Two necrotic cases and recall
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From: Maarten Meire
Sent: Wednesday, December 17, 2008 3:34 AM
Subject: [roots] 2 necrotic cases + recall
I'd like to share this one with you. 14 and 16 in the same patient,
both necrotic, CAP, both with draining fistula. 1-step treatment,
usual preparation/irigation protocol and warm vertical obturation.
8 months later, she is free of signs/symptoms/fistula and RX shows
diminishing apical lucencies - Maarten
Hi Maarten, Very nice cases, but indeed the molar should get a
new restoration - Rafael
Hi Maarten, How are you? Thanks for posting.
When I look at the radiographs of the 16, I would expect a
fourth canal. Did you look for it? Did you take a bite-wing to
assess the restorability of the 16? I would replace the
restoration soon. It would be a shame if re-infection occurs
due to the poor restorative margins.
The fistula is gone, so there is definitely improvement,
but it is still early days. The PDL does not
look healed yet, but it is 'at hope' - Suzette
Maarten, The molar root canal is shaped/filed and obturated
beautifully. However, an 8 month recall only tells
us that your patient is probably healing based on lack of
symptoms and no sign of a fistula. I take follow-up
radiographs for up to ten years before I can confidently
file a case in the success category. More significantly
the restoration appears to be compromised distally and
would benefit from a full coverage restoration.
Nice treatment Maarten! - Marc Balson
Marc, Thx for your reaction. I agree 8m is short. That's just
the start. She will be recalled every 12 or 24 months
from now on. Unfortunately I can't show you 10 year recalls,
since I'm practicing only 3 years ;-) !
The problem is: many patients are not interested in these
recalls, or they forget, or they want to have it done by
their GP who either doesnt care or doesn't forward the
X ray or report. The majority of recalls in our office
doesn't show up. Together with the non-response to
restorative advise after endo, these are my biggest
frustrations in referral-based practice...
Concerning the above case: I'm not classifying this one
into the 'succes' category. After 8 months the patient is
free of clinical signs and symptoms, and the radiographs
show improvement of apical lesions (although not complete).
This means my treatment got the healing going and at that
moment it is all I want to know - Maarten
Dear Maarten, I can appreciate that you have been practicing
for 3 years at this point. I only shared my philosophy
about long term post- op follow ups because I truly believe
that everyone who does root canal therapy at the specialty
level or whom aspires to elevate their game to that standard
must accept the relevance of long term outcome studies.
Cases that are 1 or 2 years old post operatively can only
give you input about the prognosis of your treatment not
its final disposition. Dr. Berghman's reference to PAI is
applicable to the cadaver studies Dr. Ostravik utilized
in his seminal article on PAI. However, Kendo correctly
alluded to radiographs are not a good diagnostic tool when
determining healing in chronic apical periodontitis cases.
In fact the literature shows that better than 60% of all
cases deemed healed by virtue of standard radiography are
in fact not healed. I have included two articles of interest
that further amplify my assertions. Read the Estrela article
which came out this year. He uses a modified PAI algorithm
to demonstrate the advantages of CBCT technology of
radiographic interpretation in determining outcomes for CAP.
Holger, my treatment protocols are in constant flux so
sometimes what I did 5 years ago is not what I do today.
However, the basics of cleaning, shaping, sterilizing and
obturating have not significantly changed over the last
20 years. The basic tenets of our specialty rarely do.
As I said I use this as feedback to as a quality control
guide. I think it is imperative that anyone doing quality
root canal therapy must have some form of post op treatment
follow up to gauge their techniques, treatment philosophies
and envelope of comfort with regards to the treatment procedures
they provide to the public. Maarten, don't despair about
lack of compliance with your follow up model. Persistence
and educating your RD's and patients takes time.
Keep at it my friend - Marc
hi marc- totally agree with your statement- BUT: what does it mean
to you personally? you will see the 10y results (btw of the same 2-d x-
rays) and after that you can change or maintain your treatment
protocol- do you have the same materials , the same protocol last 10
y? you are absolutely right- we have dna substitutes and could have
failures years later- but should we change anything cause of that?
if we cant influence the cause of failures what we can do against it?
wouldnt it be a great idea if we have a marker which tells us- if you
see after one year the development in any direction you could await
with a rate of 90% following results after 4-5 y? i would love it.
Dennhardt H, LA
Marc, I don't know if I agree with you re the necessity of
10 years follow up. Why exactly ten years and not less or more ?
We've just been discussing the issue with Dag Orstavik last week end.
One of the things he showed us was the proportion of cases considered
as healed ( PAI scores 1 and 2 ) for each PAI score 1 to 5 at the time
of treatment. He showed data of the periapical changes after treatment
during four year post - op.
Conclusions were that :
- significant healing of AP was seen for all groups at 3 months post-op
- approximately half of the teeth were healed within the first year
- after two years , improvement of periapical status continued similarly
among different preoperative AP groups of teeth
- four out of the five PAI curves never "crossed " in time
From 3 year after treatment on there was hardly any further increase in
the number of healed teeth, except for the PAI 5 group at the time of
This means that at least from an epidemiologic point of view we would
not need to follow up cases for so many years: one year post op seems
to be a reliable predictor for ultimate long term outcome - Jan Berghmans
Hi Jan, Thanks for your thoughtful reply. I guess we will agree to
disagree....respectfully of course. I don't believe a one year post op
follow-up is sufficient time to comprehensively determine a favorable
outcome assessment. Dr.Dag Ostravik's article with Kerekes and Erikson
from the J Endodontic Dental Trama in 1986 was certainly a landmark
article as were his subsequent articles relating to time-course and risk
analysis of developing and healing chronic apical periodontitis in humans.
However, there are many clinicians and researchers who do not share
Dr. Ostravik's enthusiasm for the periapical index scoring system.
The use of two dimensional radiographic interpretation is still subject
to both personal and institutional bias. Furthermore, researchers such
as David Figdor have shown conclusive evidence that microbial DNA can
survive for long periods dormant in seemingly bacteria free canals only
to become activated at a later time by human serum. The host defense
mechanism can break down for many reasons not excluding failure of the
coronal seal, host immune system breakdown due to illness and
pharmaceutical considerations, host virulence factors and substandard
endodontic treatment. From a clinical prospective there are many
factors that contribute to calibrating simple success-failure studies.
I admit to setting an an arbitrary timeline of ten years for my cases.
In effect what this does for me is give me a quality control system
which permits me to evaluate my techniques and endodontic protocols
subject to my own personal biases and the knowledge that I sometimes
have little or no impact on the critical factor of the coronal
seal. We know that digital subtraction has proven to be a less than
successful modality for diagnosing endodontic periapical radiographs
(Ostravik et al; J Endod Dent Traum 1990;6:6 - 11.) I have seen many
cases that appear to heal after 2 to 5 years only to regress or fail
as time progresses. Eriksen's epidemiologic studies employing
the PAI scoring system have no doubt conclusively proven that chronic
apical periodontitis is approaching epidemic proportions globally.
What they haven't convinced me is that the PAI scoring system can be
used effectively as anything other than a broad spectrum outcomes
assessment predictor. I am not convinced that a one year follow up
is sufficient time to conclusively assay our endodontic treatment of
chronic apical periodontitis - Marc
Marc, Great post. I just forwarded this to my postdocs! - Fred
Exactly and well said.
It's been my experience after practicing 20 years in the same location,
that we do indeed have teeth that heal at 2-5 years only to fail
periradicularly, not including catastrophic failure, 5-10 years out
- Joey D
Joey, as good as you and Marc are, how often can you get a patient
back consistently for ten years. I’ve started reviewing all the endo
that I’ve done over the past 38 years and am damned ashamed of some of
the old stuff but old is the key word. It is working as bad as it
looks compared to what we do today.
The statement below was made by Stephen Buchanan on a Roots Day.
I think the same can be said about ten year follow ups. Endodontics,
like the rest of dentistry, is changing so rapidly that ten years
makes things very obsolete when comparing it to five years ago so
where do you start. Before Ken Hargreaves made changes I hear
it took 18 months to get a paper in the JOE. Stephen could have
made that statement also don'’t remember. Heck, in 18 months,
nothing is the same.
Me looking back at the stuff I did starting in 1970 with silver
points right out of the US Army Dental Corps that are still working
…sort of negates a ten year follow up. So many things can go wrong
to ruin endo other than what you guys do that going back ten years
ends up in a sorting out process.
I watched an old grandfathered in endodontist in Jacksonville place
gutta percha points in ZOE sealer and then chase them to the apex
with a red hot silver point. I was amazed. The endo was being done
on a lower molar and it is still in there solid as a rock and she’s
94, 35 years of success using a technique that makes my skin
crawl today. How do you sort out ten year follow-ups on teeth that
break, restoratively leak, crack…etc? Just a question from an old
GP looking back.
the rate of technologic advance in instruments and techniques by
far outstripped the time
lines of more prestigious journals - Guy
Guy, Joey is in Arkansas for treatment so I will answer for both of
us. I think you are confusing two separate issues Guy. Endodontically
technology can change exponentially with time and our knowledge base
in endodontics moves forward with research and clinical trials albeit
it and hopefully more slowly. Technology becomes obsolete because
dental equipment manufacturers continually try to separate you from
your dental dollars with new toys that allow you to skin a cat ten
different ways to Sunday. However, more germaine to the missive you
penned are the tenets and foundations for good endodontic treatment
which do not significantly change unless research and clinical trials
prove there is a needs to for modification or correction in our
treatment philosophies and closely held clinical dogma.
The chronological age of the endodontic procedure only indicates what
toys were used during that era to accomplish successful endodontic
therapy. If the tooth is still symptom free, functional and free of
any evidence of radiographic pathology it doesn't matter to me if the
practitioner used silver points, hedstroms, rat tails or a Black and
Decker drill. Guy, the key element here is successful root canal therapy.
We constantly fall victim to the Sirens call for newer more expensive
technology that makes us faster, more efficient and creates pretty white
lines on our radiographs. There are some very good endodontists out
there that know full well that most of the cases referred to them require
tactile expertise, knowledge of root canal anatomy and and a comprehensive
approach to diagnosis and treatment planning. Instruments are tools to
accomplish those goals not a guarantee of excellence by any means.
I am not a Luddite by any means (a dinosaur if you will). My office is
well stocked with the latest equipment including a microscope in every
operatory and a TDO software program equal to none. However, all this
equipment in the wrong hands means absolutely nothing about the quality
of your work. Quality is determined by a broad endodontic knowledge
base and a post op recall program that annually certifies to you and
you alone that the work you have been doing with the protocols you have
embraced is in fact working. If your success rate is not between 93 to 97 %
perhaps it is time for you to re-evaluate your techniques and treatment
protocols or consider referring your cases out if you are a GP. If you
are an endodontic specialist maybe its time to become a salesperson for a dental
I have been able for the last 20 years to bring in over 60% of my patients
for follow up recall. I do not charge them for this visit and I have
paperwork I send to them to remind them of the need for me to evaluate
the progress of their treatment to insure the tooth is healing properly.
I also tell them this is a two way street, as it allows me to create a
quality control program in my office to insure my treatment concepts
and techniques stand the test of time. I receive a great deal of
satisfaction seeing one of my patients whom I treated 20 years ago coming into
my office for a new tooth and seeing radiographically that the RCT I did for
them in 1983; 1991 or 2001 looks good and functions "just fine" Don't forget
endodontics is a science and an art too. Microscopes and Twisted files are
only vehicles to an end. They are not what ultimately determines you success
or failure as a clinician. Well I'd like to chew the fat with you more Guy
but I'm leaving my office now as there are already 4 inches of snow on the
streets and more to come. Have a good weekend Guy and stay
out of trouble:::))))) - Marc
Marc, Thks for your wise comments .
And btw I don't believe we disagree that much.
I accept without any restriction your criticism about the PAI scoring system.
And I am following you even more the need of putting into perspective the
hi tech craze of endodontics - see my earlier comments on longitudinal
clinical outcome studies in endodontology ( Strindberg 1956 ; Seltzer et al
1963; Kerekes &Tronstad 1979; ;
Orstavik et al 1986; Sjögren et al 1990; Marquis et al 2006 ) on this forum
and the observation that technology has hardly improved the outcome figures since decades.
I strongly believe outcome data represent what is achievable and are extremely
important to the endodontic community as they are to medecine in general for
1) Patients deserve honest information about best treatment for their teeth
based on what is achievable, and not based on what just works in my hands
2) Care providers should be well aware of their own success and failure rates
and try to close the gap between what they achieve and what has been proven
to be achievable
3) Political and strategic " community" decision should be taken based on these
outcome data, not on impressions about what works and what doesn't
4) Thks to outcome figures business driven dentistry - medecine could be countered
No doubt we need long term outcome figures.
But I confess having difficulties to accept that we should on a year basis
recall every single one of the 17 million RCTreated tooth in the US - I don't know
the figures for the rest of the world - together with the 450 million previously
RCTreated teeth. Would the potential benefit weight out the financial, ecological and
irradiation cost ?
If the reason would be personal Q control , couldn't we just agree about
guidelines for selecting only a restricted reliable random sample of the total
amount of teeth we treat and follow only these teeth in time.
If the motivation would be to participate to multicenter long term outcome studies
like Gilberto's doing actually, we would need a strict protocol , and that is not
what most of us are doing now , do we ? ( " seeing one of my
patients whom I treated 20 years ago coming into my office for a new tooth " )
Moreover you - we all - measure our long term results with 2D X rays which
are considered to represent false negatives ( no lesion present ) in 50% of
the cases. Working in that 2 D conventional x ray paradigm we do hardly any
better than what Orstavik did with the PAI . I'd feel even more comfortable
with a calibrated evaluation of my x rays than with my own actual x ray guesswork.
Starting to talk about cone beam technology on the other hand is a totally
different story which doesn't match our actual way of observing outcome results.
I believe we should find a rationale for these recalls and I've only tried
to advocate for the elaboration of recall guidelines. I don't know if the
AAE has been elaborating on the issue . I know that the ESE has some - too -
vague guidelines about recall rates depending of the kind of treatment performed.
My intervention was not that much about the PAI scoring system, but more
about the need for determining ( obvious ) tendencies of post treatment
periapical changes in order to elaborate feasible recall protocols based on the
scientific confirmed susceptibility of success or failure depending on a
set of pre -op , per-op and post-op conditions - Jan
Jan, I'm glad that the content of our correspondence to one another is
decidedly affirmative and professionally respectful. Your sage observations
and opinions certainly resonate with me as well. I too do not believe in the
promiscuous use of radiographs to gratify clinical curiosity when it exists
as a reflexive activity rather than as a meaningful litmus test with
boundaries that are justifiable and responsive to community needs rather than
just for our statistical gratification. My follow up protocol takes into
account those considerations. Aside from the obvious....I use digital
radiography of course.....I further minimize exposure for my returning patients
by standardizing my recall program as follows.
All apical periodontitis cases: 1, 3, 5, and 10 year post op follow ups
Vital cases without trauma: 1, 5, 10 year post op follow ups
Trauma cases vital/non-vital: 6mos.,1, 5, 10 year follow ups
Surgery cases: 1, 5, 10 year post op follow ups
I get somewhere in the neighborhood 60% compliance from my patients on
their 1 year or less follow up visits. Compliance falls to about 38% at
the 3 or 5 year post up visit and the folks that come in at the 10 year post op
appointment are about 9% compliant. Of course I deal with issues of mortality,
patient migration, loss of the tooth treated and a miscellaneous laundry
list of other complications that prevent their return to my office.
Regrettably, I know of no formal or universal guidelines set by the AAE or
endodontic post grad programs in the USA. This protocol is solely one of my
own creation. I'm sure it is our joint desire to see that one day the ESE, IFEAA,
CAE and the AAE shall come to mutual accord on guidelines for long term
outcomes assessment. It is incumbent upon dentists to become more sensitive
to evidenced based practices and join their medical colleagues in the desire to
promote what is best for our patients first and not for our wallets.
I totally agree that using 2D radiographs is an imperfect system at best
and certainly must raise concerns for all of us on the validity of our results not
to mention the inherent biases we all bring to this issue. There is a better way
but unfortunately it has not been formulated yet. Perhaps CBCT technology will
allow us to take the next paradigm shift in assessment metrics. Again
thanks for your thoughtful reply and incisive comments - Marc
Thanks, Marc, and please say hello to Joey. Also, Roots should be aware of
the AMED site for Joey and you and others closer to Joey should let us know
if we need to go back again to the well.
I understand what you are saying totally and I might have been confusing in
my post. I am amazed that you can get 60% of your cases back for follow up.
I do not know a single dang endodontist who even requests follow up.
I get them automatically with recall but some I have to get in for follow up.
I do a programmed recall of endo for two years and then they go on regular
six months with a PAX q 12 months.
It would be hard to gauge my success for the first twenty years because
I was ignorant of some basics because the endo guys around me were ignorant.
I have a very new one nearby who still does not use bleach because it is
dangerous and uses CHX only. He’s three years out of a residency.
Scary isn'’t it. I'’m only tallying retreats/failures and comparing them
with total endo. I’m running at about 94% “success” right now with that
crap Resilon and EndoRez earlier. I’m having a tougher time getting the
referred patients back. Sadly, my colleagues here mostly take a
different view on care than I do.
I get what you are saying about the glitz but surely you cannot totally
discard newer techniques, irrigation systems, files, obturants, etc in
success. As much as we hate posts, I have not one dot of doubt that
there are hundreds of teeth retained in the mouth now in my practice
because of prefab posts. Technology is often within our minds.
I was using ground down bur shanks and even gem clips cut for lower
anteriors for prefab posts back in the seventies and early eighties.
I totally understand that good endodontic principles are the guts of
any endo just as good surgical principles are the guts of surgery and
good restorative principles are the guts of restorative but hellfire,
in every discipline the massive improvement in materials and techniques
has had a major role in improving success rates. We can’t toss
endodontics out of that and discard all new materials and techniques
to a minor role in our improved success. Yea, I do a hell of a lot
better endo than I did a year ago but the stuff I did many years ago
that failed might not have failed if I’d had the irrigation methods
available to me today. That’s just a simple part that I feel has made
a major difference. Maybe ultrasonics were ripping and tearing thirty
years ago in endo but I don’t think so.
I’m one of those fools who thinks he can bond an obturant in a canal
and if that is so, my endo is going to have a much better chance of
success IF I’d preceded that with those basic tenets that you are
talking about. I got this yesterday from someone who had been in hiding
from me for several years and it gave me heart to keep doing what
Who cares what Buchanan says. If he endorses he gets paid for it.
I've used it for five years and done more cases with it than anyone
in the world and know it works (and mine is not a paid endorsement!)
You recognize the language. Stephen Buchanan is teaching and using
Resilon totally in his practice/lectures. Someone had insinuated that
this was only because he was getting paid. Don’t know how my request
to Buchanan to state his affiliation with Sybron got to this class
clinician but it did. He knows it works and I know it works
and it is going to improve success rates long term. Yea, I’ll have
to wait ten years but success rates seldom are improved in leaps and
bounds. They are increased in tiny increments, a little bit at a
time… could be clinician getting better, a new apex locator, a new file,
a new obturant, a new irrigant…something. Personally, I think
that new irrigants are the future of endo. That’s an old man’s guess.
The new obturants are very technique sensitive and some clinicians…even
endodontists…are not going to be able to use them properly but I still have
to say that I have seen massive improvements in all disciplines and
endo is facing even bigger improvements in newer and better scans and
radiology. CT scanning is going to get cheaper and cheaper.
Call it cone beam if you want but it is a mini CT.
In 1967 my father fell dead from a heart attack. He and his physician
knew he had heart problems but in 1967 what was the treatment wasn’t any
meds and wait to die. I walked into our CT department as a guinea pig for
calcium grading for coronary arteries carotids, and the aorta and the
next week I was recovering from three coronary artery stents. We can'’t
discard technology and corporate need to make a buck. They make a buck by
bringing us improvements. You and every endodontist are doing endos that
would not have been possible without NiTi. I know you will not say this is
false because I know that I am and I’m not even in the same CITY that
people like you and Joey are.
No one can ever state that basic principles can be walked around or
discarded. Scott Perkins stated that and I got threatened with a lawsuit
for going after him on stepping around basic principles but from what
I’'ve seen that basic principles don’t change. There simply become more of
them to abide by. You guys are tops ! Respectfully, Guy