OUTCOME OF NON-SURGICAL ENDODONTIC TREATMENT Sarah Abitbol A thesis submitted in conformity with the requirements for the degree of Master of Science Graduate Department of Faculty of Dentistry University of Toronto Wopyright by Sarah Abitbol2001 1+1 National Library Bibliothèque nationale ofCanada du Canada Acquisitions and Acquisitions et Bibliographie Services services bibliographiques 395 Wdlhgton Street 395, nie Wsllington OttawaON KlAON4 Ottawa ON K1AW canada Canada The author has granted a non- L'auteur a accordé une licence non exclusive licence allowing the exclusive permettant à la National Library of Canada to Bibliothèque nationale du Canada de reproduce, Ioan, distribute or sell reproduire, prêter, distribuer ou copies of this thesis in microfom9 vendre des copies de cette thèse sous paper or electronic formats. la fome de microfiche/nlm, de reproduction sur papier ou sur format électronique. The author retains ownership of the L'auteur conserve la propieté du copyright in this thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts fiom it Ni la thèse ni des extraits substantiels may be printed or otherwise de celle-ci ne doivent être imprimés reproduçed without the author's ou autrement reproduits sans son permission. autorisation. Outcome of Non-surgical Endodontic Treatment Master of Science, 2001 Dr. Sarah Abitbol Graduate Department of Dentistry University of Toronto ABSTRACT This historical cohort study examined the outcome of non-surgical endodontic treatment and the influence of various factors on the outcome. Patients treated by Graduate Endodontics students were re-examined afier 4 to 6 years by an independent investigator. Outcome criteria - were dichotomous the pdradicular tissues were classified as "healed" or "diseased". For Initial Treatment, 8 1% of the teeth wefe healed. The healing rate was 18% higher for teeth without pre-operative Apical Periodontitis than those with Apical Periodontitis @ < 0.01). For Retreatment, 7 1 % of the teeth were healed. The healing rate for teeth with pre-operative perforation was 53% lower than for al1 othcr teeth (p 4 0.001 ). In conclusion, Apical Periodontitis was the major factor that influenced the outcome of Initial Treatment, while a pre-operative perforation was the major factor that influenced the outcome of Retreatment. Acknowledgments The completion of this thesis was made possible with the contribution of a nurnber of individuals. 1 would like to thank my supervisors, Dr. Shimon Friedman and Dr. Herenia P. Lawrence for their support and guidance during the elaboration of this project. 1 especially I indebted to Dr. S. Friedman; first, for giving me the opportunity to participate in this remarkable research and second, for the many hours spent reviewing this thesis. His vast knowledge in the field of endodontics and unreserved acadernic dedication makes him a great supervisor to work with. 1 express my appreciation to Dr. H.P. Lawrence for her patience and good cheer in continually impariing her knowledge with me, and for always being available and easily approachable. 1 would like to thank my cornmittee member Dr. Chris McCulloch for his positive insight and comments throughout the research. 1 own a very special acknowledpent to two people who, although not directly involved - in this thesis, volunteered to help me with it Dr. Calvin Tomeck, for reading and correcting it, and Dr. Thuan Dao, for her attention and suggestions. I am especially gratefbl to Ms. Annemarie Polis for her technical support during the recording of the data and her exnotional support throughout this research project and the writing of the thesis. Last, but not least, I am etemally gratefûl to al1 the mernbers of my family who have - supported me throughout the pursuit of my longtime dream to become a well-trained and scientif icall y sound Endodontist. iii TABLE OF CONTENTS Page .. ....................................................................................................................... ABSTRACT 11 ... .............................................................................................................. Acknowledgments 111 ............................................................................................................... Table of Contents iv ... ............................................................................................................... List of Tables vil ................................................................................................................... List of Figures x 1. INTRODUCTION. ................................................................................................. 1 ......................................................................................... 1.1 Historical Review 2 ....................................................................... 1.2 Appraisal of previous studies 5 ......................................... Early and unifom assembly of Patients IO ................................................ Description of the Referral Pattern I l ....................................... Description of the Follow-up Recall rate 12 ..................................... Definition of Objective Outcome Criteria 13 .. ......................................................... bbB lind" Outcome assessment 17 ............................. Adjustment for Extraneous Prognostic Factors 18 ........................................................................ Appraisal Summary 20 ...................... 1.3 Outcorne of treatment in teeth without Apical Periodontits 20 ............................................................................. 1.3.1 Initial Treatrnent 20 ................................................................................... 1.3.2 Retreatment -22 1.4 Outcome of treatment in teeth with Apical Periodontitis .......................... 22 . . ............................................................................ 1.4.1 initial Treatment -22 ................................................................................... 1.4.2 Retreatment -24 LI . STATEMENT OF THE PROBLEM ................................................................ -26 m . omc~nms ....................................................................... OF THE STUDY .27 IV . EYPOTHESIS .....................................................................................................2 8 V . MATERIALS AND METHODS ...................................................................... -28 V .1 Studied Population ......................................................................... 28 ......................................................................... V.2 Recording of Data -29 ............................................................... V.3 Patient Recall Strategies -30 ....................................................................... V.4 Assessrnent Criteria 30 ................................................................ V.5 Sample Size Estimation 31 ...................................................................... V.6 StatisticalAnalysis 31 V . RESULTS ............................................................................................................. 313 . . ........................................................................................ Initial Treatment. 33 . ................................................................................. V 1- 1 Total material 34 V .1 .2 Teeth without Apical Periodontitis ...............................................3. 6 . ..................................................... V 1.3 Teeth with Apical Periodontitis 36 ............................................................................................... Retreatment -37 ................................................................................. V.2.1 Total material 38 ................................................ V.2.2 Teeth without Apical Periodontitis 39 ..................................................... V.2.3 Teeth with Apical Periodontitis 39 VI . DISCUSSION ........................................................................................... 40 VII . FUTURE RESEARCH ............................................................................ 50 REFERENCES ............................................................................................................. 77 APPENDICES List of Tables Pages Table 1. Non-surgical endodontic treatrnent outcorne studies. ........................ ..52 Table 2. Outcome of Initial Treatment with and without .................................................... presperative Apical Periodontitis 3 3 Table 3. Outcome of Retreatment with and without ..................................................... pre-operative Apical Periodontitis ..54 Table 4. Relation of studies to reporting guidelines ..................................................................... by McMaster University S 5 Table 5. Univariate distribution of "the new population" subjected to ................................................................. initial Treatment (n = 277). 56 Table 6. Univariate distribution of the analyzed population subjected to ....................................................-........... Initial Treatment (n = 12 0). -57 Table 7. Response bias analysis to assess differences between the "new total population" and the responding population .......................................................... subjected to Initial Treatment. -3 Table 8. Association between pre-operative factors and the ............................. outcome of endodontic Initial treatrnent (n = 120). 58 Table 9. Association between intra-operative factors and the ............................................. outcome of Initial treatment (n = 120). ..59 Table 10. Association between post-operative factors and the .............................................. outcome of initial treatment (n = 12 0). ..S9 Table 1 1. Contingency table of pre-operative factor Pulp ........................................ Vitality and Apical Periodontitis (n = 120). .60 Table 12 . Stepwise Logistic regression analy sis for ................................................................... initial Treatment (n = 120) 60 vii Table 13. Association between pre-operative factors and the outcome of Initial Treatment in teeth without Apical Periodontitis (n = 48). .......................................................................... 60 Table 14. Association between intra-operative factors and the outcome of Initial treatment in teeth ................................................. without Apical Periodontitis (n = 48). 6 1 Table 15. Association between pst-operative factors and the outcome of initial treatment in teeth ................................................ without Apical Periodontitis (n = 48). -61 Table 16. Association between pre-operative factors and the outcome of Initial Treatment in teeth with Apical .......................................................................... Periodontitis (n = 72). 62 Table 17. Association between intra-operative factors and the outcome of Initial Treatment in teeth with Apical Periodontitis (n = 72). .......................................................................... 62 Table18 . Association between pst-operative factors and the outcome of initial Treatment in teeth with Apical ........................................................................ Periodontitis (n = 72). ..63 Table 19. Stratified table of intra-operative factor Number of Roots and Treatment Sessions in teeth with Apical ......................................................................... Periodontitis (n = 72) ..63 Table 20. Univariate distribution of "the new population" subjected to ......................................................................... Retreatrnent (n = 203). 64 Table 2 1. Univariate distribution of the analyzed population subjected to ............................................................................. Retreatment(n=56). -65 Table 22. Response bias analysis to assess differences between the "new total population" and the responding population ................................................................... subjected to Retreatment. ..66 Table 23. Association between pre-operattive factors and the ........................................................ outcome of Retreatment (n = 56). 66 Table 24. Association between intra-operative factors and the ....................................................... outcome of Retreatment (n = 56). -67 Table 25. Association between pst-operative factors and the ........................................................ outcome of Retreatment (n = 56). 67 Table 26. Association between pre-operative factors and Retreatment in teeth without Apical Periodontitis (n = 26). ................................................................................................ 68 Table 27. Association between intra-operative factors and Retreatment in teeth without Apical Periodontitis ................................................................................................. (n = 26) 69 Table 28. Association between pst-operative factors and Retreatment in teeth without Apical Periodontitis (n = 26). .............................................................................................. ..69 Table 29. Association between pre-operative factors and Reîreatment in teeth with ApicaI Periodontitis ................................................................................................. (n = 30) 70 Table 30. Association between intra-operative factors and Rdreatment in teeth with Apical Periodontitis ................................................................................................. (n = 30) 7 1 Table 3 1. Association between pst-operative factors and ..................... Retreatment in teeth with Apical Periodontitis (n = 30). 7 1