ECAT 3: complexity factors Flashcards
Complete list of things to consider when assessing complexity:
- RMH, anaesthesia and pt management
- physical & psychological limitations
- mouth opening
- radiographic difficulties
- complex diagnoses
- history of trauma
- position of the tooth, inclination and rotation
- pre-treatment prior to commencement
- crown morphology & presence of extra-coronal restoration (crown or onlay)
- access to root canal system
- root curvature and canal / apical morphology
- canal radiographic visibility
- previous endo treatment
- iatrogenic damage
- root resorption
- perio-endo lesion involvement
Medical History -
factors that could compromise healing, increase risk associated with failure or increase the challenge of treatment.
- ASA III or IV classification (incl. haemophilia or uncontrolled systemic diseases: diabetes, asthma, angina)
- Immunosuppression (e.g: steroid therapy, oncology treatment)
- MRONJ or osteoradionecrosis risk
- LA issues (allergy or vasoconstrictor intolerance)
3 medical history instances which would mean the case is better referred to hospital / more well controlled environment:
- compromised healing response / outcomes
- consequences of failed treatment
- challenging anaesthesia / treatment
Physical and Psychological Limitations
- dental anxiety or phobia (including paeds) where sedation may be required
- limitations in reclining patient (e.g: elderly, spinal injury or bariatric patient)
- limited mouth opening due to TMD issues or trauma
Classifying normal, reduced or extremely reduced mouth opening:
normal: >35 mm
reduced: 25-35 mm
extremely reduced: <25 mm
Radiographic Difficulties
- hyper responsive gag reflex
- superimposition of prostheses / anatomical structures obscuring the area of interest
- anatomical defects such as narrow / low vaulted palate, high floor of the mouth or tori
Diagnosis
- lack of clinical signs
- confusing or conflicting signs or symptoms
- unclear which tooth / teeth
- non-odontogenic pain
- additional further investigations required for diagnosis (e.g: CBCT and advanced special tests such as test cavity or orthodontic band)
Perio-Endo Lesions
- furcation involvement
- perio-endo lesion
- mobility
- fenestrations or dehiscence
- root resections / hemispheres-section expected or completed
History of Trauma
- complicated crown fracture (less invasive technique should be used such as pulpotomy)
- root fracture
- alveolar fracture
- lateral luxation, avulsion and intrusion due to resorption potential
- unknown history of trauma
Position in the Arch
- posterior teeth are more complex than anteriors
- molars have more complex root / canal morphology
Pre-Treatment -
required prior to initiating endo treatment or to facilitate dental dam isolation.
simple
- restoration replacement
- supragingival caries.
complex
- subgingival caries management (crown lengthening or marginal elevation)
- crown / bridge removal
What are the benefits of dismantling restorations?
- identify cause of disease (e.g: caries, cracks)
- assess restorability
- achieve coronal seal
- isolation
What are the risks associated with dismantling restorations prior to endodontic treatment?
- isolation challenges
- obtaining coronal seal
Extra-Coronal Restorations
- crown, bridge or onlay present but planned to be remove prior to commencing treatment
- access required through crown or onlay
- core buildup in pulp chamber
- poorly adapted post
- well adapted and firmly cemented post/cast post and core
Access to RCS
- direct restoration masking crown morphology
- amalgam core buildup in the pulp chamber without post or crown
- composite core buildup in pulp chamber without core or crown
risks - perforation or unable to locate canal orifice.
Inclination and Rotation =
e.g: proclamation, retroclination, buccal-lingual displacement and crowding.
inclination and rotation
- mild: < 20º
- moderate: 20-45º
- severe: > 45º
challenges - isolation, access, risk of perforation or missed anatomy
Crown Morphology Anomalies
- taurodontism
- microdontia
- dens invaginate
- fusion / germination
- dentinogenesis imperfecta
risks - isolation, access, canal negotiation, missed anatomy risk, complex treatment.
Root Canal Morphology
- anterior tooth or lower premolars with 2 canals
- premolars with 3 canals (use CBCT to locate)
- molar with ≥ 4 canals
- very long tooth (EWL > 30mm)
Apical Morphology
- open apex (> size 60 K file)
- open apex with history of failed surgical retrograde root end fill
risks - irrigant extrusion, dressing / obturation material extrusion, incorrect apex locator reading, achieving satisfactory apical seal.
Types of Root Resorption
internal
- inflammatory
- replacement
external
- surface
- inflammatory
- replacement
- cervical
- transient apical breakdown
Root Curvature
mild - <30º
moderate - 30-45º
severe - 45-60º
extremely severe - >60º
severe S-shape
risks - complex instrumentation, risk of instrument separation, ledging, perforation and canal transportation.
Assessing Curvature - Leutein’s Method
- identify canal orifice (point A) and apical foramen (point D)
- mark 2mm along the canal from each to get points B and C.
- draw 2 lines A-B and C-D
- angle created at the intersection of the lines is the degree of canal curvature
Unique Anatomy
- S shape canal
- C shape canal or ribbon shape root canal system
- pulp stones / calcifications
risks - ledging from instrumentation, shaping and disinfection challenges, obturation, pulp stone removal and canal identification.
Pulp Chamber and Canal Visibility
uncomplicated - large pulp chamber with wide visible canal space to apex
more complicated - clearly visible but reduced pulp chamber and/or canal diameter
complicated - pulp chamber with canal space invisible in parts
very complicated - canal space completely invisible
Pulp Chamber or Canal Visibility with Previous RCT
options:
- GP can be traced to apex
- canal space visible beyond GP (when GP short)
- canal space visible beyond GP but reduced diameter (when GP short)
- canal space completely invisible beyond GP (when GP short)
Previous Endodontics
- previously initiated but not obturated endo tx.
- canal suboptimally obturated with GP
- canal well obturated with GP or obturation is > 2mm overfilled
- canal obturated with other materials (e.g: silver points, resin based filling, bioceramic material)
risks - removing material entirely, negotiating potential pre-op ledge
Iatrogenic Incidents
- significantly misaligned precious endo access
- perforations (either supra or sub osseous)
- separated instrument (either clinically visible or invisible)
- overt ledge or apical transportation
