IT IS ABOUT THE CASE SELECTION PROCEDURE IN ENDODONTIC CASES.

2. D R . PA R T H A S A R AT H I A D H YA . B . D . S . ( W B U H S )
CASE SELECTION ON ENDODONTIC
TREATMENT

3. CONTENTS
• INTRODUCTION
• WHY CASE SELECTION IS ESSENTIAL?
• CONSIDERATIONS PRIOR TO ENDO TREATMENT
• FACTORS OF CASE SELECTION
• FACTORS ASSOCIATED WITH TEETH
• FACTORS ASSOCIATED WITH PATIENT’S HEALTH
• FACTORS ASSOCIATED WITH THE CLINICIAN
• AAE CASE DIFFICULTY ASSESSMENT FORM AND
GUIDELINES
• REVIEW OF LITERATURE
• CONCLUSION
• REFERENCES

4. INTRODUCTION
• The process of case selection and treatment planning begins after a
clinician has diagnosed an endodontic problem.
• Proper selection of cases avoid pitfalls during endodontic treatment
and helps to ensure success.
• Errors in the case selection, some of which could have been
avoided, constituted 22% of failures reported in a study conducted
by Ingle and Beveridge.
• The use of rotary instruments, ultrasonics, and microscopy as well
as new materials has made it possible to predictably retain teeth that
previously could not have been treated. But in spite of all these
development case selection is the 1st step towards saving a tooth.

5. WHY ESSENTIAL???
LEADS TO SUCCESSFUL
ENDODONTIC PROCEDURE
LIKE RCT.
HELPS TO BULID GOOD
DOCTOR PATIENT RAPPORT.
MAKE PATIENTS CONFIDENT
ABOUT FUTURE ENDODONTIC
AND DENTAL PROCEDURES.
MAKES THE DOCTOR
CONFIDENT ABOUT HIS/HER
OWN TREATMENT
PROCEDURES.
PROPER CASE
SELECTION

6. • Although it is true that root canal treatment can be
performed virtually on any tooth there are some
important considerations that must be evaluated prior to
recommending root canal treatment.some of these were
delineated by Beveridge1971.

7. CONSIDERATIONS PRIOR TO
ENDODONTIC THERAPY
1.Is the tooth needed or important? Could it some day
serve as an abutment for prosthesis?
2. Is the tooth salvageable, or is it so badly destroyed that it
cannot be restored?
3. Is the entire dentition so completely broken down that it
would be virtually impossible to restore?

8. 4. Is the tooth serving esthetically, or would the patient be
better served by its extraction and a more cosmetic
replacement?
5. Is the tooth so severely involved periodontally that it
would be lost soon for this reason?
6. Is the practitioner capable of performing the needed
endodontic procedures?

9. FACTORS OF CASE SELECTION
• Case selection is broadly based upon three factors
• Factors associated with teeth.
• Factors associated with patients health.
• Factors associated with clinician.

10. FACTORS ASSOCIATED WITH TEETH
1st step always should be examination of the teeth and oral
cavity . Clinician should judge whether the teeth needed any kind
of endodontic treatment or not.
• Indication
1.Teeth with pulpal inflammation
pulpal inflammation like irreversible pulpitis , chronic
hyperplastic pulpitis, pulpal necrosis require endodontic
treatment.

11. 2. Teeth with periapical pathosis.
Periapical pathology or diseases of periradicular tissue, like
acute or chronic apical periodontitis, acute or chronic periapical
abscess can be treated by endodontic procedure.

12. 3. Fractured teeth
Fractured teeth often require endodontic treatment which helps to
maintain its normal esthetic form and functional properties.
Deciduous teeth having pulpal involvement and crown fracture
required treatment procedure like pulpotomy, direct pulp capping,
apexification, apexogenesis.
Vertical crown fracture in multi rooted teeth involving furcation can
also be treated by endodontic procedures like hemisection followed
by root canal therapy.

13. 4. Facilitation of restoration (Intentional Endodontic Treatment).
Occasionally, intentional endodontic treatment of teeth with
perfectly vital pulps may be necessary. Examples of situations
requiring intentional endodontic treatments include hyper
erupted teeth or drifted teeth that must be reduced so
drastically that the pulp is certain to be involved.
On other occasions, a pulp is intentionally removed and the
canal filled so that a post and core may be placed for
increased crown retention.

14. CONTRAINDICATING FACTORS OR FACTORS
WHERE SPEACIAL ATTENTION IS NEEDED-
1. Insufficient periodontal support- In Teeth having grade three
mobility extraction is preffered over endodontic treatment
A tooth with a poor periodontal prognosis may have to be sacrificed,
despite a favorable endodontic prognosis.

15. The radiographic appearance of combined endodontic–periodontal
lesions may be similar to that of a vertically fractured tooth.
• Therapy for true combined lesions requires both endodontic and
periodonal therapy
• those lesions that develop as a result of both pulpal
infection and periodontal disease—respond to a
combined treatment approach in which endodontic
intervention precedes, or is done simultaneously
with, periodontal treatment.

16. 2. Improper positioning of teeth-
Partially erupted, impacted and malpositioned teeth are
contraindicated for endodontic treatment.
It is very difficult to make proper accessibility and
isolation while doing endodontic treatment in these
malposed teeth.

17. 3. Non restorable teeth-
The restorability of a tooth requiring endodontic treatment
depends on the amount of sound tooth structure remaining.
Teeth with very less amount of crown and extremely carious
are contraindicated for endodontic treatment.
Teeth which are grossly
decayed (both crown and
root)also contraindicated for
endodontic treatment

18. 4. Abnormal canal configuration-
Severely curved canal, c shaped canal, aberrant extra canals are
very difficult for instrumentation
Teeth with such canal configuration are not ideal for endodontic
treatment.
Curvature of 20º in a
narrow root canal is very
difficult to negotiate also
a curvature of 30ºwith a wide canal
is not easily negotiable.
The degree of curvature ,size and
constriction of the root canal must
be judged prior to endodontic
treatment

19. 5. Developmental anomalies-
Developmental anomalies like fusion, gemination, concresence, enamel
pearl are difficult to treat with endodontic procedures.

20. 6. calcification of canal-
Excessive calcification of canal prevents proper instrumentation .
Which may cause failure of endodontic treatment or iatrogenic errors
like perforation, ledging etc.
Such cases should be selected judiciously.

21. 7. Crown root ratio -
An unfavorable crown/root ratio that exceeds 1:1 is more
susceptible to eccentric occlusal forces, and hence
prognosis is poor.
Sometimes these teeth maybe indicated for extraction,
but before a decision for extraction is made referral to a
prosthetic dentist for an accurate evaluation maybe
necessary.

22. 8. Iatrogenic error.
Painfull Teeth where previous attempt of endodontic
treatment has been done often show ledges,
perforations, broken instruments in the canals.
Prognosis of such cases are questionable if not treated
properly.

23. FACTORS ASSOCIATED WITH PATIENT’S
HEALTH
• Before starting endodontic treatment the clinician must take
proper medical history about the patient, The clinician should
search for following informations -
 History of allergies
 History of drug interactions, adverse effects
 Anxiety (past experiences and management strategy)
 Presence of prosthetic valves, joints, stents,
pacemakers
Required Antibiotics (prophylactic or therapeutic)

24. Hemostasis (normal expected, modification to treatment)
Infiltration or block anesthesia with or without vasoconstrictor
Significant equipment concerns (radiographs, ultrasonics,
electrosurgery)
Emergencies (potential for occurrence, preparedness)

25. American Society of Anesthesiologists Physical
Status Classification System-After obtaining the above
informations the clinician should access the physical status of the patient.
P1: Normal, healthy patient; no dental management
alterations required
P2: Patient with mild systemic disease that does not interfere
with daily activity or who has a significant health risk factor
(e.g., smoking, alcohol abuse, gross obesity)
P3: Patient with moderate to severe systemic disease that is
not incapacitating but may alter daily activity
P4: Patient with severe systemic disease that is incapacitating
and a constant threat to life

26. Common Medical Findings That may Influence
endodontic treatment planning
1. Cardio vascular disorder-
 the history of patients with cardio vascular disorder should be
taken cautiously.
Patients with some forms of cardiovascular disease are
vulnerable to physical or emotional stress that may be
encountered during dental treatment, including endodontics.
Consultation with the patient’s physician is mandatory before
the initiation of endodontic treatment.
Treatment should be delayed in case of-
1. Myocardial infraction within 6 months.
2. Coronary bypass graft surgery less than 3 months.
3.H/o stroke less than 6 months.

27. oAntibiotic prophylaxis-
Antibiotic prophylaxis is needed to prevent bacterial
endocarditis which can be caused by endodontic surgeries.
PROCEDURES NOT NEEDING ANTIBIOTIC
PROPHYLAXIS-
• Restorative dentistry with or without gingival retraction cord
• Local anesthesia (non-PDL)
• Root canal therapy (not beyond apex)
• Impressions
• Suture removal
• Placement of the rubber dam

28. NEW GUIDELINES:AHA CONSIDERS HIGH
RISK INDIVIDUALS-PREMEDICATION
INDICATED
• Prosthetic cardiac valve: mechanical or tissue
• Previous history of infective endocarditis
• Congenital Heart Disease which is unrepaired
• Congenital heart defects repaired during the first six
months of endodontic surgery
• Cardiac Transplant with cardiac complications

29. CONSIDERED MODERATE RISK INDIVIDUALS-
PREMEDICATION NOT INDICATED NOW
• Mitral Valve Prolapse with or without regurgitation
• Pathological/Organic heart murmur
• Previous rheumatic fever with or without valvular dysfunction
• Previous Kawaskasi disease with or without valvular
dysfunction
• Systemic Lupus Erythematosus (1/4 of these patients have
cardiac involvement)
• Rheumatoid Arthritis with cardiac involvement
• Other acquired valvular dysfunction

30. CONSIDERED MODERATE RISK INDIVIDUALS-
PREMEDICATION NOT INDICATED NOW
(CONT.)
• Previous coronary bypass graft surgery
• Coronary artery stents
• Heart transplants patient without complications
• Cardiac pacemakers
• Implanted defibrillators

31. ANTIBIOTIC PROPHYLAXIS REGIMEN
 Following current loading guidelines:
► 30-60 minutes before procedure
► Next 1 to 2 hours is the best coverage
of antibiotics
► Ideally give subsequent loads of
antibiotics 9 to 14 days after initial treatment to allow the
oral flora to return to normal
 The dose can be given 2 hours after the procedure if it was
accidentally not given

32. PATIENTS ALREADY RECEIVING
ANTIBIOTICS
• Select an antibiotic from a different class rather than
increase dosage of current antibiotic to minimize
resistance
Example: If patient is already taking
amoxicillin, use clindamycin.

33. AMERICAN HEART ASSOCIATION
RECCOMENDATION- NEW GUIDELINES
• Adults
Amoxicillin 2 grams orally (500 X 4 tablets), 30-60
minutes before appointment
• Children
Amoxicillin 50mg/kg. orally, 30-60 minutes before
appointment

34. Situation Antibiotic Agent Regimen *
Standard Prophylaxis Amoxicillin Adults: 2.0 g.
Children : 50 mg / kg
Orally 30-60 minutes before procedure
Unable to take oral
medication
Ampicillin Adults: 2.0 g IM or IV
Children: 50 mg / kg IM or IV
within 30-60 minutes before procedure
Allergic to Penicillin Clindamycin Adults: 600 mg
Children: 20 mg / kg
Orally 30-60 minutes before procedure
** Cephalexin or cefadroxil Adults: 2.0 g
Children: 50 mg / kg
Orally 30-60 minutes before procedure
Azithromycin or
clarithromycin
Adults: 500 mg
Children: 15 mg / kg
orally 30-60 minutes before procedure
Allergic to Penicillin and
unable to take Oral
Medications
Clindamycin Adults: 600 mg
Children: 20 mg / kg IV 30-60 minutes
before procedure
Cefazolin Adults: 1.0 g
Children: 25 mg / kg IM or IV
within 30-60 minutes before procedure
* Total children’s dose should not exceed adult dose
** Cephalosporin's should not be used in individuals with immediate-type hypersensitivity reaction to penicillins

35. oAnti coagulant therapy-
There is a widespread belief among dental clinicians
and physicians that oral anticoagulant therapy in which
patients receive drugs such as warfarin (Coumadin)
must be discontinued before dental treatment to prevent
serious hemorrhagic complications.
It should be noted that the anti coagulant therapy is only
a matter of concern if there is a need of endodontic
surgery.
Minor endodontic procedures , even root canal
treatment does not need any modification in anti
coagulant therapy.

36. Before endodontic surgery the INR value should be
checked the permissible limit of INR of the patient taking
anticoagulant drug is 2.5-3.5.
If the value is more than 3.5 dentist should consult
physician before any surgical procedure.
Patients taking digitalis or patients with unstable angina
should be treated cautiously as in these cases
vasoconstrictor precipitate arrythmia.

37. 2. Pregnancy
Any type of endodontic treatment should be done only in
2nd trimester.
While in chair patient should be placed in left lateral
position.
Drug having teratogenic effect and may cross placental
barrier should be avoided.

38. 3. Diabetes mellitus
Patients with diabetes, even those who are well controlled,
require special consideration during endodontic treatment.
Studies suggest that diabetes is associated with a decrease in
the success of endodontic treatment in cases with retreatment
periradicular lesions.
There is also evidence of poor prognosis after endodontic
treatment due to more prevalence of periodontal disease.
Patients should be given short morning appointment to avoid
peak insulin action which may cause hyperglycemic shock.
Before any endodontic surgery blood sugar must be checked.
Surgery is not permissible in poorly controlled and in
uncontrolled cases.

39. 4. Hiv
when treating patients with acquired immunodeficiency
syndrome (AIDS), that the clinician understand the
patient’s level of immunosuppression, drug therapies, and
potentiality for opportunistic infections.
Although the effect of human immunodeficiency virus
(HIV) infection on long-term prognosis of endodontic
therapy is unknown, it has been demonstrated that
clinicians may not have to alter their short-term
expectations for periapical healing in patients infected with
HIV.

40. vital aspect of treatment planning for the patient with
HIV/AIDS is to determine the current CD4+ lymphocyte
count and level of immunosuppression. In general, patients
having a CD4+ cell count exceeding 400 mm3 may receive
all indicated dental treatment.
Patients with a CD4+ cell count less than 200 mm3 will have
increased susceptibility to opportunistic infections and
may be effectively medicated with prophylactic drugs.
Clinician should always use disposable instruments and
should be cautious about any type of contamination.

41. 5. End-Stage Renal Disease and Dialysis
Consultation with the patient’s physician is suggested
before any dental procedure is initiated for patients being
treated for end-stage renal disease. Depending on the
patient’s status and the presence of other diseases
common to renal failure (e.g., diabetes mellitus,
hypertension, and systemic lupus erythematosus).
The most recent American Heart Association guidelines
do not include a recommendation for prophylactic
antibiotics before invasive dental procedures for patients
receiving dialysis with intravascular access devices.

42. Some drugs frequently used during endodontic
treatment are affected by dialysis. Drugs metabolized by
the kidneys and nephrotoxic drugs should be avoided.
Endodontic treatment is best scheduled on the day after
dialysis, because on the day of dialysis patients are
generally fatigued and could have a bleeding tendency.

43. 6. Reduced mouth opening-
Patients with OSMF, ankylosis, Trismus are difficult to
treat with endodontic treatment because of their reduced
mouth openning.
7. Age of the patient-
Age of the patients should be a matter of concern for the
endodontist.
Treatment is very difficult for geriatric patients. May be
single visit .

44. 8. Epilepsy-
Once a patient with epilepsy has been identified, the
dental practitioner must learn as much as possible about
the seizure history, including the type of seizures, age at
onset, cause (if known), current and regular use of
medications, frequency of physician visits, degree of
seizure control, frequency of seizures, date of last
seizure, and any known precipitating factors.

45. Patients not taking medication or having history of
epileptic attack within last 3 months should not be
treated.
 Fortunately, most epileptic patients are able to attain
good control of their seizures with anticonvulsant drugs
and are therefore able to receive normal routine dental
care.

46. • Patients who take anticonvulsants may suffer from the
toxic effects of these drugs, and the dentist should be
aware of their manifestations. In addition to the more
common adverse effects, allergy may be seen
occasionally as a rash, erythema multiforme, or worse
(Stevens-Johnson syndrome). Endodontist should
always be cautious about such conditions.

48. erythromycin should not be administered to patients who
are taking carbamazepine because of interference with
metabolism of carbamazepine, which could lead to toxic
levels of the anticonvulsant drug.
Aspirin and nonsteroidal anti-inflammatory drugs
(NSAIDs) should not be administered to patients who are
taking valproic acid because they can further decrease
platelet aggregation, leading to hemorrhagic episodes.

49. 9. Bisphosphonate Therapy-
Bisphosphonates offer great benefits to patients at risk of
bone metastases and in the prevention and treatment of
osteoporosis.
A patient’s risk of developing osteonecrosis of the jaw
while receiving oral bisphosphonates appears to be low,
but there are factors known to increase the risk for
bisphosphonate-associated osteonecrosis (BON).

50. • For patients at higher risk of BON, surgical procedures
such as extractions, endodontic surgery, or placement of
dental implants should be avoided, if possible. Sound
oral hygiene and regular dental care may be the best
approach for lowering the risk of BON.

51. Patients taking bisphosphonates and undergoing
endodontic therapy should sign an informed consent
form, inclusive of the risks, benefits, and alternative
treatment plans.
In case of any infection in a patient taking
bisphosphonates, aggressive use of systemic antibiotics
is indicated.

52. 9. Malignancy-
When a clinician begins an endodontic procedure on a
tooth with a well-defined apical radiolucency, it might be
assumed to result from a nonvital pulp.
Pulp testing is essential to confirm a lack of pulp vitality
in such cases. A vital response in such cases is
indicative of a nonodontogenic lesion.

53. Some malignancies may metastasize to the jaws and
mimic endodontic pathosis, whereas others can be
primary lesions . A panoramic radiograph is useful in
providing an overall view of all dental structures.
Careful examination of pretreatment radiographs from
different angulations is important because lesions of
endodontic origin would not be expected to be shifted
away from the radiographic apex in the various images.

54. • Patients undergoing chemotherapy or radiation to the
head and neck may have impaired healing responses.
Treatment should be initiated only after the patient’s
physician has been consulted.
• It is advised that symptomatic nonvital teeth be
endodontically treated at least 1 week before initiating
radiation or chemotherapy, whereas treatment of
asymptomatic nonvital teeth may be delayed.

55. The effect of the external beam of radiation therapy on
normal bone is to decrease the number of osteocytes,
osteoblasts, and endothelial cells, thus decreasing blood
flow. Pulps may become necrotic from this impaired
condition.
Toxic reactions during and after radiation and
chemotherapy are directly proportional to the amount of
radiation or dosage of cytotoxic drug to which the tissues
are exposed. Delayed toxicities can occur several
months to years after radiation therapy.

56. The outcome of endodontic treatment should be
evaluated within the framework of the toxic results of
radiation and drug therapy. The white blood cell (WBC)
count and platelet status of a patient undergoing
chemotherapy should also be reviewed before
endodontic treatment.

57. • In general, routine dental procedures can be performed if
the granulocyte count is greater than 2000/mm3 and the
platelet count is greater than 50,000/mm3.
• If urgent care is needed and the platelet count is below
50,000/mm3, consultation with the patient’s physician is
required

58. 10. Asthma & other respiratory tract disorder-
Clinician should ask for respiratory disorders like
asthma, COPD or chronic bronchitis.
Endodontist should access the present physical
condition of the patient on the basis of signs, symptoms
and treatment history.
Moderate and severe cases of asthmatic patients
should not be treated by endodontist with out
consultation of physician.

59. Avoid treatment if upper respiratory tract infection is
present, and treatment should always be done at upright
position.
Avoid precipitating factors, rubber dam, gingival
retraction cord, L.A with vasoconstrictors.
Patient should bring inhaler .
Appointment should be short.

60. Drugs like NSAIDS, narcotic drugs, anti cholinergic
drugs, anti histamines should be avoided.
There is also chances of drug interaction between
asthmatic drugs and antibiotics.
 Chronic corticosteroid users may require steroid
supplementation

61. BLEEDING DISORDERS
Conditions Deffects
vWD vWF – poor platelet adhesion & factor VIII deficiency
in some
Haemophilia A Factor VIII Some develop Ab.
Haemophilia B Factor IX
Primary Thrombocytopenia
(Idiopathic)
Auto-immune destruction
Secondary Thrombocytopenia Accelerated destruction
Deficient Production
Abnormal Pooling
Liver Disease Multiple factor defect
Thrombocytopenic in Portal Hypertension
DIC Multiple factor defect due to triggered consumption
Formation of Fibrin & FDP due to fibrinolysis
Thrombocytopenia

62. 11. Bleeding disorders-
Endodontic treatment is generally low risk for patients
with bleeding disorders. If a pulpectomy is indicated, the
possibility of the tooth requiring conventional endodontic
treatment must also be considered.
It is important that the procedure be carried out
carefully with the working length of the root canal
calculated to ensure that the instruments do not pass
through the apex of the root canal.

63. The presence of bleeding in the canal is indicative of pulp
tissue remaining in the canal. Sodium hypochlorite should be
used for irrigation in all cases, followed by the use of calcium
hydroxide paste to control the bleeding.
require a written consent from the physician Specially when
prescribing analgesics and antibiotics.
• In Hemophilia patients  there may be bleeding with
injection , pulp extirpation and rubber dam application.
However RCT is more safe than extraction after consulting
physician.

64. Formaldehyde-derived substances may also be used in
cases where there is persistent bleeding or even before
the pulpectomy.
Dental pain can usually be controlled with a minor
analgesic such as paracetamol (acetaminophen). Aspirin
should not be used due to its inhibitory affect on platelet
aggregation.
The use of any non-steroidal antiinflammatory drug
(NSAID) must be discussed beforehand with the
patient's hematologist because of their effect on platelet
aggregation.
For anesthesia patient should only be given buccal
infiltration.

65. FACTORS ASSOCIATED WITH CLINICIAN
The clinician should have proper endodontic instruments and
clinical set up for the treatment.
The clinician should have well equipped hands for treatment.

66. AAE CASE DIFFICULTY ASSESSMENT FORM AND
GUIDELINES
The American Association of Endodontists has
developed a practical tool that makes case selection
more efficient, more consistent and easier to document.
The Endodontic Case Difficulty Assessment Form is
intended to assist practitioners with endodontic treatment
planning, but can also be used to help with referral
decisions and record keeping

67. The assessment form identifies three categories of
considerations which may affect treatment complexity:
patient considerations, diagnostic and treatment
considerations, and additional considerations. Within
each category, levels of difficulty are assigned based
upon potential risk factors. The levels of difficulty are
sets of conditions that may not be controllable by the
dentist.

68. Each of the risk factors can influence the practitioner’s
ability to provide care at a consistently predictable level.
This may impact the appropriate provision of care and
quality assurance.
For each level of difficulty, guidelines are given to aid the
dentist in determining whether the complexity of the case
is appropriate for his or her experience or comfort level.

70. LEVELS OF DIFFICULTY

73. REVIEW OF LITERATURE
• PERIRADICULAR RADIOGRAPHIC ASSESSMENT IN
DIABETIC AND CONTROL
INDIVIDUALS
• Leandro R. Britto,a Joseph Katz,Marcio Guelmann, and
Marc Heft, DMD, PhD,d Gainesville.
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2003;96:449-52)

74. • Objective-The purpose of this study was to investigate
the prevalence of radiographic periradicular
radiolucencies in endodontically treated and untreated
teeth in patients with and without diabetes.

75. • Method-
The study group consisted of 30 patients with diabetes, 14 men
and 16 women, ranging from 39 to 84 years old (mean, 65
years). Eleven were classified as having type 1 diabetes and 19
as having type 2 diabetes. The control group consisted of 23
control subjects without diabetes, 12 men and 11 women. They
ranged in age from 46 to 84 years (mean, 59 years) , attending
the Endodontic Graduate Clinic at the University of Florida,were
reviewed. The number of teeth with root canal treatments with
and without periradicular radiolucencies and the number of teeth
without endodontic treatment but with periradicular lesions were
recorded. Data were categorized according to 3 distinct
categories: (1) nonsurgical endodontic treatment (NSE): number
of teeth that had root canal treatment and no periradicular
radiolucency; (2) NSE with lesion: number of teeth that had root
canal treatment and an adjacent periradicular radiolucency; and
(3) no NSE with lesion: number of teeth with a periradicular
radiolucency and broken lamina dura without having received
any endodontic intervention at any time

76. • Statistical analysis-
All analyses were done in a SPSS environment (SPSS,
Inc, Version 11, Chicago, Ill). Analysis of covariance was
conducted under the general linear model approach
(SPSS, Version 11). The analysis of variance model was 2
(sex) × 3 (diabetes diagnoses) with age as a covariate.
The models were assessed separately with the number of
affected teeth as the outcome for (1) those with NSE and
lesions, (2) those with NSE and no lesions, and (3) those
without NSE with lesions.

77. • Results- . There were no main effects of sex, diabetes
diagnosis, or age (the covariate) on the 3 outcomes of
interest (NSE with lesions, NSE without lesions, and no
NSE with lesions). However, there were significant
interactions between sex and diabetes diagnosis for both
of the endodontic outcomes, NSE with lesions
(F - 4.292; P .05) and NSE without lesions (F - 4.241; P
.05). This meant that men with type 2 diabetes who had
endodontic treatments were more likely to have residual
lesions after treatment.

78. • Conclusion-
Type 2 diabetes is associated with an increased risk of ill
response by the periradicular tissues to odontogenic
pathogens.
In this study, we found that men with type 2 diabetes had
an increased number of periradicular radiolucencies—
both men with NSE with lesions and men with
NSE without lesions.
However, the finding that type 2 diabetes is associated
with an increased rate of inflammatory resorption of the
alveolar bone in untreated teeth or in treated teeth is of
clinical significance.

79. Because onlyteeth with adequate root canal treatment were
included in the study, the factor of ill treatment resulting in
an endodontic failure was reduced, but not completely
eliminated. This finding focuses on type 2 diabetes as the
main etiologic factor in endodontic failure. The finding that
men with type 2 diabetes had endodontic failure more
frequently than did women with type 2 diabetes might be
attributed to the overall better general medical care and
treatment of women.

80. CONCLUSION
• From above discussion it is evident that case selection is
influenced by both systemic and local factors. Proper
judgment of these factors lead to successful treatment out
come
• Dental professionals have the technology, methodology and
scientific rationale to repair damage to the dentition that was
viewed as irreversible only years ago. These advances
allow patients to keep their natural dentition, with a few
exceptions

81. • Any of the treatment options offered to the patient must have
the patient’s best interests and health as a primary goal. The
treatment must be delivered in a predictable manner by the
treating practitioner to optimize the healing potential.
Nonsurgical root canal therapy results in one of the highest
retention rates of any dental procedure when completed
under optimal conditions. As clinicians, we can ensure the
highest quality treatment with our ability to treatment plan for
the patient in such a way that we honestly assess the difficulty
of the case and our personal skill levels, and then determine
whether to treat or refer. In the final analysis, when the
treatment proceeds without complication and healing occurs,
the patient and the dentist benefit.

82. REFERENCES
1. Cohen’s Pathways of the Pulp- S. Cohen, K.M Hargreaves.
10th Edition.
2. Grossman’s Endodontic Practice-12th Edition.
3. ENDODONTICS- JOHN I. INGLE, LEIF K. BAKLAND. 5th Edition.
4. GUIDELINES FOR DENTAL TREATMENT OF PATIENTS WITH
INHERITED BLEEDING DISORDERS- Andrew Brewer, Maria
Elvira Correa. TREATMENT OF HEMOPHILIA MAY 2006 • NO 40.
5. Guideline on Antibiotic Prophylaxis for Dental Patients at Risk for
Infection- AMERICAN ACADEMY OF PEDIATRIC DENTISTRY,
CLINICAL PRACTICE GUIDELINES V 37 NO 6.

83. 6. Little JW, Falace D, Miller C, Rhodus N. Dental Management
of the Medically Compromised Patient, Sixth edition: Mosby
2002.
7. Calcified Canals – A Review- B.Thomas, M.Chandak, A.
Patidar, B.Deosarkar, H.Kothari; IOSR Journal of Dental and
Medical Sciences.
8. Periradicular radiographic assessment in diabetic and control
individuals Leandro R. Britto, BDS, MS,a Joseph Katz,
DMD,b Marcio Guelmann, DDS,c and Marc Heft, DMD,
PhD,d Gainesville, Fla UNIVERSITY OF FLORIDA(Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2003;96:449-52)
9. Endodontics Colleagues for excellence published for dental
professional community by American Association of
Endodontics spring – summer 2005