March 26, 2012
Hopefully, I have your attention. In the new world of dentistry, or as I like to call it, THE HUNGER GAMES, with the technologic onslaught/juggernaut, implant driven treatment planning, CAD/CAM software driven everything from surgical placement to final restorations, and a new material appearing every twelve seconds vibe, with the claims and counter-claims, with the marketing coming at you in print, online, from anyone with a room large enough in their facility to call it a center, with everyone and their brother or sister fostering mentoring programs, what and who do you believe and how do you determine “VERITAS?” As such, I’m throwing down a gauntlet to all specialty societies, to our academics, to anyone with a pulse who reads this blog to set standards for reviewing studies and articles (even those refereed by Don Cherry), for giving all dentists the ability to sift the wheat from the chaff using the following as a template/example. For those of you who can’t handle stream of consciousness writing – don’t ever pick up anything by James Joyce or William Faulkner cuz your world will end with a whimper….and now, here’s Johnny………http://www.slideshare.net/kendo160/pdf-12165869?from=share_email.
This was forwarded to the ROOTS forum by a really amazing lad. The authors of the article are some serious folks – particularly Larz Spangberg, one of the endo gods in it’s Pantheon. Here’s the commentary by the sender:
Hello dear friends… This is one of the most interesting papers I have read in recent times. Even though a cohort study, it’s prospective nature leads to significant observations related to endodontic therapy. I believe that Dr. Ricucci is one of the best dental professionals in the world. He can address the clinic and science in a very didactic and comprehensive approach. Lets go to the paper… Related to the several factors associated to the success of endodontic treatments in infected canals, at the beginning of the study, there are important statements about to need a correct disinfection of this complex system – (editor’s note – you mean ONE FILE ISN’T ALL YOU NEED?). According to the authors, scientific evidence at the moment are composed by poorly randomized studies and meta-analysis based in these studies resulting in several wrong conclusions. Sincerely, I agree with this information, cause I believe that until the moment we don’t have “randomized clinical trials” 100% controlled and randomized. In total, were performed endodontic treatments in 780 patients but only 470 could be followed (period of 5 years). This information provides a “drop out” of 40.7%. Statistically, this is a relatively high number, however, in the case of a prospective clinical study with considerable N and longitudinal follow-ups, I believe these are the averages of studies with methodological similarities. In general, success rates reached 88.6%. About this issue, is important to highlight some inherent characteristics of these analyses. All radiographic evidence of failure, teeth that had spontaneous pain, fistula, edema or any clinical symptoms were considered failures too. Also, there was an isolated assessment of teeth and roots where the root that got the worst result would represent the final classification of the entire unit.
Since requirements of the criteria associated with the endodontic success, I believe that value showed above (88.6%) can be considered high. In the study there are several tables where we can extract important information. In the first one, there is a sub-groupal analysis evaluating success and failure in different dental groups. One of the most interesting information was that the maxillary incisors had the worst indices of failure behind only the mandibular molars. Obviously, if we observe this table more closely, we can prove that N of this two subgroups are quite different, but, I believe this information is very important. In a different analysis, regardless of dental group, success rates decreased sharply when the obturation limits were to 2.5mm or more from the radiographic apex. In addition, success rates were significantly higher when obturation limits were between 1 and 2.5mm from radiographic limits compared to overfill cases and fillings coincident with the radiographic limits. Another very important issue of the study was the quality of the restorations did not influence the results of the treatments regardless of the initial diagnosis. [Restoration quality had no significant effect on outcome, regardless of treatment diagnosis (P _ .94; Table XII). The overall success rate for good quality was 88.9% versus poor quality at 89.2%](editor’s note – exqueeze me??)
Here I have a question…As far as coronal microleakage interfer in the results of a good endodontic treatment? To the surprise of the authors, higher success index were observed in older patients. This point was very interesting because generally expected to find more difficulties to perform the cleaning and disinfection in tiny canals due to physiological dentin deposition. Furthermore, I believe the authors expected an opposite result in this point as a result of diminished effectiveness of the immune system in patients with advanced age. In necrotic cases, higher success index were observed when calcium hydroxide was used. Unlike expected, success was influenced by the type of sealers used. Pulp Canal Sealer had the poorest results.
Best regards…Ricardo RICARDO MACHADO
PhD Student Department of Restorative Dentistry, School of Dentistry of Ribeirão Preto – FORP/USP Avenida do Café, s/nº, CEP. 14040-904 Ribeirão Preto – SP Brazil
I’d like to share a commentary subsequent to this from a ROOTS forum member (a notorious contrarian/curmudgeon)…..Same outcome study problems. Unless an individual practitioner is looking at his/her own results and documenting his/her results meticulously these compiled stats mean absolutely nothing to anyone else. We have no idea how any of the cases in this study were handled, the unique anatomical challenges of each tooth treated, etc. etc. etc. All the unaccounted for nuanced details which are not stated in these outcome studies determine outcome. It’s a pointless exercise in futility performed by researchers who are either completely ignorant of the issues that present in clinical endodontic practice, or choose to ignore them so they can satisfy some formally recognized outcome study protocol which in reality is completely dysfunctional.
What is the point of all this blather???? With SlideShare, articles can now be posted to the blog to compliment clinical case presentations. The literature can be reviewed in the context of the techniques and procedures employed as well as the materials used. It’s a bit of a Rube Goldberg attempt to CREATE A KNOWLEDGE NETWORK using this blog, but who knows, if it catches on…….maybe, maybe, if you believe in tooth fairies, we’ll get a Canada wide online discussion forum and MAGIC AND WONDER WILL HAPPEN!!!!