May 3, 2016
by Dr. Gary Glassman, DDS, FRCD(C) and Dr. Ian Watson, DDS, MScD, FRCD(C)
Finding the Holy Grail. Grabbing the Brass Ring. Finding the MB2 canal in maxillary molars! Pie in the sky? We think not!
With all the technological advances that have occurred in dentistry, certainly in endodontics, the biologic objectives have remained the same, those being to eliminate and/or prevent apical periodontitis. How does one do this? There is no magic wand nor is there a simple recipe to achieve this objective. However, one thing is for sure, if a general practitioner embarks on root canal treatment, whether on a tooth with relatively simple or complex anatomy, he/she should be held to the a standard that is expected of a specialist for the procedure being performed; thorough debridement of the entirety of the canal anatomy, followed by three-dimensional obturation.
There are a lot of “moving parts” involved in achieving endodontic success. The authors agree that the most common posterior tooth we see with an endodontic failure is the maxillary first molar. First off, ALL the root canals must be located and fully negotiated, with the apical termini reached in all canals. Next, the smear layer and biofilm must be removed, followed by three-dimensional obturation. Of course, no endodontic treatment is complete until the tooth is restored to function. This may sound simple, but like other dental procedures, no tooth is the same. Even the same contralateral tooth in the same individual is never always the same.
To achieve endodontic success one must be skilled, understand the biologic system that one is working in and understand the objectives of the treatment. One should also employ the correct armamentarium, as long as he/she first has the tools. There is no question that high magnification and the development of ultrasonics for conventional endodontics have enabled many practitioners to treat more complex root canal anatomic variations more thoroughly, however, one cannot treat what one cannot see.
The incorporation of ultrasonics has almost eliminated the need for the slow hand piece when searching for canal orifices. The brushing and troughing effect of the many different ultrasonic tips allows the practitioner to uncover the canal openings with better visibility and less iatrogenic tooth destruction, not to mention the facilitation of post and fractured file removal. The ultrasonic unit and dental operating microscope are as much of a fixture in the endodontic operatory as were the silver cone pliers from days gone by.
Dental imaging has made leaps and bounds with the advent and use of the Cone Beam (CBCT). Limited field of view images taken preoperatively will allow a three-dimensional rendering of the tooth to be treated. In essence, this will provide the practitioner with a more precise “road map” with respect to the anatomic makeup of the tooth to be treated. The CBCT has further enlightened us to the complexity of the root canal system and therefore obliging the practitioner to employ an obturation technique that will improve our chances of a three dimensional seal.
An updated joint position statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology is intended to provide scientifically based guidance to clinicians regarding the use of cone beam computed tomography. https://www.aae.org/uploadedfiles/clinical_resources/guidelines_and_position_statements/cbctstatement_2015update.pdf.
In addition to the many recommendations that were given for the use of CBCT in endodontics, the position paper stated that “limited FOV (Field Of View) CBCT should be considered the imaging modality of choice for initial treatment of teeth with the potential for extra canals and suspected complex morphology, such as mandibular anterior teeth, and maxillary and mandibular premolars and molars, and dental anomalies”. Why look for an MB2 canal when it doesn’t exist and risk comprising the structural integrity of the tooth and risk perforation? After all, if it does exist then the CBCT may reveal it. That being said, one should also take the CBCT results with somewhat of a “grain of salt”, as what often may appear as a lesion of endodontic origin may only be a variation of normal. A proper systematic diagnostic protocol should always be followed by, which includes but is not limited to, pulpal and periradicular testing of the tooth (teeth) in question.
So how do we reach this idyllic Endodontic Nirvana? Even with all the technological advances that we have at our fingertips, we need to provide the patient with best possible care, and the only way one can capitalize on these advances is plain old education, experience and practice, practice, practice!!!!OH
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