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Radiographic evaluation of cases referred for surgical endodontics

H. Doornbusch1, L. Broersma2, G. Boering1 & P. R. Wesselink3

Department of Oral and Maxillo-facial Surgery and 2Department of Economics, University of Groningen, Groningen, the Netherlands; and 3Department of Cariology Endodontology Pedodontology, Academic Centre for DentistryAmsterdam (ACTA), Amsterdam, the Netherlands

Doornbusch H, Broersma L, Boering G, Wesselink PR. Radiographic evaluation of cases referred for surgical endodontics. International Endodontic Journal, 35, 472^477, 2002

Aim The aim of this study is to test the hypothesis that more patients with failed root-canal treatment or other endodontic problems are referred for periradicular surgery rather than nonsurgical re-treatment. Methodology Three sets of 100 periapical radiographs representing typical cases referred for surgical treatment were collected in three departments of oral and maxillo-facial surgery situated in dierent parts of the Netherlands. Of these, a total of 278 radiographs were evaluated to determine whether endodontic surgery was indicated or whether the primary endodontic treatment or endodontic re-treatment was a realistic

option. An oral and maxillo-facial surgeon, an endodontist and a general dental practitioner viewed the radiograph independently under standard conditions. Results Overall, orthograde root-canal (re-)treatment was considered possible in 63% of the cases. The results diered between the three examiners with the oral surgeon reporting that 41% of cases were amenable to conventional treatment, for the general dental practitioner and the endodontists the gures were 67 and 80%, respectively. Conclusions Based on these observations, it is concluded that most of the teeth referred for surgical treatment to an oral surgeon could be treated by orthograde nonsurgical root-canal treatment. Keywords: endodontic re-treatment, surgery, radiographic evaluation. endodontic

Received17 November 2000; accepted 22 August 2001

A Dutch dentist encountering an endodontic problem that in his opinion cannot be treated with nonsurgical techniques will usually refer the patient to an oral and maxillo-facial surgeon for periradicular surgery. The most common reason for referral is the presence of chronic periapical inammation, visible on a radiograph as a radiolucency, in combination with a root canal with restricted coronal access. Often, this inaccessibility is caused by a previously placed insucient root-canal ll-

Correspondence: P. R. Wesselink, Department of Cariology Endodontology Pedodontology, Academic Centre for Dentistry Amsterdam (ACTA), Louwesweg 1, 1066 EA Amsterdam, the Netherlands (fax: 31 20 6692881, e-mail:

ing, or a post that is perceived to be dicult to remove. A large periapical radiolucency, a perforation, a root fracture and a wide open apex may be other reasons for referral. From an endodontic perspective, periradicular surgery is indicated onlyafter nonsurgical endodontic treatment of good quality has been attempted, but could not be completed or where following treatment healing had not taken place. An infected root canal is the primary reason for periapical inammation (Siren et al. 1997, Sjogren et al. 1997, Sundqvist et al. 1998) and sur gery should not be considered the rst-choice treatment as it does not debride the root canal, rather nonsurgical root-canal treatment or re-treatment is more likely to achieve this aim (Moiseiwitsch et al. 1998). In general practice, however, for several reasons this interpretation is not always tenable, because additional factors


International Endodontic Journal, 35, 472^477, 2002

2002 Blackwell Science Ltd

Doornbusch et al. Referrals for surgical endodontics

such as costs, type of medical insurance, operator skill and duration of treatment may also play a role. The impression exists that in the Netherlands far more patients with endodontic problems are referred to hospitals for surgical endodontics than is strictly necessary. De Cleen et al. (1993) concluded that the need for high-quality root-canal treatment was high and the standard of root-canal llings was poor. The potential of modern endodontic techniques to treat complicated primary cases or retreat endodontic failures is still underestimated. Lewis et al. (1988) emphasized that surgery should never be performed before conventional nonsurgical root-canal treatment had been provided. In order to examine whether there is an element of truth in the perception that apical surgery is over prescribed, a retrospective radiographic study was carried out to evaluate the cases referred by dentists for apical surgery to three dierent hospitals in the Netherlands.

Table 1 Item list used for the evaluation of radiographs

Most likely cause of periapical inflammation and radiolucency Missing root-canal filling Insufficient root-canal filling No endodontic problem/cause not clear Incisor/canine Premolar Molar No radiolucency Radiolucency < 2 mm Radiolucency 2^5 mm Radiolucency > 5 mm Access possible Access not possible Yes (post < 3 mm in root canal) No (post > 3 mm in root canal) Not relevant (no post in root canal) Yes No Yes No Yes No

Type of tooth to be treated

Size of radiolucency

Feasibility of coronal access to root canal and apical area Feasibility to remove a post from the root canal Presence of perforation Feasibility of improving the root-canal treatment Feasibility of endodontic nonsurgical re-treatment

Materials and methods

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

Table 2 Interpreting the values of k

Value of k k < 0.20 0.20 < k < 0.40 0.40 < k < 0.60 0.60 < k < 0.80 0.80 < k < 1.00 Strength of agreement Poor Fair Moderate Good Very good

In 6 of the 300 patient les collected, the primary radiograph was missing and 16 radiographs were of insucient quality; this gave a nal total of 278 radiographs. The results are shown in Tables 3^9. As judged on the available radiographs, the observers considered conventional root-canal treatment feasible in 40^80% of the cases (Table 3), referred for endodontic surgery. Signicantly, the endodontist and general practitioner considered re-treatment feasible more frequently compared to the oral surgeon (P < 0.05). Tooth position did not inuence this judgement (Table 4). The observers did not measure a correlation between the size of the radiolucency and the indication for surgical treatment (Table 5).

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Oral surgeon Re-treatment feasible (N 278)


Dentist GP







significantly different from others

Table 3 Percentage of cases referred for surgical endodontics in which nonsurgical endodontic (re-)treatment was considered feasible. Evaluated at T1 andT2 (at least 6 months later)

Possibility of nonsurgical (re)treatment Observer 1 oral surgeon % feasible 51 .2 41 .6 46.3 46.4 Observer 2 endodontist % feasible 79.5 78.1 87.4 81 .7 Observer 3 dentist GP % feasible 52.9 56.0 68.1 59.0

Tooth evaluated Anterior teeth Premolar Molar Total

Table 4 Feasibility of nonsurgical (re-)treatment in relation to the type of tooth as considered during the rst observation (T1)

Size of radiolucency Absent <2 mm 2^5 mm >5 mm

Observer 1 oral surgeon % feasible 60.3 34.0 38.8 46.3

Observer 2 endodontist % feasible 76.3 83.6 79.7 84.1

Observer 3 dentist GP % feasible 62.5 66.1 54.1 59.1

Table 5 Feasibility of nonsurgical (re-)treatment in relation to size of radiolucency as considered during the rst observation (T1)

Endodontic situation Missing root-canal filling Insufficient root-canal filling Good root-canal filling (cause not clear) Total

Observer 1 oral surgeon (%) 30.2 51.4 18.4 100.0

Observer 2 endodontist (%) 29.3 51 .9 18.8 100.0

Observer 3 dentist GP (%) 25.1 50.2 24.7 100.0

Table 6 Assessment quality of root-canal llings of referred cases

The inter- and intraobserver agreement for the various evaluation items are shown in Tables 6 and 7. As far as the interobserver agreement was concerned, a low level of agreement was observed for the feasibility to redo or improve the treatment and the presence of perforations observed in the radiograph. The values for intraobserver agreement between observation periods are shown in Table 8; least agreement occurred when judging a perforation.

The question whether re-treatment was considered feasible is detailed in Table 9. It can be seen that signicantly more teeth (76%) were considered re-treatable from the population of the hospital in Groningen than those from the hospital in Haarlem (53%) with 66% for the cases of the Drachten hospital. As far as the regional dierence was concerned, it appeared that in 71% of the cases from the northern region hospitals (Groningen and Drachten) re-treatment was judged feasible,


International Endodontic Journal, 35, 472^477, 2002

2002 Blackwell Science Ltd

Doornbusch et al. Referrals for surgical endodontics

Table 7 Interobserver agreement (Cohens kappa) on evaluation criteria on the radiographs as mentioned in the checklist (Table 1) at the rst observation
k-Value Observers 1and 2 (surgeon vs. endodontist) 0.54 0.91 0.50 0.46 0.57 0.21 0.15 0.28 Observers 1and 3 (surgeon vs. dentist) 0.55 0.95 0.42 0.54 0.71 0.36 0.45 0.43 Observers 2 and 3 (endodontist vs. dentist) 0.61 0.93 0.49 0.70 0.67 0.45 0.36 0.42

Question Probable cause of inflammation Type of tooth Size lucency Access root canal Postremoval possible Perforation Improvement root-canal treatment feasible Re-treatment feasible k, Cohens kappa.

Table 8 Intraobserver agreement of the topics mentioned in the checklist (Table 1)

Value of k for comparing Observer 1 at time T1 and T2 0.58 0.96 0.67 0.55 0.73 0.36 0.43 0.52 Observer 2 at time T1 and T2 0.71 0.86 0.49 0.63 0.57 0.29 0.48 0.61 Observer 3 at time T1 and T2 0.75 0.95 0.61 0.82 0.88 0.51 0.58 0.54

Question Probable cause of inflammation Type of tooth Size lucency Access root canal Postremoval feasible Perforation Improvement root-canal treatment feasible Re-treatment feasible

Table 9 Dierences between hospitals and regions with respect to feasibility of re-treatment
Question Re-treatment feasible Hospital/region AZG NSD KZH North West Mean 1.24 1.34 1.47 1.29 1.47 95% confidence interval .33 1.15 1 .44 1.241 .58 1.371 1.22^1 .35 1.37^1 .58

Percentage feasible 76 66 53 71 53

AZG, Academic Hospital Groningen; NSD, Ny Smellinghe Hospital Drachten; KZH, Kennemer Hospital Haarlem. Significant difference at 0.05 level.

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whereas this was the case in only 53% in the western region hospital in Haarlem.

Based on radiographic information only, the observers judged at the rst observation that 46^82% of the cases were amenable to nonsurgical re-treatment; this reduced to 37^80% after the second observation.The endodontist considered far more teeth feasible for re-treatment than the general practitioner and oral surgeon, suggesting that previous training and experience inuenced the decision making. This observation conrms previous ndings (Reit & Grondahl1988). Although the observers had some dierence in opinions, a substantial percentage of the referrals were judged as unnecessary to conrm the supposition that patients with endodontic problems were referred for surgical treatment more often than seems strictly necessary, as judged radiographically. It can be seen from Table 6 that in 75^80% of the referred cases, the root-canal lling was either missing or of poor quality. Similar results have recently been shown in UK where 79.5% of the referrals failed to meet guideline criteria on the provision of periradicular surgery (Bell 1998), whereas Beckett (1996) found that 35% did not meet the criteria for apical surgery. So, theoretically, the most appropriate strategy to prevent about 80% of the referrals for endodontic surgery would be to improve the technical standards of root-canal treatments performed by the practitioner.This need for better quality endodontic treatment in the Netherlands has been observed previously (De Cleen et al. 1993), who observed that approximately 50% of root llings were inadequate and were often associated with periapical pathology. Although the success rate of nonsurgical endodontic re-treatments are lower than de novo endodontic treatments (Bergenholtz et al. 1979, Danin et al. 1996), there may be other factors that have inuenced the decision of the dentist to refer cases that seemed feasible for retreatment. First of all, it should be realized that the observers made their decisions on radiographs only, whereas clinical signs and symptoms may also have inuenced the dentistsdecisions (Friedman & Stabholz 1986). However, it is hard to believe that many teeth considered feasible for re-treatment had to be referred because of acute pain and swelling. It seems more probable that in many cases the dentist considered re-treatment a dicult and time-consuming procedure. It is questionable, however, whether this is a valid reason for recommending a surgical procedure.

There has been a little research where comparisons can be made on the outcome between surgical or nonsurgical re-treatment of nonhealing periapical lesions. In a comprehensive review of the literature, Hepworth & Friedman (1997) tried to estimate the success rate for re-treatment by means of a weighted average calculation and reported 59 and 66% for surgical and nonsurgical approaches, respectively. Allen et al. (1989) found in a retrospective analysis of 633 cases that the success rate for re-treatment was 66% with an additional18% uncertain cases, whereas for surgery the success rate was 54%. In a prospective randomized study on 37 teeth, Danin et al. (1996) did not nd signicant dierences after 1 year between the surgical and nonsurgical retreatment even though more failures were seen in the nonsurgical group. Kvist & Reit (1999) did not see any systematic dierence inthe outcome of surgical and nonsurgical endodontic re-treatment in a prospective randomized study of 102 anterior teeth. Thus, at the present time, there is no clear indication which of the two methods guarantees the most favourable outcome. It is, therefore, unlikely that the endodontic knowledge of the practitioners had inuenced their decision to refer. An important consideration mayhave beena nancial one. For many patients inthe Netherlands, specialist care such as that provided byan oral surgeon, will be completely reimbursed by insurance companies, whereas this is not the case for the treatment by the general practitioner. It will be interesting to nd out to what extend this factor has inuenced the treatment decision. Since specialist care is usually more expensive than primary care by general practitioners, and so far no signicant dierence in treatment outcome between surgical and nonsurgical re-treatment has been shown, it seems that based on the present observations there is an overuse of specialist oral surgery care. It would, therefore, be interesting to compare in a prospective study the outcome of surgical and nonsurgical (re-)treatment in cases similar to those evaluated inthe present paper. Only after evaluating these results can a denite conclusion be made as to what extent overuse of surgical specialist care is occurring in the Netherlands. In Table 9, it appears that there were more teeth considered amenable to conventional re-treatment in the patients referred to the hospital in the northern part (71%) of the country than in the western part (53%). It is dicult to explain this dierence, but a reason could be that the dentist:patient ratio in the northern area (1:3100) is much higher than in the western part (1:2200) of the country and that it is a simple time problem (Van Dam & Van Rossum 2000).


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1 Under the conditions of this retrospective study, far more cases were referred for surgical re-treatment than was considered strictly necessary from a technical point of view. 2 Signicant interobserver dierences occurred when judging teeth amenable to conventional re-treatment between the oral surgeon and both the endodontist and general practitioner. 3 More cases were considered amenable to conventional re-treatment from the patients referred to an oral surgery department in the northern part of the country than in the western part.

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