CASE SELECTION AND TREATMENT PLANNING IN ENDODONTICS.ppt

case selection and treatment planning , various cases

1. CASE SELECTION AND CASE SELECTION AND
TREATMENT PLANNING IN TREATMENT PLANNING IN
ENDODONTICSENDODONTICS

2. CONTENTSCONTENTS
IntroductionIntroduction
Common medical findings that may Common medical findings that may
influence Endodonticsinfluence Endodontics
PregnancyPregnancy
Cardiovascular diseaseCardiovascular disease
CancerCancer
HIV and AIDSHIV and AIDS
DialysisDialysis
DiabetesDiabetes

3. Behavioral and Psychiatric disordersBehavioral and Psychiatric disorders
Psychosocial evaluationPsychosocial evaluation
Dental evaluationDental evaluation
Periodontal considerationsPeriodontal considerations
Surgical considerationsSurgical considerations
Restorative considerationsRestorative considerations
Other factorsOther factors
Prognosis of Endodontic treatmentPrognosis of Endodontic treatment

4. Developing the Endodotic treatment planDeveloping the Endodotic treatment plan
Retreatment casesRetreatment cases
Immature teethImmature teeth
Endodontic and Periodontic considerationsEndodontic and Periodontic considerations
Endodontic surgeryEndodontic surgery
Single visit versus multivisit treatmentSingle visit versus multivisit treatment
Scheduling considerationsScheduling considerations
ConclusionConclusion

5. INTRODUCTIONINTRODUCTION
After the clinician has identified an After the clinician has identified an
endodontic problem, the process of case endodontic problem, the process of case
selection and treatment planning begins.selection and treatment planning begins.
Patient evaluation includes medical, Patient evaluation includes medical,
psychosocial, and dental histories.psychosocial, and dental histories.
Although most medical conditions do not Although most medical conditions do not
contraindicate endodontic treatment, contraindicate endodontic treatment,
some can influence the course of some can influence the course of
treatment.treatment.

6. ASA ClassificationASA Classification
The American society of Anesthesiologists(ASA) The American society of Anesthesiologists(ASA)
physical status classification was devised in physical status classification was devised in
1941 and revised in 19831941 and revised in 1983
ASA I-ASA I- Normal, healthy patient; no dental Normal, healthy patient; no dental
management alterations required.management alterations required.
ASA II-ASA II- A patient with mild systemic disease that A patient with mild systemic disease that
does not interfere with daily activity or who has does not interfere with daily activity or who has
significant health risk factor. E.g. alcohol abuse, significant health risk factor. E.g. alcohol abuse,
smoking, gross obesity); may or may not need smoking, gross obesity); may or may not need
dental management alterations.dental management alterations.

7. ASA III-ASA III- A patient with moderate to severe A patient with moderate to severe
systemic disease that is not incapacitating but may systemic disease that is not incapacitating but may
alter daily activity; may have significant drug alter daily activity; may have significant drug
concerns; may require special patient care; would concerns; may require special patient care; would
generally require dental management alterations .generally require dental management alterations .
Egs – Type I Diabetes , Stage III Hypertension , Egs – Type I Diabetes , Stage III Hypertension ,
Unstable Angina Pectoris, Recent Myocardial Unstable Angina Pectoris, Recent Myocardial
Infarction, AIDS and Hemophilia.Infarction, AIDS and Hemophilia.
ASA IVASA IV – A patient with severe systemic disease – A patient with severe systemic disease
that is a constant threat to life;that is a constant threat to life;

8. Definitely requires dental management Definitely requires dental management
alterations, best treated in special facility.alterations, best treated in special facility.
Egs- Kidney Failure, Liver Failure and Egs- Kidney Failure, Liver Failure and
advanced AIDS.advanced AIDS.

9. Common medical findings that may Common medical findings that may
influence Endodonticsinfluence Endodontics
PREGNANCYPREGNANCY

Although pregnancy is not contraindication Although pregnancy is not contraindication
to endodontics, it does modify treatment to endodontics, it does modify treatment
planningplanning..

10. The dentist should consult with the patient’s The dentist should consult with the patient’s
physician to clarify individual treatment physician to clarify individual treatment
issues, especially when dental emergencies issues, especially when dental emergencies
arise in the first trimester.arise in the first trimester.
Unless emergency treatment is required, it is Unless emergency treatment is required, it is
advisable to defer elective dental treatment advisable to defer elective dental treatment
during the first trimester because of the during the first trimester because of the
potential vulnerability of the fetus.potential vulnerability of the fetus.

11. The second trimester is the safest period The second trimester is the safest period
during which to provide routine dental care.during which to provide routine dental care.
Treatment planning should be directed at Treatment planning should be directed at
eliminating potential problems that could eliminating potential problems that could
arise later in pregnancy or during the arise later in pregnancy or during the
immediate post partum periodimmediate post partum period

12. CARDIOVASCULAR DISEASECARDIOVASCULAR DISEASE
Patients with some forms of cardiovascular Patients with some forms of cardiovascular
disease are vulnerable to physical or disease are vulnerable to physical or
emotional stress that may be encountered emotional stress that may be encountered
during dental treatment, including during dental treatment, including
endodontics.endodontics.

13. Patients who have had a myocardial Patients who have had a myocardial
infarction within the past 6 months should infarction within the past 6 months should
not have elective dental care.not have elective dental care.
A patient who has a history of a murmur or A patient who has a history of a murmur or
mitral valve prolapse with regurgitation, mitral valve prolapse with regurgitation,
rheumatic fever, or a congenital heart rheumatic fever, or a congenital heart
defect must be placed on antibiotic therapy defect must be placed on antibiotic therapy
to minimize the risk of bacterial to minimize the risk of bacterial
endocarditis.endocarditis.

14. Patients with artificial heart valves are Patients with artificial heart valves are
considered to be highly susceptible to considered to be highly susceptible to
bacterial endocarditis.bacterial endocarditis.
Therefore consulting with the patients Therefore consulting with the patients
physician regarding antibiotic premedication physician regarding antibiotic premedication
is essential.is essential.

15. CANCERCANCER
Some cancers may metastasize to the jaws Some cancers may metastasize to the jaws
and mimic endodontic pathosis.and mimic endodontic pathosis.
When a dentist begins an endodontic When a dentist begins an endodontic
procedure with a well defined radiolucency, procedure with a well defined radiolucency,
it is assumed to be because of a nonvital it is assumed to be because of a nonvital
pulp that has been confirmed by pulp pulp that has been confirmed by pulp
testing.testing.

16. If a local anesthetic is not administered, and If a local anesthetic is not administered, and
if the patient experiences pain during access if the patient experiences pain during access
or canal instrumentation, it is advisable to or canal instrumentation, it is advisable to
reconsider the original diagnosis because the reconsider the original diagnosis because the
radiolucency may be a lesion of radiolucency may be a lesion of
nonodontogenic origin.nonodontogenic origin.
Patients undergoing chemotherapy or Patients undergoing chemotherapy or
radiotherapy may have impaired healing radiotherapy may have impaired healing
responses.responses.
Treatment should be initiated only after the Treatment should be initiated only after the
patients physician has been consulted.patients physician has been consulted.

17. HIV and AIDSHIV and AIDS
Although the problem of accidental Although the problem of accidental
instrument wounds is a concern in terms of instrument wounds is a concern in terms of
potential transmission of HIV in the dental potential transmission of HIV in the dental
office, the actual occupational risk is very office, the actual occupational risk is very
low.low.
A major consideration for the management A major consideration for the management
of patients with HIV is the current CD4 of patients with HIV is the current CD4
lymphocyte count.lymphocyte count.

18. It is also important to determine the It is also important to determine the
presence of opportunistic infections and the presence of opportunistic infections and the
medications the patient may be taking.medications the patient may be taking.
Medical consultation is necessary before Medical consultation is necessary before
endodontic surgical procedures for HIV-endodontic surgical procedures for HIV-
infected patients.infected patients.

19. DIALYSISDIALYSIS
Hemodialysis tends to aggravate bleeding Hemodialysis tends to aggravate bleeding
tendencies.tendencies.
Therefore elective endodontic treatment Therefore elective endodontic treatment
should be postponed until the day after should be postponed until the day after
hemodialysis.hemodialysis.
Some drugs used during endodontics are Some drugs used during endodontics are
affected by dialysis, like aspirin and affected by dialysis, like aspirin and
acetaminophen, which may have to be acetaminophen, which may have to be
avoided or have increased intervals avoided or have increased intervals
between doses.between doses.

20. DIABETES DIABETES
The diabetic who is well controlled medically The diabetic who is well controlled medically
and free of serious complications, such as and free of serious complications, such as
renal disease, hypertension, or coronary renal disease, hypertension, or coronary
atherosclerotic disease, is a candidate for atherosclerotic disease, is a candidate for
endodontic treatment.endodontic treatment.

21. However, there are special considerations in However, there are special considerations in
the presence of acute infections.the presence of acute infections.
The non-insulin controlled patient may The non-insulin controlled patient may
require insulin, or the insulin dose of some require insulin, or the insulin dose of some
insulin-dependent patients may have to be insulin-dependent patients may have to be
increased.increased.

22. When the pulp is non vital, bacteriologic When the pulp is non vital, bacteriologic
cultures should be taken from the infected cultures should be taken from the infected
area for antibiotic sensitivity testing to area for antibiotic sensitivity testing to
provide information in cases that do not provide information in cases that do not
respond to the initial antibiotic adjunct.respond to the initial antibiotic adjunct.
Endodontic infections in the diabetic patient Endodontic infections in the diabetic patient
should be treated using the standard should be treated using the standard
protocol, chlorhexidine oral rinses before protocol, chlorhexidine oral rinses before
treatment, incision and drainage, pulpectomy treatment, incision and drainage, pulpectomy
and antibiotics as indicated.and antibiotics as indicated.

23. Awareness of the patients normal meal and Awareness of the patients normal meal and
insulin schedule is also important, along with insulin schedule is also important, along with
an effort to reduce stress.an effort to reduce stress.
A treatment plan that includes periradicular A treatment plan that includes periradicular
surgery requires communication with the surgery requires communication with the
physician to review the planned procedure physician to review the planned procedure
and its systemic implications. and its systemic implications.

24. BEHAVIORAL AND PSYCHIATRIC BEHAVIORAL AND PSYCHIATRIC
DISORDERSDISORDERS
Stress reduction is an important component in Stress reduction is an important component in
the treatment of patients with behavioral and the treatment of patients with behavioral and
psychiatric disorders.psychiatric disorders.
Sensitivity to the patient’s needs must be a Sensitivity to the patient’s needs must be a
part of the entire dental team’s approach.part of the entire dental team’s approach.

25. Significant drug interactions and side effects Significant drug interactions and side effects
are associated with tricyclic antidepressants, are associated with tricyclic antidepressants,
monoamine oxidase inhibitors, and monoamine oxidase inhibitors, and
antianxiety drugs.antianxiety drugs.
Consultation with the patient’s physician is Consultation with the patient’s physician is
essential before using sedatives, hypnotics, essential before using sedatives, hypnotics,
antihistamines, and opiods.antihistamines, and opiods.

26. PSYCHOSOCIAL EVALUATIONPSYCHOSOCIAL EVALUATION
The initial visit, during which medical and The initial visit, during which medical and
dental histories are taken, provides an dental histories are taken, provides an
opportunity to begin to consider the opportunity to begin to consider the
patient’s psychosocial status.patient’s psychosocial status.
Although some patients are anxious to Although some patients are anxious to
maintain a tooth with a questionable maintain a tooth with a questionable
prognosis, others lack the necessary prognosis, others lack the necessary
sophistication to comprehend the potential sophistication to comprehend the potential
risks and benefits.risks and benefits.

27. It is a mistake to lead patients beyond what It is a mistake to lead patients beyond what
they can appreciate, and patients should not they can appreciate, and patients should not
be allowed to dictate treatment that has be allowed to dictate treatment that has
little chance of success.little chance of success.
Part of the dentist’s role is to educate the Part of the dentist’s role is to educate the
patient and present reasonable treatment patient and present reasonable treatment
plans.plans.

28. DENTAL EVALUATIONDENTAL EVALUATION
The strategic value of the tooth with an The strategic value of the tooth with an
endodontic problem must be considered at endodontic problem must be considered at
the outset of treatment planning.the outset of treatment planning.
Although such decisions are often Although such decisions are often
straightforward, they can also be straightforward, they can also be
intellectually challenging as the dentist intellectually challenging as the dentist
considers multiple factors that will play a considers multiple factors that will play a
role in determining the ultimate success or role in determining the ultimate success or
failure of a case.failure of a case.

36. PERIODONTAL CONSIDERATIONSPERIODONTAL CONSIDERATIONS
Extensive periodontal lesions frequently Extensive periodontal lesions frequently
complicate the endodontic procedure being complicate the endodontic procedure being
considered.considered.
Periodontal probing is an essential element Periodontal probing is an essential element
in endodotic case selection.in endodotic case selection.
A tooth with a poor periodontal prognosis A tooth with a poor periodontal prognosis
may have to be sacrificed, despite the may have to be sacrificed, despite the
probability of a favourable endodontic probability of a favourable endodontic
prognosis.prognosis.

37. In some situations it may not be clear if the In some situations it may not be clear if the
primary problem is periodontal or primary problem is periodontal or
endodontic.endodontic.
This fact can influence the treatment plan; This fact can influence the treatment plan;
the pathogenesis can be better understood the pathogenesis can be better understood
after vitality testing, periodontal probing, after vitality testing, periodontal probing,
radiographic assessment, and evaluating the radiographic assessment, and evaluating the
dental history.dental history.

38. SURGICAL CONSIDERATIONSSURGICAL CONSIDERATIONS
Surgical evaluations are of particular value in Surgical evaluations are of particular value in
the diagnosis of lesions that may be the diagnosis of lesions that may be
nonodontogenic.nonodontogenic.
Biopsy is the only definitive means of making Biopsy is the only definitive means of making
a diagnosis of such a lesion.a diagnosis of such a lesion.
In cases where retreatment is being In cases where retreatment is being
considered and the prior endodontic therapy considered and the prior endodontic therapy
was done well, biopsy is a valuable procedure was done well, biopsy is a valuable procedure
to refine treatment planning after surgery.to refine treatment planning after surgery.

39. RESTORATIVE CONSIDERATIONSRESTORATIVE CONSIDERATIONS
A satisfactory restoration may be jeopardized A satisfactory restoration may be jeopardized
by a number of factors.by a number of factors.
Subosseous root caries, poor crown/root ratio, Subosseous root caries, poor crown/root ratio,
and extensive periodontal defects or and extensive periodontal defects or
misalignment of teeth may have a serious misalignment of teeth may have a serious
effect on the final restoration.effect on the final restoration.
Therefore it is wise to recognise these problems Therefore it is wise to recognise these problems
before endodontic treatment.before endodontic treatment.

40. A restorative treatment plan should be A restorative treatment plan should be
in place before starting endodontic in place before starting endodontic
treatment in a non emergency treatment in a non emergency
situation.situation.
Some teeth may be endodontically Some teeth may be endodontically
treatable but nonrestorable, or they treatable but nonrestorable, or they
may represent a potential restorative may represent a potential restorative
complication in a large prosthesis.complication in a large prosthesis.

41. Furthermore, reduced coronal tooth Furthermore, reduced coronal tooth
structure under a full coverage restoration structure under a full coverage restoration
makes endodontic access more difficult makes endodontic access more difficult
because of reduced visibility and a lack of because of reduced visibility and a lack of
radiographic information about the radiographic information about the
anatomy of the chamber.anatomy of the chamber.
Whenever reasonably possible, restorations Whenever reasonably possible, restorations
should be removed before endodontic should be removed before endodontic
treatmenttreatment..

42. OTHER FACTORS THAT MAY INFLUENCE OTHER FACTORS THAT MAY INFLUENCE
ENDODONTIC CASE SELECTIONENDODONTIC CASE SELECTION
A variety of factors may complicate proposed A variety of factors may complicate proposed
endodontic therapy.endodontic therapy.
Calcifications, dilacerations, and resorptive Calcifications, dilacerations, and resorptive
defects may compromise endodontic defects may compromise endodontic
treatment of a tooth with potentially treatment of a tooth with potentially
strategic value.strategic value.

43. The inability to isolate a tooth is also a The inability to isolate a tooth is also a
problem and may result in bacterial problem and may result in bacterial
penetration of the canals.penetration of the canals.
Extra roots and canals pose a particular Extra roots and canals pose a particular
anatomic challenge that radiogrphs do not anatomic challenge that radiogrphs do not
always reveal.always reveal.
Retreatment cases offer particular Retreatment cases offer particular
mechanical challenges. Ledges, perforations mechanical challenges. Ledges, perforations
or posts may be present, all of which or posts may be present, all of which
complicate treatment and alter the complicate treatment and alter the
prognosisprognosis..

44. PROGNOSIS OF ENDODONTIC TREATMENTPROGNOSIS OF ENDODONTIC TREATMENT
The most important factor influencing the The most important factor influencing the
prognosis of endodontic treatment is the prognosis of endodontic treatment is the
preoperative status of the tooth.preoperative status of the tooth.
Teeth with an apical radiolucency may have Teeth with an apical radiolucency may have
upto a 20% lower success rate than teeth upto a 20% lower success rate than teeth
without such lesionswithout such lesions..

45. Among factors analyzed, the preoperative Among factors analyzed, the preoperative
status of the pulp and periapical tissue appear status of the pulp and periapical tissue appear
to be extremely important to the outcome of to be extremely important to the outcome of
endodontic treatment.endodontic treatment.
Other important endodontic and systemic Other important endodontic and systemic
variables existvariables exist
The patient’s systemic resistance and the The patient’s systemic resistance and the
quality of instrumentation and obturation play a quality of instrumentation and obturation play a
role in the ultimate outcome of endodontic role in the ultimate outcome of endodontic
treatment.treatment.

46. DEVELOPING THE ENDODONTIC DEVELOPING THE ENDODONTIC
TREATMENT PLANTREATMENT PLAN
The acute vital case is best managed with a The acute vital case is best managed with a
biologically based approach.biologically based approach.
It has been shown that simply debriding the It has been shown that simply debriding the
pulp chamber is a highly predictable pulp chamber is a highly predictable
method of providing pain relief.method of providing pain relief.

47. Once a canal has been entered, the Once a canal has been entered, the
practitioner is committed to remove all practitioner is committed to remove all
tissue. Partial instrumentation may leave tissue. Partial instrumentation may leave
the patient with more pain than at the the patient with more pain than at the
outset of treatment.outset of treatment.
Where sensitivity to percussion is a Where sensitivity to percussion is a
problem, occlusal relief is a critical problem, occlusal relief is a critical
component of the emergency visit.component of the emergency visit.

48. RETREATMENT CASESRETREATMENT CASES
A retreatment plan should be developed A retreatment plan should be developed
after the practitioner has determined the after the practitioner has determined the
cause of failure and weighed other factors cause of failure and weighed other factors
that may affect the prognosis. Eg. Root that may affect the prognosis. Eg. Root
fractures, defective restoration.fractures, defective restoration.
Retreatment cases may require surgical Retreatment cases may require surgical
endodontics in combination with endodontics in combination with
nonsurgical treatment.nonsurgical treatment.

49. IMMATURE TEETHIMMATURE TEETH
Primary and immature permanent teeth Primary and immature permanent teeth
may have pulpal pathosis caused by caries may have pulpal pathosis caused by caries
or trauma; preserving these young teeth is or trauma; preserving these young teeth is
essential.essential.
Premature loss of an anterior tooth can Premature loss of an anterior tooth can
lead to malocclusion, predispose the lead to malocclusion, predispose the
patient to tongue habits, impair esthetics, patient to tongue habits, impair esthetics,
and damage the self esteem of the patient.and damage the self esteem of the patient.

50. ENDODONTIC AND PERIODONTIC ENDODONTIC AND PERIODONTIC
CONSIDERATIONSCONSIDERATIONS
The relationship between the pulpal The relationship between the pulpal
and periodontal tissue complex begins and periodontal tissue complex begins
during the embryonic stage of dental during the embryonic stage of dental
development.development.
The richly vascularized dental papillae The richly vascularized dental papillae
and the surrounding, future periodontal and the surrounding, future periodontal
tissues have a shared circulation.tissues have a shared circulation.
This interrelationship provides the This interrelationship provides the
anatomic basis for potential pathosis. anatomic basis for potential pathosis.

51. CLASSIFICATION OF ENDO-PERIO CLASSIFICATION OF ENDO-PERIO
LESIONSLESIONS
Based on etiology by Simon, Glick and Based on etiology by Simon, Glick and
Frank Frank
Type 1Type 1 - Primary endodontic lesions - Primary endodontic lesions
Type 2Type 2 - Primary endodontic lesions with - Primary endodontic lesions with
secondary periodontal involvement. secondary periodontal involvement.
Type 3Type 3 – Primary periodontal lesions – Primary periodontal lesions
Type 4Type 4 – Primary periodontal lesions with – Primary periodontal lesions with
secondary endodontic involvement. secondary endodontic involvement.
Type 5Type 5 – True combined lesions. – True combined lesions.

52. The prognosis and treatment of each The prognosis and treatment of each
endodontic-periodontal disease type varies.endodontic-periodontal disease type varies.
Primary endodontic disease should only be Primary endodontic disease should only be
treated by endodontic therapy and has a treated by endodontic therapy and has a
good prognosis.good prognosis.
Primary periodontal disease should only be Primary periodontal disease should only be
treated by periodontal therapy. In this case treated by periodontal therapy. In this case
the prognosis depends on severity of the the prognosis depends on severity of the
periodontal disease and patient response.periodontal disease and patient response.

53. Primary endodontic disease with secondary Primary endodontic disease with secondary
periodontal involvement should first be periodontal involvement should first be
treated with endodontic therapy.treated with endodontic therapy.
Treatment results should be evaluated in 2-3 Treatment results should be evaluated in 2-3
months and only then should periodontal months and only then should periodontal
treatment be considered.treatment be considered.

54. The prognosis depends primarily on the The prognosis depends primarily on the
severity of periodontal involvement, severity of periodontal involvement,
periodontal treatment and patient response.periodontal treatment and patient response.
Primary periodontal disease with secondary Primary periodontal disease with secondary
endodontic involvement and true combined endodontic involvement and true combined
lesions require both endodontic and lesions require both endodontic and
periodontal therapies.periodontal therapies.

55. SINGLE VISIT VERSUS MULTIVISIT SINGLE VISIT VERSUS MULTIVISIT
TREATMENTTREATMENT
The first and important criteria is that The first and important criteria is that
single – visit endodontics should not single – visit endodontics should not
be undertaken by inexperienced be undertaken by inexperienced
clinicians. clinicians.

56. The dentist must posses a full understanding The dentist must posses a full understanding
of endodontic principles and the ability to of endodontic principles and the ability to
exercise these principles fully and efficiently. exercise these principles fully and efficiently.
As a guideline, the case should be one that As a guideline, the case should be one that
can be completed within 60 minutes. can be completed within 60 minutes.
Treatments that take considerably longer Treatments that take considerably longer
time should be done in multiple visits.time should be done in multiple visits.

57. INDICATIONS FOR SINGLE – VISIT INDICATIONS FOR SINGLE – VISIT
Uncomplicated vital or non vital teeth.Uncomplicated vital or non vital teeth.

Fractured anterior or bicuspid teeth where Fractured anterior or bicuspid teeth where
esthetics is a concern and temporary post esthetics is a concern and temporary post
and crown are required.and crown are required.

Patients who are physically unable to return Patients who are physically unable to return
for the completion. for the completion.

58. Necrotic, uncomplicated teeth with draining Necrotic, uncomplicated teeth with draining
sinus tracts .sinus tracts .
Patients who require sedation or operating Patients who require sedation or operating
room treatment. room treatment.

59. Contra – Indications for Single – visit. Contra – Indications for Single – visit.
Painful, necrotic tooth with no sinus tract for Painful, necrotic tooth with no sinus tract for
drainage. drainage.
Teeth with severe anatomic anomalies or Teeth with severe anatomic anomalies or
cases with procedural difficulties. cases with procedural difficulties.
Asymptomatic nonvital molars with periapical Asymptomatic nonvital molars with periapical
radiolucencies and no sinus tract. radiolucencies and no sinus tract.

60. Patients who have acute apical periodontitis with Patients who have acute apical periodontitis with
severe pain on percussion.severe pain on percussion.

Most of the re-treatment cases. Most of the re-treatment cases.

61. SCHEDULING CONSIDERATIONSSCHEDULING CONSIDERATIONS
When vital cases are to be treated using a When vital cases are to be treated using a
multivisit approach, it is wise to permit multivisit approach, it is wise to permit
sufficient time between canal instrumentation sufficient time between canal instrumentation
and obturation.and obturation.
Generally 5-7 days provides sufficient recovery Generally 5-7 days provides sufficient recovery
time for periradicular tissues before obturation.time for periradicular tissues before obturation.
Non vital case appointments should be Non vital case appointments should be
scheduled more closely than vital case scheduled more closely than vital case
appointmentsappointments