disease prognosis

8/13/2019 disease prognosis

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Disease, Prognosis, Retention

Prognosis of Endodontic Therapy: Controlling Disease and Retaining Teeth


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Prognosis

is thepro spec t o f recovery

as anticipated from theus ual co urs e of d i sease or

p ecu l iar i t ies o f th e case m-w.com


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Prospect of Recovery

From disease to health from pulp i t i s to freedom from

pain and infection byregeneration or replacement from apical per iodon t i t i s to

normal apical periodontium byregeneration


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Prognosis - Outcome

Outcome studies may also address

the func t ion and surv iva l of thetreated tooth

Caplan & Weintraub, 1997


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Treatment ofapical periodontitis

Prevention ofapical periodontitis

Common purpose:No root canal infection; no apical periodontitis.

This is what we usually think of when we say prognosis ofendodontic treatment


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Pulpitis

.. is tissue reactions to traumaand/or in fec t ions of the pulp-dentinorgan

.. includes acute and chronicphases, abscesses, but may bereversible


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Effective prevention is possible only when you know the etiology andpathogenesis of the disease in question, so..

Vital Pulp Treatment

The prognosis ofendodontic treatment ofteeth with initially vital

pulps or uninfectednecrotic pulps isunrelated to the pulp; itis a matter of preventingapical periodontitis


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What is Apical Periodontitis?


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Why Apical Periodontitis? A defensemechanism

developed for theprotection of thebody interior from

life-threateninginfections Transition from

continuouslyshedding topermanent teethwith pulps


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Apical Periodontitis

20081200


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Apical Periodontitis

How well do we do? What is the status of apical periodontitis inthe population at large? We need to respond to such issues.

When treatingindividual patients,epidemiology is of littleconcern, and prognosisof interest only inpredicting the fate ofthat particular tooth.

But as a profession, wewill be judged by howwell we can control andeliminate the disease.


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Fig. 6. The prevalence of apical periodontitis in different populations.a, Dugas et al 2003; b, Marques et al 1998; c, Frisk & Hakeberg 2005; d, Loftus et al 2005; e, Buckley &Spangberg 1995; f, DeCleen et al 1993; g, Eriksen et al 1991; h, Dugas et al 2003; i, Kirkevang et al 1991; j, Frisk& Hakeberg 2005; k, Chen et al 2007; l, Jimnez-Pinzn et al 2004; n, De Moor et al 2000; o, Saunders et al 1997;p, Sidaravicius et al 1999; q, Tsuneishi et al 2005; r, Kabak & Abbott 2005; s, Segura-Egea et al 2005.

a b c d

e f g h i j

k

ln

o p q

r s

0

20

40

60

80

100

I n d i v i d u a

l s w

i t h A P

, %

Adapted from: Harald Eriksen 2008in: rstavik & Pitt Ford, EssentialE n d o d o n to lo g y


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Harald Eriksen 2008in: rstavik & Pitt Ford,Essen t ia l Endodo n to logy

Maintaining a highnumber of retainedteeth into old age is agoal common to all ofdentistry;

Endodontology dealswith bringing down theprevalence of apicalperiodontitis


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Reasons for Extraction In a survey of 31 investigations dealing with reasons for

extraction of permanent teeth, in only three was apicalperiodontitis mentioned explicitly as the reason forextraction. One of them was an investigation performed

by Brekhus as early as 1929. An interesting observationwas that some additional investigations mentionedfailed endodontic treatment and pain as reasons forextraction without explicitly defining pulpitis or apicalperiodontitits. It can therefore be con clud ed that

apical per iod on t i t is has no t been app reciated as adisease compared to, for instance, marginalperiod on t i t is , bu t rather con sidered as a sequ el todental c ar ies .

Harald Eriksen in: rstavik & Pitt Ford, Essen t ia l Endo don to logy 2008


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Reasons for Extraction

Caries

Pulp/AP Perio

0

4

8

12

16

20

Per cent

Brennan DS, Spencer AJ, Szuster FS. Provision of extractions by main diagnoses. Int Dent J. 2001 Feb;51(1):1-6. Australia: Practitioners completed service logs over one to two typical clinical days.


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Caries

Pulp/AP

Perio Caries

Pulp/AP

Perio

1

3

5

7

Odds ratio

18-44 r 45+

Brennan DS, Spencer AJ, Szuster FS. Provision of extractions by main diagnoses. Int Dent J. 2001 Feb;51(1):1-6.

Australia: Practitioners completed service logs over one to two typical clinical days.

On the road to damnation

On the road to salvation


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Caries

Pulp/APPerio Pulp/AP

PerioPulp/AP

Perio

0

10

20

30

40

50

Per cent

overall urban rural

Spalj S, Plancak D, Juri H, Paveli B, Bosnjak A. Reasons for extraction of permanent teeth in urbanand rural populations of Croatia. Coll Antropol. 2004 Dec;28(2):833-9. Survey among practitioners.


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Reasons for Extraction ofEndodontically Treated Teeth

Caplan DJ, Weintraub JA. Factors related to loss of root canal filledteeth. J Public Health Dent. 1997 Winter;57(1):31-9.

No. of approximal contacts .000 Age .000No. of missing teeth .000

Anxiety .002Bridge abutment .006Medication .007Diabetes .022Denture/partial .037Poor hygiene .039


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Fig. 6. The prevalence of apical periodontitis in different populations.a, Dugas et al 2003; b, Marques et al 1998; c, Frisk & Hakeberg 2005; d, Loftus et al 2005; e, Buckley &Spangberg 1995; f, DeCleen et al 1993; g, Eriksen et al 1991; h, Dugas et al 2003; i, Kirkevang et al 1991; j, Frisk& Hakeberg 2005; k, Chen et al 2007; l, Jimnez-Pinzn et al 2004; n, De Moor et al 2000; o, Saunders et al 1997;p, Sidaravicius et al 1999; q, Tsuneishi et al 2005; r, Kabak & Abbott 2005; s, Segura-Egea et al 2005.

a b c d

e f g h i j k

ln

o p q

r s

0

20

40

60

80

100

I n d i v i d u a l s w

i t h A P

, %

Segura-Egea JJ, Jimnez-Pinzn A, Ros-Santos JV, Velasco-Ortega E,Cisneros-Cabello R, Poyato-Ferrera M. Int Endod J. 2005 Aug;38(8):564-9.High prevalence of apical periodontitis amongst type 2diabetic patients. Department of Stomatology, School of Dentistry,

University of Seville, Seville, Spain.RESULTS: Apical periodontitis in at least one tooth wasfound in 81.3% of diabetic patients and in 58% of controlsubjects (P = 0.040; OR = 3.2; 95% CI = 1.1-9.4). Amongst diabeticpatients 7% of the teeth had AP, whereas in the control subjects 4% of teethwere affected (P = 0.007; OR = 1.8; 95% CI = 1.2-2.8). CONCLUSIONS:Type 2 diabetes mellitus is significantly associated with an increased

prevalence of AP.


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Loss of Endodontically TreatedTeeth

Caplan DJ, Cai J, Yin G, White BA. Root canal filled versus non-rootcanal filled teeth: a retrospective comparison of survival times. J

Public Health Dent. 2005;65(2):90-6.


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Salehrabi R, Rotstein I. Endodontic treatment outcomes in a largepatient population in the USA: an epidemiological study. J Endod.

2004 Dec;30(12):846-50.

treatment done in 1,462,936 teeth of1,126,288 patients from 50 states across theUSA was assessed over a period of 8 yr.

.

Overall, 97% of teeth were retained in theoral cavity 8 yr after initial nonsurgical

endodontic treatment.


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Salehrabi R, Rotstein I. Endodontic treatment outcomes in a largepatient population in the USA: an epidemiological study. J Endod.

2004 Dec;30(12):846-50.

Analysis of the extracted teeth revealed that85% had no full coronal coverage. A

significant difference was found betweencovered and noncovered teeth for all toothgroups tested (p < 0.001).


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Loss of Endodontically TreatedTeeth: Primary Teeth

Rocha MJ, Cardoso M. Survival analysis of endodontically treatedtraumatized primary teeth. Dent Traumatol. 2007 Dec;23(6):340-7.

51 teeth, 10-60

months of age 0

102030405060

708090

100

0

6

7

1 2

1 3

1 8

1 9

2 4

2 5

3 0

3 1

3 6

3 7

4 2

4 3

4 8

Time from treatment, months

P e r c e n

t o

f t r e a t e

d t e e

t h

Failure (%) Cumulative success %


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Usual Course of Disease

Prognosis assessment is impossiblewithout knowing the naturalhistory of AP:

The infectious process The inflammatory response Variations and deviations from case

to case


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The Infectious Process

Sources of infection Caries diminishing importance

Physical exposure filling margins, previouspulp/dentin trauma

Traumatic fractures special concerns

Anachoresis questionable occurrence

Relative importance? few/no data Public health perspective: adequate conservative

treatment is the best prevention of apical periodontitis


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The Infectious Process

Pulpitis NecrosisCanalinfection

Apicalperiodontitis

Time

Spread toapex

Increasing infectious load;increasingly difficult to treat


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Further course ofdisease:Sequels to theinitial events


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Severity

Incidence Adielsson et al 1999


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The Inflammatory Response

Acute and chronic Acute AP

Chronic AP: primary, persistent, secondary

Exacerbating AP: Phoenix abscess

Acute periapical abscess

Chronic periapical abscess with sinus tract

Radicular cyst: detached or pocket cyst


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Time-Course of Apical

Peridontitis Dynamics of pulpal infection

Bacterial succession and variations in

virulence and pathogenicity Host factors modulating inflammation

and spread of the infection

Ultimate consequences of root canalinfection


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Percentage of teeth at risk ofdeveloping apical periodontitis

rstavik 1994

0

2

4

6

8

0 1 2 3 4

TIME, years

R O O T S

, p e r c e n t

AP % of at risk General risk* Risk for RF teeth* Risk for noRF teeth*

0

2

4

6

8

0 1 2 3 4TIME, years

R O O T S

, p

e r c e n t



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Percentage of teeth at risk ofdeveloping apical periodontitis

rstavik 1994

0

2

4

6

8

0 1 2 3 4

TIME, years

R O O T S

, p

e r c e n t


0

2

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8

0 1 2 3 4TIME, years

R O O T S

, p

e r c e n t



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Time-Course of ApicalPeridontitis

Bacterial succession and variations invirulence and pathogenicity

Primary infection self-explanatory Persistent infection original flora, no cure

Recurrent infection residuals reemerging

Secondary infection new infection throughleaking root filling


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Natural Course of the Disease:Pain

Varying in intensity and severity Pain sometimes accompanies pulpitis and apical

periodontitis

Unpredictable if untreated Pulpitis and acute apical periodontitis dominate as

sources for acute dental pain in children and adults

(Zeng et al 1994, Lygidakis et at 1998) which may bedebilitating to the patient and lead to absence fromwork and involvement of costly health services.(rstavik, 2009)


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Natural Course of the Disease:Pain

Unpredictable if untreated While we know that emergency dental services are in

great demand in most countries, in urban as well asrural areas, there is very scant information on theactual incidence and prevalence of acute pulpal andapical periodontal disease. Therefore, one can onlyspeculate that there is still, even in communities withwell-developed dental services, a significant impacton the general well-being by acute pulpal andperiodontal conditions (Sindet-Pedersen et al 1985,Richardsson 2005). (rstavik 2009)


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Natural Course of the Disease:

Conclusions Unpredictable if untreated It does not heal

Potentially very painful

Serious complications/sequelae are rare

Pulpitis ->Necrosis->Apical Perio->Acute phases->Local spread->Systemic spread

Filling therapy Endodontics Extraction

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disease prognosis