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 »  Home  »  Endodontic Articles 6  »  Radiographic evaluation of cases referred for surgical endodontics
Radiographic evaluation of cases referred for surgical endodontics
Discussion - References.



Discussion.
Based on radiographic information only, the observers judged at the ¢rst observation that 46^82% of the cases were amenable tononsurgical re-treatment; this reduced to37^80%after the secondobservation.The endodontist considered far more teeth feasible for re-treatment than the general practitioner and oral surgeon, suggesting that previous training and experience in£uenced the decision making. This observation con¢rms previous ¢ndings (Reit & Gro≪ ndahl1988). Although the observers had somedi!erence inopinions, a substantialpercentage of the referrals were judged as unnecessary to con¢rm the supposition that patients with endodontic problems were referred for surgical treatment more often than seems strictly necessary, as judged radiographically.
It can be seen from Table 6 that in 75^80% of the referred cases, the root-canal ¢lling was either missing or of poor quality. Similar results have recently been shown in UKwhere 79.5% of the referrals failed to meet guideline criteria on the provision of periradicular surgery (Bell 1998), whereas Beckett (1996) found that 35% did not meet the criteria for apical surgery. So, theoretically, the most appropriate strategy to prevent about 80% of the referrals for endodontic surgery would be to improve the technical standards of root-canal treatments performed by the practitioner.This need for better quality endodontic treatment in the Netherlands has been observed previously (De Cleen et al. 1993), who observed that approximately 50% of root ¢llings were inadequate and were often associated with periapical pathology.
Although the success rate of nonsurgical endodontic re-treatments are lower than de novo endodontic treatments (Bergenholtz et al. 1979, Danin et al. 1996), there may be other factors that have in£uenced the decision of the dentist to refer cases that seemed feasible for retreatment. First of all, it should be realized that the observers made their decisions on radiographs only, whereas clinical signs and symptoms may also have in£uenced the dentists’decisions (Friedman & Stabholz1986).However, it is hard to believe that many teeth considered feasible for re-treatment had to be referred because of acute pain and swelling. It seems more probable that in many cases the dentist considered re-treatment a di⁄- cult and time-consuming procedure. It is questionable, however, whether this is a valid reason for recommending a surgical procedure.
There has been a little research where comparisons can be made on the outcome between surgical or nonsurgical re-treatment of nonhealing periapical lesions. In a comprehensive review of the literature, Hepworth & Friedman (1997) tried to estimate the ‘success rate’ for re-treatment bymeans of aweighted average calculation and reported 59 and 66% for surgical and nonsurgical approaches, respectively.Allen et al. (1989) found ina retrospective analysis of 633 cases that the success rate for re-treatmentwas 66%withanadditional18%uncertain cases, whereas for surgery the success rate was 54%. In a prospective randomized study on 37 teeth, Danin et al. (1996) did not ¢nd signi¢cant di!erences after 1 year between the surgical and nonsurgical retreatment even though more failures were seen in the nonsurgical group. Kvist & Reit (1999) did not see any systematic di!erence inthe outcome of surgicalandnonsurgical endodontic re-treatment inaprospective randomized study of 102 anterior teeth. Thus, at the present time, there is no clear indicationwhich of the two methods guarantees themost favourable outcome. It is, therefore, unlikely that the endodontic knowledge of the practitioners had in£uenced their decision to refer.
Animportant considerationmayhave beena ¢nancial one. Formany patients intheNetherlands, specialist care suchas that provided byanoral surgeon,will be completely reimbursed by insurance companies, whereas this is not the case for the treatment by the general practitioner. Itwill be interesting to ¢ndouttowhat extendthis factor has in£uenced the treatment decision. Since specialist care is usually more expensive than primary care by general practitioners, and so far no signi¢cant di!erence in treatment outcome between surgical and nonsurgical re-treatment has been shown, it seems that based on the present observations there is an overuse of specialist oral surgery care. It would, therefore, be interesting to compare in a prospective study the outcome of surgical and nonsurgical (re-)treatment in cases similar tothose evaluated inthepresent paper.Only after evaluating these results can a de¢nite conclusion be made as towhat extent overuse of surgical specialist care is occurring in the Netherlands.
In Table 9, it appears that there were more teeth considered amenable to conventional re-treatment in the patients referred to the hospital in the northern part (71%) of the country than in the western part (53%). It is di⁄cult to explain this di!erence, but a reason could be that the dentist:patient ratio in the northern area (1:3100) is much higher than in the western part (1:2200) of the country and that it is a simple time problem (Van Dam & Van Rossum 2000).

References.

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