This gentleman presented with pain and swelling as well as probing to the apex on the distal aspect of the tooth. Many people would say the tooth was cracked. But we’ve saved many, many teeth that fit this profile. J-shaped ragiographic findings are not pathognomatic for cracked roots. The the embrasure right with the tipping of the back tooth will be tough. Amalgam is a better choice when we are down on bone with potential contact issues in the future. Removing fiber posts if you have a chairside assistant in the scope is a breeze. The tooth had some reasonable buccal and lingual tooth structure so it makes it a decent retreatment candidate when following the Retreatment Algorithm.
This was a retreatment case where we had to negotiate towards the apical 1/3 before finding the canal. 3D imaging shows resolution of the distal apical finding. In deciding whether to retreat the tooth we followed the retreatment algorithm. The tooth was symptomatic, and while there was some significant tooth removal during the prior treatment and crown, the tooth still has enough tooth structure to meet the patients expectation.
A more traditional approach to retreatment thinking was given to me courtesy of Ken Serota with this first algorithm. The focus of the decision making is on the quality of the root filling. Decision making with such a matrix often results in retreatment without necessarily improving patient centered outcomes. The second algorithm is restorativley driven with the expressed interest in improving patient centered outcomes and meeting treatment planning objectives. The other pillars of restoratively driven endodontics are present as well including conservation of tooth structure, and determination of restorability based on remaining tooth structure.
Precision endodontics was a concept John and I were planning to explore in more depth in the text Advanced CBCT for Endodontics: Technical Considerations, Perception, and Decision-Making (Khademi). Like many other noble concepts John wanted to bring to light in that work, the topic was edited bringing the focus back to CBCT by the editor. Still I think the topic is well worth exploring especially in terms of treatment planning and prognostication in endodontics. Wikipedia defines precision medicine as “a medical model that proposes the customization of healthcare with medical decisions, treatments, practices, or products being tailored to the individual patient.” It follows that precision endodontics is a dental model that proposes the customization of healthcare with endodontic decisions, treatments, practices, or products being tailored to the individual patient. In this model, diagnostic testing is often employed for selecting appropriate and optimal therapies based on the context of a patient’s endodontic condition.
The context of precision endodontics is wide ranging as are the management strategies clinicians chose to prescribe and execute. Generally speaking in endodontic management, decisions are based on which teeth or roots of teeth are to be managed, and how they are to be managed.
In this case, precision endodontics refers to both which, and how the patient was managed. This patient presented with pain and swelling associated with this anterior bridge abutment. CBCT imaging suggested an apical finding limited to the mesial root only. Early in my career, I would retreat the entire tooth. In some instances we would see radiographic clearing of the problematic root only to see radiographic findings and develop on another root that previously presented without findings leading to symptoms. Sort of along the lines of if it ain’t broke, you can’t fix it. CBCT appears to give us better indications of what is “broke” and what isn’t. In this case, in determining whether to retreat the distal root we appreciated the screw post and the bridge that the core supported and realized there were significant associated risks with retreatment and little potential benefit. In this way, imaging diagnostics helped us tailor which tooth and which roots were to be managed. To this extent, we were able to address precision endodontics and further explored the idea as it pertains to interim CBCT’s and management of maxillary molars.
The concept of how to tailor care for patients based on similar case types has been around for a long time with it’s inception stemming from the observations about outcome failure. Humans are pattern generating machines by nature and as such clinicians categorize patients and their conditions and then assign probabilities of the success of their management strategies based on followups. Say for example a clinician has a patient who has significant swelling or drainage from a tooth. Perhaps the clinician, with experience, notes that if endodontic management of that patient type is performed in a single visit there may be an increase in complications, failure to resolve the condition, or subsequent failure to meet patient disease centered or patient centered outcomes. Alternative strategies including management with an interim medication such as calcium hydroxide with temporization is employed and perhaps an increased predictability is observed. Both the duration of time during which the medication is utilized and the frequency with which it is applied can be customized to the perceived needs of the patient. The idea of providing as little or as much therapy as deemed necessary has been referred to as a “titrated treatment”. Managing the case with as many or as few appointments as necessary has been referred to as an “N step” treatment. Both concepts are related to customizing treatment based on the need for varying degrees of time and or type medicament to achieve a favorable outcome.
Many cases are straightforward such as a tooth with caries to the pulp and can be predictably managed in a single visit. For many clinicians, resolution of symptoms offers a degress of predictability, and many teeth are amenable to 2 visit endodontics. However, there are degrees of case types that present as a problem in that they aren’t as predictable with single or even two visit endodontic management. These are loosely referred to as problem case types. For those problem case types in addition to resolution of symptoms we may value clinical features such as resolution of sinus tracts, resolution of deep probing depths, resolution of intraradicular drainage, decreased mobility, and radiographic clearing. Certainly the number of problem cases one may encounter is a function of both the spectrum of patients that are referred, as well as the inclination to evaluate outcomes at different time intervals. The conclusions are no doubt subject to confirmation bias among other cognitive problems that murky the waters of outcomes and thus endodontic decision making.
In this case, we employed calcium hydroxide medication over the course of 3-4 months. We waited for resolution of symptoms as well as the cessation of intraradicular drainage. Additionally, signs of radiographic clearing are evident at the obturation apppointment.
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