Quality Resource Guide

A Guide to Contemporary Endodontic Technology 4th Edition

www.metdental.com

effective treatment, including emergency treatment

if necessary. Proper diagnosis also allows the

provider to recognize non-endodontic pathosis

that may mimic endodontic disease, and make an

appropriate and timely referral to other health care

providers and avoid medico-legal problems.

In addition, it is now well established that the

preoperative diagnosis significantly influences the

prognosis of treatment. Studies of endodontic

treatment outcomes have shown that the prognosis

of cases with vital/inflamed pulp with no infection

is generally over 90%. However, cases with pulp

necrosis with periapical lesions (established

infection), and cases with persistent disease (after

previous endodontic treatment) generally have a

lower prognosis in the range of 74-85%.

1,2

These

studies documented the long-term complete

radiographic healing related to endodontically-

treated teeth, in addition to absence of clinical

signs and symptoms. In these and several other

longitudinal studies examining the biological

healing of periapical tissues, the treatment was

done under controlled conditions, with meticulous

attention devoted to technique, asepsis and follow-

up of patients.

Other studies have examined the survival of

endodontically-treated teeth in the mouth for

periods of 4-8 years, regardless of radiographic

findings. These studies found that the survival of

endodontically-treated teeth is 94-97%.

3,4

These

are two distinctly different measures of endodontic

outcomes: complete radiographic and clinical

resolution of disease vs. survival of teeth that may

be functional but not completely healed.

When discussing the merits of endodontic treatment

with the patient, the question of the prognosis

of endodontic treatment versus implant therapy

frequently arises. Recent systematic reviews have

shown that there are no differences in outcomes

between the restored endodontically-treated tooth

and a dental implant.

5,6

Moreover, several studies

in which the outcomes of both procedures were

studied showed that implants have on average a

higher level of maintenance than endodontically-

treated teeth.

7-9

Finally, despite the publication of

some case reports to the contrary, recent cohort

studies have not documented a negative effect

electronic apex locators, rotary instrumentation, root

canal disinfection, and endodontic obturation. This

guide is not necessarily intended to recommend a

particular product or technology, rather it describes

the rationale for making a change in the dentist’s

practice, and the principles involved in making a

selection among available technologies.

Endodontic Diagnosis,

Treatment Planning and

Prognosis

In any health care discipline, an accurate diagnosis

based on the health history, clinical examination

and diagnostic testing is essential prior to initiation

of treatment. In endodontics, this fact is not only

true but it is becoming even more important in

contemporary practice due to many reasons. Many

dental patients are older and present in the dental

office with significant medical conditions that can

influence the presentation or prognosis of disease,

and the choice of the most appropriate treatment

for them. Patients also have much better access to

dental care, and retain many more teeth on average

than they did in the past. Therefore, patients have

on average a more extensive and involved dental

treatment history that may complicate the diagnosis

and the treatment plan. Patients are much better

educated about their rights as patients, and about

selecting the most appropriate treatment, based on

the best available evidence and their own values

and priorities. Patients expect the dentist to present

them with treatment alternatives, risks involved,

specific outcome expectations and the option to

see specialists, so that they are able to make

educated decisions. Finally, patients are more

interested in improving their quality of life, including

an interest in painless dental procedures and

preservation of natural dentition whenever possible,

while keeping their expenses to a reasonable

minimum. Therefore, it is essential that the dentist

is sensitive to these issues, and knowledgeable

enough to be able to provide accurate feedback to

common patient concerns and queries.

For optimal endodontic treatment, it is essential that

the dentist be able to establish an accurate pulpal

and periapical diagnosis for the tooth or teeth to

be treated. This allows correct identification of the

source of a patient’s complaint, and provision of

of endodontic pathosis on neighboring implants.

It is important to keep these facts in mind when

presenting both treatment modalities to the patient.

As is noted before, pulpal diagnosis is very

important as it provides an important consideration

in discussing the prognosis with the patients, and

in the degree to which the root canal system needs

to be disinfected prior to filling (see root canal

disinfection below). Sensibility tests such as thermal

and electrical tests are still the standard of care in

determining pulp vitality. In particular, the use of

a cold test, like Endo Ice or carbon dioxide snow,

together with an electric pulp tester in difficult cases

should render an accurate assessment. In cases

with difficult interpretation of the test results, the

aim should be reproducing the patient’s symptom.

For example, for a hard to localize pain with cold,

teeth can be individually isolated with dental dam,

and tested with ice-cold water. Heat testing is

used in cases that present with sensitivity to heat.

Hot gutta percha is commonly used, together with

isolation and exposure to hot water. Studies have

shown that cold testing (such as CO

snow or Endo

Ice) is more reliable in most patients, particularly

in children, in teeth with crowns, particularly when

using a large applicator surface area.

However,

in patients older than 50, cold testing has a higher

degree of false negative responses than EPT, and

so the latter is more reliable.

Recent findings

show that combined electric and thermal pulp

testing is able to accurately diagnose 97% of vital

pulps and 90% of necrotic pulps, as confirmed by

a bleeding pulp upon access preparation.

Other

pulp testing methods that assess vitality rather than

sensitivity, such as laser Doppler flowmtery and

pulse-oximetry, are still in development phases.

One of the most important outcomes of endodontic

treatment is the resolution of symptoms, most

notably, pain. Painful endodontic conditions

represent the most prevalent conditions that

cause orofacial pain

and most common dental

emergencies.

In the great majority of endodontic

cases, the symptoms resolve after elimination of

the etiologic factors, if the cause of symptoms was

accurately identified. Occasionally, post-operative

pain may occur due to unidentified non-endodontic

condition, that may cause symptoms that mimic