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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 4  »  The perceived benefit of endodontic retreatment
The perceived benefit of endodontic retreatment
Discussion - References.



Discussion.
Intuitively, a considered medical procedure is regarded as meaningful only if it is thought to bring about some benefit to the patient. Accordingly, the consequences of treating or not treating the disease in question must be at the core of the clinical decision-making process. However, there is an element of subjectivity in what might be experienced as beneficial, and patients differ in their preferences regarding both medical and dental treatment. Studies have also demonstrated a marked difference in the value of treatment outcomes between patients and professionals (Fyffe & Kay 1992). Therefore, it must be noted that the present study was only concerned with dentists, and that other results would probably have been obtained if patients, rather than dentists, had been studied.
The traditional classification of endodontic treatment outcome into ‘success’ and ‘failure’ leaves little room for subjectivity or deliberation over consequences. For example, the idea underlying Strindberg’s (1956) system appears to be the concept that ‘normal’ biological conditions should always be restored. Consequences and preferences are neglected in the decision-making process, whilst the focus is on the ‘duty’ of the dentist to treat cases of persistent periapical lesions in root-filled teeth. This approach to case management is illustrated by one of the participants in the present study who, despite reporting no utility gain (RTB = 0) by moving from health state B to health state A, decided to re-treat every case where a lesion was present (RPS = 0.6).
The RPS data in the present study indicate that Swedish endodontic experts are not always inclined to re-treat cases with a persistent periapical lesion. Furthermore, there does not seem to be a consensus on a definite retreatment criterion. Similar observations amongst staff and instructors at 10 French-speaking European dental schools have recently been reported by Aryanpour et al. (2000). The interindividual variation in RPS is well explained by the PC theory and data support the hypothesis that PC is also valid amongst endodontic experts.
From a utilitarian ethical point of view, resources should be used to produce as much benefit, or utility, as possible. In the present study a methodology for numerical measurement of the benefit of endodontic retreatment (RTB) was proposed. Ideally, such a method may be used to make comparisons, direct capacity and set priorities. It was found that the assessment of RTB was subjected to substantial interindividual variation. This was mainly due to the experts’ deviations in their judgement of the U -value of the persistent periapical lesion (health state B).
The natural history of periapical lesions in root-filled teeth is not well known. Information from longitudinal epidemiological studies (Lavstedt et al. 1982, Eckerbom et al. 1989, Petersson et al. 1991), repetitive cross-sectional studies (Eriksen & Bjertness 1991) and case series (Strindberg 1956, Grahnén & Hansson 1961, Engström 1964, Kerekes & Tronstad 1979, Bergenholtz et al. 1979) is inconclusive. Experts differ greatly when they are asked to predict the risk of disease progression (Reit & Gröndahl 1987) or exacerbation of the process (Reit et al. 1985). Data from epidemiological studies indicate the risk of an acute exacerbation to be less than 5% per year for cases with chronic apical periodontitis (Eriksen 1998). Root canal infection as a systemic health hazard has been debated over the years, however, controlled clinical studies are rare and most authors judge the risk for the medically uncompromised individual as low (Debelian et al. 1994, Murray & Saunders 2000).
The inclusion of U -values in the decision-making process has been suggested in the ‘expected utility theory’ (EUT) concept (von Neumann & Morgenstern 1947, Weinstein & Fineberg 1980, Torrance 1986). However, the methodology used to elicit U -values is complex (Griffin 1986, Mulley 1989) and illogical results have been reported (Revicki 1992, Zug et al. 1995, Reit & Kvist 1998). In the present study the stability of U -values over time (1 year) was investigated. Values, particularly for health state B, were found to vary considerably. The intrarater reliability problem has met only scarce recognition. Torrance (1986) judged reliability to be ‘acceptable’ but to decrease with extended time intervals. Other investigators have found repeatability to be ‘poor’ (Groome et al. 1999). Based on the data from the present study, the use of U -values in direct EUT decision-making calculations cannot be recommended.
The RPS was found to be subject to substantial intraindividual variation over time. Apart from having methodological origins, the variation may reflect changes in attitude toward retreatment. Recent technical developments (surgical microscopes, ultrasonic retrotips, new root-end filling materials, nickel–titanium instruments, rotary systems) and reconsidered retreatment strategies (Molander et al. 1998, Waltimo et al. 1999) have changed the scope of retreatment and, consequently, may exert an influence on decision making. Decision making may also fluctuate over time for non-rational reasons. As has been suggested by Kahneman et al. (1982), and explored in endodontic retreatment situations (Reit et al. 1985), individuals faced with a complex decision-making situation often rely on a limited number of heuristic principles. The results of such decisions are expected to vary over time.
No statistically significant correlation between the retreatment prescriptions of the experts, as reflected in the RPS and retreatment benefit (RTB), was found. The personal values involved could not systematically be captured in the U -values or the RTB. A dentist’s clinical decisions are influenced by his moral values (Kay & Blinkhorn 1996). Morality may be defined as a system of beliefs and values concerning the rightness or wrongness of human acts (Björklund 2000). In the present study it was hypothesized that the endodontists above all acted in terms of possible consequences, and that the more potential utility that could be produced, the more the individual should tend to prescribe retreatment. However, it can be argued that although the decision makers acted from a position that considered the possible consequences, they might have used a decision strategy that was directed more toward minimizing the ‘losses’ than maximizing the ‘wins’. Instead of considering what could be gained by retreatment, they focused on ‘doing no harm’ and favoured a low-risk project. Such a strategy could not be captured by our experimental design. Furthermore, as mentioned above, individuals might approach clinical decision making not only from a consequentialist position, but might also regard the retreatment of periapical lesions as a moral ‘duty’.

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