Objectives

At the end of this case, the reader should understand the importance of treatment planning in endodontic cases and be aware of the key clinical features and differing treatment protocols that will affect the complexity of the treatment.

Introduction

A female, 63 years old, presented to her dentist regarding the lower right second molar (LR7). The tooth was restored with a crown about 20 years ago.

Chief Complaint

Tooth was tender on biting.

Medical History

The patient was a non‐smoker and had well‐controlled hypertension.

Dental History

Regular dental attendance since joining the practice eight years ago. When she was a child some molar teeth were extracted, and she wore a removable brace for the upper teeth.

Clinical Examination

Extraoral examination was unremarkable. Intraoral examination revealed a moderately restored dentition with good oral hygiene. The LR6 and LL6 had been extracted and there was some space closure.

The LR7 was firm, with tenderness to palpation and percussion. The LR7 had periodontal probing of less than 2 mm, with no bleeding on probing. It was restored with a metal–ceramic full‐coverage crown and was unresponsive to sensibility tests.

What did the radiograph reveal?

• 15% bone loss LR5.
• Mesial angulation of LR7 and LR8 and distal angulation of LR5, following loss of LR6.
• LR7 metal–ceramic crown with negative distal margin.
• LR7 existing root canal filling, sparsely condensed, short of the radiographic apex. The canal beyond the root filling was visible on the mesial root but not on the distal root.
• Apical radiolucency associated with the mesial and distal root apices (Figure 1.4.1).

Diagnosis and Treatment Planning

The diagnosis for the LR7 was symptomatic apical periodontitis associated with an existing root canal treatment.

What are the treatment options for this patient?

• Non‐surgical root canal retreatment
• Surgical endodontic treatment
• Extraction
• No treatment

Is there a systematic way to plan the treatment of endodontic cases?

Treatment planning requires the clinician to consider many inter‐related factors. Planning for endodontic treatment is not only about the complexity of the root canal system, but must also take into account the periodontal condition, the integrity of the remaining tooth structure, the patient’s medical history, dental conditions and patient expectations and wishes. This can be challenging and employing a methodical treatment planning tool can assist in making logical and coherent treatment planning decisions.

The Dental Practicality Index (DPI) aims to break down treatment planning into four categories (Table 1.4.1):

• Tooth structural integrity:
  • How much sound tooth structure remains?
  • Is it restorable?
• Endodontic considerations:
  • Are the canals easily identifiable on the radiograph?
    

    Weighting	Tooth integrity	Endodontic	Periodontal	Extra considerations
    0 No treatment required	Unrestored Existing restoration OK	Vital pulp Existing root canal treatment OK	Probing <3.5 mm Periodontal disease treated	Local: Adjacent teeth are healthy
    				General: History of intravenous bisphosphonates, head and neck radiotherapy
    1 Simple treatment required	Simple direct or indirect restoration Suitable for general dental practitioner	Simple root canal treatment Canal(s) visible, straight	Probing 3.5–5.5 mm Root surface debridement suitable for hygienist or general dental practitioner	Local: Whether this tooth will be a bridge abutment
    				General: Planned radiotherapy of head and neck region Immunocompromised patient
    2 Complex treatment required	Minimal sound tooth Subgingival margins	Complex root canal system Sclerosed canal(s)	Probing >5.5 mm Short root	Local: Prosthodontic treatment planned of multiple teeth
    				General:High caries rate Poor oral hygiene, active perio
    	Post‐core	Acute curvatures Fractured instrument Perforation	Crown lengthening Grade 2 mobility Grade 2–3 furcation involvement	Parafunctional habits/tooth surface loss Limited mouth opening/severe gags Anxious, requiring sedation
    6 Impractical to treat	Inadequate structure for ferrule	Untreatable root canal system	Untreatable periodontal disease	Local: Keeping the tooth would complicate a simple plan, e.g. one remaining over‐erupted tooth affecting denture construction
    				General: Potentially life‐threatening medical conditions where the objective of dental treatment is pain relief only

  • Are the canals sclerosed or curved, or are there fractured instruments, perforations or resorption?
  • Are there signs of a crack?

• Periodontal condition:
  • Can the patient maintain good oral hygiene?
  • Is there gingival inflammation?
  • Is there an isolated deep probing depth? (indicates a crack)
  • Will crown lengthening be required?
• Extra considerations/context:
  • Medical history, bisphosphonates, radiotherapy
  • Is the patient anxious and will sedation be required?
  • Can the patient lay flat for long treatment?
  • Is there limited mouth opening?
  • Will the tooth be used as a bridge abutment?
  • Would retaining this tooth compromise other restorative treatment?

Each category is given a score, 0, 1, 2 or 6 to indicate the complexity of the treatment. The sum of the category scores indicates the complexity of the treatment (Table 1.4.2).