Apical Periodontitis in Root-Filled Teeth: Endodontic Retreatment and Alternative Approaches

140 Pages·2018·4.68 MB·English

by  Thomas Kvist (eds.)

Thomas Kvist
Editor
Apical Periodontitis
in Root-Filled Teeth
Endodontic Retreatment
and Alternative Approaches
123
Apical Periodontitis in Root-Filled Teeth
Thomas Kvist
Editor
Apical Periodontitis in
Root-Filled Teeth
Endodontic Retreatment and
Alternative Approaches
Editor
Thomas Kvist
Department of Endodontology
University of Gothenburg The Sahlgrenska Academy
Gothenburg
Sweden
ISBN 978-3-319-57248-2 ISBN 978-3-319-57250-5 (eBook)
https://doi.org/10.1007/978-3-319-57250-5
Library of Congress Control Number: 2017957215
© Springer International Publishing AG 2018
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Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Thomas Kvist
2 Incidence, Frequency, and Prevalence . . . . . . . . . . . . . . . . . . . . . 7
Fredrik Frisk
3 Aetiology of Persistent Endodontic Infections
in Root-Filled Teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Luis E. Chávez de Paz
4 Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Fredrik Frisk and Thomas Kvist
5 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Thomas Kvist and Peter Jonasson
6 Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Thomas Kvist
7 Surgical Retreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Peter Jonasson and Magnús Friðjón Ragnarsson
8 Non-surgical Retreatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Charlotte Ulin
9 Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Thomas Kvist
10 Alternatives: Extraction and Tooth Replacement . . . . . . . . . . . 117
Pernilla Holmberg
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
v
List of Contributors
Luis E. Chávez de Paz, DDS, MS, PhD Division of Endodontics,
Department of Dental Medicine, Karolinska Institute, Huddinge, Sweden
Fredrik Frisk, DDS, PhD Department of Endodontology, Institute for
Postgraduate Dental Education, Jönköping, Sweden
Department of Endodontology, Institute of Odontology, University of
Gothenburg, The Sahlgrenska Academy, Göteborg, Sweden
Pernilla Holmberg, DDS Department of Oral Prosthodontics and National
Oral Disability Centre, Institute for Postgraduate Dental Education,
Jönköping, Sweden
Peter Jonasson, DDS, PhD Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy, University of Gothenburg, Göteborg,
Sweden
Thomas Kvist, DDS, PhD Department of Endodontology, Institute of
Odontology, The Sahlgrenska Academy, University of Gothenburg, Göteborg,
Sweden
Magnús Friðjón Ragnarsson, DDS Endodontist in private practice,
Reykjavik, Iceland
Charlotte Ulin, DDS Specialist Clinic of Endodontics, Public Dental
Service Västra Götaland, Göteborg, Sweden
vii
1
Introduction
Thomas Kvist
Our discussion will be adequate if it has as much clearness as the subject-matter admits
of, for precision is not to be sought for alike in all discussions,… for it is the mark of an
educated man to look for precision in each class of things just so far as the nature of the
subject admits.
Aristotle (350 BC) Nicomachean Ethics. Translated by W D Ross
Abstract
Diagnosis and treatment of the pathological conditions of the dental pulp
and the periradicular tissues is the primary focus of Endodontology. Over
more than 100 years, clinical experience and scientific research have gen-
erated a substantial base of critical knowledge. Reports published in jour-
nals and textbooks have indeed established the principles for endodontic
therapy. As a consequence, endodontics has become a well-established
and natural branch of restorative dentistry. Billions of teeth are saved from
extraction. However, the powerful diagnostic and treatment potential char-
acterizing endodontology, today has resulted in new clinical, scientific and
ethical challanges.
1.1 Contemporary Endodontics restorative dentistry. Billions of teeth are saved
from extraction and dentistry, at least in devel-
Diagnosis and treatment of the pathological con- oped countries, has abandoned the “Pull and be
ditions of the dental pulp and the periradicular Damned Road” [1].
tissues is the primary focus of Endodontology. The advancement of new instruments and tech-
Over more than 100 years, clinical experience niques for diagnosis and treatment in endodon-
and scientific research have generated a sub- tics has been a predominant feature of research
stantial base of critical knowledge. Reports and development over the past 25 years. By vir-
published in journals and textbooks have tue of the strong technological expansion in the
indeed established the principles for endodon- discipline, endodontic therapy is currently a very
tic therapy. As a consequence, endodontics has feasible and attractive discipline that allows the
become a well- established and natural branch of prudent and skillful endodontists and many gen-
eral dental practitioners to properly manage most
teeth in need of endodontic treatment.
However, in a “globalized world,” the power-
T. Kvist, PhD, DDS ful diagnostic and treatment potential character-
Department of Endodontology, Institute of
izing endodontics, as well as most other disciplines
Odontology, The Sahlgrenska Academy,
in medicine and dentistry, today have resulted in
University of Gothenburg, Göteborg, Sweden
e-mail: [email protected] new clinical, scientific, and ethical challenges.
© Springer International Publishing AG 2018 1
T. Kvist (ed.), Apical Periodontitis in Root-Filled Teeth,
https://doi.org/10.1007/978-3-319-57250-5_1
2 T. Kvist
1.2 The Continued High including preventive measures. Saving teeth by
Prevalence of Caries endodontic treatment risks to become a privi-
in a Growing and Aging lege only for a few [5].
Population
For most of the twentieth century, the incidence 1.4 The Lack of Solid Evidence
of dental caries declined in many developed for Many Methods
countries, but from a worldwide perspective, of Diagnostic and Treatment
dental caries remains the most prevalent human Procedures in Endodontics
ailment. In 2010 it was calculated that 2.4 billion
people were affected by untreated caries in the Several careful analyses of the evidence basis for
permanent dentition. At the same time, the global the methods that we apply in endodontics have
population is growing and the life expectancy is demonstrated extensive shortcomings. The situa-
increasing while tooth loss is decreasing. tion is worrying for diagnostic and treatment
Consequently, the need for “saving teeth” by procedures as well as for evaluation of the results
endodontic therapy is inexhaustible in the fore- of our methods [6]. This is not least when it
seeable future [2]. comes to the presence of apical lesions in root-
In many countries, people keep their teeth lon- filled teeth.
ger, and with increasing age, the prevalence of
the number of teeth in need of endodontic treat-
ment increases [3]. At the same time, the medical 1.5 The Importance of Technical
and technical challenges and d ifficulties may be Skills and Good Clinical
very extensive for the c linician [4]. Judgment
Endodontics is not only about applying best sci-
1.3 The Increasing Costs entific evidence to clinical practice. As a mat-
and Fair Distribution ter of fact, the operator’s clinical expertise and
of High-Quality Dental Care patient’s preferences in any clinical situation are
equally important. There are different forms of
Modern endodontics is associated with seem- skills a good clinician must acquire. The techni-
ingly constant pressure in increasing cost of cal skill a clinician must gain in order to render
delivering endodontic care. During my practice proper treatments can only partially be gained
lifetime, 30 years, I have seen the necessary from research or “reading.” Therefore, practi-
armamentarium for root canal treatment go cal training on models, careful implementation
from some hand files, gutta-percha, chloro- of new clinical methods and watching skillful
form, a few spreaders, and analog X-rays to colleagues at work, and reflecting on what has
ever more expensive technology like micro- been learned are consistently important for the
scopes, Ni-Ti machine driven instruments, development of a skillful endodontist. The clini-
ultrasonics, apexlocators, and CBCT imaging cal situation also demands that dentists exercise
equipment. Whatever new technology the good clinical judgment. This means “to do the
future brings, it is unlikely to reduce the cost of right thing at the right moment.” In the tradition
delivering care. So, one of the big challenges of the works of the Greek philosopher Aristotle,
in the future will be staying current with tech- the ability has been termed “phronesis” and can
nological innovations and scientific develop- be translated to “practical wisdom.” In order to
ment while keeping costs low enough for poor, provide patients with proper clinical care, an
retired, disabled, low, or flat income people to endodontist cannot rely on clinical research only
be able to keep teeth that are in need of end- but needs also the practical skills of a craftsman,
odontic procedures. If not, fewer people can where clinical and moral judgements are integral
afford the cost of high-quality dental care, components [7].
1 Introduction 3
1.6 The Still Large Proportion 1.9 The Possible Link
of Root-Filled Teeth Between General Health
with Less than Entirely and Root Canal Infections
Satisfactory Treatment
Results The availability of information of varying quality
has likely contributed partly to regenerate the
Despite the technological developments in our interest in a possible association between end-
discipline, so far, there is no convincing evidence odontic infections and general health. Our disci-
to suggest that the overall prognosis of root canal pline is facing an inevitable task to better describe
treatments has increased over a period of and evaluate any such connection [11].
50 years. In epidemiological studies, the preva-
lence of apical periodontitis in root-filled teeth
repeatedly is reported to be 25–50% or even 1.10 The Awareness
more. The gap between “what is possible to of the Complexity of Biofilm
achieve” and “what is actually achieved” has to Infections
be analyzed from cognitive, psychological, and
ethical perspectives [8]. The increased understanding of the complexity and
diversity of the biofilms that are present in necrotic
root canals and many root-filled teeth has chal-
1.7 The Implant Threat lenged the view that root canal treatment is about
getting root canals sterile. However, the essential
The history of the dental implant era is not yet objective of endodontic treatment still remains, to
completely written, but the long-term perfor- combat bacterial populations within the root canal,
mance of replacements seems to be equal to at least to significantly reduce to levels that are com-
tooth-supported constructions. The technique is patible with periradicular tissue healing [12, 13].
nowadays spread worldwide. So far the overall
costs of replacing an endodontically involved
tooth with an implant are often higher than 1.11 The Two Sides
those of a root canal therapy. But when more of the CBCT-Coin
and less expensive are brought to the market,
the implant technology may prevail over end- With new technologies, like the advent of CBCT,
odontics and, in particular, when primary root it also stands clear that postoperative situations
canal treatment has failed [9]. without symptoms and even teeth-u nobjectionable
conditions, as can be assessed on an intraoral
X-ray, may still prove to have signs of residual
1.8 The Internet as a Source inflammation and thus accommodate intraoral
of Patients’ Information microorganisms. These observations put your
finger on a crucial point. What should be regarded
Patients’ increased abilities to retrieve informa- as a period or sick and what needs to be treated
tion resulted in a public that is more demanding and what does not need to be addressed? [14, 15]
of better outcomes to treatment [10]. The
To retreat or not to retreat, that’s the question?
response from governments and authorities
could be more regulatory intervention to con-
trol perceived lapses in quality and ethics
among dentists. While the intent would be 1.12 What Is a Disease?
noble, the implementation will probably lead to
an increase in administration time and less time It has been argued that both modern medicine and
to devote to professional development and dentistry face fundamental ethical problems if too
patient care. rigorous and consistent concepts of disease prevail.
4 T. Kvist
The discussion about different concepts of disease ness and sickness” [17]. The triad and its implications
goes back to ancient philosophy and has bewil- on dentistry were elaborated by Hofmann and
dered and engaged philosophers ever since. This Eriksen [18]. Kvist et al. [19] made initial attempts
book about apical periodontitis in root-filled teeth to apply the theory to the problem of asymptomatic
can only hint at the central questions. For further root-filled teeth with apical periodontitis. In a
reading, the interested reader should seek in books Chapter in Molar Endodontics edited by Peters
on philosophy of medicine [16]. 2017, I again and more profoundly discussed “the
Two fundamentally different concepts of dis- triad” from a theoretical point of view [20].
ease can by tradition be recognized. The issue of “apical periodontitis in root-filled
teeth” is very well suited as an example of how
The naturalist theory defines disease in terms of “the triad” can be applied to a human ailment and
biological processes. Disease is a value-free give some new perspectives of this “dilemma”
concept, existing independently of its social that in different ways characterized and plagued
and cultural context. Disease is discovered, our discipline for so many years (Table 1.1).
studied, and described by means of science.
The normativist theory, on the other hand, Disease means the disorder in its’ physical form,
declares that there is no value-free concept of the biological nature, and the clinical and
disease. Rather than discovered, the concept paraclinical findings (histology, microbiology,
of disease is invented. It is contextual and radiography, etc.).
given by convention. Illness is used to describe a person’s own experi-
ence of the disease, how it feels, and what suf-
These theories address different aspects and pose ferings it gives now or in the future. Illness
different challenges to medicine and dentistry. But also includes anxiety and anguish.
the two predominant concepts have been challenged Sickness is the third label; it tries to capture the
for several reasons. For example, they do not neither social role of a person who has illness or dis-
one separately or together fully acknowledge all ease (or both) in a particular cultural context.
important perspectives on human disorders. A dif- What is eligible for being “sick” can conse-
ferent approach is to apply the “triad of disease, ill- quently vary over time and between societies.
Table 1.1 An attempt to apply the triad of disease, illness, and sickness to root-filled teeth with apical periodontitis
Disease Illness Sickness
Phenomena studied Pathophysiological, Pain, swelling, or other Criteria for classification and
histological, microbiological, symptoms present now grading of disease
and radiographic events or in the future
Validity Objective Subjective Intersubjective
Purpose from the To study the medical facts of To identify and describe To decide upon common criteria
professions’ point of apical periodontitis in order to the incidence, frequency, for classification, define different
view improve knowledge of how to and intensity for severities of disease, and
prevent and cure patient-related outcomes construct decision aids to guide
(pain, swelling, spread) clinical action
Purpose from To get an explanation of the To value and accept or To understand what is regarded
patients’ point of situation not accept the situation “sick,” respectively “healthy,” and
view to be helped to make a clinical
decision in his or her situation
Example of issues The biofilm in root-filled teeth. Factors that can predict Reassessment of the criteria for
of concern regarding The immunological response future pain or negative “success” and “failure” following
“apical periodontitis to persistent root canal impact on general health root canal treatment
in root-filled teeth” infection
The three approaches to disease do not replace but complement each other. It is also the case that they are strongly
intertwined. However, using the matrix of “disease,” “illness,” and “sickness” possibly makes it easier to understand and
to identify and rationalize the different natures of questions and discussions.