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
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Contemporary Strategies for Achieving Endodontic Success
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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
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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.
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Contemporary Strategies for Achieving Endodontic Success
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Contemporary Strategies for Achieving Endodontic Success
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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
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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
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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?
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Contemporary Strategies for Achieving Endodontic Success
o P = Plan of treatment
Plan of Treatment
• Endodontic therapy – Emergency treatment – Elective treatment • Extraction • Referral
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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 ( with the potential for irregularities)
Maxillary molars usually have 3 canals – with many first molars having 4; trapezoidal to triangular access outline
Look for mandibular incisors to have 2 canals; canines may have 2 roots
Mandibular premolars usually have one canal; if more than one is identified all of the premolars may have 2 or more canals
Mandibular molars may have one to four canals; trapezoidal to triangular access outline
A 3-dimensional assessment of the location of the pulp chamber is essential prior to access
Access openings must be placed in the center of the tooth [straight-line access] to permit visualization and access to the entire canal system; the cavity walls are flared to permit light to enter, to enable removal of the entire pulp chamber contents, to enhance canal orifice identification and to facilitate placement of instruments into the root canal
A DG-16 Endodontic explorer is an essential tool for all root canal procedures
Eliminate the coronal ledge or bulge in all molar teeth prior to entering the canal with instruments; can be done with Orifice Shapers or small Gates Glidden Burs
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Contemporary Strategies for Achieving Endodontic Success
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Contemporary Strategies for Achieving Endodontic Success
The Future of Cleaning and Shaping
Key points to retain
Goals are to remove all organic substrate and develop a purposeful form for root canal obturation
Continuously tapering funnel shape that flows from the original canal shape while maintaining the spatial relationship of the original apical foramen in its smallest size possible to achieve the thorough removal of tissue debris – this means that paying attention to both the vertical length and the horizontal width of the root canal space is essential
Knowledge of the three-dimensional root canal anatomy is essential as is the application of all instruments within that anatomy
Pulpal Anatomy
Courtesy Dr. Sergio Kuttler
The newest concept in root canal cleaning and shaping is to use one file in a reciprocation motion as opposed to a rotational motion.
M-Wire instruments exhibit greater cyclic fatigue resistance than conventional NiTi alloys.
The rationale for keeping the apical preparation/size as small as possible is based on the facts that bacteria do not penetrate deeply into the apical dentinal tubule that are minimal and often sclerosed and the smaller the size the less chance there is to alter the apical anatomy in a deleterious manner. i.e., tearing, zipping, etc
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Contemporary Strategies for Achieving Endodontic Success
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Contemporary Strategies for Achieving Endodontic Success
Endodontic Treatment: Irrigation
Key points to retain
Canal anatomy, due to its irregularities, does not permit the active cleaning with instruments in all areas
Instrumented dentin surfaces are covered with smear layer and untouched areas are covered with organic debris
Irrigation is essential to clean the root canal walls and irregularities
Irrigating solutions should be actively delivered to the root canal during and after instrumentation - keeping the solution in motion in the canals is a key factor for effectiveness
New protocols for irrigation require the use of NaOCl followed by QMix
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Contemporary Strategies for Achieving Endodontic Success
NaOCl
• Dissolves necrotic pulp tissue • Dissolves predentin • Slowly dissolves vital pulp tissue • Dissolves biofilm • Kills biofilm bacteria
EDTA, Citric Acid
• Dissolves inorganic tissue • No effect on organic tissue • Weak/no effect on bacteria
Chlorhexidine
• Does not dissolve tissue • Does not dissolve biofilm • Kills bacteria (not fast) • Remains in dentin • Improves long term dentin bonding to resins
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Contemporary Strategies for Achieving Endodontic Success
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Contemporary Strategies for Achieving Endodontic Success
Ultrasonic tip setting – Not greater than ‘5’ for tip #3 (which is used most frequently)
IF present: Sinus Tract – Don’t need antibiotics, God created drainage already Swelling – Always have to establish drainage NaOCL accident - More likely in big lesion & young child – BE CAREFUL! o Irrigate 10 – 20 cc of sterile saline . Use Endodontic Irrigation Technique (micro suction) this pulls saline down causing negative pressure effect o Refer to specialist endodontist/oral surgeon o Always put patient on antibiotics (Amoxicillin qid) & Medral dose pack (steroid) o Inform patient they may have bruising
IRRIGATE FREQUENTLY! 19
Contemporary Strategies for Achieving Endodontic Success
Obturation Theory
Key points to retain
Objective is to seal the canal from the orifice to the apical foramen following thorough cleaning, enlarging, shaping and disinfection of the root canal space
Obturation: Methods Cold Warm Others*
• Lateral compaction • Warm lateral compaction • EndoRez • ActivGP Plus • Vertical compaction • Paste • Custom Cone • Continuous wave • Apical Barrier • Resilon • Thermo-mechanical • Injection Injection: Obtura, Calamus, (GuttaFlow) Ultrafil, Resilon Carrier: Simplifil, Successfil, Densfil II, Softcore, RealSeal1,Thermafil/GT, PT, GuttaCore
Advantages of warm, flowable gutta-percha outweighs the use of a cold compact technique
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Contemporary Strategies for Achieving Endodontic Success
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Contemporary Strategies for Achieving Endodontic Success
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Contemporary Strategies for Achieving Endodontic Success
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