BDS 11142 Success and Failure PDF

Success and failure BDS 11142 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To explain the importance of evaluating endodontic treatment outcomes 2. To details the clinical and radiographic criteria for evaluating success/ failure of endodontic treatment 3. To explain the...

Success and failure BDS 11142 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To explain the importance of evaluating endodontic treatment outcomes 2. To details the clinical and radiographic criteria for evaluating success/ failure of endodontic treatment 3. To explain the reasons behind failure of endodontic treatment Objectives: On completion of this lecture, the student should have: 1. An understanding of what causes the endodontic treatment to fail 2. An understanding of why and how to evaluate the treatment outcomes I- Definitions II- Purpose of evaluating endodontic outcomes III- Types of outcome measures IV- Factors affecting the outcome of endodontic TTT V- Causes of endodontic failures VI- Methods to assess the outcome VII- Success & failure criteria VIII- Summary I- Definitions: Vital diseased pulp Prevents bacteria from entering the root canal system Prevents development of periradicular lesion Necrotic pulp Eliminates or significantly reduces bacteria in the root canal system Allows healing of associated periradicular lesion Success of endodontic treatment Prognosis is the prediction of whether an endodontic treatment will prevent the development of apical periodontitis or heal if present II- Purpose of evaluating endodontic outcomes: 1- Effectiveness of Procedures:  Treatment procedures must be effective otherwise, there is no reason to recommend them.  The patient must be informed about risks, benefits and potential outcomes of the offered treatment 2- Factors affecting outcomes: Pooling data Evaluate factors that influence outcomes Protocols for ttt improved 3- Value for Prognostication:  Prognostication is defined as the prediction of the likely outcome of treatment  It depends on the interaction of endodontic, periodontal, and restorative prognosis III- Types of outcome measures: 1- Prepared shape of the root canal system 2- Bacterial load reduction 3- Technical quality of the root filling The ultimate clinical measure of a treatment outcome is assessing the prevention & resolution of disease IV- Factors affecting the outcome of endodontic TTT : 1- Presence of periradicular lesion which may reduce success by 10% to 20%. 2- Bacteria status of the canal. Presence of bacteria in the canal before obturation predicts a poorer prognosis. 3- The technical quality of root canal preparation. 4- Extent and quality of obturation. Extension  too short (more than 2mm) or too long  healing is less predictable Quality  voids and or less density  lower success rates. 5- The quality of coronal restoration and the effectiveness of coronal seal. Poor coronal seal  failure irrespective of the periradicular status of the tooth before treatment V- Causes of endodontic failures : Preoperative Misdiagnosis Improper TTT plan Poor case selection Operative Postoperative Mechanical Poor quality of root canal filling Biological Poor quality of coronal restoration Excessive dentin removal V- Causes of endodontic failures : Operative Mechanical 1- Access cavity: Underextended Missed canal or instrument separation Overextended Weakening and fracture Straight line access 2- Root canal preparation: a) Canal transportation (improper maintenance of canal curvature) b) Strip perforation (excessive preparation at the dangerous zone) c) Instrument separation (outcome may be unaffected if the instrument can be removed or bypassed) V- Causes of endodontic failures : Operative Mechanical 3- Obturation: a) Inappropriate obturating technique b) Over extension c) Overfilling specially in case of pulp necrosis and/or apical lesion Operative Biological 1- Contamination 2- Improper root canal disinfection 1- Proper instrumentation 2- Copious NaOCl irrigation 3- Intracanal medication VI- Methods to assess the outcome : 1- Histological examination a) Absence of inflammation Research tool b) Reconstitution of the periapical structure 2- Clinical examination Persistence of significant: a) Signs (e.g. swelling or sinus tract) Failure b) Symptoms (e.g. spontaneous pain, dull persistent ache, or mastication sensitivity) VI- Methods to assess the outcome : 3- Radiographic findings Success Elimination or no development of an area of apical radiolucency for a minimum of 1 year after treatment Questionable Radiolucent lesion has neither become larger nor significantly decreased in size (fibrous healing) Failure Enlargement or development of radiolucent lesion VII- Success & failure criteria: 1- Vital pulp therapy (indirect and direct pulp capping, pulpotomy) Quality Guidelines of the European Society of Endodontology: 1- Normal response to pulp sensitivity tests (when feasible) 2- Absence of pain and other symptoms 3- Radiologic evidence of dentinal bridge Formation 4- Radiologic evidence of continued root formation in immature Teeth 5- Absence of clinical and radiographic signs of internal root resorption and apical periodontitis VII- Success & failure criteria: Prognostic factors for vital pulp therapy: 1- Preexisting health of the pulp. 2- Adequate removal of infected hard or soft tissues. 3- Careful operative technique to avoid damage to residual tissues. 4- Elimination of microbial leakage around the final restoration VII- Success & failure criteria: 2- Non-surgical root canal treatment and retreatment  Effective and aseptic removal of the pulp tissue  If there is a periapical lesion  remove the bacterial biofilm and switching-off the periapical host response  Ideal healing would eventually result in regeneration and the formation of cementum over the apical termini, isolating the root canal system from the periapex  The outcome measures for healed periapical disease are: 1- Absence of pain, tenderness to percussion of the tooth, tenderness to palpation of the related soft tissues 2- Absence of swelling and sinus tract 3- Radiographic demonstration of reduction in the size of the periapical lesion (if enough time has lapsed) VII- Success & failure criteria: Factors influencing periapical healing following nonsurgical root canal treatment: 1- Presence and size of periapical lesion 2- Patency at the canal terminus (achieving patency significantly increased the chance of success) 3- Apical extent of chemomechanical preparation in relation to the radiographic apex 4- Outcome of intraoperative culture test (+ve culture  success rate 33%) 5- Iatrogenic perforation (if present reduces success by 30%). 6- Quality of RCT judged by the RG appearance of the root filling (0-2mm from radiographic apex) 7- Quality of the final coronal restoration. Factors having minimal impact on root canal treatment outcome: 1. Age. 2. Gender 3. Tooth morphologic type 4. RCT protocol and technique (preparation, irrigation, and obturation material and technique) VII- Success & failure criteria: Factors influencing periapical healing following nonsurgical retreatment: Periapical healing rates of root canal retreatment are generally lower compared to primary ttt due to: 1- Obstructed access to the apical infection. 2- A potentially more resistant microbiota. The most significant factor influencing the outcome of retreatment is the ability to remove or bypass pre-existing root-filling material or separated instruments VII- Success & failure criteria: 3- Surgical root canal treatment  Success of periapical surgery has been assessed with the same clinical and radiographic criteria as for nonsurgical root canal treatment.  Periodontal attachment loss in the form of marginal gingival recession is an additional criterion for measuring the outcome of periapical surgery VII- Success & failure criteria: Factors influencing periapical healing following periapical surgery: 1- Small (≤ 5 mm) versus large (> 5 mm) periapical lesion. 2- Periapical lesion involving one versus both cortical plates. 3- Absence versus presence of previous surgery. 4- Using magnification versus without the use of magnification during surgery. 5- Root-end resection with minimum versus obvious bevel. 6- Use of ultrasonic tip versus bur for retro cavity preparation. 7- Use of retro-filling material with mineral trioxide aggregate (MTA) cement VIII- Summary  The main factor shown to decrease success risk is the presence and size of periapical radiolucency  The next factor in magnitude is probably technical standard seen radiographically (overfilling reduces success risk)  Retreatment has a lower success risk than initial treatment  Apical root resorption, often resulting from long standing endodontic infection, is also associated with increased failure risk  A good coronal restoration is important to ensure endodontic success  Initial fistula presence has been recently associated with a reduced prognosis  Factors which have little effect on success are age, gender, presenting pulp pathology, mild or moderate marginal periodontitis and canal calcification VIII- Summary Root canal therapy is called successful if: 1) The treated tooth is asymptomatic & functional. 2) Soft tissue appears normal & responds normally to manual examination. 3) Radiograph reveals a normal lamina Dura. Treatment is considered failed if: 1) Treated tooth is symptomatic 2) Soft tissue response abnormally to manual examination. 3) When periapical lesion appears subsequent to endodontic treatment, or if a pre-existing lesion increases in size.  Correct diagnosis and sufficient control of microbes within the endodontic space usually leads to resolution of even extensive periapical periodontitis.  Here endodontically infected tooth 31 was prepared with manual files dressed with calcium hydroxide paste before obturation with lateral condensation.  This endodontic protocol has been established for decades and has repeatedly been shown to have a high success risk when employed to a technically high standard. To Sum it up  Give attention to details not only improves the finesse of the endodontic quality but also maximizes the success.  Regular follow ups aid in assessing the outcome and should be done at least on a yearly basis to monitor any changes.  Clinical thoroughness during the treatment phase can potentially benefit the clinician and the patient in the long run. I- Definitions II- Purpose of evaluating endodontic outcomes III- Types of outcome measures IV- Factors affecting the outcome of endodontic TTT V- Causes of endodontic failures VI- Methods to assess the outcome VII- Success & failure criteria VIII- Summary Aims: The educational aims of this lecture are: 1. To explain the importance of evaluating endodontic treatment outcomes 2. To details the clinical and radiographic criteria for evaluating success/ failure of endodontic treatment 3. To explain the reasons behind failure of endodontic treatment Objectives: On completion of this lecture, the student should have: 1. An understanding of what causes the endodontic treatment to fail 2. An understanding of why and how to evaluate the treatment outcomes Reading material: Students are advised to read details at: 1. Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapter 11) 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. (chapter 22) 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. (chapter 14) 4. Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. (chapters 6 and 9) 5. Clinical endodontics, 3rd edition, 2009, Leif Tronstad. Thank You