Endodontics

General Guidelines
The scope of endodontics includes, but is not limited to, the differential diagnosis and treatment of oral pains of pulpal and/or periradicular origin; vital pulp therapies; root canal therapy such as pulpectomy, nonsurgical treatment of root canal systems with or without periradicular pathosis of pulpal origin and the obturation of these root canal systems; selective surgical removal of pathological tissues resulting from pulpal pathosis; intentional replantation and replantation of avulsed teeth; surgical removal of tooth structure such as in apicoectomy, tooth sectioning and root amputation; bleaching of discolored dentin and enamel of teeth; retreatment of teeth previously treated endodontically; and treatment procedures related to coronal restorations by means of post and/or cores involving the root canal space.

All endodontic treatment procedures should be of such quality that predictable and favorable results will routinely occur. Patients should be aware that any treatment modality, however acceptable, may not be successful in each and every case. Extrinsic and intrinsic factors, both biological and psychological, may preclude success for any particular tooth treated.

Endodontic therapy is usually indicated in primary or permanent teeth with diseased or injured pulpal tissue. The total condition of the patient’s remaining dentition, oral cavity, and general health, as well as the condition and the endodontic history of the teeth, must be considered and recorded.

The endodontic examination should consist of a complete medical and dental history and radiographic examination and a clinical examination including electrical, thermal, percussion, palpation, translumination and bacteriological tests when indicated.

Special tests must be performed to arrive at the correct diagnosis. Recent radiographs of the tooth in question, and of the adjacent teeth and alveolar bone, must be available at the time of clinical examination and diagnosis. Records should be kept of all pertinent information, including the diagnosis made and the treatment performed.

Immediate postoperative radiographs are helpful in evaluating endodontic therapy. Periodic examinations, including periapical radiographs, clinical examinations and a record of the presence or absence of symptoms, are valuable in determining the long-term results of endodontic therapy.

Treatment Modalities
Vital pulp therapy consists of pulp capping or pulpotomy.

Pulp capping is a procedure in which an exposed or nearly exposed pulp is covered with a dressing or cement that protects the pulp against further injury and permits healing and repair. Two different techniques of pulp capping are recognized:

1. Direct pulp capping, in which a protective dressing is placed directly over a vital pulp at the site of exposure.

2. Indirect pulp capping, in which a protective dressing is placed over a thin partition of remaining dentin which, if removed, might expose the dental pulp.

Pulpotomy, or vital pulp amputation, is the surgical amputation of a portion of an exposed vital pulp, usually to preserve the vitality and function of the remaining radicular portion.

Root canal therapy consists of the complete removal of pulpal tissue and the obturation of the canal(s). It is indicated on any diseased or injured tooth, provided that the tooth can be restored to its normal function, has strategic importance for restoration, and is periodontally sound or can be made so, and that its apex can be sealed intraradicularly or surgically.

A recall for clinical evaluation of tissue repair is indicated within six months to a year following the endodontic treatment. Comparison of the new recall radiograph with the final-treatment radiograph should show improvement of the bony architecture. Complete healing may require months to years.

Endodontics Quality Evaluation Criteria

ITEM	RATING AND EXPLANATION
	ACCEPTABLE	NOT ACCEPTABLE
VITAL PULP THERAPY Direct Pulp Capping   Indirect Pulp Capping   Pulpotomy	Performed when there is a Pulpal exposure but no prior evidence of irreversible pathosis. Performed when there is no prior evidence of irreversible pulpal pathosis   Deciduous teeth (with a useful life and function). Performed only when coronal pulp pathosis is evident or when a pulp exposure is too large to be pulp capped. Permanent teeth Performed only when there is no evidence of pulpal or periapical pathosis and apical development of the root(s) is incomplete.	Performed when there is evidence of pulp necrosis.         Performed when there is evidence of massive pulp pathosis, periapical involvement in either deciduous or permanent teeth or deciduous teeth that are soon to be exfoliated and where there is complete apical development of permanent teeth.
ROOT CANAL THERAPY	Periapical radiographs show good endodontic treatment and periapical healing   The patient indicates the tooth has been asymptomatic (apart from transient discomfort immediately after filling).	No follow-up examinations established   Edema is present in the area and/or a fistula has developed in relation to periapical infection.  An area of rarefaction increases in size.
Access   Obturation	The response to endodontic treatment has been evaluated by follow-up examinations The access is suitable to accomplish intraradicular cleansing, enlarging, shaping and filling of the root canal(s). The radiographic image appears to occupy the root canal space totally, both laterally and vertically.  Inadvertent overfills or underfills are satisfactory if no postoperative sequelae of long duration have occurred.  There are no voids in the apical one-third of the tooth, which may precipitate periapical pathosis.	Perforation of the crown or root has occurred and has not been repaired.  Access is other than directly into the canal orifice, except when malpositioning or crowded conditions indicate otherwise.   The radiographic image of the filling material appears not to totally occupy the root canal space; particularly as observed in the apical one-third, chronic periapical inflammation continues or has occurred.
Apexification	Closure of the apex is evident radiographically or clinically.	A fistula or prolonged periapical inflammation persists.
SURGICAL TREATMENT	Clinical and radiographic evidence shows healing	Inadequate followup with clinical and radiographic examination
OTHER ENDODONTIC PROCEDURES Hemisection Root amputation Beaching Replantation Implants	All of the procedures are satisfactory when adequate clinical and radiographic evidence justify their use	Clinical and radiographic evidence is insufficient to justify use of the procedure.