A web-based endodontic case difficulty assessment tool

Endodontic and dental implant treatment: key considerations and comparisons

There remains huge variability in decision-making when it comes to whether a compromised tooth requiring endodontic treatment should be saved, or extracted and replaced with an implant. Both internal and external biases, as well as inconsistent data from clinical studies, further complicate this frequent clinical conundrum. This paper presents tangible outcomes for both root-filled teeth and dental implants, together with comparative research to help clinicians better understand the available data. It is hoped that we can also highlight the key considerations when treatment planning for both root-filled teeth and dental implants. Both treatment modalities have excellent survival rates, but at the same time, neither is a panacea. Holistic and thoughtful consideration is required to help guide patients to make well-informed choices regarding their treatment.

Medico-legal considerations in endodontics

A major aim of endodontic care is to successfully treat acute and chronic pulpal and periapical disease and prevent recurrence. Consequently, the tooth can be rendered free of pain and subsequently restored to function and aesthetics. However, each of the stages of the treatment - from diagnosis through to review - can be complex and compromise the intended outcome. Occasionally, this can lead to medico-legal challenges, especially where a valid consent process has not taken place or has not been properly recorded. This paper reviews the key stages in providing care with respect to the clinician's skillset, the expected standard and discusses how the consent process can mitigate the risk of medico-legal interventions.

Endodontic assessment, complexity, diagnosis and treatment planning

A systematic approach to endodontic clinical assessment, case complexity evaluation and precise diagnosis is essential for achieving successful endodontic management and favourable treatment outcomes. Neglecting these foundational elements can jeopardise the entire treatment process. This article is part of a themed issue dedicated to endodontics and serves as a practical guide for clinicians, outlining the comprehensive process of endodontic assessment. It will encompass clinical examination, radiographic interpretation and diagnostic testing, ultimately providing clinicians with the necessary tools for accurate diagnosis and effective treatment planning.

Cross-Sectional Analysis of the Challenges Faced by Undergraduate Dental Students During Root Canal Treatment (RCT) and the Oral Health-Related Quality of Life in Patients After RCT

Background and Objectives: This study examined dental students' challenges with root canal treatment (RCT). It also assessed patients' perceptions of oral health-related quality of life (OHRQoL). Materials and Methods: The study utilized three prevalidated questionnaires. One questionnaire was administered to dental students to assess their challenges related to various aspects of RCT. Another questionnaire was distributed to patients, comparing demographic factors such as age and gender to the tooth type, pain scores before and after RCT, and socioeconomic status. The third questionnaire focused on patients' OHRQoL considering age, gender, tooth types, pain, and socioeconomic status using the Oral Health Impact Profile-14 scale (OHIP-14). A total of 75 dental students filled out the survey, and patient-related questionnaires were filled out by 585 patients with the following demographics: age: young adults n = 385 (65.81%), middle-aged adults n = 200 (34.19%); gender: males n = 366 (62.56%), and females n = 219 (37.44%). Categorical data were analyzed using frequency and percentage. Chi-square tests were used for comparative analysis, and one-way ANOVA was used when more than two variables were present. A p-value of ≤0.05 was set as statistically significant. Results: Dental students perceived themselves as competent in performing RCT but faced difficulties with canal localization in middle-aged patients (p < 0.01) and in communicating with female patients (p = 0.009). There was a significant difference in preoperative (p = 0.007) and postoperative pain levels (p = 0.003) when comparing genders. Overall, there was a 30.60% reduction in pain levels. The OHIP-14 scale indicated high patient satisfaction (78.9%), with physical disability (26.16%) and psychological discomfort (23.33%) being the most affected domains. Among different variables, socioeconomic status was statistically significant, with patients of lower socioeconomic status reporting higher satisfaction levels (p = 0.02). No significant differences in OHRQoL were found based on age or gender. Conclusions: The OHRQoL was high among patients treated by dental students, with those with a low socioeconomic status being the most satisfied.

Acceptability of interactive post-endodontic restoration decision making application among undergraduate dental students

Background/Purpose

Selecting an appropriate coronal restoration after root canal treatment requires careful consideration, however, there is a lack of established web-based tool that is based on clear guidelines for suitable post-endodontic restorations. Hence, we aimed to design and determine the acceptability of an interactive application to aid the decision making process for post-endodontic restoration among the undergraduate dental students.

Materials and methods

A web-based post-endodontic restoration decision making interactive application, (RestoSmart) was developed after a detailed review of available literature. Seventy undergraduate dental students of IMU University were recruited in the study. A validated questionnaire was given to the participants before and after the use of RestoSmart to answer the provided mock clinical scenarios. Obtained data were statistically analyzed using IBM SPSS version 26 software package.

Results

The statistical analysis demonstrated that RestoSmart was acceptable among the undergraduate dental students (P < 0.05). Initially, participants recognized the potential benefits of designing an interactive application, 74% believing that it may enhance decision making and 76% emphasizing its user-friendliness. Additionally, close to half of the participants expressed the willingness to use interactive tools in future. Following the use of RestoSmart, there was a notable increase in favorability, with 94.2% finding it helpful in the decision making and 94.3% acknowledging its user-friendliness. Furthermore, 87.2% expressed intent to use RestoSmart in future.

Conclusion

RestoSmart was useful for decision making and user friendly. While overall response was positive, there exist some areas for improvement such as ease of use, updating evidence-based guidelines, and establishing its helpfulness in teaching and learning.

Comparative analysis of methods for measuring root canal curvature based on periapical radiography: A laboratory study

AIM

To evaluate the agreement between six currently available periapical radiography-based methods for measuring the root canal curvatures in mesial roots of mandibular first molars, assessed by two examiners with different proficiency levels.

METHODOLOGY

Non-endodontically treated mesial roots of 41 human mandibular first molars were radiographed using the parallelling technique. Two independent observers (a specialist in endodontics and radiology and a final-year dental student) assessed their root canal curvature using the methodologies described by Schneider (1971, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, 32, 271), Weine (1982, Endodontic therapy), Berbert and Nishiyama (1994, Revista Gaúcha de Odontología, 356), Luiten et al. (1995, Journal of Endodontics, 21, 26), Hankins and ElDeeb (1996, Journal of Endodontics, 22, 123) and Pettiette et al. (1999, Journal of Endodontics, 25, 230). Intra- and inter-examiner reliability was assessed using the intraclass correlation coefficient. The differences in curvature angle measured by the different methods were compared using the one-way anova for repeated measures test, followed by Tukey's post hoc analysis. The effect was calculated using the Cohen's d method. To determine the agreement between methods, the Bland-Altman analysis was used. The significance level was set at 5%.

RESULTS

Agreement for the observers was excellent (>0.81) for the six methods considered. For the angle comparisons between methods, the maximum differences were for Schneider versus Weine (35.77°) and Luiten versus Hankins (35.14°), whilst the highest percentage of angles with a difference >10° were Weine versus Luiten and Berbert versus Pettiette (90%) and the comparison Weine versus Hankins presented with the lowest frequency (15%). Excellent agreement was found for five comparisons: Weine versus Luiten (0.940), Berbert versus Pettiette (0.917), Weine versus Pettiette (0.907), Luiten versus Pettiette (0.904) and Berbert versus Luiten (0.812). Compared to Schneider's method, the other methods showed a tendency of increasing difference as the angles became more acute. The other methods exhibited linear differences, remaining constant for smaller and larger angles.

CONCLUSIONS

Reliability was excellent for all methods assessed separately. Maximum differences in curvature angles were found when comparing Schneider versus Weine and Luiten versus Hankins. Excellent agreement was found for Weine versus Luiten, Berbert versus Pettiette, Weine versus Pettiette, Luiten versus Pettiette and Berbert versus Luiten. In the presence of dilacerations, the method by Schneider was less sensitive.

EUROPEAN SOCIETY OF ENDODONTOLOGY Undergraduate Curriculum Guidelines for Endodontology

Undergraduate education should accomplish graduates who are skilled to provide quality care for patients, who are aware of their scope of practice, competency level and limits and who are open to referring patients whose needs are beyond their own skills and experience. They should also become self-efficacious. Quality performance begins with good diagnosis and decision-making. Graduates should understand when to treat, why to treat, what to treat and how to treat. These guidelines include a list of capabilities that the graduating student will be expected to have achieved to provide a minimum level of competency in endodontics. Theoretical knowledge, practical skills, understanding and insight should be assessed, with both formative and summative assessment procedures, making use of reflection and feedback. Endodontic procedures should be undertaken within the context of comprehensive patient care and should be evidence based. Students should not perform treatments on patients until they have demonstrated in a pre-clinical setting that they possess the required skills. Only if it is not possible to simulate a specific procedure sufficiently in a pre-clinical setting should students learn this procedure by performing it clinically under close supervision. Clinical endodontics should ideally be supervised by endodontists or by staff with special knowledge, interest and self-efficacy in endodontics. It is advised to ensure that students apply their knowledge and practice their skills periodically throughout the continuum of endodontic education until graduation. A philosophy of lifelong learning and evidence-based practice should be instilled in all dental undergraduates.

A comparison of radiographically determined periapical healing and tooth survival outcomes of root canal (re)treatment performed in two care pathways within the United Kingdom Armed Forces

AIMS

To compare radiographic periapical healing and tooth survival outcomes of root canal (re)treatment performed within two care pathways (Routine Dental Care and Referred Treatment Pathway), in the United Kingdom Armed Forces (UKAF), and determine the effects of endodontic complexity on outcomes.

METHODOLOGY

This retrospective cohort study included 1466 teeth in 1252 personnel who received root canal (re)treatment between 2015 and 2020. General Dental Practitioners treated 661 teeth (573 patients) (Routine cohort), whilst Dentists with a Special Interest treated 805 teeth (678 patients) (Referred cohort). The latter group were graduates of an MSc programme in Endodontics with 4-8 years of postgraduation experience. Case complexity was retrospectively determined for each tooth using the endodontic component of Restorative Index of Treatment Need (RIOTN) guidelines. Periapical healing was determined using loose radiographic criteria. The data were analysed using chi-square tests, univariate logistic regression and Cox proportional hazards models.

RESULTS

A significantly (p < 0.0001) larger proportion of cases of low complexity had undergone root canal treatment within the Routine versus Referred cohort. The odds of periapical healing was significantly higher within the Referred versus Routine cohort, regardless of analyses using pooled (OR = 1.17; 95% CI: 1.11, 1.22) or moderate complexity (OR = 4.71; 95% CI: 2.73, 8.11) data. Within the Routine cohort, anterior teeth had higher odds of periapical healing than posterior teeth (OR = 1.13; 95% CI: 1.04, 1.22). The 60-month cumulative tooth survival was lower (p = 0.03) in the Routine (90.5%) than the Referred (96.0%) cohort. Within the Routine cohort, the hazard of tooth loss was higher amongst posterior teeth (HR = 4.03; 95% CI: 1.92, 8.45) but lower if posterior teeth had cast restorations (HR = 0.36; 95% CI: 0.19, 0.70). For the Referred cohort, posterior teeth restored with cast restoration (vs not) had significantly lower risk of tooth loss (HR = 0.21; 95% CI: 0.08, 0.55).

CONCLUSIONS

For UKAF patients, root canal (re)treatment provided within the Referred pathway was significantly more likely to achieve periapical healing and better tooth survival than those provided within the Routine pathway. Posterior teeth restored with an indirect restoration had a higher proportion of tooth survival. This study supported the utility of the endodontic component of RIOTN for assessing case complexity.

Negotiation of Calcified Canals

The gradual formation of hard tissue along the root canal walls is a natural process associated with aging, typically progressing slowly over time. In reaction to tooth wear, operative procedures, vital pulp treatments, or regenerative endodontic procedures, hard tissue may also accumulate within the pulp canal space at a slow rate. In certain cases, such as dental trauma, autotransplantation, or orthodontic treatment, this deposition of hard tissue can accelerate unexpectedly, resulting in rapid narrowing or complete closure of the root canal space. This situation is called calcific metamorphosis (CM), root canal calcification, or pulp canal obliteration (PCO). Performing conventional endodontic therapy on severely calcified canals presents significant challenges and increases the risk of procedural accidents. Calcified canals introduce such complexity that dedicated negotiation concepts and specially designed instruments have been developed to deal with the challenge. This article seeks to review the existing methods for effectively navigating calcified canals and to introduce the buckling resistance activation test (BRAT) technique.

Expert consensus on difficulty assessment of endodontic therapy

Endodontic diseases are a kind of chronic infectious oral disease. Common endodontic treatment concepts are based on the removal of inflamed or necrotic pulp tissue and the replacement by gutta-percha. However, it is very essential for endodontic treatment to debride the root canal system and prevent the root canal system from bacterial reinfection after root canal therapy (RCT). Recent research, encompassing bacterial etiology and advanced imaging techniques, contributes to our understanding of the root canal system's anatomy intricacies and the technique sensitivity of RCT. Success in RCT hinges on factors like patients, infection severity, root canal anatomy, and treatment techniques. Therefore, improving disease management is a key issue to combat endodontic diseases and cure periapical lesions. The clinical difficulty assessment system of RCT is established based on patient conditions, tooth conditions, root canal configuration, and root canal needing retreatment, and emphasizes pre-treatment risk assessment for optimal outcomes. The findings suggest that the presence of risk factors may correlate with the challenge of achieving the high standard required for RCT. These insights contribute not only to improve education but also aid practitioners in treatment planning and referral decision-making within the field of endodontics.

Students' experience and perceptions of undergraduate endodontic education in New Zealand

This study investigated the clinical experience and perceptions of New Zealand graduating dental students (2019 and 2020) towards endodontic teaching and their clinical learning outcomes using an online survey and clinical scenarios. Quantitative data were analysed using SPSS software, and qualitative data were analysed thematically. Responses were similar for both cohorts (response rates 74%, 2019; 73%, 2020). Endodontic teaching was valuable and interesting but difficult compared with other disciplines. Molar endodontics, finding canals and managing posture were challenging. Students felt more confident and less anxious when supervised by clinicians experienced in endodontics. Time management was the most anxiety-inducing factor and significantly related to clinical experience (p < 0.001). Overall, students appropriately applied knowledge in most areas of endodontics while holistic problem-solving in complex scenarios was variable. Maximising clinical experience and supervision from teachers experienced in endodontics are important for learning, improving confidence and reducing anxiety.

Comparison of Curvature Severity Between Sagittal and Coronal Planes of Mesiobuccal Canals in Permanent Maxillary First Molars Using Multiple Complexity-risk Criteria: A CBCT Cross-sectional Study of a Brazilian Subpopulation

INTRODUCTION

This study aimed to compare the curvature severity of mesio-buccal (MB) canals between sagittal and coronal planes using cone-beam computed tomography.

METHODS

In a Brazilian subpopulation, untreated MB1 (n = 141) and MB2 (n = 72) with single curvatures in sagittal and coronal planes were measured to determine their angle and radius (r), plus the prevalence of S-shaped canals was recorded. Curvature severity was defined according to the American Association of Endodontists Case Difficulty Assessment form (AAE) and EndoApp (EA), as well as their modified versions that consider angle and radii (AAE-r, EA-r). Data were converted into mean angle and r, percentage of canals >30°, AAE, EA, AAE-r and EA-r categories. The influence of r on case severity was assessed. Statistical analysis was performed using t-tests and chi-squared tests. The level of significance was set as P ≤ .05.

RESULTS

For single curvatures, significantly higher mean degrees (SD) angles were found in the sagittal views in both canals (MB1 sagittal: 35 [11]; MB1 coronal: 13 [13]; MB2 sagittal: 29 [14]; MB2 coronal: 22 [15] [P < .05]). A greater percentage of angles >30° (MB1: 56.7% vs 6.4%; MB2: 44.4% vs 22.2%) in sagittal planes compared to coronal planes was also found. Conversely, a higher prevalence of S-shaped canals (MB1: 33.3% vs 7.1% MB2: 31.9% vs 15.3%) was observed in coronal planes. Significant differences between AAE and AAE-r were present with greater case severity when radii were considered (P < .05).

CONCLUSIONS

Sagittal planes were associated with more severe single curvatures, while coronal planes had a greater prevalence of S-shaped canals.

Effectiveness of endodontic complexity assessment tool (E-CAT) on the undergraduate students in an endodontic training program and its predictive capability on complications

INTRODUCTION

Dental students face a number of challenges when it comes to performing root canal treatments (RCTs). The Endodontic Complexity Assessment Tool (E-CAT) was developed to assist dental practitioners in assessing the complexity of RCTs before beginning treatment.

MATERIALS AND METHODS

The E-CAT was filled out independently by both the educator and the student. To allow educators to record scores and complexity classes, they transferred their and students' forms to the website https://www.e-cat.uk/. Students began endodontic treatment after learning about the complexity level of the case. The educators were responsible for recording any complications encountered in every case from the outset to 1 month after treatment.

RESULTS

A total of 70 students, 33 in fourth and 37 in fifth-grade, were included in the study. In the cases with higher E-CAT scores, complications such as misdiagnosed, faulty access cavity, furca or coronal third perforation, insufficient root canal instrumentation, working length loss, canal blockage, overpreparation, incomplete root canal filling and overfilling were experienced significantly more often compared to the cases with lower E-CAT scores (p < .05). The number of complications (r = .40, p < .001), treatment sessions (r = .44, p < .001), and teacher support (r = .24, p < .001) positively correlated with E-CAT score (p < .05).

CONCLUSION

The E-CAT is an effective tool for assisting dental students in understanding technical challenges, such as complex root canal anatomy and possible complications during treatment. Educators can also use e-CAT to pre-select clinical cases and standardise student training by offering cases of equal complexity.

An Endodontic forecasting model based on the analysis of preoperative dental radiographs: A pilot study on an endodontic predictive deep neural network

INTRODUCTION

This study aimed to evaluate the use of deep convolutional neural network (DCNN) algorithms to detect clinical features and predict the three years outcome of endodontic treatment on preoperative periapical radiographs.

METHODS

A database of single-root premolars that received endodontic treatment or retreatment by endodontists with presence of three years outcome was prepared (n = 598). We constructed a 17-layered DCNN with a self-attention layer (PRESSAN-17), and the model was trained, validated, and tested to 1) detect seven clinical features, i.e., full coverage restoration (FCR), presence of proximal teeth (PRX), coronal defect (COD), root rest (RRS), canal visibility (CAV), previous root filling (PRF), and periapical radiolucency (PAR), and 2) predict the three years endodontic prognosis by analyzing preoperative periapical radiographs as an input. During the prognostication test, a conventional DCNN without a self-attention layer (RESNET-18) was tested for comparison. Accuracy and area under the receiver-operating-characteristic (ROC) curve (AUC) were mainly evaluated for performance comparison. Gradient-weighted class activation mapping (Grad-CAM) was used to visualize weighted heatmaps.

RESULTS

PRESSAN-17 detected FCR (AUC = 0.975), PRX (0.866), COD (0.672), RRS (0.989), PRF (0.879) and PAR (0.690) significantly, compared to the no-information rate (p<0.05). Comparing the mean accuracy of 5-fold validation of two models, PRESSAN-17 (67.0%) showed a significant difference to RESNET-18 (63.4%, p<0.05). Also, the area under average ROC of PRESSAN-17 was 0.638, which was significantly different compared to the no-information rate. Grad-CAM demonstrated that PRESSAN-17 correctly identified clinical features.

CONCLUSIONS

Deep convolutional neural networks may aid in the prognostication of endodontic treatment outcome.

Present status and future directions -Management of curved and calcified root canals

Root canal curvature and calcification introduce factors that increase the risk of procedural accidents during root canal treatment. The inability to achieve patency to the apical third, asymmetrical dentine removal leading to transportation, perforation and instrument fracture inside the curved trajectories are some of the procedural problems that might jeopardize the management of intraradicular infection and result in poor treatment outcomes. In fact, curved and constricted canals introduce such complexity that total instrumentation concepts and specially designed instruments have been developed to deal with the challenge. This narrative review seeks to provide and consolidate the principles necessary for understanding the dynamics of curved and constricted canal management and to improve the understanding for future developments in this field.

Methods for measurement of root canal curvature: a systematic and critical review

The assessment of root canal curvature is essential for clinical and research purposes. This systematic review presents an overview of the published techniques for the measurement of root canal curvature features using imaging and to provide a critique of their clinical application. A database search in PubMed, PubMed Central, Embase, Scopus, EBSCO Dentistry & Oral Sciences Source and Virtual Health Library was conducted, using appropriate key words to identify measurement methods for root canal curvatures. The search strategy retrieved 10594 records in total, and 31 records fulfilled the inclusion criteria. From 2D image acquisitions, eleven studies measured exclusively the angle of curvature, an additional thirteen measured other curvature features (level, height, radius, length and shape). Seven reports described methods from 3D imaging (CBCT, μCT). Root canal curvatures should be measured, for clinical proposes, to facilitate endodontic treatment planning, and in research, to reduce the risk of selection bias. This review has revealed that there are many methods described in the literature; however, no consensus exists on which method should be used. Some of the methodologies have potential clinical translation, whereas others are suitable for research purpose only, as they require a specific software or radiographic exposure in the mesiodistal direction.