Medical condition Modifications in treatment planning 1. Patients with Valvular
Disease and Murmers
Patients are susceptible to Prophylactic antibiotics are bacterial endocarditis advocated before initiation secondary to dental treatment of the endodontic treatment
2. Patients with Hypertension
i. In these patients, stress • Give premedication and anxiety may further • Plan short
increase chances of myo- appointments cardial infarction or
cerebrovascular accidents
ii. Sometimes antihypertensive • Use local anesthetic drugs may cause postural with minimum amount
hypotension of vasoconstrictors
3. Myocardial Infarction
i. Stress and anxiety can • Elective endodontic precipitate myocardial treatment is postponed infarction or angina if recent myocardial
infarction is present, i.e.
< 6 months ii. Some degree of congestive • Reduce the level of
heart failure may be present stress and anxiety while treating patient
iii. Chances of excessive • Keep the appointments bleeding when patient short and comfortable is on aspirin
iv. If pacemaker is present, • Use local anesthetics apex locators can cause without epinephrine electrical interferences
• Antibiotic prophylaxis is given before initiation of the treatment 4. Prosthetic Valve or Implants
i. Patients are at high risk • Prophylactic antibiotic for bacterial endocarditis coverage before
initiation of the treatment
ii. Tendency for increased • Consult physician for bleeding because of any suggestion prolonged use of regarding patient antibiotic therapy treatment 5. Leukemia
Patient has increased tendency • Consult the physician.
for: • Avoid treatment during
i. Opportunistic infections acute stages ii. Prolonged bleeding • Avoid long duration iii. Poor and delayed wound appointment
healing • Strict oral hygiene
instructions
• Evaluate the bleeding time and platelet status
• Use of antibiotic pro-phylaxis
6. Cancer
Usually because of radio- • Consult the physician therapy and chemotherapy, prior to treatment.
i. These patients suffer from • Perform only emergency xerostomia, mucositis, treatment if possible trismus and excessive • Symptomatic treatment
bleeding of mucositis, trismus
ii. Prone to infections and xerostomia because of bone marrow • Optimal antibiotic cove-suppression rage prior to treatment.
• Strict oral hygiene regimen
7. Bleeding Disorders
In cases of hemophilia, • Take careful history of thrombocytopenia, prolonged the patient
bleeding due to liver disease, • Consult the physician Contd...
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Textbook of Endodontics
broadspectrum antibiotics, for suggestions patients on anticoagulant regarding the patient therapy patient experiences • Avoid aspirin containing
i. Spontaneous bleeding compounds and ii. Prolonged bleeding NSAIDs
iii. Petechiae, ecchymosis • In thrombocytopenia
and hematoma cases, replacement of
platelets is done before procedure
• Prophylactic antibiotic coverage to be given
• Incase of liver disease, avoid drugs
metabolized by liver 8. Renal Disease
i. In this patient usually has • Prior consultation with hypertension and anemia physician
ii. Intolerance to nephrotoxic • Check the blood
drugs pressure before
iii. Increased susceptibility to initiation of treatment.
opportunistic infections • Antibiotic prophylaxis iv. Increased tendency for screen the bleeding time
bleeding • Avoid drugs
metabolized and excreted by kidney 9. Diabetes Mellitus
i. Patient has increased ten- • Take careful history of dency for infections and the patient
poor wound healing • Consult with physician ii. Patient may be suffering prior to treatment
from diseases related to • Note the blood glucose cardiovascular system, levels.
kidneys and nervous • Patient should have system like myocardial normal meals before infarction, hypertension, appointment
congestive heart failure, • If patient is on insulin renal failure and peripheral therapy, he/she should
neuropathy. have his regular dose
of insulin before appointment
• Schedule the appointment early in the mornings
• Antibiotics may be needed
• Have instant source of sugar available in clinic
• Patient should be evaluated for the
i. In such patients the • Do the elective proce-harm to patient can dure in second trimester occur via radiation • Use the principles of exposures, medication *ALARA while and increased level of exposing patients to stress and anxiety the radiation
ii. In the third trimester,
chances of development • Avoid any drugs which of supine hypotension can cause harm to the
are increased fetus
• Consult the physician to verify the physical status of the patient and any precautions if required for the patient
• Reduce the number of oral microorganism (by chlorhexidine mouth-wash)
• In third semesters, don’t place patient in supine position for prolonged periods 11. Anaphylaxis
Patient gives history of • Take careful history of severe allergic reaction the patient
on administration of: • Avoid use of agents to i. Local anesthetics which patient is allergic ii. Certain drugs • Always keep the emer-iii. Latex gloves and gency kit available
rubber dam sheets • In case the reaction develops:
– Identify the reaction – Call the physician – Place patient in
supine position – Check vital signs – If vital signs are
reduced, inject epinepherine tongue – Provide CPR if
needed
– Admit the patient
*ALARA – As low as Reasonably Achievable
Sequence of treatment delivery consists of three stages
• Initial treatment
• Definitive treatment
• Patient recall check up
Sequence of Treatment Delivery
a. Initial treatment: The initial treatment mainly aims at providing the relief from symptoms for example incision and drainage of an infection with severe pain and swelling, endodontic treatment of a case of acute irreversible pulpitis, etc.
Halting the progress of primary disease, i.e. caries or periodontal problem comes thereafter. Finally the patient is made to understand the disease and its treatment which further increases his/her compliance to the treatment. This approach is beneficial for the long-term prevention of the dental caries and periodontal disease.
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Case Selection and Treatment Planning
b. Definite treatment: Definitive treatment involves root canal treatment, surgical treatment, endodontic retreatment or the extraction of teeth with hopeless prognosis. In this phase tooth is given endodontic treatment with final restoration to maintain its form, function and esthetics.
c. Patient recall check up: Regular patient recall is integral part of the planning process. It involves taking patient history, examination, diagnosing again for assessment of the endodontic treatment.
Before the clinician starts the endodontic therapy, a number of issues arise related to the treatment planning.
These include maintaining asepsis of the operatory and infection control measures, premedication and administra-tion of local anesthesia followed by review of radiographs and complete isolation of the operating site.
Summary
Efficient and successful endodontics begins with proper case selection. The clinician must know his/her limitations and select cases accordingly. Since success of endodontic treatment depends upon many factors which can be modified to get better before initiating the treatment. Therefore accurate and thorough preparation of both patient as well as tooth to be treated should be carried out to achieve the successful treatment results.
QUESTION
Q. Write short notes on:
a. Indications and contraindications of endodontic therapy b. Role of medical history in endodontics
BIBLIOGRAPHY
1. Brody HA, Nesbitt WR. Psychosomatic oral problem. J Oral Med 1967;22:43.
2. Brooks SL, Miles DA. Advances in diagnostic imaging in dentistry.
Dent Clin N Amer 1993;37:91.
3. Chambers IG. The role and methods of pulp testing in oral diagnosis: a review. Int Endod J 1982;15:1.
4. Corah NL, Gale E, Illig S. Assessment of a dental anxiety scale.
J Am Dent Assoc 1978;97:816.
5. Elfenbaum A. Causalgia in dentistry: An Abandoned pain sundrome. Oral Surg 1954;7:594.
6. Gier RE. Management of neurogenic and psychogenic problems.
Dent Clin North Am, March 1968;177.
7. Harrigan WF. Psychiatric considerations in maxillofacial pain.
J Am Dent Assoc 1955;51:408.
8. Kleinknecht R, et al. Factor analysis of the dental fear survey with cross-validation. J Am Dent Assoc 1984;108:59.
9. Murray CA, Saunders WP. Root canal treatment and general health: A review of literature. Int Endod J 2000;33:1.
10. Newton JT, Buck DJ. Anxiety and pain measures in dentistry:
A guide to their quality and application. J Am Dent Assoc 2000;131:1449.
11. Weckstein MS. Basic psychology and dental practice. Dent Clin North Am 1970;14:379.
12. Weckstein MS. Practical applications of basic psychiatry to dentistry. Dent Clin North Am 1970;14:397.