#D3/S2/W5
#Endo

Treatment planning

• sequence of case selection and treatment planning carried out based on
  • clinical factors
  • dentists knowledge of abilities, limitations, armamentarium

Failure usually from

• misdiagnosis
• errors in treatment planning
• poor case assessment

AAE Endodontic case difficulty assessment form and guidelines

Levels of difficulty

• minimal
  • routine complexity/uncomplicated
  • only factors in minimal difficulty category
  • predictable outcome for limited experience practitioner
• moderate
  • preop complicated
  • one or more patient/treatment factors in moderate difficulty category
  • predictable outcome challenging for experienced practitioner
• high
  • preop exceptionally complicated
  • several factors in moderate difficulty or one in high difficulty
  • predictable treatment outcome challenging for most experienced practitioner with history of favourable outcomes

Maxillary molars

• MB2 93% of first molars, 60% second molars
  • Stropko et al 1999

Always referral if necessary

• endo and GP same team
• best to know an endo before referral is done

Treatment planning

first questions

• is tooth suitable for endo treatment
• is referral indicated
• how will tooth be restored

RCT or Exo

• prognosis
  • restorative, periodontal, endodontic
• strategic value
  • contribution to occlusal function
• patient factors
  • medical conditions, physical impairment, oral health
• RCT contraindication
  • unrestorable crown, severe perio

Restorative assessment

• entire coronal restoration removed (ideally)
  • eliminate pathways of bacterial ingress
  • detect and assess cracks
  • assess restorative prognosis and plan future coronal restoration, e.g. post or no post
• 

Periodontal assessment

• prognosis for teeth with both endo an perio will depend primarily on ability to control perio disease progression
• seek advice from periodontist prior to finalising treatment plan

Teeth without apical periodontitis

• treatment direct at prevention of AP
  • maintenance of asepsis
• 90-100% success rate regardless of technical standard
• success = no symptoms or clinical signs

Teeth with apical periodontitis

• treatment directed at antisepsis
  • elimination of intracanal infection
• prognosis depends on abiltiy to achieve microbial control
• technical standard of treatment is critically important
• healing rate following RCT 80-85%
  • (Sjogren 1990, Friedman 2002, deChevigny 2008)
• Dependent on technical standard of Tx:
  • High technical standard: 94% healing rate
  • Inadequate standard (short/long): 68-76%
  • Calcified canals: 60-70%
  • Procedural problems: variable
    (Akerblom 1988, Sjogren 1990, Spili et al 2005)

Strategic value

• in relation to overall function of dentition
• 2nd and 3rd molar less strategic value unless supporting prosthesis

Patient factors

• values, time, cost
• medication conditions not contraindication, but may complicate
  • anxiety, gagging, rubber dam tolerance
  • mouth opening, ability to lay supine
• consider overal health of dentition
  • caries risk, perio stability