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Treatment Planning Considerations for Endodontically Treated Teeth
“Because I’ll have you know, Sancho, that a mouth without teeth is like a mill without its stone and you must value a tooth more than a diamond.”
—Miguel de Cervantes, Don Quixote
Preservation of the natural human dentition is an important factor in efforts to promote good oral health. The mouth has been referred to as “a window into our health.”1 We are attracted to a beautiful smile and have pity on those individuals with unsightly dentitions. Consciously, or even unconsciously, many make snap decisions as to a person’s socioeconomic status, integrity, reliability, and overall “value” by first impressions. Even in biblical times, the value of teeth was recognized, as justice was meted out “eye for eye, and tooth for tooth” (Matthew 5:38, The Bible, New International Version).
Before the recent option of replacing broken-down teeth with dental implants, clinicians routinely attempted—sometimes with heroic efforts—to save teeth for as long as possible before extraction. While implant placement has increased and the population in general seems to readily accept this procedure, there is some sense that the pendulum is swinging too far in the direction of replacing teeth with implants. Some dentists seem inclined to routinely recommend replacement of teeth that may otherwise have a good prognosis both endodontically and restoratively. The purpose of this chapter is to describe the various factors that must be evaluated when the practitioner is considering a treatment plan that may include endodontically treated teeth. Various clinical situations will be described in which teeth that have had—or will have—root canal treatment (RCT) are to be reviewed in developing a treatment plan.
Outcomes of Endodontic Therapy
The first consideration of importance is to recognize that for a treatment involving an endodontically treated tooth to have a predictable outcome, the endodontic procedure must be skillfully accomplished. Perhaps this statement seems selfevident, but endodontists frequently report that they need to re-treat teeth that have initially been poorly treated (Fig 2-1). In fact, when the quality of RCT in general is evaluated, the level of quality is often disappointingly low.2, 3 Patients, however, cannot see what has been done inside the roots of their teeth and can only judge a clinician on the aspect of pain relief and how they were treated.
Fig 2-1 (a) Inadequately performed RCT, including failure to find the second mesiobuccal canal, has resulted in a periapical lesion (arrow). (b) This radiograph shows well-prepared and filled root canals including two mesiobuccal canals.
When RCT is done correctly initially, it has a good prognosis. Many studies have evaluated the success rate of various types of endodontic therapy.4–7 Torabinejad et al6 did a systematic review of the literature pertaining to the outcomes of nonsurgical endodontic therapy. A strict set of parameters was followed for inclusion in the meta-analysis. Their results showed an overall radiographic success rate of 81.5% over a 5-year period. Friedman et al7 reported similar healing results after 4 to 6 years.
It is noteworthy that the rate of endodontic success is higher when RCT is performed before apical lesions are present.4 Also, when treatment mishaps occur, the prognosis