The InTernaTIonal Journal o MIcrodenTIsTry
10CLINICAL
THE GENERAL DENTIST AND TIMELY REFERRALTO THE ENDODONTIST
Andrei Berdichewsky, DDS
1
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I
nt
J M
Icrodent
2010;2:10–14
Ater an accurate diagnosis indicat-ing endodontic treatment, the rootcanal system must be cleaned,shaped, and sealed. It is crucial tocarry out both the mechanical andbiologic objectives o endodontictreatment to achieve repair o theapical region.
1
The biologic objectiveconsists o eliminating bacterial con-tamination and irritation, thus leav-ing the tooth ree o organic contentin the canals. The mechanical objec-tive consists o giving the root ca-nals a constant, uniorm, and conicalshape so they can be appropriatelyobturated.
2
Although the root canalsystem ollows certain anatomicalpatterns, the position and shape othe canals vary rom case to case,posing one o the main diculties oendodontic therapy.
3
According to the American Den-tal Association Principles o Ethicsand Code o Proessional Con-duct,
4
dental proessionals—bothgeneral dentists and specialists—must respect clinical standards ocare, dened as cautious and com-petent. To properly saeguard thepatient’s welare, reerrals becomeimportant when a specialist’s skillsand experience are needed.Failing to honor these principlesnot only shatters the trust bestowedon the dental proession, but alsoincreases the risk o lawsuits. Apatient who experiences dentalproblems as a result o not hav-ing been reerred in time may losehis or her trust in the dentist. Thismay happen even i the dentisthad the best intentions and it wasthe patient who insisted on havingthe endodontic procedure carriedout. In addition, it is harder or thespecialist to treat a patient ater acomplication. With a timely reer-ral, on the other hand, the patient isprotected, and the endodontist cancarry out a procedure or which heor she has the experience, training,and knowledge, including the useo new materials and techniques.Endodontics has made signi-cant advances in recent years,allowing clinicians to providehighly reliable clinical outcomesand excellent prognoses basedon new scientic developments.New techniques and materialsavailable or both simple andcomplex cases have raised thestandards o treatment higherthan ever beore. One such de-velopment is the regular use omagnication, which has beenshown to be an excellent ally toachieve superior outcomes.
5–7
1
Visiting Proessor, EndodonticPostgraduate Program, University oChile, Santiago, Chile.
Correspondence to:
Dr Andrei BerdichewskyAv. Estoril 100 o. 308CP 7591047 Las CondesSantiago, ChileEmail: andrei@endo.cl
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Volume 2 • Number 1 • 2010
11Berdichewsky
In turn, dental clinicians nowace greater demands by patientswho have access to more inor-mation through media such as theInternet. Tools that are now usedroutinely in dental oces, such asmagnication, electronic apex loca-tors, ultrasonics, and mechanicalinstrumentation, create more pres-sure concerning the nal outcome,because all root canals must beound, even those once consid-ered calcied. The root canal mustbe ully instrumented, all postsmust be removed, all ractured in-struments must be bypassed orremoved, and in teeth with large le-sions, the dentist must create theproper conditions or healing.This paper describes some othe clinical situations in which re-erral to a specialist is needed butoten mishandled.
THE SEARCH FOR ROOTCANALS
To avoid complications, the gener-al dentist must careully search orroot canals in maxillary teeth. Thedelicate search or a canal shouldinclude microscopy and ultrason-ics to produce more accuratendings and to prevent excessivedamage to the tooth. Unortunate-ly, the general dentist’s search orthe root canal can lead to unnec-essary tooth wear. In such cases,more timely reerral to a specialistwould have led to superior results.Only ater all canals have been lo-cated can true repair begin (Figs 1to 7).
Fig 1
While searching orthe canal, the general den-tist created dangerous toothwear in the mandibular rightfrst premolar, which had anapical lesion.
Fig 2
With the use o mag-nifcation ollowing reerral,the canal was discovered, in-strumented, and obturated.
Fig 3
One year later, re-pair o the lesion is evident.
Fig 4
In some cases, thegeneral dentist will perormendodontic crown access,especially when observingwide canals such as thoseo the maxillary let lateralincisor. Unortunately, thiscan lead to complications.
Fig 5
The specialist isbetter equipped to removedental tissue accurately anddelicately to avoid unneces-sary wear o the tooth.
Figs 6 and 7
The root canal is successully obturated.
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
The InTernaTIonal Journal o MIcrodenTIsTry
12Berdichewsky
Fig 8
(left)
Patient had acute pain inthe maxillary right frst molar, but thegeneral dentist was unable to detectthe canal openings and reerred thepatient to a specialist.
Fig 13
(left)
The general dentist at-tempted endodontic treatment o themaxillary let second premolar, whichhad an apical lesion.
Fig 9
(right)
Upon examination othe chamber, a large pulp stone block-ing the canal opening was observedand then eliminated with ultrasonictips.
Fig 14
(right)
Only the buccal canal
(arrow)
was discovered upon enteringthe pulp chamber.
Fig 10
Using new techniques withthe microscope, it was ound that themolar had fve canals: two mesial (M2,MB), two distal (D2, DB), and one pal-atal (P).
Fig 15
Ater removing dentin withultrasonic fne tips, both canals werelocated and instrumented.
Figs 16 and 17
Final result ater obturation o the pulp chamber.
Fig 11
The pulp chamber ollowingendodontic obturation. See Fig 10 orabbreviations.
Fig 12
Final result showing the cur-vature o the mesial canals and the junction o the distal canals.
MBMBM2M2PPDBDBD2D2
MBMBM2M2PPDBDBD2D2Palatal canalBuccal canal
© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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