Prevalence of periapical periodontitis and its association with previous root canal treatment and, root canal obturation length –based on CBCT
الموضوعات :Alireza Elsagh 1 , Parisa Ranjbarian 2 , Azadeh Torkzadeh 3 , Parisa Taheri 4
1 - Faculty of dentistry, Isfahan (khorasgan) Branch, Islamic Azad university, Isfahan, Iran
2 - Department of Endodontics, Faculty of Dentistry, Isfahan (Khorasgan) Branch, Isfahan, Iran
3 - Department of oral and maxillofacial radiology, Faculty of Dentistry, Isfahan (khorasgan) Branch, Islamic Azad University, Isfahan, Iran
4 - Department of oral and maxillofacial radiology, Faculty of Dentistry, Isfahan (khorasgan) Branch, Islamic Azad university, Isfahan, Iran
الکلمات المفتاحية: Periapical periodontitis, Cone-Beam Computed Tomography, Root Canal Therapy,
ملخص المقالة :
Background: Root canal obturation length may significantly affect the development of apical periodontitis lesions. This study aimed to investigate the prevalence of periapical periodontitis and its relationship with previous root canal treatment in terms of root canal obturation length. Materials and Methods: In this cross-sectional observational study, 264 root canal-treated premolars and molars from patients referred to the Faculty of Dentistry at Azad University of Isfahan, who had undergone root canal treatment at least one year prior, were examined using CBCT radiography. A total of 630 canals with previous root canal treatments were selected. The screening protocol involved an initial selection of roots, followed by alignment in three planes (coronal, sagittal, axial) to ensure centrality. The roots were then classified based on the presence of periapical periodontitis and obturation length. Data analysis was conducted using Fisher’s exact test (α=0.05) Results: There was no significant difference between quality of obturation length among root treated teeth in all study groups (p>0.05). significant difference was observed between the obturation length and the frequency of apical periodontitis. The lesions among canals with proper obturation length were significantly less than canals with under or over obturation (p<0.001). But no significant difference was shown in pairwise comparison of each teeth type. (molars-premolars, first- second) (P>0.05). Conclusion: There was a relationship between the length of root canal obturation and the prevalence of apical periodontitis, with a significantly lower presence of lesions in canals with appropriate obturation. However, this relationship was not observed based on the type of teeth.
Contemporary Orofacial Sciences (2024) 2(2): 13-18
DOI: 10.71783/cofs.2024.1105072
ORIGINAL RESEARCH |
Prevalence of periapical periodontitis and its association with previous root canal treatment and, root canal obturation length –based on CBCT
Alireza Elsagh1, Parisa Ranjbarian2*, Azadeh Torkzadeh3, Parisa Taheri4
Received: 2024-03-12/ Accepted: 2024-09-23 / First publication date: 2024-11-03
© The Author(s) 2024
Abstract
Background: Root canal obturation length may significantly affect the development of apical periodontitis lesions. This study aimed to investigate the prevalence of periapical periodontitis and its relationship with previous root canal treatment in terms of root canal obturation length.
Materials and Methods: In this cross-sectional observational study, 264 root canal-treated premolars and molars from patients referred to the Faculty of Dentistry at Azad University of Isfahan, who had undergone root canal treatment at least one year prior, were examined using CBCT radiography. A total of 630 canals with previous root canal treatments were selected. The screening protocol involved an initial selection of roots, followed by alignment in three planes (coronal, sagittal, axial) to ensure centrality. The roots were then classified based on the presence of periapical periodontitis and obturation length. Data analysis was conducted using Fisher’s exact test (α=0.05).
Results: There was no significant difference between quality of obturation length among root treated teeth in all study groups (p>0.05). Significant difference was observed between the obturation length and the frequency of apical periodontitis. The lesions among canals with proper obturation length were significantly less than canals with under or over obturation (p<0.001). But no significant difference was shown in pairwise comparison of each teeth type. (molars-premolars, first- second) (P>0.05).
Conclusion: There was a relationship between the length of root canal obturation and the prevalence of apical periodontitis, with a significantly lower presence of lesions in canals with appropriate obturation. However, this relationship was not observed based on the type of teeth.
Keywords: Periapical periodontitis; Cone-Beam Computed Tomography; Root Canal Therapy
Introduction
Corresponding author: Parisa Ranjbarian Department of endodontics, Faculty of Dentistry, Isfahan (khorasgan) Branch, Islamic Azad University, Isfahan, Iran Email: p.ranjbarian@khuisf.ac.ir
1 Faculty of Dentistry, Isfahan (khorasgan) Branch, Islamic Azad University, Isfahan, Iran 2 Department of endodontics, Faculty of Dentistry, Isfahan (khorasgan) Branch, Islamic Azad University, Isfahan, Iran 3 Department of oral and maxillofacial radiology, Faculty of Dentistry, Isfahan (khorasgan) Branch, Islamic Azad University, Isfahan, Iran 4 Department of oral and maxillofacial radiology, Faculty of Dentistry, Isfahan (khorasgan) Branch, Islamic Azad university, Isfahan, Iran |
Imaging techniques used to evaluate the presence of periapical lesions include periapical radiography, panoramic radiography, and cone beam computed tomography (CBCT). Conventional periapical radiography has several limitations. In normal radiography, a two- dimensional image is made of a three-dimensional object, and the same third-dimension compression in the image may hide important anatomy or pathological changes and lead to the failure to diagnose the periapical lesion and, ultimately, to the failure of the treatment. To prepare an ideal image, a parallel technique should be used in periapical radiography, which is rarely possible due to the conditions of the oral cavity. In addition, the possibility of superimposing anatomical structures on the image is another disadvantage of two-dimensional imaging (16). Despite all the shortcomings of two-dimensional imaging, the need to use new technologies in imaging is felt more than ever.
CBCT (cone beam computer tomography) technology is a new generation of CT, which provides 3D data with less cost and received dose than conventional CT. CBCT can provide a three-dimensional view of the target area, and this ability of CBCT to show lesions in several dimensions can solve the main defect of periapical radiography. It is apparently the most accurate method for identifying periapical lesions (17). CBCT, by reconstructing axial, sagittal, and coronal plane as well as diagonal shows all aspects of anatomy and pathology of the image (18).
As mentioned in previous studies, to achieve success in endodontic treatment with a favorable prognosis, it is considered necessary to observe four things. These include examining the presence of periapical lesions before treatment (19), use of the rubber dam (20,21), density and quality of canal obturation (22,23), and the quality of crown restoration (24). Ray and Trope (12) examined how the quality of root fillings and coronal restorations impacts the periapical status of treated teeth. They observed that teeth with good quality root fillings (GE) and good coronal restorations (GR) had a success rate of apical periodontitis index of 91.4%, compared to teeth with poor root fillings (PE) and poor coronal restorations (PR), which showed an API rate of 18.1%. Similarly, Falakakoglu et al. (25) conducted a retrospective cone-beam computed tomography study to assess apical periodontitis in relation to the quality of root canal fillings and coronal restoration in a Turkish subpopulation. They reported that the quality of root canal obturation, adequate coronal restoration, and the type of crown restoration are factors related to apical periodontitis. It has also been stated in several different studies that the main reason for the occurrence of periapical periodontitis is the improper quality of root canal obturation (26, 27). Considering the risks of apical periodontitis and the need for retreatment in patients with symptoms of this lesion, the purpose of this study was to determine the prevalence of periapical periodontitis and its relationship with previous root canal treatment in terms of length of root canal obturation based on CBCT findings.
In this cross-sectional observational study of the analytical type (Ethical code: IR.IAU.KHUISF. REC.1401.085), the 264 root-treated premolar teeth and molars in patients referred to the Faculty of Dentistry of the Azad University of Isfahan (Khorasgan) were examined by CBCT radiography. The study focused on teeth that had undergone root canal treatment at least one year ago, selected CBCT images had to include at least one premolar or molar that had undergone root canal treatment, with a minimum of one year since the procedure. The study excluded third molars, untreatable roots, impacted teeth, primary teeth, permanent teeth with immature apices, images with artifacts, as well as cases with fractured files, perforations, root fractures, resorptions, teeth without crown restorations, and maxillary molars missing the second mesiobuccal canal (MB2).
All images were prepared by the Sirona Germany system with high resolution and exposure conditions kv 85-100, mAs 5-7, and total filtration < 5/2 mm, focal point equal to 0.5 mm2 and scan time 14 seconds and then checked and measured in sidexis 3D software.
Finally, 630 canals with previous root canal treatment were selected by a trained final-year dental student under the supervision of a radiologist. The screening protocol, which included the initial selection of roots, followed by root alignment in three planes (coronal, sagittal, and axial) to have a centrality in three planes, followed by root classification according to the parameters to be evaluated, was performed.
All samples were analyzed in coronal, sagittal, and axial dental planes. Each root was classified according to the following parameters observed in each of the planes: (25)
-Presence/absence of periapical radiolucency
-Length of oburation, which was classified as below;
Under obturation: if it is 2 mm short of the radiographic apex
Suitable: in case of obturation up to 0-2 mm from the radiographic apex
Over obturation: in case of obturation beyond the apex
The obtained data were analyzed using Fisher's exact test and SPSS26 software, and the error level was considered 0.05.
Results
Apical periodontitis lesion was observed in 99 canals (15.7%) and the most common canal with a lesion was the mesiobuccal canal of the maxillary first molar (37.4%). maxillary first molar had the most lesion (33.3%) (Figure 1 and 2).
Figure 1. Frequency distribution of canal lesioned tooth in root-treated maxillary premolars and molars, mandibular premolars and molars.
Figure 2. Frequency distribution of tooth lesioned in root-treated maxillary premolars and molars, mandibular premolars and molars.
The comparison of obturation length quality between maxillary and mandibular premolars and molars showed no significant differences, as indicated by Fisher's exact test. There was no significant difference between the obturation lengths of maxillary and mandibular first premolars (p=1.00), first molars (p=0.200), second premolars (p=0.533), or second molars (p=0.370). Similarly, no significant difference was found between all maxillary and mandibular molars (p=0.064) or premolars (p=0.698) (Table 1).
Table 1. comparison of the filling length frequency in the maxillary premolar and molar teeth
Tooth | Root canal filling length | Maxillary premolar | Mandibular premolar | P value | Maxillary molar | Mandibular molar | P value |
No (%) | No (%) | No (%) | No (%) | ||||
first | Good | 72 (97.3) | 22 (100.0) | 1.00 | 139 (95.9) | 135 (91.2) | 0.200 |
Short | 2 (2.7) | 0 (0.0) | 5 (3.4) | 12 (8.1) | |||
length | 0 (0.0) | 0 (0.0) | 1 (0.7) | 1 (0.7) | |||
Second | Good | 67 (95.7) | 32 (91.4) | 0.533 | 63 (98.4) | 68 (94.4) | 0.37 |
Short | 1 (1.4) | 2 (5.7) | 1 (1.6) | 2 (5.6) | |||
length | 2 (2.9) | 1 (2.9) | 0 (0.0) | 0 (0.0) |
In terms of apical periodontitis frequency, Fisher's exact test revealed no significant difference between maxillary and mandibular teeth. This included comparisons of first premolars (p=0.586), first molars (p=0.778), second premolars (p=1.00), and second molars (p=0.494). No significant difference was observed between all maxillary and mandibular premolars (p=0.515) or molars (p=0.926).
However, a significant relationship was found between obturation length and the presence of apical periodontitis lesions (p<0.001). Canals with proper obturation had significantly fewer lesions compared to those with underfilled or overfilled obturation (Table 2).
Table 2. The relationship between filling length and apical periodontitis in maxillary premolars and molars
Apical periodontitis | Suitable | Under obturation | Over obturation | P value |
No (%) | No (%) | No (%) | ||
No | 520 (87.0) | 8 (29.6) | 3 (60.0) | < 0.001 |
Yes | 78 (13.0) | 19 (70.4) | 2 (40.0) |
Discussion
The results of the present study showed that 15.7% of the examined canals had have apical periodontitis lesions. In the study of Çalışkan et al. (28), periapical lesions were 72%; in the study of Omoregie et al. (29), 30.1%; in the study of Safi et al. (30), 15.9% and Tavares et al. (31) 33%. The different prevalence in various populations can be attributed to factors such as cultural differences, hygiene, and dentists' expertise. The present study reported the highest prevalence of apical periodontitis in maxillary first molar teeth, followed by mandibular first molars, mandibular second molars, maxillary second molars, and maxillary premolars. Mandibular premolars showed the lowest prevalence of apical periodontitis. Apical periodontitis was also not observed in the mandibular first premolar.
According to the results of the present study, the highest frequency of apical periodontitis was found in first molar teeth with under obturation, and there was a significant relationship between improper obturation in terms of length of obturation and chronic apical periodontitis lesion.
Considering the higher occurrence of apical periodontitis in upper and lower first molar teeth, it can be stated that apical periodontitis in first molar teeth with under obturation is much higher than in other teeth. Of course, it should be mentioned that one of the other reasons for the abundance of periapical lesions in the maxillary first molar in the study is the possibility of the presence of the second mesiobuccal canal in this tooth and the lack of proper and effective cleaning by the dentist (32, 33).
In a study by Falakaloglu et al (25), there was a significant relationship between apical periodontitis and root canal length obturation. They founded that apical periodontitis was much more common in first molar teeth than in other restored teeth, and have concluded that the proper obturation length of the teeth will be effective in preventing the occurrence of apical periodontitis, which is align with the results of the present study. In the study of Bürklein et al. (34), the prevalence of apical periodontitis lesions in re-rooted teeth was significantly high, and this amount in over obturation root canals, 27%, and teeth with obturation length of less than 2mm 4.4%, teeth without root treatment had 2.9% lesions. Also, the incidence of apical periodontitis in molar teeth was significantly higher than in other teeth.
According to the results of the current study, the obturation length is related to the incidence of apical periodontitis, so the lowest incidence of apical periodontitis was observed in teeth with proper obturation but this rate was 5 times higher in teeth with short obturation than with proper obturation, and the length of long obturation also had a ratio of 3 to 1 with proper obturation in the incidence of apical periodontitis, which is consistent with the results of other studies (7, 35, 36).
Insufficient root treatment generally causes a higher risk of apical periodontitis. Improper root canal treatment includes methods such as incomplete cleaning and shaping, use of poor disinfection techniques, complex canal anatomy, and failure to use rubber dams (13).
The results of a study by Sousa Gomide et al. (37) showed that the length of canal obturation can affect apical periodontitis, and the frequency of apical periodontitis in molar teeth is significantly higher than in other groups of teeth. In the study of Brati et al. (38), apical periodontitis with a high probability in the second mesiobuccal canal of maxillary first molar teeth that did not undergo root canal treatment was more than in other teeth.
Obviously, over-filled obturation also leads to stimulation and attraction of inflammatory cells to the periapical tissues and leads to the occurrence of periapical periodontitis (39). Ricucci et al. (39) stated that to prevent the occurrence of periapical periodontitis in patients undergoing root canal treatment, root canal length obturation should be performed appropriately to prevent this lesion.
Since CBCT provides better results in evaluating periapical periodontitis and the quality and manner of canal obturation. Also, the buccolingual dimension in the sagittal root obturation section can only be seen in the CBCT scan (40). In 80% of the roots, the apical hole is up to 3.8 mm shorter than the anatomical apex and is often located in the buccal or lingual part of the root (41). Therefore, many short obturation are not seen in periapical radiographs; the present study was conducted using radiographic images due to the limitation of AP assessment (36). Of course, CBCT is more expensive, and the patient is exposed to more radiation.
Maxillary molars, especially in mesiobuccal canals, showed the highest prevalence of apical periodontitis. There was a relationship between the length of root canal obturation and the prevalence of apical periodontitis, with a significantly lower presence of lesions in canals with appropriate obturation compared to those with under- and over-obturation. However, this relationship was not observed based on the type of teeth.
The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.
1. Nascimento EHL, Gaêta-Araujo H, Andrade MFS, Freitas DQ. Prevalence of technical errors and periapical lesions in a sample of endodontically treated teeth: a CBCT analysis. Clin Oral Investig. 2018;22(7):2495-2503.
2. Razavian H, KalantarMotamed MR, Saeidi A, Barekatian B, Noormohammadi H, Davoodi HR. An in vitro comparative study of digital and conventional imagingsystem for detection of endodontic procedural errors. Indian J Sci Res. 2014;4(3):430-6.
3. Estrela C, Holland R, Estrela CR, Alencar AH, Sousa-Neto MD, Pécora JD. Characterization of successful root canal treatment. Braz Dent J. 2014;25(1):3- 11.
4. Torabinejad M, Fouad AF, Shabahang SH. Endodontics principles and practice.6th ed. London: Elsevier. 2021: 317
5. Yousuf W, Khan M, Mehdi H. Endodontic Procedural Errors: Frequency, Type of Error, and the Most Frequently Treated Tooth. Int J Dent. 2015;2015:673914
6. Abbott PV. Classification, diagnosis and clinical manifestations of apical periodontitis. Endodontic Topics 2016; 8: 36–54.
7. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR. Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. J Endod. 2008;34(3):273-279.
8. Van der Veken D, Curvers F, Fieuws S, Lambrechts P. Prevalence of apical periodontitis and root filled teeth in a Belgian subpopulation found on CBCT images. Int Endod J. 2017;50(4):317-329.
9. Saunders WP, Saunders EM, Sadiq J, Cruickshank E. Technical standard of root canal treatment in an adult Scottish sub-population. Br Dent J. 1997;182(10):382-386.
10. De Moor RJ, Hommez GM, De Boever JG, Delme KIM, Martens GEI. Periapical health related to the quality of root canal treatment in a Belgian population. Int Endod J. 2000;33(2):113-120.
11. López-López J, Jané-Salas E, Estrugo-Devesa A, Castellanos-Cosano L, Martín-González J, Velasco-Ortega E, et al. López-López J, Jané-Salas E, Estrugo-Devesa A. Frequency and distribution of root-filled teeth and apical periodontitis in an adult population of Barcelona, Spain. Int Dent J. 2012;62(1):40-46
12. Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J. 1995;28(1):12-18.
13. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498-504.
14. Ricucci D. Apical limit of root canal instrumentation and obturation, part 1. Literature review. Int Endod J. 1998;31(6):384-393.
15. Fernández R, Cardona JA, Cadavid D, Álvarez LG, Restrepo FA. Survival of Endodontically Treated Roots/Teeth Based on Periapical Health and Retention: A 10-year Retrospective Cohort Study. J Endod. 2017;43(12):2001-2008.
16. Durack C, Patel S. Cone beam computed tomography in endodontics. Braz Dent J. 2012;23(3):179-191.
17. Patel S, Wilson R, Dawood A, Foschi F, Mannocci F. The detection of periapical pathosis using digital periapical radiography and cone beam computed tomography - part 2: a 1-year post-treatment follow-up. Int Endod J. 2012;45(8):711-723.
18. Lee G, Lankalis J, Tamari K, Singer SR. Use of cone-beam computed tomography in diagnosing and treating endodontic treatment failure: A case study. J Orofac Sci 2017;9:58-62
19. Ng YL, Mann V, Gulabivala K. A prospective study of the factors affecting outcomes of non-surgical root canal treatment: part 2: tooth survival. Int Endod J. 2011;44(7):610-625.
20. Ahmad IA. Rubber dam usage for endodontic treatment: a review. Int Endod J. 2009;42(11):963-972.
21. Lin PY, Huang SH, Chang HJ, Chi LY. The effect of rubber dam usage on the survival rate of teeth receiving initial root canal treatment: a nationwide population-based study. J Endod. 2014;40(11):1733-1737.
22. Ricucci D, Russo J, Rutberg M, Burleson JA, Spångberg LS. A prospective cohort study of endodontic treatments of 1,369 root canals: results after 5 years. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(6):825-842.
23. Imura N, Pinheiro ET, Gomes BP, Zaia AA, Ferraz CC, Souza-Filho FJ. The outcome of endodontic treatment: a retrospective study of 2000 cases performed by a specialist. J Endod. 2007;33(11):1278-1282
24. Landys Borén D, Jonasson P, Kvist T. Long-term survival of endodontically treated teeth at a public dental specialist clinic. J Endod. 2015;41(2):176-181.
25. Falakaloglu S, Belgin CA, Uygun LA, Adigüzel Ö. Assessment of apical periodontitis in relation to quality of root canal fillings and coronal restorations in a Turkish subpopulation: A retrospective cone-beam computed tomography study. Saudi Endod J 2020;10(2):121-25
26. Ordinola-Zapata R, Bramante CM, Duarte MH, Ramos Fernandes LM, Camargo EJ, de Moraes IG, et al. The influence of cone-beam computed tomography and periapical radiographic evaluation on the assessment of periapical bone destruction in dog's teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(2):272-279.
27. Patel S, Wilson R, Dawood A, Foschi F, Mannocci F. The detection of periapical pathosis using digital periapical radiography and cone beam computed tomography - part 2: a 1-year post-treatment follow-up. Int Endod J. 2012;45(8):711-723.
28. Çalışkan MK, Kaval ME, Tekin U, Ünal T. Radiographic and histological evaluation of persistent periapical lesions associated with endodontic failures after apical microsurgery. Int Endod J. 2016;49(11):1011-1019
29. Omoregie FO, Ojo MA, Saheeb B, Odukoya O. Periapical granuloma associated with extracted teeth. Niger J Clin Pract. 2011;14(3):293-296.
30. Safi L, Adl A, Azar MR, Akbary R. A Twenty-year Survey of Pathologic Reports of Two Common Types of Chronic Periapical Lesions in Shiraz Dental School. J Dent Res Dent Clin Dent Prospects. 2008;2(2):63-70
31. Tavares PB, Bonte E, Boukpessi T, Siqueira JF Jr, Lasfargues JJ. Prevalence of apical periodontitis in root canal– treated teeth from an urban French population: influence of the quality of root canal fillings and coronal restorations. J Endod 2009; 35(6):810-3
32. Alizade E, Ranjbarian P, Torkzade A, ShariatiNajafabadi SS. Prevalence of Technical Errors in a Sample of Endodontically Treated Teeth: a CBCT Analysis. J Res Dent Sci 2023; 20 (2) :43-50
33. Esmaeilian A, Torkzadeh A, Mortaheb A, ZakariaeeJuybari A. The Examination of Root Morphology of the Maxillary First and Second Molars Using Cone Beam Computed Tomography. J Isfahan Dent Sch 2021; 17(3): 329-336
34. Bürklein S, Schäfer E, Jöhren HP, Donnermeyer D. Quality of root canal fillings and prevalence of apical radiolucencies in a German population: a CBCT analysis. Clinical oral investigations. 2020;24(3):1217-27.
35. Liang YH, Yuan M, Li G, Shemesh H, Wesselink PR, Wu MK. The ability of cone-beam computed tomography to detect simulated buccal and lingual recesses in root canals. IntEndod J. 2012;45(8):724-9.
36. Lofthag-Hansen S, Huumonen S, Gröndahl K, Gröndahl HG. Limited cone-beam CT and intraoral radiography for the diagnosis of periapical pathology. Oral Surg Oral Med Oral Pathol Oral RadiolEndod. 2007;103(1):114-9.
37. de Sousa Gomide MR, Samuel RO, Guimarães G, Nalin EK, Bernardo RT, Dezan-Júnior E, Cintra LT. Evaluation of the relationship between obturation length and presence of apical periodontitis by CBCT: an observational cross-sectional study. Clinical oral investigations. 2019;23(5):2055-60.
38. Barati S, Torkzadeh A, Ranjbarian P, TarazJamshidi S. Prevalence of periapical radiolucency in endodontically treated teeth with untreated canals by CBCT. Contemporary Orofacial Sciences 2023; 1(3): 1-6
39. Ricucci D, Langeland K. Apical limit of root canal instrumentation and obturation, part 2. A histological study. Int Endod J. 1998;31(6):394-409.
40. van der Sluis LW, Wu MK, Wesselink PR. An evaluation of the quality of root fillings in mandibular incisors and maxillary and mandibular canines using different methodologies. J Dent. 2005;33(8):683-8.
41. ElAyouti A, Weiger R, Löst C. Frequency of overinstrumentation with an acceptable radiographic working length. J Endod. 2001;27(1):49-52.
