Asalaam Alekum
Date: 11/02/2014
CASE SELECTION AND TREATMENT
PLANNING
Dr. Gaurav Garg, Lecturer
College of Dentistry, Al Zulfi
 Once a thorough examination has determined that an
endodontic problem exists, the process of case selection
begins.
 The dentist must determine whether treatment is indicated
for this patient, what treatment will best serve the patient,
and whether the patient would be best served by being
referred to a specialist or another practitioner.
CASE SELECTION
 Evaluation of patient
 Evaluation of tooth
 Evaluation of Clinician (by Self)
Evaluation of patient
 Physical evaluation
 Psychological Evaluation
 Economic Evaluation
PHYSICAL EVALUATION
 Most medical conditions do not contraindicate endodontic
therapy, but the patient's medical condition should be
thoroughly evaluated in order to properly manage the case.
 If the treating dentist does not feel comfortable treating
medically compromised patients, such patients should be
referred to an endodontist, who may be able to provide more
expeditious treatment.
Cardiovascular disease
 A history of myocardial infarction within the past 6
months is a contraindication for elective dental
treatment.
 Emergency relief, however, should be provided in
consultation with the patient's cardiologist.
 Stress Reduction Protocol:
 Short appointments
 Sedation
 Pain and anxiety control.
 Patients with a history of Rheumatic heart disease
should be premedicated with amoxicillin,
erythromycin, or clindamycin
Bleeding disorders






Hemophilia
Von Wilbrand’s Disease
Vitamin K deficiency
Dialysis patients
Alcohol abusers
Patients taking Aspirin
 Laboratory screening tests and physician consultation are necessary for
any patient with a bleeding disorder.
 Although endodontic therapy is preferable to extraction in these
patients, the dentist should be prepared to handle any bleeding due to
impingement of the rubber dam clamp, vital pulp extirpation, or
surgical procedures.
Diabetes
 An acute endodontic infection can compromise even
a well controlled diabetic; so all diabetes patients
must be carefully monitored.
 Prophylactic antibiotics may be necessary even when
there are not yet any signs of periradicular infection.
 Patients with uncontrolled or brittle diabetes should
be monitored carefully for signs of insulin shock or
diabetic coma.
 Appointments should be scheduled so as not to
interfere with the patient's normal insulin and meal
schedule.
 A stress reduction protocol should be followed.
Cancer
 A thorough history will reveal what type of cancer the
patient has and what type of treatment is being rendered.
 Some cancers can appear as endodontic lesions, the dentist
should biopsy any suspicious ones.
 Because chemotherapy and radiation to the head and neck
region can severely compromise the healing process,
endodontic treatment should be done in close consultation
with the patient's oncologist.
AIDS
 HIV infection, including AIDS, is not a contraindication to
endodontic therapy.
 Indeed, in most instances, the patient is at less risk with
endodontic therapy than with extraction.
 Infection control procedures should be strictly followed.
Pregnancy
 Pregnancy is not a contraindication to endodontic
therapy.
 Pain and infection can and should be controlled in
consultation with the patient's obstetrician.
Allergies
 If the patient is allergic to latex
rubber, a dam should be made of
vinyl (such as a vinyl glove, which
also should be worn over the
rubber gloves).
 A highly allergic patient may be
more prone to intrappointment
flare-ups, which may be
preventable by antihistamine
premedication.
Steroid therapy
 Adrenal suppression should be suspected when a patient is
receiving steroid therapy.
 Any patient taking steroids is more susceptible to infection
than otherwise and in consultation with his physician, should
be appropriately protected with antibiotics.
 Use of Steroid containing intracanal medicament should be
avoided.
Infectious diseases
 Strict adherence to universal
infection control precautions
prevents the spread of infectious
diseases between patients and
dental personnel.
Physical disabilities
 Patients with physical disabilities such as
Parkinson's disease, Spinal cord injury,
or stroke may not be able to hold a
radiographic film, the electronic apex
locator is recommended.
Psychological Evaluation
 Motivation:
 A patient who shows no incentive to
maintain good oral hygiene or one who
constantly misses appointments may not
be a good candidate for endodontic
therapy.
 Difficult patients:
 Fear of ionizing radiation, pain, or needles
can impair a patient's ability to behave
well in the dental office.
 Many of these psychological problems can
be overcome by a gentle, caring, honest
chair side manner.
Economic Evaluation
 Evaluate the economic condition of the patient and plan
treatment accordingly
EVALUATION OF TOOTH
 A number of factors should be evaluated to determine
whether a tooth should be endodontically treated and, if so,
by a general dentist or an Endodontist:
 Morphology
 Previous treatment
 Location
MORPHOLOGY
Unusual length
 Teeth that are unusually long (greater
than 25 mm) or unusually short (less
than 15 mm) are more difficult to treat.
 The general dentist can prudently
choose whether an endodontist would
better serve the patient.
Long tooth
Short tooth
Unusual canal shapes
 Unusual canal shapes require special
techniques.
 An open apex ("blunderbuss") canal
will need either Apexification or
Apexogenesis.
 C-shaped canals, dens-in-dente,
Taurodontism, and roots with
bulbous ends are more difficult to
treat and often require more
specialized techniques that are more
likely to be acquired by the advanced
general dentist or an endodontist.
Open apex
C-Shape canal
Dens in dente
Taurodontism
Dilacerations
 Extreme curvature of the root
canal can be difficult for the
most experienced clinician to
manage.
 The use of Anticurvature filing
and nickel titanium files can
help avoid strip perforations
and Ledging.
Unusual number of canals
 The treating dentist must always
look for and expect extra canals.
 All molars should be expected
to have at least four canals
unless proven otherwise.
MB
MB2
DB
P
 When a large canal stops
abruptly on the radiograph,
branching into two or more
smaller canals should be sought.
DB
MB
MB2
MB3
P
Resorptions
 Internal Resorption can be
differentiated from external
Resorption by its radiographic
appearance
 External Resorption appears to
be superimposed on the canal,
whereas internal Resorption
appears to be continuous with
the canal.
Calcifications
 Calcification in the root canal,
whether isolated or continuous, can
make treatment very difficult for the
most skilled clinician.
 The use of chelating agents,
magnification, fiberoptic
transillumination, and pathfinding
files can help the dentist find and
treat calcified canals.
 If all measures fails, Periapical
surgery may be considered
Previous Treatment
Canal blockage
 Previously treated teeth may need to be
retreated because of persistent disease due to
incomplete root canal debridement or
obturation
 Any material blocking access to the apical extent
of the canal must be removed.
 Ultrasonic instruments have made it much easier
to remove posts, silver points, broken
instruments, and paste fillings.
 Care must be taken to avoid ledging or blocking
these canals.
 A dentist inexperienced with retreatment
techniques should refer these cases to an
endodontist.
Ledge
Ledging
 A previously treated tooth that
has a ledge in the canal can be
very difficult to treat.
 Using a file whose apical 2
mm has been bent at a 30degree angle can help bypass
and eliminate the ledge.
Bypassing Ledge
Perforations
Apical Third
 If a previously treated tooth has a
perforation that is improperly sealed, the
prognosis may be very poor.
Furcation
 When the perforation is in the apical third
of the root it may be surgically treatable.
 If it is in the furcation area it may be
possible to pack a matrix of
hydroxyapatite and seal the perforation
with a glass ionomer cement/ MTA.
 If bone loss has already occurred,
Perforation repair
hemisection, root amputation, or
extraction maybe indicated.
Lateral Perforation
18/02/14
Location of Tooth
Accessibility
 The relative location of a tooth in the arch is
directly related to accessibility.
 The further posterior the tooth, the less
accessible are all the canals for visualization
and treatment.
 Limited opening due to Trismus, scarring
from burns or surgical procedures, or
systemic problems such as scleroderma may
severely limit access.
 Angulation of the tooth can also hamper
accessibility.
 Molars that are tipped to the mesial or teeth
that are in linguoversion or labioversion can
also present problems for less experienced
dentists.
Proximity to other structures
 Anatomic structures close to the apex of the




tooth should give the thoughtful clinician pause.
Paresthesia can be caused by over
instrumentation, overfilling, or endodontic
disease close to the mental foramen or
mandibular canal.
Periradicular infections can cause concomitant
infections of the maxillary sinus, nasal cavities, or
endosseous implants.
The malar process, impacted teeth, tori, or
overlapping roots can make radiographic
visualization of the apex and periradicular region
difficult for both diagnosis and treatment.
In these situations the use of electronic apex
locators is recommended.
Restorability
 The restorability of the tooth
must be thoughtfully
considered first.
 All decay should be removed
so that the extent of healthy
tooth structure can be
gauged.
Periodontal status
 The prognosis for the endodontically
involved tooth should also be evaluated in
relation to its periodontal status.
 A tooth with very little bone support and
class III mobility also has a poor
endodontic prognosis.
 An endodontic lesion that is also
periodontally involved may never heal.
EVALUATION OF CLINICIAN
 Self-evaluation by the clinician should include the following questions:
1. Do I have the experience to treat this problem?
 Complicated treatment procedures should not be attempted until the
clinician has had experience with less complex cases of the same type.
2. Do I have the ability to treat this endodontic case?
 Not every clinician has the ability or patience to carefully clean and
shape curved, narrow canals or to do surgical procedures.
 The clinician should honestly evaluate his or her personal ability to treat
complicated cases. Clinicians have different interests and preferences.
 Patients with medical problems or disabilities might need special or
emergency response that is beyond the capability of some clinicians.
3. Do I have the availability of, and experience with, any special
technology that I will need?
4. Are unusually long or flexible files needed?
5. Does this case call for use of a microscope, ultrasonic device, or
electronic apex locator?
6.Will special Obturation techniques be necessary because of
the canal anatomy?
 It is easier to refer a patient to an Endodontist before a problem
occurs than after the problem creates stress for both the dentist
and the patient.
CASE SELECTION
Treatment by General Dentist/
Endodontic Specialist
PATIENT EVALUATION
1. Physical evaluation:
CVS Conditions, Bleeding
Disorders, Diabetes, Cancer,
AIDS, Pregnancy, Allergies,
Steroid therapy, Infections,
Physical disabilities
2. Psychological Evaluation:
Motivation, Fear & Psychological
problems
3. Economic Evaluation
TOOTH EVALUATION
1. Morphology: Unusual length,
Canal shape, Dilacerations,
Extra Canals, Resorptions,
Calcifications.
2. Previous treatment: Canal
blockage, edging, perforations.
3. Tooth Location: Accessibility,
Proximity to other structures,
Restorability, Periodontal
Status.
CLINICIAN EVALUATION
1. Experience
2. Skill And Ability
3.Availability of Special
Technology
TREATMENT PLANNING
Treatment planning
 It is essential that a proper diagnosis be made before
endodontic therapy is instituted.
 Incorrect or inadequate diagnostic procedures can lead to
improper treatment, and likely legal consequences.
Treatment planning
 The first goal of endodontic therapy is to relieve acute pain
and provide drainage of infection
 Once the patient's acute symptoms have been alleviated, the
completion of the root canal can be set aside while the
clinician conducts a comprehensive examination of the
patient and develops a customized course of treatment.
 Following this written treatment plan provides the patient
optimal care and helps prevent inappropriate treatment,
embarrassment, and patient dissatisfaction.
STEPS IN TREATMENT PLAN
1. Management of acute pulpal or
periodontal pain.
2. Oral surgery for extraction of
unsalvageable teeth.
3. Caries control of deep lesions that may
threaten the pulp.
4. Periodontal procedures to manage soft
tissue.
5. Endodontic procedures for asymptomatic
teeth with necrotic pulps and surgical
treatment or retreatment of failed root
canals.
6. Restorative and prosthetic procedures.
1
2
3
4
5
 This sequence may be altered if a dental
emergency arises or if the patient's
systemic health, dental attitude, or
financial situation changes.
6
Coordination with Other Dental Specialists
 In some instances cases must be evaluated by other dentists
or specialists before endodontic treatment is instituted.
1.Pain/
Emergency
management
2. Extraction of
Root stumps/
badly decayed
teeth
6. Definitive
Restorations/
Prosthesis
TREATMENT
PLANNING
(Multispecialty
Approach)
5. RCT/ReRCT/Periapical
surgeries
3. Deep/ Active
caries management
4. Periodontal
therapy
References:
 Pathways of the pulp (6th Edition)- Stephen Cohen,
R.C. Burns.
 Endodontics;Problem-Solving in Clinical
Practice (2002)-TR Pitt Ford, JS Rhodes, HE Pitt Ford.
 Endodontics (2005)- Ingle & Bakland.