TreatmentStandards180 N. Stetson Ave.Suite 1500Chicago, IL 60601aae.org
IntroductionEndodontics is the branch of dentistry that isconcerned with the morphology, physiologyand pathology of the human dental pulp andperiradicular tissues. Its study and practiceencompass the basic clinical sciences includingbiology of the normal pulp, and etiology, diagnosis,prevention and treatment of diseases and injuriesof the pulp and associated periradicular tissues asdefined by The American Dental Association andAmerican Association of Endodontists.The American Association of Endodontists servesas a trusted and credible source for information ondiagnosis of pulp and periapical pathosis, treatmentplanning, urgent/emergent treatment, vital pulptherapy, nonsurgical root canal treatment, surgicalendodontics, regenerative endodontic procedures,and outcome assessment.Treatment by the general dentist is expected tomeet minimum standards as set out in guidelines.The American Association of Endodontistshas developed and published as “Standards ofPractice”. These guidelines were developed to assisteducational institutions and organized dentistryin developing minimum educational requirementsand practice standards in endodontic treatment.The primary objective of endodontic treatment is toprevent and intercept pulpal/periradicular pathosisand to preserve the natural dentition when affectedby pathosis. The practice model in the United Statesis predicated on general dentists having the basicknowledge and experience regarding endodontictreatment to perform the majority of nonsurgicalroot canal procedures on uncomplicatedpermanent teeth.Access additional resources at aae.orgDespite similar predoctoral educational curricula,disparities exist in the levels of knowledge,competency and skill, and clinical experiences ofgeneral dentists. Over the past two decades therehave been significant advances in technology,materials and endodontic treatment procedures.These include but are not limited to microscopy,rotary Ni-Ti files, ultrasonics, enhanced irrigationsolutions and technologies, digital radiography,CBCT three dimensional imaging, bioceramics, etc.These changes have created a disparity in thequality of care provided by specialists versusgeneral dentists on teeth with complicatedanatomy and morphology.The effect of these developments on the Standardof Care remains unknown. Currently generaldentists perform approximately 75% of allnonsurgical endodontic procedures. Whileendodontists perform only 25% of the total rootcanal procedures, they treat 62% of the molars.With generalists performing the majority ofthe uncomplicated anteriors and premolars itappears that the predoctoral educational processand procedures in general practice should beconcentrated on uncomplicated permanent teethwith specialists treating the more complicatedmolars.Treatment is based on a thorough understandingand interpretation of all diagnostic informationincluding patient history, clinical and radiographicexamination. Following the establishment of adiagnosis, treatment planning should considerthe following patient modifiers: the strategicimportance of the tooth/teeth being treated,the periodontal status, structural integrity andrestorability of the tooth, the long term prognosisfor success, and patient factors such as the medicalstatus, attitude and desires, motivation, anxiety, jawopening, the gag reflex, disease state, and financialresources.
The scope of endodontics in general dentistryincludes: Differential diagnosis and treatment of pain and/or swelling of pulpal and/or periradicular origin Urgent/emergent treatment of pain and/orswelling to include the pharmacologic use ofantibiotics, anti-inflammatory agents, analgesicdrugs and incision for drainage of localizedabscesses Urgent/emergent management of traumaticinjuries to the dentoalveolar structures Vital pulp treatment to include step-wise cariesexcavation, indirect and direct pulp capping, andpulpotomy procedure Non-surgical root canal treatment for thepermanent dentition Bleaching of discolored dentin and enamel ofteeth Treatment procedures such as post and/or coresinvolving the root canal spaceStandard of PracticeGeneral dentists should provide endodontictreatment consistent with contemporaryendodontic standards, their knowledge and clinicalexperience, and technical skills. The standards ofpractice are constantly changing based on newevidence and technology. It is the responsibility ofall practitioners to be life-long learners, in order tomeet contemporary standards.Self-evaluation is a critical component of life-longlearning. The generalist should be able to criticallyevaluate their own competency as diagnosticiansand clinicians and identify areas that requireadditional educational experiences. Based onthis evaluation each practitioner must be ableto determine their own skill and learning inorder to determine when the patient shouldbe referred to the appropriate specialist forconsultation/treatment.Methods of traditional education and the emphasison facts are changing. Information technologyhas transformed the dental profession and placedemphasis on the evidence based practice model.Contemporary methods of education emphasizingproblem solving and critical thinking skills employand stress professional interactions and thebenefits of multidiscipline and interdisciplinarycare.AAE Case DifficultyAssessment FormFollowing examination and testing, a diagnosis isestablished, a treatment plan is formulated, andthe prognosis determined. The general dentistthen must determine the degree of difficultyand associated risks. The AAE Case DifficultyAssessment Form provides a national protocol foraccomplishing this assessment.There are many factors that influence degreesof difficulty and risk of endodontic treatment.Recognition of these factors prior to the initiationof treatment helps practitioners to understand thecomplexities that may be involved in individualcases and prevents adverse outcomes due toavoidable procedural errors.In determining the degree of difficulty, a generaldentist should not undertake treatment of acase unless he/she is prepared to also managecomplications that may arise in treatment.Treatment Standards Page 3
AAE Endodontic Case DifficultyAssessment Form and GuidelinesPatient InformationDispositionTreat in Office:YesNoFull NameStreet AddressSuite/AptCityState/CountryRefer Patient to:ZipPhoneDateEmailGuidelines for Using the AAE Endodontic Case Difficulty Assessment FormThe AAE designed the Endodontic Case Difficulty Assessment Form for use in endodontic curricula. The Assessment Form makes case selectionmore efficient, more consistent and easier to document. Dentists may also choose to use the Assessment Form to help with referral decision makingand record keeping.Conditions listed in this form should be considered potential risk factors that may complicate treatment and adversely affect the outcome. Levelsof difficulty are sets of conditions that may not be controllable by the dentist. Risk factors can influence the ability to provide care at a consistentlypredictable level and impact the appropriate provision of care and quality assurance.The Assessment Form enables a practitioner to assign a level of difficulty to a particular case.Levels of DifficultyMINIMAL DIFFICULTYPreoperative condition indicates routine complexity (uncomplicated). These types of cases would exhibit only those factors listed in the MINIMALDIFFICULTY category. Achieving a predictable treatment outcome should be attainable by a competent practitioner with limited experience.MODERATE DIFFICULTYPreoperative condition is complicated, exhibiting one or more patient or treatment factors listed in the MODERATE DIFFICULTY category.Achieving a predictable treatment outcome will be challenging for a competent, experienced practitioner.HIGH DIFFICULTYPreoperative condition is exceptionally complicated, exhibiting several factors listed in the MODERATE DIFFICULTY category or at least one in theHIGH DIFFICULTY category. Achieving a predictable treatment outcome will be challenging for even the most experienced practitioner with anextensive history of favorable outcomes.Review your assessment of each case to determine the level of difficulty. If the level of difficulty exceeds your experience and comfort, you mightconsider referral to an endodontist.Criteria and SubcriteriaMINIMAL DIFFICULTYMODERATE DIFFICULTYHIGH DIFFICULTYA. PATIENT CONSIDERATIONSMEDICAL HISTORYNo medical problem (ASA Class 1*)ANESTHESIANo history of anesthesia problemsABILITY TO OPEN MOUTHNo limitationPATIENT DISPOSITIONGAG REFLEXEMERGENCY CONDITIONCooperative and compliantNoneMinimum pain or swellingOne or more medical problem(ASA Class 2*)Complex medical history/seriousillness/disability (ASA Classes 3-5*)Anxious but cooperativeUncooperativeVasoconstrictor intoleranceSlight limitation in openingGags occasionally with radiographs/treatmentModerate pain or swellingDifficulty achieving anesthesiaSignificant limitation in openingExtreme gag reflex which hascompromised past dental careSevere pain or swellingThe contribution of the Canadian Academy of Endodontics and others to the development of this form is gratefully acknowledged. The AAE Endodontic Case Difficulty Assessment Form is designed to aid the practitionerin determining appropriate case disposition. The American Association of Endodontists neither expressly nor implicitly warrants any positive results associated with the use of this form. This form may be reproduced butmay not be amended or altered in any way. American Association of Endodontists, 180 N. Stetson Ave., Suite 1500, Chicago, IL 60601; Phone: 800-872-3636 or 312-266-7255; Fax: 866-451-9020 or 312-266-9867;E-mail: [email protected]; Website: aae.orgAccess additional resources at aae.org
Criteria and SubcriteriaMINIMAL DIFFICULTYMODERATE DIFFICULTYHIGH DIFFICULTYB. DIAGNOSTIC AND TREATMENT CONSIDERATIONSDIAGNOSISRADIOGRAPHIC DIFFICULTIESPOSITION IN THE ARCHTOOTH ISOLATIONSigns and symptoms consistent withrecognized pulpal and periapicalconditionsExtensive differential diagnosis ofusual signs and symptoms requiredAnterior/premolarSlight inclination ( 10 )Slight rotation ( 10 )1st molarModerate inclination (10-30 )Moderate rotation (10-30 )2nd or 3rd molarExtreme inclination ( 30 )Extreme rotation ( 30 )Full coverage restorationPorcelain restorationBridge abutmentModerate deviation from normaltooth/root form (e.g., taurodontismmicrodens)Teeth with extensive coronaldestructionRestoration does not reflect originalanatomy/alignmentSignificant deviation from normaltooth/root form (e.g., fusion dens indente)Minimal difficulty obtaining/interpreting radiographsRoutine rubber dam placementModerate difficulty obtaining/interpreting radiographs (e.g., highfloor of mouth, narrow or low palatalvault, presence of tori)Simple pretreatment modificationrequired for rubber dam isolationCROWN MORPHOLOGYNormal original crown morphologyCANAL AND ROOTMORPHOLOGYSlight or no curvature ( 10 )Closed apex ( 1 mm in diameter)Moderate curvature (10-30 )Crown axis differs moderatel fromroot axis. Apical opening 1-1.5 mm indiameterRADIOGRAPHIC APPEARANCEOF CANAL(S)Canal(s) visible and not reducedin sizeRESORPTIONNo resorption evidentCanal(s) and chamber visible butreduced in sizePulp stonesConfusing and complex signs andsymptoms: difficult diagnosisHistory of chronic oral/facial painExtreme difficulty obtaining/interpreting radiographs (e.g.,superimposed anatomical structures)Extensive pretreatment modificationrequired for rubber dam isolationExtreme curvature ( 30 ) or S-shapedcurveMandibular premolar or anterior with2 rootsMaxillary premolar with 3 rootsCanal divides in the middle or apicalthirdVery long tooth ( 25 mm)Open apex ( 1.5 mm in diameter)Indistinct canal pathCanal(s) not visibleMinimal apical resorptionExtensive apical resorptionInternal resorptionExternal resorptionComplicated crown fracture ofimmature teethHorizontal root fractureAlveolar fractureIntrusive, extrusive or lateral luxationAvulsionC. ADDITIONAL CONSIDERATIONSTRAUMA HISTORYUncomplicated crown fracture ofmature or immature teethComplicated crown fracture of matureteethSubluxationENDODONTIC TREATMENTHISTORYNo previous treatmentPrevious access without complicationsPERIODONTAL-ENDODONTICCONDITIONNone or mild periodontal diseaseConcurrent moderate periodontaldiseasePrevious access with complications(e.g., perforation, non-negotiatedcanal, ledge, separated instrument)Previous surgical or nonsurgicalendodontic treatment completedConcurrent severe periodontaldiseaseCracked teeth with periodontalcomplicationsCombined endodontic/periodonticlesionRoot amputation prior to endodontictreatment*American Society of Anesthesiologists (ASA) Classification System Class 1: No systemic illness. Patient healthy. Class 2: Patient with mild degree of systemic illness, but without functional restrictions, e.g., well-controlledhypertension. Class 3: Patient with severe degree of systemic illness which limits activities, but does not immobilize the patient. Class 4: Patient with severe systemic illness that immobilizes and is sometimes lifethreatening. Class 5: Patient will not survive more than 24 hours whether or not surgical intervention takes place. www.asahq.org/clinical/physicalstatus.htmTreatment Standards Page 5
Treatment ProceduresA variety of endodontic techniques, materials andtreatment philosophies present a challenge todental practitioners, patients, governing bodies andother interested parties making decisions about theappropriateness and/or quality of endodontic care.Endodontic treatment procedures should be ofsuch quality that predictable and favorable resultswill occur with the understanding that, in a biologicsystem, treatment procedures that are appropriatemay not always result in a successful outcome.Success is dependent on many variables that maypreclude a successful outcome. These factorsinclude but are not limited to the patient’s medicaland dental condition, patient compliance, variationsin anatomy and morphology, and complicationsduring the procedures.When practitioners are presented withchallenges during treatment that riskprocedural errors and poor outcomes,consultation and referral are always validoptions.ConsiderationsGeneral dentists must recognize that pulp andperiradicular pathosis is primarily a microbialdisease. Strict adherence to aseptic procedures toinclude the use of the rubber dam is required.Nonsurgical root canal treatment must employmaterials proven to be biocompatible. Forexample, the use of paraformaldehyde containingsealer/pastes are below the standard of care forendodontic treatment.Non-Surgical EndodonticsUncomplicated Mature Permanent TeethNonsurgical root canal treatment is indicatedprimarily in cases of irreversible pulpitis and whenpulp necrosis with and without periapical pathosisoccurs. However, elective root canal treatment maybe considered for restorative treatment planningand for overdentures or where teeth need to bepreserved over extraction in patients who arereceiving systemic treatments including headand neck radiation treatment, bisphosphonates,chemotherapy, and/or corticosteroids.Endodontic treatment involves chemo-mechanicalpreparation of the root canal system to eliminateorganic, inorganic and bacterial products andsealing of the radicular space with a biocompatiblematerial (obturation). Root canal sealers are usedin conjunction with the core filling material toestablish an adequate three dimensional seal andinduce hard tissue formation in healing outcomes.Root Canal DisinfectionINTENT STATEMENT: A practicing dentist shouldbe able to safely and effectively utilize standarddisinfection protocols in the irrigation andmedication of root canal spaces.The primary etiologic agents of apical periodontitisare microorganisms and their by-products thathave invaded the pulpal space and establishedmultispecies biofilm communities in the root canalsystem. Biofilms are involved in all stages of rootcanal infection and can be found on root canalwalls, in dentinal tubules, and on extraradicularsurfaces.The clinical management of infected root canalsundergoing non-surgical root canal treatmentinvolves instrumentation and disinfection.Instrumentation disrupts biofilms which colonizeinfected soft and hard tissues and provides accessfor irrigation and exposure to antimicrobialsolutions for disinfection of the root canalAccess additional resources at aae.org
system. Disinfection is achieved by the use ofboth antimicrobial agents and the mechanicalflushing action of irrigation, with the goal beingthe disruption, displacement and removal of pulpalremnants, microorganisms, metabolic byproducts,debris and the smear layer created duringinstrumentation. When treatment is providedover multiple appointments, inter-appointmentintracanal medicaments provide additionalopportunities for disinfection.The development of irrigation and disinfectionclinical protocols in current use has been basedprimarily on the findings reported in classic studiesthat used methods of aerobic and anaerobicculturing of viable microorganisms. More recentstudies using molecular and advanced imagingtechniques have shown the endodontic microflorato be significantly more complex than can be shownby culture methods, and that biofilms and debriscan remain in inaccessible areas of the root canalsystem, regardless of clinical techniques usedduring treatment. Taken together, these studieshave established that disinfection, rather thansterilization, of infected root canals is a reasonable,and achievable, expectation. The overall goal is toprovide an environment that will enable healing.Irrigants and MedicamentsThe “ideal” irrigant should be an effectiveantimicrobial agent and organic tissue solvent,non-irritating, stable and easily stored. It shouldbe active in the presence of blood and serum,non-staining, non-antigenic, non-toxic, have lowsurface tension, and be non-destructive to dentin,apical tissues and endodontic instruments. Ideally,it should remove the smear layer and disinfectdentinal tubules. Substantivity (persistence ofeffect) may be desirable as long as residue is notleft that could interfere with root canal obturation.Irrigants ideally should be convenient andinexpensive. There is no single solution currentlyavailable that possesses all of the aforementioneddesirable qualities.Irrigants currently used for endodontic treatmentmay be categorized as:1. Antimicrobial agents [e.g. sodiumhypochlorite (NaOCl), chlorhexidine (CHX)]The most commonly used antimicrobialirrigant is NaOCl, an oxidizing agent thatreleases chlorine in the form of hypochlorousacid (HOCl). NaOCl has a dose-dependenteffect on polymicrobial biofilms, with higherconcentrations being more effective. NaOClis an excellent organic tissue solvent and canbe used to remove the organic componentof the smear layer. Continuous exchange offresh solution and agitation enhances thetissue dissolution capability of NaOCl. Amajor disadvantage of NaOCl is its toxicity,particularly in the event of extrusion into theperiradicular tissues.Chlorhexidine is a cationic bisbiguanide withconcentration-dependent antibacterial andsubstantivity properties. It is available in bothliquid and gel form. While CHX has a broadspectrum of antimicrobial activity, it lackstissue solvent properties, and is less effectiveagainst biofilms than NaOCl.2. Demineralizing agents [e.g.ethylenediaminetetraacetic acid (EDTA)]During instrumentation, dentindemineralization can be facilitated by theaction of chelating agents such as EDTAwhich are capable of forming soluble nonionic chelates with metallic ions, such ascalcium found in hydroxyapatite crystals.Chelating agents assist in the negotiationand enlargement of severely constricted orobstructed root canals, as well as the removalof the inorganic component of the smear layerimmediately prior to root canal obturation.EDTA is typically used as a buffered solution,with or without a surfactant or antiseptic.Treatment Standards Page 7
3. Combinations of agents, with or withoutdetergents, antibiotics, antiseptics and futuredirectionsThe flow of antimicrobial agents can beenhanced by the addition of surfactants thatdecrease surface tension thereby potentiallyenabling better penetration and access tonarrower, confined portions of the root canalsystem. Solutions with low antimicrobialactivity may be combined with antisepticsto enhance their usefulness. In the nearfuture, advanced research with nanoparticlesand energy activation of solutions will bearwitness to endodontic inquiry addressingfuture challenges in biofilm tenacity and thecomplexity of root canal systems.Medicaments should be placed as interappointment intracanal dressings if treatmentis completed over multiple visits. Medicamentscan reduce the microbial count of speciesremaining in the root canal system, preventregrowth and detoxify endotoxin. Even for thevital tooth undergoing NSRCT over multiple visits,the placement of intracanal medicaments canhelp mitigate the consequences of inadvertentcontamination or unanticipated leakage of theinterim restoration. When used, the medicamentshould entirely fill the canal to allow for optimalefficacy.Currently, calcium hydroxide is the primarychoice of intracanal medicament. In addition toits antimicrobial action, the alkaline pH of calciumhydroxide facilitates dissolution of organic tissuesand bacterial products such as endotoxin. Calciumhydroxide can be placed as a slurry (powder mixedwith a liquid such as saline or sterile water) or asa proprietary paste via syringe, lentulo, or paperpoint delivery. It should be noted that CaOH can behighly toxic if expressed into the neurovasculaturetissues so choice of a delivery method should bebased on the clinical parameters of each case.Access additional resources at aae.orgIt should be noted that no particular antimicrobialirrigant or medicament can claim to result insuperior healing outcomes. As such, decisionson which irrigant(s) to employ may be basedon factors such as clinicians’ skill, efficiency oftreatment, case selection and costs incurred.Irrigation DeliveryThe aim of irrigation is to physically disruptand debride the root canal. Intracanal irrigationprovides a stream of chemicals to induceantimicrobial activity, demineralization, tissuedissolution, lubrication, bleaching and hemorrhagecontrol. The current or force created by irrigationcarries away debris towards the orifice; theefficacy of this process is influenced by factorssuch as access to surfaces, volume of solution andsolution exchange. Irrigation should be employedat each instrument change with the total volume ofirrigating solution dependent on the size, shape andnumber of canals. Irrigants should be confined tothe root canal space.Current irrigation delivery techniques can becategorized as follows:1. Needle and syringe (“conventional”,“positive pressure”)The most common irrigation techniqueutilizes needle and syringe delivery.Effectiveness is dependent on the depthof insertion of the needle and is improvedwith increased apical size and taper of theroot canal. Needle gauge should be based oncase selection and canal size. Canals needto be enlarged sufficiently for the needle tobe placed loosely in the canal to the desireddepth. This will depend on factors includingroot length, curvature and apical anatomy.Clinicians must avoid placing excessivepressure on the syringe during irrigation andensure that the needle is not bound in thecanal nor inserted too deeply into the canal ofa tooth with a wide-open apex.
Slow injection using side-venting needlesand constant movement in small, verticalamplitudes can help prevent hydrostaticbuildup.2. Negative pressureThe rationale behind negative pressureirrigation delivery is to reverse the directionof irrigant flow away from the apex therebyminimizing the risk of apical extrusion ofirrigant compared to other approaches.3. Energy activated devices used alone or assupplementary methodsActivation systems (sonic and ultrasonic) aimto enhance the movement of irrigant solutionswithin the confines of the root canal spacein order to disrupt biofilms and debris, andfacilitate their removal.No particular irrigation delivery techniquecan claim to induce superior healing success.Decisions on which system to employ maybe based on factors such as clinicians’ skill,efficiency of treatment, case selection andcosts incurred.Essential considerations with the usage ofNaOCl as an irrigant1. In the event that NaOCl is extruded intothe periradicular tissues, the patient mayexperience immediate severe pain, bleeding,ecchymosis and, potentially, long-termparesthesia. If a predisposing risk for irrigantextrusion into the periradicular tissuesis suspected, such as open apices, rootperforation or vertical root fracture, cliniciansshould proceed with caution, or considerusing another irrigant solution.If clinicians prefer to use lowerconcentrations, antimicrobial activity canbe facilitated by using higher volumes andincreasing the frequency of irrigation.3. The majority of information on the clinicalusage of NaOCl has been obtained onconcentrations of between 0.5% to 6%; theefficacy and toxicity associated with higherconcentrations is not known.Final considerations in root canal disinfection1. The use of rubber dam is mandatory to avoidmicrobial contamination of the root canalsystem during treatment, to retract tissuesand protect the patient, prevent aspiration orswallowing of instruments, and limit aerosols.2. While many current concepts about root canalirrigation and irrigants evolved in earliertimes, the fundamental goals of disinfection,tissue-debridement, lavage and lubricationremain unchanged.3. The majority of clinical studies haveused NaOCl as an irrigant delivered viaconventional irrigation techniques thatflushed the canal without the application ofenergy; these studies have formed the basisfor treatment outcome estimations.4. The best approach to controlling microbesduring endodontic treatment is the use ofaseptic technique, effective debridement, localantimicrobials, systemic antibiotics only ifindicated, and optimal apical and coronal seal.2. The higher the concentration of NaOCl, thegreater its antimicrobial activity, but also thegreater its toxicity and potential adverse effecton biomechanical properties of dentin.Treatment Standards Page 9
Competence in AccessPreparation andInstrumentation ofRoot Canal SystemsAccess Cavity PreparationINTENT STATEMENT: A practicing dentist shouldbe able to predictably access the pulp chamber forthe purpose of performing root canal treatment bylocating all main canal orifices.INTENT STATEMENT: A practicing dentist whenaccessing a pulp chamber should be able to minimizeexcessive removal of tooth structure, structuraldamage to the treated tooth, including prevention ofperforations.Purpose of Accessing the Pulp ChamberAll intracanal procedures require a preparationthrough the coronal structure in a prescribedlocation and opening of the pulp space. Theultimate goal of this step is to expose the pulpchamber and radicular space for subsequentinstrumentation, irrigation, debridement andantimicrobial treatment. Therefore, it is essentialthat all canal orifices are identified and renderedaccessible.Following treatment, all root canal-treated teethmust receive a definitive restoration to protect theremaining tooth structure and promote longevityand function. To fulfill this objective, it is essentialthat the coronal access opening be provided withthe least damage to dental structures.Information Gathering Prior to AccessIn order to prepare an access cavity appropriately,that is in the correct orientation and location,preoperative knowledge of the tooth anatomy andmorphology must be considered by the clinicianregarding the number and location of canal orifices,and the incidence and configuration of anatomicalvariations within any given tooth. Towards this goal,Access additional resources at aae.orgwell-angulated preoperative radiographic imagesare mandatory to facilitate a safe and efficientaccess; negotiation of the root canal system; andto minimize the risk of procedural errors that mayresult from unexpected anatomical complexity oran inappropriate orientation. Periapical films andbite-wings (for posterior teeth) provide an initialdirection and alignment of pulp chamber and rootcanal position. Although two radiographs withdifferent angulations are often sufficient to developa 3D image of the tooth to be treated, cone beamcomputed tomography (CBCT) images may bejustified and necessary to evaluate the existenceof extra canals, complex morphologies, curvaturesand/or dental developmental anomalies.Images should be studied carefully, and coronalaccess aided by enhanced magnification andlighting in complicated cases is warranted andappropriate. Currently, the use of the dentaloperating microscope is the highest achievablelevel of lighting and magnification and is justifiedwhen pulpal complexity and natural depositionof mineral reduces prognosis and affect asuccessful outcome. Cases with anatomical andmorphologic complexity and potential clinicalchallenges beyond a practitioner’s skill levelshould be referred to a colleague with specialtyskills in endodontics.Performing the Access PreparationFor optimal aseptic conditions, a rubber dammust be in place before commencing accesscavity preparation. There are rare but occasionalclinical situations in tooth alignment or rotation,particularly where treatment is undertaken byinexperienced clinicians, when accessing beforerubber dam isolation for cleaning and disinfectionmay have benefits; however, the rubber dammust be applied prior to introducing endodonticinstruments and canal preparation. Standardizedaccess cavity outlines for each tooth help tomitigate some of the risks involved. These risksinclude perforation as well a
Vital pulp treatment to include step-wise caries excavation, indirect and direct pulp capping, and pulpotomy procedure established, a treatment plan is formulated, and Non-surgical root canal treatment for the permanent dentition Bleaching of discolored dentin and enamel of teeth Treatment procedures such as post and/or cores