Which cases to refer,which to treat?

June 1, 2010
Endodontic success or failure is often determined before access is made. The importance of preoperative treatment planning in endodontics cannot be overstated.

For more on this topic, go to www.dentaleconomics.com and search using the following key words: best endodontic results, which cases to refer? Dr. Richard Mounce, The Endo File.

Endodontic success or failure is often determined before access is made. The importance of preoperative treatment planning in endodontics cannot be overstated. In order to obtain the greatest probability of clinical success, endodontic therapy should be planned in advance. A carefully planned event has a much better chance of arriving at a predetermined destination than an event that unfolds without each treatment step building on another.

The following parameters should be assessed, and questions should be asked, before a case is started. Answering these questions and addressing these issues is predictive of clinical success. Alternatively, neglecting these key points is highly problematic. These include, in no particular order:

1Is the tooth restorable? If not, can the tooth be made restorable? Coincident to the determination of restorability, the clinician should note if there is any history of bruxism, occlusal trauma, or TMJ dysfunction.2Is there a perio endo component to the patient’s clinical diagnosis? Is the problem primarily periodontal, endodontic, or a combination? If so, which is the limiting factor? As a result of this periodontal or endodontic component, should the treatment be completed in one visit or two?3Is there evidence of resorption, trauma, or an open apex? Is the case a carious exposure on a lower molar of a young patient with open apices? How will the apex be managed? Is the tooth in this scenario vital or necrotic?4 What is the difficulty level of the contemplated endodontic treatment? How high is the risk of an iatrogenic event? If high, what strategies — file sequences, instrument types, enhanced glide path, irrigant of choice, etc. — will be required to avoid iatrogenic risk?5Are there medical or behavioral issues that will impact the long-term outcome of the case or contraindicate treatment and/or require modification of usual treatment routines? Would the patient be best treated while sedated either orally or with IV means?6Has there been an adequate radiographic examination to fully evaluate the case before beginning? If the tooth is a lower molar or upper first bicuspid, for example, can a third root be observed?7Has an adequate clinical examination been made to complement the radiographic examination in No. 6? Has the patient’s chief complaint been duplicated? Is the pain odontogenic? Was a firm diagnosis established prior to initiating the case? Once a firm diagnosis is established, how will this modify expectations and protocols during treatment? If the initial diagnosis is nonvital, for example, is the clinician prepared to treat the case in two visits, and if so, what interappointment medication should be used? Does the patient have an endodontic issue with concomitant occlusal trauma or pain of a nondental origin (as can occur in complex cases)?8As treatment commences, the clinician should ask him or herself if the access is straight line. After access, has the cervical dentinal triangle been removed before progressing apically? What is the anticipated final taper and master apical diameter?9What clinical equipment and supplies will be required to accomplish the case with the greatest efficiency and predictability? While a number of systems have their champions, I favor the use of Twisted Files* and RealSeal* in the form of RealSeal master cones and RealSeal One Bonded Obturators.* Regardless of the system used, the clinician should be entirely fluent in the use of the chosen system. For example, can the system prepare the expected taper to the true working length as well as the desired master apical diameter? One advantage of the Twisted File system is that it can predictably prepare a .08 taper along the length of the root and prepare an ISO master apical diameter of 50 at the minor constriction of the apical foramen.10Is the clinician prepared to place the coronal seal at the time of the initial treatment? If not, why not?

The greater the number of complicating factors, such as those mentioned above, the greater the requirement for referral. For the best possible service as well as strengthening the relationship between doctor and patient, if there is any doubt in the ability of the clinician to deliver an excellent result, the case should be referred to a trusted specialist endodontist colleague. There is only one best chance to achieve an excellent endodontic result. The profitable event for the clinician is the one where patients are delivered world-class services that honor them and their particular needs and predictably succeed the first time.

I welcome your feedback.

*SybronEndo (Orange, Calif.)

Dr. Mounce is the author of the nonfiction book Dead Stuck, “one man’s stories of adventure, parenting, and marriage told without heaping platitudes of political correctness,” available at Pacific Sky Publishing or DeadStuck.com. Dr. Mounce lectures globally and is widely published. He is in private practice in endodontics in Vancouver, Wash.

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