-case selection and treatment planing in endodontics

1. Case Selection and
Treatment Planning

2.  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.

4.  Case selection is broadly based upon
three factors :
1) Factors associated with teeth.
2) Factors associated with patients health.
3) Factors associated with clinician.

5.  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. 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.  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.  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.  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.  Sometimes patient comes with acute dental
pain, in such cases endodontic therapy is
often indicated before a complete
examination and treatment plan doing.

11. 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.  1. Insufficient periodontal support
 InTeeth 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.  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.  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.  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.  Developmental anomalies like fusion,
gemination, concrescences, enamel pearl are
difficult to treat with endodontic procedures.

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

18.  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.  PainfulTeeth 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.  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.  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.  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 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. 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. 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.

28. 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.  Proper sequencing is a critical component of
a successful treatment plan. Complex
treatment plans often should be sequenced in
phases, including :
1) an urgent phase
2) control phase
3) re-evaluation phase
4) definitive phase
5) maintenance phase

30.  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.  It is meant to
1) eliminate active disease such as caries and
inflammation
2) remove conditions preventing maintenance
3) eliminate potential causes of disease, and
4) begin preventive dentistry activities

32.  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.  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.  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.  This includes regular recall examinations that:
1. may reveal the need for adjustments to
prevent future breakdown, and
2. provide an opportunity to reinforce home
care.

36.  The frequency of re-evaluation examinations
during the maintenance phase depends in large
part on the patient's risk for dental disease:
1) 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.
2) Those at high risk for dental caries and/or
periodontal breakdown should be examined
much more frequently (e.g. 3–4 months).

37. 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. • 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. • 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. • 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. • 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 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
• In 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.  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.  LOW DIFFICULTY
 MODERATE DIFFICULTY
 HIGH DIFFICULTY

56.  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.  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.  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.

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
ABILITYTO 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

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 INTHE ARCH –
TOOTHTYPE
Extreme inclination
(>30°)
Moderate inclination
(10-30°)
Slight inclination
(<10°)
POSITION INTHE ARCH –
INCLINATION
Extreme rotation
(>30°)
Moderate rotation
(10-30°)
Slight rotation (<10°)
POSITION INTHE 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 OFTHE ROOT
APICES
TOVITAL 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