Sir, as a specialist endodontist I am disappointed when my non-surgical root canal treatments are not successful. But I can accept that a slightly sub-100% success rate is in line with evidence-based literature and because I possess the confidence, skills and equipment to subsequently resolve the issue via a surgical approach. What I find harder to accept is that in the Wessex area where I work, all NHS apicectomy referrals are directed only to specialist oral surgeons.
Perhaps whether apicectomy should be considered endodontics or oral surgery depends on interpretation but good agreement exists across these two disciplines about what constitutes the 'Gold standard' best practice in apicectomy.1,2,3 Recently published (in both the endodontic and the oral surgery literature) guidelines state that a modern1,3 apicectomy requires magnification. It recommends cutting the affected root end with no bevel, curetting out the granulation tissue and preparing a retro cavity with ultrasonic-powered, angled cutting tips. After inspection of the cut root end with micromirrors, a root end filling (not amalgam) is placed. The wound is closed with non-resorbable sutures which ought to be removed at a review appointment after four days. Modern apicectomies performed in this way carry a significantly better chance of success (circa five times) compared to procedures attempted under more traditional, now outdated approaches.4,5
I am familiar with this modern protocol and with this armamentarium but in recent weeks I have seen a few patients with symptomatic infected teeth that have histories of prior 'apicectomy'. None of them demonstrated any signs of a retrograde filling yet these 'apicectomies' were performed within the last few months and years by oral surgeons. Inevitably I got to wondering if oral surgeons are aware of/adhere to best practice protocol and whether they are sufficiently equipped to do so?
For what little it is worth I have worked in environments where I have shared space with oral surgeons where there was not a single ultrasonic-powered, angled cutting tip in the oral surgery department.
Since we would all agree that NHS commissioning of apicectomy provision with public money ought to get a service that is being delivered along modern proven approaches, would they then feel it appropriate that specialist endodontists were also approved for apicectomy referrals?
References
Evans G E, Bishop K, Renton T . Update of guidelines for surgical endodontics – the position after ten years. Br Dent J 2012; 212: 497–497.
British Association of Oral Surgeons. Information. Available at: http://www.baos.org.uk/Resources.cfm (accessed December 2016).
Fahey T, O'Connor N, Walker T, Chin-Shong D. Surgical endodontics: a review of current best practice. Oral Surg 2011; 4: 97–104.
Kruse C, Spin-Neto R, Christiansen R, Wenzel A, Kirkevang L L . Periapical bone healing after apicectomy with and without retrograde root filling with Mineral Trioxide Aggregate: A 6-year follow-up of a randomized controlled trial. J Endod 2016; 42: 533–537.
Tortorici S, Difalco P, Caradonna L, Tetè S . Traditional endodontic surgery versus modern technique: a 5-year controlled clinical trial. J Craniofac Surg 2014; 25: 804–807.
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Raftery, P. Referrals: Apicectomy. Br Dent J 222, 2 (2017). https://doi.org/10.1038/sj.bdj.2017.2
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DOI: https://doi.org/10.1038/sj.bdj.2017.2
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