1. Endodontics
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2. Chapter 54 Lesson 54.1
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3. Learning Objectives Pronounce, define, and spell the Key Terms.
Describe the diagnostic testing performed for endodontic diagnosis.
List the conclusions of the subjective and objective tests in the endodontic diagnosis.
Assist in an electric pulp-vitality test.
Describe diagnostic conclusions for endodontic therapy.
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4. Introduction
Endodontics is the specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the periradicular tissues surrounding the root of the tooth.
General dentists are able to perform endodontic treatment.
Endodontists have 3 years of continued training in endodontics.
What is another name for endodontics?
What is the name for the specialist who deals with the diseases of the pulp?
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5. Causes of Pulpal Nerve Damage
Physical irritation
Extensive decay moving into the pulp
Trauma
Blow to a tooth or the jaw
Symptoms: pain on occlusion, pain during mastication, sensitivity to temperature, and facial swelling
Who has had a root canal?
What was the source of the nerve damage?
What were the symptoms?
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6. Signs and Symptoms of Pulpal Nerve Damage
Pain on occlusion
Pain during mastication
Sensitivity to hot or cold beverages
Facial swelling
Symptoms differ from patient to patient.
Other symptoms include a dull ache in a tooth that lasts over a period of time.
How would we put these symptoms in lay terms?
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7. Endodontic Diagnosis Subjective examination Chief complaint
Character and duration of pain
Painful stimuli
Sensitivity to biting and pressure
(Cont’d)
The subjective examination includes an evaluation of all symptoms the patient describes.
All symptoms should be documented in the patient’s chart.
What may be a patient’s chief complaint?
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8. Endodontic Diagnosis Objective examination Extent of decay
(Cont’d)
Objective examination
Extent of decay
Periodontal conditions
Extensive restoration
Tooth mobility
Swelling or discoloration
Pulp exposure
The objective examination includes all findings by the dentist in the oral cavity.
All findings must be documented in the patient’s chart.
Control tooth:
What is it?
How is it selected?
Students: If tooth 14 is hurting, which tooth would be the control tooth?
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9. Fig. 54-1 Radiograph showing extensive decay into the pulp
Fig Radiograph showing extensive decay into the pulp. (From Johnson W: Color atlas of endodontics, StLouis, 2002, Saunders.)
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10. Fig. 54-2 Radiograph of a necrotic tooth resulting from trauma
Fig Radiograph of a necrotic tooth resulting from trauma. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.)
What can we see on this radiograph?
Which teeth are involved?
What was the probable cause of pulpal damage?
What may be the No. 1 symptom this patient is experiencing?
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11. Diagnostic Testing Percussion tests
These tests are used to determine whether the inflammatory process has extended into the periapical tissues.
The dentist taps on the incisal or occlusal surface with the end of the mouth-mirror handle held parallel to the long axis of the tooth.
(Cont’d)
All findings should be documented in the patient’s chart.
Where are the periapical tissues?
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12. Fig. 54-3 Percussion test. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.)
Which tooth is the dentist testing?
Which tooth would be the control tooth?
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13. Diagnostic Testing Palpation Tests
(Cont’d)
Palpation Tests
These tests are used to determine whether the inflammatory process has extended into the periapical tissues.
The dentist applies firm pressure to the mucosa above the apex of the root.
All findings should be documented in the patient’s chart.
The dentist uses the fingertips to palpate the mucosa.
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14. Fig. 54-4 Palpation test. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.)
Which area is the dentist palpating?
What is the dentist looking for?
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15. Diagnostic Testing Thermal sensitivity Cold test Heat test
(Cont’d)
Thermal sensitivity
Necrotic pulp will not respond to cold or heat.
Cold test
Ice, dry ice, or ethyl chloride is used to determine the response of a tooth to cold.
Heat test
A piece of gutta-percha or an instrument handle is heated and applied to the facial surface of the tooth.
Thermal stimuli are never placed on a metallic restoration or the gingival tissue. Why?
A control tooth is used.
The heat test is not used very often.
Cold relieves pain = irreversible pulpitis
Pain in teeth lingers = irreversible pulpitis
What is pulpitis?
What does necrotic mean?
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16. Fig. 54-5 Ice used for testing thermal sensitivity
Fig Ice used for testing thermal sensitivity. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.)
Ice is applied to the cervical area of the tooth only.
What would be the control tooth for this photograph?
All findings must be documented in the patient’s chart.
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17. Diagnostic Testing Electric pulp testing
(Cont’d)
Electric pulp testing
A small electrical stimulus is delivered to the pulp.
Factors that may influence readings:
The patient has extensive restorations.
The patient has teeth with more than one canal.
Failing pulp produces a variety of responses.
Control teeth don’t respond as anticipated.
There is moisture on the tooth during testing.
The batteries in the tester are weak.
Electric pulp testing is used to determine whether a tooth is vital or nonvital.
The test can produce a false-positive or false-negative response.
Would this type of diagnostic testing be used alone or in conjunction with another test?
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18. Procedure 54-1 Placement of a pulp tester.
All findings must be documented in the patient’s chart.
Explain to patient that he or she may feel a tingling or warm sensation during this test.
Toothpaste is used as a conductor.
Testing should only be done on the facial surface of the cervical third of the tooth.
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19. Radiographs in Endodontics
Initial radiograph
Diagnosis
Working-length film
To determine the length of the canal
Final-instrumentation film
Final-size files in all canals
Root canal completion film
Taken after the tooth has been temporized
Recall films
Taken at evaluations
Initial radiograph should be of diagnostic quality; the dental assistant must see the apex of tooth or teeth in question.
The working-length film is taken once the pulp is accessed.
Final film: The radiograph shows the files in place in the canal.
Completed film: The root canal procedure is complete.
Recall films: Taken at prophylaxis appointments or as needed to check the status of a tooth.
What type of film should be taken?
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20. Requirements of Endodontic Films
Must show 4 to 5 mm beyond the apex of the tooth and the surrounding bone or pathologic condition
Must present an accurate image of the tooth without elongation or foreshortening
Must exhibit good contrast so that all pertinent structures are readily identifiable
What type of film would be taken?
What if we didn’t get the apex of the tooth? What would we need to do?
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21. Fig. 54-6 Good-quality radiograph in endodontics.
Top radiograph: Shows at least 4 mm beyond the apex; apex is not distorted; good contrast
Bottom radiograph: Does not show at least 4 mm beyond apex; apex is distorted; poor contrast is evident
What would we need to do to make the bottom radiograph of diagnostic quality?
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22. Diagnostic Conclusions
Normal pulp
No subjective symptoms or objective signs are noted. The tooth responds normally to sensory stimuli, and a healthy layer of dentin surrounds the pulp.
(Cont’d)
If a tooth is “normal,” what could be the cause of the pain for the patient?
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23. Diagnostic Conclusions
(Cont’d)
Pulpitis
The pulp tissues have become inflamed.
Reversible pulpitis
The pulp is irritated, and the patient is experiencing pain in response to thermal stimuli.
Irreversible pulpitis
The tooth displays symptoms of lingering pain.
“itis” = inflammation
Reversible pulpitis: When the irritant is removed, the tooth can be saved from root canal treatment.
What could be the irritant?
Irreversible pulpitis: The pulp is incapable of healing.
If root canal therapy does not improve the situation, extraction of the tooth is the next option.
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24. Diagnostic Conclusions
(Cont’d)
Periradicular abscess
This inflammatory reaction to pulpal infection may be of chronic or acute onset with pain, tenderness of the tooth in response to pressure, pus formation, and swelling of the tissues.
What is another term for pus? (Exudate.)
Odor/smell/color
Chronic periradicular abscess: presence of a draining sinus tract
Acute periradicular abscess: pain, tenderness, swelling as a result of the necrosis
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25. Diagnostic Conclusions
(Cont’d)
Periodontal abscess
This inflammatory reaction is frequently caused by bacteria trapped in the periodontal sulcus. A patient will experience rapid onset of pain, tenderness of the tooth in response to pressure, pus formation, and swelling.
Odor/smell/color
Where is the sulcus located?
Does a periodontal abscess always indicate that root canal therapy is needed?
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26. Diagnostic Conclusions
(Cont’d)
Periradicular cyst
This type of cyst develops at or near the root of a necrotic tooth. They develop as an inflammatory response to pulpal infection and necrosis of the pulp.
Not very common.
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27. Diagnostic Conclusions
(Cont’d)
Pulp fibrosis
A decrease in living cells within the pulp causes fibrous tissue to take over the pulpal canal.
Mostly seen in older patients
Patients with recent trauma to a tooth may be susceptible.
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28. Diagnostic Conclusions
(Cont’d)
Necrotic tooth
The tooth may also be referred to as nonvital. The term is used to describe a tooth that does not respond to sensory stimulus.
What is another term for necrotic?
The tooth is still attached to the alveolus by means of the cementum and periodontal ligaments.
If a tooth is necrotic, will it fall out on its own?
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29. Chapter 54 Lesson 54.2
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30. Learning Objectives List the types of endodontic procedures.
Discuss the medicaments and dental materials used in endodontics.
Provide an overview of root canal therapy.
Assist in root canal therapy.
Describe surgical endodontics and how it affects treatment.
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31. Endodontic Procedures
Pulp capping
Calcium hydroxide is placed over an exposed or nearly exposed pulp to encourage the formation of dentin at the site of injury.
Indirect pulp capping is indicated when a thin partition of dentin is still intact.
Direct pulp capping is indicated when the pulp has been slightly exposed.
(Cont’d)
Capping can be used as an attempt to save the pulp
Mostly used when bacteria have come very close to infecting the pulp
Goals: to promote pulpal healing and to stimulate production of reparative dentin
Most commonly referred to as IPC or DPC
The dentist must inform the patient that this procedure may not be a long-term solution.
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32. Endodontic Procedures
(Cont’d)
Pulpotomy
This procedure involves removal of the coronal portion of an exposed vital pulp.
It is used to preserve the vitality of the remaining portion of the pulp within the root of the tooth.
The procedure is commonly indicated for vital primary teeth, teeth with deep carious lesions, and emergency situations.
Where is the coronal portion of the tooth?
Most commonly done on deciduous teeth.
Why wouldn’t root canal therapy be done on a deciduous tooth?
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33. Endodontic Procedures
(Cont’d)
Pulpectomy
Also referred to as root canal therapy, this procedure involves the complete removal of the dental pulp.
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34. Instruments and Accessories for Endodontic Procedures
Hand instruments
Instruments for pulp preparation
Hand- and finger-operated files
Instruments attached to a low-speed handpiece
Rotary files
Ancillary instruments
Rubber stops
Paper points
Most root canal instruments are slim in design to fit inside the canals of the teeth and flexible enough to adapt to the curves of the canals.
Hand instruments: endodontic explorer, endodontic spoon excavator, spreaders, pluggers, Glick No. 1.
Finger files: broaches, K-type files, Hedstrom files.
Rotary files: Gates-Glidden burs, Pesso reamers.
Ancillary instruments: rubber stops, paper points
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35. Table 54-1 Colors and Sizes of Endodontic Files
Universal color-coded system.
For example, a white file may have a diameter of 15, 49, or 90.
Most manufacturers place the number on the handle of the file.
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36. Medicaments and Dental Materials in Endodontics
Irrigation solution
Sodium hypochlorite
Hydrogen peroxide
Parachlorophenol, or PCP
Root canal–filling materials
Gutta-percha points
Root canal sealers
Irrigation solutions help remove debris, bleach and the deodorize canal, and control hemorrhaging. Sodium hypochlorite is the most commonly used solution.
A high-volume evacuator must be used at all times during irrigation. Why is this important?
Filling materials: Gutta-percha is solid at room temperature, but a heat source is needed during filling.
Variety of sizes; the first gutta-percha point in a canal is referred to as the “master cone.” The size should be documented in the patient’s chart.
What does “obturation” mean?
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37. Overview of Root Canal Therapy
Anesthesia and pain control
Isolation and disinfection of the site
Access preparation
Débridement and shaping of the canal
Obturation
Local anesthetic is most commonly used.
Infiltration for maxillary teeth; nerve blocks for mandibular teeth.
Sedatives may also be used to alleviate apprehension.
Rubber dams are always used during root canal procedures.
Why is the use of a rubber dam important?
What is débridement?
What problems could occur if the working length is incorrect?
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38. Surgical Endodontics Indications for surgical intervention
Endodontic failure
Persistent infection, severely curved roots, perforation of the canal, fractured roots, extensive root resorption, pulp stones, or accessory canals that cannot be treated
Exploratory surgery
To determine why healing did not occur
Biopsy
Root canals have a 10% to 15% chance of failure.
Used to save a tooth from extraction.
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39. Apicoectomy and Apical Curettage
To surgically remove the apical portion of the root with the use of a high-speed handpiece and bur
To evaluate:
Inadequate sealing of the canal
Accessory canals
Fractures of the root
Pathologic tissue around the root apex
Invasive procedure.
A flap is made on the buccal mucosa to gain access to the apex.
An endodontist generally performs this procedure.
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40. Retrograde Restoration
This procedure is undertaken when an apical seal is not adequate.
A small class I preparation is made at the apex and sealed with filling materials such as gutta-percha, amalgam, or composite.
Used in conjunction with apicoectomy, apical curettage, or both.
Commonly referred to as “root-end filling.”
Amalgam is most commonly used filling material.
Why would this procedure be done by an endodontist rather than a general dentist?
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41. Root Amputation and Hemisection
This surgery is performed to remove one or more roots of a multirooted tooth without removing the crown.
Hemisection
The root and the crown are sectioned lengthwise and removed.
A root amputation is performed at the furcation.
What is furcation?
Hemisections are most commonly performed on mandibular molars.
Why wouldn’t hemisections be performed on maxillary molars?
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