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

Congratulations Endodontics!

Follow-up to Reason to celebrate? from Liviu's blog

“Cause for optimism” in the freshly out of print Journal of Endodontics:

“A systematic evaluation of the quality of meta-analyses in endodontics” by Suebnukarn et al.

It is highly advisable to learn and understand the tools used by the authors of this review article before looking into the results.

1.   Systematic review

The National Library of Medicine (3):

“Systematic review: a form of structure literature review that addresses a question that is formulated to be answered by analysis of evidence, and involves objective means of searching the literature, applying predetermined inclusion and exclusion criteria to this literature, critically appraising the relevant literature, and extraction and synthesis of data from evidence base to formulate findings.”

Intending to help users of systematic reviews to critically appraise those, Shea et al. (2007)

developed the AMSTAR ('assessment of multiple systematic reviews') using factor anylsis. 11 items were implemented into the tool:

1. Was an 'a priori' design provided?

2. Was there duplicate study selection and data extraction?

3. Was a comprehensive literature search performed?

4. Was the status of publication (i.e. grey literature) used as an inclusion criterion?

5. Was a list of studies (included and excluded) provided?

6. Were the characteristics of the included studies provided?

7. Was the scientific quality of the included studies assessed and documented?

8. Was the scientific quality of the included studies used appropriately in formulating conclusions?

9. Were the methods used to combine the findings of studies appropriate?

10. Was the likelihood of publication bias assessed?

11. Was the conflict of interest stated?

Shea et al. BMC Medical Research Methodology 2007 7:10   doi:10.1186/1471-2288-7-10

In 2009 Shea et al. concluded:

  “AMSTAR has good agreement, reliability, construct validity, and feasibility. These findings need confirmation by a broader range of assessors and a more diverse range of reviews.”

2.   Meta - analysis

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.)“

The QUOROM statement (4) (Quality of Reporting of Meta-analyses) was introduced to address “standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs)”.

3.   The CONSORT Statement

“The CONSORT Statement is intended to improve the reporting of a randomized controlled trial (RCT), enabling readers to understand a trial's design, conduct, analysis and interpretation, and to assess the validity of its results. It emphasizes that this can only be achieved through complete transparency from authors.” (5)

One can download templates of the CONSORT 2010 Statement at: http://www.consort-statement.org/consort-statement/overview0/ (5).

Results of the systematic evaluation of the quality of meta-analyses in endodontics proved “an estimated mean overall quality score for meat – analysis in the endodotic literature from 2001 to 2009 of 8,33”.

References

1.   Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, Tugwell P, Moher D, Bouter LM.; Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007 Feb 15;7:10.

2.   Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, Henry DA, Boers M.; AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews.; J Clin Epidemiol. 2009 Oct;62(10):1013-20. Epub 2009 Feb 20.

3.   Systematic Review definition [http://www.nlm.nih.gov/nichsr/hta101/ta101014.html] webcite

4.    Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF.; Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999 Nov 27;354(9193):1896-900.

5.   Consort statement [http://www.consort-statement.org/], webcite

6.   Suebnukarn S, Ngamboonsirisingh S, Rattanabanlang A.; A systematic evaluation of the quality of meta-analyses in endodontics. J Endod. 2010 Apr;36(4):602-8. Epub 2010 Feb 21.

Liviu Steier : 30 Apr 2010 19:30 |  Tags: 21St Century Endodontics In The |  Comments (0) |  Close comments |  Report a problem

Reason to celebrate?

Follow-up to Welcome to the MsC in Endodontics – Warwick Dentsitry / Warwick Medical School from Liviu's blog

An impressive retrospective epidemiologic research has been published in the JOE May 2010:

Epidemiologic evaluation of the outcomes of orthograde endodontic retreatment.

Salehrabi R, Rotstein I.

J Endod. 2010 May;36(5):790-2. Epub 2010 Mar 24

Why impressive?

1.    5 years retrospektive.

2.    Data collected from across the US.

3.    Loss of less than 5% in patient pool.

4.    All endodontic retreatment performed by specialist endodontists.

5.    4744 nonsurgical retreatment reviewed.

Quoted results:

“Overall, 89% of all teeth were retained in the oral cavity after

nonsurgical endodontic retreatment. Four percent of all teeth underwent

apical surgery, and 11% were extracted at the end of the 5-year

observation period.“

Shortcomings of the research:

1.    Discussed is “survival rate” and not the ReRCT “success rate”.

2.    There is no knowledge about CAP healing. (Are treating to gain “survival rate” or for “healing”?)

3.    There is no knowledge about systemic health implications due to non resolved CAP.

Conclusions

Are there reasons to celebrate?

Definitive yes if one intends to compare “survival rates” (…Implantology is knocking at the door!).

Liviu

Liviu Steier : 27 Apr 2010 19:01 |  Tags: 21St Century Endodontics In The |  Comments (0) |  Close comments |  Trackbacks (1) |  Report a problem

Welcome to the MsC in Endodontics – Warwick Dentsitry / Warwick Medical School

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

Welcome to the MsC in Endodontics blog!

This blog has been created to help keep in touch, inform, discuss and comment.

We hereby invite you all not only to follow and read but also post.

Dr.med.dent. L. Steier

Liviu Steier : 26 Apr 2010 11:51 |  Tags: 21St Century Endodontics In The |  Comments (0) |  Close comments |  Trackbacks (1) |  Report a problem