8. Prognosis, Endodontics and Implants Flashcards
Endodontics is NOT merely restricted to root canal treatment (RCT). Below shows us other endo- associated procedures and tx (e.g. sometimes failed tx requires a “redo” that may be done in a surgical or non-surgical way).
• We’ll learn more about these later on (after the exam)
• Follow these arrows from diseased tooth (assume apical periodontitis) to extraction to dental
implant and conventional restoration.
• Sometimes we have to make the call whether to extract or save a tooth, do an RCT or
implant. Many factors bear on the decision-making process: amount of remaining ____, broken file in the tooth, extent of ____.
• Debate (~15 yrs) on implants – critiques the position in dentistry that “implant is better” – just take out and replace the tooth with an implant that “lasts forever.” Growing body of research (w/in last few yrs), however, supports that retaining the ____ tooth at certain periods of human life-cycle may have better outcomes.
tooth structure
apical periodontitis
natural tooth
Endodontic Outcome
- no clinical signs and ____
- reconstitution of ____
- intact ____
What kinds of criteria would we include to evaluate and gauge successful endo tx objectively and predictively (e.g. so we know another patho won’t occur later)?
• Resolution of ____ - Pt doesn’t present with any follow-up symptoms at any period.
• ____ measures - AP presents as a radiolucency, so we want to see this go away. More affirmatively, we’d like to see no inflammation but rather marked healing of the PDL structure.
symptoms PDL lamina dura symptoms radiographic
Endodontic Outcome
Discussions on endodontic outcomes go hand-in-hand with surgical procedures and prognosis. Will talk about changes in tx protocols, modern techniques, etc. and also surgical re-treatments.
Key issue – Most of the time, from an historic outcome analysis, ppl were looking at strict outcome criteria. What’s the biological goal of successful endo tx? Prevention and elimination of ____.
• In the past, people scrutinized and evaluated the outcome of said biological goal. Hence, they looked at cases where AP was present. To what % rate, after tx, did we cure that periodontitis in terms of preventing future AP occurrence? With an irreversible pulpitis (IP), what’s the % probability that we are able to prevent subsequent AP to occur?
• First of all, how/why would AP occur after you treat a tooth with IP?
(a) ____ (e.g. microbes may be introduced via contaminated files or other equipment) and/or
(b) faulty ____ (e.g. placing a weaker temp vs permanent restoration; or in the future, restoration degrades permitting microbial infiltration via ____.
apical periodontitis
iatrogenically
restoration
coronal leakage
Endodontic Outcome
And, it’s exactly these 2 criteria (above), that ppl in the past examined more formally encompassed by the ____ Criteria (1956) when doing regular endo tx including initial tx and non-surgical retreatment (e.g. follow-up RCT). The ____ (PAI) by Norwegian Dr. Ostervik also includes these outcome criteria.
- Caveat – PDL may be ____x wider than normal: both indices take into account limitations of less biocompatible filling materials in the past. Therefore, in a sense, a foreign body (filler) is still present in RC. This is why PDL is permitted to be ____ in some areas where filler is located. Nonetheless, want to see dramatic return of PDL.
Continued (previous slide): Want to see Pt is free from any clinical signs & symptoms (S&S).
• No ____: Check to see if Pt has any tenderness to percussion, palpation, or even without any
stimulus.
• Painless ____: Sinus tract (see image in previous slide)
stringdberg criteria
periapical index
2
wider
pain
indications
Below show the results of meta-analyses focusing on outcome (success & failure) evaluations of endo tx.
• “Why is it imp for us to do meta-analyses in dentistry?” Gives us more ____, valid results.
◦Problem in dentistry - frequently small studies are published, but ____ sample sizes are challenged w obtaining statistically significant results between 2 diff outcomes.
‣ Hypothetical example of a study comparing the efficacy of a new vs old endo sealer: (a) small study - if findings reveal 8% difference between Intervention A (n=50) and B (n= 35), would not be statistically significant; but in the context of a (b) ____ study that yields same 8% difference btw A (n=600) and B (n=600), results would be significant!
accurate
smaller
larger
Summarizing the issue in dentistry: In medicine, it would be much easier to find a large # (~1000) of willing patients to participate in a study of a new vs old diabetes drug. However, if you were to do a clinical trial comparing 2 interventions in dentistry, it’d be much more difficult to standardize, treat, and recruit comparable # of subjects and follow them longitudinally, etc. This is why we have much more ____ sample sizes.
Not very good for us mainly for 2 reasons:
(1) Tells us there was a lack of designing adequate ____ trials in the past (2) Evidence level we have is ____.
smaller
clinical
low
Mentions article sent by librarian from “Atlantic” illustrating impact of low evidence-based dentistry:
(1) Ethical issues assoc w “over-treatment” - describes situation of 1 California provider who grossly over-treated Pts; would do xs # of RCTs and cap with lots of crowns for majorty of patients raising ethical issues of how much we should treat. Without much evidence-based dentistry, difficult to ascertain how ____ tx should be.
(2) There’s actually a very low level of acknowledging and following ____-based procedures in dentistry. ** Doesn’t actually like the article, says there are inaccuracies. Whatev.
extensive
evidence
• Shows the positive, success outcome (68-85% in which AP healed or was prevented) of initial endo tx (including vital cases) based on an MA of studies from 1950s - 2000s. 63 studies met inclusion criteria.
Criticism takes issue with the lack of ____ among studies bc endo techniques evolved over time; thus, a variety is represented in this MA. Still, this is all we have. No one has done a repeatable new study on the effects of modern endo techniques and equipment (e.g. microscope, nickel-titanium instruments). Studies are being done but haven’t been ____ for whatever reasons.
homogeneity
published
RCT: obsolete techniques included in meta-analyses
Main idea: It’s hard to compare and apply old studies to ____:
• In the 50s - there were no rotary instruments, Gate’s burs, nickel-titanium files - things that came out in
the 90s. There was nothing like IOS standardization (e.g. companies produced their own kinds of files with their respective labels and sizes) - “it was totally wild.” At some point, professionals in the field decided on standard file sizes (10, 15, 35, etc.), tapers (0.02, etc.), 16mm working-end, etc. so methods could be comparable. Main idea: Makes these studies harder to compare to ____ studies.
• 60s - Still doing hand instrumentation. Difficult to work with less flexible stainless steel files with curvy roots, so couldn’t instrument to the extent that we can now and clinicians were more prone to ____ RCs (see image w circle). Consequently, couldn’t ____ as much bacteria. Not imp to know specific details, but again challenging to compare these old studies with today.
modern times/conditions
modern day
perforate
eliminate
Success Rates (Green figure)
Irreversible pulpitis (IP): Based on very strict outcomes outlined in Strindberg Criteria or PAI, successful initial endo tx occurs in more than ____% of vital cases w IP - meaning the infection was successfully eliminated out of the RC system, the PDL remained free of inflammation around periapical tissues, and AP did not develop after tx.
Necrosis / AP: Success rates in MA vary across time; more modern and isolated studies often report success rates over ____% of healing of AP. If we sort out and compile all the necrosis/AP studies out of the MA shown previously, we find about a ~____% success rate will heal the AP typically over the course of 1yr (the follow-up time we have) and ~____% still present with AP (may be less severe, asymptomatic).
90
90
75
25
Survival rate (red figure): People looked at the long-term functionality of a tooth post-RCT ignoring any aspects of ____ healing (e.g. size of lesion, whether still present, etc.). Just concerned w whether tooth is still there and functioning. These survival criteria are actually comparable to most implant studies out there, if you know that ____% of teeth post-RCT still survive 8-12yrs later.
So, based on the studies we have, we can tell a Pt, recommended for RCT, that s/he will most likely still have that tooth in their mouth - ____ - ____ years later! Nice.
AP
93-97
asymptomatic
10
Indeed, ~10yrs ago, implants were touted as the “ultimate” tx in the field. Below summarizes criteria put forth by an influential clinician in restorative dentistry and implantology.
• Reads all the points. Main idea: There are many reasons to extract and not save!
◦Extract:
‣ PAR = periapical ____
‣ “These numbers by the way are completely arbitrary and have no meaning in the context of AP healing.
◦Save: Only 2 situations listed! Both of which sound sketch.
In sum: He’s not opposed to implants, but in the context of over-treatment, we need to critique this position by looking at the most recent literature in order to find out other tx avenues.
radiolucency
Extract
- If perio surgery will reduce ____ tissue
- If surgery will compromise the ____
- If patients need RCT & post & crown & crown lengthening under previous crown
- If patient has a high ____ rate
- If patient is prone to periodontitis
- Preservation may risk more ____ loss because of future infection
- If tooth needs RCT and has a 5 mm PAR
- Tooth and post will not withstand ____ without risk of fracture
Save
- If two implants will be ____ to each other, then save one [tooth] if possible
- If the patient has an ____ breakdown when you mention the word extraction
facial papilla decay bone occlusion
adjacent
emotional
Here’s case from Philly: A GP referred Pt to a periodontist
Patient presents w mesial pocket (green arrow) on #12 (slides says 24 - that’s wrong).
Periodontist says: “Must be a perforation on the post after the RCT. That’s why there’s a lateral lesion on that premolar, or there’s a fracture.”
What to do? If you take a CT, it would show you if there was a post-peforation but not a fracture.
◦Long story short… they extracted the tooth and did an implant. Also placed an implant in the edentulous space for the 1st molar. There was ____ wrong with it though.
Also extracted #13 bc from a prosth point-of-view, it had an ____ root, which is not great for placing crowns. So, it was replaced with a 3rd implant.
‣ What do you see when we look at the #13 implant? It appears to be in the ____ (cou be but can’t tell for sure bc it’s a 2D image).
nothing
S-shaped
sinus
3mo later, Pt developed periapical sinus tract on the 3rd implant that was placed.
• Why? Periodontist and oral surgeon said it could have been due to (a) over-____ of implant while it
was placed, or (b) the ____ - there may have been an infection before tx or introduced during tx
Finally, there was NO fracture or perforation on #12. So, what would you do? I would take the implant out. But, what they did was “cut it off at the ____,” which is ridiculous bc imagine the heat generated drilling through 3.8mm of titanium! And also, it didn’t do anything bc the infection still persisted in the periapical area of the remaining implant structure. So, in the end, they had to remove it!
Over-placement of implants could have been prevented bc, in the end, they concluded that the initial presentation (4-5mm mesial pocket on #12) was an oral hygiene and periodontal issue. In fact, given the concavity of their roots, maxillary premolars often present with lesions encountered in this case. Because of over-confidence and over-tx, Pt has 2 implants (3rd taken out). Sad outcome.
treatment
sinus
end
Do we know enough about the long-term success of implants?
… most implants function year after year without any problem. Then there are a few patients who lose their implants and why not? All spare parts that you place in the body are associated with some complications….
The drawback is of course that many dentists find it ____ to remove a tooth and place an implant than to use the data in the literature to treat the tooth for its conditions. So maybe there is an ____ of implants in the world and an underuse of teeth as targets for treatment…
Reads excerpt: “Do we know…?”
◦Draws attention to the implant debate.
‣ Over-implanting is also profit-driven. There’s more money for private practices to do them. They’re also easier to do than ____ for natural teeth.
Summarizes red text.
easier
overuse
treatment planning
Long-term Success?
Implants do not exceed the life ____ of natural teeth at 10 years, including endodontically treated or periodontally compromised teeth.
Over 5-10 years 16-28% of implant patients suffer from ____, with a higher percentage associated with ____ implants.
The loss rate of teeth is ____ than that of dental implants implants in patients that are clinically well-maintained.
expectancy
peri-implantitis
multiple
lower
… until this 2013 systematic review shook things up.
• JADA is a reputable journal in the field with wide reach. Could not do an MA bc studies in the literature were not sufficiently ____.
◦One of their inclusion criteria were studies with follow-up periods of +____yrs (super difficult to find!). Also included cases that were perio, endo, and prosth-involved.
Key issue identified: Loss rate of natural teeth over 15yrs was ____ than dental implants.
homogeneous
15
lower
Moreover… they didn’t just focus on only 1 particular aspect of the treatments but also noted that there are a lot of issues with system compatibles.
• What? Meaning a lot of ppl didn’t know what kind of ____ was placed. Without being identifiable, no one could consult the right corresponding implant company for ____. Thus, many implants were rendered unrepairable.
◦There’s now a website, whatimplantisit.com, to help identify an implant among the hundreds of lesser known “fringe” systems that currently on the market on top of the 5-6 well-knowns.
‣ Clinicians that provide “fringe” implants may create problems for Pt if the company goes bankrupt and a replacement part can’t be ____. He recalls situations like this in the past.
implant
repairs
repaired
Major recommendation of paper focuses on young ppl - There are reasons we should attempt to preserve teeth for this demographc.
• Growth of facial tissues continues after ____ (even in your 30s!) - e.g. super eruptions of teeth may occur and changes in cranio-facial skeleton. This has major implications on esthetics. For instance, if you place an implant, it is ankylosed to the bone via osseous integration and will, thus, not move around. However, in young pts, adjacent teeth may still ____ and super-erupt leading to unesthetic outcomes (e.g. high-low-high “step” pattern of teeth.
puberty
migrate
• Reads text in blue box - extrapolating from this, if a young pt were to lose the first implant, placing a 2nd implant in that same spot would be more difficult. For instance, an implant may have peri-implantitis with 3-5mm of bone attachment in the apical portion. A natural tooth in this situation would have mobility and can be extracted very easily (thanks to degraded PDL). But with an implant w no mobility, you’d have to ____ it out due to osseointegration! So you’d need a special (sounds like “Threffing”) bur to remove it. However, you’ll create a bone ____ (larger than before) in the process requiring augmentation procedure and a lengthy ____ stage.
◦Unfortunately, some studies have demonstrated that bone grafting outcomes tend to be ____ in these types of implant cases.
In light of the findings of an estimated “life-expectancy” of 20 yrs for implants, if you give a young pt an implant around 35yrs, they’d have to get a replacement at 55yrs, 75yrs, etc. Bc natural teeth last longer and subsequent implant replacement has ____ outcomes, it’s better that we try to preserve rather than extract teeth.
drill defect healing lower poorer
Relevant part:
Looking into the incidences of peri- implantintis and marginal gingivitis on implants. This article was controversial b/c of the incidence rate of peri- implantitis.
They did studies on thousands of patients and implants and a meta analysis that they did on all the studies published previously, and there is true evidence out there that there is a high rate of ____.
peri-implantitis
