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Endodontic case selection: Know when to treat, know when to refer

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When it comes to endodontic cases, the stakes are high. Successful endodontic treatment entails not only finding and treating all canals, preserving as much of the affected tooth as possible, and placing a durable permanent restoration, but also predicting the time and effort needed to bring about the best result for the patient and whether the case ultimately will be profitable for the practice. Being able to confidently assess the difficulty of any given endodontic case is essential to making the right decision of when to treat and when to refer to a specialist.

Assessing the difficulty of endodontic cases

The American Association of Endodontists (AAE) 2017 white paper on endodontic competency lays out guidelines for the knowledge and skills needed by general dentists to treat endodontic cases. These guidelines encompass all aspects of the process, from patient history to outcome assessment, and the decision to refer to an endodontist may be made based on any individual step exceeding a dentist’s personal ability, experience, or comfort level.

To help consistently and thoroughly analyze each presenting endodontic case, the AAE also has developed a case difficulty assessment form. This form lists several pretreatment considerations, along with circumstances that may pose a minimal, moderate, or high level of difficulty for dentists in general practice. Using these criteria can help determine whether it makes sense – from both a clinical and a business standpoint – to undertake a particular case.

Minimal difficulty

Cases that fall into the minimal-difficulty category are considered to have a routine, uncomplicated presentation. These patients are cooperative, have no medical conditions affecting their American Society of Anesthesiologists class or red flags in their anesthesia history, and have no signs of an emergency condition. The diagnosis is straightforward; the affected tooth is not a molar and has no evidence of unusual morphology or history of previous endodontic treatment; and if periodontal disease is present, it’s mild.

The AAE considers minimal-difficulty cases treatable by a general dentist who meets the standards of competency outlined in the guidelines, even with limited experience.

Moderate difficulty

Moderate-difficulty cases can involve patients who have medical or physical conditions affecting anesthesia or access, such as some limitation in opening their mouth. These patients also may have moderate oral pain or swelling, or signs and symptoms that lead to an extensive differential diagnosis. Radiography may be challenging to perform, and the affected teeth may be somewhat malpositioned. These teeth tend to have crown alterations (either from caries or previous restoration) or curved roots and reduced canal sizes. They may have a history of trauma or endodontic access, and moderate periodontal disease may be present.

On the AAE form, the presence of just one of these factors is enough to classify a case as moderately difficult; the existence if several puts it into the high-difficulty category. These cases are considered to be challenging even for dentists who are experienced in endodontics.

High difficulty

Cases are categorized as high difficulty if the patient has a complex medical or dental history or current illness, is uncooperative or unable to accommodate dental instruments (for example, they have an extreme gag reflex), or has severe pain. Affected teeth in this category may have superimposed radiographic structures or significant deviations from normal position or morphology, or they may be difficult to isolate or have apical resorption. These teeth also may have complications from previous trauma, endodontic treatment, or periodontal disease. Second and third molars are automatically considered high-difficulty cases.

The presence of any of these factors puts the case in the high-difficulty category, even for highly experienced dentists.

Considerations for treatable endodontic cases

If, after careful assessment, an endodontic case is deemed treatable without referral, a successful outcome requires accurate diagnostic imaging and excellent technique.

Apex length

In addition to identifying all the roots present and their morphology, clinicians must know the precise working length of each canal. Apex locators, such as Detect (Dentsply Maillefer) and the Patterson Digital Apex Locator, are indispensable for ensuring that obturation doesn’t exceed canal length. Detect uses fourth-generation multifrequency technology to track file progress and audible signals to indicate the approach of the apex, while its full-color screen provides easy-to-read visual indicators of depth. The rechargeable device requires no calibration.

The Digital Apex Locator uses digital signal processing to prevent false readings and adjusts automatically for all canal conditions. Its small size allows it to be mounted on the endodontic handpiece for maximum convenience, and both audible and LED indicators signal the depth of the file with 0.1-mm precision.

Canal preparation

Medicaments containing ethylenediaminetetraacetic acid (EDTA) can help facilitate root canal identification, clearing, and instrumentation. For example, Patterson’s 17% liquid EDTA solution helps remove calcifications and the smear layer. In addition, it’s formulated with antimicrobial activity. The chemical structure of EDTA makes its action self-limiting.

Premier’s RC-Prep paste includes glycol and urea peroxide in addition to EDTA to help lubricate the file and remove pulp debris.

Canal filling

When it’s time to fill the canal, success depends on thoroughness. Patterson’s radiopaque, color-coded, machine-rolled gutta percha points come in standard and auxiliary sizes to ensure complete filling no matter the size of the canal. Kerr’s TF Adaptive gutta percha points are sized and coded to match their TF Adaptive obturators and files, making choosing the right size for the whole process a snap. And COLTENE’s GuttaFlow eliminates the need for an obturator with its thixotropic, cold filling formulation that fits perfectly to both dentin and gutta percha and can penetrate even the smallest canals.

Chair time

No matter your level of experience and comfort with endodontics, there is still the question of time. Possessing the technical knowledge and skill to treat a difficult case doesn’t necessarily equal profitability in doing so. Referral to an endodontist may benefit not only the patient, but also your practice.

Referral tips

Endodontic referral tips

The AAE recommends that if the endodontic standard of treatment can’t be met for a particular case – for example, if a regenerative procedure or apical surgery is required – the patient should be referred to an endodontist. Regardless of the reason for referral, a few simple steps can help streamline these collaborations:

  • Refer promptly. Once an endodontic diagnosis is established and the case has been determined to be outside the dentist’s experience or capacity to treat, a prompt referral helps decrease the risk of potential complications developing.
  • Communicate clearly. Educating the patient realistically about the diagnosis and reason for referral helps set reasonable expectations before the patient meets the specialist. It also can help make future discussions more efficient and less confusing. Likewise, telling the endodontist what’s been explained to the patient, as well as plans for restoration, helps clarify the desired outcome.
  • Send diagnostic images. Radiographs, particularly periapical views, help give the specialist an immediate idea of the clinical situation. As they say, a picture is worth a thousand words.
  • Establish a relationship. Creating an ongoing relationship with a referral specialist helps develop a mutual understanding of how the other works, making collaboration smoother, more efficient, and better for patients.

Selected references

American Association of Endodontists. AAE endodontic case difficulty assessment form and guidelines.

American Association of Endodontists. Endodontic case difficulty assessment and referral. Endodontics Colleagues for Excellence. Spring/Summer 2005.

American Association of Endodontists. Endodontic competency. 2017.

Deutsch AS. Endodontic case selection: Treat or refer? Dentistry Today. August 1, 2018.

Doumani M, Habib A, Doumani A, et al. A review: The applications of EDTA in endodontics (Part I). IOSR J Dent Med Sci. 2017;16(9):83-85.

Gividen SL. Referral etiquette: Please don’t be that dentist. Dentistry IQ. September 16, 2020.

Singh H, Kapoor P. Generations of apex locators: Which generation are we in? Stomatological Dis Sci. 2019;3:4.

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This article originally appeared in the May 2022 edition of OnTarget. Read the latest edition and view current promotions at pattersondental.com/dental/ontarget.

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