Case Selection

Question 1

What does the pretreatment assessment consist of

Answer 1

○ Evaluation of patient
○ Evaluation of tooth
○ Self-evaluation of clinician

Question 2

Following examination and diagnosis, what questions do we ask for case selection

Answer 2

○ Is treatment indicated?
○ Is patients oral health needs best met by maintaining the tooth?
○ Complete patient evaluation necessary
Who should treat?

Question 3

What do we evaluate the patient for

Answer 3

• Medical status
  
  • Psychological
    Social factors

Question 4

What are important medical findings for endo

Answer 4

pregnancy
cardiovascular
cancer
diabetes mellitus 
bisphosphonate therapy
allergies

Question 5

What is the effect of pregnancy on endo

Answer 5

Not a contraindication to endodontic therapy
First trimester emergency intervention only
Avoid elective procedures in the first trimester
Pain and infection managed in collaboration with obstetrician/physician

Question 6

What is the effect of Cv disease on endo

Answer 6

MI within the past 6 months is a contraindication
Emergency treatment, should be provided in consultation with px cardiologist as risk of infection is greater
Stress reduction protocol

Question 7

How do we reduce stress for CV patients

Answer 7

Short appointments
Sedation
Pain and anxiety control

Question 8

How does cancer effect endo tx

Answer 8

§ A thorough history essential
§ Treatment for cancer
§ Chemotherapy and radiotherapy to the head and neck region can compromise healing
§ Consult with the oncologist

Question 9

How does diabetes mellitus effect endo tx

Answer 9

Acute endo infection can compromise even a well controlled diabetic so all diabetic px should be monitored
Px with uncontrolled diabetes should be monitored
Diabetes can effect healing and may effect prognosis
Appointments should be scheduled so as not to interfere with insulin and meal schedule
Minimise stress

Question 10

How does bisphosphonate therapy effect endo tx

Answer 10

§ Nonsurgical endodontic treatment is safer alternative to dental extractions which is the main trigger to BRONJ (bisphosphonate-related osteonecrosis of the jaw)
§ Those on IV bisphosphonates are at a greater risk than oral administration - all patients should be considered at some risk
§ Preventative care
§ Use entire health care team when developing treatment plans for these patients

Question 11

How does allergies effect endo tx

Answer 11

§ If patient is allergic to latex rubber, a dam should be made of vinyl
Gutta percha is not a risk as non-cross-reactive

Question 12

What are periodontal considerations for dental evaluation for case selection

Answer 12

• Periodontal probing is essential for BPE and for the tooth of interest
  
  • A poor perio prognosis may necessitate loss
  • Perio-endo or endo-perio lesion
    Treatment for perio-endo lesions include conventional endo therapy followed by periodontal therap

Question 13

What are restorative considerations for dental evaluation for case selection

Answer 13

Sub-osseous caries (gross caries)
Poor crown/root ratio
Misalignment of teeth (can it affect access)
Presence of pre-existing full coverage restorations
Is the tooth already seriously compromised from a restorative standpoint
Does full coverage modify ability to get access

Question 14

What are restorability considerations for dental evaluation for case selection

Answer 14

• The restorability of the tooth must be thoughtfully considered first, deconstruct if necessary
  All decay should be removed so that the extent of a health tooth structure can be determined

Question 15

What are other dental factors we need to consider

Answer 15

calcifications 
dilacerations
resorption
inability to isolate tooth
unusual anatomy
ledges and perforation
posts
separated instruments

Question 16

How do calcifications effect endo tx

Answer 16

§ Calcifications can be isolated or continuous can make treatment very difficult even for the most skilled clinician
□ If orthograde management is not possible then surgery may be considered

Question 17

How does resorption appear

Answer 17

Internal resorption can be differentiated from external resorption by its radiographic appearance/CBCT
External resorption appears to be superimposed on the canal, whereas internal resorption appears to be continuous with the canal

Question 18

How does unusual anatomy effect endo tx

Answer 18

§ Can see a more complex arrangement of root canal structure
§ Need to consider if there are open apices, curved root canals, c shaped anatomy

Question 19

How does ledges and perforations effect endo tx

Answer 19

§ Ledge formation that is iatrogenically created irregularity in the root canal that impedes access of instruments to the apex, and canal blockage caused by packing dentine chips and tissue debris
§ Perforations can rapidly modify outcome

Question 20

How does separated instruments effect

Answer 20

§ Removal of separations are challenging
§ Difficulty depends on where instrument separated
§ Have to recognise features that would make this more likely - importance of case selection

Question 21

What are options for treatment

Answer 21

• No active tx with review
  
  • Extraction
  • Orthograde root canal treatment
  • Surgical endodontics

Question 22

What does treatment options depend on

Answer 22

Px assessment
Dental assessment
Patient motivation
Patient time 
Financial implications

Question 23

When self evaluating ourselves as clinicians what can we use to decide whether to treat or refer

Answer 23

○ Can use a simple formula such as root number or chronic or acute
○ Can use forms
§ AAE endodontic case difficulty assessment form
□ Minimum, moderate and high degrees of difficulty
□ Allows clinicians to identify need for referral
□ Eases communication with px
§ Restorative dentistry index of treatment need complexity assessment

Question 24

What must we do for the patient in terms of communication before edno tx

Answer 24

○ Obtain valid consent explaining all relevant options and possible costs
○ Make sure the patient (or their representatives understand the decisions they are being asked to make
○ Make sure that the patient’s consent remains valid at each stage of investigation or treatment
○ Do not assume someone else has obtained consent
○ Document the decisions and process of gaining consent
○ Tailer the way you obtain consent to patient’s needs

Question 25

What needs to be communicated prior to treatment to obtain valid consent

Answer 25

options for tx Prognosis
○ Risks
○ Opportunity to ask questions
○ Agree on plan - remember endodontics is not all that will be required - restoration and review

Question 26

What are the options for tx

Answer 26

Follow up
Extraction
Orthograde root canal treatment
Surgical endo

Question 27

What are the risks we need to discuss prior to tx

Answer 27

• Need to discuss risks, and those that a patient would attach significance to must be communicated
  ○ Perforation
  Instrument separation

Question 28

What do we tell the px about pain

Answer 28

• Biologically based preventive approach relies on understanding of tissue damage, mediator release and subsequent processes
  Peri-operative ibuprofen shown to delay onset and decrease the severity of pain