Untoward Outcomes and Solutions Planning

Question 1

What are the solutions for an endo treated tooth that is hurting years later?

Answer 1

■Extraction
■Non-surgical Retreatment
■Surgical Retreatment

Question 2

Monitoring DISEASE is or is not an option?

Answer 2

Is not
“Supervised Neglect
- Can be a basis for Legal Action
- Patient may decline TX recommendations

Question 3

Not all periapical lesions are ___________ disease

Answer 3

active

Question 4

Patient may select extraction over any other recommendation. Why?

Answer 4

• Lost Faith or Fear of Additional Fees/Failures
• Weary of Unresolved Issues / Definitive Solution
• May be the High Prognosis Optio

Question 5

Why is it always preferable to retain healthy natural tooth for life?

Answer 5

■ Most Efficient Chewing
■ Normal biting force and sensation
■ Natural appearance
■ Protects other teeth from excessive wear or strain

Question 6

What do you consider after extraction of an endo treated tooth?

Answer 6

■ FPD
■ Implant
■ RPD

Question 7

A RCT tooth may not heal as expected for a number of reasons:

Answer 7

■Complicated, undetected, or untreated canal anatomy
■ Delay in placement of definitive coronal restoration
■ Inadequate previous RCT or Leaking coronal restoration
■ New problems (decay, loose, cracked, broken, root fracture)

Question 8

If you are going to be successful in solving the problem, you first must determine exactly the ________ of the problem

Answer 8

etiology

Question 9

AAE suggests that _________ should generally be the first option considered for an endo treated tooth experiencing pain

Answer 9

NSRT
non-surgical retreatment

Question 10

True/false

NSRT Prognosis is generally poorer than the 1st RCT

Answer 10

True

Question 11

Failure rate of endodontic retreatment was _____%

Answer 11

16.6%

Question 12

What is the first step of non-surgical retreatment?

Answer 12

Problem must be identified

Question 13

______________ must be done to provide access to previous obturation material

Answer 13

Deconstruction

Question 14

GP must be ___________ to facilitate removal of obturation material

Answer 14

softened

soften with solvents or heat

Question 15

True/false

Some NSRT cases may be done by skilled & trained generalist

Answer 15

True

Most should be referred

Question 16

What are the indications for surgical retreatment?

Answer 16

■ NSRT is completed & problem not resolved
■ Problem not accessible to NSRCT
■ Root Perforations or Resorptive Defects
■ DX Experimental Flap Procedure for VRF identification
■ Marked overextension of obturating material interfering with healing.
■ Biopsy of suspect lesion
■ Separated Instrument not treatable by NSRT
■ Other blockages untreatable by NSRCT e.g. Ledges, Transportations and Zips
■ Non-negotiable canals may be retrofilled (MTA)

Question 17

What is extraradicular biofilm?

Answer 17

■ Sometimes biofilm has matured so much that it grows beyond the apex or lateral canals and onto the root surface
■ Disinfecting the canal will not reach these bacteria and disease can persist

Question 18

What is endodontic micro-surgery?

Answer 18

A clinical procedure intended to remove the root tips, place a biocompatible material, and remove the associated diseased soft tissue

This procedure is referred to as “Apical Curettage”

Question 19

________ appears to be the current material of choice for the retrofill.

Answer 19

MTA
(bioceramic???)

Question 20

What is the desired result of endodontic micro-surgery?

Answer 20

Desired result is a regeneration of normal tissues and architecture in the area of surgical intervention

Question 21

What do most endodontists do after an endodontic micro-surgery (apical curettage)?

Answer 21

follow-up apical curettage @ time of surgery by removing and beveling root tip and insuring an obturation seal by placing a “retrofill” to seal the canal. MTA appears to be the current material of choice for the retrofill.

Question 22

Endodontic Micro-Surgery (Periapical Surgery) is generally:

Answer 22

A procedure most commonly done to remove persistent peri-radicular disease following apparently adequate endodontic treatment.

Question 23

__________ obturation appears to be adequate but no healing following reasonable time is an indication for Retrograde obturation

Answer 23

Orthograde

Question 24

If the tooth is asymptomatic and the peri-radicular defect is not persistent, surgery is…

Answer 24

not indicated unless reasonable follow-up is exceeded (>24 months)

Question 25

What are the contraindications for surgical retreatment?

Answer 25

■ Dangerous Proximity to anatomical entities (ie) neurovascular bundles, IA canal ■ Extreme thickness of cortical plate ■ Periodontally involved teeth (2 disciplines involved: ? Prognosis of outcome) ■ Lack of Training, Skills, Equipment, Materials or Time ■ Inability to manage possible complications ■ Patient health considerations (ie) active leukemia, neutropenia, uncontrolled diabetes, bleeding considerations, on meds such as anticoagulants, recent MI ■ Pregnant and in first trimester ■ Better prognosis from alternate TX option (Implant?)

Question 26

____________ is prohibitively thickened in some cases, making access, visibility and hemostasis for retrofilling difficult if not impossible

Answer 26

Buccal shelf

Question 27

What does the surgical technique involve?

Answer 27

■ Anesthesia ■ Elevation of Flap ■ Location of apical lesion ■ Osteotomy & Curettage ■ Root bevel & hemostasis ■ Retrofill preparation and filling ■ Suturing and PO instructions

Question 28

How do you get access for a surgical retreat?

Answer 28

Full thickness flap Vertical incisions (never over boney eminence)

Question 29

How do you do the osteotomy for a surgical retreat?

Answer 29

#6 RB or ultrasonic piezo to gain access to root tip if no lesion has perforated (keep it COOL)

Question 30

How do you do the resection for a surgical retreat?

Answer 30

Use SL fissure bur to resect apical portion of root (now, ultrasonics)

Question 31

How much apical root resection should you do?

Answer 31

3 mm

Question 32

How do you control the bleeding during a surgical retreat?

Answer 32

■ CaSulfate, Hemodent, Astringodent, Racemic Epinephrine, maybe Electrosurg Unit for bleeders. ■ Crypt management; Telfa sponges w Hemodent

Question 33

How deep to retro fill into the canal space?

Answer 33

3 mm minimum

Question 34

Amalgam, SEBA, Geristore have been used historically for retrofill, but _____ is now the material of choice

Answer 34

MTA (bioceramic???)

Question 35

Remove the gutta percha during a surgical retreat using a...

Answer 35

ultrasonic

Question 36

The MTA has been delivered to the apical retroprep and now, an instrument is used to _________ the MTA in the prep

Answer 36

compact

Question 37

How do you finish up a sugical retreat?

Answer 37

■ Surgical area is Cleaned and Inspected and then Sutured ■ Patient should be called evening of surgery to see how they are doing ■ Post-op patient & suture removal prn (5 days)

Question 38

What are the post op instructions for the patient after a surgical retreat?

Answer 38

■ Use ice pack 20” on, 5”off for 1st day to reduce P&S, warm saline rinses qid 2nd day ■ If excess bleeding occurs, place a wet tea bag over incision 15" to stop bleeding ■ Pain is usually 3/10. 3 IBU Q4H + narcotic RX if necessary. If excess pain occurs, call office ■ Soft diet for 3-4 days ■ Do not smoke for 3 days>surgery ■ Suture removal prn & POT check in 5 days