disease prognosis
TRANSCRIPT
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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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Reasons for Extraction
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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Reasons for Extraction
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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Loss of Endodontically TreatedTeeth
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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Loss of Endodontically TreatedTeeth
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
AP % of at risk General risk* Risk for RF teeth* Risk for noRF teeth*
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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
AP % of at risk General risk* Risk for RF teeth* Risk for noRF teeth*
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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