cross-sectional study of endodontic treatment in an australian population

ORIGINAL RESEARCH

Cross-sectional study of endodontic treatment inan Australian populationaej_215 140..146

Katherine Da Silva, BDent(Hons)1; Jasmine M.Y. Lam, BDent(Hons)2; Nina Wu, BDent(Hons)3; andPeter Duckmanton, BDS MDSc FRACDS FICD FPFA4

1 Private Practice, Morphett Vale, South Australia, Australia

2 Endodontics Unit, Sydney Dental Hospital, Surry Hills, New South Wales, Australia

3 Department of General Practice, Westmead Centre for Oral Health, Westmead, New South Wales, Australia

4 Endodontics Unit, Sydney Dental Hospital, Surry Hills, New South Wales, Australia

KeywordsAustralian population, Periapical Index,

standard of root canal therapy.

CorrespondenceDr Peter Duckmanton, Sydney Dental Hospital,

2-14 Chalmers St, Surry Hills,

NSW 2010, Australia. Email:

[email protected]

doi:10.1111/j.1747-4477.2009.00215.x

Abstract

The quality and technical standard of Australian endodontic treatment isgenerally unknown. Two hundred and forty-three patients from a metropoli-tan dental hospital were radiographically assessed for quality of root canaltherapy. Total teeth examined were 5647 with 499 teeth (8.84%) being root-filled. Teeth were scored using Ørstavik’s Periapical Index. Periapical Indexscores indicating a healthy periapical state were found in 392 root-filled teeth(78.56%) and those indicative of periapical disease in 107 root-filled teeth(21.43%). Of the 499 root-filled teeth, 149 (29.9%) were adequate in terms oflength, with 120 teeth (80.5%) of these healthy. Three hundred and fifteenteeth (63.1%) were filled short with 271 (86.0%) classified as healthy. Thirty-five teeth (7.0%) were filled long with only one tooth (2.9%) in this categorydeemed healthy. Four hundred and fifty-nine teeth (92.0%) were adequate indensity, with 365 teeth (79.5%) being healthy. Forty teeth (8.0%) showedinadequate density with 27 (67.5%) being healthy. One hundred and forty-five teeth (29.1%) were adequate in length and density with 117 teeth(80.7%) deemed healthy. A significant statistical correlation between rootfilling quality and periapical status was not found. Factors, such as the coronalrestoration quality, should be further investigated.

Introduction

Several cross-sectional studies performed on root canaltreatment have demonstrated very high success ratesranging from 85% to 95% (1–4). According to Eriksenand Bjertness, this high success rate is due to endodon-tic treatment being performed by specialist endodontistsor undergraduate students supervised in universityclinics (1). It has been reported that success rates ingeneral practice are substantially lower, approximately65–75% success (1,2). This discrepancy in success ratesmay be a reflection in the difference in quality of endo-dontic treatment performed. Epidemiological studies inrelation to the quality of endodontic treatment havedocumented the prevalence of apical periodontitis (AP)in various populations (Table 1). These studies drawattention to the high prevalence of AP, because of the

large number of poorly performed root canal treat-ments (2).

One method of assessing AP is with the Periapical Index(PAI) scoring system described by Ørstavik et al. (18). It isa radiographic interpretation on a 5-point scale in orderof absence to presence and increasing severity of disease,with a score of 1 and 2 classified as healthy and a score of3, 4 and 5 classified as diseased. It uses a reference set ofradiographs with corresponding line drawings and theirassociated score on a photographic print/computer file.The scores are based on a correlation with inflammatoryperiapical status confirmed by histological examination(18). Radiographic assessment of AP and its correspond-ing PAI score is illustrated in Figure 1.

Few studies on the prevalence and quality of endodon-tic treatment have been performed in Australia. Further-more, there is no information on the prevalence of AP in

Aust Endod J 2009; 35: 140–146

140 © 2009 The Authors

Journal compilation © 2009 Australian Society of Endodontology

an Australian population. The aim of the present study isto radiographically assess the prevalence and standard ofroot canal therapy in an Australian population.

Materials and methods

Patient selection

Orthopantamograms (OPGs) of patients presenting toSydney Dental Hospital for dental treatment betweenJune 2006 and June 2008 were included in this researchprogram. A total of 243 radiographs were selected wherethe patient had a root-filled tooth or teeth present on theOPGs, and such patients were then included in the study.Patient details (date of birth, total teeth present, FDI(Fédération Dentaire Internatiónale) notation of root-

filled teeth) were recorded. As this was an anonymousfile audit, there was no requirement for ethical approval.

Radiographic evaluation

Radiological assessment of the OPGs was carried out bytwo assessors. All data obtained were collated and enteredonto spreadsheets to allow for comparison. All radio-graphs were viewed on a viewing box in a darkenedroom, and a binocuscope endodontic magnifier (Troll-plast, Tröllhatten, Sweden) was used to exclude extrane-ous light. When scoring a multi-rooted tooth, the ratingfor the tooth was recorded as the worst rating scored byany root of that tooth.

Root-filled teeth were assessed for length and densityof the root filling. The technical quality of root fillings(length and density) was categorised as follows:

Length

The distance from the termination of the root filling toradiographic apex was measured using a Millimeter Scale(Produits Dentaries, Vevey, Switzerland):Adequate: fill finished 0–2 mm from radiographic apexShort: fill finished >2 mm from radiographic apexLong: root filling material was extruded beyond the

radiographic apex into the periapical region (sealantwas ignored)

Density

The density of the root filling was rated as:Adequate: uniform in radiopaque density without voids

or space between filling and the root canal wall fromits most coronal extent to its most apical extent

Table 1 Prevalence of root canal treatment and apical periodontitis in

international subpopulations

Year Study Population RT (%) AP (%)

1987 Eckerbom et al. (5) Swedish 13.00 26.40


1998 Marques et al. (4) Portuguese 1.55 21.74

1999 Sidarvicius et al. (7) Lithuania 8.22 82.19

2000 De Moor et al. (8) Belgian 6.76 40.71

2000 Kirkevang et al. (9) Danish 4.99 48.95

2004 Jimenez-Pinzon et al. (10) Spanish 2.09 64.52

2005 Tsuneishi et al. (11) Japanese 20.45 40.03

2005 Georgopolou et al. (12) Greek 4.96 60.0

2006 Skudutyte-Rysstad and Eriksen (13) Norwegian 1.54 42.62

2006 Kirkevang et al. (14) Danish 4.99 48.95


2007 Sunay et al. (16) Turkish 5.3 53.62

2008 Gulsahi et al. (17) Turkish 3.3 18.11

AP, apical periodontitis; RT, root canal treatment.

Figure 1 Radiographic assessment of apical periodontitis (18) (used with permission).

K. Da Silva et al. Endodontic Treatment in an Australian Population

141© 2009 The Authors


Inadequate: visible canal space laterally along the fillingor voids within the filling mass or identifiableuntreated canal

The periapical status of the teeth was assessed using thePAI. The results of each assessor’s interpretations of theradiographs were calibrated against a set of 100 referenceteeth. Intra-observer agreement for PAI scores assessed bycalculating Cohen’s Kappa analysis with a value of >0.61was obtained. In the event of a discrepancy in length,density or PAI score, the third assessor determined theresult.

All data were entered on an MS Excel 2007 spread-sheet and then exported to and analysed using SPSS forWindows Version 14.0 (SPSS, Chicago, IL, USA) by astatistician who was not involved in the study. Pearsonc2-test for independence was used to analyse the data anda P-value of 0.05 was considered significant.

In Australia OPGs are taken as general screening radio-graphs and were therefore used in this study. Others haveused OPGs to evaluate the prevalence of root canaltherapy and AP (3,4). Ahlqwist et al. found a high sensi-tivity and specificity in the detection of periapical pathol-ogy using OPGs compared with full-mouth surveys (19).Molander et al. found a similar high specificity in thedetection of periapical radiolucencies in OPGs (20). Theunderestimation of scoring periapical radiolucencies ongood-quality OPGs would thus appear to be low, andhence the validity of evaluating the periapical conditionson OPGs is reliable with the use of Ørstavik et al.’s PAIscoring system (18) open to some debate (21). It mayhave been preferable to obtain periapical radiographs forroot-treated teeth, but as this was a retrospective studythis was not possible.

Results

A total number of 5647 teeth were examined from apool of 243 patients with an average of 23.24 remainingteeth per subject with a range of 6–32. Four hundredand ninety-nine teeth were found to have been root-filled (8.84%). The distribution of the region of theseendodontically treated teeth is illustrated in Table 2,and it was not found to be not statistically significant(P = 0.258). There were a total of 301 root-filledteeth (60.32%) found in the maxilla and 198 root-filledteeth (39.68%) were found in the mandible. The distri-bution of root-filled teeth between men (49.50%) andwomen (50.50%) was not statistically significant(P = 0.868). Figure 2 shows that the distribution ofroot-filled teeth between men (49.50%) and women(50.0%) was not statistically significant (P = 0.868).

The PAI scores for the 499 root-filled teeth are illus-trated in Figure 3. A clinically healthy periapical region

with PAI scores of 1 and 2 was found in 391 of theseroot-filled teeth (78.36%). One hundred and eight teeth(21.64%) displayed radiographic periapical disease, witha PAI score of 3, 4 or 5.

Adequate length was observed in 148 teeth of which120 teeth (80.54%) were regarded as clinically healthy(Fig. 4). Root fillings were short of the radiographic apexin 316 (63.33%) teeth. Of these, 272 (86.08%) teethwere classified as healthy. In 35 teeth the root filling wasfound to extend beyond the radiographic apex and onlyone tooth (2.86%) in this category was deemed healthy.A statistically significant difference was seen betweenroot filling length and PAI score (P < 0.001).

Root filling density was adequate in 459 teeth of which365 teeth (79.52%) were healthy (Fig. 5). Forty teeth(8.02%) were found to be inadequate with 27 of theseteeth (67.50%) deemed healthy. A significant correlationwas observed between root filling material density andPAI score (P < 0.05).

Discussion

This study was a cross-sectional analysis based on retro-spective radiographic data. Therefore, limitations of thistype of study must be taken into account. The maindisadvantage of a cross-sectional study is that it is impos-sible to determine whether a periapical lesion is healingor failing. The radiographs only represent the periapicalstatus of a tooth at the time of radiography. Also, therewas no knowledge of pre-existing conditions prior totreatment, nor the time or place when the endodontictreatment occurred. Additionally, it was unknown if

Male

Female

30

35

25

20

15

10

5

0

0–19

20–2

9

30–3

9

40–4

9

50–5

9

60–6

9

70–7

9

80–8

9

90–9

910

0+

Figure 2 Distribution of patient population by age and sex.

Table 2 Distribution of endodontically treated teeth in the maxilla and

mandible

Location Incisors Canines Premolars Molars

Maxilla 101 (20.24%) 40 (8.02%) 102 (20.44%) 58 (11.62%)

Mandible 16 (3.21%) 8 (1.60%) 80 (16.03%) 94 (18.34%)

Endodontic Treatment in an Australian Population K. Da Silva et al.



endodontic treatment was performed in a standardisedmanner. However, the main advantage of this study wasthe ability to obtain an extensive sample size because ofthe large patient base at Sydney Dental Hospital. Patientspresenting to the hospital are eligible for treatment if theyare holders of Commonwealth Health Care concessioncards and, hence, there was a biased recruitment from a

socioeconomic perspective. However, as a result of thelarge sample size and wide variety of age groups analysed,an estimation of the prevalence and quality of root canaltherapy and AP in patients seeking treatment at theSydney Dental Hospital can be made.

Full-mouth surveys are rarely taken in Australia, andhence OPGs are taken as general screening radiographsand therefore were the radiograph of choice for thisstudy. Other epidemiological studies have used OPGs toevaluate prevalence of root canal therapy and AP (3,4).Ahlqwist et al. showed that OPGs used for epidemiologicaldental studies were acceptable (19). They found a highsensitivity and specificity rate of 86–96% for the detec-tion of periapical pathology compared with full-mouthsurveys. This has also been confirmed by the work ofMolander et al. who showed high specificity in thedetection of periapical radiolucencies in OPGs (20).Muhammed and Manson-Hing reported that the periapi-cal radiolucencies may be found more often in periapicalradiographs than in OPGs; however, the difference wasnot statistically significant (22). The underestimation ofscoring periapical radiolucencies on good-quality OPGs isthus low, and hence the validity of evaluating the peri-apical conditions on OPGs is reliable.

This is the first study to assess the prevalence andstandard of root canal therapy in Australia using PAI. Itwas found that of all teeth assessed, 8.84% were endo-dontically treated, a figure comparable to other interna-tional studies (Table 1).

Root fillings were adequate in both length and densityin 29.06% of cases. This figure is low compared with thatof Barrieshi-Nusair et al. (23) who found that 47.4% ofall root filling were considered technically adequate andChueh et al. (24) who found technically sound root fill-ings in 43.0% in endodontically treated teeth. A possibleexplanation for this low percentage in our study may beattributed to the nature in which the endodontic treat-ment was performed. Barrieshi-Nusair et al. (23) andChueh et al. (24) looked at data from teaching hospitals

Figure 3 Periapical status of root-filled teeth according to Periapical Index score.

Figure 4 Association of root filling length and presence of apical peri-

odontitis (AP). PAI, Periapical Index.

Figure 5 Association of root filling density and presence of apical peri-

odontitis (AP). PAI, Periapical Index.




and public dental hospitals, whereas all of the endodon-tically treated teeth that were analysed were not neces-sarily treated at the Sydney Dental Hospital, but fromprivate clinics performed by general dentists and in somecases the treatment may have been performed overseas.

It was found that the standard of root canal treatmentin an Australian population was high. This finding isbased on the low prevalence of periapical radiolucencydetermined by PAI compared with other countries(Table 1). Of all teeth that were endodontically treated,79.36% were healthy having a PAI score of 1 or 2. This issimilar to our studies (4,25–27). The results of our studysuggest that both length and density of root treatmenthad a significant effect on the periapical status of endo-dontically treated teeth. This is supported by Siqueiraet al. who showed that the most important factor indetermining periapical status was the quality of the rootfilling (28).

Dugas et al. found that the chance of developing AP was2.7 times higher in inadequate root filling density com-pared with adequate root filling density, and 2.5 timesgreater when the root filling length was inadequate(short or long) compared with when it was adequate(27). This study also showed that the odds of AP werethree times higher when the root filling was inadequate,in either density or length, compared with satisfactory.When both the root filling density and length were inad-equate, the odds of AP were 3.3 times higher than withany other root filling quality combination.

Reasons for the failure of endodontic treatment havebeen explored by many studies in the past (4,23–31).Previous research considered prosthetic failures as theprimary factor for the overall failure of endodonticallytreated teeth (25–31). Dugas et al. determined that thequality of both the root filling and the restorationimpacted on the periapical health of root-filled teeth,with the impact of the restoration being most criticalwhen the quality of the root filling is adequate (27).Similar findings by Segura-Egea et al. illustrated that anadequate root filling had a more substantial impact on theoutcome of endodontic treatment than the quality ofcoronal restorations (29).

Kayahan et al. examined 563 endodontically treatedteeth restored with an intracoronal filling (30). Therewere 232 teeth that had inadequate root fillings, and inthese teeth the rate of AP was 55.4%. Only 19.4% ofteeth with an adequate root filling had periapical patho-sis. A similar finding was seen in a study by Kirkevanget al. where a high percentage of teeth with inadequateroot fillings showed signs of AP (9). This study showedthat teeth with adequate length and density of root fill-ings had lower incidences of AP (44.3% and 42% respec-tively) than teeth with inadequate length and density

(57.8% and 67.6% respectively). When all parameters oflength, density and coronal seal were deemed inadequatethe incidence of AP was 78.3%. It was concluded in thisstudy that despite technically adequate endodontic fill-ings, 35.1% of the teeth still had AP indicating that thequality of the root filling is not the only parameter toinfluence periapical status.

Although this present study demonstrated that theperiapical status of a root-filled tooth was strongly influ-enced by the quality of the endodontic treatment, almost20% of teeth deemed as adequately filled still had AP.This is suggestive that the quality of the root filling maynot be the only factor influencing periapical status. Therehave been numerous studies that have showed similarfindings (9,27,31). Segura-Egea et al. looked at the impactof the quality of coronal restoration as well as the rootfilling on the periapical status of root-treated teeth (29). Itwas found that when all three parameters (coronal seal,length and density) were adequate, the probability of APwas significantly lower than any other combination.These findings were in contrast to the results of Siqueiraet al. where the quality of the root filling was found to bethe most critical factor in maintaining periradicularhealth (28). However, the assessment of coronal restora-tion for endodontically treated teeth was beyond thescope of this study.

Conclusion

The prevalence of endodontically treated teeth in anAustralian population (8.84%) is comparable to thosereported in previous studies of other subpopulations. Theprevalence of AP in root-filled teeth was low (21.44%)compared with earlier reports (Table 1). The results of thepresent study indicate that the length and density of roottreatment have a significant correlation with AP. Thepresent study only aimed to determine the prevalence ofroot canal therapy and the prevalence of AP, and henceother factors, such as coronal seal, were not considered.Future studies reviewing the success of endodontic treat-ment should include the status of the coronal seal.

Acknowledgements

The authors would like to thank Dr Michelle Heffernanfor her support and Ms Terry Whittle for assistance withthe statistical analysis.

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cross-sectional study of endodontic treatment in an australian population

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