Australian Dental Journal, December, 1975
Letters to the Editor
IS THAT APICOECTOMY REALLY NECESSARY?
Sir, In reply to Dr. Ehrmann’s letter (October 1975), although it would appear that we hold conflicting opinions on many issues, the fact is that our standpoints are basically similar in many respects. I would accept the proposal that a good apical seal will eventually lead to the elimination of many periapical areas. Where we are at conflict is the size of the areas. Should a large cyst be present, I feel that surgery is by far the best method of treatment. I find difficulty in accepting the view that cysts can be treated endodontically since these periapical ‘cyst-like’ lesions which are treated successfully by endodontic therapy cannot be classified as cysts, since no material for histological examination is taken. Therefore, this is a clinical, rather than a scientific attitude. Diagnosis of apical cysts is relatively easy by aspiration and this point should need no further elaboration. As for post crowned teeth, the danger is always present when attempting to remove the post that the tooth will fracture. I could pose the same question-when is it safe to attempt the removal of a dowel, and when the tooth fractures, how is this explained to the patient? Obviously Ehrmann. is a highly skilled endodontist and can possibly instrumentate calcitied root canals, and those canals blocked by large pulp stones. However, it is fair comment that he would not be the normal general practitioner to whom the article was addressed. Basically, surgery is limited to crowned teeth in two categories. The first is post crowned teeth; the second is a tooth with a very well fitting porcelain jacket crown in order to save the expense of a second crown which is not inconsiderable. I too have observed failed apicectomies on crowned teeth as he states, but this is often due to poor surgical technique and assessment. If all the apical delta is not removed and accessory root canals filled, treatment is doomed to failure. 1 Hobson, P.-The
bacteriological problems of root canal therapy. Dent. Practit., 16:2, 43-47 (Oct.) 1965.
As to break down occurring owing to infected tissues left ‘in situ’, I would refer Ehrmann to Hobson1 where this subject is very well discussed, although not with the same conclusion. Teeth which refuse to respond to conservative methods are by no means uncommon, according to my Endodonist specialist colleagues. This may be due to many reasons, amongst which are apical deltas, lateral canals and the virulence of the organism. It must be remembered that I treat only referral cases and amongst these patients, there have been many with necrotic pulps in a tooth with a wide open apex. Personally, I have no difficulty with the surgery but this perhaps is a reflection of how much surgery one does. As for being traumatic, I could not agree with this, as I.V. Sedation techniques or general anaesthetics render the procedure almost trivial. I would agree that more recent work tends to support the contention that filling such teeth with calcium hydroxide often produces good results, but if competent endodontists refer patients for retrograde root filling, I feel it is not my job to teach their own speciality’. Similar remarks apply to the apical third technique, since this procedure has often been requested by internationally known and respected restorative dentists. As far as Fig. 4 and Fig. 5 in the article, all line drawings are over simplified for ease of explanation in order to demonstrate the principle of conservative surgery, rather than radical surgery. In conclusion, all would agree that surgery is not a substitute for good endodontic therapy but should be used as an aid to endodontics.
L. SUMMERS, Senior Lecturer in Oral Surgery Dental School, University of Western Australia, 179 Wellington Street, Perth, W.A. 6000. October 7, 1975.