Good endo treatment planning must accept the (small) risk of failure
Featured Products Promotional FeaturesPosted by: Dental Design 9th February 2022
Patients have nothing to fear from a recommendation of root canal therapy. New tools, technologies and techniques now allow treatment to be delivered conservatively, efficiently and to an exceptionally high standard, giving patients a comfortable and cost-effective way to avoid an extraction. The data also supports positive outcomes; up to a 90% success rate, according to the British Endodontic Society.[i]
Treating a tooth endodontically to save and retain it, is always preferable to an extraction, for a host of reasons that are functional, medical and aesthetic. If the attitude is, “Just take my tooth out, so I don’t have to worry about it again!”, they should know that other issues that may arise in the future, as a result of their decision to not go ahead with root canal therapy. For example, the surrounding dentition could shift, leading to problems that require further (costly and time-consuming) appointments to fix. Their ability to chew food properly could be compromised. Even if the gap left by the extracted tooth would not be visible to most people, there are potential oral health-related complications such as painful dry socket, which is rarely relieved with over-the-counter medication alone. In fact, pain is often present for longer following an extraction than it is after root canal therapy.
Good treatment planning will outline all potential scenarios, while frankly discussing how, despite all the advances in this field of dentistry, it remains a challenging procedure. There is plenty an individual can do to prepare for endodontic treatment, and afterwards, to support a successful, stable clinical outcome in the long-term. But they will also be putting their faith in you, trusting that you will execute every step in the endodontic sequence to absolute perfection.
For every patient, and particularly if they are a referral and/or anxious, a clear explanation of these steps can be a useful way to secure acceptance of root canal therapy. When you dispel their fear of the unknown, they will feel they’re in control and in possession of all the information they need to make a decision. Structuring the conversation in this way will also allow them to see how each step comes with its own risk factors, that must be managed.
One of the most common reasons why endodontic therapy fails is poor-quality obturation. When the root canal anatomy is well-obturated, any microorganisms that have survived the debridement and disinfection processes essentially become “entombed” – what is left inside becomes isolated, and anything outside cannot enter the pulp chamber.[ii] Over-filling with gutta-percha (GP) or similar is just as much of a problem as under-filling. GP is generally used because of its biocompatibility and low-toxicity and due to the fact that it comes in different forms that can be used with a range of techniques. You may prefer to use a sealant alongside GP, to balance the few limitations it does have (it cannot bond to dentine, for example) and to support the stability of obturation. Explaining which material will be used at each step and why can also give your patient the confidence to go ahead.
Introducing the topic of retreatment means that people know a viable plan B exists, should all the risks for failure not be adequately mitigated. Or, the patient may have had failed endodontic treatment elsewhere, which is why they have arrived at your practice. Discuss how endodontic retreatments are complex; to re-access the pulp chamber can be time-consuming, particularly if extra-coronal restorations are present (these do not “rule out” root treatment or retreatment, however).[iii]
Nonetheless, retreatments can be delivered fast and efficiently. Once the chamber has been re-accessed, all residual filling material must be thoroughly removed in order for the space to be cleaned again, and so the persistent infection can finally be eliminated. For non-surgical retreatments, there are various methods that can be employed to remove GP, which include solvents and files. The big advantage of using a file is that solvents can be toxic to some patients. COLTENE has produced a REMOVER file to join its HyFlex™ range that mechanically removes GP with no solvent required. The tool respects the root canal anatomy, and is very safe with its non-cutting tip. It can be employed efficiently in the hands of a skilled endodontist, and deliver retreatment that is quick and also good value to the patient, as well as having the benefits of being highly conservative and ethical.
If you offer endodontic treatment, you’ll know that risk management is key, while keeping patients’ eyes fully open to the possibility, albeit a small one, that there might be a need for retreatment at some time in the future. Successful endodontic therapy requires the completion of certain steps, in sequence, with all risks mitigated as far is possible. Combine this approach, along with good oral hygiene, and there is an excellent chance that the treatment may last.
Mark Allen, General Manager at COLTENE
For more on COLTENE, visit www.coltene.com,
email info.uk@coltene.com or call 0800 254 5115.
[i] British Endodontic Society. Link: https://britishendodonticsociety.org.uk/patient-public/further-information/ (accessed November 2021).
[ii] Tomson, R., Polycarpou, N. & Tomson, P. Contemporary obturation of the root canal system. Br Dent J 216, 315–322 (2014). https://doi.org/10.1038/sj.bdj.2014.205
[iii] Whitworth, J., Walls, A. & Wassell, R. Crowns and extra-coronal restorations: Endodontic considerations: the pulp, the root-treated tooth and the crown. Br Dent J 192, 315–327 (2002). https://doi.org/10.1038/sj.bdj.4801365
