Essentials in endodontic practice

Endodontia ESSENTIALS

E. A.

JASPER,

IN ENDODONTIC

II.J>.s.,

F.A.C.l).,”

PRACTICE

ST. ~AOUIS, $10.

P

dentistry” is engaging the inter& of our profession today as it never has before. We have long been int,rigued by the thought of preventing dental caries? but the prospect of doing so has always seemed rather remot.e because of the complex etiology of the disease. Now it appears tha.t t.he researches of various men, a.pproaching the subject from several angles, give promise of greatly reducing its incidence. This is most welcome and stimulating news, iI.ttd it may have occurred to some of you that the need for endodontics would henceforth he negligible. The sobering thought remains t.hat t.here will always he pulp involvemcnt~s resulting from accidents and fractures, neglected caries among apathetic individuals, and a. certain percentage of nncontrolletl cnrics even among wallmeaning persons. It seems wise, therefore, to make every eftort to improve our met.hods so that we will ult.imately develop certain procetlurcs which can be relied upon R.Sthe best possible in any given case. I have in mind discussing those ess(t~itials upon which every successful endodontic practice must rtbst. Such a discussion may be of little interest to some men who! t.hrough trial and error, have learned these things for t.hemselves. T address particularly the young men in the hope of leaving with them certain ideas which ma.y prove helpful as they work out their problems.

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REVENTIVE

Surgical

Cleanliness

Paramount among the factors which influence the outcome of endoclontic therapy is an aseptic technique. Unless we have a positive means of sterilization for our instruments and dressings, and subsequent,ly handle them with meticulous care, we may rea.dily introduce bacteria into the field of operation. This is a common cause of infected t.eeth, and frrquently results in loss of t.eeth. Presented at the Afth annual meeting Chicago. 111.. Feb. 6, 1949. *Professor of Oral Medicine, St. Louis

of

the American

University, 1199

Association

School of Dentistry.

of Endodontists,

11 small autoclave (Via. I I is tleeessat*y for the sterilization of towels a~1 dressings. s~mt> rronnltly-ttlirl(l~~~l I)CI’S(IIIS vl;~im that it ~)WSSUIY (xloker s~ffitres for t.his purl)oSe, but ~~essurc~ cookers i11.einconvenient to handle at111do not. tlry Out materials aftW sterilization i1.S iltl ilUtOCl;-lVe (1WS. To l’acilitate ha~~dling a~~tl stcjrinp vatious sizes of abSort)ent points. cotton pellets, and gauze naljkills. the authot* designetl ;I covered Monel metal tray SOIIIP years ago (Id’ig. 1:) which has proved t.o be quite convenient and pnpulat*. After the tlesire~l mattt*ials have ~MWI I)lilCctl in the several CO~Il)artlnents. the tray. with its loosely fitting vo\:er, is ;~utoclavetl. S~~lil,Il instrutnellts. such ils files, reamers, :rml broaches, which cannot he sul)ject.etl to moist. heat without injury are thoroughly cleansed amI t.hen inImcrSed in some disinfectin g solution for several hours. After this t.hey are (lriec’l with A st.erile towel, ;111(1l)la(*etl ill :I sterile c~losed contn.iner having \rari uS(‘. 111 short, the treatment 01 lmlp-iuvolvetl teeth requirrs the same meticulous l)repi~.ratio~l i1Sot,her surgiC:ll cll)c’l*atio,ls.

Bacteriologic Examinations As a counterpart. of atl(~cluate sterilizing facilities, the endodontist must have equipent for makin g routine I);lc!teriol+gic exn.minations, for t.his is t.he only accurate mesns of determining when a p&less tooth may he safely filled. Such equipment nred not. he c~lahorate or espensivc. Giall dental office incuhators (Fig. 2) Sre now ;~~;lilal)le FIYIIII several manufacturers, and barmotlizc wit.h ot.her fir&lass fixtures. ( ‘ulturr mrtlia in sesled glass tnhes (F’ig. 5) may 1~ l*eadily ohtainctl ill ~111large cit.&. alltl within A. few days in out.lping dist.ricts. Thr CWS~is nominal, :uitl the mate&r1 remains stable indefinitely at ONli11ilI’y tcillpel*ilt lircs.

Case Selection Having properly equipped and organized the office, we must give ea.ch case careful consideration. A tliagnosis based on a t.horough examination is of prime importance in root vanal therapy. Many dentistv undert.ake this work haphazardly, and t.hink of the ontcome as a. “good risk,” or a had one, I do not like this attitude of uncertainty. as the situation seems to intlivate. It places the whole field in iI (*iltegory of doubt. Actually, these operations can he performed with as much a,ssurance of success as any ot.her de1icat.e surgical procedure. Many or us have serial roent.genograms, taken over a

Figs. 1 and Z.-Small autoclaves availabte from several manulacturers. other first-class equipment.

and incubators, suitable for dental office use, are now They are neat in appearance and harmonize with

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1%. A.

J:\SPER

Fig. 3.-Absorbent points, cotton pellets, and gauze napkins may be conveniently assemThe tray has a lid which bled in a Monel metal tray of this type, and then autoclaved. protects the contents from contamination for short periods. Fig. 4.-A Mynol dish and glass jars will be found very useful aids in sterilizing small instruments. Broaches. reamers. and Ales may be immersed in Zephiran or Metaphen for Thr Mynol dish, having been sterilized. serves as a storage several hours, then in alcohol. container. Paraform is placed in the center compartment, and the formaldehyde fumes given off are retained by a ground glass lid. Fig. L-Culture media in scaled glass tubr;; may be purchased from suppI.v rlwler.~ in The cost is nominal. and thv material remains ntablr indeflnitrly if kept ~1. all large cities. moderate temperatures.

.ESSENTIAI,S

I?S EIKDODONTIC

I’RACTIW

.Y lb'03

period of years, which show that damaged periapical tissue is repaired Pallowing treatment, and that such areas remain hea1thy.l C)ther?~3 have demonstrated that new cementum is deposited in the a.pical foramina of properly treated pulpless teeth, Nature thus sealing any collateral interstices remaining after canal filling. In determining what cases offer a favorable prognosis for treatments certain cardinal points are carefully considered. Good rcsu1t.s cannot be espected in persons of advanced years, nor in t.hose chronically ill. The same is true in instances of inaccessible teeth, and OEroot.s cstensivcly denuded by periapical or periodontal infection. On the other hand, endodontie surgery offers a very favorable prognosis in the majority of cases among young people, thus obviating the need for estraction and artificial replacemenb.

Minimum Trauma Since we look t.o the periapical Cssues for repair fol.lowing pulp ramoval, it is obviously unwise to traumatize them by ra.reless manipulations. Working under local anesthesia,, we may easily t.ramnatize these struct.nres unless we know the exact length of the t.ooth and are govenx~l a.ccordingly. A fine st.erile wire, previously gaged accordin g to the diagnostic rocntgenogram, should be inserted in t.he canal just as soon as the pull) is exposed. Having secured this wire in position, a second roentgenogram is taken (Fig. 6) without disturbing the rubber dam, which was placed at t.he onset. All instruments subsequently used should be checked with this measurement. Broaches, reamers, and files can be obtained in various lengths, and may be supplemented with “stops” made of tubing, or disks. It is only natural that meticulous instrnmentation should be accompaniecl In the past dcntist.s have frequently used potent 1)~the judicious use of h7gs. drugs in root canals without due rega.rd for t.heir ef’fect on the periapical tissues. Some OSthe compounds were a.ctually escharot,ic in action and severely damaged these structures. Such damage not only brought severe IAn, but. in many instances resulted in loss of teeth. A thorough knowledge of the action of the ilr77gs used is unquestionably essential in this phase of dcntist.ry. It now appears that the antibiotics may completely supers& chemot.herapy in endodontics. Pear,” Grossman,” and others have done consideral,ltJ work wit,h both penicillin and streptomycin. III the final analysis, however, t.he efleot.iveness of any sul:st.ance which we place in root canals to a.cconll)lish sterility will depend to a large degree on the mechanical c!lea.nsing of the canals. If t,his phase of the work is thoroughly done, t,he lwol~lrl~~ of antisepsis will be greatly simplified, no matter what we 77s~ as a chemical 01’ antibiotic agent.

Well-Adapted Fillings A well-adapted and well-tolerated filling is the final step in a good technique. The placement of such a filling has taxed the skill of the best operators. If a canal is overfilled there is impingement on the periapical tissues. They may tolerate such impingement, if it is not too great, but the process of healing is complicated and retarded when foreign subst.ances protrude beyond

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ideal canal right, bridge

Rig. 8.-The deposition of new wnrantum in the apical forarnina of ~ulplcsa teeth is the result of endodontic therapy. The roentgenogram at the left, taken immediately after fllling, shows ‘8. small quantity of sealer exactly at the apex. The roentgenogram at the taken six years later, indicates that the sealer has been resorbed and replaced by :L (Note similarity of projection in these roentgenograms.) of cementurn.

ESR&STI.U,S

IS ESDODOSTI(’

I’K.\CTICE

Fig. Il.--When the adjacent teeth are perfect, every reasonable effort should he made to save pulp-involved anterior teeth. Hew a porwlain jacket rrown 1~1s been ~dawd o!‘cr a gold core, following a successful root r~~aevtion.

12.A. .J.\SI’RH

1206 t11v apes.

On the other halltl. if :I filli~~g is short.--short, in rclatioll to the SIb2lCf3is IeI’t \~llPl’t’ CXlltl~ltt?S lllily il(c(‘ll1llUlRt~. HllCh 1111~l.lY’iI

ClPklllS~tl CLlllLll-a

is c*ertainly olle of lowt!rctl I’(lSiStil?lCtl, ;IIltl IlIlly JTiltlily IIWOIIIC iI ~‘IBC*US Oi: ifISimilarly, a pol’ous filling is llilZ~l?YlOUS. I’Ill(W il, ilPtlSr iItl(1 WPlIMIil~)tCd filling is inserted, lhtb pn1’p08(! of the fillillg Illily 1~ dc:f(*12tcbtl. II0 ?llil.tt.cl*how well the othcl* phaschsot the technique al*(’ \vorketl out. (iutta-percha has 10tlg IIWI~ il. favorite ttlat.eGaI for filling root: c:;tn>I.ls,wIltI is a good one when well eonclc~~~sc~l or closely :Itla.ptcd to the walls of l-he (!iItIiIl.

fiction.

(loolidge?”

Kronfelcl,”

ant1 otllcrs

ha vc shown

that

it is rmdily

t,Olt~~iltX?d. 1leW

being depositr~tl illllll~~tliil.t,~~l~ RCljil(‘(‘llt. to il. ITo\VchvPr. siiIc(l fSlttilpercha is easily displaced IQ- pressure, it is often very difficult to prevent ovrrfilling during the coIIdeIIsitIg ~l~~~wss. Tncidcntally, it, is exirctncly idions t.0 fill. the fine canals of multiroof (~1tectll with guttit-l)(‘rcha. The desire t.o simplify this import.a.nt phase ol’ endodontics pmqIteti the ~~llthol’,” in 1931, to have sil\.cr cones made which correspond to standard inst,iuinetits. The fact, tha.t root canals present. m;luy irregularititls ant1 iIYt’ ra.rely round wa.s not ovc400lrc~tl. O!’ iiwsssity (?iltln.lS TllUSt h ralllil~~Cd SO that, they can 1~ cleansecl. Sinma this cnlargitlg is tlonr! with routl(l, tapered N?lll~~tlt.lIlll

instrurncnts,

at least tht: :Ipi(A;Il portion

of the root canal is made ~~rmd ant1

tletinitely tapered. These colI(‘s c~omcspond to suds apertures. WhetI ;I cone has I:een fitted. it, is sealec‘l itI IIosition wit.h iI I~lan~l c~oml)onntl SUV~IiIS that: suggestetl 1)~ Dixon ant1 lii(~kc~l*l.i Gntta-pcrcha I joints ilre den OSC(~ in the col*ollill t.wo-thirds of the (*iIIIiI I t.0 \VCVI~Pthe silsc>y (‘oIlc 11IoTtl SW!IW~~. 1Iut t,his is simply R mechanical cldail. In suggesting these coII(ls. the >lllthor \V:IS a.\v;lI*e tl1a.t silver t*clot (*;ItIiIl points had been advocatctl hy others. T1oweFer?the desirability of having thrtii IIIade t.0 the proporlions 01’standard canal-enlarging instrutric~nls was cithet not. rcqqiizctl, or was coasich~rc~tllyiolltl the ;lVilil~lll~~ IIIanufacturiIig t’iICililiCS. If il wnv fits t.lic caiid looscl~~. 01’ makes conluc4 only where irregularities csisi., 1.00 IIIUP~ r~~li;l.n(~erllust 1:~ l)lIIr(ltl OII t htl sc;lling P.ouI~Iou~I~~. Sh t*iIIk;Ig(+ 01’ porosity may rcsdily

occur.

Tissue Tolerance .hl. 1941 the author’ I*eportcttl a series of 100 casts in which the C:HI~S had &II filled by this method. RtId which were subsequently esaminctl iIt int.er\:als up to seven years. This study indicated that the materials used were remarka.bly well tolerated. Since that. t.ime numerous ot.her cases have heen followed which bear out the earlier findings. In cases of vital pulp extirpation, it is sometimes difficult to liote periHowever, a t.hickening of the perioapical reactions roentgenographically. dontal membrane was usually observed several days after pulp removal and canat filling, followed by a gradual ret.urn to normal. Only those cases in which the periapical tissues resumed their normal appearance were considered successful, regardless of the estent of the damage found in the grossly infected c,qses(Figs. 9,lO and 11).

ESSESTIALS

IN

ENDODONTIC

PRACTICE

1207

References 1. Jasper, 2. 3. 4. 5. 6. 7.

E. A.: Adaptation and Tissue Tolerance of Silver R,oot Canal Fillings, J. D. Res. 20: 3.55. 1941. Coolidge! E. D.: ’ Status -----of Pulpless Teeth as Interpreted by Tissue Tolerance and Hepaw Following Root Canal Filling, J. Am. Dent. A. 20: 2216, 1933. Kronfeld, Rudolf: Histopathology of the Teoth and Surrounding Struct~urrs, Philadelphia, 1933, Lea & Febiger, p. 188. Pear, John R.: Preliminary Case Reports and Technic on the Treatment of Apical Infections With Penicillin and Streptomycin, J. Endodontia 1: 32, 1946. Grossman, L. I.: Preliminary Report on the Use of a Penicillin-Strcpt,omycin in Edodontia. J. Endodontia 3: 39. 1948. Jasper, F:. A.: Root Canal Therapy in Modern Dentistry, Dental Cosmos 75: S23, 1933. Histologic Verification of Results of Root-Canal Dixon, C. M., and Rickert, U. G.: Therapy in Experimental Animals, J. Am. Dent. A. 25: IiSl, 193%