Case Selection and Treatment Planning

The process of case selection and treatment planning begins after a clinician has diagnosed an endodontic problem. The clinician must determine whether the patient’s oral health needs are best met by providing endodontic treatment and maintaining the tooth or by advising extraction. The use of rotary instruments, ultrasonics, and microscopy as well as new materials has made it possible to predictably retain teeth that previously would have been extracted. In addition, even teeth that have failed initial endodontic treatment can often be successfully retreated using nonsurgical or surgical procedures.

Increased knowledge concerning the importance of anxiety control, premedication with a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen, profound local anesthesia, appropriate occlusal adjustment, and biology-based clinical procedures enables clinicians to complete endodontic procedures without intraoperative or posttreatment pain.

Questions concerning tooth retention and possible referral can be answered only after a complete patient evaluation. The evaluation must include assessment of medical, psychosocial, and dental factors as well as consideration of the relative complexity of the endodontic procedure. Although most medical conditions do not contraindicate endodontic treatment, some can influence the course of treatment and require specific modifications. A number of valuable texts are available that review the subject of dental care for the medically compromised patient. The American Academy of Oral Medicine (Edmonds, WA) has an excellent website ( www.aaom.com ) that can be used to elicit information about medically compromised patients.

Perhaps the most important advice for a clinician who plans to treat a medically compromised patient is to be prepared to communicate with the patient’s physician. The proposed treatment can be reviewed, and medical recommendations should be documented. Fig. 3-1 depicts a sample medical consultation letter that can be modified as necessary.

FIG. 3-1
Sample medical consultation letter.

The American Society of Anesthesiologists (ASA; Park Ridge, IL) Physical Status Classification system is commonly used to express medical risk ( Box 3-1 ). The ASA classification system remains the most widely used assessment method for preanesthetic patients despite some inherent limitations to its use as a peritreatment risk predictor. This classification system is a generally accepted and useful guide for pretreatment assessment of relative risk but does not advise appropriate treatment modifications. The clinician should go beyond the classification system and gather more information from the patient and physician, including the patient’s compliance with suggested medication, frequency of physician visits, and most recent visit.

Box 3-1
American Society of Anesthesiologists Physical Status Classification System

  • P1: Normal, healthy patient; no dental management alterations required

  • P2: Patient with mild systemic disease that does not interfere with daily activity or who has a significant health risk factor (e.g., smoking, alcohol abuse, gross obesity)

  • P3: Patient with moderate to severe systemic disease that is not incapacitating but may alter daily activity

  • P4: Patient with severe systemic disease that is incapacitating and a constant threat to life

Typical questions include the following: Do you take medication as prescribed by your physician? Or, when was the last time you were examined by your physician? Other systems have been proposed that would better reflect the increasing number of medically complex patients treated by clinicians as Americans live longer. Regardless of the classification system used, these generalized guidelines need to be individualized for the patient under care.

An alternative means of considering risk assessment is to review the following issues:

  • History of allergies

  • History of drug interactions, adverse effects

  • Presence of prosthetic valves, joints, stents, pacemakers, and so on

  • Antibiotics required (prophylactic or therapeutic)

  • Hemostasis (normal expected, modification to treatment)

  • Patient position in chair

  • Infiltration or block anesthesia with or without vasoconstrictor

  • Significant equipment concerns (radiographs, ultrasonics, electrosurgery)

  • Emergencies (potential for occurrence, preparedness)

  • Anxiety (past experiences and management strategy)

A review of these areas provides the clinician with essential background data before initiating treatment.

Common Medical Findings That May Influence Endodontic Treatment Planning

Cardiovascular Disease

Patients with some forms of cardiovascular disease are vulnerable to physical or emotional stress that may be encountered during dental treatment, including endodontics. Patients may be confused or ill informed concerning the specifics of their particular cardiovascular problem. In these situations, consultation with the patient’s physician is mandatory before the initiation of endodontic treatment. “For patients with symptoms of unstable angina or those who have had an MI [myocardial infarction] within the past 30 days (major risk category), elective care should be postponed.” One study found “no significant increase in the risk of experiencing a second vascular event after dental visits, including those that involved invasive procedures, in periods up to 180 days after a first recorded ischemic stroke, transient ischemic attack (TIA) or acute MI.”

The use of vasoconstrictors in local anesthetics poses potential problems for patients with ischemic heart disease. In these patients, local anesthetics without vasoconstrictors may be used as needed. If a vasoconstrictor is necessary, patients with intermediate clinical risk factors (i.e., a past history of MI without ischemic symptoms) and those taking nonselective beta-blockers can safely be given up to 0.036 mg epinephrine (two cartridges containing 1 : 100,000 epinephrine) at one appointment. For patients at higher risk (i.e., those who have had an MI within the past 7 to 30 days and unstable angina), the use of vasoconstrictors should be discussed with the physician.

Vasoconstrictors may interact with some antihypertensive medications and should be used only after consultation with the at-risk patient’s physician. Local anesthetic agents with minimal or no vasoconstrictors are usually adequate for nonsurgical endodontic procedures (see also Chapter 4 ). A systematic review of the cardiovascular effects of epinephrine concluded that the increased risk for adverse events among uncontrolled hypertensive patients was low, and the reported adverse events associated with epinephrine use in local anesthetics was minimal. Another review highlighted the advantages of including a vasoconstrictor in the local anesthesia and stated that “pain control was significantly impaired in those patients receiving the local anesthetic without the vasoconstrictor as compared to those patients receiving the local anesthetic with vasoconstrictor.”

A patient who has specific heart conditions may be susceptible to an infection of the heart valves, induced by a bacteremia. This infection is called infective or bacterial endocarditis and is potentially fatal. In 2008, the American College of Cardiology and American Heart Association (AHA) Task Force on Practice Guidelines published an update on their previous guidelines, which focused on infectious endocarditis. This guideline stated that “prophylaxis against infective endocarditis is reasonable for the following patients at highest risk for adverse outcomes from infective endocarditis who undergo dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa: patients with prosthetic cardiac valves or prosthetic material used for cardiac valve repair . . . , patients with previous infective endocarditis . . . [and] patients with congenital heart disease.”

The specific recommendations are summarized in a reference guide by the American Association of Endodontists (AAE; Chicago, IL), found online at www.aae.org/uploadedfiles/publications_and_research/guidelines_and_position_statements/antibioticprophylaxsisquickrefguide.pdf ). Because the AHA periodically revises its recommended antibiotic prophylactic regimen for dental procedures, it is essential that the clinician stay current concerning this important issue. There is a low compliance rate among at-risk patients regarding their use of the suggested antibiotic coverage before dental procedures. Therefore, the clinician must question patients concerning their compliance with the prescribed prophylactic antibiotic coverage before endodontic therapy. If a patient has not taken the antibiotic as recommended, it may be administered up to 2 hours after the procedure.

Patients with artificial heart valves are considered susceptible to bacterial endocarditis. Consulting the patient’s physician in such cases regarding antibiotic premedication is essential. Some physicians elect to administer parenteral antibiotics in addition to or in place of the oral regimen.

A dentist may be the first to detect elevated blood pressure if he or she routinely evaluates blood pressure before treatment. Furthermore, patients receiving treatment for hyper­tension may not be controlled adequately because of poor compliance or inappropriate drug therapy. Abnormal blood pressure readings may be the basis for physician referral.

Some patients may be disposed to serious life-threatening complications due to stress. Acute heart failure during a stressful dental procedure in a patient with significant valvular disease and heart failure or the development of infectious endocarditis represent two such life-threatening disorders. Careful evaluation of patients’ medical histories including the cardiac status of patients, the use of appropriate prophylactic antibiotics, and stress reduction strategies will minimize the risk of serious cardiac sequelae.

There is a widespread belief among dentists and physicians that oral anticoagulation therapy in which patients receive drugs such as warfarin (Coumadin) must be discontinued before dental treatment to prevent serious hemorrhagic complications, especially during and after surgical procedures. Aspirin is a drug commonly used as an anticoagulant on a daily basis without the supervision of a physician. Clinical studies do not support the routine withdrawal of anticoagulant therapy before dental treatment for patients who are taking such medications.

When patients report they are receiving an anticoagulant medication, they can benefit from the clinician using the following guidelines:

  • Identify the reason why the patient is receiving anticoagulant therapy.

  • Assess the potential risk versus benefit of altering the drug regimen.

  • Know the laboratory tests used to assess anticoagulation levels (i.e., the international normalized ratio [INR] value should be 3.5 or less for patients who are taking warfarin to safely undergo dental or surgical endodontic procedures). Be familiar with methods used to obtain hemostasis both intraoperatively and postoperatively.

  • Be familiar with the potential complications associated with prolonged or uncontrolled bleeding.

  • Consult the patient’s physician to discuss the proposed dental treatment and to determine the need to alter the anticoagulant regimen.

Another cardiac complication may occur in patients with Hodgkin disease or breast cancer, who often receive irradiation to the chest as an element of treatment. Although the therapy often cures the malignancy, it has been implicated in causing late-onset heart disease that may influence the development of a treatment plan and subsequent treatment. Dentists must identify patients who have received irradiation to the chest and consult with patients’ physicians to determine whether that therapy has damaged the heart valves or coronary arteries. Patients with radiation-induced valvular disease may require prophylactic antibiotics when undergoing specific dental procedures that are known to cause a bacteremia and a heightened risk of developing endocarditis. Patients with radiation-induced coronary artery disease should be administered only limited amounts of local anesthetic agents containing a vasoconstrictor. They may require the administration of sedative agents and cardiac medications to preclude ischemic episodes. Consultation with the patient’s physician is an appropriate response when a patient presents with a history that includes prior radiation to the chest.

Diabetes

The Centers for Disease Control and Prevention (CDC, Atlanta, GA) in 2011 reported that 25.8 million people, or 8.3% of the U.S. population, have diabetes. There were also about 1.9 million people aged 20 years or older newly diagnosed with diabetes in 2010. (See Centers for Disease Control and Prevention Diabetes Fact Sheet , available at cdc.gov/diabetes/pubs/estimates11.htm#2 , 2011.) Diabetes is the seventh leading cause of death in the United States, and, according to the Diabetes Fact Sheet , the risk for death among people with diabetes is about twice that of people of similar age but without diabetes. It is likely that patients with diabetes who require endodontic treatment will be increasingly common.

Diabetes mellitus appears to have multiple causes and several mechanisms of pathophysiology. It can be thought of as a combination of diseases that share the key clinical feature of glucose intolerance. Patients with diabetes, even those who are well controlled, require special consideration during endodontic treatment. The patient with well-controlled diabetes, who is free of serious complications such as renal disease, hypertension, or coronary atherosclerotic disease, is a candidate for endodontic treatment. However, special considerations exist in the presence of acute infections. The non–insulin-controlled patient may require insulin, or the insulin dose of some insulin-dependent patients may have to be increased. When surgery is required, consultation with the patient’s physician is advisable in order to consider adjustment of the patient’s insulin dosage, antibiotic prophylaxis, and dietary needs during the posttreatment period.

The clinician should ask patients with diabetes who self-monitor their glucose levels to bring a glucometer to each visit. If pretreatment glucose levels are below normal fasting range (80 to 120 mg/dl), it may be appropriate to take in a carbohydrate source. A source of glucose (e.g., glucose tablets, orange juice, or soda) should be available if signs of insulin shock (hypoglycemic reaction caused by overcontrol of glucose levels) occur. Signs and symptoms of hypoglycemia include confusion, tremors, agitation, diaphoresis, and tachycardia. The clinician can avoid a hypoglycemic emergency by taking a complete, accurate history of the time and amount of the patient’s insulin and meals. When questions arise concerning the appropriate course to follow, the patient’s physician should be contacted or treatment deferred.

Appointments should be scheduled with consideration given to the patient’s normal meal and insulin schedule. Usually, a patient with diabetes who is well managed medically and is under good glycemic control without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease can receive any indicated dental treatment. However, patients with diabetes who have serious medical complications may need a modified dental treatment plan. For instance, although prophylactic antibiotics generally are not required, it “may be prescribed a patient with brittle (very difficult to control) diabetes for whom an invasive procedure is planned but whose oral health is poor and the fasting plasma glucose exceeds 200 mg/dL.” Local anesthesia would not be an issue in the presence of well-controlled diabetes, “but for patients with concurrent hypertension or history of recent myocardial infarction, or with a cardiac arrhythmia, the dose of epinephrine should be limited to no more than two cartridges containing 1 : 100,000 epinephrine.”

Inadequate diabetic control may predispose such patients to several oral infections, including dental pulp infection. One study determined that although apical periodontitis may be significantly more prevalent in untreated teeth in patients with type 2 diabetes, the disease does not seem to influence the response to root canal treatment. However, other studies suggest that diabetes is associated with a decrease in the success of endodontic treatment in cases with pretreatment periradicular lesions. In a prospective study on the impact of systemic diseases on the risk of tooth extraction, it has been also shown that an increased risk of tooth extraction after nonsurgical root canal treatment was significantly associated with diabetes mellitus, hypertension, and coronary heart disease. Patients with diabetes and other systemic diseases may be best served by referral to an endodontist for treatment planning.

Pregnancy

Although pregnancy is not a contraindication to endodontics, it does modify treatment planning. Protection of the fetus is a primary concern when administration of ionizing radiation or drugs is considered. Of all the safety aids associated with dental radiography, such as high-speed film, digital imaging, filtration, and collimation, the most important is the protective lead apron with thyroid collar. Although drug administration during pregnancy is a controversial subject, Box 3-2 presents commonly used dental drugs usually compatible with both pregnancy and breast-feeding. Based on U.S. Food and Drug Administration pregnancy risk factor definitions, local anesthetics administered with epinephrine generally are considered safe for use during pregnancy and are assigned to the pregnancy risk classification categories B and C. (See www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm093310.htm .) Few anxiolytics are considered safe to use during pregnancy. However, a single, short-term exposure to nitrous oxide–oxygen (N 2 O-O 2 ) for less than 35 minutes is not thought to be associated with any human fetal anomalies, including low birth weight. If a need exists for antibiotic therapy, penicillins, cephalosporins, and macrolides are considered first-line agents.

Box 3-2
Partial List of Drugs Usually Compatible with Both Pregnancy and Breast-Feeding

  • Local anesthetics including lidocaine, etidocaine, and prilocaine

  • Many antibiotics including penicillins, clindamycin, and azithromycin

  • Acetaminophen

  • Acyclovir

  • Prednisone

  • Antifungals including fluconazole and nystatin

The analgesic of choice during pregnancy had been acetaminophen (category B). However, a link between acetaminophen and childhood asthma has been suggested. Research has found that “the use of acetaminophen in middle to late but not early pregnancy may be related to respiratory symptoms in the first year of life.” This finding, although not completely validated, should be discussed with pregnant patients when an analgesic is being considered. Aspirin and nonsteroidal anti-inflammatory drugs also convey risks for constriction of the ductus arteriosus, as well as for postpartum hemorrhage and delayed labor.

A major concern is that a drug may cross the placenta and be toxic or teratogenic to the fetus. In addition, any drug that is a respiratory depressant can cause maternal hypoxia, resulting in fetal hypoxia, injury, or death. Ideally, no drug should be administered during pregnancy, especially during the first trimester. If a specific situation makes adherence to this rule difficult, then the clinician should review the appropriate current literature and discuss the case with the physician and patient.

Further considerations exist during the postpartum period if the mother breast-feeds her infant. A clinician should consult the responsible physician before using any medications for the nursing mother. Alternative considerations include using minimal dosages of drugs, having the mother bank her milk before treatment, having her feed the child before treatment, or suggesting the use of a formula for the infant until the drug regimen is completed. Limited data are available on drug dosages and the effects on breast milk.

In terms of treatment planning, elective dental care is best avoided during the first trimester because of the potential vulnerability of the fetus. The second trimester is the safest period in which to provide routine dental care. Complex surgical procedures are best postponed until after delivery.

Malignancy

Some malignancies may metastasize to the jaws and mimic endodontic pathosis, whereas others can be primary lesions ( Fig. 3-2 ). The most common malignancies metastasize to the jaws are breast, lung, thyroid, and prostate. A panoramic radiograph and a cone-beam computer tomography image are useful in providing an overall view of all dental structures. When a clinician begins an endodontic procedure on a tooth with a well-defined apical radiolucency, it might be assumed to result from a nonvital pulp. Pulp testing is essential to confirm a lack of pulp vitality in such cases. A vital response in such cases indicates a nonodontogenic lesion.

FIG. 3-2
A , Periapical view of tooth #29 after endodontic treatment by a general dental clinician. The diagnosis was irreversible pulpitis. B, Patient was referred to an endodontist 4 months later to evaluate radiolucencies of teeth #29 and #30. Symptoms indicated irreversible pulpitis of tooth #30, with concurrent lower right lip and chin paresthesia. Past medical history revealed breast cancer in remission. C, Nonsurgical endodontics was performed on tooth #30. Immediate referral was made to an oncologist/oral surgeon for biopsy to rule out nonodontogenic origin of symptoms. D, Surgical posttreatment radiograph of teeth #29 and #30. The biopsy report confirmed metastatic breast cancer.
(Courtesy Dr. R. Sadowsky, Dr. L. Adamo, and Dr. J. Burkes.)

Careful examination of pretreatment radiographs from different angulations is important because lesions of endodontic origin would not be expected to be shifted away from the radiographic apex in the various images. Alternative methods, such a cone-beam computed tomography (CBC), may provide important diagnostic information (see Chapter 2 ).

A useful website for the differential diagnosis of radiographic lesions (Oral Radiographic Differential Diagnosis [ORAD] II) is available online at www.orad.org/index.html . A definitive diagnosis of periradicular lesions can be made only after biopsy. When a discrepancy exists between the initial diagnosis and clinical findings, consultation with an endodontist is advisable.

Patients undergoing chemotherapy or radiation to the head and neck may have impaired healing responses. Treatment should be initiated only after the patient’s physician has been consulted. A dialogue among the dentist, physician, and patient is required prior to determining whether a tooth or teeth should be extracted or endodontically treated prior to radiation.

The effect of the external beam of radiation therapy on normal bone is to decrease the number of osteocytes, osteoblasts, and endothelial cells, thus decreasing blood flow. Pulps may become necrotic from this impaired condition. Toxic reactions during and after radiation and chemotherapy are directly proportional to the amount of radiation or dosage of cytotoxic drug to which the tissues are exposed. Delayed toxicities can occur several months to years after radiation therapy.

Oral infections and any potential problems should be addressed before initiating radiation. It is advised that symptomatic nonvital teeth be endodontically treated at least 1 week before initiating radiation or chemotherapy, whereas treatment of asymptomatic nonvital teeth may be delayed. The outcome of endodontic treatment should be evaluated within the framework of the toxic results of radiation and drug therapy. The white blood cell (WBC) count and platelet status of a patient undergoing chemotherapy should also be reviewed before endodontic treatment. In general, routine dental procedures can be performed if the granulocyte count is greater than 2000/mm 3 and the platelet count is greater than 50,000/mm 3 . If urgent care is needed and the platelet count is below 50,000/mm 3 , consultation with the patient’s physician is required.

Medication-Related Osteonecrosis of the Jaws (MRONJ)

Bisphosphonates offer great benefits to patients at risk of bone metastases and in the prevention and treatment of osteoporosis, although this and other drugs (e.g., denosumab) are associated with a rare occurrence of osteonecrosis.

To distinguish medication-related osteonecrosis of the jaws (MRONJ) from other delayed healing conditions, the following working definition of MRONJ has been adopted by the American Association of Oral and Maxillofacial Surgeons (AAOMS): Patients may be considered to have MRONJ if all of the following three characteristics are present (see American Association of Oral and Maxillofacial Surgeons: Position paper on Bisphosphonate-Related Osteonecrosis of the Jaw—2014 update, available at www.aaoms.org/docs/position_papers/mronj_position_paper.pdf?pdf=MRONJ-Position-Paper ):

  • 1.

    Current or previous treatment with an antiresorptive drug such as a bisphosphonate or an antiangiogenic drug (e.g., sunitinib [Sutent], sorafenib [Nexavar], bevacizumab (Avastin), or sirolimus (Rapamune)

  • 2.

    Exposed, necrotic bone in the maxillofacial region that has persisted for more than 8 weeks

  • 3.

    No history of radiation therapy to the jaws

A patient’s risk of developing osteonecrosis of the jaw while receiving oral bisphosphonates appears to be low, but there are factors known to increase the risk for MRONJ ( Box 3-3 ). According to the American Association of Endodontists (available at www.aae.org/uploadedFiles/Publications_and_Research/Guidelines_and_Position_Statements/bisphosonatesstatement.pdf , 2012), such risks include a history of taking bisphosphonates, especially intravenous (IV) formulations, previous history of cancer, and a history of a traumatic dental procedure. In addition to the usual risk factors, patients receiving high-dose IV bisphosphonates for more than 2 years are at most risk for developing osteonecrosis of the jaw.

Box 3-3
Risk Factors for Development of Bisphosphonate-Associated Osteonecrosis

  • History of taking bisphosphonates for more than 2 to 3 years, especially with intravenous therapy

  • History of cancer, osteoporosis, or Paget disease

  • History of traumatic dental procedure

  • Patient more than 65 years of age

  • History of periodontitis

  • History of chronic corticosteroid use

  • History of smoking

  • History of diabetes

It has been reported that patients with multiple myeloma and metastatic carcinoma to the skeleton who are receiving intravenous, nitrogen-containing bisphosphonates are at greatest risk for osteonecrosis of the jaws. These patients represent 94% of published cases. The mandible is more commonly affected than the maxilla (2 : 1 ratio), and 60% of cases are preceded by a dental surgical procedure. Treatment outcomes of MRONJ are unpredictable, and prevention strategies are extremely important.

Management of high-risk patients might include nonsurgical endodontic treatment of teeth that otherwise would be extracted. The combination of orthodontic extrusion and bloodless extraction—exfoliation of the extruded roots after their movement—has also been suggested with the aim of minimizing trauma and enhancing the health of the surrounding tissues in patients at risk of developing MRONJ or when a patient refuses to undergo conventional tooth extraction.

For patients at higher risk of MRONJ, surgical procedures such as extractions, endodontic surgery, or placement of dental implants should be avoided. (See www.aae.org/uploadedFiles/Publications_and_Research/Guidelines_and_Position_Statements/bisphosonatesstatement.pdf , 2012.) Sound oral hygiene and regular dental care may be the best approach to lowering the risk of MRONJ. Patients taking bisphosphonates and undergoing endodontic therapy should sign an informed consent form, inclusive of the risks, benefits, and alternative treatment plans. The following recommendations have been suggested to reduce the risk of MRONJ associated with endodontic treatment :

  • Apply a 1-minute mouth rinse with chlorhexidine prior to the start of the treatment with the aim of lowering the bacterial load of the oral cavity.

  • Avoid the use of anesthetic agents with vasoconstrictors in order to prevent impairment of tissue vascularization.

  • Work under aseptic conditions, including removing of all caries and placement of rubber dam prior to intracanal procedures.

  • Avoid damage to the gingival tissues during the placement of rubber dam.

  • Avoid maintaining patency of the apical foramen to prevent bacteremia.

  • Use techniques that reduce the risk of overfilling and overextension.

Aggressive use of systemic antibiotics is indicated in the presence of an infection in a patient taking bisphosphonates. Discontinuing bisphosphonate therapy may not eliminate any risk of developing MRONJ. Some clinicians have proposed use of the CTX (C-terminal telopeptide of type I collagen α 1 chain) test (Quest Diagnostics, Madison, NJ) for assessing the risk of developing bone osteonecrosis (BON). For patients who have developed MRONJ, close coordination with an oral maxillofacial surgeon or oncologist is highly recommended.

An astute awareness of the potential risk of MRONJ in patients receiving bisphosphonate therapy is critical. Increased attentiveness to the prevention, recognition, and management of MRONJ will allow the clinician to make the best treatment decisions. Our knowledge of MRONJ is developing rapidly and it is essential that the clinician monitor the literature for changes in treatment protocols.

Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS)

From 1987 through 1994, HIV disease mortality increased and reached a plateau in 1995. Subsequently, the mortality rate for this disease decreased an average of 33% per year from 1995 through 1998, and 5.5% per year from 1999 through 2009. This dramatic improvement seems to be due to the use of a combination of highly active antiretroviral therapy (HAART) and improved preventive strategies.

It is important, when treating patients with AIDS, that the clinician understand the patient’s level of immunosuppression, drug therapies, and the potential for opportunistic infections. Although the effect of HIV infection on long-term prognosis of endodontic therapy is unknown, it has been demonstrated that clinicians may not have to alter their short-term expectations for periapical healing in patients infected with HIV. The clinical team must also minimize the possibility of transmission of HIV from an infected patient, and this is accomplished by adherence to universal precautions. (See Universal Precautions for Prevention of Transmission of HIV and Other Bloodborne Infections, available at www.cdc.gov/niosh/topics/bbp/universal.html .)

Although saliva is not the main route for transmission of HIV, the virus has been found in saliva and its transmission through saliva has been reported. Infected blood can transmit HIV, and during some procedures it may become mixed with saliva. Latex gloves and eye protection are essential for the clinician and staff. HIV can be transmitted by needlestick or via an instrument wound, but the frequency of such transmission is low, especially with small-gauge needles. Nevertheless, “Patients at high risk for AIDS and those in whom AIDS or HIV has been diagnosed should be treated in a manner identical to that for any other patient—that is, with standard precautions.”

A vital aspect of treatment planning for the patient with HIV/AIDS is to determine the current CD4 + lymphocyte count and level of immunosuppression. In general, patients having a CD4 + cell count exceeding 350 cells/mm 3 may receive all indicated dental treatments. Patients with a CD4 + cell count of less than 200 cells/mm 3 or severe neutropenia (neutrophil count lower than 500/µL) will have increased susceptibility to opportunistic infections and may be effectively medicated with prophylactic drugs. White blood cell and differential counts, as well as a platelet count, should be ordered before any surgical procedure is undertaken. Patients with severe thrombocytopenia may require special measures (platelet replacement) before surgical procedures. Care in prescribing medications must also be exercised with any medications after which the patient may experience adverse drug effects, including allergic reactions, toxic drug reactions, hepatotoxicity, immunosuppression, anemia, serious drug interactions, and other potential problems. The practitioner should also be aware of oral manifestations of the disease as far as it concerns diagnosis and treatment planning. For instance, candidiasis of the oral mucosa, Kaposi sarcoma, hairy leukoplakia of the lateral borders of the tongue, herpes simplex virus (HSV), herpes zoster, recurrent aphthous ulcerations, linear gingival erythema, necrotizing ulcerative periodontitis, necrotizing stomatitis, oral warts, facial palsy, trigeminal neuropathy, salivary gland enlargement, xerostomia, and melanotic pigmentation are all reported to be associated with HIV infection. It is essential that consultation with the patient’s physician occurs before performing surgical procedures or initiating complex treatment plans.

End-Stage Renal Disease and Dialysis

Consultation with the patient’s physician is important before dental care is initiated for patients being treated for end-stage renal disease. Depending on the patient’s status and the presence of other diseases common to renal failure (e.g., diabetes mellitus, hypertension, and systemic lupus erythematosus), dental treatment may be best provided in a hospital setting. The goal of dental care for patients being treated for end-stage renal disease is to slow the progression of dental disease and preserve the patient’s quality of life.

The most recent American Heart Association guidelines do not include a recommendation for prophylactic antibiotics before invasive dental procedures for patients receiving dialysis with intravascular access devices, unless an abscess is being incised and drained. Because controversy exists about the need for prophylactic antibiotics, consultation with the physician is important for patients receiving hemodialysis and those who have known cardiac risk factors. When prophylaxis is used, the standard regimen of the American Heart Association is recommended.

Some drugs frequently used during endodontic treatment are affected by dialysis. Drugs metabolized by the kidneys and nephrotoxic drugs should be avoided. Both aspirin and acetaminophen are removed by dialysis and require a dosage adjustment in patients with renal failure. Amoxicillin and penicillin also require dosage adjustment as well as a supplemental dosage subsequent to hemodialysis. It is advisable to consult the patient’s physician concerning specific drug requirements during endodontic treatment. Endodontic treatment is best scheduled on the day after dialysis. On the day of dialysis, patients are generally fatigued and could have a bleeding tendency.

Chronic renal failure is a disorder that may stimulate secondary hyperparathyroidism that can cause a variety of bone lesions. In some instances, these lesions appear in the periapical region of teeth and can lead to a misdiagnosis of a lesion of endodontic origin.

Prosthetic Implants

Patients with prosthetic implants are frequently treated in dental practices. The question concerning the need for antibiotic prophylaxis to prevent infection of the prosthesis has been debated for many years. A statement was issued jointly in 2003 by the American Dental Association (ADA; Chicago, IL) and the American Academy of Orthopaedic Surgeons (AAOS; Rosemont, IL) in an attempt to clarify the issue. The statement concluded that scientific evidence does not support the need for antibiotic prophylaxis for dental procedures to prevent prosthetic joint infections. It went on to state that antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it routinely indicated for most patients with total joint replacements. However, the statement indicated that some “high-risk patients” who are at increased risk for infection and undergoing dental procedures likely to cause significant bleeding should receive antibiotic prophylactic treatment. Such patients would include those who are immunocompromised or immunosuppressed, who have insulin-dependent (type 1) diabetes, who are in the first 2 years following joint replacement, or who have previous joint infections, malnourishment, or hemophilia. The advisory statement concludes that the final decision on whether to provide antibiotic prophylaxis is the responsibility of the clinician, who must consider potential benefits and risks. It should be noted that although endodontics has been shown to be a possible cause of bacteremia, the risk is minimal in comparison with extractions, periodontal surgery, scaling, and prophylaxis. In February 2009, the AAOS published a statement entitled “Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements.” In this updated publication it was stated: “Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia.” (See American Academy of Orthopaedic Surgeons: AAOS releases new statement on antibiotics after arthroplasty, www.aaos.org/news/aaosnow/may09/cover2.asp , 2012.)

However, the American Academy of Oral Medicine’s (AAOM) position on this statement is that the “2009 information statement is more an opinion than an official guideline, AAOM believes that it should not replace the 2003 joint consensus statement prepared by the relevant organizations: the ADA, the AAOS and the Infectious Disease Society of America (IDSA).” In 2012, an evidenced-based guideline was published that included recommendations of the AAOS-ADA clinical practice guideline for Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. This guideline stated that there is limited evidence for discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures. (See American Academy of Orthopaedic Surgeons: Prevention of orthopaedic implant infection in patients undergoing dental procedures, available at www.aaos.org/research/guidelines/PUDP/PUDP_guideline.pdf , 2012.)

Consultation with the patient’s physician on a case-by-case basis is advisable to assess the need for prophylaxis.

Behavioral and Psychiatric Disorders

Stress reduction is an important factor in the treatment of patients with behavioral and psychiatric disorders. Sensitivity to the patient’s needs must be part of the dental team’s approach. Significant drug interactions and side effects are associated with tricyclic antidepressants, monoamine oxidase inhibitors, and antianxiety medications. Consultation with physicians in such cases is essential before using sedatives, hypnotics, antihistamines, or opioids.

Psychosocial Evaluation

The initial visit, during which medical and dental histories are gathered, provides an opportunity to consider the patient’s psychosocial status. Although some patients may want to maintain a tooth with a questionable prognosis, others may lack the ability to comprehend the potential risks and benefits. It would be a mistake to lead patients beyond what they can appreciate, and patients should not be allowed to dictate treatment that has a poor prognosis.

The clinician should also assess the patient’s level of anxiety as an important part of preparation for the procedure to follow. It is reasonable to assume that most patients are anxious to some degree, especially when they are about to undergo endodontic treatment. A conversation describing the procedure and what the patient can expect is an important part of an anxiety-reduction protocol. It is well documented that a high level of anxiety is a predictor of poor anesthesia and posttreatment pain. More than 200 studies indicate that behavioral intervention for the highly anxious patient before treatment decreases anxiety before and after surgery, reduces posttreatment pain, and accelerates recovery.

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Apr 18, 2020 | Posted by in General Dentistry | Comments Off on Case Selection and Treatment Planning
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