History of Endodontics aae/abe



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External Inflammatory Root Resorption:

  1. Tronstad 1988– Trauma to external root surface denudes areas of precementum/cementoblasts  chemotactic for hard tissue resorbing cells (osteoclasts/odontoclasts), Pulpal infection sustains clastic cells

  2. Trope 2002 – Review Root Resorption – Pulp space infection – Bacterial TEBs pass through dentinal tubules and stimulate/prolong inflammatory response in the PDL – Multinucleated giant cells resorb until the stimulus is removed

  3. Andreasen 1995 – Ext. inflammatory resorption diagnosed w/in 1st 6 months


Replacement Resorption (Repair-related):

  1. Andreasen 1975>20% root surface damage = progressive replacement resorption

  2. Lindskog/Hammarstrom 1985 – Necrotic PDL  Ankylosis between bone and cementum due to repair confusion (osteoblasts vs. cementoblasts). 2 Types: Ankylosis w/o root resorption (cementum-bone) & Ankylosis following inflamm. root resorption (dentin-bone)


What is the role of CaOH2 in replanted teeth?

Andreasen 1981 JOE, Dent Trauma 2002

  1. CaOH2 used too soon may diffuse through apex, damage PDL/cementoblasts, and prevent repair. Should be used after initial PDL healing (7 days) has progressed.

  2. Long term CaOH2 weakens dentin, >30 days (Andreasen; Rosenberg)


Gregoriou/Jeansonne 1994 EDT – Dog study; Immed. pulpectomy/CaOH2:  replacement resorption vs delayed 18 days; Delayed 4-18 days: NSD in resorption (surface, inflamm, replacement) – Supports waiting 7-10 days
Trope 1995 EDT – Long term (12 wk) CaOH2 for established inflam root resorption or RCT started >10 days post avulsion is better than short term (1 wk) treatment.
Tronstad – CaOH2 upregulates alkaline phosphatase,  pH - inhibits collagenases, promotes hard tissue repair/formation

What is the role of fluoride?


  1. Shulman 1973 J Dent Res – Demonstrated decreased resorption of avulsed teeth using sodium fluoride.




  1. Bjorvatn/Klinge 1989 Dog study, Soaking in 1% SnF2 (45 mins) will decrease surface, inflammatory and replacement resorption




  1. Coccia 1980 JOE – Human study, Treatment of the root with 2% NaF (5 mins) before replanting makes it osteoclast resistant (fluroapatite), delaying replacement resorption. Twice the survival time can be expected.


Would you recommend systemic antibiotics after replantation?

Antibiotic Recommendations:



  1. Doxycycline 500mg q6h x 7 days ( > 12 yrs)

    1. Static, acts on ribosomes (30s rRNA)

    2. Avoid if <12 years old or pregnant

  2. Pen VK 500 mg q6h x 7 days (< 12 yrs or Pregnant)

    1. Use only if tetracycline is contraindicated


Sae-Lim/Trope 1998 EDT – Dog studies, Avulsion/replantation 1hr, compared Amox vs. Tetracycline vs. placebo to inhibit inflammatory or replacement resorption. Findings: Tetracycline has anti-resorptive properties in addition to the antibacterial properties. It inhibits Osteoclasts and Collagenase. It could be considered as an alternative to Amoxicillin after avulsion injuries.
Hammarstrom/Blomlof 1986 EDT – Use systemic antibiotic (amox) immediately after replantation to reduce inflammatory resorption. No effect seen on replacement resorption.

IADT/AAE 2014 Guidelines: Recall Schedule
Enamel-Dentin Fracture (Uncomplicated): 6-8 weeks, 1 year

Enamel-Dentin-Pulp (Complicated) Fracture: 6-8 weeks, 1 year

Horizontal Root Fracture (middle/apical 1/3rd): 4 weeks, 6-8 weeks, 4 months, 6 months, 1-5 years

Horizontal Root Fracture (cervical 1/3rd): 4 weeks, 6-8 weeks, 4 months, 6 months, 1-5 years


Concussion: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1 year – 5 years

Subluxation: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1 year – 5 years

Extrusive Luxation: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1-5 years

Lateral Luxation: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1-5 years

Intrusive Luxation: 2 weeks, 4 weeks, 6-8 weeks, 6 months, 1-5 years
Avulsions: 7-10 days (closed apex, NSRCT), 2 weeks, 4 weeks, 3 months, 6 months, 1 year, yearly to 5 years (Monitor growth: ht/wt – infrapositioning)

Pulp Testing Post Truama (Bhaskar – inaccurate tests!)

LDF: Infared light, Doppler scatter of moving RBCs, Pulpal Blood Flow



  1. Yanpisett/Trope - dog study, avulsion/reimplantation - detect return of pulpal blood flow by 4 wks

  2. Gazelius – case report, Lateral luxation 4 lower anterior incisors – detected blood flow 6 wks (partially), 9 mos (complete)

Pulse Oximeter: Red/Infared light, selective absorption by oxygenated/deoxygenated Hemoglobin, non-absorbed light = Oxy Sat.



  1. Gopikrishna –Pulse Ox signficantly improved ability to detect pulp vitality (intact vascular supply) day 0 – 1 month in comparision with EPT and Cold tests for recently traumatized teeth (concussions/subluxation only)

  2. Setzer – Pulse Ox able to differentiate mean pulpal oxygen saturation levels for pulpal conditions (ie: normal vs. reversible vs. irreversible vs. necrotic)

EPT:


  1. Pileggi – Ferrets, Concussion, 10 days return of EPT response

Decoronation

Technique: Removal of crown and submergence of root, removal of obturating materials (if present), induction of blood clot, reposition flap over socket

Indications: Replacement Resorption/Ankylosis of erupting tooth; Post Trauma; Infrapositioning >1mm

Timing: Pre-growth phase, during growth phase


  1. Malmgren/Cvek 1984 – Prospective Case Series, 1st Study on Decoronation. 24 reimplanted Maxillary incisors, ages 11-19, clincial/radiographic signs of ankylosis and infrapositioning – decoronated and followed for up to 18 months. Findings: continued growth of alveolar bone and replacement resorption




  1. Filippi/VonArx 2001 – Case report, 12 yr old, avulsion of C.I., ankylosis/replacement resorption. Decoronation resulted in preservation of alveolar ridge with 1 mm vertical bone apposition over top of the decoronated root and continued replacement resorption


Success-Failure

When should you recall a patient?


  1. Reit 1987 EDT – Recall after 1 years and annually for min of 4 years




  1. Andreasen 1972 Int J Oral Surg – Recall after 1 year and continue recall for 4 years. Wait 4 years before considering uncertain and incomplete cases a failure.




  1. Orstavik 1996 IEJ – This study recommends follow-up at 1 year. Peak incidence of healing or emerging persistent apical periodontitis occurred at 1 year. 88% showed signs of healing at 1 year. Complete healing of preoperative AP in some instances required 4 years for completion.




  1. Seltzer/Bender 1966 – Evaluation of success should occur after 6 months – 2 years. May take up to 2 years for radiographic healing or signs of persistent disease to present clinically or radiographically


Outcome Studies

Initial treatment – NSRCT (83-89%)

* = # of studies meeting inclusion criteria for meta-analysis (strict/loose criteria)



Author

% Healed

Cases

Follow-up

Date

Strindberg

87

529

4 years

1956

Seltzer

80

2921

0.5 years

1963

Grossman

86

432

1-5 years

1964

Ingle

92

1229

2 years

1965

Sjogren

91

356

8-10 years

1990

Fristad/Molven

88

265

20-27 years

2002

Salehrabi/Rotstein (surv.)

97

1.46 mil

8 years

2004

Imura

94

1376

0.5 years

2004

*Ng (sys review/meta)

75/85

*61

6 month

2007

de Chevigny (Toronto)

86/95

510

4-6 years

2008

Ng (prospective)

83/89

702

2 years

2011

Ng: Strict = no signs/symptoms, no PARL/normal PDL, Loose = no signs/symptoms/reduc. of PARL

Outcome Studies

Retreatment (80-86%)

* = # of studies meeting inclusion criteria for meta-analysis (strict/loose criteria)



Author

% Healed

Cases

Follow-up

Date

Allen/Newton

84

667

0.5 years

1989

Allen/Newton (2nd Retx)

47

41

0.5 years

1989

Sundqvist

74

54

5 years

1998

Imura

86

624

0.5 years

2007

de Chevigny (Toronto)

82/94

229

4-6 years

2008

*Ng (sys review/meta)

76/77

*17

0.5 years

2008

Torabinejad (sys. review)

71, 83

1253

2-4, 4-6 years

2009

Ng (prospective)

80/86

750

2 years

2011

Ng: Strict = no signs/symptoms, no PARL/normal PDL, Loose = no signs/symptoms/reduc. of PARL

Outcome Studies

Surgical Root Canal Treatment (88-94%)

Author

% Healed

Cases

Follow-up

Date

Rubinstein/Kim

92

59 roots

5-7 years

2002

Tsesis (sys review/meta)

92

*11

1 year

2009

Barone (Toronto)

74/94

134

4-6 years

2010

Setzer (TRS vs EMS)

Sys. review/Meta-analysis

59; 94

925; 699

0.5 years

2010

Setzer (CRS vs EMS)

Sys. review/Meta-analysis

88; 94

610; 699

1 year

2012

Song/Kim (prospective)

93

104

6-10 years

2012

Song (ReSx)

92

42

1 year

2011

Song (prospective)

88

115

4 years

2013

Tsesis (sys review/meta)

89

*18

1 year

2013

Toronto Study – Outcome Predictors

de Chevigny/Friedman 2008 – Initial NSRCT

Phase 4: 4-6 year prospective outcome studies (cohort)

Teeth: 510, Healed = PAI  2, No symptoms or clinical signs other than Perc +

Healed: 439/510 (86%)

Functional: 479/506 (95%) No signs/symptoms, PAI not considered

Pre-operative Outcome Predictors (Overall):


  1. Presence of RL: Absent 93%, Present 82%

  2. Number of Roots: Single 93%, Multiple 84%

Pre-operative Outcome Predictors (Teeth w/AP):

  1. Intraoperative complications: Absent 84%, Present 69%

  2. Root filling technique: Vertical 87%, Lateral 77%


Ingle (classic) 1965 - #1 Cause of Failure NSRCT = Incomplete obturation

VonArx - 1 year follow up, pts who had pain at initial exam had  healing rate

Ng 2007PARL, Level of Obturation (Flush (0-2 mm short) > Short > Long), Quality of Obturation, Quality of Coronal Restoration

Ng Study – Outcome Predictors

Ng 2011NSRCT & Retreatment, Prospective Clinical Study (cohort)

Recall period:  2 years, Teeth: NSRCT 702 teeth, Retx 750 teeth

Success: Strict = No signs/symptoms/No PARL, Loose = No signs/symptoms/ PARL

Strict Criteria: NSRCT 83%, Retx 80%

Loose Criteria: NSRCT 89%, Retx 86%

Pre-operative Outcome Predictors:


  1. Presence of PARL

  2. Size of PARL: < 5mm or  5 mm

  3. Presence of Sinus Tract

  4. Presence of Perforation

Intra-operative Outcome Predictors:

  1. Apical Patency: Maintenance of Patency  Success

  2. Level of Obturation: Overextended  Success, Short of terminus  Success

  3. Use of 0.2% CHX  Success, Use of 17% EDTA  Success (RETX only)

  4. Interappt Flare up:  Success

Post-operative Outcome Predictors:

  1. Quality of Coronal Restoration

Toronto Study – Outcomes

de Chevigny/Friedman 2008 – Orthograde Retreatment

Phase 3/4: 4-6 year prospective outcome studies (cohort)

Teeth: 229

Healed: 187/229 (82%)

Functional: 207/221 (94%)

Pre-operative Outcome Predictors (Overall):


  1. Root filling quality (voids, length of fill): Inadequate 88%, Adequate 66%

  2. Perforation: Absent 87%, Present 56%

  3. Presence of RL: Absent 93%, Present 80%

Pre-operative Outcome Predictors (Teeth w/AP):

  1. # Treatment sessions: One 100%, Two + 77%

  2. Root filling quality: Inadequate 86%, Adequate 50%


Imura 2007 – Outcome predictor for Retx: Pre-op AP

Ng 2008 – Outcome predictors for Retx: Pre-op PARL, Apical extent of root canal filling, and Quality of Coronal Restoration

Toronto Study – Outcomes

Barone/Friedman 2010 – Apical Surgery

Phase 3-5: 4-10 year prospective outcome studies (cohort)

Teeth: 134

Healed: 99/134 (74%)

Functional: 126/134 (94%)

Pre-operative Outcome Predictors (Overall):


  1. Age: > 45 y.o. 84%,  45 y.o. 68%

  2. Pre-operative Root filling length: Inadequate 84%, Adequate 68%

  3. Size of Surgical Crypt:  10 mm 80%, > 10 mm 53%

Pre-operative Outcome Predictors (Teeth w/AP):

None


Song – 3 mm collar of bone success

Von Arx 2010 – Prognostic factors: MTA vs. superEBA – 86% vs. 57%

Zuolo – Apical surgery 10% Higher Healing Rate w/ Retx prior to Sx

Tsesis 2013 – Progn. Factors: Use of Microscope, MTA Retrofill (vs. EBA/IRM)

Comparison Outcome Studies

Retx vs. Endodontic Surgery:


  1. Torabinejad 2009 – Systematic Review of Retx (1998-2009) vs. Endodontic Surgery (1970-2008) Outcomes using Rud’s classification system: Late Healing RETX, Late Failures Surgery

    1. 2-4 years: Endodontic Surgery: 78%, Retreatment: 71%

    2. 4-6 years: Retreatment: 83%, Endodontic Surgery: 71%




  1. Kvist/Reit 1999 – Retx vs. Endodontic Surgery. 95 endodontic failed cases. Max centrals/canines. Random assignment. Endo surgery = resection, hedstrom gp removal apically or round bur retroprep, heated gp retrofill. Recall 1-4 years. Clinical/radiographic evaluation at recall:

    1. 1 year: Endodontic Surgery > Retx

    2. 4 years: Endodontic Surgery = Retx


*Both studies suggest “long term failures” in surgery cases, follow up > 4 yrs!

Comparison Outcome Studies

Traditional vs. Endodontic Microsurgery:

  1. Setzer 2012Systematic Review of EMS vs. CRS (Contemporary Root end surgery – loupes/no magnification), EMS n = 699, CRS n = 610. EMS = 94%, CRS = 88%. Success based upon Rud or Molven’s classifications (radiographic/clinical healing) – Complete, Incomplete (scar), Uncertain (/same size RL), Unsatisfactory healing ( size RL)




  1. Setzer 2010Systematic Review of EMS vs. TRS (Traditional Root end surgery), EMS n = 699, TRS = 925. EMS = 94%, TRS = 59%. EMS 1.58 x more successful than TRS. Success based upon Rud or Molven’s classifications for surgery (radiographic/clinical healing).

EMS = microsurgical techniques, ultrasonic root end prep, IRM/SuperEBA/MTA retrofill, microscope (10X or greater)

CRS = same as EMS but with only loupes or no magnification (0-4X)

TRS = Bur for root end prep, amalgam retrofill, loupes or no magnification (0-4X)



What are some reasons for failure of non-surgical treatment?

The most common cause is previous treatment falls short of accepted standards:



POOR PAST AM = Perforation, Obturation, Overfill, Root canal missed Perio disease, Another tooth, Split tooth, Trauma, Anatomy complexities, Microleakage

When treatment is consistent with high standards, failure may occur due to:

Intraradicular infection:

  1. Lin 1992 JOE – major factors associated with endodontic failures are persistence of bacterial infection in the canal space and the presence of preoperative periradicular rarefaction.

  2. Nair 1990 JOE – In the majority of root-filled human teeth with therapy resistant periapical lesions, intraradicular microorganisms may persist and may play a role in treatment failures.

  3. Fabricius 2006 (see also Sjogren 94% vs. 68%) – Monkey study, Bacteria surviving NSRCT significantly inc failure (72% vs. 21%)

  4. Ricucci/Siqueira 2012Intraradicular biofilms responsible for AP, CAGE – Cysts: 95%, Abscess: 83%, Granuloma: 70%, Extraradicular: 6%. Most extra-radicular infections are planktonic and AAA cases.

What are some reasons for failure of non-surgical treatment?

Extraradicular Infections: Actinomyces Israelii (Actinomycosis), Propionibacterium propionicum


  1. Sjogren, Sundqvist et al 1988 IEJPropionibacterium propionicum may be implicated in Extraradicular infection

  2. Nair 1984 JOEActinomyces israelii is able to establish Extraradicular infection

  3. Sjogren, Sundqvist & Nair 1992 OMI – The pathogenicity of A. israelii is due to its ability to establish cohesive colonies of branching filamentous organisms that are enmeshed in an extracellular matrix. It seems that the organisms existing in such colonies can evade destruction and elimination by the host phagocytic cells.

  4. Sunde/Tronstad JOE 2002- Microbiota of Periapical lesions refractory to endodontic therapy: AAP or CAA cases – Sampling of Periapical lesion during surgery. 35/36 positive for extraradicular infection. 51% Anaerobes, 79% Gram +, 148 microbial strains, Avg. 4.1 strains/case

What are some reasons for failure of non-surgical treatment?

Foreign body reactions: chronic inflammatory periapical tissue reaction due to extruded root canal filling materials or food debris (ie: cellulose)

  1. Nair 1990 JOEIn the absence of microbial factors, root filling materials which contain irritating substances can evoke a foreign body reaction at the periapex, leading to the development of aymptomatic periapical lesions.

  2. Simon 1982 JOEOpen teeth can trap food particles (ie leguminous seeds “pulses”) which may travel through the tooth into the periradicular space and induce a “pulse” granuloma. The cellulose component of the seeds is the causative component.

  3. Koppang et al 1992 J Dent Asso S Afr. – Identification of common foreign material in granulomas:

    1. Black/brown fragments – amalgam

    2. Fine black/brown/yellow – sealer

    3. Basophilic fragments – CaOH2

    4. Elongated/rounded/oval/kidney-shaped, colorless – cellulose

  4. Koppang 1978 Scan J Dent ResEndodontic paper points material has been found as an etiologic factor in periapical inflammatory processes.

What are some reasons for failure of non-surgical treatment?

Apical Cysts (true cysts)

  1. Nair 1996 – Histologic examination of apical lesions were identified proportionally to be:

    1. 50% granulomas, 35% abscess

    2. 15% cysts

      1. 61% - true cysts (9%)

      2. 39% - pockets cysts (6%)

  1. Spattafore – 52% granulomas, 42% cysts, 2% scar

  2. Koivisto – 40% granulomas, 33% cysts, 20% other (KCAM)


Cholesterol Crystals

  1. Nair, Sjogren & Sundqvist 1993 IEJ – The accumulation of tissue break-down products such as cholesterol crystals, and the condition of the lesion itself, can adversely affect the healing process of the periapex following root canal therapy. Consequently, such apical lesions can remain refractory to conventional endodontic therapy for long periods of time.

Do Periapical Cysts heal?
YES


  1. Lin/Ricucci/Rosenberg 2009 – Apical cysts can heal regardless of true vs. pocket cyst. Apoptosis following removal of source of inflammation (bacteria) within canal.




  1. Caliskan 2004 – Healing of large cyst-like lesions (7-18 mm diameter). Size of lesion is not major determining factor in NSRCT vs. EMS (opposes Ng)


MAYBE


  1. Nair 1998 - Pocket cysts may heal after NSRCT, True cysts are less likely to heal without surgical intervention




  1. Natkin 1984 – Apical cysts are less likely to heal with NSRCT alone

Does the presence of a radiolucency affect the prognosis?
YES


  1. deChevigny/Friedman – The presence of apical periodontitis decreases the success by 10-25%




  1. Other studies finding a decreased success with radiolucencies:

  1. Strindberg

  2. Seltzer

  3. Sjogren

  4. Lin

  5. Molven

  6. Ng


Does a negative culture at the time of filling give better prognosis?

YES

  1. Sjogren, Sundqvist 1997 IEJHuman study, 5 years post op. Healed (cultured at time of filling): Negative culture: 94%, Positive culture: 68%. Success appears dependent on eliminating bacteria from the root canal prior to obturation. CaOH2 to eradicate infection – 2 stages




  1. Fabricius/Moller 2006Monkey study, innoculated canals with combinations of bacterial species; 2.5 yr recall, Healed (cultured at time of filling): Negative culture: 72%, Positive culture: 21%; Bacterial combinations – more common than single species




  1. Molander/Kvist 2007 JOE – Human study, PN/AAP, 2 year recall. No difference in 1 vs. 2 visit (65% vs. 75%). Healed: Neg culture: 80%, Pos. culture: 44%.


Does a negative culture at the time of filling give a better prognosis?
NO


  1. Peters/Wesselink 2002 IEJ – Complete radiographic healing was observed in 81% of the cases treated in one visit vs 71% for those treated in two visits. (NSD in study) In addition no statistical difference was found whether cultivatable bacteria were present or not present prior to obturation (opposes Sjogren and Fabricius/Moller)




  1. Stromberg 1987 EDT – Healing occurs in apical periodontitis even if bacteria are present in the canal during obturation.



Does a negative culture at the time of filling give a better prognosis?
NO

  1. Matsumoto 1987 JOE – Multiple factors usually involve in failure, NSD noted between positive and negative cultures. Risk factors observed for treatment failure included:

    1. Periradicular radiolucency

    2. Overextension – greatest inflammatory response

    3. Deep perio pockets

    4. Occlusal trauma

    5. No adjacent teeth present




  1. Seltzer 1964 OOO – This sudy compared obturation of teeth with positive and negative cultures. NSD was detected histologically. Greatest inflammatory response was seen in overfilled canals.


Does the level of root canal filling affect success?

YES

  1. Sjogren 1990 JOE – Relationship between level of fill and success

    1. Underfill >2mm – 68% success (least successful)

    2. 0-2mm from apex – 94% success

    3. Overfilled – 76% success




  1. SchaefferMeta-Analysis (level of obturation): Success – 0-1 mm short of RA (A) > 1-3 mm short of RA (B) >> overextended past RA (C). Overall success: Group A 2.7% > B and 26.2% > C




  1. Wu/Wesselink/Walton – Termination of instrumentation/obturation: Vital cases: 2-3 mm from Apex (vital apical stump), Necrotic cases: 0-2 mm from apex (elimination of apical infection)




  1. Seltzer/Bender 1963 JADA – An overextended fill decreases success but underfilling had no influence.

Does the level of root canal filling affect success?

YES (Cont.)

  1. Ng 2007 – Level of filling affected success , Overall Long  success; w/o PARL: Short = Flush (0-2 mm) > Long, w/PARL: Flush > Short = Long




  1. Fristad/Molven 2002 IEJ – Extruded material delayed healing, late periapical changes can occur more than 10 years after treatment.




  1. Ricucci/Langeland 1998 IEJ – Apical Limit of Root canal instrumentation/obturation should be the AC. Worst prognosis with I/O beyond the AC as this causes injury/larger tissue wound and introduces foreign bodies (ie: sealer, gp) into the periapical tissues.

NO

  1. Lin 1992 JOE – The apical extent of the root canal filling, ie underfilled, flush-filled or overfilled, seems to have no correlation to treatment failures.

Is one visit NSRCT more successful than two visit NSRCT?
YES

  1. Ashkenaz 1984 DCNA – Review article: findings

    1. No increase in post op pain in single visit treatment

    2. High level of success w/ single visit treatment

    3. Eliminates inter-appt. contamination potential (leakage)

    4. Disadvantage – emergency drainage complicated by filling



NO DIFFERENCE


  1. Ng 2007 – No significant differnce in odds of success between 1 and 2 visit NSRCT (1 visit = more post obturation pain)

Problem: Inaccuracies w/culturing intratubular bacteria – false neg cultures



Is one visit NSRCT more successful than two visit NSRCT?
NO DIFFERENCE (Cont.)

  1. Kvist 2004 JOE –microbio prospective, 2 visit no better than 1 visit

  2. Weiger 2001 - Prospective clinical trial, NSD in 1 vs. 2 (CaOH2), PN/AP

  3. Penesis 2008 - Randomized clinical trial, 12 month f/u, Pulpal necrosis/PARL present, NSD in 1 vs. 2 (CaOH2/CHX paste)

  4. Figini 2008Cochrane Review – PN/AP, No difference in success (radiographic) of 1 vs. 2, 1 appt – more pain/swelling (see also Ng)

  5. Su/Wang/Ye 2011Sys. Review/Meta-Analysis – PN/AP, No difference in healing rate in 1 vs. 2 visit. Less short term pain in 1 visit.

  6. Peters/Wesselink 2002 – Necrotic/PARLs: 1 visit (18), 2 visit w/ culturing (21), 4.5 yr recall: 1 visit 81%, 2 visits 71% (NSD); 88% w/ positive culture @obturation healed. Conclusions:

    1. NSD between 1 visit and 2 visit (w/CaOH2) for PARL healing

    2. Positive culture did NOT decrease success (refutes Sjogren, Fabricius)

Does 2 visit treatment with CaOH2 increase the chances of healing?

YES (goal is maximal microbial elimination from the canal system)

  • Law 2004 – CaOH2 (>7 days) is essential to help  microbial load for healing




  1. Sjogren 1997 IEJ – Influence of infection on healing (1 visit): 94% with negative culture, 68% with positive culture at time of root filling. Use intracanal medicament (2 visits) to maximize bacterial reduction.




  1. Trope/Orstavik 1999 JOE – Compared healing of PN/AP 1 vs. 2 visits w/ CaOH2 as intracanal medicament. CaOH2  the rate of healing by 10% (74% vs. 64%), Not stat. significant but clinically important.




  1. Siqueira; Nair – Instrumentation/Irrigation protocols are not effective at reaching bacterial biofilms in anatomical complexities (dentinal tubules, apical ramifications, accessory canals); CaOH2 necessary to reach these complexities and kill bacteria that may prevent healing of AP

Does 2 visit treatment with CaOH2 increase the chances of healing?

YES (goal is maximal microbial elimination from the canal system)

  1. Vera/Siqueira 2012 JOE:

    1. In vivo, Mandibular Molars, Mesial roots, Histobacteriological study

    2. Compared 1 visit vs. 2 visit w/ CaOH2 (1 wk) for bacterial status

    3. Bacterial counts (improved histobacter. status) in main canal, isthmuses, dentinal tubules, apical ramifications (DIALs)

    4. Current instrumentation/irrigation can NOT predictably (100%) disinfect the root canal system (Anatomical complexities & Biofilms) Rocas/Siqueira, Shupping/Trope, Bystrom/Sundqvist, Nair

    5. Entombed bacteria” by GP/Sealer (ARs, Lateral canals) can derive nutrients from PDL or tissue remnants  persistent AP/non-healing

    6. 2 visit w/ medicament necessary to maximize bacterial reducation ( microbial load for periapical healing) before obturation




  1. Xavier/Martinho/Oliveria 2013 JOE – 2 visit w/CaOH2 was more effective at bacterial endotoxins (LPS) (98% vs. 86%)

Does 2 visit treatment with CaOH2 increase the chances of healing?

NO (goal is to eliminate some bacteria and entomb remaining by gp/sealer)


  1. Weiger 2000 IEJ – This study had comparable success results with both single and multivisit treatment (CaOH2) of necrotic teeth w/AP. (93% multi vs 92% single)

  2. Penesis 2008 - Randomized clinical trial, Pulpal necrosis/PARL present, NSD in 1 vs. 2 visit (CaOH2/CHX paste)

  3. Figini 2008 – Cochrane Review – 2 visit with CaOH2 did not increase the success of NSRCT compared with 1 visit treatment in PN/AP cases

  4. Peters/Wesselink 2002 – Necrotic/PARLs: 1 visit (18), 2 visit w/ culturing (21), 4.5 yr recall: 1 visit 81%, 2 visits 71% (NSD); 88% w/ positive culture @obturation healed. Conclusions:

    1. NSD between 1 visit and 2 visit (w/CaOH2) for PARL healing

    2. Positive culture did NOT decrease success (refutes Sjogren, Fabricius)

Compare post operative pain / flare-ups between 1 & 2 visit Tx.


  1. Trope 1991 IEJ – Evaluation of specific preop conditions w/ flare-ups

    1. Single visit w/out AP – no flare-ups

    2. Single visit w/ AP – 1.4% flare-ups

    3. Single visit ReTx w/ AP – 13.6% flare-up– statistically the highest risk factor in the study




  1. Eleazer/Eleazer 1998 JOE – Flare-ups: 1 visit: 3%, 2 visits: 8%




  1. Ng1 visit = More post-obturation pain (along with molars, females, post instrumentation pain and/or swelling)




  1. Figini – Cochrane Review – PN/AP, 1 visit > 2 visit for post-op pain/swelling




  1. Su/Wang/Ye 2011Systematic Review/Meta-Analysis - Infected teeth, NSRCT: Post-op pain: 2 visits > 1 visit


How often does the absence of a radiolucency correspond with histological success ? (BW)


  1. Brynolf 1967 Odontol Revy – Histologic and radiographic exam indicated complete healing following NSRCT only 7%. 93% had inflammation despite no radiolucency.




  1. Walton 1997 OOO – Histologic and radiographic exam revealed 26% of specimens without radiolucencies had inflammation and 74% had complete healing. This study disputes Brynolf’s findings !!!


Does Orthodontic movement affect the healing of PA lesions?


  1. deSouza 2006 – dog study - Ortho movement (5 months) delayed but did not prevent PA healing in comparison to NSRCT (2 stage) teeth without ortho movement

How long does it take to heal?


  1. Murphy 1991 – Retrospective study, Resolution of AP can occur as early as 3 months, average rate is 3.2 mm2/month. 70% of lesions needed > 12 months for healing.




  1. Bystrom, Sjogren, Sundqvist et al. 1987 EDT – Failure of apical healing may be due to bacteria outside the canal. Most lesions heal within 2 years, some take as long as 4-5years before bone regeneration is completed.




  1. Orstavik 1996 – Prospective study, Peak incidence of healing or emerging chronic apical periodontitis (PAI  3) occurred at 1 year. 88% showed signs of healing by 1 year. 76% showed signs of disease by 1 year. Complete healing of preoperative AP in some instances required 4 years for completion.




  1. Strindberg; Reit – up to 4 years for resolution of PARL


What factors attect successful healing of a perforation ?


  1. Fuss/Trope – Time, Size, Location. Time – immediate repair  success (Seltzer 1970), SizeSmaller the perf,  success = sealing perf, Location - #1 factor – Critical zone – level of crestal bone/epi/ct att. –bacterial contamination/epithelial downgrowth/sulcular commun.




  1. Jew 1982 OOO – Prognosis depends on time lapse since perforation, location relative to attachment, size and sealability of repair material. Best prognosis: apical or middle thirds. Contamination leads to failure.




  1. Krupp/Hulsman JOE 2013 – Retrospective, MTA perf repair (90 Root perfs), Success: 73% healed at 1 year. 2 Prognostic Variables: 1) Pre-op RL w/ defect, 2) Sulcular commun. w/ defect (100% Failure)




  1. Mente JOE 2010 - Retrospective, MTA root perf repair (Furcal, Crestal, Mid root, Apical root): Success: 18/21 (86%) healed at 1 year.

Why do Retreatment instead of Apical Surgery?
Better success will occur with Retx due to the ability to determine and eliminate the etiology (missed canal, coronal leakage, incompletely debrided canal system, poor quality obturation – density/length…)


  1. Nair, Sjogren, Sundqvist 1990 JOE – In the majority of root-filled human teeth with therapy-resistant periapical lesions, microorganisms may persist in the canal and may play a role in treatment failures.




  1. Briggs 1997 Br Dent J – Conventional ReTx is most appropriate first, providing access to the root canal is possible.




  1. Trope 1998 OOO – Surgery should not be considered the primary treatment when root canal treatment or retx may be readily achieved.




  1. Lovdahl 1992 DCNA – Conservative retx should be given priority over surgery in treatment planning.

Why do Retreatment instead of Apical Surgery?


  1. Allen/Newton/Brown 1989 JOE – Retrospective study of 1200 cases:

    1. Overall success for retx 65.6%

    2. Surgical retx – 60%

    3. NS Retx – 73%

    4. ReTx of prior ReTx – 47%

Take home message – Try retx first but if unsuccessful next step is surgery.


  1. Torabinejad – Early failures Retx, Late failures Sx




  1. Zuolo10% greater success of Apical surgery when retreatment completed prior to surgery




  1. Riccuci/SiqueiraIntraradicular biofilms responsible for AP (NSRCT/RETX cases): CAGE – 6% Extraradicular biofilms. Retx over Sx to treat etiology if possible


Does a separated instrument affect prognosis?
Depends on when during treatment it occurs, location of separation, status of pulp and periapex.


  1. Crump/Natkin 1970 JADA – No statistical difference between cases with separated instruments (81%) and control cases w/out separated instruments (73%)




  1. Strindberg 1956 AOS – Separated instruments decreased success by 14%




  1. Spilli 3% incidence, NSD in cases with separated instruments or without, only PARL made significant difference




  1. PantivisaiSystematic Review/Meta-analysis, presence of separated instrument does Not affect success, PARL does affect success based on outcome studies available

Implant vs. NSRCT


  1. Doyle 2006 – Retrospective outcome study. Single tooth implant vs. NSRCT/restoration: Success: 73.5% vs 82.1%, Survival with intervention: 18% vs. 4%. Failure: 6.1% vs. 6.1%. Implants >4x incidence of post-operative complications requiring subsequent treatment intervention.




  1. Iqbal/Kim 2007Systematic review/Meta-analysis. No difference in the survival outcome between NSRCT/crown and single tooth implant. Widely differing criteria are used to measure “success”. NO agreed definitions!!




  1. Kim/Solomon 2011Cost effectiveness: EMS > Retx/Crown > FPD > Implant/Crown




  1. Woodmansey 2009 – Compared Mand molar NSRCT/Crown & Implant/Crown vs. contralateral natural tooth for maximum bite force, chewing efficiency, and areas of occlusal contact/near contact. Findings: Endo tx tooth = Contralateral > Implant for more effective occlusal contact during masticatory function. Implant/crowns have reduced masticatory function (one goal of tooth restoration)


Vital Pulp Therapy & Immature Teeth
Vital Pulp Therapy: Requirements for Success


  1. Treatment of Non-inflamed Pulp:

    1. Tronstad – Direct pulp capping of inflamed pulp tissues yields inferior success rates

    2. Pulp tissue must be removed to level of noninflamed pulp

  2. Bacteria Tight Seal (see also: Murray, Murray/Smith – RDT/Microleakage)

    1. Cox/Bergenholtz - Successful healing will occur independent of pulp capping material if exposed pulp is effectively sealed from bacterial leakage

  3. Pulpal Dressing:

    1. CaOH2Schroeder; Hollandliquefactive necrosis superficial layer, coagulative necrosis at junction of necrotic/vital tissues, mild inflammatory response, healing with hard tissue barrier

    2. MTA – Torabinejad; Holland; Nair - Healing w/MTA showed complete tubular dentin bridge formation and No inflammation in any of the pulps capped with MTA, Better healing than with CaOH2

Who described apexification of nonvital teeth and what are the possible outcomes? Al Frank
Nonvital immature teeth treated with CaOH2 developed 4 different types of barrier formations. Was the 1st to describe technique.


  1. periapex closes with definite recession of the root canal

  2. obliterated apex develops without any change in canal space

  3. no radiographic evidence of development in canal or apex; an apical stop is evident clinically.

  4. calcific bridge forms coronal to apex that is detectable radiographically.



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