Case Selection Flashcards
What does the pretreatment assessment consist of
○ Evaluation of patient
○ Evaluation of tooth
○ Self-evaluation of clinician
Following examination and diagnosis, what questions do we ask for case selection
○ Is treatment indicated?
○ Is patients oral health needs best met by maintaining the tooth?
○ Complete patient evaluation necessary
Who should treat?
What do we evaluate the patient for
- Medical status
- Psychological
Social factors
- Psychological
What are important medical findings for endo
pregnancy cardiovascular cancer diabetes mellitus bisphosphonate therapy allergies
What is the effect of pregnancy on endo
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
What is the effect of Cv disease on endo
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
How do we reduce stress for CV patients
Short appointments
Sedation
Pain and anxiety control
How does cancer effect endo tx
§ A thorough history essential
§ Treatment for cancer
§ Chemotherapy and radiotherapy to the head and neck region can compromise healing
§ Consult with the oncologist
How does diabetes mellitus effect endo tx
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
How does bisphosphonate therapy effect endo tx
§ 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
How does allergies effect endo tx
§ If patient is allergic to latex rubber, a dam should be made of vinyl
Gutta percha is not a risk as non-cross-reactive
What are periodontal considerations for dental evaluation for case selection
- 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
What are restorative considerations for dental evaluation for case selection
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
What are restorability considerations for dental evaluation for case selection
- 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
What are other dental factors we need to consider
calcifications dilacerations resorption inability to isolate tooth unusual anatomy ledges and perforation posts separated instruments
How do calcifications effect endo tx
§ 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
How does resorption appear
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
How does unusual anatomy effect endo tx
§ Can see a more complex arrangement of root canal structure
§ Need to consider if there are open apices, curved root canals, c shaped anatomy
How does ledges and perforations effect endo tx
§ 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
How does separated instruments effect
§ 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
What are options for treatment
- No active tx with review
- Extraction
- Orthograde root canal treatment
- Surgical endodontics
What does treatment options depend on
Px assessment Dental assessment Patient motivation Patient time Financial implications
When self evaluating ourselves as clinicians what can we use to decide whether to treat or refer
○ 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
What must we do for the patient in terms of communication before edno tx
○ 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
What needs to be communicated prior to treatment to obtain valid consent
options for tx Prognosis
○ Risks
○ Opportunity to ask questions
○ Agree on plan - remember endodontics is not all that will be required - restoration and review
What are the options for tx
Follow up
Extraction
Orthograde root canal treatment
Surgical endo
What are the risks we need to discuss prior to tx
- Need to discuss risks, and those that a patient would attach significance to must be communicated
○ Perforation
Instrument separation
What do we tell the px about pain
- 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
