ENDODONTIC OUTCOMES

Abstract

I would like to comment on Dr. Susan Bernstein and colleagues' May JADA article, “Outcomes of Endodontic Therapy in General Practice: A Study by the Practitioners Engaged in Applied Research and Learning Network” (Bernstein SD, Horowitz AJ, Man M, et al. JADA 2012; 143[5]:478–487). First of all, I was surprised to read that irreversible pulpitis with periapical pathosis (PP) was mentioned in Table 3 on page 483 of the article. The authors mentioned that one failure criterion of PP is having a periapical lesion with a periapical index score of 3 or higher. Unless the lesion of such size is unrelated to pulp, it is not possible to have irreversible pulpitis, a vital (non-necrotic) tooth diagnosis. Perhaps there have been some cases mistakenly diagnosed as vital. Here is a very common example. There is a tooth that hurts a lot on touch. When cold is applied to this tooth to test vitality, the patient says that it hurts. But it is not the cold but rather the actual touching of the tooth that causes the pain. This results in a misdiagnosis of tooth vitality as “irreversible pulpitis with PP” instead of a necrotic pulpal diagnosis and appropriate periapical diagnosis. Second, in Table 1 on page 482, pain on percussion should not be considered and portrayed as endodontic failure because it may have nothing to do with endodontic treatment whatsoever. The percussion could be due to a fractured/overhung restoration, hyperocclusion or periodontal or even psychological reasons. Finally, periapical pathosis was determined in a single reading of nonoriginal radiographs by just two observers, only one of whom is an endodontist. This reading is very inadequate because studies show that there is a need for a larger number of experienced observers1Tewary S Luzzo J Hartwell G Endodontic radiography: who is reading the digital radiograph (published online ahead of print April 9, 2011)?.J Endod. 2011; 37: 919-921Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 2Goldman M Pearson AH Darzenta N Endodontic radiography: who's reading the radiograph?.Oral Surg Oral Med Oral Pathol. 1972; 33 (10.1016/j.joen.2011.02.027): 432-437Abstract Full Text PDF PubMed Scopus (225) Google Scholar, 3Goldman M Pearson AH Darzenta N Reliability of radiographic interpretations.Oral Surg Oral Med Oral Pathol. 1974; 38: 287-293Abstract Full Text PDF PubMed Scopus (148) Google Scholar and that “interpreting the radiograph or digital image continues to be more of a subjective exercise than an objective one.”1Tewary S Luzzo J Hartwell G Endodontic radiography: who is reading the digital radiograph (published online ahead of print April 9, 2011)?.J Endod. 2011; 37: 919-921Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar ENDODONTIC OUTCOMES: Authors' responseThe Journal of the American Dental AssociationVol. 143Issue 9PreviewWe welcome the opportunity to respond to the questions raised by Dr. Moline concerning our article. Full-Text PDF