Endo 21 - Prognosis (Dr. Ptak)

What is the art or act of identifying a disease from its signs and symptoms?

diagnosis

What is the future of the course of a disease, and the chance of recovery from said disease?

prognosis

What is the process of examining whether or not interventions are associated with change (better or worse) in a patient’s health status?

outcome

Why do we evaluate outcomes?

- To assess effectiveness of procedures

- Prioritize factors that influence outcomes

- Determine protocols for treatment

Why do we care about prognosis?

- "Prediction, projection, prophesizing, or foretelling the likely outcome of treatment"

- Not well defined in endo

- Depends on endodontic, periodontal and restorative prognoses

- This can influence your treatment plan!

What are all of the following?

- Presence or absence of pulpal/periapical health/disease, pain and function

- Longevity or tooth survival

- Direct and indirect costs

- Oral health quality of life and esthetics

Types of Outcomes

Success or survival?

Based on specific criteria

success

Success or survival?

Based on how long a tooth was retained in the mouth

survival

Success or survival?

PARL healed, lack of sign and symptoms

success

Success or survival?

Retained in the mouth and functional - at times this can also indicate lack of signs and symptoms

survival

What three factors can affect prognosis?

- Patient factors

- Post-endo restorative factors

- Treatment factors

Does age influence the rates of PA healing?

No

What sex has a higher incidence of flare-ups?

female

HA1c >___% is associated with increased perioperative symptoms, lesions increase in size at faster rate, and decreased success after 2 years

8%

T/F: Patients receiving systemic steroids had decreased tooth longevity

true

T/F: Tooth type influences survival

true

Do the following reduce or increase success?

- Pre-op pain

- Presence and size of PA lesion

- Presence of sinus tract

- Swelling

- Apical resorption

reduce

Vital pulp (reduces or increases) success

increases

What are two post treatment restorative factors?

- Quality/type of restoration

- Use of teeth as abutments and occlusal contacts

What are the four main factors that influence the prognosis of Non-surgical root canal therapy (NS-RCT)?

- Pre-operative periapical radiolucency (PARL)

- Obturation quality

- Obturation length

- Satisfactory coronal seal

The following are other factors that influence the prognosis of what?

- Operator

- Isolation

- Positive culture at time of obturation

- One visit vs two visits

- Clinical attachment loss

- Complications

Non-surgical root canal therapy (NS-RCT)

The Toronto Study Part IV (De Chevigny & Friedman) found that two main factors negatively impacted NSRCT outcomes, what are they?

- Presence of pre-op PA radiolucency

- Number of roots

In the Toronto study, pts without a PARL had what % success?

93%

In the Toronto study, pts with a PARL had what % success?

82%

In the Toronto study, pts with a single root NSRCT had what % success?

93%

In the Toronto study, pts with multiple roots NSRCT had what % success?

84%

Root fillings with no voids and root fillings extending to ___mm within the radiographic apex are considered satisfactory root fillings

2mm

The Toronto Study showed that cold lateral obturation had what % success?

77%

The Toronto Study showed that continuous warm vertical obtruation had what % success?

87%

If a root canal obturation is short >2mm from radiographic apex or past radiographic apex, they had ___% less success

20%

Histologically, obturation success is highest where?

At or short of radiographic apex

What does overfilling a canal lead to?

Foreign body reaction

Ray and Trope Study: What % success?

Good endo + good restoration

91%

Ray and Trope Study: What % success?

Bad endo + good restoration

67%

Ray and Trope Study: What % success?

Good endo + bad restoration

44%

Ray and Trope Study: What % success?

Bad endo + bad restoration

18%

According to Salehrabi & Rotstein, RCT treated teeth with a coronal restoration had a ___% success

97%

According to Salehrabi & Rotstein, RCT treated teeth with a coronal restoration had a 97% success-- the 3% that were unsuccessful, ____% did not have a coronal restoration placed within 3 years

85%

The peak incidence of radiographic healing is at ___ year(s)

1 year

A _____ year follow up after NSRCT, is needed to define success or failure

4 year

Molven, Halse & Fristad study found that to evaluate late healing, more successes were recorded after a ___-__ year follow up after root canal treatment

10-17 year follow up

After a 4 year follow up period, a tooth with no PARL has what % success?

95%

After a 4 year follow up period, a tooth with a PARL has what % success?

86%

After a 8-10 year follow up period, a tooth with no PARL has what % success?

96%

After a 8-10 year follow up period, a tooth with a PARL has what % success?

86%

Salherabi and Rotstein conducted a study where they found that RCTs have a ___% survival rate

97%

T/F Studies have shown that RCT has a success rate >90% with no PARL

true

T/F Studies have shown that RCT has a success rate of about 10% lower with a PARL than without a PARL

true

What are the three main factors that influence the prognosis of RETXT?

- Prior obturation quality

- Respected canal morphology

- Presence of pre-op PARL

The Toronto Study found that outcome of orthograde RETX best when...?

the source of failure can be identified

(Ex: Perforation, Underfill, Overfill, Missed Canal, Periodontal Disease, Wrong Tooth, Fracture, Trauma, Separated Instrument, Coronal Leakage, etc.)

The Toronto Study found that orthograde RETX cases have a ___ % success

82%

The Toronto Study found that orthograde RETX cases have ___ % functional

94%

T/F: Crump and Natkin study showed that poor past fill/treatment gives a better prognosis for RETX

true

When doing RCT RETXT, if the first operated respected the internal morphology of the tooth, what % RETX success rate?

87%

When doing RCT RETXT, if the first operated altered the internal morphology of the tooth, what % RETX success rate?

47%

If there is presence of a pre-op PARL, at 2 years post RETXT, what % are successful?

80%

If there is presence of a pre-op PARL that was >___mm, there was seen to be statistically significant less success

>5mm

What is the RCT RETXT success rate when RCT had adequate fill?

67%

What is the RCT RETXT success rate when RCT had a PARL?

62

All of the following are treatment Factors influencing prognosis of what treatment?

- Microsurgical approach 94% vs traditional root-end surgery 59% (Kim + Kratchman)

- Small vs large (>5mm) periapical lesion

- PARL involving 1 vs 2 cortical plates

- Presence of periodontal involvement

- Absence vs presence of previous surgery

- Magnification vs not

- Minimum root end resection vs bevel

- Ultrasonic tip for retroprep vs a bur

- Use MTA vs amalgam

Surgical RCT

From the Toronto Study, what are the three main factors influencing prognosis of S-RCT?

- Age (>45 yrs 84% success, <45 yrs 68% success)

- Size of surgical crypt (>10 mm 53% success, <10 mm 80% success)

- Pre-operative filling length (Inadequate fill 84% success; adequate fill 68% success)

What is the healed success rate of S-RCT?

74%

What is the functional success rate of S-RCT?

94%

What is the success rate of microsurgery?

94%

According to Von Arx and Friedman, S-RCT has a success rate of __% at 1 year

84%

According to Von Arx and Friedman, S-RCT has a success rate of __% at 5 years

76%

According to Kvist & Reit, due to late failures in apical surgery (traditional technique)and late healing of NS retreatment, success rates of both procedures after __ years are equivalent (approximately 50%).

4 years

T/F According to Torabinejad, There are better success rates for what treatment after 4 years: NS-retreatment or S-RCT?

NS-retreatment

(83% retreatment vs. 71% for surgery after 4 years)

Which has a better success rate (24% higher)?

A) RETX + S-RCT

B) S-RCT alone

A) RETX + S-RCT

According to Zoulo, ________ before apical surgery will increase the chances for healing by 10%.

Retreatment

Re-surgery success rates can be up to ____% if you correct traditional surgical approach.

92%

All of the following are factors influencing what?

- Type of traumatic injury

- Location in the mouth

- Presence of comorbidities or other more serious injuries requiring OMFS/ENT care

- Both chronologic and dental age (stage of root development!)

- Patient compliance/recall

- Operator ability

- Time!

Prognosis of trauma

For long term CAOH direct pulp caps (vital pulp therapy), at both 5 and 10 years, were there more successes or failures?

failures

For direct pulp caps (vital pulp therapy) with MTA and Biodentine, there was a ___% success rate at 3 years

94%

For CaOH pulpotomy (vital pulp therapy), there was a __% success after 3 years

85%

Why does MTA have higher success rates with vital pulp therapy?

- Less inflammation

- More predictable dentin bridging

According to the Measures of Success in Regenerative Endodontic Procedures (AAE 2016), which goal is this?

- The elimination of symptoms and evidence of bony healing (91-94%)

primary (essential)

According to the Measures of Success in Regenerative Endodontic Procedures (AAE 2016), which goal is this?

- Increased root wall thickness and/or increased root length

secondary (desirable)

According to the Measures of Success in Regenerative Endodontic Procedures (AAE 2016), which goal is this?

- Positive response to vitality testing

tertiary

Regenerative endodontics has what % success rate?

100%

Apexification with MTA has what % success rate?

80-89%

T/F: Regeneration vs apexification has no significant difference in resolution of apical healing

true

What is more successful for increasing root lenght and root wall thickness?

A) Regeneration

B) Apexification

A) Regeneration

Define the following:

The mechanical or pathologic communication between the root canal system and the external tooth surface

Perforation

How can you detect a perforation?

- Apex locator

- Radiograph

- Blood on paper point

- Surgical operating microscope

- Periodontal probe

- CBCT

Which is better?

A) Fresh perforation

B) Old perforation

A) Fresh perforation

Which is better?

A) Small perforation

B) Large perforation

A) Small perforation

(Small usually associated with less tissue destruction, healing is more predictable, easier to seal effectively without forcing material into surrounding tissue)

Which is better?

A) Crestal perforation

B) Apical/coronal perforation

B) Apical/coronal perforation

What is the most important factor affecting prognosis?

Level of the crestal bone and epithelial attachment critical

What material is superior for perforation repair?

MTA

What is the success of a perforation with MTA?

86%

If the pre-op was vital and uninfected, with no apical pathology, the separated instrument (should or should not) affect the prognosis

Should not

(92% healing rate w/ retained instrument; 95% success w/o retained instrument)

T/F: Outcome is better if canal was instrumented to a smaller size before the separation occurred

False - Outcome is better if canal was instrumented to a larger size before the separation occurred.

T/F If the tooth was vital and there was no pre-op PARL, then separated instrument should not affect prognosis

true

What are three anatomical structures of concern with extrusion of an RCT?

- IAN

- Mental foramen

- Maxillary sinus

Prognosis of Extrusion depends on what 2 factors?

- Type of material (gutta percha, calcium hydroxide, bioceramics)

- Proximity to anatomic structures

All of the following are true from studies about extrusion EXCEPT:

A) Extrusion of obturation material caused foreign body reaction

B) When sealer and/ or the gutta percha are extruded into the periapical tissue, there was always a severe inflammatory reaction including a foreign body reaction

C) Extrusion increases intra-appointment pain, especially in non-vital teeth

D) A sealer puff indicates thorough and complete cleaning, shaping, and obturation of canal system

C) Extrusion increases intra-appointment pain, especially in non-vital teeth (should be VITAL teeth)

T/F: Success rates are equivalent for RCT and implants (94%) however implant need 5-12% more surgical intervention.

true

The size of the lesion influences the outcome of the RCT. Larger lesions are more likely to be of _______ origin

Cystic

A study from Weiger stated that a lesion that is larger than ___mm has less chance to heal w/o surgical intervention. Whereas another study from Sandqvist and Bystrom stated that the size of the lesion does not affect prognosis.

5mm