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Endo tips    Better Endo    Endo abstracts    Endo discussions

 Two necrotic cases and recall
The opinions within this web page are not ours.Authors have been credited
for the individual posts where they are. -
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 intervention. 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 manufacturing company::::)))))) 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 several reasons: 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 I’'m doing. 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

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