Transcript Treatment choices for negative outcomes with non

Treatment choices for negative
outcomes with non-surgical root
canal treatment: non-surgical
retreatment vs. surgical retreatment
vs. implants
STEVEN A. COHN
Endodontic Topics 2005
• The primary reason for a negative outcome
with endodontic treatment is the persistence
of bacteria within the intricacies of the root
canal system.
• Failure may also be attributed to the
persistence of bacteria in the periapical
tissues, foreign body reactions to overfilled
root canals, and the presence of cysts.
• 5 levels of evidence
– Prospective randomized-controlled trials (RCT)
considered the highest level of evidence (LOE 1).
• No papers dealing with non-surgical retreatment
and surgical revision that reach the highest LOE.
• The primary consideration is the patient’s values
and expectations.
Non-surgical retreatment
• The incidence of periapical lesions following
root canal procedures surveyed in many
countries is 20–60%.
Non-surgical retreatment
• Apical periodontitis
– apical periodontitis is the most important variable
influencing a positive outcome with non-surgical
retreatment.
– Hepworth&Friedman: the retreatment of teeth
without periapical lesions has a positive outcome of
95%, but in their study and others, this declines to 56–
84% in the presence of a periapical lesion.
– The true negative outcome rate may be only 10–16%.
Non-surgical retreatment
• Role of primary endodontic treatment
– Sjøgren found that 94% of periapical lesions
healed when the root filling was within 2mm of
the apex, a significant difference when compared
with overfilled canals (76%) and those more than
2mm short of the apex (68%).
Non-surgical retreatment
• Bacterial and technical considerations
– Farzanehet found that a positive outcome was most
influenced by the presence of a preoperative
perforation.
– Other negative factors were the quality of the root
filling, the lack of a final restoration, and preoperative
apical periodontitis. The overall success (or
‘healed’)rate was 81.
– 93% when asymptomatic and functional teeth were
included.
Reference set of radiographs with corresponding line drawings and their associated PAI score
• Occlusion
– The role of the occlusion following endodontic
treatment requires further investigation
• Restoration
– The quality of the restoration affects the outcome
because of the possibility of leakage.
– Teeth not crowned following endodontic
treatment were lost at 6 times the rate of those
teeth that did receive crowns.
Outcome of periradicular surgery
• Surgical retreatment
– Positive outcomes for surgical retreatment in
excess of 90% can be achieved with careful case
selection and a skilled and experienced operator
Outcome of periradicular surgery
• Lesion size and characteristics
– No clear consensus that small (less 5 mm) lesions
heal more favorably than larger lesions
• Tooth location
– be less important than the access to it and the
anatomy of the roots in determining a successful
outcome
Outcome of periradicular surgery
• Preoperative symptoms
– Symptoms do not appear to affect the outcome of
surgery
• Age and gender
– Neither the age nor the sex of the patient appears
to influence the outcome of surgery
Outcome of periradicular surgery
• Quality of the root filling
– Non-surgical retreatment of the root canals before
surgery improves the prognosis for surgery
– Short root fillings had a better outcome then roots
filled to the apex or overfilled
Outcome of periradicular surgery
• Repeat surgery
– A repeat of surgery is associated with a worse
outcome than surgery performed the first time
• Resection
– Resection of 3mm is considered sufficient to eliminate
apical pathology
• Root-end filling and materials
– IRM and MTA no significant diff.
Outcome of periradicular surgery
• Operator skill
– The complete healing rate in the endodontic unit
was approximately double that of the oral surgery
department.
Intentional replantation
• Intentional replantation is a viable alternative
to tooth extraction in selected cases.
Transplantation
– Endodontic treatment is indicated for teeth with
closed apices, usually within a month after
transplantation. The prognosis for both closed and
open apices is considered favorable
Endodontics or implants?
• Implant studies - when the criteria of EBD are
applied, there are no papers that reach the
highest level of evidence.
• Ruskin state that an immediate implant has a
more predictable outcome than an
endodontically treated tooth as a basis for
restorative dentistry.
– “The best candidate for endodontic treatment is a
single rooted tooth with an intact crown that has
become devitalized due to trauma, and that also
fulfills an esthetic need.”
Endodontics and implants: ‘success’
vs. ‘survival’
– concept of ‘survival’ is applied to implant studies
– 1.5 million teeth from an insurance company
database. The treatments were provided both by
general dentists and endodontists, and a 97%
retention rate followed up for 8 years was
reported
– the high success rates for implants may not be
duplicated at the general practitioner level
Indications for an implant
• Root resection?
– Langer reported a 38% failure rate of 100 molar
teeth that had undergone a root resection
– Blömlof reported on a 10-year follow-up of rootresected molars compared with root-filled single
rooted teeth. The survival rate was similar.
CDA Journal , vol 36 , 2008
• The preliminary electronic and manual
searches identifed 5,346 endodontic and
4,361 dental implant studies.
– Inclusion criterias:
• At least 25 cases with a minimum two-year follow-up
(endodontics - from obturation time; implant - from
placement); with treatment units described as being
single individual, implant-supported restorations,
and/or endodontically treated teeth
– Exlusion criterias:
• did not define criteria for success/survival outcomes, if
they reported on treatments no longer used in practice,
or if the patients were described as having moderate or
severe periodontal disease
• Following full-text review, 24 endodontic, and
46 implant studies were included
Implant success
Endodontic success
Implant survival
Endodontic survival
Retrospective cross sectional
comparison of initial nonsurgical
endodontic treatment and
single-tooth implants.
Doyle SL, Hodges JS, Pesun IJ, Law AS,
Bowles WR.
J Endod. 2006 Sep;32(9):822-7.
Endodontics vs implant
• Compared 196 implant restorations and 196
matched initial nonsurgical root canal
treatment (NSRCT) teeth in patients for four
possible outcomes - success, survival, survival
with subsequent treatment intervention and
failure
Endodontics vs implant
100
80
60
Prosent
40
20
0
Endo
Success
Survival
Impl
Repair
Failure
Doyle SL, Hodges JS, Pesun IJ, Law AS, Bowles WR. Retrospective cross sectional comparison of initial nonsurgical
endodontic treatment and single-tooth implants. J Endod. 2006 Sep;32(9):822-7. NSRCT outcomes were affected by
periradicular periodontitis (p = 0.001), post placement (p = 0.013), and overfilling (p = 0.003).
Endodontics vs implant
Estimated fraction not failing at each recall time