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ePaper created 2016-04-27, 11:16:12 | version 1.38.0
10 I I C.E. article_ treatment planning _Endodontic retreatment options The consequences of failure and subsequent treatmentdifferbetweenendodonticsandimplants. Endodonticfailurecanusuallybeaddressedsuccess- fully by retreatment, microsurgery or by extraction and potential implant placement. Intervention after implant failure may vary from minimal restorative repairstomultiplecorrectivesurgeriesand/ortheuse of a different prosthesis.59 Nonsurgical retreatment, or revision, is often the first choice to address post-treatment apical periodontitis,60,61 provided that the tooth is suitable for further restoration and that the restoration will have a good long-term prognosis (Figs 4a, b).62 Current best evidence indicates that the survival of nonsurgical retreatment is similar to that of pri- mary treatment, and that the two treatments share similar prognostic factors.63 Two studies specifi- cally evaluated survival following retreatment. An epidemiological study using an insurance database of 4,744 retreated teeth reported an 89 percent survivalrateatfiveyears64 andaprospectivetrialof 858 retreated teeth reported a 95 percent survival at four years.28 Modern techniques and rationale contribute to excellent potential outcomes for retreatment. An important factor when considering retreatment is the ability to identify and address the etiology of post-treatment disease.63 Primary sources of non- healing are persistent intracanal microorganisms or ingress of microorganisms following treatment. Iftheetiologyoftheproblemisdeemedcorrectable via an orthograde approach, retreatment is often the first choice. If not, a surgical approach may be the more predictable option.65 Contemporary endodontic microsurgery has undergone significant technological and proce- dural advancements.66,67 Recently performed stud- ies suggest that microsurgical techniques using biocompatible root-end filling materials provide significantimprovementsovertraditionalmethods. A meta-analysis showed contemporary microsur- gical techniques to have a significantly improved outcome(94percent)comparedtooldertechniques and instruments (59 percent).68 A recent systematic review investigating current microsurgery found survival rates of 94 percent at two to four years and 88 percent at four to six years, indicating that teethtreatedwithendodonticmicrosurgerytended to be lost at low rates over the time studied.69 Microsurgery, with appropriate case selection, is a predictable procedure for teeth that may have been considered for extraction in the past. _Ethicsandinterdisciplinaryconsultation Clinicians are ethically bound to inform patients of all reasonable treatment options, explain the risks and benefits involved with the available treat- ment options, and obtain informed consent before initiating treatment. This information should be conveyed in an impartial manner.1 Patients value participation in the decision-making process and should be encouraged to exercise autonomy by communicating their preferences.70 Clinical treat- ment decisions regarding either endodontic treat- mentortoothextractionwithimplanttherapymust always be made in the best interest of the patient using the best, most current evidence. Should it be necessary, experts from the dental team may need to be called upon to assist the clini- cian in rendering the highest quality of care (Figs. 5a, b). The standard of care must be applied equally toallclinicians,generalistsandspecialistsalike.The AAE’s Endodontic Case Difficulty Assessment Form and Guidelines provides valuable information to aid the clinician in case selection and determining whether to treat or refer. Patients are deserving of the best possible outcome for each case. Interdis- ciplinary communication and collaboration during treatment planning maximize this likelihood. Specialists and restorative dentists should be viewed as partners in the treatment planning team. Endodontists are uniquely positioned to evaluate the restorability and prognostic longevity of teeth and recommend whether to attempt natural tooth preservation or consider extraction and replace- ment with an implant.71 Likewise, the endodontist should be well-versed in implant treatment plan- ning to assist patients and referring colleagues in making an informed choice regarding all replace- ment options.72,73 If a tooth has a questionable prognosis, the en- dodontic specialist becomes an indispensable part of the treatment planning team. The endodontist roots 1_2016 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 7_Pre-op image. Fig. 8_Root-end filling with MTA. Fig. 9_Post-op image. Fig. 10_Seven-month recall image.