Veken et al-2016-international_endodontic_journal
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This document reports on a study that investigated the prevalence of apical periodontitis (AP) and root filled teeth in a Belgian subpopulation using cone-beam computed tomography (CBCT) scans. The study reviewed 631 CBCT scans containing 11,117 permanent teeth. A total of 656 teeth (5.9%) showed signs of AP and 1,357 teeth (12.2%) were root filled. Root filled teeth had significantly more AP (32.7%) than non-root filled teeth (2.2%). The technical quality of root fillings also impacted the presence of AP, with inadequate fillings associated with higher AP prevalence. The results were comparable to other epidemiological studies.
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Veken et al-2016-international_endodontic_journal
- 1. Prevalence of apical periodontitis and root filled teeth in a Belgian subpopulation found on CBCT images D. Van der Veken1 , F. Curvers1 , S. Fieuws2 & P. Lambrechts1 1 Department of Oral Health Sciences, KU Leuven – University of Leuven, University Hospitals, Leuven; and 2 Leuven Biostatistics and Statistical Bioinformatics centre KU Leuven – University of Leuven, Leuven, Belgium Abstract 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. International Endodontic Journal. Aim To investigate the prevalence of apical peri- odontitis (AP) and root filled teeth found on cone- beam computed tomography (CBCT) scans in a Bel- gian subpopulation in a retrospective cross-sectional study. Methodology At the university hospital of Leuven, 804 patients received a CBCT scan between 01/01/ 2013 and 01/01/2014. The investigated sample included 631 scans with a permanent dentition and a total of 11 117 teeth. Prevalences and their confi- dence intervals are reported and the association between treatment, position of a tooth, gender and age with AP was determined using logistic regres- sions. Results A total of 656 teeth (5.9%) had signs of AP and 1357 teeth (12.2%) had been root filled. AP was present in 212 of the 9760 nonroot filled teeth (2.2%) and in 444 of the 1357 root filled teeth (32.7%). Adequate root fillings were detected in approximately half (49.3%) of the root filled teeth. The prevalence of AP was 22.8% when the root filling was adequate, when scored inade- quate the prevalence increased to 41%. Univariate and multivariable logistic regression analyses revealed a significant relation of tooth position and treatment with AP. No difference in the prevalence of AP between male and female patients was detected. Conclusion The prevalence of AP was comparable with findings in other epidemiological studies. Root filled teeth had significantly more AP than nonroot filled teeth. The technical quality of the root fillings had a significant impact on the presence of AP. Therefore, emphasis on the quality of work and con- tinuing education in the field of Endodontology must be provided in Belgium. Keywords: apical periodontitis, cone-beam com- puted tomography, cross-sectional study, prevalence. Received 19 January 2016; accepted 15 March 2016 Introduction Apical periodontitis (AP) is an inflammatory disease that occurs in response to the presence of microor- ganisms and other irritants within the root canal sys- tem (Chala et al. 2011, Di Filippo et al. 2014). Clinical and radiographic criteria are used in the diag- nosis of AP lesions (Estrela et al. 2008a). Clinical symptoms such as pain, swelling, sinus tract forma- tion and tenderness are only moderately specific and occur to varying degrees. Therefore, oral radiography plays an important role in diagnosing AP lesions (Lof- tus et al. 2005, Al-Omari et al. 2011). Infection in the root canal system can trigger the host defence to induce changes in the periapical bone structure, resulting in resorption identified as radiolucencies on radiographs (Estrela et al. 2008b). Correspondence: Dominique Van der Veken, DDS, MS. Resident, Department of Oral Health Sciences, KU Leuven – University of Leuven, University Hospitals Leuven, Kapucij- nenvoer 33, B-3000 Leuven, Belgium (Tel.: 0032 (0)493/ 71.42.81; e-mail: dominique.vanderveken@kuleuven.be). International Endodontic Journal© 2016 International Endodontic Journal. Published by John Wiley & Sons Ltd doi:10.1111/iej.12631 1
- 2. Cone-Beam Computed Tomography (CBCT) scans provide multi-planar images in submillimetre resolu- tion with a lower radiation dose when compared to medical CT scanning. Therefore CBCT scans have replaced conventional tomography for several diag- nostic tasks in dentistry and dento-maxillofacial sur- gery (Mozzo et al. 1998, De Vos et al. 2009, Scarfe et al. 2009, Kruse et al. 2015). In Endodontology CBCT scans can be used for a number of diagnostic purposes including assessment of AP lesions, root canal systems, pathosis in the maxillary sinuses, internal and external resorption lesions and root frac- tures (Simon et al. 2006, Tyndall & Rathore 2008, Ritter et al. 2011, Lu et al. 2012, Patel et al. 2012, Helvacioglu-Yigit & Sinanoglu 2013, Pan et al. 2014). Guidelines concerning the indications for CBCT imaging in Endodontology have been published by the American Association of Endodontists in col- laboration with the American Academy of Oral and Maxillofacial Radiology and by the European Society of Endodontology (European Society of Endodontology 2014, American Association of Endodontists 2015). The prevalence of AP and root filled teeth has been studied in different populations across the world (Table 1). The interpretation of radiographs is the most common method used to evaluate AP in an epi- demiological study. Some studies used periapical radiographs for the evaluation of AP (Kirkevang et al. 2001a,b, Boucher et al. 2002, Jimenez-Pinzon et al. 2004, Georgopoulou et al. 2005, Tsuneishi et al. 2005, €Ozbasß et al. 2011), others used panoramic images (De Moor et al. 2000, Lupi-Pegurier et al. 2002, Kabak Abbott 2005, Loftus et al. 2005, Sunay et al. 2007, Gulsahi et al. 2008, Al-Omari et al. 2011, Gumru et al. 2011, Peters et al. 2011, Mukhaimer et al. 2012, Di Filippo et al. 2014) and yet others used a combination of both periapical and panoramic images (Dugas et al. 2003, Gencoglu et al. 2010, Kalender et al. 2013). An intra-oral radiograph provides a two-dimensional view of a three-dimen- sional structure, therefore AP lesions confined within the cancellous bone are usually not detected with this kind of imaging because they are masked by the over- lying cortical plate (Patel et al. 2007, 2012, Tyndall Rathore 2008, de Paula-Silva et al. 2009, Kruse et al. 2015). de Paula-Silva et al. (2009) reported the sensitivity for detecting AP lesions, this was 0.77 and 0.91 for intra-oral and CBCT images, respectively; the specificity was 1 for both imaging methods. The greater sensitivity of CBCT scans will aid the accurate assessment of the periapical region and improve the reliability of prevalence studies on apical periodontitis (Peters et al. 2011, Di Filippo et al. 2014). Paes da Silva Ramos Fernandes et al. (2013) and Dutta et al. (2014) used CBCT images to assess the periapical region around teeth in a cross-sectional manner. In Belgium the only study measuring the prevalence of apical periodontitis is the study by De Moor et al. (2000), where panoramic images were used. The purpose of this study is to measure the preva- lence of AP and root filled teeth in a Belgian subpopu- lation using three-dimensional imaging in a retrospective cross-sectional manner. Factors influenc- ing the prevalence of AP are identified. Materials and methods Study population The sample consisted of 804 CBCT scans of patients consulting at the University Hospital of Leuven. All CBCT scans were taken between 01/01/2013 and 01/01/2014 for different diagnostic reasons such as implant planning, orthognathic surgery and assess- ment of maxillofacial and endodontic pathosis. No patients underwent CBCT scans exclusively for this study. When more than one scan was available, the most recent one was used. The study was approved by the clinical trial centre (s58691) and the ethical committee of the Catholic University of Leuven and the University Hospital of Leuven. Scans containing no teeth, primary teeth and scans of low quality were excluded. Only permanent teeth were assessed and the teeth and their periapical region had to be com- pletely visible on all the multiplanar views (axial, coronal and sagittal) to be included. Maxillary and mandibular third molars were excluded from the analysis. After exclusion criteria were applied, 631 scans containing 11 117 permanent teeth, were available for statistical analysis. Radiographic evaluation CBCT scans were recorded using the 3D Accuitomo 170â (3D Accuitomo, J. Morita, Kyoto, Japan). The scans were evaluated using the i-Dixel 2.0 softwareâ (J. Morita USA Inc., Irvine, CA, USA) on a 30” moni- tor with a resolution of 2560 9 1600 pixels (Dell 3008WFP, Dell Inc., Round Rock, TX, USA) in a darkened room. For each patient the following factors were noted: age, gender, remaining teeth excluding third molars, Apical periodontitis measured on CBCT images Van der Veken et al. © 2016 International Endodontic Journal. Published by John Wiley Sons LtdInternational Endodontic Journal2
- 5. root filled teeth and teeth with coronal restorations. For each tooth the presence of AP, quality of root fill- ing and coronal restoration were surveyed. The fol- lowing criteria were applied for periapical tissue status and quality assessment of the root filling and coronal restoration: Apical periodontitis (AP) AP was defined as a radiolucency in connection with the apical part of the root, exceeding at least two times the width of the lateral part of the periodontal ligament (De Moor et al. 2000). Multirooted teeth were classified according to the root exhibiting the most severe periapical condition. Root filled teeth A tooth with a radiopaque material in the pulp cham- ber and/or root canals was considered root filled or endodontically treated. An adequate root filling was defined as a root filling contained within the tooth, terminating no more than 2 mm from the radio- graphic apex and without visible voids. A root filling more than 2 mm short of the radiographic apex, con- taining voids or extruded beyond the apical foramen was considered an inadequate root filling. Multirooted teeth were categorized by the root with the most inadequate root filling (Loftus et al. 2005, Siqueira et al. 2005, Tavares et al. 2009, Kalender et al. 2013, Di Filippo et al. 2014). Coronal restoration A coronal restoration was defined as a restoration of the coronal part of the tooth. Crowns or partial restorations such as inlays and onlays were consid- ered indirect restorations. The quality of the restora- tion was also assessed radiographically and classified inadequate if the restoration was absent or if recur- rent caries, open margins or overhangs were detect- able. In addition the presence or absence of posts was noted. For the assessment of the quality of a coronal restoration curved MPR processing (i-Dixel 2.0 soft- wareâ ) was used to create cross-sectional slices that are perpendicular to the dental arch and to generate panoramic images based on the selected curved plane. Observers Two observers, experienced in endodontics, screened all CBCT scans independently. Interobserver agree- ment was determined using Cohen’s kappa. In the event of discrepancies between the observers, both observers analysed the images together to reach a consensus. Before the investigation, 30 CBCT scans not included in this study were screened for calibra- tion purposes. Statistical methods Percentages and 95% confidence intervals (CI) are reported. For percentages and confidence intervals on tooth level, the correlation between the teeth from the same patient was taken into account using an approach proposed by Rao Scott (1992). Univariate and multivariable logistic regressions using general- ized estimating equations (GEE) methodology were used to relate patient and treatment related variables with the AP prevalence on tooth level. From these models, odds ratios (OR) and 95% CI are reported. P- values 0.05 were considered significant. All analyses have been performed using SAS 9.2 software for Microsoftâ Windowsâ (SAS Institute Inc., Cary, NC, USA). Results A total of 804 CBCT scans were examined of which 173 scans were excluded. 631 scans (267 male and 364 female), containing 11 117 permanent teeth, were included for analysis. The distribution of the patients according to age and gender is shown in Table 2. The mean age of the sampled patients was 45.6 years. AP was detected on 372 of the 631 included scans (59.0%) and 443 scans (70.2%) con- tained at least one root filled tooth. Coronal restora- tions were present in 586 CBCT scans (92.9%) and in 4624 teeth (41.6%). The sample included 11 117 teeth of which 4596 teeth (41.3%) were from male subjects. A total of 5864 teeth (52.8%) were present in the maxilla, the other 5253 teeth (47.3%) were mandibular. The Table 2 Distribution of the study population on a patient level according to gender and age (abstract values) Male Female Total 20 22 22 44 20–29 41 58 99 30–39 33 53 86 40–49 50 70 120 50–59 59 77 136 60+ 62 84 146 Total 267 364 631 Van der Veken et al. Apical periodontitis measured on CBCT images International Endodontic Journal© 2016 International Endodontic Journal. Published by John Wiley Sons Ltd 5
- 6. group of anterior teeth was the largest with a per- centage of 49.4%, followed by the premolars (28.7%) and molars (21.9%). On a tooth level, 656 teeth (5.9%) had signs of AP and 1357 teeth (12.2%) had been root filled. Maxil- lary teeth had AP in 6.9%, mandibular teeth had AP in 4.8%. Table 3 indicates the distribution of AP according to the location of the tooth and the preva- lence of AP in root filled and nonroot filled teeth. AP was more present in root filled teeth (32.7%) com- pared to nonroot filled teeth (2.2%). The prevalence of AP was 22.8% when the root filling was adequate. When the root filling was inadequate the prevalence increased to 41.0%. In general the percentages of AP were higher in teeth with an inadequate root filling compared to those with an adequate root filling (Fig- ure 1). The prevalence of AP in root filled teeth was similar between the maxilla and mandible, 32.3% and 33.4%, respectively. A higher occurrence of AP was seen in root filled molars (47.7%), when com- pared to premolars (24.7%) and anterior teeth (25.5%). In nonroot filled teeth a similar relation was detected: 3.9% of the molars, 1.5% of the premolars and 1.9% of the anterior teeth showed signs of AP. There was no relevant difference in the prevalence of root fillings between female and male patients, 12.4% vs. 12.0%, respectively. Teeth from older patients had a higher probability of root filling: 17.9% and 18.4% in the categories 60+ and 50–59 years compared to 0.8%, 3.5%, 9.9% and 14.4% in the cat- egories 20, 20–29, 30–39 and 40–49 years, respec- tively. Adequate root fillings were detected in approximately half (49.3%) of the teeth with a root canal filling. Coronal restorations were present in 4624 teeth (41.6%). More than half (65.8%) were scored ade- quate. Posts were found in 403 teeth (3.6%) and showed signs of AP in 105 teeth (26.1%). Indirect restorations were present in 753 teeth (6.8%), 61.1% of these were root filled and 21.8% had AP. The rela- tion between the quality of the root filling and the quality of the coronal restoration and their effect on AP are presented in Table 4. The highest prevalence of AP (46.6%) was found in teeth with an inadequate root filling and inadequate coronal restoration. When the root filling was scored adequate the percentages of AP were similar for the teeth with an adequate coronal restoration (23.1%) and inadequate coronal restoration (22.4%). On the other hand, when the root filling was scored inadequate, AP was more prevalent in teeth with an inadequate coronal restora- tion (46.6%) compared to those with an adequate coronal restoration (32.7%). The results of the logistic regression analyses are summarized in Table 5. Subject related factors such as gender, age and tooth position are presented next to treatment related factors. There was no significant difference in AP between teeth from male and female patients. The evidence for a relation between age and prevalence of AP in the univariate analysis, com- pletely disappeared in the multivariable logistic regres- sion model. The observed higher prevalence of AP in older patients was due to a higher occurrence of treatment in these patients. The position of a tooth had a significant and strong relation with AP in the univariate analysis. The prevalence was the highest for molars and the lowest for mandibular anteriors. However, this pattern of results completely changed in the multivariable model, due to the relation between tooth position and probability of root filling. Although, some pairwise comparisons were still signif- icant (i.e. comparison of molars versus premolars), the values of the odds ratios indicate that the strength of the differences weakened. The effect of treatment was significant in both anal- yses. Teeth with a root filling had significantly more AP than teeth without root filling. In the univariate analysis, the odds of AP for teeth with an adequate root filling and adequate coronal restoration were 26.3 (18.5; 37.5 95% CI) higher compared to teeth without root filling and without restorations. For teeth with an inadequate root filling and coronal restoration, the OR was 76.4 (54.4; 107.3 95% CI). When the root filling was adequate the odds were similar for teeth with an adequate or an inadequate coronal restoration. When the root filling was inade- quate, the odds of AP was significantly lower when the coronal restoration was adequate. The relation between treatment related factors and AP was similar in the multivariable analysis. Inter-observer agreement was determined and Cohen’s kappa was calculated for different parameters (Table 6). These results show that Cohen’s kappa was low for the quality of coronal restorations. Inter- observer agreement was high for AP and root filling. Discussion Knowledge about the endodontic and periapical status of teeth may help predict future needs for dental treatment in the growing dentate population. The assessment of the quality of treatments in a popula- Apical periodontitis measured on CBCT images Van der Veken et al. © 2016 International Endodontic Journal. Published by John Wiley Sons LtdInternational Endodontic Journal6
- 8. tion might influence the evolution and planning of under- and postgraduate education (Kirkevang et al. 2001b, Gulsahi et al. 2008). The current study has a cross-sectional design based on available CBCT scans, therefore it does not represent a random sample of the Belgian population and extrapolation of the results to the general population should be carried out with caution. Including CBCT scans of patients with endodontic problems could have caused an increase in the prevalence of AP. Ideally this study would have been conducted in a randomized manner in a general population, however, taking CBCT images of healthy patients does not conform with the guidelines provided by the AAE and ESE (European Society of Endodontology et al. 2014, American Asso- ciation of Endodontists 2015). The results were obtained from 631 CBCT scans. The studies based on CBCT images by Dutta et al. (2014) and Paes da Silva Ramos Fernandes et al. (2013) had sample sizes of 245 scans and 300 scans respectively. A recognized limitation of cross-sectional studies is the impossibility to determine whether an AP lesion is healing or expanding. Petersson et al. (1991) found that after a 10-year period the number of healed periapical lesions was equal to the number of newly developed lesions, indicating that the results of cross-sectional studies remain meaningful. To be visible radiographically, a periapical inflam- mation should induce nearly 30–50% bone mineral loss, therefore apical pathosis is not always detectable on radiographs (Estrela et al. 2008b, Gulsahi et al. 2008, Mukhaimer et al. 2012, Di Filippo et al. 2014). For the detection of AP histological examination remains the golden standard (de Paula-Silva et al. 2009, Dutta et al. 2014). Periapical lesions confined within the cancellous bone are usually not detected in two dimensional radiographs when there is no per- foration of the overlying cortical plate (Tyndall Rathore 2008, de Paula-Silva et al. 2009, Patel et al. 2012). Information about the three-dimensional anat- omy of teeth and adjacent structures is obscured unavoidably in intra-oral and panoramic images due to distortion and superimposition of dental structures (Patel et al. 2007, de Paula-Silva et al. 2009, Kruse et al. 2015). Also X-ray angulations, radiographic contrast and surrounding bone density influence radiographic interpretation (Estrela et al. 2008b). CBCT scans have been designed to produce three- dimensional information without superimposition of anatomical structures, therefore CBCT images have an improved diagnostic accuracy for diagnosing AP lesions and assessing outcomes after endodontic treat- ment (Patel et al. 2007, Estrela et al. 2008b, Peters et al. 2011, Petersson et al. 2012, Paes da Silva Ramos Fernandes et al. 2013). In this retrospective cross-sectional study the preva- lence and factors influencing AP were determined using CBCT images. Although there is a tendency for a higher sensitivity for AP detection using CBCT scans, no studies justify the standard use of CBCT in diagnosing periapical lesions (Kruse et al. 2015). All scans used in the present study were taken for clinical reasons and no CBCT scans were made exclusively for this study. Many criteria have been used in epidemio- logical studies for the assessment of AP. The Periapi- cal Index scoring system (PAI) developed by Ørstavik et al. (1986) uses a five point scale to classify apical lesions based on their extent on periapical images. Table 4 Relation between AP and the quality of the root filling and coronal restoration Root filling Coronal restoration No apical periodontitis (%) Apical periodontitis (%) Total No root filling No coronal restoration 6420 (98.9) 73 (1.1) 6493 Adequate coronal restoration 2305 (97.1) 68 (2.9) 2373 Inadequate coronal restoration 823 (92.1) 71 (7.9) 894 Adequate root filling Adequate coronal restoration 286 (76.9) 86 (23.1) 372 Inadequate coronal restoration 191 (77.6) 55 (22.4) 246 Inadequate root filling Adequate coronal restoration 200 (67.3) 97 (32.7) 297 Inadequate coronal restoration 236 (53.4) 206 (46.6) 442 477 436 141 303 0 100 200 300 400 500 600 Adequate root filling Inadequate root filling Numberofteeth(n) No apical periodonƟƟs Apical periodonƟƟs Figure 1 Correlation between the quality of the root filling and apical periodontitis. Apical periodontitis measured on CBCT images Van der Veken et al. © 2016 International Endodontic Journal. Published by John Wiley Sons LtdInternational Endodontic Journal8
- 9. This scale was developed for intra-oral images but is used in several studies on panoramic images (Loftus et al. 2005, Gencoglu et al. 2010, Gumru et al. 2011, Kalender et al. 2013). Also cut-off scores may vary between different studies, which might influence the prevalence of AP and makes comparison of results dif- ficult. Some studies used a PAI score larger than one (€Ozbasß et al. 2011, Kalender et al. 2013), others used a PAI score larger than two (Kirkevang et al. 2001a, b, Boucher et al. 2002, Jimenez-Pinzon et al. 2004, Tsuneishi et al. 2005, Gencoglu et al. 2010, Gumru et al. 2011) and yet others use a PAI score larger than three (Loftus et al. 2005) to define AP. It has been stated that the PAI system may not be suitable for all tooth positions because the location of the api- cal part of the root in relation with the cortex may vary depending on the tooth position (€Ozbasß et al. 2011). A new PAI system, based on CBCT has been proposed by Estrela et al. (2008a). This scale uses two dimensional measurements on CBCT images to clas- sify AP. It would seem more logical to use volumetric measurements on three dimensional images. In the present study, AP was defined as a radiolucency in Table 5 univariate and multivariable logistic regression analyses for apical periodontitis (AP) on tooth level Factor Prevalence of AP (AP/T), (%) Univariate logistic regression model Multivariable logistic regression model Odds ratio (95% CI) P-value Odds ratio (95% CI) P-value Subject related factors Gender Male 278/4596 (6.1) # # Female 378/6521 (5.8) 0.9 (0.8; 1.2) 0.5488 0.9 (0.7; 1.1) 0.3638 Age 0.0001* 0.0053* 20 15/903 (1.7) # # 20–29 85/2017 (4.2) 2.6 (1.2; 5.5) 0.0149* 1.6 (0.7; 3.6) 0.3111 30–39 96/1610 (6.0) 3.7 (1.8; 7.5) 0.0004* 1.0 (0.4; 2.3) 0.981 40–49 140/2051 (6.8) 4.2 (2.0; 8.7) 0.0001* 0.9 (0.4; 2.1) 0.7872 50–59 164/2391 (6.9) 4.2 (2.0; 8.5) 0.0001* 0.7 (0.3; 1.6) 0.3451 60 156/2145 (7.3) 4.5 (2.2; 9.2) 0.0001* 0.8 (0.3; 1.8) 0.5114 Tooth position 0.0001* 0.0001* Mandibular anterior 58/2636 (2.2) # # Mandibular premolar 61/1553 (3.9) 1.8 (1.2; 2.8) 0.0041* 0.7 (0.4; 1.1) 0.1283 Mandibular molar 135/1064 (12.7) 6.6 (4.5; 9.6) 0.0001* 1.5 (1.0; 2.3) 0.0678 Maxillary anterior 145/2858 (5.1) 2.4 (1.6; 3.4) 0.0001* 0.9 (0.6; 1.4) 0.7768 Maxillary premolar 96/1639 (5.9) 2.7 (1.9; 4.0) 0.0001* 0.7 (0.4; 1.1) 0.1603 Maxillary molar 161/1367 (11.8) 5.9 (4.1; 8.6) 0.0001* 1.5 (1.0; 2.3) 0.0651 Treatment related factors 0.0001* 0.0001* No root filling, no restoration 73/6493 (1.1) # # No root filling, adequate restoration 68/2373 (2.9) 2.7 (1.9; 3.8) 0.0001* 2.6 (1.7; 3.9) 0.0001* No root filling, inadequate restoration 71/894 (7.9) 7.2 (4.9; 10.8) 0.0001* 6.8 (4.4; 10.5) 0.0001* Adequate root filling, adequate restoration 86/372 (23.1) 26.3 (18.5; 37.5) 0.0001* 30.0 (20.5; 44.0) 0.0001* Adequate root filling, inadequate restoration 55/246 (22.4) 25.3 (16.9; 37.8) 0.0001* 30.2 (19.5; 46.7) 0.0001* Inadequate root filling, adequate restoration 97/297 (32.7) 41.9 (29.7; 59.2) 0.0001* 48.2 (33.0; 70.4) 0.0001* Inadequate root filling, inadequate restoration 206/442 (46.6) 76.4 (54.4; 107.3) 0.0001* 82.4 (55.7; 121.9) 0.0001* #, Reference category. *Significant results (P 0.05). Table 6 Interobserver agreement Cohen’s j ASE AP 0.9 0.0106 RF 0.9 0.0042 Adequate RF 0.7 0.0148 Inadequate RF 0.8 0.0126 CR 0.9 0.0048 Adequate CR 0.7 0.0078 Inadequate CR 0.5 0.0123 Post restoration 0.9 0.0119 AP, apical periodontitis; RF, root filling; CR, coronal restora- tion; ASE, asymptotic standard error. Van der Veken et al. Apical periodontitis measured on CBCT images International Endodontic Journal© 2016 International Endodontic Journal. Published by John Wiley Sons Ltd 9
- 10. connection with the apical part of the root, exceeding at least two times the width of the lateral part of the periodontal ligament. This definition was proposed by De Moor et al. (2000) and is used in several epidemio- logical studies (Lupi-Pegurier et al. 2002, Dugas et al. 2003, Georgopoulou et al. 2005, Kabak Abbott 2005, Sunay et al. 2007, Gulsahi et al. 2008, Al- Omari et al. 2011, Peters et al. 2011, Mukhaimer et al. 2012, Di Filippo et al. 2014, Dutta et al. 2014). This method is simple and provides results that can be compared with previous studies. The quality of coronal restorations was difficult to determine on CBCT images, this could be caused by different types of artefacts. Beam hardening artefacts occur due to errors in the mathematical reconstruction of the CBCT images, these artefacts are seen as lines in the images and blurred or dis- torted borders (Kruse et al. 2015). Metallic objects can be present in the tooth of interest or an adja- cent one and hinder the observation of CBCT images (Estrela et al. 2008a). Also movement of the patient during the scanning procedure may lead to degradation of the CBCT images (Tyndall Rathore 2008). In cross-sectional studies based on radiographs, it is difficult to assess coronal restora- tions. A combination of clinical and radiographic diagnostic tests would be useful, but is often not practical in studies with a cross-sectional study design and large sample size. Epidemiological studies in different populations (Table 1) have found an overall prevalence of AP ranging from 1.4 to 15.1%. The present study detected AP in 5.9% of all investigated teeth, which is in line with another study conducted in Belgium by De Moor et al. (2000). Endodontic treatment was present in 1357 teeth (12.2%), only a few studies presented higher percentages (Boucher et al. 2002, Lupi-Pegurier et al. 2002, Kabak Abbott 2005, Tsuneishi et al. 2005, Mukhaimer et al. 2012). High numbers of root filled teeth could be explained by an increased dental awareness together with a growth of the elderly population (Schulte et al. 1998). The quality of the root filling was scored inadequate in more than half (54.5%) of the root filled teeth. A recently published study by Neukermans et al. (2015) reported that 56% of Flemish dentists never or seldom used rubber dam isolation during root canal treatment. Longitudinal clinical studies have shown that root canal treatment applying modern principles can yield successful outcomes with healing rates above 90% (Friedman 2002, Ng et al. 2010). However, such studies are often conducted in a selected patient population by well-trained operators (Dugas et al. 2003). Epidemiological studies in different populations often reveal a high frequency of inadequate root fill- ings and a high rate of AP associated with root filled teeth (Kirkevang et al. 2000, Friedman 2002, Dugas et al. 2003, Tavares et al. 2009, Chala et al. 2011). The results of the present study indicate that 32.7% of the root filled teeth had AP; this is similar to a French study (Lupi-Pegurier et al. 2002) and lower than other reports (Kirkevang et al. 2001b, Jimenez- Pinzon et al. 2004, Georgopoulou et al. 2005, Sunay et al. 2007, Gencoglu et al. 2010, Al-Omari et al. 2011, Mukhaimer et al. 2012, Kalender et al. 2013). The prevalence of AP was 22.8% when the root fill- ing was adequate, when this was scored inadequate the prevalence increased to 41.0%. In teeth without root filling the prevalence of AP reduced drastically to 2.2%. Several studies found that the risk of AP increased in the presence of technically inadequate root fillings, which is in line with the presented results (Boucher et al. 2002, Hommez et al. 2002, Lupi-Pegurier et al. 2002, Dugas et al. 2003, Segura- Egea et al. 2004, Kabak Abbott 2005, Loftus et al. 2005, Sunay et al. 2007, Gencoglu et al. 2010, Chala et al. 2011, €Ozbasß et al. 2011, Peters et al. 2011, Mukhaimer et al. 2012). No significant differences between males and females were found for the prevalence of AP, the number of teeth with a root filling and root filled teeth with AP. These results are confirmed by several other studies (Kirkevang et al. 2001b, Jimenez-Pinzon et al. 2004, Al-Omari et al. 2011, Chala et al. 2011, Paes da Silva Ramos Fernandes et al. 2013). In this sample more females than males were included (364 vs. 267). Peters et al. (2011) observed a higher fre- quency of AP in older patients. Univariate logistic regression analysis confirmed these results and showed increased levels of AP in older patients. How- ever, the multivariable logistic regression analysis showed that this effect could for the largest part be explained by the higher prevalence of restored teeth in the elderly population. Not only the technical quality of the root filling but also the entire root canal treatment, a successful dis- infection and the avoidance of coronal leakage play an important role in the success of root fillings (Schulte et al. 1998). Ray Trope (1995) and Kirke- vang et al. (2000) found that the quality of the coro- nal restoration was even more important for Apical periodontitis measured on CBCT images Van der Veken et al. © 2016 International Endodontic Journal. Published by John Wiley Sons LtdInternational Endodontic Journal10
- 11. periapical health than the quality of the root filling. However Tronstad et al. (2000), Segura-Egea et al. (2004) and Siqueira et al. (2005) found that the qual- ity of the coronal restoration was significantly less important than the quality of the root filling. Hommez et al. (2002) found both quality of root filling and coronal restoration to be equally important. The results of the present study (Tables 4 and 5) revealed no significant impact of the coronal restoration on AP when the root filling was adequate. On the other hand, when the root filling was inadequate the qual- ity of the coronal seal was an important factor in the prevalence of AP. However the true quality of a coro- nal restoration cannot be identified accurately on a radiograph, therefore the results of studies based on radiographs should be interpreted with caution. In the future, study protocols evaluating the quality of coronal restorations in relation to the prevalence of AP should combine a clinical with a radiographic examination. It seems reasonable to emphasize that, in the interest of the patient, both coronal restoration and root canal treatment should be of the best possi- ble quality. Conclusion The prevalence of AP was comparable with findings in other epidemiological studies. Root filled teeth had significantly more AP than nonroot filled teeth. The technical quality of the root filling had a significant impact on the presence of AP. Therefore, emphasis on the quality of work and continuing education in the field of Endodontology must be provided in Belgium. More studies in other Belgian populations are neces- sary to supplement these results. Acknowledgements The authors would like to thank Eline Petitjean, Alexander Schryvers, Andres Torres and Emilie Noels for reviewing the manuscript. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. References Al-Omari MA, Hazaa A, Haddad F (2011) Frequency and distribution of root filled teeth and apical periodontitis in a Jordanian subpopulation. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontology 111, e59–65. American Association of Endodontists; American Academy of Oral and Maxillofacial Radiology (2015) Use of cone- beam computed tomography in endodontics 2015 update Joint Position Statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontology 111, 234–7. Boucher Y, Matossian L, Rilliard F et al. (2002) Radiographic evaluation of the prevalence and technical quality of root canal treatment in a French subpopulation. International Endodontic Journal 35, 229–38. Chala S, Abouqal R, Abdallaoui F (2011) Prevalence of api- cal periodontitis and factors associated with the periradicu- lar status. Acta Odontologica Scandinavica 69, 355–9. De Moor RJ, Hommez GM, De Boever JG, Delme KI, Martens GE (2000) Periapical health related to the quality of root canal treatment in a Belgian population. International Endodontic Journal 33, 113–20. De Vos W, Casselman J, Swennen GR (2009) Cone-beam computerized tomography (CBCT) imaging of the oral and maxillofacial region: a systematic review of the literature. International Journal of Oral and Maxillofacial Surgery 38, 609–25. Di Filippo G, Sidhu SK, Chong BS (2014) Apical periodontitis and the technical quality of root canal treatment in an adult sub-population in London. British Dental Journal 216, E22. Dugas NN, Lawrence HP, Teplitsky PE, Pharoah MJ, Fried- man S (2003) Periapical health and treatment quality assessment of root-filled teeth in two Canadian popula- tions. International Endodontic Journal 36, 181–92. Dutta A, Smith-Jack F, Saunders WP (2014) Prevalence of periradicular periodontitis in a Scottish subpopulation found on CBCT images. International Endodontic Journal 47, 854–63. Estrela C, Bueno MR, Azevedo BC, Azevedo JR, Pecora JD (2008a) A new periapical index based on cone beam computed tomography. Journal of Endodontics 34, 1325– 31. Estrela C, Bueno MR, Leles CR, Azevedo B, Azevedo JR (2008b) Accuracy of cone beam computed tomography and panoramic and periapical radiography for detection of apical periodontitis. Journal of Endodontics 34, 273–9. European Society of Endodontology, Patel S, Durack C et al. (2014) European Society of Endodontology position state- ment: the use of CBCT in endodontics. International Endodontic Journal 47, 502–4. Friedman S (2002) Prognosis of initial endodontic therapy. Endodontic Topics 2, 59–88. Gencoglu N, Pekiner FN, Gumru B, Helvacioglu D (2010) Periapical status and quality of root fillings and coronal restorations in an adult Turkish subpopulation. European Journal of Dentistry 4, 17–22. Van der Veken et al. Apical periodontitis measured on CBCT images International Endodontic Journal© 2016 International Endodontic Journal. Published by John Wiley Sons Ltd 11
- 12. Georgopoulou MK, Spanaki-Voreadi AP, Pantazis N, Kontaki- otis EG (2005) Frequency and distribution of root filled teeth and apical periodontitis in a Greek population. Inter- national Endodontic Journal 38, 105–11. Gulsahi K, Gulsahi A, Ungor M, Genc Y (2008) Frequency of root-filled teeth and prevalence of apical periodontitis in an adult Turkish population. International Endodontic Jour- nal 41, 78–85. Gumru B, Tarcin B, Pekiner FN, Ozbayrak S (2011) Retro- spective radiological assessment of root canal treatment in young permanent dentition in a Turkish subpopulation. International Endodontic Journal 44, 850–6. Helvacioglu-Yigit D, Sinanoglu A (2013) Use of cone-beam computed tomography to evaluate C-shaped root canal systems in mandibular second molars in a Turkish sub- population: a retrospective study. International Endodontic Journal 46, 1032–8. Hommez GM, Coppens CR, De Moor RJ (2002) Periapical health related to the quality of coronal restorations and root fillings. International Endodontic Journal 35, 680–9. Jimenez-Pinzon A, Segura-Egea JJ, Poyato-Ferrera M, Velasco-Ortega E, Rıos-Santos JV (2004) Prevalence of api- cal periodontitis and frequency of root-filled teeth in an adult Spanish population. International Endodontic Journal 37, 167–73. Kabak Y, Abbott PV (2005) Prevalence of apical periodonti- tis and the quality of endodontic treatment in an adult Belarusian population. International Endodontic Journal 38, 238–45. Kalender A, Orhan K, Aksoy U, Basmaci F, Er F, Alankus A (2013) Influence of the quality of endodontic treatment and coronal restorations on the prevalence of apical peri- odontitis in a Turkish Cypriot population. Medical Princi- ples and Practice 22, 173–7. Kirkevang LL, Ørstavik D, H€orsted-Bindslev P, Wenzel A (2000) Periapical status and quality of root fillings and coronal restorations in a Danish population. International Endodontic Journal 33, 509–15. Kirkevang LL, H€orsted-Bindslev P, Ørstavik D, Wenzel A (2001a) A comparison of the quality of root canal treatment in two Danish subpopulations examined 1974- 75 and 1997-98. International Endodontic Journal 34, 607– 12. Kirkevang LL, H€orsted-Bindslev P, Ørstavik D, Wenzel A (2001b) Frequency and distribution of endodontically trea- ted teeth and apical periodontitis in an urban Danish pop- ulation. International Endodontic Journal 34, 198–205. Kruse C, Spin-Neto R, Wenzel A, Kirkevang LL (2015) Cone beam computed tomography and periapical lesions: a sys- tematic review analysing studies on diagnostic efficacy by a hierarchical model. International Endodontic Journal 48, 815–28. Loftus JJ, Keating AP, McCartan BE (2005) Periapical status and quality of endodontic treatment in an adult Irish population. International Endodontic Journal 38, 81–6. Lu Y, Liu Z, Zhang L et al. (2012) Associations between maxillary sinus mucosal thickening and apical periodon- titis using cone-beam computed tomography scanning: a retrospective study. Journal of Endodontics 38, 1069–74. Lupi-Pegurier L, Bertrand MF, Muller-Bolla M, Rocca JP, Bolla M (2002) Periapical status, prevalence and quality of endodontic treatment in an adult French population. International Endodontic Journal 35, 690–7. Mozzo P, Procacci C, Tacconi A, Tinazzi Martini P, Bergamo Andreis IA (1998) A new volumetric CT machine for den- tal imaging based on the cone-beam technique: prelimi- nary results. European Radiology 8, 1558–64. Mukhaimer R, Hussein E, Orafi I (2012) Prevalence of apical periodontitis and quality of root canal treatment in an adult Palestinian sub-population. The Saudi Dental Journal 24, 149–55. Neukermans M, Vanobbergen J, De Bruyne M, Meire M, De Moor RJ (2015) Endodontic performance by Flemish den- tists: have they evolved? International Endodontic Journal 48, 1112–21. Ng YL, Mann V, Gulabivala K (2010) Tooth survival follow- ing non-surgical root canal treatment: a systematic review of the literature. International Endodontic Journal 43, 171– 89. Ørstavik D, Kerekes K, Eriksen HM (1986) The periapical index: a scoring system for radiographic assessment of api- cal periodontitis. Endodontics and Dental Traumatology 2, 20–34. €Ozbasß H, Asci S, Aydin Y (2011) Examination of the preva- lence of periapical lesions and technical quality of endodontic treatment in a Turkish subpopulation. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontology 112, 136–42. Paes da Silva Ramos Fernandes LM, Ordinalo-Zapata R, Hungaro Duarte MA, Alvares Capelozza AL (2013) Preva- lence of apical periodontitis detected in cone beam CT images of a Brazilian subpopulation. Dentomaxillofacial Radiology 42, 80179163. Pan HY, Yang H, Zhang R et al. (2014) Use of cone-beam computed tomography to evaluate the prevalence of root fenestration in a Chinese subpopulation. International Endodontic Journal 47, 10–19. Patel S, Dawood A, Ford TP, Whaites E (2007) The potential applications of cone beam computed tomography in the management of endodontic problems. International Endodontic Journal 40, 818–30. Patel S, Wilson R, Dawood A, Foschi F, Mannocci F (2012) The detection of periapical pathosis using digital periapical radiography and cone beam computed tomography - part 2: a 1-year post-treatment follow-up. International Endodon- tic Journal 45, 711–23. de Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR (2009) Accuracy of periapical radiography and cone-beam computed tomography scans in diagnosing Apical periodontitis measured on CBCT images Van der Veken et al. © 2016 International Endodontic Journal. Published by John Wiley Sons LtdInternational Endodontic Journal12
- 13. apical periodontitis using histopathological findings as a gold standard. Journal of Endodontics 35, 1009–12. Peters LB, Lindeboom JA, Elst ME, Wesselink PR (2011) Prevalence of apical periodontitis relative to endodontic treatment in an adult Dutch population: a repeated cross- sectional study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontology 111, 523–8. Petersson K, Hakansson R, Hakansson J, Olsson B, Wenn- berg A (1991) Follow-up study of endodontic status in an adult Swedish population. Endodontics and Dental Trauma- tology 7, 221–5. Petersson A, Axelsson S, Davidson T et al. (2012) Radiologi- cal diagnosis of periapical bone tissue lesions in endodon- tics: a systematic review. International Endodontic Journal 45, 783–801. Rao NK, Scott AJ (1992) A simple method for the analysis of clustered binary data. Biometrics 48, 577–85. Ray HA, Trope M (1995) Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. International Endodontic Journal 28, 12–18. Ritter L, Lutz J, Neugebauer J et al. (2011) Prevalence of pathologic findings in the maxillary sinus in cone-beam computerized tomography. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontology 111, 634–40. Scarfe WC, Levin MD, Gane D, Farman AG (2009) Use of cone beam computed tomography in endodontics. Interna- tional Journal of Dentistry 2009, 634567. Schulte A, Pieper K, Charalabidou O, Stoll R, Stachniss V (1998) Prevalence and quality of root canal fillings in a German adult population. Clinical Oral Investigations 2, 67–72. Segura-Egea JJ, Jimenez-Pinzon P-FM, Velasco-Ortega E, Rıos-Santos JV (2004) Periapical status and quality of root fillings and coronal restorations in an adult Spanish popu- lation. International Endodontic Journal 37, 525–30. Simon JH, Enciso R, Malfaz JM, Roges R, Bailey-Perry M, Patel A (2006) Differential diagnosis of large periapical lesions using cone-beam computed tomography measure- ments and biopsy. Journal of Endodontics 32, 833–7. Siqueira JF Jr, Rocas IN, Alves FR, Campos LC (2005) Peri- radicular status related to the quality of coronal restora- tions and root canal fillings in a Brazilian population. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontology 100, 369–74. Sunay H, Tanalp J, Dikbas I, Bayirli G (2007) Cross-sec- tional evaluation of the periapical status and quality of root canal treatment in a selected population of urban Turkish adults. International Endodontic Journal 40, 139– 45. Tavares PB, Bonte E, Boukpessi T, Siqueira JF Jr, Lasfargues JJ (2009) Prevalence of apical periodontitis in root canal- treated teeth from an urban French population: influence of the quality of root canal fillings and coronal restora- tions. Journal of Endodontics 35, 810–13. Tronstad L, Absjornsen K, Doving L, Pedersen I, Eriksen HM (2000) Influence of coronal restorations on the periapical health of endodontically treated teeth. Endodontics and Den- tal Traumatology 16, 218–21. Tsuneishi M, Yamamoto T, Yamanaka R et al. (2005) Radio- graphic evaluation of periapical status and prevalence of endodontic treatment in an adult Japanese population. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, Endodontology 100, 631–5. Tyndall DA, Rathore S (2008) Cone-beam CT diagnostic applications: caries, periodontal bone assessment, and endodontic applications. Dental Clinics of North America 52, 825–41, vii. Van der Veken et al. Apical periodontitis measured on CBCT images International Endodontic Journal© 2016 International Endodontic Journal. Published by John Wiley Sons Ltd 13