Abstract
PURPOSE:
To
ascertain whether in the presence of a previously endodontically
treated tooth with periapical pathology and/or symptoms and an uncertain
prognosis, it is better to endodontically retreat it or to replace the
tooth with a single-implant-supported crown.
MATERIALS AND METHODS:
Twenty
patients requiring the treatment of a previously endodontically treated
tooth, with periapical pathology and/or symptoms of endodontic origin
and an uncertain prognosis, as judged by the recruiting investigator,
were randomly allocated to endodontic retreatment (Endo group, 10
patients) or tooth extraction and replacement with an implant-supported
crown (Implant group, 10 patients) according to a parallel-group design
at a single centre. Patients were followed to 3 years after completion
of the treatment. Outcome measures were: failure of the procedure,
complications, marginal bone level changes at both teeth and implants,
endodontic radiographic success (teeth only), number of patients' visits
and days to complete the treatment, patients' chair time, costs,
aesthetics assessed using the pink aesthetic score (PES) for the soft
tissues and the white aesthetic score (WES) for the tooth/crown recorded
by independent assessors.
RESULTS:
No patient dropped
out. One endodontically retreated tooth fractured and another had a
crown loosening. There were no statistically significant differences for
treatment failure or complications (difference in proportions = 0.10;
95% CI: -0.09 to 0.29; P (Fisher exact test) = 1.000). The mean marginal
bone levels at endodontic retreatment/implant insertion were 2.10 ±
0.66 mm for the Endo group and 0.05 ± 0.15 mm for the Implant group.
Three years after completion of the treatment, teeth lost on average
0.23 ± 0.82 mm and implants 0.62 ± 0.68 mm, the difference not being
statistically significant (mean difference = -0.39 mm; 95% confidence
interval [CI]: -1.12 to 0.33; P (t test) = 0.267). Three years after
completion of the endodontic retreatment, of the four teeth that
originally had a periapical radiolucency, one was lost, two showed
complete healing, and one showed radiographic improvement. There were no
statistically significant differences for the number of patients'
visits (Endo = 6.67 ± 0.71; Implant = 6.10 ± 0.74; mean difference =
0.57; 95% CI: -0.14 to 1.27; P (t test) = 0.106). It took significantly
more days to complete the implant rehabilitation (Endo = 61 ± 12.97;
Implant = 191.40 ± 75.04; mean difference = -130.40; 95% CI: -184.45 to
-76.35; P (t test) < 0.001) but less patients' chair time (Endo =
629.44 ± 43.62 min; Implant = 326 ± 196.99 min; mean difference =
303.44; 95% CI: 160.87 to 446.02; P (t test) = 0.001). Implant treatment
was significantly more expensive (Endo = €1,588.89 ± 300.81; Implant =
€2,095 ± 158.90; mean difference = €-506.11; 95% CI: -735.41 to -276.82;
P (t test) < 0.001). Three years after treatment completion, mean
PES were 11.11 ± 1.97 and 6.50 ± 2.46 and mean WES were 7.78 ± 1.30 and
6.80 ± 2.39 in the Endo group and Implant group, respectively. Soft
tissues aesthetics (PES) were significantly better at endodontically
retreated teeth (mean difference 4.61; 95% CI: 2.44 to 6.78; P (t test)
< 0.001) whereas no significant differences were observed for tooth
aesthetics (WES) (mean difference 0.98; 95% CI: -0.89 to 2.85; P (t
test) = 0.281) between treatments.
CONCLUSIONS:
The
present preliminary results suggest that both endodontic retreatment and
replacement of previously endodontically treated teeth with persisting
pathology and a dubious endodontic prognosis provided similar short-term
success rates. Aesthetics of the soft tissues and time needed to
complete treatment were in favour of endodontic retreatment whereas
implant rehabilitation required half of the chair time than endodontic
retreatment, but was significantly more expensive. Much larger patient
populations and longer follow-ups are needed to fully answer this
question; however, in this scenario the less invasive endodontic
retreatment could be the first therapeutic option to be considered.
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