Phase Format Treatment for Endodontic Therapy

[Anonymous]

 PHASE I—Nonsurgical Root Canal Therapy Indications

Phase I of the outcome assessment guideline (Figure 1) involves initiating endodontic therapy according to various clinical, radiographic and patient subjective findings. Initial endodontic therapy including and/or progressing from pulpotomy, pulpectomy, apexogensis, apexification, and nonsurgical root canal therapy completing with obturation of root canal should be initiated following a history of patient symptoms and vitality testing indicating irreversible pulpitis, necrosis or prophylactic restorative purposes. The tooth should be deemed restorable according to current prosthetic standards. Initial endodontic therapy should be thorough but conservative in nature, maintaining a favorable restorative prognosis.

Outcome Evaluation
The evaluation of Phase I therapy should include and be confined to the expectations of the initial root canal therapy. First, if the tooth displays complete healing following a 6-month recall with full radiographic resolution of the lesion, with a normal periodontal ligament (PDL) space, asymptomatic, and no associated pathology, then the case can be considered a success. Second, if the tooth presents with a radiographic lesion that is decreasing in size or the same size, asymptomatic, with no gingival pathology, then the treatment is in the process of healing and the recall period should be lengthened to one to 4 years and be re-examined for complete healing. Third, if following an appropriate recall period the tooth presents with a lesion that is increasing or the patient has become symptomatic, or has developed swelling, or a sinus tract, then retreatment therapy (Phase II) or apical surgery (Phase III) should be recommended. At this stage of the treatment, the initial root canal therapy should be evaluated and an assessment of the treatment quality should be obtained. If the instrumentation and obturation appears that it can be improved and is accessible, then retreatment therapy should be recommended. If the instrumentation and obturation appear to be adequate and the accessibility of retreatment is difficult due to natural or iatrogenic blockage, then apical surgery should be recommended. The therapy should not be considered a failure at this point if the initial instrumentation and obturation appear to follow current standards, rather a building block toward achieving endodontic therapy success.

PHASE II—Nonsurgical Retreatment Therapy Indications
Phase II of the outcome assessment guideline (Figure 2) involves initiating nonsurgical retreatment root canal therapy following the evaluation of previous therapy, healing and patient symptoms. Retreatment of initial endodontic therapy is indicated if the patient presents symptomatic, demonstrates swelling, or displays a fistula tract indicative of a persistent or secondary infection. Retreatment is also indicated if the endodontic filling material has been exposed to the oral environment for an extended period, making it susceptible to reinfection. The tooth should again be deemed restorable according to the current prosthetic standards. Retreatment of the root canal system attempts to address the conservative nature of initial root canal therapy and more aggressively pursues additional canals and enlarges the instrumentation to adequately detoxify the root canal system. 
Additionally, the provider assessing the case may be unaware of the conditions under which the initial root canal therapy was performed and should aspire to complete the retreatment under current aseptic and technical standards. In addition to modifying the instrumentation, additional irrigation regimens along with fluid agitation can be used to address resistant microbial communities. Lastly, an optimal obturation following current material standards and techniques can be placed to resist leakage.

Outcomes/Evaluation 
The evaluation of Phase II therapy should include and be confined to the expectations of the retreatment root canal therapy. First, if the tooth displays complete healing following a 6-month recall period with full radiographic resolution of the lesion, with a normal PDL space, asymptomatic, and no associated pathology, then the case can be considered a success. Second, if the tooth presents with a radiographic lesion that is decreasing in size, asymptomatic, functional with no associated pathology, then the treatment is in the process of healing and the recall period should be lengthened to one to 4 years and be re-examined for complete healing. Third, if following an appropriate recall period the tooth presents with a lesion that is increasing or the same size, the patient has become symptomatic, or has developed swelling, or a sinus tract, then apical surgery (Phase III) should be recommended. At this stage of the treatment, the endodontic therapy should be evaluated and concluded that the root canals are adequately instrumented and obturated and no improvement can be accomplished. Once again, the therapy should not be considered a failure at this point if the initial or retreatment instrumentation and obturation appear to follow current standards; rather, a building block toward achieving endodontic therapy success.