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Treatment choices NO.ppt
- 1. Treatment choices fornegative outcomes with non-surgical root canal treatment: non-surgical retreatment vs. surgical retreatment vs. implants STEVEN A. COHN Endodontic Topics 2005
- 2. • The primaryreason 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.
- 3. • 5 levelsof 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.
- 4. Non-surgical retreatment • Theincidence of periapical lesions following root canal procedures surveyed in many countries is 20–60%.
- 5. Non-surgical retreatment • Apicalperiodontitis – 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%.
- 6. Non-surgical retreatment • Roleof 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%).
- 7. Non-surgical retreatment • Bacterialand 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.
- 8. Reference set ofradiographs with corresponding line drawings and their associated PAI score
- 9. • Occlusion – Therole of the occlusion following endodontic treatment requires further investigation
- 10. • Restoration – Thequality 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.
- 11. Outcome of periradicularsurgery • Surgical retreatment – Positive outcomes for surgical retreatment in excess of 90% can be achieved with careful case selection and a skilled and experienced operator
- 12. Outcome of periradicularsurgery • 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
- 13. Outcome of periradicularsurgery • 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
- 14. Outcome of periradicularsurgery • 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
- 15. Outcome of periradicularsurgery • 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.
- 16. Outcome of periradicularsurgery • Operator skill – The complete healing rate in the endodontic unit was approximately double that of the oral surgery department.
- 17. Intentional replantation • Intentionalreplantation is a viable alternative to tooth extraction in selected cases.
- 18. Transplantation – Endodontic treatmentis indicated for teeth with closed apices, usually within a month after transplantation. The prognosis for both closed and open apices is considered favorable
- 19. Endodontics or implants? •Implant studies - when the criteria of EBD are applied, there are no papers that reach the highest level of evidence.
- 20. • Ruskin statethat 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.”
- 21. 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
- 22. Indications for animplant • 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 root- resected molars compared with root-filled single rooted teeth. The survival rate was similar.
- 23. CDA Journal ,vol 36 , 2008
- 24. • The preliminaryelectronic 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
- 25. • Following full-textreview, 24 endodontic, and 46 implant studies were included
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- 31. Retrospective cross sectional comparisonof 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.
- 32. 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
- 33. Endodontics vs implant 0 20 40 60 80 100 Prosent EndoImpl Success Survival 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).
- 34. Endodontics vs implant Estimatedfraction not failing at each recall time
Editor's Notes
- #28 A forest plot is a graphical display that shows the strength of the evidence in quantitative scientific studies. It was developed for use in medical research as a means of graphically representing a meta-analysis of the results of randomized controlled trials