Endo

Question 1

Situation: tooth with post core and crown - lingual caries @ crown margin - patient wants no treatment

• inform them of the options and consent for tx

Answer 1

Option 1 - leave and monitor
Risks - decay present, will eventually lead to symptoms and eventual loss of the tooth due to catastrophic failure. Decay progress to abscess and possibly sepsis

Option 2 - remove post core and crown, re RCT and place new crown
Risks - tooth may be unrestorable once all decay is taken away, will need re RCT so file breakage, perforation, crown or root fracture, ledge formation, blockage, hypochlorite incident

Option 3 - tooth may be unrestorable requiring XLA
Risks - pain, bleeding, bruising, swelling, crown or root fracture, OAC/OAF, dry socket, infection

Question 2

Consent a patient for RCT - give an outline of the procedure
- give risks and benefits
- give the success rates

Answer 2

1. Need to numb up using LA
2. Rubber dam application - for isolation and protection from hypochlorite - dam clamp can fracture, mouth required to be open all throughout tx
3. Radiographs required pre, during and post op
4. Will access the tooth to remove the nerve using our drill and files
5. Will be cleaning the canal with NaOCl and EDTA
6. Filled with guts percha - ZoE, radiopacifier and a final restoration

Risks
- failure of RCT requiring referral / re RCT
- fracture of file in the canal - curved canals
- missing a canal
- clamp fracture
- hypochlorite incident
- failure to negotiate canals to WL
- perforation, root fracture
- extrusion of GP

Alternative options
- do nothing and monitor - risks. Come with this
- extraction

Prognosis
- good/poor/limited
- up to 90% over 10 years for irreversible pulpitis
- 80% for necrosis

Question 3

Give the possible causes of failed RCT
- give options to the patient for treatment now

Answer 3

Reasons for failure
- undiscovered perforation, tooth fracture, over/underfilled GP, missed canals, poor coronal seal leading to microleakage, file fracture, canal blockage and unable to obturate to length

Tx options
- leave and monitor the tooth - may become symptomatic
- attempt to remove RCT and RE-RCT
- referral to specialist for re-rct
- periradicular surgery if failure at root apex
- XLA and tooth loss

Question 4

Endo file fractured - explain to patient what has happened and the options

Answer 4

• thin file used to clean the tooth has broken inside the canal
• sometimes they can separate in tight or very curved canals
• dont be alarmed, it is not an emergency

Options
- if it is in my scope of practice - try to retrieve by inserting a pre bent smaller file and bringing it out
- if not, inform you are referring pt to a specialist or someone who can remove the file - dress and monitor tooth, or for periradicular surgery
- inform we can obturate to file and leave it and monitor tooth
- XLA last resort

• ask if they have any questions and check understanding

Question 5

Explain the restorative options to a patient after they have had RCT

Answer 5

• gold standard is what we call cuspal coverage - full coverage restoration of crown as RCT weakens tooth structure. This is because reduces microleakage and has good coronal seal

Crown / onlay cuspal coverage
- gold, composite, zirconia, lidisi - costs and prep needed

Core build up followed by crown - if necessary
- require us to build up the tooth structure a bit due to decay - to then prep a crown

Direct restoration
- if only occlusal cavity with sufficient 2mm thick walls

Question 6

Pulp exposure - discuss how I would place a direct pulp cap

• what would influence pulp cap vs extirpation

Answer 6

Pulp cap indications
- tooth has no history of symptoms
- tooth is vital
- exposure is small surrounded by sound dentine and not carious dentine
- dam on before pulp exposed so contamination unlikely

Explain to pt what has happened
- pulp - inside alive part has been exposed when cleaning tooth
- requires a cap over it

Procedure
- arrest haemorrhaging pulp with saline
- rinse with CHX
- blot dry with cotton wool pledget
- exposed pulp covered with setting CaOH
- covered with vitrebond RMGIC
- restored as planned

• must inform patient need to monitor tooth
• if loss of vitality / pulpitis then RCT indicated