case selection and recall

Question 1

*The single most important
factor affecting RCT
success

Answer 1

case selection

Question 2

To avoid great risk or serious error, you must examine
and fully understand:

Answer 2

• the patient
• the complexities of the root canal system
• the specialized techniques required and have the appropriate training, instrumentation & equipment

Question 3

patient personality consideration

Answer 3

⦿ The great variety of personality types
⦿ Your current patient management skills

Question 4

Primary Considerations of endo tx regarding pt

Answer 4

• Does the patient WANT endodontictreatment?
• Does the patient UNDERSTAND the commitments required of the treatment?

Question 5

tooth considerations for endo tx

Answer 5

• Is the tooth strategic & functional?
• Is the tooth restorable?
• Is it periodontally sound?
• Is the investment justified by the benefits?

Question 6

untx canals lead to?

Answer 6

PA lesions

Question 7

most commonly missed canal

Answer 7

MB of maxillary molar

Question 8

starting RCT on tooth you are unsure of

Answer 8

• 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!!!

Question 9

standard of care

Answer 9

The Standard of Care expected of the General Dentist is exactly
the same as that expected of the Endodontic Specialist

Question 10

Case Difficulty Assessment Form

Answer 10

• 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

Question 11

risk assessment form column categories

Answer 11

1. Minimal Risk
2. Moderate Risk
3. High Risk

Question 12

case assessment form procedure

Answer 12

Review each column and each related entry:
- If it is a concern, place check
- Column with most checks determines Difficulty Level

Question 13

RETX & Procedural Incidents
are all:

Answer 13

RETX & Procedural Incidents
are all High Risk Cases

Question 14

AAE Case Difficulty @ UMKC

Answer 14

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

Question 15

Invasive resorption or Perforating Int. Resorption case difficulty

Answer 15

high, requires skills and training

Question 16

how can radiographs be helpful

Answer 16

look for abberant anatomy, if unsure REFER

Question 17

fast breaks on radio=

Answer 17

more canals

Question 18

long canals

Answer 18

A long tooth may be 2x the work & time of
a normal length tooth
REFER

Question 19

issues with man molars

Answer 19

4 canals or c shape canals

Question 20

high cervical breaks

Answer 20

abrupt curvature in the canal located cervically

Question 21

cases to routinely refer

Answer 21

Procedural Incidents:
–Instrument Separation
–Most or All Perforations
–Can’t find all canals
*Surgery Cases
*Re-treatment Cases
*Insoluble Paste RCT

Question 22

open apex

Answer 22

refer: lack of ACZ
endo uses microscope and artifical stop of MTA

Question 23

When to REFER

Answer 23

• 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

Question 24

endo recall procedure

Answer 24

recall at 6, 12 and 24 months
* Outcome Discovery
* Validation of your Treatment
* Professional Responsibility
* Ethical & Moral Obligation
* Legal Mandate

Question 25

recall with symptomatic pts

Answer 25

Recall immediately if patient reports adverse S/S
Infection, pain or continued sensitivity
Draining Sinus Tract

Question 26

minimum recall intervals

Answer 26

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

Question 27

recall requirements at umkc

Answer 27

Required Recall of a minimum of 2 RCT patient Recalls:
May be asked to Recall RCT patients of graduates

Question 28

Purpose of Endodontic Recall :

Answer 28

• Assess status of treated tooth
• Healed/Healing
  *Functional
  *Diseased
• Determine need for additional treatment
• Document Recall Procedures
• (or 3 Unsuccessful Documented Attempts)

Question 29

radio evaluation of recall

Answer 29

–2 Diagnostic P/A films
* Normal PDL width
* PARL eliminated
* Normal lamina dura
* Normal to fine-meshed osseous trabeculae
* No resorption
* CBCT ?

Question 30

clinical evals of recall

Answer 30

PERCUSSION (-), PALPATION (-),
NO DRAINING SINUS TRACT (DST)

Question 31

clinical issues possible at recall

Answer 31

• 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 *

Question 32

potential etiologies of symptoms at recall

Answer 32

• Is issue non-odontogenic?
• Inadequate endodontic treatment?
• Leaking Coronal Restoration?
• Trauma/Fracture
• Unknown

Question 33

What degree of Success should be
expected/communicated?

Answer 33

• Reasonable to say well 0ver 90%
  –Assuming intelligent CASE SELECTION
  –Assuming competent & careful technic

Question 34

Referral Guidelines

Answer 34

• “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

Question 35

1 Rule for Referral

Answer 35

• 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*

Question 36

case presentation to pts

Answer 36

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

Question 37

AGD: Guidelines for Referral

Answer 37

• 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