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Methods of Diagnosis and Treatment in Endodontics

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Methods of Diagnosis and Treatment in Endodontics A Systematic Review June 2012 (The Swedish report was printed in November 2010) Swedish Council on Health Technology Assessment SBU • Statens beredning för medicinsk utvärdering SBU Evaluates Health Technology The Swedish Council on Health Technology Assessment (SBU) is a national governmental agency that assesses healthcare technologies. SBU analyses the benefits, risks, and costs of health technologies and compares the scientific facts with the prevailing practices in Sweden. Our goal is to strengthen the body of evidence available to everyone engaged in shaping health services. SBU produces several series of reports. SBU Assesses includes systematic reviews conducted by SBU’s expert panels. The series addresses established technologies (Yellow Reports) and new technologies (Alert Reports). SBU Comments summarises and comments on reviews of medical evidence from abroad. The SBU Information Service responds to questions directly from healthcare decision makers. Read more about SBU’s reports and projects at www.sbu.se. This assessment was published in 2012. Findings based on strong scientific evidence usually continue to apply well into the future. However, findings based on insufficient, limited, or contradictory evidence may have already become outdated. Order this report (No 203E) from: This report is available electronically and can be downloaded at www.sbu.se/rotfyllning Graphic Production: Anna Edling, SBU Report No: 203E Methods of Diagnosis and Treatment in Endodontics A Systematic Review Project Group Gunnar Bergenholtz Therese Kedebring (Chair) (Project Assistant) Susanna Axelsson Thomas Kvist (Assistant Project Jonas Lindblom Director) (Literature Search) Thomas Davidson Ingegerd Mejàre (Health Economics) Anders Norlund Fredrik Frisk (Health Economics) Magnus Hakeberg Arne Petersson Gert Helgesson Isabelle Portenier (Ethical Aspects) Hans Sandberg Kickan Håkanson Sofia Tranæus (Project Assistant) (Project Director) Scientific Reviewers Anders Anell Ann Wenzel Folke Lagerlöf Dag Ørstavik Jukka Meurman Swedish Council on Health Technology Assessment SBU • Statens beredning för medicinsk utvärdering Table of Contents SBU’s summary and conclusions 7 1. Introduction 29 2. Description of methods 43 3. Systematic review of the literature 49 3.1 Diagnosis of the condition of the pulp 49 3.2 Radiologic diagnosis of the periapical tissues 113 3.3 Treatment of teeth with inflamed pulps 155 3.4 Treatment of teeth with necrotic pulps 207 3.5 Revision of endodontic treatment 247 3.6 Treatment of acute conditions 265 3.7 Permanent and temporary restoration 279 of root-filled teeth 3.8 Risks for development or exacerbation of disease 311 in other organs from infections of the pulp and periapical tissues 3.9 Risks of serious side-effects and complications 321 associated with endodontic treatment procedures 4. Ethical and social aspects 341 5. Health economic aspects 353 6. Survey of established endodontic practice 361 in Sweden: a questionnaire study 7. Summary: discussion and conclusions 385 8. Knowledge gaps: research priorities 387 9. Glossary 391 10. Projectgroup, scientific reviewers, 397 translaters and conflict of interest Appendix 1. Search strategies 401 Appendix 2. SBU’s appraisal forms Published on www.sbu.se/rotfyllning Appendix 3. Questionnaire 489 Appendix 4. Excluded studies Published on www.sbu.se/rotfyllning SBU’s summary and conclusions Swedish Council on Health Technology Assessment SBU • Statens beredning för medicinsk utvärdering SBU has evaluated the methods used by dentists to diagnose, prevent and treat inflammation and infection of the dental pulp. Root canal therapy (endodontics) is conducted to ensure healthy conditions in and around teeth, which have been damaged by caries, external trauma or other causes. Despite the overall high standard of dental health in Sweden, root fillings are still common and are expensive items of treat- ment for both the individual and the society. The report forms the basis of national guidelines for dental care by the National Board of Health and Welfare. SBU’s conclusions ❑ Because of the lack of studies it is not possible to determine which diagnostic methods can disclose whether a vital but injured pulp can be maintained or whether it should be removed and replaced with a root filling. The available research provides limited direction as to what distinguishes a treatable from a non-treatable pulpal inflam- mation (pulpitis). ❑ The effects of different methods used for instrumentation, disin- fection and root filling associated with root canal therapy are insufficiently investigated. ❑ An investigation of common practice among Swedish dentists shows that great variations exist in treatment strategies and choice of mater- ials. This applies, for example, to the management of the exposed pulp or when a root filling is retreated. An exception is the use of engine driven instrumentation, which to a varying degree is used by almost two-thirds of the dentists. ❑ There is a need for prospective studies of root canal therapy, which show how teeth can be preserved in the long-term, without risk of recurrence of symptoms, periradicular inflammation or tooth fracture. The lack of good research in this field clearly indicates that priority should be given to well-planned and carefully con- SBU’S SUMMARY AND CONCLusIONS 9 ducted clinical studies of methods for diagnosis and treatment of the disease conditions of the pulp. ❑ There is a need for a national registry with quality indicators to be applied for follow-up evaluations of pulpal and root canal treatments. Background and aims For many people, toothache resulting from infection of the dental pulp is a cause of severe suffering. The infection often occurs as a result of dental caries. Pulpal infections can also occur in non-carious teeth by cracks or fractures, due to external trauma or in heavily restored teeth. The purpose of root canal treatment by root filling of teeth (endodontics) is to prevent and treat pulpal infections and thereby symptoms such as toothache and swelling because of suppuration. The aim of endodontic treatment is a functional and asymptomatic tooth, without signs of residual root canal infection, including loss of bone at the root apex. The following specific questions were addressed: • How well can different diagnostic methods determine the condition of the pulp in teeth with different types of injury (caries, trauma, restorative interventions and other causes)? • How well can different radiographic methods demonstrate loss of bone at the root apex? • Are there effective methods for treating pulpal inflammation so that the pulp can be preserved when it has been subjected to caries, trauma or other injury? • How effective are different treatment measures when the pulp is necrotic (dead)? • How effective are orthograde (root filling through the crown) and retrograde (surgical intervention at the root apex) treatments of root filled teeth showing signs of periapical inflammation (apical periodontitis)? 10 METHODS OF DIAGNOSIS AND TREATMENT IN ENDODONTICS • How effective are different methods for treatment of acute toothache? • Can the root filled tooth be restored effectively, with long-term survival of the tooth and the restoration? • Is there a risk that cases of acute and chronic infection originating in the dental pulp may cause pathological conditions in other organs? • What serious side-effects are associated with root canal therapy? • Which are the most cost-effective methods for diagnosis and treatment of diseases of the dental pulp? Method SBU has developed a thorough and systematic methodology in which all literature relevant to the question under investigation is sought in avail- able databases. Every study included has been scrutinized for quality and tabulated. The scrutiny comprised evaluation of the study relevance with regard to the subject matter and the methodological qualities – study design, internal validity (reasonable protection from systematic errors), statistical power and generalisability. Quality evaluation of the articles on health economics was undertaken as a joint effort between an endodontist and a health economist. The results were subsequently graded on the basis of the quality of the scien- tific evidence. The conclusions of the report are based solely on human studies. Ex- perimental studies in laboratory animals and in-vitro studies were not included. Study selection was restricted to randomised controlled studies (RCT), controlled clinical studies (CCT) and prospective cohort studies. For assessment of the reliability of different radiographic methods for diagnosis of periapical bone lesions, post-mortem studies were accepted. In the section on serious side-effects and complications associated with root canal therapy, case reports were included. SBU’S SUMMARY AND CONCLusIONS 11 Facts 1 Study Quality and Strength of the Evidence. Study quality refers to the scientific quality of an individual study and its ability to provide a valid answer to a specific question. Strength of the evidence refers to a judgment of the total strength of all scientific evidence and its ability to provide a valid answer to a specific question. SBU uses GRADE, an international grading system for scientific evidence. Study design is a key element in the overall judgment of each out- come measure. Other factors that can weaken or strengthen the power of the evidence are study quality, relevance, consistency, transferability, effect size, data
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