All entries for May 2010

Retained fractured instruments and treatment outcome

Writing about web page http://www2.warwick.ac.uk/fac/med/study/cpd/subject_index/dentistry/courses/endodontics/

A very controversial topic has currently been analyzed by Panitvisai et al. (1) in the May edition of Journal of Endodontics: effect of retained fractured instrument on the outcome of root canal treatment. The authors concluded:

“On the basis of the current best available evidence, the prognosis for endodontic treatment when a fractured instrument fragment is left within a root canal is not significantly reduced.” However to cite only this conclusion without mentioning the rest would be incorrect and misleading: “This conclusion,

however, might not be fully applicable in general practice conditions because data in this review were derived from specialist practices and well-controlled university clinic.”

How far does this affect clinical practice?

1.  Patient has to be informed and this has to be registered in the record (might only solve forensic implications if written consent signed by the patient previous to the treatment).

2.  Non specialists should refer the case to a specialist.

3.  Endodontic specialists will differentiate among teeth having and those non having periapical lesions (as difference in the outcome possible due to disinfection impediment).

4.  Endodontic specialists can balance decision of fragment retrieval as removal of the instrument fragment might actually worsen the situation due to possible ledge formation, over enlargement and transportation of the prepared root canal.

5.  Appropriate recall including x-ray has to be installed.

6.  In cases of non favorable healing outcome apical surgery or extraction will be considered.

Reference

Panitvisai P, Parunnit P, Sathorn C, Messer HH.; Impact of a retained instrument on treatment outcome: a systematic review and meta-analysis. J Endod. 2010 May;36(5):775-80. Epub 2010 Mar 7.

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Level of evidence of the paper: 2A

It is useful to review levels of evidence - here levels of evidence as outlined by Sackett et al. in 2000 (2):

1A = Systematic Review of Randomized

Controlled Trials (RCTs)

1B = RCTs with Narrow Confidence Interval

1C = All or None Case Series

2A = Systematic Review Cohort Studies

2B = Cohort Study/Low Quality RCT

2C = Outcomes Research

3A = Systematic Review of Case-Controlled

Studies

3B = Case-controlled Study

4 = Case Series, Poor Cohort Case Controlled

5 = Expert Opinion

Meta – analysis in The National Library of Medicine (3):

“Meta-analysis:  systematic methods that use statistical techniques for combining results from different studies to obtain a quantitative estimate of the overall effect of a particular intervention or variable on a defined outcome. This combination may produce a stronger conclusion than can be provided by any individual study. (Also known as data synthesis or quantitative overview.)“

Conclusion: a meta analysis is a subset of systematic reviews.

References

1.  Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine:

             How to Practice and Teach EBM. Philadelphia, Pa: Churchill-Livingstone;  

2000.

2.  Meta – analysis definition [http://www.nlm.nih.gov/nichsr/hta101/ta101014.html] webcite

Liviu Steier : 08 May 2010 18:48 |  Comments (0) |  Close comments |  Report a problem