Treatment of Pulpal and Periapical Diseases

Case Selection and Treatment Planning

Outline
Common medical findings that may influence endodontics Dental evaluation Treatment planning

Common medical findings that may influence endodontics

Pregnancy
Not a contradiction to endodontics Modified treatment plan
Defer elective dental treatment during the first trimester except emergency treatment Provide routine dental care during the second trimester Consult physician if necessary

Myocardial infarction
(Heart attack) within past 6 months Increased susceptibility to repeat infarctions and other cardiovascular complications Contraindication to any elective dental care

Other Cardiovascular conditions

Patients with a history of Heart murmur Mitral valve prolapse with regurgitation Rheumatic fever Congenital heart defect Artificial heart valves Increased susceptibility to infective (bacterial) endocarditis Potentially fatal complication Prophylactic antibiotic therapy

Cancer
Patients undergoing chemotherapy and/or radiation to the head and neck Impaired healing responses Consult the patients physician before initiation of treatment

AIDS
Infection control Asymptomatic patients are usually candidates for endodontic treatment Medical consultation before endodontic surgery for HIV-infected patients

Diabetes
Well controlled patients are candidates for endodontic treatment Medical consultation for patients with serious complications or before endodontic surgery
Renal disease Hypertension Coronary atherosclerotic disease

Prosthetic implants
Heart valves Vascular grafts Pacemakers Cerebrospinal fluid shunts Prosthetic joints

Antibiotic prophylaxis to prevent infection at the site of the prosthesis Medical consultation highly recommended

Dental evaluation
Periodontal considerations Restorative considerations Endodontic considerations Surgical considerations

Periodontal considerations
Periodontal probing Mobility assessment Radiographic assessment Endodontic treatment should not be planned for teeth with poor periodontal prognosis (e.g. mobility III)

Restorative considerations
Restorative treatment planning before starting endodontic treatment in a nonemergency situation Extensive loss of tooth structure Subosseous root caries (crown lengthening may be needed) Poor crown-root ratio Lack of ferrule effect Misaligned tooth Consultation with a prosthodontist

Endodontic considerations
Anatomy of roots and canals Procedural errors Small mouth Instruments Operator skill Time To determine the level of anticipated difficulty To identify cases that should be referred

Surgical considerations
Of particular value in the diagnosis of nonodontogenic lesions Biopsy prior to definitive endodontic treatment

1.3 Treatment planning

Scope of endodontics Vital pulp therapy Pulpectomy or RCT Endodontic surgery Retreatment Hemisection or root amputation Bleaching Apexification or apexogenesis

Treatment planning
Treatment or extraction? What kind of treatment ?
Endodontic Periodontal Restorative

Who will be the operator? Single-visit or multi-visit? Cost Prognosis