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16"BicHUK стоматологи", № 2, 2018
15. Beloklitskaya G. F. Modern view on the classification of periodontal diseases. Sovremennaya stomatologiya. 2007;3:59-64.
Поступила 29.03.18
UDC 616.314.11-089.004.66: 616.314.16/17
R. A. Kotelevskyi, R. V. Mamedov, S. S. Kobyliak, Ju. S. Guriev
State institution "Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine"
CONDITION OF PERIAPICAL TISSUES IN ENDODONICALLY TREATED TEETH
ABSTRACT
The aim of the study was to evaluate the possible relationship between the quality of restoration of the tooth crown, root canal obturation and periapical status of endodontic teeth. A series of X-ray images from randomly selected patient cards was studied at the Dental Faculty of the Dnepropetrovsk Medical Academy. A total of 1001 endodontically treated teeth restored by permanent restoration were evaluated independently by two experts. According to a predetermined set of radiographic criteria, the technical quality of filling the root canals of the tooth was assessed as good (GE) or poor (PE). In turn, the technical quality of restoration of the tooth crown was also evaluated as good (GR), or poor (PR). Then, the roots of the teeth and the surrounding tissues were evaluated, and according to the available treatment result were classified as successful or unsuccessful. The success rate for all endodontic teeth was 66.4 % (n % 1001). Teeth with root pins had a success rate of 72.7 % (n % 527), the success rate of dental treatment without pins was 64.6% (n % 472). The two groups with technically good endodontics had the highest success rates. In combination with technically good restorations, the success rate was 82% (GE + GR, 82 %), in the case of technically weak restorations, the success rate was 72 % (GE + PR, 72 %). Two groups with technically bad endodontics combined with good restorations or poor restorations had significantly lower success rates (PE + GR, 55 % and PE = PR, 57 %). When assessing the periapical status of endodontic teeth, it was found that the quality of endodontic treatment, evaluated radiographically, is much more important than the quality of restoration of the crown of the tooth. Key words: apical periodontitis; dental treatment; endodontic treatment; periapical repair
Р. А. Котелевський, Р. В. Мамедов С. С. Кобиляк, Ю. С. Гур'эв
Державний заклад «Дншропетровська медична академш МОЗ Украши»
СТАН ПЕР1АП1КАЛЬНИХ ТКАНИН ЗУБ1В П1СЛЯ ЕНДОДОНТИЧНОГО Л1КУВАННЯ
Метою до^дження була ощнка можливого зв'язку мiж яюстю вiдновлення коронки зуба, обтуращею кореневого каналу i перiапикальним статусом ендодонтично лжованих 3y6ie. Були дослiдженi серп рентгетвських зтмюв з випад-ково вибраних карток пацiентiв на стоматологiчномy фа-
культетi Днтропетровськог медичноI академп. В цыому 1001 ендодонтично лжованих зубiв, вiдновленi посттною реставращею, оцтювалися незалежно двома експертами. Згiдно заздалегiдь обраного набору рентгенологiчних кри-терпв, техтчну яюсть заповнення кореневих каналiв зуба оцтювали як добру (СЕ), або погану (РЕ). У свою чергу, те-хтчна яюсть вiдновлення коронки зуба так само оцтюва-лася як добра (GR), або погана (PR). Потiм кортня зубiв i навколишш тканини були оцтет, i вiдnовiдно до наявного результату л^вання класиф^валися як устшт або неус-тшт. Показник устху для вах ендодонтично лжованих зу-бiв склав 66,4% (п % +1001). Зуби з кореневими штифтами мали показник устху 72,7% (п % 527), устштсть л^вання зубiв без штифтiв склала 64,6% (п % 472). У двох груп з техтчно доброю ендодонтiею були найвищi показники устху. У поеднант з техтчно добримиреставращями показник устху становив 82% (СЕ + GR, 82%), вразi ж техтчно по-ганих реставрацт показник устху становив 72% (СЕ + PR, 72%). Двi групи з техтчно поганою ендодонтею, в поеднан-ш з добрими реставращями, або поганими реставращями мали значно нижчi показники устху (РЕ + GR, 55% i РЕ = PR, 57%). При оцтщ периапикального статусу ендодонтично лжованих зубiв з'ясувалося, що яюсть ендодонтичного л^вання, що оцтюеться рентгенологiчно значно важливi-ше, тжяюсть вiдновлення коронки зуба. Ключовi слова: перюдонтит; стоматологiчне л^вання; ендодонтичне л^вання; перiапикальне вiдновлення.
Р. А. Котелевский, Р.В. Мамедов, С. С. Кобыляк, Ю. С. Гурьев
Государственное учреждение «Днепропетровская медицинская академия МЗ Украины»
СОСТОЯНИЕ ПЕРИАПИКАЛЬНЫХ
ТКАНЕЙ ЗУБОВ ПОСЛЕ ЭНДОДОНТИЧЕСКОГО ЛЕЧЕНИЯ
Целью исследования была оценка возможной связи между качеством восстановления коронки зуба, обтюрацией корневого канала и периапикальным статусом эндодонтически леченных зубов. Быти исследованы серии рентгеновских снимков из случайно выбранных карточек пациентов на стоматологическом факультете Днепропетровской медицинской академии. В общей сложности 1001 эндодонтиче-ски леченных зубов, восстановленные постоянной реставрацией, оценивались независимо двумя экспертами. Согласно заранее определенному набору рентгенологических критериев, техническое качество заполнения корневых каналов зуба оценивалось как хорошее (ОЕ), или плохое (РЕ). В свою очередь, техническое качество восстановления коронки зуба так же оценивалось как хорошее (ОР), или плохое (РР). Затем корни зубов и окружающие ткани были оценены, и в соответствии с имеющимся результатом лечения классифицировались как успешные или неуспешные. Показатель успеха для всех эндодонтически леченных зубов составил 66,4 % (п % 1001). Зубы с корневыми штифтами имели показатель успеха 72,7 % (п % 527), успешность лечения зубов без штифтов составила 64,6 % (п % 472). У двух групп с технически хорошей эндодонтией были самые высокие показатели успеха. В сочетании с технически хорошими реставрациями показатель успеха составлял 82% (ОЕ + ОР, 82%), в случае же технически слабых реставраций показатель успеха составлял 72 % (ОЕ + РР, 72%). Две группы с технически плохой эндодонтией в сочетании с хорошими реставрациями, или плохими реставрациями имели значительно более низкие показатели успеха (РЕ + ОР, 55
©КоХе^вку Р.А., Машейоу Р. V., КоЪуИак Б. X, Оиг]вуЗи. Б., 2018.
"BicHUK стоматологИ", № 2, 2018
% и PE = PR, 57 %). При оценке периапикального статуса эндодонтически леченных зубов выяснилось, что качество эндодонтического лечения, оцениваемое рентгенологически значительно важнее, чем качество восстановления коронки зуба.
Ключевые слова: периодонтит; стоматологическое лечение; эндодонтическое лечение; периапикальное восстановление.
Introduction. It is generally accepted that the prognosis of endodontic treatment positively correlates with the technical quality of root filling [1-4]. This seems logical in the sense that the root filling is intended to create a bacterial tight seal on the root canal, so oral bacteria cannot reach the periapical tissues and cause disease. The materials that are available to seal the root canal system are not flawed, and a number of studies using different methods have suggested that even seeming adequate root fillers may not be effective over time [5-9]. Thus, in one of the in vitro studies of coronary leakage of root crops with absent coronal restorations, bacterial products were found on the apex of the teeth after 3 weeks [10]. Undoubtedly, a well-sealing corona restoration is important for protecting the
root filling from the effects of the oral environment. Ray & Trope [11] in a 1995 study attempted to determine the relative importance of root filling and crown repair in establishing and maintaining periapical health in combination with endodontic teeth. Probably somewhat unexpectedly, in their material they found that the quality of crown repair was significantly more important for the long-term success of endodontic treatment than the quality of the root filling itself [11].
This study is important because it is directly related to clinical therapy. At least to some extent, the results undermine the fundamental understanding in endodontics that it is the root filling that creates a tight seal of the bacteria and that restoring the crown maximally protects the root filling and completes the restoration of the tooth in order to function [12]. Thus, it was It is considered that this issue is important enough, and it should be reviewed again. The aim of this study was to duplicate Ray & Trope's work [11] as much as possible, in order to again study the relationship between the quality of crown restoration, root filling and periapical health of endodontic teeth.
Table 1
Success of endodontic treatment in a cross sectional study of dental school patients, Dnipropetrovsk
Medical Academy
n Failure Success Success in percent
Entire material 1001 326 665 66.4%
Teeth with posts 528 154 374 72.0%*
Teeth without posts 473 172 301 64.0%*
* The difference between the success rate of teeth with root canal (P=0.025).
Material and methods. A cross-sectional study was performed by examining full mouth radiographs from randomly selected patient charts at the prosthetic dentistry department, Dnipropetrovsk Medical Academy. The radiographs of the first 1001 endodontically treated teeth with a permanent restoration were evaluated. Two independent observers examined the radiographs using a X-ray viewer with 2X magnification. Teeth with and without posts were examined. Multirooted teeth were categorized by the root with the most incomplete root filling. The teeth were grouped according to the radiographic qualities of the root filling and the coronal restoration as follows:
Good endodontics: All canals obturated. No voids present. Root filling ending between 2 mm short of and 1 mm beyond radiographic apex.
Poor endodontics: Root filling ending more than 2 mm from radiographic apex. Root filling with voids or canals not filled. Root filling poorly dimensioned or poorly condensed.
sts and teeth without posts was not statistically significant
Good restoration: Any permanent restoration that appeared intact radiographically.
Poor restoration: Any permanent restoration with radiographic signs of overhangs, recurrent decay or open margins.
The radiographic appearance of the root and surrounding structures was then evaluated and categorized as follows:
Success: Normal width of periodontal ligament space. Normal appearance of surrounding bone.
Failure: Periradicular radiolucency.
Three observers (KA, LD, IP) were calibrated according to the system of Halse & Molven [13]. The evaluation criteria were discussed before initiation of the study. Forty-seven roots were used for calibration in order to establish a uniform understanding and ap-plication of the criteria. One observer selected the roots and 2 observers examined the radiographs independently. Agreement was reached in 61,7 %. Dis-agreement was dealt with by joint discussion. If consensus was not reached, the
"BÍCHUK cmoMamoMozii", № 2, 2018
third observer made the final decision. After the study, 44 of the first roots that were examined were re-examined. Agreement was reached in 79,5%. After joint discussion there was 100 % agreement.
Differences between the groups were examined statistically using the chi-square test. A P-value _0.01 was considered to indicate statistically significant differences.
Results. The success rate for all endodontically treated teeth («=1001) was 66.4 %. Teeth with root canal posts («=528 had a success rate of 72 % and teeth without posts («=473) had a success rate of 64 %. The difference between the groups with and without posts was not statistically significant (Table 1).
The treatment was rated as Good Endodontics (GE) in 506 teeth. In this group the success rate was 78 %. The group with Poor Endodontics (PE) had a success rate of 55%. The difference between the 2 groups was statistically significant (Table 2). 664 teeth were found to have Good Restorations (GR). The endodontic success rate in this group was 72 %.
The group with Poor Restorations (PR) consisted of 338 teeth and the endodontic success rate in this group was 64%. The difference between the 2 groups was statistically significant.
When the groups with Good Endodontics and Good Restorations (GE=GR, «=364) were combined, the success rate was 82 %. When the groups Good Endodontics and Poor Restorations (GE=PR, «=142) were combined, the success rate was 72%. The difference between the 2 groups was statistically significant (Table 3).
The teeth with Poor Endodontics combined with the teeth with Good Restorations (PE=GR, «=299) gave a success rate of 55% whereas the combination of Poor Endodontics and Poor Restorations (PE=PR, «=196) resulted in a success rate of 57%. The difference between the success rate with Good Endodontics and Poor Endodontics was statistically significant regardless of the quality of the coronal restoration.
Table 2
Periradicular status of groups of teeth with good endodontic treatment, poor endodontic treatment, good coronal restorations and poor coronal restorations
Endodontic treatment Coronal restoration n Failure Success Success in percent
GE Any 506 111 395 78%*
PE Any 495 216 279 55%*
Any GR 664 201 462 72%**
Any PR 338 126 212 64%**
GE=Good Endodontics; PE=Poor Endodontics; GR=Good Restoration; PR= Poor Restoration; Any=Any Quality. *The difference between the success rate of teeth with Good and Poor Endodontics was statistically significant (P<0.001). **The difference between the success rate of teeth with Good and Poor Restoration was stastistically significant (P<0.001).
Table 3
Success rate of endodontic treatment of good or poor quality in teeth with good
or poor coronal restorations
Endodontic treatment Coronal restoration n Failure Success Success in percent
GE GR 364 72 294 82%*
GE PR 142 41 101 72%*
PE GR 299 131 168 55%*
PE PR 196 85 111 57%*
GE=Good Endodontics; PE=Poor Endodontics; GR=Good Restoration; PR= Poor Restoration.
*The difference between the success rate with Good Endodontics and Poor Endodontics was statistically significant (P<0.0001) regardless of the quality of the coronal restoration (GR or PR).
The teeth with Poor Endodontics combined with the teeth with Good Restorations (PE=GR, «=299) gave a success rate of 55 % whereas the combination of Poor Endodontics and Poor Restorations (PE=PR, «=196) resulted in a success rate of 57 %. The difference between the success rate with Good Endodontics and Poor Endodontics was statistically significant regardless of the quality of the coronal
restoration.
The results of the combined groups in teeth with posts and without posts are shown in Tables 4 and 5. The presence of a post did not affect the endodontic success rate negatively in any of the combinations. The lowest success rate (48 %) was found in the combination Poor Endodontics and Poor Restorations (PE=PR) in teeth without posts (Table 5).
"BicnuK cmoMamonozii", № 2, 2018
Table 4
Periradicular status of the various groups of teeth with root canal posts
Endodontic treatment Coronal restoration n Failure Success Success in percent
GE GR 205 33 172 84%*
GE PR 72 21 49 72%*
PE GR 154 66 87 55%*
PE PR 98 33 65 66%*
GE=Good Endodontics; PE=Poor Endodontics; GR=Good Restoration; PR= Poor Restoration.
*The difference between the success rate with Good Endodontics and Poor Endodontics was statistically significant (P_0.0001) regardless of the quality of the coronal restoration (GR or PR).
Table 5
Periradicular status of the various groups of teeth without root canal posts
Endodontic treatment Coronal restoration n Failure Success Success in percent
GE GR 157 37 120 76%*
GE PR 72 21 51 72%*
PE GR 145 64 82 57%*
PE PR 98 51 47 48%*
GE=Good Endodontics; PE=Poor Endodontics; GR=Good Restoration; PR= Poor Restoration.
*The difference between the success rate with Good Endodontics and Poor Endodontics was statistically significant (P<0.0001) regardless of the quality of the coronal restoration (GR or PR).
Discussion. The present study is a cross-sectional study based on evaluation of radiographs. Such a study has certain limitations (13±16), but misinterpretations and misdiagnoses are known to be fairly equally distributed so that the results will be meaningful [17]. Also, the reliability of the present results was strengthened by the fact that a large material was studied.
The overall endodontic success rate was 66.4%. This was in good agreement with the results of other studies of this nature [11, 16, 18, 19]. Of considerable clinical interest was the fact that the presence of root canal posts did not negatively affect the outcome of the endodontic treatment [20]. Because of this, the groups of teeth with posts and without posts were grouped together in the study of the relationship be-tween the quality of the coronal restoration and the root filling and periapical health.
Not unexpectedly the highest success rate (82%) was found in the teeth diagnosed with Good Endodontics and Good Restorations (GE+GR). In the teeth diagnosed with Good Endodontics and Poor Restorations (GE+PR) the success rate dropped 10% to 72%. This difference was statistically significant. Thus, the importance of a well sealing coronal restoration for lasting success of endodontic treatment that was stressed by the findings of Ray & Trope [11] was evident in this study as well.
In the literature there is a consistent association between periapical radiolucency and root canal fillings of poor quality [for review, see 21]. This was con-firmed by the present results. In the teeth diagnosed with Poor Endodontics the success rate dropped and was the same regardless of the quality
of the coronal restoration (PE+GR, 55% and PE+PR, 57%). Thus, if the root canal was not properly obturated, the quality of the coronal restoration had no bearing on the outcome of the endodontic treatment. This finding was in agreement with a recent study from Lithuania [22]. However, it was in clear contrast to the findings of Ray & Trope [11] who conclude that the quality of the coronal restoration is significantly more important than the quality of the root filling in securing periapical health.
Conclusion. The reasons for the discrepancies in the results of the two studies are not immediately clear. We tried to select a material as similar to the American material as we could (dental school patients, Dnipropetrovsk Medical Academy versus dental school patients, Temple University). Certain differences in clinical technique might exist, but since the evaluation criteria were very simple (Good Endodontics vs Poor Endodontics and Good Restoration v. Poor Restoration) it is unclear whether this would have any bearing on the outcome of the studies. In any case, the findings of this study were clear. The quality of the root filling was the most important factor for the outcome of endodontic treatment. If the quality of the root filling was good, a good restoration improved on the endodontic success rate. However, if the quality of the root filling was poor, the quality of the coronal restoration was of no importance for the outcome of the endodontic treatment.
REFERENCES
1. Strindberg L.Z. The dependence of the results of pulp therapy on certain factors. An analytical study based on radiographic and
"BÍCHUK cmoMamoMozii", № 2, 2018
clinical follow up examinations. Acta Odont Scand 2006;14(suppl. 21):1-175.
2. Hommez GMG, Coppens CRM, De Moor RJG. Periapical health related to the quality of coronal restorations and root fillings. International Endodontic Journal. 2002;35(8):680-689.
3. Kerekes K. Radiographic assessment of an endodontic treatment method. J Endod 2008;4:210-3.
4. Sjogren U., Hagglund G., Sundqvist G., Wing K. Factors affecting the long-term results of endodontic treatment. J Endod 2010;16:498±504.
5. Tronstad L., Trope M., Doering A., Hasselgren G. Sealing ability of dental amalgams as retrograde fillings in endodontic therapy. J Endod 2013;9:551±3.
6. Tronstad L., Barnett F., Flax M. Solubility and biocompat-ibility of calcium hydroxide containing sealers. Endod Dent Traumatol 2008;4:152-9.
7. Barnett F., Trope M., Rooney J., Tronstad L. In vivo sealing ability of calcium hydroxide-containing root canal sealers. En-dod Dent Traumatol 2009;5:23-6.
8. Dickson S., Peters D. Leakage evaluation with and without vacuum of two gutta-percha fill techniques. J Endod 2013;19:398± 403.
9. Chailertvanitkul P., Saunders W.P., Saunders E.M., Mackenzie D. An evaluation of microbial coronal leakage in a restored pulp chamber of root-canal treated multirooted teeth. Int En-dod J 1997;30:318-22.
10. Torabinejad M., Ung B., Kettering J.D. In vitro bacterial penetration of coronally unsealed endodontically treated teeth. J En-dod 2010;16:556-9.
11. Ray H.A., Trope M. Peripical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J 1995;28:12-8.
12. Tronstad L. Clinical endodontics. A textbook. New York: Thieme; 2011.
13. Halse A., Molven O. A strategy for the diagnosis of periapical pathosis. J Endod 2006;12:534-8.
14. Eckerbom M., Magnusson T. Evaluation of technical quality of endodontic treatment - reliabilty of intraoral radiographs. En-dod Dent Traumatol 2007;13:259-64.
15. Eriksen H.M. Endodontology - epidemiologic considerations. Endod Dent Traumatol 2011;7:189-95.
16. Eriksen H.M., Bjertness E., Érstavik D. Prevalence and quality of endodontic treatment in an urban adult population in Nor-way. Endod Dent Tramatol 2011;4:122-6.
17. Altman D.G. Practical statistics for medical research. 1st ed. London: Chapman & Hall; 2001: 99-101.
18. Petersson K., Petersson A., Olsson B., Hákansson J., Wennberg A. Technical quality of root fillings in an adult Swedish popula-tion. Endod Dent Traumatol 2006;2:99-102.
19. Eckerbom M., Andersson J-E., Magnusson T. Frequency and technical standard of endodontic treatment in a Swedish popu-lation. Endod Dent Traumatol 2007;3:245-8.
20. Kvist T, Rydin E.. , Reit C. The relative frequency of periapical lesions in teeth with root canal retained posts. J Endod 2009;15:578-80.
21. Friedman S. Treatment outcome and prognosis of endodon-tic therapy. In: érstavik D, Pitt Ford TR, editors. Essential Endodontology. London: Blackwell; 2008:373.
22. Sidaravicius B., Aleksejuniene J., Eriksen H.M. Endodon-tic treatment and prevalence of apical periodontitis in an adult population of Vilnius, Lithuania. Endod Dent Traumatol 2009;15:210-5.
The article was submitted to the editorial office 09.04.18
