-case selection and treatment planing.pptx

-case selection and treatment planing in endodontics

1. BY :Mohamed turki Mousa Case Selection and Treatment Planning

2. I ntroduction The process of case selection and treatment planning begins after a clinician has diagnosed an endodontic problem . The use of ( CBCT), rotary instruments, ultrasonics, and microscopy, as well as new materials , has made it possible to retain teeth that previously would have been extracted. In addition, even teeth that have failed initial endodontic treatment can often be successfully retreated using nonsurgical or surgical procedures .

3. CASE SELECTION

4. FACTORS OF CASE SELECTION Case selection is broadly based upon three factors : Factors associated with teeth. Factors associated with patients health. Factors associated with clinician.

5. FACTORS ASSOCIATED WITH TEETH first step always should be examination of the teeth and oral cavity. Clinician should judge whether the teeth needed any kind of endodontic treatment or not.

6. Indication of ENDODONTIC THERAPY 1-Actual Reason for Endodontic Therapy If there is pulp involvement due to caries, trauma, etc. 2-Elective Endodontics elective endodontic is done with crack or heavily restored tooth, to prevent premature loss of cusp during their restoration (usually crown preparation) and eliminate fear of pulp exposure

7. 3. Teeth with periapical pathosis. Periapical pathology or diseases of periradicular tissue, like acute or chronic apical periodontitis, acute or chronic periapical abscess can be treated by endodontic procedure.

8. 4. Fractured teeth Fractured teeth often require endodontic treatment which helps to maintain its normal esthetic form and functional properties. Deciduous teeth having pulpal involvement and crown fracture required treatment procedure like pulpotomy, direct pulp capping, apexification, apexogenesis . Vertical crown fracture in multi rooted teeth can also be treated by endodontic procedures like hemisection followed by root canal therapy.

9. 5-Devitalization of Tooth In patients with attrited teeth, rampant caries or recurrent decay and smooth surface defects, it is wise to do desensitization of the teeth so that patients do not feel discomfort to cold or sweets.

10. 6-Endodontic Emergency Sometimes patient comes with acute dental pain, in such cases endodontic therapy is often indicated before a complete examination and treatment plan doing.

11. CONTRAINDICATIONS OF ENDODONTIC THERAPY Mainly there are following four factors which influence the decision of endodontic treatment : 1. Accessibility of apical foramen. 2. Restorability of the involved tooth. 3. Strategic importance of the involved tooth . 4. General resistance of the patient .

12. CONTRAINDICATING FACTORS OR FACTORS WHERE SPEACIAL ATTENTION IS NEEDED- 1 . Insufficient periodontal support In Teeth having grade three mobility extraction is preffered over endodontic treatment A tooth with a poor periodontal prognosis may have to be sacrificed, despite a favorable endodontic prognosis.

13. 2. Improper positioning of teeth Partially erupted, impacted and malpositioned teeth are contraindicated for endodontic treatment. It is very difficult to make proper accessibility and isolation while doing endodontic treatment in these malposed teeth.

14. 3. Non restorable teeth Non restorable teeth : Such teeth with extensive root caries, furcation caries, poor crown/root ratio, with fractured root are contraindicated for endodontic treatment. Because in such cases even the best canal filling is futile if it is impossible to place the restoration

15. 4. Abnormal canal configuration Severely curved canal, c shaped canal, aberrant extra canals are very difficult for instrumentation Teeth with such canal configuration are not ideal for endodontic treatment. Curvature of 20° in a narrow root canal is very difficult to negotiate also a curvature of 30° with a wide canal is not easily negotiable.

16. 5. Developmental anomalies Developmental anomalies like fusion, gemination, concrescences, enamel pearl are difficult to treat with endodontic procedures.

17. 6. Calcification of canal Excessive calcification of canal prevents proper instrumentation. Which may cause failure of endodontic treatment or iatrogenic errors like perforation, ledging etc.

18. 7. Crown root ratio An unfavorable crown/root ratio that exceeds 1:1 is more susceptible to eccentric occlusal forces, and hence prognosis is poor. Sometimes these teeth maybe indicated for extraction, but before a decision for extraction is made referral to a prosthetic dentist for an accurate evaluation maybe necessary.

19. 8. latrogenic error Painful Teeth where previous attempt of endodontic treatment has been done often show ledges, perforations, broken instruments in the canals . Prognosis of such cases are questionable if not treated properly.

20. 9-Nonstrategic teeth: There are two major factors which relegate a strategic tooth to the hopeless status ; restorability and periodontal support . The tooth that cannot be restored or that has inadequate, amenable periodontal support is hopeless . Evaluation of the oral cavity can decide whether tooth is strategic or not, For example if a person has multiple missing teeth, root canal of third molar may be needed. But in case of well maintained oral hygiene with full dentition, an exposed third molar can be considered for extraction.

21. FACTORS ASSOCIATED WITH PATIENT'S Before starting endodontic treatment the clinician must take proper medical history about the patient. Systemic conditions: Most of the medical conditions do not contraindicate the endodontic treatment but patient should be thoroughly evaluated in order to manage the case optimally.

22. FACTORS ASSOCIATED WITH CLINICIAN The clinician should have proper endodontic instruments and clinical set up for the treatment. Evaluation of the clinician : Clinician should be honest while dealing with the case. Self evaluation should be done for his experience, capability to do the case, equipment he has or not for the completion of the case.

23. The scope of endodontics The scope of endodontics has changed; the clinician now has more viable options than ever before. In recent years , there is increasing evidence to support the implementation of regenerative procedures for some immature teeth vital pulp therapy replantation of teeth with failed endodontic procedures. Treatment planning must now include those options as well as nonsurgical or surgical endodontics .

24. patient evaluation The evaluation must include assessment of medical, psychosocial, and dental factors as well as consideration of the relative complexity of the endodontic procedure . Although most medical conditions do not contraindicate endodontic treatment , some can influence the course of treatment and require specific modifications . the most important advice for a clinician who plans to treat a medically compromised patient is to be prepared to communicate with the patient’s physician

25. An alternative means of considering risk assessment is to review the following issues: ◼ History of allergies ◼ History of drug interactions, adverse effects ◼ Presence of prosthetic valves, joints, stents, pacemakers ◼ Antibiotics required (prophylactic or therapeutic) ◼ Patient position in chair ◼ Infiltration or block anesthesia with or without vasoconstrictor ◼ Significant equipment concerns (radiographs, ultrasonics, electrosurgery) ◼ Emergencies (potential for occurrence, preparedness) ◼ Anxiety (past experiences and management strategy)

26. successful endodontic therapy following steps are needed and skipping a step may lead to the endodontic failure or less desirable result : • Take proper history and medical history of the patient • Make accurate diagnosis and treatment planning • Obtain adequate anesthesia • Isolate the tooth using rubber dam • Utilize adequate visualization and lighting • Obtain straight line access to the canals • Complete biomechanical preparation of the tooth • Efficient and safe use of nickel titanium files • Copiously irrigate at all stages • Obturate the canal three dimensionally • Give the coronal restoration to tooth.

27. TREATMENT PLANNING

28. TREATMENT PLANNING The treatment planning signifies the planning of the management of the patient’s dental problems in systematic and ordered way that assumes a complete knowledge of patient needs, nature of problem and prognosis of the treatment. Thus the stage of assessment of a complete picture overlaps with the stages of decision making, treatment planning and treatment phase.

29. Treatment plan sequencing Proper sequencing is a critical component of a successful treatment plan. Complex treatment plans often should be sequenced in phases, including : an urgent phase control phase re-evaluation phase definitive phase maintenance phase

30. 1-Urgent phase The urgent phase of care begins with a thorough review of the patient's medical condition and history. So, a patient presenting with swelling, pain, bleeding, or infection should have these problems managed as soon as possible and certainly before initiation of subsequent phases.

31. 2-Control phase It is meant to eliminate active disease such as caries and inflammation remove conditions preventing maintenance eliminate potential causes of disease, and begin preventive dentistry activities

32. 2-Control phase This phase includes extractions, endodontics, periodontal debridement and scaling, occlusal adjustment as needed, caries removal, replacement/repair of defective restorations such as those with gingival overhangs, and use of caries control measures The goals of this phase are to remove etiologic factors and stabilize the patient's dental health

33. 3-Re-Evaluation phase The holding phase is the time between the control and definitive phases that allows for resolution of inflammation and time for healing. Home care habits are reinforced, motivation for further treatment is assessed, and initial treatment and pulpal responses are re-evaluated before definitive care is begun.

34. 4-Definitive phase After the dentist reassesses initial treatment and determines the need for further care, the patient enters the corrective or definitive phase of treatment. Sequencing operative care with endodontic, periodontal, orthodontic, oral surgical, and prosthodontic treatment is essential

35. 5-Maintenance phase This includes regular recall examinations that: may reveal the need for adjustments to prevent future breakdown, and provide an opportunity to reinforce home care.

36. 5-Maintenance phase The frequency of re-evaluation examinations during the maintenance phase depends in large part on the patient's risk for dental disease: A patient who has stable periodontal health and a recent history of no caries should have longer intervals (e.g. 9–12 months or longer) between recall visits. Those at high risk for dental caries and/or periodontal breakdown should be examined much more frequently (e.g. 3–4 months).

37. TREATMENT PLANNING A treatment plan for gaining the patient compliance and to have success in the pain management should progress as follows: • Treatment of acute problem includes first step of endodontic treatment which comprises of access opening, extirpation of pulp and allowing drainage through pulp. • Oral hygiene instructions, diet instructions. • Temporary restoration of carious teeth, scaling and polishing . • Definitive restorations of carious teeth. • Complete root canal treatments of required teeth. • Do endodontic surgery if needed. • Evaluate the prognosis of treated teeth. • Provide post endodontic restorations.

38. Factors Affecting Treatment Planning • Chief complaint regarding pain and swelling requires urgent treatment and planning for definitive solution. • Previous history of dental treatment (solve the residual problems of previous dental treatment). • Medical history (identify factors which can compromise dental treatment). • Intraoral examination (to know the general oral condition first before focusing on site of complaint so as not to miss the cause). • Extraoral examination (to differentially diagnose the chief complaint). • Oral hygiene .

39. Factors Affecting Treatment Planning • Periodontal status (to see the periodontal foundation for long term prognosis of involved tooth). • Teeth and restorative status (to identify replacement of missing teeth, status of the remaining dentition). • Occlusion (to check functional relationship between opposing teeth, parafunctional habits, etc.). • Special tests (to explore the unseen tissues). • Diagnosis (repeat the series of conclusion). • Treatment options (evaluate various options to decide the best choice for long term benefit of the patient).

40. Factors affecting outcome of endodontic treatment • Health and systemic status of patient • Previous restoration • Root canal anatomy • Presence or absence of periapical pathology • Complexity of root canal system • Periodontal health of tooth • Presence or absence of root resorption • Skill of clinician • Patient’s cooperation.

41. Factors Affecting Healing after Endodontic Treatment • Cleaning and shaping of apical third of canal is more important than middle third. Apical third should be thoroughly cleaned and sealed so that microorganisms cannot reach the periapical tissues . • When there is periapical radiolucency , prognosis is poorer when compared to a normal tooth. • When there is perforation on root surface , it should be sealed at the earliest for better prognosis. • When there is open apex , it is difficult to seal the canal because of its shape. In such teeth, before obturation, apexification using calcium hydroxide or MTA should be attempted for developing apical barrier. • When there is persistent acute infection in previously treated tooth , nonsurgical endodontic treatment should be tried before attempting surgical endodontics.

42. • When there is apical third fracture, and pulp is vital , stabilize the tooth. – If pulp is nonvital, attempt endodontic treatment – If it is difficult to negotiate fractured segment, check it periodically. – If radiolucency appears, manage the case surgically. • In retreatment cases , care should be taken to remove any previous root canal filling. If it cannot be retrieved from periapical tissues, surgical resection of root tip should be considered. • In case of endodontic-periodontal lesion, if extensive destruction of periodontal attachment is present, prognosis is poor. • If alveolar bone destruction involves more than half of the root , attempts should be made to improve the periodontal status. In case of grade III mobility, prognosis is poorer. • If crown is extensively damaged that it cannot be restored, root canal treatment should not be attempted.

43. MEDICAL CONDITIONS INFLUENCING ENDODONTIC TREATMENT PLANNING Medical condition Patients with valvular disease and murmurs Patients are susceptible to bacterial endocarditis secondary to dental treatment Modifications in treatment planning Prophylactic antibiotics are advocated before initiation of the endodontic therapy

44. Medical condition Patients with hypertension • In these patients, stress and anxiety may further increase chances of myocardial infarction or Cerebrovascular accidents • Sometimes antihypertensive drugs may cause postural hypotension Modifications in treatment planning • Give premedication • Plan short appointments • Use local anesthetic with minimum amount of vasoconstrictors -

45. Medical condition Myocardial infarction • Stress and anxiety can precipitate myocardial infarction or angina • Some degree of congestive heart failure may be present • Chances of excessive bleeding when patient is on aspirin • If pacemaker is present, apex locators can cause electrical interferences Modifications in treatment planning Elective endodontic treatment is postponed if recent myocardial infarction is present , i.e. < 6 months • Reduce the level of stress and anxiety while treating patient • Keep the appointments short and comfortable • Use local anesthetics without epinephrine • Antibiotic prophylaxis is given before initiation of the treatment .

46. Medical condition Prosthetic valve or implants • Patients are at high risk for bacterial endocarditis • Tendency for increased bleeding because of prolonged use of antibiotic therapy Modifications in treatment planning • Prophylactic antibiotic coverage before initiation of the treatment • Consult physician for any suggestion regarding patient treatment .

47. Medical condition Leukemia Patient has increased tendency for: • Opportunistic infections • Prolonged bleeding • Poor and delayed wound healing Modifications in treatment planning • Consult the physician • Avoid treatment during acute stages • Avoid long duration appointment • Strict oral hygiene instructions • Evaluate the bleeding time and platelet status • Use of antibiotic prophylaxis .

48. Medical condition Cancer Usually because of radiotherapy and chemotherapy • These patients suffer from xerostomia, mucositis, trismus and excessive bleeding • Prone to infections because of bone marrow suppression Modifications in treatment planning • Consult the physician prior to treatment • Perform only emergency treatment if possible • Symptomatic treatment of mucositis, trismus and xerostomia • Optimal antibiotic coverage prior to treatment • Strict oral hygiene regimen .

49. Medical condition Bleeding disorders In cases of hemophilia, thrombocytopenia, prolonged bleeding due to liver disease, Broad spectrum antibiotics, patients on anticoagulant therapy patient experiences • Spontaneous bleeding • Prolonged bleeding • Petechiae, ecchymosis and hematoma Modifications in treatment planning • Take careful history of the patient • Consult the physician for suggestions regarding the patient • Avoid aspirin containing compounds and NSAIDs • In thrombocytopenia cases, replacement of platelets is done before procedure • Prophylactic antibiotic coverage to be given • In case of liver disease, avoid drugs metabolized by liver .

50. Medical condition Renal disease • In this patient usually has hypertension and anemia • Intolerance to nephrotoxic drugs • Increased susceptibility to opportunistic infections • Increased tendency for bleeding Modifications in treatment planning • Prior consultation with physician • Check the blood pressure before initiation of treatment • Antibiotic prophylaxis screen the bleeding time • Avoid drugs metabolized and excreted by kidney .

51. Medical condition Diabetes mellitus • Patient has increased tendency for infections and poor wound healing • Patient may be suffering from diseases related to cardiovascular system, kidneys and nervous system like myocardial infarction, hypertension, congestive heart failure, renal failure and peripheral neuropathy Modifications in treatment planning • Consult with physician prior to treatment • Note the blood glucose levels • Patient should have normal meals before appointment • If patient is on insulin therapy, he/she should have his regular dose of insulin before appointment • Schedule the appointment early in the mornings • Antibiotics may be needed • Have instant source of sugar available in clinic

52. Medical condition Pregnancy • In such patients the harm to patient can occur via radiation exposures, medication and increased level of stress and anxiety • In the third trimester, chances of development of supine hypotension are increased Modifications in treatment planning • Do the elective procedure in second trimester • Use the principles of ALARA while exposing patients to the radiation • Avoid any drugs which can cause harm to the fetus • Consult the physician to verify the physical status of the patient and any precautions if required for the patient • Reduce the number of oral microorganism (by chlorhexidine mouth-wash ) • In third semesters , don’t place patient in supine position for prolonged periods .

53. Medical condition Anaphylaxis Patient gives history of severe allergic reaction on administration of: • Local anesthetics • Certain drugs • Latex gloves and rubber dam sheets Modifications in treatment planning • Take careful history of the patient • Avoid use of agents to which patient is allergic • Always keep the emergency kit available • I n case the reaction develops : – Identify the reaction – Call the physician – Place patient in supine position – Check vital signs – If vital signs are reduced, inject epinephrine tongue – Provide CPR if needed – Admit the patient .

54. AAE Endodontic Case Difficulty Assessment Form and Guidelines The Assessment Form makes case selection more efficient, more consistent and easier to document. potential risk factors that may complicate treatment and adversely affect the outcome. Levels of difficulty are sets of conditions that may not be controllable by the dentist. The Assessment Form enables a practitioner to assign a level of difficulty to a particular case. Consider using cone beam computed tomography ( CBCT ) for assessing moderate and high difficulty cases.

55. Levels of Difficulty LOW DIFFICULTY MODERATE DIFFICULTY HIGH DIFFICULTY

56. LOW DIFFICULTY Preoperative condition indicates routine complexity (uncomplicated). These types of cases would exhibit only those factors listed in the LOW DIFFICULTY category. Achieving a favorable treatment outcome should be attainable by a competent practitioner with limited experience.

57. MODERATE DIFFICULTY Preoperative condition is complicated, exhibiting one or two factors listed in the MODERATE DIFFICULTY category. Achieving a favorable treatment outcome may be challenging for a competent, experienced practitioner

58. HIGH DIFFICULTY Preoperative condition is exceptionally complicated, exhibiting three or more factors listed in the MODERATE DIFFICULTY category or at least one in the HIGH DIFFICULTY category. Achieving a favorable treatment outcome may be challenging for even the most experienced practitioner with an extensive history of favorable outcomes.

59. A. PATIENT CONSIDERATIONS

60. HIGH DIFFICULTY MODERATE DIFFICULTY LOW DIFFICULTY Criteria and Subcriteria Complex medical history/serious illness/ disability (ASA Class 4*) One or more medical problem (ASA Class 3*) No medical problem (ASA Class 1 or 2*) MEDICAL HISTORY Difficulty achieving and/or maintaining anesthesia Vasoconstrictor intolerance No history of anesthesia problems ANESTHESIA Uncooperative Anxious but cooperative Cooperative and compliant PATIENT DISPOSITION Significant limitation in opening Slight limitation in opening No limitation ABILITY TO OPEN MOUTH Extreme gag reflex Gags occasionally with radiographs/ Treatment None GAG REFLEX Severe pain or swelling Moderate pain or swelling Minimum pain or swelling EMERGENCY CONDITION

61. B. DIAGNOSTIC AND TREATMENT CONSIDERATIONS

62. complex signs and symptoms: difficult diagnosis Confusing is History of chronic oral/facial pain Extensive differential diagnosis of usual signs and symptoms required Signs and symptoms consistent with recognized pulpal and periapical conditions DIAGNOSIS Extreme difficulty obtaining/interpreting radiographs (e.g., superimposed anatomical structures) Extensive differential diagnosis of usual signs and symptoms required Minimal difficulty obtaining/interpreting radiographs RADIOGRAPHIC DIFFICULTIES 2nd or 3rd molar 1st molar Anterior/premolar POSITION IN THE ARCH – TOOTH TYPE Extreme inclination (>30°) Moderate inclination (10-30°) Slight inclination (<10°) POSITION IN THE ARCH – INCLINATION Extreme rotation (>30°) Moderate rotation (10-30°) Slight rotation (<10°) POSITION IN THE ARCH – ROTATION Extensive pretreatment modification required for rubber dam isolation Simple pretreatment modification required for rubber dam isolation Routine rubber dam placement TOOTH ISOLATION

63. Restoration does not reflect original anatomy/alignment Significant deviation from normal tooth/root form (e.g., fusion dens in dente) Full coverage restoration Porcelain restoration Bridge abutment Normal original crown morphology CROWN MORPHOLOGY C-shaped morphology Extreme curvature (>30°) or S-shaped curve Mandibular premolar or anterior with 2 roots Moderate curvature (10-30°) Crown axis differs moderately from root axis. Slight or no curvature (<10°) Closed apex (<1 mm in diameter) CANAL MORPHOLOGY Indistinct canal path Canal(s) and chamber not visible Canal(s) and chamber visible but reduced in size Pulp stones Canal(s) and chamber visible and not reduced in size RADIOGRAPHIC APPEARANCE OF CANAL(S) <3 millimeters 3-5 millimeters Vital structures 5 or more millimeters from apices PROXIMITY OF THE ROOT APICES TO VITAL STRUCTURES Extensive apical resorption Internal resorption External resorption Minimal apical resorption No resorption evident RESORPTION

64. Complicated crown fracture of immature teeth Horizontal root fracture Alveolar fracture Intrusive, extrusive or lateral luxation Avulsion Complicated crown fracture of mature teeth Subluxation No history of trauma, or Uncomplicated crown fracture of mature or immature teeth TRAUMA HISTORY Previous access with complications Previous surgical or nonsurgical Previous access without complications No previous treatment ENDODONTIC TREATMENT HISTORY Concurrent severe periodontal disease Cracked teeth with periodontal complications Root amputation prior to endodontic treatment Combined endodontic/ periodontic lesion None or mild periodontal disease or concurrent moderate periodontal disease PERIODONTAL-ENDODONTIC CONDITION C. ADDITIONAL CONSIDERATIONS

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