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Fundamentals of Endodontics Lecture 2014

This document summarizes a hands-on endodontics course held at St. George's Hospital. The summary focuses on key skills and factors that influence endodontic outcomes. It discusses that endodontics requires a team approach and emphasizes important technical skills like access preparation, locating and scouting canals, and thorough instrumentation and obturation of the root canal system. Factors like achieving working length within 2mm of the radiographic apex, minimizing voids in obturation, and providing a satisfactory coronal restoration seal were highlighted as critical to clinical success. The summary emphasizes irrigation techniques, coronal leakage prevention, and re-treatment challenges. Overall, the document stresses mastering fundamental endodontic skills and understanding factors proven to impact

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Praveena Sailenthran
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134 views46 pages

Fundamentals of Endodontics Lecture 2014

This document summarizes a hands-on endodontics course held at St. George's Hospital. The summary focuses on key skills and factors that influence endodontic outcomes. It discusses that endodontics requires a team approach and emphasizes important technical skills like access preparation, locating and scouting canals, and thorough instrumentation and obturation of the root canal system. Factors like achieving working length within 2mm of the radiographic apex, minimizing voids in obturation, and providing a satisfactory coronal restoration seal were highlighted as critical to clinical success. The summary emphasizes irrigation techniques, coronal leakage prevention, and re-treatment challenges. Overall, the document stresses mastering fundamental endodontic skills and understanding factors proven to impact

Uploaded by

Praveena Sailenthran
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Fundamentals of Endodontics

Peter Briggs, Ahmed Farooq and


Tracy Watford, Trish Moore and QED
Practical Hands-on course
St Georges Hospital, SW17 0QT

St Georges Dental Simulation

Today
Take the opportunity to enjoy the facilities
Remember that endodontics is a team sport
it is difficult to do on our own
As a profession we need to be looking at ways
of improving clinical outcome
We need to break down our goals into
important small doable tasks

Small things that we need to do well


Access
Canal(s) location
Small Scout Files (#08 / #10) to confirm presence
and patency of root canal(s) very important for
re-treatments
Preparation Coronal, Mid and Apical thirds
Obturation
Coronal Restoration

Why do we need to do these well?

What endodontic skills are we going to need


throughout the life of our patients?

We all need to know


and understand the
important factors that
influence Endodontic
outcome

March 2014

What factors have been proven to make a


difference to endodontic outcome?

www.hodsollhousedental.co.uk

March 2014

We all should all have read this critical review


on Endodontics Ng et al. (2008 a & b) Int Endod J 41: 6-31
Pre-operative apical area
Root filling ending within 2 mm of
radiographic apex (instrumentation and
obturation)
Voids within the root-filling (obturation
quality)
Satisfactory restoration coronal seal
(post-Rx Rest Dent)
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March 2014

Electronic Pulp Tester- a great tool


Get the patient to hold the pulp tester and let go when they feel something

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March 2014

Presence of pre-operative area


Why do you think this is important?
How long will it take to heal after treatment?

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March 2014

If no sign of healing or radiographic


improvement at 24 months then likely not to
have worked

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March 2014

Should see an improvement or


resolution by 24 months

PB 2011

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March 2014

Root filling ending within 2 mm of


radiographic apex (instrumentation
and obturation domains)

www.hodsollhousedental.co.uk

March 2014

Electronic Apex Locators


always use the tip (not the clip) - your nurse can put hold it on
the head of the hand-piece it doesnt need to be on the file

www.hodsollhousedental.co.uk

March 2014

Gauging & Diagnostic radiographs in a


digital age
Learn to use and trust an EAL its right
as long you can get predictable Zero
readings and its not jumping
Prepare the root canals with tip of EAL
placed on the hand piece as you work

www.hodsollhousedental.co.uk

March 2014

Verify apical size of master GP point with plastic


Maillefer ruler to apical gauge - GP points vary
massively cut flush with scalpel blade then you
have an apically gauged master GP point that can
be seated within the root canal
this will help keep your RCT within the root canal

www.hodsollhousedental.co.uk

March 2014

Teeth with apical areas you will get an


approximate 12% drop-off in outcome per
mm short of ideal length

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March 2014

Golden Rules
Never put an unmeasured endodontic
instrument into a root canal
Use your pre-operative radiographs to help
provide a guide on likely working length(s)
Share measuring responsibilities nurse with
measuring block responsible for clearly
instructed measurement of all files
Careful gauging and pre-cementation
radiographs please
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March 2014

Ng et al. (2008 a & b) Int Endod J 41: 6-31


We are now probably as good
as we can get ARE WE THERE
YET?
The older techniques hold up
well
Irrigation and bug-killing are
extremely important when
apical periodontitis is present
We must all crack a
predictable obturation
technique
www.hodsollhousedental.co.uk

2009

1999

March 2014

Ng et al. (2008) Int Endod J 41: 6-31

2009

2009

2006
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2009

March 2014

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March 2014

Irrigation & Cleaning is the key


Ultrasound 1 minute per canal using and
ultrasonic needle and 15ml of 6%
hypochlorite.
Addition of U/S gave a sevenfold increase
in the chance of a negative culture could
be obtained at the end of the procedure.
U/S significantly reduced colony forming
units (CFUs)
Carver K, et al. In vivo antibacterial efficacy of ultrasound after hand and rotary instrumentation in human
mandibular molars. J Endod (2007) 33:1038-1043
www.hodsollhousedental.co.uk

March 2014

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March 2014

Increasing bug-killing
with hypochlorite
Warm - 1% at 40 degrees is as
effective as 5.25% at room temp
Pump with final GP 30 seconds per
canal with EDTA then 30 seconds with
hypochlorite immediately prior to
obturation
This has been shown to make a big
difference to outcome for both denovo and revisions (EDH / USA)
www.hodsollhousedental.co.uk

March 2014

Re-treatments you want to get


down to the working length ASAP

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March 2014

Re-Treatment usually means


removing a GP - do not be scared
of the stuff it will not bite!

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March 2014

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March 2014

Success rates
31-96% based on strict criteria
Complete resolution of periapical lesion

60-100% based on loose criteria


Reduction in size of existing periapical lesion

80-82%
Ng et al, International Endodontic Journal
(2007)
www.hodsollhousedental.co.uk

March 2014

Ng, Mann & Gulabivala; International


Endodontic Journal, 2011

www.hodsollhousedental.co.uk

March 2014

Can we predict if our Endo is going to work?

Pre-operative:
Presence of periapical lesion (49%
lower)
Size of periapical lesion (14%
lower for every 1mm)
Presence of sinus (48% lower)
Presence of root perforation (56%
lower)
Ng, Mann & Gulabivala; International Endodontic Journal, 2011
www.hodsollhousedental.co.uk

March 2014

Predictive Discussions with the patient


CAP with exudation - presence of sinus (48%

lower)

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March 2014

Is our Endo going to work?


Intra-operative:

Achieving patency (Two-fold increase)


Canal prepared short of terminus (12% lower for
every 1mm short)
Long root filling (62% lower odds of success)
Using Chlorhexidine as irrigant (53% lower)
Using EDTA (Re-RCTx) (Two-fold increase)
Inter-appointment swelling/pain (47% lower)

Ng, Mann & Gulabivala; International Endodontic Journal, 2011


www.hodsollhousedental.co.uk

March 2014

Early patency and drainage


is very important with teeth with CAP

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March 2014

Is our Endo going to work?


Post-operative:
Good coronal restoration (Elevenfold increase in odds of success)

Ng, Mann & Gulabivala; International Endodontic Journal, 2011


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March 2014

We must protect the investment

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March 2014

Satisfactory restoration - coronal


seal (post-Rx Rest Dent)

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March 2014

Post Endodontic Restoration


and Cuspal Protection
Non-vital posterior teeth # unfavourably

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March 2014

Vital teeth fracture more favourably


(supra-gingival) and thus are usually restorable

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March 2014

Survival rates in NHS

Tooth still in mouth and asymptomatic


RCT of 174 lower 6s
12 NHS practices
Salford (NW England)
90% retained at 5 years
Most failures in first year
10% failure: 15 extracted, 1 retreated
Statistically significant difference if tooth crowned
Tickle et al, British Dental Journal (2008)
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March 2014

Protect your hard work!


Reduce the risk
of coronal
leakage by
cutting back GP so the whole
pulpal chamber
can be filled.

1992

Saunders & Saunders Coronal leakage as a cause of failure in root canal therapy: a review
Endod Dent Traumatol (1994)
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March 2014

Endodontic
Failure & Revision

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March 2014

Re-treatments
The poorer the quality of the primary
root filling in situ the easier and
more predictable will be your retreatment
Ideally you want to revise a short
poorly obturated root filling with no
iatrogenic damage!
You can then expect a 80% positive
outcome (NG et al 2011)
The Toronto study
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Sometimes we will need to carry


out apical surgery we must do it
properly
March 2014

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March 2014

Coronal Issues

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March 2014

Skills we need you to all display


today
Think about preparation break up into
coronal / mid / apical (Hand / Protaper and
Reciprication)
Apical patency / Apical gauging / Apical tune
Irrigation dynamic pumping / EDTA /
Hypochorite
Obturation vertical warm and cold lateral
condensation
Intermediate and long-term coronal seal
www.hodsollhousedental.co.uk

The End
I thank you for your
invitation
and attention
March 2014

www.hodsollhousedental.co.uk

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