Endodontology at a Glance E-Book

Alix Davies

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: At a Glance (Dentistry)
• Sprache: Englisch

Seitenzahl: 176

Veröffentlichungsjahr: 2019

Beschreibung

A practical and colourful introductory guide, Endodontology at a Glance covers all the essential topics (diagnosis, endodontic therapy, pain management and outcome of treatment) as well as the recent developments that comprise the field of endodontology. Written by experts in the field, the book explores the causes and sequelae of endodontic disease and offers suggestions for taking an effective patient history.

• New addition to the At a Glance series covering a core area of dentistry
• Review style makes for the ideal revision companion
• Includes access to a companion website with MCQs for self-assessment and downloadable images for use in teaching

Leseprobe

This title is also available as an e-book.

For more details, please see

www.wiley.com/buy/9781118994702

Endodontologyat a Glance

Alix Davies

BDS (Hons), MFDS, MJDF, MClinDent, MEndo

Specialist in Endodontics/Clinical Tutor

King's College London Dental Institute

& Specialist Practice, London, UK

Federico Foschi

BDS, MSc, PhD, FDS, FHEA

Consultant/Honorary Senior Lecturer in Endodontics

King's College London Dental Institute

& Specialist Practice, London, UK

Shanon Patel

BDS, MSc, MClinDent, MRD, PhD, FDS, FHEA

Consultant/Honorary Reader in Endodontics

King's College London Dental Institute

& Specialist Practice, London, UK

This edition first published 2019

© 2019 John Wiley & Sons, Ltd

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The right of Alix Davies, Federico Foschi and Shanon Patel to be identified as the authors of the material in this work has been asserted in accordance with law.

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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging-in-Publication Data

Names: Davies, Alix, author. | Foschi, Federico, author. | Patel, Shanon, author.

Title: Endodontology at a glance / Alix Davies, Federico Foschi, Shanon Patel.

Description: Hoboken, NJ : Wiley-Blackwell, 2018. | Series: At a glance series |

Includes index. |

Identifiers: LCCN 2018034896 (print) | LCCN 2018035389 (ebook) | ISBN

9781118994719 (Adobe PDF) | ISBN 9781118994726 (ePub) | ISBN 9781118994702 (pbk.)

Subjects: | MESH: Dental Pulp Diseases—diagnosis | Dental Pulp

Diseases—therapy | Root Canal Therapy | Endodontics—methods | Handbooks

Classification: LCC RK351 (ebook) | LCC RK351 (print) | NLM WU 49 | DDC

617.6/342—dc23

LC record available at https://lccn.loc.gov/2018034896

Cover image: © Shanon Patel

Cover design by Wiley

CONTENTS

Cover

Dedications

About the companion website

Part 1 Disease processes in endodontology

1 The causes and sequelae of endodontic disease

Acute inflammation

Chronic inflammation

Causes of apical periodontitis

2 Microbiology of apical periodontitis

Which methods of sampling are used for bacterial detection?

Which bacteria are responsible for causing apical periodontitis?

Where do the bacteria reside in the root canal system?

How does the knowledge of the bacterial species and habitats influence endodontic treatment?

3 Resorption

Internal root resorption

External root resorption

External cervical resorption (ECR)

Part 2 Diagnosis

4 History taking

Completing a patient history

5 Examination and special tests

Extraoral examination

Intraoral examination

Percussion testing

Palpation testing

Periodontal assessment

Assessment of cracks

Test cavities

Selective local anaesthesia

6 Pulp testing

Pulp tests involving nerve stimulation

Alternative pulp tests that assess the blood supply

7 Radiographic imaging for endodontics

Periapical radiography in diagnosis and management of endodontic disease

Limitations of periapical radiography in the diagnosis of endodontic disease

Cone beam computed tomography in endodontic diagnosis and management

Risks of ionising radiation

Part 3 Endodontic therapy

8 Vital pulp therapy

Role of the dental pulp after tooth development is complete

Benefits of maintaining a vital pulp

Vital pulp therapy

9 Root canal morphology

Maxillary incisors

Maxillary canine

Maxillary premolars

Maxillary molars

Mandibular central and lateral incisors

Mandibular canine

Mandibular premolar

Mandibular molars

10 Access cavity design

Aim of the access cavity

Stages in access cavity preparation

Placing of rubber dam

11 Mechanical preparation of 
the root canals

Crown down technique

Apical preparation

Patency filling

Step back technique

Rotary instrumentation

12 Irrigation

Irrigants for disinfecting the root canal

Methods of irrigation for disinfection of the root canal

Root canal lubricants

13 Root canal medicaments

Aims of root canal medicaments

Available medicaments

Should root canal treatment be performed over one or two visits?

14 Endodontic files

Hand files

Rotary files

Reciprocating files

Arguments for and against 
single-use files

15 Endodontic armamentarium

Rubber dam

Irrigating syringes and needles

Apex locators

Film holders

Ultrasonics

16 Obturation

Obturation of root canals

Root filling materials

Gutta percha

Bioceramic cements

Single cone

Root canal sealers

17 Root canal retreatment

Post removal

Removal of root fillings

Removal of fractured instruments

Negotiation of ledges and blockages

Perforation repair

18 Surgical endodontic treatment

Indications for root end surgery

Preoperative considerations

Flap design and care

Osteotomy

Root end resection and preparation

Root end fillings

Sutures

Review

Part 4 Pain and pain management

19 Odontogenic and non-odontogenic pain

Pain history

Assessment

Special tests

20 Local anaesthesia in endodontics

Administration of local anaesthetic

Assessment of success of 
local anaesthetic

Failure of local anaesthetic and alternative techniques

Additional anaesthetic requirements for endodontic surgery

Adverse effects of local anaesthetic

21 Pain management in endodontics

Management of acute pulpitis and acute apical periodontitis

Pain management for an acute 
apical abscess

Perioperative pain management

Postoperative pain management

Part 5 Outcome of endodontic treatment

22 Outcome of root canal treatment

Preoperative factors

Perioperative factors

Postoperative factors

23 Outcome of root canal surgery

Preoperative factors

Perioperative factors

Postoperative factors

Part 6 Endodontology and other aspects of dentistry

24 Endodontic–periodontic interface

Primary endodontic disease

Primary periodontal disease

Concomitant and true combined disease

Management of persistent disease

25 Endodontic–orthodontic interface

Effect of orthodontic treatment on the pulp and periapical tissues

Effect of orthodontic treatment on the diagnosis and process of root canal treatment

Effect of orthodontic treatment on root resorption

Effect of orthodontic treatment on traumatised teeth

Role of orthodontics in endodontic and restorative treatment planning

26 Restoration of the endodontically treated tooth

Placement of posts

Cuspal coverage restorations

Use of root treated teeth as abutments

27 Paediatric endodontics

Diagnosis of endodontic problems

Pulp preservation techniques

Apexification

Restoration

28 Endodontics in the older population

Medical history

Social factors

Diagnosis and management 
of the older dentition

29 Retain or replace?

Comparison of the outcomes between different procedures

Factors for consideration when deciding whether to retain or replace a tooth

30 Teeth whitening

Causes of tooth discoloration

Mechanism of tooth bleaching

Methods of tooth bleaching

Non-vital tooth bleaching

Part 7 Trauma

31 Assessment of traumatic injuries

History

Extraoral examination

Clinical photography

Radiographic examination

Referral

32 Management of crown fractures

Infractions

Uncomplicated coronal fractures

Complicated coronal fractures

33 Management of (crown-) root fractures

Crown root fracture without pulpal involvement

Crown root fracture with pulpal involvement

Root fracture

34 Management of luxation injuries

Concussion and subluxation

Lateral luxation

Extrusive luxation

Intrusive luxation

35 Management of avulsed teeth

Factors affecting the prognosis of avulsed teeth

Providing emergency advice by phone

Reimplantation of the avulsed tooth in the dental surgery

Use of antibiotics

Long-term follow-up

Part 8 Risk management

36 Risk management in endodontics

Misdiagnosis of the cause of the pain

Recent restorative work causing pulpitis

Lack of information available regarding options for management 
of the tooth

Failure to advise or offer referral to a more experienced practitioner

Complications during treatment

Fracture of the tooth after treatment

Failure of the root canal treatment

Index

End User License Agreement

Guide

Cover

Table of Contents

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E1

Dedications

Alix dedicates this book to her husband Paul, her children James and Isobel, and her parents Leigh and John.

Federico dedicates the book to Martina, Alessandro and Arianna.

Shanon dedicates the book to Almas, Genie and Zarina.

About the companion website

Don’t forget to visit the companion website for this book:

www.wiley.com/go/davies/endodontology

There you will find valuable material designed to enhance your learning:

Interactive multiple choice questions

Part 1Disease processes in endodontology

Chapters

1

The causes and sequelae of endodontic disease

2

Microbiology of apical periodontitis

3

Resorption

1The causes and sequelae of endodontic disease

Pulpitis is the inflammation of the pulp, whereas apical periodontitis is the inflammation of the tissues surrounding the apex of the tooth, including the periodontal ligament and the alveolar bone. Inflammation can be acute or chronic.

Acute inflammation

Acute inflammation is characterised by:

Redness

Heat

Swelling

Pain

Loss of function.

The redness and heat produced in an area of acute inflammation are the results of vessel dilatation and increased blood flow to that area. Swelling is caused by the accumulation of tissue exudates which contain neutrophils and inflammatory mediators (Table 1.1). The exudate aims to dilute the toxins whilst the neutrophils ingest the pathogens by phagocytosis. Pain is felt because of the swelling exerting pressure on nerve endings. Certain chemical mediators can also stimulate pain receptors. Swelling and pain can result in loss of function of the inflamed area.

Chronic inflammation

Acute inflammation can be reversible by removal of the damaging stimulus. However, if it persists, chronic inflammation ensues. Chronic inflammation is the result of a balance between continued tissue damage and attempts by the host to eradicate the disease to produce some tissue repair. Macrophages are among the main effector cells in chronic inflammation. They secrete various inflammatory mediators and have a role in phagocytosis and antigen presentation. Lymphocytes additionally recognise foreign antigens by binding to them before proliferating to mount an immune response by cell-mediated immunity (T lymphocytes) or by humoral immunity (B lymphocytes). Symptoms are usually limited at the chronic inflammation stage.

Causes of apical periodontitis

Apical periodontitis is caused by bacterial infection of the pulp. In a healthy tooth, the pulp dentine complex is protected from oral microorganisms by the overlying enamel and cementum. However, these layers can be damaged by caries, cracks or fractures, tooth wear, restorative procedures or periodontal procedures to produce portals of entry for microorganisms.

As bacteria penetrate into dentine, they release toxins that pass through the dentine tubules. The pulp responds to this by producing a layer of tertiary dentine as an additional protective layer. Increased intratubular mineral deposition may also reduce the permeability of the dentine (Figure 1.1). However, once the microorganisms penetrate into the inner dentine layers, the toxins they produce cause significant pulpal inflammation. If no treatment is provided, the bacteria eventually invade and colonise the pulp. The pulp is encased in a hard dentine shell and can therefore not expand to accommodate large amounts of fluid exudate. It also lacks sufficient collateral circulation. These factors limit the ability of the pulp to respond effectively to the insult. Pulpal inflammation can initially be reversible, with removal of the irritants resulting in resolution of the inflammation. However, as the immune challenge increases, the pulpal damage will advance beyond repair, resulting in irreversible inflammation and progressive pulpal necrosis.

Restorative procedures additionally may ‘push’ a tooth with pre-existing pulpal inflammation to irreversible pulpitis. This occurs by overheating, desiccation or chemical irritation to the dentino-pulp complex. If rubber dam is not used, or poor fitting temporary restorations are placed, microleakage can also occur. The risk of permanent damage is higher when the restorative work is close to the pulp and the dentine is permeable.

A root canal with a necrotic pulp is the ideal environment for bacterial colonisation as it provides a warm, moist, nutritious and anaerobic environment. The reduced presence of oxygen can also select aggressive anaerobic pathogens. The microorganisms are protected from the host defences as there is no blood circulation in the necrotic tissue. They derive their nutrients from the necrotic pulp tissue, periradicular tissue fluids, saliva and metabolic by-products of other bacterial species.

Over time, the bacteria progress apically down the root canal. Leakage of toxins and metabolic by-products through the apical foramen also stimulates the inflammatory response in the periapical tissues. Inflammatory mediators are released that stimulate osteoclast differentiation. This results in apical bone resorption and production of an apical lesion surrounded by chronic inflammatory cells. This stage of the disease is described as chronic apical periodontitis associated with an infected necrotic tooth (Figure 1.2).

The aim of root canal treatment is to reduce the bacterial load and seal the canals to prevent further ingress of bacteria. However, chronic inflammation can persist if inadequate disinfection is performed, with microorganisms remaining at levels sufficient to stimulate an inflammatory response. If the root canal system and coronal aspect of the tooth are not adequately sealed after root canal treatment, bacteria can re-enter and cause recurrence of the apical inflammation. It can be difficult to identify if the cause of the inflammation is persistence of, or re-entry of bacteria (or both). This stage of the disease is described as chronic apical periodontitis associated with an infected root-filled tooth (Figure 1.3).

Bacteria can egress through the apical foramen and, in some cases, cause suppuration that presents as an acute apical abscess or a chronic sinus tract.

2Microbiology of apical periodontitis

Which methods of sampling are used for bacterial detection?

Apical periodontitis is caused by the presence of microorganisms and their toxins in the root canals causing progressive inflammation and necrosis of the pulp, followed by inflammation of the periapical tissues. Root canal treatment aims to reduce the microbial load to a level that permits the body to amount an effective immune response and promote healing. It has therefore been considered important to ascertain which microorganisms are present in the root canals of teeth with apical periodontitis 
to understand how the disease progresses, as well as how to ­manage it.

Methods for isolation and detection of endodontic microorganisms fall into culturing and molecular technology (Table 2.1). For each, a sample must be taken from the root canal. This is normally performed with paper points. This will normally only allow sampling of microorganisms that are present in the main canal lumen. Files assist in collecting ‘scrapings’ from the canal walls. Collection of bacteria from dentine tubules and isthmuses is very difficult.

Culturing

The sample is transported in a medium that preserves viability whilst not enhancing growth. The microbes are then distributed onto agar media or cultured in broths under aerobic or anaerobic conditions. Species can then be identified by assessing features including colony and cellular morphology, tolerance to oxygen, gram staining and metabolic end-product analysis. Other tests that can be performed on the microorganisms include susceptibility to certain antibiotics, oxygen tolerance and cell wall profile.

Molecular technology

Molecular technology enables identification of microorganisms without the need for culturing. It can more reliably identify bacteria, including those strains that show ambiguous phenotypes. Fungi can be identified by their 18S RNA gene. The clinical sample is solubilised, DNA extracted and specific nucleic acid probes (primers) are added that are complementary to the target species being investigated. If the target species is present, hybridisation will occur. The polymerase chain reaction will then amplify the DNA to a level at which it can be detected. If the target species are absent in the sample, no hybridisation will occur and no DNA will be amplified. Electrophoresis and fluorescent in situ hybridisation can be used to assist with separation and visual identification of the strains present.

Which bacteria are responsible for causing apical periodontitis?

The culturing and molecular biology techniques have revealed the presence of more than 400 microorganisms. Different bacteria dominate the canals in primary and persistent cases of apical periodontitis (Table 2.2).

Where do the bacteria reside in the root canal system?

Bacteria occur in the main canal as well as in accessory canals, isthmuses and deltas in the following habitats:

The lumen in planktonic form

The canals walls as part of a biofilm

The dentinal tubules.

A biofilm is a bacterial population that is embedded in a polysaccharide matrix and adheres to surfaces of solid–liquid interfaces (Figure 2.1). Biofilms are present in the root canal system and occasionally are extraradicular. The biofilm is advantageous to the microorganism in the following ways:

Broader habitat range for growth:

early colonisers alter the local environment and can increase nutrient availability and remove waste products. This enables other bacterial species that would not have survived alone to attach to, and form part of the biofilm.

Increased metabolic diversity and efficiency:

bacteria cohabiting in biofilms develop food webs whereby the metabolic by-products from one species become the main food source for another. Interactions between different species also allow more effective breakdown and utilisation of host-derived substrates compared with the actions of a single species alone.

Protection from the host defences:

the extracellular polysaccharide resists phagocytosis from the host inflammatory cells. In addition, various species can produce different enzymes to neutralise the host inflammatory mediators and also inactivate antibacterial solutions that can be used to remove them during root canal treatment. Antibiotics usually require a level of bacterial activity to be effective. However, bacteria in biofilms often grow more slowly and are at the stationary phase of growth for longer. This can result in enhanced antibiotic resistance.

Genetic exchange: