Textbook of Endodontics Nisha Garg, Amit Garg
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Introduction and Scope of Endodontics1

 
INTRODUCTION
Endo is a Greek word for “Inside” and Odont is Greek for “Tooth”. Endodontic treatment treats inside of the tooth.
Endodontics is the branch of clinical dentistry associated with the prevention, diagnosis and treatment of the pathosis of the dental pulp and their sequelae.
That is, the main aim of the endodontic therapy involves to:
  1. Maintain vitality of the pulp.
  2. Preserve and store the tooth with damaged and necrotic pulp.
  3. Preserve and restore the teeth which have failed to the previous endodontic therapy, to allow the tooth to remain functional in the dental arch.
Thus we can say that the primary goal of endodontic therapy is to create an environment within the root canal system which allows the healing and continued maintenance of the health of the periradicular tissue.
Since nothing is as good as the natural teeth, one should take care of them. The endodontic therapy is a necessary treatment to cure a damaged or diseased tooth.
Endodontics has been defined as art as well as science of clinical dentistry because in spite of all the factual scientific foundation on which the endodontics is based, to provide an ideal endodontic treatment is an art in itself.
Before understanding what is root canal therapy, how and when it is performed and other facts regarding endodontic therapy, we should be familiar with the history of endodontics.
Endodontics has been practiced as early as second or third century BC. The history of endodontics begins in 17th century and since then many advances, developments and research work has been proceeded continuously.
Though advances in endodontics have been made continuously, but especially after Pierre Fauchard (1678–1761) [Founder of modern dentistry] in his textbook “Le Chirugien Dentiste” described the pulp very precisely.
Latter in 1725, Lazare Rivere introduced the use of clove oil as sedative and in 1746, Pierre Fauchard demonstrated the removal of pulp tissue. Dr Grossman, the pioneer of endodontics divided the evolution of endodontics in four eras from 1776 to 1976, each consisting of 50 years.
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Pre science (1776 to 1826): In this era, endodontic therapy mainly consisted of crude modalities like abscesses were being treated with poultices or leeches and pulps were being cauterized using hot cauteria.
Age of discovery (1826 to 1876): In this era there occurred the development of anesthesia, gutta-percha and barbed broaches. Also the medications were created for treating pulpal infections and the cements and pastes were discovered to fill them.
The dark age (1876 to 1926): In spite of introduction of X-rays and general anesthesia, extractions was the choice of treatment than endodontics in most of the cases of damaged teeth because theory of the focal infection was main concern at that time.
The renaissance (1926 to 1976): In this era, endodontics was established as science and therapy, forming its golden era. It showed the improvement in anesthesia and radiographs for better treatment results. The theory of focal infection was also fading out, resulting in more of endodontics being practiced and in 1943, because of growing interest in endodontics, the AAE, that is, the American Association of Endodontists was found.
Innovation era: It is the period from 1977 onwards in which tremendous advancements at very fast rate are being introduced in the endodontics. The better vision, better techniques of biomechanical preparations, and obturation are being developed resulting in the simpler, easier and faster endodontics with more of the successful results.
Also the concept of single visit endodontics is now globally accepted in contrast to multiple visits.
 
MODERN ENDODONTICS
As we have seen, over the years, there has been a great improvement in the field of endodontics. Many researches have been conducted and papers are being presented regarding the advances, modifications and change in attitude regarding endodontic therapy. In the past two decades, extensive studies have been done on microbial flora of pulp and the periapical tissue. The biological changes, role of innate and acquired immunological factors are being investigated in dental pulp after it gets infected, healing of the periapical tissue after undergoing root canal therapy is also being investigated.
Various ways to reduce the levels of microbial infection viz. chemical, mechanical and their combination have led to development of newer antimicrobial agents and techniques of biomechanical preparation for optimal cleaning and shaping of the root canals.
To increase the efficiency of root canal instrumentation, introduction of engine driven rotary instruments is made. Introduction of Nickel Titanium multitapered instruments with different types of cutting tips have allowed the better, easier and efficient cleaning and shaping of the root canals.
The advent of endomicroscope in the field of endodontics has opened the great opportunities for an endodontist. It is used in every phase of the treatment, i.e. from access opening till the obturation of root canals. It makes the images both magnified and illuminated, thus helps in making the treatment more predictable and eliminating the guess work.
Introduction of newer obturation systems like system B Touch and heat have made it possible to fill the canal three dimensionally. Material like MTA (Mineral Trioxide Aggregate), a root canal repair material has made the procedures like apexification, perforation repair to be done under moist field. Since endodontics is based on the principles of inflammation, pulp and periapical disease processes and the treatment available, future of endodontics lies to redefine the rationale of endodontic therapy using newer modalities and to meet the set of standards of excellence in the future.
 
SINGLE VISIT ENDODONTICS (SVE)
Single visit endodontics is gaining popularity these days as compared to multiple visits. SVE implies to cleaning, shaping and disinfection of a root canal system followed by obturation of the root canal at the same appointment. The concept of single visit endodontics started at least 100 years back. Initiating and completing an endodontic treatment in one appointment has always been surrounded by controversy. In 1982 a survey revealed that 87 percent of endodontists did not trust that most necrotic teeth could be treated successfully in one visit. In addition, the majority of endodontists thought that performing treatment in this manner would cause more postoperative pain than if performed in multiple appointments. But now many studies have shown that completing the treatment in single sitting show no difference in quality of the treatment, success rate and incidence of post-operative complications. However, a growing number dentists are practicing more and more single visit endodontics.
Though the concept of SVE is gaining the recognition, but it is still surrounded by controversies regarding post operative pain, flare-ups and the healing rate followed by root canal therapy.3
The most common factors which appear to be responsible for not performing SVE are as follows:
  1. Doubt of postoperative pain
  2. Fear of failure of the endodontic therapy.
  3. Discomfort to patient because he/she has to keep the mouth open for a long period of time.
  4. Lack of time.
  5. Lack of experience and equipment.
 
Advantages of SVE
  • Convenience: Patient doesn't have to endure the discomfort of repetitive local anesthesia, treatment procedure and postoperative recovery.
  • Efficiency: The clinicians doesn't have to refamiliarize himself/herself to patient's particular anatomy or landmarks.
  • Patient comfort: Because of reduced number of visits and injections.
  • Reduced intra-appointment pain: Mostly the mid treatment flare-ups are caused by leakage of the temporary cements. This figure has seen to be reduced in SVE cases.
  • Economics: Extra cost of multiple visits, use of fewer materials and comparatively less chair side time all increase the economics to both patient as well as doctor.
  • Minimizes the fear and anxiety: Specially beneficial for patients who have psychological trauma and fera of dentist.
  • Reduces incomplete treatment: Some patients don't return to complete the root canal therapy, SVE reduces this risk.
  • Lesser errors in working length: In multiple visits, the reference point could be lost because of fracture or unwanted grinding in case of flare-ups leading to loss of actual working length. These errors are avoided in SVE.
  • Restorative consideration: In SVE, immediate placement of coronal restoration (post and core placements) ensure effective coronal seal and esthetics.
 
Disadvantages of SVE
  • It is tiring for patients to keep their mouth open for long durations
  • If mid treatment flare ups happen to occur, it is easier to establish drainage in a tooth which is not obturated
  • Clinician may lack the proficiency to properly treat a case in single visit
    • SVE cannot be performed in all cases.
    • If hemorrhage or exudation occurs, it becomes difficult for the clinician to control and complete the case in same visit.
    • Difficult cases with very fine, curved, calcified, multiple canals may not be treatable in single visit.
 
Criteria of Case Selection as given by Oliet Include
  • Positive patient acceptance
  • Absence of acute symptoms
  • Absence of continuous hemorrhage or exudation
  • Absence of anatomical interferences like presence of fine, curved or calcified canals
  • Availability of sufficient time to complete the case
  • Absence of procedural difficulties like canal blockage, ledge formation or perforations.
 
Conditions where Single Visit Endodontics cannot be Performed
  • Teeth with anatomic anomalies such as calcified and curved canals
  • Asymptomatic non vital teeth with periapical pathology and no sinus tract
  • Acute alveolar abscess cases with frank pus discharge
  • Patients with acute apical periodontitis
  • Symptomatic non vital teeth and no sinus tract
  • Retreatment cases
  • Patients with allergies or previous flare-ups
  • Teeth with limited access
  • Patients who are unable to keep mouth open for long durations such as patients with TMJ disorders.
 
Indications of Single Visit Endodontics
  • Vital teeth
  • Fractured anteriors where esthetics is the concern
  • Patients who require sedation every time
  • Non vital teeth with sinus tract
  • Medically compromised patients who require antibiotics prophylaxis
  • Physically compromised patients who cannot come to dental clinics frequently.
    In conclusion, single-visit endodontics has been shown to be an effective treatment modality, which compared to multiple-visit therapy, is more beneficial to patients and dentists in many ways provided there is careful case selection and adherence to standard endodontic principles. The prevention and elimination of apical periodontitis are the goals of a successful endodontics therapy, once the way to accomplish these goals is determined, the decision to provide treatment in multiple visits or single visit will follow itself.4
 
PATIENT EDUCATION
Most of the patient who are given endodontic treatment, are often curious and interested in their treatment. For such patients following information should be transferred to the patient in anticipation of frequently asked questions.
 
Who Performs an Endodontic Therapy?
Generally, all dentists receive basic education in endodontic treatment but an endodontist is preferred for endodontic therapy. General dentists often refer patients needing endodontic treatment to endodontists.
 
Who is an Endodontist ?
An endodontist is a dentist who undergoes a special training in diagnosing and treating the problems associated with inside of the tooth. To become specialists, they complete dental school and an additional two or more years of advanced training in endodontics. They perform routine as well as difficult and very complex endodontic procedures, including retreatment of previous root canals that have not healed completely, as well as endodontic surgery.
 
What is Endodontics?
Endodontics is the diagnosis and treatment of inflamed and damaged pulps. Teeth are composed of protective hard covering (enamel, dentin and cementum) encasing a soft living tissue called pulp (Fig. 1.1). Pulp contains blood vessels, nerves, fibres and connective tissue. The pulp extends from the crown of the tooth to the tip of the roots where it connects to the tissues surrounding the root. The pulp is important during a tooth's growth and development. However, once a tooth is fully mature it can survive without the pulp, because the tooth continues to be nourished by the tissues surrounding it.
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Fig. 1.1: Normal anatomy of a tooth showing enamel, dentin, cementum and pulp
 
How does Pulp Become Damaged?
Number of ways which can damage the pulp include tooth decay, gum diseases, injury to the tooth by accident (Fig. 1.2).
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Fig. 1.2: Tooth decay causing damage to pulp
 
Why do I Feel Pain?
When pulp becomes infected, it causes increased blood flow and cellular activity, and pressure cannot be relieved from inside the tooth. This causes pain. Pulp can even die without causing significant pain.
 
How can You Tell if Pulp is Infected?
When pulp gets inflamed, it may cause toothache on taking hot or cold, spontaneous pain, pain on biting or on lying down. on occasion a damaged pulp is noticed by drainage, swelling, and abscess at the root end (Fig. 1.3). Sometimes, however, there are no symptoms.
 
Why do I Need Root Canal Therapy?
Because tooth will not heal by itself, the infection may spread around the tissues causing destruction of bone and supporting tissue. This may cause tooth to fall out. Root canal treatment is done to save the damaged pulp by thorough cleaning and shaping of the root canal system and then filling it with gutta-percha (rubber like) material to prevent recontamination of the tooth.5
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Fig. 1.3: Tooth with infected pulp and abscess formation
Tooth is permanently restored with crown with or without post.
 
What are Alternatives to Root Canal Therapy?
If tooth is seriously damaged and its support is compromised, then extraction is only alternative.
 
What is Root Canal Procedure?
Once the endodontic therapy is recommended, your endodontist will numb the area by injecting local anesthetic. After this a rubber sheet is placed around the tooth to isolate it. Then the opening is made in the crown of the tooth and very small sized instruments are used to clean the pulp from pulp chamber and root canals (Fig. 1.4). After thorough cleaning and shaping of root canals (Fig. 1.5), they are filled with rubber like material called gutta-percha, which will prevent the bacteria from entering this space again (Fig. 1.6).
After completion of endodontic therapy, the endodontist places the crown or other restoration so as to restore the tooth to pull function (Fig. 1.7).
 
What are Risks and Complications?
It has been seen that more than 95 percent cases of endodontic therapy are successful. However sometimes because of unnoticed canal malformations, instrument errors a root canal therapy may fail.
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Fig. 1.4: Cleaning and shaping of root canal system
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Fig. 1.5: Cleaned and shaped tooth
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Fig. 1.6: Obturation of root canal system
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Fig. 1.7: Complete restoration of tooth with crown placed over the restored tooth
Does the tooth need any special care after endodontic therapy?
Since unrestored tooth is more prone to fracture so you should not chew hard until it has been completely restored, otherwise you should continue your regular oral hygiene routine including brushing, flossing and regular check-up.
 
How many Visits will it Take to Complete this Treatment?
Nowadays most of the treatment can be completed in 1–2 visits. But treatment time can vary according to condition of the tooth.
 
Will I Feel Pain during or after Treatment?
Nowadays with better techniques, and better understanding of anesthesia most of the patients feel comfortable during the treatment. But for first few days after therapy, you might feel sensation especially if pain and infection was present prior to the procedure. This pain can be relieved by medication. If continuous severe pain or pressure remains, consult your endodontist.
 
Will I have a Dead Tooth after Root Canal Therapy?
No, since tooth is supplied by blood vessels present in periodontal ligament. It continues to receive the nutrition and remains healthy.
 
Will the Tooth Need Any Special Care or Additional Treatment after Endodontic Treatment?
You should not chew or bite on the treated tooth until you have had it restored by your dentist. The unrestored tooth is susceptible to fracture, so you should visit your dentist for a full restoration as soon as possible. Otherwise, you need only practice good oral hygiene, including brushing, flossing, and regular check-ups and cleanings.
Most endodontically treated teeth last as long as other natural teeth. In a few cases, a tooth that has undergone endodontic treatment does not heal or the pain continues. Occasionally, the tooth may become painful or diseased months or even years after successful treatment. Often when this occurs, redoing the endodontic procedure can save.
 
Can All Teeth be Treated Endodontically?
Most of the teeth can be treated endodontically. But sometimes when root canals are not accessible, root is severely fractured, tooth cannot be restored or tooth doesn't have sufficient bone support, it becomes difficult to treat the tooth endodontically. However, advances in endodontics are making it possible to save the teeth that even a few years ago would have been lost.
Newer researches, techniques and materials have helped us to perform the endodontic therapy in better way with more efficiency. Since introduction of rotary instruments and other technologies reduce the treatment time, the concept of single visit is gaining popularity nowadays. It has been shown that success of endodontic therapy depends on the quality of root canal treatment and not the number of visits. In the modern world single visit endodontics is becoming quite popular.