Eyal Rosen

Diagnosis of Vertical Root Fractures in Endodontically Treated Teeth Based on Clinical and Radiographic Indices: A Systematic Review

INTRODUCTION The diagnosis of vertical root fracture (VRF) is at times complicated for lack of specific signs, symptoms, and/or radiographic features. The purpose of this study was to systematically search and evaluate the literature regarding the diagnostic accuracy of clinical signs and symptoms and radiographic indices for the diagnosis of VRF in endodontically treated teeth by means of a systematic review. METHODS An exhaustive literature search combined with strict inclusion and exclusion criteria was undertaken to identify clinical studies that assessed the diagnosis of VRF. RESULTS There is no substantial evidence regarding the accuracy of the clinical and radiographic indices for the diagnosis of VRF in endodontically treated teeth. CONCLUSIONS Evidence-based data concerning the diagnostic accuracy and clinical effectiveness of clinical and radiographic dental evaluation for the diagnosis of VRF in endodontically treated teeth are lacking. The need for evidence-based research efforts to elucidate the currently unknown situation is of utmost significance.

Outcome of Surgical Endodontic Treatment Performed by a Modern Technique: A Meta-analysis of Literature

INTRODUCTION Numerous studies dealing with the outcome of surgical endodontic treatment have been published. However, study design, treatment protocols, follow-up periods, and inclusion and exclusion criteria are extremely variable. Thus, variable and confusing results have been reported. The aim of the present study was to assess the outcome of surgical endodontic treatment performed with a modern technique and to evaluate factors influencing the outcome by means of a meta-analysis. METHODS An exhaustive literature search combined with strict inclusion and exclusion criteria was undertaken to identify prospective case series or randomized clinical trials that deal with surgical endodontic treatment. RESULTS A successful outcome in a follow-up of more than 1 year postoperatively was 91.6%. Age, gender, tooth type, root-end filling material, and magnification type had no significant effect on the proportion of success. CONCLUSIONS Surgical endodontic treatment done by using a modern technique is a predictable treatment. Additional large-scale prospective clinical studies are needed to evaluate possible predictors of success and failure.

Outcomes of Surgical Endodontic Treatment Performed by a Modern Technique: An Updated Meta-analysis of the Literature

INTRODUCTION Numerous studies on outcomes of surgical endodontic treatment have been published to date. However, study designs, treatment protocols, follow-up periods, and inclusion and exclusion criteria have been extremely heterogeneous. Thus, inconsistent and confounding results have been reported. The aim of this systematic review of the literature was to assess the outcomes of surgical endodontic treatment performed using a modern technique, and to evaluate factors potentially influencing the outcome. METHODS Strict inclusion and exclusion criteria were adopted in order to identify randomized clinical trials, controlled trials, and prospective case series that studied surgical endodontic treatments. Treatment success rates were pooled, and the effect of various factors on treatment outcomes was evaluated. RESULTS In a follow-up of 1 year postoperatively, a successful outcome was achieved in 89.0% of patients. The outcomes obtained in studies using an operative microscope versus an endoscope were not significantly different, but both magnification devices were associated with significantly better outcomes than loupes. The use of MTA and of an operative microscope was associated with better outcomes compared with other retrofilling materials or magnification devices, respectively. CONCLUSIONS Surgical endodontic treatment performed in a modern technique is a viable treatment option. The type of retrofilling material and magnification device may affect the outcome. Additional large-scale prospective clinical studies are needed to further evaluate possible predictors of success and failure.

Effect of Guided Tissue Regeneration on the Outcome of Surgical Endodontic Treatment: A Systematic Review and Meta-analysis

INTRODUCTION The use of guided tissue regeneration (GTR) techniques has been proposed as an adjunct to endodontic surgery in order to promote bone healing. Studies assessing the added benefits of GTR for the outcome of endodontic surgery are significantly variable in their treatment protocols, follow-up periods, and inclusion criteria, thus generating inconsistent and confusing results. The aim of this study was to evaluate the influence of GTR on the outcome of surgical endodontic treatment by means of a systematic review of the literature and meta-analysis. METHODS An exhaustive literature search combined with strict inclusion and exclusion criteria was undertaken to identify clinical studies that assessed the added benefit of GTR in endodontic surgery. RESULTS A trend of better outcome was found when GTR was used compared to control cases, but the results were not statistically significant. Lesion size, lesion type, and membrane type were identified as factors significantly affecting the outcome of GTR versus control cases. GTR techniques favorably affected the outcome of surgical endodontic treatments in cases of large periapical lesions and through-and-through lesions. A favorable outcome was found when using a resorbable membrane over using a nonresorbable membrane or graft alone. CONCLUSIONS GTR techniques may improve the outcome of bone regeneration after surgical endodontic treatments of teeth with certain lesions. Additional large-scale prospective clinical studies are needed to further evaluate possible benefits of GTR techniques in endodontic surgery.

Risk Management in Endodontics

INTRODUCTION Endodontic claims are the most frequently filed malpractice claims in dentistry. The aim of this study was to categorize and review errors and complications related to endodontic procedures that resulted in legal actions against the treating practitioner. METHODS All dental malpractice complaints reported to the Medical Consultants International Company (MCI) in Israel between the years 1992-2008 were retrospectively analyzed according to a structured form. All complaints were categorized as either financial risk bearing (eg, justified) or financial non-risk bearing (eg, nonjustified). The treatment errors that were found in the files were categorized according to phases of treatment: preoperative, intraoperative, and postoperative errors. RESULTS A total of 720 complaints were analyzed including 520 complaints (72.2%) that were found to be justified and 200 complaints (27.8%) that were judged as not justified. Most of the treatment errors occurred during the intraoperative phase. In lower anterior teeth and in cases involving more than 1 tooth, significantly more errors were found during instrumentation and root canal filling (P < .05). There was a similar distribution of operator errors and of negative outcomes for teeth with elective endodontic treatment and teeth with endodontic treatment as a result of a pathologic process. CONCLUSIONS The technical skills of the dental practitioners performing root canal treatments require improvement. All possible risks and complications should be considered and explained to the patient before treatment.

Prevalence and Associated Periodontal Status of Teeth with Root Perforation: A Retrospective Study of 2,002 Patients' Medical Records

INTRODUCTION Various procedures along the course of an endodontic treatment may lead to perforations. The prognosis of perforated teeth depends on perforation location, perforation size, and time from occurrence. The aim of this study was to retrospectively evaluate the prevalence of root perforations and associated pathological changes in the adjacent periodontal tissues. METHODS Full periapical status surveys and medical records of 2,002 patients with a total of 56,175 teeth were evaluated. RESULTS Of a total of 5,048 root canal-treated teeth, 116 root perforations were identified in 101 patients. Associated pathological changes in the adjacent periodontal tissues were identified in 81 teeth with perforations. The patients age, perforation location and size, and tooth type significantly influenced the occurrence of perforation associated periodontal damage. CONCLUSIONS When a perforation occurs, the main treatment goal is to prevent long-lasting injury to the periodontium. Better knowledge of the prevalence of perforations and their possible predictors may assist the clinician in the prevention and treatment of iatrogenic root perforations.

The Diagnostic Efficacy of Cone-beam Computed Tomography in Endodontics: A Systematic Review and Analysis by a Hierarchical Model of Efficacy

INTRODUCTION The aim of this study was to evaluate the diagnostic efficacy of cone-beam computed tomographic (CBCT) imaging in endodontics based on a systematic search and analysis of the literature using an efficacy model. METHODS A systematic search of the literature was performed to identify studies evaluating the use of CBCT imaging in endodontics. The identified studies were subjected to strict inclusion criteria followed by an analysis using a hierarchical model of efficacy (model) designed for appraisal of the literature on the levels of efficacy of a diagnostic imaging modality. RESULTS Initially, 485 possible relevant articles were identified. After title and abstract screening and a full-text evaluation, 58 articles (12%) that met the inclusion criteria were analyzed and allocated to levels of efficacy. Most eligible articles (n = 52, 90%) evaluated technical characteristics or the accuracy of CBCT imaging, which was defined in this model as low levels of efficacy. Only 6 articles (10%) proclaimed to evaluate the efficacy of CBCT imaging to support the practitioners decision making; treatment planning; and, ultimately, the treatment outcome, which was defined as higher levels of efficacy. CONCLUSIONS The expected ultimate benefit of CBCT imaging to the endodontic patient as evaluated by its level of diagnostic efficacy is unclear and is mainly limited to its technical and diagnostic accuracy efficacies. Even for these low levels of efficacy, current knowledge is limited. Therefore, a cautious and rational approach is advised when considering CBCT imaging for endodontic purposes.

Cone beam computed tomography for the diagnosis of vertical root fractures: a systematic review of the literature and meta-analysis

OBJECTIVE The aim of this review was to compare the efficiency of cone beam computed tomography (CBCT) and conventional intraoral radiography for the detection of vertical root fractures (VRFs). STUDY DESIGN Data from comparative and noncomparative studies investigating CBCT, conventional radiography, or both for the diagnosis of VRFs were searched. The main outcome variables were sensitivity, specificity, and accuracy of the techniques. Data were separated into 4 groups: in vivo, ex vivo/untreated teeth, ex vivo/treated teeth, and ex vivo with post. The weighted mean of each parameter was estimated. RESULTS Twelve articles were considered for the analysis. There was a large heterogeneity of the characteristics of the studies and a wide variability in outcome variables. No significant differences were found between radiographic techniques. CONCLUSIONS No superiority of CBCT compared with conventional radiography was found for VRF detection. Adequate choice of voxel size seems to be important when diagnosing VRFs.

The Dynamics of Periapical Lesions in Endodontically Treated Teeth That Are Left without Intervention: A Longitudinal Study

INTRODUCTION The long-term dynamics of periapical lesions in endodontically treated teeth is not fully elucidated, thus presenting a clinical dilemma regarding the need for an intervention. The aim of the study was to retrospectively evaluate the long-term dynamics of periapical lesions that were left without intervention in endodontically treated teeth. METHODS Periapical status surveys of patients treated in a public dental clinic were retrospectively evaluated for the presence of periapical lesions in endodontically treated coronally restored teeth. The dynamics of the included periapical lesions was evaluated based on the periapical index (PAI) score changes between 2 consecutive periapical surveys of at least a 4-year interval. The influence of various factors on lesion dynamics was statistically evaluated. RESULTS The study cohort consisted of 74 patients with a total of 200 endodontically treated teeth having periapical lesions that fulfilled the inclusion criteria. Fifty-seven (28.5%) lesions remained unchanged, 103 (51.5%) lesions worsened (PAI score increased), and 40 (20%) lesions improved (PAI score decreased). Poor root canal filling and poor restoration were found to adversely affect the long-term dynamics of the periapical lesions (P < .05). Age, sex, and the presence of a post had no statistically significant influence on lesion dynamics (P > .05). CONCLUSIONS Poor root canal filling and poor restoration may adversely affect the long-term dynamics of periapical lesions that are left without intervention in endodontically treated teeth. Therefore, in cases of poor root canal filling or poor restoration, further intervention may be indicated.

Medico‐legal aspects of vertical root fractures in root filled teeth

AIM   To analyse the medico-legal aspects of vertical root fracture (VRF) following root canal treatment (RCT). METHODOLOGY   A comprehensive search in a professional liability insurance database was conducted to retrospectively identify cases of VRF following RCT. The complaints were categorized as either financial risk bearing or financial nonrisk bearing, and related demographic, prosthetic and endodontic variables were analysed. RESULTS   Seventy-seven legal cases of patients with VRFs following RCT were identified. Most of the cases were either in premolars or in mandibular molar teeth (P<0.05). Poor-quality root filling was associated with an extended delay of diagnosis (P<0.05). The presence of a post significantly increased the financial risk assessment (P<0.05). CONCLUSIONS   Poor quality root fillings complicate the diagnosis of VRF, which in turn extends the time for achieving an accurate diagnosis and increasing the medico-legal risk. Premolar and mandibular molar teeth were more prone to medico-legal claims related to VRF following RCT. Post should be placed only when essential for additional core support to avoid medico-legal risk.