Treatment Decisions in 330 Cases Referred for Apical Surgery

Healing and Spontaneous Realignment of Displaced Roots With Periapical Granuloma After Microsurgical Endodontic Treatment (Three Years' Follow-up): A Case Report

Endodontic therapy aims to treat or prevent apical periodontitis, a condition characterized by inflammation of the periapical tissues at the apex of the tooth root. This case study demonstrates the successful nonsurgical and surgical management of a large periapical lesion involving the lower central incisors with root displacement induced by a periapical granuloma. A patient was referred from the maxillofacial department for endodontic treatment due to persistent pain and swelling in the lower anterior region started two months ago. Upon arrival, a clinical examination and radiographic assessment were performed using cone-beam computed tomography (CBCT). The CBCT scan revealed a significant radiolucent area measuring (10x8) mm extending from the lower left lateral incisor to the right central incisor. The lower left central incisor was necrotic and tender to palpation and percussion. A nonsurgical root canal was performed followed by an apicectomy using mineral trioxide aggregate (MTA) to facilitate healing of the periapical lesion. Histopathological examination of the lesion confirmed the diagnosis of periapical granuloma. At follow-up 1, 2, and 3 years' visits, the periodontal assessment was performed and found to be free of pain upon percussion or palpation. No other clinical or radiological signs or symptoms were identified except for a small radiolucent area mesially adjacent to the root of the lower left central incisor. The development of materials such as MTA has significantly improved the prognosis of cases with large periapical lesions. In this case, healing and spontaneous realignment of the root were observed after three years.

A literature review of local and systemic considerations for endodontic treatments in older adults

OBJECTIVES

The aim of this literature review was to summarise the clinical important findings on the endodontic treatment outcome in older patients (≥60 years old) with pulpal/periapical disease considering local and systemic factors from a body of knowledge that is heterogeneous in methods or disciplines.

BACKGROUND

Due to the increasing number of older patients in the endodontic practice, and the current trend for tooth preservation, the need for clinicians to have a better understanding of age-related implications that may influence the required endodontic treatment in older adults to retain their natural dentition is indispensable.

METHODS

PubMed/Medline and Embase was searched by a medical librarian using specific terms based on inclusion/exclusion criteria. The reference list was hand-seached for additional relevant publications between 2005-2020. A combination of these terms was performed uing Boolean operators and MeSH terms.

RESULTS

Of the 1577 publications identified manually and electronically, 25 were included to be fully reviewed by the examiners. The data was derived from three systematic reviews, one systematic and meta-analysis, three case series, four prospective and 14 retrospective cohorts. Overall, there was heterogeneity in reporting as well as limitations in most studies.

CONCLUSIONS

The outcome of endodontic treatment (ET) either nonsurgical or surgical or combination of these is not affected by older age. ET can be the treatment of choice in older patients wiht pulpal/periapical disease. There is no evidence that older age per se affects the outcome of any type of endodontic treatment.

Tooth Loss after Jaw Curettage Surgery: Associated Factors and Potential Benefit of Splint Application

Background

This retrospective study is aimed at (I) assessment of tooth loss and related parameters after jaw curettage of benign lesions and (II) assessment of the outcome of jaw curettage supported by splint insertion after at least six months of follow-up. Material and Methods. For (I), patients who had jaw curettage surgery in the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University (Guangzhou, China) from July 2015 to June 2019 were included. For part (II), consecutive patients who came to the department from July to December 2019 that were additionally treated with dental splinting were involved in this study. Based on the patient records, age, gender, initial tooth mobility, follow-up outcome, and potential tooth loss (intra- or postoperatively) were recorded. Based on available radiographs, alveolar crest bone loss and root surface area supported by bone (RSA) were determined.

Results

(I) 128 patients with 305 teeth were included, of which 40 teeth were lost (success rate 86.9%), without statistical difference in gender, age, or tooth type (P > 0.05). Tooth mobility, RSA, and the presence of alveolar crest bone defects were associated to tooth loss (P < 0.001). (II) 17 patients with a medium follow-up period of 11 months (range 9 to 13 months) were enrolled. All lesion-involving teeth supported by splint treatment at risks of loss were preserved, showing an effective tooth retention rate in 17/17 cases (74/74 teeth, success rate: 100%).

Conclusions

Tooth mobility and bone loss (lesion-related and/or periodontal) are potential risk predictors for tooth loss in the first year after jaw curettage surgery. Dental splints could be recommendable for teeth involved by jaw benign lesions with little bone support.

German Dentists' Preferences for the Treatment of Apical Periodontitis: A Cross-Sectional Survey

Currently, there is no standard treatment protocol for apical periodontitis (AP). Thus, restorable teeth might get extracted and replaced prosthetically. This study evaluated German dentists’ preferred AP treatment decisions and the influencing factors for selecting tooth retention by initial/repeated surgical/non-surgical root-canal treatment (RCT) or extraction with/without prosthetic replacement. Through an online-survey, participants (n = 260) rated different treatment options for four case scenarios with AP in anterior/posterior teeth without/with previous RCT. Statistical analysis included the Friedman test for intra-case comparisons and Chi-squared test for factor-associations (p ≤ 0.05). Tooth retention using initial/repeated RCT was ranked first in all scenarios and rated as (very) appropriate by most participants, while implant-supported crowns (ISC) and apicoectomy had the second ratings. ISC were preferred more on posterior teeth or previous root-canal-treated teeth. Rating levels of treatment options displayed significant differences for all case scenarios. Posterior tooth retention by RCT demonstrated a significant association with work experience. Tooth retention with previous RCT displayed a significant correlation with dentists’ privately insured patients. Most dentists preferred tooth preserving with initial/repeated RCT, while others selected non-evidence-based choices. This reflects a lack of consensus of AP treatment decisions in Germany. Fixed treatment guidelines and further evaluation of treatment–decision-correlated factors are recommended for correct treatment planning.

Comparison of diagnostic accuracy between periapical and panoramic radiographs and cone beam computed tomography in measuring the periapical area of teeth scheduled for periapical surgery. A cross-sectional study

BACKGROUND

The aim of the study was compare the sensitivity and measurements obtained from teeth with apical lesions scheduled for periapical surgery using three different diagnostic methods: periapical radiography (Gendex Expert DC), panoramic radiography (Planmeca® Promax 3D Classic) and cone beam computed tomography (CBCT) (Planmeca® Promax 3D Classic).

MATERIAL AND METHODS

This cross-sectional study involved 35 patients (45 teeth) scheduled for periapical surgery in which periapical radiographs, panoramic radiographs and CBCT scans had been obtained. The images were used to analyze the maximum vertical and horizontal dimension and the resulting areas of the periapical lesions based on the three diagnostic methods.

RESULTS

The two-dimensional techniques (periapical radiography and panoramic radiography) yielded a sensitivity of 82% versus 100% in the case of CBCT. The mean vertical dimension of the apical areas was 5.48 mm with periapical radiography and 5.04 mm with panoramic radiography - the difference with respect to CBCT being statistically significant (6.36 mm for the coronal sections). There were no significant differences among the three techniques in terms of horizontal dimension (p>0.05) or lesion area.

CONCLUSIONS

The sensitivity of periapical radiolucencies detected using CBCT was significantly greater than with the two-dimensional imaging techniques. Significant differences between the latter and CBCT were only observed in the case of the vertical measurements. Key words:Periapical lesion, apicoectomy, CBCT, periapical radiography, panoramic radiography.

Clinical and Radiographic Assessment of Cases Referred to Endodontic Surgery

Objective

The objective of the study was to assess the quality of root canal fillings of cases referred to endodontic surgery using preoperative radiographs and correlate it with endodontic surgery treatment decision. The objective was also to analyse clinical symptoms and size of periapical lesions on radiographs and correlate them with treatment decisions including non-surgical retreatment, endodontic surgery and extraction.

Materials and Methods

A questionnaire was composed to record the data. Eighty-six patients with 109 teeth, who were referred to endodontic surgery, participated in the research. The quality of root canal filling was assessed according to its homogeneity and filling length on digital radiographs. The data were analyzed using χ2-test and t-test.

Results

Of the teeth referred to endodontic surgery, 97.2% were treated by a general practice dentist, endodontic retreatment was attempted in 20.6%, and root canal filling was homogeneous and within 1 mm from the apex in 21.6%. Endodontic surgery, retreatment, extraction and no treatment were selected in 90.1%, 5.4%, 1.8% and 2.7% of the cases, respectively.

Conclusions

Low percentage of adequate root canal fillings and high percentage of endodontic surgery decisions suggest that there is a need to increase awareness of non-surgical retreatment options.

A decision analysis for periapical surgery: Retrospective Study

Background

Periapical surgery is now a reliable therapeutic procedure for the treatment of teeth with periapical lesions, particularly when orthograde retreatment is problematic. However, little information is available regarding treatment planning of cases referred for periapical surgery. Therefore, this study was conducted to analyze and evaluate the factors that affect the decision-making process for periapical surgery.

Material and Methods

This study retrospectively assessed clinical and radiographic data from patients undergoing periapical surgery. The factors involved in deciding to perform periapical surgery were classified into technical, biological, and combined factors.

Results

Out of 821 patients, 544 (66.3%) underwent endodontic treatment/retreatment, 204 (24.8%) were treated with coronal restorations and 60 (7.3%) were treated with post. Periapical surgery was indicated for biological reasons in 35% of patients and for technical reasons in 17.9%. The common biological factor was persistent clinical symptoms (19.7%). The most common technical cause was failure of previous endodontic treatment (66.3%). Nearly half of all periapical lesions (45%) were <5 mm in size. Periapical surgery was justified in only 434 (52.9%) subjects.

Conclusions

We suggest that it is very important for patients to be informed and encouraged about endodontic retreatment in order to reduce unnecessary surgical procedures.

Key words:Periapical surgery, case selection, treatment planning.

Progression of periapical cystic lesion after incomplete endodontic treatment

We report a case of large radicular cyst progression related to endodontic origin to emphasize proper intervention and follow-up for endodontic pathosis. A 25 yr old man presented with an endodontically treated molar with radiolucency. He denied any intervention because of a lack of discomfort. Five years later, the patient returned. The previous periapical lesion had drastically enlarged and involved two adjacent teeth. Cystic lesion removal and apicoectomy were performed on the tooth. Histopathological analysis revealed that the lesion was an inflammatory radicular cyst. The patient did not report any discomfort except for moderate swelling 3 days after the surgical procedure. Although the patient had been asymptomatic, close follow-ups are critical to determine if any periapical lesions persist after root canal treatment.

Risk score algorithm for treatment of persistent apical periodontitis

Persistent apical periodontitis related to a nonvital tooth that does not resolve following root canal treatment may be compatible with health and may not require further intervention. This research aimed to develop a Deterioration Risk Score (DRS) to differentiate lesions requiring further intervention from lesions likely to be compatible with health. In this cross-sectional study, patient records (2003-2008) were screened for root-filled teeth with periapical radiolucency visible on periapical radiographs taken at treatment and at recruitment at least 4 yr later. The final sample consisted of 228 lesions in 182 patients. Potential demographic and treatment risk factors were screened against 3 categorical outcomes (improved/unchanged/deteriorated), and a multivariate independent multinomial probit regression model was built. A 5-level DRS was constructed by summing values of adjusted regression coefficients in the model, based on predicted probabilities of deterioration. Most lesions (127, 55.7%) had improved over time, while 32 (14.0%) remained unchanged, and 69 (30.3%) had deteriorated. Significant predictors of deterioration were as follows: time since treatment (relative risk [RR]: 1.11, 95% confidence interval [CI]: 1.01-1.22, p = .030, rounded beta value = 1, for every year increase after 4 yr), current pain (RR: 3.79, 95% CI: 1.48-9.70, p = .005, rounded beta value = 13), sinus tract present (RR: 4.13, 95% CI: 1.11-15.29, p = .034, rounded beta value = 14), and lesion size (RR: 7.20, 95% CI: 3.70-14.02, p < .001, rounded beta value = 20). Persistent apical periodontitis with DRS <15 represented very low risk; 15-20, low risk; 21-30, moderate risk; 31-40, high risk; and >40, very high risk. DRS could help the clinician identify persistent apical periodontitis at low risk for deterioration, and it would not require intervention. When validated, this tool could reduce the risk of overtreatment and contribute toward targeted care and better efficiency in the timely management of disease.