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Endodontics

2. Endodontics
Branch of dentistry that deals with diagnosis and treatment of diseases of the pulp and periapical tissues
Endodontic procedures include diagnosis, root canal, and periapical surgery.

3. Progress of Pulpal and Periapical Disease
Vital pulp
Healthy pulp
May be inflamed
Capable of healing after irritant is removed
Vital pulp is healthy pulp that may be inflamed but is capable of healing after irritant is removed.

4. Progress of Pulpal and Periapical Disease
Nonvital pulp
Tooth no longer responds to stimuli
Tooth is considered necrotic
Unable to heal
With nonvital pulp the tooth no longer responds to stimuli. The tooth is considered necrotic as it is unable to heal.

5. Reversible Pulpitis
Inflamed pulp is able to heal when irritant is removed
Causes
Caries
Enamel fracture
Occlusal attrition
With reversible pulpitis the inflamed pulp is able to heal when irritant is removed.
The causes of this disease are incipient caries, enamel fractures, and occlusal attrition.

6. Reversible Pulpitis Symptoms Treatment Thermal sensitivity
Remove irritant
Place sedative dressing
The symptoms of reversible pulpitis are sensitivities to hot and cold.
Treatment includes removable of irritant and placement of sedative dressings to heal the pulp.

7. Pulp Irritants Leading to Irreversible Pulpitis
Advanced dental decay
Impact trauma
Fractures
Invasive restorative procedures
Adverse reaction to dental material
Irreversible pulpitis is caused by advanced dental decay, impact trauma, fractures, invasive restorative procedures, and adverse reaction to dental material.
Inflammation continues until pulp tissue cannot recover.

8. Irreversible Pulpitis
Results from prolonged inflammation
Pulpal tissue unable to heal
Pain symptoms
Dull and continual
Short and sharp
Dull and continual pain or short and sharp pains occur with irreversible pulpitis.
Treatment usually involves root canal therapy or extraction.

9. Irreversible Pulpitis
Treatment
Root canal therapy
Extraction

10. Pulpal Necrosis Death of pulpal cells
Exudate (pus) and gas form in the pulp chamber
Process is slowed if pressure released through:
Fistula
Caries
Pulpal necrosis involves the death of pulpal cells once exudate (pus) and gas form in the pulp chamber.
The process is slowed if pressure is released through fistula or caries.

11. Periapical Diseases Apical periodontitis Periapical abscess
When an infection in the pulp reaches the apex of the tooth it continues into the periapical area.

12. Apical Periodontitis
Pulpal inflammation that has spread to the periapical tissues
Inflammation creates:
Granuloma
Tumor filled with granulation tissue
Cyst
Fluid-filled or semisolid-filled
Apical periodontitis is a periapical disease in which pulpal inflammation extends into the periapical tissues.
If left untreated, a cyst filled with liquid and semi-solid material forms.

13. Periapical Abscess Destruction of tissue Exudate present
Pressure must be released
With periapical abscess, the localized destruction of tissue and accumulation of exudate results.
A release of pressure relieves the symptoms.

14. Endodontic Diagnosis Medical and dental history Clinical examination
Referring dentist’s notes
Endodontic diagnosis includes medical and dental history, clinical examination, and review of communication from referring dentist’s notes.

15. Medical History Review and clarify medical history Medical conditions
Medications
The first step is asking the patient to complete a medical history.
The medical history is reviewed and clarified to ensure accuracy.
Medical conditions and medications are reviewed.

16. Dental History Review past dental experiences Current concerns
Subjective examination
Type of pain
Thermal sensitivity
Duration of pain
The dental history is reviewed to provide the dentist with a review of past dental experiences.
Subjective is the problem in the patients own words, such as the type of pain they are experiencing (constant aching, sudden throbbing), a sensitivity to hot or cold and the length of the pain.

17. The Clinical Examination
Objective examination
Extraoral tissues
Facial asymmetry
Swelling
Redness
Fistulas
In the clinical examination an objective examination is performed to search for extraoral tissues, facial asymmetry, swelling, redness, and fistulas.

18. Intraoral Clinical Examination
Tissues evaluated and palpated
Caries
Discoloration
Fractures
Tissues are evaluated and palpated in the intraoral clinical examination to find caries discoloration, and fractures.

19. Clinical Testing Procedures
Radiographs
Radiolucent area on x-ray indicates bone involvement
Palpation
Percussion
Tissues are evaluated and palpated in the intraoral clinical examination to find caries discoloration, and fractures.

20. Clinical Testing Procedures
Mobility
Cold Test
Dry ice, ethyl chloride, ice
Heat Test
Mobility is evaluated to determine the condition and involvement of the supporting structures of the tooth.
Teeth that move 2 to 3 mm should not have root canal therapy as they lack sufficient support.
Pressure is applied on the lingual and facial sides of the tooth.
Cold testing is accomplished using dry ice ethyl chloride, and ice to determine sensitivity.
A normal tooth will respond within a few second. Intense and long lasting pain reveals irreversible pulpitis, and no response means that necrotic pulps are present.
Heated gutta percha is applied to tooth. If tooth responds to pain, or if pain increases and lasts, irreversible pulpitis likely

21. Clinical Testing Procedures
Pulp testing
Indicates if tooth is vital or nonvital
Transillumination test
Selective anesthesia
Caries removal
High frequency currents create an electrical stimulus to the tooth to determine if a tooth is vital or nonvital.
The control tooth is the tooth in the opposite arch.
Electronic pulp testers may give a false reading; therefore, pulp testing must be done in conjunction with other testing to get a more accurate result.
Fiber-optic light shines through the crown of tooth in transillumination testing.
Shadows indicate vertical fractures.
Selective anesthesia is used if the patient cannot identify the tooth or arch that is causing the problem.
Suspect tooth is numbed. Anesthesia is injected into a selected area and if pain ceases, then problem tooth detected.
It helps determine which tooth is problematic by the process of elimination.
In order to determine the status of the pulp (whether reversible pulpitis or irreversible pulpitis exists), removal of dental caries must be performed in some patients.

22. Endodontic Instruments
Barbed broaches
Remove soft tissue from canal
Designed to cut tissue when pulled from canal
Sized xxx-fine to coarse
Color-coded handles
Barbed broaches are made of fine metal wire with tiny, sharp projections along the instrument shaft.
Broaches are used to remove soft tissue from the pulp canal.

23. Endodontic Instruments
Files
Enlarges and smoothes canals
Removes necrotic tissue
Color-coded system marks size of file
K-type or Hedstrom
Fractured anterior teeth
Apexogenesis root not fully developed
Endodontic files are used to enlarge and smooth the canal.
They are long, tapered, and twisted instruments that are moved up and down inside the canal and are available in various diameters and types.
Standard files are known as K-type files.
The Hedstrom files are shaped like pine trees.
The flex files are made from stainless steel for optimal balance, flexibility, strength, and sharpness.

24. Endodontic Instruments
Reamers
Enlarges canal
Applies with a twisting motion
Color-coded system
The reamer is not used as often as the file.
It is applied with a twisting motion.

25. Endodontic Instruments
Organizers
Various options to store and organize reamers and files
Some can be sterilized
There are a variety of organizers for storage and organization of endodontic reamers and files.
Some can be sterilized and some have gauges or stops for measurement when using the instruments.

26. Endodontic Instruments
Rubber stops
Called file stops, endo stops, or markers
Placed on reamers and files to mark length of root canal
Small circular disks have prepunched holes in center
Rubber stops (called file stops, endo stops, or markers) are small circular disks that have prepunched holes in center.
They are placed on reamers and files to mark the length of the root canal.

27. Endodontic Instruments
Gates-Glidden drills
Used with latch attachments on low-speed handpieces
Long shanked and elliptically-shaped with blunt, football-shaped ends
Six sizes are marked near notch of shank
Gates-Glidden Drills are used in the upper portion of the canal to prepare the opening access by removing obstructing dentin.

28. Endodontic Instruments
Gates-Glidden drills
Used in upper portion of canal to prepare opening access by removing obstructing dentin

29. Endodontic Instruments
Peeso reamers
Have parallel cutting sides
Used with latch attachments on low speed handpieces
Supplied in various sizes
Used to prepare canal for a post and to reduce curvature of canal orifice for straight-line access
Peeso Reamers have parallel cutting sides.
They are used with latch attachments on low speed handpieces to prepare canal for a post and to reduce the curvature of the canal orifice for straight-line access.

30. Endodontic Instruments
Lentulo spirals
Long, twisted, and very flexible wire instrument used to spin root canal sealer or cement into canal
Spirals used with low-speed handpieces and latch attachments
Lentulo Spirals are long, twisted, and very flexible wire instruments used to spin root canal sealer or cement into the canal.

31. Endodontic Instruments
Endodontic spoon excavator
Double-ended
Long-shanked
Removes
Caries
Pulp tissue
Temporary cement
Endodontic spoon excavator has a very long shank that allows the instrument to reach into the coronal portion of the tooth.
It removes deep caries, pulp tissue, and temporary cement.

32. Endodontic Instruments
Endodontic explorer
Locates opening of canals
Long tapered ends
Double-ended with sharp-pointed ends
The endodontic explorer is designed to help locate canal orifices.
It is a double-ended instrument with long, tapered ends that have sharp points.

33. Endodontic Instruments
Endodontic spreaders
Similar to pluggers but pointed at tip
Condense gutta percha into sides of canal
Endodontic spreaders are similar to pluggers but pointed at tip.
They condense gutta percha into sides of canal.

34. Endodontic Instruments
Endodontic pluggers
Used to condense gutta percha
Flat-ended
Endodontic pluggers are flat-ended instruments that are used to condense gutta percha.

35. Endodontic Instruments
Glick #1 instrument
Used to remove excess gutta percha from the coronal portion of canal
Used to condense remaining gutta percha in canal opening
The Glick #1 instrument is used to remove excess gutta percha from the coronal portion of the canal and to condense the remaining gutta percha in the canal opening.

36. Endodontic Materials Paper points Dries canals Place medications
Take cultures
X-fine to coarse
Paper points come in various sizes, from extra fine to course.
They are packaged in sterile and non-sterile and and are used to dry canals, place medications, and to take cultures.

37. Endodontic Materials Gutta Percha Obturates (fills) canals
Heated and placed in canals
Condensed with spreader and pluggers
Removal of apex and infection surrounding tooth
Gutta Percha is a thermoplastic material that is flexible at room temperature yet stiff enough to be placed in a root canal.

38. Endodontic Materials Irrigation solutions
Root canal is irrigated frequently to remove debris
Sterile water
Sodium hypochlorite
Irrigation solutions made from sterile water or sodium hypochlorite are used to irrigate during root canals, frequently to remove debris.

39. Endodontic Materials Root canal sealers and cements
Root canal series used with obturating materials prevent microleakage in canal
Powders, liquids, pastes, and capsules
Powders, liquids, pastes and capsules made from zinc oxide-eugenol, calcium hydroxide, and glass ionomer are used to cement and seal root canals to prevent microleakage in the canal.

40. Equipment Assisting Endodontic Procedures
Apex finder
Heating unit
Endodontic handpiece
Vitality scanner
Ultrasonic unit
Endodontic bender
Newer equipment is being introduced to assist in endodontic procedures.
The apex finder measures the distance to the apex of the tooth and displays the information on a digital readout.
The heating unit applies heat for vitality testing, warming the gutta percha for obturation, and provides heat for bleaching procedures.
The vitality scanner allows the dentist to scan each tooth in minutes.
It indicates endodontic problems in their early stages.
The ultrasonic unit is used to apply the right amount of pressure and vibration to the tip.
The endodontic bender bends endodontic reamers, files, posts, pluggers, and spreaders.

41. Endodontic Procedures
Root canal treatment
Usually completed in two appointments
Sometimes infection is given time to be treated before canal is sealed
Root canal treatment is usually completed in two appointments, varying with the degree of infection.

42. General Steps in Root Canal Therapy
Administer anesthetic
Isolate area
Gain access to pulp
Locate canals
Remove pulpal tissue
There are ten steps in a root canal that can be divided into two or more appointments. Steps one through eight would take place on the first visit, step 9 on the second, and the patient would follow up with their dentist for the tenth step.

43. General Steps in Root Canal Therapy
Enlarge and smooth root canal
Irrigate root canal
Place temporary filling
Obturate (seal) root canal
Refer patient to general dentist for final restoration

44. Endodontic Retreatment
Causes:
Abscess does not heal
Narrow or curved canals were not treated
New decay along filling
Complicated canal anatomy went undetected
If a tooth continues to be sensitive to heat and pain and fails to heal, treatment must be continued.

45. Endodontic Retreatment
Causes:
Restoration did not occur soon enough after treatment
Restoration became loose, cracked, or broken and exposed tooth to new decay

46. Pulpectomy Complete removal of pulp First stage of a root canal
Indicated for:
Permanent teeth with deep caries
Vertical fracture
The removal of all pulpal tissues beginning in the coronal portion of the tooth and terminating 1 to 3 mm short of the apex in the root canal of the tooth is called a pulpectomy.
It is the first stage of the root canal as it cleans and enlarges the canal.

47. Pulpotomy Pulp removed from coronal portion Pulp remains in root canal
Treatment indicated
Primary teeth with pulpal exposure
Pulp exposed after accident
Deep carious lesions
Root does not develop completely
Anterior tooth is fractured
Pulp is removed from the coronal portion of the tooth in a pulpotomy.

48. Pulpotomy Sterile cotton pellet wetted with Formocresol solution
Zinc oxide-eugenol cement
Diagram of a pulpotomy.

49. Apicoectomy Apex of root and infection is surgically removed
Apicoectomy is performed when extreme curvature of the root prevents the root canal instruments from reaching the apex, the root canal is hypercalcified and obstructs root canal therapy, or a previous endodontic treatment did not seal the canal sufficiently.

50. Root Amputation
Surgical procedure to remove one or more of the roots of a multi-rooted tooth
Extensive bone loss around the root
Root amputation is the surgical procedure to remove one or more of the roots of a multi-rooted tooth due to extensive bone loss around the root.

51. Hemisection Surgical removal of one root and overlying crown
Diseased portion is removed
Indications are similar to root amputation
Hemisection is the surgical removal of one root and the overlying crown.

52. Apexification
Treatment of the apex of the root canal in a tooth that is necrotic
Creates a calcified barrier
Apexification creates a barrier over the open apex of the root of a necrotic tooth.
Treatment involves cleaning out the canal and shaping the canal, then placing a material into the canal to create the barrier.

53. Apexogenesis Treatment of pulp of a young tooth with an open apex
Tooth is vital but has carious or traumatic exposure
The vital but exposed tooth is treated with a pulp capping to permit closure of the apex and continued growth of the root. A calcified bridge forms over the exposed area allowing it to stay vital and heal and grow.