THE SCOPE OF ENDODONTICS
The technological explosion within endodontics, specifically when applied to enhanced root canal procedures, is characterized by the development of new metals for root canal instruments, highly accurate electronic apex locators, advanced root canal sealers, irrigation solutions, and devices that promise a wide range of achievements in cleaning the root canal systems; root reparative materials for defects and surgical procedures; obturation materials and techniques that all aspire to achieve the ideal root canal fill; and the use of CBCT and magnification to improve all phases of clinical treatment and diagnosis within and around the root structure. Often lost within this expansion of tools and techniques is the essence of the specialty, which embraces the “the basic clinical sciences, including biology of the normal pulpal; the etiology, diagnosis, prevention, and treatment of diseases and injuries of the pulp and associated periradicular conditions.” Furthermore, the specialty of endodontics also encompasses a large scope of activities that go beyond “root canal procedures.” Unfortunately, this scope is not addressed in the plethora of published articles that focus on “endodontic” successful outcomes, when in actuality they are only addressing root canal procedures.
According the American Association of Endodontists, the approved scope of endodontics is as follows:
The scope of endodontics includes, but is not limited to, the differential diagnosis and treatment of oral pain of pulpal and/or periradicular origin; vital pulp therapy, such as pulp capping and pulpotomy; nonsurgical treatment of root canal systems with or without periradicular pathosis of pulpal origin and the obturation of these root canal systems; selective surgical removal of pathologic tissues resulting from pulpal pathosis; repair procedures related such surgical removal of pathologic tissues; intentional replantation and replantation of avulsed teeth; surgical removal of tooth structure, such as root-end resection, hemisection, bicupidization, and root resection; root-end filling; endodontic implants; bleaching of discolored dentin and enamel; retreatment of teeth previously treated endodontically; and treatment procedures related to coronal restorations by means of post and/or cores involving the root canal space.
Within this scope, many procedures have been abandoned in favor of different approaches to patient management, and the choices may vary based on the educational experiences and clinical expertise of the specialist and/or generalist. In fact, many are benchmark procedures that provide the specialty with its distinctive profile and have been integral components for decades, in addition to serving as the foundation for the approval of endodontics as a specialty in the United States in 1963.
Diagnosis
Difficult diagnostic challenges are a part of daily practice for both the specialist and generalist. The diagnostic phase of what is done within the scope of endodontics is just as important as what instrument to use, what material, what technique is used to fill the root canal, or where the filling is positioned apically. However, its essence is lost within the focus on endodontics as being just root canal treatment or therapy, with the glory of achievement being placed on the look of the fill on the final radiograph.
Treatment Planning Decisions
Over and above the diagnostic phase, treatment planning assumes the top position on the ladder, surpassing all of the hoopla that is focused on root canal procedures. It is this phase that determines whether or not a tooth can be retained. However, as treatment procedures are performed—such as caries excavation and/or crown lengthening—careful probing in previously inaccessible areas and disassembly of previously placed prostheses may be necessary prior to determining the integrity of the tooth in question. It goes beyond that when unanticipated issues are encountered during root canal procedures—such as a perforation or nonnegotiable root canal space—and new decisions must be made. Every step in the process is part of the scope of endodontics, yet little attention is given to the value of these entities when it comes time to announce the levels of success and failure or outcomes.
Root Canal Procedures
This part of the scope of endodontics receives the most attention, and understandably so, as it entails activities that focus on the elimination of the diseased tissues and bacteria within the root canal system. While often referred to as root canal treatment or root canal therapy, in reality, it does not qualify as treatment or therapy, as it only encompasses technical and chemical procedures that do not treat the root canal nor offer anything that is therapeutic in nature or value.
Nonsurgical Revision
The need for this procedure within the scope of endodontics is the direct result of failure to perform the initial procedures at the highest possible level in most cases. Too often, the need for revision is identified as “the original endodontic therapy failed”; however, in truth, the responsibility of the failure falls directly on the shoulders of the individual clinician who performed the initial root canal procedure.
With today’s enhanced technology, revision procedures are quite successful; however, the biggest challenge to success still focuses on the highly variable anatomy of the root canal system and the ability to eliminate the causative factors. Only too often, though, the clinician may abandon these opportunities to revise previous procedures in favor of the ease of extraction or the choice not to refer the patient to a specialist for an in-depth evaluation. This issue then reflects on the demands of the treatment-planning phase within the scope of endodontics.
Internal Reconstruction of Teeth
While the use of intraradicular posts in root-treated teeth is diminishing because of a focus on retaining sound dentin, the internal reconstruction of these teeth should be considered as essential to the ultimate success of root canal procedures. Core materials have improved significantly and offer both general practitioners and endodontists the opportunity to rebuild the ravaged tooth to a level of strength compatible with function, provided that occlusal adjustments are done properly in all working dimensions. Many of these root-treated teeth will survive with minimal, bonded restorations, while others will require full coronal coverage with margins on sound tooth structure and biological widths that have not been violated.
Root Reparative Procedures
These procedures have been quite successful due to enhanced surgical procedures and the use of contemporary materials, such as bioceramics and bioaggregates. Within the scope of endodontics, these procedures have enabled the retention of teeth that heretofore may have been extracted.
Periradicular Surgery
One of hallmarks of the specialty of endodontics is periradicular surgery and its ability to both eradicate the tissue that is reactive to the bacteria and their by-products from the root canal system and to eliminate the significant anatomical challenges that exist in the apical third of the root. Contemporary and precise techniques have characterized this procedure for the endodontist for decades, along with the establishment of a biological basis for its success.
Root/Tooth Resections
Root and tooth resections have been all but abandoned since the advent of implants 25 years ago. However, their use in tooth retention is undergoing a rethinking and rejuvenation, as implant complications and failures are beginning to become apparent in today’s populations for a multitude of reasons. Studies have shown a reasonably high level of success with resective procedures and their use within the scope of endodontics is oftentimes required for tooth retention.
Simple Tooth Extrusion
While not often encountered, a simple extrusion of a coronally fractured tooth 2 to 3 mm is well within the ability of the endodontist or general practitioner, provided treatment planning takes into account the necessary parameters of root length and width, potential aesthetic profile, and the location of the fractured or deep carious margin. This is usually accompanied by a minor crown lengthening procedure, unless the tooth is surgically repositioned and stabilized, which can also fall within the scope of endodontics.
Decompression Techniques
These techniques, used in the presence of large periradicular lesions, have all but been abandoned by the dental profession in favor of extraction or periradicular surgery and bone grafting. While the use of decompression to aid in the reduction of these large lesions is a simple and beneficial procedure, it does require patient understanding and cooperation to achieve a successful result.
Intentional Replantation/Transplantation
There are many publications that have both supported and negated the use of this procedure throughout the years, or have labeled it as the treatment of last resort. However, it still remains as a viable option. It usually requires multiple team members during the procedures, and with the intact tooth out of the mouth less than 5 minutes, retention upon replacement has an excellent prognosis.
Replantation of Avulsed Teeth and Management of Traumatic Injuries
The major emphasis focuses on the management of various types of accidental tooth fractures and the sequelae to avulsed and luxated teeth, that being tooth resorption. Contemporary techniques in early and timely management of these injuries favor tooth retention as opposed to a rapid condemning of the tooth and extraction following traumatic injuries, especially midroot and coronal root fractures.
Socket Preservation
The reader might question why an endodontist would become involved in socket preservation. There are many cases, during the diagnostic or treatment phase, in which the patient is already anesthetized, and a complication arises that would doom the tooth, eg, identification of a vertical fracture. In these cases, discussion with the patient and the referring source will often result in an agreement to remove the offending tooth at that time, when the patient is anesthetized. Subsequently, the use of grafting materials for socket preservation and ridge augmentation will provide the patient with timely and necessary treatment that favors many options for ultimate oral rehabilitation. Additionally, the use of root banking or root submergence may be advantageous and easily performed to ensure the viability of an alveolar ridge for subsequent implant or fixed bridge placement.
Regenerative Considerations
Procedures within this realm are just emerging, but they are designed to retain teeth. The characterization of these procedures to achieve predictability await clarification; however, significant research efforts are underway.
Placement of Implants and Endodontic Endosseous Implants
The placement of implants by endodontists is slowly emerging as an accepted procedure; however, there are negative perceptions on the part of some groups. The placement of endodontic endosseous implants has a long history with success being achieved and identified in limited case reports. With the advent of newer materials for both the implant and the potential sealing of the implant at the apical root-implant interface with bioceramics or bioaggregates, the use of these augmentations should be reconsidered.
CONCLUSION
While the majority of activities within endodontics represent root canal procedures, many successes are achieved using the wide range of procedures that fall within the broad and varied scope of practice. In doing so, the very essence of this specialty is defined most accurately and the impact of tooth retention for the patient is greatly enhanced.F
Editor’s Note: References to support this article can be obtained from the author.
Dr. Gutmann, a graduate of Marquette University School of Dentistry, has taught full time for more than 27 years at 3 major universities in the United States and is professor emeritus in restorative sciences at Texas A&M University Baylor College of Dentistry in Dallas. He is past president of the American Association of Endodontists and is currently president of the American Academy of the History of Dentistry. He is a consultant to DENTSPLY Tulsa Dental Specialties, editor of the Journal of the History of Dentistry, and has authored or co-authored more than 300 articles in both dental journals and texts that address scientific, research, educational, and clinical topics. He is the senior author of an endodontic text entitled Problem Solving in Endodontics, the senior co-author of a text entitled Surgical Endodontics, and co-author of the text entitled The Clinician’s Endodontic Handbook. He can be reached at (214) 449-4424 or via email at jlg4570@aol.com.
Disclosure: Dr. Gutmann serves as a consultant to DENTSPLY Tulsa Dental Specialties but has no financial interest in any products mentioned in this article.
