Patient treatment decision tree

Chronic Apical Periodontitis with sufficient orthograde RCT

CAP persistence (Mah TF, O Toole GA. Mechanisms of biofilm resistance to antimicrobial agents. Trends Microbiol 2001;56:672-7 / Russel AD. Biocide use and antibiotic resistance: the relevance of laboratory findings to clinical and environmental situation. Lancet Infect Dis 2003; 3:794-803)
Factors influencing Periapical Wound Healing:
1. Infection
2. Foreign bodies
3. Systematic disease
4. impaired host s immune system
Treatment options
1. Surgical retreatment
1.1 Surgical Retreatment RCT without graft
1.2 Surgical Retreatment with guided bone regeneration
Evidence for both procedures is controversial.
Evidence available for the use of autogenous bone graft.
Evidence available for the use of growth factors (PRGF).
2. Extraction
2.a Without socket preservation
Risk of bone resorption ==> buccal bone plate to resorp faster (first 3 months)
2.b With socket preservation
Evidence available to support procedure.
2.1 No further treatment
2.2 Removable device
2.3 Bridge
2.4 Implant


No further treatment

Benefits
"0"

Disadvantages
Bone resorption
Function limitations
Aesthetics issues
Tilting of neighbough teeth
Extrusion of antagonist teeth

Removable device

Benefits
Fast
Reduced costs

Disadvantages
Bone resorption
Function limitations
Aesthetic issues
Reduced retention

Bridge

Benefits
Time saving
Costs

Disadvantages
Bone resorption
Aesthetic issues
Removal of healthy tooth structure (adjacents teeth) long term ==> creates problems?

Implant

Benefits
Maintain bone
Preventive treatment measure

Disadvantages
Costs
Prolonged treatment time
Optional graft needed
Temporization