Clin Dent Rev (2017)1:6

DOI 10.1007/s41894-017-0006-0

TREATMENT

Evidence-based decision-making in endodontics

Eyal Rosen1 • Igor Tsesis1

Received: 15 June 2017 / Accepted: 9 July 2017

 Springer International Publishing AG 2017

Abstract Evidence-based dentistry may be defined as an approach to oral health-

care that integrates the best available clinical evidence to support a practitioner’s
clinical expertise for each patient’s treatment needs and preferences and should be
routinely adopted by practitioners. The goal of endodontic treatment is to eliminate
a bacterial infection inside the root canal system and to prevent the invasion of
bacteria and their by-products from the root canal system into the periradicular
tissues in order to preserve natural teeth. Modern endodontic technologies improve
the ability to treat and retain teeth, resulting in a predictably favorable long-term
outcome and allowing retention of the natural dentition.

Keywords Evidence-based
Decision-making
Endodontics

Quick reference/description

Evidence-based dentistry may be defined as an approach to oral healthcare that

integrates the best available clinical evidence to support a practitioner’s clinical
expertise for each patient’s treatment needs and preferences and should be routinely
adopted by practitioners.
The goal of endodontic treatment is to eliminate a bacterial infection inside the
root canal system and to prevent the invasion of bacteria and their by-products from
the root canal system into the periradicular tissues in order to preserve natural teeth.
Modern endodontic technologies improve the ability to treat and retain teeth,
resulting in a predictably favorable long-term outcome and allowing retention of the
natural dentition.

& Eyal Rosen

dr.eyalrosen@gmail.com
1
Department of Endodontology, Maurice and Gabriela Goldschleger School of Dental Medicine,
Tel Aviv University, P.O. Box 39040, Tel Aviv 6997801, Israel

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Symptoms

The following symptoms are common in endodontic patients:

• Lingering pain
• Sensitivity to cold or heat
• Sensitivity to percussion or bite
• Discomfort in a specific area
• Swelling (intraoral and extraoral)
• Draining sinus tract

Clinical examination

The following table presents various modern endodontic technologies:

Endodontic Used Working Advantages Limitations

technology mechanism

Electronic apex For working length Uses an alternating Allows the Electronic apex
locators determination electric current working length locators rarely
To diagnose with various during root canal give accurate
perforations frequencies in treatment readings in the
order to correctly procedures to be presence of
When the estimate the most located precisely conductive
maxillary sinus appropriate end fluids, pulp
prevents point for root tissue, or an open
radiographic canal treatment apex
visualization of
the apices of
maxillary
posterior teeth
Magnification For locating, Dental operation Improves Steep learning
and cleaning, and microscopes use visualization of curve
illumination filling the root convergent the treatment
systems canal system lenses to form a field
(dental magnified image Enhances the
operating and are available ability to locate
microscope in many canals
and surgical configurations
loupes) Aids in the
removal of
separated
instruments
Permits the
diagnosis of root
and tooth
fractures
Facilitates
perforation repair
Allows case
documentation

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Endodontic Used Working Advantages Limitations

technology mechanism

Digital To obtain Direct digital Immediate The obtained

radiography radiographic radiographic availability of the radiographs
images for modalities using image for show two
evaluation sensors such as a evaluation dimensions of
charge-coupled Lowers the three-
device (CCD) or radiation dosage dimensional
photostimulable required for the objects
phosphor (PSP) image acquisition
technology
Has superior
archiving and
sharing
capabilities, and
permits easier
manipulation of
several
radiographic
properties (e.g.,
image contrast,
brightness, and
sharpness)
Cone beam For endodontic X-ray-based Permits Relatively high
computed diagnosis and computed visualization of radiation dose to
tomography treatment tomography the dentition and the patients and
planning, where the X-rays the surrounding the resulting
diagnosis of diverge, creating anatomical potential long-
apical a cone structures in term harmful
periodontitis, three dimensions effects
root resorption, Scattering artifacts
dentoalveolar in the presence
traumatic injuries of radiopaque
To assess apical materials
periodontitis, the
outcomes of
endodontic
treatments, and
tooth and root
canal anatomy

Materials/instruments

• Electronic apex locators

• Dental operation microscopes
• Ultrasonic instruments
• Digital imaging systems
• Surgical loupes

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Treatment alternatives in modern endodontics

Nonsurgical Surgical Extraction Follow up

endodontic treatment endodontic treatment

When it is practical to When an endodontic disease When the tooth May be considered
achieve the treatment is present and it is not prognosis is hopeless when worsening of the
goals nonsurgically practical to achieve the endodontic condition is
treatment goals non surgically not likely to occur

Fig. 1 Flowchart of treatment alternatives in modern endodontics

Procedure

Treatment alternatives in modern endodontics include nonsurgical endodontic

treatment, surgical endodontic treatment, and management of complications such as
root perforations, separated instruments, and root fractures (Fig. 1).

Nonsurgical endodontic treatment

Nonsurgical endodontic treatment is one of the treatment alternatives for apical

periodontitis.
Case-specific factors that significantly affect the chances of successful nonsur-
gical endodontic treatment include
• the presence of a preoperative periapical lesion
• the presence of morphological changes or complications that happened during
the previous endodontic treatment which affect the ability to adequately retreat
the entire root canal system

Surgical endodontic treatment (Fig. 2)

Surgical endodontic treatment is done to prevent the invasion of bacteria and their
by-products from the root canal system into the periradicular tissues.
It is indicated for teeth with apical periodontitis in cases where nonsurgical
treatment is impractical.
Traditional surgical endodontic treatment involves a root-end resection with a
bevel of about 45, retrograde preparation of the canal with a bur, and the placement
of a root-end filling. Traditional surgical treatment leads to moderate results (a
success rate of about 50–60%).
Modern surgical endodontic treatment uses magnification to achieve a more
accurate procedure with a minimal root-end resection bevel, retrograde canal
preparation with the aid of ultrasonic retro-tips to a depth of 3–4 mm, and a root-end

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Fig. 2a–c Surgical endodontic treatment of a maxillary premolar. a A previously treated maxillary
second premolar with a coronal restoration was diagnosed with symptomatic apical periodontitis.
b Surgical endodontic treatment was performed with minimal root-end resection in order to prevent
worsening of the crown-to-root ratio. c A 2-year follow-up radiograph. The tooth was periodontally
stable, and the periapical pathosis healed

filling. With appropriate case selection, modern surgery yields good results with a
success rate of [90%.

Management of endodontic complications

Vertical root fracture (VRF)

Vertical root fracture (VRF) is defined as ‘‘a complete or incomplete fracture

initiated from the root at any level, usually directed buccolingually.’’
Usually when a tooth is diagnosed with VRF it is necessary to extract the tooth or
the fractured root. In certain cases, and based on a case selection process that
includes a combination of endodontic as well as prosthetic, periodontal, and esthetic
considerations, it is possible to repair the fractured root using mineral trioxide
aggregate (MTA).
In the case of VRF in multi-rooted teeth, there are potential alternatives that
allow the tooth to be preserved, such as amputation of the vertically fractured root.
However, for single-rooted teeth, the entire survival of the tooth relies on the ability
to treat and maintain the fractured root.
Options for treating and maintaining VRF teeth should be selected based on the
specific tooth type, the fracture type and location, and the prosthetic, periodontal,
and esthetic condition of the tooth.
These treatment options include root amputation, apical surgery with root
shaving coronally to the fracture line, sealing/cementation of the fracture following
a flap elevation approach, or extraction and replantation.

Iatrogenic root perforations (Fig. 3)

This is defined as ‘‘mechanical or pathologic communication between the root canal

system and the external tooth surface.’’
Endodontic and restorative procedures such as access cavity preparation and
canal orifice exploration, root canal instrumentation, and post-space preparation
may lead to perforations. An effective clinical approach to root perforations is to
prevent perforation.

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Fig. 3a–d Surgical treatment of a root perforation. a A periapical radiograph revealed an iatrogenic root
perforation with associated periodontal damage in the mesial aspect of the mesial root that occurred
during the extraction of an adjacent tooth. b Following flap elevation, the perforation was sealed with
MTA. c Postsurgical radiograph. d At the 20-month follow-up, the tooth was asymptomatic, with
radiographic evidence of periodontal healing

The risk of a perforation is greater in older patients due to various anatomical,

physiological, and pathological age-related factors such as apposition of secondary
dentin, narrower root canals, and morphological changes in the tooth crown.
The prevalence of perforations is higher in mandibular molar teeth, which may be
due to significant curvature and configuration of the mandibular molar root canals.
Evaluating radiographs at two different horizontal angles and CBCT, together
with clinical examination using magnification and electronic apex locators, provides
diagnostic accuracy when identifying perforations. MTA may be used to treat
perforations, with the goal being to prevent long-lasting injury to the periodontium.

Separated endodontic instruments (Fig. 4)

The retained instrument fragment may affect the prognosis of the endodontic
treatment by preventing adequate root canal preparation, disinfection, and
obturation.

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Fig. 4 In this case, the presence

of a retained separated
instrument in the apical third of
the mesial root significantly
reduced the feasibility of
efficiently retreating the entire
root canal space. Therefore, the
tooth was scheduled for
endodontic surgery

Management alternatives for separated instruments include:

• Leaving the separated instrument in the canal while endodontically treating and
sealing the more coronal parts of the canal
• Bypassing the instrument and incorporating it into the root canal filling
• Retrieving the instrument
• A retrograde endodontic surgical approach to achieve the endodontic treatment
goals
• Tooth extraction

When the fragment is located in the apical third of the canal, fragment removal or
bypass attempts are often associated with limited success and an increased risk of
root perforation and reduced root strength. In the presence of a persistent apical
periodontitis, endodontic surgery or even tooth extraction may be the only options
in such cases.

Root resorption

Root resorption is a pathological process that can occur inside the root canal
(internal resorption) or on the outer surface of the tooth (external root resorption),
and can ultimately lead to tooth loss.
External root resorption may occur when the outer tissue on the root surface is
damaged as a result of operative, traumatic, pathological, or procedural injury. It
may be associated with a continuous stimulation such as pulp infection, or occur
without further stimulation.
Rarely, root resorption can occur as a result of systemic diseases such as
hyperparathyroidism, and may sometimes continue without further stimulation.
Diagnosis of root resorption is based on radiographic and clinical examination.
Treatment goals are to stop the ongoing resorption stimulation (i.e., the pulp
infection, the pressure from the unerupted tooth, or the forces applied as a result of
orthodontic tooth movement), remove the affected tissue, and restore the root and
the tooth to allow proper function and optimize esthetics.

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If there is pulpal involvement, root canal treatment may be required. If the root
resorption is extensive, extraction may be indicated.

Differential diagnosis

• Apical periodontitis
• Reversible and irreversible pulpitis
• Caries
• Endo-perio lesions
• Tooth and root fractures
• Perforations
• Root resorption
• Dentoalveolar traumatic injuries

Pitfalls and complications

• Possible complications include patient-related complications (i.e., undesirable,

unintended, and direct results of treatment that affect the patient and are related
to patient-specific characteristics rather than to practitioner error) and practi-
tioner-related complications (i.e., a practitioner’s error that leads to undesirable
and unintended results which affect the patient)
• Vertical root fracture (VRF) is a complication of root canal treatment
• Iatrogenic root perforations
• The main complications following perforation are periodontal destruction due to
bacterial infection and superimposition of irritating restorative materials on the
perforation site
• Separated endodontic instruments
• Root resorption

Further reading
1. Rosen E, Nemcovsky CE, Tsesis I (eds.) Evidence-based decision making in dentistry: the endodontic
perspective. In: Evidence-based decision making in dentistry. Springer, Cham. doi:10.1007/978-3-319-
45733-8_3
2. Tsesis I, Taschieri S, Slutzky-Goldberg I (2012) Contemporary endodontic treatment. Int J Dent
2012:231362
3. Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K (2015) Cone beam computed
tomography in endodontics—a review. Int Endod J 48(1):3–15
4. Tsesis I, Beitlitum I, Rosen E (2015) Treatment alternatives for the preservation of vertically root
fractured teeth. In: Tamse A, Tsesis I, Rosen E (eds) Vertical root fractures in dentistry. Springer,
Cham, pp 97–109
5. Shokri A, Eskandarloo A, Noruzi-Gangachin M, Khajeh S (2015) Detection of root perforations using
conventional and digital intraoral radiography, multidetector computed tomography and cone beam
computed tomography. Restor Dent Endod 40(1):58–67

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