May 2011 – Berkshire Vocational Trainees

 

Endodontic Case Reviews with Vocational Trainee/Foundation Dentists on the Berkshire Scheme

On 26.5.11, I had the pleasure of spending time with the 12 impressive new dental graduates participating in the Berkshire Dental Foundation training scheme. Each had assembled a detailed report pertaining to an endodontic case that they had treated in their foundation year. I had scrutinised these cases in advance and so was able to spend some time with each graduate asking questions and seeking clarification on some points of interest (or contention) that their cases raised.

I was pleased to see that they were all of a very good standard, some exceptional. It struck me as a shame that not enough people would get to see these examples of high class, technically skilled procedures all executed on the NHS. Moreover the graduates later reflected upon the with abundant insight. The inflammatory, and in my opinion slightly trashy, television show broadcast on Channel 4 earlier that week would have you believe that molar root-canal treatment was never offered on the NHS let alone performed with elan.

I enjoyed passing on what pointers I could in the brief time allocated to each dentist but found myself repeating the same things on a number of occasions so after the session I wanted to let the graduates know what aspects were common to nearly all of the cases, both good and bad, so here goes.

 

Pre–operatively

Clinical exam

The pre-operative collection of clinical information was excellent. If the graduates can continue to practice with such a holistic attention to detail they will stand themselves in good stead.

Radiographic exam

This was poor. The American Association of Endodontists as well as the Royal College of Surgeons in England (page eight) give guidance on the pre-operative assessment of endodontic treatment complexity. The RCS guide was evaluated in British Dental Journal (Vol 26 pg 202 in 2007). Both hinge on the assessment of canal patency and canal curvature and not one graduate commented on either!!!

Judgement of these aspects will help inform the General Practitioners decision whether to perform the root canal treatment themselves or refer to an endodontist.

Diagnosis

Some of the diagnoses were probably inaccurate. Of course I was not there at the time of the patient examinations but I suspect most were cases of irreversible pulpitis. This is not an easy diagnosis to make as a new graduate as it involves ‘condemning’ a ‘vital’ tooth to root canal treatment and so takes some guts and consequently I was impressed with all those who included it in their report.

The most common conditions I see in my work are

  • chronic apical periodontitis (non-vital tooth, asymptomatic. Lesion detected radiographically) and ;
  • chronic apical periodontitis with acute exacerbation (same as chronic apical periodontitis but tender to percussion).

Acute apical periodontitis was included in too many reports. This is a relatively rare occurrence follows pulp death, spread of infection throughout the pulp space and an exuberant outflow of bacteria into the periapical space.

Irreversible pulpitis occurs when infection (such as decay) is overwhelming the pulps defences. The pulp gives the patient lots of pain as it is in the process of dying (NB pulp death is not always symptomatic).

Case selection

Too many cases detailed beautiful root canal treatments in mouths (and sometimes teeth!) still showing lots of decay. This must stop.

When patients present in pain it is important to facilitate relief of symptoms as soon as possible (remembering that this may be via the extraction forceps). After pain relief. exhaustive dental health education and clearance of all primary disease I would advocate a period (six months in my opinion) of no further treatment. To a new graduate this takes guts. If the patient returns with new primary disease then the cycle of education, removal of primary disease and review must be re-instigated.  It is only appropriate to discuss complex treatments like root canal treatment, crowns, dentures, cosmetic work etc, etc, when the mouth is stabilised.

I cannot stress enough that I think putting complex dentistry into mouth exhibiting uncontrolled primary disease is actually doing the patient a major disservice.

 

Inter–operatively

MB2

Try this link to help visualise where to look for the MB2.

It is present in around 60% of cases upper first molars (maybe a little higher in younger people and maybe a little lower in older people). It is difficult – but not impossible – to find without the magnification and illumination of a microscope.

Obturation condensation/compaction

In an effort to ‘seal’ the canals – it is important to compact gutta-percha into the prepared canals with a finger spreader and accessory points. Don’t get into the habit of seating a single cone un-condensed. See the image that rotates on the front page of this website . The gutta-percha has been condensed into a lateral canal.

Obturation length

There was a lot said about the length of the obturation and its significance on outcome (see below point). Whilst this is true it varies with the clinical situation. S , in a nut-shell and without wishing to get too in depth……. if the case has a large pre-operative periapical radiolucency we know the canal is infected throughout its length and therefore probably need to clean and obturate to the full canal length.

If the case does not have a large pre-operative periapical radiolucency we know the canal is probably not infected throughout its length and therefore we ought to clean and obturate to within 1-2mm of the full canal length

(Try reading Wu et al, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:99-103)

or

here

 

Post-operatively

Nice white stripes on a post op radiograph….

…..is not the same as successful treatment. Although thorough disinfection of the root canal system cannot be ‘seen’ on an x-ray, it goes much further to ensuring a successful outcome that a good obturation. Aim for excellence in both stages – but don’t get too hung up on the post op radiograph.

Post endo restoration:

The most common question of the whole day was

“How long do I wait after root canal treatment on a molar tooth before considering cuspal coverage?”

I always recommend cuspal coverage (cast onlays , amalgam onlays , ¾ crowns as well as full veneer crowns – see below) as soon as possible after completing molar root canal treatment and advise everyone else to do the same BUT I can understand it when General Practitioners elect to wait a while to assess the outcome of root canal treatment.

That said, if there is no pre-operative periapical radiolucency (as was the case in all of the case reports I saw) AND root canal treatment is executed to a high technical standard (as was the case in all of the case reports I saw) then I would advise the graduate that the success rate for root canal treatment is highest, at around 95% , and they should provide cuspal coverage immediately. Any delay merely increases the risk of fracture.

 

In Conclusion

The standard of endodontics was encouraging – keep it up! Any questions please get in touch – details on the website.

 

Post endo – cast onlay

Post endo – amalgam overlay

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Post endo – 3/4 crowns

Post endo – full veneer crown

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Post endo – full veneer crown