Universitat Internacional de Catalunya
Non-Surgical Retreatment
Other languages of instruction: Catalan, Spanish
Teaching staff
Dr. José Antonio González - jagonzalez@uic.es
Introduction
Despite recent advances in endodontics, the goal of treatment is not always achieved, and apical periodontitis may persist or appear after treatment. The first option for addressing endodontic failure is orthograde retreatment. Over the course of this subject we will focus on the causes of endodontic failure and the diagnosis and treatment indicated in retreatment.
Pre-course requirements
No prerequisites
Objectives
To learn the purpose of and justification for endodontic retreatment and how to make a good diagnosis, take decisions and prepare an appropriate treatment plan.
To acquire the knowledge to remove coronal restorations and any hard dental paste, gutta-percha and cements, as well as silver tips and separated instruments.
To acquire the ability to treat a perforation and renegotiate the root canal system.
To acquire knowledge of irrigation and medication during orthograde nonsurgical retreatment.
To learn the indications and techniques of endodontic micro-surgery.
Competences/Learning outcomes of the degree programme
Be able to make an independent diagnosis, based on studying the literature on orthograde retreatment, of pulpoperiapical pathologies that persist after endodontic treatment, caused either by the perpetuation of the original ones or the appearance of a new one.
Develop an ability for self-learning in developing new techniques for problem-solving, acquiring new scientific concepts and searching for new scientific information. To achieve this, the course will be based on analysing problems, learning methods of action and developing the skills to carry them out.
Be able to make public presentations on their own clinical cases, justifying themselves based on the scientific literature and using the correct scientific terminology as it relates to pulpoperiapical disease and treatment failure.
Argue and defend one’s own scientific ideas as well as to listen, analyse, evaluate and respond to the ideas of others.
Acquire learning skills that allow them continue studying in a self-directed and autonomous mode.
Understand how to provide a basis or opportunity for originality in developing and/or applying ideas in a research context.
Apply acquired knowledge and develop a problem-solving ability in new environments within broader (or multidisciplinary) contexts related to the field of study in question.
Communicate their knowledge, conclusions and the essential concepts that support them to specialised and non-specialised audiences in a clear and unambiguous way.
Know how to apply the appropriate diagnostic techniques and correctly interpret results derived from them.
Be familiar with the general pathological characteristics of the illnesses and disorders that affect organic systems, specifically those which have dental repercussions.
Develop the ability to integrate new knowledge acquired through research and study, and deal with complexity.
Know how to apply the correct principles to control anxiety and stress in themselves, in patients and in other members of the dentistry team.
Understand and recognise the principles of ergonomics and safety at work (including the control of cross infection, radiation protection and occupational and biological diseases).
Learning outcomes of the subject
Students will be expected to:
Identify the causes of endodontic failure by analysing the data provided by a correct anamnesis and clinical and radiographic examination.
Perform the correct diagnosis and treatment planning.
Remove coronal restorations while respecting the remaining dental tissues.
Know the indications and techniques for removing the sealing materials inside the root canal system.
Know the indications and techniques for removing intraradicular posts.
Prevent and manage of iatrogenic accidents such as perforations, stripping and steps.
Know the indications and techniques related to endodontic microsurgery.
Syllabus
Topic 1. Justification for endodontic retreatment.
Identifying possible causes of treatment failure:
Biological Failures
Cysts:
Cracked teeth and fractures.
Incorrect diagnosis and treatment.
Foreign body reactions.
Healing scars.
Neuropathic problems.
Economic constraints.
Topic 2. Decision-making and treatment planning.
Success of the retreatment: from the patient's point of view and from the clinical and histological viewpoint.
Clinical guidelines of the European Association of Endodontics: Recognize the characteristics of success and treatment failure.
Decision-making: Whether to retreat or not, endodontic retreatment, apical surgery, extraction, reference to other specialists.
Decision-making and treatment planning: Where, how and when treatment was performed. Thermal testing and radiographic examination.
Factors influencing treatment outcome: Periapical periodontitis (PAI index), instrument and sealing material limitations, the size of the periapical radiolucency, technical factors, broken instruments and silver tips, types of sealing material, perforations , coronal restoration, periodontal assessment, patient expectations, cost, risk.
Treatment Planning
Cracked teeth and fractures.
Incorrect diagnosis and treatment.
Foreign body reactions.
Healing scars.
Neuropathic problems.
Economic constraints.
Topic 3. Removal of coronal restorations.
Removal of crowns.
Crown removal methods: Chisel, forceps, crown lifter, ultrasound, chisel and mallet, WAMkey, crown section, bridges.
Removal of posts: Threaded posts, cast metal posts, devices for removing posts, Ruddle removal kit, post fracture without any remaining supra-coronal material, Masserann kit, trephine, pullers, fibre posts.
Removal of amalgam.
Topic 4. Removal of paste, gutta-percha and hard cements.
Paste: Types, radiographic appearance, appearance, consistency.
Removal of paste: Mechanical, solvent preparation (types). Removal of calcium hydroxide and calcium hydroxide/iodoform drugs.
Removal of gutta-percha.
Types of obturation: single cone, Hedström files, endosonic files, nickel-titanium rotary instruments, over-extended gutta-percha, condensed gutta-percha, Gates-Glidden drill bits, heat, solvents.
Removal of gutta-percha stems: Thermafil, Hedström files, nickel-titanium rotary instruments, quickFill.
Other systems: Gutta flow, Resilon,
Removal of hard cements: Types, radiographic appearance, appearance, consistency.
Topic 5. Removal of silver tips and separated instruments.
Removal of silver tips:
Silver tips with deficient cement:
Types, appearance.
Techniques: Meitrac kit, Cancellier kit and the steel tube and Hedström file method (IRS)
Well cemented silver tips, fractured silver tips, and twisted Hedström files.
Removal of separated instruments.
Favourable factors: straight root canals, front teeth, positioned before the dental curve, fragments larger than 5 mm, hand files.
Removal stainless steel instruments: modified Gates-Glidden drill bits.
IRS (Instrument Removal System).
Removal of nickel- titanium instruments.
Modification of cavity access, direct access, release of the instrument from the walls, over-extension of the instrument, impossibility of removing it.
Topic 6. Complications during endodontic treatment
Prevent perforations: Radiography, the pulp chamber floor, calcified root canals.
Importance factors in healing perforations: level, location, size, time.
Furcal perforation: Micro-perforation (0.5 mm)
Materials: introduction to the different materials for sealing perforations.
MTA, Super EBA, IRM.
Techniques for repairing perforations: 1 step, 2 steps.
Stripping.
Drilling to fit posts.
Apical Perforations.
Negotiating the root canal system: Locating root canals, MV root canals in the upper molars, the presence of four root canals in the lower molars, two root canals in the lower incisors, two root canals present in the lower premolars. Overcoming ledges, achieving permeability.
Effects using ultrasound in endodontic retreatment.
Topic 7. Introduction to endodontic retreatment surgery: Orthograde retreatment vs. periapical surgery.
Prognosis for endodontic surgery: Complete healing, incomplete healing, uncertain healing, failure.
Current indications for endodontic surgery.
Contraindications of endodontic surgery.
Preoperative Planning: Patient factors, systemic diseases, heart disease, respiratory diseases, haematological disorders, endocrine disorders, musculoskeletal diseases, medication (non-steroidal anti-inflammatory, Warfarin, liver and kidney disease), gastrointestinal disease, pregnancy, anatomical factors (soft tissue: alveolar mucosa, attached gingiva, access and oral cavity size, braces, palate), periodontal status, restorability of the tooth, neurovascular anatomy.
Clinical assessment: extraoral examination, intraoral radiographic evaluation.
Teaching and learning activities
In person
Weekly seminars will be held.
Evaluation systems and criteria
In person
Work will be assessed weekly through presentations and the discussion of articles.
End of course examination consisting of 10 questions.
Bibliography and resources
Advanced Endodontics. Clinical retreatment and Surgery. John S Rhodes.Ed., 2006.
Problems in Endodontics: Etiology, Diagnosis and Treatment. Michael Hülsmann, Clemens Bargholz, Claudia Barthel. Quintessence, 2009.
Pathways of the Pulp. Stephen Cohen, Kenneth M. Hargreaves. Elsevier Mosby, 2011.
Articles
De Chevigny, C., Dao, T.T., Basrani, B.R. et al, Treatment outcome in endodontics: the Toronto study—phase 4: initial treatment. J Endod. 2008;34:258–263
Sjogren, U., Hagglund, B., Sundqvist, G., Wing, K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16:498–504.
Salehrabi, R., Rotstein, I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod. 2004;30:846–850.
Ng, Y.L., Mann, V., Rahbaran, S., Lewsey, J., Gulabivala, K. Outcome of primary root canal treatment: systematic review of the literature—part 2: influence of clinical factors. Int Endod J. 2007;41:6–31
Nair, P.N. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39:249–281.
Peters, O.A., Barbakow, F., Peters, C.I. An analysis of endodontic treatment with three nickel-titanium rotary root canal preparation techniques. Int Endod J. 2004;37:849–859.
Nair, P.N., Sjogren, U., Krey, G., Sundqvist, G. Therapy-resistant foreign body giant cell granuloma at the periapex of a root-filled human tooth. J Endod. 1990;16:589–595.
Aryanpour, S., Van Nieuwenhuysen, J.P., D'Hoore, W. Endodontic retreatment decisions: no consensus. Int Endod J. 2000;33:208–218.
Madison, S., Wilcox, L.R. An evaluation of coronal microleakage in endodontically treated teeth: part III—in vivo study. J Endod. 1988;14:455–458.
Ray, H.A., Trope, M. Periapical status of endodontically treated teeth in relationship to the technical quality of the root filling and the coronal restoration. Int Endod J. 1995;28:12–18.
Ruddle, C. Nonsurgical retreatment. J Endod. 2004;30:827–845.
Hülsmann, M., Stotz, S. Efficacy, cleaning ability and safety of different devices for gutta-percha removal in root canal retreatment. Int Endod J. 1997;30:227–233.
Tasdemir, T., Yildirim, T., Celik, D. Comparative study of removal of current endodontic fillings. J Endod. 2008;34:326–329.
Friedman, S., Stabholz, A., Tamse, A. Endodontic retreatment: case selection and technique—part 3: retreatment techniques. J Endod. 1990;16:543–549.