Romanii campioni la tratamente endodontice si parodontite apicale

Putini dintre pacientii nostri  nu au  avut de-a face niciodata cu un nerv rebel dintr-un dinte care a impus la un moment dat tratamentul endodontic? sau  ceea ce toata lumea numeste scos de nerv si obturatie (plomba) radiculara sau pe canale. Mai mult, daca infectia din interiorul dintelui s-a extins iesind spre osul din jurul varfului radacinii, atunci cu siguranta aceasta experianta a ramas in mintea fiecaruia, necesitand poate mai multe vizite la dentist sau, in cazuri mai grave, chiar o rezectie apicala.

Chiar daca statistic, sansa de  reparatie a osului afectat este departe de a fi 100%, de cele mai multe ori, in urma unui tratament corespunzator realizat, simptomele se remit, osul se repara, iar dintele reintra in “exploatare” normala, iar dupa o vreme chiar uitam sau avem dificultati in a ne aminti daca a fost sau nu tratat pe canele. Nicio problema insa, deoarece pe radiografii se poate vedea daca un dinte a fost tratat pe canale si in ce masura osul din jurul radacinii este reparat sau din contra,  prezinta parodontita apicala.

Frecventa acestor tratamente endodontice difera in funtie de multi factori unul dintre acestia fiind si zona geografica cu specificul ei ( incluzand educatia, stilul alimentar, puterea economica etc).Exista multe studii statistice care, analizand radiografii ale pacientilor, ne prezinta frecventa  dintilor care au fost tratati pe canele, calitatea tehnica la care acestea au fost realizate, gradul de reparatie a osului sau alte informatii care pot fi relevante pentru o comunitate dintr-o  anumita arie geografica.

Deoarece in Romania s-au publicat doar doua astfel de studii, unul in Bucuresti si altul in Iasi, am decis sa realizam un astfel de studiu si in Cluj. Rezultatele preliminare le-am prezentat in iunie 2012 in Leipzig, in cadrul Congresului Academiei Europene de Radiologie Orala si Maxilo Faciala din care fac parte din 2006. Pe scurt, concluzia studiului a fost ca frecventa dintilor tratati endodontic este mai mare la romani decat in statisticile din alte tari, iar cea a parodontitei apicale si mai mare.

Care sunt constatarile voastre referitor la acest subiect? Am pus in continuare o prima varianta a textului, din pacate fara grafice si imagini din motive tehnice pe care sper sa le dibuiesc .

“Periapical health related to the quality of endodontic treatment in a Romanian urban subpopulation”

Introduction

Apical periodontitis ( AP) develops as a response to infection of the tissues in the root canal system and of the surrounding dentin.  . Apical periodontitis may still persist as asymptomatic radiolucencies after the root canals have been filled because of the complexity of the root canal system where residual infection may  persist. Furthermore, a complete seal from the coronal to the apical end of the treated root reestablishes the mucocutaneo-odonto barrier, whereas voids or leaks may present an opportunity for bacteria to establish a foothold close to the body’s interior [1]Radiographic diagnostic procedures are used for the detection and monitoring of changes in mineralization and structure of the surrounding bone [2]. Radiographs provide important information on the evolution of apical structures but also for evaluating the quality of root canal treatment [3] . Many studies analyze the apical health related to endodontically- treated teeth in different populations [4] , [5]using specific radiographic methods and criteria. However, studies on periapical health have not yet been performed in Cluj Napoca area so that we have no comparative information on the prevalence of AP.

The aim of this study was to determine the prevalence and technical standard of root canal fillings in a Romanian adult subpopulation. The study was carried out in relation to the prevalence of apical health using a retrospective analysis of digital panoramic radiographs.

Material and method

For the study, 4854 teeth have been analyzed on  digital panoramic radiographs. Two experienced observers ( an endodontist and a dental radiologist) have been independently  evaluated the  images. All operators who carried out the treatment were unknown.  Patients’ ages ranged from 19 to 87 years and patients with less than 10 teeth  and less than  one endodontic treatment were excluded.  The evaluation criteria were as following:

A) Apical periodontium status:  assessed by the Periapical Index (PAI) proposed by Ørstavik et al. [6]according to which 5 scores were attributed to the apical area of the radiographic images, as follows:

Score 1. no changes in periapical structure;

Score 2. small changes in bone structure;

Score 3. changes in the bone structure with little mineral loss;

Score 4. periodontitis with well-defined radiolucent area;

Score 5. severe periodontitis with exacerbating features.

B)      Root canal filling evaluation: adequate (completely filled endodontic  space, no gaps ) or inadequate (presence of voids, root filling 2 or more mm shorter or overfilled)[7];

C)      Presence and type of intracanal post:  Metal Post or  Fiber Post

D)     Presence of gaps between endodontic filling and post restauration

E)      Presennce of coronal sealing ( fellings or crowns).

The Kruskal-Wallis  and Mann-Whitney  tests were used for statistical analysis.

Results

Of 4854 teeth evaluated, 764  (15,7%) were treated endodontically. Female patients showed a higher prevalence of teeth with root fillings than male patients but not statistically significant (p˃0,05). Significant differences were found ( p˂0,001) for endodontically treated teeth  on patients 19-  30 years old versus 30-44 and  more than 45 years old patients, for these  two groups  no significant differences being found ( p˃0,025). Most endodontically treated teeth were found in people aged 45 to 65 years and the prevalence increased with age in this age range. The prevalence of endodontic treatment was 15,7%.

Tooth type

Of 764 endodontically treated teeth, 297( 38,8%) were frontals  and 467 (61,2%) were  lateral teeth. Endodontic treatment was most frequent in maxillary premolars and frontals, whereas mandibular incisors showed the lowest prevalence.

Endodontic filling quality associated with  apical periodontitis (AP)

Out of 764  root filled,  47,3% presented  apical periodontitis ( score  >1)  and 50,4% were considered technically inadequate. There was a significant correlation between the presence of periapical pathology and inadequate root-canal fillings. Inadequate root canal fillings are 11,71 times more frequent found in association with teeth  presenting also apical parodontitis, p˂0,001.

Post restoration type associated with  apical periodontitis (AP)

Metal posts were presented in 28,7% of endodontically treated teeth and 52,2 % of them also showed  apical parodontitis. Meanwhile fiber post were presented in 1% of analyzed teeth and  25% were associated with apical parodontitis. The periapical score of treated teeth with no posts were between the two categories ( FP and MP). Teeth  with MP showed the poor apical score (PAI = 1,99) comparing with Fp or no post,  p˂0,016.

Relation gap  between the remaining root canal filling and the post restoration

AP associated with high scores is statistically significant on  teeth presenting a gap  between the remaining root canal filling and the post restoration  , p˂0,05. In teeth with endodontic treatment and post restoration, there were 127 teeth that had no gap between the remaining root canal filling and the post restoration and the AP rate was 8,1%. There were 93 ( 42%) teeth that had a gap between the remaining root canal filling and the post restoration. Of these teeth, 48 (51,6%) had periapical changes.

Coronal sealing

Unsealed crowns showed the mean score statistically significant (2,61)  comparing with teeth coronally sealed with fillings ( 1,63) or crowned teeth ( 1.85)  p˂0,001.

Discutions

Our data shows a high prevalence of endodontic treatment comparing with other published studies (Loftus et al. found a prevalence of  2% [8] ; Kamberi et al. reported in 2011 a prevalence of 2,3% [9] ; Peters reported in 2011 a prevalence of 4,8% [10] ). This may be related to the fact that patients avoid going to dentist in early stages of tooth decay. Unfortunatelly there are no published studies on the prevalence of endodontic treatment in Romania.  The high rate of maxillary frontal teeth endodontically treated  may be related to the fact that molar edentation has a high prevalence in Romanian patients[11] .

The prevalence of apical periodontitis among root canal-treated teeth in the study population was 47,3, higher than other studies ( Lopez, 2012 reported a prevalence of 26%; Persic, 2011 et al. found a prevalence of 25,5-46,2 in different teeth type;  Peters et all reported a prevalence of 24,1% ; Sim, 2010 reported a prevalence of 22.8% [12]; Kabak,2005 reported a prevalence of 45% [13]. Lupi et al. reported in 2002 a prevalence of 31,5% [14], Ozbas et al. reported in 2011 a prevalence of 37,99% [15]) Studies of AP prevalence made on Romania population from other regions ( Bucharest and Moldavia) shows data similar to our study ( Cotrut et al. in 2011 reported a prevalence of 57,19% [16] ; Melian & Salceanu et all in 2009 reported a prevalence of  55,4% ). This may be related to the fact that the bad initial periapical status of patients going to dentist in a late stage of  pathology, so, the success rate can fall if there is an initial periradicular lesion[17]. Other reason could be  the fact that rubber dam is not used routinely by dental practitioners for root canal treatment with negative impact on treatment outcome. The prevalence of AP is even high on teeth with inadequate canal filling, being 79% in our study ( Al-Omari reported in 2011 the AP  prevalence of  87% for inadequate RCF [18]) or, if CBCT scan is used for evaluation. Estera et all detected  AP in 397 teeth (38.92%) by periapical radiography and in 614 (60.19%) by CBCT scans (p<0.001) [19].

The poor apical score ( PAI = 1,99)  associated with the presence of a MP could be explained by being used in extend coronal distructions with less amount of remaining dentin  after preparation [20]. Fiber post showed better periapical scores (PAI =1,25) then MP or then teeth with no posts. One reason may be the fact that fiber post use  resin cements for lutting who  tend to leak less than other cements [21], [22], [23] Mats et al. advocated that teeth with posts more often had apical periodontitis than other teeth [24] . Tronstad et al. showed that the presence of a post had no influence on the state of the periapical tissues except where the length of the residual obturation was less than 3mm (Boucher et al, 2002; Eckerbom et al, 1991; Kvist et al, 1989). Anyway the type of post and core is not relevant to survival rate of endodontically treated teeth [25], [26].

It was  advocated that the success rate of good endodontic treatment was significantly affected by the the presence of a gap who increase the risk of periapical inflammation [27], [28]. Our data indicated that  teeth presenting a gap are  6 times more frequent associated  with periapical imflamation.  AP is also influenced by the gap diameter , a larger gap resulting in  greater unfavorable outcome. Anterior teeth treatments are associated with a more favorable outcome than that of posterior teeth[29] , [30].

Poor  crown sealing could  result in bad  periapical score more often than poor endodontic sealing [31]. No statistically significant differences were found between the AP and coronal sealing methods (composites /amalgam fillings or crown/bridges), p˃0,025. Hommez et all found significant differences between amalgam and composites coronal sealing associated with AP composite-restored teeth exhibited apical periodontitis in 40.5% of cases whilst amalgam-restored teeth had apical periodontitis in 28.4% of cases [32].

CONCLUSION

For endodontically treated teeth, poor clinical outcomes may be expected with adequate root filling and inadequate coronal restoration or inadequate root filling and adequate coronal restoration, but  there is no significant difference in the odds of healing between these two situations.

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