What is endodontics in dentistry? Effective endodontics. Tools

Why do you need a dental microscope?

The microscope makes it possible to see the root canal system at multiple magnification, which allows you to:

see channels all over
detect additional root canals
find difficult areas in root canals
remove broken instruments that block the lumen of the root canals and thereby worsen the prognosis of treatment
remove old filling material
treat root canals
find and fill perforations in root canals
find cracks in teeth.

An endodontist will not treat teeth that need to be removed, as this is a waste of time and money for the patient. However, the doctor will do everything possible to preserve the natural tooth.

Endodontist's tasks

The patient is referred to a doctor who specializes in endodontics if a diseased incisor or trauma causes pulpal or root complications. Such a specialist is well trained and has sufficient experience in root canal therapy.

The endodontist deals with unfilling and re-treatment of incompletely cured units. He also performs an operation to resect the apex of the tooth root.

Endodontics is now at a high level, and this makes it possible to carry out therapeutic procedures in dental clinics of any size.

There is also advanced endodontics to help treat the most serious cases. It uses high-tech instruments (special tip, microscope and other devices).

Endodontics makes it possible to open the problematic element, extract the pulp, treat it with antibacterial agents and seal the entire length of the canal. Next, you can begin the restoration of the dentition.

What are the causes of pulpitis?

Most often, pulpitis is a complication of caries if the patient does not treat carious cavities in the teeth for a long time. It is during the process of caries that the diseased tooth is destroyed so much that the infection from the depths of the carious foci freely enters the root of the tooth, into its canal, affecting the nerve (pulp), causing its inflammation. In particular, these can be streptococci, lactobacilli, staphylococci, as well as their toxins and waste products. Also, pulpitis can be a consequence of poor-quality fillings, incorrect actions of the doctor when grinding the tooth, surgical intervention on the gums, or exposure to chemicals. In addition, pulpitis can be triggered by trauma (for example, a fracture or bruise of a tooth).

In accordance with the nature of the course of the disease, acute, chronic and chronic pulpitis with exacerbation are distinguished.

If the inflammatory process in the pulp is not treated, it spreads deeper, beyond the root canal into the tissues surrounding the tooth (tooth ligament and jaw bone). This inflammatory process is called periodontitis. Cysts, granulomas and fistulas are manifestations of periodontitis.

When is endodontic therapy performed?

Endodontics is indicated in the following cases:

deep caries;
chronic or acute pulpitis (inflammation of the connective tissue, accompanied by sharp or acute pain, sensitivity when touching cold and hot food, darkening of the enamel, as well as swelling of the gums);
periodontitis, when the tissues surrounding the tooth root become inflamed and a purulent formation appears.
preparatory work before prosthetics. Destruction of the nerve will be required when installing orthopedic elements.

What are the symptoms of pulpitis and periodontitis?

Symptoms of pulpitis include:

spontaneous aching tooth pain, which often manifests itself at night;
pain radiates to the ear, temple and along the jaw on the side of the tooth;
prolonged pain from any type of irritant;
increased sensitivity and pain to cold and sometimes hot;
rarely increased temperature;
bad breath.

It is often very difficult for the patient to determine the causative tooth on his own; the pain is diffuse and spreads to neighboring teeth, sometimes opposite ones.

To determine the causative tooth, among other examination methods, an x-ray is taken.

Periodontitis is characterized by:

pain when biting on a sore tooth;
pain when eating hot foods;
with periodontitis, the patient, as a rule, can accurately indicate the causative tooth;
redness of the gums;
swelling of the gums or cheeks;
rarely increased temperature;
bad breath.

Root canal treatment

There are primary root canal treatment and re-treatment (when the doctor re-treats the root canal for the nth time). The prognosis for success in the manipulation varies and often depends on the condition of the tooth, its anatomy, the qualifications of the doctor and the equipment of the office. With primary canal treatment, the prognosis for success in performing manipulation is higher than with repeated treatment. When repeating treatment, it becomes necessary to remove the previous filling material, which is not always possible; it is more difficult to achieve sterility of the root canal. At this stage, doctors are greatly helped by a dental microscope, which helps to see and completely remove the filling material from the root canal and, thereby, significantly improves the effect of medications during canal treatment.

Treatment of pulpitis (primary canal treatment) usually involves removing the inflamed pulp (nerve) from the root canals, cleaning them and filling them. This method is called depulpation. After removing the nerve and filling the canal, the doctor takes a control x-ray, after which a permanent restoration can be made on the tooth, suitable for the degree of its destruction (filling, ceramic inlay or crown).

There is one exception: in the early stages of nerve inflammation, a so-called biological method of treating pulpitis is possible, which allows you to preserve the nerve and not interfere with the root canal system. It consists of treating the inflamed pulp with special preparations and subsequent high-quality tooth restoration. It is relevant only in cases where irreversible changes have not yet occurred in the dental pulp. This period lasts extremely short. At a later stage, depulpation is already performed. That is why immediate consultation with a doctor is mandatory, and it is best to come for preventive examinations 2 times a year and completely prevent the development of pulpitis.

If pulpitis is not treated, the inflammatory process sooner or later spreads to the tissues surrounding the tooth, and this inflammatory process is called “periodontitis” (in other words, “granuloma” or “tooth cyst”). Periodontitis is a more extensive inflammatory process, so it is more difficult to treat than pulpitis (since the infection is not only in the root canal, but also spreads beyond it). If the treatment of pulpitis requires one visit to the dentist, then the treatment of periodontitis requires several visits, and this can take up to several months. If the doctor is unable to perform a root canal for some reason, and therefore fails to fight the infection (that is, complete sterilization in the root canal does not occur), then treatment of the dental cyst may be difficult. In this case, surgical intervention may be required, including tooth extraction followed by implantation.

What is an endodontist?

An endodontist is a doctor who has undergone special training in root canal treatment and has complete knowledge on the subject. The general practitioner is less qualified in this matter; his knowledge covers a wider range of dental problems. An endodontist must have a special diploma in endodontics. To learn how to properly treat canals, a doctor must study for several years, and this must be evidenced by a diploma. In many clinics such diplomas hang in a prominent place.

An endodontist has more manual skills than a dental therapist, as he is constantly involved in root canal treatment. A dentist-therapist has to constantly solve different problems.

The endodontist has the most modern and advanced techniques, because endodontics is an actively developing area of dentistry. A dentist-therapist works using traditional, often outdated methods.

The endodontist uses more advanced medicines and medical devices due to the technology of the process. The dentist-therapist uses classical preparations and instruments.

An endodontist provides better dental services, given that many problems cannot be solved in principle without him.

What methods of endodontic treatment exist?

Treatment consists of mechanical and medicinal treatment of the root canal. Mechanical debridement refers to the widening of the root canal with the removal of infected tissues inside the root canal (that is, pulp, destroyed tissues and dentin lining the inside wall of the root canal). Medical treatment of root canals is performed using solutions. When treating periodontitis, the doctor sometimes leaves in medication to better sterilize the root canal system. If the inflammatory process around the tooth root is small, then the drug is left for several days. If the inflammatory process is significant (cyst), then the medicine can be left even for several months. During the treatment period, the tooth is closed with a temporary sealed filling to prevent microbes from re-entering the root canal.

What does an endodontist do during treatment?

Let's first understand what endodontics is. This is a narrow specialty in dentistry that is aimed at studying problems inside the tooth, namely in the root canals. In many countries, endodontists are a kind of elite among dentists. This is, of course, due to the complexity of the work and the level of responsibility for treatment.

An endodontist is usually the specialist who saves teeth from removal. His help is necessary when the infection penetrates inside the tooth and affects the pulp or when the infection extends beyond the apex of the tooth root and causes inflammation of the periapical tissues.

A doctor working in the canals deals with microstructures that are difficult to see with the naked eye. To do this, you need an operating microscope, the work with which is honed through hours of practice, because all manipulations take place in a mirror image and it takes time to feel the hand in space. Photo 1 as seen without magnification

Photo 2 as seen through a microscope

The main task of the specialist is to find all the root canals and remove necrotic tissue from them, since it is this that is the source of infection and further complications.

Before treatment, it is recommended to do a computed tomography to visualize the tooth, its root system and see the number of root canals; on CT they are visible as dark stripes. Photo 3 root canals

In practice, it is not always possible to accurately determine the number of root canals from an image. I have come across descriptions of radiologists (professionals in reading images), in whose conclusions the number of channels did not correspond to reality. It is possible to clearly determine only with the help of a microscope, after careful mechanical and medicinal treatment of the tooth. This is due to the complex structure of the tooth root system. Photo 4 is what the entrances to the main root canals look like, but there is an additional one and we found it after special scouting in the next photo

Photo 5 Here is the mouth of an additional root canal in tooth number 16, which often causes inflammation if undetected.

The doctor’s next question is preparing a clean surgical field so that unnecessary bacteria do not enter the tooth cavity. This requires a rubber dam, which isolates the tooth from the oral cavity, from saliva and gum fluid. It is also necessary to remove all caries (this is a bacterial zone) and all old fillings and restorations before treatment. It is necessary to create a sealed, clean core section. Photo of tooth 6 before filling replacement

Photo 7 tooth is fully prepared for endodontic treatment

Next, the specialist dives into another floor of the tooth - this is the area of the coronal part. If this is primary inflammation of the pulp, then the entire main infection is concentrated here. Therefore, before moving it through the root canals, it is necessary to carry out treatment using ultrasound and an antiseptic. If a tooth is re-treated, then often this area is filled with softened dentin and necrotic tissues; everything is cleaned using an antiseptic, ultrasound and special burs. Photo of tooth 8 before cleaning

Photo 9 clean tooth after treatment

Next begins the most difficult, but at the same time interesting, work of the doctor. It must be said that endodontists who like to “rake” / “digging” in root canals cause misunderstanding among colleagues. You need to have a certain character. These are often pedantic people who love to put everything in its place and clean out their spaces, get to the bottom of things and solve all sorts of difficult problems. Only with such data can you be an excellent specialist in root canal treatment. Actually, you already understand what the doctor does at this stage :) Yes, he finds, clears, passes through, washes out, expands. Makes the root canal as clean as possible. This process takes a lot of time, since you need to work with small structures carefully. Therefore, you often need to spend about two hours in the dentist’s chair, and there may be 2 or more visits.

Also at this stage, all modern instruments : files, machine tools, antiseptics, special disposable needles for irrigating solutions and, of course , ultrasound . In our clinic we use the most modern apparatus for irrigating root canals. The unique features of ultrasound, such as cavitation, microstreaming and heat generation, make it possible for the irrigant to penetrate the deep structures of root microdentin and microtubules. All this helps to remove bacteria from the tooth root as much as possible. In addition to ultrasound, we need manual nickel-titanium files for primary streaming. Going through root canals puts stress on the metal, so these instruments are often disposable and thrown away.

Next, the working length is determined using an apex locator . A mouthpiece is hung on the patient's cheek, and we hook it to the file; this method allows us to determine the length of the root canal. An x-ray is required with the files, thanks to which we confirm the working length. And only after all the checks does the root canal expand.

To do this, we use machine tools; each canal is processed with about five machine files; between sizes, the canals are thoroughly cleaned using an irrigant and ultrasound. So let’s imagine the upper sixth tooth, a molar, 4 root canals. In total, 20 dives with mechanical files, about 8 manual dives and many dives with an ultrasonic tip and endo-needle, until the doctor sees through a microscope that the irrigant in the canal is clean, without chips and reactions. All these manipulations require concentration, time, and most importantly patience and responsibility. After all this work, medicine is often given to create an alkaline environment that is harmful to many bacteria. The tooth is closed with a dense filling, and the patient leaves for 2 weeks. There is an important point here: a good temporary filling will never pop out of a tooth. And we have already understood that it is important to create clean conditions inside the root. Therefore, if your temporary filling does not hold or chips, think about whether your treatment is truly airtight. After all, the success of treatment depends on this.

After a break of 2 weeks, the patient and doctor meet again to continue the work. On the second visit, the doctor again rinses and cleans the root canal, dries everything out and seals the passage tightly. We are guided by the principle - nature abhors a vacuum! All root canals that previously contained neurovascular tissue (pulp) must be tightly sealed with gutta-percha pins and a special sealer. There are many filling methods. In our clinic we often use one of them - the vertical condensation method. A master pin is inserted into the root canal, the excess is cut off with a hot plugger, and the apical zone is compacted with plasticized gutta-percha using a continuous wave.

photo 10 view of a filled tooth

The final stage is tooth restoration. The endodontist makes a build-up, the foundation for the future crown. It is of course completely sealed. And transfers the patient to an orthopedist to restore the coronal part using indirect restoration. The choice of design will depend on the degree of tooth decay.

Medicine is moving forward and now a device is being developed that would be able to carefully pass, expand and rinse the root canals, without using so many tools and time. The introduction of laser and vacuum systems is taking place at a slow pace. Perhaps, if we obtain positive long-term results, we will soon use such methods in practice and will be able to save more teeth from removal, reduce the treatment time, making it high-quality and at the same time fast.

What are the recommendations for dental care after endodontic treatment?

Often, after endodontic treatment, it is recommended to restore a tooth with a crown or ceramic inlay. This is due to the fact that pulpitic/periodontitis teeth, as a rule, are initially already heavily destroyed by an extensive carious process. In addition, in the process of accessing root canals during their treatment, additional loss of tooth tissue occurs, which leads to a decrease in the strength of the tooth several times. It should be remembered that if you simply put a filling on a severely damaged tooth, after some time the tooth may develop a crack, it may split in half and such a tooth will have to be removed. Read why this happens here. That is why, after root canal treatment, placing a filling is not always possible and a more adequate method of restoration would be an inlay or a crown.

However, in some cases, with slight destruction of tooth tissue, a regular filling is sufficient. The choice of restoration method after treatment is made by the doctor, justifying and coordinating his choice with the patient.

There is evidence that pulpless (“dead”) teeth do not last long. A study was conducted to determine the survival rate of teeth after endodontic treatment. On average, such teeth function for only 5 years.

This is not entirely true.

Problems in pulpless teeth may be associated with:

with poor quality treatment;
with inadequate tooth restoration after endodontic treatment (when the tooth is restored incorrectly, i.e., an unsuitable restoration is selected).

Prerequisites for successful and long-term tooth restoration are high-quality treatment and filling of root canals and a sealed restoration adequate to the degree of destruction.

But even more effective: timely treatment of caries, before root canal diseases occur.

How long does it take to treat one tooth?

There are teeth that have only one root canal, but chewing teeth, in most cases, have four root canals. The number of root canals affects the time required for treatment. At a minimum, it takes at least 40 minutes to treat one root canal. In most cases, treatment consists of two visits. On the first visit, the doctor removes the old restorations and the carious process (if there was one), restores the tightness of the wall, puts on a rubber dam (a system for temporarily isolating the tooth from oral fluid) and begins treatment of the root canal or root canals. After this, the canal is temporarily filled with medicine, and the tooth is closed with a temporary filling. The next visit, depending on the extent of the inflammatory process, is scheduled after 2-14 days. During a follow-up visit, the doctor treats the root canals with medicated solutions, seals them with a permanent filling material for canals (usually gutta-percha) and restores the tooth with a filling or prepares the tooth for a ceramic inlay/crown.