Key Points
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Describes the role of the Clinical Standards Committee of the Faculty of Dental Surgery, RCS England in producing a series of clinical guidelines.
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Introduces salient points added to the Guidelines for Surgical Endodontics over the last decade.
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Presents accumulating evidence to support the use of magnification and microsurgical techniques.
Abstract
This is the first of a series of articles, which will summarise new or updated clinical guidelines produced by the Clinical Standards Committee of the Faculty of Dental Surgery, Royal College of Surgeons of England (FDSRCS). Important developments for the dental profession from a number of clinical guidelines will be presented, commencing with the Guidelines for surgical endodontics. The impact of recent evidence relating to the outcome of surgical endodontics and techniques such as cone beam computed tomography and microsurgical techniques are considered.
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Introduction
The primary role of the Faculty of Dental Surgery, Royal College of Surgeons of England (FDSRCS) is to enable dentists to achieve and maintain the highest standards of clinical practice and patient care. This is achieved through a variety of activities, one of which is the development and maintenance of a wide range of clinical guidelines.1
The guidelines are produced by the Clinical Standards Committee of the faculty and are either the work of the committee itself or the endorsement of work by other bodies such as professional societies, NICE etc.
The committee membership includes representatives from the FDSRCS (Eng) as well as other key stakeholders including professional societies and the Department of Health. The BDJ has agreed to publish summaries of any new or updated guidelines developed by the FDSRCS (Eng), particularly if they highlight important or significant developments for the dental profession and patient care.
The first of these is an update of the committee's Guidelines for surgical endodontics which were initially produced by Professor William Saunders in 2001.2 This update has been produced by Glynis Evans, Karl Bishop and Tara Renton and was agreed by the Clinical Standards Committee of the FDSRCS (Eng) in 2011.
Outcome
The aim of root canal therapy remains the same: to clean, disinfect and seal the root canal system. Where the outcome of initial root canal therapy is uncertain or incomplete then, from an endodontic perspective, consideration can be given to either provide a nonsurgical root canal retreatment or endodontic surgery.
Since 2001 there have been two systematic reviews comparing the outcome of nonsurgical root canal retreatment and surgical endodontics.3,4 These highlight that there have been no further randomised controlled trials other than those referred to in the original guidelines.5,6 The data from this limited evidence suggests that although surgery may offer a more favourable outcome in the short-term, nonsurgical retreatment appears to offer a better long-term result.3,4 Nonsurgical retreatment may provide a better opportunity to clean the pulp space over a surgical approach and therefore remains the preferred treatment option where appropriate.5
This position appears to be supported by the historical data on the outcome of surgical endodontics, which highlights a wide range in success rates (45-97%). Recently, however, there have been a number of studies evaluating contemporary microsurgical techniques and more biocompatible filling materials. These report more consistent healing outcomes of between 88% and 96%.7,8,9 This suggests that modern surgical endodontic techniques, including appropriate case selection, are associated with a high degree of success.
Indications for surgical endodontics
There have been no significant changes to the guidelines in relation to the indications for surgical endodontics. These primarily relate to difficultly in access for conventional nonsurgical treatment or retreatment, or where access to the periapical area is necessary to aid diagnosis, for example, for biopsy or to identify a possible root fracture/perforation.
Radiographic assessment
A major development over the past ten years has been the improved access to cone beam computed tomography. The high diagnostic yield of this technique has been described with particular reference to assessment of posterior teeth before periapical surgery.10 However, for the majority of cases long-cone parallel views of teeth and adjacent structures still remains the most appropriate technique.
Clincal management
Prophylactic antimicrobials and anti-inflammatories
The routine use of prophylactic antibiotics to prevent postoperative infection in patients (not otherwise requiring such a regime for medical conditions) has not been shown to be beneficial.11 There has been no evidence, however, to negate the consideration of a peri-operative chlorhexidine mouth rinse or non-steroidal anti-inflammatory drugs (NSAIDs) to support healing and minimise swelling and postoperative discomfort.
Magnification
It would appear that most endodontists or those with an interest in the specialty use magnification during endodontic procedures including surgery. Though, the impact of magnification devices on the outcome of endodontic surgery has still not been clearly demonstrated.12
However, the use and benefits of the dental operating microscope in terms of improved visualisation and control of the surgical site is well documented.13,14 Magnification certainly allows for a more conservative approach which may reduce co-morbidities but in turn makes use of more specialised instrumentation almost essential to achieve the full advantage of a less invasive procedure.
Root-end resection
Resection of 3 mm of the root end, as close to 90 degrees to the long axis of the tooth as possible, continues to be the recommendation since this reduces the number of exposed dentinal tubules and facilitates access to all the apical anatomy.15
The resected root surface should be examined, preferably under magnification with a micro-mirror, to ensure that the resection is complete, that the surface is smooth, that there are no cracks in the root, and to check for canal irregularities.16,17
Root-end preparation
Again the recommendations remain unchanged since 2001. The preparation should be 3 mm deep, in the long axis of the tooth and incorporate the whole pulp space morphology. To achieve these objectives root-end preparation is best carried out with an angled, ultrasonically powered tip.18,19,20,21,22
The use of these tips minimises the amount of bone that has to be removed to gain access for root end preparation and allows a preparation that more readily follows the long axis of the canal as well as facilitating debridement of isthmuses. The root end cavity should be examined to ensure that the walls are free of debris, including previous root filling materials and this invariably requires the use of magnification techniques.
Root-end filling
A biologically compatible material should be used where possible and although the guidelines highlight a number of options, mineral trioxide aggregate (MTA) appears to be the material of choice at this time. Amalgam is not recommended.23,24,25,26
Outcomes of surgical endodontic intervention
The guidelines continue to highlight the importance of regular follow up to assess healing using criteria based upon clinical and radiological examination. Radiological examination should be conducted at annual intervals until healing is observed.
References
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Evans, G., Bishop, K. & Renton, T. Update of guidelines for surgical endodontics – the position after ten years. Br Dent J 212, 497–498 (2012). https://doi.org/10.1038/sj.bdj.2012.418
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DOI: https://doi.org/10.1038/sj.bdj.2012.418
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