Medical knowledge | Dentistry » Gulabivala-Walker - Treatment options

Stock Ch05.qxd 26/1/04 10:05 am Page 93 93 Chapter 5 Treatment options K Gulabivala and R T Walker GOALS OF OVERALL PATIENT CARE AND ROLE OF ENDODONTICS The health and well-being of an individual is influenced by factors as diverse as their genetic make-up, environment, nutrition and interaction with society. These factors all play a part in the physical, psychological, social, cultural and spiritual aspects of the well-being of the individual. Health-care workers in general should have an awareness of the complex interplay between such factors and their potential influence on the outcome of any health-improving measure. Those involved in the direct delivery of any intervention that may impinge on these factors should understand the nature of the broadest effect of that intervention. Oral health care is perceived by many in the general health care profession to play only a small part in the overall well-being of the individual. The truth, however, is that oral and dental problems

may influence and in turn be influenced by the overall well being of the individual. Management of oral and dental health is therefore no less important than management of the overall health of people. It requires a broad-based appreciation of life (including, social, cultural, individual, psychological and spiritual contexts) in parallel with the biological and clinical knowledge and skills necessary to deal with diseases of the pulp and periradicular tissues. The dentist must, therefore, be both a physician and surgeon Dentistry is no more than a specialty of medicine but the management of complex oral problems requires broad as well as specific advanced training and this has resulted in the development of subspecialties. This means dentists are able to develop their skills in a given subspecialty and practice within that sphere to the exclusion of other aspects. Restriction to such a narrow sphere of practice (such as endodontics) enables the development of highly skilled and

knowledgeable individuals able to deal with especially difficult problems. This does, however, mean that the onus of ensuring the coordinated and appropriate delivery of whole mouth and patient care must rest with the referring general dental practitioner, in conjunction with other specialists and the medical practitioner where necessary. The knowledge and skills of endodontics have to be deployed judiciously to ensure that the patient receives appropriate care. In order to do this, the dentist should be equally well versed in all aspects of dentistry and understand the role of each in overall management, as well as potential overlaps and interactions between the subdisciplines. In the context of a health care profession, the ‘endodontist’ must be a human being first, dentist second and endodontist last. TREATMENT OPTION SELECTION AND TREATMENT PLANNING Treatment planning, as the term implies, is the planning of the management of a patient’s dental problems in a systematic and

ordered way that assumes a complete knowledge of the patient’s needs, the precise nature of the problems and the prognoses of possible options under consideration. It is rare in dentistry, however, for both patient and dentist to have such a complete picture of the problems and outcomes of options. The phase of assessment or establishment of a more complete picture of the problem(s), therefore, often overlaps with the phases of decision-making, planning and delivery of treatment. Anticipation of a particular outcome while desirable is not always a certainty. The term ‘provisional treatment plan’ is used to describe the overlapping phases of diagnosis and treatment when further information is sought to garner a clearer picture. A ‘definitive treatment plan’ will emerge as the information becomes more complete and the wishes of the patient and dentist crystallize into a more concrete proposal. Unfortunately, even under the best set of circumstances, the most complete and

definitive picture of the problems is seldom reached and together with the variations inherent in each dentist’s knowledge, experience, skills and judgement, this gives rise to the differences evident in treatment planning between operators. Conscientious dentists, therefore, strive to reach this goal throughout their professional lives in what has now become formally recognized as continuing professional development (CPD). Unfortunately, some practitioners take the receipt of their practicing licence as the end of professional development. Their frame of reference extends no further than the teachings given at undergraduate level. Decision-making for them is a matter of following the simple decision-tree given as expedient teaching. Their knowledge is written in black and white, is clear and simple but unfortunately never approaches the truth. Their intellect and skills consequently never flower into their full potential. The true difficulty in treatment planning is only realized by

the conscious and conscientious endeavour to improve the service delivered to patients. Stock Ch05.qxd 26/1/04 10:05 am Page 94 94 ENDODONTICS The aim of this chapter is to highlight the factors important in planning the endodontic management of pulpal and periradicular diseases and how to prioritize them in the context of the patient’s overall and dental needs. Treatment planning encompasses the phases of: establishing the nature of the problem; mutual interrogation and negotiation (between patient and dentist) that precedes the decision-making inherent in selecting the best course of action; planning required to deliver the selected treatment in an effective and efficient sequence. THE IDEAL TREATMENT PLANNING SCENARIO The textbook depiction of treatment planning commences at the first encounter with the patient, when a full assessment is made of the patient’s overall dental and oral problems. In this diagnostic phase, a detailed systematic appraisal is made in the

classical manner described in Chapter 3. The end-point of this is a series of conclusions about the general health of the patient and their current oral and dental problems. This will include the state of their dentition, including that of the periodontium, the teeth (presence of caries or tooth surface loss and their pulpal and periapical status) and any restorations. A number of different solutions will be possible for management of the patient’s problems but the specific treatment options selected will be dictated by a number of other factors such as technical feasibility, cost and time involved, dentist’s preferences based on their skills, and the patient’s age, wishes and compliance in oral care. In the ideal scenario, each option should be evaluated in an objective way taking the above factors into account, weighing the effectiveness and projected long-term prognosis (based on outcome data) with compliance, cost and time commitment. As the number of dental problems to be

addressed increases (5.1), so does the interaction between options for individual problems. This may have the overall effect of either complicating management or simplifying it because more radical solutions (such as extraction) become more appropriate. In any case, the options will be discussed with the patient and after appropriate negotiation and clarification a mutually agreed choice of treatment or ‘treatment plan’ will be made (Box 5.1) 5.1 Orthopantomogram (OPG) of difficult problems A plan is then made of the sequence in which treatment will be executed, called the ‘plan of treatment’ (Box 5.2) Once the treatment is completed, the patient will be recruited to a recall system to evaluate and maintain the work. At these recall reviews note will be taken of any changes and dealt with according to a preplanned scheme for dealing with failure (planning for failure should be considered as part of the overall long-term treatment plan). Box 5.1 Treatment plan Scenario – a

patient presents in pain with a poorly maintained mouth, several carious and periapical lesions and gingival inflammation. Following history and examination, the treatment plan is as follows but beyond pain management is conditional on compliance. It includes: 1. 2. 3. 4. 5. 6. 7. 8. 9. Diet investigation. Scale and polish and oral hygiene instruction. Treatment of carious lesions. Extractions of unrestorable teeth. Root canal treatment of teeth with periapical lesions. Root canal retreatment of root-filled teeth with periapical lesions. Periapical surgery if required. Provision of crowns. Provision of denture. Box 5.2 Plan of treatment The ‘plan of treatment’ to deliver the ‘treatment plan’ will consist of checks to gauge compliance and success in pain management. It may progress as follows: 1. Treatment of acute problems including incision and drainage, first stage root canal treatment, extractions. 2. Immediate denture if necessary, oral hygiene instruction, diet

instruction and fluoride mouthwash. 3. Stabilize carious lesions in conjunction with scale and polish and reinforcement of oral hygiene instructions. 4. Gauge compliance in home-care and gingival health with further oral hygiene instruction as necessary. 5. Provide definitive plastic restorations for carious teeth in order of priority dependent on presence of sensitivity and integrity of temporaries. 6. Complete all root canal treatments where teeth restorable 7. Carry out periapical surgery where necessary 8. Review prognosis of treated teeth, design definitive denture or fixed prosthesis and decide teeth requiring cast restorations (compliance should be absolute at this stage). 9. Provide crowns 10. Provide definitive denture Stock Ch05.qxd 26/1/04 10:05 am Page 95 TREATMENT OPTIONS THE REALITY IN PRACTICE In general practice, however, where a patient has often been under long-term care by a particular practice or dentist, the majority of interactions with the patient are part

of continuing care. A plan of management will have been established at some point in the past and in the simplest cases, requires no more than a review (recall) to evaluate a change in overall status. Under these circumstances, the sudden precipitation of a pulpal or periapical problem may be managed in isolation as long as there are no complex restorative implications (5.2) Where there are such complex restorative implications, the desire or lack of desire (on the part of the dentist) to tackle them may influence management of the endodontic problem (5.3) It is therefore important that a rational analysis of the situation is carried out and difficult restorative decisions taken as necessary rather than deferred to another time when the situation is likely to be worse. In many patients on long-term recall, the dentist may place individual teeth on probation and review their status at a subsequent time because of uncertainty about a diagnosis or the progression of a lesion (5.4) A

number of potential problems, not causing current difficulties will therefore have been identified but a mutually agreed decision made to leave alone and review. Such a plan of action is not uncommon in mouths which are heavily restored and where changes can precipitate a radical review of the overall dental strategy for the patient plan, with major implications of time and cost. Small changes to the situation may be managed by minimal intervention and a ‘patchwork’ approach. The situation, however, must be understood between the patient and dentist in the so-called informed consent approach. The tooth in Figure 54 has been retreated (55) and placed on continuing review until a mutually agreed decision can be reached with regard to the restorative options. Under some circumstances, with the passage of time, the mutually agreed plan may be forgotten or fade from memory, particularly where detailed records are not maintained. Under these circumstances, the precipitation of a pulpal

or periapical problem and even worse multiple problems that occur in rapid succession may cause the need for a radical review of the options. The sudden accumulation of such unfavourable events may prompt the patient to seek a second opinion. The nature of this next encounter, in all likelihood with somebody with a different perspective, may raise different opinions about the previous management. The precise nature of the previous mutually agreed treatment plan might not be fully appreciated in the absence of accurate and detailed records. The vagaries and subtleties that lead to differences in management approach may cause patient dissatisfaction, which sometimes (and in contemporary society increasingly frequently) leads to legal action. It is therefore best to keep detailed records of initial findings, option appraisals, rationale for decisions and informed consent for treatment. 5.3 Example of endodontic problems that have complex restorative implications 5.2 Example of

endodontic problem managed in isolation 5.4 Symptomless 25 has been reviewed for some time and now has a sinus 5.5 The same 25 has been retreated and is now under review to assess healing before making a decision about restorative options 95 Stock Ch05.qxd 26/1/04 10:05 am Page 96 96 ENDODONTICS FACTORS INFLUENCING TREATMENT PLANNING Treatment planning is a challenging and complex decision-making process by both the operator and patient that involves a two-way interrogation and negotiation between them, leading preferably to short-, medium-, and long-term goals for the management of the patient’s dentition. Difficulties are often caused by the contradictory requirements and perceptions of dentist and patient. The ways in which these may be resolved are numerous, even forming the basis for practice-marketing strategies. The factors influencing the decisionmaking process are many Factors that may confound the process include differences in perception and goals between the

dentist and patient. Some examples are listed in Table 51 The dentist must be Table 5.1 Patient and dentist perceptions Patient’s complaint Dentist’s perception and goals Patient’s perception and goals Pain and swelling Requires emergency scheduling but also planning for definitive solution Priority is to eliminate immediate problem, definitive solution not always a priority Eating and chewing compromised Aim to define sources of useful support for prostheses, balancing feasibility with learning curve for patient and side-effects Has expectations of establishing normal uncompromised function Aesthetics compromised Aim to define source of problem(s) and technical feasibility of correction Expectation of ideal aesthetics (that may not match that of the dentist or that achievable) Previous history of dental treatment Aim to establish the residual problems of extensive previous dental work May harbour feelings of mistrust because of past experience and may now be

seeking correction Medical history Aim to identify factors that may compromise dental treatment Identify if the dental condition may be responsible for any systemic illness? Coping with added burden of their systemic problems may lessen patient’s priority of dental care Will wish to know if the teeth are causing the systemic problems? Extraoral examination Exclude other causes of pain and establish TMJ and mandibular function for restorative evaluation Liable to harbour doubts about relation between dental problems and extraoral factors Intraoral examination Aim to gauge general oral condition first before focusing on the specific sites of complaint so as not to miss clues May question the need to evaluate ‘peripheral factors’ Will wish dentist to investigate the problem, as they perceive it Oral hygiene Aim to identify deficiencies to improve overall dental condition Will always be crestfallen and disbelieving, ‘but I spend hours cleaning my teeth!’ Soft tissues

Aim to confirm evidence for and location of infection and inflammation by visual and tactile examination May perceive that elicitation of pain is not confirmation for diagnostic reasons but aggravation of pain Will expect dentist to believe them Teeth and restorative status Aim to identify missing units and need for replacement, state of residual dentition and restorations, confirming sources of discomfort and pain Probing and percussion of teeth is often perceived as aggravation of pain Its purpose should always be explained Periodontal status Aim to establish the state of periodontal foundation for long-term stability and to identify and correct any problems Will usually find the probing uncomfortable, viewing any bleeding caused by inflamed sites as trauma induced by the dentist and source of further problems Occlusal status Aim to establish functional relationship between opposing teeth, accounting for occlusal wear, habits and potential future loading of proposed

restorations Almost universally will deny that they parafunction or that their mandible reaches extreme excursions proven by tell-tale faceting and contact relationships Special tests Aim to reveal the status of unseen or invisible tissues, namely pulp and periapical tissues May find pulp tests painful and aggravating and will be cautious of X-radiation Diagnoses Aim to report the series of conclusions May be daunted by unexpected findings and reports, sometimes causing emotional responses Treatment option appraisal Aim to objectively evaluate the treatment options to determine the most suitable choice for the patient’s long-term benefit Priority usually placed on aesthetics and short-term benefits Importance of function and long-term considerations should be stressed Stock Ch05.qxd 26/1/04 10:05 am Page 97 TREATMENT OPTIONS aware of the potential for such problems and be prepared to take appropriate action to circumvent them. This hypothetical but familiar

illustration of operator and patient’s perspectives, which many will identify with, illustrates some sources of problematic communication. Effective communication is the key to arriving at a mutually satisfactory treatment plan. The complexities of decision-making are further explored by examining different case scenarios based on a simple situation. INFLUENCE OF VARIOUS FACTORS ON TREATMENT PLANNING IN A SIMPLE SITUATION In any given situation the options available to treat pulpal or periapical disease may be to carry out pulp therapy, root canal treatment, root canal retreatment, periapical surgery, root resection or extraction. The last option also requires a consideration of the alternative restorative options. Apart from feasibility, the cost and long-term priorities of the patient have to be weighed. A cost–benefit analysis should be performed to aid the decisionmaking process as illustrated below in Table 5.2 The outcome of such an analysis, though, is likely to be

different depending upon the exact details of the situation. As an example, consider the various presentations of an endodontic problem associated with a maxillary central incisor in an otherwise intact dental arch. biological factors) and the long-term benefit to the patient. If the tooth is not restoratively compromised and the root is mature, the high prevalence of pulp necrosis in such cases may lean the decision towards root canal treatment and the appropriate restoration as having a high chance of success (5.7, 58) Other restorative factors may not come into the equation at this stage but will be discussed with the patient. 5.6 Traumatized maxillary incisor 5.7 Maxillary incisor following endodontic treatment Scenario 1 Consider the not uncommon scenario of the pulp in a maxillary incisor of an otherwise intact dentition becoming compromised by a severe traumatic injury in a young, mature adult (5.6) The options of pulp therapy or root canal treatment may be considered. The

choice will centre on the prognosis of each treatment (based on Table 5.2 Weighing of prognosis and relative cost of endodontic and restorative options (based on average figures) Treatment option Root canal treatment Conventional retreatment and new post retained restoration Surgical endodontics Extraction/leave unrestored Extraction/denture Extraction/bridge Extraction/implant Relative cost Prognosis (% survival/years) 1.0 2.3 Difficult to determine as dependent on individual prognostic factors Each case has to be weighed independently 1.5 0.2 1.4 3.8 4.3 NB the relative cost may change depending on contemporary and local trends. 5.8 Maxillary incisor restored 97 Stock Ch05.qxd 26/1/04 10:05 am Page 98 98 ENDODONTICS Scenario 2 Scenario 3 If, under the same circumstances, the patient was younger with an incompletely formed root, the decision may now lean towards, the more conservative pulp therapy (5.9) in order to aid completion of root formation and improve the

long-term restorative prognosis (5.10) In the event that the traumatic injury in such circumstances is accompanied by severe coronal tooth fracture, the restorative prognosis may be further jeopardized (5.11a–c) Consideration of early replacement may have to be tempered by the psychological need to avoid loss of the tooth as well as to delay permanent replacement during the growth phase of the individual, especially if an implant-retained crown is a possible alternative. The compromised tooth may therefore be retained as a suitable space maintainer until a more definitive solution can be executed. Consider an identical scenario but where a traumatized, intact, mature, maxillary central incisor has been left untreated for years as the pulp slowly succumbs and the patient seeks attention either because of an acute infection or the discolouration caused by secondary dentine formation and/or pulp necrosis (5.12) On radiographic examination, it is found that the canal is sclerosed (513)

and only evident in the apical third of the root associated with a periapical lesion. Now other considerations come into play including the potential for successful outcome by conventional or surgical means, as well as the desire for correcting the discolouration. In the matter of the former problem, it has to be established, whether the operator is confident of locating the canal using a conventional coronal approach (5.14), which would improve the chances of success (5.15) If not, injudicious dentine removal may result in compromised restorability of the tooth A surgical approach may stand a better chance of finding the canal but may not help eradicate the major part of the infection in the root canal system, compromising the chances of successful healing (5.16a–c) In addition, the absence of access to the pulp chamber also compromises the chances of internal bleaching of the tooth to help correct the discolouration. In this scenario, there are an increasing number of uncertainties

as outcomes are less certain. The decision-making now has to be aided by weighing the relative chances of success of the different endodontic options and finally also the restorative/aesthetic outcome. Scenario 4 5.9 Traumatized maxillary incisor with an open apex, receiving pulp therapy 5.10 Traumatized maxillary incisor root filled following root closure Consider that the same scenario presents many years later but this time without having caused the patient any symptoms, the sole concern being tooth discolouration. The intact tooth will in all probability give negative pulp test responses and may or may not be associated with a periapical radiolucency. In the case of a periapical lesion the decision is easier as it would be reasonable to recommend root canal treatment, bleaching (5.17, 518) and if necessary a 5.11 (a) UR1 under calcium hydroxide therapy to induce root end closure following traumatic injury; (b) same tooth following cervical level fracture; (c) replacement with

an implant, still in the process of integrating LOW-RESOLUTION LOW-RESOLUTION (a) (b) LOW-RESOLUTION (c) Stock Ch05.qxd 26/1/04 10:06 am Page 99 TREATMENT OPTIONS 5.14 Example of sclerosed canal in maxillary incisor 5.12 Discolouration of tooth following trauma 5.13 Radiographic evidence of pulp calcification and dentine sclerosis 5.15 Canal successfully negotiated and obturated (b) (c) (a) 5.16 (a) Sclerosed canal in central incisor managed by apicectomy and root-end filling; (b) the treatment failed and required a further procedure when retrograde root canal treatment was performed; (c) final retrograde root filling 5.17 Central incisor requiring endodontic treatment and bleaching 5.18 Bleached central incisor 99 Stock Ch05.qxd 26/1/04 10:06 am Page 100 100 ENDODONTICS porcelain veneer to mask residual discolouration caused by increased thickness of sclerosed dentine. The morbidity of treatment, that is, the potential of an acute flare-up, should also be

considered since about 10–15% of asymptomatic periapical lesions, without sinus tracts, become acute on commencement of root canal treatment. The decision is even more difficult in the absence of a periapical lesion because of the potential to infect a necrotic pulp and precipitate further problems. Scenario 5 Consider another variation on the above scenario, where the tooth has already been root treated and restored with a post-crown. The patient now presents years later with a periapical lesion (5.19) This confronts the dentist with additional endodontic and restorative dimensions that must be considered. The endodontic question to address is the reason for treatment failure. The causes of failure include persistent intraradicular infection, new intraradicular infection, extraradicular infection, cyst, foreign body reaction, healing by scar tissue and radicular fracture. It is virtually impossible to predict which of these factors may be the prime causative factor in the absence

of other clinical clues. The presence of acute infection may narrow down the options. The presence of uninstrumented apical canal space may suggest persistent infection, whereas, a recently decemented and recemented post crown may suggest a newly established infection or root fracture. If intraradicular infection is implicated, then conventional retreatment may be the treatment of choice. In this case, the restorability of the tooth, the retrievability of the post-core and root filling should be weighed up, as should the potential for root fracture during post removal. The natural consequence of this will also be the need for redoing the root canal treatment and placing a new post crown. The chances of success using this approach should be weighed against a surgical option where the existing crown is preserved (assuming good pre-existing margins, contours and aesthetics) and retrograde apical treatment considered (5.20) This has the advantage of correcting causes of failure other than

intraradicular infection. It must be remembered that if a conventional approach is selected and the cause of the problem turns out to be extraradicular infection or a cyst, surgical correction may still be required in addition. Under these circumstances, the decision-making process is therefore more complicated If it is found that the root length is short or that the restorative management is compromised by the existing canal shape, size and length, extraction and prosthetic replacement should also be considered. Under these circumstances, further assessments have to be made for alternative replacements. The options include, leaving alone, a denture, bridge or implant. A number of factors now need to be considered, including the size and shape of the vault of the palate (for a denture), the restorative status of the adjacent teeth, including their size for the purposes of adhesive bonding, the quality and quantity of bone in the site at present as a possible indicator of bone after

extraction for an implant and finally the occlusal relationship with opposing teeth. The prognoses of each of these options, as well as their cost, should be considered. Scenario 6 The superimposition of a medical condition such as rheumatic fever that renders the patient susceptible to infective endocarditis may sway the balance of the decision depending upon the predictability of the outcome. The type of endodontic treatment planned for a particular patient should take into account the patient’s general health and dental state. SUMMARY OF FACTORS AFFECTING TREATMENT PLANNING This illustration shows how the balance of the decision may be swayed by the interaction of a number variables including the age, desire and means of the patient, endodontic status of the tooth, the restorative status of the tooth and that of adjacent teeth, the overall and specific periodontal condition of involved teeth, the overall and specific occlusal relationship of involved teeth and the prognoses and

cost of the different options of treatment. Similar considerations apply to posterior multirooted teeth. However, the root canal anatomy and its influence on management prospects have also to be considered (5.21) The situation becomes further complicated in teeth that have been previously treated and may have iatrogenic problems such as broken instruments (5.22) and canal transportation (5.23) FACTORS INFLUENCING TREATMENT PLANNING IN A COMPLEX CASE 5.19 Post-crowned incisor with periapical lesion 5.20 Retrograde apical treatment of post-crowned incisor The complexity of interacting factors increases further when more than one tooth is involved, whether they are adjacent or separated by Stock Ch05.qxd 26/1/04 10:06 am Page 101 TREATMENT OPTIONS 5.21 Multirooted maxillary premolar 5.22 Mandibular molar with iatrogenic problems 5.23 Radiograph of root-treated molar with evidence of canal transportation 5.26 Provisional sedative restoration in a molar 5.24 Patient requiring

extensive treatment 5.25 Very carious, periodontally involved mandibular molar other teeth or in different arches. Where multiple teeth are involved each should be independently evaluated initially and then the interacting aspects considered. It will often be intuitively obvious when the simple solution should take precedence over overly complicated efforts to preserve all teeth at all costs. Once the treatment options have been selected, the next phase involves the planning of the sequence of delivery of the treatment. In the case of single teeth, this is straightforward, but becomes increasingly complicated with involvement of multiple teeth, of which some may be symptomatic and others may require temporization. THE SEQUENCE OF TREATMENT DELIVERY Figure 5.24 shows the case of a patient with multiple restorative and endodontic problems. There are three stages in the planning process. These are: planned initial treatment; planned definitive treatment; planned review. Planned

initial treatment Immediate relief of symptoms The immediate relief of pain is a valuable service and should precede other forms of treatment. The provision of emergency endodontic care for patients in pain of pulpal or periradicular origin need not be anxiety ridden or time consuming, and can assist in building the reputation of a practitioner. The treatment required for the immediate relief of pain may be obvious – for example a very carious, periodontally involved, unrestorable tooth may be extracted (5.25) Where a tooth has recurrent caries, treatment of the provoked pain may only require the removal of caries, placement of an indirect pulp capping with calcium hydroxide, and the placement of a provisional sedative restoration (5.26) Where the appropriate treatment is not quite so obvious, as in some cases of post-restorative pain, interim relief may be achieved by correction of occlusal interferences and inadequate or excessive approximal contacts, to allow the stressed pulp to

recover from the restorative episode. 101 Stock Ch05.qxd 26/1/04 10:06 am Page 102 102 ENDODONTICS Cracked teeth with symptoms of irreversible pulpitis may require endodontic treatment for the relief of symptoms before making a definitive decision about the restorative future of the tooth. For example, endodontic treatment may be commenced in a painful tooth with a suspected fracture before undertaking further investigations to establish the true prognosis (5.27) Teeth with established intraradicular infection may present with severe pain and/or localized or diffuse swelling (5.28) Treatment in these situations is based on the need for the establishment of drainage (5.29), thorough disinfection of the tooth and, where necessary, the prescription of analgesics and antibiotics. The use of antibiotics alone in the relief of acute symptoms is considered inappropriate. Stabilization Stabilization involves halting the progress of primary dental disease in the dentition. Both caries

and periodontal disease fall into this category. When disease is at an advanced stage and threatens the survival of a tooth or teeth, its progression may be controlled without the delivery of full effective, definitive treatment. The most easily understood example of this is the dressing of carious teeth to arrest caries progression and protect the pulp. The primary phase in periodontal therapy may involve oral-hygiene instruction and debridement. The same principle may be applied to pulpally involved teeth. Endodontic treatment may be instituted and the canals in the teeth provisionally dressed to control the development of periradicular disease without completing the definitive therapy (5.30) Endodontically speaking, the teeth are placed ‘on hold’ while other aspects of the patient’s total care are being managed. Prevention A patient’s understanding and belief about dental disease and its treatment may affect his/her motivation, attitude to attendance and compliance to

treatment. Initial planned treatment should always incorporate an element of behavioural conditioning to address the patient’s beliefs and attitudes. This approach is crucial for the long-term prevention of dental caries and periodontal disease. Effective planning should always incorporate prevention. In addition to the identification of the aetiology of the dental disease present, patient education becomes the basis of any preventative regime This may include dietary advice, home oral-health measures, and the use of fluoride supplements. 5.28 Swelling of the palate related to endodontic intraradicular infection 5.27 Endodontic treatment commenced in painful fractured molar 5.29 Drainage established in a mandibular canine 5.30 Endodontic stabilization of maxillary first premolar 5.31 Endodontically unsound incisor Stock Ch05.qxd 26/1/04 10:06 am Page 103 TREATMENT OPTIONS Planned definitive treatment Definitive treatment options may involve pulp therapy, root canal

treatment, root canal retreatment, surgical treatment, review or extraction. Where the loss of teeth becomes a factor then replacement options should be considered These involve the construction of fixed and removable prostheses or the provision of implants. The choice of treatment may be influenced by specific factors. extensive restorations or they are required as abutments for fixed prostheses (5.34, 535) The difficulty and expense of treating teeth with large cast or ceramometal restorations should always be borne in mind. Decisions made in both simple and more complex treatment plans should follow the knowledge gained from research and evidencebased practice. Access and the final restoration Overall treatment The general state of a patient’s dentition is an indicator of dental disease experience. The age, condition and maintenance of restorations and the presence of recurrent disease are all factors that may influence the decision-making. It should be remembered that not all

teeth with pulpal and periradicular disease are candidates for endodontic treatment, and on occasions the retention of a pulpally compromised tooth should be questioned if it unnecessarily complicates the restorative plan. One such example is an endodontically compromised remaining incisor, where the restorative option is a removable prosthesis (5.31) Sometimes teeth with perfectly normal pulps are judged to require endodontic treatment for restorative reasons, as in the case of the restorative realignment of teeth or overdenture construction (5.32, 533) Endodontic treatment of teeth with low-grade symptoms may also be considered when there is the likelihood of them receiving When planning the endodontic treatment of a tooth the physical demands of the final restoration should be considered. The way in which the access and root canal preparation will influence the amount of remaining coronal tooth substance and canal space for post construction should be borne in mind. Good access

leads to success in endodontics, but access produced without thought may make the restoration of the tooth more difficult (5.36) Restorability of teeth Following endodontic treatment it should be possible to restore a tooth to function and health. Particular attention needs to be given to the support that can be provided for a coronal restoration and the position of finishing margins. Finishing margins benefit from being above the alveolar crest, and preferably supragingival. If the prospects of providing an adequate restoration seem remote, extraction should be considered as an alternative treatment. 5.32 Elective root canal treatment for mandibular canine 5.33 Overdenture in place 5.34 Molar requiring restoration with questionable vitality 5.35 Molar endodontics completed prior to restoration 5.36 Overzealous access in mandibular incisor leads to unnecessary loss of dentine 103 Stock Ch05.qxd 26/1/04 10:06 am Page 104 104 ENDODONTICS Well-treated teeth may require

elaborate and innovative restorations and possible surgery to satisfy the physical and marginal requirements of the final restoration. Further details are given in Chapter 16. Good treatment strategies should also take into account possible failure. By planning for failure operators and patients are in a much better position to cope with outcomes that are not as originally hoped for. single standing teeth, which often prevent the need for a free-end saddle denture (5.39) Canal anatomy Bizarre root forms and root canal anatomy, congenital grooves and dilacerations may all present difficulties if endodontic treatment is attempted (5.40–542) These unusual forms may affect the outcome of treatment Periodontal support Loss of periodontal attachment on its own is not a contraindication for endodontic treatment. Provided a tooth has, or can be made to have, a healthy periodontal apparatus, endodontic treatment may be carried out (5.37) Strategic importance of teeth Before deciding

whether to retain or extract a tooth, the importance of a particular tooth in the dental arch should be considered before embarking upon endodontic treatment. Clearly, unopposed and functionless teeth (5.38) are strategically less important than 5.37 Root-filled tooth with loss of periodontal support Root resorption The loss of tooth tissue structure may lead to fracture (5.43, 544) The prognosis for teeth affected by internal resorption is good. The process may be arrested by pulp removal and, provided the remaining tooth substance is strong enough, the tooth can be retained (5.45, 5.46) Treatment of resorption arising on the external surface of the root is less predictable (5.47) External inflammatory resorption is treatable and responds to root canal treatment. The treatment of other types of external resorption is unpredictable. Defects can be repaired surgically (5.48) and also made supragingival There is, however, a tendency for this type of external resorption to continue.

5.38 Unopposed molar 5.39 Tooth defending the need for a free-end saddle 5.41 Irregular root form of the premolar 5.42 Complex canal anatomy of the premolar 5.40 Mandibular premolar requiring treatment Stock Ch05.qxd 26/1/04 10:07 am Page 105 TREATMENT OPTIONS 5.43 Mandibular premolar with internal resorption 5.44 Fractured mandibular premolar through resorption 5.46 Root treatment performed to arrest the resorption 5.45 Radiographic evidence of internal resorption in a mandibular molar (a) (b) 5.48 (a) External root resorption at surgery; (b) surgical repair of the resorptive defect with glass ionomer cement 5.47 Molar with both internal and external resorption 5.49 Vertical fracture of a maxillary molar Root fractures Fractures that communicate with the oral environment provide a route for infection. Vertically fractured teeth (549, 550) have a worse prognosis than those with horizontal fractures (5.51), which are also easier to detect radiographically. 5.51 Horizontal

fracture of a maxillary incisor 5.50 Vertical fracture in an anterior tooth 105 Stock Ch05.qxd 26/1/04 10:07 am Page 106 106 ENDODONTICS Crown-root fractures passing through the attachment apparatus and involving alveolar bone require careful assessment to establish accurately the endodontic and restorative needs of the remaining tooth substance. Posterior teeth with fractures involving the floor of the pulp chamber have poor long-term prospects. 5.52 Sclerosed root canal in maxillary incisor 5.53 Sclerosed root canal in mandibular premolar Sclerosed canals Root canals that are not visible radiographically may be very difficult to locate and negotiate if endodontic treatment is necessary (5.52–559) However, in many cases they are possible to find and treat. It is impossible to predict the outcome of treatment until an 5.54 5.54–555 Drilling to locate canals 5.55 5.59 Canal in mandibular premolar located and treated 5.58 Canal in maxillary incisor located and treated

5.56 5.57 5.56–557 Sclerosed pulp chamber and canals in multirooted teeth Stock Ch05.qxd 26/1/04 10:07 am Page 107 TREATMENT OPTIONS 5.60 Maxillary molar requiring retreatment 5.61 Maxillary molar following retreatment 5.62 Mandibular molar requiring retreatment 5.63 Mandibular molar six months after retreatment and restoration 5.64 Mandibular molar with silver points requiring retreatment 5.65 Mandibular molar following retreatment attempt has been made to locate them. Teeth with a history of trauma experience progressive narrowing of the pulp space. Such teeth should be reviewed radiographically and if there is evidence of sclerotic change endodontic treatment should not be contemplated until there are radiographic periradicular indications of necrotic change occurring within the canal. Previous root treatment The decision to retreat a previously root-filled tooth (5.60, 561) should be based on clear criteria. If the treatment appears to be failing (562–563) because

it shows symptoms, sinus tracts, persistent or developing radiolucencies, separated instruments and iatrogenic perforations, retreatment may be considered (5.64, 565) The management of symptom-free periradicular lesions in previously root-treated teeth seems to give rise to considerable management variations. The inclination of a dentist to propose endodontic retreatment would seem to be variable. There does not appear to be a definite retreatment criterion for stable symptomless periradicular lesions. The replacement of coronal restorations in endodontically treated teeth can occasionally give rise to symptoms, but why this should be so is not fully understood. It has been suggested that altered occlusal loading, the effects of post-space preparation and restoration cementation hydrostatic pressures may account for the problems. Such problems are possibly related to coronal reinfection of the canal system Previously treated teeth requiring new restorations should be examined with

care, and if the adequacy of the sealing of the pulp space is in doubt retreatment should be considered. Where post-retained restorations exist in teeth requiring endodontic treatment a choice has to be made regarding the approach to treatment. Conservative treatment is likely to damage the restoration, and post removal might precipitate a root fracture. Conservative treatment gives a better opportunity to clean the canal system and eliminate coronal leakage as a possible cause for failure but does not treat extraradicular infection. A surgical retrograde approach to retreatment preserves existing restorations but does not eliminate coronal leakage as a cause of failure. It is difficult to clean the canal system thoroughly. However, a surgical approach offers an opportunity to eradicate extraradicular infection (566–568) In cases involving retreatment of teeth with large and irregularlooking lesions the use of decompression (5.69–573) and biopsy techniques should be considered to

establish a clear diagnosis. Finally, the practitioner should always assess his or her ability to improve on the existing situation. If this ability is in doubt, referral to a colleague specializing in this area should be considered. 107 Stock Ch05.qxd 26/1/04 10:07 am Page 108 108 ENDODONTICS 5.66 Lateral incisor fails to respond to conventional root canal treatment 5.67 Surgery performed to eradicate possible extraradicular infection 5.68 Resolution of the periradicular lesion 5.69 Large lesion in mandible 5.72 Placement of flanged cannula 5.70 Lesion situated between left mandibular lateral incisor and canine 5.71 Penetration of lesion 5.73 Radiographic evidence of decompression 5.74 Clinical image of implant-retained crowns Implants The apparent success of single-tooth implants has prompted extravagant claims in some quarters to the effect that the treatment modality may spell the end of endodontics. Implants are just one of several tooth replacement options and

nothing more. They have good success rates but are judged by a different set of criteria that are better described as survival rates rather than success (5.74, 5.75) Most patients will wish to retain their own natural teeth and extraction must be a considered decision based on exhaustion of all possibilities to save them within a reasonable time and cost frame. Stock Ch05.qxd 26/1/04 10:07 am Page 109 TREATMENT OPTIONS 5.76 Periradicular lesion related to bridge abutment 5.77 Healing following root canal treatment (one year later) 5.78 Postoperative radiograph of lesion 5.79 Lesion remains static 5.75 Radiograph of single tooth implant A cost–benefit analysis of the options showed retention of the tooth to be a better option (Moiseiwitsch & Caplan 2001) but this will be a changing comparison as the cost of the treatment changes. Single or multiple visit treatment It is becoming popular for members of the dental profession to favour the completion of endodontic

treatment in one visit. Currently accepted criteria for the completion of endodontic treatment include lack of symptoms and a prepared pulp space free of microorganisms. When considering whether to complete treatment in one visit or more it is worth thinking about the possible advantages and disadvantages of both the single- and multiple-visit approach. Where endodontic treatment is being performed on a vital tooth, the bacterial content of the tooth is minimal and a single visit approach is favoured, thus reducing the possibility of bacterial entry into the tooth through coronal leakage of the provisional restoration. The single visit also allows for immediate and intimate knowledge of the canal anatomy of the tooth and all important reference points. Patients also favour single visits because there is less time spent in the dental office with less anxiety and local anaesthetic. Patients with medical histories that require the administration of antibiotics for treatment also benefit

from receiving care in a single visit. When dealing with a long-standing infection in a tooth, it may be wise to consider the disinfection of the tooth over more than one visit. This approach allows greater time and the use of a medicament to supplement the chair-side irrigation and disinfection procedures. This approach seems to favour the treatment and retreatment of teeth with periradicular lesions with swelling and draining sinuses. Retreatment cases lend themselves to a multi-visit approach because of the time required to remove restorations and root fillings, and the presence of resistant bacterial strains. Planned review Reassessment and re-evaluation of the status of dental health of patients is an integral part of the planning process. It involves examining the patient again; often taking elements of the history again, re-establishing a diagnosis, and formulating a new treatment plan for whatever new or residual problems are encountered. Clinical and radiographic follow-up,

at regular intervals for an indefinite period, are essential for the assessment of endodontic treatment. Observation periods of at least four years are desirable (5.76, 577) Endodontic treatment should be assessed annually Indications of success are absence of pain, swelling and other symptoms, no sinus tract, no loss of function, and radiographic evidence of a normal periodontal ligament space around the root. The outcome of treatment is considered uncertain if radiographs reveal that a lesion has remained the same size or has diminished in size, but total repair has not occurred (5.78, 579) 109 Stock Ch05.qxd 26/1/04 10:07 am Page 110 110 ENDODONTICS 5.82 Caries leading to failure of restoration 5.83 Caries in a root canal 5.80 Pre-existing lesion 5.84 Postoperative root fracture 5.81 Lesion increasing in size 5.85 Postoperative root perforation Treatment is considered to have failed if radiographs reveal that a lesion has appeared following endodontic treatment or a

pre-existing lesion has increased in size (5.80, 581) or there is conflicting evidence with respect to symptoms and radiographic evaluation For example, a tooth may have persistent low-grade symptoms and yet appear healthy on radiography. Factors that may lead to secondary failure of a previously successful endodontic treatment include recurrent caries and coronal leakage (5.82), caries extending into the root canal (583) or furcation, root fracture (5.84) or perforation (585) In conclusion, all dental treatment should be undertaken applying the principle of continuous review. Endodontic treatment provides definite indications for scheduling review appointments and should be looked upon as an integral part of treatment planning. Reference Moisiewitsch JRD, Caplan D (2001) A cost–benefit comparison between single tooth implant and endodontics. J Endod 27, 235