Blackwell Publishing AsiaMelbourne, AustraliaAEJAustralian Endodontic Journal1329-19472006 The Authors.

Journal compilation © 2006 Australian Society of EndodontologyApril 20063217984Original

ResearchCase Assessment and Treatment PlanningK. Pothukuchi

Aust Endod J 2006; 32: 79–84

A S E U N D E R G R A D U AT E E S S AY C O M P E T I T I O N

Case assessment and treatment planning: What governs your

decision to treat, refer or replace a tooth that potentially requires
endodontic treatment?*
Kiran Pothukuchi
Oral Health Centre of Western Australia, University of Western Australia, Nedlands, Western Australia, Australia

Keywords Abstract
diagnosis, endodontist, general dental
practitioner, management, prognosis. Several factors determine whether a tooth will require treatment by a general
dentist, treatment by an endodontist or whether prosthodontic care is necessary
Correspondance after the tooth in question is extracted. This paper will present and discuss those
Mr Kiran Pothukuchi, OHCWA, 17 Monash Ave,
factors, which govern the decisions made by the general dentist, and the result-
Nedlands, WA 6009, Australia.
ant treatment options ranging from conservative endodontic therapy to the
Email: info@ohcwa.uwa.edu.au
extraction of the offending tooth and its prosthodontic replacement. The impact
doi: 10.1111/j.1747-4477.2006.00010.x of prognosis during endodontic therapy will also be discussed.

*2005 ASE Undergraduate Essay Competition:

Winner.

long-term commitment towards oral hygiene as well as

Introduction
the capacity to fund such rehabilitation. Rarely is the
Clinical assessment of the case in question requires more medical history an absolute contraindication to endo-
than an isolated diagnosis of the pathology and treatment dontic therapy; however, several factors regarding the
planning for a specific tooth. Treatment is associated with patient’s general and medical history and local factors
the process of ameliorating or preventing discomfort, relating to the presenting complaint must be reviewed
whereas management in the medical context is associated prior to management planning. For example, the need for
with the professional approach of handling a patient’s antibiotic prophylaxis for a patient with prosthetic heart
needs, which may include providing treatment (1). To best valves will complicate the management, but it is not a con-
serve the patient’s needs, decisions need to be made by the traindication to treatment (2). Other medical conditions
patient’s dental professional in the context of the overall such as rheumatoid arthritis and epilepsy must be consid-
management plan, which is accepted and approved by the ered owing to the impact they have on instituting endo-
patient. dontic therapy (2). Local factors that indicate endodontic
therapy include a restorable tooth, adequate periodontal
support and a dental status that contraindicates complete
Justification of endodontic therapy as a
denture construction (2,3).
treatment modality

First, the choice of endodontic therapy as a treatment

When to refer to an endodontist
modality, within a management plan, must be justified.
In order to accomplish this, the patient’s motivation to After determining that endodontic therapy is the best
receive dental treatment, their commitment towards oral option and that the patient agrees, the general dental prac-
hygiene and financial status must be ascertained (2), as it titioner (GDP) should subsequently determine the degree
is possible that endodontic therapy is a precursor to pros- of difficulty of treatment. This will influence the choice of
thodontic therapy for a given tooth. This will require a either managing the patient in-office or referring them to

© 2006 The Author 79

Journal compilation © 2006 Australian Society of Endodontology
Case Assessment and Treatment Planning
a specialist (2). Furthermore, the ability to accurately
gauge the difficulty of a case will circumvent potential pro-
cedural difficulties that may occur during the course of
endodontic care of the patient in question (2–4).
It has been noted that this degree of difficulty can only
be judged on an individual basis (4). That is to say, a case
that may be challenging for a general dental practitioner
may be routine for an endodontist. This is not necessarily
always the case, as a skilled general practitioner may be
able to institute endodontic therapy as effectively as an
endodontist. However, a very important issue is high-
lighted: the provision of dental services by a general dental
practitioner should be similar to that of a specialist (4).
This ethical, moral and legal obligation should be remem-
bered when determining the difficulty of any form of den-
tal treatment, as it will ensure that the referral is made in
the best interests of the patient.
There are a number of attributes associated with a
patient and their presenting complaints that can poten-
tially increase the difficulty of endodontic therapy and
therefore warrant a referral to an endodontist. These can
be grouped into patient factors, objective clinical findings
and additional conditions (2,4,5).
Patient factors
The general and medical histories, as stated before, are
important in the endodontic evaluation of a given case.
Selected conditions to note are presented below.
Debilitating disease
Diseases such as rheumatoid arthritis, epilepsy and other
acute and chronic systemic diseases influence patient
management. For instance, in a patient with rheumatoid
arthritis who has restricted mouth opening, rubber dam
isolation and periapical film taking is more difficult than in
a healthy patient with an unremarkable medical history.
Epilepsy may also potentially increase the management
difficulty of a patient owing to the possibility of intra-
appointment epileptic fits. Endodontists may have more
success with the management of this group of patients, as
they may be able to employ procedural techniques that
can circumvent the inherent difficulty of the case (2,4,5).
Compromised host defence
Relatively common medical conditions such as diabetes
mellitus or more serious conditions such as HIV/AIDS can
be classified in this category. Patients with compromised
host defence are more prone to infections, and once
established, evidence of clinical and radiographic heal-
ing requires a longer time period when compared with
80
K. Pothukuchi
patients with an unremarkable medical history (2,6). Such
patients may require specialist referral as any potential
intra-treatment complications are better managed under
the care of a specialist.
Mental illness
Patients with mental illness may not always be able to fol-
low instructions given to them during endodontic therapy
(2) or comply with postoperative instructions and oral
hygiene. These patients should be considered carefully
before referral or instituting endodontic therapy and other
treatment options such as extraction and prosthodontic
care may also be part of a sound management plan.
Xerostomia
Patients with this condition, owing to autoimmune dis-
ease, radiation therapy or age-related salivary gland hypo-
function are predisposed to dental caries and other oral
infections owing to a reduced salivary flow rate. This effect
is exacerbated in the absence of sound oral hygiene (6).
Xerostomic patients may experience intra-appointment
discomfort and mucosal dehydration from opening their
mouths for an extended period of time. If the general den-
tal practitioner deems that appointment times can be
shortened under the care of an endodontist, then a referral
is appropriate.
Anaesthetic considerations
Rarely is a patient allergic to the amide group in local
anaesthetics and care is taken by manufacturers to mini-
mise the use of preservatives that initiate anaphylaxis.
Significant problems arise if a patient has a history of
difficulty of obtaining profound anaesthesia, as endodon-
tic therapy will be made more difficult. This is significant
in patients with inflamed pulps in the mandibular arch as
the need for mandibular blocks and the associated failure
rates will exacerbate the pre-existing condition. A special-
ist referral may be warranted in these cases, as endodon-
tists are likely to have more experience and be equipped
with techniques that can be used in the management of
patients with this condition. (2,4,5)
Personal factors
Patients with restricted mouth opening, noted gaggers,
patients with a fear of needles and dentistry will all make
dental and endodontic therapy more difficult (2,4,7) and
again, a specialist referral or other treatment options
should be considered if the general dental practitioner is
not confident of managing the aforementioned issues.
© 2006 The Author
Journal compilation © 2006 Australian Society of Endodontology
K. Pothukuchi
Objective clinical findings
The diagnosis
Inconclusive or contradictory clinical and radiographic
findings will make the diagnostic process more difficult
and this can result in incorrect treatment being instituted
if an inexperienced general dental practitioner manages
the patient. (2–4) A referral to an endodontist may
improve the chances of correct treatment being instituted
for the patient.
Research has shown that endodontists showed more
inter-agreement with treatment that they have instituted,
regardless of their educational background, experience or
places of employment (8). This indicates that a consistent
diagnostic process is prevalent among endodontists, and
therefore a given pathological condition is approached in a
consistent manner. Although consistency does not imply
correctness, specialisation likely results in greater exper-
tise in diagnosis (8,9). For instance, it has been recently
recognised that endodontists consistently retreated peri-
apical radiolucencies on the basis of the technical standard
of the initial treatment or pathologic reasons (8). Also,
endodontists regarded silver point obturations, missed
canals, loss of coronal restoration integrity and fractured
instruments as relevant to their treatment approach (8).
General dental practitioners on the other hand were not as
consistent, and based their treatment decisions on the
patient’s symptoms as well, and did not retreat in the
absence of clinical symptoms (8).
In addition, the radiographic diagnosis may indicate
pathology, which in the general dental practitioner’s
judgement requires surgical intervention. To illustrate, a
study conducted in the Netherlands revealed that general
dentists were favourably disposed to a specialist referral
with the recommendation for periapical surgery in more
cases than necessary from a technical viewpoint, whereas
endodontists considered far more teeth feasible for conser-
vative retreatment rather than periapical surgery (10). In
the same study, a literature review was conducted and it
was found that there is no clear indication as to which of
the two methods ensures the more favourable outcome,
and therefore it was postulated that the endodontic
knowledge was not a basis of referral among general den-
tal practitioners (10). As a guideline, periapical surgery is
reserved for recalcitrant cases: those that show no signs of
healing after conservative orthograde treatment has been
instituted, or signs of extra-radicular infection (11).
Local anatomy
Local anatomy, such as mandibular tori, shallow palatal
vaults and constricted dental arches will all make taking
sound radiographs more difficult and hence increase the
© 2006 The Author
Journal compilation © 2006 Australian Society of Endodontology
Case Assessment and Treatment Planning
difficulty of endodontic therapy (2–4). Pulpal and root
morphology such as calcified or obliterated canals and
long, curved roots or roots with open apices will make
endodontic therapy more difficult and, in the case of open
apices, prolong the duration of therapy (2–4,12,13).
Malpositioned teeth will also make moisture control,
radiograph taking, and hence satisfactorily instituting
endodontic therapy, more challenging, and may warrant
specialist management (4).
Additional conditions
Additional conditions such as fractures or cracks in teeth,
root resorption, endodontic-periodontal lesions, trauma,
perforations and persistent signs and/or symptoms all
complicate the endodontic management and may warrant
a specialist referral (2–4).
Therefore, it can be seen that there are many factors that
make endodontic therapy more difficult. Although gen-
eral dental practitioners provide most endodontic therapy,
the above factors increase the difficulty and when a multi-
factorial case presents, the management can be expected
to be more complicated (2,4). In these circumstances, it is
recommended that referral should take place before any
definitive invasive therapy has begun rather than when a
procedural obstacle is encountered (2,4). The reason
behind this is that there is a favourable prognosis associ-
ated with teeth that have been treated without the occur-
rence of procedural errors and once they occur, they may
not always be correctable (4,14).
Prognosis
As a clinician’s guide for referral protocol, a scale has been
devised at the University of California San Francisco,
termed the UCSF Endodontic Case Selection System. This
system is said to help the clinician determine the degree of
treatment difficulty for a given case. When the degree of
difficulty exceeds the ability of a clinician, a referral to a
more capable clinician is suggested. There are many con-
siderations, grouped into patient considerations and tooth
considerations (which were discussed previously), each of
which is rated as 1, 2 or 3. The numbers correspond to
uncomplicated, moderately complicated or complicated
respectively. If all the ratings for the case fall under
uncomplicated, the general dental practitioner is usually
competent to carry out the procedure. However, if some of
the ratings are moderately complicated, or if one of the
ratings is complicated, the dentist should consider referral
to an endodontist (4).
Similar guidelines for assessing the difficulty of endo-
dontic cases have been developed by the American Asso-
ciation of Endodontists (AAE) and also the Canadian
81
Case Assessment and Treatment Planning
Academy of Endodontics (CAE) (2,5). Another classifica-
tion system developed in the Netherlands is the Dutch
Endodontic Treatment Index (DETI), which is a simpler
classification system employing a total of 15 items that are
ranked as either uncomplicated or complicated (5). If
none of the items are ranked as complicated, the general
dental practitioner can initiate root canal treatment (5).
However, if one or more of the items are ranked as compli-
cated, a more comprehensive scale similar to the UCSF
Endodontic Case Selection System should be used to accu-
rately determine the degree of difficulty of the case (5).
In determining the prognosis of teeth that require end-
odontic treatment, the general dental practitioner should
take into consideration the pathology, endodontic or
otherwise, associated with the teeth, as well as structural
and support considerations (2–4,7). Clinical trials have
shown that certain pathologies have an excellent prog-
nosis if treated conservatively by endodontic therapy
(Table 1). However, there are some pathologies that have
a poor prognosis and teeth affected by these types of
pathology should be considered for extraction and pros-
thodontic replacement (2). As dentists, we should aim to
provide patients with the most accurate pre-treatment
prognosis in order for them to make an informed decision
regarding treatment options.
Pretreatment prognosis
Pretreatment prognosis is generally influenced by endo-
dontic factors and, as a trend, if there is no periapical radi-
olucency associated with a given tooth, the prognosis is
better than if there is a radiolucency (2). This is because
infected root canal systems that manifest as periapical
radiolucencies have become established for some time and
are, as a result, slower to heal.
Table 1 Success rates of endodontic therapy with respect to various
endodontic situations
Endodontic situation % success
Teeth without periapical lesions 96–100
Teeth with periapical lesions 82
Meets technical standards of ideal treatment 94
Inadequate technical standards 68–76
Calcified canals 60–70
Procedural problems Varied, 50 or less
Restoration (posterior teeth) – full occlusal 90–95
coverage
No occlusal coverage 50–60
Periodontal problems Dictated by the
periodontal condition
From Messer HH. Clinical Judgement and decision making in endodontics
(2).
82
K. Pothukuchi
The most significant non-endodontic factor is the peri-
odontal condition of a tooth requiring endodontic therapy.
It has been stated that approximately one-third of endo-
dontically treated teeth requiring extraction are lost owing
to periodontal complications (2). Therefore, when deter-
mining the prognosis of a tooth with a compromised peri-
odontium, it is important to inform the patient and help
them decide the costs and benefits of having such a tooth
treated but possibly only retaining it for a few years.
Intra-treatment prognosis
Intra-treatment factors that influence prognosis are proce-
dural issues, which may be encountered at any stage of
endodontic therapy. These can be failing to use rubber
dam isolation, instrument fracture, incorrectly prepared
canals, root perforations, over- or under-extension of
gutta-percha and inadequate condensation. These factors
are generally preventable, if the operator makes an appro-
priate decision to institute the accepted standard of ther-
apy or refer a patient depending on their skill level
(2,14,15). It is important to remember that we as dental
practitioners are providing a service to the patient and care
needs to be taken to prevent errors from occurring, rather
than having to explain ourselves to the patient when they
do occur.
Post-treatment prognosis
One of the important post-treatment factors that influence
the success of endodontic therapy is the coronal seal. This
may take the form of a cast full coverage crown or a con-
servative composite restoration. Regardless of the restora-
tion, the primary purpose is to provide an adequate barrier
against bacterial ingress into the treated root canal system.
Another factor modifying the success rate of endodontic
therapy is the patient’s commitment to oral hygiene. The
aim is to reduce the bacterial levels in the oral cavity and
this needs to be explained to the patient and stressed if
they are to undergo subsequent prosthodontic treatment
(2).
Prosthetic replacement of a tooth
As the aim of endodontic therapy is to preserve teeth, the
general dental practitioner should guide patients so that
they are able to weigh the cost and prognosis of endodon-
tic treatment against the cost and prognosis of prostheti-
cally replacing a tooth. If the clinician is able to provide the
patient with an accurate prognosis of having a tooth
treated and the long-term oral service it can render, along
with the prognosis of extraction of the tooth and receiving
a prosthetic replacement, the patient can better make a
© 2006 The Author
Journal compilation © 2006 Australian Society of Endodontology
K. Pothukuchi
decision, which he or she will be happy with in the future
(16).
To provide this prognosis, the clinician should consider
the strategic value of the tooth to be endodontically
treated (2–4). General dental, medical and local factors,
which have been discussed previously, should be consid-
ered. In brief, patients who are not motivated towards oral
hygiene and patients who do not have the financial capa-
bility to fund endodontic treatment should be considered
for extraction. Locally, the tooth should be noted for struc-
tural integrity, remaining sound tooth structure, dimen-
sions and morphology of the root, supporting bone/PDL
and furcation involvement. If a tooth lies in the aesthetic
zone, an attempt should be made to preserve it and the
future strategic value of a tooth should also be noted (2–
4). If a tooth can serve as an abutment for a fixed or
removable prosthesis, then it would be wise to preserve it
where possible (2–4).
These considerations will aid the clinician in determin-
ing whether a tooth can be preserved via endodontic ther-
apy or whether it is in the best interests of the patient to
consider extraction and possibly a prosthodontic replace-
ment. It should be mentioned, however, that the patient’s
decision prevails, and general dental practitioner can only
guide a patient into making the most appropriate decision,
which may often involve their financial status and moti-
vation to undergo the proposed treatment.
If an extraction and further prosthodontic therapy is
decided upon, possible methods of space closure could
employ removable or fixed prosthodontics (17). Patients
who have systemic conditions such as diabetes mellitus or
other immunological conditions that need to be consid-
ered prior to reconstructive therapy may benefit from
either non-invasive or minimally invasive options such
as a removable partial denture with excellent denture
hygiene (6). Fixed bridges are an option; however, oral
hygiene must be excellent. Epileptic patients should con-
sider fixed prostheses as a precautionary measure, but oral
hygiene must be stressed owing to the gingival side-effects
of anti-epileptic medications (18).
Implants are an option for those patients who are gen-
erally systemically healthy and are committed to oral
hygiene (19). Relative contraindications exist, such as
smoking and often age, and these patients need to be
informed of the reduced success rates and maintain excel-
lent oral hygiene if they desire such treatment (19).
Conclusion
Endodontics offers the patient a conservative option of
removing the pathology, its source, symptoms and retain-
ing the tooth with which the pathology was associated.
Endodontics is therefore an important skill, and the gen-
© 2006 The Author
Journal compilation © 2006 Australian Society of Endodontology
Case Assessment and Treatment Planning
eral dental practitioner should be thoroughly familiar
with basics of this treatment and be able to institute it
when necessary. The general dental practitioner should
also be able to accurately recognise when the difficulty of
the case exceeds their skill and be able to refer the patient
to an endodontist as necessary. Patients should also be
informed of the possible complications, limitations and
expenses associated with endodontic therapy, not to
mention its dependency on other aspects of the oral
apparatus such as periodontal health, adequate remain-
ing tooth structure and sound oral hygiene for long-term
success.
Acknowledgment
Thanks go to Dr Ward Rutley and Dr Matthew Gentner,
who were examiners for this competition.
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© 2006 The Author
Journal compilation © 2006 Australian Society of Endodontology