We face this decision every day. Patients arrive symptomatic or asymptomatic with large restorations that require the teeth to be crowned. We have to decide whether endodontic treatment is indicated. The answer often seems quite simple… Is the pulp involved or not? But more often the decision is complicated by factors that must be considered when deciding whether endodontics is indicated. These factors are important in determining the success of the overall treatment.
(1) What is the original reason for treatment ? If the problem was caries, the source of the caries must be identified and corrected. Eg/ a mandibular second molar has distal caries under a crown margin because of mesial drifting caused by premature extraction of the first molar. The drifting, open contacts and/or distal food impaction caused by the poor occlusion must be addressed or the case will become carious again in the same place. Removing the pulp without proper restoration and closure of the contact does not solve this problem.
(2) Elective Endodontics in the heavily restored or cracked tooth prevents premature loss of core/cusps during crown preparation and eliminates the fear of pulp exposure. The result is a more classic preparation and less likelihood of having to make an endodontic access through that recently cemented crown! Elective endodontics is a good investment because it allows you to do more predictable, successful restorative dentistry.
(3) The Consequences of Devitalization of teeth Patients with history of rampant caries or continuing smooth surface decay represent a serious risk of recurrent decay. Unless the patient's obvious lack of hygiene is addressed, the caries will continue. While it may seem attractive to devitalize cases so patients do not feel discomfort to cold and sweets, are we really doing this patient a service or are we just treating a symptom? Post Endo hygiene is integral to the long term success of the case.
(4) Inadequate Restoration : Attempting to "patch" crown margins or use existing crowns in the case of carious "washouts" is unacceptable treatment. The endodontic literature is now beginning to show that a high percentage of endodontic failure is related to lack of coronal seal and secondary canal contamination. Attempting to "fudge" a margin or reuse a ill fitting crown is a recipe for failure. In the case of the posterior tooth with Cracked Tooth Syndrome and pulpal involvement, failure to protect cusps with castings also risks catastrophic fracture and split tooth. Always discuss restorative treatment before considering an Endo referral.
(5) Periodontal Considerations. Is crown lengthening indicated? Do we have sufficient biologic width and adequate attached gingiva for proper restoration? Is the problem a combined Perio/Endo lesion ? Has any additional treatment been discussed with the patient during the initial treatment plan and before they have been referred for endodontic treatment?
(6) Patient Triage. Patients in discomfort are often referred for emergency endodontic treatment before a complete examination and treatment plan has been performed. In the era of single appointment endodontic examination and treatment, it is important to place the endodontic case in perspective with the needs of the patient's entire mouth. While we would all like to practice on patients with unlimited finances, insurance and financial considerations are a fact of life. Do we really want to refer the patient for completion of endodontic treatment on an expensive molar when we know that they require numerous caries controls in other areas of the mouth? Would it not be better to do an emergency pulpectomy, complete the caries controls, treatment plan the case and then decide whether endodontic referral is warranted? In the case of teeth with adjacent spaces, has the possibility of using the tooth as a fixed or Partial denture abutment been discussed with the patient before referral? If not, why not?
Quality Endodontic treatment can only be successful if it is combined with a well conceived treatment plan, healthy periodontal support and a sound post endodontic coronal restoration. Communication with your patient and the specialist is essential to obtaining the optimal clinical result. The Endoexperience.com web site provides the information your patients need.