International Endodontic Joumali}9m)
17, 176-178
Endodontic treatment in Argentina
ENRIQUE BASRANI Carlos Pellegrini, 1055 lA Buenos Aires, Argentina
Introduction
An important aspect of endodontics is the
preservation of the health and vitahty of the
dental pulp. However, when it is not possible
to maintain the pulp in a healthy state, or
when it becomes necrotic, there is no other
option than to proceed to its extirpation, so as
to maintain the tooth. Techniques and forms
of treatment that can be used to maintain
teeth in the oral cavity have a solid clinical
and research background, and there are many
techniques. In Argentina there are variations
in endodontic treatment based on regional
differences, some of which stem from the educational centres where the dentists have been
trained. A survey was carried oat of the main
dental schools and postgraduate centres as weil
as some specialists in the country. Therefore,
a basic questionnaire was prepared and the
following questions were asked:
1. What techniques do you use for pulp
extirpation?
2. In intracanal treatment procedures, what
instruments do you prefer to use?
3. What is the apical limit of intracanal
preparation?
4. What irrigating solutions do you usually
use?
5. What Is your favourite root canal filling
technique?
The questionnaires were sent to the dental
schools of the universities of Buenos Aires,
Gjrdoba, Rosario, Tucuman, La Plata and
also to some specialists of the Argentine
Dental Association's School for Continuing
Education. The replies to the questions will
now be summarized.
1. Pulp extirpation
There was general agreement that extirpation
of the pulp depended on the diameter of the
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canal and on the degree of development of the
root apex. In an averaged-sized root canai,
extirpation of the pulp is carried out with
broaches. Only one respondent stated that
Hedstrom files with or without hlunt points are
used.
When the canal is very wide, two or three
instruments are used, while in very narrow
canals broaches are not used at al! and the pulp
is removed during the intracanal instrumentation. Some respondents use a broach to
remove tbe remaining pulpal remnants that
couid have been left behind in the apical third
after completing canal instrumentation.
In canals with an apical constriction, tbe
broacb is introduced up to this level, withdrawn 1—2 mm, rotated and completely
withdrawn extirpating the pulp.
In a tooth without an apical constriction, it
is necessary to determine the working length
before introducing the broach so as to limit the
histrument to tbat length; again, in a large
canal, two or more broaches may be required
to remove the pulp.
2, Instruments for intracanal treatment
procedures
In general terms, intracana! treatment procedures depended on two basic features: first,
whether the pulp was vital or non-vital and,
secondly, on the morphological characteristics
of the canal.
Where the pulp is vital, the most important
objective pursued during canal preparation is
the elimination of predentine and of connective tissue on the dentinal walls so as to allow
close adaptation of the filling material to the
canai waUs. Further, the canal has to be
shaped to give resistance and retention form,
so as to obtain the best possible obliteration of
the canal. Some respondents used only files,
whereas otheis alternated between the use of
files and reamers.
Endodontic treatment in Argentina
In cases with non-vital pulps, the intracanal
preparation is carried out until white dentine
is obtained. Care has to be taken not to alter
the canal anatomy and to avoid a ledge or perforation. The shape of the apicai end of the
canal must not be altered in a way that would
prevent a satisfactory filling.
In cases of both vital and non-vital pulps,
root canal treatment is normally started and
completed in the same appointment.
From the anatomical point of view, canals
are divided into those that do not show morphological problems for intracanal preparation
and those that do. In general terms, endodontists agree that the treatment of non-vital teeth
with simple canal morphology is begun by
using Hedstrom files in the coronal two-thirds
of the canal. Then, the working length is
obtained by using a K-file dipped in pmonochlorophenol, which is introduced a few
millimetres short of the radiographic apex. Up
to this length, the apical one-third is enlarged
with files or reamers and files, always accompanied by the use of chemical agents. The
final shaping of the apical one-third of the
canal is carried out with reamers. One specialist preferred the use of K-fiSes, which he used
almost exclusively, while in the coronal twothirds, he used Mailkfer's 'Largo' instruments.
In narrow and curved canals, most use the
telescopic technique, whereas others prefer
to penetrate to the full length of the canal,
wbich requires a previous determination of the
working length. The canals are instrumented
throughout their entire length, without being
divided into thirds; this is to avoid the creation
of steps, which are extremely difficult to
by-pass.
In the case of a tooth with an open apex or
without an apical constriction, tbe technique
is similar but the difference is in tbe size of
the instruments used.
3. Working length
For the establishment of working length, all
schools agree that in cases of teeth with vital
pulps, the intracanal procedures should stop
1—2 mm short of the radiographic apex. However, in the case of non-vital pulps, the
Intracanal preparation should reach to the
radiographic end of die root. There are some
who advocate a slightly shorter
length.
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working
4. Irrigation
For irrigation of teeth with vital pulps, there
are some who prefer to use a calcium bydroxide solution initially to arrest bleeding, if there
is any, to avoid carrying deleterious substances
into the periapical area. Irrigation is normally
done with saline or a caicium hydroxide solution, but at times, because of discoloration or
for some other reason, irrigation with sodium
hypochlorite is preferred. Some schools choose
to alternate sodium hypochlorite with hydrogen peroxide, using the first in concentrations
ranging from 0.5 to 5.0 per cent; it Is terminated with hypochlorite to neutralize any piBsible residue peroxide. For final irrigation,
saline or calcium hydroxide solution is used,
the latter for tbe purpose of raising the pH.
Normally infected canals are profusely irrigated with sodium hypochlorite solution in
concentrations ranging from 0.5 to 5.0 per
cent. Two respondents stated that they use
sodium dioxide in all cases (a few granules dissolved in 25 ml of distilled water as the initial
irrigant and calcium hydroxide solution as a
final one).
Irrigation is accomplished by passing the
needle into the coronal-third of the canal only,
thereby allowing for the escape of the fluid. In
narrow canals, some use EDTAC on files up
to size 30 or 35. Tbe enlargement is then
continued in conjunction with sodium hypochlorite irrigation, to neutralize tbe remaining
EDTAC, because it is considered that this
chelating agent could leave a layer of softened dentine which would allow leakage after
obturation of tbe canal.
5. Filling technique
Thefillingof root canals showed a wider divergence of views than any other phase of endodontic treatment. Differences were found in
the filling material as well as the terminus of
the apical end of the filling material.
Almost all used gutta-percha points and
Grossman's cement for filling, with either
the single point or the lateral condensation
technique.
178
E. Basrani
Gutta-percha is normally used as the filling
material where the width of the canal permits
its use. Where the canal is narrow and curved,
silver points are usually employed. A number
of respondents considered that silver points
should not be discarded.
The filling of the apical third alone with
gutta-percha points, thus leaving the coronal
two-thirds ofthe canal empty to receive a post
prepared by the general practitioner or prosthodontist, is a technique commonly used in the
State of Cordoba.
At La Plata Denta! School, the 'semiprecision technique' is taught. This technique
is used in teeth where, after the root canal
preparation is completed, a canal is observed
with a relatively wide and straight coronal
part but it has a slight apical curvature. The
technique consists of two steps:
(i) Using a reamer one size wideT than the
last one used for preparation, a plateau is
made by rotation, 1 mm short of the working length. Immediately afterward, the
walls of the canal are smoothed with a
Hedstrom file and a coronal flare is prepared in the canal with the file being used
2 or 3 mm shorter than the plateau. The
reamer must be blunt and this is done by
cutting off its point with a carborundum
disc.
{ii) Once the gutta-percha point is seen, on a
radiograph, to fit, I mm is cut from its end
and a notch is marked at the reference
point. An alkaline paste is placed in the
space between the plateau and the periapex, to induce repair of periapical tissue
and/or biological closure of the apex; it
also avoids the sealer coming into contact
with the periodontium, so preventing the
irritating action of xylol and eucalyptol.
The tip of the point is then softened with
xylol or eucalj-ptol and the point is coated
with cement. Lateral condensation of the
entire canal is done with a spreader.
If wide lateral canals in the middle or coronal
third of the root are suspected, the condensation is done with a hot blunt plugger, pressing
it into the middle of the filling material. The
space created is filled with additional points.
To prevent the blunt plugger from sticking to
the filling material, it is heated to cherry red
and dipped in vegetable oil. This technique
allows the material to be softened and
condensed into lateral canals.
At Buenos Aires Dental School two
methods of ohturation are used in the presence
of a periapical lesion:
A Filling with Grossman's cement and guttapercha points to the radiographic limit.
B (i) Filling of the periapical area with a
paste combining an antibiotic, chioramphenicol, and a corticosteroid, hydrocortisone acetate, by means of a
lentuls instrument,
(ii) Excess paste is removed from the
canal,
(iii) Slight overfilling with Maisto's absorbable paste,
(iv) Excess paste is removed from the
canal.
(v) Conventional filling with Grossman's
cement and gutta-percha points,
Maisto stated:
.. . The solution of the problem is not the perfect
fitting at the apeK of a point of ajiy material with
the risk of having the cement as the only filling,
or overfilling, material in contact with the periapical tissue. It seems more reasonable to place there
elements that stimulate, or allow the closure of the
foramen. {The ideal filling material that
researchers have not been able to find as yet.) That
would be a substance that, from the connective tissue surrounding the toot, would form osteocement
and fibrous scar tissue.
The biological closure of the root apex is
often referred to, and although it is not easy
to achieve, it is known that it can occur. What
is not known is what factors will achieve such
closure, every time. Time and perseverance in
research will provide the answer.
Acknowledgements
I want to express my deep gratitude to Professor Roberto Bado from Buenos Aires
University; Professor Ruben Ulfohn from
Cordoba University; Professor Alberto
Foyatier from Rosario University; Professor
Guillermo Raiden from Tucuman University;
Professor Enrique Massone from La Plata
University and Professor Jorge Canzani and
Oscar A. Maisto from the School of Continuing Education of the Argentina Dental Association and to Dr Roberto Porter for assistance
in writing and translating this paper.
