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ENDODONTIC RETREATMENT
Aspects of decision making and clinical outcome
Thomas Kvist
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.”
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
6
6. THE RESULTS OF ENDODONTIC RETREATMENT....................... 33
Own investigation........................................................ 33
Remarks..................................................................... 35
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.
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.
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).
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.
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.
12
Clinical examination
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
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).
Nonsurgical retreatment
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).
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.
16
subjective values in endodontic retreatment decision making has attracted
very little interest.
17
2. TOWARDS A THEORY OF RETREATMENT BEHAVIOUR
Retreatment No retreatment
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.
No post Post
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
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.
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
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
Retreatment No retreatment
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
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. 11. The scenarios of health state A and B as presented to the raters.
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.
____________________________________________________________
J1 J2 J1 J2
____________________________________________________________
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.
____________________________________________________________
J1 J2 J1 J2
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.
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%.
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]
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).
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
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.
34
Utility
1,0
0,6
0,4
0,2
0,0 Utility
0,0 0,2 0,4 0,6 0,8 1,0
First judgement
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).
36
6. THE RESULTS OF ENDODONTIC RETREATMENT
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%)
38
100
75
Healing (%)
50
(*)
25
0 0 12 24 36 48
6 12 24 48
Time (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.
41
7. THE COSTS OF ENDODONTIC RETREATMENT
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
0 0
25 -25
50 -50
75 -75
100 -100
VAS 0 1 2 3 4 5 6 Day
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
%
100 100
75 75
50 50
0 0
25 -25
50 -50
*
* *
75 -75
100 -100
0 1 2 3 4 5 6 Day
VAS
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.
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
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.
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).
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.
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.
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.
50
ACKNOWLEDGEMENTS
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.
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.
51
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