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Endodontics

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Overview
Endodontics (root canal treatment) is the branch of dentistry that deals with the entire pulpal cavity containing the dental pulp and root canals of the teeth.

Endodontic treatment is necessary whenever a lesion (decay or trauma) causes irreversible alterations to the pulp tissue, which may even lead to necrosis. This treatment is also useful when prosthetic rehabilitation of a tooth element is performed that could give rise to irreversible pulpal alterations (pulpal necrosis for iatrogenous causes) due to considerable reduction in the dental tissue itself.

 

How it works

Laser-assisted Root Canal Treatment
The use of lasers in Endodontics offers remarkable advantages in the treatment of vital and necrotic elements with infected roots and granulomatous or periapical cystic lesions.
By integrating traditional instrumental root canal techniques with correct laser use, the number of failures in endodontics can be drastically reduced. This limits the spread of infections inside the oral cavity and protects tissue integrity to the utmost.
The KTP (532 nm), Nd:YAG (1064 nm) and diode (810 or 980 nm) are the laser sources most widely used in endodontics.
The laser is used to ensure:
  • enhanced decontamination of the root canal area;
  • perfect drying of the canal and apical delta;
  • haemostasis in case of bleeding;
  • vitrification and sterilisation of the endodontic dentine, especially in the apical delta;
  • removal of the smear layer and any pulpal residues;
  • heating of the gutta-percha in cutting and compacting operations.

One of the main aims of root canal treatment is to obtain a highly decontaminated canal environment so as to maximise the probabilities of success.

In line with the modern approach to root canal treatment, the procedure for preparing the canal consists of:

  • total removal of the pulpal tissue and all pathogenic microorganisms present;
  • preparatory shaping of the canal to enable easy and efficacious filling.

Despite the method used, these goals are unfortunately not achieved in 100% of cases since a certain quantity of pulpal tissue and microorganisms always remains inside the canal lumen. Infection of the canal pulp allows bacteria to invade the entire canal system, and the 3D tubular network provides the perfect habitat where microorganisms can survive and multiply out of reach of the defence mechanisms. Bacteria and their toxins are free to migrate to the apical regions, inducing an inflammatory reaction with subsequent bone reabsorption. The therapeutic aim of each treatment is consequently to heal and protect the periradicular tissue, only possible when the root canal and adjacent tissues are free of infected microorganisms.

There are three main difficulties to be overcome in achieving a decontaminated environment:

  • anatomical conformation;
  • specific quality of the bacterial colonisation (anaerobic gram-negative species); bacteria resistant to oral irrigants.

The anatomical structure of the root canal represents a problem for achieving perfect decontamination in both macroscopic and microscopic terms. The residual smear layer remains in the various recesses, exacerbating the inflammatory process. The micro-environment of the dental tubules favours the selection of the relatively few types of bacteria found there. Out of approximately 300 types of bacteria present in the oral cavity, only a dozen manage to survive in the canal. When an infection is in progress, the canal dentine acts like an incubator where bacteria thrive without encountering any agents of the immune system.

Traditional root canal treatments aim at reducing the microbial load via mechanical removal of the infected pulp and washouts of the root canal with specific antibacterial irrigants. Liquid solutions with sodium hypochlorite and/or hydrogen peroxide are normally used for removing the pulpal residue (smear layer) and eliminating the pathogenic germs. The germicide potential of these irrigants develops thanks to direct contact with the cells of these microorganisms. This is obviously a disadvantage with canal irrigants since the bactericide effect is only present in the root canal. In fact, the penetration capacity of the irrigants is limited to the walls of the root canal due to the limited diameter of the tubules and high surface tension of the irrigants themselves (not more than 100-200 µm inside the dental tubules).

Since its launch, laser has represented a valid means of making the radiation penetrate deep down into the dentine thanks to the use of fine fibres with a diameter of 200 µm.
Schoop et al. ("Innovative Wavelengths in Endodontic Treatment". Laser Surg Med 2006. 38(6):624-30) demonstrated that by using suitable protocols, the antimicrobial capacity of the laser begins to decrease after a penetration of 1,000 µm in the root canal dentine, without however creating any thermal increase which could damage the periodontal structures, and preventing the risk of radicular perforation. Clearly, the decontaminant and antimicrobial action of the laser is much higher than that of the irrigants. For this reason laser-assisted endodontic procedures ensure a much higher number of successes compared to those performed using only traditional techniques.