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 »  Home  »  Endodontic Articles 6  »  Radiographic evaluation of cases referred for surgical endodontics
Radiographic evaluation of cases referred for surgical endodontics
Introduction - Materials and methods.

H. Doornbusch, L. Broersma, G. Boering & P. R.Wesselink
Department of Oral and Maxillo-facial Surgery and Department of Economics, University of Groningen, Groningen, the Netherlands.
Department of Cariology Endodontology Pedodontology, Academic Centre for DentistryAmsterdam (ACTA), Amsterdam, the Netherlands.

A Dutch dentist encountering an endodontic problem that in his opinion cannot be treated with nonsurgical techniques will usually refer the patient to an oral and maxillo-facial surgeon for periradicular surgery. The most common reason for referral is the presence of chronic periapical in£ammation, visible ona radiograph as a radiolucency, in combinationwith a root canalwith restricted coronal access. Often, this inaccessibility is caused bya previously placed insu⁄cient root-canal ¢lling, or a post that is perceived to be di⁄cult to remove. A large periapical radiolucency, a perforation, a root fracture and awide open apex may be other reasons for referral.
From an endodontic perspective, periradicular surgery is indicated onlyafternonsurgical endodontic treatment of good quality has been attempted, but could not be completed or where following treatment healing had not taken place. An infected root canal is the primary reason for periapical in£ammation (Siren et al. 1997, Sjo≪ gren et al. 1997, Sundqvist et al. 1998) and surgery should not be considered the ¢rst-choice treatment as it does not debride the root canal, rather nonsurgical root-canal treatment or re-treatment is more likely to achieve this aim (Moiseiwitsch et al. 1998). In general practice, however, for several reasons this interpretation is not always tenable, because additional factors such as costs, type of medical insurance, operator skill and duration of treatment may also play a role. The impression exists that in the Netherlands far more patients with endodontic problems are referred to hospitals for surgical endodontics than is strictly necessary. De Cleen et al. (1993) concluded that the need for high-quality root-canal treatment was high and the standard of root-canal ¢llings was poor. The potential of modern endodontic techniques to treat complicated primary cases or retreat endodontic failures is still underestimated. Lewis et al. (1988) emphasized that surgery should never be performed before conventional nonsurgical root-canal treatment had been provided. In order to examine whether there is an element of truth in the perception that apical surgery is over prescribed, a retrospective radiographic study was carried out to evaluate the cases referred by dentists for apical surgery to three di!erent hospitals in the Netherlands.

Materials and methods.
Fromthree departments of oral surgery (Ny Smellinghe Hospital, Drachten; Academic Hospital, Groningen; Kennemer Hospital, Haarlem) three sets of 100 periapical radiographs were collected at random over a 4-month period. In general, the radiographs had been taken by the referring dentist. In order that the patients’ case notes were not removed for an extended period, good contact copies were made with a radiographic duplicating printer (Blu/ray Incs Type: BXR MK II. Middletown, USA). A Kodak RP X-omat processor was used for processing with RD-omat developing and ¢xing solutions (Kodak, Chalons sur Sao“ ne, France).
After calibration training, the radiographs were evaluated independently by a general dental practitioner, an endodontist and an oral surgeon. In daylight, amagnifying viewer (type Dental X-ray 2_ magni¢cation) ona lightboxwasused forassessment.The issues studied are listed inTable 1.The assessmentwas repeated blindly withan interval of at least 6 months inorder to calculate the intraobserver reliability. These data were analyzed by means of cross-tabulations for di!erent items and the three observers. Cohen’s kappa (k) (Table 2) (Altman 1991) was calculated to evaluate the inter- and intraobserver reliability. The tables were generated using the SPSS statistical computer package, release 7.5.2. (SPSS Inc, Chicago, IL, USA). Regional di!erences between referral centres were tested using a Student’s t-test (P ј 0.05).

Table 1. Itemlist used for the evaluation of radiographs.

Itemlist used for the evaluation of radiographs

Table 2. Interpreting the values of k.

Interpreting the values of k