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Nội nha là một môn học chính cho sinh viên nha khoa đại học, cung cấp những thách thức cả về kỹ thuật và trí tuệ. Có thể lập luận rằng điều trị tủy răng hàm là yêu cầu cao nhất trong các bài tập thực hành mà bác sĩ nha khoa tổng quát sẽ phải đối mặt, kết hợp với các kỹ năng lập kế hoạch chẩn đoán và điều trị cũng như quy trình kỹ thuật chính xác. Vì vậy, nền tảng vững chắc trong chủ đề này là then chốt để tiếp tục cung cấp chất lượng cao về chăm sóc răng miệng trong suốt sự nghiệp chuyên môn của sinh viên tốt nghiệp. Nội nha đã từng là Cinderella của các chuyên ngành nha khoa phục hồi và, với sự ra đời của cấy ghép, tầm quan trọng của nội nha như một lựa chọn điều trị đã bị giảm bớt. Sự phát triển không ngừng của ngành khoa học nội nha bao gồm vi sinh, miễn dịch học và khoa học vật liệu nha khoa đảm bảo rằng các lập luận ủng hộ việc bảo tồn răng bị bệnh xung huyết và quanh răng được hiểu đầy đủ và có thể được đưa vào kế hoạch điều trị toàn diện cho bệnh nhân. Cuốn sách này cung cấp một nền tảng tuyệt vời để hiểu các nguyên tắc của nội nha và cụ thể là thực hành điều trị tủy răng và phục hồi sau đó của răng bọc chân răng. Học sinh, ở bất kỳ trình độ nào, đều được hưởng lợi từ các hướng dẫn rõ ràng dựa trên cuộc điều tra khoa học trước đây và hiện tại, tài liệu minh họa cho người đọc thấy những gì có thể được thực hiện và mức độ mà họ nên khao khát. Cuốn sách này được viết bởi các chuyên gia nội nha ở đầu trò chơi của họ. Chất lượng của các ca lâm sàng là truyền cảm hứng và văn bản rõ ràng và sơ đồ kèm theo cung cấp thông tin chính mà cả sinh viên đại học và bác sĩ nha khoa tổng quát yêu cầu để phát triển và nâng cao kỹ năng của họ. Việc đào tạo để trở thành một chuyên gia cần có thời gian và cam kết rất lớn và kiến thức và kinh nghiệm tích lũy trong nhiều năm có thể không được truyền lại cho người khác. Các tác giả của cuốn sách này đã thực hiện nghĩa vụ này và người đọc sẽ được truyền cảm hứng để làm tốt hơn cho bệnh nhân của họ.
The Principles of Endodontics www.ajlobby.com This page intentionally left blank www.ajlobby.com The Principles of Endodontics S E COND EDITION Edited by Shanon Patel Justin J Barnes www.ajlobby.com Great Clarendon Street, Oxford OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press, 2013 The moral rights of the authors have been asserted First Edition published 2005 Second Edition published 2013 Impression: All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose the same condition on any acquirer British Library Cataloguing in Publication Data Data available ISBN 978-0-19-965751-3 Printed and bound by Bell & Bain Ltd, Glasgow Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations The authors and the publishers not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breast-feeding Links to third party websites are provided by Oxford in good faith and for information only Oxford disclaims any responsibillty for the materials contained in any third party website referenced in this work www.ajlobby.com Dedication This book is dedicated to: Almas, Genie and Zarina Shanon Patel Kathleen and Michael Justin J Barnes www.ajlobby.com This page intentionally left blank www.ajlobby.com Foreword Endodontology is a core subject for the undergraduate dental student, providing both technical and intellectual challenges It could be argued that molar root canal treatment is the most demanding of practical exercises a general dental practitioner will face, combining as it does diagnostic and treatment planning skills and precise technical procedures Thus, a strong foundation in this subject is pivotal to continuing high quality provision of dental care throughout the professional career of the graduate Endodontology has been the Cinderella of the restorative dental specialties and, with the advent of implants, the importance of endodontics as a treatment option has been diminished The continuing development of the broad science of endodontology including microbiology, immunology and dental materials science ensures that the arguments in favour of preservation of teeth with pulpal and periradicular disease are understood fully and can be rightly and confidently included in holistic treatment planning of patients This textbook provides an excellent foundation for understanding the principles of endodontology, and specifically the practice of root canal treatment and subsequent restoration of the root filled tooth Students, at whatever level, benefit from clear guidelines based upon previous and current scientific investigation, illustrative material that shows the reader what can be done and the level to which they should aspire This book is written by specialist endodontists at the top of their game The quality of the clinical cases is inspirational and the clear text and accompanying diagrams provide the key information that both undergraduates and general dental practitioners require to develop and improve their skills Training to be a specialist takes time and huge commitment and the knowledge and experience accumulated over the years may be unselfishly passed on to others The authors of this book have made this obligation and the reader will be inspired to better for their patients Professor William P Saunders BDS, DSc (hc), PhD, FDS RCS Edin, FDS RCPS Glas, FDS RCS Eng, MRD, FHEA, FCDSHK Professor of Endodontology / Honorary Consultant in Restorative Dentistry University of Dundee www.ajlobby.com This page intentionally left blank www.ajlobby.com Preface to the second edition The aim of this second edition is to provide a contemporary comprehensive guide to endodontics This edition covers the many advances in endodontic knowledge, techniques, materials, and equipment since the first edition was published The intended readership remains undergraduate dental students who wish to develop an understanding of ‘why’ and ‘how’ safe, predictable, and effective endodontic treatment is carried out The book will also benefit recent graduates who want to refresh their knowledge and the established clinicians who are continuing their professional development The style of the new edition remains simple and user-friendly There are several changes since the first edition Existing chapters have been significantly revised and updated We have enlisted a group of respected academics, and also up-and-coming endodontists to help us with this project In the first edition, there were distinct sections on theory and practice of endodontics This has been revised for ease of reference; applicable chapters cover essential theory and this is followed by a guide to the practice of endodontics New chapters include restoration of the endodontically treated tooth and dento-legal aspects to endodontics There has been an effort to use the most up-to-date terminology in endodontics and ensure consistency of terminology throughout the book References are kept to a minimum with readers being invited to explore suggested further reading at the end of each chapter We hope that this second edition will continue to help your understanding of the principles of endodontics so that you can achieve satisfying results and goals in your clinical practice Shanon Patel Justin J Barnes www.ajlobby.com 156 Dealing with post-treatment disease (a) (b) (e) (c) (d) (f) (g) Figure 9.17 (a) Masserann kit; (b) a trepan bur; (c) extractor; (d) silver point retrieved using the Masserann kit (Micro-Mega, Besancon, France) ; (e) persistent disease associated with a mandibular molar tooth which has been root canal filled with silver points; (f) silver points retrieved using Masserann kit; (g) root canal retreatment carried and root canals filled with GP Wound closure involves the placement of sutures The sutured flap should be held under gentle pressure for 5–10 before discharging the patient with appropriate post-operative instructions Sutures can be removed in 3–5 days Residual scarring may arise in areas of sinus tract healing, relieving incisions, and suture placement where surgical technique has been poor Cases that require endodontic surgery should be referred to a specialist in endodontics The following sections are provided for further information only There is no suggestion that the undergraduate dental student or recent graduate would perform these techniques It is important, however, that you gain a working knowledge of the processes involved and cases that may be indicated for such treatment measures Corrective surgery Corrective surgery is often performed to repair perforation defects in the root surface created iatrogenically Calcium silicate cements are the materials of choice for this purpose Root resection Root resection is the complete removal of a root from a multi-rooted tooth without interfering with the crown (Fig 9.19) The indications for this procedure are severe periodontal disease, resorption, and vertical fractures The procedure usually involves flap reflection, bone remodelling, and crown contouring to assist with plaque control www.ajlobby.com Surgical endodontics (a) 157 (b) (c) (d) (f) Figure 9.18 (a) Endodontic micro-surgery kit; (b) surgical ultrasonic retrotips allow improved access for minimal preparation of the apical portion of the root canal; (c) a surgical micromirror compared to a conventional mouth mirror; (d) and (e) surgical ultrasonic retrotip used to prepare a root-end cavity (a) (b) (c) Figure 9.19 Root resection: (a) radiograph showing persistent disease, a GP point has been used to track a sinus adjacent to the mesio-buccal root; (b) radiograph showing root resection of the mesio-buccal root; (c) review radiograph taken 15 years later Courtesy of Dr Tom Bereznicki www.ajlobby.com 158 Dealing with post-treatment disease Tooth resection Marsupialization and decompression Tooth resection is slightly different from root resection in that it involves the cutting off of associated crown material along with root A portion of the tooth is usually extracted and the remaining part is restored Occasionally, both parts are retained and restored in a process often referred to as bicuspidization Large periapical lesions may be treated by a surgical technique that involves penetration of the lesion through the cortical plate Patency of the fistula is maintained by the use of a drain or, preferably, a flanged cannula The marsupialized lesion may be irrigated and, with time, the lesion reduces in size until the decompression can be terminated Replantation Biopsy Replantation may be performed intentionally in situations where other surgical options are not indicated In essence, the tooth is extracted and modified out of the mouth in such a way as to facilitate the disinfection and sealing of the root canals The tooth is returned to its socket and splinted for less than a week An example would be a mandibular premolar, which was extracted and replanted to avoid apical surgery and the potential risk of damage to the mental nerve Any tissue removed during surgery must be sent for routine histological examination to confirm the nature of the lesion The sample should be forwarded for examination in 10 per cent formalin and should be accompanied with comprehensive case details Summary points • It is important to recognize post-treatment disease and to identify the potential causes of persistent disease in order to formulate a comprehensive treatment plan • Persistent infection of the root canal is usually associated with poor technical quality of endodontic treatment However, even well-treated teeth may harbour microbes which may prevent healing • Non-surgical root canal retreatment should always be considered as the first line of treatment if endodontic intervention is required • Alternative causative factors should be considered in cases which are resistant to root canal retreatment These may include the presence of extraradicular infection and vertical root fracture • The restorability of a tooth must be confirmed prior to embarking on complex retreatment procedures • The outcome of root canal retreatment will depend on the removal the previous root canal filling material, full negotiation, and thorough disinfection of the entire root canal system • Surgical endodontics is indicated if root canal retreatment has not achieved a favourable outcome or is impracticable Suggested further reading Chong BS, Pitt Ford TR and Hudson MB (2003) A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end filling materials in endodontic surgery International Endodontic Journal 36, 520–6 Nair PNR (2004) Pathogenesis of apical periodontitis and the causes of endodontic failures Critical reviews in Oral Biology and Medicine 15, 348–81 Gorni FG and Gagliani MM (2004) The outcome of endodontic retreatment: a year follow-up Journal of Endodontics 30, 1–4 Torabinejad M, Corr R, Handysides R and Shabahang S (2009) Outcomes of non-surgical retreatment and endodontic surgery: a systematic review Journal of Endodontics 35, 930–7 Kim S and Kratchman S (2006) Modern endodontic surgery concepts and practice: a review Journal of Endodontics 32, 601–23 Online Resource Centre To help you to develop and apply your knowledge and skills further, we have provided interactive learning resources online at http://www.oxfordtextbooks.co.uk/orc/patel/ www.ajlobby.com 10 Dento-legal aspects of endodontics Len D’Cruz Chapter contents Introduction 160 What is consent? 160 How should inadequate root canal fillings be prevented or managed? 161 How should separated instruments be prevented or managed? 161 How should perforations be prevented or managed? 163 What risks are associated with using sodium hypochlorite as an irrigant? 163 Why should rubber dam be used? 164 Fractured teeth 165 Record keeping 165 Conclusion 165 Summary points 166 Suggested further reading 166 www.ajlobby.com 160 Dento-legal aspects of endodontics Introduction With modern techniques and materials, root canal treatment is being undertaken more often by dentists and more predictable results are being achieved Patients are increasingly keener to retain their teeth, and their expectations of success are higher than they have been in the past The standards expected of dentists in delivering care has been driven by regulatory bodies, litigation, and specialist societies In primary dental care in the UK, endodontics has the highest number of legal claims in comparison with other dental treatments (Table 10.1) There are a range of complaints and claims that may arise in relation to endodontics (Fig 10.1) Many complaints and clinical negligence claims arise out of the clinician’s failure to communicate well with the patient Even when something does go wrong, research has shown that explanations, empathy, and openness with the patient prevents an escalation of the problem This chapter aims to discuss these dentolegal issues and the factors involved in reducing and managing risk in endodontics What is consent? Consent is not a single event but a process A good working definition from the Department of Health in England is: The voluntary, continuing permission of the patient to receive particular treatments It must be based upon the patient’s adequate knowledge of the purpose, nature, likely effects, and risks of that treatment including the likelihood of its success and a discussion of any alternative to it including no treatment There are some key elements in this definition which have been set out in italic and each time root canal treatment is contemplated, it is incumbent on the clinician to provide the information with specific reference to the patient and their tooth The significance of ‘continuing permission’ is very important Take, for example, a patient who is undergoing root canal treatment on a molar tooth If, during the procedure a difficulty is encountered, such as a curved or calcified root canal, further consent is required if the outcome of the treatment may be compromised (e.g the inability to prepare the entire root canal to the desired length) and the prevailing situation is different from when treatment commenced This further consent procedure enables the patient to weigh up the risks of continuing (or leaving part of the root canal unprepared and unfilled) against a decision to extract the tooth or accept a referral to a specialist in endodontics There are three essential and interdependent components to valid consent: • Competence The patient has sufficient ability to understand the nature of the treatment and the consequences of receiving or declining that treatment The legal term is ‘capacity’ • Voluntariness The patients has fully agreed to have the treatment and there has been no coercion or undue influence to accept or decline the treatment • Information and knowledge The patient has been given sufficient and comprehensible information regarding the nature and consequences of the proposed and alternative treatments How much information should be given to a patient about endodontic treatment? The simple answer is whatever is normal practice for a dentist to advise their patient This is the professional test and was set out in Nerve damage Other Rubber dam Table 10.1 Number of claims in primary dental care in UK Inadequate root canal filling in the presence of residual infection Beyond apex Irrigant 1) Endodontics 2) Crown and bridgework Misdiagnosis Perforations 3) Nerve damage 4) Oral surgery (except 3,7,10) 5) Periodontics Separated instruments 6) Orthodontics 7) Implants 8) Veneers 9) Dentures 10) Failure to diagnose/ treat Figure 10.1 Range of complaints and claims in relation to endodontics in 2011 in the UK www.ajlobby.com How should separated instruments be prevented or managed? the case of Sidaway, the leading case in English law of this nature, and uses the ‘Bolam test’ as its basis In other words, if it is not generally appropriate to warn about something, a dentist cannot be found guilty of negligence if they fail to warn This is, however, modified by two important considerations The first relates to the case of Bolitho where there were conflicting views about a clinical intervention The House of Lords decided that whilst an opinion may be responsible, reasonable, and respectable, if it did not stand up to logic then it should not be accepted The second consideration is the concept not of what a reasonable dentist may wish to advise a patient about a particular treatment, but what a reasonable patient might wish to hear This is known as the ‘prudent patient’ test or objective test This is a very patient-centred approach and creates a significantly higher burden on the dentist to provide appropriate information with which the patient can make decisions This means that giving the ‘usual warnings’ about a particular procedure may not be sufficient if a patient is likely to attach more significance to one particular risk than another Endodontic treatment can be time-consuming and expensive (e.g using nickel-titanium (NiTi) files) Whilst in private practice these costs may be passed on to the patient, the ability to so under other national systems of pay may be restricted In obtaining consent from the patients these differences may be relevant and consideration should be given to discussing these with the patient In Chapter 3, the importance of setting out all the treatment options to the patient once a diagnosis has been made was described A definitive diagnosis is not always clear Advising the patient of 161 probable diagnosis, treatments options and other important issues such as costs (where relevant), complications, and limitations are essential to allow the patient to make the right decision for themselves Before embarking on endodontic treatment the patient should be informed about: • • How the treatment will be carried out; • • • Post-operative discomfort/pain and how to manage this; • Costs of endodontic treatment and any recommended further treatment How long it will take (expected duration and number of appointments); Information about returning if problems occur (e.g pain, swelling); Requirements for further treatment (e.g crowns, posts, cuspal coverage); Providing this information enables the patients to consider whether they would like to undertake the procedure, and may alert the clinician to issues such as an upcoming holiday or important engagements which may delay the treatment plan Much of this information will be provided verbally, with the patient encouraged to ask questions to ensure they understand what has been said It is useful to support this verbal discussion with written information, such as patient information leaflets and a consent form It should be stressed that a signed consent form is not a panacea Consent forms serve only to confirm the quantity, not the quality, of information provided to the patient How should inadequate root canal fillings be prevented or managed? The largest source of complaints and claims in endodontics arise from the technical failure to adequately fill the root canal system in the presence of persistent infection This may include: missed root canals (Fig 10.2a); overextended (Fig 10.2b), underextended (Fig 10.2c), and/or poorly compacted root canal fillings (Fig 10.2d); the use of unacceptable root canal filling materials, e.g silver points (Fig 10.2e) or formaldehyde pastes A technically inadequate root canal filling can be indicative of inadequate root canal preparation, i.e the root canal system has not been adequately disinfected The judicious use of radiographs is an important part of reducing the risk of inadequate root canal filling Many clinicians use electronic apex locators (EALs) to assess the working length of root canals and avoid taking radiographs during treatment It is still important to take intraoperative radiograph(s) (e.g a working length and/or master point radiograph) Post-operative radiographs should always be taken to confirm the quality of the root canal filling If there are radiographic shortcomings with the quality of the root canal filling, this would then be an opportunity to outline these to the patients with options on how to manage them There are situations when a patient sees another clinician (e.g an emergency dentist) after completion of endodontic treatment Clinicians should be sensitive when describing the quality of a root canal filling which has been carried out by a colleague Any inadequacies should be described diplomatically and using objective rather than subjective descriptions This should be in the context of the nature of the endodontic condition/disease (e.g infection is the essential cause of periapical periodontitis and not necessarily an overextended root canal filling), the complexity of the anatomy of the root canal system, and the intricacies of the endodontic procedure A significant number of complaints are generated when another clinician makes injudicious comments without knowing the full details of treatment provided elsewhere How should separated instruments be prevented or managed? It is not negligent to separate an instrument in a root canal if the instruments are used in a reasonable manner, such as running the correct speed for machine-driven instruments and using the instrument in accordance with the manufacturer’s instructions However, if it does occur (Fig 10.3) the patient must be informed and advised about the options which will include extraction of the tooth, completing root www.ajlobby.com 162 Dento-legal aspects of endodontics (a) (c) (b) (d) (e) Figure 10.2 Root canal fillings with inadequate technical quality: (a) no root canal filling in the mesio-buccal root canal of a maxillary molar tooth; (b) overextended root canal filling associated with a maxillary premolar tooth; (c) underextended root canal fillings associated with a mandibular molar tooth; (d) poorly compacted root canal filling associated with a maxillary incisor tooth; (e) silver point root canal fillings associated with a mandibular molar tooth canal treatment with the instrument retained in situ, or arranging referral to a specialist in endodontics It is important that this advice is recorded in the clinical records Research indicates that the retention of a separated instrument in an adequately disinfected root canal system will not significantly alter the outcome of endodontic treatment The following guidance will help to reduce the risk of a separated instrument: • Use the instrument in accordance with the manufacturer’s instructions; • Single-visit use of instruments to reduce the risk of fracture due to cyclical fatigue; • • Avoid using NiTi files in root canals with sharp curvatures; • • • Avoid forcing an instrument into a narrow or partially calcified root canal; Check the instrument before and after use for any deformation; Immediately discard any deformed instrument; Measure the instrument before and after use www.ajlobby.com What risks are associated with using sodium hypochlorite as an irrigant? Figure 10.3 Separated file in the mesial-buccal root of a maxillary molar tooth 163 Figure 10.4 Perforation of the pulp chamber wall of a maxillary molar tooth This occurred when the clinician was attempting to locate the entrance to the disto-buccal root canal How should perforations be prevented or managed? Perforations may occur in any part of the root canal system Examples include, perforation of the pulp chamber wall or floor when attempting to locate the entrance to a root canal (Fig 10.4), or strip perforation of the root canal wall when carrying out mechanical preparation or post preparation (Fig 10.5a,b) If a perforation occurs, the patient must be informed and advised about the options which will include extraction of the tooth, repair of the perforation, or arranging for its management by referral to a specialist in endodontics This advice should be recorded in the clinical notes The following guidance will help to reduce the risk of perforation: • • Consider creating the access cavity prior to placement of rubber dam as the rubber dam may mask the angulation of the root(s) • Consider removing the entire coronal restoration to aid vision and location of root canals • Use a bur with a non-cutting, safe-ended tip after initial access has been made into the pulp chamber • • Precurve stainless steel files, especially stiffer files of ISO size >20 Use a preoperative radiograph to estimate the depth of the pulp chamber floor and the angulation of the root(s) Avoid aggressive linear filing of the root canal wall closest to the furcation region Aggressive use of Gates Glidden drills should also be avoided What risks are associated with using sodium hypochlorite as an irrigant? Sodium hypochlorite (NaOCl) is the irrigant of choice and whilst 0.5 per cent concentration is effective, many clinicians use undiluted commercially available household bleach at concentrations of up to per cent This raises two issues relating to safety and the appropriateness of using a household product that is not licensed for medical/dental use Sodium hypochlorite, especially at higher concentrations, has the ability to dissolve organic tissue and this is favourable for dissolving pulp tissue remnants in the root canal However, extrusion of NaOCl into the periapical tissues can cause significant damage to the surrounding tissues (Fig 10.6), including neurological damage, and in some cases this can be life-threatening Caution must be exercised when using higher concentrations of NaOCl and precautions must be taken to prevent extrusion through the apex of a tooth or iatrogenic perforations The number of reported cases of adverse incidents with NaOCl has increased over the past 10 years (Fig 10.7) The following guidance will help to reduce the risk of an adverse incident: • Provide patients with eye shields/goggles and bibs to protect from spillages; • • • • Use rubber dam; • Follow the above guidance for reducing the risk of perforation; Determine the working length using an accurate method; Use a side-venting needle that has been premeasured to the working length; Use a syringe with threads (Luer-Lok) so the needle can be securely screwed on; www.ajlobby.com 164 Dento-legal aspects of endodontics (a) (b) Figure 10.5 (a,b) Post perforations and lateral radiolucencies associated with maxillary incisor teeth Do not force or bind the needle in the root canal; Use gentle finger (not thumb) pressure to introduce the irrigant into the root canal Some clinicians may say that they have used household bleach for irrigation in endodontic treatment for many years without adverse effects It should be remembered that household bleach is marketed for stain removal in fabrics and disinfection of domestic surfaces There are commercially available NaOCl solutions that are licensed for intraoral use and it may be more appropriate to use these in endodontics Patients may report an allergy/hypersensitivity to chlorine Ideally, this should be confirmed by allergy testing It would be advisable not to use NaOCl during endodontic treatment in these patients There are alternatives irrigants, such as chlorhexidine gluconate and iodine potassium iodide; however, these are not as effective as NaOCl The patient should be informed of this and the possible effect on the outcome of endodontic treatment Figure 10.6 Ulcerated intraoral soft tissues following a sodium hypochlorite (NaOCl) accident Courtesy of Dr Steve Williams Adapted from Patel S and Duncan H (2011) Pitt Ford’s Problem-Based Learning in Endodontology Printed with permission from Wiley-Blackwell Number of cases • • 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Figure 10.7 Number of reported cases of adverse incidents with sodium hypochlorite (NaOCl) between 2001 and 2010 Why should rubber dam be used? Rubber dam has many advantages which benefit both the patient and the clinician Unfortunately, several survey studies have reported that the use of rubber dam by clinicians is low From a dento-legal perspective, the purpose of rubber dam is to protect the oropharynx This may be protection from instruments (e.g files) or caustic substances (e.g NaOCl) being swallowed or inhaled The use of rotary instrumentation is increasingly more common so these handpiece retained instruments are no more likely to be swallowed or inhaled than handpiece retained burs There are other methods of preventing instruments slipping and being accidentally dropped into the patient’s mouth, such as parachute chains and tying a length of dental floss through the handle of the endodontic file and retaining the end of it In the absence of these safety devices, if a patient were to swallow or inhale an instrument, the chances of defending any legal claim arising out of the incident would be limited www.ajlobby.com Conclusion 165 Fractured teeth Restoration of the endodontically treated tooth is discussed in Chapter It is generally recommended that endodontically treated molars be restored with a cast restoration that provides cuspal protection (e.g crown, onlay) Endodontically treated molars are considered more susceptible to fracturing compared with their vital counterparts, especially if the tooth has little remaining tooth structure and the patient has a parafunctional habit Studies have shown that these teeth will survive longer with a cast restoration that provides cuspal protection It is usually recommended that a patient proceed with cuspal protection within a few weeks after endodontic treatment, subject to the tooth being symptom-free Some patients may want to delay cuspal protection until the outcome of endodontic treatment is deemed favourable These patients should be informed that outcome is usually assessed at least one year after completion of endodontic treatment and there is a risk that the tooth may fracture while waiting (Fig 10.8) Patients’ should be advised of cuspal protection from the outset and this should be recorded in the clinical records Figure 10.8 Extracted endodontically treated premolar tooth which had a complete vertical tooth and root fracture Record keeping The quality and standard of record keeping is usually very high amongst undergraduate dental students and recently qualified dentists Over time, however, the detail recorded diminishes with the most often quoted reason being lack time Most endodontic procedures in general practice start with the patient attending complaining of pain and/or swelling A detailed examination of the patient is necessary as outlined in Chapter Pertinent details should be recorded, e.g type of pain, duration, exacerbating and relieving factors, as well as results of special tests It is also essential to record the discussion of the various treatment options Many practices are now computerized and custom screens with prompts to ask the right questions are readily available These details often make the difference in a complaint or clinical negligence claim which may be made many months or even years after the event The question ‘Why was endodontic treatment necessary for this patient?’ may well be asked You will have only your notes and records to rely on to establish not only why, but also what was treated, when it was treated, how it was treated, and what further treatment was recommended Remember: if it was not written down, it did not happen Courts are more likely to rely on the evidence of a patient since they usually have one dentist Clinicians will have many patients and are unlikely to remember in any great detail what happened on a particular appointment without the prompting of contemporaneous records Conclusion Learning from your mistakes is the hallmark of a professional Reflecting on what has gone wrong and how it can be improved makes the difference between delivering better healthcare outcomes and making the same mistake again Of course, nobody welcomes complaints in whatever form they come to you It is a challenge to your professional integrity and can be quite dispiriting and stressful, particularly when you feel you have tried your best Beneath every complaint, no matter how unjustified it first appears, there is something to learn Even when things go drastically wrong (e.g the patient swallows an instrument, or a file separates in the root canal), it is how the situation is managed that will make the difference The world of endodontics will continue to change with a plethora of gadgets, new concepts, and new techniques Clinicians need to ensure what they is as evidence based as possible, and new materials and techniques are used with caution until their efficacy has been established When endodontic treatment is carried out well, it is rewarding to the clinician, but more importantly allows the patient to obtain more function and appearance that may not have been possible otherwise www.ajlobby.com 166 Dento-legal aspects of endodontics Summary points • Valid consent is a continuing process that involves the patient being competent, giving voluntary permission, and being given information on which to make their decision • When giving a patient information, this should include the probable diagnosis, treatment options, and other important issues such as costs, complications, and limitations • In primary dental care in the UK, endodontics has the dental treatments Most complaints and claims arise from an inadequate root canal filling in the presence of residual infection and separated instruments • It is important to recognize when something goes wrong and how to manage the situation This will start with good communication with the patient and detailed record keeping Management may include referral to a specialist highest number of legal claims in comparison with other Suggested further reading Bolitho v City and Hackney Health Authority [1997] UKHL 46; [1998] AC 232; [1997] All ER 771; [1997] WLR 1151 Bowden JR, Ethuandan M and Brennan PA (2006) Life threatening airway obstruction secondary to hypochlorite extrusion during root canal treatment Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 101, 402–4 Ng YL, Mann V and Gulabivala K (2010) Tooth survival following non-surgical root canal treatment: a systematic review of the literature International Endodontic Journal 43, 171–89 Salehrabi R and Rotstein I (2004) Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study Journal of Endodontics 30, 846–50 Chaudhry H, Wildan TM, Popat S, Anand R and Dhariwal D (2011) Before you reach for the bleach British Dental Journal 210, 157–60 Sidaway v Board of Governors of the Bethlem Royal Hospital [1985] AC871 D’Cruz L (2008) The successful management of complaints—turning threats into opportunities Dental Update 35, 182–6 Webber J (2010) Risk management in clinical practice Part Endodontics British Dental Journal 209, 161–70 Dental Protection Ltd (2009) Risk Management Module – Endodontics London, UK: DPL Publications Online Resource Centre To help you to develop and apply your knowledge and skills further, we have provided interactive learning resources online at http://www.oxfordtextbooks.co.uk/orc/patel/ www.ajlobby.com Index Page numbers in italics represent figures, those in bold represent tables A AE fibres 12 AG fibres 12, 24 abscess 91 apical 18 periapical 27 access cavity preparation 62, 63, 78–9, 80 accessory canals 60 acellular cementum acoustic microstreaming 75, 87 acrylic points 97 Actinomyces spp 18 aims of treatment allergies 24, 44, 164 amalgam restorations 123, 124 ameloblasts amoxicillin 44 anterior tooth restoration 122–3 direct 122–3 indirect 117, 118, 123 antibiotics 43–4, 44 allergy 44 bacterial resistance 75 history 24 sodium hypochlorite accident 86 anticoagulant therapy 23 apex locator, electronic 62, 64, 67, 82, 83 apexification 92 Apexit 93 apical abscess 18 apical actinomycosis 18 apical canal enlargement 84–5, 84 negotiation of 62, 64, 64, 65 preparation 64–5, 65, 82, 84, 85–6, 85, 85, 86 surgery 154–6, 156 apical constriction 62, 64, 65, 65 apical taper 84, 85 articulating paper 32 asymptomatic functional teeth 134 B backfill 106 bacteria 2, 49, 50, 51, 52, 56, 73 resistance 75 balanced-force technique 79, 80, 81 bell stage of tooth development Biodentine 95, 96 biofilms 19, 19 ‘biological’ caries excavation 50, 51, 53, 53 biopsy 158 bitewing radiographs 25 root canal preparation 78 blunderbuss roots 110, 110 Bolam test 161 bone morphogenic proteins (BMPs) 8, 52 bridges, removal of 151–2, 151, 152 broken-down teeth 44 buccal object rule 25 burs 68, 69 C C fibres 12 calcium hydroxide cements 52 properties 76 root canal filling 90, 93, 94 root canal preparation 75, 75, 76 calcium silicate cements 52, 52, 111 root canal filling 95, 96 Campylobacter spp 18 capping 51–2, 51, 51, 53–5, 53, 54 caries 2, 12–16, 12, 30 ‘biological’ excavation 50, 51, 53, 53 and dentine permeability 12 histological features 49 immune response to 13–14 carrier-based systems in root canal filling 103, 107–8, 110 caulking agents 45 cavity access set 69 cavity lining 50–2, 51, 51 direct pulp protection (capping) 51, 52, 53–5, 53, 54 indirect pulp protection (capping) 51–2 cellular cementum cementoblasts cements calcium hydroxide 52 calcium silicate 52, 52 ceramic crowns 123, 124, 126 chlorhexidine gluconate 74, 75 chloroform 96, 102, 155 clindamycin 44 clinical conditions requiring treatment see also specific conditions codeine phosphate/paracetamol preparations 43 cold lateral compaction 103 cold testing 34, 35 collagen compaction lateral 98–102, 98–102 thermoplastic 103–8, 104–8 competence complications see post-treatment disease composite cores 124 composite resin onlays/crowns 125–6 composite restorations 116 anterior teeth 122–3, 122 posterior teeth 123–6, 124 condensing osteitis 27 cone beam CT 4, 26–7, 27 www.ajlobby.com consent 160 continuing professional development continuous wave technique 104–7 core filling materials 93–7 placement 98 removal of 153 see also specific materials coronal flaring 62, 65, 81 coronal pulp 7, corrective surgery 156 cracked tooth syndrome 32 crown restorations 116–18, 118 all-ceramic 123, 124, 126 anterior teeth 117, 117 composite resin 124–5, 127 gold 125, 126 gold-porcelain 123 metal-ceramic 123, 126, 128 molar teeth 117–18, 118 post-treatment disease 148 posterior teeth 125–6, 126, 127 premolar teeth 117, 118 quality of 136, 136 removal of 151–2, 151–3 crown-down technique 84, 84 D decision-making 41 dens-in-dente 26 dental history 23, 28 dental loupes 66 dentinal tubules 9, dentine 7–9 caries-affected 49 composition 7–8 exposed 33 permeability 9, sensitivity 9, caries response 12 tertiary 12–13 types of 8–9, see also specific types dentine-pulp complex 7, response to caries 12–16 dentinogenesis 8, dento-legal issues 159–66 claims and complaints 160, 160 consent 160 fractured teeth 165 inadequate root canal treatment 161, 162 patient information 161 perforations 163, 164 record keeping 165 risks of sodium hypochlorite 163–4, 164 rubber dam 164 separated instruments 161–2, 163 168 Index development of teeth 7, diagnosis 22–7, 22 errors in 35–7 extraoral examination 24, 28 intraoral examination 24, 28–33, 29–33 radiography 24–6, 25, 26, 35 vitality testing 24, 33–5 Dialister spp 18 direct pulp capping 51, 52, 53–5, 53, 54 discoloured teeth 56, 96, 123, 124 disinfection downpack 105, 106 drainage 43, 43 dry ice sticks 34 E Eggler post remover 154 Eikenella spp 18 electric motors 66, 66 electric pulp testing 34, 34 electronic apex locator 62, 64, 67, 82, 83 embryology 7, enamel, dental 7, enamel-dentine junction Endo Ring 68 EndoActivator system 87 endocarditis, infective 24 endodontic disease clinical outcomes 133–42 definition endodontic explorers 68, 68 endodontic pluggers 102 endodontics aims and scope definition 2–3 development of 4–5 endodontology, definition Endoray film holder 67 Enterococcus spp 18 equipment see instruments and equipment erosion erythromycin 44 ethylenediaminetetraacetic acid (EDTA) 73–4, 74, 87, 121 Eubacterium spp 18 examination 29–30, 29, 30 extraoral 24, 28 intraoral 24, 28–33, 29–33 post-treatment disease 146–7 post-treatment review 137–9 extirpation, vital pulp 43 extractions 149–50 extraoral examination 24, 28 extraoral sinus 29 F ferrule effect 115, 116, 131 fibre posts 119–20, 119, 129, 130, 131 fibroblasts 10 files effect on treatment outcome 137 Hedström 70, 70, 155 manipulation of 79–81 balanced-force technique 79, 80, 81 push-pull technique 81 watch-winding technique 79 master apical 84 nickel-titanium 4, 70–2, 71, 72 stainless steel 69–70, 70, 70 ultrasonic 66, 67 Filifactor spp 18 film holders 67, 67 finger spreaders 99, 100, 101 flare-ups 91 focal infection theory fractured teeth 165 Fusobacterium spp 18 G gag reflex 29 Gates Glidden drills 68–9, 69, 69 glass ionomer cement 116, 120 gold crowns 125 gold onlays 125, 126 gold posts 119 gold-porcelain crowns 123 gutta-percha points 31, 34, 38, 65, 95, 99, 100 master 101, 102, 102, 105, 109–10, 109–10 size choice 97–8 removal of 148, 150, 155 root canal filling 94, 94–6, 95, 137 root canal preparation 65 H heat testing 34–5, 35 Hedström files 70, 70, 155 Hertwig’s epithelial sheath history taking 22–4, 28 dental history 23, 28 medical history 23–4, 28 personal history 24 HotShot device 106 hydroxyapatite hypochlorite accident 86 I ibuprofen 43 immune response to caries 13–14 indirect pulp capping 51–2 infections 16–19 extraradicular 18–19 organisms causing 18 primary intraradicular 17 routes of pulp invasion 16, 17 secondary persistent intraradicular 17–18 viral 19 see also specific conditions infective endocarditis 24 instruments and equipment root canal preparation 66–72, 66–72 chemical 72–4, 73 general 66–9, 66–9 mechanical 68–72, 69–72, 69 www.ajlobby.com separated instruments 161–2, 163 see also specific items insulin-like growth factors interappointment medicaments 90, 137 intermediate restorative material (IRM) 76, 76 intraoral examination 24, 28–33, 29–33 intraoral swelling 31 intratubular (peritubular) dentine iodine compounds 74, 75–6 IRM see intermediate restorative material irrigants/irrigation 74–5, 75, 85, 86, 87 agitation of 74–5, 87 effect on treatment outcome 137 hypochlorite accident 86 see also specific irrigants irrigation syringes 72, 73 isolation of operating field see rubber dam K K-Flex files 97 L labial sinus 31 Lactobacillus spp 18 lateral canals 60 lateral compaction (condensation) in root canal filling 98–102, 98–102 latex allergy 24 Ledermix paste 75, 76 ledging 70 life-cycle of tooth 6–20 embryology 7, see also specific regions local anaesthesia 41–3, 42 locking tweezers 68 long shank excavator 68 Ludwig’s angina 43 M Machtou pluggers 102 mantle dentine marginal leakage 30 marsupialization 158 Masserann kit 156 master apical file (MAF) 84 master gutta-percha points 101, 102, 102 placement 105, 109–10, 109–10 matrix bands 125 measuring devices 68, 68 medical history 23–4, 28 medicaments interappointment 90, 137 intracanal 75–6, 75, 76, 76, 87 metal posts 119, 129 metal-ceramic crowns 123, 126, 128 metronidazole 44 microorganisms see bacteria mineral trioxide aggregate (MTA) 51, 52, 55, 110 minimally invasive dentistry 49–50, 49, 50 ‘biological’ caries excavation 50, 51, 53, 53 cavity lining 50–2, 51, 51, 53–5, 53, 54 Index mirrors 67, 68 modified double flare technique 84–5, 84 Monoject syringe 73 mouth examination of 29–30, 29, 30 opening 29, 29 MTA see mineral trioxide aggregate N Neisseria spp 18 nickel-titanium files 4, 70–2, 71, 72, 85–6 apical preparation 85–6 fracture of 72 no treatment option 147, 148 non-steroidal anti-inflammatory drugs (NSAIDs) 43 Nyyar cores 124 O Obtura III Max system 106 obturation see root canal filling occlusion assessment 32–3, 33 and restoration 115–16, 116 odontoblasts 7, 10, 10 caries response 13, 14 Olsenella spp 18 onlays 117 operating microscope 66 oral hygiene 23, 29 orthodontic band 44 osteitis, condensing 27 outcomes of treatment 133–42 assessment 137–9, 138 classification 139–41, 139, 140, 141 meaning of 134–5, 134 prognostic factors 135–7, 135 preoperative status 135 quality of coronal restoration 136, 136 quality of root canal filling 135–6, 136 surgical treatment 137, 138 overextended root fillings 135 P palpation 31, 31 paper points 87 paracetamol (acetoaminophen) 43 parafunction 116, 116 parallax principle 25 Parojet 42 Parvimonas spp 18 patency filing 65, 86 patients attendance 23 cooperation 29, 29 dietary habits 23 information for 161 management 41–7, 92–3 oral hygiene 23, 29 symptoms 91, 91 post-treatment 138 treatment planning 39 Peptostreptococcus spp 18 percussion 31, 32 perforations 163, 164 periapical abscess 27 periapical osseous dysplasia 36 periapical periodontitis 3, 14–16, 15, 16, 19, 27 periapical radiographs 35, 36, 37, 37 periapical tissues 7, 7, 9, 11, 11 bacterial invasion 16, 18 preoperative 135 status of 90–1, 91 periodontal probing 32, 32 personal history 24 phenolic compounds 76 planning treatment see treatment planning platelet-derived growth factor points acrylic 97 gutta-percha 31, 34, 38, 65, 95, 97–8, 99, 100 paper 87 polymer-based 95 silver 96–7, 96, 155 polymer-based fillers 95, 96 polymorphonuclear neutrophils (PMNs) 14 Porphyromonas spp 18 post-treatment disease 143–58 management options 147–50 extraction 149–50 no treatment 147, 148 root canal treatment 147–8, 150 surgical endodontics 148–9, 149, 150 non-endodontic 147 recognition of 144–7, 144, 146, 147 referral 150–1 understanding of 144 posterior tooth restoration 123–6 direct 123–5, 124, 125 indirect 125–6, 126 posts 118–20, 126, 128–31, 129 bonding 120, 120 direct 129, 130, 131, 131 indirect 128, 129 materials and type 119–20, 119, 119 performance 119 placement 126 preparation systems 130 purpose of 118–19 removal of 148, 149, 153–4, 154 potassium iodide 74 predentine presenting complaint 23, 28 Prevotella spp 18 procedural difficulties 92, 92 Propionibacterium spp 18 ProRoot MTA 95, 96 prudent patient test 161 Pseudoramibacter spp 18 Pulp Canal Sealer 93 pulp capping 51–5, 51 direct 51, 52, 53–5, 53, 54 indirect 51–2 pulp, dental 7, 7, 9–12 composition 10, 10 coronal 7, extirpation 43 functions 9–10 www.ajlobby.com histological zones 10 infection 16, 17 inflammation 13–14 innervation 11, 11, 12 necrosis 27 radicular 7, status of 91, 91 vascularization 10–11, 11 pulp stones 61 pulp vitality see vitality pulpitis 14, 27, 91 pulpotomy 52, 55, 55, 56 Pyramidobacter spp 18 R radicular pulp 7, radiography 24–6, 25, 26, 35 beam-aiming devices 36 bitewing radiographs 25 cold lateral compaction 101 diagnostic errors 35–6, 39 parallax views 35, 38, 39 periapical 35, 36, 37, 37 post-treatment disease 146–7, 146, 147 post-treatment review 139 pulp therapy 56 root canal assessment 77, 78, 78 working length determination 82, 83 radiolucent lesions 40 reactionary dentine 8, 12–13, 13 record keeping 39 dento-legal issues 165 referral 150–1 Rely X Unicem 131 reparative dentine 8, 14 replantation 158 resin cements 131 resin sealers 93, 94 restorations 113–32 anterior teeth 122–3 composite 116, 122–3, 122 crowns see crown restorations indications 114–15, 114, 115, 121 objectives 114, 114 posterior teeth 123–6 procedure 121 treated vs vital teeth 114, 114 treatment decisions 115–16, 116, 116 root canal bonding in 120, 120 calcification 40 files for 70, 71 drainage 43, 43 features 63 infection 19 location of 62, 63 weeping 92 root canal filling 40, 59, 89–112 core fillers 93–7 gutta-percha point size 97–8 ideal 97, 97 inadequate, management of 161, 162 indications 59 lateral compaction 98–102, 98–102 169 170 Index root canal filling (continued) necessity for 90, 90 open apices 110–11, 110 post-treatment disease 147–8, 149, 149 preparation see root canal preparation quality of 135–6, 136 sealers 93, 93, 94 placement 98 removal of 154, 154, 155, 155 single vs multiple visit 90, 91, 91 success criteria 111 thermoplastic compaction 103–8, 104–8 timing of 90–3, 91, 91, 92 root canal preparation 58–88 aims of 59 challenges 60–1, 60, 61 chemical 59–60, 72–6, 86–7 how to achieve 72–3 instruments and equipment 72–4, 73 irrigation 74–5, 75, 85, 86, 87 see also specific irrigants medicaments 75–6, 75, 76, 76, 87 smear layer removal 74, 74, 87, 87 instruments and equipment 66–72 chemical preparation 72–6, 73 general 66–9, 66–9 mechanical preparation 68–72, 69–72, 69 mechanical 59, 60, 62–5 instruments and equipment 68–72, 69–72, 69 pretreatment assessment 77–8, 77, 78 procedural difficulties 92, 92 procedure access cavity preparation 62, 63, 78–9, 80 apical negotiation 62, 64, 64, 65, 81–2 apical preparation 64–5, 65, 82, 85–6, 85 coronal flaring 62, 65, 81 initial negotiation 62, 81 tooth preparation 62 working length determination 62, 64, 64, 65, 82, 83 root canal entrance location 79 temporary restorations 76, 76, 87 root resection 156, 157 rubber dam 4, 43, 44–7, 45 dento-legal issues 164 effect on treatment outcome 137 root canal preparation 66 single tooth isolation 44–5, 46 split dam method 45–7, 46, 47 S sclerotic dentine 8–9 Sealapex 93 sealing agents root canal filling 93, 93, 94, 98 rubber dam see rubber dam sensibility testing 24, 33–5 cold testing 34, 35 electric 34, 34 heat testing 34–5, 35 separated instruments 161–2, 163 septicaemia 43 Sharpey’s fibres siloranes 122 silver points 96–7, 96 removal of 155 sinus tract 137 extraoral 29 labial 31 radiography 38 smear layer removal 74, 74, 87, 87 sodium hypochlorite 73, 73 accident 86 risks of 163–4, 164 Solobacterium spp 18 special investigations 24–7 speed reducing handpiece 66, 66 spiral fillers 72, 73 split dam method 45–7, 46, 47 stainless steel files 69–70, 70, 70 Hedström 70, 70, 155 K-type 69–70 pre-curved 70 posts 119 Steiglitz forceps 154 stepwise excavation 50 Streptococcus spp 18 surgical endodontics 154–8 apical surgery 154–6, 156 biopsy 158 corrective surgery 156 incisional drainage and trephination 154 indications/contraindications 149 marsupialization 158 outcome 137, 138 post-treatment disease 148–9, 149 replantation 158 root resection 156, 157 tooth resection 158 swelling differential diagnosis 36, 40 incision and drainage 43, 43 non-inflammatory 36–7 syringes, irrigation 72, 73 T Tannerella spp 18 temporary restorations 76, 76, 87 test cavity 35 thermoplastic compaction in root canal filling 103–8, 104–8 Thomas post remover 154 titanium posts 119 tooth bud cap fracture 30, 40 grinding 116, 116 mobility 32, 32 www.ajlobby.com resection 158 structure surface loss 2, 30 survival 115 tooth slooth 33 transforming growth factor-beta 8, 52 trauma 2, 23, 23 treatment outcomes see outcomes of treatment treatment planning 37–41 definition 38 definitive phase 38–9 factors affecting 39–41 initial phase 38 maintenance and review 39 record keeping 39 trephination 154 Treponema spp 18 Tubliseal 93 ‘tugback’ 98, 109 U ultrasonic instrumentation files 66, 67 tips 66, 67 ultrasonic units 66, 67 V Veilonella spp 18 veneers 123 vertical compaction see warm vertical compaction vitality loss of 114, 114 preservation of 48–58, 50 ‘biological’ caries excavation 50, 51, 53, 53 cavity lining 50–2, 51, 51, 53–5, 53, 54 importance of 49, 49 minimally invasive dentistry 49–50, 49 outcome 55–7 prognosis 56 pulpotomy 52, 55, 55, 56 vitality testing 23, 33–5 cold testing 34, 35 electric 34, 34 heat testing 34–5, 35 W WAMkeys 152, 152 warm lateral compaction 103–4 warm vertical compaction continuous wave 103, 104–8, 105–7 multiple wave 103, 104 wedge test 33 working length, determination 62, 64, 64, 65, 82, 83 Z zinc oxide-eugenol sealers 76, 93, 94 ... www.ajlobby.com Great Clarendon Street, Oxford OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford It furthers the University’s objective of excellence in research,.. .The Principles of Endodontics www.ajlobby.com This page intentionally left blank www.ajlobby.com The Principles of Endodontics S E COND EDITION Edited by Shanon Patel Justin J Barnes www.ajlobby.com... publishing worldwide Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press, 2013 The moral rights of the authors have been