Evidence-based decision-making in endodontics

Transcription

1 Clin Dent Rev (2017) 1:6 TREATMENT Evidence-based decision-making in endodontics Eyal Rosen 1 Igor Tsesis 1 Received: 15 June 2017 / Accepted: 9 July 2017 / Published online: 2 August 2017 Ó Springer International Publishing AG 2017 Abstract Evidence-based dentistry may be defined as an approach to oral healthcare that integrates the best available clinical evidence to support a practitioner s clinical expertise for each patient s treatment needs and preferences and should be routinely adopted by practitioners. The goal of endodontic treatment is to eliminate a bacterial infection inside the root canal system and to prevent the invasion of bacteria and their by-products from the root canal system into the periradicular tissues in order to preserve natural teeth. Modern endodontic technologies improve the ability to treat and retain teeth, resulting in a predictably favorable long-term outcome and allowing retention of the natural dentition. Keywords Evidence-based Decision-making Endodontics Quick reference/description Evidence-based dentistry may be defined as an approach to oral healthcare that integrates the best available clinical evidence to support a practitioner s clinical expertise for each patient s treatment needs and preferences and should be routinely adopted by practitioners. The goal of endodontic treatment is to eliminate a bacterial infection inside the root canal system and to prevent the invasion of bacteria and their by-products from the root canal system into the periradicular tissues in order to preserve natural teeth. Modern endodontic technologies improve the ability to treat and retain teeth, resulting in a predictably favorable long-term outcome and allowing retention of the natural dentition. & Eyal Rosen dr.eyalrosen@gmail.com 1 Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, P.O. Box 39040, Tel Aviv , Israel

2 6 Page 2 of 8 Clin Dent Rev (2017) 1:6 Symptoms The following symptoms are common in endodontic patients: Lingering pain Sensitivity to cold or heat Sensitivity to percussion or bite Discomfort in a specific area Swelling (intraoral and extraoral) Draining sinus tract Clinical examination The following table presents various modern endodontic technologies: Endodontic technology Used Working mechanism Advantages Limitations Electronic apex locators Magnification and illumination systems (dental operating microscope and surgical loupes) For working length determination To diagnose perforations When the maxillary sinus prevents radiographic visualization of the apices of maxillary posterior teeth For locating, cleaning, and filling the root canal system Uses an alternating electric current with various frequencies in order to correctly estimate the most appropriate end point for root canal treatment Dental operation microscopes use convergent lenses to form a magnified image and are available in many configurations Allows the working length during root canal treatment procedures to be located precisely Improves visualization of the treatment field Enhances the ability to locate canals Aids in the removal of separated instruments Permits the diagnosis of root and tooth fractures Facilitates perforation repair Allows case documentation Electronic apex locators rarely give accurate readings in the presence of conductive fluids, pulp tissue, or an open apex Steep learning curve

3 Clin Dent Rev (2017) 1:6 Page 3 of 8 6 Endodontic technology Used Working mechanism Advantages Limitations Digital radiography Cone beam computed tomography To obtain radiographic images for evaluation For endodontic diagnosis and treatment planning, diagnosis of apical periodontitis, root resorption, dentoalveolar traumatic injuries To assess apical periodontitis, the outcomes of endodontic treatments, and tooth and root canal anatomy Direct digital radiographic modalities using sensors such as a charge-coupled device (CCD) or photostimulable phosphor (PSP) technology X-ray-based computed tomography where the X-rays diverge, creating a cone Immediate availability of the image for evaluation Lowers the radiation dosage required for the image acquisition Has superior archiving and sharing capabilities, and permits easier manipulation of several radiographic properties (e.g., image contrast, brightness, and sharpness) Permits visualization of the dentition and the surrounding anatomical structures in three dimensions The obtained radiographs show two dimensions of threedimensional objects Relatively high radiation dose to the patients and the resulting potential longterm harmful effects Scattering artifacts in the presence of radiopaque materials Materials/instruments Electronic apex locators Dental operation microscopes Ultrasonic instruments Digital imaging systems Surgical loupes

4 6 Page 4 of 8 Clin Dent Rev (2017) 1:6 Treatment alternatives in modern endodontics Nonsurgical Surgical Extraction Follow up endodontic treatment endodontic treatment When it is practical to When an endodontic disease When the tooth May be considered achieve the treatment is present and it is not prognosis is hopeless when worsening of the goals nonsurgically practical to achieve the endodontic condition is treatment goals non surgically not likely to occur Fig. 1 Flowchart of treatment alternatives in modern endodontics Procedure Treatment alternatives in modern endodontics include nonsurgical endodontic treatment, surgical endodontic treatment, and management of complications such as root perforations, separated instruments, and root fractures (Fig. 1). Nonsurgical endodontic treatment Nonsurgical endodontic treatment is one of the treatment alternatives for apical periodontitis. Case-specific factors that significantly affect the chances of successful nonsurgical endodontic treatment include the presence of a preoperative periapical lesion the presence of morphological changes or complications that happened during the previous endodontic treatment which affect the ability to adequately retreat the entire root canal system Surgical endodontic treatment (Fig. 2) Surgical endodontic treatment is done to prevent the invasion of bacteria and their by-products from the root canal system into the periradicular tissues. It is indicated for teeth with apical periodontitis in cases where nonsurgical treatment is impractical. Traditional surgical endodontic treatment involves a root-end resection with a bevel of about 45, retrograde preparation of the canal with a bur, and the placement of a root-end filling. Traditional surgical treatment leads to moderate results (a success rate of about 50 60%). Modern surgical endodontic treatment uses magnification to achieve a more accurate procedure with a minimal root-end resection bevel, retrograde canal preparation with the aid of ultrasonic retro-tips to a depth of 3 4 mm, and a root-end

5 Clin Dent Rev (2017) 1:6 Page 5 of 8 6 Fig. 2a c Surgical endodontic treatment of a maxillary premolar. a A previously treated maxillary second premolar with a coronal restoration was diagnosed with symptomatic apical periodontitis. b Surgical endodontic treatment was performed with minimal root-end resection in order to prevent worsening of the crown-to-root ratio. c A 2-year follow-up radiograph. The tooth was periodontally stable, and the periapical pathosis healed filling. With appropriate case selection, modern surgery yields good results with a success rate of [90%. Management of endodontic complications Vertical root fracture (VRF) Vertical root fracture (VRF) is defined as a complete or incomplete fracture initiated from the root at any level, usually directed buccolingually. Usually when a tooth is diagnosed with VRF it is necessary to extract the tooth or the fractured root. In certain cases, and based on a case selection process that includes a combination of endodontic as well as prosthetic, periodontal, and esthetic considerations, it is possible to repair the fractured root using mineral trioxide aggregate (MTA). In the case of VRF in multi-rooted teeth, there are potential alternatives that allow the tooth to be preserved, such as amputation of the vertically fractured root. However, for single-rooted teeth, the entire survival of the tooth relies on the ability to treat and maintain the fractured root. Options for treating and maintaining VRF teeth should be selected based on the specific tooth type, the fracture type and location, and the prosthetic, periodontal, and esthetic condition of the tooth. These treatment options include root amputation, apical surgery with root shaving coronally to the fracture line, sealing/cementation of the fracture following a flap elevation approach, or extraction and replantation. Iatrogenic root perforations (Fig. 3) This is defined as mechanical or pathologic communication between the root canal system and the external tooth surface. Endodontic and restorative procedures such as access cavity preparation and canal orifice exploration, root canal instrumentation, and post-space preparation may lead to perforations. An effective clinical approach to root perforations is to prevent perforation.

6 6 Page 6 of 8 Clin Dent Rev (2017) 1:6 Fig. 3a d Surgical treatment of a root perforation. a A periapical radiograph revealed an iatrogenic root perforation with associated periodontal damage in the mesial aspect of the mesial root that occurred during the extraction of an adjacent tooth. b Following flap elevation, the perforation was sealed with MTA. c Postsurgical radiograph. d At the 20-month follow-up, the tooth was asymptomatic, with radiographic evidence of periodontal healing The risk of a perforation is greater in older patients due to various anatomical, physiological, and pathological age-related factors such as apposition of secondary dentin, narrower root canals, and morphological changes in the tooth crown. The prevalence of perforations is higher in mandibular molar teeth, which may be due to significant curvature and configuration of the mandibular molar root canals. Evaluating radiographs at two different horizontal angles and CBCT, together with clinical examination using magnification and electronic apex locators, provides diagnostic accuracy when identifying perforations. MTA may be used to treat perforations, with the goal being to prevent long-lasting injury to the periodontium. Separated endodontic instruments (Fig. 4) The retained instrument fragment may affect the prognosis of the endodontic treatment by preventing adequate root canal preparation, disinfection, and obturation.

7 Clin Dent Rev (2017) 1:6 Page 7 of 8 6 Fig. 4 In this case, the presence of a retained separated instrument in the apical third of the mesial root significantly reduced the feasibility of efficiently retreating the entire root canal space. Therefore, the tooth was scheduled for endodontic surgery Management alternatives for separated instruments include: Leaving the separated instrument in the canal while endodontically treating and sealing the more coronal parts of the canal Bypassing the instrument and incorporating it into the root canal filling Retrieving the instrument A retrograde endodontic surgical approach to achieve the endodontic treatment goals Tooth extraction When the fragment is located in the apical third of the canal, fragment removal or bypass attempts are often associated with limited success and an increased risk of root perforation and reduced root strength. In the presence of a persistent apical periodontitis, endodontic surgery or even tooth extraction may be the only options in such cases. Root resorption Root resorption is a pathological process that can occur inside the root canal (internal resorption) or on the outer surface of the tooth (external root resorption), and can ultimately lead to tooth loss. External root resorption may occur when the outer tissue on the root surface is damaged as a result of operative, traumatic, pathological, or procedural injury. It may be associated with a continuous stimulation such as pulp infection, or occur without further stimulation. Rarely, root resorption can occur as a result of systemic diseases such as hyperparathyroidism, and may sometimes continue without further stimulation. Diagnosis of root resorption is based on radiographic and clinical examination. Treatment goals are to stop the ongoing resorption stimulation (i.e., the pulp infection, the pressure from the unerupted tooth, or the forces applied as a result of orthodontic tooth movement), remove the affected tissue, and restore the root and the tooth to allow proper function and optimize esthetics.

8 6 Page 8 of 8 Clin Dent Rev (2017) 1:6 If there is pulpal involvement, root canal treatment may be required. If the root resorption is extensive, extraction may be indicated. Differential diagnosis Apical periodontitis Reversible and irreversible pulpitis Caries Endo-perio lesions Tooth and root fractures Perforations Root resorption Dentoalveolar traumatic injuries Pitfalls and complications Possible complications include patient-related complications (i.e., undesirable, unintended, and direct results of treatment that affect the patient and are related to patient-specific characteristics rather than to practitioner error) and practitioner-related complications (i.e., a practitioner s error that leads to undesirable and unintended results which affect the patient) Vertical root fracture (VRF) is a complication of root canal treatment Iatrogenic root perforations The main complications following perforation are periodontal destruction due to bacterial infection and superimposition of irritating restorative materials on the perforation site Separated endodontic instruments Root resorption Further reading 1. Rosen E, Nemcovsky CE, Tsesis I (eds.) Evidence-based decision making in dentistry: the endodontic perspective. In: Evidence-based decision making in dentistry. Springer, Cham. doi: / _3 2. Tsesis I, Taschieri S, Slutzky-Goldberg I (2012) Contemporary endodontic treatment. Int J Dent 2012: Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K (2015) Cone beam computed tomography in endodontics a review. Int Endod J 48(1): Tsesis I, Beitlitum I, Rosen E (2015) Treatment alternatives for the preservation of vertically root fractured teeth. In: Tamse A, Tsesis I, Rosen E (eds) Vertical root fractures in dentistry. Springer, Cham, pp Shokri A, Eskandarloo A, Noruzi-Gangachin M, Khajeh S (2015) Detection of root perforations using conventional and digital intraoral radiography, multidetector computed tomography and cone beam computed tomography. Restor Dent Endod 40(1):58 67