Contemporary Strategies Fro Achieving Endodontic Success

Contemporary Strategies for Achieving Endodontic Success Presented by: George A. Bruder, D.M.D. Key points to retain Levels of evidence to support what we do are based on a five-fold categorization and indicate the trustworthiness of the research and publications in endodontics – the lowest levels are personal opinion, anecdotal communications, case reports and bench research; the highest levels of evidence are prospective, randomized, controlled studies An understanding of the oral disease processes within the dental pulp and supporting periodontium is essential along with the application of the principles of inflammation, infection and immunological responses The presence of microorganisms, their byproducts and their protective biofilms cause disease in the pulp, which can extend to the supporting periodontium [apical/periradicular periodontitis] Root canal procedures are designed to prevent apical/periradicular periodontitis and to provide an environment within the tooth to allow the human body to heal this inflammatory/infectious process Every procedure within the realm of root canal treatment, i.e. diagnosis, access, canal location, canal penetration, canal debridement, disinfection and enlargement, obturation and the provision of sound coronal restoration significantly affects the outcome. Outcomes are defined as: o Healed—Functional, asymptomatic teeth with no or minimal radiographic periradicular pathosis. [Clinical assessment within normal limits] o Non-healed—Nonfunctional, symptomatic teeth with or without radiographic periradicular pathosis. [Reduced apical radiolucency, asymptomatic and clinical assessment within normal limits; or no radiolucency, mild symptomology and clinical assessment within normal limits] Contemporary Strategies for Achieving Endodontic Success o Not Healing—Teeth with periradicular pathosis, which are asymptomatic and functional, or teeth with or without radiographic periradicular pathosis, which are symptomatic but whose intended function is not altered. [Overt signs of infection, swelling, increase in radiolucency, or presence of a sinus tract – symptoms present] o Functional—A treated tooth or root that is serving its intended purpose in the dentition. Success rates: o For initial root canal procedures on teeth without apical periodontitis 88- 92% o For initial root canal procedures on teeth with apical periodontitis 73-90% - however when considering the tooth as functional 88-97% o For non-surgical root canal retreatment procedures on teeth without apical periodontitis 93-98% o For surgical root canal retreatment procedures on teeth without apical periodontitis 31-91% - however when considering the tooth as functional 70-91% Dental dam isolation is essential for root canal procedures - “Only dental dam isolation minimizes the risk of contamination of the root canal system by indigenous oral bacteria” – in addition to preventing an adverse sequelae and outcome It is below the standard of care not to use dental dam isolation Always – reproduce the chief complaint – determine the etiology – treatment plan to eliminate the etiology Notes: 2 Contemporary Strategies for Achieving Endodontic Success Notes: 3 Contemporary Strategies for Achieving Endodontic Success Endodontic Treatment - Restorations Key points to retain Root canal procedures are not complete until the tooth is fully restored to function Outcomes of Endodontic Therapy Dependent on quality of the cleaning and shaping of the canal system Dependent on the skill and experience of the clinician Dependent on materials, their usage Dependent on radiographic interpretation Outcome is also dependent on restoration of the tooth and the health of the supporting periodontium When faulty, all restorations and caries must be removed prior to root canal treatment. Once all old restorations are removed, the tooth must be examined for structural integrity, i.e., fractures, subgingival margins, status of the biologic width, etc. Leak proof temporary fillings are essential Proper tooth isolation is essential for restoration and the use of the dental dam is indicated Root treated teeth should be restored as soon as possible, with posterior teeth receiving full cuspal coverage Root treated teeth are not more brittle, but rather weakened due to suffer the loss of tooth structure, alterations in the collagen cross-linking and the impact of restorative and endodontic procedures Posts do not strengthen roots – they provide support for the core material 4 Contemporary Strategies for Achieving Endodontic Success Post Endodontic Treatment • When and why we use a post – The sole purpose of the post is to retain a core in a tooth that has significant loss of coronal tooth structure • Anterior teeth – with conservative access preparations, a bonded restoration can be used, eliminating the need for a post • Posterior teeth – without extensive loss of tooth structure, the pulp chamber can provide sufficient retention of the core The ferrule is the amount of remaining tooth surface area that is contacted by the internal surface of crown restoration. The ferrule does not include core structure and so it can be regarded as the amount of crown area that telescopes over the remaining natural tooth structure. This is required for strength and resistance to dislodgement of the restoration. The amount of ferrule area of the tooth needs to be maximized, and any tooth with a restoration that makes minimal use of the ferrule will be doomed to dislodgement in any area which is under occlusal load. A minimum of 1.5 to 2.0 mm is essential. Five mm of gutta-percha minimum should be left apical to the post. In curved or thin roots, one may not be able to place the post even this far apically. Due to the increased risk of strip perforation in thin mesial roots of mandibular and maxillary molars, post placement should be avoided in these roots Decreasing the diameter of the post will minimize stresses on the root. Resin cements have high shear strength and will serve well as core buildup materials. Many specific core materials that can be bonded to tooth structure are available, however, glass ionomers are not indicated for use as core materials. 5 Contemporary Strategies for Achieving Endodontic Success Notes: 6 Contemporary Strategies for Achieving Endodontic Success Notes: 7 Contemporary Strategies for Achieving Endodontic Success A consistent and reproducible way to approach the diagnosis is the use the “SOAP” concept o S = Subjective information Subjective Information • History of pain • Duration of pain • Stimulus of pain • Location of pain • Severity of pain • Spontaneity of pain • Frequency of pain • Nature of pain o O = Objective information Objective Findings • Clinical examination – Extraoral – Intraoral • Radiographic assessment – Comparative testing Notes: 8 Contemporary Strategies for Achieving Endodontic Success Clinical Tips • Images • Perio probe – record – Must be current depth measurements – Must show tooth and • Mobility surrounding tissues – Slight, moderate, extensive • Percussion and palpation – Grade I, II, III (vertical) – Start with uninvolved teeth – Get patient accustomed to “normal” – Work towards suspected tooth Comparative testing – thermal, electric pulp test, bite test, transillumination, anesthetic test, cavity test o A = Assessment Assessment “Diagnostic categories should correspond to treatment-oriented categories” “Diagnosis should indicate the pulpal and periradicular status and the kind of treatment needed to rectify the problem.” Gutmann et al, 1992 Notes: 9 Contemporary Strategies for Achieving Endodontic Success Assessment – Pulpal Diagnosis Reversible pulpitis Irreversible pulpitis Irreversible pulpitis (symptomatic) (asymptomatic) • Non-lingering • Spontaneous • No clinical symptoms (thermal tests) • Pain lingers after • Inflammation • Not spontaneous stimuli (thermal tests) produced by: • Usually severe – Caries – Caries excavation – Trauma, etc. Assessment – Pulpal Diagnosis Pulp necrosis Previous root Previously canal therapy initiated therapy No response to Canals are Partial endodontic thermal or obturated therapy electrical stimuli (e.g. pulpotomy, pulpectomy) Assessment – Periapical Diagnosis Normal apical Symptomatic Asymptomatic tissues apical periodontitis apical periodontitis • Asymptomatic, • Pain to biting and • Cannot elicit pain intact lamina dura percussion or altered sensation • May or may not • Apical radiolucent have associated area PA radiolucency Assessment – Periapical Diagnosis Acute Chronic Facial cellulitis apical abscess apical abscess • Localized swelling, • Minimal or no pain • Extraoral spread of pain, pus formation infection • Pus drains from a • Tender to pressure sinus tract • Dangerous – treat aggressively • Fever? Lymphadenopathy? • PA radiolucency? 10 Contemporary Strategies for Achieving Endodontic Success o P = Plan of treatment Plan of Treatment • Endodontic therapy – Emergency treatment – Elective treatment • Extraction • Referral Notes: 11 Contemporary Strategies for Achieving Endodontic Success Access and Canal Preparation Key points to retain Knowledge of tooth morphology, both normal and abnormal is essential to understand the application of the principles of root canal treatment; root canal systems are seldom straight and usually curve to the distal or palatal/lingual The vast majority of maxillary anterior teeth have one canal Maxillary first premolars usually have 2 roots/canals – oval access opening Maxillary second premolars usually have one canal (

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