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ePaper created 2016-09-05, 09:33:59 | version 1.38.0
treatment planning CE article | 11 roots 3 2016 teeth reported an 89 percent survival rate at five years64 and a prospective trial of 858 retreated teeth reported a 95 percent survival at four years.28 Modern techniques and rationale contribute to excellent potential outcomes for retreatment. An importantfactorwhenconsideringretreatmentis the ability to identify and address the aetiology of post-treatment disease.63 Primary sources of non- healing are persistent intracanal microorganisms or ingress of microorganisms following treatment. If the aetiology of the problem is deemed correctable 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 un- dergone significant technological and procedural advancements.66, 67 Recently performed studies sug- gestthatmicrosurgicaltechniquesusingbiocompat- ible root-end filling materials provide significant im- provementsovertraditionalmethods.Ameta-analy- sis showed contemporary microsurgical techniques to have a significantly improved outcome (94 per- cent) compared to older techniques and instruments (59 percent).68 A recent systematic review investigat- ing current microsurgery found survival rates of 94percentattwotofouryearsand88percentatfour to six years, indicating that teeth treated with end- odontic microsurgery tended to be lost at low rates over the time studied.69 Microsurgery, with appropri- atecaseselection,isapredictableprocedureforteeth that may have been considered for extraction in the past. Ethics and interdisciplinary consultation Clinicians are ethically bound to inform patients of allreasonabletreatmentoptions,explaintherisksand benefits involved with the available treatment op- tions, 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 toexerciseautonomybycommunicatingtheirprefer- ences.70 Clinical treatment decisions regarding either endodontic treatment or tooth extraction with im- planttherapymustalwaysbemadeinthebestinterest of the patient using the best, most current evidence. Should it be necessary, experts from the dental teammayneedtobecalledupontoassisttheclinician in rendering the highest quality of care (Figs. 5a & b). The standard of care must be applied equally to all clinicians, generalists and specialists alike. The AAE’s Endodontic Case Difficulty Assessment Form and Guidelines provides valuable information to aid the clinician in case selection and determining whether totreatorrefer.Patientsaredeservingofthebestpos- sible outcome for each case. Interdisciplinary com- municationandcollaborationduringtreatmentplan- ning maximizes 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 pres- ervationorconsiderextractionandreplacementwith animplant.71 Likewise,theendodontistshouldbewell- versed in implant treatment planning to assist pa- tientsandreferringcolleaguesinmakinganinformed choice regarding all replacement options.72, 73 Ifatoothhasaquestionableprognosis,theendodon- ticspecialistbecomesanindispensablepartofthetreat- ment planning team. The endodontist has experience with various treatment options that have potential to preserve the natural dentition. Consultation regarding aquestionabletoothisofteninthepatient’sbestinter- est prior to considering extraction. If the prognosis of arestorabletoothiscategorizedasquestionableorun- favourable in multiple areas of evaluation, extraction should be considered after appropriate consultation withallrelevantspecialists.Onlythenisthedecisionto extractaninformedchoice.Extractionisanirreversible treatment, but if necessary, dental implants provide an excellentoptiontoreplacemissingteeth(Figs.6a&b). Fig.7: Pre-op image. Fig.8: Root-end filling with MTA. Fig.7 Fig.8 32016