PRACTICE

2
IN BRIEF
● An accurate diagnosis of the patient’s condition is essential before an appropriate treatment
plan can be formulated for that individual.
● A logical approach to clinical examination should be adopted.
● A high quality long-cone parallel radiograph is mandatory before commencing root canal
treatment, and should be carefully examined to obtain all possible information.
● Root canal treatment may not be the most appropriate therapy, and treatment plans should
take into account not only the expected prognosis but also the patient’s dental condition,
expectations and wishes.
VERIFIABLE
CPD PAPER

Endodontics: Part 2
Diagnosis and treatment planning
P. Carrotte1 NOW AVAILABLE
AS A BDJ BOOK

As with all dental treatment, a detailed treatment plan can only be drawn up when a correct and accurate diagnosis has been
made. It is essential that a full medical, dental and demographic history be obtained, together with a thorough extra-oral and
intra-oral examination. This part considers the classification of diseases of the dental pulp, together with various diagnostic
aids to help in determining which condition is present, and the appropriate therapy.

ENDODONTICS The importance of correct diagnosis and treat- practitioner should be consulted before any
1. The modern concept of ment planning must not be underestimated. endodontic treatment is commenced. This also
root canal treatment There are many causes of facial pain and the dif- applies if the patient is on medication, such as
2. Diagnosis and treatment ferential diagnosis can be both difficult and corticosteroids or an anticoagulant. An example
planning demanding. All the relevant information must be of the particulars required on a patient’s folder is
3. Treatment of endodontic collected; this includes a case history and the illustrated in Table 1.
emergencies results of both a clinical examination and diag- Antibiotic cover has been recommended for
nostic tests. The practitioner should be fully certain medical conditions, depending upon the
4. Morphology of the root
canal system
conversant with the prognosis for different complexity of the procedure and the degree of
endodontic clinical situations, discussed in bacteraemia expected, but the type of antibiotic
5. Basic instruments and
Part 12. Only at this stage can the cause of the and the dosage are under continual review and
materials for root canal
problem be determined, a diagnosis made, the dental practitioners should be aware of current
treatment
appropriate treatments discussed with the patient opinion. The latest available edition of the Dental
6. Rubber dam and access and informed or valid consent obtained. Practitioners’ Formulary1 should be consulted for
cavities the current recommended antibiotic regime.
7. Preparing the root canal CASE HISTORY However, when treating patients who may be
8. Filling the root canal The purpose of a case history is to discover considered predisposed to endocarditis, it may be
system whether the patient has any general or local con- advisable to liaise with the patient’s cardiac
9. Calcium hydroxide, root dition that might alter the normal course of
resorption, endo-perio treatment. As with all courses of treatment, a Table 1 A simple check list for a medical history
lesions comprehensive demographic, medical and previ- (Scully and Cawson2)
10. Endodontic treatment for ous dental history should be recorded. In addi- Anaemia
children tion, a description of the patient’s symptoms in
Bleeding disorders
11. Surgical endodontics his or her own words and a history of relevant
Cardiorespiratory disorders
12. Endodontic problems dental treatment should be noted.
Drug treatment and allergies
1*Clinical Lecturer, Department of Adult Medical history Endocrine disease
Dental Care, Glasgow Dental Hospital and There are no medical conditions which specifi- Fits and faints
School, 378 Sauchiehall Street, Glasgow Gastrointestinal disorders
G2 3JZ cally contra-indicate endodontic treatment, but
*Correspondence to: Peter Carrotte there are several which require special care. The Hospital admissions and attendances
Email: [email protected] most relevant conditions are allergies, bleeding Infections
Refereed Paper
tendencies, cardiac disease, immune defects or Jaundice or liver disease
doi:10.1038/sj.bdj.4811612 patients taking drugs acting on the endocrine or Kidney disease
© British Dental Journal 2004; 197: CNS system. If there is any doubt about the state Likelihood of pregnancy or pregnancy itself
231–238 of health of a patient, his/her general medical

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 231

PRACTICE

Fig. 1 A facial sinus It is usually possible to decide, as a result of

associated with a questioning the patient, whether the pain is of
severe periapical
abscess on the upper pulpal, periapical or periodontal origin, or if it is
canine. non-dental in origin. As it is not possible to
diagnose the histological state of the pulp from
the clinical signs and symptoms, the terms acute
and chronic pulpitis are not appropriate. In cases
of pulpitis, the decision the operator must make
is whether the pulpal inflammation is reversible,
in which case it may be treated conservatively,
or irreversible, in which case either the pulp or
the tooth must be removed, depending upon the
patient’s wishes.
If symptoms arise spontaneously, without
stimulus, or continue for more than a few sec-
onds after a stimulus is withdrawn, the pulp may
be deemed to be irreversibly damaged. Applica-
tions of sedative dressings may relieve the pain,
specialist or general medical practitioner. Not all but the pulp will continue to die until root canal
patients with cardiac lesions require antibiotic treatment becomes necessary. This may then
prophylaxis, and such regimes are not generally prove more difficult if either the root canals
supported by the literature.2 However, if it is have become infected or if sclerosis of the root
agreed that the patient is at risk, they would nor- canal system has occurred. The correct diagno-
mally be prescribed the appropriate prophylactic sis, once made, must be adhered to with the
antibiotic regime, and should be advised to appropriate treatment.
report even a minor febrile illness which occurs In early pulpitis the patient often cannot
up to 2 months following root canal treatment. localise the pain to a particular tooth or jaw
Prior to endodontic surgery, it is useful to pre- because the pulp does not contain any proprio-
scribe aqueous chlorhexidine (2%) mouthwash. ceptive nerve endings. As the disease advances
and the periapical region becomes involved, the
Patient’s complaints tooth will become tender and the proprioceptive
Listening carefully to the patient’s description nerve endings in the periodontal ligament are
of his/her symptoms can provide invaluable stimulated.
information. It is quicker and more efficient to
ask patients specific, but not leading, ques- CLINICAL EXAMINATION
tions about their pain. Examples of the type of A clinical examination of the patient is carried
questions which may be asked are given out after the case history has been completed.
below. The temptation to start treatment on a tooth
1. How long have you had the pain? without examining the remaining dentition must
2. Do you know which tooth it is? be resisted. Problems must not be dealt with in
3. What initiates the pain? isolation and any treatment plan should take the
4. How would you describe the pain? entire mouth and the patient’s general medical
Sharp or dull condition and attitude into consideration.
Throbbing
Mild or severe Extra-oral examination
Localised or radiating The patient’s face and neck are examined and
5. How long does the pain last? any swelling, tender areas, lymphadenopathy, or
6. Does it hurt most during the day or night? extra-oral sinuses noted, as shown in Figure 1.
7. Does anything relieve the pain?
Intra-oral examination
An assessment of the patient’s general dental
Fig. 2 An assessment state is made, noting in particular the following
should be made of the
patient’s general
aspects (Fig. 2).
dental condition. • Standard of oral hygiene.
• Amount and quality of restorative work.
• Prevalence of caries.
• Missing and unopposed teeth.
• General periodontal condition.
• Presence of soft or hard swellings.
• Presence of any sinus tracts.
• Discoloured teeth.
• Tooth wear and facets.

Diagnostic tests
Most of the diagnostic tests used to assess the
state of the pulp and periapical tissues are

232 BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004

 PRACTICE

Fig. 3 The anatomical detail

a b obtained from a radiograph taken by
the long-cone paralleling technique
(a) is far clearer and more accurate
than when the bisecting angle
technique (b) is used.

relatively crude and unreliable. No single test, Radiography

however positive the result, is sufficient to make a In all endodontic cases, a good intra-oral paral-
firm diagnosis of reversible or irreversible pulpi- lel radiograph of the root and periapical region
tis. There is a general rule that before drilling into is mandatory. Radiography is the most reliable
a pulp chamber there should be two independent of all the diagnostic tests and provides the most
positive diagnostic tests. An example would be a valuable information. However, it must be
tooth not responding to the electric pulp tester emphasised that a poor quality radiograph not
and tender to percussion. only fails to yield diagnostic information, but
also, and more seriously, causes unnecessary
Palpation radiation of the patient. The use of film holders,
The tissues overlying the apices of any suspect recommended by the National Radiographic
teeth are palpated to locate tender areas. The site Guidelines3 and illustrated in Part 4, has two dis-
and size of any soft or hard swellings are noted tinct advantages. Firstly a true image of the
and examined for fluctuation and crepitus. tooth, its length and anatomical features, is
obtained (Fig. 3), and, secondly, subsequent
Percussion films taken with the same holder can be more
Gentle tapping with a finger both laterally and accurately compared, particularly at subsequent
vertically on a tooth is sufficient to elicit any ten- review when assessing the degree of healing of a
derness. It is not necessary to strike the tooth with periradicular lesion.
a mirror handle, as this invites a false- A radiograph may be the first indication of the
positive reaction from the patient. presence of pathology (Fig. 4). A disadvantage of
the use of radiography in diagnosis, however,
Mobility can be that the early stages of pulpitis are not
The mobility of a tooth is tested by placing a fin- normally evident on the radiograph.
ger on either side of the crown and pushing with If a sinus is present and patent, a small-sized
one finger while assessing any movement with (about #40) gutta-percha point should be
the other. Mobility may be graded as: inserted and threaded, by rolling gently
1 — slight (normal) between the fingers, as far along the sinus tract
2 — moderate as possible. If a radiograph is taken with the
3 — extensive movement in a lateral or gutta-percha point in place, it will lead to an
mesiodistal direction combined with a area of bone loss showing the cause of the
vertical displacement in the alveolus. problem (Fig. 5).
Fig. 4 A radiograph taken as part
of a periodontal assessment also
reveals a previously undiagnosed
and asymptomatic periradicular
lesion on the palatal root of tooth
UL6 (26).

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 233

PRACTICE

between them. Most pulp testers manufactured

Fig. 5 A gutta-percha point has been
a
today are monopolar (Fig. 6).
threaded into a sinus tract adjacent to
a recently root-treated canine (a). The As well as the concerns expressed earlier
radiograph (b) reveals the source of the about pulp testing, electric pulp testers may give
infection to be the first premolar. a false-positive reading due to stimulation of
nerve fibres in the periodontium. Again, posteri-
or teeth may give misleading readings since a
combination of vital and non-vital root canal
pulps may be present. The use of gloves in the
treatment of all dental patients has produced
problems with electric pulp testing. A lip elec-
trode attachment is available which may be
used, but a far simpler method is to ask the
patient to hold on to the metal handle of the pulp
tester. The patient is asked to let go of the handle
if they feel a sensation in the tooth being tested.
The teeth to be tested are dried and isolated
b with cotton wool rolls. A conducting medium
should be used; the one most readily available is
toothpaste. Pulp testers should not be used on
patients with pacemakers because of the possi-
bility of electrical interference.
Teeth with full crowns present problems with
pulp testing. A pulp tester is available with a
special point fitting which may be placed
between the crown and the gingival margin.
There is little to commend the technique of cut-
ting a window in the crown in order to pulp test.

Thermal pulp testing

This involves applying either heat or cold to a
tooth, but neither test is particularly reliable and
may produce either false-positive or false-
negative results.

Heat
Pulp testing There are several different methods of applying
Pulp testing is often referred to as ‘vitality’ test- heat to a tooth. The tip of a gutta-percha stick
ing. In fact, a moribund pulp may still give a may be heated in a flame and applied to a tooth.
positive reaction to one of the following tests Take great note that hot gutta-percha may stick
as the nervous tissue may still function in fast to enamel, and it is essential to coat the
extreme states of disease. It is also, of course, tooth with vaseline to prevent the gutta-percha
possible in a multirooted tooth for one root sticking and causing unnecessary pain to the
canal to be diseased, but another still capable patient. Another method is to ask the patient to
of giving a vital response. Pulp testers should hold warm water in the mouth, which will act on
only be used to assess vital or non-vital pulps; all the teeth in the arch, or to isolate individual
they do not quantify disease, nor do they meas- teeth with rubber dam and apply warm water
ure health and should not be used to judge the directly to the suspected tooth. This is explored
degree of pulpal disease. Pulp testing gives no further under local anaesthesia.
indication of the state of the vascular supply
which would more accurately indicate the Cold
degree of pulp vitality. The only way pulpal Three different methods may be used to apply a
blood-flow may be measured is by using a cold stimulus to a tooth. The most effective is the
Laser-Doppler Flow Meter, not usually avail- use of a –50°C spray, which may be applied using
able in general practice! a cotton pledget (Fig. 7). Alternatively, though
Doubt has been cast on the efficacy of pulp less effectively, an ethyl chloride spray may be
testing the corresponding tooth on the other side used. Finally, ice sticks may be made by filling
of the mid-line for comparison, and it is sug- the plastic covers from a hypodermic needle with
gested that only the suspect teeth are tested. water and placing in the freezing compartment
of a refrigerator. When required for use one cover
Electronic is warmed and removed to provide the ice stick.
The electric pulp tester is an instrument which However, false readings may be obtained if the
uses gradations of electric current to excite a ice melts and flows onto the adjacent tissues.
Fig. 6 A modern electric pulp tester response from the nervous tissue within the pulp.
combined with an endodontic apex Both alternating and direct current pulp testers Local anaesthetic
locator. are available, although there is little difference In cases where the patient cannot locate the pain

234 BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004

 PRACTICE

and routine thermal tests have been negative, a of the perforation, followed by the provision of
reaction may be obtained by asking the patient to new posts and cores, and crowns.
sip hot water from a cup. The patient is instructed However, success in this case may depend
to hold the water first against the mandibular upon the correct planning of treatment. For
teeth on one side and then by tilting the head, to example, what provisional restorations will be
include the maxillary teeth. If a reaction occurs, used during the root canal treatment, and during
an intraligamental injection may be given to the following re-evaluation period. Temporary
anaesthetise the suspect tooth and hot water is post-crowns have been shown to be very poor at
then again applied to the area; if there is no reac- resisting microleakage.4 The provision of a tem-
tion, the pulpitic tooth has been identified. It porary over denture, enabling the total sealing
should be borne in mind that a better term for of the access cavities, would seem an appropri-
intraligamental is intra-osseous, as the local ate alternative, but if this has not been properly
anaesthetic will pass into the medullary spaces planned for, problems may arise and successful
round the tooth and may possibly also affect the treatment may be compromised.
proximal teeth.
INDICATIONS FOR ROOT CANAL TREATMENT
Wooden stick All teeth with pulpal or periapical pathology are Fig. 7 A more effective source of
If a patient complains of pain on chewing and candidates for root canal treatment. There are also cold stimulus for sensibility testing.
there is no evidence of periapical inflammation, situations where elective root canal treatment is
an incomplete fracture of the tooth may be sus- the treatment of choice.
pected. Biting on a wood stick in these cases can
elicit pain, usually on release of biting pressure. Post space
A vital tooth may have insufficient tooth sub-
Fibre-optic light stance to retain a jacket crown so the tooth may
A powerful light can be used for transilluminat- have to be root-treated and restored with a post-
ing teeth to show interproximal caries, fracture, retained crown (Fig. 9).
opacity or discoloration. To carry out the test,
the dental light should be turned off and the Overdenture
fibre-optic light placed against the tooth at the Decoronated teeth retained in the arch to pre-
gingival margin with the beam directed through serve alveolar bone and provide support or
the tooth. If the crown of the tooth is fractured, removable prostheses must be root-treated.
the light will pass through the tooth until it
strikes the stain lying in the fracture line; the Teeth with doubtful pulps
tooth beyond the fracture will appear darker. Root treatment should be considered for any
tooth with doubtful vitality if it requires an exten-
Cutting a test cavity sive restoration, particularly if it is to be a bridge
When other tests have given an indeterminate abutment. Such elective root canal treatment has
result, a test cavity may be cut in a tooth which a good prognosis as the root canals are easy to
is believed to be pulpless. In the author’s opin- access and are not infected. If the indications are
ion, this test can be unreliable as the patient may
give a positive response although the pulp is
necrotic. This is because nerve tissues can con-
tinue to conduct impulses for some time in the
absence of a blood supply.

TREATMENT PLANNING
Having taken the case history and carried out the
relevant diagnostic tests, the patient’s treatment is
then planned. The type of endodontic treatment
chosen must take into account the patient’s med-
ical condition and general dental state. The indi-
cations and contra-indications for root canal
treatment are given below and the problems of re-
root treatment discussed. The treatment of frac-
tured instruments, perforations and perio-endo
lesions are discussed in subsequent chapters.
It should be emphasised here that there is a
considerable difference between a treatment
plan and planning treatment. Figure 8 shows a
radiograph of a patient with a severe endodontic
problem. A diagnosis of failed root canal treat-
ments, periapical periodontitis (both apically
and also associated with a perforation of one
root), and failed post crowns could be made. A Fig. 8 This complicated case exhibits a number of
treatment plan for this patient may be different endodontic problems, and requires careful
orthograde re-root canal treatment, with repair treatment planning if success is to be achieved.

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 235

PRACTICE

Fig. 9 Tooth UL1 (21) requires a sure. In some cases these teeth should be elec-
crown, but there is insufficient tively root-treated.
coronal tissue remaining. One
possible treatment plan would be
elective endodontic treatment Periodontal disease
followed by the provision of a post- In multirooted teeth there may be deep pocket-
retained core build-up and crown. ing associated with one root or the furcation.
The possibility of elective devitalisation follow-
ing the resection of a root should be considered
(see Part 9).

Pulpal sclerosis following trauma

Review periapical radiographs should be taken
of teeth which have been subject to trauma.
If progressive narrowing of the pulp space is
seen due to secondary dentine, elective root
canal treatment may be considered while the
coronal portion of the root canal is still patent.
This may occasionally apply after a pulpotomy
has been carried out. However, Andreasen6
refers to a range of studies that show a maxi-
mum of 16% of sclerosed teeth subsequently
cause problems, and the decision over root
canal treatment must be arrived at after full
ignored and the treatment deferred until the pulp consultation with the patient. If the sclerosing
becomes painful or even necrotic, access through tooth is showing the classic associated discol-
the crown or bridge will be more restricted, and oration the patient may elect for treatment, but
treatment will be significantly more difficult, with otherwise the tooth may better be left alone
a lower prognosis.5 (Fig. 10).

Risk of exposure CONTRA-INDICATIONS TO ROOT CANAL

Preparing teeth for crowning in order to align TREATMENT
them in the dental arch can risk traumatic expo- The medical conditions which require special
precautions prior to root canal treatment have
already been listed. There are, however, other
a conditions both general and local, which may
contra-indicate root canal treatment.

General
Inadequate access
A patient with restricted opening or a small
mouth may not allow sufficient access for root
canal treatment. A rough guide is that it must
be possible to place two fingers between the
mandibular and maxillary incisor teeth so that
there is good visual access to the areas to be
treated. An assessment for posterior endodon-
tic surgery may be made by retracting the
Fig. 10 A 23-year-old female patient cheek with a finger. If the operation site can
b suffered trauma to tooth UL1 (21) when be seen directly with ease, then the access is
aged 16, and is complaining about the
yellow discoloration of the tooth (a). A sufficient.
radiograph (b) reveals that the pulp
space has sclerosed. Poor oral hygiene
As a general rule root canal treatment should
not be carried out unless the patient is able to
maintain his/her mouth in a healthy state, or
can be taught and motivated to do so. Excep-
tions may be patients who are medically or
physically compromised, but any treatment
afforded should always be in the best long-term
interests of the patient.

Patient’s general medical condition

The patient’s physical or mental condition due to,
for example, a chronic debilitating disease or old
age, may preclude endodontic treatment. Similar-
ly, the patient at high risk to infective endocardi-

236 BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004

 PRACTICE

Fig. 11 Tooth UL1 (21) was so extensively decayed Fig. 12 The vertical root fracture can be clearly seen in
subgingivally that restoration would have proved this extracted tooth which had been fitted with a post
impossible even if endodontic treatment had been carried crown.
out.
tis, for example one who has had a previous pathological fracture of the tooth. Internal resorp-
attack, may not be considered suitable for com- tion ceases immediately the pulp is removed and,
plex endodontic therapy. provided the tooth is sufficiently strong, it may be
retained. Most forms of external resorption will
Patient’s attitude continue (see Part 9) unless the defect can be
Unless the patient is sufficiently well motivated, repaired and made supragingival, or arrested with
a simpler form of treatment is advised. calcium hydroxide therapy.

Local Bizarre anatomy

Tooth not restorable Exceptionally curved roots (Fig. 13), dilacer-
It must be possible, following root canal treat- ated teeth, and congenital palatal grooves
ment, to restore the tooth to health and function may all present considerable difficulties if
(Fig. 11). The finishing line of the restoration must root canal treatment is attempted. In addition,
be supracrestal and preferably supragingival. any unusual anatomical features related to the
An assessment of possible restorative problems roots of the teeth should be noted as these
should always be made before root canal treat- may affect prognosis.
ment is prescribed.
Re-root treatment
Insufficient periodontal support One problem which confronts the general
Provided the tooth is functional and the dental practitioner is to decide whether an
attachment apparatus healthy, or can be made inadequate root treatment requires replace-
so, root canal treatment may be carried out. ment (Fig. 14). The questions the operator
should consider are given below.
Non-strategic tooth
Fig. 13 The tooth UR4 (14) has such a
Extraction should be considered rather than bizarre root canal anatomy that
root canal treatment for unopposed and non- endodontic treatment would probably
functional teeth. be impossible.

Root fractures
Incomplete fractures of the root have a poor prog-
nosis if the fracture line communicates with the
oral cavity as it becomes infected. For this reason,
vertical fractures will often require extraction of
the tooth while horizontal root fractures have a
more favourable prognosis (Fig. 12).

Internal or external resorption

Both types of resorption may eventually lead to

BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 237

PRACTICE

Fig. 14 Tooth UL4 (24) has previously

been root treated (and obturated with
silver points) but is symptomless.
However, the tooth now requires a full
crown restoration. A decision must be
made as to whether the tooth should
be re-treated before fitting the
advanced restoration.

1 Is there any evidence that the old root filling root canal filling of a tooth with a periradicu-
has failed? lar lesion falls to about 65%.
• Symptoms from the tooth. The final decision by the operator on the treat-
• Radiolucent area is still present or has ment plan for a patient should be governed by the
increased in size. level of his/her own skill and knowledge. General
• Presence of sinus tract. dental practitioners cannot become experts in all
2 Does the crown of the tooth need restoring? fields of dentistry and should learn to be aware of
their own limitations. The treatment plan pro-
3 Is there any obvious fault with the present
posed should be one which the operator is confi-
root filling which could lead to failure?
dent he/she can carry out to a high standard.
Practitioners should be particularly aware
of the prognosis of root canal re-treatments. 1. Dental Practitioners’ Formulary 2000/2002. British
Dental Association. BMA Books, London
As a rule of thumb, taking the average of the 2. Scully C, Cawson R A. Medical problems in dentistry.
surveys reported in the endodontic literature Oxford: Butterworth-Heinemann, p74, 1998.
(see Part 12) suggests a prognosis of 90–95% 3. National Radiographic Protection Board. Guidance
for an initial root canal treatment of a tooth Notes for Dental Practitioners on the safe use of
x-ray equipment. 2001. Department of Health,
with no radiographic evidence of a periradicu- London, UK.
lar lesion. When such a lesion is present prog- 4. Fox K, Gutteridge D L. An in vitro study of coronal
nosis will fall to around 80–85%, and the microleakage in root-canal-treated teeth restored by
the post and core technique. Int Endod J 1997; 30:
longer the lesion has been present the more 361–368.
established will be the infection, treatment (ie 5. Ørstavik D. Time-course and risk analysis of the
removal of that infection from the entire root development and healing of chronic apical
canal system) will be more difficult and the periodontitis in man. Int Endod J 1996; 29: 150–155.
6. Andreasen J O, Andreasen F M. Chapter 9 in Textbook
prognosis significantly lower. The average and colour atlas of traumatic injuries to the teeth. 3rd
reported prognosis for re-treatment of a failed Ed, Denmark, Munksgard 1994.

Fifty years ago today

British Dental Journal, January 1954
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BRITISH DENTAL JOURNAL VOLUME 197 NO. 5 SEPTEMBER 11 2004 238