Endo Case selection Flashcards
risk in endodontics
appropriate case assessment and selection are cornerstones of endodontic therapy
it is essential to recognise the difficult case
reasons for endodontic claims
- 50 Unsatisfactory’ treatment (including other procedures)
- 35 Failed/inadequate endodontic treatment
- 18 Post-treatment complications: infection, persistent pain and fractured teeth
- 14 Fractured and/or retained instrument
- 14 Adverse incidents during treatment, e.g. burn to lip, swallowed instrument
- 13 Poor management, including failure to take radiographs or refer appropriately
- 8 Perforation
- 3 Valid consent not obtained
problems that may occure pre-tx assessment resulting in issues in tx
- Evaluation of patient
- Evaluation of tooth
- Self-evaluation of Clinician
case selction for endo problems
occurs after examination and diagnosis
includes
- Is treatment indicated?
- Is patient’s oral health needs best met by maintaining the tooth?
- Complete patient evaluation necessary
- Who should treat?
evaluation of pt
Medical
- E.g.
- Pregnancy
- Cardiovascular disease
- Cancer
- Diabetes mellitus
- Bisphosphonate therapy
- Allergies
- No absolute contraindication to endodontic treatment
- If in doubt speak with patient’s physician
Psychological
Social factors
pregnancy and endo
Not a contraindication to endodontic therapy
First trimester emergency intervention only – can elect this
Pain and infection managed in collaboration with obstetrician/physician
cardiovascular disease and endo
Myocardial infarction within the past 6 months is a contraindication
Emergency treatment, should be provided in consultation with the patient’s cardiologist
Stress Reduction Protocol
- Short appointments
- Sedation
- Pain and anxiety control
cancer and endo
thorough history essential
Treatment for cancer?
- Chemotherapy and radiotherapy to the head and neck region can compromise healing
Consult with the oncologist
diabetes and endo
An acute endodontic infection can compromise even a well controlled diabetic; so all diabetes patients must be carefully monitored
Patients with uncontrolled diabetes should be monitored Appointments should be scheduled so as not to interfere with the patient’s normal insulin and meal schedule
Minimise stresses
bisphosphates and endo
BRONJ
IV bisphosphonates greater risk than oral administration – all patients should be considered at some risk (AAE)
Preventive care
Non-surgical endodontic treatment of teeth that might otherwise be extracted
Use the entire health care team, when developing treatment plans for these patients
allergies and endo
If the patient is allergic to latex rubber, a dam should be made of vinyl
Gutta Percha not a risk as non-cross-reactive (studies done)
evaulation of tooth for endo
- Periodontal considerations
- Restorative considerations
- Restorability
- Other factors
- Calcifications,
- dilacerations
- resorption
- Inability to isolate a tooth
- Unusual anatomy
How is this going to affect my ability to carry out treatment/prognosis?
perio considerations for endo
Periodontal probing essential – BPE and tooth of interest
Poor perio prognosis may necessitate loss
Perio-endo or endo-perio (which is primary and which is secondary
restorative consideration for endo
- Sub-osseous caries
- Poor crown/root ratio
- Misalignment of teeth
- Presence of pre-existing full coverage restorations
restorability considerations for endo
The restorability of the tooth must be thoughtfully considered first, deconstruct if necessary
All decay should be removed so that the extent of healthy tooth structure can be determined
calcifications and endo
Isolated or continuous pulp chamber - can make treatment very difficult even for the most skilled clinician
orthograde management not possible –> surgery
resorption and endo
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
ususual anatomy and endoNot simple
enging
Not simple
Intra oral radiography
Cone beam computed tomography
- “CBCT should be considered on a case‐by‐case basis where lower dose conventional radiography does not provide adequate diagnostic information.”
ledges - previously RCT
perforations - can be repaired
posts
separated instruments - removal challenging
instruments for endo
Use front surface mirrors
Most mirrors are rear surface reflecting
This causes increasing distortion as the angle of the mirror is increased e.g. when looking down canals, (faint reflecting)
self-evaluation of clinician
GDC standard 7 - must work winthin your knowledge, skills, professional competence and abilities
options for tx
- No active treatment with review
- Extraction
- Orthograde root canal treatment
- Surgical endodontics
Results of
- Patient assessment
- Dental assessment
- Patient motivation
- Patient time
- Financial implications
tx or refer
Simple formula such as root number or chronic or acute
American Association of Endodontists Endodontic Case Difficulty
Assessment Form
- Minimum, Moderate and High degrees of difficulty
- form to complete
- Allows clinicians to identify need for referral
- Eases communication with patient
consent
needed to have for assessment and Tx plan
active dialogue is expected by pt
obtaining consent
Options for Treatment
- Follow-up
- Extraction
- Orthograde root canal treatment
- Surgical endodontics
What do procedures involve in brief
Prognosis Alternatives Risks Opportunity to ask questions Agree on plan – remember endodontics is not all that will be required – restoration and review
what risks to explain to pt
all “…whether a reasonable person in the patient’s position would be likely to attach significance to the risk, or should reasonably be aware that the particular patient would be likely to attach significance to it’.
- perforation - curved roots
- failed RCT
complexity of tooth 36
- Reduce pulpal volume increases complexity of access
- Possible root end resoprtion may increase complexity due to difficulties in controlling length of obturation.
- ???
A furcal lucency may indicate a perforation, however in this case it may be related to a lateral canal or if a sinus tract in present may result from cortical plate disruption. This may affect prognosis. Deep distal margin and amalgam restoration may make isolation and apex location more complex. Restorative prognosis may be reduced.
how to deal with pain
“if you have pain, take the medication” - NOOOO
- Reactive not recognising the biological process (just taking after)
Biologically based preventive approach relies on understanding of tissue damage, mediator release, and the subsequent processes
Peri-operative ibuprofen shown to delay the onset and decrease the severity of pain
- Have before operation in anticipation
