Endodontic treatment planning

Question 1

Indications for endodontic treatment (7)

Answer 1

Irreversible pulpitis
Periapical pathology
Post retained restoration 
Overdenture
Teeth with doubtful pulps
Periodontal disease
Pulp sclerosis following trauma

Question 2

Post retained restoration (2)

Answer 2

Where a tooth has lost too much tooth structure to retain an indirect restoration without the use of an endodontic post
Careful assessment of the remaining tooth structure is required - can a direct composite core be used?

Question 3

Overdenture (3)

Answer 3

Teeth may be decoronated to provide support as an overdenture abutment
These teeth should undergo endodontic treated
The only exception would be if the canal is highly sclerosed with no periapical pathology

Question 4

Teeth with doubtful pulps (4)

Answer 4

Consideration should be given to undertaking endodontic treatment on teeth with doubtful vitality status
This is especially if the case is to have a crown or be used as a bridge abutment
If endodontic treatment is undertaken at this stage it will be easier to undertake and have a better prognosis
Research has shown that a significant number of vital teeth will become non-vital following crown/bridge preparation

Question 5

Perio-endo lesions (2)

Answer 5

In multi-rooted teeth one root may have significant pathology, giving an indication for root resection
If root resection is planned, the endodotnic treatment should be undertaken prior to resection

Question 6

Pulp sclerosis following trauma (4)

Answer 6

Teeth which retain vitality after trauma may respond by laying down secondary dentine resulting in gradual narrowing of the pulp space
This is not an indication for endodontic treatment in isolation
However, endodontic treatment will be easier if undertaken prior to complete pulp sclerosis
The patient may also be concerned regarding yellow discolouration which can only be reliably treated with elective endodontics and internal bleaching

Question 7

General contra-indications to RCT (3)

Answer 7

Inadequate access
Poor oral hygiene/status/attitude
General medical condition

Question 8

Local contra-indications to RCT (6)

Answer 8

Tooth not restorable
Insufficient periodontal support
Non-strategic tooth
Root fractures
Root resorption
Bizarre anatomy

Question 9

Inadequate access reasons (5) and rules (2)

Answer 9

Reasons for limited access:
-microstomia
-TMD
-previous radiotherapy
-overeruption of lower anterior teeth
-scleroderma
A general rule is that it should be possible to place 2 fingers between the patient’s incisors
Consider using mouth props if the patient finds wide mouth opening challenging

Question 10

Poor OH/ status/ attitude (4)

Answer 10

Endodontic treatment should not be carried out if the patient is not able to maintain a healthy oral status
Medically compromised patients may be an exception to this
Think about the long-term outcome
Patients with poor motivation towards dental treatment are unlikely to complete the treatment

Question 11

General medical condition (3)

Answer 11

There are no specific medical contraindications to endodontic treatment
However, the patient has to be well enough to undergo a relatively long dental procedure possibly for multiple appointments
If the patient is older, this will be compounded by the endodontic treatment itself being more complex due to canal sclerosis

Question 12

Tooth not restorable (3)

Answer 12

It must be possible following root canal treatment to restore the tooth to health and function
The finishing line of the restoration must be supracrestal and preferably supragingival
Don’t start endodontics on a tooth with questionable restorability – your not doing yourself or the patient any favours!

Question 13

Insufficient periodontal support (3)

Answer 13

The tooth should have sufficient periodontal support to ensure the medium to long-term survival of the tooth
Endodontics is difficult enough without having to hit a moving target!
Remember, teeth with significant periapical infection/ acute abscess may be mobile due to the pathology, but this will hopefully heal following the endodontic treatment

Question 14

Non-strategic tooth (2)

Answer 14

If a tooth is unopposed and non-functional, the benefit of endodontic treatment versus extraction should be considered
A reason to save an unopposed tooth may be to maintain a distal abutment for a partial denture

Question 15

Root fractures (3)

Answer 15

Sub-crestal/vertical root fractures have a very poor prognosis and extraction is the only option
Clinical signs include an isolated, narrow, deep periodontal pocket
Radiographic signs include a ‘J’ shaped radiolucency around the tooth or obvious displacement of the root fragments

Question 16

Root resorption types (3)

Answer 16

External root resorption
-external cervical resorption
-external replacement resorption
Internal root resorption

Question 17

External cervical root resorption (10)

Answer 17

Unknown aetiology
May be associated with previous trauma
Resorption usually starts subgingivally in the cervical region
The pulp is usually vital and only becomes involved when the lesion has progressed extensively
Often asymptomatic
Diagnosis is based on clinical and radiographic findings
CBCT may be useful to assess the extent of the lesion
Treatment involves surgical exploration of the lesion followed by repair
Endodontic treatment may or may not be required
This is specialist treatment and referral should be instigated as soon as a diagnosis is suspected

Question 18

External replacement resorption (7)

Answer 18

The root surface is gradually replaced with bone – also known as ankylosis
Often has a traumatic origin
Can be transient and self-limiting, but will often progress until complete root replacement occurs
The rate of replacement is often faster in children
Diagnosis is based on radiological appearance and clinical examination, which will show a high-pitched, metallic sound on percussion
The tooth will be non-mobile and may become infra-occluded in children who are still growing
There is no treatment which can stop the ankylosing process

Question 19

Internal root resorption (9)

Answer 19

Occurs entirely within the canal system
Results in an ovoid expansion of the root canal
The outline of the canal will be lost around the area of resorption
The pulp will likely be chronically inflamed
A ‘pink spot lesion’ may be visible through the enamel
The tooth is usually partially vital and there may be symptoms of pulpitis
Endodontic treatment is required
Obturation can be difficult due to the unusual canal anatomy
Thermal obturation techniques (involving backfill with molten GP) is required

Question 20

Bizarre anatomy (4)

Answer 20

A pre-treatment assessment should identify any unusual features that will increase the complexity of the endodontic treatment
Features may include
-exceptionally curved roots
-dilacerated teeth
Referral to a specialist would be recommended for a further opinion and treatment if possible

Question 21

Radiotherapy (3)

Answer 21

Radiotherapy is often used for the treatment of cancers, either as the sole treatment modality, or as an adjunct to surgery/chemotherapy
The mandible and/or maxilla is often involved in the radiotherapy beam in head and neck cancer
The effect on bone tissue is to reduce its vascularity (end arteritis obliterans)

Question 22

Osteoclast inhibitors (5)

Answer 22

Bisphosphonates are a class of drug which are used to inhibit bone resorption
They are used to treat diseases which present with increased bone resorption such as osteoporosis, Paget’s disease and bone cancers/metastases
Examples include alendronate (Fosamax) and zolendronic acid
They can be delivered orally or IV, depending on the dose and aetiology
Newer drugs, such as denosumab have a similar effect but are not part of the bisphosphonate group

Question 23

Osteoclast inhibitors and radiotherapy (5)

Answer 23

Patients who have undergone radiotherapy in the head and neck region or who have taken osteoclast inhibitors are at increased risk of osteonecrosis of the jaw
This is a serious and painful condition which is difficult to treat and can result in significant disfigurement
Causes of osteonecrosis include dental extractions
For this reason, people who are at risk of osteonecrosis should be strongly considered for endodontic treatment rather than extraction
This may mean trying to endodontically treat a tooth which would otherwise be considered unrestorable
In this case the tooth can be de-coronated and left as a root face with an appropriate restoration covering the root.

Question 24

Endo vs implants (7)

Answer 24

Endodontics has a 80-90% success rate, whereas with implants it’s more like 95% - shouldn’t patients just have an implant instead?
This was an argument proposed by eager implantologists keen to cure patients of acute titanium deficiency!
The success rate of implants is actually more correctly a ‘survival’ rate ie the implant is still in situ
Success depends on certain factors, for example is the implant still functional, has it suffered any complications or pathology?
When strict success criteria are applied to implants the success rate declines dramatically
Implants are still a very successful treatment option, but patients should be aware of all the associated complications and limitations
Implants should not be considered an alternative for endodontics
They are an option (for certain patients) to replace a missing tooth once a tooth has failed and is deemed unrestorable

Question 25

When to refer? (3)

Answer 25

Endodontic treatment is complicated and as a newly qualified dentist you would not be expected to deal with every endodontic case that comes your way
The GDC state that you should only perform treatment which you feel adequately trained and confident to perform (ie work within your limitations)
This is not an excuse to give up endodontics upon qualification!

Question 26

What to refer to? (3)

Answer 26

If you are lucky enough to have a dental hospital or department with an endodontic service nearby then you can refer to them
Many will have acceptance criteria eg the CCDH does not accept referrals for endodontics in molar teeth unless in exceptional circumstances
The alternative is to refer to a local endodontist (specialist or a dentist with ‘special interest’) – however, they will charge!

Question 27

Irreversible pulpitis

• history
• exam
• treatment

Answer 27

Will prevent when symptoms arise
Patient history:
-lingering pain
-spontaneous
-kept awake
Clinical exam:
-exaggerated response to sensibility testing
-may be difficult to locate the tooth responsible
Placing a sedative dressing may relieve the symptoms but the diagnosis stays!
Endodontic treatment should be scheduled

Question 28

Periapical pathology

• diagnoses
• presentations

Answer 28

Diagnoses may include
-acute/chronic apical periodontitis
-acute/chronic apical abscess
Early presentations of chronic disease may be difficult to diagnose
Use patient history, clinical examination (including special tests) and radiographic findings to reach a diagnosis