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E N D O D O N T I C T R E AT M E N T
O U T C O M E S
Guided by:
Dr. K. Madhu Varma
Professor
Presentation by:
M. Sowmya
I MDS
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INTRODUCTION
• Outcome assessment of endodontically treated teeth has been extensively studied.
• The terminology used to assess outcomes is varied and may be confusing to practicing
dentists.
• The knowledge gained from the outcome studies should be applied to the case assessment
before the commencement of endodontic treatment.
• This information must be part of preoperative discussion, treatment planning, and informed
consent
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Methods used to evaluate the outcome of endodontic therapy include :
• clinical examination for resolution of clinical symptoms and signs,
• radiographic evaluation of periapical osseous status,
• and histopathologic findings of biopsy specimens.
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• Clinical judgment of the outcome of treatment is based on the
absence of signs of infection and inflammation,
such as pain, tenderness to pressure/ percussion of the tooth,
tenderness to palpation of the related soft tissues,
absence of swelling and sinus tract,
• radiographic demonstration of
reduction in the size of the periapical lesion (if sufficient time has lapsed),
with a completely normal development of the periodontal ligament space.
• Although the majority of periapical lesions heal within 1 year, healing may continue for up to 4
years or longer.
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STRINDBERG (1956)
• A landmark study on endodontic outcome assessment by Strindberg laid the foundation for
conduct of future endodontic outcome studies.
• The evaluation - was based on comparative analysis of clinical presentation and radiographic
evaluation of the treated tooth at the time of treatment and follow-up examination.
• Determination of endodontic outcome was expressed as “success,” “failure,” or “uncertain”
and became known as Strindberg criteria
Strindberg LZ. The dependence of the results of pulp therapy on certain factors. Acta
Odontol Scand 1956;14:1–175
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SUCCESS
Clinical
• No symptoms
Radiographic
• Contours and width of periodontal ligament are normal
• Periodontal ligament contours are widened mainly around excess root filling
• Lamina dura is intact
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FAILURE
Clinical
• Symptoms present
Radiographic
• Unchanged peri radicular rarefaction
• Decrease in peri radicular rarefaction but no resolution
• Appearance of new rarefaction or an increase in the size of initial rarefaction
• Discontinuous or poorly defined lamina dura
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UNCERTAIN
Radiographic
• Ambiguous or technically unsatisfactory radiograph that could not be interpreted with
certainty
• Peri radicular rarefaction less than 1 mm and disrupted lamina dura
• Tooth extracted prior to recall due to reasons not related to endodontic outcome
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• These criteria were accepted as a standard by which the outcome of endodontically treated
teeth are evaluated and continue to be widely used.
• It became evident that Strindberg criteria were rigid.
• For example, only teeth with complete absence of clinical signs and symptoms and normal
radiographic presentation are classified as “success”.
• In contrast, an asymptomatic tooth with the appearance of broken or poorly defined lamina
dura is classified as uncertain, and clinical judgment is required for its subsequent management.
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BENDER ET AL (1966)
SUCCESS
Clinical
• Absence of pain/swelling;
• disappearance of fistula;
• no loss of function;
• no evidence of tissue destruction
Radiographic:
An eliminated or arrested area of rarefaction after a posttreatment interval of 6 months to 2
years
Bender IB, Seltzer S, Soltanoff W. Endodontic success–a reappraisal of criteria. 1. Oral Surg
Oral Med Oral Pathol 1966;22:780–9. 20/55
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VARIABILITY OF RADIOGRAPHIC
INTERPRETATION
• Radiographs provide a static image of the degree of mineralization in the tooth and its
surrounding periodontal structures.
• For changes in bone to be radiographically apparent, there must be sufficient demineralization
(or remineralization) within the lesion.
• A classic study - showed that periapical lesions confined to the cancellous bone are not
predictably detected
• Furthermore, radiographic evaluations tend to be subjective and influenced by observer bias.
• These data underscore the need to calibrate evaluators and minimize inconsistencies in
radiographic evaluation when designing studies evaluating endodontic treatment outcomes
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PERIAPICAL INDEX
• The periapical index (PAI) is a structured scoring system for categorization of radiographic
features of apical periodontitis.
• It is based on a visual scale of periapical periodontitis severity and was built on a classic study of
histologic-radiologic correlations.
• It is a 5-point ordinal scale:
1. Normal periapical structures
2. Small changes in bone structure with no dimineralization
3. Changes in bone structure with some diffuse demineralization
4.Apical periodontitis with well-defined radiolucent area
5. Severe apical periodontitis, with exacerbating features
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Ørstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic
assessment of apical periodontitis. Endod Dent Traumatol 1986;2: 20–34. 23/55
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• The PAI provides more objective criteria for radiographic evaluation of periapical status of
teeth that have undergone endodontic treatment.
• It has been used in several endodontic outcome studies for the assessment of periapical
status.
• Recently CBCT has found considerable applications in endodontic diagnosis and treatment
planning.
• The CBCT - PAI was developed to apply standardization in approaches to assess the severity
of apical periodontitis by CBCT.
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CBCT - PAI
• This index is a 6-point scale that includes a score (0–5) plus 2 variables that assess expansion
and destruction of cortical bone.The CBCT - PAI scale is as follows:
0: Intact periapical bone structures
1: Diameter of periapical radiolucency 0.5 mm to 1 mm
2: Diameter of periapical radiolucency 1 mm to 2 mm
3: Diameter of periapical radiolucency 2 mm to 4 mm
4: Diameter of periapical radiolucency 4 mm to 8 mm
5: Diameter of periapical radiolucency 8 mm
E: Expansion of periapical cortical bone
D: Destruction of periapical cortical bone
Estrela C, Bueno MR, Azevedo BC, et al. A new periapical index based on cone beam
computed tomography. J Endod 2008;34:1325–31.
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• CBCT is more sensitive than conventional periapical radiography for detection of apical
radiolucencies.
• Thus, it can be expected that the CBCT-PAI likely reduces the number of false-negative
diagnoses on periapical radiographs.
• A recent study demonstrated, however, significant variation in the periodontal ligament space
morphology of clinically healthy teeth.
• This underscores the need to better evaluate and clearly define normal and abnormal features
on CBCT imaging before considering systematic application of this new technology to
outcomes assessment.
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• A series of articles, now known as the TORONTO STUDY, introduced yet another set of
terms deemed more appropriate to assess endodontic treatment results.
• The assessment of outcome was based on the PAI and categorized outcomes as
• “healed” when the PAI score is less than 3 or
• “disease” for PAI scores greater than or equal to 3.
• A novel category, “functional,” was introduced for all teeth that were asymptomatic, regardless
of PAI score.
Friedman S, Mor C. The success of endodontic therapy-healing and functionality. J Calif
Dent Assoc 2004;32:493–503
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THE AMERICAN ASSOCIATION OF
ENDODONTISTS OUTCOME CRITERIA
• Healed - functional*, asymptomatic teeth with no or minimal radiographic periradicular
pathosis
• Nonhealed - nonfunctional, symptomatic teeth with or without radiographic periradicular
pathosis
• Healing - teeth with periradicular pathosis, which are asymptomatic and functional, or teeth
with or without radiographic periradicular pathosis, which are symptomatic but whose
intended function is not altered
• Functional* - a treated tooth or root that is serving its intended purpose in the dentition.
The American Association of Endodontists Communique´ . AAE and Foundation approve
definition of Endodontic Outcomes. Volume XXIX, August/September 2005. Page 3. 28/55
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OUTCOME RATES FOR ORTHOGRADE
ENDODONTIC TREATMENT
• The results of Strindberg’s seminal study on outcomes of endodontic treatment at the end of
the 4-year follow-up are presented.
• The presence of a preoperative periapical radiolucency, denoting apical periodontitis,
represents a powerful prognostic indicator.
Strindberg LZ. The dependence of the results of pulp therapy on certain factors. Acta
Odontol Scand 1956;14:1–175. 29/55
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• A systematic review of clinical studies pertaining to success and failure of nonsurgical
endodontic treatment reported an overall radiographic success rate of 81.5% over a period of
5 years.
Torabinejad M, Kutsenko D, Machnick TK, et al. Levels of evidence for the outcome of
nonsurgical endodontic treatment. J Endod 2005;31:637–46.
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PERIAPICAL SURGERY
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VITAL PULP THERAPY
• The overall goal of vital pulp therapy –
to preserve vitality and functionality of dentin pulp complex in a tooth
that has been challenged with caries, iatrogenic pulp exposure or a traumatic injury,
and diagnosed clinically with reversible pulpitis.
• The ultimate goal of the treatment –
to promote growth and maturation of the immature root
and thereby preserve the natural dentition in young patients.
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INDIRECT AND DIRECT PULP CAPPING
• Indirect pulp capping procedures do not involve direct manipulation of pulp tissue and
preserve nascent odontoblasts
• Direct pulp capping involves placement of dental material, such as
calcium hydroxide, mineral trioxide aggregate (MTA,) or other bioceramic or
calcium silicate based cements directly over an exposed pulp but without pulp tissue removal.
PULPOTOMY
• The pulpotomy procedure involves selective partial pulp amputation based on the extent of
pulpal injury as assessed clinically.
• The remaining pulp stump is covered with an appropriate dental material to promote hard
tissue deposition and apexogenesis
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SUCCESS
Clinical
• Regression of clinical symptoms
• Maintenance of pulp vitality
Radiographic
• Progressive root growth in length
• Maturation of the apex
• Thickening of the root canal walls
FAILURE
Clinical
• Persistence or recurrence of clinical symptoms
• Loss of pulp vitality
Radiographic
• Cessation of root growth
• Cessation of maturation of the apex
• Lack of thickening of root canal walls
OUTCOME ASSESSMENT OF VITAL PULP
THERAPY
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OUTCOME RATES FOR VITAL PULP THERAPY
• A systematic review of vital pulp therapy in permanent teeth with carious pulp exposure
showed that the success rates after 3-year follow-up were 72.9% for direct pulp capping and
up to 99.4% for pulpotomy.
Arguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously
exposed pulp: a systematic review. J Endod 2011;37:581–7.
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APEXIFICATION
• Conventional root canal therapy for immature permanent teeth with a necrotic pulp is
challenging - because of thin, fragile canal walls, and divergent open apex.
• Therefore, when the pulps of immature permanent teeth become necrotic, traditionally,
apexification is the treatment of choice.
• Apexification is defined as a method to induce a calcified barrier in a root with an open apex
or the continued apical development of an incompletely formed root in teeth with necrotic
pulps.
• Apexification - achieved by calcium hydroxide dressing or MTA to create an apical barrier to
prevent extrusion of root canal filling into the periapical tissues.
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SUCCESS
Clinical
• Regression of clinical symptoms
Radiographic
• Resolution of apical radiolucency
FAILURE
Clinical
• Persistence or recurrence of clinical
symptoms
Radiographic
• Lack of resolution of periapical
radiolucency
• Increased size of periapical radiolucency
OUTCOME ASSESSMENT OF
APEXIFICATION PROCEDURES
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OUTCOME RATES FOR APEXIFICATION
THERAPY
• Apexification procedure has shown to have a high success rate in terms of elimination of
clinical symptom/ sign and radiographic resolution of periapical lesion.
• According to a systematic review and meta-analysis comparing apexification of immature teeth
with calcium hydroxide to that of MTA, the clinical outcome of the 2 treatments is similar in
clinical success.
Chala S, Abouqal R, Rida S, et al. Apexification with calcium hydroxide or mineral trioxide
aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2011;112:36–42.
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• The recent systematic review and meta-analysis comparing MTA and calcium hydroxide
apexification of immature permanent teeth reported
the clinical success rate range from 93% to 100% in the MTA groups
and from 87% to 100% in the calcium hydroxide groups.
• The radiographic success rate was
100% in the MTA groups
and ranged from 87% to 93% for the calcium hydroxide groups.
Lin JC, Lu JX, Zeng O, et al. Comparison of mineral trioxide aggregate and calcium
hydroxide for apexification of immature permanent teeth: a systematic review and meta-
analysis. J Formos Med Assoc 2016;115:523–30.
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REGENERATIVE ENDODONTICS
• In 2001, a new treatment procedure, termed, revascularization, was introduced and involved an
immature permanent tooth with a necrotic pulp and apical periodontitis.
• This case report described a technique that allowed further root maturation with thickening
of the canal walls and apical closure.
• Since then, there have been many published reports attesting to the efficacy of regenerative
endodontic protocols which has the potential for strengthening of the root with apposition of
new mineralized tissue.
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OUTCOME ASSESSMENT OF REGENERATIVE
ENDODONTIC PROCEDURES
• The degree of success of regenerative endodontic procedures (REPs) - is largely measured by
the extent to which it is possible to attain primary, secondary, and tertiary goals.
1. Primary goal (essential): the elimination of symptoms and the evidence of bony healing
2. Secondary goal (desirable): increased root wall thickness and/or increased root length
3. Tertiary goal: positive response to vitality testing
• Tooth discoloration is an adverse risk of the procedure and should be considered a patient-
centered outcome.
Geisler TM. Clinical considerations for regenerative endodontic procedures. Dent Clin North
Am 2012;56:603–26.
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SUCCESS
Clinical
• No pain, soft tissue swelling, or sinus tract (primary goal)
• Response to pulp vitality tests (tertiary goal)
Radiographic
• Resolution of apical radiolucency (often observed 6–12 months after treatment) (primary goal)
• Increased width of root walls (this is generally observed 12–24 months after treatment)
(secondary goal)
• Increased root length (secondary goal)
FAILURE
• Non attainment of primary goal
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OUTCOME RATES FOR REGENERATIVE
ENDODONTIC THERAPY
• Studies report that
healing of apical periodontitis occurred in greater than 90% of cases
but changes in the extent of further root development were much more variable.
• There are few systematic reviews of outcomes for REPs.
Diogenes A, Ruparel NB, Shiloah Y, et al. Regenerative endodontics. A way forward.
J Am Dent Assoc 2016;147:372–80.
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• Four cohort studies have assessed changes in root width and length and all 4 reported that
immature teeth treated with REPs showed increased root width and length.
• Studies also compared outcomes of REPs with traditional apexification with either calcium
hydroxide and/or MTA and showed superior outcomes for teeth treated with REPs.
Bose R, Nummikoski P, Hargreaves K. A retrospective evaluation of radiographic outcomes in
immature teeth with necrotic root canal systems treated with regenerative endodontic
procedures. J Endod 2009;35:1343–9.
Jeeruphan T, Jantarat J, Yanpiset K, et al. Mahidol study 1: comparison of radiographic and
survival outcomes of immature teeth treated with either regenerative endodontic or
apexification methods—a retrospective study. J Endod 2012;38: 1330–6.
Nagy MM, Tawfik HE, Hashem AA, et al. Regenerative potential of immature permanent teeth
with necrotic pulps after different regenerative protocols. J Endod 2014;40:192–8.
Alobaid AS, Cortes LM, Lo J, et al. Radiographic and clinical outcomes of the treatment of
immature permanent teeth by revascularization or apexification: a pilot retrospective cohort
study. J Endod 2014;40:1063–70.
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CONCLUSION
• Assessment of endodontic treatment outcomes has evolved from disease-based criteria
proposed by Strindberg to patient-centered values,
• emphasizing survival and function of endodontically treated teeth even in the presence of
inflammatory periapical disease.
• It is important that patients are fully informed of the difference between disease-free and
disease-associated treatment outcome.
• Ideally, disease-free treatment outcome should always be the goal of all endodontic
treatments.
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REFERENCES
• Strindberg LZ.The dependence of the results of pulp therapy on certain factors. Acta Odontol Scand
1956;14:1–175.
• Bender IB, Seltzer S, Soltanoff W. Endodontic success–a reappraisal of criteria. 1. Oral Surg Oral Med
Oral Pathol 1966;22:780–9.
• Bender IB, Seltzer S, Soltanoff W. Endodontic success-a reappraisal of criteria. II. Oral Surg Oral Med
Oral Pathol 1966;22:790–802.
• Ørstavik D, Kerekes K, Eriksen HM.The periapical index: a scoring system for radiographic assessment
of apical periodontitis. Endod Dent Traumatol 1986;2: 20–34.
• Friedman S,Abitbol S, Lawrence HP.Treatment outcome in endodontics: theToronto Study. Phase 1:
initial treatment. J Endod 2003;29:787–93.
• Farzaneh M,Abitbol S, Lawrence HP, et al,Toronto Study.Treatment outcome in endodontics-the
Toronto Study. Phase II: initial treatment. J Endod 2004;30:302–9.
• de Chevigny C, Dao TT, Basrani BR, et al.Treatment outcome in endodontics: the Toronto study–
phase 4: initial treatment. J Endod 2008;34:258–63
53/55
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• Estrela C, Bueno MR,Azevedo BC, et al.A new periapical index based on cone beam computed
tomography. J Endod 2008;34:1325–31.
• Friedman S, Mor C.The success of endodontic therapy-healing and functionality. J Calif Dent
Assoc 2004;32:493–503.
• The American Association of Endodontists Communique´ .AAE and Foundation approve
definition of Endodontic Outcomes.Volume XXIX,August/September 2005. Page 3.
• Bose R, Nummikoski P, Hargreaves K.A retrospective evaluation of radiographic outcomes in
immature teeth with necrotic root canal systems treated with regenerative endodontic
procedures. J Endod 2009;35:1343–9.
• Alobaid AS, Cortes LM, Lo J, et al. Radiographic and clinical outcomes of the treatment of
immature permanent teeth by revascularization or apexification: a pilot retrospective cohort
study. J Endod 2014;40:1063–70.
• Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic treatment outcomes. Dental Clinics. 2017
Jan 1;61(1):59-80.
54/55
05/11/2024 55

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Endodontic treatment outcomes and healing

  • 2. 05/11/2024 2 E N D O D O N T I C T R E AT M E N T O U T C O M E S Guided by: Dr. K. Madhu Varma Professor Presentation by: M. Sowmya I MDS
  • 5. 05/11/2024 INTRODUCTION • Outcome assessment of endodontically treated teeth has been extensively studied. • The terminology used to assess outcomes is varied and may be confusing to practicing dentists. • The knowledge gained from the outcome studies should be applied to the case assessment before the commencement of endodontic treatment. • This information must be part of preoperative discussion, treatment planning, and informed consent 5/55
  • 6. 05/11/2024 Methods used to evaluate the outcome of endodontic therapy include : • clinical examination for resolution of clinical symptoms and signs, • radiographic evaluation of periapical osseous status, • and histopathologic findings of biopsy specimens. 6/55
  • 7. 05/11/2024 • Clinical judgment of the outcome of treatment is based on the absence of signs of infection and inflammation, such as pain, tenderness to pressure/ percussion of the tooth, tenderness to palpation of the related soft tissues, absence of swelling and sinus tract, • radiographic demonstration of reduction in the size of the periapical lesion (if sufficient time has lapsed), with a completely normal development of the periodontal ligament space. • Although the majority of periapical lesions heal within 1 year, healing may continue for up to 4 years or longer. 7/55
  • 8. 05/11/2024 STRINDBERG (1956) • A landmark study on endodontic outcome assessment by Strindberg laid the foundation for conduct of future endodontic outcome studies. • The evaluation - was based on comparative analysis of clinical presentation and radiographic evaluation of the treated tooth at the time of treatment and follow-up examination. • Determination of endodontic outcome was expressed as “success,” “failure,” or “uncertain” and became known as Strindberg criteria Strindberg LZ. The dependence of the results of pulp therapy on certain factors. Acta Odontol Scand 1956;14:1–175 8/55
  • 9. 05/11/2024 SUCCESS Clinical • No symptoms Radiographic • Contours and width of periodontal ligament are normal • Periodontal ligament contours are widened mainly around excess root filling • Lamina dura is intact 9/55
  • 13. 05/11/2024 FAILURE Clinical • Symptoms present Radiographic • Unchanged peri radicular rarefaction • Decrease in peri radicular rarefaction but no resolution • Appearance of new rarefaction or an increase in the size of initial rarefaction • Discontinuous or poorly defined lamina dura 13/55
  • 17. 05/11/2024 UNCERTAIN Radiographic • Ambiguous or technically unsatisfactory radiograph that could not be interpreted with certainty • Peri radicular rarefaction less than 1 mm and disrupted lamina dura • Tooth extracted prior to recall due to reasons not related to endodontic outcome 17/55
  • 19. 05/11/2024 • These criteria were accepted as a standard by which the outcome of endodontically treated teeth are evaluated and continue to be widely used. • It became evident that Strindberg criteria were rigid. • For example, only teeth with complete absence of clinical signs and symptoms and normal radiographic presentation are classified as “success”. • In contrast, an asymptomatic tooth with the appearance of broken or poorly defined lamina dura is classified as uncertain, and clinical judgment is required for its subsequent management. 19/55
  • 20. 05/11/2024 BENDER ET AL (1966) SUCCESS Clinical • Absence of pain/swelling; • disappearance of fistula; • no loss of function; • no evidence of tissue destruction Radiographic: An eliminated or arrested area of rarefaction after a posttreatment interval of 6 months to 2 years Bender IB, Seltzer S, Soltanoff W. Endodontic success–a reappraisal of criteria. 1. Oral Surg Oral Med Oral Pathol 1966;22:780–9. 20/55
  • 21. 05/11/2024 VARIABILITY OF RADIOGRAPHIC INTERPRETATION • Radiographs provide a static image of the degree of mineralization in the tooth and its surrounding periodontal structures. • For changes in bone to be radiographically apparent, there must be sufficient demineralization (or remineralization) within the lesion. • A classic study - showed that periapical lesions confined to the cancellous bone are not predictably detected • Furthermore, radiographic evaluations tend to be subjective and influenced by observer bias. • These data underscore the need to calibrate evaluators and minimize inconsistencies in radiographic evaluation when designing studies evaluating endodontic treatment outcomes 21/55
  • 22. 05/11/2024 PERIAPICAL INDEX • The periapical index (PAI) is a structured scoring system for categorization of radiographic features of apical periodontitis. • It is based on a visual scale of periapical periodontitis severity and was built on a classic study of histologic-radiologic correlations. • It is a 5-point ordinal scale: 1. Normal periapical structures 2. Small changes in bone structure with no dimineralization 3. Changes in bone structure with some diffuse demineralization 4.Apical periodontitis with well-defined radiolucent area 5. Severe apical periodontitis, with exacerbating features 22/55
  • 23. 05/11/2024 Ørstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;2: 20–34. 23/55
  • 24. 05/11/2024 • The PAI provides more objective criteria for radiographic evaluation of periapical status of teeth that have undergone endodontic treatment. • It has been used in several endodontic outcome studies for the assessment of periapical status. • Recently CBCT has found considerable applications in endodontic diagnosis and treatment planning. • The CBCT - PAI was developed to apply standardization in approaches to assess the severity of apical periodontitis by CBCT. 24/55
  • 25. 05/11/2024 CBCT - PAI • This index is a 6-point scale that includes a score (0–5) plus 2 variables that assess expansion and destruction of cortical bone.The CBCT - PAI scale is as follows: 0: Intact periapical bone structures 1: Diameter of periapical radiolucency 0.5 mm to 1 mm 2: Diameter of periapical radiolucency 1 mm to 2 mm 3: Diameter of periapical radiolucency 2 mm to 4 mm 4: Diameter of periapical radiolucency 4 mm to 8 mm 5: Diameter of periapical radiolucency 8 mm E: Expansion of periapical cortical bone D: Destruction of periapical cortical bone Estrela C, Bueno MR, Azevedo BC, et al. A new periapical index based on cone beam computed tomography. J Endod 2008;34:1325–31. 25/55
  • 26. 05/11/2024 • CBCT is more sensitive than conventional periapical radiography for detection of apical radiolucencies. • Thus, it can be expected that the CBCT-PAI likely reduces the number of false-negative diagnoses on periapical radiographs. • A recent study demonstrated, however, significant variation in the periodontal ligament space morphology of clinically healthy teeth. • This underscores the need to better evaluate and clearly define normal and abnormal features on CBCT imaging before considering systematic application of this new technology to outcomes assessment. 26/55
  • 27. 05/11/2024 • A series of articles, now known as the TORONTO STUDY, introduced yet another set of terms deemed more appropriate to assess endodontic treatment results. • The assessment of outcome was based on the PAI and categorized outcomes as • “healed” when the PAI score is less than 3 or • “disease” for PAI scores greater than or equal to 3. • A novel category, “functional,” was introduced for all teeth that were asymptomatic, regardless of PAI score. Friedman S, Mor C. The success of endodontic therapy-healing and functionality. J Calif Dent Assoc 2004;32:493–503 27/55
  • 28. 05/11/2024 THE AMERICAN ASSOCIATION OF ENDODONTISTS OUTCOME CRITERIA • Healed - functional*, asymptomatic teeth with no or minimal radiographic periradicular pathosis • Nonhealed - nonfunctional, symptomatic teeth with or without radiographic periradicular pathosis • Healing - teeth with periradicular pathosis, which are asymptomatic and functional, or teeth with or without radiographic periradicular pathosis, which are symptomatic but whose intended function is not altered • Functional* - a treated tooth or root that is serving its intended purpose in the dentition. The American Association of Endodontists Communique´ . AAE and Foundation approve definition of Endodontic Outcomes. Volume XXIX, August/September 2005. Page 3. 28/55
  • 29. 05/11/2024 OUTCOME RATES FOR ORTHOGRADE ENDODONTIC TREATMENT • The results of Strindberg’s seminal study on outcomes of endodontic treatment at the end of the 4-year follow-up are presented. • The presence of a preoperative periapical radiolucency, denoting apical periodontitis, represents a powerful prognostic indicator. Strindberg LZ. The dependence of the results of pulp therapy on certain factors. Acta Odontol Scand 1956;14:1–175. 29/55
  • 30. 05/11/2024 • A systematic review of clinical studies pertaining to success and failure of nonsurgical endodontic treatment reported an overall radiographic success rate of 81.5% over a period of 5 years. Torabinejad M, Kutsenko D, Machnick TK, et al. Levels of evidence for the outcome of nonsurgical endodontic treatment. J Endod 2005;31:637–46. 30/55
  • 33. 05/11/2024 VITAL PULP THERAPY • The overall goal of vital pulp therapy – to preserve vitality and functionality of dentin pulp complex in a tooth that has been challenged with caries, iatrogenic pulp exposure or a traumatic injury, and diagnosed clinically with reversible pulpitis. • The ultimate goal of the treatment – to promote growth and maturation of the immature root and thereby preserve the natural dentition in young patients. 33/55
  • 34. 05/11/2024 INDIRECT AND DIRECT PULP CAPPING • Indirect pulp capping procedures do not involve direct manipulation of pulp tissue and preserve nascent odontoblasts • Direct pulp capping involves placement of dental material, such as calcium hydroxide, mineral trioxide aggregate (MTA,) or other bioceramic or calcium silicate based cements directly over an exposed pulp but without pulp tissue removal. PULPOTOMY • The pulpotomy procedure involves selective partial pulp amputation based on the extent of pulpal injury as assessed clinically. • The remaining pulp stump is covered with an appropriate dental material to promote hard tissue deposition and apexogenesis 34/55
  • 35. 05/11/2024 SUCCESS Clinical • Regression of clinical symptoms • Maintenance of pulp vitality Radiographic • Progressive root growth in length • Maturation of the apex • Thickening of the root canal walls FAILURE Clinical • Persistence or recurrence of clinical symptoms • Loss of pulp vitality Radiographic • Cessation of root growth • Cessation of maturation of the apex • Lack of thickening of root canal walls OUTCOME ASSESSMENT OF VITAL PULP THERAPY 35/55
  • 38. 05/11/2024 OUTCOME RATES FOR VITAL PULP THERAPY • A systematic review of vital pulp therapy in permanent teeth with carious pulp exposure showed that the success rates after 3-year follow-up were 72.9% for direct pulp capping and up to 99.4% for pulpotomy. Arguilar P, Linsuwanont P. Vital pulp therapy in vital permanent teeth with cariously exposed pulp: a systematic review. J Endod 2011;37:581–7. 38/55
  • 39. 05/11/2024 APEXIFICATION • Conventional root canal therapy for immature permanent teeth with a necrotic pulp is challenging - because of thin, fragile canal walls, and divergent open apex. • Therefore, when the pulps of immature permanent teeth become necrotic, traditionally, apexification is the treatment of choice. • Apexification is defined as a method to induce a calcified barrier in a root with an open apex or the continued apical development of an incompletely formed root in teeth with necrotic pulps. • Apexification - achieved by calcium hydroxide dressing or MTA to create an apical barrier to prevent extrusion of root canal filling into the periapical tissues. 39/55
  • 40. 05/11/2024 SUCCESS Clinical • Regression of clinical symptoms Radiographic • Resolution of apical radiolucency FAILURE Clinical • Persistence or recurrence of clinical symptoms Radiographic • Lack of resolution of periapical radiolucency • Increased size of periapical radiolucency OUTCOME ASSESSMENT OF APEXIFICATION PROCEDURES 40/55
  • 43. 05/11/2024 OUTCOME RATES FOR APEXIFICATION THERAPY • Apexification procedure has shown to have a high success rate in terms of elimination of clinical symptom/ sign and radiographic resolution of periapical lesion. • According to a systematic review and meta-analysis comparing apexification of immature teeth with calcium hydroxide to that of MTA, the clinical outcome of the 2 treatments is similar in clinical success. Chala S, Abouqal R, Rida S, et al. Apexification with calcium hydroxide or mineral trioxide aggregate: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:36–42. 43/55
  • 44. 05/11/2024 • The recent systematic review and meta-analysis comparing MTA and calcium hydroxide apexification of immature permanent teeth reported the clinical success rate range from 93% to 100% in the MTA groups and from 87% to 100% in the calcium hydroxide groups. • The radiographic success rate was 100% in the MTA groups and ranged from 87% to 93% for the calcium hydroxide groups. Lin JC, Lu JX, Zeng O, et al. Comparison of mineral trioxide aggregate and calcium hydroxide for apexification of immature permanent teeth: a systematic review and meta- analysis. J Formos Med Assoc 2016;115:523–30. 44/55
  • 45. 05/11/2024 REGENERATIVE ENDODONTICS • In 2001, a new treatment procedure, termed, revascularization, was introduced and involved an immature permanent tooth with a necrotic pulp and apical periodontitis. • This case report described a technique that allowed further root maturation with thickening of the canal walls and apical closure. • Since then, there have been many published reports attesting to the efficacy of regenerative endodontic protocols which has the potential for strengthening of the root with apposition of new mineralized tissue. 45/55
  • 46. 05/11/2024 OUTCOME ASSESSMENT OF REGENERATIVE ENDODONTIC PROCEDURES • The degree of success of regenerative endodontic procedures (REPs) - is largely measured by the extent to which it is possible to attain primary, secondary, and tertiary goals. 1. Primary goal (essential): the elimination of symptoms and the evidence of bony healing 2. Secondary goal (desirable): increased root wall thickness and/or increased root length 3. Tertiary goal: positive response to vitality testing • Tooth discoloration is an adverse risk of the procedure and should be considered a patient- centered outcome. Geisler TM. Clinical considerations for regenerative endodontic procedures. Dent Clin North Am 2012;56:603–26. 46/55
  • 47. 05/11/2024 SUCCESS Clinical • No pain, soft tissue swelling, or sinus tract (primary goal) • Response to pulp vitality tests (tertiary goal) Radiographic • Resolution of apical radiolucency (often observed 6–12 months after treatment) (primary goal) • Increased width of root walls (this is generally observed 12–24 months after treatment) (secondary goal) • Increased root length (secondary goal) FAILURE • Non attainment of primary goal 47/55
  • 50. 05/11/2024 OUTCOME RATES FOR REGENERATIVE ENDODONTIC THERAPY • Studies report that healing of apical periodontitis occurred in greater than 90% of cases but changes in the extent of further root development were much more variable. • There are few systematic reviews of outcomes for REPs. Diogenes A, Ruparel NB, Shiloah Y, et al. Regenerative endodontics. A way forward. J Am Dent Assoc 2016;147:372–80. 50/55
  • 51. 05/11/2024 • Four cohort studies have assessed changes in root width and length and all 4 reported that immature teeth treated with REPs showed increased root width and length. • Studies also compared outcomes of REPs with traditional apexification with either calcium hydroxide and/or MTA and showed superior outcomes for teeth treated with REPs. Bose R, Nummikoski P, Hargreaves K. A retrospective evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures. J Endod 2009;35:1343–9. Jeeruphan T, Jantarat J, Yanpiset K, et al. Mahidol study 1: comparison of radiographic and survival outcomes of immature teeth treated with either regenerative endodontic or apexification methods—a retrospective study. J Endod 2012;38: 1330–6. Nagy MM, Tawfik HE, Hashem AA, et al. Regenerative potential of immature permanent teeth with necrotic pulps after different regenerative protocols. J Endod 2014;40:192–8. Alobaid AS, Cortes LM, Lo J, et al. Radiographic and clinical outcomes of the treatment of immature permanent teeth by revascularization or apexification: a pilot retrospective cohort study. J Endod 2014;40:1063–70. 51/55
  • 52. 05/11/2024 CONCLUSION • Assessment of endodontic treatment outcomes has evolved from disease-based criteria proposed by Strindberg to patient-centered values, • emphasizing survival and function of endodontically treated teeth even in the presence of inflammatory periapical disease. • It is important that patients are fully informed of the difference between disease-free and disease-associated treatment outcome. • Ideally, disease-free treatment outcome should always be the goal of all endodontic treatments. 52/55
  • 53. 05/11/2024 REFERENCES • Strindberg LZ.The dependence of the results of pulp therapy on certain factors. Acta Odontol Scand 1956;14:1–175. • Bender IB, Seltzer S, Soltanoff W. Endodontic success–a reappraisal of criteria. 1. Oral Surg Oral Med Oral Pathol 1966;22:780–9. • Bender IB, Seltzer S, Soltanoff W. Endodontic success-a reappraisal of criteria. II. Oral Surg Oral Med Oral Pathol 1966;22:790–802. • Ørstavik D, Kerekes K, Eriksen HM.The periapical index: a scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;2: 20–34. • Friedman S,Abitbol S, Lawrence HP.Treatment outcome in endodontics: theToronto Study. Phase 1: initial treatment. J Endod 2003;29:787–93. • Farzaneh M,Abitbol S, Lawrence HP, et al,Toronto Study.Treatment outcome in endodontics-the Toronto Study. Phase II: initial treatment. J Endod 2004;30:302–9. • de Chevigny C, Dao TT, Basrani BR, et al.Treatment outcome in endodontics: the Toronto study– phase 4: initial treatment. J Endod 2008;34:258–63 53/55
  • 54. 05/11/2024 • Estrela C, Bueno MR,Azevedo BC, et al.A new periapical index based on cone beam computed tomography. J Endod 2008;34:1325–31. • Friedman S, Mor C.The success of endodontic therapy-healing and functionality. J Calif Dent Assoc 2004;32:493–503. • The American Association of Endodontists Communique´ .AAE and Foundation approve definition of Endodontic Outcomes.Volume XXIX,August/September 2005. Page 3. • Bose R, Nummikoski P, Hargreaves K.A retrospective evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures. J Endod 2009;35:1343–9. • Alobaid AS, Cortes LM, Lo J, et al. Radiographic and clinical outcomes of the treatment of immature permanent teeth by revascularization or apexification: a pilot retrospective cohort study. J Endod 2014;40:1063–70. • Chugal N, Mallya SM, Kahler B, Lin LM. Endodontic treatment outcomes. Dental Clinics. 2017 Jan 1;61(1):59-80. 54/55