A scoping review of four decades of outcomes in non-surgical root canal treatment, non-surgical retreatment and apexification studies. Part 1: process and general results

Impact of passive ultrasonic irrigation on the outcome of non-surgical root canal treatment: a systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

This systematic review aimed to assess the impact of Passive Ultrasonic Irrigation on the periapical healing rate of primary root canal treatment compared to conventional syringe irrigation.

METHODS

Registered a priori in the PROSPERO database, this review was conducted by two independent reviewers who performed an electronic search up to December 2023. The search included databases such as MEDLINE (PubMed), Scopus, Web of Science, Embase, LILACS, and the Cochrane Library, as well as grey literature. We included randomized clinical trials (RCTs) that focused on patients undergoing primary root canal treatments. The study compared intervention groups using PUI with control groups that did not use activation techniques. Periapical healing was assessed over follow-up periods of at least six months, utilizing either periapical radiographs or cone-beam computed tomography. To synthesize the findings, a meta-analysis and trial sequence analysis were conducted, employing the Relative Risk as the measure of effect, with a 95% confidence interval. The GRADE approach was utilized to assess the certainty of the evidence.

RESULTS

The meta-analysis incorporated three RCTs, involving 474 patients (501 teeth). The analysis revealed that PUI led to a higher rate of periapical healing compared to CSI (Relative Risk: 1.10; 95% Confidence Interval: 1.01-1.21, I² = 0%), with moderate certainty of evidence.

CONCLUSIONS

Despite the limited number of high-quality RCTs, the findings showed a positive impact of PUI on periapical healing rates in primary root canal treatments, in comparison to CSI.

REGISTER

CRD42021290894.

Outcome of Contemporary Nonsurgical Endodontic Retreatment: A Systematic Review of Randomized Controlled Trials and Cohort Studies

INTRODUCTION

The success rates of NS-ReTx have varied across decades of prior research. Nonetheless, recent endodontic advances have substantially enhanced case management. This systematic review aimed to identify rigorous studies on contemporary NS-ReTx, investigating both periapical healing-evaluated strictly for complete resolution or loosely for size reduction of periapical radiolucency-and success, denoting clinical normalcy combined with periapical healing.

METHODS

We systematically searched MEDLINE, Embase, Web of Science, the Cochrane Library, and gray literature from January 1988 to December 2022. Article selection and data extraction were independently conducted by 3 reviewers. Selected studies underwent risk of bias assessment, and evidence quality using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Meta-analysis and meta-regression established pooled outcome rates, 95% confidence intervals (CIs), and significant clinical prognostic factors (P < .05).

RESULTS

Twenty-nine articles were included. Pooled periapical healing rates using strict and loose criteria were 78.8% (95% CI: 75.2-82.4) and 87.5% (95% CI: 83.8-91.2), respectively. Pooled success rates using strict and loose criteria were 78.0% (95% CI: 74.9-81.2) and 86.4% (95% CI: 82.6-90.1), respectively. Meta-regression analyses revealed significant influences on NS-ReTx outcomes (P < .05), including periapical status, lesion size, apical root filling extent, and follow-up duration.

CONCLUSIONS

Contemporary NS-ReTx shows encouraging outcomes, achieving periapical healing and success rates ranging from approximately 78% (strict criteria) to 87% (loose criteria). The absence of or smaller preoperative lesions, adequate root filling length, and extended follow-ups significantly improve NS-ReTx outcomes. Integrating these factors into treatment planning is pivotal for optimizing the outcome of NS-ReTx.

A critical look at outcome measures: Comparison between four dental research journals by use of a hierarchical model

AIM

To assess the status quo of outcome measures used in treatment studies in Endodontics, and potentially identify strategies for improvement, by (i) systematically assessing the outcome measures using a conceptual model and (ii) comparing these with measures used in corresponding studies in the adjacent fields.

METHODOLOGY

The International Endodontic Journal, Caries Research, The Journal of Clinical Periodontology and The Journal of Oral & Facial Pain and Headache were selected to cover four adjacent dental disciplines. In each journal, the 50 most recent consecutive publications fulfilling inclusion criteria were included. A hierarchical model for diagnostic imaging studies was modified to assess studies related to treatment. The model comprised six levels, with technical as the lowest level and societal as the highest. Extracted data included study origin, study type, and identified outcome measures. Fisher's Exact Tests with Bonferroni corrections compared studies. p < .05 was considered statistically significant.

RESULTS

Amongst 756 publications, the 200 most recent studies matching the inclusion criteria were identified. Less than half (36.5%) assessed the clinical, patient, or societal aspects of treatment; 10.0% in International Endodontic Journal, 28.0% in Caries Research, 38.0% in Journal of Clinical Periodontology, and 70.0% in Journal of Oral & Facial Pain and Headache (p < .001).

CONCLUSIONS

According to included publications, research on treatment within the endodontic field is mainly focusing on technical and biological outcomes. The benefits of patients and society were less frequently examined than in corresponding journals in adjacent disciplines. When designing studies, including higher-level outcomes should be considered.

Process-related Factors Are as Important as Outcomes for Patients Undergoing Nonsurgical Root Canal Treatment, Nonsurgical Root Canal Retreatment, and Endodontic Microsurgery

INTRODUCTION

There is considerable variation in the reporting of treatment outcomes in endodontics. Patient-centered outcomes are often inadequately reported in endodontic outcome studies. This paper explores patients' expectations and reported outcomes in nonsurgical root canal treatment (NS-RCT), nonsurgical root canal retreatment (NS-ReTx), and endodontic microsurgery (EMS).

METHODS

We used a qualitative description approach and conducted telephone and virtual semi-structured interviews with participants who had the following treatments within the preceding 3-12 months: NS-RCT (n = 10), NS-ReTx (n = 10), or EMS (n = 10). Half of these treatments were performed by senior endodontic residents in an academic setting and the other half by a community-based endodontist at a private practice.

RESULTS

Participants identified several outcomes that were important to them and integral to treatment success, such as tooth survival, resolution of symptoms, aesthetics, and radiographic healing. Process-related factors were as important as treatment outcomes for participants. Communicating with and educating patients during treatment increased participants' satisfaction and lowered their stress. Dissatisfaction was linked to the lack of a comprehensive treatment and follow-up plan. Thorough planning ensured that patients were fully informed and had a structured approach to achieving their desired outcomes.

CONCLUSIONS

This study provides a list of outcomes that are important for patients undergoing NS-RCT, NS-ReTx, and EMS. These outcomes should be considered when developing a core outcome set related to endodontic treatments. Additionally, this study reports patients' expectations regarding process-related factors that are essential for providing patient-centered care and improving patient experience.

Apexification Outcomes in the United States: A Retrospective Cohort Study

INTRODUCTION

This epidemiological analysis used procedure codes from dental insurance claims data to identify apexification cases and evaluate survival at the tooth-level.

METHODS

Dental insurance claims data from New York State (2006-2019) and Massachusetts (2013-2018) were used in an observational, retrospective cohort study to evaluate the provision and treatment outcomes of apexification. Statistical analyses included Kaplan-Meier survival estimates and Cox proportional hazards regression. Cox proportional hazard regression was used to evaluate the hazard of adverse event occurrence by age, gender, tooth type, placement of permanent restoration, and dental provider type. A sensitivity analysis evaluated potential bias in the survival estimates and adjusted hazard ratios (aHRs) due to differential loss to follow-up. Robust standard errors were used to account for potential dependence between teeth within an individual.

RESULTS

The analytic cohort of 575 individuals included 632 teeth, with an average follow-up time of 64 months. The survival rates of apexification procedures were 95% at 1 year; 93% at 2 years; 90% at 3 years; and 86% at 5 years. Tooth retention following apexification was 98% at 1 year; 96% at 2 years; 95% at 3 years; and 90% at 5 years. Tooth type and subsequent placement of a permanent restoration were significant predictors of survival after apexification.

CONCLUSIONS

The procedural and tooth survival outcomes of apexification were high and comparable to studies that analyzed clinical data on tooth survival following apexification.

DENTAL PATIENT-REPORTED OUTCOMES IN ENDODONTICS - A NARRATIVE REVIEW

Recently in oral health care settings, the focus of assessing treatment outcomes has shifted from the perspective of the clinician towards that of the patient. Endodontology is a specialty of dentistry concerned with the prevention and treatment of pulp and periapical diseases. Research in endodontology and its associated treatment outcomes have focused mainly on clinician-reported outcomes (CROs) and not dental patient-reported outcomes (dPROs). As a result, there is a need to emphasize the importance and relevance of dPROs to researchers and clinicians. The aim of this review is to present an overview of dPROs and dPROMs within endodontics in an attempt to create a better understanding of the patient experience, highlight the need to place the patient at the center of treatment, enhance patient care and encourage more research into dPROs. The key dPROs following endodontic treatment include pain, tenderness, tooth function, need for further intervention, adverse effects (exacerbation of symptoms, tooth discoloration) and Oral Health-Related Quality of Life. dPROs are important following endodontic treatment because they assist clinicians and patients when they discuss and select the most appropriate management options, help clinicians make decisions on pre-operative assessment, prevention and treatment, and improve the methodology and design of future clinical studies. Clinicians and researchers in endodontology should prioritize patient welfare and undertake routine analyses of dPROs using appropriate and robust measures. Due to the lack of agreement over the reporting and definition of endodontic treatment outcomes, a comprehensive project to define a ``Core Outcome Set for Endodontic Treatment Methods (COSET)'' is currently ongoing. In the future, a new and exclusive assessment tool should be developed to reflect the viewpoints of patients receiving endodontic treatment more accurately.

Global research trends on photodynamic therapy in endodontics: A bibliometric analysis

BACKGROUND

Photodynamic therapy (PDT) is an adjunctive treatment that aims to inactivate microorganisms through an oxidative reaction produced by irradiating a photosensitizing agent. The quest for improved root canal disinfection has sought supplementary methods when performing chemomechanical procedures. From this perspective, PDT protocols were proposed as an auxiliary approach in endodontics. Thus, the aim of this study was to investigate publication metrics and research trends related to this scope.

METHODS

This review is reported in accordance with the PRISMA 2020 recommendations. Two blinded and independent reviewers systematically searched five electronic databases until December 2021. The acquired bibliometric parameters were analyzed through descriptive statistics and graphical mappings with VOSViewer software.

RESULTS

The search retrieved 342 studies from 84 journals originating from 33 countries. About 85% of the included studies were published over the last decade. Most of the available evidence is laboratory-based (74.5%), and the main clinical outcomes evaluated were microbiological load reduction and postoperative pain. Mayram Pourhajibagher is the researcher with the most publications as the first author (n = 16). Tehran University of Medical Sciences carried out the highest number of studies (n = 29), and Photodiagnosis and Photodynamic Therapy is the journal that most published on the theme (n = 111).

CONCLUSIONS

This bibliometric analysis mapped and discussed the scientific progress and publication metrics in PDT in endodontic research. Additionally, future perspectives were highlighted and should focus on discovering new photosensitizer agents, standardizing optimal photoactivation protocols, and conducting more clinical-oriented research.

Outcomes reporting in systematic reviews on non-surgical root canal treatment: A scoping review for the development of a core outcome set

BACKGROUND

Studies related to non-surgical root canal treatment are amongst the most frequently performed clinical studies in endodontics. However, heterogeneity in reporting outcomes and lack of standardization is a significant challenge to evidence synthesis and guideline development.

OBJECTIVES

The aims of the present scoping review were to (a) identify outcomes reported in systematic reviews evaluating non-surgical root canal treatment; (b) identify how and when the reported outcomes were measured; (c) assess possible selective reporting bias in the included studies. The information obtained in this study should inform the development of a core outcome set (COS) for non-surgical root canal treatment.

METHODOLOGY

Structured literature searches were performed to identify systematic reviews on non-surgical root canal treatments published in English between January 1990 and December 2020. Two reviewers undertook study selection and data extraction. Outcomes were categorized according to a healthcare taxonomy into five core areas (survival, clinical/physiological changes, life impact, resource use, and adverse events). The outcome measurement tools and length of follow-up were recorded.

RESULTS

Seventy-five systematic reviews were included, of which 40 included meta-analyses. Most reviews reported on physiological and clinical outcomes, primarily pain and/or radiographic assessment of periapical status, and a variety of measurement tools and scales were used. Few reviews focused on tooth survival, life impact, resources, and adverse events. The heterogeneity amongst the reviews was large on all parameters. Less than 40% of the reviews assessed the risk of selective reporting.

DISCUSSION

Overall aims of the included reviews were highly heterogenic; thus, outcomes and how they were measured also varied considerably. Patient-centred outcomes and the use of resources were rarely reported on.

CONCLUSIONS

Most studies reported on physiological and clinical outcomes, in particular pain and/or radiographic healing. Measurement tools, scales, thresholds, and follow-up periods varied greatly within each outcome, making comparison across studies complicated. Less than 40% of the reviews assessed risk of selective reporting; thus, selective bias could not be ruled out. The presented information on reported outcomes, measurement tools and scales, and length of follow-up may guide the planning of future research and inform the development of a COS for non-surgical root canal treatment.

Comparison Study of Diagnosis and Treatment Planning for Dental Infections between Dental Students and Practitioners

This study aimed to access the knowledge in diagnosing dental infections and the practice in treatment planning for the affected teeth among dental practitioners (DPs) and senior (final-year) students. A survey questionnaire containing two cases (Case A; periodontal abscess and Case B; periapical abscess) with four questions per case was delivered to potential participants. Fifty-nine DPs voluntarily participated in the survey. For senior students, the case study was a part of their course requirements; one of the two cases (either Case A or B) was randomly assigned to the 126 seniors. The distribution of responses was significantly different between the DP and senior groups except for the diagnosis of Case B (Fisher’s exact test; p = 0.05). Only 31% of the participants diagnosed Case A as periodontal abscess; most of them selected periodontal surgery as the first treatment option. Despite a high agreement in diagnosing Case B, the choice of treatment was significantly different; the most frequent treatment option was extraction (51%) from the DP group and root canal retreatment (57%) from the senior group. The study revealed that the diagnosis of periodontal abscess was more challenging than that of periapical abscess among dental professionals.