Failing before starting: when not to do endodontics

It's a fact: Perfect endodontic treatment can be unsuccessful. Unfortunately, endodontic failure often can result from an inadequate preliminary diagnosis or prognosis assessment. Many variables should be considered before endodontic treatment begins, including assessing the endodontic case, addressing periodontal concerns, determining restorative issues, and detecting root fractures. If these parameters are not evaluated carefully, then short- or long-term endodontic failure will result. Unfortunately, an endodontic prognosis assessment is often subjective. Although dentists must rely on evidence-based research to determine the best modality of treatment, good clinical judgment and experience may override the most objective findings. This article discusses the objective and subjective nuances involved in evaluating the potential prognosis of endodontic treatment.     

Clinical Judgement And Decision Making In Endodontics

Clinical judgement in endodontics consists of much more than diagnosis and treatment planning for the affected tooth. The issues involved in clinical judgement and decision making can be summarised by three questions:

• 1 Is endodontic treatment appropriate for the patient? Endodontic treatment should be undertaken only as part of an agreed, comprehensive treatment plan that takes into account patient concerns as well as objective clinical findings.
• 2 How difficult is the endodontic treatment? The difficulty of the case should be balanced with the skill and experience of the dentist, in deciding whether to manage the case in general practice or to refer the patient to an endodontist. The use of a standard form for assessing the difficulty of each endodontic case will aid in consistent, systematic assessment of patients. An example of such a form is provided.
• 3 What is the prognosis for the tooth? The outcome of endodontic treatment depends not only on the endodontic treatment but on other factors such as restorability and periodontal status. The prognosis will be compromised by procedural problems and by restorative and periodontal factors.

In all but routine cases, the steps involved in decision making may be more complex and less easily resolved than the practical clinical aspects of endodontic therapy.     

Splinting and replantation after traumatic avulsion

A rational approach can be taken in the dental office to avulsion and replantation. Consideration must be given to: Extraoral time. During this critical time, the prognosis for successful replantation noticeably decreases as the out-of-mouth time increases. Transport. Preferably the tooth will be transported in the socket, but milk or water may be used to keep the tooth moist. The buccal vestibule may be recommended for adults and teenagers but not for young children. Root surface. The root surface must not be handled, scraped, brushed, or have any part removed; it can be rinsed with sterile water, saline, or tap water but not with caustic solutions, disinfectants, or medicaments to clean the surface. Endodontic treatment. A tooth with an open apex should be evaluated bimonthly for revitalization. A tooth with a fully formed apex should have the pulp removed in 7 to 14 days after avulsion. Status of the alveolar process. Alveolar fractures may require a modified splint design to provide additional strength for a longer splinting duration. Obturation materials. Calcium hydroxide paste is used for a minimum of 6 to 24 months before filling permanently with gutta-percha. Selection of a splint. Each case is different and should be treated as such. Special consideration must be given to splint design, which will directly influence the desired result. Although any number of splints may be effective, inherent advantages and disadvantages of each should be understood fully by the clinician. This is where the art, the clinical experience, and the common sense of endodontic therapy dictate the proper splint and appropriate duration of splinting for the patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis and treatment planning are essential prior to commencing endodontic treatment: discuss this statement as it relates to clinical endodontic management

Diagnosis and treatment planning are essential to the practice of endodontics. Diagnosis aims to determine whether pathological involvement of the dental pulp has or is occurring. Treatment planning meanwhile, involves appropriately selecting cases, determining how difficult the treatment may be to perform on a specific individual and sequencing treatment procedures to achieve a healthy and functional dentition. In endodontic management, this may involve establishing whether the tooth is restorable and periodontally sound, the patient is able to tolerate the treatments and the clinician has the skills to perform the required treatment procedures. Careful consideration of these issues must be given prior to commencing treatment.     

Endodontische Diagnose

Endodontic diagnostics are similar to the construction of a puzzle. The physician must systematically gather all of the necessary information to make a probable diagnosis. In order to render correct treatment, a complete endodontic diagnosis must include a diagnosis of both the pulp and the periapical area for each tooth evaluated. It is also important to recognize that treatment should not be rendered without a diagnosis and in these situations the patient may have to wait and be reassessed at a later date or be referred to an endodontist.     

Restorative management of the worn dentition: 3. Localized posterior toothwear

In the management of localized posterior occlusal toothwear, care must be taken not only in determining whether the worn teeth are restorable, but also the desirable occlusal scheme. Assessments of the periodontal, endodontic, and coronal tooth tissues, and the occlusal relationship are necessary for a comprehensive treatment plan for worn posterior teeth.     

Secondary hyperparathyroidism: a case report

A thorough diagnostic examination is essential before providing endodontic treatment. The sequence of diagnostic procedures must begin with a well-organized review of the medical history. In the early screening process, a health history that reveals a systemic disorder must be investigated further because it may have a significant impact on the dental diagnosis and ultimate endodontic treatment. There are a number of systemic diseases that can cause bone lesions throughout the body. Chronic renal failure is one disorder that may stimulate a secondary hyperparathyroidism that can cause a variety of bone lesions. In some instances these lesions appear in the periapical region of teeth and can lead to a misdiagnosis of a lesion of endodontic origin. The following case report of a patient referred for endodontic treatment demonstrates the importance of understanding the effects of end-stage renal disease on the dental structures.     

Endodontic problems

If modern clinical techniques were carefully followed, many common endodontic problems would never occur. Incorrectly designed access cavities may make root canals both difficult to identify and to instrument. Careful study of the pre-operative radiograph is essential. Various aids are available to remove fractured instruments and failed root fillings, but the problem must first be correctly diagnosed. As more patients seek cosmetic procedures, the practitioner should be familiar with the 'walking bleach' procedure, again after careful diagnosis of the cause of the discolouration. The practitioner should also be fully aware of the prognosis for this and other endodontic procedures.     

Occlusal considerations in determining treatment prognosis

To function in occlusal harmony, the masticatory apparatus--composed of the teeth and its supporting structures, temporomandibular joints, and associated neuromusculoskeletal structures--must operate in an integrated and dynamic manner. Loss of integrated function, or of homeostasis in response to functional demand, may generate problems in occlusion. In health, adaptive changes occur with the teeth and periodontium in response to functional occlusal forces. With periodontal and endodontic disease, this adaptive capacity diminishes. The ability to foresee how these changes may influence dental treatment is important in the art of determining treatment prognosis.     

恒牙外伤的牙髓保存和牙髓治疗

牙外伤造成牙体硬组织和牙周组织的损伤,可能会引起牙髓暴露、感染或影响牙髓组织的血液供应,继而对牙髓组织的预后造成影响。本文通过分类阐述恒牙外伤的牙髓组织预后和牙髓治疗方案,为临床及时准确判断外伤牙的牙髓状态、合理选择牙髓保存和治疗技术、提高恒牙外伤的远期疗效提供参考。     

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??Dental trauma can cause damage of dental hard tissue??or supporting tissues?? which may cause pulp exposure?? pulp infection or influence the pulp blood supply?? and then impact the prognosis of pulp tissue. This paper tried to elaborate pulp prognosis and endodontic management of traumatized permanent teeth?? in order to choose the reasonable endodontic treatment and improve the long-term effect of the traumatized permanent teeth.     

The missing link: the endodontic/restorative continuum

The endodontic treatment and the restoration of compromised teeth have largely been viewed as two separate unrelated procedures. The research, however, suggests that the way the endodontic procedure is performed may influence the long-term prognosis for the restored pulpless tooth. Also, studies suggest that the protocol followed when restoring pulpless teeth may affect the long-term prognosis of the endodontic treatment. This article explores the synergistic relationship between these two procedures and suggests how new resin technologies might help to increase success rates of endodontically treated teeth. New methodologies for obturating roots for better seals, for placing posts to strengthen roots against fracture and to retain cores, and the need for ferrules are discussed, with a review of the evidence pertaining to these subjects.     

A radiographic study of the prevalence of endodontically treated teeth and procedural errors of root canal filling.

The aim of this radiographic investigation was to study procedural errors encounterd in root canal treatment in a Jordanian population as evidenced using periapical radiographs A total of 2380 periapical radiographs including 3178 endodontically treated teeth were assessed in respect of the quality of endodontic treatment. The results indicated that the prevalence of endodontically treated teeth in the maxilla was higher than that in the mandible ( P < 0.001 ), the maxillary central incisors have the highest prevalence of endodontic treatment, and the maxillary second molars have the lowest prevalence of endodontic treatment. In respect of the quality of endodontic treatment, 30.2% of endodontically treated teeth exhibited an ideal length of root canal filling, 23.64% of the evaluated teeth were mummified, 37.45% of the teeth have short root canal fillings, 6.25% were overfilled, 1.35% were with preparations which deviated from the line of the root canal and 1.10% of the evaluated teeth have perforations of the root walls or the floor of the pulp chamber. It is concluded that the Maxillary teeth were found to be endodontically treated more frequently than the mandibular teeth, anterior teeth were found to be endodontically treated more than premolar and molar teeth, maxillary central incisors have the highest prevalence of endodontic treatment whilst the maxillary second molars have the lowest prevalence. The quality of endodontic treatment was disappointing. Therefore, emphasis on continuing education and post graduate courses in endodontics must be a priority in Jordan.     

Endodontic leakage studies reconsidered. Part II. Statistical aspects

The aim of many endodontic studies is to compare two or more treatment methods, techniques or materials, for example, to detect differences in mean leakage scores. As it is not feasible to study large populations, samples are taken. The important question then arises as to how large the sample sizes have to be in order to establish the‘true’(= populations') mean scores. First, it must be determined which magnitude of the difference (= v) between the mean scores is of endodontic interest. Based upon v and a few related statistical parameters, one may calculate how large the samples must be in order that a statistical test yields a significant result for a difference that is of endodontic importance. In other words, the‘power’of a test, depending on the sample size among other factors, must be large enough to detect the‘true’a priori determined difference between the populations. The use of small sample sizes may imply that a rather large difference between two mean leakage scores is not found to be significant, thereby leading to incorrect conclusions. This article describes the power and the statisti-cal related factors that determine the adequate size of samples. Examples of power calculation are presented. Next, the power of publicized endodontic leakage studies was evaluated. Almost two-thirds of the sample sizes were 10 or less, and about 90% were 20 or less. Less than one-half of the tests had an adequate power (conventionally ≤ 0.80). It is necessary to be cautious when extrapo-lating the results of such studies, because of the limited power of the statistical tests. The power may be increased by using larger sample sizes or, alternatively, by enlarging the‘effect size', by either taking an interest in a larger difference between the mean scores, or by minimizing the variability of the data.     

Access to original canal trajectory after deviation and perforation with guided endodontic assistance

Procedural accidents are eventualities that may occur during endodontic treatment because of lack of attention to detail or even unforeseeable situations. Knowledge of the root canal anatomy and its variations is a prerequisite for successful endodontic treatment. This case report describes an endodontic treatment where there was an intercurrence, generating deviation and perforation, which was solved with the aid of guided endodontics. A 37 years old, ASA1, was referred to the clinic for localisation and treatment of a calcified canal of the second right upper premolar. The tomographic images revealed the presence of only one canal and deviation with apical perforation. With the help of CBCT and CAD/CAM, it was possible to perform the guided access technique even after deviation and root perforation. Once again, this technique proved to be safe and predictable, allowing for a favourable prognosis in the long term.     

Orthognathic surgery. Study of nerve injuries

The correction of oral and maxillo-facial mal-formations causes lesions to sensitive nerves due to the invasive and traumatic surgery techniques required. Generally neuro-sensory and cutaneous-mucosal defects are reversible, with full recovery within 6-12 months. In a follow-up study (2 and 8 years) we found altered tactile and pain sensitivity in 43% of patients at subjective evaluation, with objective alteration in 17% of the group. Dental sensitivity evaluated by a pulp test showed an increase in for all teeth tested; values were higher for superior than for inferior teeth. Despite the increased pulp sensitivity threshold, due to the surgical damage, no signs of pulp disease were detected. Quality of life was not affected even by such a high subjective change in sensitivity. We therefore believe that patients undergoing orthognathic surgery must be fully informed; they must be made to understand the risks involved, and that damage may occur to sensitive nerves following surgery. All surgeons, including those with experience in the field, should continually seek to improve their skill and learn new techniques, in order to reduce complications to a minimum.     

Root perforations following endodontics: a case for surgical management

Despite technological advancements in dental instrumentation and techniques, endodontic mishaps remain commonplace. Perforations during access preparation, canal instrumentation, root filling, or preparation of post space are not unusual and instruments may fracture during filing or reaming or when attempting to bypass fractured instruments in the root canal. Many of these complications are hard to avoid due to extreme variations in root canal anatomy, root shapes, curvatures, and canal calcification. Procedural errors impede proper endodontic therapy and increase the risk of treatment failure; as a result, the prognosis is compromised, especially in nonvital teeth or teeth with periradicular lesions. Perforations may lead to short-term or long-term complications (that is, infection, periapical cyst, or granuloma formation); in addition, restorative material may be extruded through the perforation. Clinicians often have difficulty diagnosing and treating root perforations, particularly in posterior teeth (specifically in the area of the mandibular bifurcation); however, such complications do not mean that the tooth must be extracted. This article discusses treatment of perforations near the bifurcation of a mandibular first molar and an apical perforation in a premolar. Both teeth were salvaged via surgery without the use of additional biomaterials.     

牙周牙髓病损预后的临床分析

目的 通过临床病例回顾分析牙周牙髓病损原发病因的诊断，治疗方案的选择对患牙预后的重要性。方法 选择31颗牙周牙髓病损患牙，临床详细检查，根据患牙的分类选择相应牙周，牙髓治疗方法，6－24个月评价临床愈合。结果 源于牙髓感染的牙周病损，牙周治疗需要量小，预后最好；源于牙周感染的牙髓病损，患牙预后取决于牙周病变程度，牙髓治疗未显著提高骨缺损的修复。评估牙周牙髓联合病变的预后，需监测阶段性治疗效果，牙周治疗需要量大。结论 牙周牙髓病损的临床需详细分析原发病因，选择优化治疗方案，监测阶段性治疗效果。     

A practical guide to endodontic access cavity preparation in molar teeth

The main objective of access cavity preparation is to identify the root canal entrances for subsequent preparation and obturation of the root canal system. Access cavity preparation can be one of the most challenging and frustrating aspects of endodontic treatment, but it is the key to successful treatment. Inadequate access cavity preparation may result in difficulty locating or negotiating the root canals. This may result in inadequate cleaning, shaping and filling of the root canal system. It may also contribute to instrument separation and aberrations of canal shape. These factors may ultimately lead to failure of treatment. Good access cavity design and preparation is therefore imperative for quality endodontic treatment, prevention of iatrogenic problems, and prevention of endodontic failure.