INDICATIONS AND CONTRAINDICATIONS OF ENDODONTIC TREATMENTS
- Introduction :
Technological developments and the contribution of new endodontic instruments have allowed the recovery of many teeth intended for extraction a few years ago, however endodontic treatment on some of them remains contraindicated for many reasons.
- Definition of endodontic treatment (ET):
Is a procedure that consists of treating diseases of the pulp and periapex as well as transforming a pathological tooth into a healthy, asymptomatic and functional entity on the arch, applying from the coronal end to the apical end of a canal network of a tooth or a dental root.
- The objectives of endodontic treatment:
- Eliminate and neutralize all organic substances contained in the canal network.
- Root canal widening: This involves debridement or root canal trimming.
- Obturation of the canal network: (three-dimensional obturation)
- The indications:
The indications for endodontic treatment include all diseases of the dental pulp, their complications and more generally all pathological or traumatic events which can affect the dental root.
- Irreversible pulpitis.
- Necrotic pulp with or without complications.
- clinical and/or radiographic signs of apical periodontitis.
INDICATIONS AND CONTRAINDICATIONS OF ENDODONTIC TREATMENTS
- Unfavorable prognosis of pulp vitality, high probability of pulp exposure during coronal restoration not allowing direct capping, root amputation or hemisection.
- Prosthetic reasons.
- Tooth fracture with pulp exposure:
- the therapeutic decision will respond to:
- From the stage of root development (mature, immature tooth).
- From the size of the pulp exposure.
- The amount of time elapsed between the time of the trauma and the consultation.
- Contraindications:
- General:
- Contraindications related to the patient or practitioner:
It is illusory and useless to undertake complex endodontic treatment in a patient who has not been able to be motivated and who does not participate in the treatment.
Conversely, the practitioner’s lack of experience, organization, interest or training are major reasons for abstention in complex cases.
- Medical contraindications:
They are rare, classic and some of them need to be discussed.
1/Age:
Definition of elderly patient:
The elderly patient can be defined as a person over 75 years old or over 65 years old with multiple pathologies.
Age is not a contraindication to endodontic treatment.
INGLE says: “A patient who has kept his teeth until old age deserves better than an extraction.”
That said, certain difficulties related to aging can be encountered.
2/ pregnancy:
- Endodontic treatment is always preferable to extraction in the case of a normal pregnancy without any particular contraindications.
- No routine endodontic treatment will be undertaken during the first trimester of pregnancy.
- Emergency treatments will be carried out at a minimum, delaying as much as possible until the second trimester.
- All urgent care aimed at treating pain or infection must be carried out without delay.
- After the second trimester, care will be postponed to avoid the risk of premature delivery, except in cases of extreme emergency.
3/Pathological conditions:
Certain serious diseases are considered incompatible with endodontic treatment.
A/ Patients at risk of bacterial or infectious endocarditis:
- General:
Definition: Infective endocarditis is the consequence of a microbial graft on a heart valve. It has local (valve lesions) and general (risk of heart failure, infectious, vascular or renal complications) repercussions.
Classification:
- Contact with the medical team is mandatory to know the true nature of the heart disease and especially to assess the importance of the risk of infection.
- In patients at high risk of infective endocarditis, certain invasive procedures are contraindicated.
- Any authorized invasive procedure requires antibiotic prophylaxis.
- Endodontic treatments can only be carried out after verification of pulp vitality.
- Endodontic treatments are reserved for single-rooted vital teeth in a single session and under a dam.
- Endodontic treatments on teeth with non-vital pulp and endodontic retreatment are contraindicated.
- Endodontic treatments on teeth with living pulp in several sessions or without a dam are contraindicated.
B/ Osteoradionecrosis:
This is a complex problem that should only be treated after consultation with the medical team.
- Before irradiation: endodontic treatment will be reserved for teeth without complications and avoiding metal fillings.
- After irradiation: extractions pose complex problems, which is why endodontic treatments can be considered after antibiotic therapy and agreement from the medical team.
C/ Diabetes:
Diabetes is not a contraindication to endodontic treatment. There are only two precautions to take: the first is anesthetic, the second will consist of avoiding cellular or bone complications that can take a serious turn.
- For the unbalanced patient in whom endodontic treatment is necessary, two scenarios are possible:
- if this is an initial treatment on a pulped tooth, treatment may be considered;
- If it is an initial treatment or a retreatment on an infected tooth and the tooth is of major strategic interest, after having assessed its feasibility, the treatment can be carried out under antibiotic prophylaxis. This is based on the protocol for infective endocarditis.
- We will then favor single-session treatments in order to avoid multiplying antibiotic prophylaxis. If necessary, the tooth will have to be extracted.
D/ Chronic leukemia and terminal stage cancer:
It seems that after advice from the medical team, endodontic treatment can be undertaken.
E/ Coagulation disorders:
Endodontic treatment will always be preferable to extraction because of the risk of bleeding; the medical team should always be consulted.
- Local order:
1/Impossibility of coronary reconstruction:
Any inability to reconstruct the crown of the tooth, often linked to coronal decay, contraindicates endodontic treatment.
2/Short roots:
These roots should not be treated because they are prophetically unusable in fixed prostheses , as well as the inevitable periodontal recession over time preventing a favorable prognosis.
3/Isolated teeth without antagonists:
For these teeth, the subsequent prosthetic interest will have to be assessed.
4 / Endodontic treatment doomed to failure for periodontal reasons:
- Very advanced periodontal lesions: are almost always a contraindication for endodontic treatment. We will be very careful in the diagnosis and we will avoid performing endodontic treatment if there are periodontal lesions at the terminal stage.
- Two situations are often overlooked by the endodontist and two of them always end in failure: “Dehiscence and fenestration”
- dehiscence: this is a complete loss of the external table (or of both bony tables, which is rarer) up to the apical region: no cure is possible.
- fenestration: this is the passage of the apical end through the external table, this situation, without being frequent, is not exceptional and leads to unexplained failures when it is not recognized. Endodontic surgery by resection of the root end allows very good results.
5/Vertical root fracture:
They represent an impossibility of treatment rather than a contraindication. Horizontal fractures are amenable to endodontic treatment.
6/Internal perforating resorptions:
They are eligible for endodontic treatment provided that it is supplemented by periapical surgery when possible.
- Conclusion :
A correct clinical examination and a well-conducted interview allow us to make the correct diagnosis and propose the ideal treatment for each pathology, taking into account local and general environmental factors.
Good oral hygiene Regular scaling at the dentist Dental implant placement Dental x-rays Teeth whitening A visit to the dentist The dentist uses local anesthesia to minimize pain