Five-year changes in periodontal parameters after apical surgery

Outcomes reporting in systematic reviews on surgical endodontics: A scoping review for the development of a core outcome set

BACKGROUND

Evidence-informed decision-making in healthcare relies on the translation of research results to everyday clinical practice. A fundamental requirement is that the validity of any healthcare intervention must be supported by the resultant favourable treatment outcome. Unfortunately, differences in study design and the outcome measures evaluated often make it challenging to synthesise the available research evidence required for secondary research analysis and guideline development. Core outcome sets (COS) are defined as an agreed standardised set of outcomes which should be measured and reported as a minimum in all clinical trials on a specific topic. The benefits of COS include less heterogeneity, a reduction in the risk of reporting bias, ensuring all trials contribute data to facilitate meta-analyses, and given the engagement of key stakeholders, it also increases the chances that clinically-relevant outcomes are identified. The recognition of the need for COS for assessing endodontic treatment outcomes lead to the development of Core Outcome Sets for Endodontic Treatment modalities (COSET) protocol, which is registered (No. 1879) on the Core Outcome Measures in Effectiveness Trials (COMET) website.

OBJECTIVES

The objectives of this scoping review are to: (1) identify the outcomes assessed in studies evaluating surgical endodontic procedures; (2) report on the method of assessment used to measure the outcomes; (3) and assess selective reporting bias in the included studies. The data obtained will be used to inform the development of COS for surgical endodontics.

METHODS

A structured literature search of electronic databases and the grey literature was conducted to identify systematic reviews on periradicular surgery (PS), intentional replantation (IR) and tooth/root resection (RR), published between January 1990 and December 2020. Two independent reviewers were involved in the literature selection, data extraction and the appraisal of the studies identified. The type of intervention, outcomes measured, type of outcomes reported (clinician- or patient-reported), outcome measurement method, and follow-up period, were recorded using a standardised form.

RESULTS

Twenty-six systematic reviews consisting of 19 studies for PS, three studies for IR and four studies for RR were selected for inclusion. Outcome measures identified for PS and IR included pain, swelling, mobility and tenderness, outcomes related to periodontal/soft tissue healing (including sinus tract), periradicular healing, tooth survival, life impact (including Oral-Health-Related-Quality-of-Life), resource use and/or adverse effects. For RR, in addition to tooth survival, endodontic complications, and adverse effects, the outcome measures were primarily periodontal-related, including pocket depth reduction, attachment gain, periodontal disease, and periodontic-endodontic lesions. The majority of outcome measures for PS, IR, and RR were assessed clinically, radiologically and/or via patient history. Specific tools such as rating scales (Visual Analog Scale, Verbal rating Scale, Numerical Rating Scale, and other scales) were used for the assessment of pain, swelling, and tenderness, and validated questionnaires were used for the assessment of oral health-related quality of life. The range of follow-up periods were variable, dependent on the outcome measure and the type of intervention.

CONCLUSIONS

Outcome measures, method of assessment and follow-up periods for PS, IR and RR were identified and categorised to help standardise the reporting of outcomes for future research studies. Additional outcome measures that were not reported, but may be considered in the COSET consensus process include loss of root-end filling material, number of clinic visits, surgery-related dental anxiety and muco-gingival aesthetic-related measures, such as scarring, black triangles, root surface exposure, and tissue discolouration.

Effect of full sulcular versus papilla-sparing flap on periodontal parameters in periradicular surgeries: A systematic review and meta-analysis

Background:

Access to apical root canal system is gained after flap elevation using various incision techniques. Soft-tissue healing after periradicular surgery may include gingival recession, papilla recession, changes in probing depth, and clinical attachment loss.

Objective:

The objective of this study was to compare the effect of full sulcular flap design versus papilla-sparing flap design on the periodontal parameters in periradicular surgeries.

Materials and Methods:

It was a systematic review and meta-analysis. Electronic and manual searches were conducted in multiple databases including PubMed, Dental and Oral Sciences, Cochrane, and CINAHL Plus until May 2019. Initial search yielded 2575 studies with 5 articles meeting the inclusion criteria. The primary outcomes assessed were gingival recession and change in the papilla height. The secondary outcomes evaluated were probing depth, clinical attachment loss, postoperative pain, bleeding, and discomfort. Random-effects model was employed for computation of effect size, and forest plots were made.

Results:

Out of the five articles that satisfied the inclusion criteria, three were randomized control trials and two were nonrandom trials. No significant differences were found in the gingival recession (P = 0.79), papilla height (P = 0.55), gingival bleeding, and plaque indices. Statistically significant differences in probing depth (P = 0.006) and clinical attachment loss (P = 0.0004) were observed for the two flap designs in probing depth (P = 0.006) and clinical attachment loss (P = 0.0004).

Conclusions:

The present systematic review and meta-analysis showed that probing depth and attachment loss are affected by the choice of flap design. On the other hand, gingival recession and papilla height are not influenced by the type of incision. However, finding of the present review may change if more studies on this topic will be included in the future. Therefore, more clinical trials with long-term follow-ups are needed.

Influence of incision on periodontal parameters after apical surgery: a meta-analysis

INTRODUCTION

The aim of the present meta-analysis was to determine the effect of the different incision designs used in apical surgery on periodontal parameters.

METHODS

An electronic search in Cochrane Library, Pubmed (MEDLINE), and Scopus was conducted on April 2020. Two independent investigators included clinical trials and prospective cohort studies comparing the influence of different incision designs used in apical surgery on gingival recession, periodontal probing depth, and clinical attachment level. A pairwise and network meta-analysis was performed in order to meta-analyze the direct and the indirect comparisons among the incision designs.

RESULTS

Six articles were included for the qualitative and the quantitative syntheses, involving a total of 401 teeth (372 patients). The pairwise meta-analysis did not reveal statistically significant differences between the incision designs in any of the outcomes evaluated. However, to reduce the amount of buccal gingival recession, the papilla base incision presented the highest probabilities of being ranked the most effective incision (85.7%), followed by submarginal incision (50.0%) and intrasulcular incision (14.3%).

CONCLUSION

Regardless of the incision design used, the periodontal parameters did not statistically differ after apical surgery.

CLINICAL RELEVANCE

Periodontal parameters did not significantly change despite the incision used in apical surgery. However, based on the results of the present review, the papilla base incision seems to be the best option to reduce the amount of buccal gingival recession.

Outcome of Endodontic Surgery: A Meta-analysis of the Literature-Part 3: Comparison of Endodontic Microsurgical Techniques with 2 Different Root-end Filling Materials

INTRODUCTION

The aim of the present study was to investigate the influence of root-end preparation and filling material on endodontic surgery outcome. A systematic review and meta-analysis was conducted to determine the outcome of resin-based endodontic surgery (RES, the use of high-magnification preparation of a shallow and concave root-end cavity and bonded resin-based root-end filling material) versus endodontic microsurgery (EMS, the use of high-magnification ultrasonic root-end preparation and root-end filling with SuperEBA [Keystone Industries, Gibbstown, NJ], IRM [Dentsply Sirona, York, PA], mineral trioxide aggregate [MTA], or other calcium silicate cements).

METHODS

An exhaustive literature search was conducted to identify prognostic studies on the outcome of root-end surgery. Human studies conducted from 1966 to the end of December 2016 in 5 different languages (ie, English, French, German, Italian, and Spanish) were searched in 4 electronic databases (ie, Medline, Embase, PubMed, and Cochrane Library). Relevant review articles on the subject were scrutinized for cross-references. In addition, 5 dental and medical journals (Journal of Endodontics; International Endodontic Journal; Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics; Journal of Oral and Maxillofacial Surgery; and International Journal of Oral and Maxillofacial Surgery) were hand checked dating back to 1975. All abstracts were screened by 3 independent reviewers (H.B., M.K., and F.S.). Strict inclusion-exclusion criteria were defined to identify relevant articles. Raw data were extracted from the full-text review of these selected articles independently by each of the 3 reviewers. In case of disagreement, an agreement was reached by discussion, and qualifying articles were assigned to group RES. For EMS, the same search strategy was performed for the time frame October 2009 to December 2016, whereas up to October 2009 the data were obtained from a previous systematic review with identical criteria and search strategy. Weighted pooled success rates and a relative risk assessment between RES and EMS were calculated. To make a comparison between groups, a random effects model was used.

RESULTS

Sixty-eight articles were eligible for full-text review. Of these, per strict inclusion exclusion criteria, 14 studies qualified, 3 for RES (n = 862) and 11 for EMS (n = 915). Weighted pooled success rates for RES were 82.20% (95% confidence interval [CI], 0.7965-0.8476) and 94.42% for EMS (95% CI, 0.9295-0.9590). This difference was statistically significant (P < .0005).

CONCLUSIONS

The probability for success for EMS proved to be significantly greater than the probability for success for RES, providing best available evidence on the influence of cavity preparation with ultrasonic tips and/or SuperEBA (Keystone Industries, Gibbstown, NJ), IRM (Dentsply Sirona, York, PA), MTA, or silicate cements as root-end filling material instead of a shallow cavity preparation and placement of a resin-based material. Additional large-scale randomized clinical trials are needed to assess other predictors of outcome.

Changes of Periodontal Parameters after Apical Surgery: Correlation of Clinical and Cone-beam Computed Tomographic Data

INTRODUCTION

The purpose of this study was to evaluate the changes of the marginal periodontium 1 year after apical surgery.

METHODS

Clinical and radiographic (cone-beam computed tomographic) examinations of 54 teeth treated with buccal access flaps for apical surgery were performed at baseline and after 1 year. Clinical assessment included measurements of probing pocket depth, the level of gingival margin (GM), and the width of keratinized tissue. Subsequently, the clinical attachment level (CAL) and the width of the attached gingiva were calculated. On bucco-oral cone-beam computed tomographic sections, the height and thickness of the crestal bone and the thickness of the alveolar bone were measured at different levels.

RESULTS

In general, the calculated mean changes of periodontal tissue and crestal/alveolar bone were only minimal. Significant mean changes included only GM and CAL on midoral aspects and the distance from the cementoenamel junction or restoration margin on midbuccal sites. CAL was further correlated with the thickness of the alveolar bone at 3 mm below the cementoenamel junction or restoration margin. None of the clinically and radiographically calculated mean changes were correlated with sex, biotype, or incision techniques. With regard to age, older patients showed significantly more gingival recession on the buccal aspect compared with younger individuals. Furthermore, mean changes of the midbuccal width of the attached gingiva were positively correlated with the healing outcome, whereas mean changes of the midoral GM and CAL were negatively correlated with the healing outcome.

CONCLUSIONS

Within an observation period of 1 year, the marginal periodontium and its underlying bone structures did not suffer from significant changes after apical surgery.

Haemostatic agents in apical surgery. A systematic review

Background

Blood presence in apical surgery can prevent the correct vision of the surgical field, change the physical properties of filling materials and reduce their sealing ability.

Objetive

To describe which are the most effective and safest haemostatic agents to control bleeding in patients undergoing apical surgery.

Material and Methods

TWe carried out a systematic review, using Medline and Cochrane Library databases, of human clinical studies published in the last 10 years.

Results

The agents that proved more effective in bleeding control were calcium sulphate (100%) and collagen plus epinephrine (92.9%) followed by ferric sulphate (60%), gauze packing (30%) and collagen (16.7%). When using aluminium chloride (Expasyl®), over 90% of the apical lesions improved, but this agent seemed to increase swelling. Epinephrine with collagen did not significantly raise either blood pressure or heart rate.

Conclusions

Despite the use of several haemostatic materials in apical surgery, there is little evidence on their effectiveness and safety. The most effective haemostatic agents were calcium sulphate and epinephrine plus collagen. Epinephrine plus collagen did not seem to significantly raise blood pressure or heart rate during surgery. Aluminium chloride did not increase postoperative pain but could slightly increase postoperative swelling. Randomized clinical trials are needed to assess the haemostatic effectiveness and adverse effects of haemostatic materials in apical surgery.

Key words:Haemostasis, apical surgery.

Does the Papilla Preservation Flap Technique Induce Soft Tissue Modifications over Time in Endodontic Surgery Procedures?

INTRODUCTION

The aim of the present controlled clinical trial was to compare 2 incision techniques, papilla base incision (PBI) and sulcular incision (IS), evaluating changes in papilla and recession height over a 12-month period.

METHODS

A total of 24 subjects requiring endodontic surgery on a single tooth were enrolled. PBI was used in 1 group and IS in the other group. The primary outcomes were changes in gingival recession of the tooth affected by periapical lesions and the mesial and distal teeth and the mesial and distal papilla height using the treated tooth as the reference. Outcome variables were assessed at baseline and 12 months after the surgical intervention. Statistical analysis was performed by a blinded operator through appropriate tests, with significance set at a P value equal to .05.

RESULTS

In the PBI group, the papilla height at the 12-month follow-up in the mesial and distal aspect decreased 0.10 ± 0.32 mm and 0.10 ± 0.32 mm, respectively, and 0.23 ± 0.68 mm and 0.25 ± 0.40 mm, respectively, in the IS group without any significant differences. There were no differences found for recession change values between groups.

CONCLUSIONS

The PBI and IS approaches in endodontic surgery showed similar results in terms of papilla height preservation and recession changes.

Prognostic factors on periapical surgery: A systematic review

Background

Analyze the most important prognostic factors when performing periapical surgery and compare the success rates of distinct authors.

Introduction

Periapical surgery is an approach to treat non-healing periapical lesions and it should be viewed as an extension of endodontic treatment and not as a separate entity.

Material and Methods

A search of articles published in Cochrane, PubMed (MEDLINE) and Scopus was conducted with the key words “prognostic factors”, “prognosis”, “periapical surgery”, “endodontic surgery” and “surgical endodontic treatment”. The inclusion criteria were articles including at least 10 patients, published in English, for the last 10 years. The exclusion criteria were nonhuman studies and case reports.

Results

33 articles were selected from 321 initially found. Ten articles from 33 were excluded and finally the systematic review included 23 articles: 1 metaanalysis, 1 systematic review, 2 randomized clinical trials, 6 reviews, 12 prospective studies and 1 retrospective study. They were stratified according to their level of scientific evidence using the SORT criteria.

Conclusions

Factors associated with a better outcome of periapical surgery are patients ≤45 years old, upper anterior or premolar teeth, ≤10 sized lesions, non cystic lesions, absence of preoperative signs and symptoms, lesions without periodontal involvement, teeth with an adequate root-filling length, MTA as root-end filling material, uniradicular teeth, absence of perforating lesions, apical resection < 3 mm, teeth not associated to an oroantral fistula and teeth with only one periapical surgery.

Key words:Prognostic factors, prognosis, periapical surgery, endodontic surgery and surgical endodontic treatment.