Medical and Dental Considerations in Endodontic Surgery

Factors to consider before initiation of endodontic surgery are directly effecting on the success rate of treatment.

Although there are few absolute contra-indications to endodontic surgery, a well-documented medical history is essential. In general, heart disease, diabetes, blood dyscrasias, debilitating illnesses and steroid therapy may contra-indicate surgery and special measures are necessary if surgery is contemplated. Consideration must also be given to psychological factors. As a rule, local analgesia is preferable, but patients who are particularly apprehensive may wish to have any surgery carried out under sedation.
Chlorhexidine mouthwashes may also be beneficial, and these, together with systemic non-steroidal anti-inflammatory drugs, should be considered from the day prior to surgery.
The choice of anaesthetic may also be governed by the nature of the operation, the site of the tooth and ease of access. A history of rheumatic fever or heart valve problem are not contra-indication for endodontic surgery, provided appropriate antibiotic cover is given. If there is any doubt about a patient’s fitness to undergo any surgical endodontic procedure, then the patient’s physician should always be consulted.
The first considerations are whether the tooth is worth saving and how important it is in the overall treatment plan. No matter how successful the result of surgery would be, if there is not enough tooth structure to warrant a reasonable restorative outcome, the surgery should not be initiated.
The general state of the mouth should be considered, both hard and soft tissues. If numerous teeth have been missing and treatment plan involves a removable prosthetic appliance, then in some cases it is advantageous financially for patient to extract rather than trying to save the tooth in question. The quality of restorative work in the tooth concerned should be particularly noted, and an assessment must also be made of the effects of any proposed surgery on the periodontal condition. The presence of any detectable dehiscence or bony fenestration will influence the design and extent of the flap.
A periapical radiograph should provide all the information required for assessment of the tooth, although it may be necessary to expose more than one film, from different angles. At least 3 mm of the periradicular tissues should be clearly visible. Use of cone-beam CT would be beneficial to evaluate a topographic view of the roots, lesions and surrounding area. Assessment should be made of the root shape, taking into account any unusual curvature and the number of foramina that may be exposed at the apex as a consequence of the operation. If a sinus is present in the soft tissues, the sinus tract should be visualised by taking a radiograph with a gutta-percha point threaded into the tract.
Good visual access is extremely important, and the anatomy of the area must be thoroughly understood. The position of any major structures such as neurovascular bundles and the maxillary sinus must be noted. This become more important when the operation is planned at the site of upper first and second molars or lower premolars. A buccal or labial approach is always preferred, as a palatal approach is difficult and should only be undertaken in exceptional circumstances by experienced practitioners.
One of the key factors influencing the success or failure or periradicular surgery is the experience and expertise of the operator. Consideration should always be given to referral to an appropriate specialist, especially in difficult cases. A letter of referral should include a full clinical and medical history, and all relevant radiographs. Both the referring dentist and the specialist providing treatment have a responsibility to obtain informed consent to the procedure.

P. Carrotte, British Dental Journal 198, 71 - 79 (2005), 
Published online: 22 January 2005 | 



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