Endodontic retreatments, clinical opportunities and challenges

Ilma Robo^1* Saimir Heta², Megi Tafa¹, Nevila Alliu²�

¹University of Medicine, Faculty of Dental Medicine, Tirana, Albania�² University of Medicine, Faculty of Medicine, Tirana, Albania

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Introduction

• A successful root canal therapy has been a clinical endodontic success that ensured “apical sealing”.
• There are cases where we have seen changes in the periapical tissues even when “apical sealing” of the tooth canal has been achieved, as well as cases where it has not been achieved.
• In order to clearly determine the reasons that have led to the failure of endodontic treatment, the dentist must have a very good knowledge of the clinical and radiological signs, of periapical pathologies such as persistent apical periodontitis or re-acute apical periodontitis.
• By knowing the reasons for the failure of endodontic treatment, it is possible to carry out the correct endodontic retreatment.

• The reasons for clinical endodontic failure, although they may be numerous and diverse in their categorization, all present with the pathology of persistent apical periodontitis.(1)
• Persistent apical periodontitis can be caused by a pathology with the following origins: Intraradicular: with infectious origin from the root canals.(2) Extraradicular: from the transmission of bacteria beyond the apex, mainly A. Actinomycetemcomitans.(3,4) Cystic reaction: when after an endodontic treatment persistent bacteria promote epithelial proliferation of Malassez residues on the affected tooth surface.(3) Reaction to a foreign body such as the presence of endodontic materials outside or beyond the apex.(5)

• Diagnosis, as in any branch of dentistry or any clinical dental case, is the most difficult procedure, especially before an endodontic retreatment.(6)
• Collection of objective and subjective complaints for endodontic retreatment, taking into account not to express negatively about the initial endodontic treatment.(7)
• Radiographic control of the affected tooth.(2) Palpation, percussion and bite tests with the affected tooth.(8)

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Purpose and specific objectives of the study

• The study is oriented around the collection of clinical data on endodontic retreatments, on the reasons for endodontic retreatments, on the clinical signs and complaints of patients about previous endodontic treatments, in order to compare the values ​​encountered.
• Our study aims to: Evaluate teeth initially treated unsuccessfully endodontically, seen in a comparative manner with radiographic evaluation of the outcome of endodontic retreatment.

Specific Objectives of the Study

To assess:

• The number of teeth indicated for endodontic retreatment, divided by gender of patients included in the study.
• The number of teeth indicated for endodontic retreatment divided by the arch to which the tooth belongs and by the classification of tooth types depending on their function.
• Evaluation of initial endodontic treatments classified based on the quadrants of teeth indicated for endodontic retreatment in order to assess the access and manual skills and anatomical difficulties encountered during endodontic treatments in this perspective.
• The presence of periapical pathologies as an indication for endodontic retreatment, assessed based on the clinical reason for the failure of endodontic treatment.

Patient selection criteria

• Patients with persistent apical periodontitis after initial endodontic treatment were selected;
• Patients presenting randomly to two dental clinics for different dental treatments, assessed by the same data recorder;
• Patients willing and able to cooperate for accurate data collection;
• Patients who agreed to be included in the radiographic assessment after verbal consent.

Data sources and search metadata�

• The study of this topic is based on the processing of data collected from patients who previously agreed to be included in the study.
• The patients included in the study were patients presented to two Dental Clinics, with the aim of endodontic retreatment of teeth or teeth presented with clinical signs or not of persistent apical periodontitis, in the period of 8 months.

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• The study is of the retrospective type

Steps of the work protocol:

• The demographic data of the patients were recorded,
• Radiographic examinations of the teeth/teeth with persistent apical periodontitis were performed,
• The number of natural teeth was recorded,
• From the radiographic examination of the teeth, the reason for the clinical failure of the initial endodontic treatment was assessed,
• The classification of the teeth included in the study was performed based on the recorded radiographic signs of the pathology of apical periodontitis presented after the initial endodontic treatment.

• After the patients were informed about the study protocol, the purpose of the study and the subsequent procedure, verbal consent was requested.
• Verbal consent in full consensus to be part of the study, and to proceed with the established protocol was obtained from each patient included in the study.
• The study was conducted on a total of 60 patients, of whom 23 patients were female, and the remaining 37 patients were male.
• Patients included in the study were divided according to the number, type of tooth or group of teeth indicated for endodontic retreatment as a result of the confirmed presence of persistent apical periodontitis.

Results and discussions

• Data collection was conducted based on the selection criteria of patients included in this study.
• After analyzing the collected data, the graph shows the aggregated data of the division of patients depending on gender.

• Graphical representation of the distribution of patients based on the number of endodontically treated teeth presenting with persistent apical periodontitis in the oral cavity and the number of patients classified by gender.

• The gender of the patients and the type of tooth with persistent apical periodontitis is another data collected from the patients included in the study.
• The graph shows the categorization of patients depending on gender and the number, by type, of teeth initially treated endodontically and presenting with persistent apical periodontitis.

Based on graph 3:

• The highest number of teeth initially treated endodontically and subsequently presented with persistent apical periodontitis is presented under the molar category at a value of about 52%.
• Premolars at a value of about 32% and then incisors at a value of 16%. So, the incisors:premolars:molars ratio is presented at values ​​of 1:2:3, where the most affected teeth are molars.
• Data also supported in other studies.(11)
• A more approximate male:female ratio of 1:1 is also shown in terms of the number of teeth affected by persistent apical periodontitis.
• Age, gender and race do not have an impact on the clinical success rate of endodontically treated teeth. This result is supported by Nazih Shaaban Mustafa et al.2018.(12)

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• The table presents the categorization of patients according to the positioning of the teeth in the jaw and gender, also showing the calculation of dependency or not.

Based on the data in the table:

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The distribution of affected teeth is 50% in the maxilla and 50% in the mandible, where both according to gender and according to the arches where the teeth affected by the pathology of persistent apical periodontitis are included, the ratio is clearly 1:1.

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Data that are also consistent with other studies.(12,13)

• Grafiku paraqet të dhënat mbi trajtimin fillestar endodontik të dhëmbëve në kavitetin oral të paraqitur me periodontit apikal persistent, klasifikuar sipas llojit të dhëmbit, pozicionimit në harkadë dhe gjinisë së pacientit të prekur.

• The graph presents data on the reason for endodontic retreatment assessed from patient history data and initial radiographic examination, in men.

• The graph presents data on the reason for endodontic retreatment assessed from patient history data and initial radiographic examination, in women.

Based on the data from the graphs, it is observed:

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The first reason for tooth re-sharpening is related to prosthetic replacements and endodontic health of the prosthetic cult

The second reason is pain

The data is supported by the study conducted by Rawski AA et al. 2003.(14)

These data are also supported by Tabussum S et al. 2016.(15)

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Based on the data in the table:

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The most common reason for clinical failure of initial endodontic treatment is the treatment protocol. Based on clinical cases, the presence of cervical shoulders in the mesial areas of molars and in the lingual areas of incisors.

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12% is the endodontic error due to the morphology of the endodontically treated tooth, mainly bayonet curves in the roots of premolars.

• This table presents the data collected on the logical reasons for fillings beyond the apex.

Based on the data in the table:

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It is noted that against the 3 radiographic distinct clinical signs there is no visible and significant difference.

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The possibilities for successful endodontic retreatment are limited only to the morphology of the tooth that prevents endodontic retreatment, requiring the application of even the latest endodontic treatment instruments.

Conclusions and recommendations

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• The patient's gender does not have a direct impact on the frequency of apical periodontitis

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• The ratio of incisors:premolars:molars affected by persistent apical periodontitis is 1:2:3, with the molars being the most affected teeth.

• Endodontic retreatments as reasons for clinical implementation have in most cases the certainty of having an endodontically healthy tooth for fixed prosthetic replacements.
• The clinical challenges of endodontic retreatments are mainly oriented around the application of the correct stages of the routine endodontic treatment protocol.

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• In rare clinical cases, professionals encounter anatomical and morphological difficulties of the teeth.

References

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11. Solete, Pradeep. (2021). Association of Age, Gender and Tooth Related Study on Patients Undergoing Endodontic Retreatment. International Journal of Dentistry and Oral Science. 3976-3980. 10.19070/2377-8075-21000812.
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�Thank you for your attention!