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QUALITY GUIDELINES
ª 2006 International Endodontic Journal International Endodontic Journal, 39, 921–930, 2006 921
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Quality guidelines European Society of Endodontology
means of a core and/or a post involving the root canal lymphadenopathy, presence of sinus tracts and pres-
space and/or endodontically related measures in con- ence of temporomandibular joint dysfunction.
nection with crown-lengthening and forced eruption
procedures and treatment of traumatized teeth. As part Intra-oral examination
of dentistry’s main goal to maintain a healthy, natural The practitioner should look for the standard of oral
dentition for the public, the aim of endodontic treat- hygiene, condition of oral mucosa, presence of swell-
ment is to preserve functional teeth without prejudice ings and sinus tracts, condition of teeth present,
to the patient’s health. Every dental practitioner is periodontal condition, quantity and quality of restor-
expected to be able to recognize and treat effectively ative work.
pulpal and periapical injuries and diseases that are
commonplace and within the skills acquired by gradu-
Diagnosis
ates of dental schools in Europe (European Society of
Endodontology 2001). The cases that are beyond an The cause of the patient’s complaint should be identi-
individual dental practitioner’s means concerning fied. Some or all, of the following diagnostic tests may
diagnostic and/or technical alternatives should be be applied: palpation, mobility test, percussion, perio-
referred to a colleague who has completed specialty dontal examination, occlusal analysis, testing for
training in Endodontology (European Society of Endod- possible cracked teeth, pulp sensitivity tests, transillu-
ontology 1998) or to a colleague who has acquired the mination, selective local anaesthesia, radiography
necessary expertise elsewhere. (normally by using the paralleling technique and a
beam guiding device for good reproducibility), colour
matching and sinus tract exploration. It may be
History, diagnosis and treatment planning
necessary to take radiographs from more than one
Many features of evaluation in Endodontics are com- angle, sometimes supplemented with bitewing and
mon to all aspects of dental practice. These elements occlusal plane radiographs. Some patients may have
are herein abbreviated, yet included for the purposes of to be recalled at periodic intervals to compare some of
completeness. the examination data from one time interval to another
to make an accurate diagnosis of the onset, progression
or arrest of a certain process. At times it is advisable to
Medical and dental history
obtain radiographs from previous practitioners to have
Medical history should reveal any medical condition or a clearer understanding of the progress of a condition
medication which might influence diagnosis, e.g. (as it presents to the clinician at a given time). This is
sinusitis, neoplasia, or treatment which may be influ- the case especially where previous root canal treatment
enced by dental procedures; this should include allergy. has been carried out.
Dental history discovers factors that may be import-
ant for diagnosis and treatment planning. History of
Treatment planning
present complaint is recorded briefly and preferably in
the patient’s own words. Pain history is recorded to Treatment should be planned for those teeth that are
give information on the pain, but phrased to avoid functionally or aesthetically important and have rea-
leading questions. The questions may include: the sonable prognosis. Procedures to maintain pulp health
nature, duration, site, periodicity, precipitating or are described in ‘Management of the vital pulp’.
relieving factors and associated symptoms.
Indications for root canal treatment
Root canal treatment may be carried out on all patients
Clinical examination
where other dental procedures may be undertaken.
The patient should be examined both extra- and intra- Specific indications are
orally and may also need to be checked for pyrexia and 1 An irreversibly damaged or necrotic pulp with or
blood pressure. without clinical and/or radiological findings of apical
periodontitis.
Extra-oral examination 2 Elective devitalization, e.g. to provide post space,
The practitioner should look for asymmetry, presence prior to construction of an overdenture, doubtful pulp
and extent of swelling in the head and neck region, health prior to restorative procedures, likelihood of
922 International Endodontic Journal, 39, 921–930, 2006 ª 2006 International Endodontic Journal
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
European Society of Endodontology Quality guidelines
pulpal exposure when restoring a (misaligned) tooth tial for medico-legal reasons. These guidelines are
and prior to root resection or hemisection. limited specifically to record keeping in relation to
endodontic treatment.
Contra-indications for root canal treatment
1 Teeth that cannot be made functional nor restored.
The following should be recorded
2 Teeth with insufficient periodontal support.
3 Teeth with poor prognosis, uncooperative patients or Presenting symptoms, history of the present complaint
patients where dental treatment procedures cannot be with a dental history related to this, results of clinical
undertaken. examination and sensitivity tests, report on radio-
4 Teeth of patients with poor oral condition that graphs taken, diagnosis and treatment plan.
cannot be improved within a reasonable period.
Informed consent
Indications for root canal retreatment
1 Teeth with inadequate root canal filling with radio- Where there are alternative treatments or special
logical findings of developing or persisting apical problems, these should be explained and discussed
periodontitis and/or symptoms. with the patient along with the likely prognosis and
2 Teeth with inadequate root canal filling when the recorded. It is good practice to provide the patient with
coronal restoration requires replacement or the coronal written information. It should be recorded that the
dental tissue is to be bleached. patient has agreed to the treatment and to the cost.
ª 2006 International Endodontic Journal International Endodontic Journal, 39, 921–930, 2006 923
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Quality guidelines European Society of Endodontology
924 International Endodontic Journal, 39, 921–930, 2006 ª 2006 International Endodontic Journal
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
European Society of Endodontology Quality guidelines
Radiographic
Preoperative radiograph
The instrument should be equipped with some form of
A preoperative radiograph showing at least the full length indicator and be of sufficient size so that its tip
root(s) and approximately 2–3 mm of periapical region, can be clearly identified on the radiograph. A radio-
must be examined prior to treatment. graph is then taken which should show the instrument
and the apex with minimal distortion. The desired
working length is determined. If the distance between
Local anaesthesia
the tip of the instrument and the desired working
The need for local anaesthesia should be considered length is >3 mm, the working length of the file is
and given as appropriate. adjusted and a further radiograph taken. It may be
necessary to take more than one working length
radiograph.
Preparation of tooth
All caries and defective restorations should be removed
Preparation of the root canal system
and, if necessary, the occlusion adjusted and the tooth
protected against fracture. The tooth should be capable The objectives of preparation are to: remove remaining
of being restored and isolated and the periodontal pulp tissue, eliminate microorganisms, remove debris
status should be sound or capable of resolution. and shape the root canal(s) so that the root canal system
can be cleaned and filled. The use of magnification and
additional sources of light facilitate identification of root
Isolation of tooth
canal anatomy. The requirements should be: the pre-
Root canal treatment procedures should be carried out pared canal should include the original canal, the apical
only when the tooth is isolated by rubber dam to: constriction should be maintained, the canal should end
prevent salivary and bacterial contamination, prevent in an apical narrowing and the canal should be tapered
inhalation and ingestion of instruments and prevent from crown to apex. Preparation should be undertaken
irrigating solutions escaping into the oral cavity. with copious irrigation. The final length of the prepar-
ation should not be reduced by treatment.
Access cavity preparation
Irrigation
The objectives of the access cavity preparation are to:
remove the roof of the pulp chamber so that this The objectives of irrigation are to: eliminate microor-
chamber can be cleaned and good visibility of the canal ganisms, flush out debris, lubricate root canal instru-
orifices can be obtained, enable root canal instruments ments and dissolve organic debris. The irrigant solution
to be introduced into the root canal(s) without undue should preferably have disinfectant and organic debris
bending, offer sufficient retention for a temporary dissolving properties, whilst not irritating the periradi-
restoration and conserve as much sound tooth tissue cular tissues. The irrigant solution should be delivered in
as possible that is compatible with the above. copious amounts as far up the canal as possible without
risking extrusion beyond the foramen. This can be
performed with a syringe, ensuring that the solution is
Determination of working length
allowed to escape freely into the pulp chamber and is not
The objective of determining the working length is to delivered with excessive force. The solution may also be
enable the root canal to be prepared as close to the delivered by ultrasonic or sonic systems.
apical constriction as possible. The location of the
apical constriction normally varies between 0.5 and
Inter-appointment medication
2 mm from the radiographic apex. Recommended
methods are electronic and radiographic. The objectives of inter-appointment medication are to
prevent growth and multiplication between visits of
Electronic microorganisms left in the canal system despite clean-
Electronic devices measure the length of the root canal ing. They should be used following proper cleaning and
accurately in most cases. The working length should irrigation and to support the tissue-dissolving effects of
normally be confirmed radiographically. irrigating solutions. This stage is rarely necessary after
ª 2006 International Endodontic Journal International Endodontic Journal, 39, 921–930, 2006 925
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Quality guidelines European Society of Endodontology
pulpectomy and root canal preparation of a tooth with following are standard sub-procedures: incision and
a vital pulp. An effective temporary restoration is drainage, apical surgery, other surgical endodontic
essential to prevent contamination of the canal procedures and extraction with replantation. Pre-sur-
system between visits. The requirements of an inter- gical planning is necessary.
appointment disinfectant are: have long-lasting disin-
fectant action, be biocompatible, be removable and be
Incision and drainage
nondamaging to tooth structure or the restorative
material. The objective is to release exudate that is entrapped
within tissue and cannot be drained through the root
canal or as an emergency treatment prior to starting root
Filling of the root canal system
canal treatment in cases of fluctuant swelling. Anaes-
The objectives are: to prevent the passage of microor- thesia should be obtained. An incision is made into the
ganisms and fluid along the root canal and to fill the fluctuant swelling and drainage established. If microbial
whole canal system, not only to block the apical sensitivity testing is to be carried out, aspiration of
foramina but also the dentinal tubules and accessory contents of the swelling should be performed prior to
canals. Materials used to fill the root canal system incision. A drain may be positioned in the incision
should be: biocompatible, dimensionally stable, able to wound. The tooth is then, or shortly thereafter, isolated
seal, unaffected by tissue fluids and insoluble, nonsup- and the root canal(s) prepared. If no drainage can be
portive of bacterial growth, radiopaque, and removable obtained and there are systemic effects from the infec-
from the canal if retreatment needed. tion, the use of antibiotics may be considered.
The root canal filling should consist of a (semi-) solid
material in combination with a root canal sealer to fill
Apical surgery
the voids between the (semi-) solid material and root
canal wall. Sealers containing organic materials such General principles
as aldehydes are not recommended. Filling should be Suitable anaesthesia is obtained. An appropriate
undertaken after the completion of root canal prepar- surgical flap design is chosen and the mucoperio-
ation and when the infection is considered to have been steum, handled with minimal trauma, is reflected.
eliminated and the canal can be dried. In some cases it Bone overlying the lesion is then removed, the
might be recommended that prior to filling, the appropriate procedure (see below) is performed and
completion of root canal preparation is verified by the flap is replaced and then sutured. A postoperative
taking a radiograph with the root canal instrument(s) radiograph is then taken. Advice is given on post-
(or filling cones) inserted to the full working length. operative care.
The end-point of the inserted instrument (or cone) and
the apex should be visible on this verification radio- Exploratory surgery
graph. The quality of filling should be checked with a The objective of exploratory surgery is to diagnose an
radiograph. This radiograph should show the root apex endodontic problem that cannot be diagnosed in any
with preferably at least 2–3 mm of the periapical region other way. It is necessary to reflect a flap to examine
clearly identifiable. The prepared root canal should be the area, e.g. for a longitudinal root fracture. Appro-
filled completely unless space is needed for a post. The priate treatment is then carried out.
prepared and filled canal should contain the original
canal. No space between canal filling and canal wall Periradicular curettage
should be seen. There should be no canal space visible The objective of curettage is to remove diseased tissue
beyond the end-point of the root canal filling. and/or foreign material from the alveolar bone in the
The tooth should be adequately restored after root apical or lateral region surrounding a pulpless tooth.
canal filling to prevent bacterial recontamination of the The procedure is rarely used alone and only when the
root canal system or fracture of the tooth. root canal system has been considered satisfactorily
disinfected and filled.
Surgical endodontics
Biopsy
Surgical endodontics is performed when intracanal The objective of biopsy is the surgical removal of a
approaches are technically difficult or impractical. The tissue specimen for microscopic examination. It is
926 International Endodontic Journal, 39, 921–930, 2006 ª 2006 International Endodontic Journal
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
European Society of Endodontology Quality guidelines
ª 2006 International Endodontic Journal International Endodontic Journal, 39, 921–930, 2006 927
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Quality guidelines European Society of Endodontology
4 years the root canal treatment is usually considered diagnosis and treatment. These quality guidelines
to be associated with post-treatment disease. mainly focus on the endodontic component of dental
trauma.
Root canal treatment has an unfavourable outcome In addition to the regular medical and dental history,
This occurs when other information is required such as photographs and
1 The tooth is associated with signs and symptoms of the type, time and location of the accident. Depending
infection. on previous vaccinations the patient may require
2 A radiologically visible lesion has appeared subse- immunization against tetanus, if a wound or replanted
quent to treatment or a pre-existing lesion has tooth has been contaminated with soil. More than one
increased in size. tooth may be affected by different types of injury. The
3 A lesion has remained the same size or has only practitioner carrying out endodontic treatment may
diminished in size during the 4-year assessment period. not have seen the patient at the time of injury.
4 Signs of continuing root resorption are present.
In these situations it is advised that the tooth
Crown infraction
requires further treatment.
An incomplete fracture of the enamel, which may
Exception An extensive radiological lesion may heal extend into dentine, without the loss of tooth sub-
but leave a locally visible, irregularly mineralized area. stance. Usually no treatment is indicated.
This defect may be scar tissue formation rather than a
sign of persisting apical periodontitis. The tooth should
Crown fracture
continue to be assessed.
Uncomplicated
A fracture of enamel or enamel and dentine without
Assessment of surgical endodontics
pulp exposure. Enamel fractures may require selective
Surgical endodontics should be assessed after 1 year grinding of the incisal edge only and/or restoration.
and subsequently as required. The following findings When a fragment can be repositioned, it should be
indicate a favourable outcome: absence of pain, bonded in place. Fractures of enamel and dentine
swelling and other symptoms, satisfactory healing of require coverage of the exposed dentine as soon as
soft tissue, no sinus tract, no loss of function and possible for protection against the oral environment.
radiological evidence of repair of apical periodontitis
including reformation of the periodontal ligament Complicated
space. It should be noted that occasionally a radiolu- A fracture of enamel and dentine that exposes the pulp.
cent area, ‘surgical defect’ or ‘scar’, may persist. If
there is a persisting lesion after 1 year, it should be Vital pulp, open apex If the patient is seen up to several
followed up for 4 years (see ‘Assessment of outcome of days after injury, pulp amputation should be performed
root canal treatment’). (see ‘Treatment procedures for reversible pulp
damage’). The level of amputation should be in the
most coronal pulp tissue, which is not inflamed and
Secondary sources of compromised treatment
where haemorrhage can be easily controlled. The
outcomes
exposed dentine should be covered and a bacteria-
Factors that may lead to new disease and thus tight seal applied. The pulp status should be monitored.
jeopardize endodontic treatment include, e.g. recurrent
caries and coronal leakage, caries extending into the Necrotic pulp, open apex This requires the preparation
root canal or furcation, root fracture, root perforation of an access cavity, establishment of canal length,
or extending marginal periodontitis. cleaning and minimal mechanical preparation of the
canal supported by much irrigation (see ‘Irrigation’).
The canal is dried and filled with a material that permits
Traumatic injuries
healing and repair of the root-end and surrounding
Traumatic injuries may have an effect on dental hard tissues, prevents bacterial contamination and can be
substances, the pulp and the periodontium. Therefore, easily removed; the access cavity is sealed. The
often a multidisciplinary approach is needed in development of an apical barrier should be monitored.
928 International Endodontic Journal, 39, 921–930, 2006 ª 2006 International Endodontic Journal
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
European Society of Endodontology Quality guidelines
Necrotic pulp, fully formed root Root canal treatment is Lateral luxation
indicated (see ‘Root canal treatment’). Displacement of a tooth in a direction other than
axially with comminution or fracture of the alveolar
bone. The tooth should be repositioned immediately
Crown-root fracture
and further treatment performed as described in
A fracture that involves enamel, dentine and cemen- ‘Extrusive luxation’.
tum. The tooth needs to be assessed for restorability.
Where it is restorable, treatment of pulp tissue in this Intrusive luxation
situation is similar to the treatment of crown fractures Displacement of the tooth into the alveolar bone with
(see ‘Crown fracture’). It may be necessary to consider comminution or fracture of the alveolar bone.
root extrusion and/or periodontal surgery.
Open apex In cases of minor displacement no treatment
should be undertaken as the tooth may re-erupt
Root fracture
spontaneously. If the intrusion is severe orthodontic
A fracture of dentine and root cementum involving the and orthodontic/surgical reposition should be
pulp. The pulp is damaged but not exposed to the oral considered. The pulp status should be monitored.
cavity. Treatment is aimed at maintaining pulp vitality; Where signs of periradicular radiolucency or
this may include repositioning of the coronal part and inflammatory root resorption are seen the necrotic pulp
placement of a splint attached to the injured and should be removed immediately, the tooth should be
adjacent unaffected teeth. The splint should be main- treated endodontically (see ‘Necrotic pulp, open apex’).
tained for approximately 3 weeks (longer in cases of
great mobility) and allow optimal oral hygiene. If the Root formation completed The tooth is repositioned
coronal pulp becomes necrotic, that part of the canal orthodontically and/or surgically, the pulp should then
should be treated endodontically. A root-end closure be removed as soon as possible and the canal cleaned to
procedure (see ‘Crown fracture’) for this part may be prevent infection. The tooth should be treated
considered. On those rare occasions where the apical endodontically (see ‘Root canal treatment’).
part becomes necrotic this should also be treated; if root
canal treatment of the apical part associated with
Minor fractures of the alveolar process associated
apical periodontitis is impossible via the coronal part,
with traumatized teeth
the apical part of the root should be removed surgically.
Bony fragments should be repositioned and soft tissue
wounds sutured as necessary. The teeth involved
Luxation
should be splinted to include at least one unaffected
These injuries have caused damage to the periodontal tooth on each side. The splint is left in place for up to
ligament and the alveolar bone; the greater the affected 3 weeks.
root area, the more the prognosis is reduced. Inflam-
matory root resorption is a sequel to pulp necrosis and
Avulsion of the tooth (exarticulation)
infection. Ankylosis, the replacement of the root by
bone, is a late complication and progressive. Cervical A displacement of the tooth out of its socket. The tooth
resorption is another possible complication. should be replanted as soon as possible, by the patient,
ª 2006 International Endodontic Journal International Endodontic Journal, 39, 921–930, 2006 929
13652591, 2006, 12, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2591.2006.01180.x by Cochrane Mexico, Wiley Online Library on [24/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Quality guidelines European Society of Endodontology
930 International Endodontic Journal, 39, 921–930, 2006 ª 2006 International Endodontic Journal