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success and failure of endodontic treatment

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nirvana mansour

on 2 August 2015

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Transcript of success and failure of endodontic treatment

Success and Failure of Endodontic Treatment
Evaluation of success of RCT:
CLINICAL RADIOGRAPHIC HISTOLOGICAL
Factors affecting success and failure of RCT in every case
Diagnosis and the treatment planning
Radiographic interpretation
Anatomy of the tooth and root canal system
Debridement of the root canal space
Quality and extent of the apical seal
Quality of post endodontic restoration
Systemic health of the patient
Skill of the operator
In different studies success rate ranges from 54% to 95% for RCT,
Nonsurgical retreatment showed a higher rate of success (83.0%) compared with endodontic surgery (71.8%).
Success is defined by goals established to be achieved so the usual goal of endodontic treatment is to heal or prevent the disease.
Endodntic treatment outcome:
HEALED : both clinical and radiographic presentations are normal.

HEALING: it's a dynamic process, reduced radiolucency combined with normal clinical presentation.

DISEASE: no change or increase in radiolucency, clinical signs may or may not be present.
CLINICAL EVALUATION:
RADIO-GRAPHIC EVALUATION:
Normal lamina dura and PLS
Reduction or elimination of previous rarefaction
No evidence of resorption
A study was undertaken at univ. of washington school reported 91- 95% of all endodontic treatment have a successful outcome.
Also Sjogren and his associates's study on success vs failure reported that 96% success rate of RCT, but this rate dropped to 86% if the pulp is necrotic, and dropped still lower to 62% if the teeth had been retreated.
The definition of success in RCT is ambiguous:
- Stringent: radiographic and clinical normalcy.
- Lenient: only clinical normalcy.
No tenderness to percussion or palpation
Normal tooth mobility
No evidence of subjective discomfort
Tooth having normal form, function, aesthetic
No sign of infection or swelling
No sinus tract or integrated periodontal disease
minimal to no scarring or discoloration
HISTOLOGICAL EVALUATION
Absence of inflammation
Presence of osseous repair and cementum repair
Regeneration of PDL fibres
Absence of resorption and repair of previously resorbed area.
Factors affecting success or failure of a particular case:
Pupal and Periodontal status
Size of periapical radioleucency
Canal anatomy
Crown and root fracture
Iatrogenic errors
Extent and quality of the obturation
Quality of the post endodontic restoration
Time of post treatment evaluation
Local factors affecting success or failure :
Infection
Incomplete debridement of the root canal system
Excessive hemorrhage
Chemical irritants
Iatrogenic errors
INFECTION
Infected and necrotic pulp tissue
main irritant to the periapical tissues.

The host parasite relationship virulence of microorganisms , ability of infected tissues to heal→influence the repair of the periapical tissues
Endo success →debridement
If the apical or coronal rest. are not optimal reinfection will occur.
Main objective of root canal therapy→complete elimination of the microorganisms and their byproducts.
Poor debridement → residual microorganisms, byproducts and tissue debris → recolonize and contribute to endodontic failure
(Grossman 1970)
Incomplete debridement of the root canal system
Excessive hemorrhage
Extirpation of pulp and instrumentation beyond periapical tissues cause Local accumulation of the blood→mild inflammation
Extravasated blood cells and fluid act as foreign body nidus for bacterial growth.
Instrumentation beyond apical foramen→PDL and alveolar bone trauma→the prognosis of endodontic treatment ↓
Over instrumentation
Intracanal medicaments ( e.g FORMCRESOL) →extruded in the periapical tissues→the prognosis of endodontic treatment ↓.
One should take care while Using medicaments to avoid their periapical extrusion
Chemical irritants
Iatrogenic errors
Separated instrument:
Caused by improper or overuse of instruments and forcing them in curved canals.
Prognosis : no much affected in vital pulps poor in necrotic tissue
( Seltzer et al. ).
Canal blockage and ledge formation: Accumulation of dentin chips or tissue debris prevent the instruments to reach its full working length• Ledge formation—straight instruments in curved canals• These lead to bacteria & debris remained and endo failure.
Iatrogenic errors
Perforations: Lack of knowledge of anatomy of the tooth, attention, misdirection of the instruments
Prognosis : location, time, perforation seal and size.
Incompletely filled teeth: Teeth filled more than 2mm short of apex, Several studies shown poor prognosis with underfillings with necrotic pulps


Iatrogenic errors
Anatomic factors:(
acc. to Ostrander 1985)
Such as : overly curved canals, calcifications, numerous lateral and accessory canals, C or S shaped canals• Problems in cleaning and shaping & incomplete filling of root canals lead to endodontic failure.
Partial or complete fractures of roots
Prognosis of teeth: vertical root has poor prognosis than horizontal fractures.
Traumatic occlusion: Cause endo failures because of its effect on periodontium.
Corrosion of root canal filling:
e.g: silver points, mainly at apical and coronal portion.
Overfilling of root canals:
Overfilling extending 2mm beyond radiographic apex, Continuous irritation of the periapical tissues causing endo failure, but According to
Crump (1979)
, it is not necessary to treat overfill unless clinical symptoms develop

Causes: 1. Failure in determine the exact location of the apical foramen. 2. An absence of apical stop or constriction in mature teeth 3. Incorrect selecting of master cone. 4. Open apices.
Iatrogenic error
Nutritional deficiencies
Diabetes mellitus
Renal failure
Blood dyscrasias
Hormonal imbalance
Autoimmune disorders
Opportunistic infections
Aging
Long term steroid therapy
Systemic factors causing endodontic failures
Before going to endodontic retreatment, following factors should be considered:
If the patient asymptomatic, the retreatment should be postponed
Patient’s needs
Strategic importance of the tooth Periodontal evaluation of the tooth
Chair time & cost
The retreatment differ from treatment in its unique consideration and technique.
Before performing to endodontic retreatment following points should be considered:
May to prevent the potential disease
Remove/remade extensive coronal restoration
Technical problems
May not achieve better results
Filling materials have to be removed
Prognosis could be poorer
Patient might be more apprehensive
Case selection for retreatment:
Careful history
Anatomy of root canal
canal curvature
calcifications and unusual configurations
Quality of obturation
Cooperation of the patient
Periapical radiolucency
Quality of the obturation
Apical extension of the obturation material
Bacterial status
Observation period
Post endodontic coronal restoration
Iatrogenic complication
Factors affecting prognosis of endodontic treatment
Unfavorable root anatomy, Untreatable root resorptions or perforations, Root or bifurcation caries, Insufficient crown/root ratio.
Contra-indications of endodontic retreatment
Problems of endodontic retreatment
Unpredictable result• Frustration• Cost factor• Time consuming
Occurence of endodontic failure doesnot depend on
type of tooth to be treated
location of the tooth
age and sex of the patient
cause of the pulpal injury
number of appointment for root canal treatment
type of root canal obturating material
pre and postoperative pain

Treatment options :
Non- surgical root canal re -treatment. (secondary root canal treatment)
Surgical root canal treatment (using endodontic conventional / microsurgical techniques)
Leave alone
Extraction
What are the indications for endodontic microsurgery?
- Failure of endodontic ortho-retreatment
- Teeth with long, wide post( risk of fracture with conventional retreatment)
- Obstruction within the root canal
- Perforation that can't be treated non- surgically
External root resorption
Coexistent periodontal-periradicular lesion
Developing apical cyst, adjacent pulpless tooth
Accessory canal unfilled
Constant trauma
Perforation of the nasal floor
Non-clinical factors  Hysterical  Abusive  Non-compliant
Case Selection
Causes of the endodontic failures: Bacteria somewhere in the root canal system.
Peptostreptococcus was the most prevalent species 16% followed by Streptococcus 14.2%, Porphyromonas 12.2%, and Enterococcus faecalis 9.6%. Strains of P. provetti, S. sanguis, S. salivarius, P. endodontalis, and especially E. faecalis were prevalent in the unsuccessfully-treated root canals ( Gajan et al 2009).
Missed canals
Non surgical retreatment comes with risks:
The clinician is encouraged to remove all restorations from the tooth
Remove the obturation material from all canals
Perform a thorough disinfection of the root canal space Weakening of the tooth structure through unwanted removal of dentin and potential iatrogenic errors .
Unwanted heat generation during post removal can result in damage to the tooth and its surrounding periodontium
Thank u
presented by : Nirvana Khalaf
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