Diagnosis and treatment planning

A diagnosis of irreversible pulpitis was reached for the 16. The patient was advised that endodontic treatment was necessary if she wished to retain her tooth, after which the tooth would require a cuspal coverage restoration (for example, a crown or onlay). The patient was advised that a cuspal coverage restoration would reduce the likelihood of the tooth fracturing.

Before embarking on endodontic treatment, how would you assess the restorability of the tooth?

The overall restorability of the tooth must be established before carrying out endodontic treatment (Table 6.2.1); the following factors have to be assessed:

Table 6.2.1 Factors affecting the prognosis of a tooth requiring endodontic intervention

• Periodontal status The periodontal probing profile should be determined by ‘walking’ a periodontal probe around the circumference of the tooth. Localized increased probing depths may be of significance (for example; vertical fractures, furcation defects or perforation), and generalized increased probing depths indicating periodontal disease may adversely influence the long-term prognosis of the tooth.
• Prosthodontic status The amount and location of sound dentine should be assessed as this determines, firstly, whether the tooth can be restored back to function and, secondly, what type and design of coronal restoration is indicated. A minimum of 2 mm sound coronal dentine around the circumference of the tooth is necessary to provide a ferrule effect for the subsequent cuspal coverage restoration (for example, crown or onlay). Ideally, the entire existing restoration should be completely removed, to confirm quantity of sound dentine available for the subsequent coronal restoration, before embarking on endodontic treatment.
• Endodontic status Is it possible to identify and negotiate all the root canals to their ideal working length for subsequent preparation, disinfection and obturation? If these objectives can be met, then the endodontic prognosis of the tooth in question is excellent, regardless of whether the tooth is being root treated for the first time or being re-treated.

The above factors will determine the overall restorability of the tooth. It is essential to advise the patient that the existing restoration may have to be removed to assess the restorability of the tooth before attempting endodontic treatment. In some circumstances, extraction may be necessary if the tooth is found to be unrestorable. The patient should always be made aware that a new post-endodontic restoration may be required after the tooth has been successfully root treated.

How do endodontically treated teeth differ from vital teeth?

Endodontically treated teeth appear to be more susceptible to fracture compared with teeth with vital pulps (Figure 6.2.2). This is due to a cumulative effect of the following:

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