Satnam Singh Virdee shares his guide to making safe, informed decisions about endodontic treatment.
Root-filled teeth that potentially require endodontic treatment are often examined by generalists, specialists and consultants in different dental disciplines. Treatment planning for these cases can however prove difficult due to patients presenting with a wide range of symptoms, clinical signs and radiographic features.
Thus, the following communication aims to assist clinicians in such decision-making processes with a particular emphasis on determining when and when not to proceed with endodontic revision.
Indications for repeat treatment
According to the European Society of Endodontics (ESE) 2006 quality guidelines, there are two indications for endodontic revision:
1. “Inappropriate root canal filling with clinical and/or radiological findings of developing/persistent apical periodontitis”
The rationale for this pathologic indication is to reduce the endodontic microbial load to a threshold compatible with healing in a root-filled tooth with active endodontic disease.
In order to meet this definition and proceed with orthograde retreatment, clinical and radiographic findings should reveal:
- A tooth showing symptoms typical of active endodontic pathology (eg, pain, tenderness to percussion or palpation, sinus or diffuse swelling)
- Pathology likely from an endodontic source (ie, no recollection of elastic dam use, poor quality coronal seal, or primary root filling)
- A tooth that can be restored (adequate natural coronal tooth structure and clinical levels of attachment, no vertical root fractures).
2. “Teeth with inadequate root canal filling when the coronal restoration requires replacement or the coronal tooth tissue needs to be bleached”
The rationale for this technical indication is to prevent the entry of bacteria or bleaching materials into the root canal system during the restorative operation, the latter of which may lead to the initiation of external root resorption.
Presentation of symptoms
Patients attending a consultation for a root-filled tooth will often present with:
- Asymptomatic with or without a previous acute episode
- Symptomatology consistent with endodontic pain
- Symptom inconsistent with endodontic pain.
Orofacial pain of non-odontogenic origin (eg, temporomandibular (TMJ) disorders secondary to myofascial pain, sinusitis, tension and vascular headaches and neuropathies, specifically post-traumatic neuropathic trigeminal pain and persistent idiopathic alveolar pain) usually presents as tooth pain (P et al, 2021). When the patient has or has previously experienced symptoms, it is therefore imperative to confirm that these are typical of endodontic pathology through a comprehensive pain history.
Features such as dull, throbbing, long-lasting, and well-localized pain that has been successfully treated with over-the-counter analgesics or antimicrobials are a common presentation of root-filled teeth with active periapical disease.
Conversely, descriptions of pain such as numbness, tingling, or burning, or failure of initial root canal treatment and analgesics to successfully treat the pain, should raise suspicion of a non-odontogenic origin for the pain at a very early stage. consultation and may warrant referral to an orofacial pain clinic in the absence of obvious clinical and/or radiographic findings.
Determine the outcome of primary root canal filling
Subsequent clinical and radiographic workup should be systematic and focused on categorizing the outcome of primary root canal treatment into one of the following (ESE 2006):
- Favorable: Absence of pain, swelling and other symptoms, absence of sinus tract, no loss of function and radiographic evidence of normal periodontal ligament around the root
- Adverse: The tooth is associated with signs and symptoms of infection. A radiographically visible lesion has appeared after treatment or a pre-existing lesion has increased in size. A lesion has remained the same size or has only decreased in size during the four-year assessment period. There are points of continued root resorption
- Uncertain: X-rays reveal that a lesion has remained the same size or has only decreased in size.
It is worth noting that the above results are independent of the technical quality of the existing root filling and, unless extensive coronal restoration or non-vital internal whitening is to be provided, a poor quality root filling in the absence of active periradicular pathology is not a sufficient indication for to proceed with the endodontic repetition.
Determining the most appropriate course of treatment
The above categories can be used to determine the most appropriate course of treatment. For example, a favorable result would indicate no further endodontic intervention.
If, however, a patient is symptomatic in the absence of obvious clinical signs and symptoms from the tooth in question, further investigations such as a small-field high-resolution cone-beam CT scan together with an actionable radiological report or referral to an oral fascial pain clinic may be justified to confirm the diagnosis. It is important not to start treatment before the diagnosis is confirmed, so as not to worsen the patient’s symptoms, as can happen with post-traumatic trigeminal neuropathic pain (Figure 1).
If initial root canal filling is judged to have an adverse outcome, then the next challenge is to ascertain the potential source of the pathology. For example, the guide to endodontic pathology is likely to originate from within the root canal if an elastic barrier was not used, there is a defective coronal seal, poor quality primary root filling, or missed canals, all of which are amenable to non-surgical root canal retreatment .
Conversely, persistent periapical pathology in the presence of a guiding standard root canal treatment and coronal sealing, foreign body reactions to extruded materials, and self-sustaining cystic lesions are more amenable to an endodontic microsurgical approach (Figure 2).
In case of uncertain outcome, continuous annual clinical and radiographic monitoring of the tooth is indicated up to four years from the point of initial occlusion. If within this period the radiographic lesion resolves, the outcome changes to favorable.
Conversely, if the tooth becomes symptomatic alongside the clinical features, the radiographic lesion increases in size or only decreases in size at four years, then the outcome changes to unfavorable. The corresponding therapeutic pathways can then be offered to the patient.
conclusion
It is hoped that the above provides clinicians with guidance on when and when not to perform endodontic recession and introduces them to the subtleties in these types of cases that would warrant further investigations.
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