BDS 11134 Plan of treatment.pdf

lecture Outline: 1. Considerations during Endodontic Treatment Planning 2. Phases Of Treatment Planning 3. Single versus multiple visit endodontic treatment 4. Vital versus non-vital cases 5. Flare-ups 6. Immature cases 7. Retreatment cases 8. The use of antibiotics • It is achieving the best po...

lecture Outline: 1. Considerations during Endodontic Treatment Planning 2. Phases Of Treatment Planning 3. Single versus multiple visit endodontic treatment 4. Vital versus non-vital cases 5. Flare-ups 6. Immature cases 7. Retreatment cases 8. The use of antibiotics • It is achieving the best possible long-term outcomes for the patient, while, addressing all patient concerns and minimum/conservative necessary intervention • The treatment plan signifies the process of planning the management of the patient dental problems active problems, with the ▪ To determine the correct treatment and avoid misdiagnosis, it is essential to follow a systemic approach: 1. Determine the patient’s chief complain. 2. Take an accurate medical and dental history. 3. Perform a thorough examination, including all necessary tests. 4. Carefully evaluate all necessary radiographs. 5. Analyze the results to arrive at the proper diagnosis. 6. Evaluate the difficulty of the case and the ability of the clinician. Establish an appropriate treatment plan Proper Case Selection Starts right after thorough diagnosis with the recent advances that made diagnosis very meticulous . • Proper selection of cases avoids pitfalls during treatment and helps to ensure success. • Local and systemic considerations in case selection should be properly evaluated. Periodontal Surgical Prosthetic and restorative • Loss of periodontal attachment is not a contraindication to endodontic treatment; however, it may complicate the treatment. • Tooth mobility may affect the decision for endodontic treatment or extraction. • Presence of endo-perio lesions. 1. Failure of non surgical retreatment. 2. Failure of non surgical treatment and retreatment is not practical. 3. Need for biopsy. • However, the indications can be grouped as follows: 1. Need for surgical drainage: a. Soft tissue (I&D). b. Hard tissue (trephination). 2. Failed non surgical treatment: a. Rendered twice. b. Irretrievable root canal filling/post. 3. Calcific metamorphosis of pulp space (solid tooth). 4. Procedural errors and non surgical retreatment or correction failed: a. Instruments separation. c. Root perforation. b. Ledging. d. Symptomatic overfilling. • 5. Anatomic variations: • a. Root dilacerations. b. Apical root fenestration. • 6. Need for biopsy. • 7. Corrective surgery: • a. Root resorption. b. Root caries. c. Root resection (amputation). • d. Hemi section. e. Bisection (bicuspidization). • 8. Intentional replantation. • 9. Implant surgery: • a. Endodontic implant. • b. Osseointegrated implant. Contraindications: • Few contraindications to endodontic surgery exist. 1. Anatomic considerations: The major anatomical landmark of importance to endodontic surgery include: Nasal floor, maxillary sinus, mandibular canal and it’s neurovascular bundle and mental foramen. 2. Patient medical condition. 3. Dentist skill and experience. • Resistant cysts and periapical pathosis • Complicated iatrogenic conditions • Large perforations Altered anatomy and canal transportation • • • • Coronal portion is mutilated / poor crown root ratio Extensive caries affecting the furcation Massive Bone resorption Leakage 1. Control phase: 2. Holding phase: • eliminates pain, active disease, causes of disease • Time between the control and definitive • removes maintenance conditions preventing • Allows for resolution of inflammation and • begins maneuvers. time for healing. 4. Maintenance phase: 3. Definitive phase: • After the phase dentist reassesses initial treatment • Determination of further care. • Endodontic treatment is part of definitive phase for correction of dental problem. • Regular recall examinations. • The frequency examinations of depends reevaluations mainly patient's risk for dental disease. on the When to Refer the case ? • If the level of difficulty exceeds the practitioner’s experience and comfort. • Explain the reason for referral to the patient. • Advantages: • Minimizes the possibility of potential complications such as pain or swelling associated with untreated endodontic pathosis. • Minimize procedural errors. Pulpal And Periapical Diseases Pulpal diseases Periapical diseases Vital diseased Nonvital Necrotic pulp pulp Acute pulpitis Chronic pulpitis Acute Apical periodontitis Acute Apical Abscess Chronic Apical lesions Vital diseased Necrotic pulp Necrotic pulp pulp 1 Single Visit Multiple Visit Studies have been made to answer 2 basic questions: 1. Is single visit endodontic therapy more or less painful postoperatively than multiple visits therapy? 2. Is single visit endodontic therapy more or less successful than multiple visits therapy? It has been found that there was no detectable difference in the effectiveness of root canal treatment between single and multiple visits in terms of: 1-Success rate 2- Postoperative pain 4-Short and long term postoperative complications 3-Flare ups Single Visit Endodontics 1-It reduces the number of patient appointments specially for those who : a. Suffer fear and anxiety, b. Need premedication c. Patients that don’t return to complete the treatment 2- It eliminates the chance for interappointment microbial contamination and flare ups. 3-It eliminates the need of the clinician to re-familiarize the canal anatomy at the next visit. 4- It allows for the immediate use of the canal space for retention of a post and construction of an aesthetic temporary crown when required . 1-Flare ups cannot be easily treated by opening the tooth for draining as it is already obturated. 2-The long appointments may be tiring and uncomfortable for some patients who cannot keep their mouth open for a long time Single visit root canal therapy should be considered in the following cases: • Vital cases without preoperative apical periodontitis. • Necrotic uncomplicated cases with sinus tract. • Fracture anterior teeth where aesthetic is of importance. • Medically compromised patients who need repeated regimens of prophylactic antibiotics. • Patients who are physically unable to return for a second visit. • Patients requiring sedation or operating room treatment. Case Selection for Single-visit treatment Criteria for (Success) Positive patient’s acceptance. Absence of Apical periodontitis. Sufficient time available for treatment Periapical tissues either inflamed or infected Case Selection for Single-visit treatment Criteria for (Success) Absence of the need for drainage through the canal. Absence of periapical radiolucency. Absence of persistent continuous flow of exudate or blood. Absence of anatomical difficulties Calcification Tortuous/severely curved canals Absence of iatrogenic errors Over instrumentation Optimal apical and lateral seal can be achieved. Single visit should be avoided in: 1. Asymptomatic non-vital teeth with apical radiolucency and no sinus tract. 2. Most re-treatment cases. 3. Cases where hemorrhage or exudate can’t be controlled Indications Contraindications • Periapical pathosis • Periodontitis • Periapical abscess • Patient under general anesthesia • Medically compromised patient Advantages Disadvantages • Less Postoperative Pain ( debatable) • Patient acceptance • Increase chance of leakage and recurrent infection • Multiple injection times • Time required between visits Should not be too close nor too far • Too close Too far Periapical Tissues do not have opportunity to recover before next visit Secondary infection due to dislodgment of temporary filling Average time between visits 3-5 days • Not less than 48 hours and not more than 2 weeks Treating a non-vital pulp with apical periodontitis in a single or multiple visit has been a matter of controversy • Some researchers postulated that the inter visit use of an • Others found no differences in success and periapical healing between treating such cases in single or multiple visits, stating antimicrobial dressing is essential to that, it is possible that total elimination of completely disinfect the root canal bacteria may not be necessary for healing system ,but what matters: 1-Maximal reduction of bacteria 2-Effective root canal filling 3-Satisfactory coronal restoration 2- Vital Versus Non-Vital Cases Vital Cases: 1- Acute irreversible Non-Vital Cases: pulpitis 1- Pulp Necrosis 2- Chronic irreversible 2- Pulp necrosis with acute pulpitis apical abscess 3- Acute irreversible 3- Pulp necrosis with pulpitis chronic apical lesion with acute apical periodontitis A-Acute vital cases B-Acute non -vital cases These are cases with pain and or swelling that need an unscheduled appointment for quick treatment. Acute Pulpitis Acute Pulpitis With Apical Periodontitis Acute Apical Abscess Relief Acute Pain Establish Drainage Of Infection Once the acute symptoms have been relieved the clinician conduct a thorough examination of the patient and develops a customized Treatment plan A-Acute vital cases: Pain in such cases is due to: Increased intrapulpal pressure Acute Pulpitis Release of inflammatory mediators and extension of the pathologic process into periapical tissue Acute Pulpitis With Apical Periodontitis Treatment: 1- Pulpotomy 2- Pulpectomy( if time permits) The tooth should be closed with temporary filling in order to prevent bacterial contamination (emergency treatment) After instrumentation of vital tooth with a history of pain on percussion: 1- The canals should be medicated with calcium hydroxide 2- Occlusal reduction is important to prevent post-operative pain 3- Analgesics Scheduling Considerations Vital cases • Adequate time must be scheduled, so that the clinician can finish comfortably the procedure if single visit is intended. • If a vital case is to be treated by multi-visit approach, the clinician should allow 5-7 days between instrumentation and obturation in order to allow periapical tissue recovery A-Acute non- vital cases: Acute non-vital cases present a microbiological challenge A tooth that had an asymptomatic non-vital pulp for some time may suddenly become acutely symptomatic The cause of this dramatic change is due to the imbalance In the host-microbial relationship due to: Increase of bacterial virluence Changing environment of bacterial flora by simply opening the tooth. Reduction of host defense mechanism. Therapeutic Goals Reduce Bacterial Content In The Root Canal System Promote Decompression In The Periapical Tissues • Instrumentation :cleaning and copious irrigation. • In case of an acute periapical abscess: instrumentation and irrigation should be accompanied by establishing drainage through the root canal or incision and drainage when a fluctuant swelling exists. • Calcium hydroxide should be used as inter-visit dressing. • The tooth should be sealed. • Antibiotics and or analgesics should be prescribed. Scheduling Considerations • Endodontic treatment should be completed as soon as possible to prevent bacterial penetration in the canal. • Obturation is done when there is no pain, discharge or odor. • To fill a non-vital case, it should be scheduled 1 week after instrumentation to maximize the antimicrobial effect of the inter-visit intracanal medication. • Acute non vital cases should be seen every 24 to 48 hours to monitor the patient’s progress and control acute symptoms • Long delay between visits may lead to development of resistant microbial strains and should be avoided. 3- Flare ups Acute exacerbation of a periapical pathosis after the initiation or continuation of root canal treatment, that needs an unscheduled Emergency treatment Overinstrumentation Pushing dentinal debris in periapical area Incomplete removal of pulp Chemical irritation of periapical tissues Overextension of root canal filling ➢ Many of the Flare up cases could be treated pharmacologically or by occlusion adjustment. ➢ Resisting cases may require re-entry into the root canal or the establishment of drainage either through the root canal or via trephination especially with non-vital cases . The prophylactic use of antibiotics before treatment of necrotic teeth to decrease incidence of Flare ups has been a subject of controversy 4-Immature teeth Immature teeth with limited pulpal pathosis caused by caries or trauma • Vital pulp therapy to preserve pulp vitality to allow for continuation of root formation Immature teeth with necrotic pulps • Apexification to initiate root closure • Tissue regeneration to allow complete root formation 5-Retreatment Cases Before re-treatment is done, important issues should be considered:➢ Cause of failure. ➢ Presence of procedural error ➢ Accessibility for re entry of root canal. Retreatment Conventional Therapy Surgical Treatment • According to this: • Re- treatment could be done by conventional therapy alone and or surgical treatment. • The use of operating microscope and ultrasonics facilitated the non-surgical re-treatment in many cases that were re-treated surgically before. • Nonsurgical re-treatment is always preferable attempted before restoring to surgery. and should be • Surgery should be planned only when practitioner is certain that the failing case was initially treated properly and can’t be improved. Use of Antibiotcs: The use of antibiotics is a controversial issue due to : 1- Overprescribing of antibiotics have led to a)increased bacterial resistance b) patient sensitization c) increases the risk of potentially fatal anaphylactic reactions and exposes people to unnecessary side effects. 2- Antibiotics have been mistakenly prescribed for patients who have severe pain and the tooth is vital (antibiotics don’t relief pain) Indications Of Systemic Antibiotics In Endodontics: 1- Acute apical abscess in medically compromised patient. 2- Acute apical abscess with systemic involvement (elevated body temperature > 38°C, malaise, lymphadenopathy, trismus.) 3- Progressive infections (rapid onset of severe infections in less than 24 hours, cellulitis or spreading infection) . 4- Replantation of avulsed teeth (also topical administration of antibiotics is required). 5- Soft tissue trauma requiring treatment (sutures or debridement). 6- Medically compromised patients (as host defense mechanisms are thought to be inadequate). Note : antibiotic therapy is not an alternative to root canal treatment , it is only an adjunct to it. Indications for antibiotics as an adjunct during endodontic therapies Recommendations based on the International Association of Dental Traumatology (IADT) guidelines (Andersson et al. 2012), Contraindications for systemic antibiotics: 1- Symptomatic irreversible pulpitis with pain only and no other signs or symptoms of infections. 2- Pulp necrosis. 3- Symptomatic apical periodontitis ( pain , pain on percussion and widening of periodontal membrane space). 4- Chronic apical abscess (teeth with sinus tract and apical radiolucency) 5- Acute apical abscess without systemic involvement (only localized swelling). Otherwise most endodontic infections are confined within the tooth and can be successfully managed by root canal treatment ( root canal debridement ) and drainage or surgical removal of extraradicular infection. Antibiotic Prophylaxis For Medically Compromised Patients • Aim of antibiotic prophylaxis is: 1- To prevent local postoperative infections 2- To prevent metastatic spread of infection in susceptible individuals (impaired immunologic function) • Most individuals do not need antibiotic prophylaxis in connection with dental care. • Surgical endodontic treatment on teeth with persistent infection is considered a higher medical burden than conventional endodontic treatment. • In healthy individuals the microorganisms are scavenged from the bloodstream within minutes up to 1 h without causing any complications in healthy individuals Medically Compromised Patients: 1- Leukaemia , HIV/AIDS patients 2-Chronic disease (such as end-stage renal disease and dialysis or uncontrolled diabetes). 3-Medications such as chemotherapy, radiation, steroids. 4- Immunosuppressive post-transplant medications. 5-Genetic (such as inherited genetic defects). 6-Individuals with certain pre-existing heart defects (congenital heart defects, prosthetic cardiac valve or a history of infective endocarditis) are considered at risk for developing endocarditis when a bacteraemia occurs. 7-Patients with artificial joints, previous recent infection of the joint 8-Jawbones exposed to high dose of radiation for cancer treatment in the head and neck are more susceptible to local infection-related complications. 9-Prolonged use of bisphosphonates (more than 3 years). • Usually prescribed 1-2 hours before treatment • Penicillin is the drug of choice • Incase of Penicillin Allergy ---- Clindamycin is prescribed. • Anticipation of a particular treatment outcome does not increase certainty of its achievement but careful planning with attention to detail may. • Hence, the term “Provisional Treatment Plan” that is used to describe the interim plan containing an overlapping phases of diagnosis and treatment • Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapter 3) • Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. (chapter 3) • Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. • Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. • Clinical endodontics, 3rd edition, 2009, Leif Tronstad. (chapters 5 and 6)