R E S T O R A T I V ER ED SE TN O

TRI SATTRIYV E D E N T I S T RY

Current Practice in Endodontics

PETER V. CARROTTE

some form of advanced restorative

Abstract: The aim of this series of six articles is to improve the quality of endodontic treatment. One of many similar surveys
treatment in general dental practice by considering what is currently being taught in dental
showed that almost 50% of root-treated
schools. This first article considers the rationale behind endodontic treatment, what we are
aiming to achieve and why. It looks at the dental and medico-legal issues which dictate the
molars and premolars suffer cusp fracture
standards of our practice, and sets out the programme for the series. within three years of endodontic
treatment if cuspal protection is not
Dent Update 2000; 27: 338-340 provided.1
The root-treated tooth may even be
Clinical Relevance: The demand for endodontic treatment increases every year, prepared as a retainer for a bridge. Such
particularly as an ageing population retains more and more teeth. Through these articles
restorations are naturally expensive.
general practitioners may better assess the quality of treatment, and improve their technique
where necessary. When a patient has spent several
hundred pounds for treatment to a single
tooth, they will be more likely to
complain if the treatment fails. It may be
possible to resolve the complaint ‘in-
henever postgraduate tutors ask This first article considers the rationale house’, perhaps by offering a free re-
W a group of dentists on which
subjects they would like more courses,
behind endodontic treatment, what we
are aiming to achieve and why. The
treatment or a bridge to replace the
extracted tooth. Alternatively, local
endodontics is always towards the top of second article will address the diagnosis resolution may fail, and a complaint
the list. Attendees on such courses and treatment planning of endodontic may be made to the Health Authority, or
generally wish to learn how to make lesions. The third will consider access, a civil claim made through a solicitor.
endodontics quicker, easier, and more perhaps the most important single aspect Whether locally resolved or not, the
successful. There are probably more of endodontic treatment, and the use of time and trouble involved in resolving a
gadgets and gizmos around to achieve rubber dam. The fourth will look at the complaint or claim will far outweigh any
this in endodontics than in any other latest developments in preparation savings made by taking shortcuts in the
branch of dental practice. techniques, and current thinking in original endodontic treatment. Indeed,
The aim of this series of six articles is intervisit medication. Obturation of the such shortcuts will almost certainly
to improve the quality of endodontic entire canal system will be the subject of compromise the subsequent defence of
treatment in general dental practice by the fifth article, and the final article in the the treatment in question.
considering what is currently being series will consider retreatments and The defence society involved will seek
taught in dental schools. We often forget peri-radicular surgery. an endodontic expert to prepare a report
the basic science which should inform in support of their member’s treatment.
our endodontic practice. Frequent If the treatment is considered not to be in
reference will therefore be made to the WHY? line with current teaching and practice
biological principles of clinical practice. Before we consider what we are aiming then no expert will be forthcoming, and
However, the series will also present the to achieve, let us look at ‘why’. The settlement may have to be explored. It is
‘helpful hints’ which may make life obvious answer is that we would like all not being suggested that endodontic
easier, and lead to more consistent our treatment to be successful. But treatment provided under the terms and
success. endodontics is slightly different. conditions of the National Health Service
Virtually all the teeth considered for must be of the same standard as that
endodontic treatment are already broken provided by specialists or consultants. It
Peter V. Carrotte, MDS, LDS RCS(Eng.), MEd. down and compromised to some extent. must, however, be of the same standard
Clinical Lecturer, Glasgow Dental Hospital and
Once the endodontic treatment is as that performed by a competent final
School, Glasgow.
completed the tooth will usually require year dental student – the standard

338 Dental Update – September 2000

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which may make depressing reading.

WHAT?
So let us consider what exactly we are
trying to achieve in endodontic
treatment. In very simple terms,
immediate success will only result when
all the bacteria are eliminated from the
root canal system.4 Long-term success Figure 3. One of a series of sections taken
will depend on the quality of the through an upper first premolar, showing
obturation in its ability to resist further division of the buccal canal.
bacterial invasion.5,6
Kakehashi and his co-workers
demonstrated as long ago as 1965 that specifically considering access, it may
Figure 1. A periapical radiograph showing no periapical lesion developed in the be worthwhile briefly addressing some
an inadequate root canal treatment on an absence of bacteria.7 Endodontic of the more common anatomical
upper incisor, which resulted in an treatment must therefore be aseptic, and aberrations which frequently lead to
appearance before a Dental Service
aimed primarily at the elimination of the problems. Perhaps the most common is
Committee.
infected canal contents. Root canal the lower incisor, of which some 40%
infections are polymicrobial, dominated have two canals. Examination of the
by obligate anaerobic bacteria.8 pre-operative radiograph may indicate
However, in a closed root canal there this. A single canal will show a uniform
currently being taught in centres of will usually be only a small number of radiolucency in the entire length of the
excellence. species, between two and eight. If the canal. A division into two canals may
To illustrate this point, Figure 1 shows canal becomes contaminated by saliva be seen as a radiographic change of
a radiograph of a tooth which was root during active treatment, that situation density. Cutting the access cavity
filled by a young dentist. He had will change dramatically, with a far correctly will help in locating the
finished his vocational training year and more complex microbial flora, and a frequently missed lingual canal.9
was working in a new practice. The resultant reduction in the long-term Lower canines may have two or even
principal had issued the following rules prognosis for success. Such micro- three canals.10 Lower premolars may
for endodontic treatments in the practice. organisms harboured in residual debris, divide into two canals as shown in
No local anaesthesia was to be used for missed canals, lateral canals and Figure 2. Again, careful study of the
non-vital teeth, both to save money but anastomoses may subsequently lead to pre-operative film, and the use of
also as a novel way to save x-ray films. failure. magnification when preparing the canal,
The instructions were that once access Reference has been made to the will help in the diagnosis of such cases.
had been made, a fine file was to be ‘entire canal system’. How well can you Very occasionally this division may
pushed up the tooth until the patient remember the differing canal anatomy of affect one of the canals in an upper first
registered pain. That, quite simply, was the normal dentition? Whilst the premolar, as shown in Figure 3.
the working length. Little preparation morphology of the pulp chambers will Finally, students are now taught always
was carried out as the practice used a be referred to later in the series, when to assume that upper molars have four
formaldehyde containing obturation canals unless careful examination proves
method, which, it was claimed, fixed any otherwise.11 The second canal lies in the
remaining debris. Not surprisingly, the mesio-buccal root, approximately one-
first such treatment carried out by this third of the distance along a line
dentist failed, and the subsequent NHS connecting the orifice of the major
complaint proved extremely difficult to mesio-buccal canal to the orifice of the
defend. palatal canal. The easiest way to find it
Now I am sure that everyone would is to identify the three main canals, clean
agree that this treatment could not and shape them, and then explore the
possibly comply with current teaching. floor of the clean pulp chamber. The
But are you sure that everything you do fourth canal may still contain vital
in your endodontic treatment would be tissue, and is often a cause of pain from
Figure 2. A periapical radiograph taken as part
supported by an endodontic expert? of a routine full-mouth examination, showing a what appears to be a well root-filled
There have been several surveys recently division of the root canal in the second upper molar. The incidence of a fourth
into the quality of endodontic treatment2,3 premolar. canal in a lower first molar is less, and

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endodontics’. Figure 4 illustrates just for endodontic treatment – what we are

how much irrigant should be used! trying to achieve and why. The
Household bleach is approximately biological principles of infection
5.75% sodium hypochlorite. Used neat control must be considered at every
it will immediately start to dissolve the stage of treatment and, as we shall see
organic debris in the canal. However, later, even more so when carrying out
should bleach of this concentration be retreatments of failed cases.
expressed under pressure through the The next article in this series will
apex of the tooth, by incorrect consider the diagnosis of endodontic
irrigation procedures, it may cause a lesions, special tests, radiographs and
Figure 4. A simple illustration of how much serious inflammatory reaction. Most treatment planning. It will also,
irrigant should be used during canal preparation.
general practitioners therefore dilute hopefully, start to show how to make
the neat bleach with water. A 50:50 endodontic treatment more successful,
dilution will still dissolve organic more predictable and more profitable!
the diagnosis is usually made when debris, but this ability reduces with
difficulty is experienced in instrumenting further dilution. A 5:1 dilution is still
the normally wide distal canal. Lateral completely antibacterial, but quite safe
exploration may then reveal a fourth with careful use.12 If the solution is RE F E R E N C E S
orifice, again usually patent to the apex. warmed it is more effective, and if it 1. Hanson EK, Asmussen E. Cusp fracture of
I have long supported the view that fees can be agitated within the canal it will endodontically treated teeth restored with
amalgam. Teeth restored in Denmark before
for root canal treatment should be paid penetrate fins and lateral canals. Care 1975 versus after 1979. Acta Odontol Scand
per canal and not per tooth. When that must be taken to avoid contact of the 1993; 51: 73-77.
happens, these paragraphs may well solution with the patient’s skin or eyes 2. Saunders WP, Saunders EM, Sadiq J,
become more relevant to the busy (protective spectacles should be used Cruickshank E. Technical standard of root canal
treatment in an adult Scottish sub-population.
practitioner, and those old anatomy routinely in modern dental practice) Br Dent J 1997; 182: 382-386.
textbooks may be dusted off! and, of course, bleach should not come 3. Dummer PMH. The quality of root canal
into contact with the patient’s clothes. treatment provided by general dental
practitioners working within the general dental
The detailed use of sodium hypochlorite services of England and Wales. Part Two. Dent
ROOT CANAL TREATMENT and other irrigants will be considered in Profile 1998; 19: 8-10.
Having established why we are seeking part four of this series. 4. Engström B, Hård AF, Segerstad L, Ramström G,
success, and refreshed our canal anatomy, Frostell G. Correlation of positive cultures
with the prognosis for root canal treatment.
let us now turn to the rationale of Odontologisk Rev 1964; 15: 257-270.
treatment. It was stated earlier that the SHAPING 5. Barbokaw FH, Cleaton Jones PE, Friedman D.
primary aim of root canal treatment is the If the prime aim in endodontic treatment An evaluation of 566 cases of root canal
elimination of the infected canal is the use of antibacterial agents, it may therapy in general dental practice. 2
Postoperative observations. J Endod 1980; 51:
contents. It is, however, virtually be asked why it is necessary to shape the 552-559.
impossible to sterilize the root canal canals with files and other instruments? 6. Smith CS, Setchell DJ, Harty FJ. Factors
system completely, and the aim of It has been shown that irrigants cannot influencing the success of conventional root
treatment may be more realistically stated penetrate far into the narrow canal therapy - a five year retrospective study.
Int Endod J 1993; 26: 321-333.
to be the reduction of the microbial uninstrumented root canal. Thus 7. Kakehashi S, Stanley HR, Fitzgerald RJ. The
contents of the canal as far as is possible. widening the canal greatly facilitates effects of surgical exposure of dental pulps in
Any remaining micro-organisms are irrigation. However, the principal germ-free and conventional laborator y rats.
then entombed in the canal system object of canal instrumentation is to Oral Surg Oral Med Oral Pathol 1965; 20: 340-
349.
following an efficient obturation. It is create a smooth, tapering canal which 8. Sundqvist G. Taxonomy, ecology and
thus necessary to shape the canal system can be easily and quickly obturated. pathogenicity of the root canal flora (review)
in order to facilitate this obturation. The obturation has three purposes, to Oral Surg Oral Med Oral Pathol 1994; 78: 522-
530.
Endodontic preparation therefore has block communication from the oral 9. Mauger MJ, Waite RM, Alexander JB, Schindler
two distinct phases, cleaning and cavity to the periradicular tissues, to WG. Ideal endodontic access in mandibular
shaping. entomb remaining micro-organisms, and incisors. J Endod 1997; 25: 206-207.
to prevent the ingress of apical tissue 10. Holtzman L. Root canal treatment of a
mandibular canine with three root canals. Int
fluids which may provide nutrients for Endod J 1997; 4: 291-293.
CLEANING any such residual bacteria. 11. Cohen S, Burns RC. Pathways of the Pulp. 7th
Cleaning is performed by anti- edn. St Louis: Mosby, 1994; p.168.
microbial agents, the most efficient of 12. Baumgartner JC, Cuenin PR. Efficacy of several
CONCLUSION concentrations of sodium hypochlorite for
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has been described as ‘liquid We have now established the rationale 612.

340 Dental Update – September 2000