VOL.9 NO.

10 OCTOBER 2004

Dental Bulletin

Recent Advances in Endodontics

Dr Robert PY Ng BDS, MSc, MClinDent, MRD RCSEd, AdvDipEndodont, FRACDS, LDS RCSEng
Assistant Professor, Faculty of Dentistry, The University of Hong Kong

Dr Robert PY Ng

Introduction
Endodontics is the branch of dentistry concerned with the
aetiology, prevention, diagnosis and treatment of diseases
and injuries that affect the dental pulp, tooth root and
periradicular tissues.1 At the beginning of the last century,
focal infection theory had severely threatened the
existence of the discipline. Since then, the issue of focal
infection has reappeared and become a concern in
dentistry, but a definite causal effect has not been shown.2
In recent years, advances have been made in various
aspects of endodontics, from diagnosis to treatment. This
has been made possible mainly by a better understanding
of the pathophysiology of the pulp and periradicular
tissues and the emergence of new technologies.

Diagnosis of Pulpal/Periradicular Diseases

Diagnosis of pulpal and periradicular diseases has been
made difficult due to the inaccessibility of the diseased
tissues for direct inspection. Indirect signs, such as
radiographic findings, presence of pain and swelling, have
been used to aid in the diagnostic process. However, it
has been shown that the correlation between pulpal
inflammation and pain is poor3 and the radiograph is not
a very sensitive tool in detecting minor changes in the
periradicular tissues.4 The various methods of testing pulp
sensibility each have their own drawbacks.
It has been suggested that by sampling pulpal fluids to
detect certain inflammatory markers, the pulpal status
could be determined more accurately.5 Hopefully, this
would differentiate between reversible and irreversible
pulpitis and thereby allowing the selection of the correct
treatment modality either to preserve or to extirpate the
inflamed pulp. It is important, especially in cases of
trauma, to determine whether the dental pulp has retained
its blood supply. Traditionally, this has been inferred by
testing the sensibility of the dental pulp but errors could
occur. With the advent of laser Doppler flowmetry (LDF),
the blood supply in a tooth could be assessed and its vitality
determined accurately. Due to a possible loss of nerve supply
in traumatised teeth, LDF is useful as a tool to monitor the
vitality and recovery of such teeth from trauma.6

Prevention of Pulpal Diseases

Although caries and restorative procedures could cause
pulpal inflammation, the predominant cause of pulpal
inflammation is microbial microleakage.7 Much effort has

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Dantal Bulletin.p65

been used to improve the properties of dental materials

in order to control microleakage. These improved
materials are used to reduce the gap at the restorationcavity wall interface or to coat exposed dentine surface.
However, during function, a tooth would deform, the
physical barrier formed by these materials would break
down as they could not deform to the same degree as the
tooth. Until this stumbling block is overcome, it is unlikely
that any dental materials could achieve a total and
permanent seal against microleakage. From a biological
perspective, adherence of bacteria to exposed tooth
surfaces is a prerequisite to establishment of bacterial
colonies and biofilms leading to subsequent microleakage.
It is likely that research into preventing bacterial
adherence onto tooth surfaces would provide the answer
to microbial microleakage

Treatment of Exposed Pulp

The outcome of direct pulp capping depends on the
presence of a healthy pulp, asepsis as well as the absence
of microbial microleakage. Traditionally, calcium
hydroxide had been the material of choice as a direct pulp
capping agent. Recently, adhesive materials have been
suggested as a replacement for calcium hydroxide, but
the reported results have been equivocal.8,9 A recently
introduced material - mineral trioxide aggregate (MTA),
has been shown to be highly biocompatible.10 MTA is
capable of stimulating dentine bridge formation adjacent
to the exposed dental pulp. Direct pulp capping with MTA
has been reported to result in less inflammation,
hyperaemia, necrosis and thicker dentinal bridges and
more frequent odontoblastic layer formation with MTA
than calcium hydroxide. Apart from direct pulp capping,
MTA is also suitable for repair of root perforation,
obturation of incompletely formed roots and as a root end
filling material.11

Root Canal Treatment

The process of root canal treatment aims to remove
microorganisms, organic and inorganic debris from the
root canal system by mechanical instrumentation with
files and chemical disinfection with irrigating solutions
and intra-canal medicaments. Given the complexity of the
root canals, preparation of the root canals is fraught with
difficulties and iatrogenic problems are not uncommon.
One of the common obstacles faced by the operator in root
canal treatment is the location of the root canals. In teeth

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with large deposits of reparative dentine and sclerotic

canals, location of the root canal orifices could be
problematic. Naturally, a thorough knowledge of root canal
anatomy and fine tactile sense are essential. However, with
the help of good magnification and illumination provided
by an operating microscope, in experienced hands, location
of root canals could be made easier.12 In addition, using a
microscope, with the help of a suitable dye, minute crack
lines could be more easily identified.12
Apart from helping to locate canals, an operating
microscope (or some other form of magnification) is
invaluable in endodontic retreatment.12 With its enhanced
vision and lighting, an operator could carry out various
procedures, such as bypassing or removing separated
instruments, negotiation of ledged canals, repair of root
canal perforations and placement of materials such as
MTA, more efficiently.
A new breed of endodontic files, made from a nickeltitanium (Ni-Ti) alloy, has been introduced. The Ni-Ti alloy
has the desirable property of superelasticity, which makes
endodontic files made of this alloy very flexible. These files
are able to prepare curved canals concentrically and reduce
the incidence of iatrogenic errors13, with comparable ability
to remove intra-canal bacteria as stainless steel hand files.14
Furthermore, because of its flexibility, the files could be
manufactured with an increased taper and potentially could
enable the operator to complete root canal preparation with
less time and effort.
In an ideal world, in order to preserve the maximal amount
of tooth substance after endodontic therapy, its root canals
should not be mechanically prepared but cleaned
thoroughly with irrigants. A group of researchers in
Switzerland has pioneered a method called the Noninstrumentation Technique, using a partial vacuum
system to deliver the irrigant into the root canal system.15
This could be a potentially useful system but at present,
is still regarded as experimental.
Various alternative methods to enhance disinfection of
root canals have been introduced recently. Photo-activated
disinfection (PAD) is a process whereby microorgansisms
are sensitised by a photoactive agent, tolonium chloride.
When the agent is stimulated by a light of an appropriate
wavelength, radicals are released and bacteria are
ruptured.16 Ozone gas is a powerful oxidative agent and
is potently bactericidal.17 For endodontic purposes, it has
been suggested that ozonated oil should be used instead,
although there has been no reports on its efficacy.
Ozonated oil has been claimed to be equally bactericidal
and has a long shelf life. Numerous types of lasers are
available and some of them such as, Er:YAG, Er,Cr:YSSG
and Ho:YAG, appear to be promising in root canal
preparation.18 These types of laser have been touted by
their manufacturers as replacement of traditional root
canal files but further development and scientific proof
of their efficacy are required.
Cold lateral condensation of gutta-percha with sealer is the
most widely used root canal obturation technique practised
by dentists. The technique is easily mastered and requires
little ancillary equipment. However, it has been shown in
leakage studies that the apical seal produced by cold lateral
condensation is far from ideal.19 Various thermoplasticised

Dental Bulletin
gutta-percha techniques have been reported to produce a
better apical seal 19 and it has been shown that the same
technique could fill a higher percentage of lateral canals.20
However, to some researchers, gutta-percha is not the ideal
root canal obturation as potentially a path for leakage is
always present between the canal wall and the obturation
material.21 A resin-based obturation material has recently
been introduced to eliminate this weak link. By bonding
the obturation material to the root canal wall, a monobloc
of root dentine and composite resin would be formed and
minimise microleakage.21

Surgical endodontics
When a patient does not wish to undergo non-surgical
endodontic retreatment or when the procedure is not
indicated, then surgical endodontics should be considered
in order to preserve the tooth.
The use of an operating microscope and miniaturised
ultrasonic tips and hand instruments has revolutionised
surgical endodontics.22 An operating microscope provides
co-axial lighting and a range of magnification from x 5 to
x 30. This will enable the operator to examine the apical
region of a root for crack lines and the resected root end
for presence of any accessory anatomical features such as
fins or isthmuses between root canals.22
Using specially designed miniaturised ultrasonic tips to
prepare the root end cavities enables the operator to
perform root resection at approximately right angle to the
long axis of the root, as opposed to a forty-five degrees
root resection in earlier days.22 Some of the advantages of
this modern approach are minimising the risk of iatrogenic
errors, reducing the number of exposed dentinal tubules
and preservation of root dentine.
MTA was originally tested as a root end filling material
before its wider applications in endodontics, such as direct
pulp capping, were recognised. MTA has been shown to
promote deposition of cementum on its surface and to be
perfectly compatible with the periapical tissues 23 .
Compared to other root end filling materials with a longer
history of use, such as amalgam, IRM or Super EBA cement,
little or no inflammatory cells could be detected in the
vicinity of MTA but the same cells would be present around
the older materials in greater quantity.23 However, the
handling properties of MTA are not as user friendly as the
other materials and its use would require some practice.

Conclusion
There have been advances in all aspects of endodontics,
which allow the operator to provide high quality
endodontic treatment. Regardless of whether the
treatment is preservation of the exposed pulp, first time
root canal treatment, root canal retreatment or surgical
endodontics, the key to success is still the attainment of
sterility within the root canal system.24 Unless this is
achieved, endodontic treatment is likely to fail, despite
all the new equipment and technology at our disposal.
Moreover, it is interesting to note that the success rates of
first time root canal treatment and root canal retreatment
reported in the literature have not changed significantly
since the second half of the last century.24
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Dental Bulletin
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