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4 Case Selection and Treatment Planning Paul A. Rosenberg The process of case selection and treatment planning begins after a clinician has diagnosed an endodontic problem. The clinician must determine if the patient's oral health needs are best met by providing endodontic treatment and maintaining the tooth or by advising extraction. This question is more complex than ever before because of the wide array of treatment modalities. The use of ultrasonics and microscopy as well as new materials has made it possible to predictably retain teeth that previously could not have been treated. Even teeth that have failed initial endodontic treatment can often be successfully retreated using nonsurgical or surgical procedures. Increased knowledge about the importance of anxiety control, nonsteroidal antiinflammatory drug (NSAID) premedication, profound local anesthesia, occlusion, and biologically based clinical procedures enables clinicians to complete endodontic procedures in the absence of intraoperative or postoperative pain (see Chapters 19 and 20 for more information on pain control and anesthesia). Thus preoperative pain should not influence treatment selection because modern techniques for profound local anesthesia can provide complete comfort for the great majority of patients receiving endodontic treatment (see Chapter 19 , "Local Anesthesia in Endodontics," for details). page 80 page 81 Add to lightbox Figure 4-1 Sample medical consultation letter. Questions concerning tooth retention and possible referral can be answered only after a complete patient evaluation. The evaluation must include assessment of medical, psychosocial, and dental factors as well as a consideration of the relative complexity of the endodontic procedure. Although most medical conditions do not contraindicate endodontic treatment, some can influence the course of treatment and require specific modifications. A number of valuable texts are available that review the subject of dental care for the medically compromised patient. 6, 31, 47, 53 An excellent website is also available and can be used to elicit information. 2
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4 Case Selection and Treatment Planning Paul A. Rosenberg

The process of case selection and treatment planning begins after a clinician has diagnosed an endodontic problem. The clinician must determine if the patient's oral health needs are best met by providing endodontic treatment and maintaining the tooth or by advising extraction. This question is more complex than ever before because of the wide array of treatment modalities. The use of ultrasonics and microscopy as well as new materials has made it possible to predictably retain teeth that previously could not have been treated. Even teeth that have failed initial endodontic treatment can often be successfully retreated using nonsurgical or surgical procedures.

Increased knowledge about the importance of anxiety control, nonsteroidal antiinflammatory drug (NSAID) premedication, profound local anesthesia, occlusion, and biologically based clinical procedures enables clinicians to complete endodontic procedures in the absence of intraoperative or postoperative pain (see Chapters 19 and 20 for more information on pain control and anesthesia). Thus preoperative pain should not influence treatment selection because modern techniques for profound local anesthesia can provide complete comfort for the great majority of patients receiving endodontic treatment (see Chapter 19, "Local Anesthesia in Endodontics," for details).

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    Figure 4-1 Sample medical consultation letter.

Questions concerning tooth retention and possible referral can be answered only after a complete patient evaluation. The evaluation must include assessment of medical, psychosocial, and dental factors as well as a consideration of the relative complexity of the endodontic procedure. Although most medical conditions do not contraindicate endodontic treatment, some can influence the course of treatment and require specific modifications. A number of valuable texts are available that review the subject of dental care for the medically compromised patient.6,31,47,53 An excellent website is also available and can be used to elicit information.2

Perhaps the most important advice for a clinician who plans to treat a medically compromised patient is to be prepared to communicate with the patient's physician. The proposed treatment can be reviewed, and medical recommendations should be documented. Fig. 4-1 depicts a sample medical consultation letter that can be modified as necessary.

The American Society of Anesthesiologists (ASA) Physical Status Classification was devised in 1941 and revised to its present form in 1983. The ASA website lists the following:

ASA I- Normal, healthy patient; no dental management alterations required. ASA II- A patient with mild systemic disease that does not interfere with daily activity or

who has significant health risk factor (e.g., smoking, alcohol abuse, gross obesity); may or may not need dental management alterations.

Examples: Stage I or II hypertension, type 2 diabetes, allergy, well-controlled asthma. ASA III- A patient with moderate to severe systemic disease that is not incapacitating but

may alter daily activity; may have significant drug concerns; may require special patient

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care; would generally require dental management alterations. Examples: Type 1 diabetes, stage 3 hypertension, unstable angina pectoris, recent

myocardial infarction, poorly controlled congestive heart failure, AIDS, chronic obstructive pulmonary disease, hemophilia.

ASA IV- A patient with severe systemic disease that is a constant threat to life; definitely requires dental management alterations; best treated in special facility.

Example: Kidney failure, liver failure, advanced AIDS.

Excerpted from Little JW, Falace DA, Miller CS, Rhodus NL: Dental Management of the Medically Compromised Patient, ed 6, St Louis, 2002, Mosby, pp 10-11.

The ASA classification remains the most widely used assessment method for preanesthetic patients despite some inherent limitations to its use as a perioperative risk predictor. This is a generally accepted and useful guide for preoperative assessment of relative risk. However, the prudent clinician should also take into account other factors not considered in the classification scheme, such as age, obesity, and skill of the health care provider. Other systems have been proposed that would better reflect the increasing number of medically complex patients treated by clinicians as Americans live longer.22

COMMON MEDICAL FINDINGS THAT MAY INFLUENCE ENDODONTIC TREATMENT PLANNING

Pregnancy

Although pregnancy is not a contraindication to endodontics, it does modify treatment planning. An extensive body of literature exists concerning the use of radiographs and drugs while treating pregnant patients.31 Protection of the fetus is a concern when administration of ionizing radiation or drugs is considered.49 Of all the safety aids associated with dental radiography, such as high-speed film, digital imaging, filtration and collimation, the most important is the protective lead apron with thyroid collar.3,58 Drug administration during pregnancy is a controversial subject. A major concern is that a drug may cross the placenta and be toxic or teratogenic to the fetus. In addition, any drug that is a respiratory depressant can cause maternal hypoxia, resulting in fetal hypoxia, injury, or death. Ideally, no drug should be administered during pregnancy, especially during the first trimester. If a specific situation makes adherence to this rule impossible, then that clinician should review the appropriate literature7,34 and discuss the case with the physician and patient.

Further considerations exist during the postpartum period if the mother breast feeds her infant. Although most drugs are only minimally transmitted from the maternal serum to the breast milk and the infant's exposure is not significant, the clinician should avoid using any drug known to be harmful to the infant. A dentist should consult the responsible physician before using any medications for the nursing mother. Alternative considerations include using minimal dosages of drugs, having the mother bank her milk before treatment, having her feed the child before treatment, or suggesting the use of a formula for the infant until the drug regimen is completed. The U.S. Food and Drug Administration (FDA) and the American Academy of Pediatrics have issued a list of drugs that are thought to be compatible with breastfeeding (see http://www.fda.gov/fdac/features/895_brstfeed.html). Box 4-1 summarizes this list.

In terms of treatment planning, elective dental care is best avoided during the first trimester because of the potential vulnerability of the fetus. The second trimester is the safest period in which to provide routine dental care. Significant surgical procedures are best postponed until after delivery.

Cardiovascular Disease

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Box 4-1 Partial List of Drugs Usually Compatible with Breast Feeding

Acetaminophen Many antibiotics Aspirin (should be used with caution) Codeine Ibuprofen Insulin Quinine

Thyroid medications

   From the FDA and American Academy of Pediatrics. Available at Click here

Patients with some forms of cardiovascular disease are vulnerable to physical or emotional stress that may be encountered during dental treatment, including endodontics. Patients may be confused or ill informed concerning the specifics of their particular cardiovascular problem. In these situations, consultation with the patient's physician is mandatory before the initiation of endodontic treatment. Patients who have had a myocardial infarction (i.e., "heart attack") within the past 6 months should not have elective dental care. This is because patients have increased susceptibility to repeat infarctions and other cardiovascular complications and may be taking medications that could potentially interact with the vasoconstrictor in the local anesthetic. In addition, vasoconstrictor should not be administered to patients with unstable angina pectoris or to patients with uncontrolled hypertension, refractory arrhythmias, recent myocardial infarctions (less than 6 months), recent stroke (less than 6 months), recent coronary bypass graft (less than 3 months), uncontrolled congestive heart failure, and uncontrolled hyperthyroidism. Vasoconstrictors may interact with some antihypertensive medications and should be prescribed only after consultation with the patient's physician (see Chapter 19 for more information). For example, vasoconstrictors should be used with caution in patients taking digitalis glycosides (e.g., digoxin ) because the combination of these drugs could precipitate arrhythmias. Local anesthetic agents with minimal or no vasoconstrictors are usually adequate for nonsurgical endodontic procedures.31

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A patient who has a heart murmur as a result of a pathologic condition may be susceptible to an infection on or near the heart valves, which is caused by a bacteremia. This infection is called infective or bacterial endocarditis and is potentially fatal. Patients who have a history of murmur or mitral valve prolapse with regurgitation, rheumatic fever, or a congenital heart defect must be given antibiotic therapy prophylactically before endodontic therapy to minimize the risk of bacterial endocarditis. Because the American Heart Association periodically revises its recommended antibiotic prophylactic regimen for dental procedures, it is essential for the clinician to stay current concerning this important issue. A low compliance rate exists among at-risk patients regarding their use of the suggested antibiotic coverage before dental procedures. Therefore the clinician must question patients concerning their compliance with the prescribed prophylactic antibiotic coverage before endodontic therapy. If the patient has not taken the antibiotic, the procedure must be delayed.

Patients with artificial heart valves are considered highly susceptible to bacterial endocarditis. Therefore consulting this patient's physician regarding antibiotic premedication is essential. Some physicians elect to administer parenteral antibiotics in addition to or in place of the oral regimen.

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The coronary artery bypass graft is a common form of cardiac surgery. Ideally, vasoconstrictors should be minimized during the first 3 months after surgery to avoid the possibility of precipitating arrhythmias. Ordinarily these patients do not require antibiotic prophylaxis after the first few months of recovery unless there are other complications. The clinician can play an important role in the detection of hypertension. The clinician may be the first to detect an elevated blood pressure. Further, patients receiving treatment for hypertension may not be controlled adequately because of poor compliance or inappropriate drug therapy. Abnormal blood pressure readings become the basis for physician referral. Few conditions exist in which there is a possibility that dental treatment could seriously injure or even result in the death of a patient. However, acute heart failure during a stressful dental procedure in a patient with significant valvular disease and heart failure or the development of infectious endocarditis represent two such life-threatening disorders.50 Careful evaluation of patients' medical histories including the cardiac status of patients, the use of appropriate prophylactic antibiotics, and stress reduction strategies will minimize the risk of serious cardiac sequelae.

UPDATE Date Added: 28 March 2006

Ken Hargreaves, DDS, PhDCardiovascular implications of apical periodontitis, pulp stones, and endodontic treatment

The last decade has seen a growing interest in the idea that chronic dental infections might be correlated with certain systemic diseases or disorders. Indeed, some, but not all, epidemiologic studies have found a significant association between periodontitis and systemic factors such as cardiac disease or low-birth-weight children. Although enthusiastic proponents gush that we must "floss or die," there is a major flaw in this thinking. Simply put, if we find that two factors, called "A" and "B," are correlated, then it is possible that factor A causes factor B, or that factor B causes factor A, or that some underlying factor "C" causes both factor A and factor B. In other words, correlation does not equal causation. Thus, the mere correlation of two conditions does not prove causation. Instead, prospective clinical studies are needed to test whether reduction of inflammation by periodontal treatment, for example, leads to a reduction in some measure of cardiac disease.

In terms of chronic infections related to apical periodontitis, far fewer studies have evaluated whether certain endodontic measures might correlate with systemic disease. This is a potentially interesting area of research, and therefore this update will review studies addressing this topic.

Edds and colleagues1published a recent study evaluating whether the radiographic presence of pulp stones might be correlated with cardiovascular disease (CVD). The hypothesis in this study is quite innovative. The authors propose that a similar underlying pathogenic mechanism might induce both calcification of dental pulp and calcified atheromas in larger blood vessels. Put more simply, the authors propose that a fundamental factor "C" (susceptibility to calcifications) might mediate two correlated but functionally unrelated conditions (i.e., pulp stones and cardiovascular disease). To reduce the chance that pulp stones were detected due to pulpal pathosis, the study consisted of patients aged 20 years to 55 years with radiographic assessment of pulp stones in non-carious, minimally restored molars (the upper age limit was imposed due to the well recognized increase in pulp stones with age). CVD was defined as a positive history of angina pectoris, myocardial infarction, heart surgery, hypertension, congestive heart failure, cerebrovascular accident, hypercholesterolemia, or arrhythmia. The presence of pulp stones was associated with a 4.4-fold increase in the risk of CVD in these patients (95% CI = 1.1 - 18.7). Indeed, 74% of the patients with a history of CVD had detectable pulp stones. In contrast, there was no significant association between pulp stones and family history of CVD (odds ratio of 1.7; not significant). This study suggests that radiographic interpretation of pulp stones might be considered as a useful screening evaluation for CVD.

Two other studies have evaluated whether apical periodontitis or the presence of root canal-filled teeth are correlated with coronary heart disease (CHD). The first study 2 evaluated 1056 women

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aged 38 years to 84 years from Sweden and correlated the presence of apical periodontitis or root canal-filled teeth with two measures of CHD (angina pectoris or myocardial infarction). A multivariate logistic regression analysis found no association between AP or root canal therapy (RCT) and CHD. Importantly, the study demonstrated assay sensitivity, since other known risk factors (e.g., age or tooth loss) were significantly associated with CHD. However, it is important to note that, in general, women are at a lower risk for CHD, and therefore studies in males are important to consider. Therefore, it is interesting to review a recent publication,3 which has evaluated 34,683 males participating in the Health Professionals Follow-up Study (HPFS). In this study, RCT was used as a marker for a history of inflammation, and CHD was defined as non-fatal myocardial infarction or fatal coronary disease. The results demonstrated that patients with teeth having prior RCT have a 21% increased risk for developing CHD as compared to patients without prior RCT (mean relative risk = 1.21 with 95% CI = 1.05 - 1.40). Interestingly, dentists had a greater increased risk (38%) with RCT as compared to non-dentists (RR = 1.03; not significant). The reasons for this increased risk are unclear but may be related to study design, since patients self-reported the presence of RCT and it is likely that dentists would report this more accurately, or undergo RCT for different reasons than non-dentists. These data suggest a possible modest association between pulpal inflammation and CHD, although the authors stress the need for confirmatory research. Indeed, the authors conclude3 their study by stating: "There have been no publications suggesting that RCT has any adverse systemic effects since the dismissal of the focal infection theory of the early 1900s. RCT in our study is a surrogate for pulpal inflammation; we do not expect the RCT itself to lead to adverse systemic outcomes. Further research is needed to corroborate the association between pulpal inflammation and CHD in other populations, to assess whether the association is causal, and to evaluate pathways for this association."

Cancer

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Figure 4-2 A, Essentially normal periradicular appearance of #29 following endodontic treatment. Treatment was due to a diagnosis of irreversible pulpitis. B, Rapid periapical

breakdown of #29 and new periradicular radiolucencies associated with #30 four months after endodontic treatment of #29. The patient's complaints now included pain isolated to #30 as

well as lip and chin paresthesia. C, Nonsurgical endodontics of #30. D, Surgical postoperative radiograph of #30 and #29. Biopsy results following endodontic surgery were positive for

metastatic breast cancer. (Courtesy Dr. Robert Sadowsky, Dr. Lee Adamo, and Dr. Jeffrey Burkes.)

Some cancers may metastasize to the jaws and mimic endodontic pathosis, whereas others can be primary lesions (Fig. 4-2). A panoramic radiograph is useful in providing an overall view of all dental structures. When a clinician begins an endodontic procedure with a well-defined apical radiolucency, it might be assumed to result from an extension of infectious agents from a nonvital pulp. Careful examination of preoperative radiographs from different angulations is important since lesions of endodontic origin would not be expected to be shifted away from the radiographic apex in the different images. If a local anesthetic is not administered and if the patient experiences pain during access or canal instrumentation, it is advisable to reconsider the original diagnosis because the radiolucency may be a lesion of nonodontogenic origin. A useful website for the differential diagnosis of radiographic lesions (ORAD II) was created by Dr. Stuart White

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and is available on-line at http://www.orad.org/difDiag.html. A definitive diagnosis of a periradicular osteitis can be made only after biopsy. When a discrepancy exists between the initial diagnosis and clinical findings, consultation with an endodontist is advisable. Patients undergoing chemotherapy or radiation to the head and neck may have impaired healing responses. Treatment should be initiated only after the patient's physician has been consulted. Resolving the question of endodontic treatment or extraction for preradiation patients often requires a dialogue between the dentist and physician.

The effect of the external beam of radiation therapy on normal bone is to decrease the number of osteocytes, osteoblasts, and endothelial cells, thus decreasing blood flow. Pulps may become necrotic from this impaired condition. Toxic reactions during and after radiation and chemotherapy are directly proportional to the amount of radiation or dosage of cytotoxic drug to which the tissues are exposed. Delayed toxicities can occur several months to years after radiation therapy. The outcome of endodontic treatment should be evaluated within the framework of the toxic results of radiation and drug therapy. The cancer patient's white blood cell (WBC) count and platelet status should also be reviewed before endodontic treatment. In general, routine dental procedures can be performed if the granulocyte count is greater than 2000/mm3 and the platelet count is greater than 50,000/mm. If urgent care is needed and the platelet count is below 50,000/mm, consultation with the patient's oncologist is required.56

Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome

It is important for clinicians treating acquired immunodeficiency syndrome (AIDS) patients to understand their patient's level of immunosuppression, drug therapies, and potential for opportunistic infections. Although the effect of human immunodeficiency virus (HIV) infection on long-term prognosis of endodontic therapy is unknown, studies have shown that HIV patients do not have increased risk for postoperative pain or inflammation after endodontic treatment. The clinical team must also minimize the possibility of transmission of HIV from an infected patient, and this is accomplished by adherence to universal precautions (see http://www.cdc.gov/ncidod/hip/BLOOD/UNIVERSA.HTM for details). Although saliva has not been demonstrated to have transmitted the virus in a dental situation, the potential for it to do so exists.12,18,31 Infected blood can transmit HIV, and during some procedures it may become mixed with saliva. Latex gloves and eye protection are essential for the clinician and staff. HIV can be transmitted by needlestick or an instrument wound, but the frequency of such transmission is low, especially with small-gauge needles.31

A vital aspect of treatment planning for the patient with HIV/AIDS is determining the current CD4 lymphocyte count and level of immunosuppression. Generally patients having a CD4 count of more than 400 mm3 may receive all indicated dental treatment. Patients with a CD4 count of less than 200 mm3 will have increased susceptibility to opportunistic infections and may be effectively medicated with prophylactic drugs.31 Medical consultation is advisable before surgical procedures and before initiating complex treatment plans.

End-Stage Renal Disease

Consultation with the patient's physician is suggested before dental care is initiated for patients being treated for end-stage renal disease. Depending on the patient's status and the presence of other diseases common to renal failure (e.g., diabetes mellitus, hypertension, systemic lupus erythematosus), dental treatment may be best provided in a hospital setting. The goal of dental care for patients being treated for end-stage renal disease is to restore and maintain the mouth to a healthy state and prevent infection.31

Dialysis

The most recent American Heart Association guidelines do not include a recommendation for

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prophylactic antibiotics before invasive dental procedures for patients with intravascular access devices. However, other investigators advise that prophylactic antibiotics are prudent for hemodialysis patients with arteriovenous shunts/grafts when invasive dental procedures are performed.13,32,37,55 Although controversy exists, antibiotic prophylaxis should be provided for patients receiving hemodialysis who have known cardiac risk factors. For patients undergoing hemodialysis who do not have known cardiac risk factors, consultation with the managing physician or nephrologist is advised. When prophylaxis is used, the standard regimen of the American Heart Association is recommended. Some drugs frequently used during endodontic treatment are affected by dialysis. Drugs metabolized by the kidneys or nephrotoxic drugs should be avoided.

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Both aspirin and acetaminophen are removed by dialysis and require a dosage increase in patients with renal failure. Amoxicillin and penicillin V also require a dosage adjustment following hemodialysis. It is advisable to consult the patient's physician concerning specific drug requirements during endodontic treatment.31 Endodontic treatment is best scheduled on the day following dialysis, since on the day of dialysis patients are generally fatigued and could have a bleeding tendency.

Diabetes

The Centers for Disease Control and Prevention (CDC) reported a 6% increase in the incidence of diabetes mellitus in the United States in the year 2001. The dramatic increase has been linked to a remarkable 57% increase in obesity among Americans during the last 10 years. Twenty percent of Americans are classified as obese. It has been estimated that 15.7 million persons in the United States representing 5.9% of the population have diabetes.31 It is likely that diabetic patients requiring endodontic treatment will be increasingly common.11 Diabetes mellitus appears to have multiple causes and several mechanisms of pathophysiology.31 Diabetes mellitus can be thought of as a combination of diseases that share the key clinical feature of glucose intolerance. Patients with diabetes, even those who are well controlled, require special consideration during endodontic treatment. The patient with diabetes who is well controlled medically and free of serious complications, such as renal disease, hypertension, or coronary atherosclerotic disease, is a candidate for endodontic treatment. However, special considerations exist in the presence of acute infections. The non-insulin-controlled patient may require insulin, or the insulin dose of some insulin-dependent patients may have to be increased.31 In cases in which surgery is required, consultation with the patient's physician is advisable to consider adjustment of the patient's insulin and dosage, antibiotic prophylaxis, and dietary needs during the postoperative period. A source of glucose (orange juice, soda, Glucola) should be available if symptoms of an insulin reaction occur. Acute infections in the diabetic patient should be managed using the standard approach of: incision and drainage, pulpectomy, antibiotics, and warm rinses.

Appointments should be scheduled with consideration given to the patient's normal meal and insulin schedule.31 The patient with diabetes who is well managed medically and is under good glycemic control without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease can receive any indicated dental treatment.16 However, patients with diabetes who have serious medical complications may need a modified dental treatment plan.43 Moreover, recent studies suggest that diabetes is associated with a decrease in the success of endodontic treatment in cases with preoperative periradicular lesions.8,17 These patients may require referral to an endodontist for alternative treatment considerations.

UPDATE Date Added: 14 March 2006

Karl Keiser, DDS, MSPrevalence of apical periodontitis among type 2 diabetics

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As defined by the American Diabetes Association, diabetes mellitus is a "disease in which the body does not produce or properly use insulin."1 Type 1 diabetes is caused when the body does not produce sufficient quantities of insulin, and type 2 diabetes results when the body's tissues cannot properly use insulin (termed insulin resistance). Both result in abnormally high serum glucose levels, with a host of potentially adverse effects. According to Miley and Terezhalmy, oral manifestations of diabetes may include xerostomia, periodontal disease, candidiasis, and burning mouth syndrome. 2 Advanced glycation end products (AGEs) are formed under conditions of hyperglycemia, and underlie some of mechanisms by which clinical changes occur. AGEs have been shown to cause increased production of pro-inflammatory cytokines in response to stimulation by cell wall components of gram-negative bacteria and to effect neutrophil chemotaxis and phagocytosis, all part of the body's response to pathogenic microbes.

Thomson et al.3 report a higher incidence of periodontal attachment loss among diabetics, and rodent models of diabetes demonstrate that bacterial challenge to the pulp canal system results in more alveolar bone resorption compared to normal animals. 4,5,6 Fouad7 suggests that diabetes may alter the progression of endodontic infections in humans, and Bender and Bender have suggested that humans with diabetes are also more prone to the development of apical periodontitis (AP). 8 A recent study by Segura-Egea et al. examined this possibility in a Spanish population. 9 Records of 32 patients reporting well-controlled type 2 diabetes were matched with a cohort of healthy non-diabetics. Full-mouth radiographic surveys were examined by using the Periapical Index system (PAI). 10 One calibrated examiner evaluated the radiographs (intra-observer kappa = 0.77), and analysis of variance and logistic regression were used to determine the significance of differences of the number of teeth with AP (both root filled and untreated) between normal and diabetic patients. AP (as defined by a PAI of > 2) was found in 81% of diabetics as compared to 58% of controls (p = 0.04). This relationship was especially significant in untreated teeth (p= 0.004).

According to the 2004 American Dental Association's and the U.S. Food and Drug Administration's Guidelines for Prescribing Dental Radiographs, 11 the individualized radiographic examination for the new adult patient may consist of posterior bitewings with panoramic or selected periapical images. It is noted, however, that these recommendations are subject to clinical judgment. While the prudent clinician must evaluate every patient for the presence of apical periodontitis, the results of Segura-Egea et al. suggest that increased vigilance is appropriate for even patients with well-controlled diabetes.

1. Click here

2. Miley DD, Terezhalmy GT. The patient with diabetes mellitus: etiology, epidemiology, principles of medical management, oral disease burden, and principles of dental management. Quintessence Int. 36:779-795, 2005. Medline Similar articles

3. Thomson WM, Slade GD, Beck JD et al: Incidence of periodontal attachment loss over 5 years among older South Australians. J Clin Periodontol 31:119-125, 2004.

4. Kohsaka T, Kumazawa M, Yamasaki M, Nakamura H: Periapical lesions in rats with streptozotocin-induced diabetes. J Endod 22:418-421, 1996. Medline Similar articles

5. Fouad A, Barry J, Russo J et al: Periapical lesion progression with controlled microbial inoculation in a type 1 diabetic mouse model. J Endod. 28:8-16, 2002.

6. Iwama A, Nishigaki N, Nakamura K et al: The effect of high sugar intake on the development of periradicular lesions in rats with type 2 diabetes. J Dent Res 8:232-325, 2003.

7. Fouad AF. Diabetes mellitus as a modulating factor of endodontic infections. J Dent Educ 674:459-67, 2003.

8. Bender IB, Bender AB. Diabetes mellitus and the dental pulp. J Endod 296:383-389, 2003.

9. Segura-Egea JJ, Jimenez-Pinzon A, Rios-Santos JV et al: High prevalence of apical periodontitis amongst type 2 diabetic patients. Int Endod J 388:564-569, 2005.

10. Orstavik D, Kerekes K, Eriksen HM. The periapical index: A scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 21:20-34, 1986.

Prosthetic Implants

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Patients with prosthetic implants are frequently being treated in dental practices. The question concerning the need for antibiotic prophylaxis to prevent infection of the prosthesis has been debated for many years. A lack of scientific data has resulted in empiric recommendations to give dental patients prophylactic antibiotics.29,30,40 A statement was issued jointly in 1997 by the American Dental Association and the American Academy of Orthopedic Surgeons in an attempt to clarify the issue.31 The statement concluded that scientific evidence does not support the need for antibiotic prophylaxis for dental procedures to prevent prosthetic joint infections. It went on to state that antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it routinely indicated for most patients with total joint replacements. However, the statement indicated that some "high risk patients" who are at increased risk for infection and undergoing dental procedures likely to cause significant bleeding should receive antibiotic prophylactic treatment. Such patients would include those who are immunocompromised or immunosuppressed, who have insulin-dependent (type I) diabetes, who are in the first 2 years following joint replacement, or who have previous joint infections, malnourishment, or hemophilia.31 The advisory statement concludes that the final decision on whether to provide antibiotic prophylaxis is the responsibility of the clinician who must consider potential benefits against the risk. It should be noted that endodontics has been shown to be an unlikely cause of bacteremia,4,39 in contrast to extractions, periodontal surgery, scaling, and prophylaxis. Consultation with the patient's physician on a case-by-case basis is advisable to establish the need for prophylaxis.

Behavioral and Psychiatric Disorders

Stress reduction is an important factor in the treatment of patients with behavioral and psychiatric disorders. Sensitivity to the patient's needs must be part of the dental team's approach. Significant drug interactions and side effects are associated with tricyclic antidepressants, monoamine oxidase inhibitors, and antianxiety drugs.31 Consultation with the patient's physician is essential before using sedatives, hypnotics, antihistamines, and opioids.

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The initial visit, during which medical and dental histories are gathered, provides an opportunity to consider the patient's psychosocial status. Although some patients may want to maintain a tooth with a questionable prognosis, others may lack the necessary sophistication to comprehend the potential risks and benefits. It would be a mistake to lead patients beyond what they can appreciate, and patients should not be allowed to dictate treatment that has a poor prognosis.

The clinician should also assess the patient's level of anxiety as an important part of preparation for the procedure to follow. It is reasonable to assume that most patients are anxious to some degree, especially when they are about to have endodontic treatment. A conversation describing the procedure and what the patient can expect is an important part of an anxiety reduction protocol. It is well documented that a high level of anxiety is a predictor of poor anesthesia and postoperative pain.10,35 More than 200 studies indicate that behavioral intervention for the highly anxious patient before treatment decreases anxiety before and after surgery, reduces postoperative pain, and accelerates recovery.10

Recent Medical Research: Dental Implications

Patients with Hodgkin's disease or breast cancer often receive irradiation to the chest as an element of treatment.19 Although the therapy often cures the malignancy, it has been implicated in causing late-onset heart disease that may influence the development of a treatment plan and subsequent treatment.19 Therapeutic irradiation of the chest results in the inadvertent inclusion of the heart within the irradiation field. Some patients may experience pathologic changes of the heart valves that could predispose them to endocarditis, accelerated atherosclerosis of the

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coronary artery that increases their risk of experiencing a fatal myocardial infarction, or both.19 Clinicians need to identify patients who have received irradiation to the chest and consult with patients' physicians to determine whether therapy has damaged the heart valves or coronary arteries. Patients with irradiation-induced valvular disease may require prophylactic antibiotics when undergoing specific dental procedures that are known to cause a bacteremia and a heightened risk of developing endocarditis. Patients with radiation-induced coronary artery disease should be administered only limited amounts of local anesthetic agents containing a vasoconstrictor; they may require the administration of sedative agents and cardiac medications to preclude ischemic episodes.19 Consultation with the patient's physician is an appropriate response to a history that includes prior radiation to the chest.

There is a widespread belief among dentists and physicians that oral anticoagulation therapy in which patients receive drugs such as warfarin sodium (Coumadin) must be discontinued before dental treatment to prevent serious hemorrhagic complications, especially during and after surgical procedures. Aspirin is a commonly used drug as an anticoagulant on a daily basis without the supervision of a physician. Clinical studies published within the past 5 years do not support the routine withdrawal of anticoagulant therapy before dental treatment for patients who are taking such medications.26 When patients report that they are receiving an anticoagulant medication, dentists and patients can benefit from using the following guidelines:

Identify the reason the patient is receiving anticoagulant therapy. Assess the potential risk versus benefit of altering the drug's regimen. Know the laboratory tests used to assess anticoagulation levels. Be familiar with local methods of obtaining hemostasis both intraoperatively and

postoperatively. Be familiar with the potential complications associated with prolonged or uncontrolled

bleeding.

Consult the patient's physician to discuss the proposed dental treatment and determine the need to alter the anticoagulant regimen.

UPDATE Date Added: 31 July 2006

Karl Keiser, DDS, MS; University of Texas Health Science Center at San AntonioCan smoking lead to an increase in the need for root canal therapy?

Smoking is a known risk factor for many important bacterial and viral infections, including influenza, meningococcal disease, otitis media, pneumococcal pneumonia, and periodontitis.1 Mechanisms suggested to explain this increased risk of infections in smokers include changes in the respiratory tree, vascular changes, and a decrease in the host's immune response. Some of these changes can have important effects on the health of tooth pulp and periradicular tissues.

A pilot study performed at the University of Washington calculated an odds ratio (OR) for the presence of persistent periapical disease after root canal therapy associated with current cigarette smoking to be 2.6 with a 95% CI of 0.8-9.0.2 (The OR is the ratio of the odds of an event occurring in an experimental group divided by the odds in a control group; an OR >1 indicates that the event is more likely in the experimental group). Although this OR was not statistically significant (P < .14), the authors concluded that it warranted further study with a larger sample size.

A recent article by Krall et al.3 examined the hypothesis that by virtue of its effects on vascular and immune function in dental tissues, smoking results in a higher incidence of root canal treatment. The study enrolled 811 men with complete smoking histories, including 234 cigarette smokers, 137 cigar or pipe smokers, 210 former cigarette smokers, and 230 never-smokers. Over the 5-year course of the study, 385 participants received root canal therapy on 998 teeth. As expected, these teeth were more likely to have caries, large restorations (five surfaces), or crowns. When these factors were controlled for, current cigarette smokers had an OR for root

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canal treatment of 1.9 with a 95% CI of 1.4-2.5. In men who had quit smoking >9 years prior to the study, the incidence of root canal therapy was similar to that of the men who had never smoked.

The outcome measure for this study, root canal therapy, is an indirect reflection of the presence of apical periodontitis, which is likely underrepresented because only the teeth that were treated by endodontic therapy were counted. The risk of apical periodontitis among smokers is probably much greater than estimated. Although exact mechanisms cannot be discerned from this study, its longitudinal nature, large sample size, and regular follow-up, and the findings of dose relationships are highly suggestive of a causal relationship between smoking and the need for root canal treatment. Practitioners who offer smoking cessation programs in their dental offices could take advantage of these findings and use this information to help motivate their patients: "It's either quit smoking, or you're going to need a root canal."

References

1. Arcavi L, Benowitz NL: Cigarette smoking and infection. Arch Intern Med 164:2206-2216, 2004. Medline Similar articles

2. Gonzales SM, Hollender LG, Hujoel PP: Tobacco use and root canal failure: a case-control study. Available at: Click here

3. Krall EA, Sosa CA, Garcia C, et al: Cigarette smoking increases the risk of root canal treatment. J Dent Res 85:313-317, 2006. Medline Similar articles

UPDATE Date Added: 21 March 2006

Ken Hargreaves, DDS, PhDBisphosphonate-associated osteonecrosis of the jaws

The most common orofacial pain conditions are typically related to acute inflammation, infection, or injury to peripheral nerves. Therefore, we have become accustomed to evaluating typical pain presentations, establishing whether the pain is of odontogenic or non-odontogenic origin, and then developing a differential diagnosis for our patients. Occasionally, new pain conditions are recognized (e.g., herpetic infections of pulpal nerves), but these, too, generally fit into one of these three basic categories.

Recently, however, a new disorder has been recognized that fundamentally changes our understanding of pain mechanisms and forces rapid recognition of new risk factors and treatment strategies. In 2003, Marx and colleagues reported on bisphosphonate-associated osteonecrosis of the jaws (BONJ) and many case reports have followed (see references). Due to the current lack of any effective treatment for this painful condition, its impact on endodontic treatment planning, and its ability to mimic odontogenic pain, it is very important that clinicians understand this new entity.

Bisphosphonates are a class of drugs that are used to treat patients with osteoporosis, Paget's disease, and certain cancers such as multiple myeloma and bone metastases originating from primary tumors located in tissues such as breast or prostate gland. Bisphosphonates act as pyrophosphate analogs and are thought to preserve bone due to their inhibitory actions on osteoclasts, although other actions such as inhibition of blood vessel growth have also been reported. Examples of bisphosphonates are given in the associated Table 1. Given the broad range of indications, it should not be surprising that some bisphosphonates such as the oral formulations of alendronate, ibandronate, etc., have >20 million prescriptions written yearly, whereas the IV formulations (e. g., zolendronate, pamidronate) are used much less often and generally for patients with cancer. This distinction may be important because to date, most case reports of BONJ are associated with the IV bisphosphonates. Although early reports suggested that BONJ was a "drug effect" (i.e., occurring only with i.v bisphosphonates), a recent report by the FDA (Chang, 2004) stated that BONJ appeared to be a class effect because oral bisphosphonates such as alendronate have been reported to be associated with BONJ. The best

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available current evidence suggests that IV bisphosphonates impose a greater risk while the oral bisphosphonates have a lower risk for BONJ.

BONJ typically presents as an intraoral mucosal ulceration with irregular borders, exposed bone, pain that can be severe in intensity, and occasionally purulence and altered sensation of the area (e. g., paresthesia, "heaviness" sensation). Although bisphosphonates are incorporated into bone throughout the skeleton, it is not known why the osteonecrosis occurs only in the jaws and not in any other bones of the body. Case reports often associate these patients with having a history of a traumatic dental procedure (e.g., tooth extraction, implant placement, periodontal surgery, etc) preceding the development of BONJ. This traumatic event may have occurred weeks or months prior to the presentation of BONJ. The mechanism for BONJ is not currently known, although one hypothesis is that the osteonecrosis develops due to an interaction of the traumatic dental procedure with healing bone in a susceptible patient taking bisphosphonates. There currently is no effective treatment for BONJ; several treatments including surgical resections, hyperbaric oxygen, and antibiotics have been attempted with little to no improvement. Accordingly, preventive strategies are paramount, and recommendations are similar to those used to treat a patient with a risk for osteoradionecrosis. Most of the present data consist of case reports, case series, and expert opinion and thus constitute a lower level of evidence. Of course, ethical constraints preclude randomized controlled trials, and clinical recommendations for adverse conditions such as BONJ are often developed only with these lower levels of clinical evidence.

The AAE has recently developed a set of recommendations for endodontic implications in managing patients taking bisphosphonates (Click here ). These recommendations are:

Recognize the risk factors of bisphosphonate-associated ONJ Apply preventive dental therapies. Preventive procedures are very important to reduce

the risk of developing ONJ because treatment of ONJ is not predictable at this time. Preventive care might include caries control, conservative periodontal and restorative treatments, and, if necessary, appropriate endodontic treatment. Similar to the management of the patient with osteoradionecrosis, this might include non-surgical endodontic treatment of teeth that otherwise would be extracted. Teeth with extensive carious lesions might be treated by non-surgical endodontic therapy, possibly followed by crown resection and restoration similar to preparing an overdenture abutment.

To the extent possible, avoid traumatic procedures including surgery and soft tissue trauma, and reduce the risk of trauma (e. g., smooth off restorations, adjust dentures, etc.).

Consider bisphosphonate-associated ONJ when developing a differential diagnosis of non-odontogenic pain.

Use the entire health care team, including the patient's general dentist, oncologist, and oral surgeon, when developing treatment plans for these patients.

Be aware that the knowledge base for bisphosphonate-associated ONJ is rapidly increasing and it is likely that these recommendations may change over time. Thus, the prudent practitioner is encouraged to continue to review new publications in this area

DENTAL EVALUATION

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The strategic value of the tooth in question should be considered before presenting alternative treatment plans to the patient. Although a final decision may be straightforward, the consideration of alternative treatment options can also be challenging as the clinician considers multiple factors that will play a role in determining the ultimate success or failure of a case. Referral of the patient to a specialist should be considered when the complexity of the procedure is beyond the ability of the clinician. Factors that affect endodontic prognosis, including periodontal and restorative, must be considered (see Chapter 2 for additional information). The alternative of a dental implant offers another choice when the endodontic prognosis is poor.

Case Selection: Endodontics or a Dental Implant

Prognosis of Endodontic Treatment *References 20, 21, 33, 36, 48, 51, 52.

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The prognosis of endodontic therapy has been extensively studied. The study designs are marked by their diversity and vary in their case selection, numbers of subjects, operative techniques, follow-up periods, definitions of success, and who provided the treatment. Many studies have demonstrated that the success rate is significantly influenced by a preexisting periradicular radiographic lesion.* Teeth with a preexisting apical radiolucency have been shown to have a lower success rate than teeth without such lesions. In a classic study, Strindberg54 found that remineralization of periapical lesions could take up to 9 years after treatment. More recently, Sjogren and associates52 noted that uncertainty exists concerning the influence of the size of the preoperative periapical lesion on clinical success. Results of studies with short follow-up periods may be skewed and not reflect the true prognosis. Cohort studies of 3 or 4 years may be required to record a stable treatment outcome.9,28,38

The objective of a recent study, established in 1993, is to prospectively assess the 4- to 6-year outcome of endodontic treatment performed in a university graduate clinic environment.21 The project is designed to provide cumulative data with the completion of each phase that will be used to determine the influence of potential prognostic factors on the outcome of treatment. The initial phase of the project studied 450 teeth. The "healed" rate was significantly higher for teeth treated without apical periodontitis (92%) than with apical periodontitis (74%). The overall "healed" rate was 81%. This study confirmed apical periodontitis as the main prognostic factor in initial treatment cases. The patient's systemic resistance and the quality of instrumentation, obturation, and final restoration also play an important role in the ultimate outcome of endodontic treatment (Fig. 4-3).5 The scope of modern endodontics has been enhanced by the use of ultrasonics and microscopy as well as improved instruments and new materials. Teeth can be retained today that would not have been treated in the past. Biologically, it has become increasingly clear that elimination of intraradicular infection is the key to endodontic success.

An important advantage of providing endodontic therapy is to allow rapid return of the patient's compromised dentition to full function and aesthetics. This rapid return is in marked contrast to the use of provisional restorations associated with dental implants while waiting for osseous integration.

UPDATE Date Added: 02 May 2006

Karl Keiser, DDS, MS, University of Texas Health Science Center at San AntonioWhat impact does instrument separation have on the outcome of nonsurgical endodontic treatment?

While techniques can be used to minimize the fracture of any endodontic instrument (for review, see "Causes of Instrument Separation" in Chapter 25 by Drs. Roda and Gettleman), instrument separation is a fact of life and will likely happen in the career of any clinician who performs endodontic treatment. With the recent acceptance of rotary nickel titanium (NiTi) instrumentation

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techniques, the concern over file separation has increased, although data on the prevalence of fracture in clinical practices are scarce. Patients often want to know whether the prognosis is affected by this procedural mishap. There have been studies regarding the effect of instrument separation on outcome; however, these studies generally involved stainless steel files used in a hand instrumentation technique and were not well controlled.1-3 Since the problem cannot be addressed in a prospective manner for ethical reasons (that is, purposefully breaking a file in a root canal during treatment), prospective, randomized clinical trials are not possible. The highest level of evidence that can be used to assess the effect of instrument separation on outcome would be retrospective case-control studies (see "Glossary of Evidence-Based Terms" on the Pathways of the Pulp home page for a description of study designs).

Recently, Spili, Parashos, and Messer published the results of a case-control study involving 146 teeth in which instruments had separated during endodontic treatment that were matched with 146 control teeth.4 All cases treated nonsurgically from 1990 to 2003 in two endodontic practices (seven endodontists) were evaluated for the presence of instrument fracture. Out of 8460 cases, 277 were found to have at least one separated instrument (including both stainless steel hand files and NiTi rotary files), for a prevalence of 3.3%. Of these 277, certain cases were excluded for outcome determination if the tooth showed evidence of a fractured instrument before treatment, if there was a clearly defective coronal restoration, or if clinical and radiographic recall information of at least one year's duration was not available, yielding 146 teeth available for outcome assessment. Appropriate matching controls were randomly selected from a pool of 956 nonsurgical treatments in which there had not been a file separation. Blinded and calibrated examiners reviewed all cases and matching controls. Healing occurred in 91.8% of cases with separated instruments compared to 94.5% of matched controls. This difference was not statistically significant. If a periapical radiolucency was present preoperatively, healing rates for both groups were diminished: to 86.7% in the separated instrument group and to 92.9% in the control group. This is in agreement with existing endodontic outcome studies, the majority of which have found apical periodontitis to be a risk factor for nonhealing.

Although prudence dictates that techniques to minimize the risk of instrument fracture must be employed during endodontic treatment, a relatively high level of evidence exists that allows the clinician to assuage the fears of patients regarding the prognosis of their root canal therapy, all of whom must be informed if an instrument separates during treatment.

1. Strindberg LZ: The dependence of the results of pulp therapy on certain factors: an analytical study based on radiographic and clinical follow-up examinations. Acta Odontol Scand 14:78, 1956.

2. Grossman LI: Guidelines for the prevention of fracture of root canal instruments. Oral Surg Oral Med Oral Pathol 28:746-752, 1969. Medline Similar articles

3. Fox J, Moodnik RM, Greenfield E, Atkinson JS: Filing root canals with files radiographic evaluation of 304 cases. NY State Dent J 38:154-157, 1972.

4. Spili P, Parashos P, Messer HH: The impact of instrument fracture on outcome of endodontic treatment. J Endod 31:845-850, 2005. Medline Similar articles

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Figure 4-3 A, Inflamed, edematous interproximal tissue (arrow) caused by acute endodontic pathosis. B, Soft tissue healing (arrow) 3 days after initiation of endodontic treatment. C,

Periradicular pathosis. D, Completed endodontic therapy. E, Periradicular healing at 1-year recall.

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Dental Implants

The advent of dental implants as a predictable alternative provides the clinician with new treatment options. Although research on the long-term efficacy and success of dental implants is ongoing, it seems clear that when appropriately utilized they offer a valuable alternative when preservation of the natural dentition is not possible. Currently, perspective randomized clinical trails are lacking that compare tooth retention with endodontic treatment with replacement of a tooth with an implant. Such a study would have to recognize, among a long list of variables, patients' systemic health, periodontal status, restorative treatment, type of implant used, and pretreatment status of the endodontically treated tooth.

Patients benefit when clinicians consider the entire range of treatment options. The options considered should be based on sound biologic principles and individually selected on a case-by-case basis.

Periodontal Considerations

Extensive periodontal lesions frequently complicate the endodontic procedure being considered. Such lesions may necessitate consultation with an endodontist or periodontist or both to gather more information about the tooth's prognosis. Periodontal probing is an essential element in endodontic case selection. Multirooted teeth with periodontal complications offer a variety of multidisciplinary complexities and treatment possibilities. A tooth with a poor periodontal prognosis may have to be sacrificed, despite the probability of a favorable endodontic prognosis. In some situations it may not be clear if the primary problem is periodontal or endodontic. This fact can influence the treatment plan; the pathogenesis can be better understood after vitality testing, periodontal probing, radiographic assessment, and evaluating the dental history. The risk to the total treatment plan should be kept in mind when questionable procedures are considered. It is not prudent to incorporate a chronic problem into a new complex prosthesis (Figs. 4-4 and 4-5).

Surgical Considerations

Surgical evaluations are particularly valuable in the diagnosis of lesions that may be nonodontogenic. Biopsy is the only definitive means of diagnosing such a lesion. When retreatment is being considered, the clinician must determine if nonsurgical, surgical, or combined treatment is appropriate. This decision is influenced by the presence of complex restorations, posts, and the radiographic assessment of prior endodontic therapy.

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Figure 4-4 Tooth #19 has a poor prognosis. Periodontal probing reached the apex of the distal root. Extraction is indicated and should be done as soon as possible to prevent further damage to the mesial bone associated with tooth #18. There are restorative questions concerning the ultimate treatment plan: Should the mesial root of tooth #19 be retained? Should tooth #20 be

used as an abutment? Should an implant be placed? (Courtesy Dr. Brian Licari.)

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    Figure 4-5 The large, bony defect associated with tooth #29 healed after endodontic therapy. The tooth was nonvital, and no significant periodontal probing depth indicated pulpal disease.

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Figure 4-6 Four years after endodontic therapy, the patient complained of pain and swelling associated with tooth #6. The initial impression was that apical surgery was indicated.

However, further radiographs revealed the true cause of the endodontic failure. The initial endodontic access through the crown or caries damaged the coronal seal.

Restorative Considerations

A satisfactory restoration may be jeopardized by a number of factors. Subosseous root caries (perhaps requiring crown lengthening), poor crown/root ratio, and extensive periodontal defects or misalignment of teeth may have serious effects on the final restoration. Therefore these problems must be recognized before endodontic treatment is initiated. For nonemergency complicated cases, a restorative treatment plan should be in place before starting endodontic treatment. Some teeth may be endodontically treatable but nonrestorable, or they may represent a potential restorative complication in a large prosthesis. Further, reduced coronal tooth structure under a full-coverage restoration makes endodontic access more difficult because of reduced visibility and lack of radiographic information about the anatomy of the chamber (see also Chapter 7). Thus it is not unusual for restorations to be compromised during endodontic access (Fig. 4-6). Whenever possible, restorations should be removed before endodontic treatment

Other Factors That May Influence Endodontic Case Selection

A variety of factors may complicate proposed endodontic therapy. Calcifications, dilacerations, and resorptive defects may compromise endodontic treatment of a tooth with potentially strategic value (Fig. 4-7). The inability to isolate a tooth is also a problem and may result in bacterial contamination of the root canal system. Extra roots and canals pose a particular anatomic challenge that radiographs do not always reveal (Fig. 4-8). Retreatment cases offer particular mechanical challenges (Fig. 4-9) and are discussed in detail in Chapter 25. Ledges, perforations, or a post may be present, all of which complicate treatment and alter the prognosis. The dentist should recognize these potential problems and be able to manage and factor them into the decision concerning the tooth's prognosis, including the possibility that the patient should be referred to a specialist. An approach has been suggested that permits a clinician to evaluate each patient to determine the level of anticipated difficulty and helps the generalist to identify which cases should be referred for specialty care.46

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    Figure 4-7 Resorptive defects can be successfully treated. Early intervention, before there is perforation of the root, increases the chance of success. (Courtesy Dr. Leon Schertzer.)

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   Figure 4-8 Radiographs do not always demonstrate canal complexities. A, Initial radiograph. B, Highly magnified view of the pulp chamber. C, Completed endodontic treatment. (Courtesy Dr.

Lee Adamo.)

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    Figure 4-9 Retreatment of tooth #30 was complicated by the presence of four canals.

Some clinicians use a simple formula for determining which endodontic cases they treat and which they refer to a specialist. The number of roots may be the determining factor in a decision concerning referral, or the key factor may be the chronic or acute status of the case. Having specific goals at each visit helps to organize the treatment. For example, in an uncomplicated molar or premolar, some clinicians will set a specific goal for the first visit that includes access and thorough instrumentation, while deferring the obturation to a second visit. Uncomplicated single-rooted, vital teeth may be planned for a single-visit approach. It is important that ample time be allowed so that the procedure can be completed without stress. These recommendations have a biologic basis. It is not biologically sound to partially instrument root canal systems, thereby leaving residual inflamed pulpal remnants or necrotic debris in the canal, since such remnants may cause pain and be susceptible to infection.5 The clinician would be well advised to begin canal instrumentation only if time permits for the extirpation of all pulp tissue.

The most important variables in determining whether to refer a patient to a specialist are the skills of the clinician and the complexity of the case.

Recently the American Association of Endodontists (AAE) developed guidelines for assessing endodontic case difficulty.1 The AAE Endodontic Case Difficulty Assessment Form enables a clinician to assign a level of difficulty to a particular case. The form describes cases of minimum,

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moderate, and high degrees of difficulty. This form lists criteria that can be used to identify when a clinician should refer a patient to a specialist (see Fig. 2-6).1 The use of surgical operating microscopes, endoscopes, and ultrasonics enable the specialist to predictably treat teeth that would not have been treatable before.

DEVELOPMENT OF THE ENDODONTIC TREATMENT PLAN

Vital Case

The acute vital case is best managed using a biologically based approach. Pain in such cases may be due to increased intrapulpal pressure and inflammatory mediators such as prostaglandins. The challenge for the clinician is to painlessly treat inflamed and well-innervated tissue. Performing a complete pulpotomy or, if time permits, establishing measurement control and completing a pulpectomy have a high degree of predictability in alleviating pain.5,23 It has been shown that simply debriding the pulp chamber is also a highly predictable method of providing pain relief.23 When a canal has been entered the clinician is committed to removing all tissue. Partial instrumentation (i.e., leaving tissue remnants in the canal) may result in increased postoperative pain.5 Teeth should be closed with a temporary filling at the conclusion of the visit.

Nonvital Case

The acute nonvital case represents a microbiologic challenge for the clinician. A tooth that has had a nonvital pulp for some time may suddenly become acutely painful (see Chapter 2 for managing these emergency cases). The cause of this dramatic change is due to an imbalance in the host-parasite relationship.5 This can be due to an increase in the virulence of bacteria, a change in the flora, or a reduced host defense mechanism.5 These changes can be initiated simply by opening the tooth and changing the environment of the bacterial flora. The therapeutic goals in such cases are to reduce as much as possible the bacterial content in the root canal system and to promote decompression of the periradicular tissues by instrumentation and irrigation of the canal. Calcium hydroxide should be temporarily sealed into the root canal or canals with a cotton pellet in the pulp chamber. Teeth should be closed and the endodontic treatment completed as soon as possible to prevent continued bacterial penetration into the canal. When a fluctuant swelling exists, incision and drainage may be performed in conjunction with canal instrumentation (Fig. 4-10).

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Retreatment cases offer a particular set of challenges to the clinician, and this topic is covered extensively in Chapter 25. Leading questions to be considered before retreatment include the following:

Why did the case fail? Are prior radiographs available for review? Is there an obvious procedural problem that can be corrected? Is the canal system readily accessible for reentry? Are there additional factors (other than endodontic) that may have contributed to the

failure? Is the tooth critical to the treatment plan?

Does the patient understand the prognosis for the tooth and want to attempt retreatment?

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    Figure 4-10 Incision and drainage should be performed on this fluctuant swelling (arrow) in conjunction with canal instrumentation.

A retreatment plan should be developed after the clinician has determined the cause of failure and weighed other factors that may affect the prognosis (e.g., root fracture, defective restoration) (Figs. 4-11 to 4-14). Retreatment cases may require surgical endodontics in combination with nonsurgical retreatment. Referral to a specialist is often helpful when planning treatment for complex cases.

Immature Teeth

Primary and immature permanent teeth may have pulpal pathosis caused by caries or trauma; preserving these young teeth is essential. Premature loss of an anterior tooth can lead to malocclusion, predispose the patient to tongue habits, impair aesthetics, and damage the self-esteem of the patient. The reader is referred to Chapter 22 for further information.

Endodontic and Periodontic Considerations

The relationship between the pulpal and the periodontal tissue complex begins during the embryonic stage of dental development. The richly vascularized dental papillae and the surrounding, future periodontal tissues have a shared circulation. This interrelationship provides the anatomic basis for potential pathosis as described in Chapter 17.

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Figure 4-11 Two years after endodontic therapy on tooth #8, the patient returned with pain and swelling. A dentist mistakenly began endodontic access on tooth #7, without confirming the apparent radiographic diagnosis with vitality testing. Tooth #7 was vital, and tooth #8 was

successfully retreated after removal of the post. (Courtesy Dr. Leon Schertzer.)

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Figure 4-12 Many years after endodontic treatment of tooth #30, the patient returned with a chief complaint of pain and an inability to chew on the tooth. Despite the radiographic

appearance of excellent endodontic treatment, the tooth was retreated and the patient's pain disappeared. Note the unusual distal root anatomy, which was not apparent during the initial procedure. A, Initial radiograph. B, Completion of initial endodontic therapy. C, Retreatment.

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   Figure 4-13 Retreatment of tooth #26 resulted in healing of the periradicular lesion. The initial radiograph was misleading and implicated tooth #25 and tooth #26. Pulp testing indicated a

vital pulp in tooth #25, so it was not treated. (Courtesy Dr. Leon Schertzer.)

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Figure 4-14 Nonsurgical retreatment of tooth #30. Note additional root located and treated. A, Note inadequate endodontic treatment and large periapical lesion. B, Bite wing radiograph. C,

Retreatment after post removal. D, Eighteen-month recall radiograph indicates periapical healing.

Endodontic Surgery

Endodontic surgery may be performed as an initial treatment or as a retreatment procedure. Before considering the actual treatment, the clinician should consider the most prudent measure to prevent recurrence of the problem. For example, if the cause of failure is a leaking coronal restoration, then apical surgery will probably fail. As a primary treatment modality, apical surgery may be performed when there is a completely calcified canal. As a retreatment procedure, apical surgery is performed as a secondary effort to salvage failed endodontic treatment. The primary reason for apical surgery is to improve the quality of the apical seal. In recent years dramatic changes have occurred in the techniques and materials used for surgical resolution of complex cases as discussed in Chapter 20.

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Single-Visit Versus Multivisit Treatment

Debate is ongoing about the merits of a single-visit or multivisit approach to endodontic treatment. An extensive body of research has sought to determine relative success rates, pain associated with each approach, and its relationship to pulp vitality and the presence of periapical oseitis.15,24,41,44

Vital Cases

Vital cases are often suitable for single-visit treatment. The number of roots, time available, and the clinician's skills are factors to be considered. Severity of the patient's symptoms is another important consideration. For example, a patient in severe pain should not experience a long visit including access, instrumentation, and obturation. Treatment in such cases may be directed at alleviating pain, with filling of the canal postponed for a later visit. The clinician's judgment of what the patient can comfortably tolerate (regarding duration of the visit) is on a case-by-case basis. Whenever possible, it is desirable to complete endodontic treatment for vital teeth in one visit for several reasons, including less posttreatment pain.15,24,41,44

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Nonvital Cases

Although consensus exists that teeth with nonvital pulp and apical periodontitis are more complex cases with greater resistance to endodontic treatment (i.e., reduced success rate), agreement is lacking concerning the appropriateness of single-visit endodontics for treating these cases. Some have postulated that the intervisit use of an antimicrobial dressing is essential in eradicating infection completely from the root canal system.51,52 In contrast, other researchers have found no statistically significant difference in success when using the single-visit or multivisit approach to the nonvital tooth with apical periodontitis.20,42,57 The final answer is yet to be determined.

Research Review

Agreement is lacking concerning long-term success rates associated with single-visit and multivisit procedures. Sjogren and associates51 investigated the influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. Periapical healing was observed for 5 years. They concluded that "Complete periapical healing occurred in 94% of cases that yielded a negative culture. When the samples were positive before root filling, the success rate of treatment was just 68%-a statistically significant difference." They concluded that the objective of eliminating bacteria from the root canal system "cannot be reliably achieved in a one-visit treatment because it is not possible to eradicate all infection from the root canal without the support of an interappointment antimicrobial dressing." The findings of Friedman,20 Weiger et al,57 and Peters and Wesselink42 contrast with those of Sjogren et al.51 Those studies found no statistically significant differences in healing observed between teeth treated in one visit and two visits with the inclusion of calcium hydroxide as an intravisit medication.42,57 This is a complicated issue since the inability to detect differences between groups might also be due to sample size, duration of follow-up times, treatment methods, and so on.

A recent study concerning the outcome of initial treatment noted the complexity of treating apical periodontitis. The author commented that "…treatment of this disease cannot be improved merely by changing treatment techniques. Because apical periodontitis results from interactions between microorganisms, their environment and the host immune system, only use of effective modifiers of any of these three factors might significantly improve the outcome of treatment."20

Scheduling Considerations

If a vital case must be treated using a multivisit approach, it is the author's opinion that the clinician should allow 5 to 7 days between canal instrumentation and obturation for the periradicular tissue to recover. When a vital case is to be treated in a single visit (usually the

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preferred treatment plan), adequate time must be scheduled so the clinician can complete the procedure without stress. It is wise to schedule patients who require mandibular block anesthesia to arrive 15 to 20 minutes before their treatment visit. This avoids the frustration of "losing treatment time" while the anesthetic agent becomes fully effective.

Subsequent appointments for treating nonvital cases should be scheduled with approximately 1 week between visits in order to maximize the antimicrobial effect of the intracanal dressing when calcium hydroxide is used.5,51,52 Acute (painful) nonvital cases must be seen every 24 to 48 hours in order to monitor the patient's progress and bring the acute symptoms under control. Further cleaning and shaping are important components of the treatment as the clinician seeks to eliminate persistent microbes in the canal system. Long delays between visits contribute to the development of resistant microbial strains and should be avoided.

References

1. American Association of Endodontists website: Click here

2. American Academy of Oral Medicine website: www.aaom.com.

3. Bean LR Jr, Devore WD: The effects of the protective aprons in dental roentgenography, Oral Surg Oral Med Oral Pathol 28:505, 1969. Medline Similar articles

4. Bender IB, Naidorf IJ, Garvey GJ: Bacterial endocarditis: a consideration for physician and dentist, J Am Dent Assoc 109:415, 1984. Medline Similar articles

5. Bergenholtz G, Horsted-Bindslev P, Reit C: Textbook of Endodontology, ed1, Oxford, UK, 2003, Blackwell.

6. Bricker SL, Langlais RP, Miller CS: Oral Diagnosis, Oral Medicine, and Treatment Planning, ed 2, Philadelphia, 1994, Lea & Febiger.

7. Briggs GG, Freeman RK, Yaffe SJ: Drugs in Pregnancy and Lactation: a Reference Guide to Fetal and Neonatal Risk, ed 5, Baltimore, 1998, Williams & Wilkins.

8. Britto LR, Katz J, Guelmann M, Heft M: Periradicular Radiographic Assessment in Diabetic and Control Individuals, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 96:449, 2003. Medline Similar articles Full article

9. Bystrom A, Happonen RP, Sjogren U, Sundqvist G: Healing of periapical lesions of pulpless teeth after endodontic treatment with controlled asepsis, Endodon Dent Traumatol 3:58, 1987.

10. Carr DB, Goudas LC: Acute pain, Lancet 353:2051, 1999. Medline Similar articles Full article

11. Centers for Disease Control and Prevention: The status of diabetes mellitus in the U.S.: surveillance report, MMWR Morb Mortal Wkly Rep 50(3):101, 2001.

12. Cottone JA, Molinari JA: State of the art infection control in dentistry, J Am Dent Assoc 122(9):33, 1991.

13. Dajani A et al: Prevention of bacterial endocarditis: recommendations by the American Heart Association, Clin Infect Dis 25:1448, 1997. Medline Similar articles

14. Dionne RA: New approaches to preventing and treating post operative pain, J Am Dent Assoc 123:27, 1992. Medline Similar articles

15. Fava LRG: One appointment root canal treatment: incidence of postoperative pain using a modified double flapped technique, Int Endodon J 24:258, 1991.

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