Endodontic Periodontal Lesions EvidenceBased Multidisciplinary Clinical Management

Endodontic-Periodontal Lesions Evidence-Based Multidisciplinary Clinical Management Igor Tsesis Carlos E Nemcovsky Joseph Nissan Eyal Rosen Editors 123 Endodontic-Periodontal Lesions www.ajlobby.com Igor Tsesis  •  Carlos E Nemcovsky Joseph Nissan  •  Eyal Rosen Editors Endodontic-Periodontal Lesions Evidence-Based Multidisciplinary Clinical Management www.ajlobby.com Editors Igor Tsesis Department of Endodontology School of Dental Medicine Tel Aviv University Tel Aviv Israel Joseph Nissan Department of Oral- Rehabilitation School of Dental Medicine Tel Aviv University Tel Aviv Israel Carlos E Nemcovsky Department of Periodontology and Implant Dentistry The Maurice and Gabriela Goldschleger School of Dental Medicine Tel Aviv University Tel Aviv Israel Eyal Rosen Department of Endodontology School of Dental Medicine Tel Aviv University Tel Aviv Israel ISBN 978-3-030-10724-6    ISBN 978-3-030-10725-3 (eBook) https://doi.org/10.1007/978-3-030-10725-3 Library of Congress Control Number: 2019931053 © Springer Nature Switzerland AG 2019 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland www.ajlobby.com Contents 1 Lesions of Endodontic Periodontal Origin������������������������������������   1 Igor Tsesis, Carlos E Nemcovsky, Joseph Nissan, and Eyal Rosen 2 Etiology and Classification of Endodontic-Periodontal Lesions����������������������������������������������������������������������������������������������   7 Eyal Rosen, Carlos E Nemcovsky, Joseph Nissan, and Igor Tsesis 3 Endodontic Considerations in the Management of Endodontic-Periodontal Lesions����������������������������������������������������   15 Kenneth J Frick, Eyal Rosen, and Igor Tsesis 4 Prosthetic Considerations in the Management of Endodontic-Periodontal Lesions����������������������������������������������������   53 Joseph Nissan, Roberto Sacco, and Roni Kolerman 5 Endodontic-Periodontal Lesions: Periodontal Aspects����������������   59 Carlos E Nemcovsky, José Luis Calvo Guirado, and Ofer Moses 6 Modern Clinical Procedures in Periodontal Reconstructive Treatment ��������������������������������������������������������������   87 Carlos E Nemcovsky and Jose Nart 7 VRF as an Endodontic Periodontal Lesion����������������������������������� 125 Spyros Floratos, Aviad Tamse, and Shlomo Elbahary 8 Treatment Alternatives Following Extraction of Teeth with Periodontal-Endodontic Lesions���������������������������������� 141 Carlos E Nemcovsky, Massimo del Fabbro, Ilan Beitlitum, and Silvio Taschieri 9 Dental Implants Biological Complications: Tooth Preservation Reevaluated ���������������������������������������������������� 195 Carlos E Nemcovsky and Eyal Rosen 10 Integration of Clinical Factors and Patient Values into Clinical Decision-Making in the Management of Endodontic-­Periodontal Lesions������������������������������������������������ 215 Igor Tsesis, Russell Paul, and Eyal Rosen v www.ajlobby.com Lesions of Endodontic Periodontal Origin Igor Tsesis, Carlos E. Nemcovsky, Joseph Nissan, and Eyal Rosen The association of the degenerative changes in the pulp tissues and periodontal disease presents a clinical and conceptual dilemma ever since it was first described in the beginning of the twentieth century by Cahn (1927) [1] Multiple investigations on that topic were later on published Being one of the earliest published by Simring and Goldberg in 1964 [2], claiming that pulpal and periodontal problems are responsible for more than 50% of tooth mortality [2, 3] During the following years many possible etiologies, definitions, classifications, and management alternatives based on different paradigms have been proposed As a consequence, the understanding of this clinical scenario is a matter for ongoing debate Due to the close relationship between endodontic and periodontal diseases, Weine (1972) I Tsesis (*) · E Rosen Department of Endodontology, School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel C E Nemcovsky Department of Periodontology and Implant Dentistry, The Maurice and Gabriela School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel e-mail: carlos@tauex.tau.ac.il J Nissan Department of Oral Rehabilitation School of Dental-Medicine, Tel Aviv University, Tel Aviv, Israel [4] suggested that endodontics is actually “periapical periodontics.” However, this term, like many others’ proposed definitions, has not been widely accepted Regardless of the exact definition and selected characterization scheme, the etiology of these endodontic-periodontal lesions derives from the etiologies of the associated endodontic and periodontal diseases The relative parts of the endodontic and of the periodontal associated diseases in the ensuing endodontic-periodontal lesion vary depending on the nature and pathogenesis of the endodontic-periodontal lesion It ranges from solitary endodontic lesions, in which most, if not the entire etiology, is of endodontic origin, to solitary periodontal lesion, in which the etiology is of periodontal origin only Root canal space infection is the main etiology of apical periodontitis [5] The advance of the disease involves inflammatory reaction of the peri-radicular tissues and periodontal ligamental space [6] Periodontal disease, on the other hand, involves marginal periodontium and results in the progressive loss of the supportive tissues [7] While the etiology of both is bacterial, their clinical presentation is different [8–11] Endodontic disease initiates with the involvement of dental pulp and clinical signs and symptoms may include sensitivity to thermal stimuli Rabin Medical-Center, Belinson Hospital, Petah-Tikva, Israel © Springer Nature Switzerland AG 2019 I Tsesis et al (eds.), Endodontic-Periodontal Lesions, https://doi.org/10.1007/978-3-030-10725-3_1 www.ajlobby.com I Tsesis et al and radiographic presentation of damage to the hard tissue of the tooth such as carries, trauma, or extensive restoration If not treated, the pulp becomes progressively contaminated and peri-­ radical bone resorption becomes evident radiographically (Fig. 1.1) This process may remain asymptomatic or result in purulent inflammation, chronic or acute [12] Infection is the main etiology for periodontal disease [13, 14] Perio-pathogenic bacterial plaque together with calculus accumulation on the external root surfaces progress apically leading to gingival marginal inflammation that may progress to deeper supporting periodontal structures Endotoxins from bacterial plaque together with inflammatory mediators lead to destruction of gingival connective tissue, periodontal ligament, and alveolar bone [15] (Fig. 1.2) The transition of an endodontic disease or of a periodontal disease into a combined endodontic-­ periodontal disease depends on the anatomical communications between the root canal space and of the marginal periodontium There are multiple routes of communication between the root canal space and marginal periodontium [8, 11, 16–23] The main root canal opening (apical foramen) is the main pathway between the infected pulp in periodontal tissues In addition, open dentinal tubuli and lateral canals may contain bacteria and had been Fig 1.1  Second maxillary premolar—the patient presented with a sensitivity to percussion: preoperative radiograph—extensive coronal restoration and radiolucent periapical area; radiograph immediately after root canal treatment, resolution of the periapical lesion at the 1 year follow-up a b Fig 1.2 (a) Anterior mandibular teeth with severe periodontal disease: gingival recession and deep periodontal pockets (b) Following flap elevation, calculus on root surface with large loss of periodontal support is evident www.ajlobby.com 1  Lesions of Endodontic Periodontal Origin a b Fig 1.3  Central maxillary incisor with pulp necrosis and periapical lesion (a) Following root canal filling: lateral canals communicating between the main root canal and periapical lesion are clearly seen (b) reported as possible communication routes for bacteria [8, 11, 16–23] (Fig.  1.3) In addition, various pathological conditions, such as root fractures, perforations, resorption, or anatomical anomalies, may present a pathway for the bacteria [24] By these communications the bacteria from the root canal space may contaminate and infect the marginal periodontium and vice versa [2, 5, 10, 15, 25] The unique etiology and pathogenesis of the endodontic-periodontal disease dictates the required management plan of these challenging clinical cases and the prognosis of the affected teeth The management of the pulpal disease is almost exclusively based on the elimination of the bacteria from the infected root canal space and reinfection prevention [26] Unlike in endodontic disease, in periodontally affected teeth, bacteria reside on the exposed root surfaces in the gingival sulcus and periodontal pockets [8, 9, 14, 15, 25] Accordingly, the manage- ment of the periodontal disease is different, consisting on plaque and calculus elimination to render the root surface biocompatible that may be combined with periodontal reconstructive procedures to enhance periodontal support [27] (Fig. 1.4) The diagnosis of endodontic-periodontal lesions may be intriguing, since both periodontal and endodontic diseases have similar clinical and radiographic symptoms and may mimic each other Moreover, the simultaneous occurrence of the pulpal and periodontal pathology can complicate diagnosis and treatment and compromise the prognosis of the involved teeth While in most cases the manifestation of the periodontal and endodontic diseases is clearly distinct, there are certain clinical scenarios when the signs and symptoms may be confusing, making the final diagnosis complicated and ­subsequently result in the wrong treatment choice [8, 23, 28, 29] (Fig. 1.5) Misdiagnosis and subsequent wrong treatment choice may ultimately result in tooth extraction www.ajlobby.com I Tsesis et al a b Fig 1.4 (a, b) Clinical and radiographic (respectively) aspect of lower anterior teeth shows generalized loss of periodontal support, especially on distal aspect of lateral left incisor (c) Radiograph taken 1 year following reconstructive periodontal treatment with use of enamel matrix proteins derivative, enhanced periodontal support may be a c d appreciated in most involved teeth, note large bone fill on distal aspect of lateral left incisor (d) Radiograph taken 3 years following periodontal surgical treatment, further enhancement of periodontal support may be appreciated in most involved teeth b Fig 1.5  First maxillary molar: the tooth was diagnosed as having a necrotic and infected pulp, chronic apical abscess with a sinus tract traced to the disto-buccal root using a gutta-percha cone (a), peri-radicular bone resorption, and advanced periodontal disease (b) [28, 30, 31] Numerous reports in the literature have presented possible options for the diagnosis and treatment of this condition [32] Following treatment of teeth with endodontic-­ periodontal lesions, appropriate restorative plan is crucial for the prognosis of the teeth Endodontic as well as periodontal pathologies are closely related to the restorative aspects of dentistry Any restorative procedure may cause some degree of pulp damage, and at the same time faulty restoration may result in periodontal involvement [4] Besides, all root canal treated teeth require some type of coronal restoration, and in cases of severe damage to the tooth hard tissues, there may be even needs for surgical treatment In consequence, restoration of teeth with endo-perio lesion is challenging due to uncertain prognosis while tooth structure preservation and proper restorative materials and techniques are essential for long-term success Permanent restoration, direct or indirect, should be placed as soon as possible after the completion www.ajlobby.com 1  Lesions of Endodontic Periodontal Origin of root canal therapy due to the fact that coronal leakage is considered as one of the important factors that influence tooth survival during and after endo-perio treatment From the above mentioned it is clear that the topic of endodontic- periodontal lesion is ultimately relevant to all areas of dentistry The comprehensive multidisciplinary approach is of outmost importance in the diagnosis and management of the endodontic-­ periodontal lesions in order to provide the best chance of providing an optimal treatment A simple and clinically relevant classification and appropriate treatment alternatives and considerations together with biological perspectives of the endodontic periodontal lesions are presented in the following book chapters References Cahn LR. The pathology of pulps found in pyorrhetic teeth Dent Items Int 1927;49:598–617 Simring M, Goldberg M.  The pulpal pocket approach: retrograde periodontitis J Periodontol 1964;35:22–48 Chen SY, Wang HL, Glickman GN. The influence of endodontic treatment upon periodontal wound healing J Clin Periodontol 1997;24(7):449–56 Weine F.  Endodontic therapy Saint Luis: Mosby; 1972 Signoretti FG, Gomes BP, Montagner F, Jacinto RC. Investigation of cultivable bacteria isolated from longstanding retreatment-resistant lesions of teeth with apical periodontitis J Endod 2013;39(10):1240–4 Jakovljevic A, Knezevic A, Karalic D, Soldatovic I, Popovic B, Milasin J, et  al Pro-inflammatory cytokine levels in human apical periodontitis: correlation with clinical and histological findings Aust Endod J 2015;41(2):72–7 Ferreira MC, Dias-Pereira AC, Branco-de-Almeida LS, Martins CC, Paiva SM.  Impact of periodontal disease on quality of life: a systematic review J Periodontal Res 2017;52(4):651–65 Belk CE, Gutmann JL.  Perspectives, controversies and directives on pulpal-periodontal relationships J Can Dent Assoc 1990;56(11):1013–7 Kerekes K, Olsen I. Similarities in the microfloras of root canals and deep periodontal pockets Endod Dent Traumatol 1990;6(1):1–5 10 Rocas IN, Siqueira JF Jr, Santos KR, Coelho AM “Red complex” (bacteroides forsythus, porphyromonas gingivalis, and treponema denticola) in endodontic infections: a molecular approach Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91(4):468–71 11 Simon JH, Glick DH, Frank AL.  The relation ship of endodontic-periodontic lesions J Endod 2013;39(5):e41–6 12 Zanini M, Meyer E, Simon S.  Pulp inflammation diagnosis from clinical to inflammatory mediators: a systematic review J Endod 2017;43(7):1033–51 13 Genco RJ, Borgnakke WS. Risk factors for periodontal disease Periodontol 2013;62(1):59–94 14 Haffajee AD, Socransky SS. Microbiology of periodontal diseases: introduction Periodontol 2005;38:9–12 15 Loe H.  The role of bacteria in periodontal diseases Bull World Health Organ 1981;59(6):821–5 16 Arambawatta K, Peiris R, Nanayakkara D.  Morphology of the cemento-enamel junction in premolar teeth J Oral Sci 2009;51(4):623–7 17 Bender IB, Seltzer S.  The effect of periodontal disease on the pulp Oral Surg Oral Med Oral Pathol 1972;33(3):458–74 18 Gautam S, Galgali SR, Sheethal HS, Priya NS. Pulpal changes associated with advanced periodontal disease: a histopathological study J Oral Maxillofac Pathol 2017;21(1):58–63 19 Gutmann JL.  Prevalence, location, and patency of accessory canals in the furcation region of permanent molars J Periodontol 1978;49(1):21–6 20 Komabayashi T, Nonomura G, Watanabe LG, Marshall GWJ, Marshall SJ.  Dentin tubule numerical density variations below the CEJ. J Dent 2008;36(11):953–8 21 Ricucci D, Siqueira JF Jr Fate of the tissue in lateral canals and apical ramifications in response to pathologic conditions and treatment procedures J Endod 2010;36(1):1–15 22 Simon JH, Glick DH, Frank AL.  The relationship of endodontic-periodontic lesions J Periodontol 1972;43(4):202–8 23 Torabinejad M, Trope M. Endodontic and periodontal interrelationships In: Walton RE, Torabinejad M, editors Principles and Practice of Endodontics; 1996 24 Tsesis I, Rosenberg E, Faivishevsky V, Kfir A, Katz M, Rosen E.  Prevalence and associated periodontal status of teeth with root perforation: a retrospective study of 2,002 patients’ medical records J Endod 2010;36(5):797–800 25 Kurihara H, Kobayashi Y, Francisco IA, Isoshima O, Nagai A, Murayama Y. A microbiological and immunological study of endodontic-periodontic lesions J Endod 1995;21(12):617–21 26 Ng YL, Mann V, Gulabivala K.  Tooth survival following non-surgical root canal treatment: a systematic review of the literature Int Endod J 2010;43(3):171–89 27 Martin-Cabezas R, Davideau JL, Tenenbaum H, Huck O. Clinical efficacy of probiotics as an adjunctive therapy to non-surgical periodontal treatment of chronic periodontitis: a systematic review and meta-­ analysis J Clin Periodontol 2016;43(6):520–30 www.ajlobby.com 9  Dental Implants Biological Complications: Tooth Preservation Reevaluated Fig 9.30  Particulate bone graft is applied supported and covering the tenting screws Fig 9.32  Final sutures after the procedure, tensionless primary soft tissue closure has been procured by flap releasing and internal mattress sutures Fig 9.34  CT scan serial slices months after bone augmentation procedure show extensive vertical hard tissue healing, as compared to Fig.  9.27, covering almost the 207 Fig 9.31  Cross-linked collagen barrier membrane is applied in a selective two-layer procedure, the second layer covers mainly the occlusal area Fig 9.33  Aspect of the surgical area after weeks, note primary soft tissue closure with advanced soft tissue healing entire extent of the tenting screws, making implant placement possible www.ajlobby.com C E Nemcovsky and E Rosen 208 Fig 9.35  Clinical aspect of the alveolar ridge at the time of implant placement shows that primary soft tissue closure over the augmented area has been preserved throughout the complete healing period Fig 9.36  After flap elevation, tenting screws are completely covered by newly formed hard tissue Compare to situation at the time of the bone augmentation procedure in Figs. 9.28 and 9.29 Fig 9.37  Three of the tenting screws have been retrieved, the fourth is completely embedded in newly formed hard tissue even covering the screw head Fig 9.38  Tenting screws removed and implant recipient sites prepared Note quality of newly formed hard tissue Fig 9.39  Implants in place Fig 9.40  Periapical X-ray 3 months after implant placement shows good implant integration with surrounding tissue www.ajlobby.com 9  Dental Implants Biological Complications: Tooth Preservation Reevaluated Fig 9.41  Periapical X-ray 1-year post implant supported reconstruction shows stable situation that enable the management of complications such as retained separated instruments [107], root perforations [5, 6], root resorptions [108], and tooth fractures [109] Some of these modern endodontic modalities adopted the “minimally invasive dentistry” concept As an example, recent studies have suggested treatment of mature permanent teeth with carious pulp exposure by direct pulp capping using modern endodontic bioceramic materials and not by conventional root canal treatment [110] Another modern trend in endodontics, termed “Regenerative endodontics,” is aimed to provide an alternative for the management of immature permanent teeth with pulpal necrosis This approach is based on the assumption that regenerating functional pulpal tissue will eventually enable the replacement of damaged structures, and continued development of the tooth tissues including dentin and root structures [111] However, although these modern “minimally invasive” endodontic modalities seem promising, their scientific basis is lacking and they are mainly based on case reports and small cases series evaluation Recent systematic literature reviews have revealed that there is still no consensus concerning the most appropriate clinical protocol for regenerative endodontic therapy [112] Significant knowledge gaps still exist within the available evidence being unable to provide definitive conclusions on the predictability of regenerative endodontic treatment outcomes [113] 209 Clinical decision-making should be based on solid scientific data, and new treatment modalities, such as regenerative endodontic treatments, should be researched and carefully reviewed before implemented in the daily practice [4] Nevertheless, many modern endodontic treatment modalities such as surgical endodontic treatment of cases where the traditional root canal treatment is impractical are already scientifically well established [114], and may provide predictable results even for compromised teeth and complex cases Moreover, to date most of the teeth that are endodontically treated and adequately restored are expected to survive and function for many years, and those which are finally lost are usually extracted due to non-­endodontic-­related complications, such as periodontal or prosthetic causes [4, 115, 116] Nowadays it is clear that when the treatment plan is appropriate and well performed, both endodontically treated teeth and dental implants exhibit similar survival rates [11] However, since a tooth extraction is irreversible, and since there is no guarantee for either a natural tooth or a dental implant, during the clinical decision-making, both modalities should be considered as complementing, rather than competing treatment alternatives [4, 11] 9.5 Conclusions The main goal of dentistry is to provide patients long-term dental functioning and quality of life [4–6, 15] The alternative to maintain even compromised natural teeth by additional treatments should be carefully considered before an irreversible decision to extract the natural teeth and their replacement with an implant is made [4, 11] Modern endodontic, periodontal, and rehabilitation treatment strategies offer outstanding conservative treatments, that have proven predictable outcomes even in the management of compromised natural dentitions [4–6] Moreover, in most cases, and in light of the significance and magnitude of peri-implant diseases and complications, the choice to replace natural teeth with implants should be made only after all conservative treatments have been considered and discarded or www.ajlobby.com C E Nemcovsky and E Rosen 210 failed, and teeth present with a hopeless or irrational to treat clinical prognosis [3–6, 15] Hopefully, this emerging shift towards conservative dentistry and the preservation of natural teeth will even gain more momentum in the future, ensuing benefits for both the dental practitioners and the patient are expected The practitioners will encounter less unnecessary implant-related medical complication and medico-­legal consequences, and the long-term satisfaction and quality of life of the patients will improve References Iqbal MK, Kim S.  A review of factors influencing treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy J Endod 2008;34(5):519–29 Lundgren D, Rylander H, Laurell L.  To save or to extract, that is the question Natural teeth or dental implants in periodontitis-susceptible patients: clinical decision-making and treatment strategies exemplified with patient case presentations Periodontol 2008;47:27–50 Nemcovsky CE, Rosen E. Biological complications in implant-supported oral rehabilitation: as the pendulum swings back towards endodontics and tooth preservation Evid Based Endod 2017;2(4):1–8 Rosen E, Nemcovsky CE, Tsesis I. Evidence-based decision making in dentistry Switzerland: Springer; 2017 Tsesis I, Nemkowsky CE, Tamse E, Rosen E. Preserving the natural tooth versus extraction and implant placement: making a rational clinical decision Refuat Hapeh Vehashinayim 2010;27(1):37– 46, 75 Tsesis I, Rosenberg E, Faivishevsky V, Kfir A, Katz M, Rosen E. Prevalence and associated periodontal status of teeth with root perforation: a retrospective study of 2,002 patients' medical records J Endod 2010;36(5):797–800 Faggion CM Jr, Schmitter M. Using the best available evidence to support clinical decisions in implant dentistry Int J Oral Maxillofac Implants 2010;25(5):960–9 Fardal O, Grytten J.  A comparison of teeth and implants during maintenance therapy in terms of the number of disease-free years and costs an in  vivo internal control study J Clin Periodontol 2013;40(6):645–51 Topcu AO, Yamalik N, Guncu GN, Tozum TF, El H, Uysal S, Hersek N. Implant-site related and patient-­ based factors with the potential to impact patients' satisfaction, quality of life measures and percep- tions toward dental implant treatment Implant Dent 2017;26(4):581–91 10 Levin L, Halperin-Sternfeld M.  Tooth preservation or implant placement: a systematic review of long-­ term tooth and implant survival rates J Am Dent Assoc 2013;144(10):1119–33 11 Setzer FC, Kim S. Comparison of long-term survival of implants and endodontically treated teeth J Dent Res 2014;93(1):19–26 12 Hannahan JP, Eleazer PD.  Comparison of success of implants versus endodontically treated teeth J Endod 2008;34(11):1302–5 13 Tsesis I. Complications in endodontic surgery: prevention, identification and management Berlin: Springer; 2014 14 Derks J, Tomasi C. Peri-implant health and disease A systematic review of current epidemiology J Clin Periodontol 2015;42(Suppl 16):S158–71 15 Setzer F, Kim S.  Preserving the natural tooth versus extraction and implant placement: an evidence-­ based approach In: Rosen E, Nemcovsky CE, Tsesis I, editors Evidence-based decision making in dentistry Berlin: Springer International Publishing; 2017 p. 73–95 16 Canullo L, Schlee M, Wagner W, Covani U. Montegrotto Group for the Study of P ­ eri-­implant disease International brainstorming meeting on etiologic and risk factors of Peri-implantitis, Montegrotto (Padua, Italy), August 2014 Int J Oral Maxillofac Implants 2015;30(5):1093–104 17 Ericsson I, Berglundh T, Marinello C, Liljenberg B, Lindhe J.  Long-standing plaque and gingivitis at implants and teeth in the dog Clin Oral Implants Res 1992;3(3):99–103 18 Leonhardt A, Adolfsson B, Lekholm U, Wikstrom M, Dahlen G.  A longitudinal microbiological study on osseointegrated titanium implants in partially edentulous patients Clin Oral Implants Res 1993;4(3):113–20 19 Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang NP. Experimentally induced peri-­ implant mucositis A clinical study in humans Clin Oral Implants Res 1994;5(4):254–9 20 Renvert S, Quirynen M.  Risk indicators for peri-­ implantitis A narrative review Clin Oral Implants Res 2015;26(Suppl 11):15–44 21 Salvi GE, Aglietta M, Eick S, Sculean A, Lang NP, Ramseier CA.  Reversibility of experimental peri-implant mucositis compared with experimental gingivitis in humans Clin Oral Implants Res 2012;23(2):182–90 22 Lindhe J, Meyle J, D o E.  W o P.  Group Peri-­ implant diseases: consensus report of the sixth European workshop on periodontology J Clin Periodontol 2008;35(8 Suppl):282–5 23 Roos-Jansaker AM, Renvert H, Lindahl C, Renvert S.  Surgical treatment of peri-implantitis using a bone substitute with or without a resorbable membrane: a prospective cohort study J Clin Periodontol 2007;34(7):625–32 www.ajlobby.com 9  Dental Implants Biological Complications: Tooth Preservation Reevaluated 24 Jepsen S, Berglundh T, Genco R, Aass AM, Demirel K, Derks J, Figuero E, Giovannoli JL, Goldstein M, Lambert F, Ortiz-Vigon A, Polyzois I, Salvi GE, Schwarz F, Serino G, Tomasi C, Zitzmann NU.  Primary prevention of peri-implantitis: managing peri-implant mucositis J Clin Periodontol 2015;42(Suppl 16):S152–7 25 Daubert DM, Weinstein BF, Bordin S, Leroux BG, Flemming TF. Prevalence and predictive factors for peri-implant disease and implant failure: a cross-­ sectional analysis J Periodontol 2015;86(3):337–47 26 Albrektsson T, Buser D, Chen ST, Cochran D, DeBruyn H, Jemt T, Koka S, Nevins M, Sennerby L, Simion M, Taylor TD, Wennerberg A. Statements from the Estepona consensus meeting on peri-­ implantitis, February 2-4, 2012 Clin Implant Dent Relat Res 2012;14(6):781–2 27 Carcuac O, Berglundh T.  Composition of human peri-implantitis and periodontitis lesions J Dent Res 2014;93(11):1083–8 28 Konstantinidis IK, Kotsakis GA, Gerdes S, Walter MH.  Cross-sectional study on the prevalence and risk indicators of peri-implant diseases Eur J Oral Implantol 2015;8(1):75–88 29 Smeets R, Henningsen A, Jung O, Heiland M, Hammacher C, Stein JM.  Definition, etiology, prevention and treatment of peri-implantitis a review Head Face Med 2014;10:34 30 Kumar PS, Dabdoub SM, Hegde R, Ranganathan N, Mariotti A.  Site-level risk predictors of peri-­ implantitis: a retrospective analysis J Clin Periodontol 2018;45(5):597–604 https://doi org/10.1111/jcpe.12892 31 Derks J, Schaller D, Hakansson J, Wennstrom JL, Tomasi C, Berglundh T.  Effectiveness of implant therapy analyzed in a Swedish population: prevalence of peri-implantitis J Dent Res 2016;95(1):43–9 32 Ong CT, Ivanovski S, Needleman IG, Retzepi M, Moles DR, Tonetti MS, Donos N. Systematic review of implant outcomes in treated periodontitis subjects J Clin Periodontol 2008;35(5):438–62 33 Pjetursson BE, Helbling C, Weber HP, Matuliene G, Salvi GE, Bragger U, Schmidlin K, Zwahlen M, Lang NP. Peri-implantitis susceptibility as it relates to periodontal therapy and supportive care Clin Oral Implants Res 2012;23(7):888–94 34 Salvi GE, Zitzmann NU.  The effects of anti-­ infective preventive measures on the occurrence of biologic implant complications and implant loss: a systematic review Int J Oral Maxillofac Implants 2014;29(Suppl):292–307 35 Apse P, Ellen RP, Overall CM, Zarb GA. Microbiota and crevicular fluid collagenase activity in the osseointegrated dental implant sulcus: a comparison of sites in edentulous and partially edentulous patients J Periodontal Res 1989;24(2):96–105 36 Bragger U, Burgin WB, Hammerle CH, Lang NP.  Associations between clinical parameters assessed around implants and teeth Clin Oral Implants Res 1997;8(5):412–21 211 37 Kohavi D.  Complications in the tissue integrated prostheses components: clinical and mechanical evaluation J Oral Rehabil 1993;20(4):413–22 38 Koka S, Razzoog ME, Bloem TJ, Syed S. Microbial colonization of dental implants in partially edentulous subjects J Prosthet Dent 1993; 70(2):141–4 39 Leonhardt A, Berglundh T, Ericsson I, Dahlen G.  Putative periodontal pathogens on titanium implants and teeth in experimental gingivitis and periodontitis in beagle dogs Clin Oral Implants Res 1992;3(3):112–9 40 Mombelli A, Marxer M, Gaberthuel T, Grunder U, Lang NP.  The microbiota of osseointegrated implants in patients with a history of periodontal disease J Clin Periodontol 1995;22(2):124–30 41 Quirynen M, Listgarten MA. Distribution of bacterial morphotypes around natural teeth and titanium implants ad modum Branemark Clin Oral Implants Res 1990;1(1):8–12 42 Mombelli A, van Oosten MA, Schurch E Jr, Land NP.  The microbiota associated with successful or failing osseointegrated titanium implants Oral Microbiol Immunol 1987;2(4):145–51 43 Theodoridis C, Grigoriadis A, Menexes G, Vouros I.  Outcomes of implant therapy in patients with a history of aggressive periodontitis A ­ systematic review and meta-analysis Clin Oral Investig 2017;21(2):485–503 44 Safii SH, Palmer RM, Wilson RF.  Risk of implant failure and marginal bone loss in subjects with a history of periodontitis: a systematic review and meta-analysis Clin Implant Dent Relat Res 2010;12(3):165–74 45 Serino G, Strom C.  Peri-implantitis in partially edentulous patients: association with inadequate plaque control Clin Oral Implants Res 2009;20(2):169–74 46 Apatzidou DA, Riggio MP, Kinane DF.  Impact of smoking on the clinical, microbiological and immunological parameters of adult patients with periodontitis J Clin Periodontol 2005;32(9): 973–83 47 Cesar-Neto JB, Benatti BB, Sallum EA, Casati MZ, Nociti FH Jr The influence of cigarette smoke inhalation and its cessation on the tooth-supporting alveolar bone: a histometric study in rats J Periodontal Res 2006;41(2):118–23 48 Gamal AY, Bayomy MM. Effect of cigarette smoking on human PDL fibroblasts attachment to periodontally involved root surfaces in  vitro J Clin Periodontol 2002;29(8):763–70 49 Graswinckel JE, van der Velden U, van Winkelhoff AJ, Hoek FJ, Loos BG.  Plasma antibody levels in periodontitis patients and controls J Clin Periodontol 2004;31(7):562–8 50 Keenan JR, Veitz-Keenan A.  The impact of smoking on failure rates, postoperative infection and marginal bone loss of dental implants Evid Based Dent 2016;17(1):4–5 212 51 Morozumi T, Kubota T, Sato T, Okuda K, Yoshie H. Smoking cessation increases gingival blood flow and gingival crevicular fluid J Clin Periodontol 2004;31(4):267–72 52 Ryder MI, Fujitaki R, Lebus S, Mahboub M, Faia B, Muhaimin D, Hamada M, Hyun W.  Alterations of neutrophil L-selectin and CD18 expression by tobacco smoke: implications for periodontal diseases J Periodontal Res 1998;33(6):359–68 53 Tanur E, McQuade MJ, McPherson JC, Al-Hashimi IH, Rivera-Hidalgo F.  Effects of nicotine on the strength of attachment of gingival fibroblasts to glass and non-diseased human root surfaces J Periodontol 2000;71(5):717–22 54 Tipton DA, Dabbous MK.  Effects of nicotine on proliferation and extracellular matrix production of human gingival fibroblasts in  vitro J Periodontol 1995;66(12):1056–64 55 Tran DT, Gay IC, Diaz-Rodriguez J, Parthasarathy K, Weltman R, Friedman L.  Survival of dental implants placed in grafted and nongrafted bone: a retrospective study in a university setting Int J Oral Maxillofac Implants 2016;31(2):310–7 56 Veitz-Keenan A.  Marginal bone loss and dental implant failure may be increased in smokers Evid Based Dent 2016;17(1):6–7 57 Alrabiah M, Al-Aali KA, Al-Sowygh ZH, Binmahfooz AM, Mokeem SA, Abduljabbar T.  Association of advanced glycation end products with periimplant inflammation in pre-diabetes and type diabetes mellitus patients Clin Implant Dent Relat Res 2018;20(4):535–40 https://doi org/10.1111/cid.12607 58 Al-Sowygh ZH, Ghani SMA, Sergis K, Vohra F, Akram Z.  Peri-implant conditions and levels of advanced glycation end products among patients with different glycemic control Clin Implant Dent Relat Res 2018;20(3):345–51 https://doi org/10.1111/cid.12584 59 Korsch M, Robra BP, Walther W. Cement-associated signs of inflammation: retrospective analysis of the effect of excess cement on peri-implant tissue Int J Prosthodont 2015;28(1):11–8 60 Linkevicius T, Puisys A, Vindasiute E, Linkeviciene L, Apse P.  Does residual cement around implant-­ supported restorations cause peri-implant disease? A retrospective case analysis Clin Oral Implants Res 2013;24(11):1179–84 61 Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Maslova N, Puriene A.  The influence of the cementation margin position on the amount of undetected cement A prospective clinical study Clin Oral Implants Res 2013;24(1):71–6 62 Wilson TG Jr The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study J Periodontol 2009;80(9):1388–92 63 Raes M, D'hondt R, Teughels W, Coucke W, Quirynen M.  A 5-year randomized clinical trial C E Nemcovsky and E Rosen comparing minimally with moderately rough implants in patients with severe periodontitis J Clin Periodontol 2018;45(6):711–20 https://doi org/10.1111/jcpe.12901 64 Thoma DS, Naenni N, Figuero E, Hämmerle CHF, Schwarz F, Jung RE, Sanz-Sánchez I.  Effects of soft tissue augmentation procedures on peri-implant health or disease: a systematic review and meta-­ analysis Clin Oral Implants Res 2018;29(Suppl 15):32–49 https://doi.org/10.1111/clr.13114 65 Aguirre-Zorzano LA, Estefania-Fresco R, Telletxea O, Bravo M. Prevalence of peri-implant inflammatory disease in patients with a history of periodontal disease who receive supportive periodontal therapy Clin Oral Implants Res 2015;26(11):1338–44 66 Costa FO, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE.  Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up J Clin Periodontol 2012;39(2):173–81 67 Frisch E, Ziebolz D, Vach K, Ratka-Kruger P. Supportive post-implant therapy: patient compliance rates and impacting factors: 3-year follow-up J Clin Periodontol 2014;41(10):1007–14 68 Tonetti MS, Chapple IL, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and peri-­ implant diseases: introduction to, and objectives of the 11th European workshop on periodontology consensus conference J Clin Periodontol 2015;42(Suppl 16):S1–4 69 Monje A, Aranda L, Diaz KT, Alarcon MA, Bagramian RA, Wang HL, Catena A.  Impact of maintenance therapy for the prevention of peri-­ implant diseases: a systematic review and meta-­ analysis J Dent Res 2016;95(4):372–9 70 Renvert S, Polyzois I. Treatment of pathologic peri-­ implant pockets Periodontol 2018;76(1):180–90 https://doi.org/10.1111/prd.12149 71 Esposito M, Grusovin MG, Worthington HV.  Treatment of peri-implantitis: what interventions are effective? A Cochrane systematic review Eur J Oral Implantol 2012;5:S21–41 72 Lang NP, Wilson TG, Corbet EF.  Biological complications with dental implants: their prevention, diagnosis and treatment Clin Oral Implants Res 2000;11(Suppl 1):146–55 73 Carcuac O, Abrahamsson I, Charalampakis G, Berglundh T.  The effect of the local use of chlorhexidine in surgical treatment of experimental peri-implantitis in dogs J Clin Periodontol 2015;42(2):196–203 74 Menezes KM, Fernandes-Costa AN, Silva-Neto RD, Calderon PS, Gurgel BC.  Efficacy of 0.12% Chlorhexidine Gluconate for non-surgical treatment of Peri-implant Mucositis J Periodontol 2016;87(11):1305–13 75 Porras R, Anderson GB, Caffesse R, Narendran S, Trejo PM.  Clinical response to different thera- 9  Dental Implants Biological Complications: Tooth Preservation Reevaluated peutic regimens to treat peri-implant mucositis J Periodontol 2002;73(10):1118–25 76 Renvert S, Lessem J, Dahlen G, Lindahl C, Svensson M.  Topical minocycline microspheres versus topical chlorhexidine gel as an adjunct to mechanical debridement of incipient peri-implant infections: a randomized clinical trial J Clin Periodontol 2006;33(5):362–9 77 Hammerle CH, Fourmousis I, Winkler JR, Weigel C, Bragger U, Lang NP.  Successful bone fill in late peri-implant defects using guided tissue regeneration A short communication J Periodontol 1995;66(4):303–8 78 Persson LG, Ericsson I, Berglundh T, Lindhe J. Guided bone regeneration in the treatment of periimplantitis Clin Oral Implants Res 1996;7(4):366–72 79 Wetzel AC, Vlassis J, Caffesse RG, Hammerle CH, Lang NP. Attempts to obtain re-osseointegration following experimental peri-implantitis in dogs Clin Oral Implants Res 1999;10(2):111–9 80 Figuero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of peri-implant mucositis and peri-­ implantitis Periodontol 2014;66(1):255–73 81 Schwarz F, Becker K, Sager M.  Efficacy of professionally administered plaque removal with or without adjunctive measures for the treatment of peri-implant mucositis A systematic review and meta-analysis J Clin Periodontol 2015;42(Suppl 16):S202–13 82 Lu HK, Chei CJ. Efficacy of subgingivally applied minocycline in the treatment of chronic periodontitis J Periodontal Res 2005;40(1):20–7 83 Bland PS, Goodson JM, Gunsolley JC, Grossi SG, Otomo-Corgel J, Doherty F, Comiskey JL.  Association of antimicrobial and clinical efficacy: periodontitis therapy with minocycline microspheres J Int Acad Periodontol 2010;12(1):11–9 84 Bassetti M, Schar D, Wicki B, Eick S, Ramseier CA, Arweiler NB, Sculean A, Salvi GE.  Anti-infective therapy of peri-implantitis with adjunctive local drug delivery or photodynamic therapy: 12-month outcomes of a randomized controlled clinical trial Clin Oral Implants Res 2014;25(3):279–87 85 Renvert S, Lessem J, Lindahl C, Svensson M.  Treatment of incipient peri-implant infections using topical minocycline microspheres versus topical chlorhexidine gel as an adjunct to mechanical debridement J Int Acad Periodontol 2004;6(4 Suppl):154–9 86 Salvi GE, Persson GR, Heitz-Mayfield LJ, Frei M, Lang NP.  Adjunctive local antibiotic therapy in the treatment of peri-implantitis II: clinical and radiographic outcomes Clin Oral Implants Res 2007;18(3):281–5 87 Schar D, Ramseier CA, Eick S, Arweiler NB, Sculean A, Salvi GE.  Anti-infective therapy of peri-implantitis with adjunctive local drug delivery or photodynamic therapy: six-month outcomes of 213 a prospective randomized clinical trial Clin Oral Implants Res 2013;24(1):104–10 88 Faggion CM Jr, Listl S, Fruhauf N, Chang HJ, Tu YK.  A systematic review and Bayesian network meta-analysis of randomized clinical trials on non-surgical treatments for peri-implantitis J Clin Periodontol 2014;41(10):1015–25 89 D'Aiuto F, Nibali L, Parkar M, Suvan J, Tonetti MS. Short-term effects of intensive periodontal therapy on serum inflammatory markers and cholesterol J Dent Res 2005;84(3):269–73 90 Persson GR, Salvi GE, Heitz-Mayfield LJ, Lang NP.  Antimicrobial therapy using a local drug delivery system (Arestin) in the treatment of peri-­ implantitis I: microbiological outcomes Clin Oral Implants Res 2006;17(4):386–93 91 Bonito AJ, Lux L, Lohr KN.  Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review J Periodontol 2005;76(8):1227–36 92 Eger M, Sterer N, Liron T, Kohavi D, Gabet Y. Scaling of titanium implants entrains inflammation-­induced osteolysis Sci Rep 2017;7:39612 93 Jurczyk K, Nietzsche S, Ender C, Sculean A, Eick S.  In-vitro activity of sodium-hypochlorite gel on bacteria associated with periodontitis Clin Oral Investig 2016;20(8):2165–73 94 Roos-Jansaker AM, Almhojd US, Jansson H. Treatment of peri-implantitis: clinical outcome of chloramine as an adjunctive to non-surgical therapy, a randomized clinical trial Clin Oral Implants Res 2017;28(1):43–8 95 Jepsen K, Jepsen S, Laine ML, Anssari Moin D, Pilloni A, Zeza B, Sanz M, Ortiz-Vigon A, Roos-­ Jansaker AM, Renvert S.  Reconstruction of peri-­ implant osseous defects: a multicenter randomized trial J Dent Res 2016;95(1):58–66 96 Suarez F, Monje A, Galindo-Moreno P, Wang HL. Implant surface detoxification: a comprehensive review Implant Dent 2013;22(5):465–73 97 Kar K. Teeth in the era of implant dentistry J Calif Dent Assoc 2014;42(12):821–7 98 Norkin FJ.  An era of evidence-based implant dentistry: 30 years since Toronto Compend Contin Educ Dent 2012;33(8):618–9 99 Doyle SL, Hodges JS, Pesun IJ, Law AS, Bowles WR.  Retrospective cross sectional comparison of initial nonsurgical endodontic treatment and single-­ tooth implants J Endod 2006;32(9):822–7 100 Dalli M, Colak H, Mustafa Hamidi M.  Minimal intervention concept: a new paradigm for operative dentistry J Investig Clin Dent 2012;3(3): 167–75 101 Schulein TM.  Significant events in the history of operative dentistry J Hist Dent 2005; 53(2):63–72 102 Gutmann JL.  Minimally invasive dentistry (Endodontics) J Conserv Dent 2013;16(4):282–3 214 103 Endodontists AA o ENDODONTICS colleagues for excellence: the dental operating microscope in endodontics Chicago, IL: AAE; 2016 104 Tsesis I, Blazer T, Ben-Izhack G, Taschieri S, Del Fabbro M, Corbella S, Rosen E. The precision of electronic apex locators in working length determination: a systematic review and meta-analysis of the literature J Endod 2015;41(11):1818–23 105 Weber MT, Stratz N, Fleiner J, Schulze D, Hannig C.  Possibilities and limits of imaging endodontic structures with CBCT.  Swiss Dent J 2015;125(3):293–311 106 Taschieri S, Del Fabbro M, Weinstein T, Rosen E, Tsesis I. Magnification in modern endodontic practice Refuat Hapeh Vehashinayim 2010;27(3):18–22, 61 107 Rosen E, Venezia NB, Azizi H, Kamburoglu K, Meirowitz A, Ziv-Baran T, Tsesis I.  A comparison of cone-beam computed tomography with periapical radiography in the detection of separated instruments retained in the apical third of root canal-filled teeth J Endod 2016;42(7):1035–9 108 Kaval ME, Guneri P, Caliskan MK. Regenerative endodontic treatment of perforated internal root resorption: a case report Int Endod J 2018;51(1):128–37 109 Rosen E, Beitlitum I, Tsesis I. The preservation of teeth with root-originated fractures Evid Based Endod 2018;3(2):1–7 110 Linu S, Lekshmi MS, Varunkumar VS, Sam Joseph VG. Treatment outcome following direct pulp cap- C E Nemcovsky and E Rosen ping using bioceramic materials in mature permanent teeth with carious exposure: a pilot retrospective study J Endod 2017;43(10):1635–9 111 Endodontists AA o Endodontics colleagues for excellence: regenerative endodontics Chicago, IL: AAE; 2013 112 Bucchi C, Valdivia-Gandur V, Sánchez-Bizjak R, Tallón-Walton V, Manzanares-Céspedes C.  Regenerative endodontic therapy: a systematic review of clinical protocols Int J Clin Exp Med 2017;10(3):2006–15 113 Tong HJ, Rajan S, Bhujel N, Kang J, Duggal M, Nazzal H.  Regenerative endodontic therapy in the Management of Nonvital Immature Permanent Teeth: a systematic review-outcome evaluation and meta-analysis J Endod 2017;43(9):1453–64 114 Tsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y, Ceresoli V, Del Fabbro M. Outcomes of surgical endodontic treatment performed by a modern technique: an updated meta-analysis of the literature J Endod 2013;39(3):332–9 115 Ng YL, Mann V, Gulabivala K.  Tooth survival following non-surgical root canal treatment: a systematic review of the literature Int Endod J 2010;43(3):171–89 116 Salehrabi R, Rotstein I.  Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study J Endod 2004;30(12):846–50 Integration of Clinical Factors and Patient Values into Clinical Decision-Making in the Management of Endodontic-­ Periodontal Lesions 10 Igor Tsesis, Russell Paul, and Eyal Rosen 10.1 Introduction is “common” for all the patients This assumption doesn’t necessarily direct the practitioner as to Since the introduction of evidence-based medi- what is best and preferred for the specific patient cine in the early 1990s, the medical community It seems that although it is generally accepted has developed a practice that incorporates the that it is important to treat the patient and not just best available scientific evidence to support the his disease [2, 3], in practice there is a lack of clinical decision-making process [1] Various sci- clinical decision-making mechanisms available entific groups and specialty committees have to practitioners to aid the incorporation of the worked ever since to improve the quality and the preferences and values of individual patients [4] global use of clinical decision-making in To translate evidence into clinical practice, clinihealthcare cians need to judge how to apply the evidence to The clinical decision-making in the manage- individual patients [5] ment of endodontic-periodontal lesions is comAn extensive, broad dental treatment that plex and presents significant clinical challenges to includes tooth extractions, and large prosthetic practitioners as far as diagnosis, treatment plan- restorations, while sometimes is a “correct” treatning, and prognosis assessment Appropriately, ment plan, may be not suitable for a specific in this era of evidence-based decision-­making, patient with a specific clinical problem (Fig. 10.1) practitioners usually tend to utilize scientific eviKeeping in mind that preservation of the natdence to guide them in these complex clinical ural teeth is an ultimate goal, in some clinical cases scenarios extraction may be the best treatment However, the scientific evidence usually choice On the other hand, the decision-making guides the practitioner in his clinical decision-­ process regarding endodontic treatment should making based on the assumption that the disease be guided by the strategic importance of the tooth Certain conditions may present a contraindication for endodontic treatment, such as poor compliance, patients with Parkinson’s disease, I Tsesis (*) · R Paul · E Rosen tremors, or dementia The appropriateness of preDepartment of Endodontology, School of Dental serving the tooth should be considered [6] Medicine, Tel Aviv University, Tel Aviv, Israel © Springer Nature Switzerland AG 2019 I Tsesis et al (eds.), Endodontic-Periodontal Lesions, https://doi.org/10.1007/978-3-030-10725-3_10 215 I Tsesis et al 216 a b c Fig 10.1  The patient is an elderly female who complains of pain and swelling in the buccal vestibule of the maxilla She is satisfied with the fixed prosthetic restoration which has been present for many years Her only concern relates to pain elimination In the radiograph, the maxillary first premolar has a necrotic pulp, a periapical lesion, and an osseous periodontal defect on the distal aspect of the root The treatment decision was made following a discussion with the patient to perform endodontic surgery, thus preserving the existing restoration (a) Pretreatment radiograph (b) Immediate posttreatment radiograph (c) At the 1  year follow-up appointment, there is complete resolution of the apical disease While there is still a periodontal lesion, the patient is symptom-free and satisfied with the treatment outcome Although there is wide agreement as to the immense value of the practice of evidencebased medicine in the art and science of clinical decision-­ making, its clinical usefulness could be enhanced if clinicians understood the gaps that exist between the research evidence and the care of the individual patient, and dealt with them accordingly [7] Data collected from carefully conducted and controlled studies may not be directly applicable to an individual patient Applying average results derived from groups of patients to a unique patient is bound to be problematic [7, 8] In addition, the patients themselves vary significantly in their willingness to take part in the decision-making process, ranging from “traditional patients” that grant all responsibilities and decision to the practitioner, to more involved patients that prefer the modern shared decision-­ making approach in which the practitioner and the patient work collaboratively to assess and chose the preferred treatment alternative [9] 10  Integration of Clinical Factors and Patient Values into Clinical Decision-Making in the Management a b 217 c Fig 10.2  The patient presented with discomfort relating to the maxillary first molar Upon examination, the tooth had a necrotic pulp with an apical periodontitis accompanied by advanced periodontal disease While the prognosis in such cases is not favorable and extraction may be a good treatment choice, in this case the patient refused extracting the tooth and was willing to accept the financial risk including any costs relating to the treatment Following a discussion with the patient, the decision was made to treat the tooth endodontically in order to make an effort to retain it as long as possible (a) Preoperative radiograph—a carious lesion with extensive bone loss in the periradicular area (b) Immediate postoperative radiograph (c) A 2 year follow-up of the treatment While the long-term prognosis remains questionable, the treatment results are in agreement with the patient’s expectations In clinical decision-making, it is not only important to empirically estimate the probability of the possible outcomes with each treatment alternative The patient preferences and value judgments associated with these outcomes must also be recognized and incorporated into the process to guide individual patient decision-making [4, 9, 10] A patient’s own wishes and preferences may determine how evidence is applied to them (Fig. 10.2) There are delicate but crucial differences between the terms “patient preferences” and “patient values.” Patient preferences can be defined as “the relative importance that patients place on various health outcomes.” On the other hand, patient values can be defined as “a person’s beliefs, desires, and expectations of what is right or wrong.” Values are not specific to a certain context [11] The patient’s autonomy, rights, and point of view should be respected and taken into consideration [7] It is a generally accepted idea that patients should have a say in treatment decision-­making [12] Treatment options should be clearly and objectively communicated to the patient and the patient should be fully informed regarding the disease Subjectivity and personal values may then influence the decision-making process [13] While patient autonomy in decision-making is desired, if the information presented by the dentist or dental specialist is biased, it could influence the patient toward one treatment option over another, clinicians’ decision-making style may affect patients’ preferences [14] (Fig. 10.3) In this study [14], first-year dental students simulated the role of patients All students were given the same scenario of a tooth with failed endodontic therapy and asked to select from between two treatment options Biased presentations significantly influenced the treatment selection by the students Thus, if treatment options are presented in a biased manner toward one option, the patient is more likely to select that treatment option It is important for dentists to recognize that the preferences of patients can differ from their own [15] While there is a general impression that patients themselves are in the best position to evaluate the trade-offs between the benefits and risks of alternative treatments [16, 17], patient I Tsesis et al 218 a b c Fig 10.3  A patient with an extensive restoration in the anterior mandibular area presented with a draining sinus tract and periodontal pockets in the labial area of the mandibular lateral incisor While the prognosis of the tooth is questionable, after discussing the possible treatment choices with the patient, which included an obvious option of extraction of the lateral incisor, a conservative approach of surgical endodontic treatment was chosen (a) Preoperative radiograph showing an extensive bone loss in the mesial area of the mandibular lateral incisor with an endo-perio communication (b) Immediate postoperative radiograph (c) Complete healing in the periapical area and bone regeneration year following the treatment autonomy in itself is not a rationale for treatment and does not give the patient the right to choose inappropriate treatment [18] Psychological or emotional considerations appear to influence a seemingly irrational treatment choice by the patient Sometimes the patient’s request for certain type of treatment is based not on rational considerations, but instead on fear or some other psychological condition [18] Patients’ preferences are influenced by: demographic variables (with younger, better educated patients and women being quite consistently found to prefer a more active role in decision-­ making), their experience of illness and medical care, their diagnosis and health status, the type of decision they need to make, the amount of knowledge they have acquired about their condition, their attitude toward involvement, and the interactions and relationships they experience with health professionals [17] Patients’ impressions of dentists’ examination styles, personali- ties, and ability to relate to them as individuals seem to mediate both treatment acceptance and willingness to participate in the decision-making process [19] When patient values and dentist perceptions were examined, the dentists’ perceptions were not closely matched to patient values [20] While research has shown that doctors underestimate the amount of information that patients want, it is less clear how much patients actually want to be involved in making decisions about their treatment and what influences their preference for involvement [17, 21] Thus, patients and health professionals often have different views on and preferences for treatment because they look at treatment from different standpoints The direction and magnitude of these preference differences not appear to be consistent and may vary with the clinical condition of interest [22] Regardless of how involved with the decision-making the 10  Integration of Clinical Factors and Patient Values into Clinical Decision-Making in the Management patient wants to be, it is essential for the clinician to explore the patient’s values about the treatment and its potential risks and benefits in order to incorporate them into decision-making process [5] Patient expectations about their role in choice and decision-making have been influenced by living in a consumer society [16] One of the most important aspects of patient values and preferences is the cost of dental treatment It has been suggested that in many cases cost outcomes are just as important as clinical and humanistic outcomes, and should be discussed with patients who would actively participate in making their treatment decisions [23, 24] Illness-related costs consist of three components: direct, indirect, and intangible costs Direct illness-related costs relate to financial expenses that must be incurred in order to treat a disease It comprises monetary payments, travel expenses to visit the doctor, and nonmedical costs (i.e., costs for nonmedical services that are results of illness or disease such as transportation or travel costs) [23] Indirect cost—measured as loss of productive time (loss of productivity), lost leisure time, and absences from work Every hour not worked due to illness is regarded as a loss of productivity [25] Finally there is the cost type that is termed intangible cost Intangible cost refers to patients’ psychological pain and discomfort [26] It is a cost in the form of pain and suffering, or generally a lowered quality of life, and these are borne by patients, relatives, and those close to the patient [27] Thus, the cost of treatment and patients’ financial ability to afford more expensive treatments may affect their decision-making potential 219 Higher annual family income was associated with a higher rate of participants’ preferring endodontic therapy to retain a posterior tooth [15] Differences related to the population (genetic, cultural, environmental, healthcare facilities) and individual differences (age, comorbidity, past or current treatments, nonbiological variables) may affect the translation of evidence from a study sample to an individual patient [7, 8] More recently, there is an increase in the life expectancy of the world population, and consequently a growing number of elderly individuals Various surveys indicate that increasing numbers of adults are retaining teeth into old age [28] It is widely accepted that root canal treatment is as predictable in the old as the young, provided that pulp canal infection can be properly managed The response of teeth in older healthy adults to high-quality endodontic procedures is as good as it would be in younger adults [29] However, technical challenges to proper infection control may be encountered in damaged, biologically old teeth [6] The teeth of elderly patients present various alterations of pulp tissue [30], pulp tissue fibrosis, and decrease in vascularization [31], making it difficult to perform endodontic treatment [28, 32] In conclusion, dentists’ preferences notwithstanding, the important ethical principle of patient autonomy is that patients’ values should play a very substantial role in clinical decisions [15] (Fig. 10.4) In this person-centered approach, the patient is dynamic, context-aware, and cooperates with the health professional in order to achieve the most satisfactory treatment decision for him/herself, creating a balance between the preferences of the former and the expertise of the latter [33] I Tsesis et al 220 a b c d Fig 10.4  Preoperative radiograph of the mandibular second molar There was a deep caries lesion, the pulp was necrotic with an apical periodontitis coupled with periodontal involvement of the furcation (a) Preoperative radiograph (b) Immediate postoperative radiograph (c) One year following the treatment The tooth was asymptomatic; radiographically a partial resolution of the apical References Rosenberg W, Donald A.  Evidence based medicine: an approach to clinical problem-solving BMJ 1995;310(6987):1122–6 Ausman JI.  Treat the patient not the disease Surg Neurol 2003;59(2):139 Zvulunov A.  Primum non nocere, or treat the patient, not the disease J Am Acad Dermatol 2013;69(6):1055–6 Fallah A.  Moving beyond evidence-based medicine: incorporating patient values and preferences Epilepsy Behav 2015;53:209–10 Straus SE, McAlister F.  Applying the results of trials and systematic reviews to our individual patients Evid Based Ment Health 2001;4(1):6–7 Allen PF, Whitworth JM.  Endodontic considerations in the elderly Gerodontology 2004;21(4):185–94 Schattner A, Fletcher RH. Research evidence and the individual patient QJM 2003;96(1):1–5 lesion could be seen, while there was no improvement of the marginal periodontium in the furcation area (d) At the 4 year follow-up, the tooth was still asymptomatic without any changes radiographically However, the adjacent implant failed (a broken surgical bur can be seen in the area, probably following an attempt to remove the broken implant) Mant D.  Evidence and primary care: can randomized trials inform clinical decisions about individual patients? Lancet 1999;353:743–6 Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et  al Shared decision making: a model for clinical practice J Gen Intern Med 2012;27(10):1361–7 10 Mileman PA, van den Hout WB. Evidence-based diagnosis and clinical decision making Dentomaxillofac Radiol 2009;38(1):1–10 11 Boyd CM, Singh S, Varadhan R, Weiss CO, Sharma R, Bass EB, et  al Methods for benefit and harm assessment in systematic reviews Rockville (MD): AHRQ Methods for Effective Health Care; 2012 12 Montgomery AA, Fahey T.  How patients' treatment preferences compare with those of clinicians? Qual Health Care 2001;10(Suppl 1):i39–43 13 Kvist T. Endodontic retreatment Aspects of decision making and clinical outcome Swed Dent J Suppl 2001;144:1–57 14 Foster KH, Harrison E. Effect of presentation bias on selection of treatment option for failed endodontic 10  Integration of Clinical Factors and Patient Values into Clinical Decision-Making in the Management therapy Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106(5):e36–9 15 Azarpazhooh A, Dao T, Figueiredo R, Krahn M, Friedman S. A survey of patients' preferences for the treatment of teeth with apical periodontitis J Endod 2013;39(12):1534–41 16 Charles C, Gafni A, Whelan T.  Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model Soc Sci Med 1999;49(5):651–61 17 Say R, Murtagh M, Thomson R.  Patients' preference for involvement in medical decision making: a narrative review Patient Educ Couns 2006;60(2):102–14 18 Broers DLM, Brands WG, Welie JV, de-Jongh A.  Deciding about patients’ requests for extraction: ethical and legal guidelines J Am Dent Assoc 2010;141(2):195–203 19 Redford M, Gift HC.  Dentist-patient interactions in treatment decision-making: a qualitative study J Dent Educ 1997;61(1):16–21 20 Weinstein P, Harrison R, Benton T. Motivating mothers to prevent caries: confirming the beneficial effect of counseling J Am Dent Assoc 2006;137(6):789–93 21 Guadagnoli E, Ward P.  Patient participation in decision-­making Soc Sci Med 1998;47(3):329–39 22 Sathorn C, Parashos P, Messer H.  Australian endodontists' perceptions of single and multiple visit root canal treatment Int Endod J 2009;42(9):811–8 23 Tai BB, Bae YH, Le QA.  A systematic review of health economic evaluation studies using the patient's perspective Value Health 2016;19(6):903–8 221 24 Porter ME.  What is value in health care N Engl J Med 2010;363:2477–81 25 Larg A, Moss JR.  Cost-of-illness studies: a guide to critical evaluation PharmacoEconomics 2011;29(8):653–71 26 Tarricone R.  Cost-of-illness analysis What room in health economics Health Policy 2006;77(1):51–63 27 Kvist T, Reit C. Postoperative discomfort associated with surgical and nonsurgical endodontic retreatment Endod Dent Traumatol 2000;16(2):71–4 28 Rutz-da-Silva F, Padilha EZ, Cândido VS, Cavassim R, Pereira AC, Hebling E. Relationship between quality of root canal obturation and periapical lesion in elderly patients: a systematic review Gerodontology 2016;33(3):290–8 29 Friedman S. Prognosis of initial endodontic therapy Endod Topics 2002;2:59–88 30 Morse DR.  Age-related changes of the dental pulp and their relationship to systemic aging Oral Surg Oral Med Oral Pathol 1991;72:721–45 31 Burke FM, Samarawickrama DY. Progressive changes in the pulpo-dentinal complex and their clinical consequences Gerodontology 1995;12:57–66 32 Redford M, Drury TF, Kingman A, et al Denture use and the technical quality of dental prostheses among persons 18–74  years of age: United States J Dent Res 1996;75:714–25 33 Re D, Ceci C, Cerutti F, Fabbro MD, Corbella S, Taschieri S. Natural tooth preservation versus extraction and implant placement: patient preferences and analysis of the willingness to pay Br Dent J 2017;222(6):467–71 .. .Endodontic- Periodontal Lesions www.ajlobby.com Igor Tsesis  •  Carlos E Nemcovsky Joseph Nissan  •  Eyal Rosen Editors Endodontic- Periodontal Lesions Evidence-Based Multidisciplinary Clinical. .. of endodontic- periodontal lesions that was mainly based on diagnosis, prognosis, and treatment This classification included primary endodontic lesions, primary periodontal lesions, primary endodontic. .. treatment point of view: endodontic origin, periodontal origin, combined endo-perio lesions, separate endodontic and periodontal lesions, lesions with communication, lesions with no communication