Download 4 Case Selection and Treatment Planning

4 Case Selection and Treatment Planning
Paul A. Rosenberg
The process of case selection and treatment planning begins after a clinician has diagnosed an
endodontic problem. The clinician must determine if the patient's oral health needs are best met
by providing endodontic treatment and maintaining the tooth or by advising extraction. This
question is more complex than ever before because of the wide array of treatment modalities.
The use of ultrasonics and microscopy as well as new materials has made it possible to
predictably retain teeth that previously could not have been treated. Even teeth that have failed
initial endodontic treatment can often be successfully retreated using nonsurgical or surgical
procedures.
Increased knowledge about the importance of anxiety control, nonsteroidal antiinflammatory drug
(NSAID) premedication, profound local anesthesia, occlusion, and biologically based clinical
procedures enables clinicians to complete endodontic procedures in the absence of
intraoperative or postoperative pain (see Chapters 19 and 20 for more information on pain control
and anesthesia). Thus preoperative pain should not influence treatment selection because
modern techniques for profound local anesthesia can provide complete comfort for the great
majority of patients receiving endodontic treatment (see Chapter 19, "Local Anesthesia in
Endodontics," for details).
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Figure 4-1 Sample medical consultation letter.
Questions concerning tooth retention and possible referral can be answered only after a complete
patient evaluation. The evaluation must include assessment of medical, psychosocial, and dental
factors as well as a 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. A number of valuable texts
are available that review the subject of dental care for the medically compromised patient. 6,31,47,53
An excellent website is also available and can be used to elicit information. 2
Perhaps 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. The proposed treatment
can be reviewed, and medical recommendations should be documented. Fig. 4-1 depicts a
sample medical consultation letter that can be modified as necessary.
The American Society of Anesthesiologists (ASA) Physical Status Classification was devised in
1941 and revised to its present form in 1983. The ASA website lists the following:
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ASA I- Normal, healthy patient; no dental management alterations required.
ASA II- A patient with mild systemic disease that does not interfere with daily activity or
who has significant health risk factor (e.g., smoking, alcohol abuse, gross obesity); may
or may not need dental management alterations.
Examples: Stage I or II hypertension, type 2 diabetes, allergy, well-controlled asthma.
ASA III- A patient with moderate to severe systemic disease that is not incapacitating but
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may alter daily activity; may have significant drug concerns; may require special patient
care; would generally require dental management alterations.
Examples: Type 1 diabetes, stage 3 hypertension, unstable angina pectoris, recent
myocardial infarction, poorly controlled congestive heart failure, AIDS, chronic obstructive
pulmonary disease, hemophilia.
ASA IV- A patient with severe systemic disease that is a constant threat to life; definitely
requires dental management alterations; best treated in special facility.
Example: Kidney failure, liver failure, advanced AIDS.
Excerpted from Little JW, Falace DA, Miller CS, Rhodus NL: Dental Management of the
Medically Compromised Patient, ed 6, St Louis, 2002, Mosby, pp 10-11.
The ASA classification remains the most widely used assessment method for preanesthetic
patients despite some inherent limitations to its use as a perioperative risk predictor. This is a
generally accepted and useful guide for preoperative assessment of relative risk. However, the
prudent clinician should also take into account other factors not considered in the classification
scheme, such as age, obesity, and skill of the health care provider. Other systems have been
proposed that would better reflect the increasing number of medically complex patients treated by
clinicians as Americans live longer.22
COMMON MEDICAL FINDINGS THAT MAY INFLUENCE ENDODONTIC
TREATMENT PLANNING
Pregnancy
Although pregnancy is not a contraindication to endodontics, it does modify treatment planning.
An extensive body of literature exists concerning the use of radiographs and drugs while treating
pregnant patients.31 Protection of the fetus is a concern when administration of ionizing radiation
or drugs is considered.49 Of all the safety aids associated with dental radiography, such as highspeed film, digital imaging, filtration and collimation, the most important is the protective lead
apron with thyroid collar.3,58 Drug administration during pregnancy is a controversial subject. A
major concern is that a drug may cross the placenta and be toxic or teratogenic to the fetus. In
addition, any drug that is a respiratory depressant can cause maternal hypoxia, resulting in fetal
hypoxia, injury, or death. Ideally, no drug should be administered during pregnancy, especially
during the first trimester. If a specific situation makes adherence to this rule impossible, then that
clinician should review the appropriate literature7,34 and discuss the case with the physician and
patient.
Further considerations exist during the postpartum period if the mother breast feeds her infant.
Although most drugs are only minimally transmitted from the maternal serum to the breast milk
and the infant's exposure is not significant, the clinician should avoid using any drug known to be
harmful to the infant. A dentist should consult the responsible physician before using any
medications for the nursing mother. Alternative considerations include using minimal dosages of
drugs, having the mother bank her milk before treatment, having her feed the child before
treatment, or suggesting the use of a formula for the infant until the drug regimen is completed.
The U.S. Food and Drug Administration (FDA) and the American Academy of Pediatrics have
issued a list of drugs that are thought to be compatible with breastfeeding (see
http://www.fda.gov/fdac/features/895_brstfeed.html). Box 4-1 summarizes this list.
In terms of treatment planning, elective dental care is best avoided during the first trimester
because of the potential vulnerability of the fetus. The second trimester is the safest period in
which to provide routine dental care. Significant surgical procedures are best postponed until after
delivery.
Cardiovascular Disease
Box 4-1 Partial List of Drugs Usually Compatible with Breast
Feeding
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Acetaminophen
Many antibiotics
Aspirin (should be used with caution)
Codeine
Ibuprofen
Insulin
Quinine
Thyroid medications
From the FDA and American Academy of Pediatrics. Available at Click
here
Patients with some forms of cardiovascular disease are vulnerable to physical or emotional stress
that may be encountered during dental treatment, including endodontics. Patients may be
confused or ill informed concerning the specifics of their particular cardiovascular problem. In
these situations, consultation with the patient's physician is mandatory before the initiation of
endodontic treatment. Patients who have had a myocardial infarction (i.e., "heart attack") within
the past 6 months should not have elective dental care. This is because patients have increased
susceptibility to repeat infarctions and other cardiovascular complications and may be taking
medications that could potentially interact with the vasoconstrictor in the local anesthetic. In
addition, vasoconstrictor should not be administered to patients with unstable angina pectoris or
to patients with uncontrolled hypertension, refractory arrhythmias, recent myocardial infarctions
(less than 6 months), recent stroke (less than 6 months), recent coronary bypass graft (less than
3 months), uncontrolled congestive heart failure, and uncontrolled hyperthyroidism.
Vasoconstrictors may interact with some antihypertensive medications and should be prescribed
only after consultation with the patient's physician (see Chapter 19 for more information). For
example, vasoconstrictors should be used with caution in patients taking digitalis glycosides (e.g.,
digoxin ) because the combination of these drugs could precipitate arrhythmias. Local anesthetic
agents with minimal or no vasoconstrictors are usually adequate for nonsurgical endodontic
procedures.31
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A patient who has a heart murmur as a result of a pathologic condition may be susceptible to an
infection on or near the heart valves, which is caused by a bacteremia. This infection is called
infective or bacterial endocarditis and is potentially fatal. Patients who have a history of murmur
or mitral valve prolapse with regurgitation, rheumatic fever, or a congenital heart defect must be
given antibiotic therapy prophylactically before endodontic therapy to minimize the risk of
bacterial endocarditis. Because the American Heart Association periodically revises its
recommended antibiotic prophylactic regimen for dental procedures, it is essential for the clinician
to stay current concerning this important issue. A low compliance rate exists among at-risk
patients regarding their use of the suggested antibiotic coverage before dental procedures.
Therefore the clinician must question patients concerning their compliance with the prescribed
prophylactic antibiotic coverage before endodontic therapy. If the patient has not taken the
antibiotic, the procedure must be delayed.
Patients with artificial heart valves are considered highly susceptible to bacterial endocarditis.
Therefore consulting this patient's physician regarding antibiotic premedication is essential. Some
physicians elect to administer parenteral antibiotics in addition to or in place of the oral regimen.
The coronary artery bypass graft is a common form of cardiac surgery. Ideally, vasoconstrictors
should be minimized during the first 3 months after surgery to avoid the possibility of precipitating
arrhythmias. Ordinarily these patients do not require antibiotic prophylaxis after the first few
months of recovery unless there are other complications. The clinician can play an important role
in the detection of hypertension. The clinician may be the first to detect an elevated blood
pressure. Further, patients receiving treatment for hypertension may not be controlled adequately
because of poor compliance or inappropriate drug therapy. Abnormal blood pressure readings
become the basis for physician referral. Few conditions exist in which there is a possibility that
dental treatment could seriously injure or even result in the death of a patient. However, acute
heart failure during a stressful dental procedure in a patient with significant valvular disease and
heart failure or the development of infectious endocarditis represent two such life-threatening
disorders.50 Careful evaluation of patients' medical histories including the cardiac status of
patients, the use of appropriate prophylactic antibiotics, and stress reduction strategies will
minimize the risk of serious cardiac sequelae.
UPDATE
Date Added: 28 March 2006
Ken Hargreaves, DDS, PhD
Cardiovascular implications of apical periodontitis, pulp stones, and endodontic treatment
The last decade has seen a growing interest in the idea that chronic dental infections might be
correlated with certain systemic diseases or disorders. Indeed, some, but not all, epidemiologic
studies have found a significant association between periodontitis and systemic factors such as
cardiac disease or low-birth-weight children. Although enthusiastic proponents gush that we must
"floss or die," there is a major flaw in this thinking. Simply put, if we find that two factors, called
"A" and "B," are correlated, then it is possible that factor A causes factor B, or that factor B
causes factor A, or that some underlying factor "C" causes both factor A and factor B. In other
words, correlation does not equal causation. Thus, the mere correlation of two conditions does
not prove causation. Instead, prospective clinical studies are needed to test whether reduction of
inflammation by periodontal treatment, for example, leads to a reduction in some measure of
cardiac disease.
In terms of chronic infections related to apical periodontitis, far fewer studies have evaluated
whether certain endodontic measures might correlate with systemic disease. This is a potentially
interesting area of research, and therefore this update will review studies addressing this topic.
Edds and colleagues1published a recent study evaluating whether the radiographic presence of
pulp stones might be correlated with cardiovascular disease (CVD). The hypothesis in this study
is quite innovative. The authors propose that a similar underlying pathogenic mechanism might
induce both calcification of dental pulp and calcified atheromas in larger blood vessels. Put more
simply, the authors propose that a fundamental factor "C" (susceptibility to calcifications) might
mediate two correlated but functionally unrelated conditions (i.e., pulp stones and cardiovascular
disease). To reduce the chance that pulp stones were detected due to pulpal pathosis, the study
consisted of patients aged 20 years to 55 years with radiographic assessment of pulp stones in
non-carious, minimally restored molars (the upper age limit was imposed due to the well
recognized increase in pulp stones with age). CVD was defined as a positive history of angina
pectoris, myocardial infarction, heart surgery, hypertension, congestive heart failure,
cerebrovascular accident, hypercholesterolemia, or arrhythmia. The presence of pulp stones was
associated with a 4.4-fold increase in the risk of CVD in these patients (95% CI = 1.1 - 18.7).
Indeed, 74% of the patients with a history of CVD had detectable pulp stones. In contrast, there
was no significant association between pulp stones and family history of CVD (odds ratio of 1.7;
not significant). This study suggests that radiographic interpretation of pulp stones might be
considered as a useful screening evaluation for CVD.
Two other studies have evaluated whether apical periodontitis or the presence of root canal-filled
teeth are correlated with coronary heart disease (CHD). The first study 2 evaluated 1056 women
aged 38 years to 84 years from Sweden and correlated the presence of apical periodontitis or
root canal-filled teeth with two measures of CHD (angina pectoris or myocardial infarction). A
multivariate logistic regression analysis found no association between AP or root canal therapy
(RCT) and CHD. Importantly, the study demonstrated assay sensitivity, since other known risk
factors (e.g., age or tooth loss) were significantly associated with CHD. However, it is important to
note that, in general, women are at a lower risk for CHD, and therefore studies in males are
important to consider. Therefore, it is interesting to review a recent publication, 3 which has
evaluated 34,683 males participating in the Health Professionals Follow-up Study (HPFS). In this
study, RCT was used as a marker for a history of inflammation, and CHD was defined as nonfatal myocardial infarction or fatal coronary disease. The results demonstrated that patients with
teeth having prior RCT have a 21% increased risk for developing CHD as compared to patients
without prior RCT (mean relative risk = 1.21 with 95% CI = 1.05 - 1.40). Interestingly, dentists had
a greater increased risk (38%) with RCT as compared to non-dentists (RR = 1.03; not significant).
The reasons for this increased risk are unclear but may be related to study design, since patients
self-reported the presence of RCT and it is likely that dentists would report this more accurately,
or undergo RCT for different reasons than non-dentists. These data suggest a possible modest
association between pulpal inflammation and CHD, although the authors stress the need for
confirmatory research. Indeed, the authors conclude3 their study by stating: "There have been no
publications suggesting that RCT has any adverse systemic effects since the dismissal of the
focal infection theory of the early 1900s. RCT in our study is a surrogate for pulpal inflammation;
we do not expect the RCT itself to lead to adverse systemic outcomes. Further research is
needed to corroborate the association between pulpal inflammation and CHD in other
populations, to assess whether the association is causal, and to evaluate pathways for this
association."
Cancer
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Figure 4-2 A, Essentially normal periradicular appearance of #29 following endodontic
treatment. Treatment was due to a diagnosis of irreversible pulpitis. B, Rapid periapical
breakdown of #29 and new periradicular radiolucencies associated with #30 four months after
endodontic treatment of #29. The patient's complaints now included pain isolated to #30 as
well as lip and chin paresthesia. C, Nonsurgical endodontics of #30. D, Surgical postoperative
radiograph of #30 and #29. Biopsy results following endodontic surgery were positive for
metastatic breast cancer. (Courtesy Dr. Robert Sadowsky, Dr. Lee Adamo, and Dr. Jeffrey
Burkes.)
Some cancers may metastasize to the jaws and mimic endodontic pathosis, whereas others can
be primary lesions (Fig. 4-2). A panoramic radiograph is useful in providing an overall view of all
dental structures. When a clinician begins an endodontic procedure with a well-defined apical
radiolucency, it might be assumed to result from an extension of infectious agents from a nonvital
pulp. Careful examination of preoperative radiographs from different angulations is important
since lesions of endodontic origin would not be expected to be shifted away from the radiographic
apex in the different images. If a local anesthetic is not administered and if the patient
experiences pain during access or canal instrumentation, it is advisable to reconsider the original
diagnosis because the radiolucency may be a lesion of nonodontogenic origin. A useful website
for the differential diagnosis of radiographic lesions (ORAD II) was created by Dr. Stuart White
and is available on-line at http://www.orad.org/difDiag.html. A definitive diagnosis of a
periradicular osteitis can be made only after biopsy. When a discrepancy exists between the
initial diagnosis and clinical findings, consultation with an endodontist is advisable. 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.
Resolving the question of endodontic treatment or extraction for preradiation patients often
requires a dialogue between the dentist and physician.
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. The outcome of endodontic treatment should be evaluated within the
framework of the toxic results of radiation and drug therapy. The cancer patient's white blood cell
(WBC) count and platelet status should also be reviewed before endodontic treatment. In general,
routine dental procedures can be performed if the granulocyte count is greater than 2000/mm 3
and the platelet count is greater than 50,000/mm. If urgent care is needed and the platelet count
is below 50,000/mm, consultation with the patient's oncologist is required. 56
Human Immunodeficiency Virus and Acquired Immunodeficiency
Syndrome
It is important for clinicians treating acquired immunodeficiency syndrome (AIDS) patients to
understand their patient's level of immunosuppression, drug therapies, and potential for
opportunistic infections. Although the effect of human immunodeficiency virus (HIV) infection on
long-term prognosis of endodontic therapy is unknown, studies have shown that HIV patients do
not have increased risk for postoperative pain or inflammation after endodontic treatment. The
clinical team must also minimize the possibility of transmission of HIV from an infected patient,
and this is accomplished by adherence to universal precautions (see
http://www.cdc.gov/ncidod/hip/BLOOD/UNIVERSA.HTM for details). Although saliva has not been
demonstrated to have transmitted the virus in a dental situation, the potential for it to do so
exists.12,18,31 Infected blood can transmit HIV, and during some procedures it may become mixed
with saliva. Latex gloves and eye protection are essential for the clinician and staff. HIV can be
transmitted by needlestick or an instrument wound, but the frequency of such transmission is low,
especially with small-gauge needles.31
A vital aspect of treatment planning for the patient with HIV/AIDS is determining the current CD4
lymphocyte count and level of immunosuppression. Generally patients having a CD4 count of
more than 400 mm3 may receive all indicated dental treatment. Patients with a CD4 count of less
than 200 mm3 will have increased susceptibility to opportunistic infections and may be effectively
medicated with prophylactic drugs.31 Medical consultation is advisable before surgical procedures
and before initiating complex treatment plans.
End-Stage Renal Disease
Consultation with the patient's physician is suggested before dental care 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, systemic lupus
erythematosus), dental treatment may be best provided in a hospital setting. The goal of dental
care for patients being treated for end-stage renal disease is to restore and maintain the mouth to
a healthy state and prevent infection.31
Dialysis
The most recent American Heart Association guidelines do not include a recommendation for
prophylactic antibiotics before invasive dental procedures for patients with intravascular access
devices. However, other investigators advise that prophylactic antibiotics are prudent for
hemodialysis patients with arteriovenous shunts/grafts when invasive dental procedures are
performed.13,32,37,55 Although controversy exists, antibiotic prophylaxis should be provided for
patients receiving hemodialysis who have known cardiac risk factors. For patients undergoing
hemodialysis who do not have known cardiac risk factors, consultation with the managing
physician or nephrologist is advised. When prophylaxis is used, the standard regimen of the
American Heart Association is recommended. Some drugs frequently used during endodontic
treatment are affected by dialysis. Drugs metabolized by the kidneys or nephrotoxic drugs should
be avoided.
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Both aspirin and acetaminophen are removed by dialysis and require a dosage increase in
patients with renal failure. Amoxicillin and penicillin V also require a dosage adjustment
following hemodialysis. It is advisable to consult the patient's physician concerning specific drug
requirements during endodontic treatment.31 Endodontic treatment is best scheduled on the day
following dialysis, since on the day of dialysis patients are generally fatigued and could have a
bleeding tendency.
Diabetes
The Centers for Disease Control and Prevention (CDC) reported a 6% increase in the incidence
of diabetes mellitus in the United States in the year 2001. The dramatic increase has been linked
to a remarkable 57% increase in obesity among Americans during the last 10 years. Twenty
percent of Americans are classified as obese. It has been estimated that 15.7 million persons in
the United States representing 5.9% of the population have diabetes. 31 It is likely that diabetic
patients requiring endodontic treatment will be increasingly common. 11 Diabetes mellitus appears
to have multiple causes and several mechanisms of pathophysiology.31 Diabetes mellitus can be
thought of as a combination of diseases that share the key clinical feature of glucose
intolerance. Patients with diabetes, even those who are well controlled, require special
consideration during endodontic treatment. The patient with diabetes who is well controlled
medically and free of serious complications, such as renal disease, hypertension, or coronary
atherosclerotic disease, is a candidate for endodontic treatment. However, special considerations
exist in the presence of acute infections. The non-insulin-controlled patient may require insulin, or
the insulin dose of some insulin-dependent patients may have to be increased.31 In cases in
which surgery is required, consultation with the patient's physician is advisable to consider
adjustment of the patient's insulin and dosage, antibiotic prophylaxis, and dietary needs during
the postoperative period. A source of glucose (orange juice, soda, Glucola) should be available
if symptoms of an insulin reaction occur. Acute infections in the diabetic patient should be
managed using the standard approach of: incision and drainage, pulpectomy, antibiotics, and
warm rinses.
Appointments should be scheduled with consideration given to the patient's normal meal and
insulin schedule.31 The patient with diabetes who is well managed medically and is under good
glycemic control without serious complications such as renal disease, hypertension, or coronary
atherosclerotic heart disease can receive any indicated dental treatment. 16 However, patients with
diabetes who have serious medical complications may need a modified dental treatment plan. 43
Moreover, recent studies suggest that diabetes is associated with a decrease in the success of
endodontic treatment in cases with preoperative periradicular lesions.8,17 These patients may
require referral to an endodontist for alternative treatment considerations.
UPDATE
Date Added: 14 March 2006
Karl Keiser, DDS, MS
Prevalence of apical periodontitis among type 2 diabetics
As defined by the American Diabetes Association, diabetes mellitus is a "disease in which the
body does not produce or properly use insulin."1 Type 1 diabetes is caused when the body does
not produce sufficient quantities of insulin, and type 2 diabetes results when the body's tissues
cannot properly use insulin (termed insulin resistance). Both result in abnormally high serum
glucose levels, with a host of potentially adverse effects. According to Miley and Terezhalmy, oral
manifestations of diabetes may include xerostomia, periodontal disease, candidiasis, and burning
mouth syndrome. 2 Advanced glycation end products (AGEs) are formed under conditions of
hyperglycemia, and underlie some of mechanisms by which clinical changes occur. AGEs have
been shown to cause increased production of pro-inflammatory cytokines in response to
stimulation by cell wall components of gram-negative bacteria and to effect neutrophil chemotaxis
and phagocytosis, all part of the body's response to pathogenic microbes.
Thomson et al.3 report a higher incidence of periodontal attachment loss among diabetics, and
rodent models of diabetes demonstrate that bacterial challenge to the pulp canal system results
in more alveolar bone resorption compared to normal animals. 4,5,6 Fouad7 suggests that diabetes
may alter the progression of endodontic infections in humans, and Bender and Bender have
suggested that humans with diabetes are also more prone to the development of apical
periodontitis (AP). 8 A recent study by Segura-Egea et al. examined this possibility in a Spanish
population. 9 Records of 32 patients reporting well-controlled type 2 diabetes were matched with
a cohort of healthy non-diabetics. Full-mouth radiographic surveys were examined by using the
Periapical Index system (PAI). 10 One calibrated examiner evaluated the radiographs (intraobserver kappa = 0.77), and analysis of variance and logistic regression were used to determine
the significance of differences of the number of teeth with AP (both root filled and untreated)
between normal and diabetic patients. AP (as defined by a PAI of > 2) was found in 81% of
diabetics as compared to 58% of controls (p = 0.04). This relationship was especially significant
in untreated teeth (p= 0.004).
According to the 2004 American Dental Association's and the U.S. Food and Drug
Administration's Guidelines for Prescribing Dental Radiographs, 11 the individualized radiographic
examination for the new adult patient may consist of posterior bitewings with panoramic or
selected periapical images. It is noted, however, that these recommendations are subject to
clinical judgment. While the prudent clinician must evaluate every patient for the presence of
apical periodontitis, the results of Segura-Egea et al. suggest that increased vigilance is
appropriate for even patients with well-controlled diabetes.
1. Click here
2. Miley DD, Terezhalmy GT. The patient with diabetes mellitus: etiology, epidemiology, principles of medical
management, oral disease burden, and principles of dental management. Quintessence Int. 36:779-795, 2005.
Medline
Similar articles
3. Thomson WM, Slade GD, Beck JD et al: Incidence of periodontal attachment loss over 5 years among older South
Australians. J Clin Periodontol 31:119-125, 2004.
4. Kohsaka T, Kumazawa M, Yamasaki M, Nakamura H: Periapical lesions in rats with streptozotocin-induced diabetes. J
Endod 22:418-421, 1996. Medline
Similar articles
5. Fouad A, Barry J, Russo J et al: Periapical lesion progression with controlled microbial inoculation in a type 1 diabetic
mouse model. J Endod. 28:8-16, 2002.
6. Iwama A, Nishigaki N, Nakamura K et al: The effect of high sugar intake on the development of periradicular lesions in
rats with type 2 diabetes. J Dent Res 8:232-325, 2003.
7. Fouad AF. Diabetes mellitus as a modulating factor of endodontic infections. J Dent Educ 674:459-67, 2003.
8. Bender IB, Bender AB. Diabetes mellitus and the dental pulp. J Endod 296:383-389, 2003.
9. Segura-Egea JJ, Jimenez-Pinzon A, Rios-Santos JV et al: High prevalence of apical periodontitis amongst type 2
diabetic patients. Int Endod J 388:564-569, 2005.
10. Orstavik D, Kerekes K, Eriksen HM. The periapical index: A scoring system for radiographic assessment of apical
periodontitis. Endod Dent Traumatol 21:20-34, 1986.
Prosthetic Implants
Patients with prosthetic implants are frequently being treated in dental practices. The question
concerning the need for antibiotic prophylaxis to prevent infection of the prosthesis has been
debated for many years. A lack of scientific data has resulted in empiric recommendations to give
dental patients prophylactic antibiotics.29,30,40 A statement was issued jointly in 1997 by the
American Dental Association and the American Academy of Orthopedic Surgeons in an attempt
to clarify the issue.31 The statement concluded that scientific evidence does not support the need
for antibiotic prophylaxis for dental procedures to prevent prosthetic joint infections. It went on to
state that antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws,
nor is it routinely indicated for most patients with total joint replacements. However, the statement
indicated that some "high risk patients" who are at increased risk for infection and undergoing
dental procedures likely to cause significant bleeding should receive antibiotic prophylactic
treatment. Such patients would include those who are immunocompromised or
immunosuppressed, who have insulin-dependent (type I) diabetes, who are in the first 2 years
following joint replacement, or who have previous joint infections, malnourishment, or
hemophilia.31 The advisory statement concludes that the final decision on whether to provide
antibiotic prophylaxis is the responsibility of the clinician who must consider potential benefits
against the risk. It should be noted that endodontics has been shown to be an unlikely cause of
bacteremia,4,39 in contrast to extractions, periodontal surgery, scaling, and prophylaxis.
Consultation with the patient's physician on a case-by-case basis is advisable to establish the
need for prophylaxis.
Behavioral and Psychiatric Disorders
Stress reduction is an important factor in the treatment of patients with behavioral and psychiatric
disorders. Sensitivity to the patient's needs must be part of the dental team's approach.
Significant drug interactions and side effects are associated with tricyclic antidepressants,
monoamine oxidase inhibitors, and antianxiety drugs.31 Consultation with the patient's physician
is essential before using sedatives, hypnotics, antihistamines, and opioids.
Psychosocial Evaluation
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The initial visit, during which medical and dental histories are gathered, provides an opportunity to
consider the patient's psychosocial status. Although some patients may want to maintain a tooth
with a questionable prognosis, others may lack the necessary sophistication to comprehend the
potential risks and benefits. It would be a mistake to lead patients beyond what they can
appreciate, and patients should not be allowed to dictate treatment that has a poor prognosis.
The clinician should also assess the patient's level of anxiety as an important part of preparation
for the procedure to follow. It is reasonable to assume that most patients are anxious to some
degree, especially when they are about to have endodontic treatment. A conversation describing
the procedure and what the patient can expect is an important part of an anxiety reduction
protocol. It is well documented that a high level of anxiety is a predictor of poor anesthesia and
postoperative pain.10,35 More than 200 studies indicate that behavioral intervention for the highly
anxious patient before treatment decreases anxiety before and after surgery, reduces
postoperative pain, and accelerates recovery.10
Recent Medical Research: Dental Implications
Patients with Hodgkin's disease or breast cancer often receive irradiation to the chest as an
element of treatment.19 Although the therapy often cures the malignancy, it has been implicated in
causing late-onset heart disease that may influence the development of a treatment plan and
subsequent treatment.19 Therapeutic irradiation of the chest results in the inadvertent inclusion of
the heart within the irradiation field. Some patients may experience pathologic changes of the
heart valves that could predispose them to endocarditis, accelerated atherosclerosis of the
coronary artery that increases their risk of experiencing a fatal myocardial infarction, or both. 19
Clinicians need to identify patients who have received irradiation to the chest and consult with
patients' physicians to determine whether therapy has damaged the heart valves or coronary
arteries. Patients with irradiation-induced valvular disease may require prophylactic antibiotics
when undergoing specific dental procedures that are known to cause a bacteremia and a
heightened risk of developing endocarditis. Patients with radiation-induced coronary artery
disease should be administered only limited amounts of local anesthetic agents containing a
vasoconstrictor; they may require the administration of sedative agents and cardiac medications
to preclude ischemic episodes.19 Consultation with the patient's physician is an appropriate
response to a history that includes prior radiation to the chest.
There is a widespread belief among dentists and physicians that oral anticoagulation therapy in
which patients receive drugs such as warfarin sodium (Coumadin) must be discontinued before
dental treatment to prevent serious hemorrhagic complications, especially during and after
surgical procedures. Aspirin is a commonly used drug as an anticoagulant on a daily basis
without the supervision of a physician. Clinical studies published within the past 5 years do not
support the routine withdrawal of anticoagulant therapy before dental treatment for patients who
are taking such medications.26 When patients report that they are receiving an anticoagulant
medication, dentists and patients can benefit from using the following guidelines:
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Identify the reason the patient is receiving anticoagulant therapy.
Assess the potential risk versus benefit of altering the drug's regimen.
Know the laboratory tests used to assess anticoagulation levels.
Be familiar with local methods of obtaining hemostasis both intraoperatively and
postoperatively.
Be familiar with the potential complications associated with prolonged or uncontrolled
bleeding.
Consult the patient's physician to discuss the proposed dental treatment and determine
the need to alter the anticoagulant regimen.
UPDATE
Date Added: 31 July 2006
Karl Keiser, DDS, MS; University of Texas Health Science Center at San Antonio
Can smoking lead to an increase in the need for root canal therapy?
Smoking is a known risk factor for many important bacterial and viral infections, including
influenza, meningococcal disease, otitis media, pneumococcal pneumonia, and periodontitis. 1
Mechanisms suggested to explain this increased risk of infections in smokers include changes in
the respiratory tree, vascular changes, and a decrease in the host's immune response. Some of
these changes can have important effects on the health of tooth pulp and periradicular tissues.
A pilot study performed at the University of Washington calculated an odds ratio (OR) for the
presence of persistent periapical disease after root canal therapy associated with current
cigarette smoking to be 2.6 with a 95% CI of 0.8-9.0.2 (The OR is the ratio of the odds of an event
occurring in an experimental group divided by the odds in a control group; an OR >1 indicates
that the event is more likely in the experimental group). Although this OR was not statistically
significant (P < .14), the authors concluded that it warranted further study with a larger sample
size.
A recent article by Krall et al.3 examined the hypothesis that by virtue of its effects on vascular
and immune function in dental tissues, smoking results in a higher incidence of root canal
treatment. The study enrolled 811 men with complete smoking histories, including 234 cigarette
smokers, 137 cigar or pipe smokers, 210 former cigarette smokers, and 230 never-smokers. Over
the 5-year course of the study, 385 participants received root canal therapy on 998 teeth. As
expected, these teeth were more likely to have caries, large restorations (five surfaces), or
crowns. When these factors were controlled for, current cigarette smokers had an OR for root
canal treatment of 1.9 with a 95% CI of 1.4-2.5. In men who had quit smoking >9 years prior to
the study, the incidence of root canal therapy was similar to that of the men who had never
smoked.
The outcome measure for this study, root canal therapy, is an indirect reflection of the presence
of apical periodontitis, which is likely underrepresented because only the teeth that were treated
by endodontic therapy were counted. The risk of apical periodontitis among smokers is probably
much greater than estimated. Although exact mechanisms cannot be discerned from this study,
its longitudinal nature, large sample size, and regular follow-up, and the findings of dose
relationships are highly suggestive of a causal relationship between smoking and the need for
root canal treatment. Practitioners who offer smoking cessation programs in their dental offices
could take advantage of these findings and use this information to help motivate their patients:
"It's either quit smoking, or you're going to need a root canal."
References
1. Arcavi L, Benowitz NL: Cigarette smoking and infection. Arch Intern Med 164:2206-2216, 2004. Medline
articles
Similar
2. Gonzales SM, Hollender LG, Hujoel PP: Tobacco use and root canal failure: a case-control study. Available at: Click
here
3. Krall EA, Sosa CA, Garcia C, et al: Cigarette smoking increases the risk of root canal treatment. J Dent Res 85:313317, 2006. Medline
Similar articles
UPDATE
Date Added: 21 March 2006
Ken Hargreaves, DDS, PhD
Bisphosphonate-associated osteonecrosis of the jaws
The most common orofacial pain conditions are typically related to acute inflammation, infection,
or injury to peripheral nerves. Therefore, we have become accustomed to evaluating typical pain
presentations, establishing whether the pain is of odontogenic or non-odontogenic origin, and
then developing a differential diagnosis for our patients. Occasionally, new pain conditions are
recognized (e.g., herpetic infections of pulpal nerves), but these, too, generally fit into one of
these three basic categories.
Recently, however, a new disorder has been recognized that fundamentally changes our
understanding of pain mechanisms and forces rapid recognition of new risk factors and treatment
strategies. In 2003, Marx and colleagues reported on bisphosphonate-associated osteonecrosis
of the jaws (BONJ) and many case reports have followed (see references). Due to the current
lack of any effective treatment for this painful condition, its impact on endodontic treatment
planning, and its ability to mimic odontogenic pain, it is very important that clinicians understand
this new entity.
Bisphosphonates are a class of drugs that are used to treat patients with osteoporosis, Paget's
disease, and certain cancers such as multiple myeloma and bone metastases originating from
primary tumors located in tissues such as breast or prostate gland. Bisphosphonates act as
pyrophosphate analogs and are thought to preserve bone due to their inhibitory actions on
osteoclasts, although other actions such as inhibition of blood vessel growth have also been
reported. Examples of bisphosphonates are given in the associated Table 1. Given the broad
range of indications, it should not be surprising that some bisphosphonates such as the oral
formulations of alendronate, ibandronate, etc., have >20 million prescriptions written yearly,
whereas the IV formulations (e. g., zolendronate, pamidronate) are used much less often and
generally for patients with cancer. This distinction may be important because to date, most case
reports of BONJ are associated with the IV bisphosphonates. Although early reports suggested
that BONJ was a "drug effect" (i.e., occurring only with i.v bisphosphonates), a recent report by
the FDA (Chang, 2004) stated that BONJ appeared to be a class effect because oral
bisphosphonates such as alendronate have been reported to be associated with BONJ. The best
available current evidence suggests that IV bisphosphonates impose a greater risk while the oral
bisphosphonates have a lower risk for BONJ.
BONJ typically presents as an intraoral mucosal ulceration with irregular borders, exposed bone,
pain that can be severe in intensity, and occasionally purulence and altered sensation of the area
(e. g., paresthesia, "heaviness" sensation). Although bisphosphonates are incorporated into bone
throughout the skeleton, it is not known why the osteonecrosis occurs only in the jaws and not in
any other bones of the body. Case reports often associate these patients with having a history of
a traumatic dental procedure (e.g., tooth extraction, implant placement, periodontal surgery, etc)
preceding the development of BONJ. This traumatic event may have occurred weeks or months
prior to the presentation of BONJ. The mechanism for BONJ is not currently known, although one
hypothesis is that the osteonecrosis develops due to an interaction of the traumatic dental
procedure with healing bone in a susceptible patient taking bisphosphonates. There currently is
no effective treatment for BONJ; several treatments including surgical resections, hyperbaric
oxygen, and antibiotics have been attempted with little to no improvement. Accordingly,
preventive strategies are paramount, and recommendations are similar to those used to treat a
patient with a risk for osteoradionecrosis. Most of the present data consist of case reports, case
series, and expert opinion and thus constitute a lower level of evidence. Of course, ethical
constraints preclude randomized controlled trials, and clinical recommendations for adverse
conditions such as BONJ are often developed only with these lower levels of clinical evidence.
The AAE has recently developed a set of recommendations for endodontic implications in
managing patients taking bisphosphonates (Click here ). These recommendations are:
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Recognize the risk factors of bisphosphonate-associated ONJ
Apply preventive dental therapies. Preventive procedures are very important to reduce
the risk of developing ONJ because treatment of ONJ is not predictable at this time.
Preventive care might include caries control, conservative periodontal and restorative
treatments, and, if necessary, appropriate endodontic treatment. Similar to the
management of the patient with osteoradionecrosis, this might include non-surgical
endodontic treatment of teeth that otherwise would be extracted. Teeth with extensive
carious lesions might be treated by non-surgical endodontic therapy, possibly followed by
crown resection and restoration similar to preparing an overdenture abutment.
To the extent possible, avoid traumatic procedures including surgery and soft tissue
trauma, and reduce the risk of trauma (e. g., smooth off restorations, adjust dentures,
etc.).
Consider bisphosphonate-associated ONJ when developing a differential diagnosis of
non-odontogenic pain.
Use the entire health care team, including the patient's general dentist, oncologist, and
oral surgeon, when developing treatment plans for these patients.
Be aware that the knowledge base for bisphosphonate-associated ONJ is rapidly
increasing and it is likely that these recommendations may change over time. Thus, the
prudent practitioner is encouraged to continue to review new publications in this area
DENTAL EVALUATION
The strategic value of the tooth in question should be considered before presenting alternative
treatment plans to the patient. Although a final decision may be straightforward, the consideration
of alternative treatment options can also be challenging as the clinician considers multiple factors
that will play a role in determining the ultimate success or failure of a case. Referral of the patient
to a specialist should be considered when the complexity of the procedure is beyond the ability of
the clinician. Factors that affect endodontic prognosis, including periodontal and restorative, must
be considered (see Chapter 2 for additional information). The alternative of a dental implant offers
another choice when the endodontic prognosis is poor.
Case Selection: Endodontics or a Dental Implant
Prognosis of Endodontic Treatment
*References 20, 21, 33, 36, 48, 51, 52.
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The prognosis of endodontic therapy has been extensively studied. The study designs are
marked by their diversity and vary in their case selection, numbers of subjects, operative
techniques, follow-up periods, definitions of success, and who provided the treatment. Many
studies have demonstrated that the success rate is significantly influenced by a preexisting
periradicular radiographic lesion.* Teeth with a preexisting apical radiolucency have been shown
to have a lower success rate than teeth without such lesions. In a classic study, Strindberg 54
found that remineralization of periapical lesions could take up to 9 years after treatment. More
recently, Sjogren and associates52 noted that uncertainty exists concerning the influence of the
size of the preoperative periapical lesion on clinical success. Results of studies with short followup periods may be skewed and not reflect the true prognosis. Cohort studies of 3 or 4 years may
be required to record a stable treatment outcome.9,28,38
The objective of a recent study, established in 1993, is to prospectively assess the 4- to 6-year
outcome of endodontic treatment performed in a university graduate clinic environment. 21 The
project is designed to provide cumulative data with the completion of each phase that will be used
to determine the influence of potential prognostic factors on the outcome of treatment. The initial
phase of the project studied 450 teeth. The "healed" rate was significantly higher for teeth treated
without apical periodontitis (92%) than with apical periodontitis (74%). The overall "healed" rate
was 81%. This study confirmed apical periodontitis as the main prognostic factor in initial
treatment cases. The patient's systemic resistance and the quality of instrumentation, obturation,
and final restoration also play an important role in the ultimate outcome of endodontic treatment
(Fig. 4-3).5 The scope of modern endodontics has been enhanced by the use of ultrasonics and
microscopy as well as improved instruments and new materials. Teeth can be retained today that
would not have been treated in the past. Biologically, it has become increasingly clear that
elimination of intraradicular infection is the key to endodontic success.
An important advantage of providing endodontic therapy is to allow rapid return of the patient's
compromised dentition to full function and aesthetics. This rapid return is in marked contrast to
the use of provisional restorations associated with dental implants while waiting for osseous
integration.
UPDATE
Date Added: 02 May 2006
Karl Keiser, DDS, MS, University of Texas Health Science Center at San Antonio
What impact does instrument separation have on the outcome of nonsurgical endodontic
treatment?
While techniques can be used to minimize the fracture of any endodontic instrument (for review,
see "Causes of Instrument Separation" in Chapter 25 by Drs. Roda and Gettleman), instrument
separation is a fact of life and will likely happen in the career of any clinician who performs
endodontic treatment. With the recent acceptance of rotary nickel titanium (NiTi) instrumentation
techniques, the concern over file separation has increased, although data on the prevalence of
fracture in clinical practices are scarce. Patients often want to know whether the prognosis is
affected by this procedural mishap. There have been studies regarding the effect of instrument
separation on outcome; however, these studies generally involved stainless steel files used in a
hand instrumentation technique and were not well controlled.1-3 Since the problem cannot be
addressed in a prospective manner for ethical reasons (that is, purposefully breaking a file in a
root canal during treatment), prospective, randomized clinical trials are not possible. The highest
level of evidence that can be used to assess the effect of instrument separation on outcome
would be retrospective case-control studies (see "Glossary of Evidence-Based Terms" on the
Pathways of the Pulp home page for a description of study designs).
Recently, Spili, Parashos, and Messer published the results of a case-control study involving 146
teeth in which instruments had separated during endodontic treatment that were matched with
146 control teeth.4 All cases treated nonsurgically from 1990 to 2003 in two endodontic practices
(seven endodontists) were evaluated for the presence of instrument fracture. Out of 8460 cases,
277 were found to have at least one separated instrument (including both stainless steel hand
files and NiTi rotary files), for a prevalence of 3.3%. Of these 277, certain cases were excluded
for outcome determination if the tooth showed evidence of a fractured instrument before
treatment, if there was a clearly defective coronal restoration, or if clinical and radiographic recall
information of at least one year's duration was not available, yielding 146 teeth available for
outcome assessment. Appropriate matching controls were randomly selected from a pool of 956
nonsurgical treatments in which there had not been a file separation. Blinded and calibrated
examiners reviewed all cases and matching controls. Healing occurred in 91.8% of cases with
separated instruments compared to 94.5% of matched controls. This difference was not
statistically significant. If a periapical radiolucency was present preoperatively, healing rates for
both groups were diminished: to 86.7% in the separated instrument group and to 92.9% in the
control group. This is in agreement with existing endodontic outcome studies, the majority of
which have found apical periodontitis to be a risk factor for nonhealing.
Although prudence dictates that techniques to minimize the risk of instrument fracture must be
employed during endodontic treatment, a relatively high level of evidence exists that allows the
clinician to assuage the fears of patients regarding the prognosis of their root canal therapy, all of
whom must be informed if an instrument separates during treatment.
1. Strindberg LZ: The dependence of the results of pulp therapy on certain factors: an analytical study based on
radiographic and clinical follow-up examinations. Acta Odontol Scand 14:78, 1956.
2. Grossman LI: Guidelines for the prevention of fracture of root canal instruments. Oral Surg Oral Med Oral Pathol
28:746-752, 1969. Medline
Similar articles
3. Fox J, Moodnik RM, Greenfield E, Atkinson JS: Filing root canals with files radiographic evaluation of 304 cases. NY
State Dent J 38:154-157, 1972.
4. Spili P, Parashos P, Messer HH: The impact of instrument fracture on outcome of endodontic treatment. J Endod
31:845-850, 2005. Medline
Similar articles
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Figure 4-3 A, Inflamed, edematous interproximal tissue (arrow) caused by acute endodontic
pathosis. B, Soft tissue healing (arrow) 3 days after initiation of endodontic treatment. C,
Periradicular pathosis. D, Completed endodontic therapy. E, Periradicular healing at 1-year
recall.
Dental Implants
The advent of dental implants as a predictable alternative provides the clinician with new
treatment options. Although research on the long-term efficacy and success of dental implants is
ongoing, it seems clear that when appropriately utilized they offer a valuable alternative when
preservation of the natural dentition is not possible. Currently, perspective randomized clinical
trails are lacking that compare tooth retention with endodontic treatment with replacement of a
tooth with an implant. Such a study would have to recognize, among a long list of variables,
patients' systemic health, periodontal status, restorative treatment, type of implant used, and
pretreatment status of the endodontically treated tooth.
Patients benefit when clinicians consider the entire range of treatment options. The options
considered should be based on sound biologic principles and individually selected on a case-bycase basis.
Periodontal Considerations
Extensive periodontal lesions frequently complicate the endodontic procedure being considered.
Such lesions may necessitate consultation with an endodontist or periodontist or both to gather
more information about the tooth's prognosis. Periodontal probing is an essential element in
endodontic case selection. Multirooted teeth with periodontal complications offer a variety of
multidisciplinary complexities and treatment possibilities. A tooth with a poor periodontal
prognosis may have to be sacrificed, despite the probability of a favorable endodontic prognosis.
In some situations it may not be clear if the primary problem is periodontal or endodontic. This
fact can influence the treatment plan; the pathogenesis can be better understood after vitality
testing, periodontal probing, radiographic assessment, and evaluating the dental history. The risk
to the total treatment plan should be kept in mind when questionable procedures are considered.
It is not prudent to incorporate a chronic problem into a new complex prosthesis (Figs. 4-4 and 45).
Surgical Considerations
Surgical evaluations are particularly valuable in the diagnosis of lesions that may be
nonodontogenic. Biopsy is the only definitive means of diagnosing such a lesion. When
retreatment is being considered, the clinician must determine if nonsurgical, surgical, or combined
treatment is appropriate. This decision is influenced by the presence of complex restorations,
posts, and the radiographic assessment of prior endodontic therapy.
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Figure 4-4 Tooth #19 has a poor prognosis. Periodontal probing reached the apex of the distal
root. Extraction is indicated and should be done as soon as possible to prevent further damage
to the mesial bone associated with tooth #18. There are restorative questions concerning the
ultimate treatment plan: Should the mesial root of tooth #19 be retained? Should tooth #20 be
used as an abutment? Should an implant be placed? (Courtesy Dr. Brian Licari.)
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Figure 4-5 The large, bony defect associated with tooth #29 healed after endodontic therapy.
The tooth was nonvital, and no significant periodontal probing depth indicated pulpal disease.
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Figure 4-6 Four years after endodontic therapy, the patient complained of pain and swelling
associated with tooth #6. The initial impression was that apical surgery was indicated.
However, further radiographs revealed the true cause of the endodontic failure. The initial
endodontic access through the crown or caries damaged the coronal seal.
Restorative Considerations
A satisfactory restoration may be jeopardized by a number of factors. Subosseous root caries
(perhaps requiring crown lengthening), poor crown/root ratio, and extensive periodontal defects or
misalignment of teeth may have serious effects on the final restoration. Therefore these problems
must be recognized before endodontic treatment is initiated. For nonemergency complicated
cases, a restorative treatment plan should be in place before starting endodontic treatment. Some
teeth may be endodontically treatable but nonrestorable, or they may represent a potential
restorative complication in a large prosthesis. Further, reduced coronal tooth structure under a
full-coverage restoration makes endodontic access more difficult because of reduced visibility and
lack of radiographic information about the anatomy of the chamber (see also Chapter 7). Thus it
is not unusual for restorations to be compromised during endodontic access (Fig. 4-6). Whenever
possible, restorations should be removed before endodontic treatment
Other Factors That May Influence Endodontic Case Selection
A variety of factors may complicate proposed endodontic therapy. Calcifications, dilacerations,
and resorptive defects may compromise endodontic treatment of a tooth with potentially strategic
value (Fig. 4-7). The inability to isolate a tooth is also a problem and may result in bacterial
contamination of the root canal system. Extra roots and canals pose a particular anatomic
challenge that radiographs do not always reveal (Fig. 4-8). Retreatment cases offer particular
mechanical challenges (Fig. 4-9) and are discussed in detail in Chapter 25. Ledges, perforations,
or a post may be present, all of which complicate treatment and alter the prognosis. The dentist
should recognize these potential problems and be able to manage and factor them into the
decision concerning the tooth's prognosis, including the possibility that the patient should be
referred to a specialist. An approach has been suggested that permits a clinician to evaluate each
patient to determine the level of anticipated difficulty and helps the generalist to identify which
cases should be referred for specialty care.46
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Figure 4-7 Resorptive defects can be successfully treated. Early intervention, before there is
perforation of the root, increases the chance of success. (Courtesy Dr. Leon Schertzer.)
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Figure 4-8 Radiographs do not always demonstrate canal complexities. A, Initial radiograph. B,
Highly magnified view of the pulp chamber. C, Completed endodontic treatment. (Courtesy Dr.
Lee Adamo.)
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Figure 4-9 Retreatment of tooth #30 was complicated by the presence of four canals.
Some clinicians use a simple formula for determining which endodontic cases they treat and
which they refer to a specialist. The number of roots may be the determining factor in a decision
concerning referral, or the key factor may be the chronic or acute status of the case. Having
specific goals at each visit helps to organize the treatment. For example, in an uncomplicated
molar or premolar, some clinicians will set a specific goal for the first visit that includes access
and thorough instrumentation, while deferring the obturation to a second visit. Uncomplicated
single-rooted, vital teeth may be planned for a single-visit approach. It is important that ample
time be allowed so that the procedure can be completed without stress. These recommendations
have a biologic basis. It is not biologically sound to partially instrument root canal systems,
thereby leaving residual inflamed pulpal remnants or necrotic debris in the canal, since such
remnants may cause pain and be susceptible to infection.5 The clinician would be well advised to
begin canal instrumentation only if time permits for the extirpation of all pulp tissue.
The most important variables in determining whether to refer a patient to a specialist are the skills
of the clinician and the complexity of the case.
Recently the American Association of Endodontists (AAE) developed guidelines for assessing
endodontic case difficulty.1 The AAE Endodontic Case Difficulty Assessment Form enables a
clinician to assign a level of difficulty to a particular case. The form describes cases of minimum,
moderate, and high degrees of difficulty. This form lists criteria that can be used to identify when
a clinician should refer a patient to a specialist (see Fig. 2-6).1 The use of surgical operating
microscopes, endoscopes, and ultrasonics enable the specialist to predictably treat teeth that
would not have been treatable before.
DEVELOPMENT OF THE ENDODONTIC TREATMENT PLAN
Vital Case
The acute vital case is best managed using a biologically based approach. Pain in such cases
may be due to increased intrapulpal pressure and inflammatory mediators such as
prostaglandins. The challenge for the clinician is to painlessly treat inflamed and well-innervated
tissue. Performing a complete pulpotomy or, if time permits, establishing measurement control
and completing a pulpectomy have a high degree of predictability in alleviating pain.5,23 It has
been shown that simply debriding the pulp chamber is also a highly predictable method of
providing pain relief.23 When a canal has been entered the clinician is committed to removing all
tissue. Partial instrumentation (i.e., leaving tissue remnants in the canal) may result in increased
postoperative pain.5 Teeth should be closed with a temporary filling at the conclusion of the visit.
Nonvital Case
The acute nonvital case represents a microbiologic challenge for the clinician. A tooth that has
had a nonvital pulp for some time may suddenly become acutely painful (see Chapter 2 for
managing these emergency cases). The cause of this dramatic change is due to an imbalance in
the host-parasite relationship.5 This can be due to an increase in the virulence of bacteria, a
change in the flora, or a reduced host defense mechanism.5 These changes can be initiated
simply by opening the tooth and changing the environment of the bacterial flora. The therapeutic
goals in such cases are to reduce as much as possible the bacterial content in the root canal
system and to promote decompression of the periradicular tissues by instrumentation and
irrigation of the canal. Calcium hydroxide should be temporarily sealed into the root canal or
canals with a cotton pellet in the pulp chamber. Teeth should be closed and the endodontic
treatment completed as soon as possible to prevent continued bacterial penetration into the
canal. When a fluctuant swelling exists, incision and drainage may be performed in conjunction
with canal instrumentation (Fig. 4-10).
Retreatment Cases
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Retreatment cases offer a particular set of challenges to the clinician, and this topic is covered
extensively in Chapter 25. Leading questions to be considered before retreatment include the
following:
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Why did the case fail?
Are prior radiographs available for review?
Is there an obvious procedural problem that can be corrected?
Is the canal system readily accessible for reentry?
Are there additional factors (other than endodontic) that may have contributed to the
failure?
Is the tooth critical to the treatment plan?
Does the patient understand the prognosis for the tooth and want to attempt retreatment?
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Figure 4-10 Incision and drainage should be performed on this fluctuant swelling (arrow) in
conjunction with canal instrumentation.
A retreatment plan should be developed after the clinician has determined the cause of failure
and weighed other factors that may affect the prognosis (e.g., root fracture, defective restoration)
(Figs. 4-11 to 4-14). Retreatment cases may require surgical endodontics in combination with
nonsurgical retreatment. Referral to a specialist is often helpful when planning treatment for
complex cases.
Immature Teeth
Primary and immature permanent teeth may have pulpal pathosis caused by caries or trauma;
preserving these young teeth is essential. Premature loss of an anterior tooth can lead to
malocclusion, predispose the patient to tongue habits, impair aesthetics, and damage the selfesteem of the patient. The reader is referred to Chapter 22 for further information.
Endodontic and Periodontic Considerations
The relationship between the pulpal and the periodontal tissue complex begins during the
embryonic stage of dental development. The richly vascularized dental papillae and the
surrounding, future periodontal tissues have a shared circulation. This interrelationship provides
the anatomic basis for potential pathosis as described in Chapter 17.
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Figure 4-11 Two years after endodontic therapy on tooth #8, the patient returned with pain and
swelling. A dentist mistakenly began endodontic access on tooth #7, without confirming the
apparent radiographic diagnosis with vitality testing. Tooth #7 was vital, and tooth #8 was
successfully retreated after removal of the post. (Courtesy Dr. Leon Schertzer.)
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Figure 4-12 Many years after endodontic treatment of tooth #30, the patient returned with a
chief complaint of pain and an inability to chew on the tooth. Despite the radiographic
appearance of excellent endodontic treatment, the tooth was retreated and the patient's pain
disappeared. Note the unusual distal root anatomy, which was not apparent during the initial
procedure. A, Initial radiograph. B, Completion of initial endodontic therapy. C, Retreatment.
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Figure 4-13 Retreatment of tooth #26 resulted in healing of the periradicular lesion. The initial
radiograph was misleading and implicated tooth #25 and tooth #26. Pulp testing indicated a
vital pulp in tooth #25, so it was not treated. (Courtesy Dr. Leon Schertzer.)
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Figure 4-14 Nonsurgical retreatment of tooth #30. Note additional root located and treated. A,
Note inadequate endodontic treatment and large periapical lesion. B, Bite wing radiograph. C,
Retreatment after post removal. D, Eighteen-month recall radiograph indicates periapical
healing.
Endodontic Surgery
Endodontic surgery may be performed as an initial treatment or as a retreatment procedure.
Before considering the actual treatment, the clinician should consider the most prudent measure
to prevent recurrence of the problem. For example, if the cause of failure is a leaking coronal
restoration, then apical surgery will probably fail. As a primary treatment modality, apical surgery
may be performed when there is a completely calcified canal. As a retreatment procedure, apical
surgery is performed as a secondary effort to salvage failed endodontic treatment. The primary
reason for apical surgery is to improve the quality of the apical seal. In recent years dramatic
changes have occurred in the techniques and materials used for surgical resolution of complex
cases as discussed in Chapter 20.
Single-Visit Versus Multivisit Treatment
Debate is ongoing about the merits of a single-visit or multivisit approach to endodontic treatment.
An extensive body of research has sought to determine relative success rates, pain associated
with each approach, and its relationship to pulp vitality and the presence of periapical
oseitis.15,24,41,44
Vital Cases
Vital cases are often suitable for single-visit treatment. The number of roots, time available, and
the clinician's skills are factors to be considered. Severity of the patient's symptoms is another
important consideration. For example, a patient in severe pain should not experience a long visit
including access, instrumentation, and obturation. Treatment in such cases may be directed at
alleviating pain, with filling of the canal postponed for a later visit. The clinician's judgment of what
the patient can comfortably tolerate (regarding duration of the visit) is on a case-by-case basis.
Whenever possible, it is desirable to complete endodontic treatment for vital teeth in one visit for
several reasons, including less posttreatment pain.15,24,41,44
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Nonvital Cases
Although consensus exists that teeth with nonvital pulp and apical periodontitis are more complex
cases with greater resistance to endodontic treatment (i.e., reduced success rate), agreement is
lacking concerning the appropriateness of single-visit endodontics for treating these cases. Some
have postulated that the intervisit use of an antimicrobial dressing is essential in eradicating
infection completely from the root canal system.51,52 In contrast, other researchers have found no
statistically significant difference in success when using the single-visit or multivisit approach to
the nonvital tooth with apical periodontitis.20,42,57 The final answer is yet to be determined.
Research Review
Agreement is lacking concerning long-term success rates associated with single-visit and
multivisit procedures. Sjogren and associates51 investigated the influence of infection at the time
of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Periapical
healing was observed for 5 years. They concluded that "Complete periapical healing occurred in
94% of cases that yielded a negative culture. When the samples were positive before root filling,
the success rate of treatment was just 68%-a statistically significant difference." They concluded
that the objective of eliminating bacteria from the root canal system "cannot be reliably achieved
in a one-visit treatment because it is not possible to eradicate all infection from the root canal
without the support of an interappointment antimicrobial dressing." The findings of Friedman, 20
Weiger et al,57 and Peters and Wesselink42 contrast with those of Sjogren et al.51 Those studies
found no statistically significant differences in healing observed between teeth treated in one visit
and two visits with the inclusion of calcium hydroxide as an intravisit medication. 42,57 This is a
complicated issue since the inability to detect differences between groups might also be due to
sample size, duration of follow-up times, treatment methods, and so on.
A recent study concerning the outcome of initial treatment noted the complexity of treating apical
periodontitis. The author commented that "…treatment of this disease cannot be improved merely
by changing treatment techniques. Because apical periodontitis results from interactions between
microorganisms, their environment and the host immune system, only use of effective modifiers
of any of these three factors might significantly improve the outcome of treatment."20
Scheduling Considerations
If a vital case must be treated using a multivisit approach, it is the author's opinion that the
clinician should allow 5 to 7 days between canal instrumentation and obturation for the
periradicular tissue to recover. When a vital case is to be treated in a single visit (usually the
preferred treatment plan), adequate time must be scheduled so the clinician can complete the
procedure without stress. It is wise to schedule patients who require mandibular block anesthesia
to arrive 15 to 20 minutes before their treatment visit. This avoids the frustration of "losing
treatment time" while the anesthetic agent becomes fully effective.
Subsequent appointments for treating nonvital cases should be scheduled with approximately 1
week between visits in order to maximize the antimicrobial effect of the intracanal dressing when
calcium hydroxide is used.5,51,52 Acute (painful) nonvital cases must be seen every 24 to 48 hours
in order to monitor the patient's progress and bring the acute symptoms under control. Further
cleaning and shaping are important components of the treatment as the clinician seeks to
eliminate persistent microbes in the canal system. Long delays between visits contribute to the
development of resistant microbial strains and should be avoided.
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