Tuesday, 10 March 2015

Are you referring to me? Endodontic Calamities.

This blog post is based on a talk by Dr Simon Stone at the Young Dentist Conference.


As I have discussed in one of my previous posts (see here), root canal treatment is often strikes fear into the hearts of young dentists like myself. Knowing which cases are suitable for treatment, as well as which ones should be referred onto a specialist is a skill which we all need to know so that patients are able to have realistic expectations in terms of whether their tooth can be saved or not. 

Predictability of root canal treatment is determined by the following:
  1. Pre-treatment assessment
  2. Preparation of pulp space
  3. Irrigation, disinfection and instrumentation
  4. Sealing of pulp space
  5. Coronal restoration
Difficulties which are often encountered before or during root canal include:

Decision making - is this tooth restorable? Don't be forced into treatments by patients

Managing patient's expectations - do not promise anything. How long will the root canal last depends on so many factors including your experience at endodontics and the case itself. 

Clinical Examination

  • The general state of the dentition - caries and periodontal status? Is root canal really the right option?
  • Quality and quantity of the remaining tooth tissue?
  • Do you have a solid foundation for a definitive restoration?
  • What to do if the tooth has an existing crown?
If in doubt about restorability, strip down the restorations and caries to make a decision.


Radiographic Examination

A radiograph is essential in order to come to the correct diagnosis and treatment plan. A periapical is usally sufficient, but sometimes parallax or CBCT can be helpful.

Things to assess on a radiograph:
  • Coronal quality - restorations, remaining tooth
  • Visible pulp chambers and radicular pulp - shape and size
  • Has this tooth been previously root treated?
  • Apical status e.g. apical periodontitis, abscess, cyst, granuloma?
Remember to report on your films fully!

Diagnosis and Treatment Planning

Beware if a patient presents with an odd history e.g. changing nature of pain, abnormal radiation, exacerbating factors, crosses the midline of the face etc. 
In these cases you should consider other possible diagnoses e.g. TMD, phantom tooth pain, trigeminal neuralgia, cracked tooth syndrome. 

If in doubt, other clinical tests you could employ include:
  • Hot/cold/TTP/EPT testing
  • Comparative testing to other teeth
State clearly your diagnosis e.g. symptomatic apical periodontitis 16 due to caries, then your treatment plan e.g.
  1. Assess restorability 16
  2. RCT 16
  3. Composite core 16
  4. Emax onlay 16

Instrumentation

The key message in instrumentation is know your system! There are lots of systems out there including Wave One, Reciproc, Sendoline, Protaper. 
Make sure you have a glide path and irrigate regularly with copious sodium hypochlorite which means you need to work under rubber dam!

If you are using a rotary system, follow the instructions for each system, but make sure you never force the instrument and a 'three peck rule' may be useful to minimise the risk of file separation. 

And remember to maintain patency throughout to prevent accumulation of dentine sludge. 

To read about obturation, see my previous endodontic post here

When should I refer?

Sometimes, things do go wrong. If you have trouble providing effective treatment, or even if you'd like a second opinion then referral is a sensible option. 
Questions you should ask yourself if you are considering referring a case include:
  • Does the tooth have a strong prognosis for (re)RCT?
  • Is it going to be a predictable treatment?
  • If not why not?
  • Can I (or anyone else) do a better job?
  • Do the alternatives have a strong prognosis?
There are 4 options for these teeth:
  1. Do nothing, observe/monitor
  2. Extract
  3. Orthograde treatment or retreatment
  4. Surgery 

So what sort of things are commonly referred?

  • Patients with a medical risk for XLA e.g. bisphosphonates, post radiotherapy
  • Anterior/premolar teeth are prioritised (often 7s are not accepted)
  • Important teeth with strong long term prognosis (>2mm ferrule, prognosis of endodontics better than prosthetic replacement)
  • Trauma and its sequelae including root resorption 
  • Atypical pain
  • Suspicious pathology
  • Surgical endodontics
Remember to always send a good quality radiograph when referring a case - either an original film, a copy printed on photography paper, or a CD ROM copy. 


Having seen a few cases in practice that I have struggled to treat, this talk has helped to clarify what cases are usually accepted for referrals. It was great to be lectured by one of my old tutors from Newcastle too - made me miss the old days of student life a bit!

See my latest post from the Young Dentist Conference - Are you referring to me? Mishaps of oral surgery. 

Do you find it difficult to decide when to refer endodontic cases to secondary care? Please leave your comments in the section below!


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