Lec 1- Treatment Planning in Endodontics

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TREATMENT PLANNING IN ENDODONTICS Dr. Saurabh S. Chandra, MDS Conservative Dentistry & Endodontics

Contents : 

Contents Introduction & Scope of Endodontics The Art of “Obtaining History” Anatomical Considerations Endodontic Diagnosis Case Selection

The Core Science of Endodontics : 

The Core Science of Endodontics

Slide 5: 

Patient tells the clinician why he/she is seeking advice Clinician questions the patient about the symptoms and history that led to the visit. The clinician performs objective clinical tests Clinician correlates the objective findings with the subjective details and creates a tentative differential diagnosis. Clinician formulates a definitive diagnosis and executes treatment Follow up

Slide 6: 

Why seek treatment

Slide 7: 

Pain Swelling Sleeplessness Trauma

Slide 11: 

Alleviating Factors Associated Factors Relationship to Other Complaints When did you first notice this? Frequency Intensity Duration Have you ever had this type of pain before? Daily Not daily Constant Fluctuant Intermittent Duration Temporal pattern Quality What makes this pain worse? What makes this pain better? How much better? Swelling Discoloration Numbness Would your jaw hurt if your tooth didn’t hurt? Prior Consults/Treatment Who? When? What was the diagnosis? What was done? How did it affect the pain?

Pain : 

Pain Acute Chronic At Night time On bending over Referred


CLINICAL EXAMINATION VISUAL EXAMINATION: Extra oral examination Intra oral examination Soft tissues: Color Contour Consistency Sinus opening


VISUAL INSPECTION COLOUR Normal crown- life like translucency Discolored opaque – inflamed, degenerated or necrotic pulp. Calcified Canal – Light Yellow Hue of the Crown Pink Tooth – Indicates Internal Resorption CROWN CONTOUR Wear Facets, Fractures and Restorations Caries Examination Diagnodent – is useful for early caries diagnosis.


PALPATION Digital pressure is used to check for tenderness in the oral tissues overlying the suspected teeth. Bimanual palpation is most efficient to detect incipient swellings before it is clinically evident.


PERCUSSION Normal resonant sound on percussion indicates good periodontal ligament Dull sound on percussion indicates ankylosis. Response to percussion not only indicates the involvement of the PDL but also the extent of the inflammation.(degree of response directly proportional to degree of inflammation). Chronic periapical inflammation is often negative to Percussion.

Slide 18: 

Inflammation of the PDL may be caused by occlusion, trauma, sinusitis, periodontal disease or extension of pulpal disease . Percussion is not a test of pulp vitality.


PERIODONTAL CONSIDERATIONS Periodontal probing should be carried out by sounding or walking the probe around the tooth, while pressing gently on the floor of the sulcus. Horizontal bone loss with generalized pocket is not as worrisome as isolated vertical bone loss which frequently indicates vertical root fracture.


MOBILITY Tooth mobility provides an indication of the integrity of the attachment apparatus. Causes may be recent trauma, crown/root fracture, chronic bruxism, habits and orthodontic tooth movement. Grade I – Noticeable horizontal movement in its socket. Grade II – within 1 mm of horizontal movement. Grade III – Horizontal movement greater than 1 mm and/or vertical depressibility.


RADIOGRAPHS Radiographs are an important and necessary adjunct in Endodontics. Periapical and Bite wing radiographs are mainly used. Accurate radiographic techniques and proper interpretation are essential for sound diagnosis and treatment. Radiographs are used for determining pulpal anatomy prior to access openings. Establishing working length. Confirm master cone placement and for evaluating the success of treatment.

Bite wing radiographs are helpful to Detect recurrent decay Detect the depth of pulp chamber.

Features seen in high quality periapical radiographs (ortho radial projection) include : 

Features seen in high quality periapical radiographs (ortho radial projection) include caries Sharp outline of the root Tooth length Number of roots and canals Calcification Hard tissue deposits Internal/External resorption Periapical lesions Perforations Fractures


CARIES Caries progression is divided into five radiographic grades Grade 1 – Caries in enamel Grade 2 – Reaches the DE junction Grade 3 – Radiolucency extends halfway into dentin thickness Grade 4 – Deeper dentin Grade 5 – involving the pulp

Caries Examination : 

Caries Examination Receding pulp horn – age changes, chronic carious lesion In Posterior teeth, Mesial Carious Lesion – more commonly involves pulp, Distal Carious Lesion – Silent Killer – takes a longer time. Deep caries involvement of mesial Pulp horn causes minimal periapical changes either in mesial/distal root.

The morphological features to be noted regarding root canal anatomy : 

The morphological features to be noted regarding root canal anatomy Length – longer or shorter Shape – Blunder buss Taurodontism Dens in Dente Root with bulbous ends Curved canals – Degree of curvature X-ray exposed at 15º horizontal angle can help visualize curvature in bucco-lingual plane.

Etiology of Disease : 

Etiology of Disease Physical Mechanical Thermal Electrical Chemical Bacterial Traumatic Iatrogenic

Anatomy : 


Terminology : 

Terminology Root canal system (RCS)/Pulp Space Pulp Chamber Root Canal Periapex Apical Constriction / Minor Diameter Apical Foramen / Major Diameter CDJ

Diagnostic Aids : 

Diagnostic Aids Subjective symptoms Objective symptoms Visual – 3 C’s – Color, Contour, Consistency Palpation Percussion Special tests – Thermal (Cold, Heat), EPT Bite test, Mobility, Periodontal Radiographs – Conventional & Digital

Tracking a Sinus : 

Tracking a Sinus

Diagnosis : 

Diagnosis Pulpitis Symptomatic (Acute) – Hyperemia Asymptomatic (Chronic) Reversible Irreversible & its variants eg. Pulp Polyp Necrosis

Periapical : 

Periapical Apical Periodontitis Acute Chronic Periapical radiolucency Granuloma Cyst Others

Slide 41: 

Periapical Abscess Aim is to differentiate from Other abscesses

Slide 42: 

Extra Oral Sinus

Case Selection : 

Case Selection Diagnosis and treatment planning can yield success and can also help the practitioner select cases to treat or not to treat Preoperative radiology Medical history

Slide 44: 

Abnormal anatomy a. Mandibular anterior teeth with two canals b. Premolars with more than one canal c. Severe curves d. Calcifications e. Long roots f. Maxillary first molar g. Mandibular first molars Access through crowns or more complex restorations Surgical procedures

Slide 45: 

Medically compromised patients a. Cardiovascular diseases b. Cerebrovascular considerations c. Bleeding disorders d. Renal dysfunction

Slide 46: 

ENDODONTIC LIMITATIONS FOR THE ENDODONTIC SPECIALIST Severe curvatures Retreatment Surgical intervention Failed RCT’

Take Home Messages… : 

Take Home Messages… History Examination Diagnosis Treatment Planning

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