Case assessment and treatment planning: what governs your decision to treat, refer or replace a tooth that potentially requires endodontic treatment?

Prognostic validity of the Periapical and Endodontic Status Scale for the radiographically assessed 2-year treatment outcomes in teeth with apical periodontitis: a prospective clinical study

Background

Endodontic treatment planning and treatment success evaluation are largely based on radiographic assessment of anatomical and treatment-related parameters of teeth with apical periodontitis (AP). This prospective clinical study aimed to assess radiographically the 2-year endodontic treatment outcomes for teeth with AP, and to evaluate prognostic validity of Periapical and Endodontic Status Scale (PESS).

Methods

A total of 128 patients, representing 176 teeth with AP were examined by cone-beam computed tomography at baseline and at 24 months after endodontic treatment. Treatment outcome was evaluated using estimates of periapical radiolucency and the relationship between anatomical structures and location. The strength of the associations between these and treatment-related parameters was tested by logistic regression analysis. PESS sensitivity and specificity were calculated for every treatment risk group (low, moderate, high) of teeth.

Results

One hundred and fifty-seven teeth, representing 350 root canals had a positive treatment outcome, while 19 teeth, representing 53 root canals had a negative treatment outcome at 24 months. The probability of negative outcome was 25 times higher in the moderate/high-risk group than in the mild-risk group of teeth (OR = 25.1; 95%CI [12.2–51.5]). Pre-treatment complications and retreatment cases with radiolucency were associated with negative outcomes (OR = 35.9; 95%CI [12.6–102.4]; OR = 26.437; 95%CI [10.9–64.1], respectively). PESS sensitivity and specificity was over 80% in all risk groups except for high risk group, due to very low number of cases.

Conclusions

Endodontic treatment outcome depends on the severity of periapical changes. The presence of complications and retreatment cases with periapical lesions are associated with negative treatment outcome. The PESS is a valid instrument to predict outcome of teeth with low-moderate treatment risk of AP.

The Dental Practicality Index - assessing the restorability of teeth

The Dental Practicality Index (DPI) has been designed to describe on a clinical level, the 'practicality' of dental restorative treatment. Applicable to everyday clinical practice, the DPI also aims to assist the clinician in deciding when to seek advice and/or refer a patient for secondary or tertiary dental care. It is hoped that this tool will aid in the systematic assessment of dental restorative problems, enhance communication between collaborating practitioners and help to manage patient expectations before carrying out restorative treatment(s).

Prevalence of referral reasons and clinical symptoms for endodontic referrals

Objectives

To investigate the prevalence of different primary reasons for endodontic referrals and the clinical symptoms of the referred cases.

Materials and Methods

Clinical data of total endodontic treatment cases (1,014 teeth) including endodontic referral cases (224 teeth) between January 1, 2010 and December 31, 2012, at Kangdong Sacred Heart Hospital, were investigated retrospectively. The one major reason for referral, the clinical symptoms, and the resulting treatment procedures of referral cases were recorded. The percentages of clinical symptoms of the endodontic referral cases and the total endodontic treatment cases were compared by χ² test for each symptom.

Results

Persistent pain was the most frequent reason for endodontic referral (29.5%), followed by presence of gingival swelling and sinus tract (24.1%), and apical radiolucency (12.9%). Referrals in cases involving endodontic difficulties such as canal calcification, broken instruments, post, perforation, and resorption were less than 5.0%, respectively. The percentages of four major clinical symptoms of pain, apical radiolucency, previous endodontic treatment, and gingival swelling and sinus tract were significantly higher in the endodontic referral cases than those in the total endodontic cases (p = 0.001). Among the included referral cases, 72.8% were treated with nonsurgical endodontic treatment only. Teeth other than the referred teeth were diagnosed as the origin of the problem in 5.8% of the referrals.

Conclusions

The high prevalence of pain, apical radiolucency, previous treatment, and gingival swelling and sinus tract in endodontic referral cases suggest that these symptoms may be what general practitioners consider to be difficult and refer to endodontists.

Treatment planning the endodontic case

Following a definitive diagnosis of the need for root canal treatment, the treatment planning stage should be straightforward if a logical sequence of decision-making is followed. Very few contra-indications exist for providing root canal treatment, but the planning must include several aspects. Firstly, is root canal treatment best for the patient to maintain a functional dentition long term? Secondly, who should provide the treatment? Thirdly, what are the restorative options that will ensure the best long-term prognosis? The sequencing of root canal treatment generally occurs early in a typical treatment plan, and prompt restoration after treatment is crucial to long-term survival of the tooth.