few extractions;
moderate quality
Norway
Many extractions;
moderate quality
Lithuania
20
10
0
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
20
16
Pulp/AP
Perio
12
Per cent
8
4
Caries
0
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
Perio
7
”On the road to damnation”
5
”On the road to salvation”
Odds ratio
3
Caries
Pulp/AP
Pulp/AP
Perio
Caries
1
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.
Reasons for Extraction
50
40
30
Per cent
Caries
Pulp/AP
Perio
Pulp/AP
Pulp/AP
Perio
Perio
20
10
0
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
No. of approximal contacts
Age
.000
.000
No. of missing teeth
Anxiety
Bridge abutment
.000
.002
.006
Medication
Diabetes
Denture/partial
Poor hygiene
.007
.022
.037
.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
100 of Stomatology, School of Dentistry,
diabetic patients. Department
University of Seville, Seville, Spain.
RESULTS: Apical periodontitis
Individuals with AP, %
r s
in at least one tooth was
80 patients and in 58% of control
found in 81.3% of diabetic
o p q
subjects (P = 0.040; OR = 3.2; 95% CI = 1.1-9.4). Amongst diabetic
n
l
patients 7% of the teeth had AP, whereas in the control subjects 4% of teeth
60
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 k
prevalence of AP.
f g h i j
40
a b
e
c d
20
0
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
History of trauma
.066
.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
Cumulative success %
Time from treatment, months
Rocha MJ, Cardoso M. Survival analysis of endodontically treated
traumatized primary teeth. Dent Traumatol. 2007 Dec;23(6):340-7.
43–48
37–42
31–36
25–30
19–24
13–18
7–12
100
90
80
70
60
50
40
30
20
10
0
0–6
51 teeth, 10-60
months of age
Per cent of treated teeth
Failure (%)
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
Pulpitis
Necrosis
Canal
infection
Spread to
apex
Apical
periodontitis
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
ROOTS, per cent
Percentage of teeth at risk of
developing apical periodontitis
8
6
4
2
0
0
1
2
3
4
TIME, years
AP % of at risk
General risk*
Risk for RF teeth*
Risk for noRF teeth*
Ørstavik 1994
ROOTS, per cent
Percentage of teeth at risk of
developing apical periodontitis
8
6
4
2
0
0
1
2
3
4
TIME, years
AP % of at risk
General risk*
Risk for RF teeth*
Risk for noRF teeth*
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
} 20-70%
• 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
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