Dentistry may be viewed as a speciality of medicine, yet it is itself a diverse and broad discipline. Dentists are trained to recognize the majority of commonly presenting oral problems and to manage them appropriately through a process of selecting the right course of treatment for each patient. Many dental or oral problems may be managed in different ways depending on the judgement about the presence, progression and morbidity of the disease, the options available for management and the needs of the patient. The dentist will have been trained, by necessity, to recognize only the commonly presenting tendencies in each disease. Further personal experience and development may lead to recognition of rarer presentations as well. The typical pattern of clinical behaviour in the primary care (practice) setting is that recognition of a problem will lead to the triggering of a set treatment protocol. Such treatment patterns, based on clinical rationale but also shaped and influenced by business and management needs may lead to the passive application of heuristic principles to select treatment. On the whole, this approach probably works when preceded by active learning through assessment of personal outcomes over a lengthy period. However, the recognition and management of the full spectrum of complex oral and dental problems requires an approach based on deeper understanding of the problem and a higher level of engagement of cognitive, technical and clinical skills, acquired through specific advanced training. The breadth of complex restorative problems has increased in modern populations because of better general health and longer survival of people and their teeth. Surviving teeth are more ravaged by repair of disease and wear and tear. The restorative challenges posed coupled with the desire of people to retain functional and aesthetic dentitions into later life have driven the development of the restorative subspecialities of endodontics, periodontics and prosthodontics into ever more complex scenarios. The opportunities of specialization have allowed clinicians to develop their skills and knowledge in a restricted area of practice to a much higher level, but usually to the exclusion of other generalist skills. Conscientious general dental practitioners in many countries are, therefore, faced with the prospect of making a judgement about their own knowledge and skill limitation in the context of what a colleague with specialist status may achieve. Ideological, philosophical, financial, medico-legal and indemnity frameworks have, therefore guided the development of a referral culture for specific items of care. This does, however, mean that the onus of ensuring the coordinated and appropriate delivery of whole mouth and patient care rests with the referring general dental practitioner, in conjunction with other specialists and the medical practitioner where necessary. Honest and critical recognition of personal limitation is a key aspect of any governance structure that enables either further appropriate personal development or referral.
Conversely, the knowledge and skills of endodontics must be deployed judiciously to ensure that the patient receives appropriate care, meaning that the specialist must also understand the broader context within which their expertise is exercised. In simple terms, this means that the dentist should be well versed in all aspects of dentistry, understanding the role of each aspect in overall patient management, as well as being aware of potential overlaps and interactions between the subdisciplines. In the context of a healthcare profession, the “endodontist” must, therefore be a human being first, dentist second and endodontist last (Fig. 5.1).
The general dental practitioner with a special interest in endodontics will have the advantage that they will grasp both the broader aspects of the patients’ needs, as well as be able to deliver a higher level of care in endodontics, albeit perhaps not at a specialist level. The foregoing also means that a dentist uncomfortable with the practice of dentistry and seeking escape into a limited area of practice because it is their area of greatest comfort will seldom make the rounded clinician that a good endodontist should be.
The underlying rule in the appropriate utilization and coordination of the proliferating specialisms is effective and professional communication between the healthcare workers. Such communication should be recorded in writing and formalized in letters. Since these become important legal records, their composition demands appropriate care and professionalism.
Treatment planning, as the term implies, is the planning of the management of a patient’s dental and oral problems in a systematic and ordered way that assumes a complete knowledge of the patient’s needs, the precise nature of the problems and the prognoses of possible management options under consideration. In the case of simple dental problems, the dentist may be able to identify the problem efficiently, characterize it together with the patient’s needs and select the correct management option expeditiously. In the case of complex dental problems, it may be rare for both patient and dentist to develop such complete pictures of the problems and outcomes of restorative options as early as the first consultation. The dentist must gauge the problems correctly, as well as the patient’s attitude, motivation and compliance. The phase of assessment (establishment of a more complete picture of the problem(s) and patient compliance), therefore, often overlaps with the phases of decision making, planning and delivery of treatment (Fig. 5.2).
Anticipation of a particular treatment outcome does not increase certainty of its achievement but careful planning with attention to detail may. The term “provisional treatment plan” is used to describe the interim plan containing overlapping phases of diagnosis and treatment, when further information is sought to garner a clearer picture to determine a firmer action plan. A “definitive treatment plan” emerges as the information becomes more complete and the wishes of the patient and dentist crystallize into a more concrete, mutually acceptable proposal. This implies an ongoing process of information exchange and informed consent whereby the full extent of risks and benefits are shared and acted upon.
Even under the best set of circumstances, the most complete and definitive picture of the problems may not be reached because of deficiencies in diagnostic certainty and prognostic data on treatment outcomes. Despite this, dedicated, active practice, with continuous proactive personal development may propel a dentist to the state of mastery of their field relative to contemporary knowledge. Variations inherent in dentists’ philosophy, knowledge, experience, skills and judgement can give rise to differences in treatment planning between clinicians. Conscientious dentists, therefore, strive for improvement throughout their professional lives in what has now become formally recognized as continuing professional development (CPD). Active engagement in CPD is mandatory in some countries but not all. Unfortunately, some dental practitioners take the receipt of their practising licence as the end of formal professional development. Their frame of reference extends no further than the teachings at undergraduate level. Decision-making for them is a matter of following the simple heuristic decision-tree delivered as expedient undergraduate teaching. Their knowledge is therefore written in black and white, is clear and simple and may still serve the needs of those patients falling into the “central tendency” of disease presentation. It may not, however, serve those presenting with problems lying on the fringes of the normal distribution of the particular disease. The intellect and skills of such practitioners may consequently be stunted from flowering into their full potential.
The true scale of difficulty in treatment planning is only truly appreciated by those conscious and conscientious enough to endeavour to improve the service delivered to their patients. It is exemplified by the realization of the conscientiously developing dentist that the more they begin to understand the more they realize the extent of their knowledge limitation. A central pillar of clinical governance is the responsibility on each dentist to engage in ongoing personal development.
The aim of this chapter is to highlight the factors important in planning the endodontic management of pulpal and periradicular diseases and how to prioritize them in the context of the patient’s overall dental and oral needs. Treatment planning encompasses the phases of:
The textbook depiction of treatment planning commences at the first encounter with the patient, when a full assessment is made of the patient’s overall dental and oral problems. In this diagnostic phase, a detailed systematic appraisal is made in the classical manner described in Chapter 4. The end point of this is a series of conclusions about the general health of the patient and their current oral and dental problems; these will be juxtaposed with the patient’s own perception of their problem(s) and desires for correction of the same. The dentist’s insight will include the state of the patient’s dentition, periodontium, the teeth (presence of caries or tooth surface loss and their pulpal and periapical status), any restorations and soft tissues. A number of different solutions will be possible for management of each of the patient’s problems but the specific treatment options selected will be dictated by the particular effects of interaction of these problems on the patient’s desires, which may include their well-being, aesthetic demands, and functional requirements (eating, speaking, socializing). Factors such as technical feasibility, cost and time involved, dentist’s preferences based on their skills and knowledge, and the patient’s age, means, wishes and compliance in oral care may all play a part in determining the final outcome. In the ideal scenario, each option should be evaluated in an objective way taking the above factors into account, weighing the effectiveness and projected long-term prognosis (based on outcome data) with compliance, cost and time commitment. As the number of dental problems to be addressed increases (Fig. 5.3), so does the interaction between options for individual problems. This may have the overall effect of either complicating management or simplifying it because more radical solutions (such as extraction) become more appropriate. In any case, the options will be discussed with the patient and, after appropriate dialogue, negotiation and clarification, a mutually agreed choice of treatment or “treatment plan” will emerge (Box 5.1).
In essence, the process consists of assessing and accounting for the relevant problems at the level of the patient (their personal perspective on health and social well-being), then at the level of oral function (eating, speaking and aesthetics), and then at the level of the tooth (specific tooth-related problems). The dentist must understand clearly (defining the problem) what the patient expects at the first level. The dentist and patient will need to have a clear and open discussion (dialogue and negotiation) about concordance between the desired and the possible, at the second level. The dentist must use their skills and knowledge to deliver the integrated treatment that will meet the patient’s expectations at the tooth level.
A plan is then made of the sequence in which treatment will be executed, called the “plan of treatment” (Box 5.2). This may be defined as a strategic list or maybe detailed by visit. Once the treatment is completed, the patient will be recruited to a recall system to evaluate and maintain the work. At these recall reviews, note will be taken of any changes and dealt with according to a preplanned scheme for dealing with failure. Planning for failure should be considered as part of the overall long-term treatment plan.
In general dental practice, where a patient has often been under long-term care by a particular practice or dentist, the majority of interactions with the patient are part of continuing care. A plan of management will have been established at the first encounter at some point in the past and, in the simplest cases, requires no more than a review (recall) to evaluate a change in overall status and provide motivation for maintenance. Under these circumstances, the sudden precipitation of a pulpal or periapical problem may be managed in isolation as long as there are no complex restorative implications (Fig. 5.4). Where there are such complex restorative implications, the lack of insight or desire (on the part of the dentist) to tackle them may influence outcome of the endodontic problem (Fig. 5.5). It is therefore important that a rational analysis of the situation is performed conscientiously and difficult restorative decisions taken promptly as necessary, rather than procrastinating to another time when the situation is likely to be worse. Recognition of personal limitations in knowledge and skills, or seeking appropriate referral, is the key to finding a solution.
It is not uncommon and perfectly valid for patients on long-term recall, to have the supervising dentist place individual teeth on probation to review their status at a subsequent time because of uncertainty about a diagnosis or the progression of a lesion (Fig. 5.6a). A number of potential problems, not causing current difficulties will, therefore have been identified but a mutually agreed decision made between patient and dentist to leave the tooth/teeth alone and periodically review them. Such a plan of action is not uncommon both in unrestored mouths and in those that are heavily restored and on the borderland of catastrophic transition to a different, perhaps partially edentulous state. The latter situation describes the not uncommon condition of an ageing or restoratively ravaged dentition, where one further change could precipitate a radical review of the overall dental strategy for the patient, with major implications of time and cost. Small changes to the situation may be managed by minimal intervention and a “patchwork” approach but this also demands a more vigilant rather than complacent review strategy. The situation, however, must be clearly recognized and understood by both the patient and dentist using the so-called informed consent approach. The tooth in Figure 5.6a has been retreated (Fig. 5.6b) and placed on continuing review until a mutually agreed decision can be reached with regards to which of the previously discussed restorative options to pursue.
Fig. 5.6 (a) Symptomless 25 has been reviewed for some time and now has a sinus; (b) the same 25 has been retreated and is now under review to assess healing before making a decision about restorative options
It is not unheard of that, under some circumstances, with the passage of time, the mutually agreed plan may be forgotten or fades from memory, particularly where detailed medical or dental records are not maintained. Under these circumstances, the precipitation of a pulpal or periapical problem and even worse multiple problems that occur in rapid succession may cause the need for a radical review of the options. The sudden accumulation of such unfavourable events may prompt the patient to seek a second opinion. The nature of this next encounter, in all likelihood with somebody with a different philosophical perspective, may raise different opinions about the previous management. The precise nature of the previous mutually agreed treatment plan might not be fully appreciated in the absence of accurate and detailed records. The vagaries and subtleties that lead to differences in management approach may cause patient dissatisfaction, which sometimes (and in contemporary society increasingly frequently) leads to legal action. It is therefore considered best practice to keep detailed records of initial findings, option appraisals, discussions, rationale for decisions and informed consent for treatment.
Treatment planning may be categorized into a very broad spectrum of complexity from simple isolated problems to those multiple problems requiring complicated multidisciplinary management. At its most complex, treatment planning is a challenging, complicated and rewarding decision-making process for both the clinician and patient that involves a two-way dialogue (interrogation and negotiation), leading preferably to short-, medium-, and long-term goals for the management of the patient’s dentition. Difficulties are often caused by the contradictory desires, requirements and perceptions of both dentist and patient. The ways in which these may be resolved are numerous, even forming the basis for practice-marketing strategies. The factors influencing the decision-making process are many and can be classified into general patient factors, professional background and philosophy of the dentist, general oral and dental condition, and local factors related to the problem tooth (teeth). Factors that may confound the process include differences in perception and expectations between the dentist and patient. The dentist must be aware of the potential for such problems and be prepared to take appropriate action to circumvent them.
This hypothetical yet familiar illustration of operator and patient perspectives, which many will identify with, illustrates some sources of problematic communication. Clear and effective communication is the key to arriving at a mutually satisfactory treatment plan.
The options available to treat endodontic problems include dentine and pulp protection, vital pulp therapy, root canal treatment, root canal retreatment or periradicular surgery (including root-end management, root repair, root resection or extraction). The last option also requires a consideration of the alternative restorative options. Apart from feasibility, the cost and long-term priorities of the patient have to be weighed.
A cost–benefit analysis should be performed to aid the decision-making process as illustrated in Table 5.1. The outcome of such an analysis, though, is likely to be different depending upon the exact details of the situation. A recent health economic study using a Markov model evaluating the cost-effectiveness of clinical intervention over the life-time of an adult patient revealed that root-canal treatment is highly cost-effective as a first line intervention for a maxillary central incisor. Orthograde retreatment is also cost-effective, if a root-canal treatment subsequently fails, but surgical retreatment is not. Implants may have a role as a third line intervention if root canal retreatment fails.
Consider the not uncommon scenario of the pulp in a maxillary incisor of an otherwise intact dentition becoming compromised by a severe traumatic injury in a young, mature adult (Fig. 5.7a). The options of vital pulp therapy or root-canal treatment may be considered. The choice will centre on the prognosis of each treatment (based on biological factors) and the long-term benefit to the patient. If the tooth is not restoratively compromised and the root is mature, the high prevalence of pulp necrosis in such cases may lean the decision towards root-canal treatment and the appropriate restoration as having a high chance of success (Fig. 5.7b,c). Other restorative factors may not come into the equation at this stage but will be discussed with the patient.
If, under the same circumstances, the patient was younger with an incompletely formed root, the decision may now lean towards the more conservative vital pulp therapy (Fig. 5.8a) in order to aid completion of root formation and improve the long-term restorative prognosis (Fig. 5.8b). In the event that the traumatic injury in such circumstances is accompanied by severe coronal tooth fracture, the restorative prognosis may be further jeopardized (Fig. 5.9). Consideration of early replacement may have to be tempered by the psychological need to avoid loss of the tooth, as well as to delay permanent replacement during the growth phase of the individual, especially if an implant-retained crown is a possible alternative. The compromised tooth may, therefore, be retained as a suitable space maintainer until a more definitive solution can be executed.
Consider an identical scenario but where a traumatized, intact, mature, maxillary central incisor has been left untreated for years as the pulp slowly succumbs and the patient seeks attention either because of an acute infection or the discoloration caused by secondary dentine formation and/or pulp necrosis (Fig. 5.10a). On radiographic examination, it is found that the canal is sclerosed (Fig. 5.10b) and only evident in the apical third of the root associated with a periapical lesion. Now other considerations come into play, including the potential for successful outcome by conventional or surgical means, as well as the desire for correcting the discoloration. In the matter of the former problem, it has to be established whether the operator is confident of locating the canal using a conventional coronal approach (Fig. 5.10c), which would improve the chances of success (Fig. 5.10d). If not, injudicious dentine removal may result in compromised restorability of the tooth. A surgical approach may stand a better chance of finding the canal but may not help eradicate the major part of the infection in the root-canal system, compromising the chances of successful healing (Fig. 5.11). In addition, the absence of access to the pulp chamber also compromises the chances of internal bleaching of the tooth to help correct the discoloration. In this scenario, there is an increasing number of uncertainties as outcomes are less predictable. The decision-making now has to be aided by weighing the relative chances of success of the different endodontic options and, finally, also the restorative/aesthetic outcome.
Fig. 5.10 (a) Discoloration of tooth following trauma; (b) radiographic evidence of pulp calcification and dentine sclerosis; (c) example of sclerosed canal in maxillary incisor; (d) canal successfully negotiated and obturated