**Non- Surgical Retreatment** Mostafa El Kholy Senior Lecturer, School of Dentistry, UWA # **Non-Surgical Retreatment** Mostafa El Kholy Senior Lecturer, School of Dentistry, UWA - Etiology - Microbiology - Diagnosis - Treatment Plan - Outcomes ## **Outline** - Etiology - Microbiology - Diagnosis - Treatment Plan - Outcomes Etiology A man with a beard holding a magnifying glass up to his eye, symbolizing investigation or scrutiny. # **Etiology** # Etiology ## Causes of “Failure” - Poor access cavity design - Untreated canals - Canals that are poorly cleaned and obturated - Complications of instrumentation (ledges, perforations, or separated instruments) - overextensions of root-filling materials - Coronal leakage ## **Causes of “Failure”** - Poor access cavity design - Untreated canals - Canals that are poorly cleaned and obturated - Complications of instrumentation (ledges, perforations, or separated instruments) - overextensions of root-filling materials - Coronal leakage **Etiology** *Poor Access and untreated canals* Wolcott et al, J Endod 2005; 262-4 Two images: left shows a tooth with a dental dam and access cavity; right shows a radiograph with a red arrow pointing to an untreated canal. ### **Poor Access and untreated canals** Wolcott et al, J Endod 2005; 262-4 **Etiology** *Poorly Cleaned and Obturated Canals* Chungal et al, Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 2003:81-91 Radiographic images showing teeth with poorly cleaned and obturated canals. ### **Poorly Cleaned and Obturated Canals** Chungal et al, Oral Surg Oral Med Oral Pathol Oral Radiol Endod; 2003:81-91 **Etiology** *Complication of Instrumentation* Sundqvist et al, *Essential endodontology: prevention and treatment of apical periodontitis*, London, 1998, Blackwell Science, p 242. ### **Complication of Instrumentation** Sundqvist et al, *Essential endodontology: prevention and treatment of apical periodontitis*, London, 1998, Blackwell Science, p 242. **Etiology** *Over-extended Root Canal Filling* Nair et al, J Endod; 1990, 16:589-95 Three dental radiographs showing examples of over-extended root canal fillings. ### **Over-extended Root Canal Filling** Nair et al, J Endod; 1990, 16:589-95 # Etiology ## Coronal Leakage - Lazarski et al. J Endod 2001; 27:791-6 - Saunders et al. Endod Dent Traumatol 1994; 10:105-108 - Ray and Trope Int Endod J 1995; 28: 12-18 Radiographic images showing dental structures with evidence of coronal leakage, one with a red arrow indicating the area of concern. ## **Coronal Leakage** - Lazarski et al. J Endod 2001; 27:791-6 - Saunders et al. Endod Dent Traumatol 1994; 10:105-108 - Ray and Trope Int Endod J 1995; 28: 12-18 Table 2. Periradicular status for various combinations of treatment quality | Group | Endo | Coronal | No. teeth | PPI | API | %API | |-------|------------|--------------|-----------|-------|-------|------| | 1 | Good (GE) | Good (GR) | 330.5 | 28.5 | 302.0 | 91.4 | | 2 | Good (GE) | Poor (PR) | 164.5 | 92.0 | 72.5 | 44.1 | | 3 | Poor (PE) | Good (GR) | 302.5 | 98.0 | 204.5 | 67.6 | | 4 | Poor (PE) | Poor (PR) | 188.0 | 154.0 | 34.0 | 18.1 | PPI, presence of periradicular inflammation. API, absence of periradicular inflammation. •Ray and Trope Int Endod J 1995; 28: 12-18 ### **Periradicular status for various combinations of treatment quality** <table border="1" style="width:100%; border-collapse: collapse;"> <thead> <tr> <th style="padding: 8px; text-align: left;">Group</th> <th style="padding: 8px; text-align: left;">Endo</th> <th style="padding: 8px; text-align: left;">Coronal</th> <th style="padding: 8px; text-align: left;">No. teeth</th> <th style="padding: 8px; text-align: left;">PPI</th> <th style="padding: 8px; text-align: left;">API</th> <th style="padding: 8px; text-align: left;">%API</th> </tr> </thead> <tbody> <tr> <td style="padding: 8px;">1</td> <td style="padding: 8px;">Good (GE)</td> <td style="padding: 8px;">Good (GR)</td> <td style="padding: 8px;">330.5</td> <td style="padding: 8px;">28.5</td> <td style="padding: 8px;">302.0</td> <td style="padding: 8px;">91.4</td> </tr> <tr> <td style="padding: 8px;">2</td> <td style="padding: 8px;">Good (GE)</td> <td style="padding: 8px;">Poor (PR)</td> <td style="padding: 8px;">164.5</td> <td style="padding: 8px;">92.0</td> <td style="padding: 8px;">72.5</td> <td style="padding: 8px;">44.1</td> </tr> <tr> <td style="padding: 8px;">3</td> <td style="padding: 8px;">Poor (PE)</td> <td style="padding: 8px;">Good (GR)</td> <td style="padding: 8px;">302.5</td> <td style="padding: 8px;">98.0</td> <td style="padding: 8px;">204.5</td> <td style="padding: 8px;">67.6</td> </tr> <tr> <td style="padding: 8px;">4</td> <td style="padding: 8px;">Poor (PE)</td> <td style="padding: 8px;">Poor (PR)</td> <td style="padding: 8px;">188.0</td> <td style="padding: 8px;">154.0</td> <td style="padding: 8px;">34.0</td> <td style="padding: 8px;">18.1</td> </tr> </tbody> </table> PPI, presence of periradicular inflammation. API, absence of periradicular inflammation. - Ray and Trope Int Endod J 1995; 28: 12-18 # Etiology 1. Persistent or reintroduced intraradicular microorganisms 2. Extraradicular infection 3. Foreign body reaction 4. True cysts Sundqvist G, Figdor D: Endodontic treatment of apical periodontitis. In Orstavik D, Pitt-Ford TR, editors: *Essential endodontology: prevention and treatment of apical periodontitis*, London, 1998, Blackwell Science, p 242 ## **Additional Etiological Factors** 1. Persistent or reintroduced intraradicular microorganisms 2. Extraradicular infection 3. Foreign body reaction 4. True cysts Sundqvist G, Figdor D: Endodontic treatment of apical periodontitis. In Orstavik D, Pitt-Ford TR, editors: *Essential endodontology: prevention and treatment of apical periodontitis*, London, 1998, Blackwell Science, p 242 # Etiology **Persistent or reintroduced intraradicular microorganisms** - The major cause of posttreatment disease. - The major cause of posttreatment disease polymicrobial, predominantly anaerobic flora. Nair et al, J Endod; 1990, 16:589-95 ### **Persistent or reintroduced intraradicular microorganisms** - The major cause of posttreatment disease. - The major cause of posttreatment disease polymicrobial, predominantly anaerobic flora. Nair et al, J Endod; 1990, 16:589-95 # Etiology ## Extraradicular Infection - Direct spread of infection from the root canal space via contaminated periodontal pockets that communicate with the apical area. - Extrusion of infected dentin chips - Contamination with overextended, infected endodontic instruments. - By producing an extracellular matrix or protective plaque. - Weiger *et al*; Endod Dent Traumatol 11:15, 1995 - Holland *et al*; Oral Surg Oral Med Oral Pathol 49:366, 1980 - Tronstad *et al*; Endod Dent Traumatol 6:73, 1990. ### **Extraradicular Infection** - Direct spread of infection from the root canal space via contaminated periodontal pockets that communicate with the apical area. - Extrusion of infected dentin chips - Contamination with overextended, infected endodontic instruments. - By producing an extracellular matrix or protective plaque. - Weiger *et al*; Endod Dent Traumatol 11:15, 1995 - Holland *et al*; Oral Surg Oral Med Oral Pathol 49:366, 1980 - Tronstad *et al*; Endod Dent Traumatol 6:73, 1990. # Etiology ## Foreign Body Reaction - Oral Pulse Granuloma - Cellulose Granuloma - Filling material extrusion leads to a lower incidence of healing - Simon et al, *J Endod 8:116, 1982* - Koppang et al, *J Endod 15:369, 1989* - Sjogren et al, *J Endod 16:498, 1990* ### **Foreign Body Reaction** - Oral Pulse Granuloma - Cellulose Granuloma - Filling material extrusion leads to a lower incidence of healing - Simon et al, *J Endod 8:116, 1982* - Koppang et al, *J Endod 15:369, 1989* - Sjogren et al, *J Endod 16:498, 1990* **Etiology** **True Cyst** - The incidence of periapical cysts has been reported to be 15% to 42% of all periapical lesions. - There are two types of periapical cysts: the periapical true cyst and the periapical pocket cyst. Nair : *Int Endod J 31:155, 1998* ### **True Cyst** - The incidence of periapical cysts has been reported to be 15% to 42% of all periapical lesions. - There are two types of periapical cysts: the periapical true cyst and the periapical pocket cyst. Nair : *Int Endod J 31:155, 1998* **Microbiology** - *Enterococcus faecalis*, the root canal survivor and ‘star’ in posttreatment disease. - *Candida albicans*, are found frequently in persistent endodontic infections and may be responsible for the recalcitrant lesion. - *Actinomyces israelii* and *Propionibacterium propionicum*, are present in the periapical tissues and may prevent healing after root canal therapy - Fukushima *et al*, J Endod 1990; 534-8 - Rôças *et al*, J Endod 2004; 315-320 - Siqueira *et al*, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:632-41 - Sjogren *et al*, Int Endod J 1988; 21:277. - Sundqvist, J Endod 1980; 6: 602-606. # **Microbiology** - *Enterococcus faecalis*, the root canal survivor and ‘star’ in posttreatment disease. - *Candida albicans*, are found frequently in persistent endodontic infections and may be responsible for the recalcitrant lesion. - *Actinomyces israelii* and *Propionibacterium propionicum*, are present in the periapical tissues and may prevent healing after root canal therapy - Fukushima *et al*, J Endod 1990; 534-8 - Rôças *et al*, J Endod 2004; 315-320 - Siqueira *et al*, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:632-41 - Sjogren *et al*, Int Endod J 1988; 21:277. - Sundqvist, J Endod 1980; 6: 602-606. Figure with sparse text and labels, no significant content to extract. **Diagnosis** The clinician must rule out non-odontogenic etiology, perform all of the appropriate tests, properly interpret the patient’s responses to these tests, derive at a definitive diagnosis, and decide on treatment options. Panoramic dental X-ray showing full dentition with multiple dental implants. # **Diagnosis** The clinician must rule out non-odontogenic etiology, perform all of the appropriate tests, properly interpret the patient’s responses to these tests, derive at a definitive diagnosis, and decide on treatment options. # Diagnosis - In cases of persistent disease, the diagnosis may not be as straightforward as the clinician may be dealing with Flowchart with three green boxes labeled "Partially treated canals", "Missed canals", and "Mishaps", each connected by a downward arrow from the main text. In cases of persistent disease, the diagnosis may not be as straightforward as the clinician may be dealing with **Diagnosis** The diagnostic method requires collecting subjective information, developing objective findings, and using these to arrive at a diagnosis and plan of treatment. The diagnostic method requires collecting subjective information, developing objective findings, and using these to arrive at a diagnosis and plan of treatment. Diagnosis **Visual** **examination** **(intra-oral** **and** **extra-oral)** aided by magnification and illumination, which can allow the clinician to identify significant conditions invisible to the naked eye, such as fine fractures on root surfaces Clinical Examination ## **Clinical Examination** ### **Visual examination (intra-oral and extra-oral)** aided by magnification and illumination, which can allow the clinician to identify significant conditions invisible to the naked eye, such as fine fractures on root surfaces **Diagnosis** *Clinical Examination* - Exposed dentin from recession and narrow based probing defects may be the result of an endodontic infection draining through the sulcus; however, they sometimes indicate vertical root fracture. Clinical image showing a dental probe inserted into a sulcus adjacent to teeth, illustrating a probing defect. - Exposed dentin from recession and narrow based probing defects may be the result of an endodontic infection draining through the sulcus; however, they sometimes indicate vertical root fracture. Diagnosis • The presence of occlusal wear facets indicates the presence of occlusal trauma that may complicate diagnosis and treatment outcome by predisposing the tooth to fracture, and it has been associated with posttreatment disease. Clinical Examination - The presence of occlusal wear facets indicates the presence of occlusal trauma that may complicate diagnosis and treatment outcome by predisposing the tooth to fracture, and it has been associated with posttreatment disease. **Diagnosis** *Radiographic Examination* Radiographic images showing various dental conditions and treatments, including root canals and dental implants. ## **Radiographic Examination** # Diagnosis ## Radiographic Examination Bitewing radiographs are useful for determining periodontal bone height and looking for caries or fractures. All sinus tracts should be traced with a cone of gutta-percha followed by a radiograph to localize their origin. Three dental radiographs showing bitewing views with visible caries, fractures, and a sinus tract traced with gutta-percha. Bitewing radiographs are useful for determining periodontal bone height and looking for caries or fractures. All sinus tracts should be traced with a cone of gutta-percha followed by a radiograph to localize their origin. # Diagnosis **CBCT** The CBCT allows the clinician to determine the true size, extent, and position of periapical and resorptive lesions and gives added information about tooth fractures, missed canals, root canal anatomy, and the nature of the alveolar bone topography around teeth. *Patel et al, Int Endod J 2015; 3–15.* ### **CBCT** The CBCT allows the clinician to determine the true size, extent, and position of periapical and resorptive lesions and gives added information about tooth fractures, missed canals, root canal anatomy, and the nature of the alveolar bone topography around teeth. *Patel et al, Int Endod J 2015; 3–15.* **Diagnosis** *Comparative Testing* Percussion, bite, and palpation to evaluate the status of the periradicular tissues. ## **Comparative Testing** Percussion, bite, and palpation to evaluate the status of the periradicular tissues. # Diagnosis ## Comparative Testing Pulp vitality tests are often of little value when examining teeth with previous endodontic therapy. However, if the patient’s chief complaint reveals the need for these tests, they must be performed because it is possible that the pain may be referred from a nearby vital tooth and not from the root canal– treated tooth. Image of Endo Freeze refrigerant spray and dental instrument Pulp vitality tests are often of little value when examining teeth with previous endodontic therapy. However, if the patient’s chief complaint reveals the need for these tests, they must be performed because it is possible that the pain may be referred from a nearby vital tooth and not from the root canal– treated tooth. Man thinking while holding a question mark # Treatment Planning If the cause of the post-treatment condition remains unknown despite thorough diagnostic workup, then any decision results in an empirical “trial and error” type of treatment. This approach should be avoided if possible. *The patient is then allowed to make a decision based on his or her own perceptions of the options, not by the clinician’s opinion as to what is “best” for the patient.* # **Treatment Planning** If the cause of the post-treatment condition remains unknown despite thorough diagnostic workup, then any decision results in an empirical “trial and error” type of treatment. This approach should be avoided if possible. *The patient is then allowed to make a decision based on his or her own perceptions of the options, not by the clinician’s opinion as to what is “best” for the patient.* **Removal of Obturating Materials** # **Removal of Obturating Materials** # Obturation Materials - Gutta Percha - Solid core obturators. - Paste - Resilon - Silver points. ## **Types of Obturation Materials** - Gutta Percha - Solid core obturators. - Paste - Resilon - Silver points. **Removal of Gutta Percha** Dental radiograph showing a tooth with gutta percha filling in the root canal. ## **Removal of Gutta Percha** # Removal of Gutta Percha - Single cone GP - Condensed GP - Single cone GP - Condensed GP # Removal of Gutta Percha - Removal of gutta percha manually - Removal of gutta percha using rotary system - Removal of gutta percha using LASER ### **Methods for Gutta Percha Removal** - Removal of gutta percha manually - Removal of gutta percha using rotary system - Removal of gutta percha using LASER Two dental instruments for manual removal of gutta percha: one metallic with a pointed tip, the other with a blue handle and serrated shaft. A dental tool with a blue handle and a thin metal shaft ending in a red, curved tip, used for the manual removal of gutta percha. Removal of gutta percha manually ### **Manual Removal of Gutta Percha** Three dental radiographs showing the sequential manual removal of gutta percha from root canals. Five labeled bottles of chemical solvents: A (Chloroform), B (Eucalyptol), C (Halothane), D (Rectified turpentine), E (Xylenes). Diagram showing three rotary instruments (D1, D2, D3) for gutta percha removal, labeled with specifications and intended use: D1 (30/.09) for coronal filling removal (16 mm), D2 (25/.08) for mid-root filling removal (18 mm), D3 (20/.07) for apical filling removal (22 mm). Series of dental or endodontic files labeled by taper percentages: 12%, 8%, 6%, 4%. Tooth with dental clamp undergoing gutta-percha (GP) removal Close-up image of a dental procedure showing "Removal of GP" (gutta-percha) from a tooth using dental clamps and rubber dam isolation. Dental procedure showing teeth with dental dam and a dental drill beside the image. Dental drill bit next to a close-up of a dental procedure in progress, showing a tooth being worked on with a dental instrument. Dental procedure using rubber dam and mirror; endodontic file shown Canal negotiation W.L. determination Close-up of a dental procedure showing a tooth with a blue instrument inserted, labeled for canal negotiation and working length determination. - Canal negotiation - W.L. determination Close-up image of dental procedure showing cavity preparation with rubber dam isolation and dental mirror Just remember - Irrigate - Irrigate - irrigate - Just remember - Irrigate - Irrigate - irrigate A translucent, elongated, pinkish object suspended inside a clear rectangular container against a dark background. Remove solid core obturators ## **Removal of Solid Core Obturators** ThermaPrep 2 oven with obturator heating process shown across four figures: device overview, obturator insertion, control panel, and manual handling. **Therma fill plus with vent** Diagram showing Therma Fill Plus with venting mechanism highlighted by a red arrow. ### **Therma fill plus with vent** GuttaCore (Dentsply) Diagram illustrating the GuttaCore (Dentsply) device with magnified views showing molecular structure before and after treatment. ### **GuttaCore (Dentsply)** Radiograph and clinical view of a tooth with caries and restoration, showing internal structure and decay. Dental radiograph and clinical image showing tooth with endodontic treatment, alongside close-up of dental files on gauze. Dental X-ray showing root canal treatment in progress with instruments visible inside the tooth. Two surgical forceps, one with straight tips and the other with curved tips, displayed side by side. Close-up image of a dental procedure showing a rubber dam isolation with clamp and matrix band placement around a tooth. **Paste removal** Radiographic images showing stages of paste removal in dental procedures, labeled A, B, and C. ## **Paste Removal** - **Removal of Non setting or Soft paste** - Solvent - Hand or rotary instrument (copious Naocl irrigation). - Ultrasonically activated and irrigated files ### **Removal of Non-setting or Soft paste** - Solvent - Hand or rotary instrument (copious Naocl irrigation). - Ultrasonically activated and irrigated files Hard sitting paste Product image showing RESORCINOL FORMALDEHYDE PASTE kit with box, jars, bottles, and mixing tray ### **Hard Setting Paste** - Resorcinol-formaldehyde resin “Russian Red” - Resorcinol-formaldehyde resin “Russian Red” • Removal of Hard sitting pastes: **Burs**, Ultrasonic tips (accessible straight portion of the canal) **Precurved small hand files** (apical area) **Use of Solvent** (Endosolve – R, Septodent) - **Removal of Hard setting pastes:** - **Burs**, Ultrasonic tips (accessible straight portion of the canal) - **Precurved small hand files** (apical area) - **Use of Solvent** (Endosolve – R, Septodent) A small dark bottle with a white ribbed cap and an orange symbol on top. The label reads "Endosolv R" and includes additional text, with a red band at the bottom. The caption below the image states "(Endosolve – R, Septodent )". Removal of Silver Point Image showing four silver-colored dental instruments against a blue background. ## **Removal of Silver Point** [[L1 Non-Surgical Retreatment.pdf#page=1|L1 Non-Surgical Retreatment, p.1]] [[L1 Non-Surgical Retreatment.pdf#page=2|L1 Non-Surgical Retreatment, p.2]] [[L1 Non-Surgical Retreatment.pdf#page=3|L1 Non-Surgical Retreatment, p.3]] [[L1 Non-Surgical Retreatment.pdf#page=4|L1 Non-Surgical Retreatment, p.4]] [[L1 Non-Surgical Retreatment.pdf#page=5|L1 Non-Surgical Retreatment, p.5]] [[L1 Non-Surgical Retreatment.pdf#page=6|L1 Non-Surgical Retreatment, p.6]] [[L1 Non-Surgical Retreatment.pdf#page=7|L1 Non-Surgical Retreatment, p.7]] [[L1 Non-Surgical Retreatment.pdf#page=8|L1 Non-Surgical Retreatment, p.8]] [[L1 Non-Surgical Retreatment.pdf#page=9|L1 Non-Surgical Retreatment, p.9]] [[L1 Non-Surgical Retreatment.pdf#page=10|L1 Non-Surgical Retreatment, p.10]] [[L1 Non-Surgical Retreatment.pdf#page=11|L1 Non-Surgical Retreatment, p.11]] [[L1 Non-Surgical 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