When to Decide to Remove an Endodontically Treated Tooth?


Dental News Volume XVIII, Number III, September, 2011

by Dr. Yaser Al Asousi




Abstract    
                                                        
Failure in endodontic treatment is considered as one of the main reason for removal of teeth. Other endodontic treatment options like retreatment, peri apical surgery should be given due consideration before deciding on removing a failed root canal treated tooth. The article discusses the need for proper treatment planning, review and the need to opt for other endodontic procedures with the help of a case which had failed after primary endodontic therapy.


Introduction


Fortunately, the changes when the microscope, microinstruments, ultrasonic tips, and more biologically acceptable root-end filling materials were introduced in the last decade. The concurrent development of better techniques has resulted in greater understanding of the apical anatomy, greater treatment success and a more favorable patient response (1). With the advent of implants and popularity of implants among patients and dentists, removal of failed endodontically treated teeth is on the rise without giving proper consideration of the treatment options available.  The decision to extract   an endodontically treated tooth should be taken only after due diligence and exploring all other possibilities to save the tooth (2-7).  Failure of an endodontic treatment can occur due to various factors including operator inefficiency, operational mishaps, missed canals, incomplete sterilization of the root canal system, improper post endodontic restorations, fracture of tooth and poor oral hygiene. The decision to remove an endodontically treated tooth must be taken by an Endodontist or with consultation with an Endodontist after assessing the patient clinically and exploring all possibilities to save the natural tooth. To substantiate this, a case report is presented where all endodontic treatment possibilities were explored.


Case Report

A 64 year old male patient reported to the endodontic facility with symptoms on endodontically treated mandibular right central incisor, that warranted further dental intervention. The patient had undergone Endodontic treatment six years ago and had a resin restoration which sealed the access cavity. On clinical examination, soft tissue swelling was observed. A buccal sinus stoma was present between the mandibular central incisors at 1 cm below gingival margin. There was slight gingival recession, pain on percussion, no mobility and there was no evidence of crown or root fracture. Radiographic examination with Intra Oral Peri Apical (IOPA) radiograph (Fig:1) showed peri radicular radiolucency of 6 X 8 mm in size and inadequate obturation and generalized alveolar bone loss.  


Fig 1



Treatment plan

Detailed treatment plan was made and explained to the patient. Endodontic re-intervention was decided taking into consideration the clinical symptoms and radiographic findings. Retreatment will be performed as initial stage and after periodic evaluation, surgical intervention can be opted if signs and symptoms do not improve satisfactorily. The patient was taken in to confidence and informed consent was sought.


Retreatment Phase

The previous Gutta Percha was completely removed and access was established to full working length. Endodontic retreatment was performed using Pro Taper rotary system in two visits. 5.25 % Sodium hypochlorite, 17% EDTA Solution and Glyde Path were used during the retreatment phase and Calcium Hydroxide was used as intra canal medicament between appointments. Retreatment was completed after symptoms subsided and the canal was completely dry. Intracanal cleaning, shaping and obturation were performed under operating microscope. Post operative IOPA (Fig:2) showed complete obturation of the pulp space and patient was scheduled for 6 and 12 months post operative review.


Fig 2



Follow Up Phase

Follow up review is important in any treatment plan and should be given due importance. On 6 months postoperative review, patient was asymptomatic although no radiographic changes were evident. At 12 months review intraoral fistula was noted buccally ( Fig:3) and radiographic examination revealed increase of peri apical radiolucency (Fig:4).

Based on the signs and symptoms, it was noted that the retreatment had not succeeded completely and decision was made to intervene surgically. Patient was intimated the need for surgical intervention and was motivated enough to save the tooth.


Fig 3

Fig 4



Surgical Phase

After completing all pre surgical examinations and precautions, modern microsurgical technique was performed using Carl Zeiss microscope and retro grade filling with Mineral Trioxide Aggregate (MTA). Intra sulcular incision with 15 C blade was made extending from tooth number 32 to 43 and two vertical release incision made distal to tooth number 32 and mesial to tooth number 43. Rectangular full thickness flap was raised and cortical bone fenestration ( Fig:5 ) in relation to tooth 41 was identified. Tissue at the site of the lesion appeared to be encapsulated and it was excised as a unilocular lesion and was sent for biopsy and the result was periapical true cyst . ( Fig:6)


Fig 5

Fig 6



Osteotomy with saline irrigation was done with  Number 6 round bur, and 3 mm of root tip was resected with Lindemann bur. Bleeding was controlled using two epi pellets under pressure for 2 minutes at the bone crypt. Using ultrasonic tip, 3 mm retrograde cavity preparation was made and filled with MTA.  After review radiograph, (Fig:7) the flap was repositioned and massaged with wet gauze and was sutured with 8 interrupted sutures using 5.0 silk. Post-surgical instructions were given. Patient tolerated the procedure well and suture removal was done 5 days later.    


Fig 7



Review Phase

Patient was reviewed periodically and clinical progress was noted. In 8 months post surgical review, intra orally there was no swelling, no sinus tract, slight gingival recession, no periodontal pockets, no mobility. Peri Apical radiograph showed radiographic evidence of bone healing (Fig:8).      


Fig 8



The patient was recalled four years post operatively and radiograph showed excellent healing and clinically the tooth is sound and functional ( Fig : 9)


Fig 9



Discussion

With the emergence of improved instruments and devices, endodontic treatment gives excellent and predictable results if treated following all endodontic principles.  Treatment failures can occur as in any other treatment modality due to various factors. A failed endodontic treatment should not be considered as the end game in our objective of saving a tooth from extraction.  Although implant dentistry has developed and evolved much in recent years, a natural teeth is still the best option available for the patient as long as it can play the aesthetic and functional role assigned to it. Every available endodontic treatment options should be explored before deciding to remove a tooth with failed endodontic treatment and the patient should be given the choice to make the informed decision ( 8-13) . 
In the present case, the primary nonsurgical endodontic treatment failed due to improper cleaning, shaping and the inability of the clinician to reach and fill  the apical one third satisfactorily. Instead of opting for removal, the patient was informed, educated and motivated to save the tooth and all possible outcomes including peri apical surgery and removal was explained.  All endodontic procedures warrant regular follow up review and especially if it is a retreatment. The case discussed here was regularly followed up and decision to intervene surgically was taken as and when required without waiting too long. If the case was not followed properly, it would have ended up in greater bone loss and mobility leading to removal of the tooth. Surgical intervention is needed in very few cases were a true cyst has developed following a pulpal pathosis. Majority of the cases with peri apical pathology heals with a complete cleaning, shaping  and obturation of  the root canal space.( 14-16)
Use of Surgical Microscope for better visibility, ultrasonic tips for accurate root end preparation  and Mineral Trioxide Aggregate (MTA) as root end filling material, greatly enhances the ability to heal a large bony lesion.  Clinical reviews showed very good response to the surgical treatment (1) .


Conclusion

Proper diagnosis, treatment planning and involving the patient in the decision making process, help the clinician to deliver the best results even when the prognosis is guarded. Removal of teeth should be the last resort and all efforts should be made to save the natural teeth.    




References

1. Modern endodontic surgery concepts and practice: a review. Kim S, Kratchman S. J Endod. 2006 Jul;32(7):601-23
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16. Siqueira JF Jr. Aetiology of root canal failure: why well treated can fail. Int Endod J 2001: 34: 1–10.




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