2011-2012 Endodontology Course Curriculum for

Yale New Haven Hospital GPR

Endodontic Section:

Bruce Y. Cha, D.M.D., Section Chief

Yiming King, D.M.D., M.D.S.

Course Director: Bruce Y. Cha, D.M.D

Correspond with Course Director at cha@rootcanaldrs.com for questions

Course Requirements

1.      Attendance and Participation in Didactic Course Sessions

2.      Final Written Examination

3.      Clinical Case Presentation

4.      Clinical Competency

5.      Presentation of Written Essay

Methods of Learning

，         Lecture

，         Seminar

，         Patient Care

Online Syllabus: http://rootcanaldrs.com/syllabusynhh.htm

Course Objectives

1.       Develop consistent application of appropriate ethical standards in the provision of dental care to patients.

2.       Become familiar with the anatomy, histology, physiology, microbiology and immunology of pulp and           periradicular tissue and the basic principles of the endodontic treatment.

3.       Become familiar with the diagnostic process and clinical testing of the pulp and periradicular diseases;    differential diagnosis; treatment planning and case selection.

4.       Learn the importance of asepsis and infection control in endodontic treatment.

5.       Become familiar with the management of endodontic emergencies.

6.       Understand the delivery of endodontic treatment in a general practice setting and the basis for consultation and referral.

7.       Become familiar with the management of pain and anxiety in endodontic treatment in various age group or with diverse medical, socioeconomic, psychosocial, or ethnic backgrounds.

8.       Learn to provide profound pulpal anesthesia in endodontic treatment.

9.       Become familiar with the management of dental traumatic injuries.

10.   Become familiar with the clinical procedures of asepsis, access preparation, working length determination with radiograph and/or electronic apex locator, cleaning and shaping with hand and rotary instrumentation, the use of intracanal medicaments, and temporization

11.   Become familiar with three dimensional obturation of root canal system

12.   Become familiar with the management of endodontic failures; endodontic retreatment and periradicular surgery

13.   Become familiar with the management of procedural errors and post endodontic treatment management including the coronal restoration.

14.   Learn to evaluate the effectiveness of therapy via assessment of short and long-term treatment outcomes.

15.   Be familiar with the concepts of peer review, standard of care, and legal ramifications of endodontic treatment.

16.   Learn the importance of documentation of care in written and electronic forms.

17.   Be able to perform adequate presentation of an endodontic case, outlining the quality of treatment and the long-term outcome of care.

18.   Become familiar with the critical interpretation of the current literature on the advances in endodontic field and understand the recent developments in endodontics.

Chronological List of Deadlines for Endodontic Requirements

• February 29, 2012: Completion of Didactic Course and Written Examination

• April 30, 2012: Completion of Case Presentation

• June 30, 2012: Completion of Written Essay

Method of Evaluation

1.      20% course attendance and participation

2.      20% written examination

3.      20% clinical competency

4.      20% clinical case presentation

5.      20% written essay

Remediation

Failure to obtain the minimal grade of 70% will result in the remediation of this course and the termination of the clinical privileges in the GPR clinic on endodontic procedures

Attendance

Mandatory Attendance is required in all didactic and clinical sessions in accordance with the current department policies.

Didactic Course

Time:  7:30-8:30 AM

Room: GPR Conference Room

Didactic Course Schedule

2011-2012 Endodontic Curriculum and Schedule

Description of Endodontic Course Components

1.      Didactic Course

a.      This portion of the course will consist of a series of clinical seminars presented by the endodontic attendings on various topics on biologic basis of endodontic treatment.

b.      The schedule of the seminar is attached.

c.      The copies of the literature are available in the department library located in the conference room.

d.      The attendance is mandatory and the participation is important.

2.      Written Examination

a.      The examination will be based on the topics covered during the seminars.

b.      The passing grade is 70%.

c.      The written examination will be given during the month of December.

3.      Clinical Competency

A. The clinical competency shall be evaluated throughout the year for all the endodontic treatment performed by residents.

B. It is important that residents shall be in close communication with (endodontic) attendings with regards to all the clinical circumstances involving endodontic issues including diagnosis, treatment planning, consultation, case selection, referral to specialists, treatment, and posttreatment evaluation. If necessary, residents may obtain consultation from endodontic attendings through e-mail communication.

C. All the endodontic cases should be consulted with (endodontic) attending prior to the treatment.

D. Residents are required to assess the level of difficulty prior to perform endodontic treatment. Residents should treat patients with 'high difficulty' level of cases only with endodontic attendings.

E. Residents may treat patients with 'minimal' and 'moderate' difficulty level of cases with general dentist attending who has clinical privileges in endodontics.

F. It is important that residents are equipped with magnification and illumination devices to adequately perform endodontic treatment.

G. The following data collection* (see below) is essential in making endodontic diagnosis and treatment planning.
H. In case of 'no show', residents are encouraged to perform endodontic treatment in extracted teeth.

I. Referral Procedures: Please make sure that the patient has means of transportation to the endodontic specialist office.  When a patient is referred to a specialist endodontist, residents should inform the patients about the reason for the referral to an endodontic specialist and give a copy of the Yale-New Haven Hospital consultation and Transferral Record Form after filling out the form. 

The resident or clinic staff should call the office of Drs. Cohen & Siracuse: One Century Tower, 265 Church Street, New Haven, CT 06510 at (203) 777-6461 or fax the consultation form to (203) 777-0787.

The resident must send e-mail to Dr. Kamran Safavi, Head, UCONN School of Dental Medicine, Clinic #2 (Endodontics) at safavi@nso1.uchc.edu The UCONN Dental Clinic #2 will contact the patients for scheduling. It is important that the referred patients should be informed of the traveling time and distance to the UCONN Dental Clinic #2 which is located in Farmington, CT.

The following information should be included: Patient Name, Phone Number, Tooth #, Reason for Referral e.g. RCT, Post Space Preparation,Radiograph (Print Out or E-mail the Digital Image), Type of Coverage, Additional Information that will facilitate treatment e.g. Prophylactic Antibiotics

  4.      Literature Review

         a. The residents will review the assigned literature to determine the level of evidence as follows:

             Level 1: Highest level of evidence containing systematic reviews and randomized, controlled clinical trials

             Level 2: Low-quality randomized , clinical trials

             Level 3: Case-control studies, systematic reviews of case-control studies

             Level 4: Low-quality cohort studies, case control studies, case series

             Level 5: Case reports, epidemiologic studies, expert opinions literature reviews

         b. The residents will prepare a presentation based on Power Point format at each session regarding the             assigned literature.

  5. Clinical Case Presentation

a.  Residents will present the necessary documentation involved with the patient care including all the collected diagnostic data, treatment progress and relevant data in Power Point format.

b.  Resident will demonstrate the ability to provide critical analysis of the patient care.

c.  Resident will offer short and long-term prognosis and the management strategy for the future.

  6. Written Essay

    a.  Residents will choose an endodontic topic of interest and write an essay paper based on literature review.

    b.  The essay paper should be written between 1,000 and 1,200 words excluding the bibliography.

    c.  The residents should print the written essay in single space and distribute them to colleague residents and  course director before the presentation.

* Guidelines for Clinical Endodontic Procedures

1.    Data Collection

1.     Chief Complaint

2.     Medical History

3.     Dental History

4.     Clinical Examination

a.      Pulp Testing: Cold, Heat, EPT

b.     Percussion

c.      Palpation

d.     Probing depths and furcation involvement

e.      Mobility

f.       Discoloration

g.      Lymphadenopathy

h.      Temperature measurement

i.       Radiograph with diagnostic quality

 2.    Problem List

1.     Pain, Thermal Sensitivity, Discomfort

2.     Localized or diffuse swelling

3.     Odontogenic infection

4.     Sinus tract

5.     Cracked tooth

6.     Vertical root fracture

7.     Tooth discoloration

8.     Evidence of microleakage

9.     Previous endodontic treatment of poor quality

10.  Carious pulp exposure

11.  Mechanical pulp exposure

12.  Isolated probing defect of endodontic etiology

3.    Endodontic Diagnostic Terminology

 1. Pulpal
Normal Pulp: A clinical diagnostic category in which the pulp is symptom-free and normally responsive to pulp testing.       

Reversible Pulpitis: A clinical diagnosis based on subjective and objective findings indicating that the inflammation should    resolve and the pulp return to normal.

Symptomatic Irreversible Pulpitis: A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous pain, referred pain.

Asymptomatic Irreversible Pulpitis: A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but inflammation produced by caries, caries excavation, trauma

Pulp Necrosis: A clinical diagnostic category indicating death of the dental pulp. The pulp is usually nonresponsive to pulp testing.

Previously Treated: A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal medicaments.

Previously Initiated Therapy: A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (eg, pulpotomy, pulpectomy).

2. Apical 

Normal Apical Tissues: Teeth with normal periradicular tissues that are not sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact, and the periodontal ligament space is uniform.

Symptomatic Apical Periodontitis: Inflammation, usually of the apical periodontium, producing clinical symptoms including a painful response to biting and/or percussion or palpation. It might or might not be associated with an apical radiolucent area.

Asymptomatic Apical Periodontitis: Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms.

Acute Apical Abscess: An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues.

Chronic Apical Abscess: An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract.

Condensing Osteitis: Diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth.

4. Endodontic Treatment Planning Guidelines

1.     In cases where endodontic treatment is potentially indicated, residents should obtain consultation from general dentist attending with regards to the restorability, the type of the final restoration and its contribution to the overall restorative plan.

2.     It is highly recommended that residents should obtain endodontic consultation with data collected through the diagnostic procedures. The patient does not have to be present for the endodontic consultation unless it is necessary.

3.     If indicated, periodontal consultation is necessary to determine the feasibility of the crown lengthening procedure.

4.     After its restorability is finalized, residents should make determination as to whether the endodontic treatment should be attempted in the adult GPR clinic or by referral to specialists by using the criteria in the case difficulty assessment form.

5.     When a patient is referred to a specialist endodontist, residents should inform the patients about the reason for the referral and give a copy of the Yale-New Haven Hospital consultation and transferral Record Form after filling out the form. Currently, the following specialty clinic/office are recommended for specialty endodontic services:

a.     The resident or clinic should call Drs. Cohen & Siracuse: One Century Tower, 265 Church Street, New Haven, CT 06510 at (203) 777-6461 or fax the consultation form to (203) 777-0787.

b.     The clinic must send e-mail to Dr. Kamran Safavi, Head, UCONN School of Dental Medicine, Clinic #2 (Endodontics) at safavi@nso1.uchc.edu The UCONN Dental Clinic #2 will contact the patients for scheduling. It is important that the referred patients should be informed of the traveling time and distance to the UCONN Dental Clinic #2 which is located in Farmington, CT.

6.     In all cases with a vital pulp an deep caries or large restorations, the patient must be informed of the likelihood of pulp exposure, and the plan if occurs. In case of a sterile exposure of a vital pulp, i.e. made with a sterile instrument, in the absence of visible caries, and with an adequately sealed rubber dam in place, the patient should be informed of the alternative treatment by direct pulp capping. However, the patient should be informed that direct pulp capping is less successful than endodontic treatment.

7.     Patients with rampant deep caries in teeth that are responsive to pulp testing and with no or mild symptoms, should have the caries excavated to determine the pulp exposure.

8.   Teeth with subgingival caries should be consulted for crown lengthening procedure with periodontal attending

9.     Patient with pain or with swelling of endodontic origin should be relieved of pain through pulpectomy and root canal debridement.

10.     Antibiotics are prescribed in cases of systemic symptoms (fever, malaise, etc.) if the infection involves a fascial space, or if the patient's immune system is compromised.

11.     Endodontic treatment of a tooth with vital pulp should ideally be performed in one visit, to minimize the chances of root canal contamination.

12.     Endodontic treatment of a tooth with necrotic pulp should be medicated with calcium hydroxide for at least one week after instrumentation, prior to obturation.

13.     Teeth with mildly symptomatic coronal cracks, and with a vital pulp, require full coronal coverage. If after the crown preparation and temporization the patient is still symptomatic, especially if spontaneous pain is present, the endodontic treatment is indicated.

14.     Teeth with previous endodontic treatment must be evaluated as to whether the treatment is successful, and if so whether there is evidence of coronal leakage. The prognosis is best determined if there are 2-3 radiographs available, that were taken over 2-4 year period because the current radiographic information represent the situation at only one point in time.

15.     Teeth or roots that have a vertical root fracture have negative prognosis. Either the tooth should be extracted or the involved root amputated.

16.     Asymtomatic teeth with poorly performed previous endodontic treatment often require retreatment when crown or bridge need to be placed or replaced.

17.     In case of cancellation of endodontic patients, it is highly recommended that residents may exercise endodontic procedures on the extracted teeth with endodontic attendings.

5.  Patient Referral to an Endodontic Specialist (High Difficulty Criteria in Case Assessment Form)

1.     Comples Medical History (ASA Class 3-5)

        ASA Class 1: WNL
        ASA Class 2: mild degree of systemic illness, but without functional restrictions e.g. well controlled hypertension
        ASA Class 3: severe degree of systemic illness which limits activities, but does not immobilize the patient

        ASA Class 4: severe systemic illness that immobilizes and is sometimes life threatening

        ASA Class 5: patient will not survive more than 24 hours whether or not surgical intervention takes place
2.     Difficulty in achieving anesthesia

3.     Uncooperative

4.     Significant limitation in jaw opening

5.     Extreme gag reflex

6.     Severe pain or swelling requiring urgent care 

7.     Diagnostic Difficulties: confusing or complex signs and symptoms, chronic orofacial pain

8.     Difficulty in obtaining /interpreting radiographs

9.     Difficult position in the arch: 2nd and 3rd molars, inclined >30‘, rotated >30‘

10.     Rubber dam isolation problems

11.     RCT through the crown/bridge that altered the original anatomy/alignment

12.     Complex root canal anatomy: apical or mid-root canal bifurcation, C-shaped canals, lateral or accessory canals, lingual groove defects, dens-in-dente, fusion, germination, Mandibular bucuspid or anterior with two roots, 3-canaled maxillary bicuspids, five-canaled molars, immature apex (>1.5 mm in diameter), very long tooth (>25mm) etc.
              

13.     Severe canal calcifications - indistinct canal path, invisible canal(s)

 

14.     Severe root curvatures >30‘ or S-Shaped curve

15.     Difficult radiographic visualization of the tooth apex, such as in cases of superimposed impacted teeth, tori or malar processes

16.     Difficult access or isolation, such as for patients with limited mouth opening, posterior teeth prepared for crowns or severe crowding of teeth. Most second and third molars fall into this category as well.

17.     Cases with complicated traumatic injuries that require long term treatment and evaluation.

18.     Difficult patient management, such as children with unmanageable behavior.

19.     Significant medical problems that require controlling stress, efficient use of time and/or least number of visits

20.     Cases requiring retreatment, such as those involving post removal, paste retreatments, or complicated multicanal retreatments.

21.     Cases requiring apicoectomy, root amputations, hemisections, bicuspidizations, interntional replantations, or orthodontic extrusion.

22.     Cases with large periapical lesions requiring biopsy together with apical surgery or decompression

23.     Teeth with internal resorption, external replacement resorption or cervical root resorption.

24.    Complicated crown fracture of immature teeth, Horizontal root fracture, intrusive, extrusive or lateral luxation, avulsion

25.    Previous access with complications (e.g. perforation, non-negotiated canal, ledge, separated instruemnt).       Previously completed surgical or nonsurgical treatment

26.    Perio-endo problems: concurrent severe peridontal disease, cracked teeth with peridontal complications, combined endo-perio lesion, root amputated teeth prior to RCT

6.  Evaluation Checklist for Clinical Endodontic Procedures

1.     Performed the appropriate clinical diagnostic tests.

2.     Obtained correct pulpal and apical diagnoses

3.     Identified localized vs. spreading infections

4.     Recognized canal morphology variations for tooth

5.     Identified difficulties with treatment preoperatively

6.     Identified correct endodontic treatment plan for patient

7.     Identified appropriate pretreatment prognosis

8.     Performed adequate behavioral management of patient

9.     Demonstrated adequate reasoning and efficiency throughout procedure

10.   Determined need for, and adequately prescribed post-operative medications

11.   Demonstrated sufficient concern for patient¨s welfare

12.   Communicated essential elements of an informed consent for endodontic treatment

13.   Performed appropriate local anesthetic technique; and patient had minimal discomfort

14.   Performed acceptable isolation and re-isolation as needed

15.   Performed adequate caries removal and access preparation

16.   Made a correct determination of working length without periapical irritation

17.   Performed adequate canal instrumentation: no tissue irritation or irreversible errors

18.   Exercised appropriate judgement and skill in placing calcium hydroxide

19.   Chose a well fitting master cone that extended to the working length

20.   Filled the entire canal space to the working length without extrusion

21.   Removed excess GP and sealer to level of CEJ

22.   Placed a well sealing & discluding temporary restoration

23.   Exposed acceptable radiographs including pre-op, working, and post-op

24.   Performed acceptable radiographic interpretation

25.   Performed adequate and timely self-evaluation

26.   Recognized ways of correcting errors

27.   Used strict aseptic technique throughout treatment

28.   Performed adequate and timely entries in the patient¨s paper and electronic records

29.   Determined a correct indication and follow-up period for endodontic recall

30.   Determine the appropriate prognosis of all endodontically-treated teeth in the patient¨s mouth

Required Reading

1.      Pathways of the Pulp 9^th Edition Cohen S, Hargreaves K, Mosby Elsevier 2006

2.      Kakehashi S, Stanley HR, Fitgerald RJ: The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg 20:340, 1965

3.      Horsted P, Nygaard-Ostby B: Tissue formation in the root canal after total pulpectomy and partial root filling. Oral Surg 46: 275, 1978

4.      Hasler JF, Mitchell DF: Painless pulpitis. JADA 81:671-677, 1970

5.      Mitchell DF, Tarplee, RE: Painful pulpitis, Oral Surg 11:1360-1370, 1960

6.      Pineda F and Kuttler Y: Mesiodistal and buccolingual roentgenographic investigation of 7,275 root canals. Oral Surg. 33:101-110, 1972

7.      Bergenholtz G: Micro-organisms from necrotic pulp of traumatized teeth. Odont. Revy 25:347-358, 1974

8.      Nair PNR et al: Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: A long-term light and electron microscopic follow-up study. JOE 16:580-588, 1990

9.      Bystrom A, Sundqvist G: The antibacterial action of sodium hypochlorite and EDTA in 60 cases of endodontic therapy. Int Endo J 18:35, 1985

10.  Sjogren U, Figdor, D, Spangberg L, Sundqvist G: The antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. Int. Endo. J 24:119-125, 1991

11.  Spangberg L, Rutberg M, Rydinge E: Biologic effects of endodontic antimicrobial agents. J Endo 5:166, 1979

12.  Heithersay GS: Calcuim hydroxide in the treatment of pulpless teeth with associated pathology. J Br Endo Soc 8:74, 1975

13.  Schilder H, Goodman A, Aldrich W: The thermomechanical properties of gutta-percha. I. The compressibility of gutta-percha. Oral Surg. 37:946-953, 1974

14.  Goodman A, Schilder H, Aldrich W: The thermomechanical properties of gutta-percha. II. The history and molecular chemistry of gutta-percha. 37:954-961, 1974

15.  Schilder H, Goodman A, Aldrich W: The thermomechanical properties of gutta-percha. III Determination of phase transition temperatures for gutta-percha. Oral Surg. 38:109-114, 1974

16.  Godman A, Schilder H, Aldrich W: The thermomechanical properties of gutta-percha. Part IV. A thermal profile of the warm gutta-percha packing procedure. Oral Surg. 51:544-551, 1981

17.  Marlin J, Schilder H: Physical properties of gutta-percha when subjected to heat and vertical condensation. Oral Surg. 36:872-881, 1973

18.  Allison DA, Michelich RJ, Walton RE: The influence of master cone adaptation on the quality of the apical seal. JOE 7:61-65, 1981

19.  Swanson K, Madison S: An evaluation of coronal microleakage in endodontically treated teeth. Part I. Time Periods. JOE 13:56-59, 1987

20.  Helfer AR, Melnick, S, Schilder H: Determination of the moisture content of vital and pulpless teeth. Oral Surg. 34:661-669, 1972

21.  Randow K, Glantz P: On cantilever loading of vital and non-vital teeth. An experimental study. Acta Odont Scand 44:271-277, 1986

22.  Salehrabi R, Rotstein I: Endodontic treatment outcomes in a large patient population in the USA: An epidemiological study. JOE 30:846-850, 2004

23.  Fimple JL et al: Photodynamic treatment of endodontic polymicrobial infection In Vitro. JOE 34:728-734, 2008