1. 1 Endodontic Retreatment A Chance to Rewrite History

2. 2 Up to 40 million endodontic cases treated annually in USA

3. 3 In fact, it is estimated thatIn fact, it is estimated that roughly 10 percent of endodontic roughly 10 percent of endodontic treatments fail. treatments fail. this number of failed treatments can be overwhelming! this number of failed treatments can be overwhelming! What does this mean to you ? What does this mean to you ?

4. 4 1.It means that we need to look into what causes endodontic treatment to fail. 2.and what we can do to improve the chances of success with the initial treatment. 3.we need to know more about retreatment and how, hopefully, we can help patients save their natural teeth.

5. 5 Prognosis Prognosis is a key wordPrognosis is a key word It refers to the prediction of success or failure in a given situationIt refers to the prediction of success or failure in a given situation The advantages of understanding the prognosis for RC procedures Include:The advantages of understanding the prognosis for RC procedures Include:

6. 6 include: @ development of more rationale TX methods. @ development of more rationale TX methods. @ avoidance of factors that increases failure rate, @ avoidance of factors that increases failure rate, @and a better understanding of the healing process @and a better understanding of the healing process

7. 7 Success Rates RCT. ● Success rates ranging from 95 percent 95 percent 53 percent. 53 percent. ● Such discrepancies are difficult to reconcile with today’s scientifically based therapy AND ● there are many reasons for these discrepancies.

8. 8 Factors Influencing Success & Failure Some of the factors that influence outcome are: The presence of apical pathosisThe presence of apical pathosis Extension of obturation (short or long )Extension of obturation (short or long ) Quality and technique of obturationQuality and technique of obturation Type of intracanal medicationType of intracanal medication Bacterial status of the canal before obturationBacterial status of the canal before obturation Observation periodObservation period

9. 9 Some of the factors that have no influence on the treatment outcome are: Tooth location (maxilla or mandible)Tooth location (maxilla or mandible) Tooth type (anterior or posterior)Tooth type (anterior or posterior) AgeAge SexSex Medical (health) status of the patient.Medical (health) status of the patient.

10. 10 When to Evaluate Suggested follow-up periods range fromSuggested follow-up periods range from 6 months to 4 years 6 months to 4 years ● probably 6 months is a reasonable evaluation period for the first recall and 4 years for the final evaluation( while keeping in mind that failure may evaluation( while keeping in mind that failure may occur many years later). occur many years later).

11. 11 Methods of Evaluation Clinical ExaminationClinical Examination Radiographic ExaminationRadiographic Examination Histologic ExaminationHistologic Examination

12. 12 Clinical Examination Clinical criteria for success include : 1.Absence of pain and swelling 2. Disappearance of sinus tract. 3.No loss of function 4.No evidence of soft tissue destruction, including probing defect.

13. 13 Radiographic Finding According to the findings, each case is classified as Success, failure, or questionable Success Is indicated by the absence of a radiographic Restorative apical lesion. This means that a lesion Restorative apical lesion. This means that a lesion Present at the time of treatment has resolved or that a Present at the time of treatment has resolved or that a Lesion not present at the time of treatment has Lesion not present at the time of treatment has Not developed. Not developed.

14. 14 Failure is the persistence or development or development of radiographically evident pathosis. Specifically, this is a radiolucent lesion that Specifically, this is a radiolucent lesion that has Enlarged, has Enlarged, has Persisted, or has Persisted, or has Developed since the TX has Developed since the TX Questionable indicates a state of uncertainty. The radiolucent lesion has neither become worse nor significantly improved.

15. 15 Why do root canals fail?

16. 16 Common causes of failure: 1.Leaking restorations 2.Root fractures 3.Untreated canals 4.Inadequately cleaned canals 5.Procedural errors

17. 17 Procedural errors, such as errors in placing posts, errors in placing posts, broken instruments, broken instruments, perforations, blocks, ledges, perforations, blocks, ledges, We need to keep these problems in mind as we perform root canal treatment. No two patients are alike, and therefore no two canals are alike. We need to keep these problems in mind as we perform root canal treatment. No two patients are alike, and therefore no two canals are alike.

18. 18 Even with a seemingly successful treatment, problems can arise months or even years after treatment. When this occurs, we need to examine the situation and then determine the best course of action.

19. 19 When should retreatment be considered ? When is it time to endodontically retreat a tooth ?

20. 20 That depends on a variety of circumstances...  Retreatment may not always be necessary or even possible.  It is up to you to assess each patient’s unique situation and determine the treatment that will provide the best outcome for the patient.  Biological, clinical, esthetic, functional, and financial factors must be considered.

21. 21 A.Evaluate periodontal status Periapical/bitewingPeriapical/bitewing Attachment apparatusAttachment apparatus Periodontal probingPeriodontal probing MobilityMobility Crown-to-root ratioCrown-to-root ratio

22. 22 The ability to distinguish between an endodontic problem and a periodontal problem is of the utmost importance.The ability to distinguish between an endodontic problem and a periodontal problem is of the utmost importance. If retreatment of the tooth is considered, you should first take periapical and bitewing radiographs. This will allow you to evaluate the status of the root, crown, and PDL. If retreatment of the tooth is considered, you should first take periapical and bitewing radiographs. This will allow you to evaluate the status of the root, crown, and PDL. If there is a sinus tract, it should be traced to the source of origin using a a gutta-percha cone.If there is a sinus tract, it should be traced to the source of origin using a a gutta-percha cone.

23. 23 Assess periodontal status by taking periodontal probings and examining mobility and crown-to-root ratios.Assess periodontal status by taking periodontal probings and examining mobility and crown-to-root ratios. When taking periodontal probings, look for a narrow, deep pocket, which can indicate vertical root fracture.When taking periodontal probings, look for a narrow, deep pocket, which can indicate vertical root fracture. Each of these factors can affect the success of the retreatment procedure. Each of these factors can affect the success of the retreatment procedure.

24. 24 B. Evaluate tooth restorability Periodontal supportPeriodontal support Strategic valueStrategic value Remaining tooth structureRemaining tooth structure

25. 25 There are several factors affecting the restorability: Is the periodontal support adequate? Is the periodontal support adequate? What is the strategic value of the tooth? What is the strategic value of the tooth? Will the tooth be a bridge abutment? Will the tooth be a bridge abutment? Is it a front tooth that is important esthetically? Is it a molar that is an important part of the patient’s occlusion? Is it a molar that is an important part of the patient’s occlusion?

26. 26 You must also consider the stability of the tooth structure: Has too much dentin been destroyed during previous endodontic treatment or by caries or fracture? Is there at least 2 millimeters of sound tooth structure above the depth of the sulcus on which to place the crown? Is there at least 2 millimeters of sound tooth structure above the depth of the sulcus on which to place the crown? If not, the crown and/or post and core will eventually fail. Is crown lengthening surgery required? If so, Is crown lengthening surgery required? If so, what are the cost factors? what are the esthetic concerns?

27. 27 C. Consider impact of retreatment Consider the impact that retreatment will have on the overall treatment plan. Is the prognosis reasonable? Consider the impact that retreatment will have on the overall treatment plan. Is the prognosis reasonable? If this was your tooth, would you have it retreated, given a similar set of circumstances? If this was your tooth, would you have it retreated, given a similar set of circumstances? Remember, however, that the tooth and the treatment decision ultimately belong to the patient. Remember, however, that the tooth and the treatment decision ultimately belong to the patient.

28. 28 D. Assess patient concerns ExpectationsExpectations MotivationMotivation CostCost

29. 29 As with all forms of treatment, it is important to assess the patient’s concerns.As with all forms of treatment, it is important to assess the patient’s concerns. Will the patient be happy with the results of the treatment?Will the patient be happy with the results of the treatment? Does the patient value his or her dental health enough that he or she will follow treatment with a timely restoration? Does the patient value his or her dental health enough that he or she will follow treatment with a timely restoration? If not, it may not be worth considering retreatment as an option.If not, it may not be worth considering retreatment as an option. It is also important to determine if the results will justify the expense.It is also important to determine if the results will justify the expense.

30. 30 E.Consider practice productivity Retreatment is labor-intensiveRetreatment is labor-intensive Adequate reimbursement !Adequate reimbursement ! Retreatment difficultiesRetreatment difficulties TechnologyTechnology ExperienceExperience TrainingTraining

31. 31 Retreatment often involves other problems as well — problems that aren’t seen in initial endodontic treatments.Retreatment often involves other problems as well — problems that aren’t seen in initial endodontic treatments. These problems include separated instruments, perforations, ledges, and obstructions such as resins/cements, posts, and calcification.These problems include separated instruments, perforations, ledges, and obstructions such as resins/cements, posts, and calcification.  Can you handle any problem that might arise during retreatment?  Do you have the latest technologies that will help you to achieve the best possible outcome?  Have you had sufficient experience in successful retreatment to give the patient the best possible prognosis?

32. 32 Because of the special problems that retreatment presents, some dentists choose to devote their time to other, more productive area and refer retreatment cases to endodontists.Because of the special problems that retreatment presents, some dentists choose to devote their time to other, more productive area and refer retreatment cases to endodontists. Others do some retreatment cases in their own offices, but refer the more difficult cases.Others do some retreatment cases in their own offices, but refer the more difficult cases. Each dentist needs to make this decision on his or her own. Examine your practice and determine what types of treatment you can and want to do.Each dentist needs to make this decision on his or her own. Examine your practice and determine what types of treatment you can and want to do.

33. 33 Communication is the key DiagnosisDiagnosis PrognosisPrognosis Treatment optionsTreatment options

34. 34 Most importantly, before you make the decision to retreat a tooth endodontically: 1.you must present the facts objectively to the patient. 2.Explain the diagnosis and discuss the different treatment options that are available, explaining the pros and cons of each option. 3.Help the patient to determine which option is best for him or her.

35. 35 Most importantly, before you make the decision to retreat a tooth endodontically: 4.You don’t want to give the patient false hope that retreatment is going to be a simple procedure, and you definitely don’t want to guarantee success. 5.Keep in mind that you should always anticipate the worst case scenario. 6.The key is to be honest and present all the facts. Your patient will thank you for it later!

36. 36 Treatment Options Nonsurgical retreatment vs. Surgical intervention vs. Extraction Treatment Options Nonsurgical retreatment vs. Surgical intervention vs. Extraction

37. 37 perhaps the most important thing to consider is what strategy will offer the best prognosis. You already know that something must be done about the tooth. Now you must decide:You already know that something must be done about the tooth. Now you must decide: whether to nonsurgically retreat it, whether to nonsurgically retreat it, to surgically retreat it, to surgically retreat it, to consider both treatment options, or to consider both treatment options, or to extract the tooth. to extract the tooth. What procedure will produce the best outcome? What procedure will produce the best outcome?

38. 38 Nonsurgical retreatment is performed because: It is the Best optionIt is the Best option It Reduces need for surgeryIt Reduces need for surgery It Improves prognosis for future surgeryIt Improves prognosis for future surgery

39. 39 Endodontic surgery Common factors to consider surgery:  Calcified canals  Procedural errors  Posts  Root fractures  Root anomalies

40. 40 Extraction because of  Nonrestorability  Guarded periodontal prognosis  Split tooth  Vertical root fracture

41. 41 Case Study #1 Previously treated with postPreviously treated with post Apical resorptionApical resorption Severe decaySevere decay Post perforationPost perforation Not retreatableNot retreatable Logical option is ExtractionLogical option is Extraction

42. 42 Case Study #2 Significant decaySignificant decay Crown leakageCrown leakage SymptomsSymptoms

43. 43 Case Study #2 Crown removed Filling materials removed Retreated entirely New amalgam core

44. 44 Restoration removal Disassembling restorations has been facilitated by advances in technology, including ultrasonics, crown and bridge removers, and instruments to loosen and remove posts.Disassembling restorations has been facilitated by advances in technology, including ultrasonics, crown and bridge removers, and instruments to loosen and remove posts. But removing the restoration isn’t always possible But removing the restoration isn’t always possible

45. 45 Once the restoration is removed, you may be able to identify what caused the initial procedure to fail — caries, restoration failures, fractures, untreated canals, blockages, ledges, and perforations.you may be able to identify what caused the initial procedure to fail — caries, restoration failures, fractures, untreated canals, blockages, ledges, and perforations. Determining the causes of previous failure can help you to Determining the causes of previous failure can help you to be more successful with the retreatment procedure. be more successful with the retreatment procedure.

46. 46 Restoration removal alternatives If you can not remove restoration consider: If you can not remove restoration consider:  Retreatment through the crown  Surgical treatment

47. 47 Sometimes the restoration should be left in place because of the  cost of replacing a complex restoration,  patient comfort,  dental function,  or esthetics. If this is not an option, you must prepare for surgical treatment.If this is not an option, you must prepare for surgical treatment.

48. 48 Post removal Each of these will affect how the post is removed. oDiameter oDirection oCementing agents oDesign ( threaded, tapered, or cast )

49. 49 Remove obturation materials Gutta-perchaGutta-percha Silver pointsSilver points Carrier-based obturatorsCarrier-based obturators PastePaste

50. 50 Removing gutta-percha  Rotary instruments  Heat  Ultrasonics  Solvents  Any combination of these

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55. 55 Removing silver points Magnification/illumination Magnification/illumination Ultrasonics Ultrasonics Solvents Solvents Pliers/microforceps Pliers/microforceps Any combination of these Any combination of these

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59. 59 Removing paste Magnification/illuminationMagnification/illumination UltrasonicsUltrasonics SolventsSolvents Any combination of theseAny combination of these

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63. 63 Other considerations:Other considerations: When removing obturation materials, it is important to anticipate canal blockages, bacterial invasion, and possible flare-ups.When removing obturation materials, it is important to anticipate canal blockages, bacterial invasion, and possible flare-ups. Placement of the final restoration will complete the retreatment procedure and offer a better prognosis.Placement of the final restoration will complete the retreatment procedure and offer a better prognosis. It is important to see patients for follow-up exams after six months to evaluate healing and render an updated prognosis.It is important to see patients for follow-up exams after six months to evaluate healing and render an updated prognosis.

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