case selection and recall Flashcards
*The single most important
factor affecting RCT
success
case selection
To avoid great risk or serious error, you must examine
and fully understand:
- the patient
- the complexities of the root canal system
- the specialized techniques required and have the appropriate training, instrumentation & equipment
patient personality consideration
⦿ The great variety of personality types
⦿ Your current patient management skills
Primary Considerations of endo tx regarding pt
- Does the patient WANT endodontictreatment?
- Does the patient UNDERSTAND the commitments required of the treatment?
tooth considerations for endo tx
- Is the tooth strategic & functional?
- Is the tooth restorable?
- Is it periodontally sound?
- Is the investment justified by the benefits?
untx canals lead to?
PA lesions
most commonly missed canal
MB of maxillary molar
starting RCT on tooth you are unsure of
- Never start RCT on any tooth for which an excellent
result cannot be reasonably expected . . . in your hands
at that time with that patient. - If not, you must ethically & morally REFER!!!
standard of care
The Standard of Care expected of the General Dentist is exactly
the same as that expected of the Endodontic Specialist
Case Difficulty Assessment Form
- The AAE has developed a form which will help you determine thedifficulty/risk level of each case in question.
- Once you determine the difficulty level, you have a reasonable basis to decide if you should ACCEPT the case or REFER.
- Do you want the LIABILITY?
- A dentist only LOSES $ in Court
risk assessment form column categories
- Minimal Risk
- Moderate Risk
- High Risk
case assessment form procedure
Review each column and each related entry:
- If it is a concern, place check
- Column with most checks determines Difficulty Level
RETX & Procedural Incidents
are all:
RETX & Procedural Incidents
are all High Risk Cases
AAE Case Difficulty @ UMKC
Category 1 Cases only: Undergraduates
No 2nd or 3rd Molars
No Molars until 2-3 successful anteriors done
Nothing through a crown
Approved by endo faculty for all undergrad
Category 2 Cases: Endo Honors/Advanced Endo
Category 3 Cases: Advanced Endo only
Invasive resorption or Perforating Int. Resorption case difficulty
high, requires skills and training
how can radiographs be helpful
look for abberant anatomy, if unsure REFER
fast breaks on radio=
more canals
long canals
A long tooth may be 2x the work & time of
a normal length tooth
REFER
issues with man molars
4 canals or c shape canals
high cervical breaks
abrupt curvature in the canal located cervically
cases to routinely refer
Procedural Incidents:
–Instrument Separation
–Most or All Perforations
–Can’t find all canals
*Surgery Cases
*Re-treatment Cases
*Insoluble Paste RCT
open apex
refer: lack of ACZ
endo uses microscope and artifical stop of MTA
When to REFER
- May refer at ANY TIME Before or during the DX or treatment
- The BEST TIME to refer is:
- BEFORE a problem occurs and
- BEFORE your Liability is incurred and
- BEFORE your Credibility is Compromised
endo recall procedure
recall at 6, 12 and 24 months
* Outcome Discovery
* Validation of your Treatment
* Professional Responsibility
* Ethical & Moral Obligation
* Legal Mandate
recall with symptomatic pts
Recall immediately if patient reports adverse S/S
Infection, pain or continued sensitivity
Draining Sinus Tract
minimum recall intervals
6 months to 1 year * “Greatest Improvement” (Klevant, et al. 1983)
2 years
4 years (Örstavik 1996), no longer necessary for recall after 4 yrs
recall requirements at umkc
Required Recall of a minimum of 2 RCT patient Recalls:
May be asked to Recall RCT patients of graduates
Purpose of Endodontic Recall :
- Assess status of treated tooth
- Healed/Healing
*Functional
*Diseased - Determine need for additional treatment
- Document Recall Procedures
- (or 3 Unsuccessful Documented Attempts)
radio evaluation of recall
–2 Diagnostic P/A films
* Normal PDL width
* PARL eliminated
* Normal lamina dura
* Normal to fine-meshed osseous trabeculae
* No resorption
* CBCT ?
clinical evals of recall
PERCUSSION (-), PALPATION (-),
NO DRAINING SINUS TRACT (DST)
clinical issues possible at recall
- Persistent subjective symptoms
- Recurrent sinus tract or swelling
- Discomfort to percussion and / or palpation
- Evidence of fractured tooth
- Excessive mobility or progressive periodontal breakdown
- Inability to function on the tooth *
potential etiologies of symptoms at recall
- Is issue non-odontogenic?
- Inadequate endodontic treatment?
- Leaking Coronal Restoration?
- Trauma/Fracture
- Unknown
What degree of Success should be
expected/communicated?
- Reasonable to say well 0ver 90%
–Assuming intelligent CASE SELECTION
–Assuming competent & careful technic
Referral Guidelines
- “We have the professional, moral, ethical and legal responsibility to recognize the extent of our patient’s treatment needs and to refer when referral is in the best interests of the patient.” ADA
⦿“It is the role of the general dentist to manage the overall dental health care of the patient. When appropriate, any care rendered by a specialist should be coordinated with that of a general dentist, with a clear understanding of the role of each in providing care to the patient” AGD
⦿“It is the responsibility of the specialist to refer the patient back to the generalist for restoration when RCT is completed.” AAE
1 Rule for Referral
- Refer when in the BEST INTERESTS of patient*
- Secondary Concerns (equipment - time?)
- “Do the Math” If you lose money and incur liability, WHY
would you undertake the service? REFER*
case presentation to pts
must qualify as “Informed Consent”
- Whether you do it In-house or Refer:
–Patient must UNDERSTAND (simple language) - The current condition and all reasonable options
- The Sequelae of no treatment
- Risks v. Benefits of TX options (>90%)
- Possible procedural complications of RCT
–Separated Instrument & Perforation
–Fracture of root or tooth (need for Crown)
–Other unforeseen complications
–Approximate expectation of success (Prognosis) - The approximate cost of RCT & all related services
AGD: Guidelines for Referral
- Name & contact info for the patient
- Appointment time
- Reason for the referral
- General background which may affect the case
- Medical & dental information
–Medical consultations & specific problems
–Previous contributory dental history
–Radiographs !
2 Way Communication: Endodontist should call GD office at completion of RCT to schedule Restoration
