case selection in tics
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One of the greatest frustrations for abusy dentist is to begin a scheduledroot canal treatment and find surprisesas to the difficulty or the amount oftime required to complete the
treatment. How to avoid this?
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The key to avoid this ENDODONTIC DISASTER"involves multiple factors of which
y
accurate diagnosis andy proper case selection
carry prime importance.
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The process of case selection and treatment planningbegins after the clinician has diagnosed an endodonticproblem.
DECISION MAKING:
EXTRACT OR RETAIN
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COMPLETE PATIENT EVALUATION
Medical factors
Psychosocial factorsDental factors
Complexity of the procedure
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ASA I Normal healthy patient No dentalmanagementalterations required
ASA II Patient with mild systemic diseasethat does not interfere with dailyactivity or who has significanthealth risk factor.
Examples: Stage I or IIhypertension, Type 2diabetes, Allergy, Wellcontrolled asthma
May or may not needdental managementalterations
ASA III Patient with moderate to severesystemic disease that is notincapacitating but may alter dailyactivity.
Type I diabetes, StageIII hypertension,Unstable angina,Recent MI, COPD,
Require dentalmanagementalterations
ASA IV Patient with severe systemicdisease that is a constant threat tolife.
Kidney failure, Liverfailure, Advanced
AIDS
Definitely requiredental managementalterations, besttreated in specialfacility.
The American Society of Anesthesiologists (ASA) Physicalstatus classification devised in 1941 and revised in 1983
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y Pregnancy Radiation?
y Cardiovascular disease Adrenaline in localanaesthetic , Infective endocarditis prophylaxis!
y
Cancer Metastasis or even primary lesionsmimicking endodontic pathosis!
y AIDS Possibility of transmission of infection to theoperator/Can be avoided by strict adherence touniversal precaution protocols
CD4 count
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y Level of anxiety of the patienty Socio economic status
y Comprehending ability of the patient
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y Strategic value of the tooth
y Periodontal considerations
y Restorative considerationsy Patient considerations
y Endodontic considerations
y Surgical considerations
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STRATEGIC VALUE OF THE TOOTH
y The primary concern is thelong-term preservation of a
healthy functional dentition.y The dentist should consider
the strategic value of thetooth to be endodonticallytreated in relation to theoverall function of thedentition.
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PERIODONTAL CONSIDERATIONSy Periodontal probing
y Mobility assessment
y Radiographic assessment
y Endodontic treatment shouldnot be planned for teeth withpoor periodontal prognosis(e.g. mobility III)
y Insufficient periodontal
support may thus be viewedas a contraindication to rootcanal treatment.
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RESTORATIVE CONSIDERATIONSy Restorative treatment planning
before starting endodontictreatment in a nonemergencysituation
y Extensive loss of toothstructure
y Subosseous root caries(crown lengthening maybe needed)
y Poor crown-root ratio
y Lack of ferrule effecty Misaligned tooth
y Consultation with aprosthodontist
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PATIENT CONSIDERATIONS
(1) Is endodontic treatment in the patients best
interest?
(2) What are the patients expectations?(3) Will the patient be able to tolerate the treatment
planned?
(4) Will the patient be able to afford the treatment
planned?
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ENDODONTIC CONSIDERATIONSy To determine the level of anticipated difficulty
y To identify cases that should be referredFactors that may complicate and increase the difficulty of anendodontic case include:
(1) calcifications(2) inability to isolate the tooth with a rubber dam
(3) resorptive defects
(4) extra roots and canals
(5) retreatment cases
(6) presence of a post
(7) ledges and perforations
(8) Dilacerations
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CALCIFICATIONS
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INABILITY TO ISOLATE THE TOOTH WITH RUBBER DAM
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RESORPTIVE DEFECTS
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EXTRA ROOTS AND CANALS
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RETREATMENT CASES
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PRESENCE OF POSTS, LEDGES ANDPERFORATIONS
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ACUTE DILACERATIONS
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PROGNOSIS OF ENDODONTIC TREATMENTENDO CASE SELECTION CHART
BETTER WORSE Vital Anterior
Maxillary anterior Mandibular anteriorMandibular molar Maxillary molarFirst molar Second molarGradual canal curve Sharp canal curveLarge pulp Calcification
Average length roots Long rootsNo crown in place Crown in placeNo swelling SwellingFirst endo treatment RetreatmentNon-strategic tooth Abutment
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IDENTIFICATION OF REFERRAL CASES
y The American Association of Endodontists hasdeveloped a practical tool that makes case selectionmore efficient, more consistent and easier todocument.
y The Endodontic Case Difficulty Assessment Form isintended to assist practitioners with endodontictreatment planning, but can also be used to help withreferral decisions and record keeping.
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The assessment form identifies three categories of
considerations which may affect treatment complexity:
PATIENT CONSIDERATIONS
Medical historyAnesthesia
Patient disposition
Mouth opening
Gag reflex
Emergency condition
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Diagnosis
Radiographic difficulties
Position in the arch
Tooth isolationMorphologic aberrations in the crown
Canal and root morphology
Radiographic appearance of the canal
Resorption
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History of trauma
History of endodontic treatment
Periodontal-endodontic condition
Within each category, levels of difficulty are assigned
based upon potential risk factors which may not be
controllable by the dentist.
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y LEVELS OF DIFFICULTY
MINIMAL DIFFICULTYPreoperative condition indicatesroutine complexity
(uncomplicated). These types ofcases would exhibit only thosefactors listed in the MINIMALDIFFICULTY category. Achievinga predictable treatment outcomeshould be attainable by a
competent practitioner withlimited experience.
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y LEVELS OF DIFFICULTY
MODERATEDIFFICULTYPreoperative condition iscomplicated, exhibiting one or
more patient or treatmentfactors listed in the MODERATEDIFFICULTY category. Achievinga predictable treatment outcomewill be challenging for acompetent, experienced
practitioner.
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y LEVELS OF DIFFICULTY
HIGH DIFFICULTY
Preoperative condition isexceptionally complicated,
exhibiting several factors listedin the MODERATEDIFFICULTYcategory or at least one in theHIGH DIFFICULTY category.
Achieving a predictabletreatment outcome will be
challenging for even the mostexperienced practitioner with anextensive history of favorableoutcomes
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DIAGNOSIS ENDODONTIC CONDITION
GINGIVAL/PERIODONTAL
ASSESSMENT
RESTORABILITY
DEEP PERIODONTAL POCKETS
ENDO PERIO LESION
EXCESSIVE BONE LOSS
POOR PERIODONTAL PROGNOSIS
PERIODONTIUM INTACT
HEALTHY CONDITION
EXTRACTION
TOOTH CANNOT BE
RESTORED
TOOTH CAN BE
RESTORED
ASSESSMENT OFRADICULAR DAMAGE
AND CANAL
NEGOTIABILITY
CANALSOBSTRUCTED
AND NON
NEGOTIABLE
PREVIOUSINADEQUATE OR
FAILING
ENDODONTIC
TREATMENT
CANALSUNOBSTRUCTED
AND NEGOTIABLE
SURGICAL
ENDODONTIC
THERAPY
ENDODONTIC
RETREATMENT
NON SURGICAL
ENDODONTIC
THERAPY
TREATMENT DECISION