Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology

The assurance of the quality of a service rendered by a member of the dental profession is an essential feature of any system of peer review in dentistry. This document addresses two essential elements: (i) appropriateness of treatment modality and (ii) quality or level of treatment rendered. In revising these guidelines the European Society of Endodontology is responding to a public and professional need. In receiving care of a specialized nature such as endodontic treatment, patients need and deserve treatment that meets the standard of care generally given by competent practitioners. The European Society of Endodontology has the expertise and professional responsibility necessary to assist the dental profession by instituting guidelines on the standard of care in the special area of Endodontics. In accepting this responsibility the European Society of Endodontology formulated treatment guidelines that are intended to represent current good practice.

Clinical applications of mineral trioxide aggregate

An experimental material, mineral trioxide aggregate (MTA), has recently been investigated as a potential alternative restorative material to the presently used materials in endodontics. Several in vitro and in vivo studies have shown that MTA prevents microleakage, is biocompatible, and promotes regeneration of the original tissues when it is placed in contact with the dental pulp or periradicular tissues. This article describes the clinical procedures for application of MTA in capping of pulps with reversible pulpitis, apexification, repair of root perforations nonsurgically and surgically, as well as its use as a root-end filling material.

Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol?

A new technique is presented to revascularize immature permanent teeth with apical periodontitis. The canal is disinfected with copious irrigation and a combination of three antibiotics. After the disinfection protocol is complete, the apex is mechanically irritated to initiate bleeding into the canal to produce a blood clot to the level of the cemento-enamel junction. The double seal of the coronal access is then made. In this case, the combination of a disinfected canal, a matrix into which new tissue could grow, and an effective coronal seal appears to have produced the environment necessary for successful revascularization.

The potential applications of cone beam computed tomography in the management of endodontic problems

AIM

To provide core information on cone beam computed tomography (CBCT) technology and its potential applications in endodontic practice.

SUMMARY

CBCT has been specifically designed to produce undistorted three-dimensional information of the maxillofacial skeleton as well as three-dimensional images of the teeth and their surrounding tissues. This is usually achieved with a substantially lower effective dose compared with conventional medical computed tomography (CT). Periapical disease may be detected sooner using CBCT compared with periapical views, and the true size, extent, nature and position of periapical and resorptive lesions can be assessed. Root fractures, root canal anatomy and the true nature of the alveolar bone topography around teeth may be assessed. CBCT scans are desirable to assess posterior teeth prior to periapical surgery, as the thickness of the cortical and cancellous bone can be accurately determined as can the inclination of roots in relation to the surrounding jaw. The relationship of anatomical structures such as the maxillary sinus and inferior dental nerve to the root apices may also be clearly visualized.

KEY LEARNING POINTS

CBCT has a low effective dose in the same order of magnitude as conventional dental radiographs. CBCT has numerous potential applications in the management of endodontic problems.

A comparison of weights of debris extruded apically by conventional filing and Canal Master techniques

Sixty extracted human teeth were divided into three groups of 20 each. Apically extruded debris and irrigant were collected, dried, and weighed by the following three instrumentation techniques: (a) group 1, filing 1 mm short of the foramen; (b) group 2, Canal Master instrumentation to the foramen; and (c) group 3, filing to the foramen (for a relative comparison). The results indicated that all three groups were significantly different from one another. Group 1 had the least amount of debris extruded. Of the two groups instrumented to the foramen, group 3 had twice as much debris extruded as group 2. An apical dentinal plug was frequently found in group 1 and was probably a major reason why this group had the least amount of extruded debris. The significance of this dentinal plug and possible indications for instrumentation to the foramen are discussed.

The anticurvature filing method to prepare the curved root canal

The anticurvature filing method maintains the integrity of canal walls at their thin portion and reduces the possibility of root perforation or stripping. With this method, the dental practitioner maintains digital control over the endodontic instrument, and the preparation of the curved canal is eased.

In vitro comparison of intact endodontically treated teeth with and without endo-post reinforcement

In an in vitro experiment, the failure loads of 59 intact endodontically treated teeth with and without Kerr Endo-Post reinforcement were compared. Fifty-eight teeth fractured below the cementoenamel junction. One tooth fractured through the pulp chamber with a chisel fracture involving both the crown and root. Teeth without posts fractured through the middle or coronal one third of the root. Teeth with posts fractured through the body of the post. No statistically significant reinforcement was demonstrated by cementing a Kerr Endo-Post No. 100 into a sound endodontically treated tooth.

Treatment options: biological basis of regenerative endodontic procedures

Dental trauma occurs frequently in children and often can lead to pulpal necrosis. The occurrence of pulpal necrosis in the permanent but immature tooth represents a challenging clinical situation because the thin and often short roots increase the risk of subsequent fracture. Current approaches for treating the traumatized immature tooth with pulpal necrosis do not reliably achieve the desired clinical outcomes, consisting of healing of apical periodontitis, promotion of continued root development, and restoration of the functional competence of pulpal tissue. An optimal approach for treating the immature permanent tooth with a necrotic pulp would be to regenerate functional pulpal tissue. This review summarizes the current literature supporting a biological rationale for considering regenerative endodontic treatment procedures in treating the immature permanent tooth with pulp necrosis.

Incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy

The purpose of this prospective study was to evaluate the incidence of postoperative pain after intracanal procedures based on an antimicrobial strategy. Data were examined from 627 teeth that had necrotic pulps or required retreatment. Information was obtained for each patient treated with regard to presence of preoperative pain. Occurrence of periradicular bone destruction detected by radiographs was also recorded. The operators consisted of undergraduate students, who were in their first year of clinical training. Root canals were instrumented and then medicated with a calcium hydroxide/camphorated paramonochlorophenol paste. No systemic medication was prescribed. Approximately 1 week after the initial appointment, patients were asked about the occurrence of postoperative pain and the level of discomfort was rated as no pain, mild pain, moderate pain, or severe pain. Data were statistically analyzed using the Chi-square test. Mild pain occurred in 10% of the cases, moderate in 3.3%, and severe (flare-up) in 1.9%. Postoperative pain was significantly associated with the treatment of previously symptomatic teeth without periradicular lesions (p < 0.01). No other correlations were detected between the occurrence of postoperative discomfort and other clinical conditions. There was also no difference regarding the incidence of postoperative pain between treatment and retreatment (p > 0.01). The intracanal procedures used in this study to control root canal infections showed a small incidence of postoperative pain, particularly flare-ups, even performed by inexperienced undergraduate dental students.

The use of calcium hydroxide, antibiotics and biocides as antimicrobial medicaments in endodontics

Bacteria have been implicated in the pathogenesis and progression of pulp and periapical diseases. The primary aim of endodontic treatment is to remove as many bacteria as possible from the root canal system and then to create an environment in which any remaining organisms cannot survive. This can only be achieved through the use of a combination of aseptic treatment techniques, chemomechanical preparation of the root canal, antimicrobial irrigating solutions and intracanal medicaments. The choice of which intracanal medicament to use is dependent on having an accurate diagnosis of the condition being treated, as well as a thorough knowledge of the type of organisms likely to be involved and their mechanisms of growth and survival. Since the disease is likely to have been caused by the presence of bacteria within the root canal, the use of an antimicrobial agent is essential. Many medicaments have been used in an attempt to achieve the above aims but no single preparation has been found to be completely predictable or effective. Commonly used medicaments include calcium hydroxide, antibiotics, non-phenolic biocides, phenolic biocides and iodine compounds. Each has advantages and disadvantages, and further research is required to determine which is best suited for root canal infections.

Tissue-engineering-based strategies for regenerative endodontics

Stemming from in vitro and in vivo pre-clinical and human models, tissue-engineering-based strategies continue to demonstrate great potential for the regeneration of the pulp-dentin complex, particularly in necrotic, immature permanent teeth. Nanofibrous scaffolds, which closely resemble the native extracellular matrix, have been successfully synthesized by various techniques, including but not limited to electrospinning. A common goal in scaffold synthesis has been the notion of promoting cell guidance through the careful design and use of a collection of biochemical and physical cues capable of governing and stimulating specific events at the cellular and tissue levels. The latest advances in processing technologies allow for the fabrication of scaffolds where selected bioactive molecules can be delivered locally, thus increasing the possibilities for clinical success. Though electrospun scaffolds have not yet been tested in vivo in either human or animal pulpless models in immature permanent teeth, recent studies have highlighted their regenerative potential both from an in vitro and in vivo (i.e., subcutaneous model) standpoint. Possible applications for these bioactive scaffolds continue to evolve, with significant prospects related to the regeneration of both dentin and pulp tissue and, more recently, to root canal disinfection. Nonetheless, no single implantable scaffold can consistently guide the coordinated growth and development of the multiple tissue types involved in the functional regeneration of the pulp-dentin complex. The purpose of this review is to provide a comprehensive perspective on the latest discoveries related to the use of scaffolds and/or stem cells in regenerative endodontics. The authors focused this review on bioactive nanofibrous scaffolds, injectable scaffolds and stem cells, and pre-clinical findings using stem-cell-based strategies. These topics are discussed in detail in an attempt to provide future direction and to shed light on their potential translation to clinical settings.

Treatment of the immature tooth with a non-vital pulp and apical periodontitis

Traditional methods of treatment of immature root with necrotic pulp and apical periodontitis pose multiple challenges. These challenges include disinfection of the root canal with standard protocols that aggressively use endodontic files, filling the root canal with an open apex that provides no barrier for stopping the root filling material before impinging on the periodontal tissues, and the susceptibility of the teeth to fracture because of their thin roots. Disinfection using sodium hypochlorite, apical barrier formation using calcium hydroxide as well as mineral trioxide aggregate, and pulp revascularization of fractured tooth with the help of blood clot and collagen-enhanced matrix has been discussed in detail in this article.