Prevalence of persistent pain 3 to 5 years post primary root canal therapy and its impact on oral health-related quality of life: PEARL Network findings.

INTRODUCTION: The frequency of persistent pain 3-5 years after primary root canal therapy and its impact on the patient's perceived oral health-related quality of life was determined in a practice-based research network. METHODS: All patients presenting to participating network practices who received primary root canal therapy and restoration for a permanent tooth 3-5 years previously were invited to enroll. Persistent pain was defined as pain occurring spontaneously or elicited by percussion, palpation, or biting. The patient also completed an oral health-related quality of life questionnaire (Oral Health Impact Profile-14). RESULTS: Sixty-four network practices enrolled 1323 patients; 13 were ineligible, 12 did not receive a final restoration, and 41 were extracted, leaving 1257 for analysis. The average time to follow-up was 3.9 ± 0.6 years. Five percent (63/1257) of the patients reported persistent pain, whereas 24 of 63 (38%) exhibited periapical pathosis and/or root fracture (odontogenic pain). No obvious odontogenic cause for persistent pain was found for 39 of 63 (62%). Teeth treated by specialists had a greater frequency of persistent pain than teeth treated by generalists (9.3% vs 3.0%, respectively; P < .0001). Sex, age, tooth type, type of dentist, and arch were not found to be associated with nonodontogenic persistent pain; however, ethnicity and a preoperative diagnosis of pulpitis without periapical pathosis were. Patients reporting pain with percussion tended to experience pain with other stimuli that negatively impacted quality of life including oral function and psychological discomfort and disability. CONCLUSIONS: These results suggest that a small percentage (3.1%) of patients experience persistent pain not attributable to odontogenic causes 3-5 years after primary root canal therapy that may adversely impact their quality of life.

Outcomes of implants and restorations placed in general dental practices: a retrospective study by the Practitioners Engaged in Applied Research and Learning (PEARL) Network.

OBJECTIVES: The authors conducted a study to determine the types, outcomes, risk factors and esthetic assessment of implants and their restorations placed in the general practices of a practice-based research network. METHODS: All patients who visited network practices three to five years previously and underwent placement of an implant and restoration within the practice were invited to enroll. Practitioner-investigators (P-Is) recorded the status of the implant and restoration, characteristics of the implant site and restoration, presence of peri-implant pathology and an esthetic assessment by the P-I and patient. The P-Is classified implants as failures if the original implant was missing or had been replaced, the implant was mobile or elicited pain on percussion, there was overt clinical or radiographic evidence of pathology or excessive bone loss (> 0.2 millimeter per year after an initial bone loss of 2 mm). They classified restorations as failures if they had been replaced or if there was abutment or restoration fracture. RESULTS: The authors enrolled 922 implants and patients from 87 practices, with a mean (standard deviation) follow-up of 4.2 (0.6) years. Of the 920 implants for which complete data records were available, 64 (7.0 percent) were classified as failures when excessive bone loss was excluded from the analysis. When excessive bone loss was included, 172 implants (18.7 percent) were classified as failures. According to the results of univariate analysis, a history of severe periodontitis, sites with preexisting inflammation or type IV bone, cases of immediate implant placement and placement in the incisor or canine region were associated with implant failure. According to the results of multivariate analysis, sites with preexisting inflammation (odds ratio [OR] = 2.17; 95 percent confidence interval [CI], 1.41-3.34]) or type IV bone (OR = 1.99; 95 percent CI, 1.12-3.55) were associated with a greater risk of implant failure. Of the 908 surviving implants, 20 (2.2 percent) had restorations replaced or judged as needing to be replaced. The majority of P-Is and patients were satisfied with the esthetic outcomes for both the implant and restoration. CONCLUSIONS: These results suggest that implant survival and success rates in general dental practices may be lower than those reported in studies conducted in academic or specialty settings. PRACTICAL IMPLICATIONS: The results of this study, generated in the private general practice setting, add to the evidence base to facilitate implant treatment planning.

Effectiveness of a resin-modified glass ionomer liner in reducing hypersensitivity in posterior restorations: a study from the practitioners engaged in applied research and learning network.

BACKGROUND: The objectives of this randomized comparative effectiveness study conducted by members of the Practitioners Engaged in Applied Research and Learning (PEARL) Network were to determine whether using a resin-modified glass ionomer (RMGI) liner reduces postoperative hypersensitivity (POH) in dentin-bonded Class I and Class II resin-based composite (RBC) restorations, as well as to identify other factors (putative risk factors) associated with increased POH. METHODS: PEARL Network practitioner-investigators (P-Is) (n = 28) were trained to assess sensitivity determination, enamel and dentin caries activity rankings, evaluation for sleep bruxism, and materials and techniques used. The P-Is enrolled 341 participants who had hypersensitive posterior lesions. Participants were randomly assigned to receive an RBC restoration with or without an RMGI liner before P-Is applied a one-step, self-etching bonding agent. P-Is conducted sensitivity evaluations at baseline, at one and four weeks after treatment, and at all visits according to patient-reported outcomes. RESULTS: P-Is collected complete data regarding 347 restorations (339 participants) at baseline, with 341 (98 percent) (333 participants) recalled at four weeks. Treatment groups were balanced across baseline characteristics and measures. RBC restorations with or without an RMGI liner had the same one-week and four-week POH outcomes, as measured clinically (by means of cold or air stimulation) and according to patient-reported outcomes. CONCLUSIONS: Use of an RMGI liner did not reduce clinically measured or patient-reported POH in moderate-depth Class I and Class II restorations. Cold and air clinical stimulation findings were similar between groups. Practical Implications. The time, effort and expense involved in placing an RMGI liner in these moderate-depth RBC restorations may be unnecessary, as the representative liner used did not improve hypersensitivity outcomes.

Treatments for hypersensitive noncarious cervical lesions: a Practitioners Engaged in Applied Research and Learning (PEARL) Network randomized clinical effectiveness study.

BACKGROUND: The Practitioners Engaged in Applied Research and Learning (PEARL) Network conducted a three-armed randomized clinical study to determine the comparative effectiveness of three treatments for hypersensitive noncarious cervical lesions (NCCLs): use of a potassium nitrate dentifrice for treatment of hypersensitivity, placement of a resin-based composite restoration and placement of a sealant. METHODS: Seventeen trained practitioner-investigators (P-Is) in the PEARL Network enrolled participants (N = 304) with hypersensitive posterior NCCLs who met enrollment criteria. Participants were assigned to treatments randomly. Evaluations were conducted at baseline and at one, three and six months thereafter. Primary outcomes were the reduction or elimination of hypersensitivity as measured clinically and by means of patient-reported outcomes. RESULTS: Lesion depth and pretreatment sensitivity (mean, 5.3 on a 0- to 10-point scale) were balanced across treatments, as was sleep bruxism (present in 42.2 percent of participants). The six-month participant recall rate was 99 percent. Treatments significantly reduced mean sensitivity (P < .01), with the sealant and restoration groups displaying a significantly higher reduction (P < .01) than did the dentifrice group. The dentifrice group's mean (standard deviation) sensitivity at six months was 2.1 (2.1); those of the sealant and restoration groups were 1.0 (1.6) and 0.8 (1.4), respectively. Patient-reported sensitivity (to cold being most pronounced) paralleled clinical measurements at each evaluation. CONCLUSIONS: Sealing and restoration treatments were effective overall in reducing NCCL hypersensitivity. The potassium nitrate dentifrice reduced sensitivity with increasing effectiveness through six months but not to the degree offered by the other treatments. Practical Implications. Sealant or restoration placement is an effective method of immediately reducing NCCL sensitivity. Although a potassium nitrate dentifrice did reduce sensitivity slowly across six months, at no time was the reduction commensurate with that of sealants or restorations.

Restoration variables and postoperative hypersensitivity in Class I restorations: PEARL Network findings. Part 2.

BACKGROUND: This study investigated postoperative hypersensitivity at 1, 4, and 13 weeks following resin-based composite restoration of occlusal caries as well as the relationship to materials and technique employed by PEARL Network Practitioner Investigators (P-Is). METHODS: PEARL P-Is (n = 45) enrolled patients with early occlusal caries lesions deemed to require treatment and placed restorations using their routine technique. Data on 485 restorations at 4 weeks included: baseline sensitivity; ranking of dentin caries activity; post-preparation use of antimicrobials, liners, and dentin bonding agent; type of resin-based composite (RBC) employed; whether layer or bulk fill was used; and patient demographics. Patients anonymously reported at 1, 4, and 13 weeks any sensitivity to hot, cold, sweets, clenching, and chewing as well as quality of life (QOL) related to the restoration(s). RESULTS: Appreciable hypersensitivity (AH)--ie, sensitivity of 3 or greater on an 11-point anchored scale--was reported in 30% of all 668 eligible carious teeth at baseline. Among them, 10% of study teeth with no baseline AH had developed AH at 4 weeks post-treatment. With restoration, 63% of teeth with baseline AH no longer had AH, while the remainder had no improvement. Neither change in AH nor change in greatest sensitivity was associated with use of a liner, use of flowable or hybrid RBC, or bulk or layer technique. With use of an antimicrobial, at 1 week, there was a significant but transient effect on AH (P = 0.006), which was generally not present at 4 weeks, although it continued for one product. At 4 weeks, the change in greatest sensitivity was associated with the type of dentin bonding agent, total etch or self etch, (P = 0.004). Using similar materials and techniques, P-Is had widely differing patient-reported outcomes. CONCLUSION: Patient self-reported post-restoration AH-either acquired or remaining-at 4 weeks was generally not related to the materials or techniques recorded in these small- to moderate-sized occlusal restorations. However, the change in greatest sensitivity was associated with the type of dentin bonding agent used; but the clinical significance of this difference is questionable. CLINICAL IMPLICATIONS: The post-restoration levels of AH in early and moderate-sized posterior RBC restorations provide no justification for the use of a liner (CaOH, GI/RMGI, or flowable composite) as compared to the use of a dentin-bonding agent alone. Use of an antimicrobial had an effect on AH at 1 week that was generally transient.

Postoperative hypersensitivity and its relationship to preparation variables in Class I resin-based composite restorations: findings from the practitioners engaged in applied research and learning (PEARL) Network. Part 1.

BACKGROUND: This study investigated postoperative hypersensitivity at 1, 4, and 13 weeks following resin-based composite (RBC) restorations of occlusal caries and its relationship with prepreparation (baseline) sensitivity and preparation-related variables, including dentin caries activity, cavity dimension and volume, and lesion radiographic visibility. METHODS: Investigators in a practice-based research network enrolled patients with occlusal caries deemed to require operative treatment. The 45 dental practitioners then placed restorations using their preferred techniques. Complete baseline data on 665 restorations from 602 patients included patient-reported sensitivity (pre-preparation); dentists' ranking of dentin caries on opening the enamel; measurements of preparation depth, width, and length; and patient demographics. At 1, 4, and 13 weeks post-treatment, patients anonymously reported any sensitivity to hot and cold stimuli, sweets, clenching, and chewing, as well as quality-of-life indicators related to the restorations. RESULTS: At baseline, 30% of teeth had reported sensitivities of ≥3 on an anchored scale from 0 to 10 points and were designated as appreciable hypersensitivity (AH). Appreciable hypersensitivity at baseline was related to lesion radiographic visibility and patient age but not to dentin caries activity ranking, type of posterior tooth, gender, or race/ethnicity. Patients reported on 491 restorations at 4 weeks post-treatment--18% had AH. Of those who had AH, 39% (34 of 87) had no baseline AH. With restoration, 63% of teeth with baseline AH no longer had AH. Changes in AH were not associated with preparation depth, length, width, or volume. CONCLUSION: Patient-reported occlusal caries tooth sensitivity was high at baseline and eliminated by RBC restoration in 63% of cases; however, new sensitivity after restoration was reported in 10% of lesions that had none at pretreatment. Sensitivity was not related to preparation dimensions, volume, tooth type, or patient demographics (other than age) in these early lesions.

Restorative outcomes for endodontically treated teeth in the Practitioners Engaged in Applied Research and Learning network.

BACKGROUND: The authors aimed to determine the outcome of and factors associated with success and failure of restorations in endodontically treated teeth in patients in practices participating in the Practitioners Engaged in Applied Research and Learning (PEARL) Network. METHODS: Practitioner-investigators (P-Is) invited the enrollment of all patients seeking care at participating practices who had undergone primary endodontic therapy and restoration in a permanent tooth three to five years earlier. P-Is classified endodontically reated teeth as restorative failures if the restoration was replaced, the restoration needed replacement or the tooth was cracked or fractured. RESULTS: P-Is from 64 practices enrolled in the study 1,298 eligible patients who had endodontically treated teeth that had been restored. The mean (standard deviation) time to follow-up was 3.9 (0.6) years. Of the 1,298 enrolled teeth, P-Is classified 181 (13.9 percent; 95 percent confidence interval [CI], 12.1-15.8 percent) as restorative failures: 44 (3.4 percent) due to cracks or fractures, 57 (4.4 percent) due to replacement of the original restoration for reasons other than fracture and 80 (6.2 percent) due to need for a new restoration. When analyzing the results by means of multivariate logistic regression, the authors found a greater risk of restorative failure to be associated with canines or incisors and premolars (P = .04), intracoronal restorations (P < .01), lack of preoperative proximal contacts (P < .01), presence of periodontal connective-tissue attachment loss (P < .01), younger age (P = .01), Hispanic/Latino ethnicity (P = .04) and endodontic therapy not having been performed by a specialist (P = .04). CONCLUSIONS: These results suggest that molars (as opposed to other types of teeth), full-coverage restorations, preoperative proximal contacts, good periodontal health, non-Hispanic/Latino ethnicity, endodontic therapy performed by a specialist and older patient age are associated with restorative success for endodontically treated teeth in general practice. CLINICAL IMPLICATIONS: These results contribute to the clinical evidence base to help guide practitioners when planning the restoration of endodontically treated teeth.

Outcomes of endodontic therapy in general practice: a study by the Practitioners Engaged in Applied Research and Learning Network.

BACKGROUND: The authors undertook a study involving members of a dental practice-based research network to determine the outcome and factors associated with success and failure of endodontic therapy. METHODS: Members in participating practices (practitioner-investigators [P-Is]) invited the enrollment of all patients seeking treatment in the practice who had undergone primary endodontic therapy and restoration in a permanent tooth three to five years previously. If a patient had more than one tooth so treated, the P-I selected as the index tooth the tooth treated earliest during the three- to five-year period. The authors excluded from the study any teeth that served as abutments for removable partial dentures or overdentures, third molars and teeth undergoing active orthodontic endodontic therapy. The primary outcome was retention of the index tooth. Secondary outcomes, in addition to extraction, that defined failure included clinical or radiographic evidence (or both) of periapical pathosis, endodontic retreatment or pain on percussion. RESULTS: P-Is in 64 network practices enrolled 1,312 patients with a mean (standard deviation) time to follow-up of 3.9 (0.6) years. During that period, 3.3 percent of the index teeth were extracted, 2.2 percent underwent retreatment, 3.6 percent had pain on percussion and 10.6 percent had periapical radiolucencies for a combined failure rate of 19.1 percent. The presence of preoperative periapical radiolucency with a diagnosis of either irreversible pulpitis or necrotic pulp was associated with failure after multivariate analysis, as were multiple canals, male sex and Hispanic/Latino ethnicity. CONCLUSIONS: These results suggest that failure rates for endodontic therapy are higher than previously reported in general practices, according to results of studies based on dental insurance claims data. CLINICAL IMPLICATIONS: The results of this study can help guide the practitioner in deciding the most appropriate course of therapy for teeth with irreversible pulpitis, necrotic pulp or periapical periodontitis.

Dentin caries activity in early occlusal lesions selected to receive operative treatment: findings from the Practitioners Engaged in Applied Research and Learning (PEARL) Network.

BACKGROUND: Members of the practice-based research network Practitioners Engaged in Applied Research and Learning (PEARL) Network investigated the dentin caries activity in early occlusal lesions and its relationship to patient age, preoperative tooth sensitivity and radiographic appearance, as well as its influence on preparation depth and volume. METHODS: PEARL Network practitioner-investigators (P-Is) (n = 45), general dentists who were trained but whose methods were not calibrated, conducted a study regarding postoperative hypersensitivity in resin-based composite restorations. The P-Is enrolled as study participants 613 patients with occlusal carious lesions that, in the P-Is' clinical judgment, required restoration. The P-Is used baseline radiographs to assess the depth and extent of the lesions. Data for 671 restorations included baseline sensitivity; ranking of dentin caries activity on the opening of the enamel; radiographic visibility (n = 652); and measurements of preparation depth, width and length. RESULTS: P-Is found rapidly progressing dentin caries in 38.5 percent (258 of 671) of lesions and slowly progressing (and potentially inactive dentin) caries in the remainder of the lesions. Rapidly progressing caries was not related to the participant's age or participant-reported preoperative hypersensitivity but was related to the lesion depth as seen radiographically (P < .001) and depth (P < .001) and volume (P < .001) of the preparation. Molars had slightly higher but not statistically significant levels of caries activity. CONCLUSION: Rapidly progressing dentin caries, while present in only 38.5 percent of lesions, was related to the lesion's radiographic appearance but not to the participant's age or the study tooth's pre-operative sensitivity. CLINICAL IMPLICATIONS: On the basis of the low level of rapidly progressing dentin caries in this study population and the fact that slowly progressing caries can be inactive or remineralizing, the authors advise sealing versus operative treatment of early or shallow occlusal lesions.

Level of oral health impacts among patients participating in PEARL: a dental practice-based research network.

OBJECTIVES: To determine whether participants of a dental practice-based research network (PBRN) differ in their level of oral health impact as measured by the Oral Health Impact Profile (OHIP) questionnaire. METHODS: A total of 2410 patients contributed 2432 OHIP measurements (median age = 43 years; interquartile range = 28) were enrolled in four dental studies. All participants completed the Oral Health Impact Profile (OHIP-14) during a baseline visit. The main outcome of this study was the level of oral health impact, defined as follows: no impact ('Never' reported on all items); low ('Occasionally' or 'Hardly ever' as the greatest frequency score reported on any item); and high ('Fairly often' or 'Very often' as the greatest frequency reported on any item). Polychotomous logistic regression was used to develop a predictive model for the level of oral health impact considering the following predictors: patient's age, gender, race, practice location, type of dentist, and number of years the enrolling dentist has been practicing. RESULTS: A high level of oral health impacts was reported in 8% of the sample; almost a third (29%) of the sample reported a low level of impacts, and 63% had no oral health impacts. The prevalence of impacts differed significantly across protocols (P < 0.001). Women were more likely to be in the high oral impact group than in the no impact group compared to men (OR = 1.46; 95% CI = 1.06-1.99). African Americans were more likely to report high oral impacts when compared to other racial/ethnic groups (OR = 2.11; 95% CI = 1.26-3.55). Protective effects for being in the high or in the low-impact groups were observed among patients enrolled by a solo practice (P < 0.001) or by more experienced dentists (P = 0.01). A small but highly significant statistical association was obtained for patient age (P < 0.001). In the multivariate model, patient's age, practice size, and gender were found to jointly be significant predictors of oral health impact level. CONCLUSIONS: Patients' subjective report of oral health impact in the clinical setting is of importance for their health. In the context of a dental PBRN, the report of oral health-related quality of life (OHRQoL) was different across four dental studies. The observed findings validate the differential impact that oral health has on the patients' perception of OHRQoL particularly among specific groups. Similar investigations to elucidate the factors associated with patient's report of quality of life are warranted.

Postoperative hypersensitivity in class I resin-based composite restorations in general practice: interim results.

Posterior permanent teeth with carious lesions radiographically extending no further than halfway into dentin (N = 565) were restored by 38 dentists in a practice-based research network, using a resin-based composite. Preoperative and 1-, 4-, and 13-week posttreatment hypersensitivity was recorded with an 11-point visual analog scale that was completed anonymously by participants. The analyses determined whether any correlation or association existed among several variables, including degree of carious activity; cavity extent; application of antimicrobial or desensitizing agents; application of liner, dentin-bonding agent and resin-based composite employed; and composite placement method. Three results were fairly unexpected: Only 36% of lesions were ranked as caries-active, 31% of teeth had appreciable preoperative hypersensitivity, and 16% of teeth with no preoperative hypersensitivity had appreciable hypersensitivity at 1 week posttreatment. Preoperative hypersensitivity was correlated with lesion visibility on radiographs but not with dentin caries activity (ranked on opening enamel), preparation depth, or preparation volume. Accrual to the study continues, and conclusions regarding other relationships await 13-week results.