1 ROOT CANAL TREATMENT: A CLINICAL GUIDE FOR DENTAL STUDENTS, GENERAL DENTISTS
1 ROOT CANAL TREATMENT: A CLINICAL GUIDE FOR DENTAL STUDENTS, GENERAL DENTISTS WHO LIKE DOING RCTS AND GENERAL DENTISTS WHO HATE DOING RCTS Greg Y. Kim, DDS Red Rock Endodontics This document is intended as an easy-to-read guide for dental students and general practitioners of different clinical capacity who seek to improve their root canal treatment skills and obtain a more consistently predictable outcome in their everyday practice. Doing a root canal treatment (RCT), for the most part, is not a complicated task and the procedure should become easier and more systematic as the clinician gains more experience in doing it. There are, however, different components of development in becoming a more skilled clinician, and becoming technically good is only one aspect of it. In order to be truly proficient in this field, a clinician must also improve his/her diagnostic skills and understanding of its biological principles. This guide is divided into different topics and subtopics which are deemed important for understanding of those fundamental endodontic principles. DIAGNOSIS Good diagnostic skills are undeniably important for better management of endodontic cases. Day in and day out, we see a whole slew of errors associated poor diagnosis, whether it be prescribing wrong medications or treatment-planning for a wrong procedure. The importance of this first step of treatment can’t be stressed enough. Starting out with a good diagnosis at the onset can really spare the dentist of unnecessary headaches during follow-up phase. For the purpose of this guide, different pulpal and periapical diagnoses are not going to be discussed comprehensively, but some of the most common errors associated with either doing an erroneous diagnosis or NO diagnosis deserve a discussion here. o Prescribing Antibiotics for Pulpitis Pulpitis by definition is an inflammation of the pulp tissue and could be exceedingly painful under acute inflammatory conditions. For pain relief, either this inflamed pulp tissue needs to be removed or the tooth needs to be removed. When the pulp is still vital and inflamed (note: blood upon access opening), taking antibiotics actually does nothing for pain relief and only adds the hassle of having to take medications for multiple days for an already distressed patient. For antibiotics to be effective at reducing symptoms, the pulp has to be necrotic and infected for the most part (note: absence of blood upon entering pulp space). Now, it has to be noted that percussion sensitivity could present with both vital and nonvital pulp. But, in general, the cases where antibiotics can work for pain relief do not respond to thermal stimuli (endo ice, hot coffee, etc.) but instead display marked percussion sensitivity that can be localized by the patient. Tenderness of soft tissue in the vestibule near the apices of the associated tooth 2 may be present as well. On the other hand, if a patient’s chief complaint is having severe pain upon drinking something cold or hot, do not give that patient antibiotics for the purpose of addressing that chief complaint. At least do a pulpotomy if you have time, or find an endodontist who can provide an emergency treatment for you. Be sure to do a thorough diagnosis as many patients will present with a tooth that is necrotic and infected but will also complain of thermal sensitivity from adjacent teeth as well. The key is to address the tooth that is the main cause of acute symptoms. o Not Instrumenting the Canals for a Necrotic Tooth with Infected Root Canals This is another common error commonly encountered. When pulpal inflammation progresses and the pulp becomes necrotic, full instrumentation of the canals is required to eliminate the infection and reduce symptoms. A necrotic tooth has infection in the canals, the most common cause of which is bacterial insult from caries. These patients can present with swollen gums and/or face. Instrumenting to at least size 30/04 with a good amount of sodium hypochlorite irrigation is recommended. Otherwise, give the patient antibiotics (or you can do both) and the patient will typically see relief of symptoms within a day or two. Diagnosis dictates treatments: A 8-year-old boy presented with an exposure of #9 from trauma. Patient’s history of chief complaint and diagnostic tests indicated that the pulp was still in a reversible state of inflammation. The tooth structure immediately adjacent to the site of exposure was cleaned out with a small round bur and disinfected with sodium hypochlorite. This area was capped with a Bioceramic Putty material and the patient was referred back to the general dentist for a composite restoration. A 9-month follow- up showed (despite foreshortening in the first two x-rays) that the tooth maintained its vitality and continued its normal development. If RCT had been done without properly diagnosing the state of the pulp and the periapex, the tooth would have stopped its normal development and would have resulted in a clinically more complicated situation. (1st x-ray: Preop, 2nd x-ray: Immediate Postop, 3rd x-ray: 9 Month Follow-Up) ANTIBIOTICS o The go-to medication for an odontogenic infection is Pen VK 500 mg (bactericidal, narrower spectrum of action than amoxicillin, taken 4 times per day). For patients with amoxicillin/penicillin allergy, Clindamycin should first be considered. o For patients with a large, noticeable swelling: Refer to an oral surgeon if not totally comfortable dealing with the situation. If you give 2 different antibiotics together, the most effective combination would be 2 bactericidal antibiotics, such as Pen VK and metronidazole. A combination of bactericidal and 3 bacteriostatic antibiotics (such as penicillin with clindamycin) may counteract the effectiveness of each other and may not be as helpful. THE TREATMENT: STEP BY STEP Before initiating any treatment, take a long, close look at the x-rays. Most of the worst experiences associated with root canal procedures, by you and by the patient, can be avoided by choosing NOT to do the most complicated cases. Older patients have a higher likelihood of presenting with calcified canals and may not be able to tolerate longer treatment sessions at the same time. If you have difficulty discerning the canals due to calcification, it may be advisable to refer to a specialist. Looking at bitewing x-rays as well as periapicals can also give you additional information as to what kind of difficulty level to expect. o Access A good access can facilitate the rest of the procedure. A poor access, by the same token, can make the procedure more difficult than needed. Study the bitewing x-ray before picking up a high-speed handpiece to gauge how much you have to go down to be in the pulp chamber. It should always be remembered that the pulp chamber depth is largest on top of the bigger canals, meaning that it would be easier to expose this part of the chamber first and then peel away from here. For example, for upper molars, it’s easiest to expose the palatal canal first because it’s the largest canal with the most amount of coronal chamber space on top of it. As you peel away the roof of the pulp chamber, a dark pulpal floor reveals itself and the other canals are found at the outer edges of this darker floor. It also helps to remember that the pulp chamber is centered and concentric with the tooth outline at the level of the CEJ. Make a habit of looking at the CEJ outline and envisioning the pulp chamber at the center of this cross section. Doing this occasionally while access-prepping can help you get reoriented if you are drilling in a wrong direction. Caution: This information regarding the CEJ may be distorted in crowned teeth. o Measuring Working Length The very first files placed in a canal must always be pre-curved with the smallest possible radius. That is, all 10 and K15 files have to be curved (there are instruments specifically used for this purpose but if you don’t have those, a college plier will do) at the tip in order to negotiate around the curvature of the canal and to preserve that natural curvature with the least amount of transportation. This curving of the tip of a small file is utterly important. Once the tip of a small file is curved, it is placed in the canal and gently worked with a circumferential watch-winding motion until it is able to reach the apex. It is important to remember that, in your endeavor to get to the apex, the circumferential watch-winding motion may prove to be much more effective than a straight up-and-down filing motion. For narrower canals, you may not be able to reach the apex immediately. The goal is to work yourself down incrementally 4 without distorting the canal anatomy. When you are successfully working yourself down to reach the apex, the canal feels sticky and this is a good indication that you can continue to carefully work yourself down to establish the length. A canal that no longer feels sticky but feels like a hard wall indicates that you could be transporting the canal out of its natural curvature uploads/Sante/ rct-guide.pdf
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- Publié le Fev 19, 2022
- Catégorie Health / Santé
- Langue French
- Taille du fichier 0.6761MB