Aim: To prospectively investigate the incidence of symptoms and changes in the size of the apical bone destruction in symptom-free root-filled teeth with persistent apical periodontitis (AP) over 1 year without treatment.

Methodology: Patients referred to two specialist endodontic clinics in Västra Götaland, Sweden, with asymptomatic periapicalbone destructions (summing to ≤ 10 mm in diameter, when measured in two dimensions) on intraoral radiographs were invited.After informed consent, participants underwent cone-beam computed tomography (CBCT). Patients with bone destructionsbeyond cortical boundaries were excluded. A 1-year follow-up included recording subjective symptoms, clinical findings andestimating bone destruction size.

Results: Of 187 eligible patients, 171 (91.4%) participated. After CBCT, four were excluded, and 10 were lost to follow-up. Among 157 patients, three developed symptomatic AP and were treated, and one tooth was lost due to fracture. Of the 153 patients with complete follow-up, eight (5.2%) reported mild pain or discomfort but did not seek care. Lesion size changes were small(M = 0.059 mm), with the mean increasing from 7.25 mm (SD 2.11) to 7.31 mm (SD 2.33), which was not statistically significant.

Conclusion: The findings align with previous studies, suggesting that patients with symptom-free root-filled teeth with apicalperiodontitis rarely experience exacerbation or significant increase in size of bone destruction in the short term. Longer follow-upis needed to identify potential risk factors.

European Society of Endodontology har udarbejdet retningslinjer for behandling af pulpitis, som vi i denne artikel beskriver og vurderer fra et skandinavisk perspektiv. 

Introduction: Epidemiological studies indicate that root filled teeth exhibit higher rates of apical periodontitis and extraction compared to non-root filled teeth, underscoring the importance of vital pulp treatment (VPT) when feasible in teeth with pulpitis. The European Society of Endodontology has established guidelines for treatment of pulpitis, which this article evaluates from a Scandinavian perspective.

Review of available scientific literature: The guidelines are based on three systematic reviews on pulpitis management. For teeth with pulpitis without spontaneous pain, evidence is insufficient to favour direct pulp capping over pulpotomy or selective/stepwise caries removal. In teeth with pulp exposure due to caries, direct pulp capping and pulpotomy show comparable short-term outcomes. For teeth diagnosed with pulpitis, with or without spontaneous pain, pulpotomy and root canal treatment demonstrate similar short-term effectiveness. Root canal treatment is suggested to be performed on teeth as soon as the diagnosis necrosis is confirmed to prevent apical periodontitis.

Discussion: VPT offers advantages, though concerns persist regarding long-term pulp survival and undetected disease progression. ESE’s guidelines are in line with the Scandinavian’s, though evidence is weak concerning balancing short-term benefits against long-term outcomes, emphasizing the need for careful clinical judgment and further research.

Keywords: dental caries, dental pulp capping, dental pulp exposure, pulpectomy, pulpotomy

AIM: A successful outcome of root canal treatment is defined by the Strindberg Concept (SC) as the absence of symptoms and no periapical radiolucency. Hence, other outcomes are deemed unacceptable and should render retreatment, or extraction. However, empirical as well as experimental studies within the area of endodontic decision-making have repeatedly challenged the position of the SC among clinicians. A fundamentally different clinical approach is a conservative concept (CC), which is to prescribe treatment only if new or persistent symptoms (exacerbations) occur in order to keep the patient asymptomatic. The aim in this study is to compare the expected costs of SC versus CC, depending on varying risk of exacerbation and outcome of the interventions.

Methodology: Decision trees were constructed with the main branches representing treatment strategies SC or CC. Estimated costs for both treatment strategies were calculated using the 2025 Swedish Dental and Pharmaceutical Agency’s reference pricelist. Outcomes of ortho- and retrograde retreatment were based on data in recently published high-quality reviews. A one-way sensitivity analysis varying the likelihood of exacerbation was performed.

Results: Preliminary results To strictly adhere to the SC in the Swedish population would render a cost of approximately €2.50 billion. Setting the probability of exacerbation to 10%, it would be at least 11 times as expensive to pursue the SC strategy compared to the CC. The sensitivity analyses revealed that it is not cost-effective to choose the SC in favour of the CC strategy unless the probability of exacerbation exceeds 80–90%. '

Conclusions (mandatory): Within the limitations and assumptions of this study, strictly adhering to the SC in the Swedish population is an expensive strategy that risks blocking other urgent dental care.

Acknowledgements (optional): Funding source: Uppsala County Council, Sweden

AIM: Threshold concepts are concepts that, when grasped, will promote mastery of a subject by leading to proper understanding of its most central features. Some features of threshold concepts are that they are transformative, troublesome, irreversible, integrative, and bounded. The aim of this study is to report on the development and initial assessment of threshold concepts introduced in undergraduate endodontic education at Malmö University.

Methodology: By systematically reviewing published literature we evaluated how threshold concepts affect students’ experiences in dental or medical education. Through collegial discussions three central concepts were identified: “Physical and physiological barriers”, “Gradual disease development” and “Localization of inflammation/infection”. These concepts were then integrated into all theoretical learning activities in Endodontology. At the written examination, the students replied in short essays to questions about pathogenesis regarding pulpal and periapical disease. Through systematic text condensation (Malterud 2012) the answers were analyzed to discover whether their arguments indirectly or directly reflected the threshold concepts.

Results: The systematic review failed to identify studies evaluating how threshold concepts affect students’ experiences in dental education. Four papers from medical education reported that threshold concepts act as tools to overcome obstacles and foster new ways of thinking. The systematic text condensation identified four main themes: “Barrier functions and their role in the pulp defense”, “Inflammation and infection in the pulp and surrounding tissues”, “Clinical approach to endodontic diagnostics” and “Details of disease development”. These main themes were then further divided into subthemes. The results showed that the students reflected well on the central concepts of Endodontology and showed good understanding of the meaning of threshold concepts.

Conclusions (mandatory): The identified concepts were integrated into the learning activities and seem to have affected the students’ ability to grasp central concepts within Endodontology. Further studies are needed to confirm whether learning the concepts also promoted retention of knowledge over time.

Aim: This prospective follow‐up study aimed to assess patient satisfaction with root canal treatment (RCT) 7–9 years after initiation in a general dental practice setting.

Method: A study population of 243 patients initiated RCT at 20 public dental clinics in the Västra Götaland Region, Sweden. One to 3 years later, 159 patients (67.4%) responded to an 8‐item questionnaire assessing patient satisfaction with RCT and treatment results. The questionnaire was sent out again 7–9 years after treatment initiation. Descriptive and analytical statistics were used to compare respondents and non‐respondents, tooth groups and comparison over time.

Results: A total of 156 patients (72.2%) responded to the 7–9 years' questionnaire; 82 women (52.6%) and 74 men (47.4%) with a mean age of 59.3 years (SD = ±15.3). Non‐respondents were significantly younger ( p  < 0.001). The majority of RCTs were reported as completed with a root filling ( n  = 102, 65.4%), although significantly fewer molars were completed ( n  = 43, 56.6%; p  < 0.001). Sixty‐six patients (63.5%) reported no current pain, while most of those reporting pain described it as mild ( n  = 30, 90.9%). More than half of the root filled incisors were associated with current pain ( n  = 15, 57.7%; p  < 0.009). A total of 111 patients (76.0%) recalled the procedure as painful. Chewing ability received the highest satisfaction rating (mean = 1.3). The majority of patients reported they would choose RCT again ( n  = 114, 77.0%). Among the 17 who answered ‘No’, 13 had undergone extraction, and 3 reported persistent pain following RCT. Over time, the number of extracted teeth increased ( p  < 0.001), while current pain intensity decreased and retrospective satisfaction with RCT improved ( p  < 0.001).

Conclusions: Seven to nine years after the initiation of RCT in this general dental practice setting, patient satisfaction remains high despite one‐third of treated teeth being reported as extracted. These findings highlight the importance of incorporating patient‐reported outcomes in the evaluation of dental procedures, including endodontic treatments.

Aim: To explore the context in which general dental practitioners (GDPs) decide to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with persistent asymptomatic apical periodontitis (PAAP).

Methodology: Fifteen GDPs were strategically selected for in-depth interviews. The informants were encouraged to describe in their own words and in as much detail as possible, the three most recent patient cases of PAAP of a root canal filled tooth, in which they decided to refrain from further treatment. The interviews were recorded digitally and transcribed verbatim. The collected material was analysed according to Qualitative Content Analysis with an inductive approach.

Results: A pattern of varying degrees of uncertainty associated with the decision process was identified. The motives to refrain intervention had great diversity. The result from analysis of the qualitative data was formulated in an overall theme 'Between doubt and certainty in a complex clinical context' covering the latent content. The first main category covering the manifest content was 'The continuum of confidence' with three subcategories 'Experienced uncertainty', 'Reluctant approval' and 'At ease with refraining' illustrating the feelings and attitudes experienced by the informants. The second category was 'In support of acceptance' with three subcategories 'Patient's autonomy, risks and cost-benefits', 'Emotional aspects' and 'Relieving measures' representing the reasons for refraining from intervention.

Conclusions: The decision to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with PAAP was made with some measure of confidence, combined with compensatory strategies to support the decision, taking into account not only values beneficial to the patient and awareness of limited external resources, but also factors related to the informants' personal preferences, convenience, concerns, ambition and emotions.

Objective: This study aimed to evaluate the impact of root canal treatment on Oral Health-Related Quality of Life (OHRQoL) in general dental practice and compare it with tooth extraction. Additionally, patient satisfaction following tooth-preserving treatment was assessed.

Material and methods: In all, 65 patients were recruited from 6 general dental clinics in Västra Götaland over 8 weeks, with 37 starting root canal treatment and 28 having extractions. Questionnaires, including Oral Health Impact Profile-14 (OHIP-14) and 9 questions assessing patient satisfaction, were administered at treatment initiation, and at 1, 6, and 12 months. The responses from both modalities were analysed using descriptive and analytical statistical methods.

Results: The response rate ranged from 73.8% to 92.3%. Regarding OHRQoL, differences between the groups were few compared to baseline. However, significant improvements were observed in the extraction group at the 6- and 12-month follow-ups, in the ‘total score’, and the dimensions ‘pain’, ‘discom-fort’, and ‘handicap’. Patient satisfaction was generally high, with cost being the least satisfactory item. Pain intensity remained consistently low.

Conclusions: In this prospective cohort study few differences were found between the two treatment modalities. However, significant improvements were observed in the extraction group in several dimen-sions. The patient satisfaction regarding root canal treatment was considered high.

Artikeln beskriver apikal parodontit med respektive utan systemisk spridning, och hur olika prioriterade åtgärder kan appliceras på ett antal typfall.

INTRODUCTION: Prospective studies assessing the relation between endodontic inflammatory disease and subsequent cardiovascular events are few. The present aim was to explore associations between endodontic variables and future cardiovascular events in patients with myocardial infarction and matched controls participating in the PAROKRANK (Periodontitis and Its Relation to Coronary Artery Disease) study.

METHODS: Eight-hundred five patients hospitalized for a first myocardial infarction and 805 controls were recruited between 2010 and 2014. Signs of endodontic inflammatory disease were assessed in panoramic radiographs taken at baseline. Mortality and morbidity data during the approximately 8 years of follow up were obtained from national registries. The risk for future cardiovascular events (first of mortality and nonfatal myocardial infarction, stroke, or hospitalization for heart failure) was analyzed with the log-rank test and Cox proportional hazards regression adjusted for the following confounders: sex, age, smoking, myocardial infarction, diabetes, education, marital status, family history of cardiovascular disease, and marginal periodontitis.

RESULTS: In total, 285 future events were observed during the follow-up period. Unadjusted analyses revealed that ≥1 root-filled tooth increased the risk of a future event. After adjustment, the number of remaining teeth and non-root-filled teeth decreased the risk of future events, whereas a higher Decayed, Missing and Filled Teeth score increased the risk and ≥1 primary apical periodontitis decreased the risk of suffering cardiovascular events. A higher Decayed, Missing and Filled Teeth score and decayed teeth increased the risk of all-cause mortality.

CONCLUSIONS: Tooth loss is a strong indicator of an increased risk for future cardiovascular events. Root-filled teeth seem of limited value as a risk indicator when accounting for other risk factors. The potential effect of dental interventions on future events should be assessed in future research.