Coronal restoration of the root filled tooth - a qualitative analysis of the dentists' decision-making process

Why do dentists refrain from intervention in cases of persistent asymptomatic apical periodontitis in root canal filled teeth? An interview study among general dental practitioners

AIM

To explore the context in which general dental practitioners (GDPs) decide to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with persistent asymptomatic apical periodontitis (PAAP).

METHODOLOGY

Fifteen GDPs were strategically selected for in-depth interviews. The informants were encouraged to describe in their own words and in as much detail as possible, the three most recent patient cases of PAAP of a root canal filled tooth, in which they decided to refrain from further treatment. The interviews were recorded digitally and transcribed verbatim. The collected material was analysed according to Qualitative Content Analysis with an inductive approach.

RESULTS

A pattern of varying degrees of uncertainty associated with the decision process was identified. The motives to refrain intervention had great diversity. The result from analysis of the qualitative data was formulated in an overall theme 'Between doubt and certainty in a complex clinical context' covering the latent content. The first main category covering the manifest content was 'The continuum of confidence' with three subcategories 'Experienced uncertainty', 'Reluctant approval' and 'At ease with refraining' illustrating the feelings and attitudes experienced by the informants. The second category was 'In support of acceptance' with three subcategories 'Patient's autonomy, risks and cost-benefits', 'Emotional aspects' and 'Relieving measures' representing the reasons for refraining from intervention.

CONCLUSIONS

The decision to refrain from further treatment, that is, ortho- or retrograde retreatment or extraction of a root canal filled tooth with PAAP was made with some measure of confidence, combined with compensatory strategies to support the decision, taking into account not only values beneficial to the patient and awareness of limited external resources, but also factors related to the informants' personal preferences, convenience, concerns, ambition and emotions.

Oral health-related quality of life and perceptions of patients following primary root canal treatment or non-surgical retreatment

This retrospective cohort study compared the effect of primary root canal treatment (RCT) with root canal retreatment (Re-RCT) on patient-reported outcomes in Kuala Lumpur, Malaysia. Forty randomly selected adults participated (RCT n = 20; Re-RCT n = 20). The impact their dentition had on the Oral Health Impact Profile-14 (OHIP-14) was assessed by calculating the prevalence of oral health impact, and the severity score. Focus group discussions using a semi-structured guide were arranged through an online meeting platform. Qualitative content analysis identified common themes, and relevant quotes gathered. The impact on OHIP-14 was limited for both RCT and Re-RCT groups with no significant differences in the prevalence of oral health impact. Significant differences were found for functional limitation (RCT higher) and psychological discomfort (Re-RCT higher). Common themes from the discussions include the importance of retaining teeth, the significance of effective communication between clinicians and patients and that the respondents were satisfied with the treatment.

Further Interventions after Root Canal Treatment Are Most Common in Molars and Teeth Restored with Direct Restorations: A 10-11-Year Follow-Up of the Adult Swedish Population

INTRODUCTION

The aims were to investigate 1) the frequency of nonsurgical retreatment, root-end surgery, extraction, and further restorative treatment during a follow-up of 10-11 years after root filling and compare the frequencies according to tooth group and type of coronal restoration and 2) the timing of nonsurgical retreatment, root-end surgery, and extraction.

METHODS

Data were collected from the Swedish Social Insurance Agency's register. A search for treatment codes identified teeth root filled in 2009 and the type of coronal restoration (direct, indirect, and unspecified) registered within 6 months of root filling. The root-filled teeth were followed 10-11 years, and further interventions were recorded. Descriptive statistics and chi-square tests were used for statistical analysis.

RESULTS

In 2009, root fillings were registered for 215,611 individuals/teeth. Nonsurgical retreatment, root-end surgery, and extraction were undertaken in 3.5%, 1.4%, and 20% teeth, respectively. The frequency of further interventions varied with respect to tooth group and type of coronal restoration, but only slightly for endodontic retreatments. Further interventions, except for root-end surgery, were registered more often for molars and directly restored teeth (P < .001). The majority of endodontic retreatments were undertaken within 4 years, while extractions were evenly distributed over 10-11 years.

CONCLUSIONS

The frequency numbers of nonsurgical retreatment and root-end surgery were low, despite 1 in 5 root-filled teeth registered as extracted. Further interventions were most common in molars and directly restored teeth. Endodontic retreatments were performed more often during the first 4 years.

Determinants of Clinical Decision Making under Uncertainty in Dentistry: A Scoping Review

Clinical decision-making for diagnosing and treating oral and dental diseases consolidates multiple sources of complex information, yet individual clinical judgements are often made intuitively on limited heuristics to simplify decision making, which may lead to errors harmful to patients. This study aimed at systematically evaluating dental practitioners' clinical decision-making processes during diagnosis and treatment planning under uncertainty. A scoping review was chosen as the optimal study design due to the heterogeneity and complexity of the topic. Key terms and a search strategy were defined, and the articles published in the repository of the National Library of Medicine (MEDLINE/PubMed) were searched, selected, and analysed in accordance with PRISMA-ScR guidelines. Of the 478 studies returned, 64 relevant articles were included in the qualitative synthesis. Studies that were included were based in 27 countries, with the majority from the UK and USA. Articles were dated from 1991 to 2022, with all being observational studies except four, which were experimental studies. Six major recurring themes were identified: clinical factors, clinical experience, patient preferences and perceptions, heuristics and biases, artificial intelligence and informatics, and existing guidelines. These results suggest that inconsistency in treatment recommendations is a real possibility and despite great advancements in dental science, evidence-based practice is but one of a multitude of complex determinants driving clinical decision making in dentistry. In conclusion, clinical decisions, particularly those made individually by a dental practitioner, are potentially prone to sub-optimal treatment and poorer patient outcomes.

Patient-related outcomes and Oral Health-Related Quality of Life in endodontics

There is increased interest in outcome measures that complement the classic goal of endodontics, being the prevention and healing of apical periodontitis. Possible outcome measures can be subdivided into patient-centred outcomes (PCOs), encompassing data collected by nonpatients aiming to assess the effectiveness of an intervention and patient-reported outcomes (PROs), which are reported directly by the patient. PROs can be subsequently classed into PRO measures that ascertain patients' view of their symptoms, their functional status, and their health-related quality of life, and patient-reported experience measures that focus on aspects including the humanity of care, patient satisfaction, patient preference and adherence, personal costs, expectation fulfilment, and decision regrets. The present review aims to define various patient-related outcomes and discuss the literature available regarding PCOs and PROs in endodontics. This includes those proposed to assess the effectiveness of endodontic treatment for pulpitis and apical periodontitis for use in the development of European Society of Endodontology S3-level clinical practice guidelines that have been included by all working groups, except for the radiographic assessment of apical periodontitis. Based on limited evidence in the field, it can be summarized that after recall periods of various lengths, endodontic treatment is associated with a high likelihood of tooth survival and limited need for further intervention, including extraction and further restorative procedures. Oral Health-Related Quality of Life (OHRQoL) is likely to improve following the completion of treatment. Nonetheless, the literature assessing the association between OHRQoL and endodontics is hampered by the use of instruments that have not been previously validated. Amongst the remaining outcome measures discussed in the present review, it is worth highlighting that there is only one study assessing exacerbations in teeth with the presence of endodontic pathosis, which suggests a very low incidence of this adverse effect following endodontic treatment. Patients' expectation fulfilment, adherence, and satisfaction are closely inter-related and depend also on various nonclinical factors. Further studies assessing PCOs and PROs, in association with healing and prevention of apical periodontitis, are required to better understand endodontic treatment from the perspective of patients.

Tooth survival after endodontic treatment

BACKGROUND

There are several measures that are, or could be, in use in relation to estimating the outcome of endodontic treatments. It is important to reflect on when and why a certain outcome measure is used; when caring for an individual patient it is obvious that the goal always should be a tooth in a healthy state, that is striving to remove any infection and aim for the tooth to have healthy periapical tissues. For patients in general and for society, it is also interesting to know if endodontic treatments will lead to retention of teeth in a functioning state. From epidemiological studies, with high prevalence of root filled teeth with periapical radiolucencies, it is implied that dentists and/or patients accept the retention of a root filled tooth with persistent apical periodontitis. In conjunction with an endodontic treatment the prognosis is considered and since the prognostic factors seem to be somewhat different depending on whether one is considering for example the outcome 'healthy periapical tissues' or 'tooth survival' they are equally important to know. Factors affecting the outcome 'healthy periapical tissues' probably has to do with removal of infection and reconstituting the barrier to prevent leakage whilst 'tooth survival' is more likely associated with factors outside of the classical endodontic field such as restorability and avoidance of further destruction of tooth substance. Objective This narrative review will focus on tooth survival after endodontic treatment and root canal treatment will be the focus. Method The search was performed in PubMed. Results As a crude estimation, there is to be an annual loss of 2% of teeth which have received a root canal treatment. Conclusion Of the pre-, peri- and postoperative factors that have been studied in conjunction with root canal treatments the restoration of the tooth is the factor that has been most extensively studied. Many studies imply that root filled teeth restored with indirect restorations have a better survival than teeth restored with direct restorations, it is not possible to determine whether this indeed is a prognostic factor. Registration None.

Coronal restoration of the root filled tooth - a qualitative analysis of the dentists' decision-making process

Aim

To describe the decision‐making process of the general dental practitioner (GDP) underlying the choice of coronal restoration of a root filled tooth.

Methodology

GDPs were strategically selected with respect to gender, age, undergraduate dental school, service affiliation and duration of professional experience. Semistructured in‐depth interviews were conducted, focusing on the informant’s personal experience of the process which leads to a decision as to how to restore a root filled tooth. The informants were invited to describe in their own words the latest two cases involving decisions of direct or full crown restorations respectively. The interviews were digitally recorded and transcribed verbatim. Interviews from 14 informants, aged 27–64 (mean age 46 years), were included and analysed according to Qualitative Content Analysis.

Results

A theme (latent content) was identified: Clinical factors were considered important but were overruled by context and patient opinions, if in conflict. Three main categories, including seven subcategories (manifest content), were identified. The categories were clinical factors, contextual factors and patient's views. Clinical factors underlying the GDPs' decision included the current dental status and the estimated longevity of the intended restoration. In certain cases, contextual factors were also of importance, either supporting the GDPs' decision or modifying it. However, the patient's views played a decisive role in the final choice of coronal restoration, leading to either mutual acceptance or a compromise, taking into account the patient's economic status and opinions.

Conclusions

With respect to coronal restoration of a root filled tooth, the GDPs’ decision‐making process was based not only on clinical factors, but also on decisive contextual factors and consideration of the patients’ views.