ENDODONTIC

Case Presentation
TOOTH # 45
BACOCO, MARIA MAGDALENA M.
MULTI- ROOTED LIVE PATIENT
 Name:
XXX
Patient
Profile Gender
Male

Age
 “Ipapapasta ko po sana
ngipin ko kung pwede
Chief
pa”
Complain
(If possible I want my
tooth to be restored)
 ❑ Patient visited the dental infirmary seeking
composite tooth restoration for his tooth 45
since it was not painful,
❑But clinically there was ¾ coronal structure
History
lost and visible pulpal canal.
of ❑According to him, last 2016 the restoration of
Present said tooth was removed and didn’t even
Illness bother to visit a dentist for that problem.
❑Upon clinical test, tooth 45 only reacted to
percussion.
 PAST DENTAL HISTORY:
extraction of 35 last 2017

MEDICAL HISTORY:
Patient Never been hospitalized
Not under any medication/vitamin
History

SOCIO-OCCUPATIONAL HISTORY
Criminology Student at King’s College
Drinks alcoholic beverages occasionally but
Pre-operative Picture
and X-ray
 PAIN CLINICAL TEST
TEETH ALLEV
VITALITY TEST
TESTED IATING
DUR LOC FACTO SINUS
SEVE TYP PERC PALP XRAY PROBE
ATIO ATIO STIMU R MOBI TRAC
RITY E HEA USSIO ATIO DEPTH
N N LUS COLD LITY T
T N N

Crestal bone
loss
M:4.5mm
Pulpal and
45 D:6mm
Prob
_ _ _ _ _ - - ++ - N - periodontal
involvement B:2.5 mm
L:4 mm
Tooth
Clinical Test:
Cold Test Heat Test Percussion
Vitality
Test Negative Negative Positive
of
tooth # 45
 Pulpal and periodontal
Clinical Test:
involvement
X-ray
interpretation
Crestal
of
tooth # 45 bone
loss
C. Critique the
interpreted clinical
and radiographic sign
and symptoms to
determine the indication for
endodontic treatment.
CRITIQUE REFERENCE: Cohen’s Pathways of the Pulp 10th ed.
Chapter1 pg.37

✔ pulp necrosis, the tooth will not respond to

electric pulp tests or to cold stimulation
(vitality test: both are negative result)
✔ tooth may become symptomatic to
percussion or exhibit spontaneous pain (Px
percussion result: positive)
✔ thickening of the periodontal ligament space
to the appearance of a periapical radiolucent
lesion
D. State the
provided differential
and final diagnoses.
If such is not
provided the student should
provide as per CC and HPI.
 ENDO DIAGNOSIS
Tentative diagnosis:
Total Necrosis with Periodontitis

Diagnosis Differential diagnosis:

of Asymptomatic Irreversible Pulpitis
tooth # 45 Chronic Periapical Periodontitis

PERIO DIAGNOSIS:
Independent Perio
E. Critique the
provided
differential
and final
diagnosis
CRITIQUE REFERENCE: Cohen’s Pathways of the Pulp 10th ed.
Chapter1 pg.37

I DO AGREE with the clinical diagnosis

Total Necrosis
✔ the pulp becomes completely necrotic, the tooth will typically
become asymptomatic until such time that symptoms develop as a
result of extension of the disease process into the periradicular
tissues (preoperative picture and x-ray:there is a presence of pulpal
and periodontal involvement already. Lost of clinical crown is visible
to the patient)
✔ when the infection (or the bacterial toxins from this infection)
extends into the periodontal ligament space, the tooth may become
symptomatic to percussion or exhibit spontaneous pain (Px
percussion result: positive)
CRITIQUE REFERENCE: Cohen’s Pathways of the Pulp 10th ed.
Chapter1 pg.37

Asymptomatic Periodontitis
✔ generally presents with no clinical symptoms
✔ tooth does not respond to pulp vitality tests
(Vitality test: hot and cold is negative result)
✔ the patient on percussion (HPI: Upon clinical
test, tooth 45 only reacted to percussion)
 CRITIQUE
DIFFERENTIAL DIAGNOSIS
❖ Asymptomatic Irreversible Pulpitis
✔ pertains to a tooth that has no symptoms, but with deep
caries or tooth structure loss that, if left untreated, will cause
the tooth to become symptomatic or nonvital
✔ the pulp may already be exposed
✔ A radiograph may also show exposure of the pulp, caries
under a filling, or a deep cavity or filling threatening the
integrity of the pulp

REFERENCE: Cohen’s Pathways of the Pulp 10th ed.

Chapter2 pg.41
 CRITIQUE
DIFFERENTIAL DIAGNOSIS
❖ Chronic Periapical Periodontitis
✔ death of the pulp, followed by a continued, mild infection or
irritation of the periradicular tissue that stimulates a
productive cellular reaction
✔ develops only some time after the pulp has died
✔ cannot be differentiated from other periradicular diseases
unless the tissue is examined histologically

REFERENCE: Grossman’s Endodontic Practice 13TH Ed.

Chapter6 pg.120
 REFERENCE: : Cohen’s Pathways of the Pulp 10th ed.
REFERENCE: Grossman’s Endodontic Practice 13TH Ed.
Total Necrosis
Description Asymptomatic, until such
time that symptoms develop
as a result of extension of the
disease process into the
periradicular tissues
Radiographic features thickening of the periodontal
ligament space to the
appearance of a periapical
radiolucent lesion
Clinical features Asymptomatic in nature
Pain on percussion Positive
CRITIQUE
Asymptomatic
Irreversible Pulpitis
The tooth is asymptomatic
and if left untreated will
become symptomatic
irreversible pulpitis, or the
pulp might become necrotic
radiographs show no
periradicular changes
Asymptomatic in nature
Negative
Chronic Periapical
Periodontitis
asymptomatic, death of the
pulp, followed by a continued,
mild infection or irritation of
the periradicular tissue that
stimulates a productive
cellular reaction
area of rarefaction is well
defined, with lack of
continuity of the lamina dura
Asymptomatic in nature
F. Describe and discuss the provided
protocol in order
to address the CC, restore
normal function, esthetic and comfort. If
such is not provided the student should
provide thru discussion with illustration,
then proceed to “H”
A. Tooth isolation
B. Access preparation
C. Determining the working length
D. Pulp extirpation, biochemical cleaning and
shaping
E. Doing bacteriologic examination
F. Root canal obturation
G. Proper restoration
H. Radiographs to determine the success or failure
of restoration
 Tooth isolation
✔ Using rubber dam
is mandator in root canal treatment
✔ When placed properly, the rubber
dam facilitates treatment by
isolating the tooth from obstacles (e.g. saliva and tongue) that
can disrupt any procedure
✔ Proper rubber dam placement can be done quickly and will
enhance the entire procedure
REFERENCE: Cohen’s Pathways of the Pulp 10th Ed.
Chapter5 pg.109
 Access
preparation
 ❖ Oral Prophylaxis
st ❖ Caries Removal & Build Up
1 ❖ Access Preparation with Rubber
Meeting Dam Isolation

(October
15, 2018)
❖ Working Length Establishment at 22
mm
❑Xray
❑Apex Locator
Pulp extirpation, biochemical
cleaning and shaping
complete removal of a normal or
diseased pulp from the pulp cavity of
the tooth
Using a barbed broach in extirpating
of the entire pulp and for the removal
of necrotic debris, absorbent points,
cotton pledgets, and other foreign
materials from the root canal

REFERENCE: Grossman’s Endodontic Practice 13TH Ed.

Chapter13 pg.291
Doing bacteriologic examination
❖ Cleaning and Shaping
HYBRID TECHNIQUE
❑ 1st : Step Back Technique
❖ Phase 1 (Apical 3rd
Widening)

▪ IAF K#15
@ WL 22mm
▪ MAF K#35
@ WL 22mm
❖ Cleaning and Shaping
HYBRID TECHNIQUE
❑2 : Crown Down Technique
nd

❖Protaper S Files
(Middle to Coronal
rd
3 Widening)

▪S1 @ WL 22 mm
▪S2 @ WL 22 mm
▪Using IAF K#15
@ WL 22mm
❖ Placement of
❑ Intracanal Medicament (Calcium Hydroxide)

❑ Temporary Filling Material

Coltosol
 Properly Flared
2nd Asymptomatic
Negative To Percussion
Appt
Negative To Palpation
No Foul Odor
Dryable
Negative To Culture Test
 Properly Flared
rd
3 Asymptomatic
Negative To Percussion
Appt
Negative To Palpation
No Foul Odor
Dryable
Negative To Culture Test
 Root canal obturation
❑ Greater Taper
Gutta Percha #40

❑ Root Canal
Sealer
 ❑ 1 Recall (After more than 1 week)
st

4rth
Meeting
 ❑ 2 Recall (After 1 Month)
nd

❑ Approved for Final Restoration

❑Post and Core
5th
Meeting
❑ Final Restoration (Post and Core)
❑ Endodontically treated tooth should have:

Good Apical Seal

No Sensitivity To Pressure
No Exudate
No Fistula
No Apical Sensitivity
No Active Inflammation
Final Restoration
(Post and Core)

Installation of
PJC
 Radiographs to determine the
success or failure of restoration

❑ Final Recall
(After 3 months)
Tooth number 45 (Before and After)

BEFORE AFTER
October 16,2018 April 2, 2019
Tooth number 45 (Before and After)
BEFORE AFTER
October 16,2018 April 2, 2019
C. Critique the
provided
treatment
protocol
CRITIQUE REFERENCE: Grossman’s Endodontic Practice 13TH Ed.
Chapter13 pg.319

I AGREE with Hybrid technique

✔ combination of step-down instrumentation
followed by a step-back technique (familiar
technique, during endo subj.)
✔ ability to shape the canal predictably with
a combination of hand and rotary stainless
steel instruments
CRITIQUE REFERENCE: Grossman’s Endodontic Practice 13TH Ed.
Chapter14 pg.337

Calcium Hydroxide
✔ has antibacterial properties and
has the ability to induce repair
and stimulate hard-tissue
formation
✔ associated with periradicular
healing and few adverse
reactions
CRITIQUE REFERENCE: Grossman’s Endodontic Practice 13TH Ed.
Chapter13 pg.369

AH plus --- does not release

formaldehyde compare to other
resin-based sealers which release
formaldehyde during setting
REFERENCES
❑ Grossman’s Endodontic Practice 13TH Ed.
❑ COHEN’S PATHWAYS OF THE PULP 10TH EDITION