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

Factors associated with the outcome of root canal treatment-A cohort study conducted in a private practice

AIM

To investigate the association of various pre-, intra- and post-operative factors on root canal treatment outcome.

METHODOLOGY

In this cohort study, primary or secondary root canal treatment of mature permanent teeth was performed by a single endodontist in a private practice over 13 years, and followed 1-4 years after treatment. Treatment details and clinical and radiographic data were collected. The proportion of successfully treated teeth and roots based on strict radiographic (periapical index (PAI) ≤2) and clinical criteria (absence of pain, swelling or sinus tract) was estimated. To evaluate joint associations of prognostic factors and treatment success probability, 44 pre, intra- and post-operative factors were investigated using bivariate associations, and a multiple logistic regression model was fitted using Generalized Estimating Equations.

RESULTS

1259 teeth (2445 roots, 3149 canals) were assessed with a recall rate of 91%. The proportion of successfully treated teeth was 79.9% [95% confidence interval 77.7-82.1]. Eleven prognostic factors were identified that significantly reduced the odds ratio (OR) for treatment success at tooth level. Six were preoperative: injury history (OR = 0.05[0.01-0.24]), root PAI (OR = 0.29[0.20-0.42], 0.21[0.13-0.34] and 0.22[0.12-0.42] for PAI = 3, 4 and 5, respectively, against PAI = 1), lesion diameter (OR = 0.30[0.21-0.43] and 0.24[0.16-0.37] for diameters of 1-5 mm and ≥6 mm, respectively, against no lesion), tooth type (OR = 0.51[0.27-0.97] and OR = 0.45[0.24-0.83] for premolars and molars, respectively, against incisors or canines), tenderness to periapical palpation (OR = 0.64[0.43-0.94]) and two canals per root (OR = 0.67[0.54-0.83]). Four factors were intraoperative: root filling of unsatisfactory quality (OR = 0.18[0.08-0.40]) or extending beyond or shorter than 2 mm from the apex (OR = 0.44[0.26-0.75] and 0.62[0.40-0.97] respectively), resin sealer (OR = 0.58[0.39-0.87] against bioceramic sealer) and single visit treatment (OR = 0.40[0.21-0.75] against multiple visits). One factor was post-operative: defective coronal restoration (OR = 0.35[0.21-0.56]).

CONCLUSION

The following factors were associated with unsuccessful root canal treatment: (i) history of injury, apical periodontitis with increased severity (larger lesion, higher PAI, tenderness to periapical palpation), or complicated anatomic conditions (premolar or molar, two canals in a single root); (ii) technically suboptimal root filling (of unsatisfactory quality or not ending within 2 mm of radiographic apex) performed in a single-visit, or use of resin sealer instead of novel bioceramic sealer; (iii) suboptimal quality coronal restoration.

An international consensus study to identify "what" outcomes should be included in a core outcome set for endodontic treatments (COSET) for utilization in clinical practice and research

BACKGROUND

Development of a standardized set of topic-specific outcomes known as a Core Outcome Set (COS) is important to address issues of heterogeneity in reporting research findings in order to streamline evidence synthesis and clinical decision making.

AIM

The aim of the current international consensus study is to identify "what" outcomes to include in the Core Outcome Set for Endodontic Treatments (COSET). Outcomes of various endodontic treatments (non-surgical root canal treatment, surgical endodontics, vital pulp treatment and revitalization procedures) performed on permanent teeth were considered.

METHODS

A standard validated methodology for COS development and reporting was adopted. The process involved identification of existing outcomes through four published scoping reviews. This enabled creation of a list of outcomes to be prioritized via semi-structured patient interviews, e-Delphi process and a consensus meeting with a range of relevant global stakeholders. Outcomes were prioritized using a 1-9 Likert scale, with outcomes rated 7-9 considered critical, 4-6 are important and 1-3 are less important. Outcomes rated 7-9 by ≥70% and 1-3 by <15% of participants were considered to achieve consensus for inclusion in the COS. The outcomes that did not achieve consensus in the first round were considered for further prioritization in the second Delphi round and consensus meeting. Final decisions about the outcomes to include in COSET were made by voting during the consensus panel meeting using the Zoom Poll function.

RESULTS

A total of 95 participants including patients contributed to the COS development process. The consensus panel recommended, with strong consensus, eight outcomes shared across all treatment modalities for inclusion in COSET: pain; signs of infection (swelling, sinus tract); further intervention/exacerbation; tenderness to percussion/palpation; radiographic evidence of disease progression/healing; function; tooth survival; and patient satisfaction. Additional treatment specific outcomes were also recommended.

DISCUSSION

Many of the outcomes included in COSET are patient reported. All should be included in future outcomes studies.

CONCLUSION

COSET identified outcomes that are important for patients and clinicians and validated these using a rigorous methodology. Further work is ongoing to determine "how" and "when" these outcomes should be measured.

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.

Expert consensus on odontogenic maxillary sinusitis multi-disciplinary treatment

ABSTARCT

Odontogenic maxillary sinusitis (OMS) is a subtype of maxillary sinusitis (MS). It is actually inflammation of the maxillary sinus that secondary to adjacent infectious maxillary dental lesion. Due to the lack of unique clinical features, OMS is difficult to distinguish from other types of rhinosinusitis. Besides, the characteristic infectious pathogeny of OMS makes it is resistant to conventional therapies of rhinosinusitis. Its current diagnosis and treatment are thus facing great difficulties. The multi-disciplinary cooperation between otolaryngologists and dentists is absolutely urgent to settle these questions and to acquire standardized diagnostic and treatment regimen for OMS. However, this disease has actually received little attention and has been underrepresented by relatively low publication volume and quality. Based on systematically reviewed literature and practical experiences of expert members, our consensus focuses on characteristics, symptoms, classification and diagnosis of OMS, and further put forward multi-disciplinary treatment decisions for OMS, as well as the common treatment complications and relative managements. This consensus aims to increase attention to OMS, and optimize the clinical diagnosis and decision-making of OMS, which finally provides evidence-based options for OMS clinical management.

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.

Scanning Electron Microscopic Analysis of Deformation of TruNatomy File Systems: An Ex-vivo Study

Aim The aim of the study was to assess the instrument deformation following the usage of the TruNatomy (Dentsply Sirona, USA) file system in extracted premolars using Scanning Electron Microscopy (SEM). Materials and Methods For the present study, 84 extracted mandibular bicuspids were selected. The teeth were divided into two groups: Group 1, TruNatomy (n=42), and Group 2, Hero Shaper (Micro Mega, France) (n=42). The samples were shaped with 0.03 taper to size 36 with TruNatomy instruments and 0.04 taper to size 30 with Hero Shaper instruments. 5 ml of 5.25% Sodium Hypochlorite (NaOCl) and 2 ml of 17% ethylenediaminetetraacetic acid (EDTA) were used for the final irrigation of root canals. The master apical file was used to instrument seven teeth samples for assessing the safety of the instruments after multiple uses and autoclaving. So, a total of six files per group was used for the analysis of any distortions, cracks or micro-fractures after instrumentation of 42 teeth, at the tip (D0) and 5 mm from the tip (D5) of the rotary file under SEM at 500x magnification. Statistical analysis To determine the significance between the groups, the Mann-Whitney U-test was applied. Results The mean surface wear of the instruments, at the tip (D0) in Group 1 was 1.2857 and in Group 2 was 1.4762. The mean spiral distortion of the instruments, at the tip (D0) in Group 1 was 1.1905 and in Group 2 was 1.4286. A statistically significant difference (P<0.05) was observed between the groups for surface wear and spiral distortion at the tip of the file (D0). There was no significant difference between groups for surface wear and spiral distortion values of the instruments at 5 mm from the tip (D5) (P>0.05). Conclusion The instrument distortion of the rotary file systems analysed was minimal following the biomechanical preparation of seven mandibular bicuspids without root curvature, using a single file. Therefore, both rotary file systems can be considered safe.

The importance of establishing a core outcome set for endodontic clinical trials and outcomes studies

Endodontic therapy aims to preserve teeth by preventing and treating apical disease, therefore, evaluation of treatment outcome in clinical trials and outcomes studies should effectively assess if it achieves these aims. Traditionally, treatment outcomes have been reported by clinicians after history and clinical examination in what is known as clinician-reported outcomes (CROs). Much less commonly employed however, are patient-reported outcomes (PROs) in which patients directly report on their condition. Endodontic treatment outcome reporting is evolving from a focus on CROs to increasing consideration for patient and disease-focused outcomes, with different criteria being proposed for assessment of treatment outcomes. Unfortunately, this has led to considerable variability and a lack of consensus on the definition, appropriate measurement and reporting of these outcomes. Heterogeneity in outcome reporting in clinical research provides a significant major barrier to conduct meta-analysis, guidelines development, clinical decision making, and ultimately affecting patient care. These effects could, however, be reduced by the establishment of a core outcome set (COS) in endodontics, which is defined as an agreed, standardized set of outcomes that should be included, measured and reported as a minimum in all trials and outcome studies. COS development is a regulated and validated process requiring involvement of appropriate stakeholders as well as a rigorous methodology. To date, COS has been developed for the management of traumatic dental injuries, orthodontic and periodontal treatment and is currently being developed for endodontic treatment. The aim of this review is to discuss the importance of COS in endodontics with focus on the evidence for and impact of heterogeneity in reporting endodontic treatment outcomes. An overview of an ongoing process for development of COS for different endodontic treatment modalities will also be provided.

What does epidemiology tell us about treatment outcomes in endodontics

BACKGROUND

Available information on endodontic treatment outcome derives from clinical studies, of which the main part is observational with no randomization and little or no control of confounding factors. Several sources of bias may hamper the interpretation of results from observational studies if the problems are not addressed properly.

OBJECTIVE

The purpose of this narrative review is to describe and explain the potential benefits of employing epidemiological methodology when designing, conducting and reporting on observational, clinical outcome studies.

DISCUSSION

Epidemiology provides methodology that can be used to reduce the impact of several types of problems related to observational studies. These problems concern, external validity, which describes the generalisability of the study findings, and internal validity, which describe data quality parameters, such as selection bias, information bias and confounding. Furthermore reporting of a study should be systematized, and to that use, several checklists have been developed.

CONCLUSION

It can be concluded that epidemiological methods are important for conducting and interpretation of findings from clinical, observational studies in endodontology.

Post-Operative Quality of Life after Single-Visit Root Canal Treatment Employing Three Different Instrumentation Techniques-An Institutional Randomized Clinical Trial

Root canal treatment (RCT) eliminates damaged pulpal tissue and protects the tooth from recurrent microbial invasion. Post-endodontic pain (PEP) is a frequently encountered complication of root canal therapy. It can have an impact on patients' quality of life (QoL) and their subjective perception of treatment options. Thus, a self-assessment questionnaire was used to evaluate and compare the influence of manual, rotary, and reciprocating file shaping procedures on immediate post-operative quality of life (POQoL) involving single-visit root canal therapy. It was a double-blinded, randomized, controlled clinical trial. A total of 120 participants were randomly assigned sequentially to three groups comprising 40 patients in each group: Group A: Hand K file (positive control); Group B: ProTaper Next file system; and Group C: WaveOne Gold. Post-operative pain was evaluated using a 4-point visual analog scale (VAS) after 12 h, 24 h, 48 h, 72 h, and 1 week. The highest post-operative pain was with manual instrumentation using hand K files, and the lowest was with reciprocating and rotating instrumentations. No significant difference was noted between the parameters of quality of life assessed, suggesting the filing system or technique had a similar effect.

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

BACKGROUND

Revitalization is a type of regenerative endodontic treatment (RET) that offers the exciting prospect of revitalizing damaged tissue, therefore improving outcomes for non-vital immature teeth. To evaluate its potential, there needs to be consistency in outcome reporting of clinical studies investigating revitalization to allow for evidence synthesis and inform clinical decision making.

OBJECTIVES

The aim of this scoping review was to identify outcomes that are reported in systematic reviews on revitalization including how and when these outcomes are measured. Additionally, evidence of selective reporting bias in the reviews was assessed.

METHODS

A comprehensive electronic search of healthcare databases and grey literature was conducted to identify systematic reviews published in the English language reporting outcomes of revitalization in permanent immature teeth. There was no restriction on the date of publication. Outcome data was extracted by four reviewers independently and mapped with a healthcare taxonomy into five core areas: survival, clinical/physiological changes, life impact, resource use and adverse events. Selective reporting bias and how it was measured was assessed independently by two reviewers.

RESULTS

Twenty-six systematic reviews were included in this scoping review. There was lack of standardization in reporting and significant heterogeneity across reviews in outcome endpoints. The outcomes reported could be aligned within the five core areas of the taxonomy including tooth survival which was reported in nine reviews. Patient-reported outcomes were generally limited and no review reported on Oral Health Related Quality of Life. Many of the reviews reporting on randomized control trials were at low risk of selective reporting bias whilst other study designs were at higher risk.

DISCUSSION

Consistency in outcome reporting is necessary to realize the benefits of old but particularly novel therapies. Data from this review confirmed heterogeneity in reporting outcomes of revitalization and the need for development of a core outcome set (COS).

CONCLUSIONS

Several important outcomes including survival, root development, tooth discolouration and periapical healing have been identified in this review which could inform the development of a COS in this area.

REGISTRATION

Core Outcome Measures in Effectiveness Trials (COMET) database (registration no. 1879).