Untoward Outcomes and Solutions Planning Flashcards
What are the solutions for an endo treated tooth that is hurting years later?
■Extraction
■Non-surgical Retreatment
■Surgical Retreatment
Monitoring DISEASE is or is not an option?
Is not
“Supervised Neglect
- Can be a basis for Legal Action
- Patient may decline TX recommendations
Not all periapical lesions are ___________ disease
active
Patient may select extraction over any other recommendation. Why?
- Lost Faith or Fear of Additional Fees/Failures
- Weary of Unresolved Issues / Definitive Solution
- May be the High Prognosis Optio
Why is it always preferable to retain healthy natural tooth for life?
■ Most Efficient Chewing
■ Normal biting force and sensation
■ Natural appearance
■ Protects other teeth from excessive wear or strain
What do you consider after extraction of an endo treated tooth?
■ FPD
■ Implant
■ RPD
A RCT tooth may not heal as expected for a number of reasons:
■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)
If you are going to be successful in solving the problem, you first must determine exactly the ________ of the problem
etiology
AAE suggests that _________ should generally be the first option considered for an endo treated tooth experiencing pain
NSRT
non-surgical retreatment
True/false
NSRT Prognosis is generally poorer than the 1st RCT
True
Failure rate of endodontic retreatment was _____%
16.6%
What is the first step of non-surgical retreatment?
Problem must be identified
______________ must be done to provide access to previous obturation material
Deconstruction
GP must be ___________ to facilitate removal of obturation material
softened
soften with solvents or heat
True/false
Some NSRT cases may be done by skilled & trained generalist
True
Most should be referred
What are the indications for surgical retreatment?
■ 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)
What is extraradicular biofilm?
■ 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
What is endodontic micro-surgery?
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”
________ appears to be the current material of choice for the retrofill.
MTA
(bioceramic???)
What is the desired result of endodontic micro-surgery?
Desired result is a regeneration of normal tissues and architecture in the area of surgical intervention
What do most endodontists do after an endodontic micro-surgery (apical curettage)?
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.
Endodontic Micro-Surgery (Periapical Surgery) is generally:
A procedure most commonly done to remove persistent peri-radicular disease following apparently adequate endodontic treatment.
__________ obturation appears to be adequate but no healing following reasonable time is an indication for Retrograde obturation
Orthograde
If the tooth is asymptomatic and the peri-radicular defect is not persistent, surgery is…
not indicated unless reasonable follow-up is exceeded (>24 months)
What are the contraindications for surgical retreatment?
■ 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?)
____________ is prohibitively thickened in some cases, making access, visibility and hemostasis for retrofilling difficult if not impossible
Buccal shelf
What does the surgical technique involve?
■ Anesthesia
■ Elevation of Flap
■ Location of apical lesion
■ Osteotomy & Curettage
■ Root bevel & hemostasis
■ Retrofill preparation and filling
■ Suturing and PO instructions
How do you get access for a surgical retreat?
Full thickness flap Vertical incisions (never over boney eminence)
How do you do the osteotomy for a surgical retreat?
6 RB or ultrasonic piezo to gain access to root tip if no lesion has perforated (keep it COOL)
How do you do the resection for a surgical retreat?
Use SL fissure bur to resect apical portion of root (now, ultrasonics)
How much apical root resection should you do?
3 mm
How do you control the bleeding during a surgical retreat?
■ CaSulfate, Hemodent, Astringodent, Racemic Epinephrine, maybe Electrosurg Unit for bleeders.
■ Crypt management; Telfa sponges w Hemodent
How deep to retro fill into the canal space?
3 mm minimum
Amalgam, SEBA, Geristore have been used historically for retrofill, but _____ is now the material of choice
MTA
(bioceramic???)
Remove the gutta percha during a surgical retreat using a…
ultrasonic
The MTA has been delivered to the apical retroprep and now, an instrument is used to _________ the MTA in the prep
compact
How do you finish up a sugical retreat?
■ 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)
What are the post op instructions for the patient after a surgical retreat?
■ 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
