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