Influence of filling quality on the periapical status of endodontically treated teethAbstract
Objective To evaluate the radiographic quality of endodontic treatments and their respective coronal restorations, correlating it with periapical status.
Material and method The root filling quality of four hundred and sixteen teeth was carefully evaluated regarding three radiographic parameters: i) apical extension, ii) homogeneity and iii) taper, being E0, E1 and E2. E0 and E1 corresponding to sharp and mild deviation from normality, respectively; while E2 corresponding to the gold standard. Due to the combination of the assigned scores, filling was classified as perfect (PF), with three E2 scores; satisfactory (ST), with two E2 scores; or deficient (DF), with one or no E2 score. In addition, periapical status was considered to be a healthy periodontium; thickening of the periodontal ligament and presence of apical periodontitis. Coronary restorations were classified according to the presence and type of restoration. Associations between variables were analyzed using Spearman's Correlation test (p<0.05).
Result Two hundred and twenty-one teeth had DF filling (53.1%). The apical extension was the parameter with the highest number of E0, accounting for 38.94% of assigned scores. Individually, the observed parameters did not show statistically significant association with periapical status (p>0.05); however, it was significantly associated with the general filling quality (p=0.021).
Conclusion Fillings presented low quality standard, being the most critical parameter, negatively influencing the periapical status of the entire sample.
Descriptors: Endodontics; root canal obturation; periapical periodontitis; radiography
Resumo
Objetivo Avaliar a qualidade radiográfica de tratamentos endodônticos e suas respectivas restaurações coronárias, correlacionando-os ao status periapical.
Material e método A qualidade da obturação de quatrocentos e dezesseis dentes foi criteriosamente avaliada em três parâmetros radiográficos: i) limite apical, ii) homogeneidade e iii) conicidade, sendo E0, E1 e E2. E0 e E1 corresponderam a acentuado e suave desvio da normalidade, respectivamente; enquanto E2 correspondeu ao padrão-ouro. Em função da combinação dos escores atribuídos, a obturação foi classificada em perfeita (PF), com três escores E2; satisfatória (ST), com dois escores E2; ou deficiente (DF), com um ou nenhum escore E2. Além disso, o status periapical foi considerado como periodonto sadio; espessamento do ligamento periodontal e presença de periodontite apical. Restaurações coronárias foram classificadas quanto à presença e tipo de restauração. As associações entre as variáveis foram analisadas através do teste de Correlação de Spearman (p<0.05).
Resultado Duzentos e vinte e um dentes apresentaram obturação DF (53.1%). O limite apical foi o parâmetro com maior número de E0, perfazendo 38,94% dos escores atribuídos. Individualmente, os parâmetros observados não apresentaram associação estatisticamente significativa com o status periapical (p>0.05); entretanto, o mesmo associou-se significativamente com a qualidade geral da obturação (p=0.021).
Conclusão As obturações apresentaram baixo padrão de qualidade, sendo o parâmetro mais crítico, influenciando o status periapical de toda a amostra.
Descritores: Endodontia; obturação do canal radicular; periodontite periapical; radiografia
INTRODUCTION
Endodontic therapy has great demand in the routine of dental offices. Even with the increase in preventive dentistry, the need for this type of treatment remains due to deep carious lesions, infiltration in old coronary restorations or dental trauma1. In addition, the increase in the life expectancy of populations in general and the desire to preserve natural teeth as much as possible, result in decrease in the number of tooth extractions, leading to higher prevalence of endodontically treated teeth in elderly patients2.
There are many factors that indicate the success or failure of treatment. Radiographically, the radiolucent periapical appearance is associated with teeth that require endodontic treatment3. This radiolucency, present due to apical periodontitis, has strong association with the inadequate technical filling quality. The success of endodontic treatment is due to the correct cleaning, shaping and filling of the root canal system, procedures that are necessary for the healing of periapical tissues4,5.
The periapical lesion is the way in which the periapex reacts to the colonization of the root canal by microorganisms. When the endodontic treatment fails, it means that some of the cleaning, shaping and filling procedures of the root canal system failed to perform its function correctly, with the presence of persistent microorganisms2,6.
Successful endodontic treatment remains a challenge for endodontics, despite the existence of a protocol for its implementation. Although there are still doubts, studies have addressed the relationship between absence or poor adaptation of the coronary restoration and endodontic failure4,6.
The aim of this study was to evaluate endodontically treated teeth through previously performed periapical radiographs, correlating the periapical status with the filling quality in terms of apical extension, homogeneity and taper, presence and type of coronal restoration, in patients treated by undergraduate dental students in a school clinic.
MATERIAL AND METHOD
To carry out this study, digital periapical radiographs were collected from patients who received dental care at PUC Minas Periodontics clinics in 2018. All radiographs were located in Radiocef Studio®, the radiographic database used by the institution. As inclusion criteria, periapical radiographs of endodontically treated teeth were selected, in which it was possible to evaluate the entire tooth structure, the periodontal ligament and adjacent alveolar bone.
Initially, radiographs were collected from 274 patients. Of these, 41 did not have radiographs in the database and 93 did not have endodontically treated teeth, resulting in 140 patients (50 men and 90 women) qualified for evaluation. Periapical radiographs were selected and mounted in Microsoft® PowerPoint® file, in order to analyze one tooth per slide. When the radiograph had more than one tooth that met the criteria for analysis, slides were created with the same images, so that each tooth was evaluated separately. In total, the file consisted of 416 slides.
In the radiographic evaluation, the filling quality was analyzed in terms of Apical Extension, Homogeneity and Taper, using criteria according to Santos et al.7 (Table 1). Subsequently, the following criteria were added in the evaluation: periapical status, presence or absence of coronary restoration and type of coronary restoration (Table 2). In multi-rooted teeth or teeth with more than one root canal, each one was evaluated separately, considering only the worst evaluated canal for each parameter, giving the value found for the tooth as a whole.
To perform the analysis, two experienced endodontists performed calibration to obtain result of relative reliability. In this calibration, 20 radiographs were randomly selected and evaluated twice by evaluators, following the same criteria of the study. Evaluations were carried out with an interval of 15 days, so that remnants of the first evaluation could not compromise calibration. Subsequently, intra- and inter-examiner reliability was determined using Spearman's Rank Correlation Coefficient (Table 3).
Finally, radiographs were evaluated in dark room for better visualization of the projected image. An average of 50 radiographs per day were evaluated to avoiding fatigue and wrong assessments.
This study was conducted after submitting the project to the Ethics Research Committee of the Pontifícia Universidade Católica de Minas Gerais, with approval No. 3.040.554.
RESULT
For this study, 416 teeth obtained from 140 patients were evaluated, 28.1% belonging to male patients and 71.9% to female patients.
The numbers obtained in evaluations are shown in Table 4. The apical extension was the endodontic parameter with the highest number of E2, obtaining 55.1%. In contrast, it was also the parameter with the highest number of E0, obtaining 38.9%. Teeth with filling ending at the apex, corresponding to E1, were present in 6% of evaluations.
In the homogeneity parameter, filling was homogeneous, with no visible voids, in 53.9% of evaluated teeth. It presented only one visible void in 24% of teeth and several visible voids or porosities in 22.1% of evaluations.
The highest number of E1 was given to the taper parameter, with 49.5% of evaluations. This score corresponds to fillings with mild strangulation or reduced taper. It presented conical-progressive pattern in 34.2% of teeth and marked strangulation in 16.3% of evaluations.
For the periapical status, 59.1% had healthy ligament. Thickening of the periapical periodontal ligament was observed in 25% of evaluations, which was even greater in 15.9%, being considered periapical lesion.
They were also evaluated for the presence or absence of coronary restoration. Of 416 teeth evaluated, 88.9% had coronal restoration, being absent in 11.1%.
Regarding the type of restoration present in the 370 teeth, most were full crown with intraradicular retainer, with 45.7% of cases, followed by direct composite resin, with 22.7% of cases, full crown with 14.3% of cases, only intraradicular retainer with 8.6% of cases, two materials of different radiopacities with 7.6% of cases and restoration without radiopacity with 1.1% of cases.
In Table 5, it is possible to observe the correlation between endodontic filling and coronal restoration parameters with the periapical status. Of endodontic parameters, individually, there was no statistically significant association. When the overall filling quality was correlated with the periapical status, the P-value obtained was 0.021, showing statistically significant association.
Correlation using the Spearman’s Coefficient between the evaluated parameters and the Periapical Status
When correlating presence of coronary restoration and type, correlation was inversely proportional to periapical status, with rs -0.005 for the presence of restoration and -0.036 for the type of restoration. The P values obtained were, respectively, 0.918 and 0.490, not showing statistically significant results.
DISCUSSION
In the present study, higher prevalence of female patients was observed, corresponding to 72.59% of evaluated teeth. When endodontically treated teeth and apical periodontitis were correlated, an index of 40.9% was found in this study, indicating that these treatments failed.
This is a study that only involved the collection and analysis of images present in a radiographic database, in which radiographs were saved at a given time and subsequently evaluated; therefore, it was not possible to follow up on the evolution of the case presented in each radiographic image. In the same way that a “gold standard” endodontic treatment performed on a tooth that presented apical periodontitis could, over time, lead to the regression of the lesion, inadequate treatment could lead to inadequate periapical status.
The fit of coronal restorations would be best evaluated using interproximal radiographs. As these images were not available, only the presence and type of coronary restoration were evaluated. The type of restoration was evaluated according to the radiopacity of the restorative material and the restoration contour.
Apical periodontitis is more present both in filling with presence of voids and in inadequate apical extension8. Therefore, it is important that the endodontic treatment is performed aiming at obtaining the “gold standard” in the three parameters: apical extension, homogeneity and taper7. In literature, some numbers related to success regarding the apical extension were found. With filling ending from 1 to 3 mm from the apex, a 92% success rate was obtained9. When using 0 to 2 mm, the value obtained was from 49.5 to 90.4%. When filling ended up to > 2 mm from the radiographic apex, success rate from 42.6% to 63.64% was obtained. In cases where canals were overfilled, success rate ranged from 0% to 53%5,10-13. In the current study, canals that had apical extension of 0.5 to 2 mm from the radiographic apex had 61.57% success rate. Canals in which filling ended exactly at the radiographic apex had 52% success rate, while canals overfilled or filling ended > 2 mm from the apex had 56.79% success rate.
Homogeneity also influenced the success of endodontic treatment8. In studies found, homogeneous filling presented 40.3% - 80.5% success rate. The presence of voids reduced this number to 16.6% - 57.7%5,11-13. In this study, canals with homogeneous filling presented 63.39% success rate. The presence of voids decreased this number to 54%, while canals with multiple voids had 54.35% success rate.
Regarding the taper, in one study, fillings that presented progressive conical shape had success rate of 40.5%. In the case of another shape of the canal filling, such as parallel walls or funneling, the number dropped to 20.3%13. In the current study, fillings with progressive conical shape had success rate of 61.57%. In the case of reduced taper, success rate was 60.19%, reducing to 51.47% when there was strangulation.
It is important to emphasize that a quality multidisciplinary treatment is performed, so that endodontic and restorative treatments are successful.
CONCLUSION
The overall quality of root canal fillings showed low quality standard, negatively influencing the periapical status in the entire sample. There was no specific critical parameter that influenced this result, and each one of them is equally important for the success of the endodontic treatment. There was no relationship between presence or type of coronary restoration and periapical status.
ACKNOWLEDGMENTS
We would like to thank the entire team of the Departamento de Odontologia da Pontifícia Universidade Católica de Minas Gerais, especially Professor Ana Maria Abras da Fonseca for her support and for making the radiographic database of patients available as needed to carry out this research.
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How to cite:
Lima MSFF, Sá PPA, Tonelli SQ, Bruzinga FFB, Nunes E, Silveira FF. Influence of filling quality on the periapical status of endodontically treated teeth. Rev Odontol UNESP. 2024;53:e20240019. https://doi.org/10.1590/1807-2577.01924
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FUNDING
None.
REFERENCES
-
1 Elsayed RO, Abu-bakr NH, Ibrahim YE. Quality of root canal treatment performed by undergraduate dental students at the University of Khartoum, Sudan. Aust Endod J. 2011;37(2):56-60. http://doi.org/10.1111/j.1747-4477.2010.00273.x PMid:21771183.
» http://doi.org/10.1111/j.1747-4477.2010.00273.x -
2 Connert T, Truckenmüller M, ElAyouti A, Eggmann F, Krastl G, Löst C, et al. Changes in periapical status, quality of root fillings and estimated endodontic treatment need in a similar urban German population 20 years later. Clin Oral Investig. 2019;23(3):1373-82. http://doi.org/10.1007/s00784-018-2566-z PMid:30022270.
» http://doi.org/10.1007/s00784-018-2566-z -
3 Kirkevang LL, Hörsted-Bindslev P, Ørstavik D, Wenzel A. A comparison of the quality of root canal treatment in two Danish subpopulations examined 1974-75 and 1997-98. Int Endod J. 2001;34(8):607-12. http://doi.org/10.1046/j.1365-2591.2001.00436.x PMid:11762497.
» http://doi.org/10.1046/j.1365-2591.2001.00436.x -
4 Gillen BM, Looney SW, Gu LS, Loushine BA, Weller RN, Loushine RJ, et al. Impact of the quality of coronal restoration versus the quality of root canal fillings on success of root canal treatment: a systematic review and meta-analysis. J Endod. 2011;37(7):895-902. http://doi.org/10.1016/j.joen.2011.04.002 PMid:21689541.
» http://doi.org/10.1016/j.joen.2011.04.002 -
5 Kielbassa AM, Frank W, Madaus T. Radiologic assessment of quality of root canal fillings and periapical status in an Austrian subpopulation – an observational study. PLoS One. 2017;12(5):e0176724. http://doi.org/10.1371/journal.pone.0176724 PMid:28464019.
» http://doi.org/10.1371/journal.pone.0176724 -
6 Koch M, Wolf E, Tegelberg Å, Petersson K. Effect of education intervention on the quality and long-term outcomes of root canal treatment in general practice. Int Endod J. 2015;48(7):680-9. http://doi.org/10.1111/iej.12367 PMid:25112721.
» http://doi.org/10.1111/iej.12367 -
7 Santos SMC, Soares JA, Costa GM, Brito-Júnior M, Moreira NA, Magalhães CS. Radiographic parameters of quality of root canal fillings and periapical status: a retrospective cohort study. J Endod. 2010;36(12):1932-7. http://doi.org/10.1016/j.joen.2010.08.050 PMid:21092808.
» http://doi.org/10.1016/j.joen.2010.08.050 -
8 İlgüy D, İlgüy M, Fişekçioğlu E, Ersan N, Tanalp J, Dölekoğlu S. Assessment of root canal treatment outcomes performed by turkish dental students: results after two years. J Dent Educ. 2013;77(4):502-9. http://doi.org/10.1002/j.0022-0337.2013.77.4.tb05496.x PMid:23576596.
» http://doi.org/10.1002/j.0022-0337.2013.77.4.tb05496.x -
9 Kerekes K. Radiographic assessment of an endodontic treatment method. J Endod. 1978;4(7):210-3. http://doi.org/10.1016/S0099-2399(78)80185-X PMid:283184.
» http://doi.org/10.1016/S0099-2399(78)80185-X -
10 Craveiro MA, Fontana CE, de Martin AS, Bueno CES. Influence of coronal restoration and root canal filling quality on periapical status: clinical and radiographic evaluation. J Endod. 2015;41(6):836-40. http://doi.org/10.1016/j.joen.2015.02.017 PMid:25799533.
» http://doi.org/10.1016/j.joen.2015.02.017 -
11 Dugas NN, Lawrence HP, Teplitsky PE, Pharoah MJ, Friedman S. Periapical health and treatment quality assessment of root-filled teeth in two Canadian populations. Int Endod J. 2003;36(3):181-92. http://doi.org/10.1046/j.1365-2591.2003.00640.x PMid:12657144.
» http://doi.org/10.1046/j.1365-2591.2003.00640.x -
12 Schulte A, Pieper K, Charalabidou O, Stoll R, Stachniss V. Prevalence and quality of root canal fillings in a German adult population. Clin Oral Investig. 1998;2(2):67-72. http://doi.org/10.1007/s007840050047 PMid:15490778.
» http://doi.org/10.1007/s007840050047 -
13 Tarim Ertas E, Ertas H, Sisman Y, Sagsen B, Er O. Radiographic assessment of the technical quality and periapical health of root-filled teeth performed by general practitioners in a Turkish subpopulation. ScientificWorldJournal. 2013;2013(1):514841. http://doi.org/10.1155/2013/514841 PMid:23431255.
» http://doi.org/10.1155/2013/514841
Publication Dates
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Publication in this collection
14 Oct 2024 -
Date of issue
2024
History
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Received
26 July 2024 -
Accepted
08 Aug 2024
