case selection and treatment planning intervention

CASE SELECTION AND TREATMENT PLANNING

1. Case selection i n endodontic treatment DR. AISHWARYA KHARE . M .D.S . (2 ND YEAR)

2. CONTENTS INTRODUCTION WHY CASE SELECTION IS ESSENTIAL? CONSIDERATIONS PRIOR TO ENDO TREATMENT FACTORS OF CASE SELECTION FACTORS ASSOCIATED WITH TEETH FACTORS ASSOCIATED WITH PATIENT’S HEALTH FACTORS ASSOCIATED WITH THE CLINICIAN AAE CASE DIFFICULTY ASSESSMENT FORM AND GUIDELINES REVIEW OF LITERATURE CONCLUSION REFERENCES

3. introduction The process of case selection and treatment planning begins after a clinician has diagnosed an endodontic problem. Proper selection of cases avoid pitfalls during endodontic treatment and helps to ensure success. Errors in the case selection, some of which could have been avoided, constituted 22% of failures reported in a study conducted by Ingle and Beveridge . The use of rotary instruments, ultrasonics , and microscopy as well as new materials has made it possible to predictably retain teeth that previously could not have been treated. But in spite of all these development case selection is the 1 st step towards saving a tooth .

4. WHY ESSENTIAL???

5. Although it is true that root canal treatment can be performed virtually on any tooth there are some important considerations that must be evaluated prior to recommending root canal treatment.some of these were delineated by Beveridge1971.

6. Considerations Prior to Endodontic Therapy 1.Is the tooth needed or important ? Could it some day serve as an abutment for prosthesis? 2 . Is the tooth salvageable, or is it so badly destroyed that it cannot be restored ? 3. Is the entire dentition so completely broken down that it would be virtually impossible to restore ?

7. 4. Is the tooth serving esthetically, or would the patient be better served by its extraction and a more cosmetic replacement? 5 . Is the tooth so severely involved periodontally that it would be lost soon for this reason? 6 . Is the practitioner capable of performing the needed endodontic procedures?

8. 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.

9. Factors associated with teeth 1 st 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. Indication 1.Teeth with pulpal inflammation pulpal inflammation like irreversible pulpitis , chronic hyperplastic pulpitis, pulpal necrosis require endodontic treatment.

10. 2. 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.

11. 3. 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 involving furcation can also be treated by endodontic procedures like hemisection followed by root canal therapy.

12. 4. Facilitation of restoration (Intentional Endodontic Treatment). Occasionally , intentional endodontic treatment of teeth with perfectly vital pulps may be necessary. Examples of situations requiring intentional endodontic treatments include hyper erupted teeth or drifted teeth that must be reduced so drastically that the pulp is certain to be involved. On other occasions, a pulp is intentionally removed and the canal filled so that a post and core may be placed for increased crown retention .

13. CONTRAINDICATING FACTORS OR FACTORS WHERE SPEACIAL ATTENTION IS NEEDED- 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 .

14. The radiographic appearance of combined endodontic–periodontal lesions may be similar to that of a vertically fractured tooth . Therapy for true combined lesions requires both endodontic and periodonal therapy those lesions that develop as a result of both pulpal infection and periodontal disease—respond to a combined treatment approach in which endodontic intervention precedes, or is done simultaneously with, periodontal treatment.

15. 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.

16. Non restorable teeth- The restorability of a tooth requiring endodontic treatment depends on the amount of sound tooth structure remaining. Teeth with very less amount of crown and extremely carious are contraindicated for endodontic treatment. Teeth which are grossly decayed (both crown and root)also contraindicated for endodontic treatment

17. 4. Abnormal canal configuration- Severely curved canal, c shaped canal, aberran t extra canals are very difficult for instrumentation Teeth with such canal configuration are not ideal for endodontic treatment. Curvature of 20º in a narrow root canal is very difficult to negotiate also a curvature of 30ºwith a wide canal is not easily negotiable. The degree of curvature ,size and constriction of the root canal must be judged prior to endodontic treatment

18. 5. Developmental anomalies- Developmental anomalies like fusion, gemination , concresence , enamel pearl are difficult to treat with endodontic procedures.

19. 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. Such cases should be selected judiciously.

20. 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.

21. 8. Iatrogenic error. Painfull 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.

22. FACTORS ASSOCIATED WITH PATIENT’S HEALTH Before starting endodontic treatment the clinician must take proper medical history about the patient, The clinician should search for following informations - History of allergies History of drug interactions , adverse effects Anxiety (past experiences and management strategy) Presence of prosthetic valves, joints, stents, pacemakers Required Antibiotics ( prophylactic or therapeutic)

23. Hemostasis (normal expected, modification to treatment) Infiltration or block anesthesia with or without vasoconstrictor Significant equipment concerns (radiographs, ultrasonics , electrosurgery ) Emergencies (potential for occurrence, preparedness)

24. American Society of Anesthesiologists Physical Status Classification System- After obtaining the above informations the clinician should access the physical status of the patient. P1 : Normal, healthy patient; no dental management alterations required P2 : Patient with mild systemic disease that does not interfere with daily activity or who has a significant health risk factor (e.g., smoking, alcohol abuse, gross obesity) P3 : Patient with moderate to severe systemic disease that is not incapacitating but may alter daily activity P4 : Patient with severe systemic disease that is incapacitating and a constant threat to life

25. Common Medical Findings That may Influence endodontic treatment planning Cardio vascular disorder - the history of patients with cardio vascular disorder should be taken cautiously. Patients with some forms of cardiovascular disease are vulnerable to physical or emotional stress that may be encountered during dental treatment, including endodontics . Consultation with the patient’s physician is mandatory before the initiation of endodontic treatment . Treatment should be delayed in case of- 1. Myocardial infraction within 6 months. 2. Coronary bypass graft surgery less than 3 months. 3.H/o stroke less than 6 months.

26. Antibiotic prophylaxis- Antibiotic prophylaxis is needed to prevent bacterial endocarditis which can be caused by endodontic surgeries. PROCEDURES NOT NEEDING ANTIBIOTIC PROPHYLAXIS- Restorative dentistry with or without gingival retraction cord Local anesthesia (non-PDL) Root canal therapy (not beyond apex) Impressions Suture removal Placement of the rubber dam

27. NEW GUIDELINES: AHA Considers High Risk Individuals- Premedication Indicated Prosthetic cardiac valve: mechanical or tissue Previous history of infective endocarditis Congenital Heart Disease which is unrepaired Congenital heart defects repaired during the first six months of endodontic surgery Cardiac Transplant with cardiac complications

28. CONSIDERED MODERATE RISK INDIVIDUALS- Premedication NOT Indicated Now Mitral Valve Prolapse with or without regurgitation Pathological/Organic heart murmur Previous rheumatic fever with or without valvular dysfunction Previous Kawaskasi disease with or without valvular dysfunction Systemic Lupus Erythematosus (1/4 of these patients have cardiac involvement) Rheumatoid Arthritis with cardiac involvement Other acquired valvular dysfunction

29. CONSIDERED MODERATE RISK INDIVIDUALS- Premedication NOT Indicated Now (cont.) Previous coronary bypass graft surgery Coronary artery stents Heart transplants patient without complications Cardiac pacemakers Implanted defibrillators

30. Antibiotic Prophylaxis Regimen Following current loading guidelines: ► 30-60 minutes before procedure ► Next 1 to 2 hours is the best coverage of antibiotics ► Ideally give subsequent loads of antibiotics 9 to 14 days after initial treatment to allow the oral flora to return to normal The dose can be given 2 hours after the procedure if it was accidentally not given

31. Patients already receiving Antibiotics Select an antibiotic from a different class rather than increase dosage of current antibiotic to minimize resistance Example: If patient is already taking amoxicillin, use clindamycin.

32. AMERICAN HEART ASSOCIATION RECCOMENDATION- new guidelines Adults Amoxicillin 2 grams orally (500 X 4 tablets), 30-60 minutes before appointment Children Amoxicillin 50mg/kg. orally, 30-60 minutes before appointment

33. Situation Antibiotic Agent Regimen * Standard Prophylaxis Amoxicillin Adults: 2.0 g. Children : 50 mg / kg Orally 30-60 minutes before procedure Unable to take oral medication Ampicillin Adults: 2.0 g IM or IV Children: 50 mg / kg IM or IV within 30-60 minutes before procedure Allergic to Penicillin Clindamycin Adults: 600 mg Children: 20 mg / kg Orally 30-60 minutes before procedure ** Cephalexin or cefadroxil Adults: 2.0 g Children: 50 mg / kg Orally 30-60 minutes before procedure Azithromycin or clarithromycin Adults: 500 mg Children: 15 mg / kg orally 30-60 minutes before procedure Allergic to Penicillin and unable to take Oral Medications Clindamycin Adults: 600 mg Children: 20 mg / kg IV 30-60 minutes before procedure Cefazolin Adults: 1.0 g Children: 25 mg / kg IM or IV within 30-60 minutes before procedure * Total children’s dose should not exceed adult dose ** Cephalosporin's should not be used in individuals with immediate-type hypersensitivity reaction to penicillins

34. Anti coagulant therapy- There is a widespread belief among dental clinicians and physicians that oral anticoagulant therapy in which patients receive drugs such as warfarin (Coumadin) must be discontinued before dental treatment to prevent serious hemorrhagic complications. It should be noted that the anti coagulant therapy is only a matter of concern if there is a need of endodontic surgery. Minor endodontic procedures , even root canal treatment does not need any modification in anti coagulant therapy.

35. Before endodontic surgery t he INR value should be checked the permissible limit of INR of the patient taking anticoagulant drug is 2.5-3.5 . If the value is more than 3.5 dentist should consult physician before any surgical procedure . Patients taking digitalis or patients with unstable angina should be treated cautiously as in these cases vasoconstrictor precipitate arrythmia .

36. 2. Pregnancy Any type of endodontic treatment should be done only in 2 nd trimester. While in chair patient should be placed in left lateral position. Drug having teratogenic effect and may cross placental barrier should be avoided.

37. 3. Diabetes mellitus Patients with diabetes, even those who are well controlled, require special consideration during endodontic treatment. Studies suggest that diabetes is associated with a decrease in the success of endodontic treatment in cases with retreatment periradicular lesions . There is also evidence of poor prognosis after endodontic treatment due to more prevalence of periodontal disease. Patients should be given short morning appointment to avoid peak insulin action which may cause hyperglycemic shock. Before any endodontic surgery blood sugar must be checked. Surgery is not permissible in poorly controlled and in uncontrolled cases.

38. 4 . Hiv when treating patients with acquired immunodeficiency syndrome (AIDS), that the clinician understand the patient’s level of immunosuppression, drug therapies, and potentiality for opportunistic infections. Although the effect of human immunodeficiency virus (HIV) infection on long-term prognosis of endodontic therapy is unknown, it has been demonstrated that clinicians may not have to alter their short-term expectations for periapical healing in patients infected with HIV.

39. vital aspect of treatment planning for the patient with HIV/AIDS is to determine the current CD4+ lymphocyte count and level of immunosuppression. In general, patients having a CD4 + cell count exceeding 400 mm3 may receive all indicated dental treatment . Patients with a CD4+ cell count less than 200 mm3 will have increased susceptibility to opportunistic infections and may be effectively medicated with prophylactic drugs. Clinician should always use disposable instruments and should be cautious about any type of contamination.

40. 5. End-Stage Renal Disease and Dialysis Consultation with the patient’s physician is suggested before any dental procedure is initiated for patients being treated for end-stage renal disease. Depending on the patient’s status and the presence of other diseases common to renal failure (e.g., diabetes mellitus , hypertension, and systemic lupus erythematosus ). The most recent American Heart Association guidelines do not include a recommendation for prophylactic antibiotics before invasive dental procedures for patients receiving dialysis with intravascular access devices.

41. Some drugs frequently used during endodontic treatment are affected by dialysis. Drugs metabolized by the kidneys and nephrotoxic drugs should be avoided. Endodontic treatment is best scheduled on the day after dialysis, because on the day of dialysis patients are generally fatigued and could have a bleeding tendency.

42. 6 . Reduced mouth opening- Patients with OSMF, ankylosis , Trismus are difficult to treat with endodontic treatment because of their reduced mouth openning . 7. Age of the patient- Age of the patients should be a matter of concern for the endodontist . Treatment is very difficult for geriatric patients. May be single visit .

43. 8. Epilepsy- Once a patient with epilepsy has been identified, the dental practitioner must learn as much as possible about the seizure history, including the type of seizures, age at onset, cause (if known), current and regular use of medications, frequency of physician visits, degree of seizure control, frequency of seizures, date of last seizure, and any known precipitating factors.

44. Patients not taking medication or having history of epileptic attack within last 3 months should not be treated. Fortunately, most epileptic patients are able to attain good control of their seizures with anticonvulsant drugs and are therefore able to receive normal routine dental care.

45. Patients who take anticonvulsants may suffer from the toxic effects of these drugs, and the dentist should be aware of their manifestations. In addition to the more common adverse effects, allergy may be seen occasionally as a rash, erythema multiforme , or worse (Stevens-Johnson syndrome). Endodontist should always be cautious about such conditions.

46. erythromycin should not be administered to patients who are taking carbamazepine because of interference with metabolism of carbamazepine, which could lead to toxic levels of the anticonvulsant drug . Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) should not be administered to patients who are taking valproic acid because they can further decrease platelet aggregation , leading to hemorrhagic episodes.

47. 9. Bisphosphonate Therapy- Bisphosphonates offer great benefits to patients at risk of bone metastases and in the prevention and treatment of osteoporosis. A patient’s risk of developing osteonecrosis of the jaw while receiving oral bisphosphonates appears to be low , but there are factors known to increase the risk for bisphosphonate-associated osteonecrosis (BON ).

48. For patients at higher risk of BON, surgical procedures such as extractions, endodontic surgery, or placement of dental implants should be avoided, if possible. Sound oral hygiene and regular dental care may be the best approach for lowering the risk of BON.

49. Patients taking bisphosphonates and undergoing endodontic therapy should sign an informed consent form, inclusive of the risks, benefits, and alternative treatment plans. In case of any infection in a patient taking bisphosphonates, aggressive use of systemic antibiotics is indicated.

50. 9. Malignancy- When a clinician begins an endodontic procedure on a tooth with a well-defined apical radiolucency, it might be assumed to result from a nonvital pulp. Pulp testing is essential to confirm a lack of pulp vitality in such cases. A vital response in such cases is indicative of a nonodontogenic lesion.

51. Some malignancies may metastasize to the jaws and mimic endodontic pathosis , whereas others can be primary lesions . A panoramic radiograph is useful in providing an overall view of all dental structures. Careful examination of pretreatment radiographs from different angulations is important because lesions of endodontic origin would not be expected to be shifted away from the radiographic apex in the various images .

52. Patients undergoing chemotherapy or radiation to the head and neck may have impaired healing responses. Treatment should be initiated only after the patient’s physician has been consulted. It is advised that symptomatic nonvital teeth be endodontically treated at least 1 week before initiating radiation or chemotherapy, whereas treatment of asymptomatic nonvital teeth may be delayed.

53. The effect of the external beam of radiation therapy on normal bone is to decrease the number of osteocytes, osteoblasts, and endothelial cells, thus decreasing blood flow. Pulps may become necrotic from this impaired condition . Toxic reactions during and after radiation and chemotherapy are directly proportional to the amount of radiation or dosage of cytotoxic drug to which the tissues are exposed. Delayed toxicities can occur several months to years after radiation therapy.

54. The outcome of endodontic treatment should be evaluated within the framework of the toxic results of radiation and drug therapy. The white blood cell (WBC) count and platelet status of a patient undergoing chemotherapy should also be reviewed before endodontic treatment.

55. In general, routine dental procedures can be performed if the granulocyte count is greater than 2000/mm3 and the platelet count is greater than 50,000/mm3. If urgent care is needed and the platelet count is below 50,000/mm3, consultation with the patient’s physician is required

56. 10. Asthma & other respiratory tract disorder- Clinician should ask for respiratory disorders like asthma, COPD or chronic bronchitis. Endodontist should access the present physical condition of the patient on the basis of signs , symptoms and treatment history. Moderate and severe cases of asthmatic patients should not be treated by endodontist with out consultation of physician.

57. Avoid treatment if upper respiratory tract infection is present, and treatment should always be done at upright position. Avoid precipitating factors, rubber dam, gingival retraction cord, L.A with vasoconstrictors. Patient should bring inhaler . Appointment should be short.

58. Drugs like NSAIDS, narcotic drugs, anti cholinergic drugs, anti histamines should be avoided. There is also chances of drug interaction between asthmatic drugs and antibiotics. Chronic corticosteroid users may require steroid supplementation

59. BLEEDING DISORDERS Conditions Deffects vWD vWF – poor platelet adhesion & factor VIII deficiency in some Haemophilia A Factor VIII Some develop Ab. Haemophilia B Factor IX Primary Thrombocytopenia (Idiopathic) Auto-immune destruction Secondary Thrombocytopenia Accelerated destruction Deficient Production Abnormal Pooling Liver Disease Multiple factor defect Thrombocytopenic in Portal Hypertension DIC Multiple factor defect due to triggered consumption Formation of Fibrin & FDP due to fibrinolysis Thrombocytopenia

60. 11. Bleeding disorders- Endodontic treatment is generally low risk for patients with bleeding disorders. If a pulpectomy is indicated, the possibility of the tooth requiring conventional endodontic treatment must also be considered. It is important that the procedure be carried out carefully with the working length of the root canal calculated to ensure that the instruments do not pass through the apex of the root canal.

61. The presence of bleeding in the canal is indicative of pulp tissue remaining in the canal. Sodium hypochlorite should be used for irrigation in all cases, followed by the use of calcium hydroxide paste to control the bleeding. require a written consent from the physician Specially when prescribing analgesics and antibiotics. In Hemophilia patients  there may be bleeding with injection , pulp extirpation and rubber dam application. However RCT is more safe than extraction after consulting physician.

62. Formaldehyde-derived substances may also be used in cases where there is persistent bleeding or even before the pulpectomy . Dental pain can usually be controlled with a minor analgesic such as paracetamol (acetaminophen ). Aspirin should not be used due to its inhibitory affect on platelet aggregation. The use of any non-steroidal antiinflammatory drug (NSAID) must be discussed beforehand with the patient's hematologist because of their effect on platelet aggregation. For anesthesia patient should only be given buccal infiltration .

63. FACTORS ASSOCIATED WITH CLINICIAN The clinician should have proper endodontic instruments and clinical set up for the treatment. The clinician should have well equipped hands for treatment.

64. AAE CASE DIFFICULTY ASSESSMENT FORM AND GUIDELINES The American Association of Endodontists has developed a practical tool that makes case selection more efficient, more consistent and easier to document. The Endodontic Case Difficulty Assessment Form is intended to assist practitioners with endodontic treatment planning, but can also be used to help with referral decisions and record keeping

65. The assessment form identifies three categories of considerations which may affect treatment complexity: patient considerations, diagnostic and treatment considerations , and additional considerations. Within each category, levels of difficulty are assigned based upon potential risk factors. The levels of difficulty are sets of conditions that may not be controllable by the dentist .

66. Each of the risk factors can influence the practitioner’s ability to provide care at a consistently predictable level. This may impact the appropriate provision of care and quality assurance. For each level of difficulty, guidelines are given to aid the dentist in determining whether the complexity of the case is appropriate for his or her experience or comfort level.

67. Levels of difficulty

68. revIew Of literature PERIRADICULAR RADIOGRAPHIC ASSESSMENT IN DIABETIC AND CONTROL INDIVIDUALS Leandro R. Britto,a Joseph Katz,Marcio Guelmann , and Marc Heft, DMD, PhD,d Gainesville. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:449-52)

69. Objective- The purpose of this study was to investigate the prevalence of radiographic periradicular radiolucencies in endodontically treated and untreated teeth in patients with and without diabetes.

70. Method- The study group consisted of 30 patients with diabetes, 14 men and 16 women, ranging from 39 to 84 years old (mean, 65 years). Eleven were classified as having type 1 diabetes and 19 as having type 2 diabetes. The control group consisted of 23 control subjects without diabetes, 12 men and 11 women. They ranged in age from 46 to 84 years (mean, 59 years) , attending the Endodontic Graduate Clinic at the University of Florida,were reviewed. The number of teeth with root canal treatments with and without periradicular radiolucencies and the number of teeth without endodontic treatment but with periradicular lesions were recorded. Data were categorized according to 3 distinct categories: (1) nonsurgical endodontic treatment (NSE): number of teeth that had root canal treatment and no periradicular radiolucency; (2) NSE with lesion: number of teeth that had root canal treatment and an adjacent periradicular radiolucency; and (3) no NSE with lesion: number of teeth with a periradicular radiolucency and broken lamina dura without having received any endodontic intervention at any time

71. Statistical analysis- All analyses were done in a SPSS environment (SPSS, Inc , Version 11, Chicago, Ill). Analysis of covariance was conducted under the general linear model approach (SPSS, Version 11). The analysis of variance model was 2 (sex) × 3 (diabetes diagnoses) with age as a covariate. The models were assessed separately with the number of affected teeth as the outcome for (1) those with NSE and lesions, (2) those with NSE and no lesions, and (3) those without NSE with lesions.

72. Results- . There were no main effects of sex, diabetes diagnosis, or age (the covariate) on the 3 outcomes of interest (NSE with lesions, NSE without lesions, and no NSE with lesions). However, there were significant interactions between sex and diabetes diagnosis for both of the endodontic outcomes, NSE with lesions ( F - 4.292; P .05) and NSE without lesions (F - 4.241; P .05). This meant that men with type 2 diabetes who had endodontic treatments were more likely to have residual lesions after treatment.

73. Conclusion- Type 2 diabetes is associated with an increased risk of ill response by the periradicular tissues to odontogenic pathogens. In this study, we found that men with type 2 diabetes had an increased number of periradicular radiolucencies — both men with NSE with lesions and men with NSE without lesions. However, the finding that type 2 diabetes is associated with an increased rate of inflammatory resorption of the alveolar bone in untreated teeth or in treated teeth is of clinical significance.

74. Because onlyteeth with adequate root canal treatment were included in the study, the factor of ill treatment resulting in an endodontic failure was reduced, but not completely eliminated. This finding focuses on type 2 diabetes as the main etiologic factor in endodontic failure. The finding that men with type 2 diabetes had endodontic failure more frequently than did women with type 2 diabetes might be attributed to the overall better general medical care and treatment of women.

75. CONCLUSION From above discussion it is evident that case selection is influenced by both systemic and local factors. Proper judgment of these factors lead to successful treatment out come Dental professionals have the technology, methodology and scientific rationale to repair damage to the dentition that was viewed as irreversible only years ago. These advances allow patients to keep their natural dentition, with a few exceptions

76. Any of the treatment options offered to the patient must have the patient’s best interests and health as a primary goal. The treatment must be delivered in a predictable manner by the treating practitioner to optimize the healing potential. Nonsurgical root canal therapy results in one of the highest retention rates of any dental procedure when completed under optimal conditions. As clinicians, we can ensure the highest quality treatment with our ability to treatment plan for the patient in such a way that we honestly assess the difficulty of the case and our personal skill levels, and then determine whether to treat or refer. In the final analysis, when the treatment proceeds without complication and healing occurs, the patient and the dentist benefit.

77. REFERENCES Cohen’s Pathways of the Pulp- S. Cohen, K.M Hargreaves. 10 th Edition. Grossman’s Endodontic Practice-12 th Edition. ENDODONTICS- JOHN I. INGLE, LEIF K. BAKLAND. 5 th Edition . GUIDELINES FOR DENTAL TREATMENT OF PATIENTS WITH INHERITED BLEEDING DISORDERS- Andrew Brewer, Maria Elvira Correa. T REATMENT OF HEMOPHILIA MAY 2006 • NO 40. Guideline on Antibiotic Prophylaxis for Dental Patients at Risk for Infection- AMERICAN ACADEMY OF PEDIATRIC DENTISTRY, CLINICAL PRACTICE GUIDELINES V 37 NO 6 .

78. Little JW, Falace D, Miller C, Rhodus N. Dental Management of the Medically Compromised Patient, Sixth edition: Mosby 2002. Calcified Canals – A Review- B.Thomas , M.Chandak , A. Patidar , B.Deosarkar , H.Kothari ; IOSR Journal of Dental and Medical Sciences. Periradicular radiographic assessment in diabetic and control individuals Leandro R. Britto , BDS, MS,a Joseph Katz, DMD,b Marcio Guelmann , DDS,c and Marc Heft, DMD, PhD,d Gainesville, Fla UNIVERSITY OF FLORIDA(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:449-52 ) Endodontics Colleagues for excellence published for dental professional community by American Association of Endodontics spring – summer 2005