Introduction
- The endodontic system is the pulp tissue (vessels, nerves, and connective tissue) that are in the root canals and pulp chambers.
- Endodontic disease refers to inflammation ( pulpitis) or necrosis (partial or complete) of the pulp tissues.
- The goal of endodontic therapy is to maintain a vital pulp system. Failing in maintaining pulp vitality, the goal is to remove the infection from while leaving the tooth in place. Thus, endodontic therapy is comprised of two main branches: vital and non-vital pulp therapy (root canal, surgical root canal, and apexification).
- Vital pulp therapy consists of procedures to keep vital teeth alive, which are direct and indirect pulp capping.
- Non-vital pulp therapy results in non-vital tooth, but can be performed on a living tooth to remove pain and infection. The three main procedures are: standard root canal
, surgical root canal, and apexification. - These therapies present a viable alternative to extraction.
These are advanced procedures and should not be attempted without significant study and practice.
Uses
- Vital pulp therapy
:
- Fresh fractures in immature (incomplete apex) tooth.
- Crown amputation for traumatic occlusions (orthodontic or post-operative mandibulectomy).
- Disarming aggressive patients.
- NOT recommended for mature teeth (standard RCT is preferred).
- Standard root canal therapy
:
- Fractured mature teeth (generally > 18 months of age).
- Non-vital teeth (intrinsically stained
). - Hemi-sected teeth (from periodontal disease ).
- Luxated/avulsed teeth (following re-implantation).
- Surgical root canal therapy :
- Failed standard root canal therapy.
- Root fractures.
- Inaccessible canals (stenotic root canals, instrument fracture).
Advantages
- Vital pulp therapy and standard root canal therapy :
- Resolves the problem (infection, pain, trauma) while maintaining the function of the tooth.
- Much less painful than extraction (especially with strategic teeth).
- Less immediate complications.
- Surgical RCT :
- Maintains the function of a tooth.
Disadvantages
- Very technically demanding and if not performed perfectly will fail.
- Time intensive.
- Expensive set-up.
- Long-term follow-up is required.
- High failure rate if incorrectly performed.
- Lack of clinical signs with failure.
Preparation
- Dental prophylaxis and dental radiographs 30-60 mins.
Requirements
Materials required
Minimum equipment
- High speed air-driven dental drill system.
- Dental radiology.
- Autoclave.
- Eye protection.
- Burrs:
- FG 699, 701, surgical length 701 (cross cut-taper-fissure).
- Assorted sizes of coarse, round diamond.
- Fine to ultra-fine cone-shaped diamond.
- Mineral trioxide aggregate.
- Sterile paper points.
- Calcium hydroxide.
- Schein forceps No. 8 serrated and 202 self-locking.
- Sterile, dedicated hand piece.
- Glass ionomer (light cured).
- Hybrid composite for final resorative.
- Recent generation bonding agent.
- Light curing gun.
- Finishing disks and burrs as required.
Standard root canal therapy
- High-speed air-driven dental drill system.
- Dental radiology.
- Autoclave.
- Dental file organizer.
- Burrs:
- Round FG: surgical length 2, and 4.
- Pear shaped FG 330.
- Fine to ultra-fine cone-shaped diamond.
- Hedstrom files - 60 mm long/all sizes 15-80.
- Hedstrom files - 40 mm long/all sizes 90-140.
- Hedstrom files - 25 mm long/all sizes 15-140.
- K-reamer - 60 mm long/all sizes 15-110.
- K-files 31 mm long/all sizes 10-140.
- Kerr pathfinder files - 25 mm.
- Premier RC prep cream - chelating agent.
- Schein forceps No.8 serrated aad 202 self-locking.
- Gutta Percha points - 31 mm all ISO sizes from 15-140.
- Parallax Gutta Percha points - 60 mm all ISO sizes from 15-140.
- Paper points -25 mm assorted coarse to fine, 60 mm assorted coarse to fine.
- 5.25% sodium hypochlorite (household bleach).
- Endodontic needle 27 g/30 mm and 21 g/45 mm.
- 5 ml syringe.
- Root canal plugger/spreader - Henry Schein 608.
- Kerr's finger pluggers - assorted 21 mm and 25 mm.
- Kerr's finger spreaders - 25 mm (assorted).
- Holmstrom pluggers (assorted).
- Glass mixing slab and spatula.
- Zinc oxide Eugenol sealer.
- Sealapex (Kerr) root canal sealer - polymeric calcium hydroxide.
- Lentulo paste fillers - 60 m (sizes 3 and 4) and 29 mm.
- Hybrid composite for final resorative.
- Glass ionomer restorative.
- Recent generation bonding agent.
- Light curing gun.
- Finishing disks and burrs as required.
Ideal equipment
- Heated gutta percha system (sucessfil, obtura II, etc).
- AH plus, thermaseal, or comparable acrylic sealant.
- Chloroform, or eucalyptus oil.
- Digital radiology.
- Eye loupes.
Optional equipment
- Rotary endodontic system (Light Speed, Tulsa, etc).
- Gates Glidden drills - assorted size 1-6.
- Tubliseal (Kerr) root canal sealer - zinc oxide/eugenol.
- Mcspadden compactor.
- Piezo-electric endodontic system.
Sequelae
Complications
- Endodontic infection.
- Abscessation.
- Future crown fracture.
Prognosis
- VPT: very good prognosis when performed on an intact tooth, 88% if performed on a fractured tooth within 48 hours, poor if exposed greater than 48 hours
- Standard RCT: if performed correctly, has an excellent long term prognosis. If incorrectly, very poor prognosis.
- Surgical RCT: if performed correctly, has an excellent long term prognosis. If incorrectly, very poor prognosis.
Reasons for treatment failure
-
The vast majority of time failure is due to improper procedure.
-
For VPT it is generally marginal microleakage from the restoration.
Sources
Publications
- Recent references from PubMed.
- Niemiec B A (2006) Surgical endodontic therapy of the mandibular canine tooth. J Vet Dent 23 (1), 62-66 PubMed.
- Niemiec B A (2005) Fundamentals of Endodontics. Vet Clin North Am Small Anim Pract 35 (4):837-868, vi PubMed.
- Niemiec B A (2005) Dental radiographic interpretation. J Vet Dent 22 (1), 53-59 PubMed.
- Niemiec B A (2001) Treatment of mandibular first molar teeth with endodontic-periodontal lesions in a dog. J Vet Dent 18 (1), 21-25 PubMed.
- Niemiec B A (2001) Vital pulp therapy. J Vet Dent 18( 3), 154-156 PubMed.
- Niemiec B A (2001) Assessment of vital pulp therapy for nine complicated crown fractures and fifty-four crown reductions in dogs and cats. J Vet Dent 18 (3), 122-125 PubMed.
- Niemiec B A (2001) Endodontic treatment of vital pulp tissue. Clin Tech Small Anim Pract 16 (3):159-167.
- Niemiec B A (2000) Management of a complicated maxillary fourth premolar crown-root fracture in a dog. J Vet Dent 17 (3), 128-133 PubMed.
