Is apical periodontitis in root filled teeth associated with the type of restoration?

OBJECTIVE

To study the association between type of restoration and apical periodontitis (AP) in root filled teeth.

MATERIALS AND METHODS

The present study used data from surveys conducted in 1983, 1993 and 2003. In 1983, 130 randomly selected subjects aged 3-80 years in the city of Jönköping, Sweden, were invited for a clinical and radiological examination. The study was repeated in 1993 and 2003. New participants were, thus, recruited with the same sampling criteria and sample size in the same geographical area in 1993 and 2003, respectively. In the present study, only dentate individuals aged 20-70 years with ≥1 root filled tooth were included, yielding a sample of 788 subjects with 2634 root filled teeth. Apical periodontitis on the tooth level was the dependent variable. Periapical status was assessed according to Periapical Index (PAI). Independent variables were root filling quality, recurrent caries, type of restoration, number of teeth with apical periodontitis, age and gender. Root fillings appearing homogenous and ending within 2 mm from radiographic apex were regarded as adequate, otherwise inadequate. All radiographs were re-studied by one observer regarding periapical status and root filling quality. Risk was analyzed by means of a GEE model.

RESULTS

Type of restoration, root filling quality, number of teeth with apical periodontitis within the individual and age were found to be predictors of AP in root filled teeth. Presence of recurrent caries and gender were not found to be associated with AP.

CONCLUSIONS

According to the present study, root filling quality and type of restoration may be predictive of AP in root filled teeth.

Periapical status of root-filled teeth in Norwegian children and adolescents

OBJECTIVE

To study the periapical status of root-filled permanent teeth of 9-17-year-olds in Møre & Romsdal county, Norway.

MATERIALS AND METHODS

All permanent teeth with endodontic treatment in patients born in 1994-2001 were identified in the dental records of the Public Dental Service. The data collected consisted of chart entries and radiographs. Of 1182 teeth, 174 teeth in 155 patients met further inclusion criteria, i.e. completed endodontic treatment and a follow-up with a readable radiograph of at least 1 year. Periapical status was assessed with the Periapical Index (PAI) and the technical quality of the root fillings was also quantified on a 4-grade visual scale.

RESULTS

Apical periodontitis was found on follow-up radiographs in 25% of all teeth and in 48% of the teeth with pre-operative apical periodontitis. Forty-two per cent of root fillings were of adequate technical quality. Adequate technical quality of the root filling was significantly correlated with radiographic success.

CONCLUSIONS

About one fourth of all root-filled teeth and almost half of the teeth with pre-operative apical periodontitis showed clear signs of the disease at recall.

Periodontal-endodontic interdisciplinary treatment--a case report

Periodontal-endodontic lesions pose a difficult diagnostic and therapeutic challenge to the dental practitioner. A careful diagnostic examination consisting of a thorough patient and dental history, comprehensive clinical examination, and use of appropriate dental radiographs is necessary to arrive at a proper diagnosis of the periodontal-endodontic lesion. Despite these measures, it is not always possible to make an accurate diagnosis, which is imperative to provide the proper therapy in the correct treatment sequence. In some instances, endodontic or periodontal therapy alone may suffice; however, in other instances, a combination of endodontic and periodontal therapy may be required to successfully treat the case. In this article, classifications of periodontal-endodontic lesions are discussed, including the appropriate treatment and correct treatment sequence for each classification. Prognosis of periodontal-endodontic lesions depends on the diagnosis, treatment, and chronicity of the lesion, as well as the duration of periodontal involvement. A clinical case is presented in which a periodontal endodontic lesion has been successfully treated with a combination of conventional endodontic therapy and regenerative periodontal surgery.

Tooth-specific risk indicators for apical periodontitis

The present study aimed at identifying tooth-specific risk indicators for apical periodontitis (AP) and to investigate their interrelations in order to identify those teeth that would benefit from a radiographic examination. The study included 311 males and 302 females who gave written informed consent and attended a full-mouth radiographic examination. All teeth were assessed individually. AP was scored by the periapical index (PAI); other variables were root fillings, coronal fillings and crowns, pulpal posts, and caries. A conditional logistic regression analysis was used to assess the effect of tooth-specific risk indicators on the presence of apical periodontitis. The dependent variable was presence of AP versus absence of AP in the tooth. A total of 536 teeth with AP were identified. A highly increased risk for AP was seen in teeth with root fillings, particularly for technically inadequate ones. Presence of coronal fillings also increased the risk for AP, and inadequate fillings were associated with a slightly higher risk than adequate fillings. A similar pattern was seen for crowns. Teeth with caries also had an increased risk of AP, but the difference was only statistically significant for primary caries. Compared to first incisors, second incisors and canines had a significantly reduced risk, and molars, especially first maxillary molars, had a significantly increased risk for having AP.

Tobacco smoking and dental periapical condition

The relation between smoking and apical periodontitis has been little studied to date. The aim of the present study was to investigate whether tobacco smoking might be associated with the prevalence or severity of periapical lesions. A total of 247 individuals, 81 current smokers, 63 former smokers, and 103 non-smokers participated in the study. The periapical condition was expressed as the number and percentage of radiographically detectable lesions and, in addition, as a severity index. The overall prevalence of apical periodontitis was 52% and the overall prevalence of endodontic treatment 58%. There was no significant influence of smoking on the prevalence of either apical periodontitis or endodontic treatment. The mean number (percentage) of periapical lesions per person was 1.9 (6%) in current smokers, 1.5 (4%) in former smokers, and 1.0 (3%) in non-smokers. Controlling for age, the association between smoking and periapical lesions was not statistically significant. The mean periapical severity index including all teeth, or teeth affected by periapical lesions alone, did not significantly differ between smoking groups. It is concluded that the present observations do not lend support to the assumption that tobacco smoking is associated with apical periodontitis.

Aetiology, classification and pathogenesis of pulp and periapical disease

At present, the majority of the treatments that are performed in the clinic are due to disease entities involving the dental pulp and periapex. Dental pulp is a richly vascularized and innervated tissue, enclosed by surrounding tissues that are incapable of expanding, such as dentin. It has terminal blood flow and small-gauge circulatory access the periapex. All of these characteristics severely constrain the defensive capacity of the pulp tissue when faced with the different aggressions it may be subjected to. Pulp tissue can also be affected by a retrograde infection, arising from the secondary canaliculi, from the periodontal ligament or from the apex during the course of periodontitis. Due to the fact that periapical disease is almost inevitably preceded by pulp disease, we shall begin by describing the causes of pulp disease and will then proceed to a discussion of the causes of periapical disease. The course of illness and classification of these pathological entities will depend on the aetiology involved. We will analyse pulp necrosis and pulp degeneration that are capable of triggering reversible apical periodontitis or irreversible apical periodontitis.

Comparison between PAI and quantitative digital radiographic assessment of apical healing after endodontic treatment

OBJECTIVE

The purpose of this study was to compare both subjective (Periapical Index, PAI) and objective (densitometric) radiographic evaluation of healing after endodontic treatment for apical periodontitis.

STUDY DESIGN

Standardized radiographs of 103 teeth taken at baseline (immediately after endodontic treatment) and at 1, 4, 12, 26, and 52 weeks were evaluated. Consensus PAI scores obtained from 7 calibrated observers served as "true scores." Densitometric estimates of periapical status were obtained from digitized radiographs as the ratio of mean gray value of an area of radiolucency (AR) to an adjacent and similar-sized normal (N) area (AR/N). The selected regions of interest on baseline images were automatically superimposed on postoperative images. All estimates of change were measured with respect to baseline. The subtraction estimate was expressed as AR(S)-N(S). Linear regression was used to analyze longitudinal changes against baseline and to assess the relationship of PAI and AR/N and of change in PAI with respect to baseline and AR(S)-N(S).

RESULTS

Five hundred fifty-six PAI scores were generated, with 547 AR/N values and 444 subtraction estimates. PAI, AR/N, and AR(S)-N(S) demonstrated statistical significance for change (P < or = .05) starting at 12 weeks. PAI was significantly correlated with AR/N (P < .0001), as was CHPAI with AR(S)-N(S) (P < .024).

CONCLUSION

The PAI and 2 densitometric estimates (AR/N and AR(S)-N(S)) detected healing of apical periodontitis at 12 weeks after treatment. No difference could be observed among the methods.

A prognostic model for assessment of the outcome of endodontic treatment: Effect of biologic and diagnostic variables

OBJECTIVE

Many biological variables, endodontic treatment factors, and restorative considerations have been suggested in the literature to affect the outcome of endodontic treatment. However, few attempts have been made recently to study these variables further. The purpose of this study was to identify the biologic and endodontic treatment-associated variables that are most predictive of treatment outcome for conventional endodontic therapy and to determine the magnitude of risk these variables pose on the outcome.

STUDY DESIGN

The population of this historical prospective cohort study comprised a total of 200 teeth with 441 root canals. Diagnostic and treatment information was abstracted from the original patient records. An endodontic follow-up examination was conducted 4 +/- 0.5 years after obturation. Each tooth/root was analyzed according to 3 indices of periradicular status at 2 time points. The main outcome measure was the presence of apical periodontitis. The criteria used for evaluation of the outcome were modified from Strindberg. Data were subjected to univariate and multivariate analysis. Logistic regression models were fit by using various clinical measures to determine which combination of biologic and treatment-associated factors best predicted treatment outcome.

RESULTS

The preoperative pulp diagnosis, the periapical diagnosis, the preoperative periapical radiolucency size, and the sex of the patients were revealed, by means of univariate analysis, to exert a significant influence on endodontic treatment outcome (P <.05). In the logistic regression model, the strongest effect on postoperative healing was the presence and magnitude of preoperative apical periodontitis. In the presence of this variable, no other factor contributed value to the prediction. The correct prediction of this model was 74.7% (P <.05).

CONCLUSION

The major biologic factors influencing the outcome of endodontic treatment appear to be the extent of microbiological insult to the pulp and periapical tissue, as reflected by the periapical diagnosis and the magnitude of periapical pathosis.

Periapical status and quality of root fillings and coronal restorations in a Danish population

AIM

The aim of this study was to investigate the quality of endodontic and coronal restorations and the association with periapical status in a Danish population.

METHODOLOGY

A total of 614 randomly selected individuals (20-60+ years of age) from Aarhus County had a full-mouth radiographic examination. The quality of endodontic and coronal restorations and the periapical status of endodontically treated teeth were assessed by radiographic criteria. Root fillings were categorized as 'adequate' or 'inadequate' with regard to root filling length and lateral seal. Coronal restorations were categorized into 'adequate' and 'inadequate', defined by the absence or presence of radiographic signs of overhangs or open margins. Results were analysed statistically using the chi-squared test.

RESULTS

The total number of endodontically treated teeth was 773, and 52.3% had apical periodontitis (AP). Root-filled teeth with an adequate lateral seal had a lower incidence of AP than teeth with an inadequate seal (44.3% vs. 57.8%), and teeth with an adequate root filling length were associated with a better periapical status than teeth with inadequate length of the root filling (42.0% vs. 67.6%). Similarly, adequate coronal restorations were associated with better periapical status than inadequate restorations (48.0% vs. 63.9%). When both root filling and coronal restoration quality were assessed, the incidence of AP ranged from 31.2% (optimal quality) to 78.3% (all parameters scored as inadequate).

CONCLUSIONS

Inadequate root canal and coronal restorations were associated with an increased incidence of AP.

Perspectives, controversies and directives on pulpal-periodontal relationships

While established clinical, radiographic and histologic criteria exist to explain the intimate relationship of the pulp and periodontium during pathological states, the recognition, diagnosis and treatment of this perplexing interplay remains a challenge for the practitioner. This dynamic interrelationship is investigated with a focus on simplicity and succinctness to enhance diagnostic probabilities, clarify treatment modalities and provide realistic prognoses in management.