1. Chapter 24 Endodontics

2. Endodontic Procedure

3. Objectives
Understand some of the indications and contraindications for doing a RCT
Know the four fracture classifications
Know the different diagnostic tests for determining if an RCT is needed
Understand the difference between reversible pulpitis and irreversible
pulpitis
Understand the difference between: pulpectomy, pulpotomy, RCT, open
and medicate, incise & drain
Know the steps involved in performing a non-surgical RCT
Understand the difference between a surgical and non-surgical endodontic
treatment
Be able to define these surgical tx’s: apicoectomy, root amputation,
hemisection

4. Endodontist
Deals and treats diseases of the pulp and periapical tissues.
2 additional years of training.
General dentists can do RCT, refer difficult cases to endodontist.
Curved roots
additional canals
re-treats

5. Indications Periapical abscess Advanced decay Impact trauma
infection around the end of the root
Advanced decay
caries at or near the pulp chamber
Impact trauma
auto accident
sporting event
fight or battery

6. Indications Fractures Invasive restorative procedures
near or through the pulp chamber
Invasive restorative procedures
very deep fillings
crown prep close to pulp chamber
Reaction to dental materials
materials used to restore the tooth

7. Fracture Classifications
Enamel only
Class II
Dentin involved
Possible RCT
Class III
Pulp involved
RCT
Class IV
gumline (no crown)

8. Diagnosis Pt. Medical/dental history General dentists diagnosis
Radiographs (x-rays)
Extra-oral exam
redness
facial symmetry
swelling
external fistula
(pathway for pus to drain)

9. Diagnosis: Intra-oral exam discoloration fractures visual caries
abscesses
fistulas

10. Diagnostic Tests Radiographs most useful diagnostic tool
correct position
good contrast
must see the apex
must see 2 mm of bone

11. Diagnostic Tests Palpation (feeling with fingers)
tissue around apex is palpated for an
abscess
several teeth are palpated for
comparison
control tooth (same tooth, opposite
arch)
May be done by the doctor or an
assistant.

12. Diagnostic Tests Percussion (tapping on the tooth)
Lightly tap the occlusal or incisal
edge.
Usually done with the handle of the
mouth mirror
will tap control tooth
will tap adjacent teeth
will tap suspect tooth
Assistant can do this, too!

13. Mobility Diagnostic Tests (Movement of a tooth within a socket
Determines condition of supporting tissues
Moderate to severe mobility is a contraindication for a RCT
Pt will lose tooth to periodontal disease

14. Diagnostic Tests Cold Test Dry ice Chemicals ethyl chloride (Endo Ice)
frozen water

15. Diagnostic Tests Heat Test Ball of warm gutta percha
on the end of an instrument.
Frictional heat
rubber prophy cup applied to the
tooth
may indicate irreversible pulpitis

16. HA HA!

17. Diagnostic Tests Transillumination Electronic or Digital Pulp Testing
Fiberoptic light shined
through crown of the
tooth.
May show a shadow
or a Vertical fracture
determines tooth vitality
(if the tooth is dead or
alive)
battery operated device,
sends small “shock” to
tooth .
- Do not place on an amalgam
or a crown
A dead tooth will not feel the
“shock”

18. Diagnostic Tests Selective anesthetic Caries Removal:
can’t determine which tooth.
Numb a tooth / area
if pain subsides, we have located the tooth or quad.
Normally done on Max.
Caries Removal:
caries removed, tooth
stays the same, gets worse
= Possible RCT
Carries removed, tooth
gets better = No RCT

19. Diseases and Conditions
Irreversible Pulpitis
Reversible pulpitis
inflammation of the pulpal tissues.
When you treat or remove the cause.
Caries, fracture, or attrition.
Inflammation subsides
Pulp is able to heal
Inflammation of the
pulp that does not
subside.
Pulp will not heal
Tx: RCT or EXT

20. Review Questions from Yesterday
Name some of the diagnostic tests used to determine if a patient is in need of a root canal treatment
What are some indications and contraindications for doing a root canal treatment?
Name the four classifications of fractures and what types of fractures are included in each.

21. Diseases and Conditions
Pulpal Necrosis
death of the pulp cells
result of irreversible\
pulpitis
creates exudate
pus and gas that forms in
the pulp chamber
Cold relieves the pain.
Ligament
Bone
Gingiva
Can form a granuloma or
a cyst
Apical Periodontitis
when infection reaches
the surrounding tissues

22. Diseases and Conditions
Periapical (PA) abscess
localized area of infection.
mod - severe discomfort; can cause swelling Tx
RCT
EXT

23. Related Terms
Cellulitis: swelling and discomfort caused by the abscess spreading into the facial tissue.
Osteomyelitis: Advanced PA infection that has spread into the bone.

24. Treatment Prescription therapy: No Tx given. I & D (incise and drain)
RX for analgesic
RX for antibiotic
I & D (incise and drain)
Tx done to relieve pressure from
the abscess or cellulitis
O & M (open and medicate)
Tooth is opened to relieve the pressure. Medication is
placed. Pt comes back for RCT

25. Treatment Pulpotomy Pulpectomy
removal of pulpal tissue to about 1-3 mm short of the apex
1st step or appointment of RCT
RCT is done next
clean
enlarge
obturate (fill) the canals
Pulpotomy
removal of pulpal tissue from the pulp chamber only
Tissue is left in the canals
Done on baby teeth w/pulp exposure
Root end(s) not fully developed (apexogenesis)

26. RCT Root Canal Treatment / Therapy Done after a pulpectomy
Can be a “1-step”. Pulpectomy and RCT done at the
same appointment.
Clean, shape, smooth, and enlarge the canals.
Rinse / irrigate (sodium hypochlorite solution)
Fill & Seal w/ Gutta percha = OBTURATION
Master cones and accessory cones or
Warm gutta percha.

27. Obturation, Obturation…

28. My Office’s Endo Cart Special Endo. Rotary Handpiece Sodium
Hypochlorite

29. On The ____ Day of Endo. My Dentist Gave To Me
A Lidocaine in a main nerve
Two Rubber dams
Three Long burs
Four Hiding holes
Five Endo. Rings
Six Gates a-gliding
Seven Barbs a-broaching
Eight Files a’flexing
Nine Diluted Bleaches
Ten Papers Pointing
Eleven Guttas perching
Twelve Composites curing

30. Endo. Activity p. #15: Post-Op Instructions
You will be numb for 1-3 hours, depending upon the type of
anesthetic given
2. Try not to bite your lip or tongue during the time you are numb
3. Your tooth may be sore to bite on for 2-3 days.
Your tooth has a temporary filling in it, stay away from sticky
foods on that side of your mouth.
If the filling comes out, please call the office to schedule a
time to replace it. Food can get trapped in the opening
6. Take your medications as directed or prescribed
If you notice any swelling on your gum above the tooth, or
have any bad taste, or drainage, contact the office
immediately.
8. Please call the office if you have any questions or concerns.

31. Surgical Endodontics Apicoectomy
- Complete removal of the apex of the tooth.
Single rooted tooth or multiple rooted tooth
Must do a retrograde restoration,
(filling at the bottom of the tooth)
Amalgam
Composite
Gutta percha

32. Apicoectomy / Retro-grade Restoration

33. Apicoectomy / Retro-grade Restoration

34. Apicoectomy /Retro-Grade Restoration

35. Root Amputation Complete removal of one root.
Only done on a multi-rooted tooth
Must do a retro-grade restoration.

36. Hemisection Surgical removal of part of a multi-rooted tooth,
including the overlying
crown.
Only done on
Multi-rooted teeth.

37. Hemisection
Post-op x-ray
Pre-op photo
Post-op photo

38. Closing Understanding Indications, contra-indications, and
Treatment is a very important part of your job.
You should be able to confidently explain
RCT to your patient.
If in doubt…ask questions.
(( Activities to Follow this Page))

39. Group Questions
What is the difference between a open and medicate and a pulpotomy?
What is the difference between a pulpectomy and a pulpotomy?
What is an incise and drain?
Which instrument would you use to locate the canals during an endodontic treatment?
What is the difference between a root amputation and a hemisection?
What is a retrograde restoration? When would you see one placed?

40. Activity: Endo Instruments
Work on p. #14 in your lab book
On p #14 in your lab book, write the steps in
performing an endodontic tx.
If you get stuck, use your endo. instrument packet & p. #517 in
your textbook

41. Steps in A Root Canal Tx Administer Anesthetic
Isolate the area (a.k.a. Using a Rubber Dam)
Gain access to the pulp w/burs
Locate the canals (with an endo. exploer, of course! )
Use the gates glidden to open and widen the canal
Use the barbed broaches to remove the majority of the nerve
& soft tissue
Enlarge and smooth the root canal with k-files and/or
hedstrom files
Irrigate the root canal (with an irrigating syringe full of NaOCl
& H20
Dry the canals with paper points
Obturate (seal) the root canal with sealer & gutta percha
Place temporary filling or build up over tooth