Increased width of the apical periodontal membrane space in endodontically treated teeth may represent favourable healing.

AIM: To examine cases showing increased width of the periodontal space (IW) at a long-term follow-up examination and to determine whether this finding could be explained by endodontic or nonendodontic factors. METHODOLOGY: A series of intraoral radiographs was obtained from 131 patients 20-27 years after root canal treatment. The same individuals had been examined 10 years earlier, and radiographs taken immediately after treatment were also available. Fourteen roots (5.6%) demonstrated increased width of the apical periodontal space at the end of the study period. These were subjected to further analysis in an attempt to disclose possible explanatory factors. RESULTS: Two of the 14 cases had reduced marginal bone levels interpreted as the origin of the IW. In three cases, overextended root filling material present 10 years earlier had disappeared and the persistent IW was interpreted as representing a remodelling process. In six cases the findings were explained as being caused by physical and anatomical factors that represented healing without complete re-formation of the apical periodontal structures, or both. Three cases were judged as unfavourable, on the basis of lacking progress in healing, unsatisfactory obturation of the apical portion of the root canal or dentine resorption close to the apical end of the root filling. CONCLUSION: Most of the 14 IW cases examined after 20-27 years could be explained by reduced marginal bone support, or by physical and anatomical factors or they might represent incomplete reformation of the typical apical morphology and were thereby recorded as favourable outcomes.

Nonsurgically retreated root filled teeth--radiographic findings after 20-27 years.

AIM: To identify periapical changes in nonsurgically retreated root-filled teeth 20-27 years after root canal treatment. METHODOLOGY: From an original material of 429 roots, retreated by undergraduate students in a teaching clinic, 112 roots in 70 individuals could be evaluated radiographically 20-27 years after treatment. The same roots had been studied 10-17 years earlier. The periapical condition was registered and compared by three observers in two series of intraoral radiographs taken 10-17 and 20-27 years after treatment. A retrospective analysis was performed to gain information about probable endodontic and nonendodontic reasons for extractions of lost roots, by evaluating their periapical status immediately after retreatment and at the 10-17-year follow-up. RESULTS: Favourable outcomes were observed in 11 roots that had radiolucencies at the 10-17-year follow-up. Eight of these roots had periapical pathosis preoperatively, five of them filled with surplus root filling material. The percentage of cases recorded as normal condition at the final follow-up was 95.5%, including five cases initially recorded with increased width of the apical periodontal space. Delayed healing as a result of surplus root filling material explained most of the cases with favourable outcome assessed many years after treatment. Twenty-eight roots were lost because of extraction during the observation period, 17 during the last 10 years. Based on status at previous follow-ups, endodontic failure seems to represent a minor reason for extraction in the material. CONCLUSION: Late periapical changes, with more successful cases, were recorded when a 10-17-year follow-up after root canal treatment was extended for another 10 years. Persistent asymptomatic periapical radiolucencies, especially those with overfill, should generally not be classified as failures, as many of them will heal after an extended observation period.

Idiopathic osteosclerosis of the jaws followed through a period of 20-27 years.

AIM: The aim of the present study was to examine the prevalence of idiopathic osteosclerosis (IO) in a baseline sample and to follow the patients through an extended period of time. METHODOLOGY: The sample consisted of 210 patients treated in a dental school and having a complete series of intraoral radiographs at the time of treatment and at a follow-up 10-17 years later. A further 10 years later, 130 patients had another follow-up. RESULTS: Sixteen of the 210 patients were found to have IO, mostly in the mandibular molar and premolar regions. Fourteen had one lesion, one had two lesions and one had three lesions. The mean age of these patients was 47 years as compared to 44 years for the rest of the patient group. No sex predilection was found. At the first follow-up, one lesion had disappeared, one had reduced in size and one new lesion appeared. At the second follow-up, eight patients with IO could be re-examined. Two lesions, unchanged at the first follow-up, had reduced in size and two new lesions appeared. In the area of the new lesions, residual roots were observed in the earlier radiographs. CONCLUSION: Our findings support the theory that IO lesions should be considered anatomical variants. In some cases, however, a local aetiological agent may cause development of structures with an identical appearance.

Periapical changes following root-canal treatment observed 20-27 years postoperatively.

AIM: The aim of the present study was to identify periapical changes 20-27 years after root-canal treatment. METHODOLOGY: The periapical condition of 265 roots filled by undergraduate students was evaluated in two series of intraoral radiographs taken 10-17 and 20-27 years after treatment. Roots (72) not recorded with a normal periapical situation on both occasions by two observers, were re-evaluated by other two examiners, separately and jointly. Final decisions about diagnoses were made by all four examiners. A strict definition was used for the identification of cases with an unfavourable outcome. RESULTS: Favourable outcomes were observed in 6.4% of the roots that had radiolucencies at the 10-17-year follow-up. Periapical radiolucencies after 20-27 years appeared in 1.5% of all other roots. The radiographic failure frequency for the total material was 4.9%. The percentage of cases with normal periapical findings at the final follow-up was 86.4%, whilst 8.7% were recorded with increased width of the apical periodontal space. Delayed healing owing to surplus root-filling material explained nearly all of the cases with favourable outcome assessed many years after treatment. CONCLUSIONS: Late periapical changes, with more successes than failures, were recorded when a 10-17-year follow-up period after root-canal treatment was extended for another 10 years.

Diagnosing periapical lesions--disagreement and borderline cases.

AIM: The aim of this paper is to present a selection of disagreement and borderline cases from a methodological study on the radiographic diagnosis of periapical disease. METHODOLOGY: Thirty-two roots, 12% of the material in an earlier study, were subjected to joint discussion because of diagnostic problems. The aim was consensus. Six cases representing different teeth/roots illustrating typical problems are presented. RESULTS: The varying morphology of apical areas and varying density of surrounding bone present a number of challenges. Even so, the joint discussion resulted in an agreement for all the cases. Twenty-five diagnoses were established and seven cases were not diagnosed owing to substandard radiographs. CONCLUSION: A detailed analysis of the periodontal ligament space, the lamina dura, trabecular pattern and bone marrow spaces is mandatory for the radiographic diagnosis of periapical disease

Long-term reliability and observer comparisons in the radiographic diagnosis of periapical disease.

AIM: The aim of this study was to evaluate and compare the long-term diagnostic consistency of two examiners, an endodontist and a radiologist, and to make comparisons with findings recorded by an observer with more recent scientific and clinical experience in endodontics. METHODOLOGY: Three groups, each consisting of 20 full mouth series of intraoral radiographs, with 79, 93 and 85 endodontically-treated roots, respectively, were successively evaluated for periapical disease. Evaluations were at first performed separately by the three observers. Disagreement and difficult, borderline cases were subjected to joint evaluation. Intra- and interexaminer comparisons were made. For two of the observers the observations were compared with findings recorded several years before for the same cases in the same radiographs. RESULTS: The intra- and interobserver long-term reliability of the two original examiners resulted in 83% overall agreement, the kappa values were 0.54, 0.57 and 0.53. Comparisons between all three observers disclosed 82%, 85% and 86% agreement and kappa values 0.55, 0.58 and 0.60. The joint evaluations and decisions did not indicate a dominating influence from any of the observers. CONCLUSIONS: The long-term reliability of the two original observers was judged as being satisfactory. All three observers judged the overall disease status of the material in the same way. The joint discussions of selected cases might reduce observer variation to an acceptable level, avoid a number of false recordings and increase the reliability and validity of the findings.

Prodromal herpes zoster--a diagnostic challenge in endodontics.

This case report highlights the diagnostic challenge that herpes zoster represents if pain develops in the prodromal stage. A 58-year-old male presented with pain in the left maxilla. The symptoms had lasted for 7 months. The first premolar had been extracted soon after the onset, and the second premolar root filled shortly thereafter. Symptoms were experienced as sudden pain attacks lasting for several hours and analgesics gave some pain relief. Clinical examination showed that the second premolar was tender to percussion. No sinus tract or swelling were present. Radiographic examination showed previously root-filled second premolar and first molar teeth, and no evidence of apical pathosis. Due to the uncertainty about the quality of the root filling in the second premolar and incomplete root filling in the first molar, retreatment was started prior to prosthetic treatment in the region. The pain continued and became more intense during the treatment. A diagnosis of herpes zoster was determined, when an acute attack with oedema and vesicles occurred, 2 months after retreatment was started. In the present case, therefore, the primary attack presented itself after months and the herpes zoster diagnosis could not be made until then. points. Key learning points. * A long lasting prodromal stage is an unusual event. * Symptoms combined with inadequate technical standard of root fillings may confuse the diagnostics. * No available data support or suggest the use of antiviral treatment as a diagnostic tool.

Lateral breakdown of nonendodontic origin adjacent to maxillary left incisors.

CASE REPORT: A 16-year-old female presented with a labial fistula located between the central and lateral left maxillary incisors. The teeth had normal colour, responded positively to pulp testing, demonstrated negative percussion tests and had no evidence of periodontal pockets. The patient reported no history of trauma, but mentioned that she had received orthodontic treatment. Radiographic examination showed bone loss between these two teeth. Explorative surgery followed by antibiotic treatment was performed, but a fistula reappeared after 22 months. Surgical retreatment combined with antibiotic treatment resulted in gradual healing over a three-year period. No root canal treatment was performed. Aetiological considerations connected to tissue injury and inflammation are discussed. Inflammation induced disturbances in local homeostasis may possibly explain the lateral breakdown of bone. Such areas of reduced resistance may, under unfavourable conditions, be infected by blood-born pathogens. Information about such aberrant cases is important in endodontic decision making.

Root resorption and apical breakdown during orthodontic treatment of a maxillary lateral incisor with dens invaginatus.

A 13-year-old girl was referred for endodontic treatment of a maxillary right lateral incisor with root resorption and apical radiolucency after orthodontic treatment. Radiographically the tooth had an invagination canal (Oehlers' Type III) and responded positively to pulp testing. The invagination canal extending to the lateral resorption was opened. Vital bleeding tissue was found, and the canal was cleaned and obturated. The pulp in the main root canal remained vital. The radiolucent lesion gradually decreased during the 3-year follow-up. The bone resorption seen here, despite vital tissue in the invagination canal, was probably due to osteoclastic activity caused by a low grade chronic infection, influenced by an injury-induced inflammation in the periodontium during orthodontic treatment.

Incomplete healing (scar tissue) after periapical surgery--radiographic findings 8 to 12 years after treatment.

Twenty-four cases treated by periapical surgery--which 2 to 6 yr after surgery were classified radiographically as incomplete healings (scar tissue)--were further followed, extending the observation period to 8 to 12 yr. One case healed completely, 1 failed, and 22 were still recorded in the same healing group. All the 22 scar tissue cases were characterized by a reduction of the defect in bone. In 13 cases, continuous periodontal structures were seen and the defect thereby separated from the root. The findings support the conclusion that cases clearly showing features of incomplete healing (scar tissue) at the regular follow-up 1 yr after surgery can be regarded as successes. They need not be recorded for further systematic control. A general follow-up program for apicectomy cases is suggested.

[Compulsory reporting of accidents and injuries in somatic hospitals. Is the existing system adequate for quality assurance?]. / Meldeordningene ved uhell og skader i somatiske sykehus. Er de tjenlige som ledd i sikring av kvalitet?

Doctors in Norway are obliged by law to submit reports to central authorities about injuries and risk of injury arising from medical equipment and drugs. Deaths following health care procedures must be reported to the police, and major injuries to the County Medical Officer. Most hospitals have their own rules requiring health care providers to report all incidents resulting in injury or risk of injury. The author contends that fewer than 5% of the injuries are reported. Neither the law, nor the hospital rules, require that the incidents in general are evaluated, with feed-back to the care providers. Most incidents do not seem to be evaluated. There is much left to do, both in building a set of regulations and in implementing better hospital practice, by using records of injuries and mishaps to identify and prevent further mishaps.

The duty to report hospital occurrences resulting in injuries and risks of injury: The Norwegian system.

In Norway a series of complementary systems have been established for the reporting of injuries and accidents occurring during the course of hospital treatment. Alongside a number of obligations to report such matters to an external body, depending on the nature of the event, many hospitals have created their own internal reporting systems. The latter were originally conceived largely as a defence mechanism for the event that the patient should bring legal action against the hospital, but like the various external reporting mechanisms these systems are today increasingly viewed as an instrument for quality assurance, enabling the hospital to benefit from experience.Although many of the elements are in place, including an increasingly clear view on patients' rights to information, concern has to be expressed at the multiplicity of mechanisms which now exists, some simplification is called for. There is also a need to ensure much greater compliance with these systems if they are to serve their purpose.

Follow-up after periapical surgery: the value of the one-year control.

A total of 474 teeth treated with periapical surgery were examined after one year. Complete healing was unequivocally demonstrated for 250 teeth. Two hundred and fourteen teeth were scheduled for further follow-up, and of these, 194 (91%) could be followed until a stable situation was recorded. Of 41 cases judged as completely healed after one year, but with initial observer disagreement, only 2 (5%) failed later. The 76 cases showing incomplete healing (scars) after one year with few exceptions ended as completely healed or persisted as incomplete healings. The uncertain group (n = 72) was equally re-distributed as successes (completely or incompletely healed) or failures at the end control. Five cases showing no healing after one year all ended as failures. Based on these findings it is concluded that the one-year control will provide a valid diagnosis for the majority of cases. Only a minor number, the uncertain healings, need further follow-up.

Scanning electron microscopy of bacteria in the apical part of root canals in permanent teeth with periapical lesions.

The most apical 2 mm of the root canals of periapically diseased roots were examined for microorganisms by scanning electron microscopy (SEM). Bacteria in this area were observed in 10 out of 12 (83.3%) cases. The two remaining cases exhibited bacteria more coronally, with tissue remnants between the bacterial front and the apical foramen. Rod-shaped bacteria dominated, but filaments, spirochetes and cocci were also seen. Cocci and rods sometimes formed micro-colonies. Occasionally, cocci were seen attached to filaments forming "corn-cob"-like structures. Deposits resembling bacterial plaque were also found inside the root canal. SEM is useful for studying microbial topography of the apical root canal.

[In-hospital injury reports and the injury evaluation work. Intentions and practice in somatic hospitals]. / Intern skademelding og skadeutvalgsarbeid. Intensjoner og praksis ved somatiske sykehus.

Doctors have no general obligation to report injuries to patients to the hospital administration, and hospitals have no obligation to establish committees to evaluate the cases reported. Most hospitals, however, have defined their own internal rules for reporting cases, and have established committees. The number of cases reported are few, but the reporting practice differs from hospital to hospital. Not all committees do evaluate the cases, and most patients do not receive the results of the evaluation. In order to realize important goals of health policy, such as better quality assurance and better information to patients, most hospitals have much left to do. One way to initiate a better practice may be to establish a uniform system throughout and a legal obligation to report and evaluate injuries.

[Fairness of compensations. Possibilities for patients injured in hospitals claim compensation]. / Billighetserstatning. Sykehusskadede pasienters muligheter til å oppnå det.

Patients injured in hospitals can claim economic compensation from insurance companies for negligence or inconnect treatment. Where there is no fault, patients have the right to apply to a parliamentary committee for compensation for reasons of equity. Practice indicates that applications are normally granted. The decisive issue is whether the patient has been "especially unlucky". Examples are presented. On average the injured patients receive NOK 75,000, and often up to NOK 150,000. This arrangement is not well known, however, and there are only a few injured patients who apply for such compensation. Information from doctors could change this situation.

Surgical management of endodontic failures: indications and treatment results.

Two-hundred and twenty-four teeth with failures after conventional endodontic treatment were treated by periapical surgery by one surgeon and followed up for 1-8 years. Indications for surgery were: inaccessibility to the apical part of the root by a coronal approach due to posts, calcifications or procedural accidents. Cysts, a few acute cases and wide-open apices were also treated surgically. Healing was judged radiographically and classified into one of four healing groups: (1) complete healing, (2) incomplete healing (scar tissue); (3) uncertain healing, and (4) unsatisfactory healing. The grouping was performed separately by the oral surgeon and an endodontist. Deviating cases were then evaluated jointly, difficult cases and borderline cases were judged by an oral radiologist. Complete healing was observed for 76.6 per cent and incomplete healing (scar tissue) for 8.1 per cent of the teeth. The size of the latter group was strongly influenced by the number of cases with large preoperative rarefaction. A success/failure grouping of the material (success = complete and incomplete healing) revealed that 27 per cent of the retrofilled cases failed compared with 3.6 per cent in the orthograde group. The main conclusion is that retrofills should be avoided whenever possible.

Effects of extensive apical reaming and calcium hydroxide dressing on bacterial infection during treatment of apical periodontitis: a pilot study.

An apical dentine sampling technique was applied in order to monitor the bacteriology of the pulp canal and radicular dentine before and during treatment of teeth with chronic apical periodontitis. Twenty-three teeth with a radiographic diagnosis of apical periodontitis were studied. They were subjected to a standardized two-appointment treatment regimen of extensive apical reaming in the absence of antimicrobial agents and 1-week dressing with calcium hydroxide. Bacteriological samples were taken from the root canal at the start, and apical dentine samples at the end, of each sitting. Provision was made to allow growth of anaerobic bacteria. All root canals but one showed growth at the start of treatment. Dentine samples were positive in 14 of the 23 teeth at the end of the first appointment. Eight of the 23 canals had detectable growth from the canal at the start of the second appointment, but in sufficient numbers for quantification in only one root canal. The subsequent dentine samples were otherwise negative at the second appointment. There was a tendency for teeth causing symptoms to harbour more bacteria than symptomless teeth.

Periapical surgery in a Norwegian county hospital: follow-up findings of 477 teeth.

Four-hundred seventy-seven teeth treated by periapical surgery by one surgeon were followed up until a stable radiographic situation was recorded. Radiographic findings were classified into one of four groups: 1, complete healing; 2, incomplete healing (scar tissue); 3, uncertain healing; or 4, unsatisfactory healing. Evaluation was performed independently by an endodontist and the oral surgeon and cases of disagreement were subjected to joint evaluation. Difficult cases and borderline cases were judged by an oral radiologist. Complete healing was observed for 78% and incomplete healings (scar tissue) for 9% of the teeth. The size of the latter group was strongly influenced by the number of cases with large preoperative lesions. When the material was grouped as "success" (complete healing, scar tissue healing) and "failure" (uncertain healing, unsatisfactory healing), a 13% failure frequency was recorded. Twenty-eight percent of the cases treated with retrograde fills failed compared with 4% in the orthograde group.

[Patient ombudsmen at the Rikshospitalet. Experiences with a 2-year trial]. / Pasientombudordningen ved Rikshospitalet. Erfaringer med et toårig forsøk.

A patient-ombudsman has been engaged in some somatic hospitals in order to improve the level of legal protection. This article deals with a two-year experiment at Rikshospitalet (The National University Hospital). Formal complaints against the hospital increased dramatically as a result of the presence of the ombudsman. Many more patients' complaints were assessed by medical experts. Hospital routines were also changed. The owner had to pay much more to patients who claimed damages. The executive work in the health service was not effective. It took a long time to process the claims for compensation, to reach a decision on proper and correct application of the law, and to actually pay the compensation. Patients and hospital staff alike evaluated the experiment positively. It has not yet been decided whether the arrangement should be established permanently.