The importance of identifying the correct endodontic treatment to save a tooth

By Karun Dewan, Consultant in Restorative Dentistry & Specialist in Prosthodontics, Endodontics, and Periodontics

It is increasingly recognised that the impact of disease on quality of life should be taken into account when assessing health status. It is likely that tooth loss, in most cases being a consequence of oral diseases, affects Oral Health-Related Quality of Life. Tooth loss causes disorder in the individual’s quality of life, mainly when it affects their well-being and appearance.

In many cases of root canal treatment, your saved tooth will last a lifetime; but not every case is cut and dry. If you’ve already had endodontic treatment and you’re experiencing issues again, or if you’ve been told that a root canal procedure is no longer an option for you, know that there are endodontic treatment alternatives. These are endodontic retreatment or endodontic surgery. Often different names such as apical surgery, apicectomy or endodontic microsurgery are used instead of endodontic surgery.

So, when is endodontic surgery needed?

Endodontic microsurgery is needed when the tooth does not heal as expected after initial root canal treatment or root canal retreatment. In some cases, root canal treatment is insufficient to save your tooth. In such a situation, your endodontist may recommend alternative strategies, which may include endodontic microsurgery. The endodontic microsurgery is a surgical procedure performed under microscope. As with any dental or medical procedures, occasionally, a tooth may fail to heal following the initial treatment for several reasons.

There are several situations in which endodontic surgery can help save a tooth where normal root canal therapy would be lacking and below are some broad indications (British Endodontic Society and Royal College of Surgeons of England):

1. When orthograde root canal treatment cannot be completed due to persistent exudation into the root canal despite repeated chemo-mechanical debridement.
2. When previous treatment has been carried out to guideline standards but symptomatic or progressing periradicular disease associated with an optimally root-filled tooth.
3. Symptomatic or progressing periradicular disease associated with a well root-filled tooth and in which root canal retreatment:
   1. Has failed
   2. May be detrimental to the structural integrity of the tooth
   3. Would be destructive to a restoration or fixed prosthesis
   4. Would involve the removal of a post with a high risk of root fracture.
4. Symptomatic or progressive periradicular disease associated with a tooth in which iatrogenic or developmental anomalies prevent orthograde root canal treatment being undertaken.
5. When a biopsy of periradicular tissue is required. The sample should be sent in formalin for histopathological examination to the local head and neck pathology service.
6. When visualisation of the periradicular tissues and tooth root is required if perforation or root fracture is suspected.

Surgical endodontic treatment performed in a modern technique is a viable treatment option for failed or failing root canal treated tooth. The type of advanced retro filling material and magnification (microscope) device may affect the outcome in a positive way.