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AGD Chicago Handout Endodontic Success Reliable Endodontic Outomes Please Efficiency Through Simplicity Restoration Irrigation Be cautious about integrating new technology into your David Landwehr D.D.S., M.S. Capital Endodontics practice Madison, Wisconsin InstrumentationDiagnosis Obturation Case Selection Bacteria, Bacteria, Bacteria… Goals of Treatment S Kakehashi, HR Stanley, RJ Fitzgerald. The effects of surgical exposures of dental pulps in germ-free and Prevent / resolve apical conventional laboratory rats. Oral Surg Oral Med Oral periodontitis by: Pathol 1965; 20:340-49. Removal of all organic G Sundqvist. Bacteriological studies of necrotic dental substrate from the canal pulps [odontologic dissertation no.7]. 1976 University of Umea Umea, Sweden system AJ Möller, L Fabricius, G Dahlén, et al. Influence on Prevention of re-infection periapical tissues of indigenous oral bacteria and necrotic pulp tissue in monkeys. Scan J Dent Res 1981; 89:475-84. Oral Surg Oral Med Oral Path 1965;20:340-9 Schilder, Dent Clin Nor Am 1974 Cracked Tooth ?? Goals of Treatment J-Shaped Lesion J-Shaped Bone Loss -Safely deliver irrigant to Narrow Deep Pocket within 2-3 mm of the working length Sinus Tract Location -Preserve the natural anatomy Pain on release of Bite Limited Restorative History of the tooth Mobility Tooth Location Apical Healing no Obturation Dental History Medical History The success of Pulp Testing endodontic treatment depends on the Endodontic Diagnosis Percussion Tooth Sleuth elimination of the Periodontal Probing microorganism, host response and coronal Palpation seal Radiographs JOE 2006 Pulpal Reversible Pulpitis Reversible Pulpitis • Normal Stimulation is uncomfortable to the patient but Stimulation is uncomfortable to the patient but reverses quickly after irritation reverses quickly after irritation • Reversible Pulpitis • Irreversible Pulpitis Caries, exposed dentin, recent dental treatment, Caries, exposed dentin, recent dental treatment, • Symptomatic and defective restorations and defective restorations • Asymptomatic Conservative removal of the irritant will resolve Conservative removal of the irritant will resolve • Necrotic the symptoms the symptoms Irreversible Pulpitis Irreversible Pulpitis Symptomatic Asymptomatic Intermittent or spontaneous pain Deep caries may not produce any Heightened and prolonged episodes symptoms If a marginal ridge crack is identified early enough in of pain even after the thermal teeth with a diagnosis of RP and a crown is placed, root stimulus has been removed Left untreated, the tooth may become canal treatment will be necessary in about 20% of these symptomatic or the pulp will become cases within a 6-month period sharp or dull necrotic localized or diffuse referred Pulp Necrosis Pulp Necrosis Pulp Necrosis Pulpal blood supply is nonexistent and Will not respond to electric pulp tests or to cold Partial or complete the pulpal nerves are nonfunctional stimulation May not involve all of the canals in a If heat is applied for an extended period of time, Only clinical classification that directly multirooted tooth attempts to describe the histologic status the tooth may respond to this stimulus of the pulp (or lack thereof) Confusing symptoms Pulp Necrosis Pulp Necrosis Bacterial growth can be sustained within the canal Radiographic changes may occur, ranging from a thickening of the periodontal ligament space to the appearance of a Periapical bone lesions suggesting necrosis When bacterial toxins extend into the periapical radiolucent lesion developed in 8.5% periodontal ligament space, the tooth may become symptomatic to percussion or Routine endodontic intervention of teeth with exhibit spontaneous pain ongoing obliteration of the root canal does not seem justified Previously Initiated Previously Treated Treatment Periapical Has obturating material in canals Pulpotomy or pulpectomy performed before • Normal presenting for root canal • Asymptomatic Apical Perio May or may not present with signs or symptoms • Symptomatic Apical Perio • Acute Apical Abscess Will require additional nonsurgical or surgical endodontic procedures to retain the tooth • Chronic Apical Abscess Asymptomatic Apical Normal Apex Perio Symptomatic Apical Perio Asymptomatic Apical radiolucency Painful response to biting pressure or Tooth responds normally to percussion and Presents with no clinical symptoms percussion palpation testing Does not respond to pulp vitality tests May or may not respond to pulp vitality tests Intact lamina dura and periodontal ligament space around all the root apices This tooth is generally not sensitive to biting May or may not have an apical radiolucency pressure but may “feel different” to the patient associated with one or all of the roots on percussion Acute Apical Abscess Acute Apical Abscess Chronic Apical Abscess Painful to biting pressure, percussion, and palpation Usually asymptomatic Swelling Does not respond to any pulp vitality tests Does not respond to pulp vitality tests Fever Mobility Apical radiolucency Lymph node tenderness Radiograph can exhibit anything from a widened Not sensitive to biting pressure but can “feel periodontal ligament space to an apical different” to the patient on percussion radiolucency Chronic Apical Abscess Testing Goals Pulp Testing Sinus tract •Repeatable •Thermal •Redundancy •Electric • Laser Doppler Flowmetry (LDF) •Chief Complaint • Pulse Oximetry • Test Cavity • Selective Anesthesia Thermal EPT Periapical Testing • Cold Response by the pulp to the • CO₂ snow (-108∘F/-75∘C) electric current only denotes • Percussion that some viable nerve fibers • Palpation • Endo Ice (-14∘F/ -50∘C) are present in the pulp and are capable of responding • Bite Stick •Heat ? Limitations of pulp Other Testing testing Pulp Testing • Periodontal Probing Limitations The vitality of the pulp is determined by the health • Transillumination of the vascular supply, not the status of the pulpal nerve fibers Sensibility Testing is not vitality testing Limitations of pulp Correlation of Histology testing No Proprioception and Clinical Diagnosis -Not a good correlation Patients can localize The classification of pulp between the objective clinical painful tooth 73.3% signs and symptoms and the conditions as normal pulps, pulpal histology reversible pulpitis, and 89% if periradicular irreversible pulpitis have high -No proprioception in pulp chances of guiding the correct therapy in the large majority of cases JOE 2010 Oral Sx 1963 JOE 2014 Limitations of pulp Limitations of pulp Limitations of pulp testing testing testing Specificity is the ability of a If a mature, untraumatized Sensitivity is ability of a test to test to identify teeth without tooth does not respond to identify teeth that are diseased disease both electric pulp test and 93% were correctly identified cold test, then the pulp Cold test correctly identified should be considered 83% of the teeth that had a by both cold and EPT necrotic necrotic pulp 41% of the teeth with healthy Heat 86% pulps were identified Electric pulp tests 72% correctly by the heat test Peters DD, Baumgartner JC, Lorton L: Adult pulpal diagnosis. 1. Evaluation of the positive and negative T Petersson K, Soderstrom C, Kiani-Anaraki M, Levy G: Evaluation of the ability of thermal T Petersson K, Soderstrom C, Kiani-Anaraki M, Levy G: Evaluation of the ability of responses to cold and electric pulp tests. J Endod 1994; 20:506 and electric tests to register pulp vitality. Endod Dent Traumatol 1999; 15:127. ext thermal and electric tests to register pulp vitality. Endod Dent Traumatol 1999; 15:127. ext Limitations of pulp Who is testing Radiology Reading the Cold test and EPT used limitations in conjunction resulted in Radiograph ? a more accurate method One piece of Subjective diagnostic Interexaminer agreement ~ for diagnostic testing information 50% Intraexaminer agreement ~ Ten percent of the teeth not responding to any of 75 - 80 % the tests contained vital Goldman M, Pearson A, Darzenta N. Reliability of pulps radiographic interpretations. Oral The Validity of Pulp Testing: A Clinical Study Rebeca Weisleder, Shizuko Yamauchi, Daniel J. Caplan, Martin Trope and Fabricio B. Teixeira J Am Dent Assoc 2009;140;1013-1017 Surg 1974; 38(2):340. Who is Reading the Radiology limitations Radiology limitations Digital Bone loss will not be Certain teeth are more detected if the lesion is only Radiograph ? prone to exhibit in cancellous bone 100% agreement < 25% radiographic changes than 5 agree ~ 50% others, depending on their PA lesion when bone loss anatomic location Intraobserver reliability extends to the junction of 41 % - 85 % the cortical and cancellous Average 68 % bone Tewary S, Luzzo J, Hartwell G. Endodontic radiography: who is Bender IB, Seltzer S: Roentgenographic and direct observation of Bender IB, Seltzer S: Roentgenographic and direct observation of reading the digital radiograph? J Endod. 2011 Jul;37(7):919-21. experimental lesions in bone. Part I. J Am Dent Assoc 1961; 62:152. experimental lesions in bone. Part II. J Am Dent Assoc 1961; 62:708. Radiology limitations Radiology limitations Cone-Beam Computed 7.1% mineral bone loss to Can have PA produce a radiolucency radiolucency or PDL Tomography changes and inflamed (CBCT) Lesions 1-7 mm didn’t tissue in root canal produce a lesion in cancellous bone Yamasaki M1, Kumazawa M, Kohsaka T, Nakamura H, Kameyama Bender IB. Factors influencing the radiographic appearance of bony Y. Pulpal and periapical tissue reactions after experimental pulpal lesions. J Endod 1982 Apr;8(4):161-70. exposure in
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