Endodontics

Endodontics is the medical science, within the field of dentistry, that deals with the treatment of the endodontium, i.e. the inner part of the tooth, called the pulp.The aim of endodontics is to maintain, whenever possible, the vitality of the pulp with methods designed to stimulate the repair of the part damaged by infection. If neglected, infections can progress to the point of causing necrosis of the pulp itself and promote the onset of root and periodontal disease (bone-gum ligament).In the case of extensive damage or death of the pulp, removal of the inflamed or necrotic pulp tissue is necessary.

The anatomy of the tooth
Teeth are held in a stable position within the jawbone by means of the roots that are inserted and fixed in it. The anterior teeth, i.e. the incisors and canines, have only one root, while the posterior teeth, the molars and premolars, may have one or more roots: it is the tip of each root that is called the apex of the tooth. The apex is the portion of the root through which blood and nerve vessels irrigate and innervate the tooth, supplying blood and sensitivity and passing through the root canal to the pulp chamber. Inside the pulp chamber houses the pulp, the vital portion of the tooth, which is covered and protected from all external physical and chemical insults by the dental crown.In addition to the vascular supply, the pulp provides nutrients to the dentine, and, being highly receptive to changes in temperature, trauma and pressure variations, the pulp imparts sensitivity to the tooth through the nerve bundles enclosed within it. Toothache and dentinal hypersensitivity are the two main complaints caused by an inflammation of the pulpal tissues.When a tooth is particularly damaged, to the point of exposing the pulp and creating uncontrollable pain and excessive sensitivity.

Diseases of the dental pulp
Severe trauma, a severe tooth chipping or an infection in the tooth can severely impair the function and structure of the tooth element, causing very intense pain and initiating a series of disorders that can irreversibly damage the tooth. Infection of the pulp is almost always caused by bacteria that are present in the mouth, but normally cannot reach it, because the enamel is impermeable to bacteria. But if the enamel is damaged, they reach it causing inflammation and then death (pulp necrosis). Once the pulp is dead, the bacteria pass through the apex of the root and manage to reach the bone, causing an infection (abscess).Pulpitis is the general inflammation of the pulpal tissues, a typical consequence of inadequately treated caries. It cannot be treated by simple dental filling, devitalisation is required. Only in extremely severe cases, extraction of the tooth is required.Abscess is an accumulation of bacteria, white blood cells, plasma and pus in the tissues surrounding the tooth. When the abscess involves the dental pulp, the patient experiences a stabbing toothache that is difficult to relieve with classic analgesic drugs.If diagnosed in time, before the infection spreads to the pulp or socket, the abscess can be treated with antibiotic treatment or drainage of the purulent material that has accumulated inside. Root cyst is the typical complication of dental pulp necrosis, which is in turn induced by trauma, deep caries or pulpitis.apicectomy is the treatment of first choice to cure it. Dental granuloma is a chronic, generally asymptomatic inflammation of the root apex and neighbouring tissues. When not treated in time by devitalisation or apicoectomy, dental granuloma can encroach into the dental pulp, causing pulpitis and necrosis of the dental pulp.

Devitalisation or root canal therapy
This treatment is necessary when, in the presence of traumatic injury or a penetrating (or deep) caries lesion, the pulp tissue becomes inflamed resulting in bacterial contamination (pulpitis). Root canal therapy involves the removal of inflamed or necrotized pulp tissue from the tooth, either at crown or root level, in order to eliminate the infection that is often painful for the patient and ensure the preservation of the tooth element itself.This procedure is commonly referred to as devitalisation, as it deprives the tooth of the nerve and vascular endings that make it vital and sensitive. The devitalisation process involves a few essential steps: emptying the crown and root canals of the tooth by removing necrotic pulp tissue and shaping the root canals to make them suitable for receiving the filling material. The root canal cleaning and sterilisation to prevent the spread of bacteria and toxins. The permanent filling of the canals by means of the root filling material and radiographic control of the result. In this way, it is as if the tooth were dead, no longer vital but still fully functional, so that its sensitivity and pain complaints are eliminated, while its basic function remains intact.Sometimes, root canal therapy is necessary on a healthy tooth because of special prosthetic rehabilitations that require the use of a tooth element as an abutment, or because of excessive sensitivity to thermal stimuli (pain to heat and cold).

Prevention after endodontic procedures
After a root canal treatment session, sensitivity and slight swelling may appear, which can normally be resolved with analgesic medication. It is important not to chew food on the treated tooth until it is fully restored. A tooth treated with root canal treatment, if particularly weakened by the caries that made devitalisation necessary, may be more fragile and require covering with a crown to avoid fractures.Sometimes, for a few weeks after root canal treatment has been completed, sensitivity to percussion or chewing may persist. If the symptoms persist longer, it may be necessary to check for possible complications.Although root canal treatment has a very high success rate, there are cases in which infections appear after treatment that require further treatment or even extraction of the tooth. In fact, even treated teeth can be re-infected with caries with the difference that, being devitalised, one no longer feels pain and if one is not careful one only notices the infection when it is in an advanced state.After the endodontic treatment has been completed, regular check-ups (normally every six months) are essential for the health of the tooth undergoing root canal treatment. Regular check-ups combined with scrupulous oral hygiene not only keep the teeth and gums healthy but also enable the treated tooth to last a long time.

The retrograde filling
It is performed in the case of abscess or granulomatous lesions that endontic therapy alone has failed to heal or in cases where correct orthodontic therapy cannot be performed due to the presence of previous prosthetic restorations and/or endocanal pins. Granuloma is a pathology frequently related to pulpal inflammation and can evolve into an abscess. It is a lesion caused by the propagation of infection beyond the end of the tooth root (root apex) with consequent involvement of the surrounding tissue and bone. When an attempt to resolve the problem with a second root canal therapy could cause further damage rather than resolving the infection, the removal of the root tip (apicoectomy) and the infected tissue by surgery must be resorted to.If this is not possible, the alternative therapy remains the extraction of the tooth and its root, with replacement of the missing element by a prosthesis, bridge or dental implant.