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| Title |
Guided Endodontics for Non-Surgical Root Canal Therapy Results in Greater Accuracy and Overall Success with Comparable Symptom Reduction When Compared to Conventional Endodontics |
| Clinical Question |
In adults with pulpal and periapical pathology, how does the use of endodontic guides for non-surgical root canal therapy compare to conventional pre-operative planning and clinical therapy in terms of accuracy, reduction in symptoms, and overall success? |
| Clinical Bottom Line |
In adults with pulpal and periapical pathology, the use of endodontic guides for non-surgical root canal therapy results in greater accuracy and overall success when compared to conventional endodontics, with a comparable reduction in symptoms. In addition to shortening treatment duration, several studies demonstrate that guided endodontics is able to provide a solution to complex endodontic cases and, as shown in one particular study, to dentists of varying experience. Given the minimally invasive pre-planning involved in guided endodontics, it appears to be a practical and clinically safe tool in the field of endodontics. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 36384556 | Zhang/2022 | 58 single-rooted virgin pre-molars; 40 teeth used in accuracy test, 18 teeth used in temperature test | In vitro comparative study | | Key results | The study was performed on extracted, single-rooted virgin premolars. In terms of accuracy, the actual location of the tip of the bur had a mean distance from the planned path of 0.30 mm +/- 0.20 mm SD mesiodistally (95% CI, 0.23-0.36 mm) and 0.28 mm +/- 0.23 mm SD buccolingually (95% CI, 0.20-0.36 mm). The base of the bur had a mean distance from the planned path of 0.28 mm +/- 0.12 mm SD mesiodistally (95% CI, 0.24-0.32 mm) and 0.25 mm +/- 0.20 mm SD buccolingually (95% CI, 0.19-0.32 mm). The angle of the bur deviated with a mean degree of 3.62 +/- 1.89 SD (95% CI, 2.98-4.26) from the planned path. After 120 seconds of continuous working using different files, the root surface temperature of the guided approach group increased by a mean of 5.07°C, which was lower than the other two non-guided approach groups: ProTaper F3 group (6.58°C; P=0.046), and the ET20 group (18.17°C; P<0.01). The researchers state limitations to this study, as “continuous work without coolant can’t be applied in clinical practice,” which was how the temperature experiment was carried out. | | #2) 30803541 | Connert/2019 | Three dentists operating on 8 teeth per technique (guided versus conventional), for 16 teeth per dentist | In vitro comparative study | | Key results | Using 3D-printed incisors with calcified canals, this study examined the number of detected canals, mean substance loss, and treatment duration. Combined, canals were located in 10/24 cases (41.7%) using the conventional technique and in 22/24 cases (91.7%) using guided endodontics. Mean substance loss (defined as loss of tooth structure during access) across all three dentists for the conventional technique was 49.9 mm^3 (95% CI, 42.2-57.6 mm^3), whereas using the guided technique, dropped to 9.8mm^3 (95% CI, 6-8-12.9 mm^3). Lastly, mean treatment duration for all dentists using the conventional technique was 21.8 minutes (95% CI, 15.9-27.7 minutes) and 11.3 minutes (95% CI, 6.7-15.9 minutes) using the guided technique. Given the results of accuracy testing, researchers state that a guided approach is skill-independent and may lead to more predictable outcomes compared to conventional endodontic access. | | #3) 29571910 | Lara-Mendes/2018 | 61-year-old female with pulpally calcified maxillary second and third molars presented for endodontic treatment | Case report | | Key results | A 3D-printed template was used to access a calcified palatal canal of the maxillary second molar and a calcified distobuccal canal of the maxillary third molar, confirmed by a CBCT scan, both of which were not able to be accessed by the dentist through conventional means. Following completion of treatment, an absence of symptoms was reported. A 3-month follow-up revealed regression of lesions. A 1-year follow-up revealed an even greater regression of lesions, with pain and percussion remaining negative. | |
| Evidence Search |
guided endodontics temperature, guided endodontics versus conventional, guided endodontic access case report |
Comments on
The Evidence |
The Zhang study fails to mention the skill level of the operator performing the procedure and while this is mitigated by studies demonstrating guided endodontics to be skill-independent, the risk of bias is still present. This study examined accuracy and temperature changes during instrumentation and is therefore applicable to the PICO question. The study results show that accuracy is acceptable, and that the temperature increase with continuous rotary shaping using an endodontic guide is low; 95% CI’s were provided and support these findings. Researchers mentioned that a periodontium heated more than 7°C can lead to injury and can “undergo reversible histologic changes when the temperature [is] raised more than 10°C,” so efforts to reduce the increase in temperature during the procedure should be of clinical relevance. The Connert study used a design in which the patient group was synthetic incisors; three operators of different experience were given identical sets of teeth to perform canal access using conventional versus guided endodontics. While the risk of bias appears high due to the varying skill levels of the operators, the study sought to determine if skill plays a factor in the success of guided endodontics. With the only other varying factor being the comparator (guided versus conventional) in addition to the 95% CI’s provided, the usage of guided endodontics appears strongly supported in terms of accuracy, treatment duration, and substance loss, although the lack of variety of teeth used in the study, as well as the use of synthetic teeth, contributes to a moderate risk of bias. The loss of tooth substance during access is described as “relevant in terms of a reduced fracture resistance of teeth” and that “dentin losses…can occur in any direction and lead to an unpredictable destruction of the root.” Researchers emphasized that a guided approach in which substance loss is minimized may be beneficial to the prognosis of teeth undergoing endodontic treatment. In Lara-Mendes’s case report, a 61-year-old woman presented with maxillary second and third molars needing endodontic treatment. Two calcified canals were located via CBCT scan and were clinically found to be too difficult for conventional endodontic treatment. Guided endodontics was then carried out and successfully used to treat the calcified canals. While limited in scope due to its nature as a case report, researchers believe that guided endodontics can successfully be performed on posterior regions of the mouth, as their study showed. In the event of complex endodontic anatomy, such as calcified canals, the researchers assert that guided endodontics provide “safe and accurate…expedited, and predictable conditions” that can be taken advantage of even by “less experienced professionals.” A 3-month and 1-year follow-up was performed in which the patient reported an absence of symptoms and “a drastic reduction of the periradicular lesions,” further supporting guided endodontics as at least comparable to conventional endodontics in terms of symptom reduction. |
| Applicability |
Endodontics using a guided approach has greater accuracy and reduced clinical time compared to conventional approaches. Guided endodontics proves particularly helpful for cases involving calcified canals and other complex anatomy, providing comparable and, due to the nature of its accuracy, perhaps a more consistent reduction in symptoms. The additional time required to fabricate endodontic guides is offset by the reduced clinical time of using the guides. A factor that may limit applicability of guided endodontics is cost; however, a study by Kamburoğlu in 2023 (PMID: 37443609) mentions that material used for fabrication of the guides themselves can be selected based on availability and cost, as accuracy is not sacrificed among the different approved materials. Researchers emphasized “the need to access calcified canals around curvatures” as a limitation, as the corresponding drill should remain straight, stating that the “development of more adequate drills in both length and gauge” is something that must be addressed in future works. Extrapolation to all teeth is uncertain as in the Zhang and Connert studies, the teeth selected were all single-rooted virgin pre-molars and 3D-printed incisors, respectively. Guided endodontics may open the door for inexperienced operators to perform more complex cases as evidenced by the selected studies. Given that there are no official guidelines regarding guided endodontics, it could benefit from further research to determine its true efficacy. |
| Specialty/Discipline |
(Endodontics) (General Dentistry) |
| Keywords |
Guided endodontics, non-surgical root canal therapy (NSRCT), conventional endodontics
|
| ID# |
3558 |
| Date of submission: |
06/03/2024 |
| E-mail |
nathantyang1998@gmail.com |
| Author |
Nathan Yang |
| Co-author(s) |
Houston Hakala |
| Co-author(s) e-mail |
hakalah@livemail.uthscsa.edu |
| Faculty mentor/Co-author |
Kelly C. Lemke, DDS, MS |
| Faculty mentor/Co-author e-mail |
lemkek@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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