Endodontic Treatment Planning

Question 1

Indications for endodontic treatment?

Answer 1

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

Question 2

Irreversible pulpitis pt history?

Answer 2

Lingering pain
Spontaneous
Keeps pt awake

Question 3

Irreversible pulpitis clinical examination findings?

Answer 3

Exaggerated response to sensibility testing

May be difficult to locate tooth responsible

Question 4

How to treat irreversible pulpitis?

Answer 4

Sedative dressing may relieve symptoms

Endo

Question 5

Periapical pathology diagnosis?

Answer 5

Acute/chronic apical periodontitis

Acute/chronic apical abscess

Question 6

How to reach a diagnosis with periapical pathology?

Answer 6

Pt history
Clinical examination (including special tests)
Radiographic findings

Question 7

When to have a post retained restoration?

Answer 7

Where a tooth has lost too much tooth structure to retain an indirect restoration without the use of an endodontic post
- DO ENDO BEFORE POST

Question 8

Overdenture?

Answer 8

Teeth may be decoronated to provide support as an overdenture abutment
These teeth should undergo endo tx
Only exception for no RCT is if the canal is highly sclerosed with no periapical pathology

Question 9

When to treat teeth with doubtful pulp vitality (early signs of disease)?

Answer 9

Thinking of doing a crown or tooth be used as bridge abutment on a tooth with early signs of pulpitis
= Easier to undertake endo at this stage and have a better prognosis

Research = significant number of vital teeth will become non-vital following crown/bridge prep

Question 10

What to consider with perio-endo lesions?

Answer 10

If one root has significant pathology = root resection = endo tx before

Question 11

Pulp sclerosis following trauma - how will the tooth respond to trauma and when should endo be completed?

Answer 11

Teeth which retain vitality after trauma:

• May respond by laying down secondary dentine resulting in gradual narrowing of the pulp space = not an indication for endo tx in isolation
• Endo tx easier if undertaken prior to complete pulp sclerosis
• Pt may be concerned regarding yellow discolouration which can be reliably treated with elective endodontics and internal bleaching

Question 12

Contraindications to root canal treatment?

Answer 12

General

• Inadequate access
• Poor OH/status/attitude
• General medical condition

Local

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

Question 13

When may there be inadequate access?

Answer 13

Pts with limited mouth opening
Microstomia
TMD
Previous radiotherapy
Scleroderma
= 2 fingers should fit between the pt’s incisors to be able to complete RCT
Consider using mouth props if the pt finds wide mouth opening challenging

Question 14

When may a pt with poor OH/staus/attitude be allowed to have a RCT?

Answer 14

Medically compromised pt - think of the long term outcome

Poor motivated pt unlikely to complete the tx

Question 15

MH for endo?

Answer 15

No medica contraindicated
Well enough for long tx for multiple appts
If pt older - more complex endo due to canal sclerosis

Question 16

What must the tooth be to complete endo tx on it?

Answer 16

Tooth must be restorable - finishing line of restoration must be supracrestal and preferably supragingival

Sufficient periodontal support to ensure the medium to long term survival of the tooth
- Significant periapical infec/acute abscess = mobility but should heal after endo tx

Question 17

When to consider extraction? Why save it?

Answer 17

If a tooth is unopposed and non-functional

A reason to save an unopposed tooth may be to maintain a distal abutment for a partial denture

Question 18

Which types of root fractures have a hopeless prognosis and need to be extracted?

Answer 18

Sub-crestal/vertical root fractures

Question 19

Clinical and radiographic signs of root fractures?

Answer 19

An isolated, narrow, deep periodontal pocket

Radiographic signs - J shaped radiolucency around tooth or obvious displacement of the root fragments

Question 20

Types of root resorption?

Answer 20

External root resorption

• External cervical resorption
• External replacement resorption

Internal root resorption

Question 21

External cervical root resorption features?

Answer 21

Unknown aetiology
May be associated with previous trauma
Resorption usually starts subgingivally in the cervical region
Pulp is usually vital and only becomes involved when the lesion has progressed extensively
Often asymptomatic

Question 22

Diagnosis of external cervical root resorption?

Answer 22

Clinical and rad findings
= Pink lesion as gingival proliferation
Hard catch on the probe
CBCT to assess extent of lesion

Question 23

How to treat external cervical root resorption?

Answer 23

Surgical exploration of the lesion followed by repair
Endo tx maybe
Specialist tx - referral

Question 24

External replacement resorption features?

Answer 24

Root surface is gradually replaced by bone = ankylosis
Traumatic origin
Transient and self limiting but will often progress until complete root replacement occurs
Rate of replacement faster in children

Question 25

Diagnosis of external replacement resorption?

Answer 25

Rad appearance and clinical exam
- High pitched, metallic sound on percussion
Tooth will be non-mobile and may become infra-occluded in children who are still growing
No tx to stop ankylosis

Question 26

Internal root resorption features?

Answer 26

Occurs within the canal system
Results in ovoid expansion of the root canal
Outline of the canal will be lost around the area of resorption
Pulp will likely be chronically inflamed
Pink spot lesion may be visible through enamel
Tooth is usually partially vital and there may be symptoms of pulpitis

Question 27

Tx of internal root resorption?

Answer 27

Endo tx required
Obturation can be difficult due to unusual canal anatomy
Thermal obturation

Question 28

When may the anatomy of a tooth require a referral for endo tx?

Answer 28

Exceptionally curved roots

Dilacerated teeth

Question 29

What to keep in mind with pts undergoing radiotherapy?

Answer 29

Mandible/maxilla involved in radiotherapy in head and neck cancer
= Reduces bone vascularity

Question 30

What do bisphosphonates do?

Answer 30

Inhibit bone resorption (inhibit osteoclasts)
Treat diseases with increased bone resorption e.g. osteoporosis, paget’s disease and bone cancers

Delivered orally or IV
Newer drugs e.g. denosumab have a similar effect but are not part of the bisphosphonate group

Question 31

What are pts on osteoclast inhibitors and undergoing radiotherapy at risk of?

Answer 31

Increased risk of osteonecrosis of the jaw

= Serious, painful, difficult to treat, can cause disfigurement

Question 32

If a pt is on osteoclast inhibitors and undergoing radiotherapy, what may you do?

Answer 32

Consider endo tx rather than extraction

• May mean RCT a tooth that would otherwise be considered unrestorable
• Tooth can be decoronated and left as a root face with an appropriate restoration covering the root

Question 33

Endodontics and implant success rates?

Answer 33

Endo - 80-90%

Implants - 95%

Question 34

When to refer a patient?

Answer 34

Only perform tx you are trained and confident to perform

Question 35

Who to refer to for endo?

Answer 35

Dental hospital/department
Local endodontist (specialist) - charge