L5 Prep for treat + temp's - 2018_formatted_text

Preparation for Endodontic Treatment & Temporisation during Treatment¹²

Assessing Prognosis³

Mandatory Considerations⁴⁵⁶

• Sufficient tooth structure left for further restoration?

• What type of restoration will be required?

• Post-retained core required?

• Any other alternative restorations?

• Periodontal (crown lengthening) surgery required?

• How predictable is the entire procedure?

  • Endodontics, periodontics, restorations

• Are there alternative procedures?

  • No treatment, extraction, various prostheses, etc.

Info

All of these factors must be discussed with the patient to ensure informed consent.

Difficulty in Assessment⁷⁸⁹

• It is difficult to accurately assess teeth when restored due to:
  • Cracks and / or fractures
  • Marginal breakdown
  • Caries - coronal, root

Example Case

A case involving tilted first and second molars with extensive restorations illustrates this difficulty. The patient had a history of food packing due to a missing premolar, leading to repeated restorative cycles. A radiograph revealed 21 distinct issues, including:

• Periodontal bone loss and pocketing
• Furcation involvements
• Caries under an amalgam restoration
• Periapical radiolucencies
• Severe tilting of the molars

Despite the wealth of information, the primary question of whether sufficient tooth structure remains for restoration could not be answered without first removing the existing restorations.

General Principles for Treating All Diseases^101112131415

Tip

The approach to treating endodontic disease can be understood through the general principles of managing any disease, as illustrated by the analogy of an infected splinter in a finger.

• IDENTIFY the disease and its cause
• REMOVE the CAUSE of the disease
• TREAT the EFFECT of the disease
• PREVENT further disease and complications
• RESTORE to normal function
• MONITOR healing and stability over time

Principles for Treating Endodontic Diseases^{16171819202122}

• IDENTIFY the disease and its cause
  • History, Examination, Diagnosis, Cause
• REMOVE the CAUSE of the disease
  • Remove the cause - restorations, caries, cracks, etc
• TREAT the EFFECT of the disease
  • Clean the canal - remove bacteria, debris
  • Medicate canal - modify periapical response

Info

This treats the infection within the tooth (the disease) to resolve the periapical inflammation (the effect).

• PREVENT further disease and complications

  • Root canal filling

• Coronal restoration

• RESTORE to normal function

  • Coronal restoration

• MONITOR healing and stability over time

  • Review 6 months, 3 years, 5 years, etc

The Traditional Approach: A Critique²³

Warning

The traditional approach involves cutting an access cavity directly through an existing restoration to reach the pulp chamber. This method is flawed because it:

• Ignores the cause(s) of the pulp and periapical diseases
• Hinders assessment of the prognosis
• Difficult to accurately assess teeth when restored
  • → Caries, Cracks, Fractures, Restoration Breakdown

The Rationale for Removing Existing Restorations²⁴

Primary Cause of Pulp and Periapical Diseases

• Primary cause - Bacteria
• Main pathways for bacterial penetration:
  • Caries
  • Cracks
  • Breakdown of restoration margins
  • Fractures

Study 1: Assessing Restored Teeth (Abbott, P.V. 2004)²⁵

Aust Dent J 2004: 49; 33-39.

Methodology²⁶²⁷

• 220 consecutive patients (245 teeth)

• Referred for specialist endodontic assessment and treatment

• All teeth previously restored

• All had pulp and / or periapical disease

• No history of direct trauma

• No concurrent periodontal disease

Info

These exclusion criteria were used to isolate cases where the pathways of infection were related specifically to the existing restorations, rather than other causes like trauma or primary periodontal disease.

Pre-Operative Assessment²⁸

• Clinically assessed for:
  • Marginal breakdown
  • Caries
  • Cracks / fractures
  • Combinations of the above
• Periapical radiographs assessed for:
  • Caries
  • Fractures

Re-assessment after Restoration Removed²⁹

• Marginal breakdown
• Caries
• Cracks / fractures
• Suitability for further restoration
• Need for endodontic treatment
• Interproximal periodontal pockets

Info

The assessment looked for deep, narrow pockets, which can be indicative of a vertical root fracture.

Examination Methods (Both Stages)³⁰³¹

• Visual inspection

• Probing of restoration margins, pockets

• Probing of pits, fissures, grooves, etc

• Transillumination with fibre optic light

  • Used from several directions

How Transillumination Works

This technique illuminates sound tooth structure. Light is blocked or deflected by a crack, which makes the crack line appear dark and visible.

• Rubber dam isolation (cuff technique) used for investigation of all teeth

The

Rubber Dam “Cuff Technique”

Results³²³³³⁴

• 2.9% of teeth didn’t require endodontics
  • Pulpitis was reversible
• 4.5% were recommended for extraction
  • Extensive caries, periodontal disease, vertical root fractures, crown:root fractures

Radiographs vs. Actual Findings³⁵³⁶

• 45 teeth (18.4%) with pre-operative radiographic evidence of caries

• 211 (86.1%) - caries found after restorations removed

• Periapical radiographs are poor indicators of caries under existing restorations

Findings Before vs. After Restoration Removal³⁷³⁸³⁹

• 245 teeth examined

	Before	After
Nil	107	1
Marg. B’down	96	244
Caries	91	211
Cracks	57	147

• 93% had > 1 factor

• Of 245 teeth, only ONE tooth had NO evidence of caries, cracks or marginal breakdown of the restoration.

  • Was restored only 8 months prior to referral - had apical periodontitis symptoms then
  • Periapical radiolucent area
  • Misdiagnosed when restored

Example

The patient’s symptoms persisted because the original diagnosis was missed. The previous dentist had correctly identified and removed the cause of the problem (a failing filling), but had failed to treat the effect (the existing root canal infection and apical periodontitis).

Conclusions (Abbott, 2004)⁴⁰⁴¹

• Clinical and radiographic examinations do not provide sufficient information to enable clinicians to accurately assess teeth that have been restored and have pulp &/or periapical pathosis.

• The presence of the most common causative factors of pulp and periapical disease (such as marginal breakdown, caries, cracks & fractures) can not be fully assessed without removing the existing restorations.

Clinical Recommendations: The “Investigation” Phase^42434445

MUST REMOVE ALL existing restorations prior to commencing endodontic treatment to:

• Remove causative factors for the disease(s)
• Prevent bacterial penetration during treatment
• Assess suitability for further restoration of tooth
  • How it can be restored; Other treatment required
• Help assess if endodontic treatment is required
• Assess long term prognosis

Patient Communication

This investigation phase should be clearly explained to the patient, including its two potential outcomes:

• Favorable: The tooth is deemed treatable and restorable, and the clinician proceeds with root canal treatment.
• Unfavorable: The tooth is deemed non-restorable due to extensive, previously hidden damage, and the recommendation is extraction.

Study 2: Bacterial Contamination of Restorations (Kwang & Abbott, 2012)⁴⁶

Bacterial contamination of the fitting surfaces of restorations in teeth with pulp and periapical disease: a scanning electron microscopy study Aust Dent J 2012; 57: 421-428

Inclusion Criteria⁴⁷

• Infected root canal system
  • Confirmed by presence of apical periodontitis
• Restorations were “clinically satisfactory”
• No cracks evident clinically
• No caries evident
  • Clinically or radiographically
• Sectioned restoration to obtain a “piece” for SEM examination

Findings: Fitting Surfaces of Restorations⁴⁸⁴⁹

Amalgam Restoration

Porcelain-Metal Crown

Composite Resin

Summary of Results (Kwang & Abbott, 2012)⁵⁰⁵¹⁵²

Restoration Type	No. Examined	No. with Bacteria
Amalgam	10	10
Crown	10	10
Composite	10	10
Totals	30	30

i.e. EVERY restoration !!

Live Bacteria Found

Examination under the scanning electron microscope (SEM) revealed not just bacterial presence, but also dividing cells. This confirmed that the bacteria were alive and actively multiplying at the time of removal, forming a viable biofilm.

Conclusions (Kwang & Abbott, 2012)⁵³

• The pathway of entry for the bacteria to infect the root canal systems must have been between the tooth and the restoration
  • Since no other pathways were present
  • And all of the restorations had bacteria under them

Failure

This demonstrates that a standard clinical examination cannot reliably detect the microscopic leakage pathways that are sufficient to cause pulpal infection.

• BUT - the clinical examination did not disclose the presence of bacteria underneath the restorations
• Supports the need to remove all restorations from teeth prior to commencing endodontic treatment

Consider this Composite Restoration …

Knight G. ADA NewsBulletin 2011

Updated Rationale for “Investigation”⁵⁴⁵⁵

MUST REMOVE ALL existing restorations prior to commencing endodontic treatment to:

• Remove all potential causes of the disease(s)

• Prevent bacterial penetration during treatment

• Assess suitability for further restoration of tooth

  • → How it can be restored & other treatment required

• Assess the longer term prognosis

  • Improve the predictability of treatment

• Assess the longer term prognosis

  • = Improve the predictability of treatment

Historical Perspective: J.I. Ingle’s “Endodontics”⁵⁶

1st Edition (1965), p. 114

Endodontic Cavity Preparation - Principle III: Removal of the remaining carious dentine & defective restorations

• “Caries and restorations … must be removed to:

  1. Eliminate as many bacteria as possible
  2. Eliminate the possibility of saliva getting into the prepared cavity.”

• “The last point is especially true of proximal caries.”

• “It is much easier to complete the radicular preparation through an open cavity than through the restored crown. As a matter of fact, the more of the crown that is missing, the easier the canal preparation becomes”

• “It is much easier to complete the radicular preparation through an open cavity than through the restored crown. As a matter of fact, the more of the crown that is missing, the easier the canal preparation becomes”

3rd Edition (1985)⁵⁷

• “An absolutely essential diagnostic procedure is the complete removal of carious dentine … and restorations”
• “Although frequently considered a part of treatment, it is infrequently included as an important diagnostic procedure” (NOTE: emphasis was placed by the author)
• “… complete caries excavation is imperative both to diagnose the condition and to plan proper treatment”

“Investigation” Courtesy of the AAE (American Association of Endodontists)

“Investigation”

Clinical Recommendation: Access Cavities⁵⁸⁵⁹⁶⁰

• Endodontic access cavities should not be made through existing restorations

Rationale

Cutting a small access hole through a crown or large filling is an inadequate approach that can lead to treatment failure. It fails to address the underlying cause of the disease and may leave significant defects like cracks or caries undetected.

Possible Exceptions^61626364

• Where a recent restoration has been placed and pulpitis has developed as a result of the operative procedure
  • BUT - take extra care when assessing composite resins as they may have shrinkage immediately on placement
• Where the history establishes that the canal was infected prior to the current restoration being placed

Note

This situation represents a diagnostic failure at the time of restoration and is not an ideal scenario. These exceptions are uncommon, and the default approach should always be complete removal of the restoration.

Then … will need to consider temporary restorations in far more detail than has been done in the past

Temporisation during Endodontics⁶⁵⁶⁶⁶⁷

Major Functions

• Prevent bacterial ingress during and after treatment
• Provide a sound base for rubber dam placement
• Protect against tooth fracture during treatment
• Provide a stable reference point
• Provide aesthetics where required

Two Key Considerations⁶⁸

Restoration of the:

• Tooth
• Access cavity

1. Interim Restoration of the Tooth⁶⁹⁷⁰

• After previous restorations removed

• Materials:

  • Glass ionomer (e.g. Ketac Silver, Ketac Fil)
    • ± SS bands

Stainless Steel (SS) Orthodontic Bands⁷¹

Main Function

• To retain the interim restoration

Other Functions⁷²⁷³

• Prevent tooth fracture - “splint”

• Base for rubber dam placement

• Stable reference point for WL measurement

• Assist with aesthetics

  • Upper premolars - e.g. Bu cusp missing
    • Buccal veneer of Ketac Fil over band

• Some cases: Allow long-term reassessment

• Matrix for amalgam core

Interim Restoration Materials (GICs)⁷⁴⁷⁵

• Ideally use traditional “chemical set” GIC’s
  • Do not need to light cure
    • Can not light cure through a stainless steel band
  • Minimal (? no) shrinkage
    • Especially in large cavities
• Recommended materials:
  • Ketac Silver, Ketac Fil

Ketac Silver⁷⁶

• Preferred wherever possible
  • Colour contrast helps removal
    • Can conserve more tooth structure
  • Stronger material - less brittle
    • Esp. during later access cavity preparation
  • Less sensitive to moisture loss
    • During setting
    • Later when isolated with rubber dam

Ketac Fil⁷⁷⁷⁸⁷⁹

• If aesthetic restoration required:

  • Upper and lower anterior teeth

  • Upper 1st premolars

  • Some lower premolars & upper 2nd premolars

    • Buccal “veneer” of Ketac Fil - if using SS Bands for retention of temporary

Application of Ketac Silver and Ketac Fil⁸⁰⁸¹⁸²

• Must follow the manufacturer’s instructions
• Use dentine conditioner
  • Retention: little difference
  • Sealing: more reliable if conditioned
• Use resin cover (Ketac Glaze) while setting
  • For moisture control - in and out

Using dentine conditioner before applying GIC Applying Ketac Glaze to help shape and protect the GIC

Clinical Application Examples⁸³⁸⁴⁸⁵

Molars - 163 teeth

	Uppers	Lowers	%
Ketac Silver	12	8	12.2
Ketac Silver + SS Band	65	77	* 87.2
Temporary Crown	1	-	0.6

Premolars - 52 teeth⁸⁶⁸⁷

	Uppers	Lowers	%
Ketac Fil	3	-	5.8
Ketac Silver	10	5	28.8
Ketac Fil + SS Band	21	4	48.1
Ketac Silver + SS Band	1	8	17.3
			65.4 %

Anterior Teeth - Options after post / crowns removed^888990919293

• CW / Cavit: deep in post hole
  • Temp. post / crown - with IRM or ZnPO₄ cement
• CW / Cavit in pulp chamber
  • GIC over exposed dentine
  • Temporary overlay denture
• CW / Cavit in pulp chamber
  • Temporary composite bridge bonded to root and to the adjacent teeth

Dressing

• CW
• Cavit

Anterior teeth - 30 teeth⁹⁴⁹⁵

	Uppers	Lowers	%
Ketac Fil	11	4	50
Temporary Crown	14	1	50

2. Temporary Restoration of the Access Cavity⁹⁶⁹⁷⁹⁸

• For subsequent appointments
  • Cavit
  • IRM

Access Temporaries: Cavit⁹⁹

Composition

• Calcium sulphate
• Zinc oxide
• Glycol acetate
• Polyvinyl acetate
• Polyvinyl chloride acetate
• Triethanolamine
• Red pigment

Properties^100101102

• Prevents moisture penetration

  • (Teplitsky & Meimaris - J Endod 1988)

• NO research reported about its ability to prevent bacterial penetration

• Poor strength
• Poor wear resistance
• High solubility

Supporting Evidence: Liberman et al. (2001)^103104105106

Effect of repeated vertical loads on microleakage of IRM and calcium sulphate-based temporary fillings. J Endod 2001; 27: 724-9.

• “Passive” temporaries:

  • No difference in “seal” against radioactive tracer

• With repeated occlusal loading:

  • IRM - no change

  • Calcium sulphate materials “deteriorated rapidly”

    • Penetration was “total and immediate”
    • “Equivalent to an open access cavity”

• Conclusion: Penetration tests without occlusal loading are of limited, or no, value.

Access Temporaries: IRM^107108109

Composition

• Zinc oxide
• Eugenol
• Reinforced

Properties^100101102

• Prevent bacterial penetration

  • Hume’s diffusion studies
  • Brannström’s “upside down restorations”

• High wear resistance

• Low solubility

• Does not prevent moisture penetration

Supporting Evidence: Mechanism of Action^110111112

• Eugenol is released by progressive hydrolysis.
• Hydrolysis occurs at:
  • External surface (saliva)
  • Cavity floor (dentinal fluid)

• Eugenol Concentrations:
  • 10⁻² M: Anti-bacterial
  • 10⁻³ M
  • 10⁻⁴ M: Reduces inflammation
• (Hume ‘84, ‘86, ‘87)

Supporting Evidence: Brännström et al. (1979)^{113114115116117}

J Prosthet Dent 1979

• Brännström’s “upside down restorations”

• Method:

  • Human teeth in vivo

  • Class V cavities restored

  • Teeth extracted

  • Examined histologically

• Group 1: Silicate Restorations

  • No lining
  • Question: Acid effect on pulp?

• Result (Silicate alone):

  • Pulp inflamed
  • Bacteria under restoration & in the tubules

• Group 2: Silicate with ZO-E Cover

  • Result:
    • No pulp inflammation
    • No bacteria seen

• Conclusion: ZO-E prevented entry of bacteria into the cavities.

The “Double Seal” Technique^118119120121

• There is NO SINGLE IDEAL temporary filling material available for endodontic access cavities.

• All of the available materials have:

  • Advantages and
  • Disadvantages

• The “Double Seal” is used to:

  • Use the advantages and to
  • Overcome the disadvantages of the materials available.

Application¹²²

• A layered approach is used:
  • IRM (outer layer)
  • CAVIT (inner layer)
  • Cotton wool
  • Medicament

The Role of Cotton Wool^123124125126

• Place a VERY SMALL pellet of CW over canal orifices.
• Prevents temporary filling going into the canals:
  • During placement of temporary, and
  • During removal of temporary
• Provides “matrix” / “stop” against which the Cavit can be placed.

• NO evidence that sterile CW allows bacterial penetration if adequate temporary placed.

Summary: Materials Required for Temporisation¹²⁷¹²⁸

• Cavit
• IRM
• Ketac Silver
• Ketac Fil
• St. steel orthodontic bands
• Temporary crown forms
• Cold cure acrylic resin
• Temporary posts

Temporisation during Endodontics⁶⁵⁶⁶⁶⁷

The “Double Seal” Concept

![An illustration of a tooth with labels pointing to each layer and boxes of the corresponding materials (IRM and CAVIT) next to the tooth illustration. ”/>

“Double Seal”

• Caulk Dentsply IRM

  • INTERMEDIATE RESTORATIVE MATERIAL
  • IVORY ELFENBEIN IVOIRE MARFIL
  • REORDER
  • FOR DENTAL USE ONLY
  • CONTENTS
    • 1 POWDER (38 G)
    • 1 LIQUID (14 ML)

• ESPE CAVIT

  • Provisorische Verschlußmasse/ Temporary Filling Material
  • G
  • ESPE CAVIT
  • Verschlu
  • Temporary Filing

Access Temporaries¹²³¹²⁴

Use of Cotton Wool

• Place a VERY SMALL pellet of CW over canal orifices
  • Prevents temporary filling going into the canals
    • During placement of temporary, and
    • During removal of temporary
  • Provides “matrix” / “stop” against which the Cavit can be placed
• NO evidence that sterile CW allows bacterial penetration if adequate temporary placed

Two dental radiographs with red arrows pointing to apical radiolucencies.

Materials Required^127125126128

• Cavit
• IRM
• Ketac Silver
• Ketac Fil
• St. steel orthodontic bands
• Temporary crown forms
• Cold cure acrylic resin
• Temporary posts

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