Selection Of Cases for Endodontic Treatment

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CONTENTS

                       INTRODUCTION

• In the past injured/diseased teeth were indicated for extraction
• Now the trend has been changed and the teeth can be saved by endodontic treatment because clinician and  general population is becoming more aware of the importance of natural teeth
• Once a thorough examination has determined that an endodontic problem exists, the process of case selection begins.
• The dentist must determine

1.     whether treatment is indicated for this patient
2.      what treatment will best serve the patient
3.             whether  the patient would be best served by being referred to a specialist or another practitioner.

• The first step in treating the patient is planning the case in full.This initially involves a comprehensive medical review to predictory conditions that may require modification of the usual treatment regimens. The identification of medical conditions that may complicate endodontic treatment will help the dentist avoid potential medical emergencies during treatment. In addition, consideration of complicating patient factors such as anxiety, limited opening or gag reflex will allow the dentist to avoid situations that may compromise treatment outcomes.
• Proper selection of cases avoids pitfalls during endodontic treatment and helps to ensure the success
• Before selecting a case for endodontic therapy,the clinician should consider the following factors that influence the outcome of the treatment
• ·        Health &systemic status of the patient
• ·        Anatomy of the root canal system
• ·        Extent of previous tooth restoration
• ·        Presence/absence of periradicular pathosis
• ·        Radiographic interpretation
• ·        Degree of difficulty in locating,cleaning,shaping and obturating the complete root canal system
• ·        Periodontal status of the tooth
• ·        Presence of crown/root fractures
• ·        Presence of root resorption
• ·        Patient’s desire,motivation,cooperation and pain threshold
• ·        Clinical skill& expertise of the operator

                 ASSESSMENT OF PATIENT’S SYSTEMIC STATUS

• A concise medical history including careful questioning should be obtained whenever possible
• Identification of medical conditions that may complicate endodontic treatment helps the dentist avoid potential medical emergencies during treatment
•  Inaddition consideration of complicating patient factors such as anxiety,limited opening/gag reflex will allows the dentist to avoid situations that may compromise treatment outcomesMost medical conditions do not contraindicate endodontic therapyPatient's medical condition should be thoroughly evaluated in order to properly manage the case.

                                                VALVULAR DISEASE

Patients are susceptible to bacterial endocarditis secondary to dental treatment

Modification in treatment planning:

Prophylactic antibiotics before initiation of endodontic treatment

                                            

               MYOCARDIAL INFARCTION

·        Stress/anxiety can precipitate myocardial infarction/angina

·        Some degree of congestive heart failure may be present

·        Chances of excessive bleeding when patient is on aspirin

·        If pacemaker is present,apex locators can cause electrical interferences

                            Modification in treatment planning:

·        Elective endodontic treatment is postponed if recent myocardial infarction present(<6 months)

·        Reduce the level of stress &anxiety while treating patient

·        Keep the appointments short &comfortable

·        Use LA without epinephrine

·        Antibiotic prophylaxis

                                                 PROSTHETIC VALVE

·        High risk of bacterial endocarditis

·        Tendency for increased bleeding because of prolonged use of anticoagulant therapy

                               Modification of treatment planning

·        Prophylactic antibiotic coverage

·        Consult physician

GUIDELINES ON ANTIBIOTIC PROPHYLAXIS

Endocarditis prophylaxis recommended

• ·        Prosthetic cardiac valves        
• ·        History of infective endocarditis
• ·        Certain specific ,serious congenital heart diseases such as unrepaired/incompletely repaired cyanotic congenital heart disease,completely repaired congenital heart defect with prosthetic device placed during the first 6 months after the procedure,repaired congenital heart defect with residual defect at the site /adjacent to the site of a prosthetic device

Endocarditis prophylaxis not  recommended

• ·        Mitral valve prolapse
• ·        Rheumatic heart disease
• ·        Bicuspid valve disease
• ·        Calcified aortic stenosis
• ·        Congenital heart  conditions such as Ventricular septal defect,Atrial septal defect

AHA- RECOMMENDED ANTIBIOTICS PROPHYLAXIS REGIMEN FOR DENTAL PROCEDURES

ORAL

Amoxicillin:2g—adults

                   50mg/kg--children

UNABLE TO TAKE ORAL MEDICATION

Ampicillin:2g IM/IV—Adults

                 50 mg/kg IM/IV--children

Cefazolin/ceftriaxone:1g IM/IV—Adults

                                   50mg/kg IM/IV—Children

ALLERGIC TO PENICILLIN/AMPICILLIN--ORAL

Cephalexin: 2g—Adults

                   50 mg/kg --Children

Clindamycin: 600mg—Adults

                      20 mg/kg—Children

Azithromycin/Clarithromycin: 500mg—Adults

                                                 15mg/kg--Children

ALLERGIC TO PENICILLIN/AMPICILLIN &UNABLE TO TAKE ORAL MEDICATIONS

Cefazolin/Ceftriaxone :1g IM/IV—Adults

                                     50mg/kg IM/IV --children

Clindamycin: 600 mg IM/IV—Adults

                      20 mg/kg IM/IV—Children

         HYPERTENSION       

Stress & anxiety may further increase chances of MI/cerebrovascular accidents

Sometimes antihypertensive drugs may cause postural hypotension

                                     Modification in treatment planning

·        premedication

·        Short appointments

·        Use LA with minimum amount of vasoconstrictors

                                                       LEUKEMIA

·        Opportunistic infections

·        Prolonged bleeding

·        Poor & delayed wound healing

                              Modification in treatment planning

·        Consult the physician

·        Avoid treatment during acute stages

·        Avoid long duration appointments

·        Strict oral hygiene instructions

·        Evaluate the bleeding time & platelet status

·        Use of antibiotic prophylaxis

CANCER

·        Because of chemotherapy & radiotherapy, patient may be suffering from mucositis,xerostomia,trismus &excessive bleeding

·        Prone to infections because of bone marrow suppression

Modification in treatment planning

·        Consult the physician prior to treatment

·        Perform only emergency treatment if possible

·        Symptomatic treatment  of mucositis,trismus,& xerostomia

·        Optimal antibiotic coverage prior to treatment

·        Strict oral hygiene regimen

BLEEDING DISORDERS

Modification in treatment planning

·        Take careful history of the patient

·        Consult the physician

·        Avoid aspirin containing compounds &NSAIDs

·        Thrombocytopenia—replacement of platelets

·        Prophylactic antibiotics

          Liver disease:Avoid drugs metabolized in liver

RENAL DISEASE

·        Patient usually has hypertension & anemia

·        Intolerance to nephrotoxic drugs

·        Susceptibility to opportunistic infections

·        Increased tendency for bleeding

Modification in treatment planning

·        Prior consultation with physician

·        Check BP before treatment

·        Antibiotic prophylaxis

·        Avoid drugs metabolized &excreted by kidney

                                DIABETES MELLITUS

·        Increased tendency for infections &poor wound healing

·        Patient suffering from disease related to CVS ,kidneys &nervous system

Modifications in tratment planning

·        Take careful history

·        Consult with the physician

·        Note the blood glucose levels

·        Patient should have normal meals before appointment

·        If patient is on insulin therapy,he should have his regular dose of insulin before appointment

·        Antibiotics

·        Early morning appointments

·        Have instant source of sugar available in the clinic

·        Patient should be evaluated for the presence of MI,HTN, renal failure

                                        PREGNANCY

·        Harm to the patient can occur via radiation exposures,medications&increased level of stress &anxiety

·        Chances of development of supine hypotension are increased in third trimester

Modification in treatment planning

·        Do the elective procedure in second trimester

·        Avoid drugs which can cause harm to the fetus

·        Consult the physician

·        Use principles of ALARA

·        In third trimester don’t place the patient in supine position for prolonged periods

ANAPHYLAXIS

·        Patient gives H/O severe allergic reaction on administration of LA,Certain drugs,Latex gloves & rubber dam sheets

Modifications in treatment planning

·        Take careful history

·        Avoid use of agents to which patient is allergic

·        Always keep the emergency kit available

In case the reaction develops

·        Identify the reaction

·        Call the physician

·        Place the patient in supine position

·        Check vital signs

·        If vital signs are reduced,inject epinephrine

·        Admit the patient

                                                RADIOGRAPHS

• case selection is dictated by what we see in the radiographs
• An examination of the radiograph  disclose certain problems
• ·        Extent of carious lesion involvement in the tooth
• ·        Periapical lesions
• ·        Internal/External resorption
• ·        Fracture of a tooth/root
• ·        Periodontal status of the tooth
• ·        Complex anatomy of the root canal
• ·        Fusion
• ·        Supernumerary root/root canal
• ·        Dilacerated/curved root canal
• ·        Pathologically resorbed root tip
• ·        Wide open apex in a young tooth
• ·        Partial/completely calcified root canal
• ·        Any obstruction in the canal
• ·        Pulp stone occupying almost the entire pulp chamber &root canal
• ·        Subgingival decay of a crown
• ·        Dens invaginatus
• ·        Gemination
• ·        Extent of root canal obturation in an endodontically treated teeth
• ·        Iatrogenic errors like ledging &seperated instruments
• ·        Taurodontism

                           CASE DIFFICULTY ASSESSMENT FORM

• Developed by AAE which makes the case selection more efficient,more consistent & easier to document
• The Endodontic CDAF is intended to assist practitioners with endodontic treatment planning,but can also be help with referral decisions &record keeping
• Assessment form identifies three categories of considerations which may affect treatment complexity
• ·        Patient considerations
• ·        Diagnostic & treatment considerations
• ·        Additional considerations

1)Patient considerations

·        Medical history

·        Anesthesia

·        Patient disposition

·        Mouth opening

·        Gag reflex

·        Emergency condition

2)Diagnostic& treatment considerations

·        Diagnosis

·        Radiographic difficulties

·        Position in the arch

·        Tooth isolation

·        Morphologic aberrations of the crown

·        Canal & root morphology

·        Radiographic appearance of the canals

·        Resorption

3) Additional considerations

·        History of traumaHistory of endodontic treatment

·        Periodontic-enodontic condition

For each level of difficulty, guidelines are given to aid the dentist in determining whether the complexity of the case is appropriate for his experience or comfort level.

                         CASE DIFFICULTY ASSESSMENT FORM

 Patient considerations

Criteria &subcriteria	Minimal difficulty	Moderate difficulty	High difficulty
Medical history	No medical problem(ASA class 1)	One /more medical problems(ASAclass2)	COMPLEX MEDICAL HISTORY/serious illness/disability(ASA class 3-5
anesthesia	No history of anesthesia problems	Vasoconstrictor intolerance	Difficulty achieving anesthesia
Patient disposition	Cooperative	Anxious but cooperative	Un cooperative
Ability to open mouth	No limitation	Slight limitation in opening	Significant limitation in opening
Gag reflex	none	Occassionally with radiographs/treatment	Extreme gag reflex which has compromised past dental care
Emergency condition	Minimum pain /swelling	Moderate pain /swelling	Severe pain/swelling

             DIAGNOSTIC AND TREATMENT CONSIDERATIONS

Criteria &sub criteria	Minimal difficulty	Moderate difficulty	high difficulty
diagnosis	Signs & symptoms consistent with recognized pulpal &periapical conditions	Extensive DD of usual signs & symptoms required	-confusing & complex signs &symptoms:difficult diagnosis -history of chronic oral /facial pain
Radiographic difficulties	Minimal difficulty in obtaining & interpreting radiographs	Moderate difficulty in obtaining/interpreting radiograph(high floor of mouth,narrow palatal vault,tori)	High difficulty(superimposed anatomical structures)
Position in the arch	-Anterior/premolar -slight inclination(<10°) -slight rotation(<10°)	-1st molar -moderate inclination(10-30°) -moderate rotation(10-30°)	-2nd/3rd molar -extreme inclination(>30° -extreme rotation(>30°)

Tooth isolation	Routine rubber dam placement		Simple pretreatment modification required		Extensive pretreatment modification required
Morphologic aberrations of crown	Normal original crown morphology		-full coverage restn -porcelain restoration -bridge abutment -moderate deviation from normal tooth/root form(taurodontism) -extensive coronal destruction		Restoration does not reflect original anatomy/ alignment -significant deviation from normal tooth/root form(fusion,dens in dente)
Canal &root morphology	Slight /no curvature(<10°) -closed apex		Moderate curvature(10-30°) -crown axis differs moderately from root axis(apical opening 1-1.5 mm in dm)		Extreme curvature(>30°)/s shaped curve --mand PM /Anterior with 2 roots -Max. PM with 3 roots -Canal divides in the middle or apical 3rd -Very long tooth (>25mm) -Open apex(>1.5mm in dm)
Radiographic appearance of canals		Canals visible are not reduced in size		-Canals & chamber visible but reduced in size -Pulp stones		-Indistinct canal path -Canals not visible
Resorption		No resorption evident		Minimal apical resorption		-Extensive apical resorption -Internal resorption -External resorption

3) ADDITIONAL CONSIDERATIONS

Criteria & subcriteria	Minimal difficulty	Moderate difficulty	High difficulty
Trauma history	Uncomplicated crown fracture of mature or immature teeth	-Compliated crown fracture of mature teeth -Subluxation	-Complicated crown fracture of immature teeth -Horizontal root fracture -Alveolar fracture -Intrusive, extrusive or lateral luxation -Avulsion
Endo.treatment history	No previous treatment	Previous access without complications	-Previous access with complications -Previous surgical or nonsurgical endo.treatment completed
Periodontic-endodontic condition	None or mild pdl disease	Concurrent moderate periodontal disease	-Concurrent severe periodontal disease -Cracked teeth with pdl.complications -Combined endo-perio lesion -Root amputation prior to endo treatment

GUIDELINES FOR USING THE AAE ENDODONTIC CASE DIFFICULTY ASSESSMENT FORM

Conditions listed in this form should be considered potential risk factors that may complicate treatment and adversely affect the outcome.

The assessment form enables a practitioner to assign a level of difficulty to a particular case

                                           LEVELS OF DIFFICULTY

Minimal difficulty

          Preoperative condition indicates routine complexity(uncomplicated)These types of cases would exhibit only those factors that are listed in the minimal difficulty category.Achieving a predictable treatment outcome should be attainable by a competent practitioner with limited experience

Moderate difficulty

Preoperative condition is complicated ,exhibiting one /more patient/treatment factors listed in the moderate difficulty category.Achieving a predictable treatment outcome will be challenging for a competent, experienced practitioner.

High difficulty

Preoperative condition is exceptionally complicated,exhibiting several factors listed in the moderate difficulty category/at least one in the high difficulty category.Achieving a predictable treatment outcome will be challenging for even the most experienced practitioner with an extensive history of favorable outcomes.

USE OF ENDODONTIC CASE DIFFICULTY ASSESSMENT FORM

A point score be assigned to each item within each difficulty category.

 This  is  for educational purpose only,not for clinical practice.

Minimal difficulty-point value of 1

Moderate difficulty-point value of 2

High difficulty-point value of 3

Less than 20 points

·        Dental student may treat

·        Level of faculty supervision should be tailored to the student’s level of experience

20-40 points

·        An experienced & skilled dental student may treat with very close supervision by an endodontist/the case referred to a graduate student /endodontist

Above 40 points

·        The case should not be treated by a predoctoral dental student

·        The patient should be referred to a graduate student/endodontist

Factors influencing healing after endodontic treatment

Presence of periapical radiolucency

          Strong negative influence on the healing

Size of periapical radiolucency

·        Earlier studies—teeth with periapical lesions(5mm in diameter) exhibited better healing potential than those larger than 5mm

·        Recent studies—size of radiolucency does not influence the healing potential

Cleaning&shaping of apical third of canal

          Root canal of a pulp less tooth with a radiolucent area can be obstructed by

          --a curved root

          --tortuous canal

          --secondary dentin

          -- pulpstone,that cannot be removed/bypassed,

          --calcified/partially calcified canal,

          -- malformed tooth

          -- broken instrument

          --Prognosis is poor---when it is impossible to instrument the root canal/to fill  

             apically for atleast 3-4mm

          --Apical third of root canal is critical and must be disinfected &obturated so that  microorganism can no longer reach the periapical tissues & continue their destruction

If cannot be done because of blockage of apical portion of the canal,repair of the damaged bone not occur

When there is accidental /pathologic perforation of root surface

Perforation may occur accidentally by misdirection of the bur while attempting to reach the pulp chamber/by internal&external resorption

Incase of resorption,induce repair by CaOH/MTA or perforated area walled off  by MTA,otherwise hemorrage will continue into the root canal&will not be possible to disinfect & fill the canal properly

In some cases external surgical approach is necessary.

When there is incomplete development of the root apex with death of the pulp

Root canal is difficult to fill satisfactorily

Apexification with calcium hydroxide /MTA &root canal should be obturated after developing the apical barrier

When there is persistent excessive periapical exudate that cannot be controlled prior to filling the root canal

          Canals that exhibits serous drainage should not be obturated in a single sitting and an intracanal medicament calcium hydroxide is employed

Persistent drainage in spite of multiple applications of intracanal medicament warrants a reassessment of  the case & sometimes a surgical intervention

In case of retreatment

After retreatment, a foreignbody (fragment of guttapercha) may lie in the periapical tissues  Foreign body increases the difficulty of eliminating infection by intracanal treatments alone

Root end surgery & canal filling to clear the foreign body

When persistent and repeated acute infections occur in a previously treated &filled pulpless tooth

Firstline of treatment is nonsurgical retreatment

If not feasible /fails surgical intervention should be considered

       

                In apical third root fracture with periapical changes

Root fracture alone is not a reason for endodontic treatment& resection is contraindicated if pulp is vital &tooth can be stabilized

If fracture in apical third& pulp has died.endodontic treatment should be carried out

If clinician is unable to negotiate apical fragment through main canal ,radiographically monitor the apical root tip &treated root segment

If an area of rarefaction develops,apical root fragment managed surgically

Combined periodontal endodontic lesion in which an acutely infected pulpless tooth communicates with the gingival sulcus through a sinus tract that cannot be eliminated

Consideration should be given to the extent of periodontal lesion prior to endodontic treatment

Eliminate infection in the root canal by simultaneous periodontal treatment& gingival sulcus area heals once the endodontic treatment completed

If destruction of periodontal attachment is considerable,repair of periodontal fibers may not occur even after endodontic treatment

When alveolar resorption is extensive,involving at least half the root surface

When pdl involvement is severe &tooth is mobile/crown root ratio is unfavorable,improve the periodontal status in conjunction with endodontic therapy

If Class III mobility is present,extraction is preferable.

If tooth is firm(despite radiographic evidence of considerable bone resorption),endodontic treatment is not contraindicated

Damage to the crown is so extensive that endodontic treatment cannot be carried out under aseptic conditions

If the crown of the tooth can be restored & if a rubberdam can be applied,endodontic treatment should be done

                         Consideration warranting removal of tooth

·        Symptomatic teeth in which canals are non negotiable due to calcifications /iatrogenic errors & whose surgical management is not feasible

·        Endodontically treated teeth exhibiting failure ,which is not amenable to either nonsurgical /surgical retreatment

·        Irreparable fracture of the tooth

·        Extensive periodontal disease with loss of bone support,causing irreversible mobility of the tooth

                         

                         Endodontics and prosthodontic treatment

The following types of teeth can be retained and used for fixed- bridge abutments or as abutments  for removable bridges or dentures:

·        Any vital tooth requiring pulp extirpation

·        Any pulpless tooth without an area of rarefaction

·        pulpless tooth with an area of rarefaction requiring root resection ,provided sufficient alveolar support remains

·        pulpless tooth with an area of rarefaction considered to be of strategic importance to the retention of the denture & the potential for repair is good

·        Any previously treated pulpless tooth with no periapical involvement

                           Endodontics and orthodontic treatment

•      No difference in the degree of tooth movement regardless of whether the tooth moved is vital /pulpless

•      Relieve any strain on the tooth by an orthodontic appliance while the tooth is under treatment to avoid confusion as to whether the discomfort is from the appliance or from endodontic treatment

•      Appliances  should not be placed for a week or two after endodontic treatment to allow sufficient time for recovery

•        periodontal ligament is sometimes irritated during endodontic treatment and need a rest for recovery

                     Endodontics and single tooth implants

In deciding whether to retain or to extract a pulpless tooth,it should be remembered that

•      Pulpless teeth generally are not the cause /contributing cause of systemic disease

•      In patients with severe systemic disease,infected pulpless teeth with areas of rarefaction may not respond as readily to treatment;

•      repair of periapical tissue may be delayed

•      In certain cases,extraction is contraindicated  because of an existing systemic condition of the patient (leukemia,radiation necrosis)

•      In patients with acute/chronic leukemia, hemophilia,rheumatic heart disease,radiation necrosis/other severe illness

•            Endodontic treatment is preferable to extraction

•      Patient related factors:Systemic& oral health and patients’ comfort& perceptions  about treatment

•      Tooth & periodontium related factors :Pulpal & periodontal conditions,Biological environmental conditions,Colour characteristics of  the teeth,Quantity &quality of bone,Soft tissue anatomy

•      Treatment related factors:Assessment of potential procedural complications,required adjunctive procedures and treatment outcomes data

Detailed history of the case is recorded& the required diagnostic test is conducted,including radiographs.The clinician arrives at a provisional diagnosis & treatment planning.The endodontist present a comprehensive treatment plan including financial considerations,time taken &prognosis to the patient/patient’s relative

INFORMED CONSENT

•      Always obtained prior to starting any dental treatment

                      

GENERAL GUIDELINES

1)Disclose the following information in understandable lay language

•      Diagnosis of existing problem

•      Nature of proposed treatment/procedure

•      Inherent risk associated with treatment

•      Prognosis

•      Feasible alternatives to the proposed treatment or procedure

•      Inherent risk associated with alternative treatment/procedures

•      Prognosis of alternative treatments or procedures

2) Provide an opportunity to question to the doctor about anyof the above

                                      

                                         

                                      

References

•      Grossman’s endodontic  practice-Twelfth edition

•      Pathways of pulp---COHEN

•      Text book of Endodontics--- NISHA GARG