4/22/2021

The aim of this lecture is to provoke our thoughts

when making clinical decisions especially in the
case of post-treatment asymptomatic apical
periodontitis Handouts ? Download from www.shemesh.nl

1. The ideal outcome: what are our aims ?

2. The incidental finding
3. Additional relevant points

1 2

Chapter 17 : Evaluation of outcomes (Y-L.Ng & K.Gulabivala)

“ The ideal outcome… consists of

the controlled reduction of
inflammation, accompanied by
healing through regeneration ,
although sometimes repair may
follow instead”

3 4

• What are our goals when we treat AP ? • What are our goals when we treat AP ?

Function &
Function & symptoms
Infection free Infection free
symptoms

No threat to No threat to
Inflammation Inflammation
general general
free free
health health

5 6

1
 4/22/2021

Function & Symptoms The success of endodontic therapy-healing and

functionality.
97% of 1.4 million teeth were functional 8 years
following non-surgical root canal treatment Functionality = 86-92%

Salehrabi & Rotstein 2004 JOE Friedman & Mor 2004 J Calif Dent Assoc

7 8

• What are our goals when we treat AP ?

Function & Infection free

sympthoms

No threat to
Inflammation
general
free
health

9 10

Bacteria recovered from teeth with apical periodontitis after In 90% of the infected
antimicrobial endodontic treatment.
canals, bacterial biofilm
remained in the apical 3
mm after root canal
Once established, nonmutans streptococci,
treatment.
enterococci and lactobacilli appear to survive
commonly following root-canal treatment of
teeth with clinical and radiographical signs of
apical periodontitis.

Chavez de Pas et al. 2003 IEJ Nair et al. 2005 OOOOE

11 12

2
 4/22/2021

Current procedures are not • What are our goals when we treat AP ?

effective in eliminating root

infection.

Function & Infection free

sympthoms

Inflammation
No threat to
free
general
health
Courtesy Dr. Frank Paqué

13 14

Lesions of endodontic origin and risk of coronary heart disease. Endodontic variables and coronary heart disease.

“These findings are consistent with research that “ This cross-sectional study did not reveal a
suggests relationships between chronic periodontal significant association between endodontically
inflammation and the development of CHD, treated teeth and CHD nor between teeth with
especially among younger men.” periapical disease and CHD.”

Caplan et al. 2006 JDR Frisk et al. 2003 ACTA odontol Scand

15 16

Association of Endodontic Lesions with Coronary Artery

Apical periodontitis and cardiovascular diseases: previous findings and ongoing
research.
Disease

RESULTS AND CONCLUSIONS:

(i) Poor oral health and endodontic infections are associated with cardiovascular
diseases, and endodontic infection appears to be associated with initial endothelial “Our findings support the hypothesis that
damage,
endodontic lesions are independently
(ii) preventive measures for IE should be adopted during endodontic treatment of associated with coronary artery disease and in
patients at risk for cardiovascular events according to the American and European
available official guidelines, and particular with acute coronary syndrome”
(iii) more research focused on apical periodontitis and systemic diseases is needed.

Cotti and Mercuro 2015 IEJ Liljestrand et al. 2016 JDR

17 18

3
 4/22/2021

The impact of Endodontic Infections on the pathogenesis of Cardiovascular
disease : A systematic review with meta- analysis using GRADE
“Whether the presence of a lesion of
endodontic origin may or may not have some
impact on cardiovascular disease, the level of
evidence is low, and our confidence in the
assessment is low”.
Aminoshariae et al. 2018 JOE
Endodontics and diabetes: association versus causation.
…once a significant statistical association has
been found …, it is necessary to exclude the
presence of bias, which would imply that the
association is artefactual, and to analyze if the
causation criteria defined by Hill (1965) are
fulfilled to establish a causal relationship. Only if
they are satisfied, can it be concluded that the
association is causal.
Segura Egea et al. 2019 IEJ in print

19 20

Association Between Periodontal Disease and Erectile Dysfunction:

A Systematic Review

• ‘ At present time the

It is emphasized that physicians
association between
should refer patients with ED to oral health care providers for a endodontic disease and
comprehensive oral evaluation and treatment.
different systemic conditions
There are several confounders, such as age and the type of ED, that failed to be rests on shaky grounds.”
adjusted and that generate bias and affect the correlation between the incidence
of ED and PD.

Kellesarian et al. 2016 Am J Mens Health Frisk & Kvist 2019 AP in root-filled teeth

21 22

• What are our goals when we treat AP ?

Outcome is
determined
Function &
symptoms
Infection free clinically (lack
of signs &
No threat to symptoms) and
Inflammation
free
general
health radiographically

23 24

4
 4/22/2021

Diagnostic accuracy of CBCT used Diagnostic accuracy of periapical

for assessment of apical radiography and CBCT in detecting apical
periodontitis: an ex vivo periodontitis using histopathological
histopathological study on human findings as a reference standard.
cadavers.

Periapical lesion
(Radiograph/ Inflammation Diagnostic accuracy of CBCT used for CBCT had significantly higher diagnostic
CBCT) diagnosis of AP is dependent on the accuracy in detecting AP compared to PR
treatment status of the tooth.

Kruse et al. 2019 IEJ Kanagasingam et al. 2017 IEJ

25 26

• What are our goals when we treat AP ?

Clinical endodontics is defined as the prevention

and/or elimination of apical periodontitis.
Function &
symptoms Infection free Improve procedures

Most targets could not be achieved

No threat to
Inflammation general
free health
Change targets ?

Ørstavik & Pitt Ford 2002 Essential Endodontology

Friedman 2003 Endodontic Topics

27 28

Chapter 17 : Evaluation of outcomes (Y-L.Ng & K.Gulabivala)

A periapical lesion could be limited or kept under
control but not always disappear
“ The ideal outcome… consists of
the controlled reduction of
Maybe we should learn to live with it inflammation, accompanied by
healing through regeneration ,
although sometimes repair may
follow instead”

29 30

5
 4/22/2021

irrelevant
Function &
symptoms Infection free

Inflammation No threat to
free general health
2012 2014

2018 2018 2019

31 32

The incidental discovery of apical periodontitis. •The lesion may flare up

Case : A. Braun
•The lesion may expand and damage surrounding structures
•The lesion may affect general health

Wesselink 2014 Endodontic Topics

33 34

•The lesion may flare up

Van Nieuwenhuysen et al.

“ it can get painful/ swollen IEJ 1994 1-2%
while you are on vacation “

Yu et al. JOE 2012 5,8%

“It can spread to adjacent (20 years)
teeth”

Tsesis et al. 2013

“We do not know when will
it get painful but it will, so Kirkevang et al. 2017
why take the chance ?”

35 36

6
 4/22/2021

•The lesion may expand and damage

surrounding structures

37 38

Paresthesia of the mental nerve after an acute

exacerbation of chronic apical periodontitis.
Gilbert & Dickerson 1981 JADA

Apical infection spreading to adjacent teeth: a

case report. Kombayashi et al. 2011 OOOOE

39 40

•The lesion may affect general health

Risk of severe events, requiring hospitalization
because of a root filled tooth with AP is extremely
small and is estimasted to be around 1:200,000
Still no final conclusion can be made.
Hospital-based Emergency Department
Visits with Periapical Abscess: Updated
Estimates from 7 Years.

Rampa et al. 2019 JOE

41 42

7
 4/22/2021

•The lesion is there many years

•The treatment is burdensome, costly,limited effective and
•The lesion is there many years
may induce pain
•The tooth will be weakened

Periapical changes following root-canal treatment

observed 20-27 years postoperatively.

“Late periapical changes, with more successes than failures, were

recorded when a 10-17-year follow-up period after root-canal treatment
was extended for another 10 years.”
Molven et al. 2002 IEJ

43 44

•The treatment is burdensome,

costly,limited effective and may Treatment may induce pain

induce pain
20- 50% of the patients experience some pain after
endodontic treatment 3-5% is severe

Genet et al. 1987 IEJ

45 46

•The tooth will be weakened

Influence of Irrigation Sequence on the
Adhesion of Root Canal Sealers to Dentin: A
Contribution of Root Canal Fourier Transform Infrared Spectroscopy
Treatment to the Fracture and Push-out Bond Strength Analysis.
Resistance of Dentin Neelakantan et al. 2015 JOE

There is a decrease in the strength Fracture Strength of Endodontically

of radicular dentin with aging, but Treated Teeth with Different Access Cavity
prior root canal treatment increases Designs.
the extent of degradation. Plotino et al. 2017 JOE
Yan et al. 2019 JOE

47 48

8
 4/22/2021

Uncontrolled Removal of Dentin during In Vitro Diagnosis: Asymptomatic apical periodontitis

Ultrasonic Irrigant Activation in Curved Root
Canals.
Retsas et al. 2016 JOE

Uncontrolled Removal of Dentin during In Vitro

Ultrasonic Irrigant Activation.
Boutsioukis & Tzimpoulas al. 2016 JOE

49 50

•The lesion may flare up

•The lesion is there many years
•The lesion may expand and
•The treatment is burdensome,
damage surrounding structures
costly,limited effective and may
•The lesion may affect general
induce pain
health
•The tooth will be weakened

51 52

Returning to our patient… The decision of the patient

53 54

9
 4/22/2021

The decision of treating or not treating

asymptomatic apical periodontitis is an opinion
rather than evidence based
Patient-centered outcome: Disease-centered outcome:
Quality of Life Healing of the periapical
Costs/ pain lesion
Functionality

55 56

• Hopefully, we can soon agree on a set of

criteria for a clinical decision, until more
evidence becomes available

Keinan et al. 2011 JADA

57 58

Adapted from Keinan et al. 2011 Asymptomatic endodontically treated tooth

+ Quality of the RCT -

A few additional points that emerge from the
+ Coronal restoration
-
Periapical lesion
previous discussion…
Periapical lesion

- + - + Older
radiograph

Lesion shrank Lesion grew 1. Outcome ↔ innovation

Temporary restoration and
follow up (6 months) 2. Individually designed treatments
Lesion shrank Lesion grew
3. Prevention
Final restoration Retreatment/ surgery

59 60

10
 4/22/2021

Technical innovations • The most

extensively studied
- Operating microscope • Surge of
- Irrigation enthusiasm in the
- Instrumentation early ‘2000s
- Obturation : materials and methods
- 3D imaging
- .....wireless
Example : ultrasonic irrigation
- .....Digital

61 62

A few emerging concepts…

…no strong clinical
recommendations could be formulated.
Căpută PE et al. 2019 JOE - Individually designed treatments
- Preventive endodontology
…there was no evidence of effective improvement
on periapical healing …that supports the use of
ultrasonic irrigation…
Silva EJNL et al. 2019 Br Dent J

63 64

The partial retreatment The partial retreatment

• When we preform apical
micro-surgery we only treat
the “ involved” root. Why then
can't we do that with
orthograde retreatment?

65 66

11
 4/22/2021

The partial retreatment

Hend Sabri

67 68

The partial retreatment

• João Martins Brochado & Olavo Guerreiro Viegas –

2012
Case series/ outcome study 2009 2015

João Martins Brochado & Olavo Guerreiro Viegas 2019

69 70

Patient-centered Disease-
outcome: centered However…
Quality of Life outcome:
Healing of the
There is a difference between
Costs/ pain
Functionality periapical lesion initial apical periodontitis and post-
treatment lesion

1. Bacterial infection is different

2. Healing in scar/ partial healing…
Quality of life and satisfaction outcomes of endodontic treatment. Dugas
NN, Lawrence HP, Teplitsky P, Friedman S.
Dugas et al. 2002 JOE

71 72

12

A few emerging concepts…
- Individually designed treatments
- Preventive endodontology
73
Although endodontic retreatment/
surgery is mostly a predictable and
successful option, risk assessment of
possible complications and predicting
factors for success should be
considered first.
75
3 PhD projects from ACTA to pay attention to…
Davide Musu Pradeep Kumar
77
4/22/2021
Apical periodontitis is an inflammation
process resulting from an infection.
Ideally, we would like to eliminate it
However, since our capacity is limited,
and from financial reasons, the
possibility of monitoring a post-
treatment asymptomatic lesion should
be considered together with the patient
as a viable option, along with other
relevant options
74
- Try to fit the treatment to the patient
and not the other way around
- Innovations do not necessarily lead to
better outcome
- Prevention of root canal treatment is
the future of endodontics rather than
technical innovations…
76
Shlomo Elbahary ACTA=Academisch Centrum voor Tandheelkunde Amsterdam
78
13