Radiographic outcome of root canal treatment in general dental practice: tooth type and quality of root filling as prognostic factors

A Comparative Analysis of the Quality of Root Canal Fillings of In Vivo Studies Conducted in Saudi Arabia and Worldwide: A Systematic Review

Aim

Root canal treatment (RCT) is a common procedure practiced daily by dentists worldwide. The current systematic review aimed to evaluate and compare clinical studies on the quality of root canal fillings (RCFs) carried out by dentists with different levels of experience conducted worldwide with those conducted specifically in Saudi Arabia (SA).

Materials and Methods

A full literature search was conducted in Clarivate Analytics' Web of Science, Elsevier's Scopus, Embase, CINHAL, and PubMed, without a restriction to studies published before January 2015. Also, a manual search was carried out by checking papers that may have been missed during the electronic search. The following keywords were used: [(quality of root canal filling(s)) OR (quality of root canal obturation)) and dental practitioners as (general dental practitioners; final year students; endodontist; specialist) AND (root canal obturation) OR (endodontic treatment)]. Parameters of the quality of RCFs, such as length, density, and taper, were assessed and counted.

Results

A total of 13 worldwide and nine SA studies were included in this review, published between 2015 and 2023. Molars were the most treated teeth, at 42.3% and 40.2% for the worldwide and SA studies, respectively. Cases treated by final year students had the highest percentage, at 60.0% for both study groups. The percentages of acceptable quality, with regard to the length, density, and taper of RCFs, were 70.9%, 77.6%, and 84.3%, and 73.2%, 64.6%, and 67.8% for the worldwide and SA studies, respectively.

Conclusion

The overall acceptable quality of RCFs was marginally higher in worldwide studies than in SA studies. Both prevalences can be considered as good, which indicates that the quality of RCFs is moving in the right direction.

Progress of Artificial Intelligence-Driven Solutions for Automated Segmentation of Dental Pulp Space on Cone-Beam Computed Tomography Images. A Systematic Review

INTRODUCTION

Automated segmentation of 3-dimensional pulp space on cone-beam computed tomography images presents a significant opportunity for enhancing diagnosis, treatment planning, and clinical education in endodontics. The aim of this systematic review was to investigate the performance of artificial intelligence-driven automated pulp space segmentation on cone-beam computed tomography images.

METHODS

A comprehensive electronic search was performed using PubMed, Web of Science, and Cochrane databases, up until February 2024. Two independent reviewers participated in the selection of studies, data extraction, and evaluation of the included studies. Any disagreements were resolved by a third reviewer. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess the risk of bias.

RESULTS

Thirteen studies that met the eligibility criteria were included. Most studies demonstrated high accuracy in their respective segmentation methods, although there was some variation across different structures (pulp chamber, root canal) and tooth types (single-rooted, multirooted). Automated segmentation showed slightly superior performance for segmenting the pulp chamber compared to the root canal and single-rooted teeth compared to multi-rooted ones. Furthermore, the second mesiobuccal (MB2) canalsegmentation also demonstrated high performance. In terms of time efficiency, the minimum time required for segmentation was 13 seconds.

CONCLUSION

Artificial intelligence-driven models demonstrated outstanding performance in pulp space segmentation. Nevertheless, these findings warrant careful interpretation, and their generalizability is limited due to the potential risk and low evidence level arising from inadequately detailed methodologies and inconsistent assessment techniques. In addition, there is room for further improvement, specifically for root canal segmentation and testing of artificial intelligence performance in artifact-induced images.

Frequency of apical periodontitis in root-filled teeth restored with post and core: A 5-year retrospective study

BACKGROUND

In conjunction with post placement in root-filled teeth with periapical healthy conditions, root canal retreatment may be performed to improve the seal of the root canal. Whether root canal retreatment for technical reasons (retreatments in teeth without apical periodontitis (AP)) results in lower frequency of AP is unknown.

OBJECTIVE

To examine whether there is a difference in frequency of AP between roots with root canals retreated for technical reasons, and roots with root canals not retreated before post placement, with a minimum follow-up of 5 years. Also, to examine changes in root filling quality following root canal retreatment for technical reasons.

METHODS

This retrospective study included radiographs of 441 root-filled roots without periapical radiolucencies at baseline, scheduled for post and core treatment. Follow-up data for a minimum of 5 years were available for 305 roots (loss to follow-up 30.8%), 46 of which were retreated for technical reasons. Two calibrated observers assessed root filling sealing quality and length, respectively, and periapical status according to the Periapical Index. The main outcome of the study, AP, was used as the dependent variable and all analyses were performed at root level.

RESULTS

The overall frequency of AP at follow-up was 13.8%. The difference in frequency of AP between retreated (4.3%) and nonretreated (15.4%) root canals was not statistically significant, p = .061. Analyses including only roots with preoperatively inadequate root filling quality showed a statistically significant difference (p = .017) between the two treatment groups (2.4% vs. 22.9%).

CONCLUSIONS

Root canal retreatment for technical reasons before post and core placement significantly reduces the frequency of AP in roots with inadequate root filling quality.

GIRFT and Measuring Outcomes in MCNs: endodontics in 646 teeth treated in Tier 2 (Primary Care) and Tier 3 (Secondary Care) settings in England

AIM

This paper aims to assess the complexity, quality and outcome of endodontic treatment provided in Managed Clinical Networks (MCNs) in England to understand if we are "getting it right first time" (GIRFT).

METHODS

In a convenient sample of endodontic treatments provided between May 2011 and April 2017, the complexity of teeth treated, the quality of treatment procedure, the radiographic appearance of root fillings, as well as clinical and radiographic healing were retrospectively assessed using records taken as part of treatment. Trained, calibrated examiners independently scored radiographs using previously published scoring systems.

RESULTS

646 teeth were followed up for 24.7 months (standard deviation [SD] 17.08). The average age of those patients treated was 46.7 years (SD 15.38) with 48.3% being male. Of teeth treated, 70.4% were of complexity level 3. 88.2% of teeth were asymptomatic, and 80% demonstrated complete radiographic healing. Procedural errors inhibited achieving correct working length and taper, with more voids within root canal fillings. When patency filing was reported as being carried out, complete radiographic healing was more likely.

CONCLUSIONS

It is possible to collate outcome data in the NHS system, especially if there is provision for ongoing follow up and time allocated for collection of data. Endodontic treatment provided within primary and secondary care settings are of high quality, with outcomes being better with single operators carrying out high volumes of endodontic treatment.

Dental findings frequently overlooked in sinus computed tomography reports

OBJECTIVES

Computed tomography (CT) and cone beam computed tomography (CBCT) represent the main imaging modalities used in rhinosinusitis patients and are also important in odontogenic sinusitis (OS) diagnostics. Reports, however, often lack information on dentition. Here, we aimed to determine how maxillary dentition is initially interpreted in rhinosinusitis patients' CT/CBCT reports and which dental findings in particular are potentially missed, thus needing more attention.

STUDY DESIGN

CT/CBCT scans and radiological reports from 300 rhinosinusitis patients were analysed focusing specifically on dental findings. An experienced oral and maxillofacial radiologist re-evaluated the scans and the assessment was compared to the original reports using the McNemar test.

RESULTS

From the 300 original reports, 233 (77.7%) mentioned the maxillary teeth. The most frequent statement (126/300, 42.0%) was 'no apical periodontitis'. Apical periodontitis and severe alveolar bone loss were significantly overlooked (p < 0.001). Amongst the 225 patients for whom the CT/CBCT report initially lacked information on dental pathology, 22 patients were diagnosed with apical periodontitis and 16 with severe alveolar bone loss upon re-evaluation.

CONCLUSIONS

Dental pathology remains underreported in rhinosinusitis patients' CT/CBCT reports. Because these reports affect OS diagnostics, a routine and structured review of the maxillary teeth by a radiologist is necessary. Such examinations should encompass the maxillary teeth.

Survival of endodontically treated teeth in public dental service in Northern Finland: a practise-based register study

OBJECTIVE

The aim of this study was to explore the factors associated with the survival of root canal treated teeth in a practise-based study setting in a 5-year period.

MATERIAL AND METHODS

This retrospective study used data from the electronic patient registration system of the public dental services of the City of Oulu, Finland. The inclusion criteria for this study were patients aged ≥ 20 years who had root canal treatment (RCT) that was initiated in 2014. One RCT per patient was included in the study. A total of 713 patients met the inclusion criteria. The outcome variable for this study was the extraction of the RCT tooth during the 5-year period. Explanatory variables included age, diagnosis, tooth type (incisive, canine, premolar, molar), RCT technique (manual, motorized), time from RCT initiation to final restoration and type of final restoration (composite, glass ionomer, fixed dental prosthesis). To evaluate the association between the outcome variable and explanatory variables, Cox regression analyses were performed.

RESULTS

The overall survival rate was 91%. The middle-aged (40-59-years-old) and the oldest (60 and older) patients had a two-fold risk of extraction compared to younger (20-40-years-old) patients. Similarly, a short length of time from RCT initiation to final restoration (0-14 days) resulted in a nearly three times higher risk of extraction compared to a longer period (≥ 90 days).

CONCLUSIONS

The 5-year survival rate of RCTs seems high. Extractions were more common among patients over 40 years of age and if the RCT was completed shortly after its initiation.

General dental practitioners' fees for root canal treatment, coronal restoration and follow-on treatment in the adult population in Sweden: A 10-year follow-up of data from the Swedish Dental Register

OBJECTIVES

To analyze the accumulated fees connected with root filling, permanent coronal restoration and follow-on treatment charged by Swedish dentists over a 10-11-year follow-up period. Furthermore, analyzing these fees with reference to the type of restoration, tooth group, and the root-filled teeth which survived compared to those requiring extraction.

MATERIAL AND METHODS

In 2009, the data register of the Swedish Social Insurance Agency recorded a total of 215,611 teeth as root-filled. The accumulated fees for each tooth encompassed the following interventions: initial root filling, coronal restorations, and follow-up treatments during the designated period. The outcomes were analyzed using descriptive and analytic statistics, including t tests and one-way analysis of variance. The fees are presented in Euros (€1 = SEK 8.94).

RESULTS

The total accumulated fees for root fillings amounted to 72 million Euros: the mean fee per root filled tooth was €333.6. The total mean fee over a 10-11-year period, comprising root canal treatment, coronal restorations, and any follow-up treatments, was €923.4. Root-filled teeth with indirect restorations presented a higher mean fee (€1 279.3) compared to those with direct restorations (€829.4) or those without specified restorations (€832.7; p < .001). Moreover, molars presented a significantly higher mean fee (€966.4) compared to premolars (€882.8) and anterior teeth (€891.3; p < .001). Lastly, the mean fee for extracted teeth was €1225.3, which was higher compared to those who survived the follow-up period (€848.0; p < .001).

CONCLUSIONS

Fees charged by general dental practitioners for root-filled teeth accumulate over time, probably due to the need for further treatment of the tooth. The total mean fee was significantly higher for molars and root-filled teeth with indirect restorations. However, an analysis of the total costs would require prospective clinical cost-effectiveness studies.

Why and when older people lose their teeth: A study of public healthcare patients aged 60 years and over in 2007-2015

OBJECTIVES

This register-based study on public sector patients aged 60 years and over assessed annual age-specific volume of and reasons for tooth extractions as well as changes in these across the period 2007-2015.

BACKGROUND

Alongside the rapidly ageing population, the demand for public oral healthcare services is growing. Damaged teeth may induce a long-lasting inflammation burden in old age.

MATERIALS AND METHODS

Data used the electronic documentation of oral healthcare procedures recorded according to healthcare regulation. The study population consisted of all patients over 60 years of age (n = 216 059) who were treated 2007-2015 in public oral health care available to all citizens of Helsinki, Finland. Data for the 9-year time series included reasons for tooth extractions and were aggregated by patient age into 5-year groups. Statistical analyses included rates and proportions, mean values, correlation coefficients and linear regression modelling.

RESULTS

Extraction patients (n = 48 623) were more likely in the older age groups: 21.8% in the age group 60-64 and 27.5% in the age group 90+. Mean number of tooth extractions among all patients was 0.4 per patient and 1.7 per extraction patient. Among all tooth extractions (n = 82 677), main reasons were caries 29.5%, apical periodontitis 19.4%, tooth remnant 19.4% and periodontitis 18.0%. Tooth remnant predominated as extraction reason in the oldest age groups, while apical periodontitis displayed an upward trend by calendar year.

CONCLUSION

Tooth extractions attributable to caries were common in all old-age groups, tooth remnant extractions were most common in older age groups, and apical periodontitis abounded as extraction reason during 2007-2015.

Endodontic Outcome of Root Canal Treatment Using Different Obturation Techniques: A Clinical Study

OBJECTIVE

To evaluate the clinical outcome of root canal treatment by obturation technique, root canal filling quality, and tooth- and patient-related variables.

METHODS

This clinical study investigated the endodontic outcome of 114 teeth treated between the years 2009 and 2012. Three different obturation methods were used: (1) adhesive obturation using the continuous wave of condensation technique with Resilon® (CWR), (2) matching-taper single-cone technique with gutta-percha and AH Plus® (SCGP), and (3) matching-taper single-cone technique with gutta-percha and GuttaFlow® (SCGF). Pre- and postoperative periapical radiographs were performed to detect the presence of endodontic lesions (PAI classification) and to assess the quality of both the obturation and the restoration. Tooth- and patient-related data were collected.

RESULTS

The overall endodontic success rate was 75.4% after a mean observation period of 6.3 years. There were no significant correlations between the type or overall quality of obturation and the treatment outcome. Teeth with preoperative lesions had the highest odds ratio (factor of 4.98) for endodontic failure. Tooth- and patient-related variables had no significant effect on endodontic outcome.

CONCLUSIONS

The preoperative periapical status of teeth requiring endodontic treatment was a substantial prognostic factor for endodontic outcome, whereas the type of obturation material or technique did not affect it.

Periapical status and technical quality in root canal filled teeth in a cross sectional study in Jönköping, Sweden

OBJECTIVE

To investigate the quality of root canal fillings and frequency of apical periodontitis (AP) in root canal filled teeth in a Swedish population.

MATERIAL AND METHODS

This study used data from a cross-sectional survey conducted in 2013. The root canal filling quality and periapical status were assessed in 491 root canal filled teeth in 196 individuals aged 20-70 years, randomly selected from the population of Jönköping, Sweden. All root canal filled teeth were examined with periapical radiographs. Three calibrated observers recorded length and density in root canal fillings as well as periapical status according to the Periapical Index. A root filling ending within 0.5-2 mm from the radiographic apex without lateral or apical voids was considered adequate. Data were analyzed in a generalized estimating equation (GEE) model with AP as dependent variable and gender, age, number of teeth, number of root filled teeth, tooth type, and root filling quality as independent variables.

RESULTS

Teeth with technically inadequate root fillings were associated with AP in a simple GEE-analysis. In the multiple GEE-model, the association between technical quality and apical peridontitis was nonsignificant when controlling for tooth type and gender.

CONCLUSIONS

The quality of root canal fillings is poor and the prevalence of AP in root canal filled teeth is high, particularly in molar teeth, in a Swedish population.

Factors that affect the outcomes of root canal treatment and retreatment-A reframing of the principles

This paper undertakes a broad and comprehensive synthesis of relevant clinical, biological, biomechanical, technical and healthcare services data to understand the factors affecting outcomes of periapical healing after root canal (re)treatment. The medical and dental evidence-based era (1980-present) is contextualized with the earlier evidence drive in endodontics (1911-1940) triggered by the focal infection era. The current evidence-based approach has a sharper focus on evidence quality and derivation of practice guidelines. Contrary views question whether guideline-driven, or expertise-development-driven endeavours would best serve outcome improvement in society. The endodontic discipline functions in a broad healthcare framework and sustains industrial, economic and trend pressures that may be deemed to influence outcomes. The nature of root canal treatment and the challenges in determining the factors that affect its outcomes is discussed. The factors potentially affecting periapical healing after root canal treatment are classified into pre-operative, intra-operative and postoperative groups. These categories subsume multiple elements with interactive influences, creating a complex picture, further confounded by some apparently surprising, counter-intuitive and contradictory findings. The technical versus biological conundrum in root canal treatment continues to cause cognitive dissonance. However, due reflection and cross-discipline-synthesis resolve the apparent data conflicts into a very simple, consistent and plausible picture of how root canal treatment works and the key factors that affect periapical healing. Root canal retreatment is considered mainly in the context of its differences from primary treatment as the majority of factors influencing outcomes are common to both. The exceptional difference is that retreatments have a proportionately reduced probability of healing by virtue of compromised apical root canal ramification access or modified host/infection interactions. Root canal (re)treatment outcomes are dominantly influenced by the nature of prior dynamic host/infection interaction (pre-operative patient factors) and how the direction of this dynamic is influenced by two factors: (1) the active efficacy of the operators' root canal treatment protocol to sustain a microbial ecological shift (intra-operative treatment factors) and dampen periapical inflammation; and (2) the passive ability of the functional tooth (and its restoration margin) to maintain its integrity to resist infection reversal (postoperative restorative factors).

Root Canal Obturation by Electrochemical Precipitation of Calcium Phosphates

Achieving adequate disinfection and preventing reinfection is the major goal in endodontic treatment. Variation in canal morphology and open porosity of dentine prevents achieving complete disinfection. Questionable biocompatibility of materials as well as a lack of sealing ability questions the usefulness of current obturation methods. With a novel disinfection approach based on the use of boron-doped diamond (BDD) electrodes having shown promising results it was the goal of this series of experiments to investigate the possibility of BDD-mediated in situ forming of a biocompatible obturation material. A combination of calcium phosphate and maleic acid was used as precursor solution while Ion Chromatography Mass Spectrometry (IC-MS), Raman spectroscopy (RAMAN), X-ray diffraction (XRD), energy dispersive X-ray spectroscopy (EDX), scanning electron microscopy (SEM), dye penetration and micro-computed tomography (µCT) were applied for characterizing the precipitate. It was possible to achieve a BDD-mediated precipitation of brushite in a clinically applicable timeframe. However, tight sealing of the canal system based on brushite could not be achieved.

A Scoping Review of Four Decades of Outcomes in Nonsurgical Root Canal Treatment, Nonsurgical Retreatment, and Apexification Studies: Part 3-A Proposed Framework for Standardized Data Collection and Reporting of Endodontic Outcome Studies

INTRODUCTION

Despite initiatives to standardize and improve reporting of rapidly growing endodontic outcome research studies, issues related to missing and ambiguous information are still of great concern. In this article, we propose a framework for standardized data collection and a compiled checklist for reporting of various study designs on endodontic outcome.

METHODS

A comprehensive search was carried out to locate randomized controlled trials, cohorts, case-control studies, or case series of >100 patients that reported on endodontic outcomes. We reviewed these articles to develop a Data Collection Template and compiled a checklist for reporting of future endodontic outcome research.

RESULTS

Out of 354 eligible articles previously reported in our scoping review on endodontic outcome studies, 109 articles were selected and screened for study variables or levels of categorization. Our complied Data Collection Template was developed in 19 domains to highlight important demographic, preoperative, intraoperative, and postoperative variables. Because of the specific needs for endodontic outcome literature, we also proposed a compiled checklist (consisting of 4 main domains) to facilitate the reporting of various study designs on endodontic outcome studies. This checklist included simple descriptions of the required items and examples on reporting from published endodontic studies.

CONCLUSIONS

By facilitating the collection and reporting of relevant research data by investigators in private practice and academia, we hope that the proposed Data Collection Template and reporting guideline can highlight the importance of standardization among clinicians and researchers while producing valid scientific information that will support evidence-based treatment decisions.

Usefulness of an Endodontic Case Difficulty Assessment Form of Root Canal Treatments in Dental Education in Finland

According to current care guidelines, it would be beneficial to evaluate the difficulty of a root canal treatment (RCT) after the decision of an indicated RCT. For this matter, several difficulty assessment forms have been developed. In this pilot study, fifth-year dental students evaluated the usefulness of the Endodontic Case Difficulty Assessment Form (ECAF) presented in the Finnish Current Care Guidelines for Endodontic Treatment (2014). Another aim was to postoperatively investigate how well the evaluation by dental students using the ECAF associated with the outcome of RCT evaluated by a specialist in endodontics. The dental students’ (n = 33) and the supervisor’s assessments of the RCTs were compared postoperatively at the Dental Educational Unit, Oulu, Finland. After completing the ECAF, the students’ experiences of its use were explored with a structured form. In ECAF, patient-derived factors, such as gagging, deviant crown morphology, and complications in previous endodontic treatment, were all significantly associated with complications in RCTs by the dental students (p < 0.05). The assessments by students and the supervisor differed in 55% of cases, especially in moderately difficult cases. In the majority of these cases (71%), the students evaluated the case to be easier than the teacher. Students found the ECAF user-friendly, even if it did not demonstrate their competence in accomplishing RCTs. The ECAF appears useful for junior dentists, specifically in terms of distinguishing the least and most difficult cases. A simpler form could be useful for students and clinicians.

Patient satisfaction with root canal treatment and outcomes in the Swedish public dental health service. A prospective cohort study

AIM

To document satisfaction with root canal treatment procedures and outcomes among patients treated at Swedish public dental clinics.

METHOD

The original material comprised 243 patients who began root canal treatment (RCT) at 20 public dental clinics in the county of Västra Götaland, Sweden. One to three years later, 236 (97.1%) were posted a questionnaire of eight items, rating patient perceptions of RCT-completion, present pain intensity and satisfaction with the RCT. To evaluate the reliability of the original responses, the first 50 respondents were mailed a follow-up questionnaire. Both descriptive and analytical statistics were used to compare respondents and non-respondents and tooth groups.

RESULTS

One hundred and fifty-nine patients (67.4%) responded: 86 (54.1%) women and 73 (45.9%) men. The mean age 52.5 years, was higher than for non-respondents (P<0.001). A completed root filling was registered for the majority of the teeth (n = 112, 70.9%), but significantly fewer molars had been completed (n = 46, 59.7%, P = 0.02). Fifty percent (n = 59) of the patients reported current pain, mostly mild in intensity (n = 45, 38.1%). One hundred and twenty-three patients (80.9%) recalled experiencing pain during RCT. The highest satisfaction was registered for the item 'chewing ability' (mean = 1.6, SD = 1.9). The majority of patients (n = 114, 75.0%) stated that in retrospect they would still have chosen RCT. However, these patients belonged to the group which either registered the tooth as still present, or had not experienced much discomfort during or after RCT. Forty-four patients (88.0%) responded to the second questionnaire. The reliability of the responses was good. In summary, one to 3 years after beginning RCT at a public dental clinic, patient satisfaction was high, even though every fourth molar had been extracted or treatment had not been completed and half the patients reported persistent pain. The reliability of the patients' responses was considered to be good.

CONCLUSIONS

The results indicate a need for further clinical observational studies of RCTs undertaken in general dental practice, with special reference to patient-centred outcomes.