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Endodontic Retreatment. Aspects of decision making and clinical outcome

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 SWEDISH DENTAL JOURNAL
Supplement 144, 2001
________________________________

ENDODONTIC RETREATMENT
Aspects of decision making and clinical outcome

Thomas Kvist

Department of Endodontology/Oral Diagnosis

Faculty of Odontology
Göteborg University
Sweden
2001

1
ABSTRACT
ENDODONTIC RETREATMENT
Aspects of decision making and clinical outcome
Thomas Kvist
Department of Endodontology/ Oral Diagnosis, Faculty of Odontology
Göteborg University, Box 450, SE 405 30 Göteborg, Sweden

Epidemiological surveys have reported that 25%-35% of root filled teeth are associated with
periapical radiolucencies. Descriptive studies have demonstrated that clinicians' decision
making regarding such teeth are subject to substantial variation. A coherent model to explain
the observed variation has not been produced. In the present thesis a “Praxis Concept theory”
was proposed. The theory suggests that dentists perceive periapical lesions of varying sizes
as different stages on a continuous health scale. Interindividual variations can then be
regarded as the result of the choice of different cut-off points on the continuum for
prescribing retreatment. In the present study experiments among novice and expert decision
makers gave evidence in favour of the theory. Data also suggested that the choice of
retreatment criterion is affected by values, cost of retreatment and technical quality of
original treatment.
From a prescriptive point of view, the presence of a persistent periapical radiolucency has
often been used as a criterion of endodontic “failure” and as an indication for endodontic
retreatment. As an alternative decision strategy, the use of decision analysis has been
proposed. Logical display of decision alternatives, values of probabilities, utility values (U-
values) of the different outcomes and calculation of optimal decision strategy are features of
this theory. The implementation of this approach is impeded by the uncertainty of outcome
probabilities and lack of investigations concerning U-values.
U-values of two periapical health states in root filled teeth (with and without a periapical
lesion respectively) were investigated in a group of 82 dental students and among 16
Swedish endodontists. Two methods were used to elicit U-values: Standard gamble and
Visual Analogue Scale. Large interindividual variation for both health states were recorded.
The difference in U-values between the two health states was found to be statistically
significant regardless of assessment method. Compared with Standard gamble Visual
Analogue Scale systematically produced lower ratings. U-values were found to change
considerably in both the short and long term. Any significant correlation between
endodontists’ U-values and retreatment prescriptions could not be demonstrated.
Surgical and nonsurgical retreatment were randomly assigned to 95 “failed” root filled teeth
in 92 patients. Cases were followed clinically and radiographically for four years
postoperatively. At the 12-month recall a statistically significant higher healing rate was
observed for teeth retreated surgically. At the final 48-month recall no systematic difference
was detected. Patients were found to be more subject to postoperative discomfort when teeth
were retreated surgically compared with nonsurgically. Consequently, surgical retreatment
tended to be associated with higher indirect costs than a nonsurgical approach.
In the final part of the thesis it is argued that retreatment decision making in everyday clinical
practice normally should be based on simple principles. It is suggested that in order to

2
achieve the best overall consequences a peripical lesion in a root filled tooth that is not
expected to heal should be retreated. Arguments to withhold retreatment should be based on
(i) respect for patient autonomy, (ii) retreatment risks or (iii) retreatment costs.

Key words: endodontics, dentist behaviour, value judgement, periapical disease, disease
concepts, decision analysis, randomized clinical trial, postoperative discomfort, costs, ethical
deliberation
Swedish Dental Journal Supplement 144, 2001
ISBN: 91-628-4568-3
ISSN: 0348-6672

3
To the memory of my parents Karl and Greta Kvist.

4
“Our discussion will be adequate if it has as much clearness as
the subject-matter admits of, for precision is not to be sought for
alike in all discussions,...for it is the mark of an educated man to
look for precision in each class of things just so far as the nature
of the subject admits.”

Aristotle (350 BC) Nicomachean Ethics.

Translated by: W D Ross

“Nog finns det mål och mening i vår färd -

men det är vägen som är mödan värd.”
Karin Boye (1927) I rörelse, Härdarna.

5
CONTENTS

PREFACE.................................................................................. 7

1. BACKGROUND................................................................... 8
Endodontic treatment.................................................. 8
Prevalence of periapical lesions in root filled teeth......... 8
Variation in endodontic retreatment decision making...... 9
Clinical decision making: descriptive projects.......... 10
Clinical decision making: prescriptive projects......... 11
(a) Decision strategies I: The Strindberg system....... 11
(b) Decision strategies II: Expected utility theory..... 12
(c) Decision basis I: Empirical facts........................ 13
(d) Decision basis II: Subjective values.................... 15
Aims of the thesis........................................................ 15

2. TOWARDS A THEORY OF RETREATMENT BEHAVIOUR.............. 16

Own investigations...................................................... 17
Remarks..................................................................... 21

3. THE SUBJECTIVE VALUE OF PERIAPICAL HEALTH AND DISEASE 22

Own investigations....................................................... 23
Remarks...................................................................... 26

4. THE RELIABILITY AND STABILITY OF VALUE JUDGEMENTS........ 27

Own investigations........................................................ 27
Remarks...................................................................... 28

5. THE BENEFIT OF ENDODONTIC RETREATMENT ......................... 29

Own investigation.......................................................... 30
Remarks....................................................................... 31

6
6. THE RESULTS OF ENDODONTIC RETREATMENT....................... 33
Own investigation........................................................ 33
Remarks..................................................................... 35

7. THE COSTS OF ENDODONTIC RETREATMENT........................... 38

Own investigation........................................................ 39
Remarks..................................................................... 41
Notice......................................................................... 41

8. ENDODONTIC RETREATMENT DECISION MAKING:

CONCLUDING REFLECTIONS ................................................ 42

ACKNOWLEDGEMENTS.............................................................. 47

REFERENCES...............................................................................48

APPENDIX
PAPER I
PAPER II
PAPER III
PAPER IV
PAPER V

7
PREFACE
This thesis is based on the following papers, which will be referred to in
the text by their Roman numerals.

I. KVIST T, REIT C, ESPOSITO M, MILEMAN P, BIANCHI S,

PETTERSSON K, ANDERSSON C (1994) Prescribing endodontic
retreatment: towards a theory of dentist behaviour.
International Endodontic Journal 27, 285-90.

II. REIT C, KVIST T (1998) Endodontic retreatment behaviour:

the influence of disease concepts and personal values.
International Endodontic Journal 31, 358-63.

III. KVIST T, REIT C The benefit of endodontic retreatment.

(Submitted for publication)

IV. KVIST T, REIT C (1999) Results of endodontic retreatment:

A randomized clinical study comparing surgical and nonsurgical
procedures.
Journal of Endodontics 25, 814-7.

V. KVIST T, REIT C (2000) Postoperative discomfort associated with

surgical and nonsurgical endodontic retreatment.
Endodontics & Dental Traumatology 16, 71-4.

8
1. BACKGROUND

Endodontic treatment
Pulpal and periapical pathology is evolving as a response to
microbiological challenges and mainly as a sequel to dental caries.
Endodontic treatment is perceived as the removal of diseased or infected
pulpal tissue, instrumentation and medication of the root canal system and,
finally, the placement of a root filling. The ultimate objective is to protect
the individual from a potentially painful and harmful infection and, at the
same time, to preserve the affected tooth in the long term. Since clinical
symptoms infrequently occur, the outcome of endodontic treatment is
commonly determined by means of radiographic examination. The
diagnosis of a persistent periapical radiolucency often is used as a criterion
of treatment “failure”. Treatment failures are significantly associated with
the technical quality of the root filling.

Prevalence of periapical lesions in root filled teeth

Epidemiological surveys of the technical quality and outcome of
endodontic treatment have a long tradition in the Scandinavian countries.
Studies have reported a relatively high frequency of defective root fillings
(Bergenholtz et al. 1973, Allard & Palmqvist 1986, Petersson et al. 1986,
Erikssen et al. 1988, Eckerbom et al. 1989, Eriksen & Bjertness 1991). It
has also been found that 25-35% of endodontically treated teeth are
associated with periapical radiolucencies (Eriksen 1991). Similar findings
have recently been reported from other areas of Europe and North America
(Imfeld 1991, de Cleen et al. 1993, Buckley & Spångberg 1995, Saunders
et al. 1997, Marques et al. 1998, Sidaravicius et al. 1999, De Moor et al.
2000). The most frequently adopted study design, the cross-sectional
survey, fails to detect the dynamics of the periapical reactions. However,
in a follow-up study Petersson et al. (1991) found about equal numbers of
healing and developing periapical radiolucencies in a population over a
period of eleven years.

Biopsies obtained from periapical areas showing radiolucencies have

demonstrated the presence of pathologically altered tissue (granulomas,
cysts) in about 95% of investigated cases (Bhaskar 1966, Spatafore et al.
1990). It has been convincingly demonstrated that these reactions are
mainly caused by microbial irritants present either in the root canal
(Langeland et al. 1977, Nair et al. 1990, Molander et al. 1998, Sundqvist et
al. 1998) or in the periapical tissue (Tronstad et al. 1987, Gatti et al. 2000,

9
Sunde et al. 2000). Consequently the presence of a persisting periapical
radiolucency has been used as a criterion of endodontic “failure” and,
correspondingly, as a call for endodontic retreatment. The number of
potential retreatment cases is huge. In Sweden it has been estimated to
about 2.5 millions (Ödesjö et al. 1990). However, the attitude to the
management of periapical lesions in endodontically treated teeth has been
found to vary substantially among clinicians (Smith et al. 1981, Reit &
Gröndahl 1984, 1988, Peterson et al. 1989, 1991, Hülsmann 1994,
Aryanpour et al. 2000).

Variation in endodontic retreatment decision making

Reit and Gröndahl (1984) confronted thirty-five dental officers from the
Public Dental Health Organization in Sweden with 33 endodontically
treated teeth. In no case was the same option suggested unanimously by all
observers. The number of teeth selected for therapy (surgical or
nonsurgical retreatment or extraction) had an interexaminer range of 7 to
26 teeth. Peterson et al. (1989) scrutinized 1094 treatment plans including
radiographs submitted to the Swedish dental insurance system by general
practitioners. In 874 root filled teeth a periapical radiolucency was
diagnosed by the authors. According to the treatment plan extraction,
periapical surgery and conventional retreatment was suggested for 23%,
3% and 20% respectively. However for the remaining 472 cases (54%) no
intervention was prescribed. In another study, Peterson et al. (1991)
reexamined a sample of 351 individuals from a randomly selected cohort
of 1302 persons radiographically examined 11 years earlier. It was found
that 33 (40%) of the endodontically treated teeth with periapical
radiolucencies at first examination had been retreated or extracted, while
the remaining 49 teeth had received no radiographically detectable
treatment. These findings are in line with the variations reported when
professionals suggest other dental (Elderton & Nuttall 1983, Mileman
1985, Knutsson et al. 1992, Bader & Shugars 1995) or medical procedures
(Eddy 1984, Ham 1988).

Variation in health care procedures was recognised early, at the beginning

of the 20th century. In a classical study (American Child Association
1934) of 1000 eleven-year old schoolchildren in New York City it was
found that 650 children had undergone tonsillectomy. The remaining 350
children were sent to a group of physicians. One hundred and fifty-eight
children were selected for tonsillectomy. Those rejected (192) were sent to
another group of physicians and 88 of them were then suggested for

10
tonsillectomy. After that, the remaining children were examined by a third
group of physicians, and then only 65 children remained for whom
tonsillectomy had not been suggested. At that point the study was
interrupted owing to a shortage of physicians to consult.

In 1984 Eddy summarized the situation:

“Uncertainty creeps into medical practice through every pore. Whether a

physician is defining a disease, making a diagnosis, selecting a procedure,
observing outcomes, assessing probabilities, assigning preferences, or
putting it all together, he is walking on a very slippery terrain. It is difficult
for nonphysicians, and for many physicians, to appreciate how complex
these tasks are, how poorly we understand them, and how easy it is for
honest people to come to different conclusions.”

Owing to their complexity, clinical decision problems have attracted

interdisciplinary attention. In addition to interest from health professionals,
philosophers, psychologists and economists have also contributed (Dowie
& Elstein 1988). Two main areas of research and thinking can be
identified: descriptive and prescriptive. Descriptive projects aim at
mapping out and explaining how clinicians reason and make decisions.
Prescriptive, or normative, projects, on the other hand, are concerned with
how decisions should or ought to be made.

Clinical decision making: descriptive projects

In studies of clinical reasoning several models have been suggested and
used (Sjöberg et al. 1983, Dowie & Elstein 1988). Some investigators have
focused on the artistic, or intuitive, aspects of clinical practice (Politser
1981, Gale & Marsden 1983, Schön 1983). In the tradition of “judgement
analysis” (Brunswick 1955, Hammond 1977, Wigton 1988) researchers
have tried to reveal the pieces of information or “cues”, used at conscious
or unconscious levels, that influence a person's decision making policy.
This approach has been applied in several domains (Brehmer & Brehmer
1988) including judgements of third molar removal (Lysell et al. 1993,
Knutsson et al. 1996). In a series of investigations Kahneman & Tversky
(Kahneman et al. 1982) explored a proposition that people most often rely
on a small number of heuristic principles to make decisions.

11
Attempts have been made to explain the observed variation in the
management of periapical lesions in endodontically treated teeth. Since
several studies have demonstrated large interindividual variation in
radiographic interpretation of the periapical area (Goldman et al. 1972,
1974, Gelfand et al. 1983, Reit & Hollender 1983, Lambrianidis 1985) it
has been hypothesized that variation in retreatment decisions might be
regarded as a function of diagnostic variation. However, studies of general
practitioners have not supported this idea (Reit & Gröndahl 1988). The
influence of components including risk assessment (Reit et al. 1985),
clinical context (Smith et al. 1981, Reit & Gröndahl 1987, Aryanpour et
al. 2000), cognitive factors (Reit et al. 1985) and overall dental treatment
plans (Petersson et al. 1989) have been explored. However, the complexity
and multiplicity of factors present in each study has rendered interpretation
of the results difficult and a coherent model to explain the observed
variation has yet to be produced.

Clinical decision making: Prescriptive projects

(a) Decision strategies I: The Strindberg system
In endodontics, the system launched by Strindberg (1956) has achieved
paradigmatic status as a normative guide to clinical action. According to
Strindberg (1956) the only satisfactory posttreatment situation, after a
predetermined healing period, combines a symptom-free patient with a
normal periradicular situation. Only cases fulfilling these criteria were
classified as “successes”, and all others as “failures”.

12
 Clinical examination

success when there were no symptoms, and a

failure when symptoms were present

Radiographic examination

success when
!!!!!!!!!!!!!!(a) the contours, width and structure of the periodontal margin
!!!!!!!!!!!!!!!!!!!were normal
!!!!!!!!!!!!!!(b) the peridontal contours were widened mainly around the
!!!!!!!!!!!!!!!!!!!!excess filling; a
failure when there was
!!!!!!!!!!!!!!(a) a decrease in the periradicular rarefaction
!!!!!!!!!!!!!!(b) unchanged periradicular rarefaction
!!!!!!!!!!!!!!(c) an appearance of new rarefaction or an increase in the initial

Fig. 1. The “Strindberg system” quoted from Strindberg L Z (1956) The

dependence of the results of pulp therapy on certain factors.

Consequently, when a new or persistent periapical lesion is diagnosed in an

endodontically treated tooth the Strindberg system prescribes retreatment
(or extraction). The Strindberg system is exclusively based in biology and
can be perceived as dogmatic and inflexible. Although generally accepted
in academic institutions, studies indicate a weaker position among general
practitioners (Reit & Gröndahl 1988, Petersson et al. 1989, Petersson et al.
1991).

(b) Decision strategies II: Expected utility theory

Probably the most highly developed normative decision making model is
the “expected utility theory” (EUT) (for reviews see Hargreaves Heap et al.
1992, Bacharach & Hurley 1994). The philosophical foundation of the
model is to be found in classical utilitarianism (Bentham 1789/1982, Mill
1861/1962) while its mathematical origins are even older (Schoemaker
1982). The advent of modern EUT is associated with the influential work
of von Neumann & Morgenstern (1947) which made some of the
psychological assumptions of utilitarianism redundant. During the last 50
years EUT has prospered mainly in economics and the social sciences. The
theory was introduced to medicine by Ledley & Lusted (1959) and

13
discussed in detail by Lusted (1968) and Weinstein & Feinberg (1980).
Over the last 30 years “clinical decision analysis” has received increasing
attention in medicine and since 1985 there has been an accelerating number
of published articles (Rohlin & Mileman 2000).

EUT prescribes that the problem should be structured as a “decision-tree”,

which (i) logically displays available actions and their possible
consequences. Then (ii) the listed outcomes are assessed regarding
probabilities and subjective values (“utility”). After this (iii) the weighed
sum (expected utility) of each strategy is computed, and (iv) the action
with the highest sum is chosen.
In dentistry, decision analysis has attracted some attention among
researchers. Diagnosis and treatment of approximal caries (Mileman et al.
1986), selection of endodontic treatment strategies in teeth with apical
periodontitis (Reit & Dahlén 1988), direct pulp capping procedures
(Maryniuk & Haywood 1990), choice of treatment for oral cancer
(Velanovich 1990) and removal of asymptomatic third molars (Brickley et
al. 1995), are areas in which decision analysis has been used.

Reit & Gröndahl (1984) approached the management of periapical lesions

in endodontically treated teeth from a decision analytic point of view. The
problem was graphically structured in a decision tree.

Wait and see

Root filled
tooth with No therapy
periapical
lesion Extraction
Decide now

Therapy Surgical retreatment

Nonsurgical retreatment

Fig. 2 A decision tree logically displaying alternative actions in the

management of root filled teeth with periapical lesion.

14
Later (Reit & Gröndahl 1987) attention was drawn to the fact that some
critical information needed for the analysis were either not available
(utility-values) or very uncertain (outcome probabilities).

(c) Decision basis I: Empirical facts

Even if EUT may be questioned as a normative theory, it does point out
two essential components of a basis for making clinical decisions:
empirical facts and subjective values. The empirical basis for endodontic
retreatment decision making is fairly limited and consists mainly of data on
healing results after surgical and nonsurgical procedures.

Data on the outcome of nonsurgical retreatment are most often available as

part of general endodontic follow-up studies (Strindberg 1956, Grahnén &
Hansson 1961, Engström et al. 1964, Selden 1974, Molven & Halse 1988,
Sjögren et al. 1990, Friedman et al. 1995). Reported success rates in these
investigations vary between 56% and 88%. The issue has only been
specifically addressed by a few authors. After two years of observation,
Bergenholtz et al. (1979) found, in a prospective study, complete resolution
of apical radiolucencies in 48% of 234 retreated roots. Decreased size of
the radiolucency was observed in a further 30%. After a follow-up period
of 5 years Sundqvist et al. (1998) reported complete resolution in 74% of
54 retreated teeth.

Information on the outcome of surgical retreatment is abundant. Many

methods have been adopted and reported success rates vary between 30%
and 90% (Persson 1966, Mattila & Altonen 1968 Nordenram & Svärdström
1970, Harty et al. 1970, Rud et al. 1972, Hirsch et al. 1979, Ionnides &
Borstlap 1983, Reit & Hirsch 1986, Grung et al. 1990, Rud et al. 1991,
Jansson et al. 1997, Rubinstein & Kim 1999, Zuolo et al. 2000).

The great variation in outcome of nonsurgical and surgical retreatment

might be explained by differences in the efficacy of the clinical procedures.
However, varying inclusion criteria, length of follow-up periods,
application of criteria for evaluation and inter- and intra individual
observer variation all render generalised conclusions difficult.
Furthermore, studies have usually focused on either surgical or nonsurgical
retreatment procedures and randomized clinical trials are very rare (Danin
et al. 1996). The important clinical question of whether or not there is any
systematic difference in healing frequency following surgical or
nonsurgical retreatment has been very little considered by researchers.

15
In a comprehensive review of the literature, Hepworth & Friedman (1997)
tried to estimate the success rate of retreatment by means of a weighted
average calculation, and reported 59% and 66% for surgical and
nonsurgical approaches, respectively. In a retrospective analysis of 633
retreated cases, Allen et al. (1989) found no systematic difference between
the two approaches.

Other important “empirical facts” like costs and risks of retreatment and
risks if retreatment is not carried out have not been much researched.
Clearly, the evidence base for retreatment decision making is weak.

(d) Decision basis II: Subjective values

Traditionally, dentists and physicians have had a paternalistic approach to
clinical practice. Today, however, patient autonomy is widely regarded as
the primary ethical principle, and it is important to determinate patient's
values (Beauchamp & Childress 1974). In the EUT tradition, the
expression of subjective values has been approached systematically. It has
been suggested that values may be apprehended in acts of preferring (von
Neumann & Morgenstern 1947, Hargreaves Heap et al. 1992): When faced
with a choice, the values of an individual are reflected in his preference
behaviour. Using the “standard gamble” technique (von Neumann &
Morgenstern 1947, Torrance et al. 1972), numbers can be assigned to
values and used for mathemathical calculations. This approach has been
used in medicine (Torrance 1986, Tengs & Wallace 2000) and dentistry
(Fyffe & Kay 1992, Brickley et al. 1995). The role and influence of

16
subjective values in endodontic retreatment decision making has attracted
very little interest.

Aims of the thesis

The overall aims of this thesis were to:
i) generate and explore a theory able to explain clinicians' variation in the
management of periapical lesions in endodontically treated teeth.
ii) improve the retreatment decision basis with regard to empirical facts
and subjective values.

17
2. TOWARDS A THEORY OF RETREATMENT BEHAVIOUR

The Strindberg (1956) concept (SC) of classifying the results of endodontic

treatment represents an “ideal” concept of disease, which means, according
to Juul Jensen (1985), that it is demarcated and made explicit by a formal
definition. By no means are all our concepts defined in such a precise way.
Yet we say that these concepts exist. They exist in the sense that people use
them. Such concepts are referred to as “praxis concepts” by Juul Jensen
(1985). As mentioned above, it has been shown that the SC is not generally
accepted among practitioners. In search of a concept that is actually used,
the “Praxis concept” (PC) theory was generated. Studies show that larger
periapical lesions are more frequently suggested for retreatment than
smaller ones (Reit & Gröndahl 1984, Reit et al. 1985). Accordingly, it was
hypothesized that dentists conceive of periapical health and disease, not as
either/or situations, but as states on a continuous scale. On this scale a
major lesion represents a more serious condition than a smaller one.
Variation between decision makers could then be regarded as the result of
the individuals' selection of differing cut-off points on the scale for
prescribing retreatment.

Retreatment No retreatment

High degree Cut off point Perfect health

of poor health
(No periapical
(Big periapical lesion)
lesion)

Fig. 3. Illustration of the PC theory. Dentists are assumed to operate along

a periapical health continuum with “no lesion” and “big lesion” at either
end.

It was hypothesized that the placement of the cut-off point would be

dependent not only on features of the disease per se but also on factors

18
such as costs of retreatment, access to the root canal system and quality of
original treatment (Reit & Gröndahl 1984).

Own investigations
To test the explanatory power of the PC theory an experiment was set up
(paper I). In order to eliminate the subjective interpretation of radiographs,
written forms and line drawings of simulated radiographs were constructed.
The quality of root filling seal and the presence of post and crown were
systematically varied so that six cases could be assessed. For each case five
periapical conditions were judged (Fig. 4).

Quality of seal.

Adequate seal Defective seal Overfill

Root canal retained post.

No post Post

Fig. 4. Endodontically treated teeth were presented as schematic drawings.

Quality of seal and presence of root canal retained post or no post were

19
systematically varied, resulting in six cases to be assessed.

20
All cases were accompanied by the same clinical history:
“The patient is 45 years old, in good general health and presents with a full
set of teeth except third molars. There are no clinical symptoms from teeth
or oral tissues. The ‘radiographs’ were taken at a routine examination. The
root fillings are more than four years old. This is your first examination of
the patient, who has no other dental problems, and no further dental
treatment is being planned.”

For each case and periapical condition an examiner was asked to select one
of the following five response categories: no therapy, wait and see,
nonsurgical retreatment, surgical retreatment, and extraction, respectively.
It was assumed that an examiner's inclination to retreat a case could be
numerically expressed in a “Retreatment Preference Score” (RPS). The
construction of the score was based on the same assumptions as the PC
theory. For each case the decision maker would choose a cut-off point
(retreatment criterion) on the continuum, separating conditions requiring
and not requiring retreatment, respectively. The score was constructed to
vary between 0 and 1. The higher values indicate a higher retreatment
preference. For each individual a mean RPS over the six presented cases
was calculated.

21
 Big lesion Medium Small Widened No lesion
size lesion lesion contour

RPS
0.0 0.2 0.4 0.6 0.8 1.0

!0= !!!!no retreatment selected

!0.2= !cut-off point at “big lesion”
!0.4= !cut-off point at “medium size lesion”
!0.6= !cut-off point at “small but clearly visible lesion”
!0.8= !cut-off point at “widened periodontal contour”
!1= !!!!cut-off point at “no lesion”

Fig. 5. The construction of the Retreatment Preference Score (RPS).

In order to reduce the influence of background variables the experiment

was first conducted among final-year dental students. Fifty-seven students
in Amsterdam (NL), 48 in Gothenburg (S) and 32 in Pavia (I) participated
as decision makers.

For all observers and cases it was found that if retreatment was proposed
for a certain size of lesion, retreatment procedures were also selected for all
larger lesions. Thus, it was possible to identify one, and only one, cut-off
point on the hypothetical health continuum. Individual mean RPS ranged
0.13-0.9. A statistically significant higher mean RPS (0.66) was seen
among students in Pavia than students in Amsterdam (0.51) and
Gothenburg (0.49). When data from all 137 participants was pooled it was
found that the introduction of a post in the root canal resulted in a
statistically significant decrease in mean RPS (from 0.57 to 0.51).
Examiners from Amsterdam and Gothenburg showed a statistically

22
significant increase in mean RPS when the seal was defective as compared
with adequate seal or overfill. Overfill served as an additional factor
inducing retreatment proposals by Pavian students.

In paper III a similarly designed experiment was set up among a group of

endodontists. Sixteen dentists affiliated with the departments of
Endodontology at the dental schools in Gothenburg (7), Malmö (5) and
Stockholm (4), Sweden, served as decision makers. In order to study the
intrarater reliability of RPS, the experiment was carried out twice with a
one-year interval.

The “experts” followed the same behavioural pattern as the “novices”, and
RPS could be calculated. Interindividual variation was found to be
substantial. The individual mean RPS range was 0.27- 0.63. Moreover,
individual retreatment criteria were often found to be unstable over time
(Fig. 6).

RPS
1,0

0,8
Second judgement

0,6

0,4

0,2

0,0
0,0 0,2 0,4 0,6 0,8 1,0 RPS
First judgement

Fig. 6. Intraindividual stability of the Retreatment Preference Score (RPS).

Each square represent one endodontist. Second judgement was carried out
one year after first judgement.

23
Remarks
Data from papers I and III support the view that a periapical health
continuum is the basis of a praxis concept. Factors unrelated to the disease
per se (costs, technical quality of root filling, access problems) also seem to
contribute to the final placement of the cut-off point. Furthermore differing
values, including attitudes to risks and benefits of retreatment, might
constitute important parts of a theory explaining retreatment variation.

Personal Values

High costs Low costs

Adequate seal Defective seal
Difficult access Easy access

Retreatment No retreatment

High degree Cut off point Perfect health

of poor health
(No periapical
(Big periapical lesion)
lesion)

Fig. 7. The Praxis Concept theory. Placement of the cut-off point is value
dependent, resulting in substantial interindividual variation. Furthermore,
the retreatment criterion is influenced by factors such as costs, quality of
seal and accessibility to the root canal.

It can now be seen that the PC differs from the SC from both a descriptive
and an evaluative point of view. In contrast to SC's dichotomous view of
periapical health and disease, PC holds that, dentists conceive of periapical
health and disease as states on a continuum. SC offers no room for dentist
or patient subjectivity. PC, on the other hand, emphasizes the subjective
influence of personal values on the selection of retreatment criterion.
However, the validity of the PC model might be questioned. The written
case simulation design does reduce the complexity of the decision making
task (Jones et al. 1990), and in real clinical contexts a number of additional
factors most likely influence the decision making process. Such factors
might be revealed using a qualitative research approach (Kay & Blinkhorn
1996).

24
3. THE SUBJECTIVE VALUE OF PERIAPICAL HEALTH AND
DISEASE

According to the PC theory a person's values influence the prescription of

endodontic retreatment. The concept of value is multidimensional but it
seems reasonable to suppose that there is a close connection between an
individual´s values and his or her value judgements. A rough intuition is
that value judgements somehow depend on values (Österman 1995). It has
been suggested that one may apprehend values in acts of preferring (von
Neumann & Morgenstern 1947, Hargreaves Heap et al. 1992). This means
that when faced with a choice, the values of an individual are reflected in
his preference behaviour. For example, the value of health is given in
preferring it to disease.

Within the conceptual framework of Expected Utility theory "utility

values" (U-values) are produced. In medical contexts U-values are assigned
to different health states,varying from 1 (perfect health) to 0 (death).
Theoretically a U-value is thought to represent a condensation of the
biological, physical, sociological and psychological parameters that
influence a person's well-being, in a certain health state (Brickley et al.
1995).

Death. Perfect health.

0.0 1.0 Utility

Fig. 8. Utility scale used in medical contexts.

U-values may be generated using several different techniques (Llewellyn-

Thomas et al. 1982, Torrance 1986). Beyond the established “Standard
Gamble” method, authors have used various rating scales (Tengs &
Wallace 2000). In the Standard Gamble, based directly on the fundamental
axioms of EUT presented by von Neumann & Morgenstern (1947), the
subject is given a choice between two alternative courses of action. The
options available are to continue living in the state of health described in a
scenario (health state x), or to take a gamble. The gamble has two possible
outcomes: a “best” and a “worst” outcome. The probability (p) of attaining

25
the best outcome is systematically varied until the subject is indifferent
between continuing to stay in health state x and taking the gamble. The
utility of state x (Ux) can be calculated using the formula (Torrance et al.
1972):
Ux= (p) (Uy) + (1-p) (Uz)
If Uy = 1 and Uz = 0, then
Ux = p.

Health state x

p
Health state y
Perfect health

1-p
Health state z
Death

Fig. 9. The standard gamble technique: either stay in health state x, or take
a gamble.

Own investigations
The subjective values of two endodontic health states were investigated
among dental students (paper II) and endodontists (paper III). In health
state A the rater was told to imagine a root filled incisor with no signs of
periapical pathology, and in health state B a periapical radiolucency was
diagnosed. The two health states were placed on a utility scale extending
from “perfect pulpal and periapical health” (U-value=1) to “loss of the
tooth” (U-value=0).

26
 Perfect pulpal and
Loss of tooth. periapical health.

1.0 Utility
0.0

Fig. 10. The utility scale used in papers II and III.

Health state A: Health state B:

Imagine that this is a tooth in Identical to state A except that
your own mouth. The tooth the radiograph shows a 5mm
has a good quality root filling. large periapical radiolucency.
There are no clinical
symptoms or any
radiographically visible signs
of periapical pathology. The
situation is not expected to
change for the rest of your life.

Fig. 11. The scenarios of health state A and B as presented to the raters.

In paper II two classes of students (40 women and 42 men) at Göteborg

University, Faculty of Odontology produced U-values using either the
standard gamble (SG) technique or a 100 mm long Visual Analogue Scale

27
(VAS). Measurements were repeated after one week with either the same
or switched methods.

Large interindividual variations were found. Using SG the range was 0.05-
1.0 (health state A) and 0.0-1.0 (health state B). Corresponding values for
VAS were -0.18-1.0 (state A) and -0.25-0.92 (state B). Means and standard
deviations are given in Table 1. The difference in U-values between the
two health states was found to be statistically significant regardless of
assessment method. Compared with SG the use of VAS frequently
produced lower U-values. These differences reached statistical significance
only when health state B was judged.

28
Table 1.
U-values of 82 dental students elicited using two methods: Standard
Gamble (SG) and Visual Analogue Scale (VAS). Raters repeated their
judgements after one week (J1 and J2, respectively) with the same or
switched methods. Means and standard deviations (in parentheses) are
given.
____________________________________________________________

Health state A Health state B

J1 J2 J1 J2

SG/SG 0.91 (0.10) 0.90 (0.11) 0.83 (0.16) 0.78 (0.20)

VAS/VAS 0.78 (0.17) 0.79 (0.18) 0.53 (0.21) 0.57 (0.26)
SG/VAS 0.74 (0.22) 0.81 (0.25) 0.60 (0.24) 0.56 (0.35)
VAS/SG 0.72 (0.28) 0.74 (0.21) 0.46 (0.23) 0.60 (0.26)

____________________________________________________________

In paper III 16 dentists affiliated with the departments of Endodontology

at the dental schools in Gothenburg, Malmö and Stockholm, Sweden,
produced U-values with the SG technique. The experiment was repeated
after one year. Interindividual variations in value judgements were found to
range between 0.65-0.99 and 0.0-0.99 for health states A and B,
respectively. Means and standard deviations are given in Table 2.

Table 2.
U-values elicited by the Standard Gamble (SG) technique. Raters repeated
their judgements after one year (J1 and J2, respectively). Means and
standard deviations (in parentheses) are given.
____________________________________________________________

Health state A Health state B

J1 J2 J1 J2

0.89 (0.12) 0.87 (0.10) 0.39 (0.34) 0.47 (0.35)

____________________________________________________________

29
Remarks
In accordance with the PC theory, substantial interindividual variations in
subjective values were found among “beginners” as well as “experts”.
However, the VAS technique repeatedly resulted in lower U-values than
the Standard Gamble. Concordance between methods to produce U-values
has been reported to be poor (Hornberger et al. 1992) and systematic
differences have also been observed by others (Read et al. 1984, Revicki
1992). Assessment of the persistent periapical lesion yielded the largest
variations and even negative utilities were recorded, i. e. some raters would
preferred to have such a tooth extracted. As a group, the endodontists gave
lower U-values to health state B than did the students.

Large interindividual variation in U-values have been reported by authors

investigating a variety of medical and also a few dental health states
(Llewellyn-Thomas et al. 1982, Fyffe & Kay 1992, Brickley et al. 1995,
Zug et al. 1995). These variations may reflect true differences. However,
measuring value judgements is a controversial and complex task (Griffin
1986, Mulley 1989), and the differences could also relate to problems
inherent in the assessment methodology. Among the dental students some
distinctly illogical responses (health state B preferred to health state A)
were recorded. The same phenomenon has been observed by Revicki
(1992) and Zug et al. (1995). Obviously, some people find the health state
descriptions and/or the judgement methodology difficult to comprehend.
Consequently, it is important that precise instructions and ample time are
given to subjects.

30
4. THE RELIABILITY AND STABILITY OF VALUE
JUDGEMENTS

It has been suggested in the EUT concept that U-values should be directly
included in the decision making process (von Neumann & Morgenstern
1947, Weinstein & Fineberg 1980, Torrance 1986). For mathematical
calculations the measurements must be reliable. However, the reliability of
value judgements and their stability over time has met little recognition.
Authors have thought repeatability to be “poor” (Groome et al. 1999) or
“acceptable” (Torrance 1986), but systematic studies are few. Therefore,
experiments were set up to study the reliability and the stability of U-value
assessments of periapical health conditions.

Own investigations
The short-term reliability of value judgements was investigated among 82
dental students (paper II). U-values of health states A and B were
generated using the SG or the VAS technique. After one week the
assessments were repeated with either the same or switched methods.
Intraindividual variations of >0.1 utility were recorded for 18% and 42% of
the measurements using SG and VAS, respectively. When switched
methods were used the corresponding frequency was 63%.

The long-term stability of U-values was explored among 16 endodontists,

who repeated their assessments of the two health states using the SG
technique after one year (paper III). The judgements varied >0.1 utility in
38% of the measurements. In 20% the U-values were repeated exactly .

Standard deviations of the differences between first and second

assessments and 95% limits of agreement were calculated (Bland &
Altman 1986)(Table 3). The presence of a systematic change between
assessments was investigated using the Wilcoxon signed rank test for
matched pairs. No statistically significant changes were found.

31
Table 3.
Repeated assessments of two health states were made by forty dental
students (one week interval) and 16 endodontists (one year interval). U-
values were generated with either standard gamble (SG) or visual
analogue scale (VAS) techniques. Means, standard deviations (SD) and
95% limits of agreement are given.

____________________________________________________
Health state
______________________________
A B
Dental students (one week interval)

SG (n= 20)
Mean -0.02 -0.05
SD 0.09 0.1
95% limits of agreement [-0.2; 0.16] [-0.25; 0.15]

VAS (n=20)
Mean 0.01 0.04
SD 0.11 0.19
95% limits of agreement [-0.21; 0.23] [-0.36; 0.42]

Endodontists (one year interval).

SG (n=16)
Mean -0.02 0.07
SD 0.14 0.38
95% limits of agreement [-0.3; 0.26] [-0.69; 0.83]
____________________________________________________________

Remarks
Among the dental students, SG seemed to give more reliable assessments
than VAS. Using SG, 82% of the judgements differed <0.1 utility between
the two sessions. The SG methodology is complex and there is no
consensus regarding the level of an “acceptable” measurement precision.
When U-values are used in EUT calculations, even small changes may
significantly influence the result of the decision making. However, to a

32
certain extent, fluctuations in U-values can be balanced in a “sensitivity
analysis” (Weinstein & Fineberg 1980).

Sixty-two percent of the judgements of the endodontists differed <0.1

utility. These figures mirror not only the reliability of the measurements,
but also a possible change of preferences (Mulley 1989). In a long test-
retest interval even a person´s reflected values might change. However,
factors that influence the stability of U-values have ben very little
researched.

5. THE BENEFIT OF ENDODONTIC RETREATMENT

According to von Wright (1963), something is beneficial to a being when

the doing or having or happening of this thing affects the good of that being
favourably. He suggests that when the being in question is a human being,
the phrase “the good of a being” can be understood in two different ways:
in terms of welfare, and in terms of health. This means that a treatment
procedure is beneficial to a patient if it is in some way conducive to his
welfare (or well-being), or if it is conducive to his (bodily or mental)
health, or both (Brülde 1998).

From a dental health point of view, a patient will benefit from endodontic
retreatment if he or she moves from a health state with a periapical
inflammation to a postretreatment situation where the lesion has healed. If
the health states are placed on a utility scale, the subjective benefit of
endodontic retreatment can be defined as the distance between the two
states (Fig. 12). Well-being has been defined as “the fulfilment of informed
desire” (Griffin 1986). Presumably, endodontic retreatment will contribute
to a person's well-being in proportion to the individual length of the
distance between the health states. In the present study it was suggested
that the subjective value of benefit significantly influences the placement of
the cut-off point for retreatment, i.e. the larger the distance on the scale the
greater the inclination to suggest retreatment.

33
 Perfect pulpal
and periapical
Loss of tooth. Health state B Health state A health.

Utility
0.0 1.0

Retreatment benefit (RTB)

Fig. 12. An individual may benefit from endodontic retreatment by moving

from a state with an asymptomatic lesion (health state B) to a state where
the lesion has healed (health state A). The numerical difference in assigned
U-values was defined as the “retreatment benefit”.

Own investigation
In paper III 16 endodontists served as decision makers. For each
individual, Retreatment Preference Scores were assessed as described
above. U-values of health state A and B were generated with the Standard
Gamble method. For each individual the RTB was calculated as the
difference in U-values. The procedure was repeated after one year.

Among the endodontists, the range of RTB was 0.0-0.99 at first

assessment and 0.0-0.97 at second assessment. The corresponding mean
values of RTB were 0.5 and 0.4. The RTB assessments were found to vary
considerably over time (1 year) (Fig. 13). The proposal that variation in
RPS could be explained by variation in RTB was statistically tested. No
significant correlation was observed.

34
 Utility
1,0

Second judgement 0,8

0,6

0,4

0,2

0,0 Utility
0,0 0,2 0,4 0,6 0,8 1,0
First judgement

Fig. 13. Intraindividual stability of Retreatment Benefit (RTB). One year

separated first from second judgement. Each square represents one
decision maker.

Remarks
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 due above
all to the experts' deviations in their judgement of the U-value of the
persistent periapical lesion (health state B).

35
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” of the PC theory could not
systematically be captured in the U-values and RTB. If data reflect a “true”
lack of correlation they indicate that dentists approach retreatment decision
making either from a modified consequentialist or a nonconsequentialist
position. However the assessment of value judgements is a complex task
and the validity of obtained U-values may be questioned. Also,
interpersonal comparisons may be unjustified (Griffin 1986).

Conclusively, the findings demonstrate that the “benefit” of endodontic

retreatment varies among individuals and highlight the necessity of
“consumer” influence in clinical decision making. Consequently, the value
laden terms “success” and “failure” are meaningful only in the clinical
patient-dentist context. When referring to biological results or outcome of
retreatment procedures, more neutral expressions are to be preferred
(Ørstavik 1996).

36
6. THE RESULTS OF ENDODONTIC RETREATMENT

Studies on the outcome of endodontic retreatment usually focus on either

surgical or nonsurgical procedures. Randomized investigations including
both alternatives are rare. Therefore an investigation was designed to
observe any systematic difference between orthograde and retrograde
retreatment approaches by random designation to a cohort of
endodontically “failed” cases.

Own investigation
In paper IV maxillary and mandibular incisors and canines were selected
from consecutive patients referred for root canal retreatment to the Clinic
of Endodontics, Faculty of Odontology, Göteborg University in 1989-
1992. Only teeth which could be classified as “failures” according to the
Strindberg (1956) criteria were included in the study. Cases were
randomized to surgical or nonsurgical retreatment using the “minimization
method” (Pocock 1983). Three randomization factors were considered:
size of the periapical radiolucency, the apical position, and technical
quality of the root filling (Table 4). Ninety-five teeth in 92 patients
fulfilled the inclusion criteria. Forty-seven teeth were retreated surgically
and 48 nonsurgically. To obtain identical radiographs at consecutive
intervals, an impression (President Putty, Coltène, Altstätten, Switzerland)
was obtained of the patient's dental arch. The impression was attached to a
modified Eggen device, which could be fitted into a locating position on a
rectangular X-ray tube. Clinical and radiographic follow-ups were made at
6, 12, 24 and 48 months postoperatively. Radiographs were evaluated
independently by two examiners. The observers used a strict definition of
periapical disease and reported a positive finding only when they were
absolutely certain (Reit & Gröndahl 1983). Disputed cases were subject to
joint evaluation.

37
Table 4.
Distribution of teeth according to randomization factors to surgical (S) and
nonsurgical retreatment (NS) groups.
______________________________________________________________________
S NS
______________________________________________________________________
Size of lesion
≤ 5 mm 27 (57%) 27 (56%)
> 5 mm 20 (43%) 21 (44%)

Quality of seal
Adequate 17 (36%) 19 (40%)
Defective 30 (64%) 29 (60%)

Length of root filling

Overfill 8 (17%) 8 (17%)
0-2 mm from apex 23 (49%) 23 (48%)
>2 mm from apex 16 (34%) 17 (35%)
____________________________________________________________________

At the 12-month follow up a statistically significantly higher healing rate

was found in favour of surgical retreatment. At the final 48-month
examination no statistically significant difference between the groups was
registered. Four surgically retreated cases classified as healed did show a
relapse of the apical radiolucency, or presented with clinical symptoms at a
later follow-up. In one nonsurgically retreated tooth the periapical
radiolucency did recur.

38
 100

75
Healing (%)

50
(*)

25

0 0 12 24 36 48

6 12 24 48
Time (months)

Fig. 14. Comparison of healing rates of the surgical ( •) and nonsurgical

( ) groups at different follow-up examinations. Asterisk indicates a
statistically significant difference ( p<0.05) at 12 months.

Remarks
A randomized trial comparing periapical healing results after surgical and
nonsurgical endodontic retreatment procedures must rely on radiographic
examination. The radiographic image of a periapical lesion develops from
being impossible or difficult to reveal, to being easily distinguished from
the background (Bender & Seltzer 1961). Radiographic diagnosis of
periapical bone destructions may therefore be regarded as a signal-
detection task (Reit & Gröndahl 1983). The actual prevalence of periapical
pathology in a population is practically impossible to reveal by
radiographic means (Brynolf 1967), but if false positives can be minimised,
chances will increase for observers to reveal the true relation between
investigated factors or populations. Therefore, in the present study, a
periapical radiolucency was reported by the observers only when
absolutely certain. This implies that stated healing frequencies within the
nonsurgical and surgical groups should not be given an absolute but only a
relative meaning.

39
At the final recall, four years after retreatment, no significant difference in
healing rate was found between the nonsurgical and surgical retreatment
approaches. This observation is supported by retrospectively obtained data
(Allen et al. 1989) and metaanalysis of the literature (Hepworth &
Friedman 1997).

Surgically retreated cases seemed to heal more rapidly, and compared with
the nonsurgical group a statistically significant difference was found at the
12-month recall. The same observation, although not statistically
significant, was made by Danin et al. (1996). The significant difference
could not be confirmed at the end of the observation period. This situation
may be explained by (i) slower healing dynamics in the nonsurgical group,
and, (ii) the event of late “failures” in the surgical group. Of the cases
classified as healed one year after surgery, four presented with a recurrence
of periapical radiolucency or clinical symptoms at the final follow-up.
Similar observations were communicated by Frank et al. (1992). Forty-four
of 104 surgically retreated cases classified as healed, showed relapses of
the periapical lesions at a follow-up ten years later. Thus, the length of the
observation period is imperative, and may strongly influence the
conclusions made.

The cases included in the present study were treated between 1989 and
1992. The recent rapid development in technology may throw the validity
of our conclusions into question. The use of surgical microscopes has been
proposed for both surgical and nonsurgical retreatment procedures and
enhances both visability and precision in the operations (Kim 1997).
Furthermore, ultrasonic retrotips, specially adapted surgical instruments
and new retrofilling materials (Arens et al. 1998, Rubinstein & Kim 1999,
Zuolo et al. 2000) have substantially changed the preconditions for surgical
retreatment. The advent of nickel-titanium instruments and rotary systems
may influence the outcome of non-surgical retreatment. The microbiota of
the root filled tooth have recently been deeply explored and new
approaches to intracanal antimicrobial procedures have been suggested
(Waltimo et al. 1997, Molander et al. 1998, Sundqvist et al. 1998, Waltimo
et al. 1999). Whether these developments will lead to any systematic
difference between an orthograde and retrograde approach to root canal
retreatment, however, remains to be seen.

40
Scientific data do not support the notion of a systematic difference in
healing potential between surgical and nonsurgical retreatment. However, it
has been suggested that a surgical approach to retreatment should be
selected in certain situations. Extraradicular infections (Happonen 1986,
Tronstad et al. 1987, Sjögren et al. 1988, Sunde et al. 2000), “true”
periapical cysts (Nair et al. 1996) and periapical foreign body reactions
(Nair et al. 1990) may not resolve unless direct surgical intervention is
undertaken. However, accurate diagnostic tests to single out these
conditions are not available.

Clinicians tend to favour a surgical approach to large periapical lesions.

The endodontists (paper III) prescribed surgery in 60% of cases with
“big” lesions and in 41% of cases with “small” lesions. This tendency was
more pronounced among dental students (paper I): Surgical intervention
was chosen in 72% and 38%, respectively. This prescription behaviour is
probably due to the knowledge that major lesions are associated with a high
frequency of radicular cysts (Natkin et al. 1984).

In conclusion, the choice between a surgical and a nonsurgical retreatment

approach should primarily be based on factors including complication
risks, technical feasibility and, above all cost.

41
7. THE COSTS OF ENDODONTIC RETREATMENT

From a patient's point of view three types of monetary costs associated

with endodontic retreatment may be considered: (i) direct costs (dentist's
fees, drugs) (ii) indirect costs (patient's loss of income), and (iii) intangible
costs (monetary value of the patient's pain and suffering) (Torrance 1986).
The presence of prosthodontic reconstructions will often impede
orthograde access. Since posts and crowns have to be removed (and
replaced) a nonsurgical approach will be expensive in such situations. In
the present study 80% of the cases were equipped with crowns and posts.
Indirect and intangible costs associated with endodontic retreatment are
mainly related to postoperative sequelae such as pain and swelling. The
influence of frequency, duration and magnitude of these conditions have
not been determined. Thus, this part of the thesis was set up to record
patients' assessments of pain and swelling after surgical and nonsurgical
procedures.

42
Own investigation
In paper V patients, teeth and retreatment procedures were identical to
those described in paper IV. The patients were asked to evaluate pain and
swelling at the end of each day during the first postoperative week by
placing a mark on plain horizontal 100 mm visual analogue scales (VAS).
The boundaries of the scales were marked “no swelling/very severe
swelling” and “no pain/intolerable pain”, respectively. Patients were asked
to record any intake of analgesics and to report if their discomfort resulted
in any time off work.

Pain after surgical retreatment reached its maximum on the evening of the
day of surgery, when almost all patients reported pain, and then
progressively decreased over time. A significantly lower frequency of
patients (40%) reported pain after nonsurgical retreatment (Fig. 15).

%
100 100

75 75

50 50

*** *** *** * ** ** ***

25 25

0 0

25 -25

50 -50

75 -75

100 -100

VAS 0 1 2 3 4 5 6 Day

Fig. 15. Frequency of patients reporting pain during the 7-day

postoperative period following surgical (filled) and nonsurgical (unfilled)

43
retreatment (upper chart). Visual analogue scale mean values (VAS) with
standard error represent patients reporting pain only (lower chart).
*= p<0.05; **=p<0.01 and ***=p<0.001

All patients reported swelling after surgery. In the nonsurgical group,

swelling appeared infrequently and, when present, low values were
recorded on VAS (Fig. 16).

Intake of analgesics was recorded by 30 patients (67%) after surgical

retreatment and 7 patients (16%) after nonsurgical retreatment. Eleven
patients, in the surgical group, reported to have been absent from work at
some time during the period.

%
100 100

75 75

50 50

*** *** *** *** *** *** ***

25 25

0 0

25 -25

50 -50

*
* *
75 -75

100 -100

0 1 2 3 4 5 6 Day
VAS

Fig. 16. Frequency of patients reporting swelling during the 7-day

postoperative period following surgical (filled) and nonsurgical (unfilled)
retreatment (upper chart). Visual analogue scale mean values (VAS) with
standard error represent patients reporting swelling only (lower chart).
*= p<0.05 and ***=p<0.001.

44
Remarks
In the present study, sick leave due to postoperative symptoms was
reported only by patients in the surgical group. Swelling and discoloration
of the soft tissues were given as the main reasons by 11 (23%) individuals.
Curtis et al. (1985) observed that approximately 5% of patients treated with
periodontal surgery reported being on sick leave from work or school
during the postoperative recovery. Patient behaviour is influenced by
various factors such as day of treatment (whether or not the weekend is
soon after surgery), occupation and structure of insurance system.

Among patients retreated surgically, one individual (2%) required

emergency treatment for a postoperative infection. Data on the incidence of
such complications are scarce but has been reported to be low (Reit &
Hirsch 1986, Grung et al. 1990, Rud et al. 1991). In the nonsurgical group
a single case of interappointment flare-up was registered. Flare-ups (where
unscheduled visits are required) as a result of intracanal negotiations, are
reported to vary between 2% and 4% (Mor et al. 1992). Retreatment has
been associated with higher values than treatment of the vital or nonvital
pulp (Torabinejad et al. 1988, Imura & Zuolo 1995).

In conclusion, surgical retreatment tended to be associated with higher

indirect costs than nonsurgical retreatment. However if postoperative pain
and, above all, swelling can be controlled, the intangible and indirect costs
may be reduced. Therefore, when crowns and posts are present the total
costs of surgical retreatment may still be lower than those of the
nonsurgical approach.

Notice
These studies (Paper IV and V) were approved by the committee for
research on human subjects at Göteborg University, Gothenburg, Sweden.
(Dnr: 234-89)

45
8. ENDODONTIC RETREATMENT DECISION MAKING:
CONCLUDING REFLECTIONS

In his book Moral thinking (1981), British philosopher RM Hare makes a

distinction between two levels of moral reasoning : the intuitive and the
critical. The intuitive level is the level at which most of us think about
moral matters most of the time. We rely on relatively simple, specific and
intuitive principles to guide us in routine circumstances. However, it is also
possible to reflect on those principles, to step back and critically assess
them. This is the level of critical thinking. At this level empirical facts and
value judgements are considered rationally in order to establish and select
principles which can be followed in everyday life at the intuitive level. The
aim of this concluding section is to use Hare´s distinction and transfer it
from a discussion of pure morality to an endodontic retreatment decision
making context. In this context thinking at the critical level would concern
such things as the nature of disease concepts, the supreme goal of
endodontic treatment and the criteria of the rightness of a clinical action.
Reflection on these matters should generate rules, principles or decision
making strategies that could be used at the intuitive level.

In our interpretation of Strindberg (1956) “health” and “disease” are

regarded as nongradeable concepts, and the goal of endodontic treatment is
to restore “normal” periapical conditions. A similar “either/or”
classification was suggested by Bender et al. (1966). In their concept
successful treatment also included an arrested area of rarefaction. Both
systems are exclusively founded on biology and are neutral to different
agents and clinical situations. An action would be judged as right if
measures were taken to re-establish the predefined acceptable periapical
situation. Consequently, within the Strindberg paradigm, a tooth with a
diagnosed periapical lesion that is not expected to heal should be retreated
(or extracted). Possible exceptions to this rule are not discussed by
Strindberg.

The decision rule derived from the SC seems to be used only infrequently
by Swedish general practitioners (Reit & Gröndahl 1988, Petersson et al.
1989). Therefore, as an attempt to capture a disease concept and a
retreatment policy at use in clinical practice the PC theory was proposed.

At a critical level, the PC theory assumes that practitioners regard apical

periodontitis as a gradeable disease and that the gravity of the condition is

46
somehow expressed in the size of the lesion. This assumption was based on
data showing that large lesions were associated with a higher frequency of
therapeutic decisions than smaller ones (Reit & Gröndahl 1984, 1985,
1988). There is little scientific data to support (or reject) the “size-oriented”
attitude to periapical disease. However, some studies have reported a
positive correlation between the number of organisms in the root canal and
the size of the periapical lesion (Bergenholtz 1974, Sundqvist 1976). Major
lesions are more often diagnosed as radicular cysts than are smaller ones
(Natkin et al. 1984), and are also found to heal less frequently (Strindberg
1956, Bergenholtz et al. 1979, Hirsch et al. 1979, Sundqvist et al. 1998).

A comparable view of apical periodontitis as a gradeable disease was

proposed by Ørstavik et al. (1986). Their “periapical index” (PAI) provides
an ordinal scale of five scores ranging from “healthy” to “severe
periodontitis with exacerbating features”. The PAI is based on reference
radiographs with verified histological diagnoses originally published by
(Brynolf 1967). Although its diffusion among researchers has been slow, it
has been used in both clinical trials (Eriksen et al. 1988, Ørstavik &
Hørsted-Bindslev 1993, Trope et al. 1999) and epidemiological surveys
(Eriksen et al. 1988).

The PC theory states that personal values influence endodontic retreatment

behaviour. Individuals vary in their values, attitudes and life contexts and
consequently accept or prescribe varying cut-off points for endodontic
retreatment. Thus, a disease concept must include not only the disease from
a biological point of view but also the meaning the patient ascribes to signs
and symptoms in the context of his or her own life (Wulff et al. 1986).
Ultimately endodontic procedures are valuable to a person only in terms of
their contribution to and consequences for general well-being. Taking an
act utilitarian standpoint at the critical level the rightness of an action could
then be formulated as follows: an action, a, is right if, and only if, there is
no alternative to a with better consequences (Tännsjö 1998).

It is natural to assume that utilitarianism “is meant to give a method of

deciding what to do” (Smart 1973), which means that if one adopts the
utilitarian standard at the critical level, one thereby accepts it as a direct
and immediate guide to action. Such thoughts have influenced the school of
“Rational Choice” (Bacharach & Hurley 1991, Hargreaves Heap et al.
1992) and are also found within the tradition of “Clinical Decision
Analysis” (Lusted 1968, Weinstein & Fineberg 1980, Rohlin & Mileman
2000). As mentioned above, a decision analysis starts with a listing of all

47
the possible alternative ways a person could act in the situation. Possible
outcomes are numerically expressed as probabilities and the values of the
outcomes are assessed. The alternative associated with the greatest weighed
sum of values and probabilities, with the greatest “expected utility”, should
then be chosen. In principle there seems to be nothing wrong with this
strategy and its goals seem possible to achieve. Accordingly, to try to
maximise the expected utility of medical and dental procedures seems to be
a viable goal. However, there are many possible errors when using this type
of decision strategy. For example, the representation of the alternatives
may be too simplistic, relevant information may be ignored, possible
outcomes may be left out, and, assessments of probabilities and values
may lack validity. Also the methodological problems in eliciting U-values
(Griffin 1986, Mulley 1989, papers II, III) are great, and assessed value
judgements seem to be unstable over time (Groome et al. 1999, paper III).
Consequently, an action performed on the basis of subjectively maximised
expected utility may well be wrong from an objective point of view.

Even if it were humanly possible to compute the probabilities and utilities

of all possible outcomes it would often be absurd and counterproductive, at
least in trivial matters and routine situations. Consequently, formal decision
analysis is warranted and should be attempted only in cases of unusual
seriousness or complexity (Schwartz 1979). From a critical level
perspective, calculations should be made only if they bring about the best
consequences. If not, other decision strategies should be used. Thus,
utilitarianism at a critical level implies that one should not always reason as
a utilitarian at the intuitive level. Better results may come from acting in
accordance with other principles. In many clinical situations we can safely
act on well-established precepts and in other we ought to stick to prima
facie rules.

48
A prima facie rule is an obligation which is initially binding until a
stronger and overriding obligation emerges. The expression prima facie
means “first appearance” and in philosophy it is associated with the
reasoning initiated by Ross (1930). He argued that we intuitively perceive a
small set of foundational prima facie duties which are the basis of all
judgements when moral issues are involved. Ross lists the following seven
prima facie principles: promise keeping, reparation for harm done,
gratitude, justice, beneficence, self-improvement, and non-maleficence. In
the influential work on biomedical ethics of Beauchamp & Childress
(1994) the prima facie idea was further processed and the principles
reduced to four: respect for autonomy, beneficence, non-maleficence and
justice. According to Hare (1993) the four principles could be justified by
the Golden Rule: “Therefore all things whatsoever ye would that men
should do to you, do ye even so to them: for this is the law and the
prophets” (St Matthew 7:12).

In order to achieve the best results for everyone involved the clinician, at
the intuitive level, should probably normally follow a few simple principles
rather than engaging in difficult and timeconsuming calculations. In the
present thesis the following principles are suggested, formulated from a
dentist's perspective.

First principle: A periapical lesion in a root filled tooth that is not

expected to heal should be retreated.

Motivation: It is assumed that the best overall consequences are obtained if

dentists' primary suggestions to patients, at the intuitive level, are to
perform endodontic retreatment. The persistent lesion is an expression of a
root canal infection and people benefit from having their infections treated.
For the medically uncompromised patient the general health hazard is
probably low and therefore false positive diagnoses should be avoided.
There is no solid scientific evidence to distinguish among grades of
periapical disease.

This first principle is quite dogmatic and leaves no room for deliberation. It
implies that if retreatment is suggested and accepted no specific arguments
are needed. However, if a persistent lesion is diagnosed and retreatment is

49
not selected specific arguments have to be put forward. These are found in
the second principle.

Second principle: A persistent periapical lesion in a root filled tooth might

not be retreated with regard to:

(a) Respect for patient autonomy

Following this principle implies that the patient is fully
informed regarding the situation but does not want
retreatment. Attitudes to periapical disease vary among
persons (size of lesion, gravity of disease), and subjectivity
and personal values must be allowed to influence the
decision making process.

(b) Retreatment risks

The potential risks associated with a retreatment procedure
(e.g. root fracture associated with post removal, nerve injury
as a result of periapical surgery) are judged to be too high.
The objectively assessed risks (the probability of a certain
event) will be weighed against the subjectively evaluated
benefit of retreatment.

(c) Retreatment monetary costs

When the patient's costs for retreatment are considered (e.g.
treatment fee, drugs, loss of income, suffering) the
cost/benefit ratio might be too low to be accepted.

50
ACKNOWLEDGEMENTS

Many people have contributed to this thesis in different ways and it is my

privilege to thank them all. I especially want to express my gratitude to:

Claes Reit, my mentor and friend, for introducing me to endodontology

and research, for sharing his brilliant mind with me, for his guidance and
encouragement, and for all the inspiring discussions on philosophy and
other essential aspects of life over the years.

Gunnar Bergenholtz for his support and valuable criticism.

Anders Molander, for his encouragement and friendship, and for his
companionship during many evening research sessions over the years.

Ing-Marie Gustafsson for her outstanding clinical assistance and for being
so thorough about recalling patients.

Britt-Marie Jonsson and Bibi Bexelius for help and encouragement.

Christer Andersson, Stefano Bianchi, Marco Esposito, Phil Mileman and

Kjell Pettersson for appreciated collaboration.

All the colleagues and students who participated as decision makers.

All the patients whose kind co-operation was a prerequisite for the
completion of this thesis.

My wife, Veronica and my daughters, Lovisa and Laura, for their patience
and love and for making my life such a happy one during these years.

The studies in this thesis were supported by grants from:

Faculty of Odontology, Göteborg University
Göteborg Dental Society
Swedish Dental Society
Public Dental Service, Göteborg

51
REFERENCES

ALLARD U, PALMQUIST S (1986) A radiographic survey of periapical conditions in

elderly people in a Swedish county population. Endodontics & Dental Traumatology 2,
103-8.

ALLEN RK, NEWTON CW, BROWN CE (1989) A statistical analysis of surgical and
nonsurgical endodontic retreatment cases. Journal of Endodontics 15, 261-6.

ARENS DE, TORABINEJAD M, CHIVIAN N, RUBINSTEIN R (1998) Practical lessons in

Endodontic Surgery. Chicago: Quintessence Publishing.

AMERICAN CHILD HEALTH ASSOCIATION (1934) Physical defects: The pathway to

correction, 80-96.

ARYANPOUR S, VAN NIEWENHUYSEN J-P, D'HOORE W (2000) Endodontic retreatment

decisions. International Endodontic Journal 33, 208-18.

BACHARACH M, HURLEY SL (1994) Foundations of decision theory: issues and

advances. Cambridge, UK: Blackwell.

BADER JD, SHUGARS DA (1995) Variation, treatment outcomes, and practice

guidelines in dental practice. Journal of Dental Education 59, 61-95.

BEAUCHAMP TL, CHILDRESS FF (1994) Principles of Biomedical Ethics. 4th edn. New
York, USA: Oxford University Press.

BENDER IB, SELTZER S (1961) Roentgenographic and direct observation of

experimental lesions in bone: I and II. Journal of American Dental Association 62, 152-
60, 708-16.

BENDER IB, SELTZER S, SOLTANOFF W (1966) Endodontic success- A reappraisal of

criteria. Oral Surgery, Oral Medicine & Oral Pathology 22, 780-802.

BENTHAM J (1982) An introduction to the principles of morals and legislation. Burns

JH, Hart DLA, eds. London and New York: Methuen. (Original work published 1789)

BERGENHOLTZ G (1974) Micro-organisms from necrotic pulp of traumatized teeth.

Odontologisk Revy 25, 347-58.

BERGENHOLTZ G, LEKHOLM U, MILTHON R, HEDEN G, ÖDESJÖ B, ENGSTRÖM B

(1979) Retreatment of endodontic fillings. Scandinavian Journal of Dental Research
87, 217-24.

BERGENHOLTZ G, MALMCRONA E, MILTHON R (1973) Röntgenologisk bedömning av

rotfyllningens kvalitet ställd i relation till förekomst av peripikala destruktioner
(Summary in english). Tandläkartidningen 65, 269-79.

52
BHASKAR SN (1966) Periapical lesions, types, incidence and clinical features. Oral
Surgery, Oral Medicine & Oral Pathology 21, 657-71.

BLAND JM ALTMAN DG (1986) Statistical methods for assessing agreement between

two methods of clinical measurement. Lancet 1, 307-10.

BREHMER A, BREHMER B (1988) What have we learned about human judgment from
thirty years of policy capturing? In: Brehmer B, Joyce CRB, eds. Human judgment. The
SJT view. 75-114. Amsterdam: Elsevier Science Publishers BV.

BRICKLEY M, KAY E, SHEPHERD JP, ARMSTRONG RA (1995) Decision analysis for the
lower-third-molar surgery. Medical Decision Making 15,143-51.

BRUNSWIK E (1955) Representative design and probabilistic theory in a functional

psychology. Psychological Review 62, 193-217.

BRÜLDE B (1998) The human good (Ph D Thesis). Gothenburg: Acta Philosophica
Gothoburgiensia.

BRYNOLF I (1967) Histological and roentgenological study of periapical region of

human upper incisors. Odontologisk Revy 18, (Suppl. 11).

BUCKLEY M, SPÅNGBERG LS (1995) The prevalence and technical quality of

endodontic treatment in an American subpopulation. Oral Surgery, Oral Medicine &
Oral Pathology 79, 92-100.

CURTIS JW, MCLAIN JB, HUTCHINSON RA (1985) The incidence and severity of
complications and pain following periodontal surgery. Journal of Periodontology
56,597-601.

DANIN J, STRÖMBERG T, FORSGREN H, LINDER LE, RAMSKÖLD LO (1996). Clinical

management of nonhealing periradicular pathosis. Surgery versus endodontic
retreatment. Oral Surgery, Oral Medicine & Oral Pathology 82, 213-7.

DE CLEEN MJH, SCHUURS AHB, WESSELINK PR, WU M-K (1993) Periapical status
and prevalence of endodontic treatment in an adult Dutch population. International
Endodontic Journal 26, 112-19.

DE MOOR RJG, HOMMEZ GMG, DE BOEVER JG, DELME KIM, MARTENS GEI (2000)
Periapical health related to the quality of root canal treatment in a Belgian population.
International Endodontic Journal 33, 113-20.

DOWIE J, ELSTEIN A eds. (1988) Professional judgement. A reader in clinical decision

making. Cambridge, UK: Cambridge University Press.

ECKERBOM M, ANDERSSON J-E, MAGNUSSON T (1987) Frequency and technical

standard of endodontic treatment in a Swedish population. Endodontics & Dental
Traumatology 3, 245-8.

53
ECKERBOM M, ANDERSSON J-E, MAGNUSSON T (1989) A longitudinal study of
changes in frequency and technical standard of endodontic treatment in a Swedish
population. Endodontics & Dental Traumatology 5, 27-31.

EDDY DM (1984) Variations in physician practice: the role of uncertainty. Health

Affairs 5, 74-89.

ELDERTON RJ, NUTTALL NM (1983) Variation among dentists in planning treatment.

British Dental Journal 154, 201-6.

ENGSTRÖM B, HÅRD AF SEGERSTAD L, RAMSTRÖM G, FROSTELL G (1964) Correlation

of positive cultures with the prognosis for root canal treatment. Odontologisk Revy 15,
257-70.

ERIKSEN H (1991) Endodontology-epidemiologic considerations. Endodontics &

Dental Traumatology 7, 189-195.

ERIKSEN H, BJERTNESS E (1991) Prevalence of apical periodontitis and results of

endodontic treatment in middle-aged adults in Norway. Endodontics & Dental
Traumatology 7, 1-4.

ERIKSEN HM, BJERTNESS E, ØRSTAVIK D (1988) Prevalence and quality of endodontic

treatment in an urban adult population in Norway. Endodontics & Dental Traumatology
4, 122-6.

ERIKSEN HM, ØRSTAVIK D, KEREKES K (1988) Healing of apical periodontitis after

endodontic treatment using three different root canal sealers. Endodontics & Dental
Traumatology 4, 114-17.

FRANK AL, GLICK DH, PATTERSON SS, WEINE FS (1992) Long-term evaluation of
surgically placed amalgam fillings. Journal of Endodontics 18, 391-398.

FRIEDMAN S, LÖST C, ZARRABIAN M, TROPE M (1995) Evaluation of success and

failure after endodontic therapy using glass ionomer cement sealer. Journal of
Endodontics 21, 384-90.

FYFFE HE, KAY EJ (1992) Assessment of dental health state utilities. Community
Dentistry and Oral Epidemiology 20, 269-273.

GALE J, MARSDEN P (1983) Medical diagnosis: from student to clinician. Oxford:

Oxford University Press.

GATTI JJ, DOBECK JM, SMITH C, WHITE RR, SOCRANSKY SS, SKOBE Z (2000)
Bacteria of asymptomatic periradicular endodontic lesions identified by DNA-DNA
hybridization. Endodontics & Dental Traumatology 16, 197-204.

54
GELFAND M, SUNDERMAN EJ, GOLDMAN M (1983) Reliability of radiographical
interpretations. Journal of Endodontics 9, 71-5.

GOLDMAN M, PEARSON AH, DARZENTA N (1972) Endodontic success - who's reading

the radiograph? Oral Surgery 33, 432-7.

GOLDMAN M, PEARSON AH, DARZENTA N (1974) Reliability of radiographic

interpretation Oral Surgery 38, 287-93.

GRAHNÉN H, HANSSON L (1961) The prognosis of pulp and root canal therapy.
Odontologisk Revy 12, 146-65.

GRIFFIN J (1986) Well-being. Its meaning, measurement and moral importance.

Oxford, UK: Clarendon Press.

GROOME PA, HUTCHINSON TA, TOUSIGNANT P, HANLEY JA (1999) The repeatability

of three methods for measuring prospective patients' values in the context of treatment
choice for end-stage renal disease. Journal of Clinical Epidemiology 52, 849-60.

GRUNG B, MOLVEN O, HALSE A (1990) Periapical surgery in a Norwegian county

hospital: Follow-up findings of 477 teeth. Jornal of Endodontics 16, 411-7.

HAM C (1988) Health care variations; assessing the evidence. Research report no. 2.
London, King's Fund Institute.

HAMMOND KR (1977) Social judgment theory: Application in policy formation. In:

Kaplan MF, Schwartz S, eds. Human judgment and decision processes in applied
settings. New York: Academic Press.

HAPPONEN RP (1986) Periapical actinomycosis: a follow-up study of 16 surgically

treated cases. Endodontics & Dental Traumatology 2, 205-9.

HARE RM (1981) Moral thinking: Its levels, method and point. Oxford, UK: Oxford
University Press.

HARE RM (1993) Is medical ethics lost? Journal of medical ethics 19, 69-70.

HARGREAVES HEAP S, HOLLIS M, LYONS B, SUGDEN R, WEALE A (1992) The theory

of choice. A critical guide. Oxford, UK: Blackwell.

HARTY FJ, PARKINS BJ, WENGRAF AM (1970) The success rate of apicectomy. A
retrospective study of 1016 cases. British Dental Journal 129, 407-13.

HEPWORTH MJ, FRIEDMAN S (1997) Treatment outcome of surgical and non-surgical

management of endodontic failures. Journal of Canadian Dental Association 63,364-
71.

55
HIRSCH J, AHLSTRÖM U, HENRIKSSON P-Å, HEYDEN G, PETERSON, L-E (1979)
Periapical surgery. International Journal of Oral Surgery 8, 173-85.

HORNBERGER JC, REDELMEIER DA, PETERSEN J (1992) Variability among methods to

assess patients' well-being and consequent effect on a cost-effectiveness analysis.
Journal of Clinical Epidemiology 45, 505-12.

HÜLSMANN M (1994) Retreatment decision making by a group of general dental

practitioners in Germany. International Endodontic Journal 27:125-32.

IMFELD TN (1991) Prevalence and quality of endodontic treatment in an elderly urban

population of Switzerland. Journal of Endodontics 17, 604-7.

IMURA N, ZUOLO ML (1995) Factors associated with endodontic flare-ups: a

prospective study. International Endodontic Journal 28, 261-5.

IOANNIDES C, BORSTLAP WA (1983) Apicectomy on molars: a clinical and

radiographical study. International Journal of Oral Surgery 12, 73-9.

JANSSON L, SANDSTEDT P, LÅFTMAN A-C, SKOGLUND A (1997) Relationship between

apical and marginal healing in periradicular surgery. Oral Surgery, Oral Medicine &
Oral Pathology 83, 596-601.

JONES TV, GERRITY MS, EARP JA (1990) Written case simulations: do they predict
physicians' behaviour? Journal of Clinical Epidemiology 43, 805-15.

JUUL JENSEN U (1985) Sjukdomsbegrepp i praktiken. Det kliniska arbetets filosofi och
vetenskapsteori. Stockholm: Esselte studium.

KAHNEMAN D, SLOVIC P, TVERSKY A (1982) Judgement under uncertainty: Heuristics

and biases. Cambridge, UK: Cambridge University Press.

KAY EJ, BLINKHORN AS (1996) A qualitative investigation of factors governing

dentists´ treatment philosophies. British Dental Journal 180, 171-6.

KIM S ed. (1997) Microscopes in endodontics. Dental Clinics of North America 41, 3.

KNUTSSON K, BREHMER B, LYSELL L, ROHLIN M (1992) Asymptomatic mandibular

third molars- oral surgeon's judgement on the need for extraction. Journal of Oral and
Maxillofacial Surgery 50, 329-33.

KNUTSSON K, BREHMER B, LYSELL L, ROHLIN M (1996) Judgement of removal of

asymptomatic mandibular molars: influence of position, degree of impaction, and
patient's age. Acta Odontologica Scandinavica 54, 348-54.

LAMBRIANIDIS T (1985) Observer variations in radiographic evaluation of endodontic

therapy. Endodontics & Dental Traumatology 1, 235-41.

56
LANGELAND K, BLOCK RM, GROSSMAN LI (1977) A histobacteriologic study of 35
periapical endodontic surgical specimens. Journal of Endodontics 3, 8-23.

LEDLEY RS, LUSTED LB (1959) Reasoning foundations of medical diagnosis. Science

130, 9-21.

LLEWELLYN-THOMAS H, SUTHERLAND HJ, TIBSHIRANI R, CIAMPI A, TILL JE, BOYD

NF (1982) The measurement of patients´values in medicine. Medical Decision Making
2, 449-62.

LUSTED LB (1968) Introduction to medical decision making. Springfield, Illinois, USA:

Charles C Thomas.

LYSELL L, BREHMER B, KNUTSSON K, ROHLIN M (1993) Judgement on removal of

asymptomatic mandibular third molars: influence of the perceived likelihood of
pathology. Dentomaxillofacial Radiology 22, 173-7.

MARQUES MD, MOREIRA B, ERIKSEN HM (1998) Prevalence of apical periodontitis

and results of endodontic treatment in an adult, Portuguese population. International
Endodontic Journal 31, 161-5.

MARYNIUK GA, HAYWOOD VB (1990) Placement of cast restorations over direct pulp
capping procedures: a decision analytic approach. Journal of the American Dental
Association 120, 183-7.

MATTILA K, ALTONEN M (1968) A clinical and roentgenological study of

apicoectomized teeth. Odontologisk Tidskrift 76, 389-407.

MILEMAN P (1985) Radiographic caries diagnosis and restorative treatment decision

making (PhD Thesis). Groningen, The Netherlands: University of Groningen.

MILEMAN PA VISSERS T, PURDELL-LEWIS DJ (1986) The application of decision

making analysis to the diagnosis of approximal caries. Community Dental Health 3, 65-
81.

MILL JS (1962) Utilitarianism. Mary Warnock, ed. London and Glasgow: Collins.
(Original work published 1861)

MOLANDER A, REIT C, DAHLÉN G, KVIST T (1998) Microbiological status of root filled

teeth with apical periodontitis. International Endodontic Journal 31, 1-7.

MOLVEN O, HALSE A (1988) Success rates for gutta-percha and Kloroperka N-Ø root
fillings made by undergraduate students: radiographic findings after 10-17 years.
International Endodontic Journal 21, 243-50.

MOR C, ROTSTEIN I, FRIEDMAN S (1992) Incidence of interappointment emergency

associated with endodontic therapy. Journal of Endodontics 18, 509-11.

57
MULLEY AG (1989) Assessing patients' utilities. Can the ends justify the means?
Medical Care 27, supplement S269-81.

NAIR PNR, PAJAROLA G, SCHROEDER HE (1996) Types and incidence of human

periapical lesions obtained with extracted teeth. Oral Surgery, Oral Medicine & Oral
Pathology 81, 93-102.

NAIR PNR, SJÖGREN U, KREY G, KAHNBERG K-E, SUNDQVIST G (1990) Intraradicular

bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant
periapical lesions: A long-term light and electron microscopic follow-up study. Journal
of Endodontics 16, 41-9.

NAIR PNR, SJÖGREN U, KREY G, SUNDQVIST G (1990) Therapy-resistant foreign body

giant cell granuloma at the periapex of a root-filled human tooth. Journal of
Endodontics 16, 53-9.

NATKIN E, OSWALD RJ, CARNES LI (1984) The relationship of lesion size to diagnosis,
incidence, and treatment of periapical cysts and granulomas. Oral Surgery, Oral
Medicine & Oral Pathology 57, 82-94.

VON NEUMANN J, MORGENSTERN O (1947) Theory of games and economic behaviour,

2nd edn. Princeton, USA: Princeton University Press.

NORDENRAM A, SVÄRDSTRÖM G (1970) Results of apicectomy. A clinical -

radiological examination. Svensk Tandläkare Tidskrift 63, 593-604.

ÖDESJÖ B, HELLDÉN L, SALONEN L, LANGELAND K (1990) Prevalence of previous

endodontic treatment technical standard and occurrence of periapical lesions in a
randomly selected adult, general population.
Endodontics & Dental Traumatology 6, 265-72.

ØRSTAVIK D (1996) Time-course and risk analyses of the development and healing of
chronic apical periodontitis in man. International Endodontic Journal 29, 150-55.

ØRSTAVIK D, HØRSTED-BINDSLEV P (1993) A comparison of endodontic treatment

results at two dental schools. International Endodontic Journal 26, 348-54.

ØRSTAVIK D, KEREKES K, ERIKSEN HM (1986) The periapical index: a scoring system

for radiographic assessment of apical periodontitis. Endodontics & Dental
Traumatology 2, 20-34.

ÖSTERMAN B (1995) Value and requirements. An enquiry concerning the origin of

value. Aldershot: Avebury.

PERSSON G (1966) Evaluation of results of apicectomy. Swedish Dental Journal 59,

219-28.

58
PETERSON K, HÅKANSSON R, HÅKANSSON J, OLSSON B, WENNBERG A (1991)
Follow-up study of endodontic status in an adult swedish population. Endodontics &
Dental Traumatology 7, 221-225.

PETERSSON K, LEWIN B, HÅKANSSON J, OLSSON B, WENNBERG A (1989) Endodontic

status and suggested treatment in a population requiring substantial dental care.
Endodontics & Dental Traumatology 5, 153-158.

PETERSSON K, PETERSSON A, OLSSON B, HÅKANSSON J, WENNBERG A (1986)

Technical quality of root fillings in an adult Swedish population. Endodontics & Dental
Traumatology 2, 99-102.

POCOCK SJ (1983) Clinical trials. Apractical approach. Chichester, UK: John Wiley &
Sons.

POLITSER P (1981) Decision analysis and clinical judgement. Medical Decision Making
1, 361-89.

READ JL, QUINN RJ, BERWICK DM, FINEBERG HV, WEINSTEIN MC (1984)
Preferences for health outcomes: Comparison of assessment methods. Medical Decision
Making 4, 315-29.

REIT C, DAHLÉN G (1988) Decision making analysis of endodontic treatment strategies

in teeth with apical periodontitis. International Endodontic Journal 21, 291-9.

REIT C, GRÖNDAHL H-G (1983) Application of statistical decision theory to

radiographic diagnosis of endodontically treated teeth. Scandinavian Journal of Dental
Research 91, 213-8.

REIT C, GRÖNDAHL H-G (1984) Management of periapical lesions in endodontically

treated teeth. A study on clinical decision making. Swedish Dental Journal 8, 1-7.

REIT C, GRÖNDAHL H-G (1987) Endodontic decision-making under uncertainty: A

decision analytic approach to management of periapical lesions in endodontically
treated teeth. Endodontics & Dental Traumatology 3, 15-20.

REIT C, GRÖNDAHL H-G (1988) Endodontic retreatment decision making among a

group of general practioners. Scandinavian Journal of Dental Research 96, 112-117.

REIT C, GRÖNDAHL H-G, ENGSTRÖM B (1985) Endodontic treatment decisions: A

study of the clinical decision-making process. Endodontics & Dental Traumatology 1,
102-107.

REIT C, HIRSCH J (1986) Surgical endodontic retreatment. International Endodontic

Journal 19, 107-12.

REIT C, HOLLENDER L (1983) Radiographic evaluation of endodontic therapy and the

influence of observer variation. Scandinavian Journal of Dental Research 91, 205-12.

59
REVICKI DA (1992) Relationship between health utility and psychometric health status
measures. Medical Care 30, supplement MS 274-82.

ROHLIN M, MILEMAN PA (2000) Decision analysis in dentistry- the last 30 years.

Journal of Dentistry 28, 453-68.

ROSS WD (1930) The right and the good. Oxford, UK: Oxford University Press.

RUBINSTEIN RA, KIM S (1999) Short term observation of the results of endodontic
surgery with the use of a surgical operation microscope and super-EBA as a root-end
fillingmaterial. Journal of Endodontics 25, 43-8.

RUD J, ANDREASEN JO, MÖLLER JENSEN JE (1972) A follow-up study of 1000 cases
treated by endodontic surgery. International Journal of Oral Surgery 1, 215-28.

RUD J, MUNKSGAARD EC, ANDREASEN JO, RUD V (1991) Retrograde root filling with
composite and a dentin-bonding agent. Endodontics & DentalTraumatology 7, 126-31.

SAUNDERS WP, SAUNDERS EM, SADIQ J, CRUICKSHANK E (1997) Technichal standard

of root canal treatment in an adult Scottish sub-population. British Dental Journal 182,
382-6.

SCHWARTZ WB (1979) Sounding board. Decision analysis: A look at the chief

complaints. The New England Journal of Medicine 300, 556-9.

SCHOEMAKER PJH (1982) The expected utility model: Its variants, purposes, evidence
and limitations. Journal of Economic Literature 20, 529-63.

SCHÖN DA (1983) The reflective practitioner: How professionals think in action. New
York: Basic Books, Inc. Publishers.

SELDEN HS (1974) Pulpoperiapical disease: diagnosis and healing. Oral Surgery Oral
Medicine & Oral Pathology 37, 271-83.

SIDARAVICIUS B, ALEKSEJUNIENE J, ERIKSEN HM (1999) Endodontic treatment and

prevalence of apical periodontitis in an adult population of Vilnius, Lithuania.
Endodontics & Dental Traumatology 15, 210-5.

SJÖBERG L, TYSZKA T, WISE JA (1983) Human decision making. Bodafors, Sweden:

Bokförlaget Doxa AB.

SJÖGREN U, HAPPONEN RP, KAHNBERG K-E, SUNDQVIST G (1988) Survival of

Arachnia propionica in periapical tissue. International Endodontic Journal 21, 277-82.

SJÖGREN U, HÄGGLUND B, SUNDQVIST G, WING K (1990) Factors effecting the long-

term results of endodontic treatment. Journal of Endodontics 16, 31-7.

60
SMART JJC (1973) An outline of a system of utilitarian ethics. In Smart JJC, Williams
B (eds) Utilitarianism: for and against. Cambridge: Cambridge University Press.

SMITH J, CRISP J, TORNEY D (1981) A survey: controversies in endodontic treatment

and re-treatment. Journal of Endodontics 7, 477-483.

SPATAFORE CM, GRIFFIN JA, KEYES GG, WEARDEN S, SKIDMORE AE (1990)

Periapical biopsy report: An anlysis over a 10-year period. Journal of Endodontics 16,
239-41.

STRINDBERG LZ (1956) The dependence of the results of pulp therapy on certain

factors. Acta Odontologica Scandinavica 14 (Suppl 21).

SUNDE PT, OLSEN I, LIND PO, TRONSTAD L (2000) Extraradicular infection: a

methodological study. Endodontics & Dental Traumatology 16, 84-90.

SUNDQVIST G (1976) Bacteriological studies of necrotic dental pulps (PhD Thesis).

Umeå, Sweden. University of Umeå.

SUNDQVIST G, FIGDOR D, PERSSON S, SJÖGREN U (1998) Microbiologic analysis of

teeth with failed endodontic treatment and the outcome of conservative retreatment.
Oral Surgery, Oral Medicine & Oral Pathology 85, 86-93.

TÄNNSJÖ T (1998) Hedonistic utilitarianism. Edinburgh: Edinburgh University Press.

TENGS TO, WALLACE A (2000) One thousand health-related quality-of-life estimates.

Medical Care 38, 583-637.

TORABINEJAD M, KETTERING JD, MCGRAW JC, CUMMINGS RR, DWYER TG, TOBIAS
TS (1988) Factors associated with endodontic interappointment emergencies of teeth
with necrotic pulps. Journal of Endodontics 14, 261-66.

TORRANCE GW (1986) Measurement of health state utilities for economic appraisal.

Journal of Health Economics 5, 1-30.

TORRANCE GW, THOMAS WH, SACKETT DL (1972) A utility maximization model for
evaluation of health care programmes. Health Service Research 7, 118-133.

TRONSTAD L, BARNETT F, RISO K, SLOTS J (1987) Extraradicular endodontic

infections. Endodontics & Dental Traumatology 3, 86-90.

TROPE M, DELANO EO, ØRSTAVIK D (1999) Endodontic treatment of teeth with apical
periodontitis: Single vs. Multivisit treatment. Journal of Endodontics 25, 345-50.

WALTIMO TM, ØRSTAVIK D, SIREN EK, HAAPASALO MP (1999) In vitro susceptibility

of Candida albicans to four disinfectants and their combinations. International
Endodontic Journal 32, 421-9.

61
 WALTIMO TM, SIREN EK, TORKKO HL, OLSEN I, HAAPASALO MP (1997) Fungi in
therapy-resistant apical periodontitis. International Endodontic Journal 30, 96-101.

WEINSTEIN MC, FINEBERG HV (1980) Clinical decision analysis. Philadelphia, USA:

W B Saunders.

VELANOVICH V (1990) Choice of treatment for stage I floor-of-mouth cancer. A

decision analysis. Archives of Otolaryngology Head and neck Surgery 116, 951-6.

WIGTON RS (1988) Applications of judgment analysis and cognitive feedback to

medicine. In: Brehmer B, Joyce CRB, eds. Human judgment. The SJT view. 227-45.
Amsterdam: Elsevier Science Publishers BV.

VON WRIGHT GH (1963) The varieties of goodness. London: Routledge and Kegan
Paul.

WULFF HR, PEDERSEN SA, ROSENBERG R (1986) Philosophy of medicine: An

introduction. 2nd edn. Oxford: Blackwell Scientific Publications.

ZUG KA, LITTENBERG B, BAUGHMAN RD, KNEELAND T, NEASE RF, SUMNER W,

O´CONNOR GT, JONES R, MORRRISON E, CIMIS R (1995) Assessing the preferences of
patients with psoriasis. A quantitative, utility approach. Archives of Dermatology 131,
561-8.

ZUOLO ML, FERREIRA MOF, GUTMANN JL (2000) Prognosis in periradicular surgery: a

clinical prospective study. International Endodontic Journal 33, 91-8.

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