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Epidemiological surveys have reported that 25%-35% of root filled teeth are associated with periapical radiolucencies. Descriptive studies have demonstrated that clinicians' decision making regarding such teeth are subject to substantial... more
Epidemiological surveys have reported that 25%-35% of root filled teeth are associated with periapical radiolucencies. Descriptive studies have demonstrated that clinicians' decision making regarding such teeth are subject to substantial variation. A coherent model to explain the observed variation has not been produced. In the present thesis a "Praxis Concept theory" was proposed. The theory suggests that dentists perceive periapical lesions of varying sizes as different stages on a continuous health scale. Interindividual variations can then be regarded as the result of the choice of different cut-off points on the continuum for prescribing retreatment. In the present study experiments among novice and expert decision makers gave evidence in favour of the theory. Data also suggested that the choice of retreatment criterion is affected by values, costs of retreatment and technical quality of original treatment. From a prescriptive point of view, the presence of a persistent periapical radiolucency has often been used as a criterion of endodontic "failure" and as an indication for endodontic retreatment. As an alternative decision strategy, the use of decision analysis has been proposed. Logical display of decision alternatives, values of probabilities, utility values (U-values) of the different outcomes and calculation of optimal decision strategy are features of this theory. The implementation of this approach is impeded by the uncertainty of outcome probabilities and lack of investigations concerning U-values. U-values of two periapical health states in root filled teeth (with and without a periapical lesion respectively) were investigated in a group of 82 dental students and among 16 Swedish endodontists. Two methods were used to elicit U-values: Standard gamble and Visual Analogue Scale. Large interindividual variation for both health states were recorded. The difference in U-values between the two health states was found to be statistically significant regardless of assessment method. Compared with Standard gamble Visual Analogue Scale systematically produced lower ratings. U-values were found to change considerably in both the short and long-term. Any significant correlation between endodontists' U-values and retreatment prescriptions could not be demonstrated. Surgical and nonsurgical retreatment were randomly assigned to 95 "failed" root filled teeth in 92 patients. Cases were followed clinically and radiographically for four years postoperatively. At the 12-month recall a statistically significant higher healing rate was observed for teeth retreated surgically. At the final 48-month recall no systematic difference was detected. Patients were found to be more subject to postoperative discomfort when teeth were retreated surgically compared with nonsurgically. Consequently, surgical retreatment tended to be associated with higher indirect costs than a nonsurgically approach. In the final part of the thesis it is argued that retreatment decision making in everyday clinical practice normally should be based on simple principles. It is suggested that in order to achieve the best overall consequence a periapical lesion in a root filled tooth that is not expected to heal should be retreated. Arguments to withhold retreatment should be based on (i) respect for patient autonomy, (ii) retreatment risks or (iii) retreatment costs.
Research Interests: Dentistry, Decision Making, Treatment Outcome, Medicine, Probability, and 15 moreHumans, Freedom, Pubmed, Follow-up studies, Risk factors, Observer Variation, Time Factors, Reproducibility of Results, Statistical models, Risk Factors, Root Canal Therapy, Health Care Costs, Randomized Controlled Trials as Topic, Decision Support Techniques, and Treatment Failure
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Objectives: To assess the efficiency of AI methods in finding radiographic features in Endodontic treatment considerations. Material and methods: This review was based on the PRISMA guidelines and QUADAS 2 tool. A systematic search was... more
Objectives: To assess the efficiency of AI methods in finding radiographic features in Endodontic treatment considerations. Material and methods: This review was based on the PRISMA guidelines and QUADAS 2 tool. A systematic search was performed of the literature on cases with endodontic treatments, comparing AI algorithms (test) versus conventional image assessments (control) for finding radiographic features. The search was conducted in PubMed, Scopus, Google Scholar and the Cochrane library. Inclusion criteria were studies on the use of AI and machine learning in endodontic treatments using dental X-rays. Results: The initial search retrieved 1131 papers, from which 24 were included. High heterogeneity of the materials left out a meta-analysis. The reported subcategories were periapical lesion, vertical root fractures, predicting root/canal morphology, locating minor apical foramen, tooth segmentation and endodontic retreatment prediction. Radiographic features assessed were mostly periapical lesions. The studies mostly considered the decision of 1-3 experts as the reference for training their models. Almost half of the included materials campared their trained neural network model with other methods. More than 58% of studies had some level of bias. Conclusions: AI-based models have shown effectiveness in finding radiographic features in different endodontic treatments. While the reported accuracy measurements seem promising, the papers mostly were biased methodologically.
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In any medical treatment modality, outcome assessment is a major step. For root canal treatment, this primarily means looking at clinical symptoms and assessing radiographs. Moreover, retention is also an important outcome parameter and... more
In any medical treatment modality, outcome assessment is a major step. For root canal treatment, this primarily means looking at clinical symptoms and assessing radiographs. Moreover, retention is also an important outcome parameter and in this regard questions remain in regard to the association of endodontically treated teeth and overall health of the patient. Therefore, this chapter is dedicated to outcome assessments and decision-making for endodontically treated teeth.
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Root‐filled teeth presenting with signs of post‐treatment disease is a common finding in virtually every dental practice. There is both empirical and experimental evidence that, as long as the condition is asymptomatic, it is often left... more
Root‐filled teeth presenting with signs of post‐treatment disease is a common finding in virtually every dental practice. There is both empirical and experimental evidence that, as long as the condition is asymptomatic, it is often left untreated. Professional judgements and decision making in endodontics as in any medical discipline are based on qualified estimations of the probability and the value of relevant outcomes. In this paper we describe various aspects of clinical decision making in general, from a descriptive as well as a normative point of view, but with a particular focus on the condition of the root‐filled tooth with post‐treatment disease. We review how attention to various types of uncertainties are relevant for the decision‐making process. Additionally, we discuss the nature of value judgements and different concepts of health and disease which are important for understanding the complexity of the clinical decision‐making process. We also refer to a set of principa...
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Information of "success" rates after surgical or nonsurgical endodontic retreatment is abundant but inconclusive. Reported healing frequencies vary between 45% and 90%. The present study was designed to find any... more
Information of "success" rates after surgical or nonsurgical endodontic retreatment is abundant but inconclusive. Reported healing frequencies vary between 45% and 90%. The present study was designed to find any systematic difference between the methods. Nonsurgical and surgical retreatment was randomly assigned to 95 endodontically "failed" cases. The outcome of the procedures was clinically and radiographically recorded, and followed for 4 years. At the 12-month recall, a statistically significant (p < 0.05) higher healing rate was observed for cases surgically retreated. At the final 48-month examination, no such difference was found. These findings may be explained by (a) slower healing dynamics in the nonsurgical group and (b) the event of late "failures" in the surgical group. Within the latter category, four cases classified as healed after 1 yr failed at the final follow-up. Conclusively, this study failed to show any systematic difference in the outcome of surgical and nonsurgical endodontic retreatment. Surgical retreatment seems to result in more rapid periapical bone fill, but also may imply a higher risk of "late failures." From a scientific point of view, the length of the follow-up period is very important and may strongly influence the conclusions made.
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Introduction The aim of this study was to evaluate the frequencies of nonsurgical retreatment, root‐end surgery, extraction, and further restoration of root‐filled teeth in Sweden in 2009 during a follow‐up period of 5 years and to... more
Introduction The aim of this study was to evaluate the frequencies of nonsurgical retreatment, root‐end surgery, extraction, and further restoration of root‐filled teeth in Sweden in 2009 during a follow‐up period of 5 years and to compare the outcomes in teeth restored with direct or indirect restorations. Methods Data from the Swedish Social Insurance Agency were analyzed, and the frequencies of nonsurgical retreatment, root‐end surgery, extractions, and further restoration were calculated for all teeth registered as root filled during 2009. Chi‐square tests were applied to detect any significant differences in the frequency of further treatment in teeth registered as restored with either a direct or an indirect restoration within 6 months of root filling. Results Of the 248,299 teeth reported root filled in Sweden in 2009, nonsurgical retreatment was registered in 2.2%, root‐end surgery in 1.0%, and extractions in 9.2% during the follow‐up period. Of the teeth restored with a direct restoration within 6 months after the root filling, 30.3% were registered as having undergone at least 1 further direct restoration; the corresponding percentage of teeth with indirect restorations was 6.4%. A statistically significant difference in the frequency of nonsurgical retreatment, extraction, and further restoration was found; teeth restored with an indirect restoration within 6 months of root filling had fewer of these treatments than those restored by direct restoration. Conclusions Low frequencies of nonsurgical retreatment and root‐end surgery were reported 5 years after root filling, whereas extraction was more common. Fewer additional treatment procedures were registered for teeth with indirect restorations than for those with direct restorations.
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AimTo document treatment outcomes and related resources, in patients undergoing root canal treatment (RCT) in county public dental clinics, by monitoring patient records for 12 months from treatment start.MethodologyThe subjects comprised... more
AimTo document treatment outcomes and related resources, in patients undergoing root canal treatment (RCT) in county public dental clinics, by monitoring patient records for 12 months from treatment start.MethodologyThe subjects comprised 243 patients starting RCT at 20 public dental clinics in Västra Götaland county, Sweden. Their computerized dental records were monitored prospectively for a year after starting their endodontic treatment. Treatment was completed with either a root filling or extraction. The following treatment‐specific variables were registered: number of appointments and days until treatment was completed, possible complications and prescriptions for antibiotics, and for the root filled teeth: type of coronal restoration and further procedures undertaken within the year. The treatment outcomes were compared with the preoperative variables and in a logistic regression analysis.ResultsComplete data were available for 240 patients (98.8%): 128 women and 112 men, with a mean age of 48.5 years (SD = 16.3). Molar teeth predominated (n = 113, 47.1%). Most cases were completed with a root filling (n = 169, 70.4%). The remainder were extracted (n = 32, 13.3%) or were still uncompleted (n = 39, 16.3%). On average, a root filling was completed in 2.4 (SD = 0.9) appointments, or extraction at the third appointment (SD = 1.6). The molars were less often completed and often predominant among the extracted teeth. The indication for extraction was often for endodontic or RCT‐related reasons. Most complications were registered in the molars and antibiotics were prescribed in 20 cases. Most root filled teeth were restored with a direct restoration. Four root filled teeth (2.4%) were extracted within the time period.ConclusionsPatient records, followed from the start of treatment, show that 12 months on, the root filling had not been completed in just under 30% of the teeth. Of these, about half were extracted. Of particular concern is the outcome for endodontic treatment of molar teeth. In the general practice setting, molar endodontics are not only technically challenging but also very demanding in terms of chairside resources. In the present study, a successful outcome was achieved in just over half the cases.
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To explain dentists' variation in endodontic retreatment decision making a praxis concept (PC) has been generated. PC assumes that practitioners operate along a health continuum. Various periapical conditions are then perceived as... more
To explain dentists' variation in endodontic retreatment decision making a praxis concept (PC) has been generated. PC assumes that practitioners operate along a health continuum. Various periapical conditions are then perceived as different stages on a continuous health scale, based on their radiographic appearance. PC suggests that an individual's placement of a cut-off point for retreatment on the health continuum to a large extent is dependent on the agent's personal values. In the present study value judgements (utilities) concerning two periapical health states in endodontically treated teeth were investigated among 82 dental students. The two methods used to elicit utilities, a Visual Analogue Scale (VAS) and the Standard Gamble (SG), produced large inter- and intra-individual variations. VAS frequently generated lower utility values. The results obtained in the study satisfy a necessary criterion for the validity of PC and strengthen the position of the theory.
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– Endodontic retreatment decision‐making must include an appraisal of the costs of the different strategies proposed. In addition to direct costs, postoperative discomfort may have other consequences in terms of time off work, unscheduled... more
– Endodontic retreatment decision‐making must include an appraisal of the costs of the different strategies proposed. In addition to direct costs, postoperative discomfort may have other consequences in terms of time off work, unscheduled visits and suffering. To establish a foundation for the appraisal of such indirect and intangible costs the present study was set up in which patients' assessments of pain and swelling after surgical and nonsurgical retreatment procedures were recorded. Ninety‐two patients with 95 root‐filled incisors and canine teeth exhibiting apical periodontitis were included in the study. The mode of retreatment was randomly assigned. Each day during the first post‐treatment week patients assessed their degree of swelling and pain on horizontal 100‐mm visual analog scales (VAS). The scales ranged from “no swelling” to “very severe swelling” and “no pain” to “intolerable pain”, respectively. Consumption of self‐prescribed analgesics and time off work were also recorded. Significantly more patients reported discomfort after surgical retreatment than after nonsurgical procedures. High pain scores were most frequent on the operative day while swelling reached its maximum on the first postoperative day followed by progressive decrease both in frequency and magnitude. Postoperative symptoms associated with nonsurgical retreatment were less frequent but reached high VAS values in single cases. Analgesics were significantly more often consumed after periapical surgery. Patients reported absence from work mainly due to swelling and discoloration of the skin. This was found to occur only after surgical retreatment. Conclusively, surgical retreatment resulted in more discomfort and tended to bring about greater indirect costs than nonsurgical retreatment.
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There is substantial variation amongst dentists in the management of symptom-free periapical lesions in root-filled teeth. It has been suggested that this variation can be understood as clinicians' choice of different cut-off... more
There is substantial variation amongst dentists in the management of symptom-free periapical lesions in root-filled teeth. It has been suggested that this variation can be understood as clinicians' choice of different cut-off points on a continuous periapical health scale (the 'Praxis Concept (PC) theory'). Based on this suggestion, an individual's inclination to propose retreatment can be expressed in the Retreatment Preference Score (RPS). In the present study it was hypothesized that: (i) the PC theory is valid amongst experienced endodontists; and that (ii) interindividual variation in RPS can be explained by a corresponding variation in the perceived benefit of endodontic retreatment. The RPS was determined for 16 experienced Swedish endodontists. The retreatment benefit (RTB) was defined as the gain in utility when a root-filled tooth with a persistent periapical lesion ('health state B') moved to a state where the lesion had healed ('health state A'). For each individual the utility values of the two health states were measured by means of the standard gamble technique. The RPS and RTB were found to be subjected to substantial inter- and intrarater variation. The decision makers acted in accordance with the PC theory. No significant correlation between RPS and RTB was detected. Findings suggest that the PC theory is valid amongst endodontic experts. The study did not support the notion that the more potential utility that could be produced, the more the individual dentist should tend to perform retreatment. However, alternative consequentialist strategies focusing low risk taking may be involved.
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Research Interests: Dentistry, Medicine, Humans, Female, Male, and 15 moreRoot Canal Irrigants, Hydrogen Peroxide, Middle Aged, Sodium Hypochlorite, Endodontics, Randomized Controlled Trial, Calcium Hydroxide, Periodontitis, Root Canal Filling Materials, Dental Pulp Cavity, Randomized Clinical Trial, Root Canal Therapy, Asymptomatic, Oxidants, and root canal obturation
AimTo test the hypothesis that in the daily routine of a specialist clinic in endodontics that irrigation during root canal preparation with 3.0% NaOCl will result in fewer postoperative samples with cultivable bacteria than irrigation... more
AimTo test the hypothesis that in the daily routine of a specialist clinic in endodontics that irrigation during root canal preparation with 3.0% NaOCl will result in fewer postoperative samples with cultivable bacteria than irrigation with 0.5% buffered NaOCl but, at the same time, will not result in a higher frequency of postoperative pain nor swelling.MethodologyTwo hundred ninety‐eight patients were enrolled in the study and were randomly assigned into two groups – 0.5% NaOCl and 3% NaOCl. All endodontic diagnoses were included. Root canal treatment was performed, and bacterial sampling was carried out prior to root filling. The patients were requested to complete a form regarding pain and swelling seven days postoperatively. Fisher’s exact test, Mann–Whitney U‐test, Mantel–Haenszel chi‐squared and the chi‐squared test with a significance level of P < 0.05 were used for statistical analysis. Multivariable logistic regression was used to adjust for confounders.ResultsIn the 0....
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The present study examined the microbiological status of 100 root‐filled teeth with radiographically verified apical periodontitis — the pathology (P) group — and of 20 teeth without signs of periapical pathosis — the technical (T) group.... more
The present study examined the microbiological status of 100 root‐filled teeth with radiographically verified apical periodontitis — the pathology (P) group — and of 20 teeth without signs of periapical pathosis — the technical (T) group. In the P group 117 strains of bacteria were recovered in 68 teeth. In most of the cases examined one or two strains were found. Facultative anaerobic species predominated among these isolates (69% of identified strains). Growth was classified as ‘sparse’ or ‘very sparse’ in 53%, and as ‘heavy’ or ‘very heavy’ in 42%. Enterococci were the most frequently isolated genera, showing ‘heavy’ or ‘very heavy’ growth in 25 out of 32 cases (78%). In 11 teeth of the T group no bacteria were recovered, whilst the remairling nine yielded 13 microbial strains. Eight of these grew ‘very sparsely’. It is concluded that the microflora of the obturated canal differs from that found normally in the untreated necrotic dental pulp, quantitatively as well as qualitative...
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Essentially, root fillings are performed to preserve natural teeth. Over time, however, some root-filled teeth will inevitably be extracted. The aim of this historical prospective cohort study in the adult Swedish population was to... more
Essentially, root fillings are performed to preserve natural teeth. Over time, however, some root-filled teeth will inevitably be extracted. The aim of this historical prospective cohort study in the adult Swedish population was to identify factors associated with extractions within 5 y of registration of a root filling. The cohort consisted of all those whose root fillings had been reported to the tax-funded Swedish Social Insurance Agency (SSIA) in 2009. Demographic data on the individuals registered with a root filling (sex, age, country of birth, disposable income, educational level, and marital status) were received from Statistics Sweden or the SSIA. Dental care setting, tooth type, and any registration of subsequent restorations within 6 mo were received from the SSIA. Multivariable regression analysis was used, and P < 0.05 was considered statistically significant. In total, 216,764 individuals had been registered with at least 1 root filling. Individuals (n = 824) without complete data were excluded from the analyses. After 5 y, 9.3% of the root-filled teeth had been registered as extracted. Logistic regression analysis found significant associations for all variables except country of birth, disposable income, and educational level. The highest odds ratios for extractions were associated with the type of restoration: teeth with no registration of any restoration and teeth with a direct restoration combined with a post were 3 times more likely to undergo extraction than teeth restored with an indirect restoration combined with a post and core. Overall, high odds ratios for extractions were associated with any type of composite restoration, including composite fillings and crowns combined with or without any post. In summary, after root filling in the Swedish adult population, several individual- and tooth-specific variables were associated with extraction. The reasons for the extractions remain to be studied further.
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AimTo (i) investigate the frequency and characteristics of pain and discomfort associated with root filled teeth in adult patients regularly attending the Public Dental Service in Örebro County, Sweden; (ii) assess the association between... more
AimTo (i) investigate the frequency and characteristics of pain and discomfort associated with root filled teeth in adult patients regularly attending the Public Dental Service in Örebro County, Sweden; (ii) assess the association between symptoms and clinical and radiographic findings; and (iii) explore the impact of pain and discomfort from root filled teeth on daily life.MethodologyPatient records of adult patients (≥20 years) scheduled for routine check‐ups in April 2015 were screened to identify individuals with root filled teeth; all patients with ≥1 root filled tooth were asked to participate. The examination comprised of clinical and radiographic examinations and questionnaires on general health, on pain symptoms from root filled teeth and on the impact of pain on daily activities. In a general estimating equation (GEE), examination findings and patient‐related factors were independently analysed in relation to the outcome ‘presence of pain’.ResultsIn total, 550 patients wit...