Monday, November 5, 2012
An analogy exists between airplane travel and endodontics. A pre-flight air travel assessment includes weather, fuel and equipment readiness, pilot experience for the intended flight, and other details among the host of needed checks. The benefits of flying are weighed against the risks, and the flight is either undertaken or delayed.
In an endodontic context, a similar risk assessment also must take place before every case in order to optimize clinical results. How many times have we started a case and later wished we had either not begun or found ourselves deep into something unexpected for which we may or may not be prepared?
In aviation, accident analysis helps inform where pre-flight assessments have failed and points to needed safety improvements. In the published study “Analysis of Reasons for Extraction of Endodontically Treated Teeth: A Prospective Study” Touré, et al concluded “The mandibular first molar without crown was the most frequently extracted tooth. The main reasons for extractions were periodontal disease…and non-restorable tooth damage caused by fracture or caries.”
Could not each of these have been anticipated in advance? For the most part, the answer is yes. In essence, this begs the question, what pre-operative risk assessment should be undertaken prior to initiating endodontic treatment? Aside from the assessment of the patient’s medical and dental history and attainment of the endodontic diagnosis, I present several of the many possible clinical recommendations to aid the clinician:
- Pre-op assessment of case risks include observing:
- The number of roots
- Curvature
- Calcification
- Risk of perforation
- Open apices
- Presence of root resorption—internal or external or combined
- Periodontal status
- Intended tooth function after RCT
- Tooth rotation
- Tipping
- Caries
- Quality of the existing restoration—and whether it will need replacement post operatively
- Coronal fractures
- Bruxism
- Possible pre-existing vertical root fracture
- Crown root ratio
- History of trauma
- And other possible entities
- Diagnostic radiographs taken from different angles, and a cone beam where indicated to fully illustrate the anatomy before access
- Optimal visualization is essential, ideally via a surgical operating microscope, but at least with loupes
- Copious irrigation at every stage in the case
- Use of the rubber dam without exception
- Use of a bite block where possible to provide access to the tooth
- Profound anesthesia and using whatever behavioral adjuncts are necessary for patient comfort such as nitrous oxide, sedation, etc.
- When in the best interest of the patient, referral to an endodontic specialist is essential
- Staff training and education, because if the staff knows what each step of the treatment process is intended to accomplish, they can provide the needed support more efficiently
- Having the needed instruments available in the sizes required, and having them organized in a fashion that makes them easy to access and store while not in use
Mani SEC O K hand files
Mani RT hand files
- Knowing what each instrument is and how it is used
- For example, knowing when to use a safe ended hand file such as the pictured Mani SEC O K hand files versus a more aggressive cutting hand file such as the pictured Mani RT hand files is essential to avoid iatrogenic events
- Choosing the correct technique for the given anatomy
- Despite “cook book” technique regimens, not all roots should be instrumented nor obturated the same way
- Anatomy dictates technique
- Detailed informed consent is essential, especially with regard to assuring patient understanding of the needed post-endodontic restoration
Taking into account the above—among other considerations—prior to initiating treatment, clinicians are encouraged to ask themselves if they are the best option for caring for the particular tooth on the given day and/or if referral is in the best interest of the patient to bring the procedure to a safe and uneventful landing.
I welcome your feedback.