Webinar course on Complicated Endodontics and Autotransplantation

An endodontic emergency is defined as a pathology associated with pain or swelling, related to pulp and periapical tissue which should be addressed immediately, leading to an unscheduled visit. Immediate diagnosis and treatment are required to give relief to the patient. Because dental pain has many causes, the clinician must diagnose its origins as quickly as possible to provide fast and effective relief.

Four topics will be addressed in the webinar: Is it really toothache? It’s toothache. So what is your plan?

The pain has lessened a little, but the jaw is swollen like a golf ball. It still hurts. What’s wrong? The first challenge for the clinician is to understand if the pain is odontogenic or non-odontogenic; a correct diagnosis must be assessed, determining the patient’s complaint together with the medical history. Pain characteristics, such as site, irradiation, time and circumstances of onset, relieving factors, and diagnostic aids should make the clinician able to determine a pulpal and periradicular diagnosis.

Another condition is acute periapical abscess. This may be considered an advanced stage of apical periodontitis. Treatment of acute apical abscesses involves incision for drainage and root canal treatment or extraction of the involved tooth to remove the source of infection. Drainage can be achieved through root canals by first opening up the pulp chamber, but, when swelling is present, incision for drainage should also be performed. The choice to leave the access cavity open for drainage will be discussed. Acute pain following root canal procedures is another not uncommon cause of unscheduled visits. There are several factors associated with pain after root canal treatment, including the presence of pulp remnants in the canals, over instrumentation, canal contents extruded through the apex, missed canals, too high temporary filling.

The introduction of rotary and reciprocating endodontic instruments has been one of the greatest innovations in dentistry. Long and difficult procedures, largely dependent on the operator’s skills, have become now easy, fast and predictable. Anyway, most of the protocols proposed are based upon commercial criteria, and not on clinical reality. In other words, most brands propose protocols based upon the exclusive use of their instruments, often with a manual phase performed with stainless steel hand files. In the real world of contemporary endodontics, the use of hand instruments is no longer needed in most of the root canals; mixing rotary and reciprocating instruments of different brands, often without hand instruments, can lead to consistently excellent results with minimum risks and efforts. This saves a lot of time, and this time can be spent for the use of irrigation procedures, always remembering that instruments shape, but irrigants clean. Sodium hypoclorite is, still today, the gold standard for irrigation, but it can’t be used without some techniques and devices in  order to achieve the needed effect.

Endodontic retreatment represents often a clinical dilemma. In contemporary dentistry, the introduction of osseointegrated implants should have narrowed the indications for retreatment; but this is not always true. Thus, the decision-making process of retreatment is of most importance, and this, along with the formulation of a reasonable prognosis, must be deeply evaluated and discussed with the patient. A patient-centered approach is needed in order to achieve the best results. Once that the decision of retreating the tooth has been taken, it comes the time of the techniques for disassembling, that must be known and applied with due precision, avoiding damages to the remaining tooth structure. If it has been decided that the restoration is to be maintained, these techniques must be planned with the goal of an easy and predictable repair of the access cavity.

Dental autotransplantation entails extracting and repositioning a tooth into a different site in the mouth of the same patient. A successfully transplanted tooth offers several advantages, given the preservation of the periodontal ligament: the proprioceptive function is maintained, the alveolar bone volume is preserved, orthodontics can be included in the treatment plan, and the dentofacial development and growth of the jaws are not impaired. Moreover, pulp regeneration and continued root development can be expected when a donor tooth with incomplete root formation is chosen and infection of the pulp tissue is prevented. The advantage of autotransplantation over implants is that it is a biological replacement, in which a vital periodontal ligament remains. This makes it possible to move a transplanted tooth orthodontically after the operation and to effect bone regeneration if necessary. In contrast to implants, a transplanted tooth normally erupts in harmony with the neighbouring teeth during further growth and development. The surrounding gingivae and interdental papillae are thus retained. Autotransplantation can be considered an established treatment option with very high success rates. In addition to moving developing teeth, the autotransplantation of fully formed teeth could be considered an alternative to implant placement when suitable donor teeth are available.