Diagnosis and management of pulpal and periradicular disease — a survey

Key Points

• Root canal treatment follow-up times in practice are in general too short.

• Patients should be educated on the benefits of root canal treatment.

• There should be increased funding for root canal treatment in the National Health Service.

Abstract

Objective

To identify factors influencing the diagnosis and management of periradicular disease by general dental practitioners.

Design

The study was conducted in two stages. 1. Analysis of recent returns to the Scottish Dental Practice Board. 2. Data collection via a postal questionnaire distributed to 617 general dental practitioners in Scotland (33% of practitioners registered with the Dental Practice Board).

Results

417 (69%) questionnaires were completed and returned. The majority of respondents undertook root canal treatment and the number of cases treated had increased in the last five years. The vast majority of the respondents (89.3%) were confident in their diagnosis of periradicular disease and 77.1% were confident of their treatment of the disease. A referral system for treatment was used by 31% of respondents of whom the majority used a specialist in a hospital. Over 50% of the respondents undertook surgical root canal treatment. Only 40% of respondents followed up their completed cases for longer than six months. Constraints on the provision of treatment included the time available and the low level of fees.

Conclusions

Current arrangements for the treatment of periradicular disease in general dental practice are less than optimal. The fiscal arrangements for the provision of these treatments must be developed to encourage a high standard of treatment to be performed thereby maximising the likelihood of success. In addition, efforts to inform patients of the benefits of the treatment of periradicular disease should be increased.

Main

Factors influencing the diagnosis and management of teeth with pulpal and periradicular disease by general dental practitioners. Part 1 W. P. Saunders, I. G. Chestnutt, and E. M. Saunders Br Dent J 1999; 187: 492–497

Comment

The aim of this paper was to determine those factors that dentists in Scotland reported influenced their ability to diagnose and manage periradicular disease. Given the relatively high prevalence of periradicular disease in the population and the often inadequate standard of root canal treatment, the paper is timely.

The first part of the paper reviews data from the Scotland Dental Practice Board, Interestingly, the proportion of incisors and canines root filled in Scotland under the GDS regulations is larger than that in molars. This is in contrast to that found in England and Wales where since 1996/97 the proportion of molars being root filled has been greater.¹ It is also worth noting that many roots were resected apically but did not have root-end fillings placed; it is generally believed that the enhancement of the apical seal with such a filling is advisable.^2,3

Part 2 (to be published in the next issue) of the paper evaluates the responses to a questionnaire. The rigorous design of this aspect of the study and the good response rate mean that the data is representative of Scottish general dental practitioners.

The fact that respondents were largely confident in diagnosing periradicular disease is not surprising. However, when this is linked to the fact that prevalence of periradicular disease in the population is relatively high,⁴ it must be a cause of concern. This relationship has been highlighted by the authors who correctly emphasised the need for more rigorous examination of the periradicular condition of teeth, particularly following root canal treatment.

The few cases referred for specialist care reflects the embryonic nature of the speciality of endodontics and the limited accessibility of specalist advice; hopefully this situation will improve as the speciality matures.

Failure of root canal treatment is related to infection of the root canal system, either as a result of microorganisms remaining in the tooth or from reinfection by oral micro-organisms through coronal leakage.⁵ It is critical that general dental practitioners are aware of both the need to clean the canal system thoroughly at the time of treatment and also to ensure that the crown of the tooth is restored with a permanent restoration that provides an effective seal.

Although the fee scale is probably an important disincentive for quality care there is little, if any, evidence to suggest that raising the fee per treatment in isolation would result in enhanced quality; rather it is likely that a package of measures are necessary including continuing professional education.

In conclusion, the paper is timely and relevant as it addresses an important area of clinical dentistry and attempts to determine the practices and beliefs of general dental practitioners.