1. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontics Chapter 24

2. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontics Branch of dentistry that deals with diagnosis and treatment of diseases of pulp and periapical tissues

3. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Progress of Pulpal and Periapical Disease Vital pulp –Healthy pulp –May be inflamed –Capable of healing after irritant removed

4. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Progress of Pulpal and Periapical Disease Nonvital pulp –Tooth no longer responds to stimuli –Tooth considered necrotic –Unable to heal

5. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Reversible Pulpitis Inflamed pulp able to heal when irritant removed Causes: –Caries –Enamel fracture –Occlusal attrition

6. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Reversible Pulpitis Symptoms: –Thermal sensitivity Treatment: –Remove irritant –Place sedative dressing

7. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Pulp Irritants Leading to Irreversible Pulpitis Advanced dental decay Impact trauma Fractures Invasive restorative procedures Adverse reaction to dental material

8. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Irreversible Pulpitis Results from prolonged inflammation Pulpal tissue unable to heal Pain symptoms: –Dull and continual –Short and sharp Treatment: –Root canal therapy –Extraction

9. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Pulpal Necrosis Death of pulpal cells Exudate (pus) and gas form in pulp chamber Process slowed if pressure released through: –Fistula –Caries

10. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Periapical Diseases Apical periodontitis Periapical abscess Courtesy of Clifton O. Caldwell, Jr., DDS., FICD, FACD.

11. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Apical Periodontitis Pulpal inflammation that has spread to periapical tissues Inflammation creates: –Granuloma Tumor filled with granulation tissue –Cyst Fluid-filled or semisolid-filled

12. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Periapical Abscess Destruction of tissue Exudate present Pressure must be released

13. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Diagnosis Medical and dental history Clinical examination Referring dentist’s notes

14. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Medical History Review and clarify medical history –Medical conditions –Medications

15. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Dental History Review past dental experiences Current concerns –Subjective examination Type of pain Thermal sensitivity Duration of pain

16. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Clinical Examination Current concerns –Objective examination Extraoral tissues Facial asymmetry Swelling Redness Fistulas

17. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Intraoral Clinical Examination Tissues evaluated and palpated –Caries –Discoloration –Fractures

18. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Clinical Testing Procedures Radiographs –Radiolucent area on x- ray indicates bone involvement Palpation Percussion © Cengage Learning 2013

19. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Clinical Testing Procedures Mobility Cold test –Dry ice, ethyl chloride, and ice Heat test © Cengage Learning 2013

20. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Clinical Testing Procedures © Cengage Learning 2013

21. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Clinical Testing Procedures Pulp testing –Indicates if tooth is vital or nonvital Transillumination test Selective anesthesia Caries removal

22. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Dental Check What is an advanced stage of periapical infection that spreads into the bone? –Osteomyelitis

23. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

24. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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 –Flex files © Cengage Learning 2013

25. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Reamers –Enlarges canal –Applies with twisting motion –Color-coded system © Cengage Learning 2013

26. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Organizers –Various options to store and organize reamers and files –Some can be sterilized

27. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Rubber stops –Also known as 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

28. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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 marked near notch of shank

29. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Gates-Glidden drills –Used in upper portion of canal to prepare opening access by removing obstructing dentin Courtesy of Sybron Endo

30. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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 post and to reduce curvature of canal orifice for straight-line access

31. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. 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

32. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Endodontic spoon excavator –Double-ended –Long-shanked –Removes: Caries Pulp tissue Temporary cement Courtesy of Hu-Friedy Mfg., Co., Inc.

33. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Endodontic explorer –Locates opening of canals –Long, tapered ends –Double-ended with sharp-pointed ends Courtesy of Hu-Friedy Mfg., Co., Inc.

34. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Endodontic spreaders –Similar to pluggers But pointed at tip –Condense gutta percha into sides of canal © Cengage Learning 2013

35. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Endodontic pluggers –Used to condense gutta percha –Flat-ended

36. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Instruments Glick #1 instrument –Used to remove excess gutta percha from coronal portion of canal –Used to condense remaining gutta percha in canal opening

37. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Dental Check Which intracanal instrument comes in diameters ranging from xxx-fine to coarse? –Barbed broach

38. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Materials Paper points –Extra-fine to coarse –Uses: Dries canals Places medications Takes cultures © Cengage Learning 2013

39. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Materials Gutta percha –Obturates (fills) canals –Heated and placed in canals –Condensed with spreader and pluggers –Removal of apex and infection surrounding tooth

40. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Materials Irrigation solutions –Root canal irrigated frequently to remove debris Sterile water Sodium hypochlorite

41. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Materials Root canal sealers and cements –Root canal series used with obturating materials prevent microleakage in canal –Powders, liquids, pastes, and capsules

42. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Equipment Assisting Endodontic Procedures Apex finder Heating unit Endodontic handpiece Vitality scanner Ultrasonic unit Endodontic bender Dental microscope Endodontic obturation system

43. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Procedures Root canal treatment –Usually completed in two appointments –Sometimes infection given time to be treated before canal sealed

44. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. General Steps in Root Canal Therapy 1.Administer anesthetic 2.Isolate area 3.Gain access to pulp 4.Locate canals 5.Remove pulpal tissue

45. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. General Steps in Root Canal Therapy 6.Enlarge and smooth root canal 7.Irrigate root canal 8.Place temporary filling 9.Obturate (seal) root canal 10.Refer patient to general dentist for final restoration

46. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Retreatment Causes: –Abscess did not heal –Narrow or curved canals were not treated –New decay grew along filling –Complicated canal anatomy went undetected

47. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Endodontic Retreatment Causes: –Restoration did not occur soon enough after treatment –Restoration became loose, cracked, or broken and exposed tooth to new decay

48. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Pulpectomy Complete removal of pulp First stage of root canal Indicated for: –Permanent teeth with deep caries –Vertical fracture

49. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Pulpotomy Pulp removed from coronal portion Pulp remains in root canal

50. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Pulpotomy Treatment indicated: –Primary teeth with pulpal exposure –Pulp exposed after accident –Deep carious lesions –Root does not develop completely –Anterior tooth is fractured

51. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Pulpotomy Sterile cotton pellet wetted with Formocresol solution Zinc oxide- eugenol cement © Cengage Learning 2013

52. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Surgical Endodontics Sometimes required to save tooth Involves facial surface incision to expose bone Root exposed and treatment performed

53. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Apicoectomy Apex of root and infection surgically removed © Cengage Learning 2013

54. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Root Amputation Surgical procedure to remove one or more of the roots of multi- rooted tooth Extensive bone loss around root Courtesy of Dr. Gary Shellerud

55. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Hemisection Surgical removal of one root and overlying crown Diseased portion removed Indications similar to root amputation Courtesy of Dr. Gary Shellerud

56. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Apexification Treatment of apex of root canal in necrotic tooth Creates calcified barrier

57. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Apexogenesis Treatment of pulp of young tooth with open apex Tooth vital, but has carious or traumatic exposure

58. ©2013 Delmar, Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part. Dental Check What are some reasons for a root canal treatment (RCT) to fail? –Abscess did not heal –Narrow or curved canals were not treated –New decay grew along filling –Complicated canal anatomy went undetected –Too long in between treatment appointments –New infection due to trauma