|Year : 2017 | Volume
| Issue : 4 | Page : 237-240
Radiographic evaluation and predictors of periapical lesions in patients with root-filled and nonroot-filled teeth in Kuwait
Manal Maslamani1, Jawad Behbahani1, Amal K Mitra2
1 Department of Restorative Sciences, Faculty of Dentistry, University, Kuwait
2 Department of Epidemiology and Biostatistics, Jackson State University, Jackson, Mississippi, USA
|Date of Web Publication||1-Dec-2017|
Department of Restorative Sciences, Faculty of Dentistry, Kuwait University, P.O. Box: 24923, Safat 13110
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study was to determine the association between periapical health status with the quality of the root filling and was the coronal restoration and identify the predictors of periapical lesion. Subjects and Methods: It was conducted among 197 adult patients who visited Kuwait University. Periapical status was measured by periapical index. The presence or absence of periapical lesions was evaluated using panoramic radiographs. Statistical Analysis: Data were analyzed using the Statistical Package for Social Sciences. Chi-square tests were performed to assess associations between categorical variables. Results: Of the 4,841 teeth examined, 2.7% were root-filled (n = 130). Thirty-four percent of the root-filled teeth (n = 44), and 3% of the nonroot-filled teeth (n = 141 of 4711) exhibited periapical radiolucency. Of the root filled teeth, 49% were judged to be inadequate (n = 64) and 91% of the inadequate ones had short root filling (n = 58). The presence of periapical lesion was significantly predicted by inadequate coronal restoration, dental caries, periodontal bone loss, and the presence of post crown. Conclusion: This study demonstrated a large number of untreated teeth with periapical pathology. The quality of root fillings in this population appeared to be poor and was significantly associated with a high prevalence of apical periodontitis.
Keywords: Apical periodontitis, coronal filling, periapical lesion, root filling
|How to cite this article:|
Maslamani M, Behbahani J, Mitra AK. Radiographic evaluation and predictors of periapical lesions in patients with root-filled and nonroot-filled teeth in Kuwait. Indian J Dent Sci 2017;9:237-40
|How to cite this URL:|
Maslamani M, Behbahani J, Mitra AK. Radiographic evaluation and predictors of periapical lesions in patients with root-filled and nonroot-filled teeth in Kuwait. Indian J Dent Sci [serial online] 2017 [cited 2019 Jan 17];9:237-40. Available from: http://www.ijds.in/text.asp?2017/9/4/237/219630
| Introduction|| |
Radiographs are used for the diagnosis and assessment of the health of periapical tissues. The prevalence of nonroot-filled teeth with periapical lesion varies widely from 0.8% to 21%.,, However, the prevalence of periapical lesion in root-filled teeth ranges from 23% to 87%,,,, which is about 25-fold higher than that of non-root-filled teeth. In a meta-analysis, 36% of the 28,881 endodontically treated teeth showed periapical radiolucencies.
Inadequate treatment was frequently observed as one of the most important factors associated with poor outcome of apical periodontitis in most cross-sectional studies. Teeth with adequate filling length had a lower prevalence of periapical lesion than those with inadequate length. Of the 8743 teeth examined in a French population, only 21% had an acceptable standard of treatment, and 27% of the unacceptable root filling exhibited periapical pathology. The technical quality of root filling was also poor and consistent with a high prevalence of periapical lesion in an Irish population.
Among the factors that determine the outcome of root canal treatment is the quality of the coronal restoration of the tooth. Sunay et al. found that 91% of the teeth with a poor quality of treatment had apical periodontitis. Similarly, Al-Omari et al. observed that 87% of a Jordanian population who received inadequate endodontic treatments showed periapical lesion.
Most cross-sectional studies evaluating the periradicular status of root filled teeth were reported from Europe, North America, and Asia; there is a dearth of research on this topic in the Middle Eastern countries. Therefore, the aims of this study were to provide information of the periapical health status of patients who are treated at dental clinics in Kuwait and to determine the predictors of periapical lesions.
| Subjects and Methods|| |
The study sample was obtained prospectively from Mubarak Al-Kabeer hospital from September to December 2005. Ethical approval was obtained from the Research Committee of the Faculty of Dentistry, Kuwait University. Written informed consent was obtained from all participants.
All orthopantomogram (OPGs) were obtained using PM 2002 Proline radiographic equipment (Planmeca, Helsinki, Finland) and exposed by the same technician.
Two endodontists evaluated each OPG independently using the same viewer with ×2.5 magnification in a darkened room. Before the investigation, the examiners examined 10 OPGs separately using the periapical index (PAI). These radiographs were double-read by the same examiners with 2-week interval to assess intraobserver agreement.
Teeth were categorized as root filled if there was radiopaque material in the root canal system. The periapical status was assessed for each tooth using the PAI. The periapical area around each root was categorized as either: normal, small changes in bone structure, changes in bone structure with some mineral loss, periodontitis with well-defined radiolucent area, or severe periodontitis with exacerbating features. Multirooted teeth were scored according to the root with the most severe periapical status. The location of any periradicular radiolucency was recorded.
The quality of the root fillings was assessed and the length of root filling was categorized as follows: (a) Adequate: root canal filling 0–2 mm short of the radiographic apex, and (b) Inadequate: root canal filling >2 mm short of the radiographic apex, root canal filling extruded beyond the radiographic apex, or root canal filling limited to the pulp chamber. Root filling density was assessed based on the following criteria: (a) Adequate – radiodensity of the root filling was uniform and appeared to be well-adapted to the root canal walls and (b) Inadequate – canal spaces (voids) were visible. The presence of periapical lesion in association with nonroot filled teeth was determined.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 23.0 (SPSS ®: Inc., Chicago, IL, USA). Descriptive analysis was conducted to determine the frequencies and estimate proportions of categorical variables. Chi-square tests were performed to assess associations between categorical variables. Multiple logistic regression models were evaluated for the predictors of periapical lesion and adjusted odds ratios and their 95% confidence intervals were calculated. P value of ≤0.05 was considered statistically significant.
| Results|| |
Of the 197 OPGs, five (2.5%) were excluded due to poor quality. Interobserver and intraobserver Kappa statistics demonstrated high levels of agreement with k = 0.97 and k = 0.90, respectively.
The median age of the 192 patients was 51 years. The majority were male (92%) and non-Kuwaitis (85%). The total number of teeth examined was 4841, of which 130 (2.7%) were root filled in 47/192 (24.5%) patients. Of the 130 teeth, there were 23 (17.7%) anterior teeth and 107 (82.3%) posterior teeth.
Of the 130 root-filled teeth, 44 (33.8%) had periapical lesions. Among the nonroot-filled teeth (n = 4711), 141 (2.99%) exhibited periapical lesions. Periapical lesions had no significant association with age, gender, or smoking status. Kuwaitis had a significantly more periapical lesions associated with root canal treated teeth than nonKuwaitis (28.6 vs. 13.4% or 8/28 vs. 22/164; P= 0.04). A significantly higher proportion of patients with periodontal bone loss had periapical lesions compared with those without periodontal bone loss (86.5 vs. 31.4%; P= 0.001).
Relationship of periapical lesion with root filling and coronal restoration
Of the 130 root-filled teeth, a vast majority of the inadequate root fillings (58/64) were short in length [Table 1]. Of the 44 teeth which had periapical lesions, 12 were short. The distribution of quality of root filling was significantly associated with the presence of a periapical lesion (P < 0.001, Fisher's exact test).
|Table 1: Relationship between length of root filling and periapical lesion|
Click here to view
[Table 2] shows the type of coronal filling- amalgam (40%), crowns (34%), and presence of a post (14%). However, these differences in coronal filling were not statistically significant with periapical lesions (P = 0.49).
|Table 2: Relationship between type of coronal restoration and periapical lesion|
Click here to view
Multiple logistic regression analyses were done separately for the following two dependent variables: (1) Periapical lesion in nonroot-filled teeth; and (2) Periapical lesion in root-filled teeth [Table 3]. For the nonroot-filled teeth, periapical lesion was significantly predicted by inadequate coronal filling, presence of dental caries, and periodontal bone loss. For the root-filled teeth, predictors of periapical lesion included inadequate coronal filling and presence of post crown. The models were adjusted for age, gender, nationality, occupation, income, and smoking status.
|Table 3: Multiple logistic regression model to predict periapical lesion|
Click here to view
| Discussion|| |
In this study, periapical lesion was associated with both root-filled and nonroot filled teeth and about 45% of the root-filled teeth were found inadequately treated. In addition, inadequate coronal restoration was demonstrated as one of the significant predictors of periapical lesions in both root-filled and nonroot-filled teeth.
The presence of periapical lesion in nonroot-filled teeth has a big implication in public health point of view. These teeth were untreated for root filling because they were asymptomatic, i.e., asymptomatic apical periodontitis appears as an apical radiolucency and does not present clinical symptoms.
The prevalence of periapical lesion in root-filled teeth varies widely. Comparison of the findings from different epidemiological studies should be made with caution because of the variation in sample sizes, types of radiographs used, and criteria of evaluation. For example, two studies , conducted in Turky found widely varied rates of periapical lesion in root-filled teeth. The study  that used Ørstavik's PAI, similar to ours, had a comparable rate, whereas the study  which used the criteria proposed by De Moor et al. had a much lower rate (18%) of periapical lesion than the rate observed in the current study. The rate of periapical lesion in root-filled teeth in this study was similar to some other populations including Japanese (40%), Belarusian (45%), French (33%), and American (31%), but lower than that of Spanish (64.5%), German (61%).
This study emphasizes the importance of an adequate coronal seal after root canal treatment. Teeth with adequate coronal restoration were found to have a significantly lower proportion of periapical lesions than teeth with an inadequate coronal restoration. This study conforms to the study in Jordan. Similarly, a high prevalence of periapical lesion associated with inadequate length of root filling was reported in a Danish population. It can be concluded that although the quality of the root canal filling plays a key role in the outcome of endodontic therapy, the quality of coronal restoration is also a contributing factor in the treatment outcome.,
In this study, the periapical lesion was about 10 times higher when there was periodontal bone loss, similar to a study in Belgium, who found a positive correlation between the presence of periapical lesion and periodontal bone loss.
It is acknowledged that some of the limitations such as lack of a systematic sampling and some poor quality of radiographs might have affected the results. In addition to OPG used in this study, intraoral periapical radiographs could be used to observe the periapical areas more closely. However, we followed other cross-sectional studies similar to ours which used OGP only, for example, studies done in Turkey, Japan, Jordan, Spain, France, and Ireland.,,,, Another limitation was that we used radiographic method alone for the evaluation of periapical lesions. Use of both clinical and radiographic methods showed a greater impact on the postoperative evaluation of periapical status. In addition, cone-beam computed tomography, which gives a three-dimensional image was not available in Kuwait at the time of the study.
| Conclusions|| |
This study provides evidence that periapical lesion was associated with both root-filled and nonroot-filled teeth. As these lesions constitute a potential oral health risk, the issue needs to be addressed in the community by applying screening tools for asymptomatic cases for the prevention of complications. Quality of the root canal filling appears to play a key role in the outcome of endodontic therapy, with the quality of the coronal restoration a contributing factor in the treatment outcome. Training of practitioners should ensure a better technical quality of root and coronal fillings, which should help to prevent the development of lesions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gulsahi K, Gulsahi A, Ungor M, Genc Y. Frequency of root-filled teeth and prevalence of apical periodontitis in an adult Turkish population. Int Endod J 2008;41:78-85.
Tsuneishi M, Yamamoto T, Yamanaka R, Tamaki N, Sakamoto T, Tsuji K, et al.
Radiographic evaluation of periapical status and prevalence of endodontic treatment in an adult Japanese population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:631-5.
Al-Omari MA, Hazaa A, Haddad F. Frequency and distribution of root filled teeth and apical periodontitis in a Jordanian subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:e59-65.
Kabak Y, Abbott PV. Prevalence of apical periodontitis and the quality of endodontic treatment in an adult Belarusian population. Int Endod J 2005;38:238-45.
Jimenez-Pinzon A, Segura-Egea JJ, Poyato-Ferrera M, Velasco-Ortega E, Rios-Santos JV. Prevalence of apical periodontitis and frequency of root-filled teeth in an adult Spanish population. Int Endod J. 2004;37:167-73.
Skudutyte-Rysstad R, Eriksen HM. Endodontic status amongst 35-year-old Oslo citizens and changes over a 30-year period. Int Endod J 2006;39:637-42.
Segura-Egea JJ, Jimenez-Pinzon A, Poyato-Ferrera M, Velasco-Ortega E, Rios-Santos JV. Periapical status and quality of root fillings and coronal restorations in an adult Spanish population. Int Endod J 2004;37:525-30.
Pak JG, Fayazi S, White SN. Prevalence of periapical radiolucency and root canal treatment: A systematic review of cross-sectional studies. J Endod 2012;38:1170-6.
Georgopoulou MK, Spanaki-Voreadi AP, Pantazis N, Kontakiotis EG, Morfis AS. Periapical status and quality of root canal fillings and coronal restorations in a Greek population. Quintessence Int 2008;39:e85-92.
Boucher Y, Matossian L, Rilliard F, Machtou P. Radiographic evaluation of the prevalence and technical quality of root canal treatment in a French subpopulation. Int Endod J 2002;35:229-38.
Loftus JJ, Keating AP, McCartan BE. Periapical status and quality of endodontic treatment in an adult Irish population. Int Endod J 2005;38:81-6.
Sunay H, Tanalp J, Dikbas I, Bayirli G. Cross-sectional evaluation of the periapical status and quality of root canal treatment in a selected population of urban Turkish adults. Int Endod J 2007;40:139-45.
Orstavik D, Kerekes K, Eriksen HM. The periapical index: A scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;2:20-34.
Kayahan MB, Malkondu O, Canpolat C, Kaptan F, Bayirli G, Kazazoglu E, et al.
Periapical health related to the type of coronal restorations and quality of root canal fillings in a Turkish subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e58-62.
De Moor RJ, Hommez GM, De Boever JG, Delmé KI, Martens GE. Periapical health related to the quality of root canal treatment in a Belgian population. Int Endod J 2000;33:113-20.
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;35:810-3.
Buckley M, Spångberg LS. The prevalence and technical quality of endodontic treatment in an American subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:92-100.
Weiger R, Hitzler S, Hermle G, Löst C. Periapical status, quality of root canal fillings and estimated endodontic treatment needs in an urban German population. Endod Dent Traumatol 1997;13:69-74.
Kirkevang LL, Ørstavik D, Hörsted-Bindslev P, Wenzel A. Periapical status and quality of root fillings and coronal restorations in a Danish population. Int Endod J 2000;33:509-15.
Kalender A, Orhan K, Aksoy U, Basmaci F, Er F, Alankus A, et al.
Influence of the quality of endodontic treatment and coronal restorations on the prevalence of apical periodontitis in a Turkish Cypriot population. Med Princ Pract 2013;22:173-7.
Stassen IG, Hommez GM, De Bruyn H, De Moor RJ. The relation between apical periodontitis and root-filled teeth in patients with periodontal treatment need. Int Endod J 2006;39:299-308.
Maslamani M, Khalaf M, Mitra AK. Association of quality of coronal filling with the outcome of endodontic treatment: A follow-up study. Dent J 2017;5:5.
[Table 1], [Table 2], [Table 3]