Endod Dent Traumatot 99; : 9 Printed in Denmark. Alt rigtits reserved Copyright Munksgaard 99 Endodontics & Dental Traumatology ISSN 0090 Periapical status, quality of root canal fillings and estimated endodontic treatment needs in an urban man population Weiger R, Hitzler S, Hermle G, Lost C. Periapical status, quality of root canal fillings and estimated endodontic treatment needs in an urban man population Endod Dent Traumatol 99; : 9. Munksgaard, 99. Abstract The objective of this study was to determine the periapical status and the quality of root canal fillings and to estimate the endodontic treatment needs in a man population. Glinical and radiographic data and the operative procedures performed were evaluated on patients coming to a dental surgery in Stuttgart, many, in 99. In individuals at least one tooth exhibited a root canal filling, a necrotic pulp or an irreversible pulpitis. Out of the 9 teeth examined, (.%) had a root canal treatment (category A), being nendodontically treated (.%) did t respond to the sensitivity test (categoiy B) and (0.%) were diagsed as having irreversible infiamed pulp tissue (category G). The prevalence of teeth associated with radiographic signs of periapical pathosis was % in the group of root canal filled teeth and % in the group of pulpless and nendodontically treated teeth. Using the level and the density of the root canal filling as criteria for evaluating the technical standard, only % of the endodontic treatments of napicectomized teeth were qualified as adequate. The minimal endodontic treatment need is.% related to all examined teeth when the root canal filled teeth with clinical symptoms of periapical periodontitis (category A) and those of categories B and G are included. The real endodontic treatment need is suggested to be larger when considering that the technical quality of the obturation is poor in most symptomless endodontically treated teeth associated with a periapical lesion. In the case of retreatment of these teeth, the endodontic treatment need wolild then be calculated at.%. Epidemiological data on the periapical status, the quality of root canal treatments and the endodontic treatment needs in many are scarce. Three studies () have been performed analysing selected patient groups of a University dental clinic. Attention was focused on the prevalence and the quality of root canal fillings by evaluation of intraoral or paramic radiographs. In one paper only (), an attempt was made to estimate radiographically the need for endo R. Weiger, S. Hitzler, G. Hermie, C. Lost Department of Conservative Dentistry, University of Tubingen, many Key words; endodontics; epidemiology; root canal treatment R. Weiger, Abteilung Poliklinik fur Zahnerhaltung, ZMKKlinik, Osianderstr., W0 Tubingen, many Accepted September, 99 dontic treatment in 00 individuals suffering from periodontal diseases. Glinical examinations, including sensitivity tests or the results of operative procedures which could probably reveal the need for additional root canal treatments, were t considered. In many, the number of specialists focusing on clinical endodontics is negligible. The vast majority of patients seeking dental care or emergency treatment will primarily consult general dental practitioners. In 9
Weiger et al. Table. Age distribution of the patient sample (n=). Group I represents the patients having at least one tooth with an obturated root canal or one tooth associated with an irreversibly inflamed or necrotic pulp. This type of tooth is t present in the individuals of Group II Age group 9 09 09 09 09 09 09 09 Group Group II 9 Total (%) (.%) (.%) (.9%) (0.%) (.%) (.%) (.0%) (0.%) (00.0%) contrast, patients of a dental clinic affiliated with a University are frequently referrals or have special dental problems, thus representing a highly selected material. This study was designed to determine retrospectively the periapical status and the quality of root canal fillings in indi\n.duals seeking examination/ treatment in a selected man general dental surgery. Furthermore, an estimation of their endodontic treatment was done on the basis of clinical and radiographic data and of the operative procedures performed accordingly. Material and methods Patients who came to a general dental practice during the regular consultation hours for the first time or after a period of years in 99 were included in this study. Three fulltime general dental practitioners examined and treated the patients in their private surgery situated in the centre of Stuttgart, a city with about 00,000 inhabitants in the southern part of many. Ghildren less than years old were t considered in this study. Out of the subjects examined, % were females and % males. The average patient age was. years. The age distribution is illustrated in Table. The patients' records including intraoral and/or paramic radiographs formed the basis for the study. Clinical criteria The recorded history of dental pain, if present, and the outcomes of the clinical examination were evaluated for each patient. The criteria listed in a special form included clinical symptoms indicating symptomatic pulpitis or an endodontically induced periapical periodontitis, tooth vitality, potential causes for pulpal involvement, type of coronal restoration and marginal seal of the restoration (Table ). Third molars were excluded from the analysis. 0 Radiographic criteria Periapical radiographs were available for most teeth which did t clearly respond to the sensitixdty test. In some patients, paramic radiographs had been taken for other reasons. All films were processed in a standardized automated machine. Radiographs which were t available or which did t allow a proper evaluation of any single criteria of interest due to technical shortcomings or overprojections of anatomical structures were separately registered. A tooth with radiopaque material within the confines of the suggested root canal(s) was rated as "endodontically treated" tooth. Signs of periapical pathosis, the density of the root canal filling and its apical extension related to the radiographic apex and the presence of an intracanal post were recorded (Table ). The widening of the periapical periodontal ligament space exceeding about two times the width of a rmal lateral periodontal ligament space was assessed as "periapical radiolucency". Multirooted teeth were categorized according to the root with the most insufficient root canal filling and/or with the highest periapical score. Radiographic interpretation In the preliminary^ phase of the study, a prior calibration of two dentists (SH and GH) was carried out by an experienced endodontist (RW). Thirtyone radiographs showing teeth with obturated root canals Table. Clinical and radiographical criteria for categorization of the teeth Clinical symptoms absent present Sensitivity test positive negative Coronal restoration restoration crown (or filling) crown (or filling) with intracanal post Marginal seal of the restoration sufficient insufficient absent present Apical level of the root canal filling 0 mm short of the radiographic apex > mm short of the radiographic apex extruded beyond fhe radiographic apex Density of the root canal filling voids and close adaptation to root canal walls voids and/or insufficient adaptation to root canal walls Causes for irreversible pulpitis caries trauma unclear
Weiger et al. Table. Distribution of the teeth of category A according to tooth group, periapical radiolucency, density and length of the root canal filling and marginal seal of coronal restoration (u.: upper, I.: lower, ant.: anterior, apicect.: apicectomized, ext.: extruded) Density Marginal seal n + 0 > ext. + u. ant. teeth u. premolars u. molars. ant. teeth. premolars. molars subtotal apicect. teeth 0 0 9 0 0 9 0 9 0 9 9 0 9 total 9 0 Category A endodontic treatment need would then be calculated at approximately.%. Discussion The study material consisting of patients from a general dental practice does t represent a random sample of the man population in the area of Stuttgart. However, it may provide useful data on the endodontic quality and the endodontic treatment needs in many compared to a highly selected pa Table. Distribution of the teeth of category B according to tooth group, periapical radiolucency and type of restoration (u.: upper, I.: lower, ant.: anterior) Category B u. ant. teeth u. premolars u. molars. ant. teeth. premolars. molars total Restoration n 9 0 0 0 0 Table. Distribution of the teeth of category C according to tooth group, periapical radiolucency, type of restoration and causes for pulpal involvement (u.: upper, I.: lower, ant.: anterior, car.: caries, trau.: trauma, un.: unclear) Restoration Causes Category C n car trau. un. u. ant. teeth u. premolars u. molars. ant. teeth. premolars. molars total 0 Length tient population of a dental school clinic affiliated with a university. Such patient groups have served as a basis for more recent investigations (^) documenting the prevalence and the quality of endodontic treatment as well as the periapical status. The present study was restricted to patients who came to the selected dental surgery for the first time or after a period of at least years. The reasons why these subjects chose this practice have t been recorded. Of the patients, women dominated slightly with %. The age distribution clearly showed that the younger individuals (^9 years) made up % of the whole sample. The average number of remaining teeth per individual was (third molars excluded). How far this figure is comparable with that of the whole man population could t be definitively assessed. The patient's dental history, the clinical examination and the operative procedures supply important information about the presence of an irreversible pulpitis, the potential causes of pulpal exposure and the number of pulpless teeth without any radiological signs of periapical pathosis. However, a misdiagsis made by one of the three practising dentists might t be completely excluded, possibly resulting in a false treatment or a ntreatment. Particularly the sensitivity test on teeth with full ceramic crowns or with radiographically obliterated root canals might yield misleading results. Undoubtedly, the true endodontic treatment need can be estimated more comprehensively when radiographic data are supplemented by clinical findings. Periapical radiographs or orthopantomograms were used to evaluate the technical standard of root canal fillings and to detect periapical lesions. The presence or absence of periapical or lateral lesions was assessed instead of applying a more detailed periapical scoring system according to 0rstavik et al. (). In this connection, the widening of the periodontal ligament space exceeding two times the width of the lateral periodontal ligament space was interpreted as
Endodontic status in a man population Table. Prevalence of apical periodontitis and root canal fillings in many compared to some other European countries (ap. perio.: apical periodontitis; : many; Neth: The Netherlands; Switz: Switzerland; Swe: Sweden; Nor: Norway) Study Present study Hulsmann et al. () Hulsmann et al. () Klimek et al. () DeCleen () Imfeld () Eckerbom et al. () Odesjoetal. () Eriksen & Bjertness () Eriksen etal. () Country Neth Switz patient age in years 0. 0>0 0>0 0. 0>9 Swe Swe Nor 0>0 0>0 Nor (9) (99) 0 root canal fillings periapical periodontitis per person % of teeth per person % of teeth % with ap. perio. 0..0.....9.. 0. 0. 0. 0.90 0.99 0..... 0.9 0...... 0 S 9 0..0.. 0. 0. 0. 0. an initial radiographic sign of periapical pathosis and classified as periapical radiolucency. With respect to the accuracy of diagsing a periapical radiolucency, the intraoral radiograph was found to be somewhat superior to the paramic one (). Thus, in this study the number of periapical lesions might be slightly underestimated unless periapical radiographs were available. The radiographic appearance of an obturated root canal is only a rough measure of the sealing capacity of a root canal filling. Neither the homogeneity r the apical extension related to the apical constriction can be exactly examined by using a radiograph taken in a buccooral direction (). In vitro, t even a root canal filling of high quality seems to prevent the penetration of bacteria and microbial byproducts along the obturated root canal (, ) unless a sufficient coronal restoration is present (9). At present, however, the only way of routinely judging the technical standard of a root canal filling is offered by the radiograph. Likewise, it has to be kept in mind that the operator is t capable of radiographically assessing the quality of the root canal debridement procedures. These limitations should be taken into account when interpreting the present results. Endodontic treatment had been performed on.% of the teeth. Recently, slightly higher values (.".%) were published for many (Table ), which might be attributed to the highly selected patient groups examined in these investigations. In comparison with some other European countries, the corresponding numbers also tended to be higher particularly when older patients were investigated (Table ). In the present study, most (%) of the teeth with obturated root canals were associated with a periapical lesion confirming the results of Hulsmann et al. (, ) and Klimek et al. (). In Sweden, Norway, Switzerland and the Netherlands, however, this percentage ranged between % and 9%, being markedly lower than that recorded in many (Table ). 0..0..0.. This obvious discrepancy might t only be due to the different patient material examined but also to improper techniques applied by some man dentists combined with poor kwledge on the principles of adequate endodontic treatment focusing on the control and elimination of root canal infection. This assumption might be further supported by the results of the present study that the radiographic appearance of the root canal filling was satisfactory in length and condensity in only % of the cases which have t been apicectomized. Most of the root canal fillings were t well condensed (%) or ended more than mm short of the radiographic apex (%). Out of the pulpless, nendodontically treated teeth, the vast majority (%) showed radiographic signs of periapical pathosis. In a man population, Hulsmann et al. () reported a similar percentage of teeth with radiologically detectable periapical lesions. However, the real percentage may be still higher than the calculated figures as lesions confined to cancellous bone may t be detected in radiographs. Furthermore, it can only be speculated as to the causes for the formation of the diagsed endodontically induced lesions. Goronal leakage \da defect restorations or deep carious lesions and traumatic injuries might explain their occurrence. The smallest percentage of teeth which needed endodontic treatment constituted the cases with an irreversible pulpitits. Most of them had carious lesions compromising the pulp tissue. Molars were predominantly associated with a widening of the periapical periodontal ligament space, indicating a progressing infiammation in radicular portions of the pulp. There was actual data from other studies concerning the prevalence of teeth with an irreversibly damaged pulp in an adult man population. The endodontic treatment need for the selected patient group can only be estimated if consecutive crosssectional or longitudinal studies are performed. In the present