TREATMENT PLANNING IN ENDODONTICS : TREATMENT PLANNING IN ENDODONTICS Dr. Saurabh S. Chandra, MDS
Conservative Dentistry & Endodontics Contents : Contents Introduction & Scope of Endodontics
The Art of “Obtaining History”
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
Relationship to Other Complaints
When did you first notice this?
Have you ever had this type of pain before?
Daily Not daily
Constant Fluctuant Intermittent
What makes this pain worse?
What makes this pain better?
How much better? Swelling
Would your jaw hurt if your tooth didn’t hurt?
What was the diagnosis?
What was done?
How did it affect the pain? Pain : Pain Acute
At Night time
On bending over
Referred CLINICAL EXAMINATION : CLINICAL EXAMINATION VISUAL EXAMINATION:
Extra oral examination
Intra oral examination
Sinus opening VISUAL INSPECTION : 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
Wear Facets, Fractures and Restorations
Diagnodent – is useful for early caries diagnosis. PALPATION : 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 : 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 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 : 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 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
Number of roots and canals
Hard tissue deposits
Fractures CARIES : 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
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
Iatrogenic Anatomy : Anatomy Terminology : Terminology Root canal system (RCS)/Pulp Space
Apical Constriction / Minor Diameter
Apical Foramen / Major Diameter
CDJ Diagnostic Aids : Diagnostic Aids Subjective symptoms
Visual – 3 C’s – Color, Contour, Consistency
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
Irreversible & its variants eg. Pulp Polyp
Necrosis Periapical : Periapical Apical Periodontitis
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
Medical history Slide 44: Abnormal anatomy
a. Mandibular anterior teeth with two canals
b. Premolars with more than one canal
c. Severe curves
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
Failed RCT’ Take Home Messages… : Take Home Messages… History