Endodontic Treatment Plan

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ENDODOCTIC
TREATMENT PLAN
LAM KIM TRIEN DDS
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Terminology
• Reversible pulpitis: viêm tủy có hồi phục
• Symptomatic irreversible pulpitis: viêm tủy không hồi phục có triệu chứng
• Asymptomatic irreversible pulpitis: viêm tủy không hồi phục không triệu chứng
• Chronic hyperplastic pulpitis: viêm tủy triển dưỡng/polyp tủy
• Internal Resorption: nội tiêu
• Pulp necrosis: hoại tử tủy
• Necrobiosis/ partial necrosis: hoại tử tủy bán phần
• Acute Apical periodontitis: Viêm quanh chóp cấp/ viêm khớp cấp
• Acute apical abscess: áp xe quanh chóp cấp
• Chronic apical abscess/ Chronic Alveolar Abscess: áp xe quanh chóp mạn
• Phoenix Abscess/ Acute Exacerbation of Asymptomatic Apical Periodontitis: Áp xe quanh chóp tái phát
• Condensing osteitis: viêm xương tụ cốt
• Radicular Cyst: nang quanh chóp
• External Root Resorption: ngoại tiêu

TREATMENT PLANNING
“Every tooth on the jaw from central incisor to third molar can be
a potential candidate for root canal therapy”
However, not every tooth is suitable for endodontic treatment.
Errors in case selection, some of which could have been
avoided, constituted 22% of failures reported in a study by Ingle
and Beveridge.
- Grossman ‘s Endodontic Practice-

- Explaining the treatment

immediately is essential as the
current disease progresses if it is
managed early, increasing the
chances of successful treatment

Chief Complaint
Diagnostic Process:
Past/recent Medical &
Dental History
Clinical Examination:
Extraoral & Intraoral
Clinical testing:
Pulp/periapical test
Radiographic analysis
Differential Diagnosis,
Definitive Diagnosis
Treatment Planning
Indications of Endodontic Treatment

- caries, trauma, fracture,...

Elective
Endodontics

Abrasion Abfraction Erosion
Tooth wear
Attrition
Erosion
Contraindications
- Only few absolute contraindications of the endodontic therapy
- Poor candidates for endodontic treatment:

• extensive root caries, furcation caries, poor crown/root ratio and fractured root
• not possible instrumentation like roots with dilacerations, calcifications, dentinal sclerosis
• limited mouth opening like trismus or scarring from surgical procedures or trauma
• large, multiple external root resorptive lesions
• vertical root fractures
• teeth with no strategic value
• Systemic conditions: not contraindicate the endodontic treatment, need to evaluate
thoroughly

Mandibular first molar with extensive caries and periapical radiolucency

Mandibular first molar with extensive root and furcation caries

Radiograph showing extensive external resorption of maxillary right central incisor

Pulpal Diseases
Progression of Pulpal Pathologies
https://www.nature.com/articles/sj.bdj.2015.812
A Healthy pulp
B Reversible pulpitis
C Irreversible pulpitis
D Pulp necrosis
Fig. 1.20 A, Pulp polyp, also known as hyperplastic pulpitis. The involved tooth is usually
carious with extensive loss of tooth structure; the pulp remains vital and proliferates
from the exposure site
Source: https://eu-ireland-custom-media-prod.s3-eu-west-
1.amazonaws.com/UKMEAEU/eSample/9780323624367.pdf
Apical Diseases

Acute apical periodontitis (AAP) Chronic apical periodontitis
Souce: https://codental.uobaghdad.edu.iq/wp-
content/uploads/sites/14/2018/10/Raghad-2.pdf
Acute apical abscess

Condensing osteitis
Source:https://www.smilesforlifeoralhealth.org/to
pic/periapical-abscess/ Source:https://codental.uobaghdad.edu.iq/wpcont
ent/uploads/sites/14/2018/10/Raghad-2.pdf

Medical Conditions Influencing Endodontic

Treatment Planning
• Valvular disease: Prophylactic antibiotics before the endodontic therapy
• Hypertensive condition: check the blood pressure before initiation of
treatment, use local anesthetic with minimum amount of vasoconstrictors
• Prosthetic valve: Prophylactic antibiotic and consult a doctor prior to
treatment
• Leukemia: consult the doctor, avoid treatment during acute stages,
evaluate the bleeding time and platelet status, use of antibiotic prophylaxis
• Bleeding disorders: Take history of the patient, consult the doctor,
prophylactic antibiotic

• Renal disease: consult the doctor, check the blood pressure before
initiation of treatment, avoid drugs metabolized and excreted by
kidney
• Diabetes mellitus: consult the doctor, note the blood glucose levels,
schedule the appointment early in the morning
• Pregnancy: can treat in second trimester, consult the doctor, not take
a radiograph, avoid any harmful drugs to the fetus
• Anaphylaxis: take careful history of the patient, avoid contact the
allergic agent, always keep the emergency kit available

FOR PULP DISEASES

Clinical Symptoms Diagnostic tests Radiographically
classification
Normal pulp - No symptoms - Response to cold testing - Normal PDL space
and effect lasts only for and intact lamina
1–2 sec, then disappear dura
- Response normally to
electrical pulp testing


classification
- Reversible - Sharp, short pain with cold, - Cold test: response to - Normal PDL space
pulpitis sweet, and sour stimuli. cold testing and effect and intact lamina
- It last for a few seconds, lasts only for 1–2 sec, dur
then relieved then disappear, - Normal periapical
- Pain never spontaneous enough for diagnosis area
- Response normally to
electrical pulp testing
- Percussion and
Palpation—negative,
no response

Treatment planning
Reversible pulpitis (deep carious lesion,
hypersensitive dentin, recent restoration, traumatic
occlusion,undetected fracture)
Ø Preserve pulp vitality (indirect or

direct pulp capping), restore cavity
Ø Place desensitizer on the exposured
dentin tubules
Ø Adjust occlusion


classification
-Irreversible - Spontaneous sharp pain - Responsive to heat test - Intact lamina dura,
- Pain lasts for minutes to hours - EPT test: positive Slight widening of PDL
pulpitis (with - Poorly localized referred pain space
or without apical response
- Pain increases on bending and - If infection is
pathosis)
during sleep - Percussion/Palpation persistent, periapical
- Aggravated by hot, relieved test: radiolucency can be
by cold May or may not be positive seen

Treatment planning
Irreversible pulpitis (Deep caries
and/or restorations, exposed dentin (attrition,
abrasion, and erosion), traumatic injuries)
ü Pulpotomy/apexogenesis
ü Pulpectomy/ root canal
treatment, restore cavity
Mandibular right first molar of irreversible pulpitis
Sources:Textbook of Endodontics

Chronic Hyperplastic Pulpitis

ü Teeth of children and adolescents
ü Asymptomatic
ü Thermal test: respond feebly or not
ü Electrical pulp test: more than normal response
ü Treatment planning:
- Removal of hyperplastic pulp tissue using

periodontal curette or spoon excavator, followed by
root canal treatment/ extraction

Internal Resorption
Ø History of trauma or persistent chronic pulpitis, or
pulpotomy.
Ø Asymptomatic, recognized clinically through routine
radiograph, “pink tooth”
Ø Partial or complete necrotic pulp
Ø Clearly well-defined radiolucency of uniform density
which balloons out of root canal
Ø Treatment planning:
• Root canal treatment
• Surgical treatment is indicated if conventional
treatment fails
Sources:Textbook of Endodontics

Clinical classification Symptoms Diagnostic tests Radiographically
Necrotic pulp (with • Asymptomatic • Nonresponsive to heat • Intact lamina

or without apical • History of pulpitis or trauma test dura
pathosis) • Lack of normal translucent • EPT test: negative • Slight widening of
Etiology enamel or discoloration of tooth response PDL space
Deep caries and/or • If apical infection is • If infection is
restorations, exposed present, tenderness on persistent,
dentin (attrition, percussion is there periapical
abrasion, and erosion), radiolucency can be
traumatic injuries, seen
orthodontic forces

Treatment planning
Necrotic pulp:
Ø Root canal treatment followed by restoration
Ø Extraction of nonrestorable tooth.
Necrotic pulp in immature

teeth:
Ø Apexification

FOR APICAL DISEASES

classification
Acute Apical - Dull, throbbing, and - EPT and thermal - Slight
periodontitis constant pain, a short tests may be normal, or widening of
period of time similar to irreversible PDL space or
- Pain on biting and pulpitis or pulpal not be present
mastication necrosis - Periapical
-Palpation/percussion radiolucency
Positive response or not be seen

Treatment planning
Acute Apical periodontitis (Irreversible pulpitis,
traumatic injuries, periodontal disease, orthodontic forces,
restoration in hyperocclusion, root canal treatment
procedure):
ØAdjust the occlusion

ØEndodontic treatment, analgesics if
needed
ØExtraction if nonrestorable teeth


classification
- Acute apical - Spontaneous pain - Negative - Slight widening of
abscess - Pain on biting response to pulp PDL space or not
- Swelling of apical area vitality tests - Periapical
- Fever, discomfort, and - Positive response radiolucency or
spread widely leading to palpation and not
to formation of cellulitis percussion
- Slightly mobile
and extruded
from tooth ‘s
socket

Treatment planning
Acute apical abscess:
• Incision and drainage, endodontic treatment in
case of localized infections
• Incision and drainage, endodontic treatment,
antibiotics, nonsteroidal anti-inflammatory
drugs in the case of systemic complications
• Adjust occlusion in hyperocclusion cases
• Extraction if nonrestorable teeth


classification
- Chronic - Asymptomatic - Positive response - Slight
apical - The presence of a sinus to palpation and widening of
abscess/ tract or not percussion PDL space or
Chronic not
Alveolar - Periapical
Abscess. radiolucency
present
Complications: Formation of periapical granuloma, radicular cyst, sinus tract, and acute
exacerbation of the disease

Treatment planning
Chronic apical abscess:
o Establish drainage
o Root canal treatment

Treatment planning
Phoenix Abscess/ Acute Exacerbation of Asymptomatic
Apical Periodontitis:
• Establish drainage
• Endodontic treatment

Treatment planning
Condensing osteitis:

Treatment planning
Radicular Cyst:
• Apicoectomy
• Extraction (severe bone loss)

Treatment planning
External Root Resorption:
• Removal of stimulus
• Endodontic treatment before attempting
surgical treatment

Case 1:
- Following the placement of a full gold crown on the
maxillary right second molar, the patient complained of
sensitivity to both hot and cold liquids; now the
discomfort is spontaneous.
- Upon application of Endo-Ice® on this tooth, the patient
experienced pain and upon removal of the stimulus, the
discomfort lingered for 12 seconds. Responses to both
percussion and palpation were normal
- Radiographically, there was no evidence of osseous
changes.

Case 2:
- Maxillary left first molar has occlusal-mesial
caries and the patient has been complaining of
sensitivity to sweets and to cold liquids.
There is no discomfort to biting or
percussion. The tooth is hyper-responsive to
Endo-Ice® with no lingering pain.

Case 3:
- Mandibular left first molar demonstrates a
relatively large apical radiolucency
encompassing both the mesial and
distal roots along with furcation
involvement. Periodontal probing depths
were all within normal limits.
- The tooth did not respond to thermal
(cold) testing and both percussion and
palpation elicited normal responses.
There was a draining sinus tract on the
mid-facial of the attached gingiva which
was traced with a gutta-percha cone.
There was recurrent caries around the
distal margin of the crown.

Case 4:
- Maxillary left first molar was

endodontically treated more than 10
years ago. The patient is complaining
of pain to biting over the past three
months.
- There appear to be apical
radiolucencies around all three roots.
- The tooth was tender to both
percussion and to the Tooth Slooth®.

Case 5:
- Maxillary left lateral incisor exhibits an apical
radiolucency. There is no history of pain and the tooth
is asymptomatic.
- There is no response to Endo-Ice® or to the EPT,
whereas the adjacent teeth respond normally to both
tests. There is no tenderness to percussion or
palpation.

Case 6:
- Mandibular right first molar had
been hypersensitive to cold and
sweets over the past few months
but the symptoms have subsided.
- Now there is no response to
thermal testing and there is
tenderness to biting and pain to
percussion.
- Radiographically, there are diffuse
radiopacities around the root
apices.

Endodontic Treatment Plan

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This Document has been modified with Flexcil app (Android) https://www.fexcil.

Flexcil - The Smart Study Toolkit & PDF, Annotate, Note

Flexcil - The Smart Study Toolkit & PDF, Annotate, Note

Flexcil - The Smart Study Toolkit & PDF, Annotate, Note

- Explaining the treatment

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Indications of Endodontic Treatment

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Abrasion Abfraction Erosion

- Poor candidates for endodontic treatment:

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Mandibular first molar with extensive caries and periapical radiolucency

Mandibular first molar with extensive root and furcation caries

Radiograph showing extensive external resorption of maxillary right central incisor

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Acute apical periodontitis (AAP) Chronic apical periodontitis

Acute apical abscess

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Medical Conditions Influencing Endodontic

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FOR PULP DISEASES

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Clinical Symptoms Diagnostic tests Radiographically

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Ø Preserve pulp vitality (indirect or

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Clinical Symptoms Diagnostic tests Radiographically

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Mandibular right first molar of irreversible pulpitis

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Chronic Hyperplastic Pulpitis

- Removal of hyperplastic pulp tissue using

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Clinical classification Symptoms Diagnostic tests Radiographically

Necrotic pulp (with • Asymptomatic • Nonresponsive to heat • Intact lamina

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Necrotic pulp in immature

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FOR APICAL DISEASES

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ØAdjust the occlusion

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Clinical Symptoms Diagnostic tests Radiographically

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Clinical Symptoms Diagnostic tests Radiographically

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Endo-Ice® with no lingering pain.

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- Maxillary left first molar was

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