INTRODUCTION Basic Concept of Root Canal Therapy

ENDODONTICS If bacteria and by-products of pulpal inflammation have been

The branch of dentistry concerned with the morphology, reduced to a non-critical level of infection, it will effect a
physiology and pathology of the human dental pulp and cure, allowing resolution and repair of damaged periradicular
periradicular tissues. tissue.
Its study and practice encompass the basic and clinical The extent of damage depends on the virulence and number
sciences including the biology of the normal pulp and the of microorganisms and the resistance of the host.
etiology, diagnosis, prevention and treatment of diseases Lower down the level of bacteria: goal
and injuries of the pulp and associated periradicular HISTORY
conditions. • Pre-Science: 2nd/3rd century B.C.- 1826
SCOPE Age of Discovery: 1826 – 1876
• Endodontics includes, but is not limited to: • The Dark Age: 1876 - 1926
1. Differential diagnosis • The Renaissance: 1926 - 1976
2. Treatment of oral pains of pulpal and/or periapical origin • The Innovation Era: 1979- Present
(orthograde conventional RCT)
3. Vital pulp therapy • Began in the 17th century
a pulp capping • 1687 - Charles Allen wrote the first English-language book
b. pulpotomy devoted exclusively to the field of dentistry
4. Nonsurgical treatment of root canal systems with or • Pierre Fauchard-precisely described the dental pulp in his
without periradicular pathosis of pulpal origin textbook "Le Chirurgien Dentiste (The Dental Surgeon).
5. Selective surgical removal of pathological tissues resulting • 1725 - Lazare Riviere introduced the use oil of cloves for its
from pulpal pathosis sedative properties
6. Intentional replantation and replantation of avulsed teeth
7. Surgical removal of tooth structure: • 1746 - Fauchard described the removal of pulp tissue
a. root-end resection • 1820 - Leonard Koecker cauterized exposed pulp with a
b. bicuspidization heated instrument, protected it with lead foil
c. hemisection 1836 - Shearjashub Spooner recommended arsenic trioxide
d. apicoectomy (retrograde/non-conventional endo) for pulp devitalization
8. Bleaching of discolored dentin and enamel 1838 - Edwin Maynard (Washington, DC) introduced first root
9. Retreatment of teeth canal instrument
10. Treatment procedures related to coronal restorations • Dr. Angelo Sargenti - first to introduce single visit endodontics
OBJECTIVES
1. To be able to retain a tooth inside the oral cavity which • 1847 - Edwin Trumann introduced gutta-percha as a filling
may otherwise require extraction material
2. Relief of pain, if present • 1850 - WW. Codman confirmed that aim of pulp capping was
3. Removal of pulp from root of tooth to form a dentin bridge
4. Disinfection of root and surrounding bone by cleaning and • 1864 - S.C. Barnum (NY) prepared thin rubber leaf as isolation
shaping of the root canal walls tool
5. Complete filling of root canals (obturation) • 1867 - GA Bowman used gutta-percha cones as sole material
6. Placement of final restoration (if not restorable, extract) for obturating root canals
7. Main contraindication non-restorable tooth o Magitot suggested use of an electric current to test pulp
BASIC PRINCIPLES vitality
1. Chain of Asepsis - infection control • 1873 - Barnum and Bowman introduced the rubber dam
2. Correct diagnosis and treatment planning - careful planning clamp forceps
3. Atraumatic handling of tissues • 1885 - Lepkoski exchanged formalin for arsenic to “dry” non-
4. Cleaning of the canal - debridement and removal of biofilm vital pulp stumps left in the root canals
sticking on the canal walls • Prosthetic restorations became popular at the end of the
5. Shaping of the Canal century
6. Complete Obturation • 1891 - Otto Valkhoff introduced use of camphorated
7. Restoration chlorophenol as medicament to sterilize RCs
8. Recall
Rationale • 1895 - Konrad Wilhelm von Roentgen discovered the x-ray
1. Saving the natural teeth to health • Walkhoff took the first dental radiograph
2. Restore efficient mastication • C. Edmund Kells quickly grasped the potential for applying the
3. Control pain and swelling xray to dentistry
4. Speech and phonation • 1900 - Price described PA radiolucencies as "blind abscesses”,
5. Preserve occlusion advised using radiography to diagnose pulpless teeth
6. Aesthetics
• 1908 - Dr. Meyer L. Rhein introduced technique for
establishing canal length and level of obturation
• G.V. Black - suggested measurement control to determine
canal length and size of apical foramen
• 1904 - Frank Billings showed relationship between oral sepsis
and bacterial endocarditis
• 1909 - E.C. Rosenow developed the "focal infection theory" -
non vital teeth cause disease daw.
• Mayrhofer published work connecting the nature of pulpal
infection with specific MOs
• October 1909 - William Hunter lectured on focal infection
(The Role of Sepsis and Antisepsis in Medicine) at the
University of Montreal, having an impact on endodontics
• It was believed that all systemic diseases could be cured by
extracting teeth
• American dentists continued to extract devitalized teeth for
almost 40 years
• A group of dentists aimed to improve current procedures by
utilizing aseptic techniques, bacteriological and histological
methods, and x rays for diagnosis
• Late 1940s/early 1950s - lab research and clinical evidence
confirmed that devitalized teeth did not play a role in causing
systemic disease
Renaissance (1926-1976)
• Golden period of endodontics
• Better anesthesia and radiographs
• Many RC medicaments appeared on the scene
• Focal infection theory started during out
• First textbook by De Grossman, "Root Canal Therapy”
• RC instruments became standardized and more readily
available
• Establishment of American Association of Endodontics and
the American Board of Endodontics
• Teaching endodontics as a dental specialty
• Journals devoted to this specialty
• Rise and eventual decline of silver points as filling material of
RCs
• GP became the material of choice for obturation
• Vertical condensation (Dr. Herb Schilder), lateral
condensation, softened GP, thermoplastic GP
Innovation Era (1977-present)
Improved and better forms of biomechanical preparation
Obturation techniques becoming simpler, easier, faster
SVE globally accepted by all schools of thought
Improved visibility with the endodontie microscope
Newers, better, more reliable apex locators
Conclusion
To appreciate Endodontics, all of the scope, history, rationale
and principles must be fully understood.
Dentin-Pulp Complex; Biology of the Pulp and Periradicular
tissues
Dental Pulp
Loose connective tissue in the center of the tooth
Primary function: form and support dentin that surrounds it,
forms the bulk of the tooth
Contains odontoblasts
Remains vital throughout life
Responds to external stimuli
Dentin and pulp contain nociceptive nerve fibers
Autonomic (sympathetic) nerve fibers only occur in the pulp
More dentin is laid down and new odontoblasts
differentiated when needed for repair
Pulp equipped with all necessary peripheral components of
the immune system
Injury and foreign antigens = inflammation, pain -
incompressible ang pulp
Good health of the pulp vital to restorative and
prosthodontics dental procedures
Size and shape of pulp depend on:
o Type of tooth
o Degree of tooth development related to px's age
o Any restorative procedures carried out
Development of the Dental Pulp - Early Development
Starts as a band of epithelial cells on the surface of the
embryonic jaws = dental lamina
Downgrowths from the band form the teeth
Initially looks like a bud (bud stage)  bud becomes
invaginated (cap stage)  deepening of invagination (bell
stage)
Enamel organ = bell-shaped downgrowth
Tissue within the invagination = dental pulp (dental papilla)
o Bell stage: inner layer of cells of enamel organ
differentiate into ameloblasts - outer layer of cells
differentiate into odontoblasts
Tissue layer begins to differentiate around the enamel organ
and DP = dental follicle  periodontal attachment
Tooth germ = DP + DF
Histo- and morphodifferentiation of tooth germ genetically
determined and executed by growth factors, transcription
factors, signaling molecules
Differentiation of odontoblasts from undifferentiated
ectomesenchymal cells initiated and controlled by
ectodermal cell of IDE of EO  basal lamina of IDE
disappears, odontoblasts begin to lay down dentin IDE
cells start to deposit enamel
Deposition of unmineralized dentin matrix begins at the cusp
tip, continues in a cervical (apical) direction at an average of
4.5 um/day
 Crown shape predetermined by proliferative pattern of IDE
cells
1st layer of dentin formed = mantle dentin
Matrix formation, mineralization continues throughout
dentin deposition
Predentin: between 10-50 um of dentin matrix immediately
adjacent to odontoblast layer
Nerves and BVs migrate into pulp from future root apex in a
coronal direction as crown formation occurs
o Branch and narrow toward the OL and form plexuses
beneath
Dentin formation continues throughout life in an incremental
pattern
o Lines in the matrix changes in the direction of the tubules
Rate of deposition slows in adulthood, but never completely
stops
Root Formation
Cervical loop = point where cells of IDE + ODE meet
o Delineates the end of the anatomic crown
o Site where root formation begins
Hertwig's epithelial root sheath (HERS): apical proliferation
of the fused epithelia, where root formation is initiated
o Provides signals for odontoblast differentiation
o Acts as template for the root
o Pattern of cell proliferation here determines root
configuration
Formation of the Periodontium
After first dentin in root has formed, basement membrane
beneath (HERS) breaks up and innermost cells secrete
hyaline material overly newly formed dentin = hyaline layer
of Hopewell-Smith
Fragmentation of HERS then occurs = allows cells of DF to
migrate and contact newly formed dentin differentiate
into cementoblasts  initiate acellular cementum formation
Epithelial cell rests of Malassez: remnants of root sheath
found in the periodontium close to the root (after
completion of root development)
Formation of Lateral Canals and Apical Foramen
Lateral canals/accessory canals: channels of communication
between the pulp and PDL
Forms when a localized portion of the root sheath is
fragmented before dentin formation
Single/multiple, small/large
May occur anywhere along the root, but most common in
apical third
o Molars: may join pulp chamber PDL in root furcation
During root formation: AF usually located at end of anatomic
root
When tooth development has completed: AF is smaller,
found a short distance coronal to the anatomic root end
o Distance increases as more apical cementum is formed
One or multiple foramina at apex
o Multiple foramina occur more often in multirooted
teeth
if there are multiple foramina: largest is referred to as AF,
smaller ones are accessory canals = apical delta
Diameter = usually 0.3-0.6 mm
Largest diameters found on D canal of Md molars, palatal
root of Max molars
Develop from ectomesenchyme-derived tissue (dental
follicle)
Root sheath breaks down after mineralization has occurred
o Allows cells from the follicle to proliferate and
differentiate into cementoblasts
Bundles of collagen are embedded in forming cementum and
will become principal fibers of the PDL
Cells in outermost area of follicle differentiate into
osteoblasts = form bundle bone that will anchor periodontal
fibers
Periodontal fibers produce more collagen that binds
anchored fragments together = principal periodontal fibers
Loose fibrous CT that has nerves and BVs remains between
the principal fibers
Numerous undifferentiated mesenchymal cells (tissue-
specific stem cells) possess ability to form new
cementoblasts, osteoblasts, or fibroblasts
Blood supply derived from surrounding bone, gingiva, and
branches of the pulpal vessels
Supports high level of cellular activity in the area
Neural supply has small, unmyelinated sensory and
autonomic nerves & larger myelinated sensory nerves
Anatomic Regions
Tooth has crown and root, joined at the cervix (cervical
region)
Pulp space divided into coronal and radicular regions
o Shape and size of tooth surface reflect shape and size of
the pulp space
o Coronal pulp-pulp horns, pulp chamber
o Pulp space become asymmetrically smaller after
completion of root growth due to slower dentin
production
o Molars: apico-occlusal dimension is reduced more than
MD dimension
o Excessive reduction in pulp space can lead to problems in
locating, cleaning, and shaping the RCS
Anatomy of root canal differs between and within tooth
types
Variation in size and location of the AF influences degree to the original dentin
which blood flow to pulp may be compromised after trauma
o young partially developed teeth have better prognosis for
pulp survival
Disparity between radiographic apex and AF seen when
there is post-eruptive deposition of cementum in the area of
the AF
o Creates a funnel shaped opening to the foramen larger
than intraradicular portion of the foramen
Apical constriction: narrowest portion of the canal
o Coincides with the cementodentinal junction (CDJ)
o Estimated to be 0.5-0.75 mm coronal to apical opening
o Point where the pulp terminates and the PDL begins
Cleaning, shaping and obturation of RC should terminate
short of the AF
o Must also be confined to the canal to avoid injury to the
periapical tissues
Determination of root length and establishment of a working
length are important steps in RC prep
o Radiographs, electronic apex locators
PULP FUNCTION
Induction
Formation
Nutrition
Defense
Sensation
Induction
Participates in the initiation and development of dentin - enamel
formation
Enamel epithelium induces the differentiation of
odontoblasts, odontoblasts and dentin induce formation of
enamel
Formation
Odontoblasts participate in dentin formation by:
o Synthesizing and secreting inorganic matrix
o Initially transporting inorganic components to newly
formed matrix
o Creating an environment that allows mineralization of the
matrix
Primary dentinogenesis: occurs during early tooth
development; rapid process
Secondary dentinogenesis: happens after tooth maturation and
when root elongation is complete; slower rate, less symmetric
pattern
Tertiary dentin: forms in response to injury
Less organized than 1° and 2° dentin
Mostly localized to site of injury
Reactionary dentin: tubular, tubules continuous with those of
Formed by original odontoblasts
Reparative dentin: atubular
formed by new odontoblasts differentiated from stem cells
after original odontoblasts have been killed
Nutritive
Supplies nutrients essential for dentin formation, for
maintaining integrity of the pulp
Defensive
Dentin formed in event of an Injury, particularly when
original dentin thickness has been reduced (caries, attrition,
trauma, resto procedures)
Also formed at sites where its continuity is lost ex site of pulp
exposure
o Induction, differentiation and migration of new
odontoblasts to exposure site
Can process and identity foreign substances and elicit on
immune response to their presence
Sensation
Unmyelinated fibers = slow, dull pain
Myelinated nerves = fast and sharp pain; transmitted by A
fibers
MORPHOLOGIC ZONES OF THE PULP
Odontoblast layer
Cell-Poor Zone
Cell-Rich Zone
Pulp Proper
Pulp and dentin function as a unit
Odontoblasts are in periphery of pulp tissue, extending into
inner part of dentin
Impacts on dentin affects pulpal components; pulpal
disturbances affects quantity and quality of dentin produced
Odontoblast Layer (OL)
Outermost stratum of cells
Cell bodies of odontoblasts: capillaries, nerve fibers,
dendritic cells
Coronal pulp has more cells per unit area than the radicular
pulp
Coronal pulp: columnar
o Midportion of radicular pulp: cuboidal
o Near apical foramen: squamous
Tight Junctions determine permeability of OL when dentin is
 o Disrupted during cavity prep = increased dentin Odontoblast Process
permeability Dentinal tubule Forms around each of major odontoblastic
Cell-Poor Zone process
Immediately subjacent to OL Occupies most of the space within the tubule
Narrow zone 40 um in width Coordinates formation of peritubular dentin
Cell-free layer of Well Microtubules and microfilaments (principal components).
Blood capillaries unmyelinated nerve fibers, cytoplasmic collagen fibrils, ground substance
processes of fibroblasts Membrane junctions join cell bodies: gap junctions, fight
Presence/absence relies on functional status of pulp junctions, desmosomes
Cell-Rich Zone Gap junctions: allow communication between cells in the
Contains high proportion of fibroblasts layer
More prominent in coronal pulp Desmosomal junctions: mechanically link cells into a
Abo has immune cells (macrophages, dendritic cells), coherent layer
undifferentiated mesenchymal stem cells Tight junctions: control permeability of the layer
Pulp Proper Type and number of receptors vary greatly between cell
Central mass of the pulp types and at different times of cell's life
Loose connective tissue, larger BVs and nerves Odontoblast has many types of receptors on or within its cell
Fibroblast is the most prominent cell membrane
Cells of the Pulp Toll-like receptors (TLR 2 & TLR 4) cause odontoblasts to
Odontoblast release proinflammatory cytokines
Odontoblast Process Other receptors are thermosensitive can sense heat- or cold-
Fibroblast induced fluid movement in tubules
Macrophage Synthesizes mainly type I collagen
Dendritic Cell Secretes dentin sialoprotein and phosphophoryn
Lymphocyte Secretes acid phosphatase and alkaline phosphatase
Mast Cell Resting/inactive odontoblast: decreased number of
Odontoblast organelles, may become shorter
Most characterized and specialized cell of the D-P complex Stem Cells (Preodontoblasts)
Form dentin and dentinal tubules Undifferentiated mesenchymal cells
Matrix that has collagen fibrils, noncollagenous proteins Newly differentiated odontoblasts develop after injury,
proteoglycans results in death of existing odontoblasts
Highly ordered RER, prominent Golgi complex, secretory Densest in pulp core
granules, numerous mitochondria Migrate to the site of injury and differentiate
Rich in RNA, nuclei contain one or more prominent nucleoli Key signaling molecules: bone morphogentic protein (BMP),
Form a single layer at periphery family and transforming growth factor B
Synthesize the matrix control mineralization of dentin Fibroblast
Produce collagen that becomes fibrous, 3 noncollagenous Most common cell type in pulp, seen in greatest numbers in
proteins in which collagen fibers are embedded coronal pulp
Coronal part of the pulp space: 45,000-65,000/mm2 Tissue-specific cells capable of creating cells involved in
o Relatively large differentiation
o Columnar in shape Synthesize Type l and III collagen, as well as proteoglycans
Cervical & midportion of roots lower in number, appear and GAGS
flattened Responsible for collagen turnover
Larger cells have well-developed synthetic apparatus, Abundant in cell-rich zone
capacity to synthesize more matrix As cells mature, they become stellate in form, Golgi complex
Continues at varying levels of activity for a lifetime (some die enlarges. RER proliferates, secretory vesicles appear,
by apoptosis) fibroblasts take on appearance of protein-secreting cells
Disease processes (mainly caries) can kill odontoblasts Increase in number of BN's, nerves, collagen fibers: decrease
o Are end cells = do not undergo further cell division in number of fibroblasts in the pulp
2 major components: cell body, cell processes Many fibroblasts are undifferentiated
Cell body: subjacent to unmineralized dentin matrix Macrophage
(predentin): synthesizing portion Monocytes that have left the bloodstream, entered the
One large cell process: extends outward through a tubule in issues, and differentiated into subpopulations
the predentin and dentin Act as scavengers-remove extravasated RBCs dead cells,
o Other smaller processes extend from the body & connect foreign bodies from tissue
odontoblasts to each other land possibly to fibroblasts) Take an active part la signaling pathways in the pulp
ER and Golgi apparatus prominent, many vesicles and When activated by appropriate inflammatory stimuli, con
mitochondria produce factors (L-1, INF GF cytokines)
Dendritic Cell
Accessory cells
Most prominent Immune cell in pulp
Antigen-presenting cells
Present most densely in OL and around BV
Recognize wide range of foreign antigens and initiate
immune response (together with odontoblasts)
Lymphocyte
• T8 (suppressor) lymphocytes are the predominant subset
• B lymphocytes are rarely found in normal pulp
Mast Cell
• Seldom found in normal pulp tissue, but have been routinely
found in chronically informed pulps
• Role in inflammatory reactions
• Granules contain heparin (anticoagulant), histamine
(inflammatory mediator), other chemical factors
Extracellular Components - Fibers
Predominant collagen in dentin: Type I
Types I and III collagen found in pulp in ratio of 55:45
Odontoblasts only produce type I collagen
o For incorporated into dentin matrix
Fibroblasts produce type I and III collagen
Present as fibrils 50 nm wide and several micrometers long
Form Irregularly arranged bundles, except in periphery (lie
approx. parallel to predentin surface)
o Noncollagenous fiber present 10-15 mm wide beaded
fibrils of fibrillin
Elastic fiber absent from pulp
Proportion of collagen types in pulp is constant
With age, there is an increase in the overall collagen content
increase in organization of collagen fibers into collagen
bundles
Apical portion of pulp contains more collagen
Calcifications
Free stones, attached stones, embedded stones
o Free: Surrounded by pulp tissue
o Attached: continuous with dentin
o Embedded: surrounded entirely by tertiary dentin
Can occur in both young and old patients and in one or more
teeth in normal and chronically inflamed pulps
Do not produce painful symptoms. regardless of size
May also occur in the form of diffuse or linear deposits
associated with neurovascular bundles in pulp core
o Seen in aged, chronically inflamed, traumatized pups
May or may not be seen on a radiograph
May block access to canals or root apex during RCT
Noncollagenous matrix
Collagenous fibers embedded in clear gel made up of GAGs
and other adhesion molecules
GAGs link to protein and other saccharides = proteoglycans
Around 6 types of adhesion molecules detected in pulp
metric
o Fibronectin-responsible for cell adhesion to matrix
Blood Vessels – Afferent Blood Vessels (Arterioles)
Branches of the inferior alveolar artery, superior posterior
alveolar artery, infraorbital artery
Once inside the radicular pulp, arterioles travel toward the
crown, narrow then branch extensively and lose their muscle
sheath, then form a capillary bed
o Precapillary sphincters formed be muscle fibers before
the bed central blood flow and pressure
Efferent Blood Vessels
Venules comprise the efferent (exit) side of pulpal circulation
Slightly larger than corresponding arterioles
Formed from the junction of venous capillaries, enlarge as
more branches unite with them
Run with arterioles and exit at AF
Drains posteriorly into Mx vein through pterygoid plexus
Drains anteriorly into facial vein
Lymphatics
Arise as small, thin-walled vessels in periphery
Pass through to exit as one or two larger vessels through the
AF
Walls composed of an endothelium rich in organelles and
granules
Porosities in the walls and in basement membrane
o Permits passage of interstitial tissue fluid and
lymphocytes (when necessary)
Assist in removal of inflammatory exudates, transudates and
cellular debris
After exiting the pulp, these join similar vessels from the PDL
drain into regional lymph glands (submental, submandibular,
cervical) - empty into subclavian & Internal Jugular veins
Vascular Physiology
Young dental pulp is highly vascular
Capillary blood flow in coronal area almost twice that of
radicular area
Blood supply largely regulated by precapillary sphincters and
their sympathetic innervation
Volume of vascular bed greater than volume of blood
normally passing through = allows for increases in blood flow
in response to injury
Concentration gradients, osmosis, hydraulic pressure: factors
determining what passes in and out between blood and
tissue
Hydraulic Pin pulpal capillaries = 35 mm Hg (arteriolar end),
19 mm Hg (Venular end)
Interstitial fluid P outside vessel would normally be 6 mm Hg
(but varies)
Vascular Changes During Inflammation
Initial immune response in nonspecific but rapid (minutes or
hours)
2nd response: specific, includes production of specific
antibodies
All cardinal signs of inflammation are vascular in origin
(except pain)
o increased blood flow = heat, redness
o Increased formation of interstitial tissue fluid = swelling =
increase in tissue fluid P
Elevations in tissue fluid P remain localized to injured area
Intraluminal (inside) P of local capillaries increase to balance
any rise in Interstitial fluid P
Gradients by which nutrients and wastes leave and enter the
capillaries change to allow greater exchange (during
response to injury)
o Lymphatic vessels work more, removing excess tissue
fluid and debris
o Anastomoses allow blood to be shunted around an area
of injury
If injury persists and increases in size = tissue necrosis
o Can remain localized as a pulpal abscess, but more often
spreads throughout the pulp
o Necrosis extends as toxins from carious lesion diffuse
through tissue
Neurogenic Inflammation - mechanism in which excitation of
sensory elements results in increased blood flow and
increased capillary permeability
Innervation
2nd and 3rd divisions of CN V provide principal sensory
innervation to pulp of Mix and Md teeth
Md PMs also receive sensory branches from mylohyoid nerve
of V, (motor nerve)
Branches reach teeth via small foramina on Li aspect of Md
Md molars occasionally receive sensory Innervation from
2nd and 3rd cervical spinal nerves C2 and C3)
Pulpal and Dentinal Nerves
Contain both unmyelinated and myelinated axons
Myelinated axons - almost all narrow, slow-conducting AS
axons (1-6 um in diameter) associated with nociception
o Small percentage ore test-conducting AB axons (6-12 um
in diameter) proprioceptive/mechanoreceptive
o Terminating fiber form subodontoblastic plexus of
Developmental Aspects
Type and number of nerves depend on the state of tooth
maturity
Myelinated and unmyelinated nerves enter the pulp at about
the same time but not form plexus of Raschkow until after
tooth eruption = variations in responses of partially
developed teeth to pulp vitality tests
Number of nerves diminishes with age
Theories of Dentin Hypersensitivity
2 explanations for peripheral dentin sensitivity:
o Stimuli that are effective in eliciting pain from dentin
cause fluid flow through dentinal tubule hydrodynamic
hypothesis
o Some substances diffuse through dentin and act directly
on pulpal nerves
Age Changes in Pulp and Dentin
Secondary dentin is laid down throughout life = pulp
chamber and root canals become smaller, eventually
becoming invisible on the radiograph
More peritubular dentin is laid down as age increases =
decreased dentin permeability
Pulp tissue becomes less cellular and less vascular, has fewer
nerve fibers
Between 20-70 y/o cell density decrease by approx. 50%
Repair and Regeneration
Pulp can respond positively to external irritants
Inflammation is part of response that leads to new dentin
formation
o Tertiary response dentin and Tertiary reparative dentin
o Type of dentin laid down determined by intensity of
stimulus
Periradicular Tissues
Periodontium originates from the DF; formation Initiated
when root development begins
Dentogingival junction GE+RDE (enamel)
o Protects underlying periodontium from potential irritants
Pulp and periodontium form a continuum along sites of root
where BV's enter and exit pulp at AF & lateral and accessory
canals
Cementum
Bonelike tissue covering the root
Provides attachment for principal periodontal fibers
Types:
o Primary acellular intrinsic fiber
o Primary acellular extrinsic fiber
o Secondary cellular intrinsic fiber
o Secondary cellular mixed fiber
o Acellular afibrillar
 Primary acellular intrinsic fiber cementum - 1st cementum Alveolar Bone
formed Alveolar process-bone of Jaws supporting teeth
o Present before principal perio fibers are fully formed Alveolar bone proper - bundle bone, cribriform plate
o Extends from cervical margin to cervical third of tooth in o Bone lining the socket and into which principal perio fiber
some teeth/around entire root in other teeth (incisors, are anchored to
cuspids) o Denser than surrounding cancellous bone
o More mineralized on the surface o Distinct opaque appearance in radiographs = lamina dura
o Contains collagen produced initially by cementoblasts o Principally lamellar
and later by fibroblasts o Constantly remodels
Primary acellular extrinsic fiber cementum - continues to be
formed about the primary perio fibers after incorporation
into PAIF cementum
Secondary cellular intrinsic fiber cementum - bonelike in
appearance
o Minor role in fiber attachment
o Occurs mostly in apical part of PM and molar roots
Secondary cellular mixed fiber cementum - adaptive type
which incorporates perio fibers as they continue to develop
o Recognized by cementocytes, laminated appearance,
cementoid on surface
Acellular fibrillary cementum - sometimes seen overlapping
enamel; no role in fiber attachment
Cementoenamel Junction (CEJ)
Varies in arrangement
o Cementum overlaps enamel
o Enamel overlaps cementum
o Gap between cementum and enamel = exposed denim may
be sensitive
Periodontal Ligament
Specialized CT
Specially arranged collagen fiber bundles support the tooth
in the socket & absorb forces of occlusion
PDL space is small (0.21 mm in young teeth 0.15 mm in older
teeth)
o Uniformity of width is one criteria used to determine is
health
Cementoblasts, osteoblasts line the space
Interwoven between principal perio fibers is loose CT
containing fibroblasts, stem cells, macrophages, osteoclasts,
BVs, nerves, lymphatic; also ERM
Receives both autonomic and sensory Innervation
Autonomic nerves-sympathetics arising from superior
cervical ganglion and terminating in the smooth muscle of
the perio arterioles
Activation of sympathetic fibers = constriction of vessels
Sensory nerves arise from 2nd and 3rd divisions of CN V
Mixed, small and large diameter
Unmyelinated sensory nerve fibers terminate as noci ceptive
free endings
Large fibers-mechanoreceptors that terminate in special
endings throughout the ligament
o Greatest concentration in apical third of perio space
o Highly sensitive (record P associated with tooth
movement)
L2: DIAGNOSIS, PULPAL & PERIAPICAL DISEASES
DIAGNOSIS
• Art and science of determining the disease process by:
o Systematic collection and recording of facts
o Careful analysis and integration of these facts
• Science of recognizing diseases by means of signs,
symptoms, and tests
• Correct diagnosis proper treatment and success case =
better prognosis
• Determine what problem a patient is having and why the
patient is having that problem
• No appropriate treatment recommendation can be made
until all the whys are answered
• Planned, methodical and systemic approach
• Patient tells clinician why the patient is seeking advice
• Clinician questions patient about symptoms and history
that led to the visit
• Clinician performs objective clinical tests
• Clinician correlates objective findings with subjective
details, and creates a tentative differential diagnosis
• Clinicians formulates a definitive diagnosis
STEPS
o Chief complaint
o History medical and dental
o Oral examination (intra and extra)
o Data analysis (differential diagnosis)
o Treatment plan
CHIEF COMPLAINT
• First information obtained, volunteered by the patient
• Direct and unbiased
• Clinician must pay close attention to:
o Actual expressed complaint
o Chronology of events leading up to this complaint
o Question any other pertinent issues
• Should be properly documented using patient’s own words
MEDICAL HISTORY
• Baseline BP and PR recorded at each visit. Take other vital
signs
• Evaluate:
o Medical conditions and current medications that may
alter manner in which dental care is provided
o Medical conditions that may have oral manifestations
or mimic dental pathosis
• Take note also of:
o Drug allergies or allergies to dental products
o Artificial joint prosthesis
o Organ transplants
o Taking medications that may negatively interact with
common local anesthetics, analgesics, antibiotics
Medical Conditions That Warrant Modification of Dental Care
or Treatment
Cardiovascular: High- and moderate-risk categories of
endocarditis, pathologic heart murmurs, hypertension, unstable
angina pectoris, recent myocardial infarction, cardiac
arrhythmias, poorly managed congestive heart failure 3.78
Pulmonary: Chronic obstructive pulmonary disease, asthma,
tuberculosis
Gastrointestinal and renal: End-stage renal disease;
hemodialysis; viral hepatitis (types B, C, D, and E); alcoholic liver
pseudomembranous colitis
Hematologic: Sexually transmitted diseases, HIV and AIDS,
diabetes mellitus, adrenal insufficiency, hyperthyroidism and
hypothyroidism, pregnancy, bleeding disorders, cancerand
leukemia, osteoarthritis and rheumatoid arthritis, systemic lupus
erythematosus 2009
Neurologic: Cerebrovascular accident, seizure disorders. anxiety,
depression and bipolar disorders, presence or history of drug or
alcohol abuse, Alzheimer's disease, schizophrenia, eating
disorders, neuralgias, multiple sclerosis, Parkinson's disease
• Medication side effects: stomatitis, xerostomia, petechiae,
ecchymoses, lichenoid mucosal lesion, bleeding of oral soft
tissues
• Medical conditions have clinical presentations that mimic
pathological lesions:
o Lymph node enlargement due to odontogenic infection:
lymphomas, TB, involving cervical and subMd lymph
nodes
o Odontogenic pain, loss of trabecular bone pattern in
radiographs in lesions of endo origin – sickle cell anemia
o Tooth mobility: multiple myeloma
o Increased sensitivity of teeth, osteoradionecrosis:
radiation therapy to head and neck
o Dental pain: trigeminal neuralgia, multiple sclerosis
o Tooth pain in Mx posterior quadrant - acute Mx sinusitis
ANTIBIOTIC PROPHYLAXIS
• Condition (AHA)
o Artificial heart valve
o Previous history of infective endocarditis
o Incomplete or repaired congenital heart tissue repair
o Heart transplants
• Conditions (AAOS)
o Those who have had joint replacement within the past
year, particularly those who are immunocompromised or
immunosuppressed
o Those with hemophilia or insulin-dependent diabetes
o Those who have previous joint prosthesis infections
• Instrumentation beyond the apex
• Periapical surgery
• Procedures that may produce bleeding (aggressive rubber
dam placement, incision, and drainage)
• Regimen:
o Adults: amoxicillin 2g 30-60 minutes prior to the procedure
o Children: 50 mg/kg
o Allergic to amoxicillin: Clindamycin 600mg 30-60 minutes
prior to procedure
DENTAL HISTORY
• Guide to which diagnostic tests must be performed
• Must include past and present symptoms, procedures or
trauma that elicit CC (chief complaint)
• Past dental procedures, frequency of dental visit, oral
hygiene status, adverse reaction to local anesthetics
DENTAL HISTORY INTERVIEW
• 5 basic directions of questioning:
o Localization
o Commencement
o Intensity (1-10. Sever, mild)
o Provocation (what triggers, what reduces the pain)
o Duration (when the stimulus or irritant is present, how
 • Pain: most common symptoms that leads to consultation or
treatment
o Location: localized, diffuse, radiating, referred
o Quality: sharp, piercing, dull
o Onset: spontaneous, provoked
o Provoking/alleviating factor: cold, heat, biting, sweets
o Intensity: mild, moderate, severe
o Duration: constant, momentary, intermittent
Questions to ask - PAIN
• When did the pain began?
• Where is the pain located?
• Is the pain always in the same place?
• What is the character of the pain (short, sharp, long-lasting,
dull, throbbing, continuous, occasional)?
• Does the pain prevent sleeping or working?
• Is the pain worse in the morning?
• Is the pain worse when you lie down?
• Did or does anything initiate the pain (trauma, biting)?
• Once initiated, how long does the pain last?
• Is the pain continuous, spontaneous, or intermittent?
• Does anything make the pain worse (hot, cold, biting)?
• Does anything make the pain feel better (cold, analgesic)?
QUESTIONS TO ASK- SWELLING
• When did the swelling begin?
• How quick has the swelling increased in size?
• Where is the swelling located?
• What is the nature of the swelling (soft, hard, tender)?
• Is there drainage from swelling?
• Is the swelling associated with a loose or tender tooth?
EXAMINATION AND TESTING - EXTRAORAL EXAMINATION
• Observe patient as soon as they enter the operatory
• Signs of physical limitations, facial asymmetry
• do visual and palpation exams
INTRAORAL SWELLINGS
• IO swellings should be visualized and palpated-
localized/diffuse, firm/fluctuant
• Attached gingiva, alveolar mucosa, mucobuccal fold, palate,
sublingual tissue
• Anterior part of palate: infection at apex of Mx lateral incisor
or P root of the Mx 1st PM
• Posterior part of the palate: associated with P root of Mx
molar
• Mucobuccal fold: infection associated with apex of root of
any Mx tooth exiting the alveolar bone on the facial aspect
and is inferior to the muscle attachment present in that area;
same as in the Md, but if root apices are superior to the level
of muscle attachment
• Sublingual space: infection from root apex spreads to the
lingual and exits the alveolar bone superior to the mylohyoid
muscle attachment
• Submandibular space: exits to the lingual of Md molars and
is inferior to mylohyoid muscle attachment
• Parapharyngeal space (swelling of tonsillar and pharyngeal
areas): extension of severe infections of Mx and Md molars

EXAMINATION AND TESTING- INTRAORAL EXAMINATION

• Evaluate soft tissues
o Dry mucosa and gingiva with air syringe or gauze
o Retract tongue and cheek to get a better view of the soft
tissues- check abnormalities in color and texture PRESENTATION AND LOCATION OF DENTAL ABSCESSES
o Take note of any raised lesions or ulcerations- biopsy or Tooth Common Less Common
referral if needed Mandible Central Incisor Labial Lingual
• Intraoral exam: Lateral Incisor Lingual Labial
o ST: check the lips, oral mucosa, cheeks, tongue, Canine Labial Lingual
periodontium, palate, muscles Premolar Buccal Lingual
o Dentition: check for discolorations, fractures, abrasions, Molars Buccal Lingual
erosions, caries, failing restorations Maxilla Central Incisor Labial Palatal
Lateral Incisor Labial Palatal
 First Premolar Labial (B roots) - o Immature root apices
Palatal(P roots) o Tooth/root fractures
Second Buccal Palatal DIAGNOSTIC TESTS
Premolar • Thermal test5s
Molars Buccal (B roots) - • Electric pulp test
Palatal (P roots) • Percussion
• Palpation
INTRAORAL SINUS TRACTS • Periodontal probing depths
• Drainage of chronic endodontic infection through an • Mobility
intraoral communication to the gingival surface • Special tests
• Extends directly from the source of infection to a surface • Do more than one endodontic diagnostic test
opening (stoma) on the attached gingival surface • Do tests on at least three or more teeth
• Provides a pathway for release of infectious exudate and o Involved
subsequent relief of pain o Adjacent
• Aids in finding out the source of an infection o Contralateral
• Stoma may be directly adjacent or at a distant site from the PALAPATION, PERCUSSION, MOBILITY, PERIODONTAL
infection EXAMINATION
• Perform sinus tract tracing • Palpation: note any soft tissue swelling or bony expansion in
• Stomata may open in alveolar mucosa, attached gingiva, or alveolar hard tissue
through furcation or gingival crevice o Question the patient about any areas that feel unusually
o May exit through facial/lingual tissues on the proximity to sensitive
root apices to cortical bone • Percussion: indicator of inflammation in PDI
• Presents a narrow defect in 1 or 2 isolated areas along the o Secondary to physical trauma, occlusal prematurities,
root surface if opening is in gingival crevice periodontal disease, extension do pulpal disease in PDL
o Periradicular endo lesion, vertical root fracture, space
developmental groove o Test contralateral tooth first (control) then adjacent teeth
o Differentiated from a primary perio lesion (pocket with o Gloved finger tapping initially, applying light pressure
bone loss around root) o Repeat test using blunt end of an instrument; occlusal,
buccally, lingually
• Mobility
o Indication of compromised periodontal attachment
apparatus
o Result of acute/chronic physical trauma, occlusal trauma,
parafunctional habits, periodontal disease, root fractures,
rapid orthodontic movement, extension of pulpal disease
into PDL space
OBJECTIVE EXAMINATION o Apply finger pressure: visually subjective
• Extraoral exam: general appearance, skin tone, facial o Use backs of two mouth mirrors
asymmetry, swelling, discoloration, redness, EO scars or o Evaluate on how mobile affected tooth is relative to
sinus tracts, lymphadenopathy. adjacent and contralateral teeth
RADIOGRAPHIC EXAMINATION AND INTERPRETATION Recording Tooth Mobility
• Intraoral radiograph +1 mobility: the first distinguishable sign of movement
• Digital radiography greater than normal
• Cone-beam volumetric tomography +2 mobility: Horizontal tooth movement no greater than 1
INTRAORAL RADIOGRAPHY mm
• 2-dimensional image of 3-dimensional structure +3 mobility: Horizontal tooth movement greater than 1
• High quality processing is needed for maximum diagnosis mm, with or without the visualization of rotation or vertical
value depressability
• Understanding of anatomy is needed in differentiating Recording Furcation Defects
anatomical and pathological images Class I furcation defect: the furcation can be probed but not
• Various views from multiple angles to capture more to a significant depth
• What to look for: Class II furcation defect: the furcation can be entered into
o Continuity of lamina dura but cannot be probed completely through to the opposite
o Width of the periodontal space side.
o Any evidence of demineralization Class III furcation defect: the furcation can be probed
o in the bony architecture completely through to the opposite side.
o Condition of the root canal system: resorption and • Periodontal exam: probing
calcification o Record pocket depths on the mesial, middle, and distal
o Anatomic landmarks aspects in both buccal and lingual sides (mm)
PULP TEST
• Thermal
• Electric
• Laser Doppler Flowmetry
o Assesses blood flow in microvascular systems
• Pulse oximetry
o Measures oxygen concentration in blood and the pulse
rate
Thermal
• Baseline/normal response: sensation is felt but disappears
immediately on removal of stimulus
o Abnormal responses: lack of response
lingering/intensification of a painful sensation after the
stimulus is removed, immediate, excruciating painful
sensation as soon as stimulus is placed.
• Heat test: hot water, heated GP, dry rubber polishing wheel
(seldom used)
(1) Isolate and place Vaseline on tooth
(2) Use the Glick place a piece of white Gutta Percha
stopping on it. Heat it over a flame and mold it.
(3) inform the px to raise hand if sensation is felt and
not to raise hand if no sensation is felt.
(4) Place in flame until it becomes smokey. Place on
tooth. It cools quickly so be fast
(5) Time the duration
• Cold test: primary pulp testing method for many clinicians
o Used in conjunction with EPT to verify findings of each
test
o Dry ice/carbon dioxide snow
o Refrigerant spray
(1) make a cotton pellet and place on locking pliers.
(2) inform the px to raise hand if sensation is felt and not
to raise hand if no sensation is felt.
(3) Time the duration
(4) saturate cotton pellet with endo ice
• No response: nonvital pulp
• False negative response: excessive calcification, immature
apex, recent trauma, premedication
Electric
• Assesses pulp vitality, along with cold test
• Response to EPT does not reflect histologic health or disease
of the pulp
• Lack of response = necrotic pulp
o False positive:
 Patient anxiety
 Wet tooth
 Metallic restorations
 Liquefaction necrosis
o False negative response:
 Premedication (drugs/alcohol)
 Immature teeth
 Trauma
 Inadequate conductor
 Partial necrosis with vital pulp in apical portion of the
root
 Atrophied pulps
 High pain threshold
SPECIAL TEST
• Bite test
• Test cavity
• Staining and transillumination
• Selective anesthesia
Bite Test
• Indicated along with percussion when a px presents with
pain while biting.
• Periradicular periodontist: pain to both tests regardless of
where pressure is applied to coronal part of the tooth
• Cracked tooth/fractured cusp; pain only when test is applied
in a certain direction to one cusp or section
• Tooth sloth (professional result), fracFinder (Hu-Friedy)
o Note whether pain is elicited during pressure phase or
on quick release of the pressure
Test Cavity
Used only when all other methods are found impossible or
result of other tests are inconclusive
Small class 1 cavity preparation made through occlusal
surface
No anesthesia. Px is asked to respond if a painful sensation is
felt during drilling
• Staining and Transillumination
o Determines crack
• Selective Anesthesia
o Symptoms cannot be localized, pulp testing is inconclusive
o Mx arch anesthetized first- intraligamentary injection (from
most posterior tooth at distal sulcus moving anteriorly)
o More useful in identifying the affected arch
CLINICAL CLASSIFICATION OF PULPAL PERIAPICAL DISEASES
PULP DISEASES
• Normal Pulp
• Reversible Pulpitis
• Irreversible Pulpitis – Symptomatic Asymptomatic
• Pulp Necrosis
• Previously Treated
• Previously Initiated Therapy
Normal Pulp
• Do not exhibit any spontaneous symptoms
• Mild response to pulp test
o does not cause px distress
o transient sensation that disappears in seconds
• R: varying degrees of pulp calcification
o no evidence of resorption, caries, mechanical pulp
exposure
• no endo tx indicated
Reversible Pulpitis
• Pulpal irritation wherein any stimulation is uncomfortable to
the ox but reverses quickly after the irritation
• Caries, exposed dentin, recent dental tx. Defective restos
• Conservative removal of irritant
• Dentin/dentinal hypersensitivity: sharp, quickly reversibl pain
 when subjected to thermal, evaporative, tactile, mechanical,
osmotic, chemical stimuli
• Clinical condition associated with subjective and objective
findings indicating presence of mild inflammation in the pulp
tissue
• Inflammation reverses, pulp returns to normal state once
cause is eliminated
• Mild/short acting stimuli: incipient caries, cervical erosion,
occlusal attrition
o Most operative procedures, deep perio curettage,
enamel fractures
• Usually, asymptomatic
• Application of hot/cold stimuli or air may produce sharp,
transient pain
• Removal of stimuli results in immediate relief
• Heat: delayed initial response, but pain increases in intensity
as temperature rises
• Cold: response is immediate. Intensity decreases if
maintained
Symptomatic Irreversible Pulpitis
• Intermittent or spontaneous pain
• Heightened and prolonged episodes of pan due to temperate
changes especially cold stimuli even after the stimulus
removal
• Sharp/dull pain, localized/diffuse referred
• R: Minimal to no changes of periradicular bone
o If advanced, PDL thickening
• Deep restos, caries, pulp exposure, direct/indirect inj ury to
pulp (prior to recent)
Asymptomatic Irreversible Pulpitis
• No symptoms produced by deep caries, even if it has
reached the pulp clinically/radiographically
• Symptomatic or asymptomatic
• Indicates presence of severe inflammation
• Does not resolve, even if cause is removed
• Pulp incapable of healing, and slowly or quickly becomes
necrotic
• Usually, asymptomatic but some pxs may report mild
symptoms
• Intermittent/ continuous episodes of spontaneous pain
• Pain may be sharp/dull, localized/diffuse, lasts from a few
minutes to a few hours
• RCT or extraction
Hyperplastic pulpitis
• Pulp polyp
• Form of IP that originates from overgrowth of a chronically • Pulpotomy or pulpectomy performed as emergency
inflamed young pulp onto the occlusal surface
• Found on carious crowns of young px
• Usually asymptomatic
• Appears as reddish, cauliflower-like outgrowth, CT into
caries into caries that has resulted in a large occlusal
exposure
• Responds within normal limits to percussion or palpation
Hard tissue changes caused by pulpal inflammation
• Pulp calcification: pulp stones, diffuse calcification
o Occurs as a response to trauma, caries, perio disease,
other irritants
o Calcific metamorphosis, extensive formation of hard
tissue on dentin walls, often in response to irritation
or death and replacement of odontoblasts
 Palpation, percussion
 Not pathologic in nature
 Does not require tx
• Internal (Intracanal) Resorption
o Dentinal walls are resorbed from the center to the
periphery
o Most cases are asymptomatic
o Advanced IR = pink spots in crown
o Pulpal and periapical tests: WNL
o R: RL with enlargement of RC compartment
o Tx:RCT
Pulp Necrosis
• Nonvital pulp
• Pulpal blood supply is non-existent, pulpal nerve are not
functional
• No response to cold EPT, but may respond to heat if applied
for a long period of time
• Partial or complete
• Bacterial growth can be sustained and may extend to PDL
• Exudate is absorbed or drains through caries/pulp exposure
in oral cavity = delayed necrosis, radicular pulp may be vital
for a long time
• Closure/sealing of inflamed pulp= rapid and total pulp
necrosis and periradicular pathosis
• Usually asymptomatic, but may be associated with episodes
of spontaneous pain and discomfort or pain from
periradicular tissues on pressure
• Often sensitive to percussion because inflammation spreads
to periradicular tissues
• Tx: RCT extraction
Previously Treated
• Tooth has already had nonsurgical RCT performed, and RCS
filled with obturating material
• May or may not present signs or symptoms
• Will require additional nonsurgical/surgical endodontic
procedures to retain the tooth
Previously Initiated Therapy
• Partial endodontic therapy has been performed
procedure for SIP/AIP
APICAL (PERIAPICAL) DESEASES
• Normal apical tissues
• Symptomatic apical periodontitis
• Asymptomatic apical periodontitis
• Acute apical abscess
• Chronic apical abscess
Normal Apical Tissues
• Px is asymptomatic
• Tooth responds normally to percussion and palpation testing
• R: Intact LD and PDL space
• Clinically and radiographically has normal periapical tissues
• Not abnormally sensitive to percussion or palpation
• Normal LD and PDL structures
Symptomatic Apical Periodontitis
• Acutely painful response to biting pressure or percussion
• May or may not respond to pulp vitality tests
• R: Widened PDL space, may or may not have an apical
radiolucency with one or all roots
• First extension of pulpal inflammation into periradicular
tissues
o Inflammatory mediators an from an irreversibly
inflamed pulp
o Egress of bacterial toxins from necrotic pulp
o Chemicals (irritants, disinfecting agents)
o Restoration in hyperocclusion
o Over instrumentation of the root canal
o Extrusion of obturating materials
• Moderate to severe spontaneous discomfort
• Pain on biting or percussion
• Tx: Adjustment of occlusion, removal of irritants or a
pathologic pulp, removal or periapical exudate
Asymptomatic Apical Periodontitis
• Generally presenting with no clinical symptoms
• Does not respond to pulp vitality test
• R: Apical radiolucency
• Generally, not sensitive to biting pressure, but may feel
different on percussion
• Results from pulp necrosis, usually a sequel to SAP
• Percussion produces little to no pain
• Slight sensitivity to palpation
• Interruption of LD to extensive destruction of PA and
interradicular tissues
• Removal of irritants (necrotic pulp) and complete obturation
of RCS
Condensing Osteitis
• Variation of AAP
• Increased in trabecular bone in response to persistent
irritation
• Irritant diffusing from root canal into periradicular tissues
• Lesion usually found apices of mandibular posterior teeth;
but can occur in association with apex of any tooth
• Asymptomatic/associated with pain (depending on cause-
pulpitis or necrosis)
• May or may not respond to electrical or thermal stimuli
• R: Diffuse, concentric arrangement of radiopacity around
the root
• Tx: RCT
Acute Apical Abscess
• Acutely painful to biting pressure, percussion, palpation
• Will not respond to any pulp vitality test
• Exhibit varying degrees of mobility
• R: Widened PDL space, apical radiolucency
• IO swelling present, facial tissues adjacent to tooth will
almost always present with some degree of swelling
• Febrile (hilanat)
• Cervical and subMd lymph nodes exhibit tenderness to
palpation
• Tx: Removal of underlying cause, release of pressure
(drainage where possible) RCT
Chronic Apical Abscess
• Not generally present with clinical symptoms
• Will not respond to vitality tests
• Apical radiolucency
• Generally, not sensitive to biting pressure but feels different
on percussion
o Intermittent drainage through an associated sinus tract
ARMAMENTARIUM • Foldable plastic frame - has a hinge to facilitate film or
HAND INSTRUMENTS sensor placement without disengaging the entire frame
• Front surface mouth mirror, regular /diagnostic explorer (D-5 • Insti-Dam (Zirc), Hond Dam (Aseptico) - radiolucent plastic
explorer), D-16 endodontic explorer, cotton pliers, spoon frame
excavator, set of pluggers, plastic instrument, hemostat,
periodontal probe, ruler
• Endodontic explorer: 2 straight, sharp end that are angled in
two different directions from the long axis
• Endodontic spoon excavator: much longer offset from the
• OptraDam (Ivoclar Vivadent) - disposable, singlesolation,
long axis than regular spoons
flexible outer ring
o Removes carious material, excise pulp tissue
• Cotton pliers: should be of the locking type
• Periodontal probe: should be flexible
• Other: Instrument trays, endodontic pliers
• Metal frames - can also be used, bul radiopacity blocks out
the radiograph
RUBBER DAM CLAMPS/RETAINERS
• Anchor the dam to the tooth requiring treatment, or to the
INSTRUMENTS FOR TAKING RADIOGRAPHS most posterior tooth in multiple tooth isolation
• Film • Aids in soft tissue reduction
• Film positioner • Stainless heel
• Film holders • Bow, 2 jaws, prongs, holes, wings/wingless
• Prongs should engage at least 4 points on the tooth

INSTRUMENTS AND MATERIALS FOR RUBBER DAM

APPLICATION - RUBBER DAM
• Mainstay of rubber dam system
• Autoclavable sheets of this, flat latex with varying thickness • Basic: winged, butterfly type for anterior teeth, universal
(thin, medium, heavy, extra heavy, special heavy) and two premolar, mandibular molar, and maxillary molar clamps
sizes (5x6”, 6x6") • Wings - extensions of the jaws, provide additional soft tissue
• Medium thickness may be best - tears less easily, retracts retraction, facilitates placement of the rubber dam frame
soft tissues better than thin type, easier to place then heavy and retainer as a unit
type
• Also available in different colors - darker ones may provide
better visual contrast (reduces eye strain)
• For patients with latex allergies: non latex type available
from
Coltene Wholedent
o Powder-free, synthetic • Some are designed for situations wherein clamp placement
o 6x6", medium gauge may be hard (ex. Tiger clamps, Silker-Glickman Clamp)
o 3 years shelf life, but only 1/3 the tensile strength of a
latex dam

RUBBER DAM PUNCH AND FORCEPS

RUBBER DAM FRAME • Punch - has a series of holes on
• Retracts and stabilizes the dam a rotating disk, selection done
• Metal and plastic frames, but plastic is recommended - according to the size of the
radiolucent, do not mask key areas on working films, do not tooth or teeth to be isolated
have to be removed before film placement • Forceps - holds and carries
• Young, Nygaard-Ostby (N-O) the retainer during
placement and removal
METHODS OF RUBBER DAM PLACEMENT o 3/4-sided with more spiral - for filling
1. position bow of clamp through the hole in the dam and BARBED BROACHES AND RASPS
place rubber over the wings of the clamp • Does not cut or machine dentin
o Attach dam to the frame, secure clamp to the tooth, then • Mostly used to engage and remove soft tissue from the canal
tease dam under the wings with a plastic Instrument • Can also remove cotton or paper points that have
2. Place damp on tooth and stretch the dam over the tooth accidentally become lodged the canal
(clamp first)
3. Clamp and dam first, then frame
4. Dam first, then clamp and frame
• Split dam technique: when there is insufficient crown
structure, prevents the possibility of the laws of the clamp K-TYPE INSTRUMENTS
chopping the margins of teeth restored with porcelain • K-file and K-reamer are oldest Instruments used for cutting
clowns or laminates and machining dentin
• Alternative for teeth with porcelain restorations - ligation • File has more flutes per length unit thong reamer
with dental floss, adjacent tooth can be clamped • Useful for penetrating and enlarging root canals
• 2 overlapping holes are punched in the dam • Works primarily by compression-and-release destruction of
• Place cotton roll under the lip in the mucobuccal fold over dentin
the tooth to be treated
• Stretch the dam over the tooth and over one adjacent tooth
on each side
• Edge of dam is eased through the contacts on the distal sides
of the 2 adjacent teeth MOTIONS OF INSTRUMENTATION
• Dental floss helps carry the dome down around the gingiva  Balanced force technique (Dr. Benin)
• Place damp over the dam  Watch winding
PUNCHING AND POSITIONING OF HOLES  Filing motion
• Divide dam into 4 equal quadrants, proper place for hole is  Reaming motion (used with reamers)
estimated according to which tooth is undergoing treatment • Reaming (constant file rotation) causes less transportation
• The more distal the tooth, the closer to the center of the than a filing motion (reciprocating or watch-winding file
dam the hole is placed rotation)
• Hole must be punched cleanly, without tags or tears • Pre-curve file to desired form to facilitate insertion and
ORIENTATION OF THE DAM minimize transportation
• Dam must be attached to the frame with enough tension to • Permanent deformation happens when
retract soft tissues and prevent bunching, without tearing the flutes become more tightly wound
the dam or displacing the damp or opened more widely = don't use
• Dam should completely cover the patient’s mouth without instrument anymore when this happens
encroaching their eyes or nose • Fracture of instruments during clockwise motion - when
• Floss is then used to carry dam through the contacts instruments become bound while force of roto son continues
• Use plastic instrument to Invert edge of the dam around the o Failure more in counterclockwise direction
tooth o Operate carefully when applying pressure in a
ENDODONTIC INSTRUMENTS counterclockwise direction
• Standardized specification to improve instrument quality
o International Standards Organization (ISO) is with the
Fédération Dentaire Internationale (FDI)
o ADA, American National Standards Institute (ANSI) H-TYPE INSTRUMENTS
• ISO No. 3630: K-type files (ANSI No. 28), Hedström files (ANSI • Spiral edges arranged to allow cutting
No. 58), barbed broaches & rasps (ANSI No. 63) only during a pulling stroke, ex.
• ISO No. 3630-3/ANS No. 71: condensers, pluggers, spreaders Hedström file
INSTRUMENTS FOR CLEANING AND SHAPING THE ROOT CANAL • Better for cutting - more positive rake angle, blade with a
SPACE cutting angle (rather than scraping)
• Provide a biologic environment (infection control) conducive • Do not bend this as it may lead to cracks and fatigue failure
to healing • Ground from a tapered blank
• Develop a canal shape receptive to obturation • Cuts canal wall when pulled or rotated clockwise
GROUP I: MANUALLY OPERATED INSTRUMENTS • Has a tendency to screw into the canal during rotation
• Files - instruments that enlarge canals with reciprocal • Introduction of nitinol (Ni-Ti), alloy of nickel and titanium,
insertion and withdrawal motions has proved a significant advancement in endodontic
o First mass produced by Kerr Manufacturing Co., hence Instruments
the name K-file/K-reamer o Superelastic metal - has the ability to return to its original
o Number of slides and the number of spirals determine shape after being deformed
whether the instrument is for filing or reaming
 o Currently are the only readily available affordable
materials with the flexibility and toughness for routine
use as effective rotary endo files in curved canals
o New alloys may be 5x flexible than currently used alloys
GROUP II: LOW-SPEED ROTARY INSTRUMENTS
• Burs with extended shanks = good visibility
during deep preparation of the pulp chamber
• Gates Glidden burs, Peeso instruments -
available in 32-mm and 28-mm lengths
(posterior teeth)
• should be limited to the straight portion of
the canal prep
• Risk of perforation if attempts are made to
instrument beyond the point of curvature or
if they are used to cut laterally
o Pronounced on furcation sides of mesial roots of molars
• Peeso reamer used mostly for post
space prep
GROUP III: ROTARY INSTRUMENTS FOR CANAL PREPARATION
• Taper: amount the file diameter increases each mm along is
working surface from the tip toward the file handle,
sometimes expressed as percentage (Ex. 2% taper)
• Flute: groove in the working surface used to collect soft
tissue and dentin chips removed from the wall of the canal
o Effectiveness depends on depth, width, configuration,
surface finish
• Leading (cutting) edge/blade: surface with the greatest
diameter that follows the groove as it rotates
o Forms and deflects chips from the canal walls
o Severs/snags soft tissue
o Effectiveness depends on angle of Incidence and
sharpness
• Rake angle: angle formed by the leading edge and radius of
the file
o Obtuse angle = positive or cutting
o Acute angle = negative or scraping
`
• Better to use electric handpiece when using rotary files since
it allows precise speed and torque control
• Design changes have been made to prevent procedural
errors, increase efficiency, improve quality of canal shaping
o Ex. Profile, Profile GT, ProTaper, Quantec, Endosequence,
etc.
GROUP IV: ENGINE-DRIVEN THREE-DIMENSIONALLY
ADJUSTING FILES
Hollow device, designed as a cylinder of thin-walled, delicate
Ni-Ti lattice with a lightly abrasive surface
Initial glide path established with #20 K-file to allow Insertion
of SAF
1 file used throughout procedure, which is initially
compressed into the root canal and gradually enlarges while
cleaning and shaping the canal
Unique, adapts to the shape of the canal longitudinally and
cross-sectionally
o Basic shape of canal is preserved
GROUP V: ENGINE-DRIVEN RECIPROCATING INSTRUMENTS
Giromatic handpiece
3000 quarter-turn reciprocating movements per minute
Endo-Eze file system (Ultradent) = designed to clean the
middle third of the canal
o SS for apical third
GROUP VI: SONIC AND ULTRASONIC INSTRUMENTS
Piezoelectric ultrasonic units
U: operate at 25-30 kHz
o Cavi-Endo (Denstply) ENAC (Osada)
o Use regular Types of instruments (K-files)
S: Operate at 2-3 kHz
o Endostar (Syntex Dental Products), Megasonic 1400
(Megasonic Corp)
o Use special instruments (Rispi-Sonic, Shaper-Sonic files)
STANDARDS FOR INSTRUMENTS
Taper .02
Working diameter: taper and
length of the tip
Standard lengths: 21 mm,
25mm, (28 cm), 31 mm
Working part of the instrument
must be at least 16 mm
DEVICES FOR MEASURING ROOT CANAL LENGTH
Radiographs, presence of bleeding on paper points, tactile
sensation, knowledge of root morphology
Sunada: developed the original electronic apex locator
Apex locator: currently considered an accurate tool for
determining WL
o But better to combine with radiographs = greater accuracy
3rd gen: Endex Plus/Apit (Osada), Neosono Ultima EZ
(Satelec)
4th gen: Apex Locator (SybronEndo), Bingo 1020/Ray-X4
(Forum Engineering Technologies)
4 parts: lip dip, file clip, instrument itself, cord connecting
the 3 other parts
o Display indicates advancement of Me toward the apex
Generally safe, but should not be used on patients with
pacemakers without consultation from the cardiologist
INSTRUMENTS FOR ROOT CANAL OBTURATION
Lateral and vertical compaction techniques most common
Spreaders, pluggers
Spreader - tapered, pointed instrument intended to displace
GP lateral
insertion of additional accessory GP cones
Plugger – similar, but has blunt end
with handles or as finger-held instruments

• Accessory cones must reach the depth of the penetration of
the spreader
o Thinner and/or with a smaller taper than the spreader
used
• Also available in NI-TI
• Heat carriers for vertical composition obturation techniques
o Electrical more common
o Introduction of battery-charged, handheld heat carries
Lentulo spiral may be used to place sealer, cement, and
calcium hydroxide dressings
o Operated clockwise, inserted not rotating to WL, then
retraded 1-2.
o Started and rotated at a slow speed
Files, paper points
MATERIALS FOR DISINFECTING THE PULP SPACE
Chemomechanical preparation - irrigating solutions
Mechanical and biologic objectives
o Mechanical: flushing out debris, lubricating the canal
dissolving organic and inorganic
o Biologic: antimicrobial effect
Ideal Characteristics of an Endodontic Irrigant
Be an effective germicide and fungicide
Be non-irritating to the periapical tissues
Remain stable in solution
Have a prolonged antimicrobial effect
Be active in the presence of blood, serum, and protein
derivatives of tissue
Have low surface tension
Not interfere with repair of periapical tissues
Not stain tooth structure
Be capable of inactivation in a culture medium
Not induce a cell-mediated immune response
Be able to completely remove the smear layer, and be able
to disinfect the underlying dentin and tubules
Be non-antigenic, non-toxic, and non-carcinogenic to tissue
cells surrounding the tooth
Have no adverse effects on the sealing ability of filling
materials
Have convenient application
Be relatively inexpensive
SODIUM HYPOCHLORITE (NaOCI)
Most commonly used irrigating solution
Excellent antibacterial agent
Capable of dissolving necrotic tissue, vile pulp tissue, and
organic components of dentin and biofilms
Hypersensitivity, contact dermatitis in rare cases (iodine
potassium iodide)
CHLORHEXIDINE (CHX)
wide-spectrum antimicrobial agent, active against gram (+)
and (-) bacteria as well as yeasts
Bacteriostatic or bactericidal (depending on concentration)
Low level of tissue toxicity
Same antibacterial efficacy as NaOCl
May delay coronal recontamination of the RCS
Locks tissue-dissolving property (unlike NaOCI)
May induce allergic reactions (rash, contact dermatitis,
urticarial)
MTAD, TETRACLEAN
New irrigants
Mixture of antibiotics, citric acid, detergent
MTAD - 1st irrigating solution capable of removing the smear
layer and disinfecting the RCS
o Biopure MTAD (Dentsply)
o Final rinse after completion of conventional chemomech
prep
TetroClean (Ogna Laboratori Farmaceutici) - similar to MTAD,
but differ in concentration of antibiotics and kind of
detergent
ETHYLENEDIAMINE TETRA-ACETIC ACID
Con chelate and remove the mineralized portion of the
smear layer
Cannot remove smear layer clone, proteolytic component is
added to remove organic components (NaOCI)
17% concentration
Direct contact with RC wall for less than 1 minute
Alternating regimen: wash out remnants of EDTA with
copious amounts of NaOCL
HYDROGEN PEROXIDE
3-5% Concentration
Active ingredient against bacteria, viruses, yeasts
No longer recommended as a routine irrigant
IODINE POTASSIUM IODIDE
2% iodine in 4% potassium iodide
Excellent antibacterial properties, low cytotoxicity
May act as a severe allergen, also stains dentin
INTRACANAL MEDICATION
Acts to inhibit proliferation of bacterial and eliminate
surviving bacteria
Minimizes ingress through a leaking restoration
Phenols, formaldehyde, halogens (chlorinated solutions),
chlorhexidine, calcium hydroxide, Ledermix, triple-antibiotics
paste, bioactive glass
CALCIUM HYDROXIDE
Kills bacteria in RC space, slow-acting
May be mixed with sterile water or saline
Best applied with Lentulo spiral
Removal is frequently incomplete = shortens setting time of
ZOE-based sealers
May interfere with the seal of the roll filling = compromised
quality
Not totally effective against
several endo pathogens (E.
faecalis C. albicans)
LEDERMIX (LEDERLE PHARMACEUTICALS) COATED GUTTA PERCHA
Corticosteroid-antibiotic paste Uniform layer places on GP by manufacturer
May be an initial dressing Resin bond is formed when the GP comes in contact with the
RC medicament or as direct/indirect resin sealer = inhibit leakage between solid core and sealer
pulp capping agent Need EndoRez sealer (Ultradent)

NEW IRRIGATION AND DISINFECTION TECHNIQUES AND MEDICATED GUTTA-PERCHA

DEVICES Melding of antibacterial substance to GP cone or other solid-
Endo Activator core obturation materials may have use in preventing RCT
Passive ultrasonic activation failures due to coronal or apical microleakage
EndoVac Not used on a regular basis
Safety-Irrigator o More testing is needed to check their toxicity,
Self-Adjusting File (SAF) antibacterial and antifungal potential, and potential for
HealOzone allergic reactions
Superoxidized water SEALERS AND CEMENTS
Photoactivation disinfection Sealer fills all the space the solid-core is unable to fill
IntraLight ultraviolet disinfection Ideal sealer:
ROOT CANAL FILLING MATERIALS - SOLID MATERIALS GUTTA o Adheres strongly to dentin and core material
PERCHA o Antimicrobial
Most commonly used RC Filling material (beta- or processed o Must have some degree of radiopacity (silver, lead, barium,
form) bismuth)
Modern cones: ZINC OXIDE EUGENOL CEMENTS
o 20% GP Zinc oxide - antimicrobial agent, low-level but
o 60-75% zinc oxide (major component) long-lasting antimicrobial effect
o 5-10% resins, waxes, metal sulfates Allergic reaction to eugenol
Disinfection: submerge cones in 5% NaOCI for 1 minute
o Rinse in ethyl alcohol after NaOCI submersion and before CHLOROPERCHA
obturation While GP mined with chloroform
COMPOSITION OF GUTTA-PERCHA FOR ENDODONTIC USE No adhesive properties
Gutta-percha (19-22%) No longer used
Zinc oxide (59-79%) CALCIUM HYDROXIDE
Heavy metal salts (1-17%) Sealapex (Sybron Endo), ApexClar (Ivoclar)
Wax or resin (1-4%) Antimicrobial effects
Requires some form of compaction pressure - compresses Poor cohesive strength
GP cones to get a more 3D complete fill of RCS
Oxidizes with exposure to air and light, eventually becoming
brittle
Store in a cool, dry place for better shelf life
Cannot be used alone since it lacks adherent properties POLYMER
necessary to seal the RC space, thus a sealer (cement) is AH26, AH Plus (Dentsply)
needed for final seal Epiphany (Pentron Clinical Technologies)
0.02, 04, .06 tapers to match rotary Instruments EndoREZ (Ultradent)
Biocompatible, low tissue toxicity
o Equal biocompatibility with Resilon
RESILON (PENTRON CLINICAL TECHNOLOGIES)
Thermoplastic, synthetic polymer-based
Designed to be used with Epiphany (resin sealer with
bonding capacity to dentin)
Can be used with any current obturation technique DELIVERY SYSTEMS: CARRIER-BASED SYSTEMS
Bioactive glass, radiopaque fillers (bismuth oxychloride, Thermafil, Thermafil Plus, ProTaper, GT Obturators
barium sulfate) (Dentsply)
Can be softened with heat or dissolved with solvents o Alpha-phase GP pre applied to a flexible solid central
(chloroform) carrier
Compatible with current restorative techniques in which o Obturator is heated in a proprietary heater (ThermaPrep
cores & posts are placed with resin bonding agents Plus Oven)
SimpliFil (Discus)
INJECTION TECHNIQUES BASIC HAND INSTRUMENTS
obtura system currently most commonly used 1. Endodontic explorer
Dispenses heavy form of GP heated to a high • Straight end – locating the canal orifice
temp • Hook part – check ledges on cavity prep
Shrinkage of GP comparable to normally
heated GP
ROTARY TECHNIQUES
2. Endodontic spoon excavator
Frictional heart can also be used to soften GP
• Regular top
McSpadden Compactor device (Dentsply)
• Endodontic bottom
Quickfil (J.S. Dental) - obturation
comparable to lateral compaction
Inability to fill entire RCS due to sealer at
apical third
TEMPORARY RESTORATIONS 3. Plastic filling instrument/Woodson
Fermin, IRM (Dentsply), TERM (Dentsply, Cavit (3M), Coltosol • Help tuck the rubber dam sheet on wings
(Coltene), ZOE • Help in placement of temporary resto
When placing Cavit or other soft temporary cements, place
at a thickness of 4-5 mm
o If left for more than 1 week, cover soft cement with OTHER BASIC HAND INSTRUMENTS
harder one (RM, GIC, resin) 1. Mouth mirror
TEMPORARY CEMENTS 2. Endodontic - tweezer
Algenol Alpp. Concol, Covlon Clearfil Core Restore 3. Periodontal probe
Dynest AP, Dyrod AP Formi', FULL-IX GP Fup LC 4. Instrument trays
GI, RMGI Template
Keloc F Gloc Fu Plus Kaloc Silver
Polycarboxylate, eugenol free
Scotch Bond Temp Bond
Ultratemp Firm
Zinc phosphate
Z100 INSTRUMENT ACCESS PREP INST. FOR WL DETERMINATION
Will not prevent coronal leakage if left for long time periods Excavabur Dentsply Measuring devices-Endobloc
"restoration...should commence as soon as possible after
RCT" (AAE)
Bonded core build-up should be placed at obturation
appointment
LASERS
Endo Access Bur Instrument stops
Neodymium-doped yttrium aluminum gamer
Erbium-doped yttrium aluminum garnet Reference point
Diode – cusp tip or
Erbium/chromium-doped yttrium scandium gallium garnet incisal edge,
instrument stop
Canal transportation, breakage of file if unfamiliar with tip
must rest on top
design
Transportation of the original axis of the canal – remaining End-Z Bur & Diamendo
too long in a curved canal with tip that has efficient cutting
ability
Angle and radius of leading edge, proximity of flute to tip
determines cutting ability of tip
Cutting ability and file rigidity determine propensity to
transport canal
Gates Glidden Drills
INSTRUMENT FOR CANAL PREP 5. Exhibit 2% taper:
INTRACANAL INST. – FILES • There is a 0.02 mm increase in taper per mm away from D0
1. Material – stainless steel – less carbon 2%; replaced by • Standardization is for:
chromium 12-24% NiTi (flexible) o Quality control, Convenience, Uniformity, Correlation of
instruments & materials, Improved communication
2. Cross-sectional shape
NON-STANDARDIZED FILES
• Exhibit greater than 2% taper
o 4,6,8,10,12 %

3. Engine vs. Hand Driven

• Engine – reduced control
• Hand – permit proper shaping of canals; maintain
maximum control; final preparation is finished with hand Top – hand spreader
filing Bottom hand
plugger: vertical
condensation or
compaction of
material

PROTAPER - ROTARY

STERILIZATION
Factors to be considered for
sterilization to be effective:
D0 – tip 1. Cleanliness – mechanical &
Working part – 16 mm physical removal of debris
2. Comes in 4 lengths: a. Ultrasonic cleaner
• 21, 25, 28, 31 mm b. Use of detergent
• Length of flutes is always 16 mm 2. Degree of contamination
3. Numbered: 3. Concentration of chemicals
• 06, 08, 10 [2] – increments of 2 difference 4. Length of time to subject instruments for sterilization
• 15-60 [5] AUTOCLAVE:
• 60-140 [10] • 121 c
# = diameter at D0 in hundredths of a millimeter • 15 psi maintained for 15 mins
4. Color-coded: GLASS BEAD STERILIZER
Pink, gray purple: #6, 8, 10 • 218 C
• Files -10s; Paper points/cotton pellets – 5s
TOOTH MORPHOLOGY
COMPONENTS OF THE ROOT CANAL SYSTEM
Entire space in the dentin where the pulp is housed
Outline corresponds to the external contour of the tooth
/Shape of the system reflects the surface outline of the
crown
Pulp chamber and pulp /root canal(s)
Pulp horns accessory, lateral, furcation canals canal orifices
apical foramina
FURCATION CANALS: in bi- or trifurcation of multi rooted
teeth
o form as a result of the entrapment of periodontal vessels
during the fusion of the epithelial diaphragm (pulp
chamber floor)
o May range from 0 to more than 20 per specimen
o May be cause of primary endodontic lesions place adhesive
restoration on chamber floor to prevent furcal breakdown

A. Furcation canal – 2nd incidence

B. mandibular 1st molar molar greater incidence of being a
lateral canal
C. combination on both
PULP HORN
Represent what one does not want to encounter during
restorative procedures, but does want to locate during
access prep
Single pulp horn associated with each cusp (posterior teeth)
Mesial and distal pulp horns in incisors
Occlusal height of pulp horns corresponds to height of
contour
PULP CHAMBER
Occupies the center of the crown and trunk of the root
Shape depends on shape of crown and trunk
Configuration with tooth age and/or irritation
Roof is usually at level of CEJ
ROOT CANALS
Begin as a funneled orifice and exiting as the apical foramen
Varies with root shape and size degree of curvature, age and
condition of tooth
Shape and number of canals reflect the facio-lingual depth ROOT CANAL ANATOMY
and shape of the root at each level 7 general configurations of the root shape in cross section:
Irregularities /aberrations o round, oval, long oval, bowling pin, kidney bean, ribbon,
o hills and valleys (bulges and concavities), intercanal hourglass
communications (isthmuses), cul-de-sacs, fins, etc. Complex anatomy occurs often enough to be considered
Canal occupies the center of root normal
Weine: categorized RCS in any root into 4 basic types bullet
8 pulp space configurations by Vertucci et al

ACCESSORY CANALS
Minute canals that extend in a horizontal, vertical, or lateral
direction from the pulp to the periodontium
Found mostly in the apical third (74 %) but can also be found
in the cervical third (15%) and middle third (11 %) – The
more apical and posterior ang tooth the more chances of
being accessory canals (posterior apical)
Contain and vessels
Serve as avenues for the passage of irritants primarily from
pulp to periodontium
 APICAL CONSTRICTION (AC)
Part of the RC with the smallest diameter/minor apical
diameter
Reference point used as apical termination for cleaning,
shaping and obturation
Pulp BVs are narrow here
Great posttreatment discomfort felt when this area is
violated by instruments or filling materials
CEMENTODENTINAL JUCTION (CDJ)
Where pulp tissue ends and periodontal tissues begin
Not in the same area as AC
Approximately 1 mm from AF
APICAL FORAMEN (AF)
Major apical diameter
“circumference or rounded edge like a funnel or crater, that
differentiates the termination of the cemental canal from the
exterior surface of the root"
Does not normally exit at the anatomic apex, but is offset
0.5-3.0 mm
Root canal prep and obscuration end short of the anatomic
root apex

Examination of the PC can give clues to location of orifices

and type of canal system
o If canal is present, usually it is in the center of the access
prep
o Explore orifices thoroughly, particularly if oval shaped,
with apically precurved small K files
 The closer the orifices are, the greater the chance
Difficult to locate AC and AF clinically: radiographic apex
they will join at some point in the body of the root
may be a more reliable reference point
o Greater chance the canals will remain separate if the
o Terminate at or within 3 mm from radiographic apex
distance between orifices increases
(depending on diagnosis)
o More separation between orifices, lesser degrees of canal
o Vital pulp = 2-3 mm short; up to 1.5 to 2 mm short daad
curvature
o Nonvital pulp = at or within 2 mm
o Direction of the file is also important
o Retreatment t = 1 - 2 mm short
 If 1st file inserted into D canal of a Md molar points
Isthmus: narrow ribbon-shaped communication between 2
either B or Li, suspect a 2nd canal
canals that contain pulp or pulp ally derived fissure
 If 2 canals are present, they will be smaller than a
o Function as bacterial reservoirs
single canal
o Any root with 2 or more canals may have an isthmus
ALTERATIONS IN INTERNAL ANATOMY
Age - dentin formation predominates in certain area difficult
in locating chamber and canals
Irritants - increased dentin formation due to dentin exposure
(caries periodontal disease, abrasion, erosion, attrition,
cavity preps root planning fractures
Calcifications - pulp stones (denticles) and diffuse
calcifications
Internal resorption - uncommon; response to irritation
ANATOMY OF THE APICAL ROOT
3 landmarks:
Type 1: thin isthmus
Apical constriction (AC)
Type 2: complete connection
Cemento dentinal junction (CDJ)
Type 3: short complete
Apical foramen (AF)
Type 4: complete and incomplete combination bet. 3 more
Kuttler: RC tapering form canal orifice to AC (0.5-1.5mm coronal
canals
to the AF)
Type 5: no visible connections between openings
ACCESS CAVITY PREPARATION
OBJECTIVES:
Remove all caries
Conserve sound tooth structure
Completely unroofed the pulp chamber
Remove all coronal pulp tissue (vital/necrotic)
Locate all RC orifices
Achieve straight-or direct-line access to the AF or to the
initial curvature of the canal
Establish restorative margins to minimize marginal leakage of
the restored tooth
Properly prepared access cavity creates a smooth,
straight-line path to the canal system and
ultimately to the apex or position of the first
curvature
Straight line access: gives best chance of canal
space debridement reduces risk of file breakage
Allows complete irrigation, shaping and cleaning, and quality
obturation
GUIDELINES FOR ACCESS CAVITY PREPARATION
Visualize position of pulp space
Diagnostic radiographs help clinician estimate position of the
pulp chamber degree of chamber calcification, number of
roots and canals, approximate canal length
Krasner and Rankow: CEJ was the most important anatomic
landmark for determining location of pulp chambers and
root canal orifices
Law of centrality: the floor of the PC is always located in the
center of the tooth at the level of the CEJ
Law of concentricity: the walls of the PC are always
concentric to the external surface of the tooth at the level of
the CEJ, that is, the external root surface anatomy reflects
the internal PC anatomy
Law of the CEJ: the distance from the external surface of the
clinical crown to the wall of the PC is the same throughout
the circumference of the tooth at the level of the CEJ
o the CEJ is the most consistent, repeatable landmark for
locating the position of the PC
First law of symmetry: canal orifices are equidistant from a
line drawn in a MD direction through the center of the PC
floor (except for Mx molars)
Second law of symmetry: canal orifices lie on a line
perpendicular to a line drawn in a MD direction across the
center of the PC floor (except for Mx molars)
Law of color change: the PC floor is always darker in color
than the walls
First law of orifice location: the orifices of the RC are always
located at the junction of the walls and the floor
Second law of orifice location: the orifices of the RC are
always located at the angles in the floor-wall junction
Third law of orifice location: the orifices of the RC are always
located at the terminus of the roots developmental fusion
lines
SUMMARY
Visualization of the likely internal anatomy
Evaluation of the CEJ and occlusal anatomies
Preparation of the access cavity through the lingual and
occlusal surfaces
Removal of all defective restorations and caries before entry
into the pulp chamber
Removal of unsupported tooth structure
Creation of access cavity walls that do not restrict straight or
direct-line passage of instruments to the AF or initial canal
curvature
Delay of dental dam placement until difficult canals have
been located and confirmed
Location, flooring, and exploration of all RC orifices
Inspection of the PC, using magnification and adequate
illumination
Tapering of cavity walls and evaluation of space adequacy for
a coronal seal
MECHANICAL PHASES OF ACCESS CAVITY PREPARATION
1. Magnification and illumination
2. Handpieces
3. Burs
4. Endodontic explorer (DG-16, DE-17)
5. Endodontic spoon
6. Explorer
7. Ultrasonic unit and tips
BURS
Round carbide (#2# 4, #6)
o Remove caries
o Create initial external outline shape
o Penetrate through and remove the of the PC
Fissure carbide and diamond with safety tips (noncutting
ends) = axial wall extension
o Can be allowed to extend to pulp floor,
and entire axial wall can be moved and
oriented all in one plane from enamel
surface to pulp floor = produces axial
walls free of gouges
o Used to level off cusp tips and incisal edges
Round diamond burs (#2, #4) to access teeth with porcelain
or ceramometal restorations
o Less traumatic to porcelain than carbide,
can penetrate without cracking or
fracturing it
o Switch to carbide to penetrate metal or
dentin
Receded PC and calcified orifices: extended shank round burs
o Mueller bur (BrasselerUSA), LN bur (Dentsply)
Munce Discovery bur (CJM Engineering)
o Moves the head of the handpiece away from
the tooth, improving visibility
o Alternative: ultrasonic units
To flare or enlarge orifices and blend them into the axial
walls: Gates Glidden burs
o Start from small and progress to larger sizes
o Be mindful in removing excessive
dentin on the furcation side of a RC =
"strip " perforation
ENDODONTIC EXPLORER, ENDODONTIC SPOON, #17
OPERATIVE EXPLORER
DG-16 endodontic explorer: identify canal orifices and
determine canal angulation If access is small:
o JW-17 (CK Dental Industries): thinner, stiffer useful for
identifying calcified canals
Endodontic spoon: remove coronal pulp and carious dentin
#17 operative explorers: detect any remaining PC roof,
particularly in the area of a pulp horn
DG 16 – TOP, JW 17 - BOTTOM
ULTRASONIC UNIT AND TIPS ACCESS CAVITY PREPARATION
Specifically designed for endo procedures
Tips can be used to trough and deepen
developmental grooves to remove tissue
and explore for canals
Provide outstanding visibility
Fine tips allow for sanding away dentin and calcifications
conservatively when exploring for canal orifices
ANTERIOR ACCESS CAVITY PREPARATIONS
Begin in the center of the lingual surface of the anatomic
crown
Use a #2 or #4 round bur to penetrate through the enamel
and slightly into dentin (approx. 1 mm)
Outline form is 1/2 - 3/4 the projected final size of the access
cavity
Bur directed perpendicular to the lingual surface
ACCESS CAVITY PREPARATION:
Cavity prepared on the crown of the
tooth for the endodontic instruments
and materials to gain direct path to
the apex, for biomechanical
preparation and obturation.
Ideal access results in:
1. straight entry into the canal orifices, with the line angles
forming a funnel that drops smoothly into the canal or
canals.
2. quality endodontic result
"Variation of root canal anatomy is more of a rule rather than
an exception.”
C -shaped canal
EVALUATION OF ACCESS CAVITY PREPARATION:
Mandibular incisors with 2 canals
WAYS OF GAINING ACCESS INTO THE CANAL
the beast area to gain access to the apical foramen is
through the labial or incisal edge.
Put access to lingual for esthetics
Main cause of persistent infection is due to:
Inadequate access
Inadequate cleaning and shaping of the canal
1. You cannot locate all of the canals
2. Incomplete cleaning because apical end can be inaccessible
*Faulty canal access = infection!
3. Perforations: man-made canals
4. ledges - step being created
5. strip side of danger zone – towards furcation-thin wall
6. zipping of the apical end
7. Opening up of the apical end
8. Formation of an elbow
1. Study the pre-operative radiograph
2. Remove all caries, weak restorations and do crown build-up
after locating the canal
3. Draw an outline for on the lingual or occlusal
surface of the tooth.
4. Rubber dam isolation
5. Use #4 round bur for initial access through the
enamel and the dentin
6. When the bur “drops-in” unroof the pulp
chamber
7. Refine the access preparation using tapering fissure
bur, non cutting end, by removing lingual cervical
bulge, enamel triangle (beveled incisal wall)
8. Explore the orifice using pathfinder or endodontic
explorer (GG, orifice shaper, orifice opener)
9. Use nerve broach to remove vital pulp on large canals and
small sized files on narrow canals.
1. Correct location of the access preparation
2. Correct outline form
3. Properly unroofed pulp chamber, lingual shelf,
enamel triangle removed
4. Gouging and ledging absent
5. Refined access preparation – smooth and
rounder
6. Canal orifices visible
7. Conserve the tooth structure
8. Straight line access
 CONCLUSION
Access cavity preparation is one of the key factor to the success
of RCT. Many problems can be avoided with a good access cavity
preparation.
Change direction to parallel to the
long axis of the roof
Continue until the roof is penetrated
drop -in " effect
Probe the access opening with an
endo explorer
Remaining roof is removed by catching the end of a round
bur under the lip of the dentin root and cutting on the bur's
withdrawal stroke
o Vital case: amputate coronal pulp at the orifice level with
an endodontic spoon or round bur, then irrigate
copiously with NGOCI
Locate canal orifices with endo explorer
Remove the lingual shoulder = aids straight line access and
allows for more intimate contact of files with canal walls
o Lingual shoulder: lingual shelf of dentin
that extends from the cingulum to a
point approximately 2 mm apical to the
orifice
o Removed with a tapered safety -tip
diamond or carbide bur or with
o GG burs: largest that can passively be
placed 2 mm apical to the orifice; lean against the
shoulder during the rotation and withdraw(withdrawal
stroke)
Flare orifice with GG burs (small to large), used in a
circumferential filing motion, flooring in sequence
o Place passively into canal and rotate as it is gently leaned
against a canal wall and withdrawn
o Rotary Ni-Ti orifice openers: used at slow speeds and low
torque
Endo file can be used to approach the AF or
first point of canal curvature undeflected to
check if there is straight-line access
o No straight- line access: ledging,
transportation, zipping
Ledge: iatrogenically created RC wall irregularity that may
impede placement of an intracanal instrument to the apex
Transportation: occurs in the portion of the canal apical to a
curvature when canal wall structure opposite the curve is
removed tending to straighten the curvature
Zipping /elliptication of the AF: when an overextended file
transports the outer wall of the AF
Evaluate SLA by passively inserting the largest file to the
AF/point of first canal curvature, then take a radiograph
o Insert file gently and withdraw all the
while "feeling " for canal binding or
deflection
o Final position of the incisal wall
determined by: complete removal of the
pulp horns, SLA
Inspect and evaluate the access cavity
Refine and smooth the CSM to avoid coronal leakage on
placement of temporary permanent restoration
Butt - joint CSM
POSTERIOR TEETH ACCESS CAVITY
PREPARATION
Mx PMs: central groove between cusp tips
Md 1st PMs: halfway up the lingual incline of
the B cusp on a line connecting the tips
Md 2nd PMs: 1/3 the way up the Li incline of
the B cusp on a line connecting the B cusp tip
and the Li
groove between the cusps
Molars: establish M and D boundary
limitations
o Mx and Md M boundary: line
connecting the M cusp tips
o Mx D boundary: oblique ridge
o Md D boundary: line connecting the B
and grooves
o Central groove halfway between the
M and D boundaries
#2 round bur for PMs and #4 round bur for molars
Direct bur perpendicular to the occlusal table, and initial
outline shape is created at about 3/4 its projected final size
PM: oval, widest in BL dimension
Molar: oval initially widest BL in Mx and MD in Md
o Final outline shape: triangular (3 canals), rhomboid (4
canals)
o Canal orifices dictate position of the corners of the
geometric shapes
Change angle of penetration
o PM: parallel to the long axis of the root(s) both in MD and
directions
o Molars: toward largest canal palatalorifice (Mx) , distal
orifice (Md)
Guard against lateral and furcation perforations in
multirooted teeth
Aggressive probing with endo explorer can help locate PC
 Cervical dentin bulges and natural coronal canal constriction
internal impediments in posterior teeth
o Cervical bulges: shelves of dentin that frequently
overhang orifices
o Remove with safety-tip diamond/carbide or GG bus =
place at orifice level and lean toward the bulge to remove
the shelf
After removing the shelf, flare the orifice and coronal portion
of the canal
o Tapered and blended into the axial wall
motion should not exceed 90 degrees if excess
clockwise rotation is used the instrument tip can get
locked inside the dentine and the file may unwind or
the file may fracture (clockwise – 90 degrees)
2. Cutting is accomplished by CCW (270) rotation applying
sufficient apical pressure to the instrument.
3. The amount of apical pressure must be very light for
fine instruments to fairly heavy
4. For large instruments pressure should maintain the
instrument at or near it

Assess each canal for SLA

Inspect PC floor
Refine and smooth the restorative margins
o Final permanent resto of choice: crown or onlay
ERRORS IN CAVITY PREPARATION:

RECAP
Visualize internal anatomy will dictate outline form Study
pre-operative radiographs
Remove carious tooth structure and defective restorations
before entry into the chamber
Prepare access cavity through the palatal /lingual (anterior
teeth) and occlusal (posterior teeth) surfaces
Remove unsupported tooth structure
Do not put the rubber dam until all canals have been located
Locate flare and explore all canal orifices
Diverge chamber walls occlusally
REMOVE DEBRIS
Remove debris for visibility, especially when gaining access
through a restoration
DO NOT USE air syringe
Control bleeding (in vital cases)
WATCH WINDING MOTION – 30 DEGREE CLOCKWISE AND 30
DEGREE COUNTER CLOCKWISE UNTIL FEEL RESISTANCE
BALANCE FORCE TECHNIQUE – rotating file inside canal\
1. Placement of the file with slight apical pressure at the
same time rotating the file a quarter turn and this
CASE SELECTION AND TREATMENT PLANNING
To be able to identify important factors to consider in case
selection
To determine which teeth are salvageable for RCT and which
are not
To be able to develop an individualized endodontic
treatment plan for each patient
REASONS FOR DOING CASE SELECTION
To determine if endodontic treatment should
KINAHANGLAN and could KAYA PA be performed
To determine need for consultation and specialist referral
Contraindications for RCT unrestorable tooth
PERFORM
Process begins after endodontic problem has been
diagnosed
Increased knowledge regarding anxiety control, NSAID
premedication, profound local anesthesia, appropriate
occlusal adjustment, and biologically based clinical
procedures
Medical, psychosocial, and dental evaluation, as well as
consideration of complexity of the procedure
Prepare to communicate with the patient's physician,
proposed treatment can be reviewed and medical
recommendations be documented
American Society of Anesthesiologists Physical Status
Classification System
P1: Normal, healthy patient no dental management alterations
required
P2: Patient with mild systemic disease that does not interfere
with daily activity or who has a significant health risk factor (e.g.,
smoking, alcohol abuse, gross obesity)
P3: Patient with moderate to severe systemic disease that is not
incapacitating but may alter daily activity
P4: Patient with severe systemic disease that is incapacitating
and a constant threat to life
RISK ASSESSMENT
History of allergies
History of drug interactions, adverse effects
Anxiety (past experiences, management strategy)
Presence of prosthetic valves, joints, stents, pacemakers, etc.
Antibiotics required (prophylactic or therapeutic)
Hemostasis (normal expected, modification to treatment)
WATCH OUT!
Patient position in chair
Infiltration or block anesthesia with or without
vasoconstrictor
Significant equipment concerns (radiographs, ultrasonics,
electrosurgery)
Emergencies (potential for occurrence, preparedness)
CARDIOVASCULAR DISEASE
Consultation with physician is mandatory, especially if
patients encounter physical or emotional stress, or are ill-
informed regarding the specifics of their medical condition
No elective dental care for patients who have undergone a
myocardial infarction within the past 6 months
DO NOT ADMINISTER VASOCONSTRICTOR TO PATIENTS WITH:
Unstable angina pectoris
Uncontrolled hypertension
Refractory arrhythmias
Recent MIs and stroke (< 6 months)
as Recent coronary bypass graft (< 3 months)
Uncontrolled CHF
Uncontrolled hyperthyroidism
Infective/bacterial endocarditis (IE)
infection of the heart valves,
induced by a bacteremia
AHA: antibiotic prophylaxis in patients with prosthetic heart
valves, history of infective endocarditis, congenital heart
abnormalities
If medication has not been taken as recommended, it can be
given up to 2 hours after the procedure
Patients with artificial heart valves are also highly susceptible
to IE
Minimize vasoconstrictor use during the first 3 months after
coronary artery bypass graft
o Do not require antibiotic prophylaxis after the first few
months of recovery unless there are complications
PATIENTS WITH BLOOD THINNERS
Identify the reason why the patient is receiving anticoagulant
therapy
Assess the potential risk versus benefit of altering the drug
regimen
Know the lab tests used to assess anticoagulation level (ex.
INR values)
o Prothrombin time test or PT test - evaluates blood
clotting also expressed as INR
o Average clotting time 10-13 sec
o INR 1.1 or below is normal
o 2-3 range ok sa gatake warfarin
o Higher INR blood clots more slowly than usual
TAKE NOTE
Be familiar with methods used to obtain hemostasis both
intra- and post-treatment
Be familiar with potential complications associated with
prolonged/uncontrolled bleeding
Consult the patient's physician to discuss proposed dental
treatment and to determine the need to alter the
anticoagulant regimen
Also identify patients who have received radiation therapy to
the chest, consult the physician to find if the therapy has
damaged the heart valves or coronary arteries
o May require prophylactic antibiotics
DIABETES
Well-controlled and free of serious complications =
candidate for endo treatment
Non-insulin-controlled patient may require insulin, or insulin-
dependent patients may need to have insulin dose increased
TAKE NOTE
Have a source of glucose readily available
5/5 of hypoglycemia confusion, tremors, agitation,
diaphoresis, tachycardia
Avoid hypoglycemic emergency by taking a complete and
accurate history of time and amount of the patient's insulin
and meals
Schedule appointments according to the patient's normal
meal and insulin schedule
PREGNANCY
Protection of fetus is primary concern when administering
drugs or ionizing radiation
Drugs concern is that it will cross the placenta and be
teratogenic to the fetus
Ideally, no drug should be given during pregnancy, especially
during the 1st trimester
Partial List of Drugs Usually Compatible with Both Pregnancy
and Breast-Feeding
Local anesthetic, including lidocaine etidocaine and
prilocaine
Many antibiotics including penicillin, clindamycin, and
azithromycin
Acetaminophen
Acyclovir
Prednisone
Antifungals including fluconazole and nystatin
IMPORTANT
Additional concern for nursing mothers - consult physician
prior to using any medications
Alternatives: minimal dosage of drugs, have mother bank
milk before treatment, have mother feed the child before
treatment, use of formula until drug regimen is completed
Avoid elective dental treatment during the 1st trimester
Complex surgical procedures best postponed until after
delivery
MALIGNANCY
Obtain a panoramic radiograph
Do pulp testing to confirm lack of pulp vitality in teeth with
well-defined apical radiolucencies
Review pre-treatment radiographs from different
angulations
PATIENTS
Impaired healing responses in patients undergoing chemo or
radiation to the head and neck
Oral infections and any potential problems should be dealt
with prior to starting radiation
o Symptomatic non vital teeth endodontically treated at
least 1 week prior to radiation or chemo
o Review WBC (>2000/mm3 and platelet 50,000/mm3)
counts
BISPHOSPHONATE THERAPY
Risk of developing bisphosphonate-associated osteonecrosis
(BON)
Extractions, endodontic surgery or dental implant placement
should be avoided in patients with high risk of BON
Sound oral hygiene and regular dental care may be best
approach to lower BON risk
Risk Factors for Development of Bisphosphonate Associated
Osteonecrosis
History of taking bisphosphonates for more than 23 years,
especially with intravenous therapy
History of cancer, osteoporosis, or Paget's disease
History of traumatic dental procedure
Patient more than 65 years of age
History of periodontitis
History of chronic corticosteroid use
History of smoking
History of diabetes
END-STAGE RENAL DISEASE AND DIALYSIS
Consultation with the physician before dental care
May be best provided in a hospital setting
AHA guidelines do not include recommendation for
prophylactic antibiotics for patients receiving dialysis with
intravascular access devices
AP for patient having hemodialysis and who have known
cardiac risk factors
TAKE NOTE
Some drugs used in endo treatment are affected by dialysis
Avoid drugs metabolized by the kidneys and nephrotoxic
drugs
Dosage adjustment with aspirin, acetaminophen, amoxicillin,
penicillin
Treatment best scheduled on the day after dialysis
DENTAL EVALUATION AND TREATMENT PLAN
Consider strategic value of a tooth
To determine need for consultation and specialist referral
FACTORS IN CASE SELECTION
Tooth considerations
Patient considerations
Clinician considerations
INDICATIONS FOR RCT
teeth with irreversible pulp disease, with or without
periradicular disease
Teeth with normal or reversibly inflamed pulps, but:
o Will be used as overdenture abutments;
o For limited correction of malposed teeth;
o Need to use pulp cavity to retain restoration;
o Extensive restoration on a tooth with questionable pulp
status
SHOULD ENDODONTIC TREATMENT BE PERFORMED?
An endodontic problem exists, but certain conditions
contraindicate RCT.
1. No, periodontal support not enough bone structure
2. Yes, even if there is bone loss, bone support is not
entirely know in all surfaces, 2D only seen, adequate pa
rin ang bone bsan may bone loss, affect esthetics and
function
3. Yes, still restorable, iatrogenic error, there is perforation
area, pwede pa ma seal off, pwede man hemisection-
taking the diseased root. Pwede pa crown lengthening
4. Yes, crown lengthening deep carious lesion
5. Yes, open apex, wider apical root -apical barrier to induce
closure
6. Yes, radiolucency in center-internal resorption, use
thermoplasticized gutta percha to follow the shape of
resorption. Take account any pathologic condition:
periodontal support, restorability
7. No, vertical root fracture, displaced apical portion of the
root, vertical bone loss and widened pdl space
8. (Failure of rct, radiolucency on the distal root) yes,
consider the location and value of tooth, address the
STRATEGIC VALUE
CHECK FOR:
Periodontal support
Restorability
Presence of Pathology Condition
Strategic value for future use
PERIODONTAL CONSIDERATIONS PATIENT CONSIDERATION
A tooth with poor periodontal prognosis, even with a good Medical conditions
endodontic prognosis, may need to be sacrificed Local anesthesia considerations: allergy, vasoconstrictor
Consider pulp vitality and extent of periodontal defect contraindication, history of difficulty in obtaining profound
Primary endodontic disease: norvital pulp, primary anesthesia
periodontal disease vital pulp Personal factors size of mouth, limited ability to open mouth,
Combined endo-perio lesion when endodontic disease gagger, motivation to preserve dentition, physical
process advances coronally and joins with a periodontal impairment, limitation to be reclined, oral hygiene
pocket progressing apically Special needs psychological and mental health, economic
o Significant attachment loss status
o Guarded prognosis Timing and length of appointments
o Similar radiographic appearance to that of a vertically TREATMENT PLANNING
fractured tooth Objective of treatment: to restore health, function, and
o Both endodontic and periodontal therapy needed esthetics
(sequencing based on initial CC) Objective of treatment planning: to achieve treatment goals
o *endo treatment then perio treatment efficiently
SURGICAL CONSIDERATIONS CHARACTERISTICS OF A GOOD TREATMENT PLAN
Biopsy is a definitive means of diagnosing osseous pathosis Individualized or personalized
(may mimic an endodontic lesion) Flexible
Nonsurgical, surgical or combined treatment depending on Patient has the FINAL CHOICE
the presence of complex restorations, posts, and PHASES
radiographic assessment of prior endotherapy 1. Pre-treatment phase
Endodontic surgery performed in an attempt to correct o To prepare the operatie field in order to facilitate
nonsurgical therapy failure performance of treatment proper
o Determine the cause of failure  OHI - oral hygiene instructions
o May also be performed as a primary procedure when  Scaling and polishing
there are complications (ex Calcific metamorphosis)  Extraction
o Endodontic surgery without any nonsurgical treatment is  Caries control
a last resort, and only when NST is not possible 2. Treatment Proper
RESTORATIVE CONSIDERATIONS o Order will depend on CC
Root caries (which may require crown lengthening), poor  endodontic treatment
crown:root ratio, extensive periodontal defects, misaligned  Operative procedures
teeth  Prosthetic rehab
Remove restorations before endodontic treatment  Periodontal therapy
CAN ENDODONTIC TREATMENT BE PERFORMED?  Complex surgical procedures
 Orthodontic treatment
3. Post-treatment or Maintenance phase
o To monitor healing
o To detect new disease
o Take radiographs
o Perform clinical exam
o Reinforce OH
o Do scaling and polishing
VITAL CASES
1. Yes, dilaceration, using niti, refer nalang to specialist Pain may be due to increased intrapulpal pressure and/or
2. Yes, taurodontism, refer release of inflammatory mediators, and extension of
3. Yes, s shaped tooth refer pathogenic process into periodontium
4. Yes, canal cannot be seen, calcified canal, refer Once a canal has been entered, clinician should remove all
5. Calcified canal tissue
6. 2 canals and 2 roots, variation, fusion? Refer Close with a temporary filling at the end of the visit
7. Yes Occlusal reduction in teeth with history of pain and
8. Broken file inside, remove it or leave behind, refer percussion sensitivity
9. Take out instrument NON VITAL CASES
OBJECTIVE CLINICAL FINDINGS: Sometimes may become acutely symptomatic = increase in
o Difficult diagnosis bacterial virulence, change in flora, reduced host defense
o Difficulty in obtaining films of diagnostic value mechanisms
o Malpositioned teeth-rotated, tipped, too far distally Goals: reduce bacterial content in RCS, promote
Clinician's level of expertise decompression of periradicular tissues by instrumentation
Availability of necessary instruments and equipment and irrigation of canal
Calcium hydroxide put into RCS between visits
Close tooth with cotton pledget in chamber, covered by a
temporary filling
Complete endodontic treatment ASAP to prevent continued
bacterial penetration into the canal
 Incision and drainage may be performed in conjunction with PRE-TREATMENT
canal instrumentation when there is a fluctuant swelling
SINGLE VS MULTIPLE VISIT TREATMENT
Vital cases: single-visit
o Consider: number of roots, time available, clinician's skills
o Directed at alleviating pain; canal filling done at a later
visit
o Clinician's skill and severity of patient's symptoms
o Allows clinician to determine the effect of the therapy on Preparation of the Operatory - Infection Control
the inflamed tissues
o Shorter initial visit
o There must be an interplay between maximal reduction
of bacteria, effective root canal filling, timely satisfactory o Must also reduce number of MOs in the immediate
coronal restoration
Multiple-visit:
o Complex cases
o Retreatment cases
o Nonvital cases with apical periodontitis
OTHER FACTORS
Calcifications, dilacerations, resorptive defects
Inability to isolate a tooth
Extra roots and canals
Retreatment cases (ledges, perforations, post)
Number of roots may be determining factors if for referral,
or acute/chronic status of case
Complexity of ultimate prosthesis
Clinician skills and complexity of case
AAE developed guidelines for assessing case difficulty
(http://www.aaeorg/dentalpro/CaseAssetReferral html)
SCHEDULING CONSIDERATIONS
Allow 5-7 days between canal inistrumentation and
obturation = allows periradicular tissues to recover. Waiting
7 days to maximize effect of calcium hydroxide
Schedule patients who need IAN block anesthesia to arrive
15-20 minutes before treatment visit
Full nonvital cases approximately 1 week after
instrumentation = maximize antimicrobial effect of calcium
hydroxide
Acute nonvital cases should be seen every 24-48 hours =
monitor patient's progress and bring acute symptoms under
control
SUMMARY
Proper case selection will affect treatment outcome
Referral to a specialist should be considered.
Correct treatment planning will enable the clinician to
efficiently manage the patient's dental problem
Clinician and patient needs
Proper infection control
Occupational safety procedures
Appropriate communication with patient
Premedication
Quality radiographic or digital image survey
Thorough isolation of the treatment site
To be able to minimize risk of cross contamination
Goals: IC procedures must protect patients and dental team
from contracting infections during the dental treatment
dental environment to the lowest level possible
ADA recommendation: Consider each patient potentially
infectious
OSHA standard 29: designed to protect any employee who
could be "reasonably anticipated" to have contact with blood
or any other potentially infectious materials (engineering and
work practice control, equipment and protective clothing,
training, signs/labels, hep B vaccinations)
All DHCP with potential occupational exposure to blood or
other potentially infectious material should have Hep B
vaccinations
All DHCP must be educated about TB
Take a thorough patient medical history and update this at
subsequent appointments
o Screen for latex allergies
Personnel must wear protective attire (PPE) and use proper
barrier techniques
o Wear latex/vinyl gloves
o Hands, wrists and lower forearms must be washed with
soap and water - when hands are soiled, after touching
potentially contaminated inanimate objects with bare
hands, before and after treating each patient, before
wearing and after removing gloves
Pxs with active TB: treat in a special negative-air pressure
room
o Room must be vented outside through high-efficiency
filters
o Use of pretreatment oral irrigants containing
chlorhexidine gluconate
Wear protective clothing; should not be worn outside the
office
o Wash them in the office, do not bring home
Don eye protection and masks before gloving
Masks and protective eyewear with solid side shields or chin-
length face shields
Protective clothing (reusable/disposable): gowns, aprons, lab
coats, cínic jackets
Patients' clothing should be protected from splatter and
caustic materials-waist-length plastic covering overlaid with
disposable patient bibs
HVE when using high-speed handpiece, water spray or
ultrasonics
Use of dental dam as protective barrier - mandatory for
NSRCT
Segregation of sharps into disposable and reusable; to be
placed into separate, leak-proof, closable, puncture-resistant
containers
Cover or disinfect countertops, operatory surfaces, and any
other surface likely to become contaminated; protective
coverings can be used
 o Change between patients and when they become
contaminated
o Wiped with absorbent toweling and sprayed with
tuberculocidal disinfectant (ex. 1:10 dilution of sodium
hypochlorite, iodophor or synthetic phenol)
0.12% chlorhexidine gluconate rinsed prior to treatment
Sterilize all instruments after treatment
Periodically flush dental unit water lines with water or 1:10
dilution of 5.25% NOCI
Dispose infectious waste in appropriate containers
Pre-Treatment Sterilization & Disinfection
Sterile - absence of life forms
Disinfection - killing most life forms, especially pathogens
(does not include spores)
Elements of a Sterilization Plan
1. Transporting contaminated Items from the operatory
a. Items must be stored in a container to prevent
perforation
2. Instrument processing area
a. Instruments must be sorted, cleaned (e.g., removal of all
visible debris by scrubbing, ultrasonic cleaner), and rinsed
with water in an area separate from sterilization
b. Instruments should be inspected, assembled into trays,
and wrapped for sterilization in packages containing
sterilization indicator
c. Instrument packages should be sterilized according to
approved methods Autoclave (Steam Under Pressure)
d. Instruments should be stored for event-related use.
3. Environmental infection control
a. Clinical contact surfaces (barrier protection, spray
disinfectants)
b. Dental unit water lines
c. Housekeeping surfaces
4. Nonregulated and regulated medical waste
5. Monitoring plan
6. Training plan
Do not overpack the sterilizer since steam cannot penetrate
as well (inadequate sterilization)
Dry instruments before removing them from the sterilizer
Pathway from the sterilizer to the point of use should not
cross the path of contaminated instruments when they are
brought from the treatment area
Autoclaving (pressurized steam), pressurized heated Disinfection
chemicals, dry heat, cold chemicals
Cold Chemicals
Difficult to monitor fime cycle; recommended only for heat-
sensitive items
Generally require extended soak times
Rinse items in sterile water to remove fraces of disinfectant
& handle with sterile tongs/gloves to place them ina sterile
storage container after treatment
Poisonous, can be harmful to patients even in small amounts
Chemiclave Chemical Vapour Sterilizer
72% ethanol and 0.23% formaldehyde (in
exchange with water)
Avoids instrument corrosion
132°C (270°F) at 20 psi for 20 minutes
(includes drying time)
Du Ventilation or filtration to handle formaldehyde fumes Patient Preparation
Can dissolve into liquids
Prolonged Dry Heat
Kills MOs through an oxidation process
320°C for 30 minutes-2 hours
Advantages:
o Complete corrosion protection for dry
instruments
o Equipment is of low initial cost
o Sterilization is verifiable
Disadvantages:
o Slow turnover time
o If temperature is too high, instruments may be damaged
Intense Dry Heat (Glass Bead Sterilizer)
Not predictable
Can sterilize contaminated hand files
Not verifiable
Not for sterilization of hand files between use of
different patients
Dry heat sterilizers (air in oven/forced air) - also avoid
corrosion of instruments
In-operatory sterilizers: ex. glass bead – transfers dry heat to
canal instruments
o No longer approved for use
o Ineffective at killing spores on cotton & paper products -
autoclave nalang
Clean stand - well in center, pwede butangan sterilizing
solution
Typical method of sterilization for most health
care facilities
30 minutes (15-40 minutes) at 121°C (250°F)
at 15 psi
Flash sterilization: 134°C (2730F), 10 minutes, 30 psi
Advantages:
o Excellent penetration of packages
o Sterilization is verifiable
Disadvantages:
o Rust and corrosion can occur
o Can destroy heat-sensitive material
Do not pack instrument sets tightly
Ideal: boxes with a lot of holes to let in steam through the
overwrap
Closed boxes should be autoclaved with lids ajar
¼ cup NaOCl + 1 gallon of water
10-30 minutes
Corrosive to metals and irritating to skin
Biocidal against: bacterial vegetative forms, viruses, spore
forms
Remove barriers and disinfect surfaces after px treatment
o All surfaces that may be touched, instrument holders &
hoses, door & drawer pulls; pens, pencils, px charts
Use appropriate disinfectant - with UV light
Rubber dam use reduces aerosols
o Also use preprocedural mouth rinses along with proper
high-velocity evavators
Handwashing should be done prior to gloving
o Avoid having long fingernails and wearing jewelry
Handle sharps with caution
Endodontic treatment usually occurs early in the total
treatment plan for the patient
Explain the nature of the treatment
Inform the patient of any risks, the prognosis, and other
important facts
 Informing before performing" Periodontal Ligament Injection
Get a thorough medical and dental history G25 or G27 short needle
Do case presentation Inserted into the mesial gingival sulcus
Get informed consent 30° angle to the long axis of the tooth
Practice radiation safety Deposit 0.2 mL of solution, then repeat on the distal surface
Determine if there is a need for premedication with Vasculature in and around the tooth
antibiotics and NSAIDs Rapid onset: 10-20 minutes duration
Importance: to have a well-informed patient who is willing to Back-pressure is important
accept RCT and whatever it entails Re-injection increases the success rate
Goals: Mild post-op discomfort or pain
o Educate the patient of the risks, as well as the benefits of Minor local damage limited to site of needle penetration
RCT
o Inform the patient what is expected of him/her before,
during, and after the treatment
o Convince the patient to accept, value, and appreciate RCT
Intrapulpal Injection
AHA Recommendation for Prophylactic
Very painful
Antibiotic Coverage
Immediate onset; 15-20 minutes duration
Orthopedic prostheses
Needle is positioned in access opening and
Shunts
moved down the canal, as the anesthetic is
Cardiac conditionsProsthetic heart vaves
slowly expressed, to the point of wedging
Congenital malformations
Maximum pressure applied on syringe handle
Systemic pulmonary shunts
for 5-10 seconds
RHD
Routine Anesthesia
Idiopathic hypertrophic sub-aortic stenosis
History of bacterial endocarditis
MVP-mitral valve prolapse with valvular regurgitation
Addison's disease
AIDS
Chronic alcoholism
Blood dyscrasias
Uncontrolled diabetes
Organ transplants
Patients undergoing irradiation
Patients taking immunosuppressive drugs/antineoplastic
drugs Supplemental Anesthesia
Prophylactic Regimens for Dental Procedures

Tooth Preparation
Anesthesia Caries control
Radiographs
Build up/temporization
Crown lengthening
Isolation
RADIOGRAPHS
Be able to master radiographic techniques to achieve films of
maximum diagnostic quality
Goal: produce diagnostic radiographs as accurate as possible
to lessen patient and dental team's radiation exposure
Primary radiograph: periapical radiograph
o Identify abnormal conditions in pulp and periradicular
tissues
o Determine the number of roots and canals, location of
canals and root curvatures
2D - major limitation
Expose additional radiographs at different angulations when
treating multi-canal and multi-rooted teeth, teeth with
 o Enhance visualization and evaluation Rubber Dam Assembly
The tooth should be in the center of the film Rubber dam sheet
3 mm of bone should be visible beyond the apex Rubber dam frame
Image must be anatomically correct as possible Rubber dam clamp
Bite-wing: also useful as a supplemental film Rubber dam punch
Examination and Interpretation Rubber dam clamp
Frequently overlooked: small areas of resorption, separated holder/forceps
files, extra canals/roots, curved and calcified canals, fracture Methods
lines 1. Rubber dam first
Mistaken for pathologic RL: incisive foramen, mental 2. Clamp, dam
foramen 3. All together
Mistaken for periradicular pathoses: maxillary sinus, nutrient 4. Split dam
canals, lateral or submandibular fossa Problem Solving - Leakage
Methods (least ang straight on) Meticulous placement of the entire system - proper selection
1. Paralleling/Long Cone Technique and placement of the clamp; sharply punched, correctly
positioned holes; dam of adequate thickness; inversion of
dam around tooth
o Small tears/holes: use Cavit, OraSeal caulking, rubber
2. Bisecting Angle Technique base adhesive, perio packing
o But if leakage continues, replace the dam
Reduce excess salivary flow with anticholinergic drugs
o Atropine: 0.3-1 mg per os, 1-2 hours before procedure
3. Buccal Object Rule/Clark's Rule/Cone or Tube Shift o Propantheline: 7.5-15 mg PO, 30-45 minutes before
Technique/SLOB appointment
Problem Solving - Unusual Tooth Shapes/Positions
Partially erupted teeth, teeth prepared for crowns, fractured
or broken down teeth
Customized retainers - modify the jaws
Place spots of self-curing resin on the cervical surface - resin
would be a scaffold or framework sa undercut
Place small acid-etched composite lips
Problem Solving - Loss of Tooth Structure
Buccal Object Rule/SLOB Determine first if tooth is periodontally sound and restorable
Identifies the spatial relation of an object Choice of clamps:
Object closes to the buccal surface appears to move in the o apically inclined jaws
opposite direction of the movement of the cone/tube head, o serrated jaws/tiger clamps
when compared with a second film Restorative procedures to build up a tooth:
o Objects closest to the lingual surface appear to move in o preformed copper band
the same direction that the cone moved o temporary crown
Locate additional canals/roots o orthodontic band
Distinguish between objects that have been superimposed Periodontal procedures:
Locate of foreign bodies o crown lengthening – gingivectomy
Locate anatomic landmarks in relation to the root apex o electrosurgery
Tooth Isolation o apically positioned flap
Use of rubber dam is mandatory in RCT Orthodontic procedures:
Routine placement of the rubber dam is considered the o extrusion - if there is fracture of the anterior tooth
standard of care. margin below the crestal bone
Facilitates treatment by isolating the tooth from obstacles o Purpose: erupt the tooth to provide 2-3 mm of root
(ex. Saliva, tongue) that can disrupt a procedure length above the crestal bone level
RUBBER DAM Conclusion
Patient is protected from aspiration or swallowing of Pre-treatment procedures should be done prior to RCT
instruments, tooth debris, medicaments and irrigating to start the treatment right.
solutions
Clinician is protected from litigation because of patient
aspiration of an endodontic file
Surgically clean operating field is isolated from saliva, blood,
and other tissue fluids
Soft tissues are retracted and protected
Visibility is improved; provides a dry field and reduces mirror
fogging
Increased efficiency: minimizes patient conversation during
treatment and need for frequent rinsing
PRETREATMENT: ROOT CANAL TREATMENT
Patient's age and gender
Position of the tooth in the arch
Extension of the root canal filling
Use of certain interappointment dressings (ex. Ca(OH)2)
Periradicular osseous lesion a relevant prognostic factor that
reduces likelihood of a favorable outcome for RCT
Pre-Treatment Evaluation
Determine normal anatomy and anatomic variations
Assess one or more pre-op radiographs of diagnostic quality
Determine degree and location of curvature
Presence of resorption
Presence of restorations
Canal Preparation
Systematic procedure of removing pulp tissue, debris, and
microorganisms, with the use of files, irrigants and chemicals
while shaping to facilitate filing of the RCS
Combination of cleaning and shaping
Orifices may be better and safely opened up with ultrasonics
U: operate at 25-30 kHz
o Cavi-Endo (Denstply) ENAC (Osada)
o Use regular types of instruments (K-files)
S: operate at 2-3 kHz
o Endostar (Syntex Dental Products), Megasonic 1400
(Megasonic Corp)
o Use special instruments (Rispl-Sonic, Shaper-Sonic files)
Essential Elements of Successful Treatment
Adequate cleaning and shaping
Establishing a coronal seal
Elimination or reduction of inflamed or necrotic pulp tissue
an MOs a critical factor
Obturation (or filling) may be significant in preventing
recontamination from the coronal and apical direction
Cleaning and Shaping of the RCS
Mechanical debridement -remove bacteria
Creation of space for the delivery of medicaments - widen
gamay para makasulod ang instruments and irrigant to flow
more
Optimized canal geometries for adequate obturation
Biologic Objectives - Canal Cleaning
Removal of infected dentin and delivery of irrigants
Enlarged apical canals more likely to allow deeper needle
placement and more irrigation = improves canal
debridement and disinfection
Free RCS of pulp, bacteria, and their endotoxins
Extirpation - removal of vital pulp
Debridement - removal of end products of inflammation
Contents
Pulp tissues
Infected material
Organic substrates
Microflora
Bacterial by-products
Caries
Food
Tissue remnants
Pulp stones
Filling materials
Principles of Cleaning
Clean dentinal shavings (adequate cleaning)
Canal enlargement 3 files sizes beyond the first instrument to
bind (adequate cleaning)
Glassy smooth walls (good cleaning)
Mechanical Objectives - Canal Shaping
Creates a continuously tapering cone - widest at the coronal
and tapers down towards apical
Preserving the natural/original configuration of the root
canal
Make the apical terminus the narrowest cross section,
providing an apical stop - para hindi maglapaw ang
instruments or materials
Prepare the canal in multiple planes - depends on motion of
instrumentation
Facilitates cleaning by removing restrictive dentin, allows
greater volume of irrigant to work deeper and into all
aspects of the RCS
Carves away restrictive dentin and sculpt a preparation that
is thoroughly cleaned and prepared for obturation in three
dimensions
NOTED: Leave as much radicular dentin as possible = prevent
weakening of the root and as such, prevent vertical fractures
0.3 mm radicular thickness is critical
Straightening canal paths can lead to minimal
remaining wall thicknesses
Principles of Shaping
Facilitate cleaning
Provide space for placing obturating materials
Main objective: maintain/develop a continuously tapering
funnel from canal orifice to apex
(Insert funnel pic)
Degree of enlargement partly dictated by method of
obturation (labs lateral compaction method)
Degree of shaping determined by pre-op root dimensions,
obturation technique, and restorative treatment plan
Anatomical considerations before starting root canal
preparation
RCS is complex
o May divide, rejoin and possess lateral ramifications
o Apical foramen lies several millimeters away from the
anatomic apex
o Roots may possess an additional canal
o All canals are curved, especially in the apical third
o In flattened and curved root, the canal may lie closer to
the bifurcation side of the root (0.5-2 mm)
Canal prep and obturation should terminate at the apical
constriction
o 0.5-1.0 mm short of radiographic apex in necrotic cases
o 1-2 mm short in Irreversible pulpitis cases
5 commonly encountered canal paths: merge, curve,
recurve, dilacerate, divide
o Risk factors for file breakage
o Check canal length, position of primary curve, canal
diameter, apical topography
Physiologic foramen/canal terminus is 1 mm coronal to
anatomic apex/root tip
Radiograph apex does not coincide with anatomic apex
Shaping to the RA is likely to produce overinstrumentation
beyond the AF
Smallest canal diameter/apical constriction = 0.5-0.7 mm
coronal to canal terminus
Foramen-to-constriction distance increases with age
Root resorption another factor to consider in length
determination
Many studies verified that canals filled more than 2 mm
short had decreased success rate
Cleaning and shaping procedures should be confined to the
radicular space to prevent extrusion
Canals filled to the RA are actually slightly overextended
Primary Objectives in Cleaning and Shaping
Remove infected soft and hard tissue
Give disinfecting irrigants access to the apical canal space
Create space for the delivery of medicaments and
subsequent obturation
Retain the integrity of radicular structures
1. Hand and Engine-Driven Instruments
Broaches, K-type files (ISO-normed instruments current
term) and reamers, Hedström files, and paste carriers
Defined increase in diameter of 0.05-0.1 mm, depending
on the instrument size
2. Broaches
Remove vital pulp from root canals
Mild inflammation: severs pulp completely at the
constriction level
Declined use since advent of Ni-Ti rotary shaping
instruments, but may be useful for hastening
procedures and removing materials from canals
3. K-files
Clockwise and counterclockwise rotational and
translational working strokes
ISO: Available in lengths 21, 25, 31 mm
All have 16 mm cutting flutes; #.02 taper (.02 mm
increase in diameter per mm of length)
o Tip size increases by 0.05 mm for #10-60, 0.1 mm
for #60-140
4. Ni-Ti K-files
Extremely flexible; for apical enlargement in severe
apical curves
Can be pre-curved, but only with strong overbending
Smaller sizes (up to #25) are of limited use
5. In very small files (#6, #3, #10):
Apical dimensions are such that a #6 file does not
significantly remove dentin other than in severely
calcified cases;
A #8 file placed 0.5-1 mm long establish patency
contacts the desired endpoint of the prep with a
diameter nearing Tip size of #10 file;
#10 file placed as small as possible through the foramen
eases the way for passive insertion of #15 file to full
length
6. Hedström files
Translational strokes; rotational strokes may lead to
fracture
Size up to #25 can efficiently relocate canal orifices and
remove overhangs
Injudicious filing can thin the radicular wall considerably
and also lead to strip perforations
Like K-files, should be single-use
7. Gates-Glidden drills
Pre-enlargement of coronal canal areas
Number of rings on shank indicates specific drill size
Long, thin shaft with parallel walls and a short cutting
head - use in sequence s-b
Can reduce radicular wall thickness if used incorrectly
Side-cutting with safety tips; cuts dentin as it is
withdrawn from the canal
Should only be used in the straight portions of the canal,
serially and passively
Motions of Instrumentation
Filing - push and pull motion
o Placing the file into the canal and pressing it laterally
while withdrawing it along the path of insertion to
scrape/plane the wall
Modification: Turn and pull - quarter turn (CW) rotation and
pull
o Place file to the point of binding, rotate 90 degrees, then
pull the instrument along the canal wall
Watch winding - about 30-60° clockwise (CW) and
counterclockwise (CCW) movement of the instrument
o Used to negotiate canals and to work files to place
Balanced force - about 90 degrees CW rotation and about
270° CCW rotation with slight apical pressure
o File is repositioned and process is repeated until WL is
reached
o considered the most effective hand instrumentation
technique
Reaming - CW cutting rotation of the file
o Instruments are placed into the canal until binding is
encountered, then rotated CW 180-360 degrees
Terminologies
Reference point - usually a cusp or incisal edge
Radiographic tooth image - distance from a reference point
up to the root apex
Apical constriction - located 0.5 - 1 mm from the
radiographic root apex where you can find the CDJ
Working length (WL) - distance from the reference point to
the apical end of the canal constriction
Working length (WL) - apical point of termination; 1 mm
from radiographic apex
Apical portion of canal - major diameter of foramen and
minor diameter of constriction
AC - narrowest portion of canal: 0.5 mm -average distance
from foramen to constriction
Actual wire length (AWL) - actual length of the initial apical
file (IAF) inserted inside the canal for WL determination -
first file that is snug fit sa canal
COMPUTATION:
WL = AWL + or - discrepancy between the file and the
tip of the apex - 1 Safety Factor (SF)
NOTE: If the discrepancy is more than 2 mm, repeat the WL #45 @ 18 mm
computation #40 @ 19 mm
CANAL PREPARATION TECHNIQUE #35 @ 20 mm
CROWN DOWN (1-4) #30 @ 2 mm
1. Coronal preparation #25 @ 22 mm
o Orifice opening and enlargement #20 @ 23 mm
o Establish tentative working length (CROWN UP)
2. Patency (Canal Patency or Glide path) 5. Working length determination
o #10 file is moved gently in a push and pull motion o Selection of IAF
o Action is repeated until the file moves easily to 2 pre- o Tactile sensation
established length o Paper point evaluation - during or after canal prep
3. Scouting o Electronic apex locator
o Involves insertion of small diameter files to evaluate o Use of radiograph
cross-sectional diameter of a canal a. Measure the length of the tooth from the pre-op
o To determine if canal is open/partially radiograph.
restricted/calcified; if they o Subtract 2 mm from this length (to compensate
merge/curve/recurve/dilacerate/ divide - Canal paths for distortions.)
o Checks presence of SLA (straight line access) through the b. Select the initial apical file (IAF).
position of the file (parallel to long axis or skewed) o Should reach the estimated trial working length
4. Radicular Preparation (TWL) ex. 25 mm so ma -2 mm = 23mm TWL
o Procedure which involves flaring of the coronal 2/3 prior imeasure sa endo block with IAF NGA #15
to apical preparation o Biggest file that should reach apical
o Serial use of larger to smaller instruments resistance/snug fit at the end of the canal -select 3
o EX. if started our sa #60 @ 15mm to #55 @ 16mm to #50 files in 23mm which has snuf fit
@ 17mm o First file that reaches tentative WL and slightly
o No. Smaller; Length increasing binds/first file that binds at WL
c. Take a radiograph
d. Compute the WL ang ky doc is 23 mm
IF THE FILE PASSED OUT OF THE APEX:
AWL = 26 mm 23 mm
WL = 26 - 2mm - 1mm SF
WL=23 mm 20 mm
Try #15 snug fit
Step-Down (Crowndown) Technique IF THE FILE IS SHORT FROM THE APEX:
Removes coronal interferences and provides coronal taper AWL = 26 mm 23 mm
Explore the canal with a small instrument to assess curvature WL = 26 mm + 2 mm - 1 mm SF
Establish WL WL = 27 mm 24 mm
Flare the coronal 1/3 of the canal with GG drills or NiTi IF THE FILE IS FLUSH WITH THE RADIOGRAPHIC APEX:
orifice shapers AWL = 26 mm 23 mm
Large file is then placed in the canal and use a watch-winding WL = 26 mm + or - 0 mm - 1 mm SF
motion until resistance is encountered WL = 25 mm 22 mm
Repeat process with sequentially smaller files until apical 6. Apical preparation/Serial Filing constant ang length
portion of the canal is reached o Sequential use of files from IAF to MAF (is the file 3 sizes
WL and IAF can then be determined if not done initially larger than IAF) at WL with recapitulation
Apical portion of canal can then be prepared by enlarging the o Motion of instrumentation: watch-winding and pull
canal to the MAF (master apical file) at WL Size WL Reference Point
MAF - biggest file that you can insert up to the working IAF #25 22 mm incisal edge
length, ex. 23 mm WL MAF #30 ang MAF nga #35 hindi dapat [1]#30 22 mm incisal edge
23 mm ang WL dapat short [2]#35 22 mm incisal edge
Apical taper achieved by using step-back technique MAF [3]#40 22 mm incisal edge
COMPUTE SAMPLE:
Sa RTI radiographic tooth image
Measure the crown and root length (23 mm (na solve na for
distortion), crown length = 10 mm, root length = 13 mm)
Divide root length into 3 (13 mm = 4/4/5)
*Recapitulation - smaller file prior to bigger file
Add to crown length to the 1st ⅓ of the root (10 mm + 4 mm
Reinsertion/reuse of an instrument previously used to re-
= 14 mm)
negotiate the original WL
Start at 14 mm = ja ma start kang crown down until reaching
Take a small file to WL to loosen accumulated debris and
to 23 mm
flush it with 1-2 ml of irrigant -always basa mag file Sodium
IAF = #20 - nadetermine na lagi
Hypochlorite
Work down until reach 23 mm
Performed between each successive enlarging instrument
#70 @ 14 mm
* Master Apical File (MAF)
#60 @ 15 mm
Biggest file used up to the WL
#55 @ 16 mm
Minimum size is #25 for narrow canals
 Ex. #47, WL = 22 mm
Take a radiograph with the MAF inserted into the canal, to
verify the length again.
7. Step-back (for lateral compaction) - pasaka ang prep, apical
to coronal ga -1 mm kaw sa length
o Body of the canal is prepared using subsequent larger files,
1-2 mm short of the WL
o Instrumentation progresses coronally, then recapitulate.
o Sequential use of successively smaller to larger sizes of
instruments to prepare the canal at millimeter increments
progressing coronally from an apical preparation
o Reduces procedural errors and improved
debridement
o After coronal flaring, use IAF to determine
apical canal diameter
o Prep the WL up to the MAF
o Succeeding larger files are shortened by 0.5-1.0
mm increments from the previous file length,
up to the final file
o Creates a flared, tapering prep
o Last file used becomes the final file
o Superior to standardized serial filing and reaming techniques
in debridement and maintaining canal shape
o Ex.
 SB #45 WL = 21 mm
 MAF #40 WL = 22 mm
 SB #50 WL = 20 mm
 MAF #40 WL = 22 mm
 SB #55 WL = 19 mm
8. Circumferential filing
o Spreader reach test - check for flaring, urihi rn gle
o Use of the MAF to smoothen all canal walls
o Used for canals that are larger and/or not round
o File is placed into the canal and withdrawn in a directional
manner sequentially against the M. D, B and Li walls
o Ex. #40, WL = 22 mm
SAMPLE TABLE: IAF TO CIRCUMFERENTIAL FILING
25mm RTI (ref. Pt to end root) - 2 mm for distortions
= AWL is 23 mm
Ang IAF ni try2 lang so Snug fit ang #20 so confirm nalang ang
WL
Sa xray short from the apex 1 mm
So 23 mm ma + 1 mm tapos ma - 1 mm for SF = 23 mm
Serial Filing working length doesn't change at all, only
increase 3 file sizes larger
IAF #20 @ 23 mm
o #25 @ 23 mm (1)
*#20 @ 23 mm - recap - previous instrument
o #30 @ 23 mm (2)
*#25 @ 23 mm - recap - previous instrument
MAF #35 @ 23 mm (3)
ANG MAF OF OUR WL IS THE RECAP OF STEP BACK
*#35 @ 23 mm
Step-back ga -1 mm kita sa kada up sang file
o #40 @ 22 mm
*#35 @ 23 mm
o #45 @ 21 mm
*#35 @ 23 mm
o #50 @ 20 mm
*#35 @ 23 mm
Spreader reach test of large enough and properly flared
Insert the MAF together with the
spreader insider the canal - during
obturation ang MAC (Master apical
cone) - first gutta percha that we insert
is usually the same size sa the MAF
Length of the spreader should be at
least 1-2 mm short of the WL = If WL is
23 mm -1 mm for the spreader = 22 mm
Done to verify if the canal has been properly flared
#30 (#4) spreader (larger canals), #25 (#3) (smaller canals) -
sa iban naka 1-6
Criteria of Canal Preparation
Developing a continuously tapered funnel
Maintaining the original shape of the canal
Maintaining the AF in its original position
Keeping the apical opening as small as possible
Developing glassy-smooth walls
Features of an Ideal Preparation
Minimal enlargement of the apical foramen
Creation of an even, progressive apical stop to the pulp
chamber following the natural curvature of the canal
Provision for an apical stop at the end of the canal
Adequate cleaning of the canal at optimum working length
Guidelines in Instrumentation
1. Check instruments prior to use for any sign of instrument
strain or metal fatigue.
2. Precurve files (if Stainless steel). If curved, use directional
stoppers.
3. Select proper instruments depending on their use and
properties.
4. Always keep debris suspended in irrigant. Irrigate copiously.
5. Use instruments in proper sequence without skipping sizes.
6. Establish a straight line access.
7. Have a vision of the shape of the canal and work towards
shaping it with the 5 mechanical objectives in mind.
8. Always recapitulate to ensure canal patency.
9. Never force down instruments. Stop at resistance.
10. Verify working length at all times.
11. Be patient. Try to do it once but well.
Ni-Ti Rotary Instruments
Superelasticity and high resistance to cyclic fatigue
Substantially reduced the incidence of several clinical
problems (blocks, ledges, transportation, perforation)
Believed to fracture more easily than hand instruments
Preceded by a manual exploration of the canal to the desired
prep length = Glide path verification
Performed with 1 or more small K-files that are not
precurved
Straight-line access to the canal is essential

Circumferential filing:
o #35 @ 23 mm
* = recap

1. Basic instrumentation sequence covering most clinical cases
2. Finishing of wide apical part
3. Finishing of vert wide apical part
Factors Governing Potential for Ni-Ti Rotary Instrument
Fractures
Clinician's handling (most important)
Torsional load, bending, axial fatigue
RC anatomy
Manufacturing process and quality
Disinfectants, Dentin Surface Modifiers, Lubricants
Ideal irrigant:
o Kills bacteria
o Dissolves necrotic tissue
o Lubricates the canal
o Removes the smear layer
o Does not irritate healthy tissues
Sodium Hypochlorite (NaOCl)
Described as the most ideal of all agents= 1:9 ratio
Broad-spectrum antimicrobial activity
Concentrations between 0.5-6%
o Low concentrations (0.5 or 1%) dissolve mainly necrotic
tissue
o High conc.: better tissue dissolution, but dissolves both
necrotic and vital
o tissue (not desirable)
ADVANTAGE
o Mechanical flushing of debris from canal
o Ability to dissolve vital and necrotic tissue
o Antimicrobial action
o Lubricating action
o Inexpensive
o Readily available
DISADVANTAGE
o Issue with toxicity - avoid extrusion
o Irrigating needle must be placed loosely in the canal
o Bend needle (⅔) slightly at appropriate length or place a
rubber stopper to control depth of insertion
o Irrigant does not move apically more than 1 mm beyond
the tip
o Move needle up and down constantly during rinsing
Chlorhexidine (CHX, 2%)
Broad-spectrum, effective against gram-negative and gram-
positive bacteria
Substantivity and long-lasting antimicrobial effect
Little toxicity
o Advocated as a final rinse irrigant
o Inability to dissolve necrotic tissue and remove smear
layer
o Has not been shown to have more superior clinical
properties than NaOCI
lodine Potassium lodide (IKI)
2-5% concentrations
Acts as an oxidizing agent
Combination of IKI and CHX may kill E. faecalis or Ca(OH),-
resistant bacteria more efficiently
IKI/CHX mixed with Ca(OH), effectively disinfected dentin
o Possible allergic reaction in some
MTAD
Mixture of tetracycline, acid, and detergent
Citric acid component effectively removes smear layer
Effectiveness is enhanced when low concentration NaOCl is
used as intracanal irrigant before MTAD use
Biocompatible
Does not alter physical properties of dentin
Enhances bond strength
o Not been shown to be clinically beneficial
Ethylene diamine tetra-acetic acid (EDTA)
Chelator
Helps prevent apical blockage and aids disinfection through
removal of smear layer
Irrigation with 17% EDTA (remove inorganic) for 1 minute,
followed by final rinse with NaOCI (organic)
Calcium Hydroxide - Ca(OH)2
Effective at eradicating intraradicular bacteria, except E.
faecalis
Increased effectiveness observed when mixed with other
irrigating solutions Ca(OH), mixed with IKI or CHX may be
able to kill Ca(OH)2 -resistant bacteria
o Not effective when used short term
o Not recommended as irrigant, but as an
interappointment medicament
Other Irrigants
Electrochemically activated water/oxidative potential water
Hydrogen peroxide (mixed with NaOCI)
0.2 or 0.5% CHX, with NaOCI, as an irrigant or mixed with
Ca(OH)2 = overcomes inhibiting effects of dentin dust on
conventional medicaments, optimizes antimicrobial
properties
Benefits of Using Irrigants in RCT
Removal of particulate debris and wetting of the canal walls
Destruction of MOs
Dissolution of organic debris
Opening of dentinal tubules by removal of smear layer
Disinfection and cleaning of areas inaccessible to endodontic
instruments
Lubricants
Emulsify and keep in suspension debris produced by
mechanical instrumentation
Facilitate mechanical action of hand/rotary files
Irrigants can serve as lubricants, but there also special gel-
type substances
 Ex. RC Prep (wax-based, EDTA & urea peroxide), Glyde
(glycol-based)
*Smear Layer Removal
Organic pulpal materials and inorganic dentinal debris
Evidence generally supports smear layer removal
before obturation
SL prevents sealer contact with the canal wall = leakage
Interferes with the action and effectiveness of RC
irrigants and interappointment disinfectants
Preparation Errors
Loss of WL
Causes:
o failure to have an adequate reference point from which
WL is determined
o Packing of tissue and debris in the apical portion of the
canal
o Ledge formation
o Inaccurate measurement of files
Apical Transportation
o (along with zipping) occur when
inflexible files are used to prepare
curved canals
o When this error continues with larger
and larger files, a teardrop shape
develops = apical perforation on
lateral root surface
Apical Perforation
Instrument Fracture
o Occurs with torsional and cyclic fatigue
o Occurs more frequently with rotary instruments, but may
also involve hand instruments (K- and H-files)
Strip Perforation
Danger zone
dentin wall near bifurcation is thin
DO NOT ENCROACH
Safety zone
Opposite side of danger zone
Errors
Transportation results from the selective removal of dentin
from the RC wall in a specified part; central point of the canal
will have moved laterally
May happen during coronal flaring to straighten the canal or
iatrogenically due to incorrect usage of instruments
Elbows and zips are caused by the file attempting to
straighten in the RC as it is worked up and down
Elbow - narrow portion of a curved canal immediately
coronal to a transportation or zip
Ledge - an artificial irregularity created on the surface of the
RC wall that impedes the placement of instruments to the
apex of an otherwise patent canal (step)
Zip - a tear-drop shape that may be formed in the AF during
preparation of a curved canal when a file extends through
the AF and subsequently transports that outer wall
Perforation - mechanical pathological communication
between the RC system and the external tooth surface
o Apical perforation - in apical 1/3 of the root
o Furcal/furcation perforation - In furcal area
o Strip perforation
 complete penetration of a RC wall due to excessive
lateral tooth structure removal during
canal prep; usually occurs in curved roots
or roots with surface invaginations
 occurs in the middle part of the inner
curve of a RC, A result of relatively large
and stiff files attempting to straighten
within the RC, or overuse of GG burs or
orifice shapers
 Occur in the furcal region of curved roots, frequently
in M roots of Mx and Md molars
 Danger (furcal wall) and safety (outer wall) zones
must be noted
Anti-Curvature Filing
Done during coronal flaring procedures to preserve the furcal
wall in the treatment of molars
GG drill should be confined to the canal space coronal to the
root curvature and used in a step-back or down way
Principles and Concepts
Initial canal exploration is always performed with smaller
hand files to gauge the canal's size, shape, and configuration.
Copious irrigation must be provided between instruments in
the canal.
Coronal preflaring facilitates placement of larger files to WL
and reduces procedural errors.
Apical canal enlargement proceeds gradually, using
sequentially larger files, regardless of flaring technique.
Debris is loosened and dentin is removed from all walls on
the outstroke or with a rotating action at or close to the WL.
Instrument binding or dentin removal on insertion should be
avoided.
Use circumferential filing for canals with cross-sectional
shapes that are not round
After each insertion, the file is removed and the flutes
cleaned of debris using clean stand; file can then be
reinserted into the canal to plane the next wall
Recap is done to loosen debris; canal walls are not planed
and canal is not enlarged
Small, long, curved canals are the most difficult and tedious
to enlarge; require extra caution - more applicable sa molars
Overenlargement of curved canal by files attempting to
straighten themselves leads to procedural errors.
Overprep of canal walls toward the furcation may result in a
strip perf in the danger zone.
Instruments, irrigants, debris, and obturating materials
should be contained within the canal.
Forcing or locking (binding) files into dentin tends to untwist
the file and lead to fracture.
An apical stop may be impossible if the AF is already very
large.
Temporary Restorations
Seal coronally, preventing ingress of oral fluids and bacteria,
and egress of intracanal medicaments
Enhance isolation during treatment procedures
Protect tooth structure until the final restoration is placed
Allow ease of placement and removal
Satisfy esthetics (secondary consideration)
Must last several days to weeks
Ex. Cavit, IRM, GICs (Fuji IX), TERM
Cavit - easy to use, good sealing ability; low strength and
rapid occlusal wear (short-term sealing)
IRM, TERM - improved wear resistance, but lesser sealing
ability than Cavit
GIC - more durable; tend to provide the best seal
Double seal of Fuji IX over Cavit - durable and effective
barrier to microbial leakage
4 mm Cavit - effective seal against bacterial penetration for 3
weeks
Critical: thickness, placement of material; cavity size
Quality of seal depends on: thickness of material, how it is
compacted into the cavity, extent of contact with sound
tooth structure or restoration
Minimum 3-4 mm around periphery, 4 mm or more to allow
for wear
3 mm thick in cingulum area in anterior teeth
Dry chamber and cavity walls
Place thin layer of cotton over the orifices
Pack Cavit into access opening with a plastic instrument in
increments from the bottom up, and pressed against the
cavity walls and into undercuts

Remove excess
Smoothen surface with moist cotton
Inform the patient to avoid chewing on the tooth for at least
an hour
Take care when removing using a high-speed bur; ultrasonic
tip can also be used
Teeth with extensive MOD cavities and without marginal
ridges or with undermined cusps need a stronger material
(high-strength GIC)
Cusp-onlay amalgam or ortho band (restored with GIC) for
severely broken down teeth
MICROBIOLOGY OF ENDODONTIC INFECTIONS o Secondary
Apical periodontitis – primarily caused by infection of RCS o Persistent
(3.1)
Endodontic infections usually develop after pulp necrosis or
in cases in which the pulp was removed for treatment
Bacteria – major MOs implicated in the etiology of apical
periodontitis
Bacteria colonizing the RCS contact the periradicular tissues
through the apical and lateral foramina
Goal of Endodontic treatment: prevent development of AP
or to create adequate conditions for periradicular tissue
healing
ROUTES OF ROOT CANAL INFECTION
Dentinal Tubules
o Pulp at risk of infection as a result of permeability of dentin
o MOs in carious lesions, in saliva amid exposed area, or in
dental plaque formed on the exposed area
o Bacterial invasion occurs more rapidly in nonvital teeth -
no circulation, the body cannot eliminate the bacteria
o Dentinal exposure will not be significant route of pulpal
infection due to:
 Outward movement of dentinal fluid and tubular
contents
 Dentinal sclerosis underneath a carious lesion
 Reparative or reactionary dentin
 Smear layer
 Intratubular accumulation of host defenses (ex.
Antibodies)
Direct Pulp Exposure
o Most obvious route of endodontic infection
 Caries – most common cause of pulp exposure
Pulp exposed to biofilms containing high
bacterial loads for a long time
 Iatrogenic restorative procedures or trauma can cause
MOs to reach the pulp via direct pulp exposure -use
rubber dam to isolate the tooth to lessen bacterial
exposure
Periodontal Disease
o Pulp necrosis only develop if ever your pocket reaches your
apical foramen
o Periodontal MOs reach the RCS ramifications, exposed
dentinal tubules, and AF
Anachoresis
o Process by which MOs are transported in the
blood or lymph to an area of tissue damage
(leave the vessel-enter damaged tissue-
establish an infection)
o No clear evidence that this is a route for RC
infection
CHARACTERISTICS OF CAUSATIVE MICROORGANISMS IN
ENDODONTIC INFECTION
Opportunistic – take advantage normal flora
Polymicrobial
Undergo a selective process (mostly anaerobic bacteria)
MICROBIOLOGY OF ENDODONTIC INFECTIONS
Intra- (IR) or extraradicular (ER)
INTRARADICULAR INFECTION
o Primary: caused by MOs that initially invade and colonize
the necrotic pulp tissue
TYPES OF BACTERIA: 3. Bacterial Interaction
1. GRAM-NEGATIVE BACTERIA
Moat common MOs in primary infections
Dialister invisus, Fusobacterium nucleatum,
Porphyromonas endodontalis, Porphyromonas gingivalis
Prevotella intermedia, Prevotella nigrescens, Tannerella
forsythia, Treponema denticola
2. GRAM-POSITIVE BACTERIA
Some have been frequently detected in prevalence
values as high as the most commonly found gram (-)
bacteria
Actinomyces israelii, Streptococcus anginosus group,
Propionibacterium propionicum
Identification of endodontic MOs done through culturing
techniques
Molecular sequencing to identify the organisms that have
never been cultivated = “next-generation
APICAL PERIODONTITIS
sequencing”/pyrosequencing
Biofilm-related disease
Provide considerable information about the true
Dominant pattern of bacterial colonization of the RCS is
differences in microbial diversity between acute and
through the formation of a biofilm that adheres to the RC
chronic infections
walls
Also about transition of microbiota from healthy oral
Biofilm: sessile, multicellular microbial community
condition to an endodontic infection
characterized by cells that are firmly attached to a surface
3. OTHER MICROORGANISMS
and interwoven in a self-produced matrix of extracellular
Fungi - found sporadically
polymeric substance
Viruses - reported to occur only in teeth with vital pulps
– only need live host The larger the AP lesion, the higher the prevalence of
bacterial biofilms in the apical canal
o HIV, HSV
MOs present in the biofilms adhering to canal walls or found
ECOLOGY OF ENDODONTIC MICROBIOTA
in isthmuses, lateral canals or dentinal tubules are harder to
Root canal with necrotic pulp space = space for bacteria
eradicate
colonization
o Moist, warm, nutritious and anaerobic environment that PERSISTENT AND SECONDARY INFECTIONS
is mostly protected from host defenses because of lack of Persistent – caused by MOs from a primary infection that is
resisted intracanal antimicrobial procedures and through
active microcirculation
periods of nutrient deprivation in a prepared canal – there na
o 1,000 different bacterial taxa have been reported in the
guid pero hindi makakas
oral cavity, 100-200 taxa in each person’s mouth; but
Secondary – caused by MOs that were not present in the
restricted groups of these bacteria is found in an infected
primary infection, but that were introduced into the RCS at
canal – selective pressure that happens for RCS to favor
the establishment of species inhabiting the growth of some time during or after professional intervention
other o During treatment – remnants of dental plaque, calculus,
caries on the crown; leakage of RD; contamination of
DIFFERENT ECOLOGICAL FACTORS:
endodontic instruments, irrigating solutions, intracanal
*Influence the composition of microbiota in necrotic canal
1. Oxygen Tension and Redox Potential medications
o Between appointments – loss or leakage of temporary
RC infection is a dynamic process, different bacterial
restorative materials; fracture of the tooth; teeth left open
species dominate at different parts
for drainage
Initial phases:
o After RC filling – loss or leakage of temporary/permanent
i. facultative bacteria predominate
restorative materials; preparation of posts or other
ii. Followed by obligate anaerobic bacteria
intracanal restorations without RD; fracture of the tooth;
iii. Then anaerobes eventually dominate
recurrent decay exposing RC filling material; delay in
2. Available Nutrients
placement of permanent restorations
Necrotic pulp tissue
EXTRARADICULAR INFECTIONS
Proteins and glycoproteins from tissue fluids and exudate
Microbial invasion of and proliferation in the inflamed
(via AF and LF)
Salivary components that may coronally penetrate into periradicular tissues
Almost always a sequel to IR infection
the RC
Most common form: Acute apical abscess
Metabolic products of other bacteria
Can depend on or be independent of the IR infection
Largest amount in main canal = most infecting
Presence of sinus tract (fistula) usually indicates ER
microbiota found in this area
occurrence of bacteria
 Once IR infection is properly controlled by RCT or extraction,
and pus drainage is done, ER infection is handled by host
defenses and usually subsides
Major cause of post-treatment disease is located within the
RCS, indicating a persistent or secondary IR infection
FASCIAL SPACE INFECTIONS
Space of the body of the mandible. The source of infection is a
mandibular tooth in which the purulent exudate has broken
through the overlying cortical plate but not yet perforated the
overlying periosteum. Involvement of this space can also occur
as a result of a postsurgical infection.

Mental space. The source of the infection is an anterior tooth in

which the purulent exudate breaks through the buccal cortical
plate, and the apex of the tooth lies below the attachment of
the mentalis muscle.
Fascial spaces are potential anatomic areas that exist between
the fascia and underlying organs and other tissues.
During infection, these spaces are formed as a result of the
spread of purulent exudate. The spread of infections of
odontogenic origin into the fascial spaces of the head and neck
is determined by the location of the root end of the involved
tooth in relation to its overlying buccal or lingual cortical plate
and the relationship of the apex to the attachment of a muscle.
SWELLINGS OF AND BELOW THE MANDIBLE
Buccal Vestibule
Body of the mandible Ludwig’s angina – life
The submental space. The source of the infection is an anterior
Mental space threatening; airway
tooth in which the purulent exudate breaks through the
Submental space obstruction; bilateral; pain
lingual cortical plate, and the apex of the tooth lies below the
Sublingual space tender
attachment of the mylohyoid muscle.
Submandibular space

The sublingual space. The source of infection is any mandibular

tooth in which the purulent exudate breaks through the lingual
cortical plate, and the apex or apices of the tooth lie above the
Mandibular buccal vestibule. In this case, the source of the attachment of the mylohyoid muscle.
infection is a mandibular posterior or anterior tooth in which
the purulent exudate breaks through the buccal cortical plate,
and the apex or apices of the involved tooth lie above the
attachment of the buccinator or mentalis muscle, respectively.

The submandibular space. The source of infection is a posterior

tooth, usually a molar, in which the purulent exudate breaks
through the lingual cortical plate and the apices of the tooth
lie below the attachment of the mylohyoid muscle. If the sub
mental, sublingual, and submandibular spaces are involved at
the same time, a diagnosis of Ludwig angina is made. This
life-threatening cellulitis can advance into the pharyngeal and
SWELLINGS OF THE LATERAL FACE AND CHEEK:
The buccal vestibule of the maxilla
The buccal space
The submasseteric space
The temporal space

Buccal vestibular space. The source of infection is a maxillary

posterior tooth in which the purulent exudate breaks through
the buccal cortical plate, and the apex of the tooth lies below
the attachment of the buccinator muscle.
The temporal space. The deep or superficial temporal spaces are
involved indirectly if an infection spreads superiorly from the
inferior pterygomandibular or submasseteric spaces,
respectively.
SWELLINGS OF THE PHARYNGEAL AND CERVICAL AREAS
The pterygomandibular space
The parapharyngeal spaces
The cervical spaces

The buccal space. The source of the infection can be either a

posterior mandibular or maxillary tooth in which the purulent
exudate breaks through the buccal cortical plate, and the apex
or apices of the tooth lie above the attachment of the
buccinator muscle (i.e., maxilla) or below the attachment of the
buccinator muscle (i.e., mandible). .
The pterygomandibular space. The source of the infection is
mandibular second or third molars in which the purulent
exudate drains directly into the space. In addition, contaminated
inferior alveolar nerve injections can lead to infection of the
space.

submasseteric space. The source of the infection is usually an

impacted third molar in which the purulent exudate breaks
through the lingual cortical plate, and the apices of the tooth lie
very close to or within the space.
The parapharyngeal spaces. The pharyngeal spaces usually
become involved as a result of the secondary spread of
infection from other fascial spaces or directly from a
peritonsillar abscess
 The canine, or infraorbital, space. The source of infection is the
maxillary canine or first premolar in which the purulent exudate
breaks through the buccal cortical plate, and the apex of the
The cervical spaces comprise the pretracheal, retrovisceral,
tooth lies above the attachment of the levator anguli oris
danger, and prevertebral spaces.
muscle. There is a chance for the infection to spread from the
The pretracheal space is the potential space surrounding the
infraorbital space into the cavernous sinus in the cranium via
trachea. It extends from the thyroid cartilage inferiorly into the
the valveless veins of the face and anterior skull base.
superior portion of the anterior compartment of the
The periorbital space is the potential space
mediastinum to the level of the aortic arch. Because of its
that lies deep to the orbicularis oculi muscle. This space
anatomic location, odontogenic infections do not spread to the
becomes involved through the spread of infection from the
pretracheal space.
canine or buccal spaces.
The retrovisceral space comprises the retropharyngeal space
MANAGEMENT OF ABSCESSES AND CELLULITIS
superiorly and the retroesophageal space inferiorly. The space
2 most important elements of effective patient management
extends from the base of the skull into the posterior
correct diagnosis and removal of the cause by controlling
compartment of the mediastinum to a level between vertebrae
endodontic] infection.
C6 and T4.
Majority of cases of endodontic infections can be treated
The danger space (i.e., space 4) is the potential space between
effectively without the use of adjunctive antibiotics;
the alar and prevertebral fascia. Because this space is composed
appropriate treatment is removal of the cause of the
of loose connective tissue, it is considered an actual anatomic
inflammatory conditions
space extending from the base of the skull into the posterior
Antibiotics are not recommended for irreversible pulpitis,
compartment of the mediastinum to a level corresponding to
acute apical periodontitis, draining sinus tracts, after
the diaphragm. It is not unknown for odontogenic infection to
endodontic surgery, to prevent flare-ups, or after incision for
spread into this space, if left untreated and undiagnosed.
drainage of a localized swelling (without cellulitis, fever, or
The consequence can be fatal. The prevertebral space is the
lymphadenopathy).
potential space surrounding the vertebral column. As such, it
Antibiotics + endodontic treatment: recommended for
extends from vertebra C1 to the coccyx. A retrospective study
progressive or persistent infections with systemic signs and
showed that 71% of cases in which the mediastinum was
symptoms such as fever, malaise, cellulitis, unexplained
involved arose from the spread of infection from the
trismus, and progressive or persistent swelling (or both).
retrovisceral space (21% from the carotid space and 8% from the
Aggressive incision is indicated for any infection with
pretracheal space).
cellulitis, no matter if indurated or fluctuant
SWELLINGS OF THE MIDFACE
o Provides a pathway of drainage to prevent further spread
The palate
of abscess/cellulitis
The base of the upper lip
o Allows decompression of the increased tissue pressure
The canine spaces
associated with edema and provides significant pain relief
The periorbital spaces
o Draining pathway for bacteria and by products, and
* Cavernous Sinus Thrombosis
inflammatory mediators
a life-threatening infection in which a thrombus formed in
Rubber dam drain or Penrose drain for patient with
the cavernous sinus breaks free, resulting in blockage of an
progressive abscess/cellulitis
artery or the spread of infection. Under normal conditions,
Patient should be followed on a daily basis to ensure that the
the angular and ophthalmic veins and the pterygoid plexus
infection is resolving
of veins flow into the facial and external jugular veins. If an
Best guide for determining duration of antibiotic therapy is
infection has spread into the midfacial area, however,
clinical improvement of the patient – if manog resolve man
edema and the resultant increased pressure from the
guid ang infection = 1-2 days lang ang antibiotics
inflammatory response cause the blood to back up into the
RCT should be completed as soon as possible after incision
cavernous sinus.
and drainage
Once in the sinus, the blood stagnates and clots. The
SYSTEMIC ANTIBIOTICS
resultant infected thrombi remain in the cavernous sinus or
Amoxicillin = Adults: 500 mg TID (3xday) (with or without a
escape into the circulation.
loading dose(first high dose-initial) of 1000 mg) for 3-7 days;
500 mg maintenance dose (half of loading dose)
 7-10 day duration largely based on studies and clinical
practice of treating infections whose etiology is not
identified/treatment of bloodstream infections in
hospitalized patients
Amoxicillin + clavulanic acid (co-amoxiclav = augmentin) =
500 mg + 125 mgBID or TID
Effective against 100% of cultivable endodontic bacteria
Use should not be done without caution due to significant GI
and hepatic side effects
Clindamycin
o Adults: 600 mg (loading dose), followed by 300 mg every 6
hours
o Children: 10-30 mg/kg (dose/body weight) divided into 4
equal doses
Issue with pseudomembranous colitis
CONTROL OF INFECTION
Removal of bacteria from the RCS
Inhibiting bacterial regrowth and re-establishment in the
canal
Prevention of re-entry and recolonization of bacteria
OBTURATION
4 FACTORS AFFECTING SUCCESS (META-ANALYSIS)
Absence of a pretreatment periapical lesion
Root canal fillings with no voids
Obturation to within 2.0 mm of the apex
Adequate coronal restoration
OBTURATION
Three-dimensional filling of the entire RCS as close to the
CDJ as possible
Minimal amount of root canal; sealers are used in
conjunction with the core filling material to establish
adequate seal
CDJ- one of the most important landmark in the apical portion of
the canal including apical constriction and apical foramen – we
don’t go beyond these areas.
Obturation is a combination of root canal sealers and core filling
material- they must work together to obturate or fill resulting to
adequate seal.
OBJECTIVE OF OBTURATION
Create a watertight seal along the length of the RCS from the
coronal opening to the apical termination
o Prevents residual microbes in the RCS from gaining access
to the PDL and cause disease
o Minimizes entry of new microbes into the RCS from the
AF, lateral/accessory canals, coronal opening,
odontoblastic tubule dead tracts
To eliminate all avenues of leakage from the oral cavity or
periradicular tissues into the root canal
To seal within the system any irritants that cannot be fully
removed during the canal cleaning and shaping procedure
REFLECTION OF THE CLEANING AND SHAPING
Evaluated on the basis of:
o Length
o Taper
o Density
o Level of gutta-percha (GP) removal
o Coronal seal (adequate provisional restoration)
Necessary to eliminate leakage
Canal system should be sealed apically, coronally, and
laterally
Reduces coronal leakage and bacterial contamination
Seals apex from the periapical tissue fluids
Entombs the remaining irritants in the canal
HISTORY
Before 1800: gold oxychloride of zinc, paraffin, amalgam
1847: Hill – first gutta percha root canal filling material (Hill’s apical and lateral portion have lesions
stopping); bleached GP and carbonate of lime and quartz
1848: patent for Hill’s stopping
1867: Bowman – made claim of the first use of GP for canal
filling in an extracted first molar
1883: Perry – used pointed gold wire wrapped with GP; GP
rolled into points
1887: S.S. White – began to manufacture GP points
1893: Rollins – GP with vermillion
1914: Callahan – softening and dissolution of GP to serve as
cementing agents through the use of rosins
TIMING OF OBTURATION
Patient’s signs and symptoms- not yet ready if in pain
Status of pulp and periradicular tissue – if vital or not
Degree of difficulty – delayed obturation w/ multiple visits
Patient management – psychological status
*Culture results – if negative
*Number of appointments – if can be done in one sitting
REGARDING THE STATUS OF THE PULP TISSUE
VITAL PULP TISSUE
One-step treatment procedures are acceptable
Obturation at the initial visit prevents contamination due to
leakage during the period between patient visits
Obturation at initial visit can be done in irreversible pulpitis
cases
NECROTIC PULP TISSUE
May be treated in one visit: pulp necrosis with/without
asymptomatic periapical pathosis (CAP, CAA, condensing
osteitis)
Delayed obturation if patient presents with acute symptoms
caused by necrosis and acute periradicular abscess
Can be performed after cleaning and shaping procedures
when the canal can be dried and there is no swelling
Obturation of a canal that cannot be dried is contraindicated
Procedural concerns and patient conditions also dictate time
of obturation
LENGTH OF OBTURATION
Importance of control relates to extrusion of materials
Studies: teeth obturated <2 mm from apex had higher
success rate compared with cases obturated >2 mm from
the apex
Instrumentation and obturation should not extend beyond
the AF
WHEN TO OBTURATE
Asymptomatic tooth
Intact seal – apical seal
Dryable seal
Dryable canal
No sinus tract (if previously present)
No foul odor – taste or smell that the px can sense
Properly flared/shaped canal – spreader reach test
Negative culture result*
Necrotic pulp – After cleaning and shaping of the canal the
clinician obturate it and was able to see that the tooth has
lateral canal(circle)that he was unable to clean and shape;
resulting to continuous of symptoms.
where after treatment it subsided but
it will not resolve totally since clincian
failed to clean and shape lateral canal.
>> this case was retreated and the
sealer extruded (square)
Short obturation from the apex- 4mm;
Gray areas indicate short filling.
Inadequate shaping of the canal
need to retreat
IDEAL ROOT CANAL FILLING
*RC sealers are used in conjuction with a biologically
acceptable semi-solid or solid obturating material to
establish an adequate RCS seal
Vary in radiopacity – silver particles, barium sulfate -
materials nga gapadugang radiopacity
REQUIREMENTS
 Be easily introduced into the canal
 Seal the canal laterally and apically
 Not shrink after being inserted
 Be impervious to moisture
 Be bactericidal or at least discourage bacterial growth >> Extrude filling material(circle red)
 Be radiopaque >>Lentulo spiral breakage (square red)- it can serve as part of
 Not stain the tooth structure the obturation ( it is left in the canal) but it eoulf depend where
 Not irritate periapical tissues or affect tooth structure canal it breaks.
 Sterile or easily sterilized >>Sealer extend to the maxillary sinus
 Be easily removed from the root canal (circle violet)- after they remove the occlusal film; this cannot be
TYPES OF SEALERS corrected by non surgical techniques, you’ll have to open the
Necessary to seal the space between the dentinal wall and tooth and remove it from the coronal(surgery) to cut off excess
obturating cone interface sealer
Also must fill voids and irregularities >>Sealer extend to apex(square violet)
Also serve as lubricants during obturation process Zinc Oxide Eugenol
Properties of an Ideal Sealer Will absorb f extruded into periradicular tissues
Exhibits tackiness when mixed to provide good adhesion Slow setting time
between it and the canal wall when set Shrinkage on setting
Establishes a hermetic seal Solubility
Radiopaque, so that it can be seen on a radiograph Can stain tooth structure
Very fine powder, so that it can mix easily with liquid Antimicrobial activity
No shrinkage on setting Calcium Hydroxide
No staining of tooth structure Sealapex (Sybron-Endo), Apexit (Ivoclar),
Bacteriostatic, or at least does not encourage bacterial solubility
growth Non-eugenol Sealers
Exhibits a slow set Nogenol (GC)
Insoluble in tissue fluids Glass Ionomer Sealers
Tissue tolerant; that is, nonirritating to periradicular tissue Dentin-bonding properties; ex. Ketoc-Endo (3M0
Soluble in a common solvent if it is necessary to remove the Must be removed if retreatment is required
root canal filling Minimal antimicrobial activity
>> each type of sealer would not satisfy all of the criteria that Resin
was listed. Provides adhesion, no eugenol; ex. AH-26, Epiphany
Tissue tolerance - should cause neither tissue destruction (Pentron)
nor cell death o Bond to the canal wall and to the core material =
No shrinkage with setting – should remain dimentionally “monoblock” concept (Epiphany)
stable or even expanding slightly on setting Silicone Sealers
Slow setting time – provide adequate working time and Ex. GuttaFow (Coltene)
manipulation of obturating material Fills canal irregularities and is biocompatible, but
Adhesiveness – tight bond between core and dentin inconsistent setting time
Radiopacity – readily visible on radiographs Resilon – core material
Absence of staining – should not stain dentin or enamel Bioceramic
Solubility in solvent Zirconium oxide, calcium silicates, calcium hydroxide, etc.
Insolubility to oral and tissue fluids o Does not shrink on setting, biocompatible, antimicrobial
Bacteriostatic properties properties
Ability to create a seal Medicated Sealers
Biocompatible Paraformaldehyde content (toxic)
Well-tolerated by periradicular tissues
Removable when exposed to tissue and tissue fluids
PLACE SEALERS USING: >>short obturation
Sealer placed using master cone, lentulo spirals, files and >>was replaced using vertical compaction
reamers, ultrasonics >> overtime it corrodes
Some studies showed that ultrasonics produced the best
sealer distribution when used circumferentially
Lateral compaction technique results in better distribution
in the mid-coronal areas (compared with warm vertical
compaction)
Paste placement using lentulo spiral drills
Paste is mixed and placed into the chamber, and the lentulo
drill is spun into the RCS
RCS is filled with paste and drill slowly withdrawal
The reverse spiral lentulo is what carries the paste into the
RCS Gutta Percha
*Before start filling of gutta percha, put sealers on canal Most popular core material
walls, rotate it counterclockwise sa sulod na Plasticity, ease manipulation, minimal toxicity, radiopacity,
ease of removal with heat or solvents
o Lack of adhesion to dentin, shrinkage on cooling (when
heated)
COMPONENTS:
o GP – 20%
o Zinc oxide – 65%
o Radiopacifiers – 10%
MIXING SEALER o Plasticizers – 5%
Drop test Standardized Taper = 0.02mm or 2% (no color coding)
o Tip sealer to the side, and good if not dropped not less and
than 15 seconds non-standardized (conventional) sizes = (color coded)
String out test Taper= 0.04-0.06mm
o Thick consistency, creamy and homogenous Sterilized by placing in 5.25% NaOCl for 1 minute
o Should string out around 1 inch from the slab Active GP (Brasseler)
o The thicker the mix, the better the properties of the Impregnated with GI on the external surface
sealer, and diminished toxicity o .04 and .06 Taper cones
CORE: Properties of an Ideal Obturation Material o Single cone technique
Easily manipulated and provides ample working time Resilon
Dimensionally stable with no shrinkage once inserted Nontoxic, nonmutagenic, biocompatible
Seals the canal laterally and apically, conforming to its Appears to be comparable to GP in ability to seal radicular
complex internal anatomy space
Nonirritating to the periapical tissues Less coronal leakage than GP (studies)
Impervious to moisture and nonporous Custom cones
Unaffected by tissue fluids – no corrosion or oxidization For irregular canals
Inhibits bacteria growth METHODS OF OBTURATION
Radiopaque and easily discernible on radiographs Lateral compaction (cold compaction/lateral condensation)
Does not discolor tooth structure Warm vertical compaction
Sterile Continuous wave compaction technique
Silver Cones Warm lateral compaction
Easy to place, permitted more predictable length control Thermoplastic injection techniques
Unable to fill irregularly shaped RCS = leakage Carrier-based gutta percha
Corrode when in contact with saliva or tissue fluid; cytotoxic Thermomechanical compaction
corrosive products Solvent techniques
Use currently is below standard of care
LATERAL COMPACTION o Approx. 1 mm below the orifice (posterior teeth) and
o Common method, can be used in most clinical situations CEJ (anterior teeth)
o Provides for length control during compaction (10) Cervical portion is vertically compacted using appropriate
o Any sealer can be used sized, pre-fitted plugger
o May not fill canal irregularities as well as warm vertical (11) Generally advisable to place a barrier over each orifice to a
compaction or thermoplastic techniques depth of at least 1 mm – help minimize leakage from
o Pair: GP and ZOE temporary restoration
o Master cone: main cone that you will
insert
o Accessory cone: misc. cones
o Master cone or bigger = MAF
o Stop na: if spreader hindi na kapanaog
beyond coronal 3rd
1. SPREADER OR PLUGGER SELECTION
Performed during cleaning and shaping of the canal
Finger spreaders/pluggers preferred over long-handled
spreaders – better tactile sensation, improved apical seal,
better instrument control, reduced dentin stress during
obturation
SS: more flexible, can be inserted deeper
NiTi: even more flexibility, less tendency to produce
FINISHING PROCEDURE
vertical root fracture
o Chamber is cleaned thoroughly with cotton pellets
2. MASTER CONE (MC) SELECTION
moistened in alcohol, followed by a dry cotton pellet
Same size as MAF or bigger
o Temporary or definitive restoration is placed
Fitting the MC
o Radiograph is taken with the restoration in place and the
o Slight resistance/”tug-back”
clamp removed to evaluate the quality of the completed
o 0.5-1.0 mm from the tip of the apex/at working length
obturation; perform occlusal check
Take a radiograph to verify the length
CORRECTING OBTURATION PROBLEMS
A MC that extends beyong the AF lack of apical stop
o Voids or length problems are seen radiographically and
“Tug-back” – resistance to displacement; definite stop
should be corrected immediately, before the sealer has set
when the cone fits into place
o Voids: remove GP with hot pluggers until spreader can be
Cone may be too small if there is buckling in the apical
reinserted just beyond the void of discrepancy
few mm
o Reapply sealer and perform lateral compaction
o Cut off 1 mm increments off the tip until there is a
o If excess GP has been seared off, ever extension can be
proper fit
corrected before sealer has set by removing all GP
Insert pre-fitted spreader to within 1-2 mm of the WL
WARM VERTICAL COMPACTION
MC is removed by grasping it at the RP
o Schilder introduced this method
Length of MC confirmed on a radiograph
o Variety of pluggers and a heat source
GP cone extending beyond AF - lack of satisfactory apical
(1) Fit master cone short of WL (0.5-2.0 mm) with resistance to
stop, poorly fitted MC
displacement
STEPS IN OBTURATION
(2) Remove cone and apply sealer
(1) Sealer is mixed and applied to canal walls
(3) Place cone in the canal and remove coronal portion with
(2) MC is inserted slowly to allow air and excess cement to
heat
escape
(4) Heated spreader or plugger used to remove portions of the
(3) Before the spreader is inserted and removed, an accessory
coronal GP and soften remaining material in the canal
cone is picked up with locking cotton pliers at the
(5) Alternatives: Touch ‘n Heat (SybronEndo), System B
measured length, ready to be inserted
(SybronEndo) = permit temperature control
(4) Measured spreader is inserted between the MC and the
o A: Filling of canal irregularities and accessory canals
walls to within 1-2 mm of the WL
o D: potential for vertical root fracture because of compaction
(5) Spreader is freed for removal by back-and-fourth rotation
forces
around its axis: spreader is removed, and measured fine
o Less length control than with lateral compaction
accessory GP is immediately inserted into the space
o Potential for extrusion of material into the periradicular
created
tissues
(6) Take radiograph after 1-2 cones have been placed
CONTINUOUS WAVE COMPACTION TECHNIQUE
(optional)
o Variation of warm vertical compaction
(7) Procedure is repeated until the spreader can no longer be
o Employs an electric heat carrier (system B unit) SS pluggers
inserted beyond the coronal 1/3 of the canal (Cohen)
(1) MC selection, then plugger is prefitted to fit within 5-7 mm
(8) Evaluate obturation with a radiograph
of canal length
(9) Excess GP is sealed off with a hot instrument at the orifice
 (2) System B unit set to 200 C, plugger is then inserted into the
canal orifice and activated
(3) Compaction is initiated by placing the cold plugger against
the GP
(4) Firm pressure is applied and heat is activated with the
device
(5) Plugger is moved rapidly (1-2 sec) to within 3 mm of the
binding point
(6) Heat is inactivated while firm pressure is maintained on the
plugger for 5-10 seconds
(7) After GP mass has cooled, 1-second application of the heat
separates plugger from GP and then removed
THERMOPLASTIC INJECTION TECHNIQUES
o Heating GP outside the tooth and injecting the material into
the canal
o Ex. Obtura III (Obtura Spartan), Calamus, Elements, HotShot
(Discus Dental), Ultrafil 3D (Coltene/Whaledent), GuttaFlow
(Coltene/Whaledent)
CARRIER-BASED GUTTA PERCHA
o Ex. Thermafil, Profile GT Obturators, ProTaper Universal
Obturators
o Thermafil (DENTSPLY)
o Plastic core with a phase PG
o Heating device that controls the temperature
(1) Sealer: Grossman formulation sealers and resin sealers
(2) Removal of smear layer enhances seal
(3) After drying the canal, a light coat of sealer is applied and a
carrier is marked to predetermined length
(4) Carrier is then placed in the heated device, and clinician
has approx. 10 seconds to retrieve it and insert it into the
canal
SOLVENT-SOFTENED CUSTOM CONES
o INDICATIONS:
o Apical stop is not present
o Stop is present, but the apical portion of the canal is very
large or irregular
o Apical 3-4 mm sa GP is dipped in chloroform for 1-2
seconds
POTENTIAL CAUSES OF FAILURE
o Apical seal – leaving debris in the RCS
o Coronal seal - irritants from the oral cavity (MOs, food,
Chemicals, etc.), restoration
o Lateral seal
o Length of obturation
 Overextension (overfill: increased inflammation and
delayed healing, postobturation discomfort)
 Short of the AC (underfill): subsequent PA inflammation
may develop, less of a problem than over fill
o Lateral Canals
o Vertical Root Fractures
EVALUATION
o Density – uniform density from the coronal portion to the
apex
o Margins should be sharp and distinct, with fuzziness
o Length – should end at the apical terminus and must be cut
below the orifices
o Flare – should reflect canal shape
RESTORATION OF ENDODONTICALLY TREATED TEETH
Structurally different than vital teeth: altered physical
characteristics, loss of tooth support, physical characteristics,
loss of tooth structure, possibly also discoloration
Loss of moisture (9%) attributed to a change in free water
Chemical used for canal irrigations and disinfection with
mineral organic contents = reduce dentin elasticity and
flexural strength and microhardness
On the other hand, disinfectants like eugenol and
formocresol, increase dentin strength
Decrease in tooth strength can be attributed to dentin aging
and to a smaller extent to dentin alteration by endodontic
irrigants
Largest reduction in tooth stiffness results from additional
prep, especially the loss of marginal ridges
Presence of residual tissue in cervical area (ferrule) and larger
amount of residual tissue increase tooth resistance to fracture
Allows axial walls of crown to encircle the tooth = restoration
retention and stabilization
Minimum of 1 mm ferrule considered necessary to stabilize
the restoration
Endodontically treated teeth with a circumferential ferrule of
2 mm height and restored without a post may survive fatigue
loading as well as teeth restored with a fiber post. However, in
teeth where a ferrule is not preserved, a post may eventually
improve retention of the restoration.
Inserting a fiber post seems not to be necessary to improve
the fracture resistance of endodontically treated teeth in
which a ferrule is preserved, whereas is effective in teeth
without any ferrule.
Avoiding extra-removal of sound tooth structure rather than
using a fiber post does protect endodontically treated teeth
against catastrophic failures, since only endodontically treated
teeth with a 2 mm ferrule and restored without fiber post did
not show not repairable root fractures
ESTHETIC CHANGES
o Color change, darkening of nonvital teeth
o Inadequate cleaning and shaping can leave necrotic tissue in
coronal pulp horns
o RC filling materials (GP cements) retained in coronal aspect
of anterior tooth
o Opaque substances, biochemically altered dentin, organic
substances in dentin
STUDY: (Ahmed and Abbott 2012)
Combined irrigants together to see discoloration effect on
tooth
o Thin gingival tissue (thin biotin) considered negative
factor esthetic outcome
o Avoid use of potentially staining cements
o Clean all materials residues in pulp chamber and access
cavity = ALCOHOL
o NaOCl + EDTA = good combination
LUTING CEMENTS
TRADITIONAL CEMENT
Zinc phosphate or polycarboxylate cements
Physical properties highly influenced by mixing ratio of
components
Compressive strength: 100 MPa; elastic moduli lower than
dentin (5-12 GPa)
Zinc phosphate: mostly used for cementing metal
restorations
Provide retention through mechanical means and have no
chemicals bond to post or dentin
Provide clinically sufficient retention for posts in teeth with
adequate tooth structure
GLASS IONOMER LUTING CEMENTS
Always number 1
Conventional or resin-modified
Compressive strength: 100-200 MPa: Young modulus –
about 5 GPa
Mechanically more resistant than zinc phosphate
Advantages: ease of manipulation, chemical setting, ability
to bond to both tooth and post
RMGICs not indicated for post cementation
o Hygroscopic expansion which can promote root fracture -
get moisture from the air
RESIN BASED LUTING CEMENTS
Polymerized through a chemical reaction,
photopolymerization, or a combination of both
Compressive strength around 200 MPa and elastic moduli
between 4-10 Gpa
Both self and light curing cements can be used for
cementation of prefabricated endodontic posts
Most cements require pretreatment with etch-and-rinse or
self-etching adhesives
Self-etching adhesives proposed as alternative for
cementation
Dual curing cements are preferred
Bonding to dentin of the pulp chamber is more reliable than
to RC dentin
Thickness of cement layer may also influence performance or
resin-based cements
o Thicker layers may be needed when the fiber post does
not fit perfectly inside the canal, but a thicker layer may
be detrimental to bond quality
Dentin conditioning procedures may improve resistance of
resin dentin bond to chemical degradation: also act as
antibacterial agent
 Alternative to conventional resin based luting cements
Have multifunctional phosphoric acid methacrylates that
react with HA; simultaneously demineralize and infiltrate
dental hard tissues
Do not require any pretreatment of tooth substrates, clinical
application accomplished in a single step
Reduces the risk for complete impregnation of the tissue by
resin and reduces technique sensitivity
Long term clinical performance still have to be assessed
PRE-TREATMENT EVALUATION
ENDODONTIC EVALUATION
Check quality of existing RCT
o New restoration should not be placed on abutment teeth
with a questionable endodontic prognosis
Retreatment indicated for teeth showing radiographic signs
of apical periodontitis or clinical symptoms of inflammation
PERIODONTAL EVALUATION
Healthy gingival tissue
Normal bone architecture and attachment levels to favor
periodontal health
Maintenance of biologic width and ferrule effect before and
after endodontic and restorative phases
BIOMECHANICAL EVALUATION
Amount and quality of remaining tooth structure
Anatomic position of the tooth
The occlusal forces on the tooth
The restorative requirements of the tooth
CLINICAL COMPLICATIONS
- Root fracture
- Coronal apical leakage
- Recurrent caries
- Dislodgement or loss of the core prosthesis
- Periodontal injury from biologic width invasion
TOOTH POSITION, OCCLUSAL FORCES, AND PARAFUNCTIONS
Restorations of damage anterior teeth with heavy function
should be designed to resist flexion
Restorative components should be stronger than would be
required for teeth with an edge-to-edge relationship
Restorations must be planned to protect posterior teeth
since they normally carry more vertical forces and sustain
greater occlusal loads than anterior teeth
Teeth that show extensive wear or sequelae from
parafunctions, especially heavy lateral function, require
components with highest physical properties to protect
restored teeth against fracture.
ESTHETIC EVALUATION AND REQUIREMENTS
Esthetic zone: anterior teeth, premolars, and often the
maxillary first molar, along with the surrounding gingiva
Require critical control of endodontic filling materials in the
coronal third of the canal and the pulp chamber
Careful selection of restorative materials, careful handling
tissues, timely endodontic intervention
MATERIALS AND OPTIONS
Protect remaining tooth from fracture
Prevent reinfection of the RCs
Replace the missing tooth Structure
Selection of appropriate restorative materials and
techniques is dictated by amount of remaining tooth
structure
DIRECT RESTORATION:
COMPOSITE RESTORATION
Minimal amount of tooth structure lost
Highly esthetic, exhibit high mechanical properties, reinforce
the tooth structure through bonding mechanisms
500-800 mw/cm2 of blue light for 30-40 seconds to
polymerize composite 1-3 mm thick
Problem is shrinkage = incremental filling
o Amount of shrinkage depends on shape of cavity prep
and ratio of bonded: unbonded surfaces (c factor)
o Restorations with high C factors (>3.0) at greatest risk for
debonding
Indicated when only one proximal surface of the tooth has
been lost
Anterior teeth that have not lost tooth structure beyond the
access prep
May also be used for small restorations in posterior teeth
Contraindicated when more than a third of coronal tissue
has been lost
Fiber-reinforced composite
Insertion of a fiber post before bonding a direct MOD
restoration
INDIRECT RESTORATIONS:
COMPOSITE OR CERAMIC ONLAYS AND OVERLAYS
Overlay: incorporate a cusp or cusps
Endocrowns: combine post, core, and crown in one
component (3in1 kape)
Both allow for conservation of remaining tooth structure: full
crown eliminates cusp and perimeter walls
Ceramics: material of choice for long term esthetic indirect
restorations = translucency, light transmission mimic enamel
In-Ceram, Cerec, IPS Empress: variations of feldspathic
porcelain
Lithium disilicate (Ex.Emax): newer composition: high
strength, high fracture toughness, high degree of
translucency
 Walls of tooth = 1.5 2 mm thickness
FULL CROWNS
When significant amount of coronal tooth structure has been
lost due to caries, restorative procedures, and endodontics
Cementation of a post in necessary to provide retention for
the core material and crown
o Post and core also protect the crown margins from
deformation under function, and prevent coronal
leakage
Foundation restoration: post, core, luting/bonding agents
Ferrule: formed by walls and margins of the crown, encases
at least 2-3 mm sound tooth structure
o Reduces incidence of fracture by reinforcing tooth as its
external surface and dissipating forces
 o Longer ferrule: significantly increases fracture Alteration of internal canal morphology may also contribute
resistance to loss of rigidity
o Resists lateral forces from posts and leverage from the Cusps become progressively weaker with repetitive flexing
o Restorations must be designed to minimize cuspal flexure
crown in function: increases resistance and retention of
restoration to protects against fracture and marginal leakage
Ferrule (dentin axial wall height) must be at least 2-3 mm
ESTHETIC FACTORS
Axial walls must be parallel Esthetic appearance: metal ceramic or all ceramic crowns
Restorations must completely encircle the tooth There must be an adequate thickness of the ceramic to
Margins must be on solid tooth structure provide a more natural appearance
Crown and crown prep must not invade the attachment More removal of tooth structure for metal-ceramic/all
apparatus ceramic crowns than in an overlay cast restoration or all
POST ceramic crown
Maximal protection of root from fracture DEFINITIVE RESTORATION SHOULD …
Maximal retention within the root and retrievability o Preserve remaining tooth structure
Maximal retention of the core and crowns o Protect remaining tooth structure, and minimize cuspal
Maximal protection of the crown margin seal from coronal flexure
leakage o Provide a coronal seal
Pleasing esthetics (when indicated) o Satisfy function and esthetics
High radiographic visibility CORONAL SEAL
Biocompatibility Major cause of endodontic failure
Prompt restoration is required - minimize risk of tooth Separate step (ex. Placing a barrier over canal orifices) or as
fracture and coronal leakage an integral part of the restoration
Confirm restorability prior to treatment If leakage occurs, guideline is that root filling should be
Remove all caries and any existing restorations replaced if it has been exposed to oral fluids for more than
o Reduce risk of leakage during treatment 2-3 months
o Reveal extent of residual tooth structure o But if there’s no periapical pathology and root filling has
Options are based on amount of remaining tooth structure been done to a high technical standard, replace only the
and functional demands lost or leaking restoration
MAJOR RISK TO RC TREATED TOOTH RESTORATION TIMING
Caries and periodontal disease Definitive restoration should be completed as soon as
Lack of definitive restoration practical
Inadequate restoration o Provisional restoration does not provide complete
o Direct restoration does not provide adequate protection protection against occlusal force
unless access prep is confined to occlusal surface only Orthodontic band can be used as form of protection
Occlusal stresses For most teeth, it’s unnecessary to wait for radiographic
o Teeth serving as abutment for FPD/RPD healing before final restoration is placed
o Teeth lacking mesial and distal proximal support from Prompt restoration may improve prognosis, as it provides
adjacent teeth better protection against fracture and loss of coronal seal
Endodontic factors: development or persistence of a Provisional restoration must be durable, must protect and
periapical lesions or procedural errors seal, and meet functional and esthetics demands
LOSS OF TOOTH STRUCTURE Good long-term posterior provisional restoration: amalgam
Greater loss of tooth structure further comprises strength core
Loss of one or more both marginal ridges is major RESTORATION DESIGN
contributor to reduced cuspal stiffness (strength) Conservation of tooth structure
Excess coronal flaring also results in greater susceptibility to
Retention
cusp fractures o From remaining dentin and restorative material core (if
Alteration of internal canal morphology may also contribute tooth is structurally compromised)
to loss of rigidity o Posts should be used only when the core cannot be
Cusp become progressively weaker with repetitive flexing retained, since they weaken teeth and may produce root
Restoration must be designed to minimize cuspal flexure to fracture perforation
protect against fracture and marginal leakage Protection of remaining tooth structure
All ceramic or metal ceramic crowns: function well, but have
less favorable physical properties than all metal restorations
All metal: more favored in patients exhibiting heavy occlusal
forces (bruxism, wear facets)
BIOMECHANICAL FACTORS ANTERIOR TEETH
Cuspal flexure (movement underloading) weakens premolars Composite resin/direct restoration when teeth are relatively
and molars over time intact
Larger and deeper preps lead to weaker unsupported cusp
 Metal ceramic or all ceramic crowns supported by a post and
core for more extensive damaged teeth (large proximal
restorations, trauma)
POSTERIOR TEETH – DIRECT RESTORATIONS
Amalgam or composite resin
Indications for restoration of the coronal access opening only
Minimal tooth structure is lost before and during RCT:
conservative access prep is present with intact marginal ridges:
tooth can be restored without further prep
Long term prognosis of the tooth is uncertain, but a durable
restoration is needed during the observation period
Amalgam in a posterior tooth with substantial loss of
structure, if esthetically acceptable and unsupported cusps are
adequately protected by amalgam
Cusps adjacent to a lost marginal ridge onlayed with sufficient
thickness of amalgam at least 2 mm
o Should extend into pulp chamber and canal orifices
o May also serves as a core for an indirect cast restoration
POSTERIOR TEETH – INDIRECT RESTORATIONS
All metal cast restorations, onlays ¾ and complete crown
Metal ceramic or all crowns: most frequent used material =
Reliable, strong, restorations that protects against root
fracture
PREPARATION FOR POST AND CORE CORONAL TOOTH
PREPARATION
o First step, prepare tooth for the type of crown to be used
o Remove and replace any thin, friable coronal tooth structure
that remains after tooth prep
POST SELECTION
Used to retain the core
Need for post dictated by amount of remaining coronal tooth
structure available
Disadvantage: further weaken the tooth by additional
removal of dentin
Only used when the core cannot be retained in the tooth by
other means
Post system and prep design should be selected as
appropriate to the tooth and its morphology
Custom cast P&C for roots with very tapered canals
Cast P&C: Md incisors, Mx 1st premolars and Md molars
Pre-fabricate round posts: teeth that have somewhat
rounded roots and canals
Tooth colored P&C materials for all ceramic crowns: ex. Fiber
posts
o Use cautiously when post length is sub-optimal), when
peripheral walls are missing, heavy occlusal forces or
parafunctional; habits are present
POST SPACE PREPARATION
Consist of removing GP to the required length, followed by
the least amount of enlargement, and shaping needed to
receive the post
For all teeth but molars: 5 mm of apical GP be retained, and
the post extended to that level
Molars: length determined by potential for root thinning
perforation
o Posts extended only 5 mm into the RC and only in
primary molar roots (D root of Md molars and Palatal
root of Mx molars)
General rule: post diameter should be minimal (especially
Tapered post preps minimize amount of tooth structure
removed apically
GP removed immediately after obturation
Depending on obturation technique, canal may be filled to
the desired length, or GP removed to desired length using a
hot instrument
Remaining GP then vertically condensed in the apical canal
before the sealer has set
Confirm with a radiograph
Solvents and mechanical techniques may also be used
o Solvents: messy and have an unpredictable depth of
penetration
o Peeso reamers, GG drills: required caution due to quick
removal of dentin: also, may create channels that thin or
perforate the root: may “grab” and displace apical GP
Ni-Ti rotary instruments specially designed for post space
preps = noncutting tip and lateral surface
FINISHING THE POST SPACE
Rotary instrument for final canal shaping, or hand
manipulation of rotary instruments
Use of cervical ferrule: key method preventing tooth
fracture
Crown ferrules that encompass >1mm of tooth fracture:
most effective in helping teeth resist fracture
Encompass 2mm around entire circumference of tooth
produce greater fracture resistance
POST TYPE, RETENTION, AND CORE SYSTEMS:
ANTERIOR TEETH
o Prefabricated post with direct core buildup or a cast P&C
o Prefab posts should passively fit the root prior to
cementation
o Cast metal P&C fabricated as a single unit
 Core shape should conform to remaining coronal tooth
structure
POSTERIOR TEETH
o Cast P&C: premolars with substantial loss of coronal
structure, particularly Mx premolars
o Palatal canal should be used for the post
o Direct core options for molars
o Most can be restored with a direct core only, no post
o Post with minimal remaining coronal structure and small
pulp chamber
o Longest and straightest canal is preferred for the post
(primary roots)
o Additional core retention supplemented by extending core
material 1-2mm into remaining canal orifices
o Parallel-sided posts provide greater retention than tapered
posts, but require more post space prep
o Post should have close approximation to RC walls without
binding
o Tooth prep for a molar core requires little removal of tooth
structure
o Core retained by pulp chamber morphology and natural
undercuts in the chamber
o Coronoradicular amalgam core (Amalcore) is condensed into
the chamber and slightly into canal orifices provides a
passive, strong core
o Alternative composite resin allows advantage of allowing
immediate crown prep
Pulps at times undergo IP or necrosis after crown placement,
requiring RCT
3 conditions:
o Interface between the restoration and the repair material
must provide a good coronal seal
o Retention of the crown must not be compromised
o Final core structure must support the restoration against
functional or minor traumatic stresses
Repair materials should have high compressive and shear
strength
o Amalgam: maintains and improves seal with time, easily
condensed into the chamber and access opening as a
single unit
o Composite resins into tooth colored crowns
BLEACHING OF DISCOLORED TEETH (Finals) Systemic Drugs
More conservative than restorative methods Most common is after tetracycline ingestion, in children
Relatively simple to perform o Both arches affected
Less expensive o Yellow/brownish/dark grey – depends on amount,
Internal (within pulp chamber) or external (on enamel frequency and type of tetracycline, as well as patient’s
surface) age during administration
Objectives
Reduce/eliminate discoloration
Improve degree of coronal translucency
Alleviate present and prevent future clinical signs and
symptoms
IMPORTANT! 3 Degrees:
Identify causes of discoloration, location of discoloring agent, o Light yellow/light brown/light gray with no banding (1st
treatment modalities; also, the ability to predict treatment degree)
outcome o More intense discoloration and no banding (2nd degree)
Tell px that this is unpredictable; sometimes improvement is o Very intense discoloration; crown has horizontal banding
slow (3rd degree)
Causes of Discoloration Chronic sun exposure of these teeth may cause formation of
Many occur during or after enamel and dentin formation, a reddish purple oxidation byproduct
sometimes even after tooth eruption Also reported in adults that have been receiving long-term
May also result from dental procedures = inflicted minocycline therapy
(iatrogenic); preventable o Gradual discoloration, generally not severe
Acquired/natural discolorations: on the surface or 2 Approaches:
incorporated into tooth structure o Internal bleaching – limited to lighter, yellowish
Also due to enamel flaws or a traumatic injury discoloration; requires multiple appointments
Acquired (Natural) Discolorations – Pulp Necrosis o RCT, followed by internal bleaching – useful for all
Bacterial, mechanical or chemical irritation = tissue degrees of discoloration, successful in the short and long
disintegration byproducts released  permeate tubule to term
stain surrounding dentin Defects in Tooth Formation
Degree of discoloration related to duration of pulp necrosis Enamel hypocalcification: brownish/whitish area on facial
Internal bleaching aspect of crown
Intrapulpal Hemorrhage Enamel is well formed and intact; feels hard to the explorer
Usually associated with an impact injury, may be reversible Pumice acid technique
If pulp, survives, discoloration may resolve and tooth regains Enamel hypoplasia: enamel is defective and porous
its original shade Hereditary (amelogenesis imperfecta; deciduous and
Internal bleaching permanent dentitions involved) or from environmental
Calcific Metamorphosis factors (involves one or several teeth)
Extensive formation of tertiary (irregular Bleaching, pumice and acid technique
secondary) dentin in the pulp chamber or on
canal walls
Follows impact injury that did not result in
pulp necrosis
Crowns have a “flat” appearance as the
gradually decrease in translucency
Yellowish/yellow-brown discoloration
Pulp usually remains vital, does not need RCT
External bleaching should be done first
If EB is not successful, RCT and internal bleaching is done
Prognosis is fair (unpredictable)
Age
Physical color change = extensive dentin apposition and
thinning of and optical changes in the enamel
Food and beverages, previously applied restorations that
degrade over time
Usually external bleaching
Developmental Defects
Endemic Fluorosis
Ingestion of excessive amounts of fluoride during tooth
formation = hypoplasia
Severity and degree of staining depends on degree of
hypoplasia (dependent on patient’s age and amount of
fluoride ingested during odontogenesis)
Has 3 degrees
External bleaching Blood Dyscrasias and Other Factors
Eryhtroblastosis fetalis: disease in fetus or newborn; massive
lysis of erythrocytes = large amounts of hemosiderin pigment
staining forming on dentin of primary teeth
Not corrected by bleaching
Now uncommon
Chronic hypoplasia: temporary disruption in enamel formation
resulting in a banding type of surface defect
Porphyria: metabolic disease, affects
both deciduous and permanent teeth
Red or brownish discoloration
NOT FOR BLEACHING, FOR
MINIMALLY INVASIVE
RESTORATIONS
Hyperbilirubinemia, Thalassemia,
Sickle Cell Anemia: intrinsic bluish,
brown, green discolorations
NOT FOR BLEACHING, FOR
MINIMALLY INVASIVE RESTORATIONS
Dentinogenesis Imperfecta: brownish violet, yellowish, gray
discoloration
Type 2 dentinogenesis imperfecta of one or the same family
Range of discolorations in every patient
Inflicted (iatrogenic) Discolorations
Caused by chemicals and materials used in the profession
Usually avoidable
Many respond well to bleaching
Endodontically Related Discolorations
Obturating materials: most common severe cause of single
tooth discoloration
o Incomplete removal of materials from the pulp chamber
upon completion of treatment
o Clean chamber using alcohol or any solvent to remove
remnants of the material
o Remove all obturating materials to a level cervical to the
gingival margin
o Sealers with metallic components often do not bleach
well; bleaching effect may regress with time
Remnants of pulpal tissue: usually pulp horns
o Internal bleaching
Intracanal medicaments: phenolic or iodoform-based
o are indirect contact with dentin, at times for long periods,
which allows dentin tubules penetration and oxidization
o Iodoform-based discolorations more severe
o Corrected by bleaching
Coronal restorations: metallic or composite
o Amalgam can turn dentin dark gray; can also discolour
crown
o Difficult to bleach, tend to recur; but bleaching can be
attempted
o Inappropriately placed metal pins and prefab posts in
anterior teeth
Microleakage of composites
o Discoloration of the composite restoration itself and thud
alters the shade of the crown
o Replace old composite or do internal bleaching first
Bleaching Materials
Act as oxidizing or reducing agents
Most bleaching agents are oxidizers
Hydrogen peroxide, sodium perborate, carbamide peroxide
External bleaching: Hydrogen peroxide, carbamide peroxide
Internal bleaching: sodium perborate (pwede man mahaluan
sang hydrogen peroxide)
External bleaching video: see shades, vitamin E sa lips,
retractor, cotton rolls, gauze to dry and protect other parts
with liquid dam for gums, apply bleaching material then
whitening machine for 15 mins (repeat 3x), remove and
rinse, do not eat staining food for 24 hrs
Hydrogen Peroxide
Available in various strengths, but 30-35% stabilized
solutions are the most common (Superoxyl, Perhydrol)
Handle the high-concentration solutions with care =
unstable, lose oxygen quickly, may explode unless
refrigerated and stored in a dark container
Caustic, will burn tissue on contact
Carbamide Peroxide
Urea hydrogen peroxide
3-15% concentrations
Commercial preparations have about 10% and have pH of 5-
6.5
Have been associated with varying degrees (usually slight) of
damage to teeth and surrounding mucosa
May adversely effect the bond strength of composite resins
and their marginal seal
Sodium Perborate
Powder form or other combinations
Stable when dry, but decomposes to form sodium
metaborate, hydrogen peroxide and nascent oxygen
Types differ in oxygen content, which determines their
bleaching efficacy
Alkaline
More easily controlled and safer than concentrated
hydrogen peroxide solutions
Internal (Nonvital) Bleaching Techniques
Thermocatalytic and walking bleach techniques
o Latter is preferred since it requires the least chair time,
and is more comfortable and safer for the patient
 Active ingredient is the oxidizer; least potent for is preferred
Indications
o Discolorations of pulp chamber origin
o Dentin discolorations
o Discolorations that are not amendable to external
bleaching
Contraindications
o Superficial enamel discolorations
o Defective enamel formation
o Severe dentin loss
o Presence of caries
o Discolored proximal composites
Thermocatalytic technique
Involves placing the oxidizing agent in the pulp chamber and
then applying heat
o From heat lamps, flamed instruments, electrical heating
devices
Possibility of external cervical root resorption – irritation to
cementum and PDL
Has not proved more effective long term
Not recommended for routine internal bleaching
UV phto-oxidation: 30-35% HP solution is placed in pulp
chamber on a cotton pellet, followed by a 2-minute exposure
to UV light applied to coronal labial surface of tooth
Probably no more effective than walking bleach technique,
but requires more chair time
Not recommended due to toxicity considerations with
concentrated hydrogen peroxide
Walking Bleach technique
As effective as other methods
Safest technique
Has the shortest chair time requirement
Technique: are the following steps
Familiarize patient with probable cause of discoloration,
procedure to be followed, expected outcome, and possibility
of future recurrence of discoloration (regression)
Take radiographs to assess status of PA tissues and quality of
RCT; treatment failure or questionable obturation requires
retreatment prior to bleaching
Assess quality and shade of any restoration present
Inform patient that the procedure may
temporarily/permanently affect seal and color match of the
restoration
Evaluate tooth color with a shade guide; take clinical photos
at the beginning of and throughout procedure
Isolate tooth with a Rubber Dam; interproximal wedges may
also be used for better isolation
o Superoxol: apply protective cream to the gingival tissues
before dam placement
Remove restorative material from the access cavity
o Refine access and remove all old obturating materials
from the pulp chamber
(Optional) Carefully remove a thin layer of stained dentin
toward the facial aspect of the chamber with a round bur in
a slow-speed handpiece
Remove all materials to a level just apical to the gingival
margin
o Use appropriate solvent to dissolve sealer remnants
Place a sufficient layer of protective cement barrier on the
obturating material if 30-35% hydrogen peroxide is used
o At least 2 mm thick; sinc phosphate, polycarboxylate, GI,
IRM, Cavit ( to avoid leakage)
Paste: sodium perborate + water/saline/anesthetic solution
o Consistency of wet sand
o No need for protective cement barrier if sodium
perborate-water mixture
Pack pulp chamber with paste using a plastic instrument
o Remove excess liquid with a cotton pellet – also
compresses and pushes paste into recesses
Remove excess paste from undercuts in the pulp horns and
gingival area with an explorer
Pack IRM or Cavit to a thickness of least 3 mm to ensure a
good seal
Schedule patient to return approximately 2-6 weeks later,
and repeat procedure (or pwede every week)
Additional procedures if results are not met in the previous
appointments:
o Thin layer of stained facial dentin is removed with small
round bur
o Paste is strengthened by mixing sodium perborate with
increasing concentrations of hydrogen peroxide (3-30%)
instead of water
Final Restoration
Fill chamber with a light-colored GP temporary stopping, GI,
or light shade of zinc phosphate cement
Then restore with composite
Curing from the labial is recommended because this results
in shrinkage of composite toward the axial walls, reducing
the rate of microleakage
Do not restore immediately after bleaching but after interval
of a few days
When to Bleach
May be performed at various intervals after RCT
Walking bleach technique may be done at the same
appointment as obturation
May also be attempted many years after discoloration, even
with porcelain veneer restorations
Shorter discoloration period tends to improve the chances
for successful bleaching, and reduce likelihood of recurrence
of discoloration
Complications
External Root Resorption
Irritating chemical diffuses through the dentinal tubules and
reaches the periodontium through defects in the CEJ
Necrosis of cementum, inflammation of the PDL, and
subsequent root resorption
Enhance in the presence of bacteria
Predisposing factors may be previous traumatic injury and
young age
Injurious chemicals and procedures should be avoided if not
essential for bleaching
Oxidizing agents should not be exposed to more the pulp
space and dentin apical to the cervical margin
Crown Fracture
Slightly increased brittleness of coronal tooth structure,
particularly when heat is applied
 Result of either desiccation or alterations to the
physicochemical characteristics of enamel and dentin
Chemical Burns
30% hydrogen peroxide is caustic and can cause chemical
burns and sloughing of the gingiva
Coat soft tissue with petroleum jelly or cocoa butter
Intrinsic Discolorations
Tetracycline - internal bleaching is more effective, but best
resolution is prevention
Drugs or ingested chemicals
Extrinsic Discoloration
Most effective is microabrasion “controlled hydrochloric
acid-pumice abrasion” technique
o Not true bleaching (oxidizing) technique
o Decalcification and removal of a thin layer of stained
enamel
o Used mainly for fluorosis and other extrinsic
discolorations
Microabrasion Technique
1. Photograph teeth to be treated; serves as a permanent
record and basis for future comparison
2. Isolate teeth with an inverted rubber dam and ligatures;
extend RD over the patient’s nostrils
3. Cover exposed areas of patient’s face and eyes with a
drape/towel to protect from acid spatter
4. Mix 36% HCl solution with equal volum of distilled water
(18% HCl solution)
(1) add pumice to form a thick paste
(2) Mix sodium bicarbonate and water in another
dappen dish to a thick paste
5. Apply HCl and pumice paste to enamel surface with a
piece of wooden tongue blade or crushed orangewood
stick
- Apply with firm pressure onto enamel surface, using a
scrubbing motion for 5 seconds
- Rinse enamel surface with water for 10 seconds
6. Reapply paste until desired color is achieved
7. Neutralize surface with bicarbonate mixture. Remove the
RD, and pumice the teeth with prophypaste to smoothen
the abraded surface
Relatively permanent if initial lightening is achieved
Concern is on the effects on enamel (excessive
decalcification) and chemical burns of soft tissue
Minimal to no pulpal effects
When and What to Refer
Most bleaching procedures can be done by the general
dentist, if the cause of discoloration is diagnosed
Practitioner may refer patients if the discoloration does not
respond to conventional methods of bleaching
PROGNOSIS
Expectation of the tooth’s outcome
Success
Vital pulp, no pre-existing apical lesion: tooth remains
asymptomatic and an apical lesion does not form
Previously necrotic pulp: tooth remains asymptomatic, pre-
existing apical lesion heals, no new lesions forms
Terms
Healed – functional, asymptomatic teeth with no or
minimal radiographic periradicular pathosis
Nonhealed – non-functional symptomatic teeth with or
without radiographic periradicular pathosis
Healing – teeth with periradicular pathosis that are
asymptomatic and functional, or teeth with or without
radiographic periradicular pathosis that are symptomatic
but for which the intended function is not altered
Functional – a treated tooth or root that is serving its
intended purpose in the dentition
When to Evaluate
Recommended follow-up: 6 months to 5 years, but 6 month
is a widely accepted and reasonable interval for most
patients
Endodontic evaluation, patient history, clinical findings,
radiographic exams: common measures of RCT outcomes
Radiographic lesion is unchanged or has increased in size
after year – unlikely to ever resolve, treatment considered
unsuccessful
Lesion is still present but smaller after 6 months –
progressing to healing, additional recall is needed
Methods for Evaluation of Endodontic Outcomes
Patient History
Complaint of persistent or worsening symptoms months or
years after completion of treatment
Symptoms related to discomfort or pain on chewing, aching,
etc. – indication of periradicular inflammation or infection
Pain on release from biting – may be cracked tooth
Bad taste – may be draining abscess
Clinical Exam
Absence of swelling and other signs of infection and
inflammation
Disappearance of sinus tract or narrow, isolated probing
defect
No evidence of soft tissue destruction, including probing
defects
Tooth has been restored and is in function
Radiographic Findings
Success: absence of an apical radiolucent lesion; evident by
the elimination or lack of development of an area of
radiolucency for a minimum of 1 year after treatment
Failure: continued persistence or development of
radiolucency
Success – reduced pathosis
Failure – appearance of radiolucency;
may leaky margin
Under observation – 1 year palang
Unknown status: includes teeth with
radiolucency that are asymptomatic and functional; pre-
existing radiolucent lesion has not yet decreased or become
larger in size
o Teeth with radiolucencies that were treated elsewhere
and for which there are no prior radiographs

Post-op Complications
Typical complications: symptoms, swelling, need for
retreatment
Recorded as failures
Prognostic Indicator
Predictors of success and failure
o Apical pathosis
o Bacterial status of the canal
o Extent and quality of the obturation
o Quality of the coronal restoration
Some factors resulting in a less favorable prognosis
o Presence of periradicular lesions and larger lesion size
o Presence of bacteria in the canal before obturation
o Obturation that are short, long, contain voids, lack
density
Diabetes Mellitus, hypertension, coronary artery disease are
associated with an increased risk of extraction after RCT
RCT may greatly benefit some patients by preventing the
need for high-risk extractions or surgical procedures
o Those with bleeding disorders, those who have
undergone head and neck irradiation, those treated with
high-dose bisphosphonates
Causes of Nonhealed, Failed RCT
Errors in the diagnosis and treatment planning
Lack of knowledge of pulp anatomy, resulting in missed
canals
Inadequate debridement and/or disinfection of the RCS,
resulting in persistent bacteria
Operative errors
Additional Factors for Failure
Obturation deficiencies
Absence of cuspal coverage in posterior teeth, allowing
vertical root fracture
Excessive removal of tooth structure, predisposing teeth to
the fracture
Coronal leakage through inadequate provisional or definitive
restorations
Preoperative Causes
Poor case selection
Treatment of a tooth with poor initial prognosis
Failure to use good radiographic projections
Prior root fracture
Operative Causes
Underextended access preparation
Overextended access cavities
Failure to maintain apical curvature
Separated instrument or broken endodontic file
Underinstrumentation short of the apical constriction
Overinstrumentation
Over- and underextended obturation
Postoperative Causes
Lack of a timely or durable coronal seal
Restorative errors
Outcomes of Treatments after Failure of Initial Nonsurgical
Endodontics
Nonsurgical retreatment
Endodontic surgery
Extraction and replacement using a single tooth implant
Extraction and replacement using a fixed dental prosthesis
Intentional replantation or autotransplantation
Extraction without replacement
Nonsurgical Retreatment
40-100% success rate
Offers more favorable long0term outcomes than endodontic
surgery
High success rate especially in teeth without periapical
lesions and when the cause of failure is identified and
corrected
Endodontic Surgery
Reserved for cases in which retreatment has failed to
produce healing or retreatment may be precluded for
technical reasons
Single Tooth Implant
Success and survival rates are now generally very high
Artificial alternative to the natural condition should only be
chosen when the alternative is superior or less costly than
maintaining the natural state
Fixed Dental Prosthesis
Prone to future disease (caries, pulpal and periodontal
problems), porcelain or root fracture
Intentional Replantation and Autotransplantation
Intentional replantation – reinsertion of a tooth into its
alveolus after tooth extraction to allow root-end surgery in
the hand while the tooth is out of the socket
o Indicated when there is no other alternative to maintain
a strategic tooth
o Often successful long-term, but require case selection
Autotransplantation – transfer of a tooth from one alveolar
socket tot another in the same patient
o Procedures: socket preparation, extraction,
transplantation, stabilization
Extraction of Endodontically Treated Teeth
Decay
Periodontal disease
Nonrestorability
Prosthodontic Failure
Fracture
Endodontic Emergencies
 • Immediate goal- eliminate the patient's primary cause of
distress (most often pain with or without swelling)
• Severe pain and swelling are hallmarks of an emergency
• Flare-up: severe pain and/or swelling after endodontic tx
requiring an unscheduled appointment and active tx
• Traumatic injuries may also be cause of an emergency visit
• Pretreatment emergency - patients have a history of long-
term, low-level discomfort which has suddenly escalated to
intolerable pain and swelling
- Accompanied by high level of anxiety
- May be associated with IP and/or symptomatic
periodontitis, or pulp necrosis with/without apical
pathosis and swelling
• Irreversible Pulpitis - pain may occur with or without
provocation and tends to increase in severity
- Infection is most often confined to the coronal site of the
pulp that is exposed to the oral cavity
- Pulpotomy - predictable approach at alleviating pain at
an emergency visit
Flare-up causes
• latrogenic mechanical irritation of the tissues beyond the
apical terminus
• Pushing of dentin chips and remnants of infected pulp tissue
into the periapical tissues
• Chemical factors (irrigants, intracanal dressings, sealers)
• Procedural errors increase risk of failure
• Number of treatment visits also examined as a factor in flare-
ups
• Interappointment flare-ups most often occur after
instrumentation of the canal system
• latrogenic errors frequently cause problems - ex. Leaving
pulp tissue in the canal system
Postobturation Emergencies
• Includes pain and diffuse swelling
- Tenderness to finger pressure or percussion, inability to
comfortably bite on the tooth-predictor of
postobturation pain
- Defer obturation until px is pain free and tooth can be
used in function
- Determine whether it is necessary to remove the root
canal filling
• Much depends of the status of the tooth before obturation,
also consider the nature of any swelling
• Tx for postobturation exacerbations: pharmacotherapeutics
(analgesics, antibiotics), retreatment with or without incision
for drainage
*we do not give antibiotics except if may infection.
Predisposing Factors
• Genetics - interleukin - 1 Beta
• Gender - women are at substantially greater risk for many
clinical pain conditions
• Anxiety
- The higher the anxiety score, the less likely it was that
pain would be eliminated during tx
Therapy
• Canal debridement and disinfection - use of disinfectants
and antibiotics
• Drainage
- From an abscess or through a sinus tract
- Surgical drainage may also be done: in-dwelling drain
Pharmacotherapy
Antibiotics
• Those that kill rapidly, by creating disruptions in the cell wall
or by direct attack on the bacterial DNA: penicillins,
cephalosporins, fluoroquinolones, metronidazole
• Those that kill more slowly by slowing bacterial protein
synthesis and their ribosomes: macrolides, tetracyclines,
chloramphenicol, clindamycin
*not enough to give antibiotics; need to eliminate cause
• 2 main indications: treat active infection, prevent infection
• Usually, oral antibiotics are prescribed for systemic infections
• Intracanal antibiotics are seeing a resurgence in tx of pulp
regeneration
• Prophylaxis indicated for several heart conditions and
prosthetic joints: high-dose, short-term, broad-spectrum
coverage
• IF the signs and symptoms indicate that infection is localized
and IF the px is immunocompetent, local debridement and
disinfection of the pulp space may be sufficient
• If the infection invades the tissues beyond the immediate
root end area, systemic drug therapy is indicated
Analgesics
• Opiods, acetaminophen - act primarily on the CNS
*Commonly use deri ang paracetamol; opiods wala padi
• Inflammation-suppressing drugs (corticosteroids), NSAIDs -
acts at the site of injury
Endodontic Surgery
Purpose
• Sealing of all portals of exit from the RCS and the isthmuses
• Eliminating bacteria and preventing their byproducts from
contaminating the periradicular tissues
• Providing an environment that allows for regeneration of
periradicular tissues
INCISION FOR DRAINAGE
• Objective: evacuate inflammatory exudates and purulence
from a soft tissue swelling
• Indications:
- Swelling originating from a symptomatic apical abscess of
pulpal origin
- Drainage may be performed through the soft tissue-
accomplished most effectively when swelling is fluctuant
• Relatively few contraindications
• Treat with caution: patients with prolonged bleeding or
clotting times, those who are on bisphosphonates (screening
is needed)
• Handle abscesses in or near an anatomic space very carefully
 Contraindications
• Anatomic factors
- Inaccessibility of surgical site due to tooth location, spaces,
unusual bony configuration, proximity of neurovascular
bundles
- Very short root length
- Severe periodontal disease
- Unrestorable teeth
• Medical or systemic complications
- Patients with blood disorders, terminal disease,
uncontrolled diabetes, severe heart disease, in those who
are immunocompromised
Anesthesia
• Indiscriminate use of surgery
• Mandibular blocks, mental blocks, PSAN blocks, infraorbital
- Surgery not indicated when nonsurgical approach is
blocks preferred choices
possible
- Supplement with infiltration technique
• Unidentified cause of treatment failure
• In addition, infiltration may be done (slowly, with limited
- Correction of treatment failure using surgery likely to be
pressure and depth), starting peripheral to the swelling
unsuccessful
moving to the center of the swelling
MTA – filling material
Procedure
Round bur – prepare sa root end  ultrasonic tips
• Vertical incision done with a no. 11 scalpel
• Incision made firmly through periosteum to bone
• Pus if fluctuant swelling, blood if nonfluctuant
• Small, closed hemostat is then placed in the incision and
opened to enlarge the draining tract (for more extensive
swelling) Micromirror & microscalpel – new instruments
• I-shaped or "Christmas tree" drain cut from a rubber dam or
a piece of iodoform gauze can be placed
• Suturing is optional
• Remove drain after 2-3 days; if not sutured, patient may
remove it at home
PERIAPICAL SURGERY (PAS) Procedures
• Performed to remove a portion of the root with undebrided • Flap design
canal space or to seal the canal apically when a complete • Incision and reflection
seal cannot be accomplished with nonsurgical RCT through • Apical access
an orthograde approach • Periradicular curettage
Indications • Root-end cavity preparation
• Anatomic complexity of the RCS • Root-end filling
- Nonnegotiable, blocked canal or severe root curvature • Flap replacement and suturing
- Nonsurgical RCT prior to surgery improves surgical success • Postoperative care and instructions
rate • Suture removal and evaluation
- Anatomic perforation of the root apex through bone Flap Design
(fenestration) 1. The flap should be designed for maximum access to the site
• Procedural accidents of surgery.
- Separated instruments, ledging, perforations, gross 2. An adequate blood supply to the reflected tissue is
overfills maintained with a wide flap base.
- Also if symptoms or lesions develop/persist after the 3. Incisions over bony defects or over the periradicular lesions
accidents should be avoided.
• Irretrievable materials in the root canal 4. The actual bony defect is larger than the size observed
- Posts, dowels, root filling materials (silver cones, amalgam, radiographically.
nonabsorbable pastes) 5. A minimal flap (should include at least 1 tooth on either side
• Symptomatic cases of the intended tooth) should be used.
- PAS considered to identify the cause/s 6. Avoid acute angles in the flap.
- Main cause usually due to incompletely cleaned canal/s 7. Incisions and reflections include periosteum as part of the
• Horizontal apical fracture flap.
• Biopsy 8. The interdental papilla must not be split, and should either
- Vital pulp with radicular radiolucency be fully included or excluded from the Bap
- Undefined PA lesions in teeth with vital pulps in patients 9. Vertical incisions must be extended to allow the retractor to
with a history of previous malignancy rest on bone and not crush portions of the flap.
- Lip paresthesia or anesthesia Submarginal flap
• Slightly curved, half-moon-shaped, horizontal incision made
in the attached gingiva with the convexity nearest the free
gingival margin
• A: Simple and easily reflected
• D: restricted access with limited visibility, tearing of the
incision corners of operator tried to stretch the tissue,
leaving the incision directly over the lesion (if defect is larger
than expected)
• Generally, not indicated or used due to many disadvantages
Modified submarginal curved flaps
• Triangular or rectangular flaps
• Scalloped horizontal incision (Ochsenbein-Luebke) made in
the attached gingiva with 1 or 2 accompanying vertical
incisions
• Used most successfully in maxillary anterior teeth crowns
• Alternative: papilla-based incision (papilla left intact)
• Prereqs: 4 mm attached gingiva, minimal probing depths,
good periodontal health
• A: Provides better access and visibility, less risk of incising
tissue over a bony defect
• D: possible scarring and hemorrhage from cut margins to
surgical site
• Provides less visibility than the full mucoperiosteal flap
Full mucoperiosteal flap
*preferred
• Incision at the gingival crest with full elevation of the
Interdental papilla, free gingival margin, attached gingiva,
and alveolar mucosa
• May either have 1 (triangular) or 2 (rectangular) vertical
releasing incisions
• A: Allows maximal access and visibility, less tendency for
hemorrhage
• D: Difficulty of replacing, suturing and making alterations to
the free gingival margin, possible recession and exposure of
crown margins
Incision and Reflection
• Firm incision made into base of sulcus (initiation of
horizontal incision) using #15 blade
• Made through periosteum to bone
• Place vertical incision/s
• Reflect tissue with a mucoperiosteal elevator/molt no. 9 (2
ends, spoon shaped end for broader amount of tissue),
contacting bone as tissue is relieved using firm, controlled
force
• Tissue reflected beyond mucogingival junction to a level that
provides adequate access to apex and allows retractor to be
placed on sound bone
• Flap reflected with periosteal elevator and held with a
retractor to allow visibility and access to surgical site
• Retractor must be placed on sound bone
Osteotomy
• Small opening: sharp round bur can be used to remove the
bone until the apex is located
• Limited cortical bone destruction: place a Radiopaque object
near apex and take radiograph to locate the apex
- Removal of bone is done using a light brushing motion
and copious sterile saline irrigation
Periradicular curettage
• Removal of pathologic Soft tissue surrounding the apex
• Tissue should be carefully peeled out, ideally in one piece,
with a suitably sized sharp curette
• Tissue sample submitted for biopsy
• Portions of tissue can be left when the lesion is very large
• Provides access and visibility of the apex
• Removes inflamed tissue
• Provides biopsy specimen for histologic exam
• Reduces hemorrhage
Root-End Resection
• Involves bevelling the apical portion of the root
• Done with a tapered fissure bur in a high speed handpiece and
copious NSS irrigation
• Bevel should be made as close to 0 degrees in a faciolingual
direction as possible
• Amount of root removed depends on reason for performing
the root-end resection
• Provide access to the palatal-lingual root surface
• Place the canal in the center of the sectioned root
• Expose additional canals, apical deltas or fractures
Root-End Cavity Preparation and Filling
• Now made with ultrasonic tips-placed so that the walls of the
prep will be parallel to the long axis of the root
• Minimum depth of 3 mm into the canals – fill with MTA
(Mineral trioxide aggregate)
• Ultrasonic tips: better control, ease of use, permits less apical
root bevelling, uniform depth of penetration – class 1 prep
- Produce smaller apical preps, allow easier penetration of
an isthmus, follow direction of canals, clean canal surfaces
better than burs, create less fatigue for the operator
 • Another approach is to use an angled vertical cut in which
the crown above the root to be amputated is recontoured
Root Hemisection
Filling Material - MTA • Surgical division of a multirooted tooth
• Able to seal well • Md molars: BL division through the bifurcation Mx molars:
• Biocompatible cut is made MD, through the furcation
• Unresorbable • Make a vertical cut through the crown into the furcation
• Easily inserted • No flap if root is periodontally involved
• Unaffected by any moisture • Make a flap before root resection if bony recontouring is
• Visible radiographically indicated
• Capable of regenerating periradicular tissues
Flap Replacement and Suturing
• After taking radiograph, inspect the bone and soft tissues for
remnants of filling materials, hemostatic agents or other
foreign objects
• Flap should then be placed in its original position and held in Root Bicuspidization
place for 5 minutes with moistened gauze using moderate • Surgical division of a Md molar
digital pressure • Crown and root of both halves are retained
• Interrupted sutures commonly used • Make a vertical cut through the crown into the furcation with
• Needle passes first through the reflected and then through a fissure bur
attached tissue • After healing of tissues, teeth can be restored as for 2
• Tie with a double surgeon's knot separate premolars
• Do not place knot over the incision line
• Remove sutures after 3 to 7 days

Postoperative Care and Instructions

• Some swelling and discoloration are common
- use an ice pack with moderate pressure on the outside of
the face (20 minutes on, 5 minutes off) prior to sleeping
• Some oozing of blood is normal
- If bleeding increases, place moistened gauze pad or facial
tissues over the area and apply finger pressure for 15
minutes
- Call the dentist's office if bleeding continues
• Do not lift lip or cheek to look at area, as stitches may be
torn
• Rinse with 0.12% chlorhexidine to promote healing
- Avoid mouthwashes with alcohol
- Brush carefully, avoid vigorous brushing
- Brush and floss all areas except the surgical site
• Observe proper diet and fluid intake-soft and cold diet, drink
plenty of fluids
• Some discomfort is normal; follow instructions of pain
medications
• If you are a smoker, smoking is not allowed the first 3 days
after the procedure.
• Call the dentist's office immediately if you experience
excessive swelling/pain or run a fever.
• Keep appointment for suture removal and call the office or
any concerns of questions.
Root Amputation
• Removal of one or more roots of a multirooted tooth
• Involved root/roots is separated at the junction of the root
and the crown
• Generally performed in Mx molars, but can also be done on Decompression = for very large cysts
Md molars • RCT didn’t work, made surgical exposure and root end
• Make a horizontal cut to separate the root from the crown; surgery
remove the root segment and cantilever the crown over the • Placed polyethylene tube to communicate cyst cavity
extracted root segment with oral cavity = to collapse the cyst
Endodontic-Periodontic Interrelationships
• Presence of MOs essential for development of pulpal and/or
periradicular pathosis
• Predominance of Gram (-) anaerobic bacteria
• Enter the RCs through direct pulp exposure (caries, traumatic
injuries) or by coronal microleakage
• Extent of periradicular lesion depends on:
o Virulence of bacteria present – how potent
o Immune response during disease process – range of
lesion
• Vary from a continued apical lesion, to an extensive lesion
communicating with the oral cavity through a sinus tract
along the root surface as a periodontal pocket A: notch
B: thickening of PDL
C & D: Lesion of the side of the root
• Dentinal tubules
o Tubules in the coronal root are larger than those in the
Diagnosis: pulpal necrosis apical root
Extended to the supporting tissues, mesial aspect of distal o Size and number decreases in the coronal-apical direction
root, may furcation involvement o Tubules calcify and decrease in number as the tooth ages
Sinus tract exploration using gutta percha: communication of or becomes irritated
lesion, sinus tract present, communication in the oral cavity o Presence of continuous layer of cementum is an
via the narrow pocket: 1 feature lesion of an endodontic effective barrier against the penetration of bacteria and
origin their byproducts from infected RCs into the periodontium
If perio origin: malapad siya and vice versa
• Mechanisms involved in perio disease similar to that in o Outward movement of dentinal tissue fluid and tubular
pathogenesis or periapical lesions contents of vital pulps can delay intratubular bacterial
o Original source invasion
o Direction of progression – periapical lesions  Accumulated host defense cell and inflammatory
(apically/coronally), Perio lesion (apically) mediators, dentinal sclerosis, reparative dentin
• Whether endo or perio treatment should be done should be Procedures on the Periodontium
based on correct diagnosis • Living irritants – bacteria, viruses, spirochetes, fungi
Pathways of Communication • Nonliving irritants – may be mechanical, thermal, chemical
• Apical foramen in nature
o Main pathway o Effect is transient, nonlingering
o Destruction of the apical PDL; resorption of bone, o E.g., dentin and cementum chips, root canal filling
cementum, dentin materials, food debris
*no substantial evidence that perio disease could affect the
vitality of the pulp
• Lateral or accessory canals
o Lateral canals - present more frequently in posterior
teeth and in the apical portion of roots
o Can carry irritants from the pulp to periodontium or vice
versa
 Ex. Necrotic pulp in periradicular tissues – you can see
a lateral lesion

• Periradicular changes can also occur anywhere adjacent to

HOW TO KNOW IF YOU HAVE A LATERAL CANAL? the root surface and drain through a sulcus (simulates a
o Notch on the lateral root surface perio pocket)
o Localized thickening of the PDL on the lateral surface of o Periradicular tissues replaced by inflammatory CT
the root
o Frank lateral lesion in the periradicular tissues
o Infected lateral canals can be the cause of persistent
narrow perio pockets not extending into the apical
foramen after RCT
 • Invasive perio treatment (ex. Deep curettage) can cause
necrosis
Clinical and Radiographic Tests for Diagnosis
Subjective Signs and Symptoms
• Take a complete history of the location, duration, intensity,
and frequency of pain, as well as any intake of pain relief
medications
Pulpal in origin – no clinical attachment loss • Perio disease is a chronic and generalized process that is
Diagnosis: Pulpal necrosis associated with little or no significant pain
Treatment of choice: Cleaning and shaping, and obturation – • Pulpal and periapical lesions are localized conditions, more
lesion will eventually resolve likely to be associated with acute symptoms that requires
Perio origin – attachment loss analgesics
Visual Examination
• Caries, extensive restorations, discolored crowns usually
associated with endodontic lesions
• Absence of obvious coronal defects, plaque, calculus,
generalized gingivitis/periodontitis – presence of perio
disease
Radiographic Examination
• Perio lesion – usually has angular bone loss extending from
cervical region toward the apex
Endodontic origin: lesion surrounding mesial root of the left o Absence of buccal or lingual plate (or both)
first molar, RCT, 18 mo. later resolved • Periapical lesions – destruction of apical periodontium
o Procedural accidents also damage the periodontium (ex. occasionally extending coronally toward the CEJ
Furcation, strip and root perforations • Perio lesions usually are found around multiple teeth
o Seal perforations with biocompatible material to • Periapical lesions usually isolated to a single tooth; heals
eliminate the infection and perio pocket of endodontic after complete cleaning, shaping, and obturation
origin

Perio lesion = left

• Post made perforation, nagka perio pocket
• Took out the post, repair perf using MTA
o Vertical root fractures after RCT
produce narrow probing defects
that simulate perio disease
o If perio origin: wide defect
o Endo origin: narrow defect
Effects of Periodontal Disease and Procedures on the Pulp
• Perio disease – comproised largely of gram-negative
anaerobic bacilli with some anaerobic cocci, and large
number of anaerobic spirochetes
• Host susceptibility and acquired and environmental risk
factors (tobacco smoking, host genetic makeup) also
determine the onset, progression and outcome
• Severe periodontitis – formation of granulomatous tissue
infiltrated with defensive cells normally containing little or
no bacteria
• Not fully substantiated that the perio lesions cause
inflammation or even pulpal necrosis
• Some evidence that severe periodontal involvement with
plaque on the root close to or at the apex causes necrosis
and inflammation in the pulp
• Deep scaling and root planning remove cementum =
opening of dentinal tubules and lateral canals
Endo lesion = right
Clinical Tests
• Vitality tests
o Necrotic pulps – no response to thermal or electric
stimuli
o Teeth with periodontal lesions – vital and responsive
pulps
• Percussion and Palpation tests
o Palpation sensitivity of coronal soft tissues –
gingivitis/periodontitis
o Palpation sensitivity over the root apex – periapical
lesions
o Positive percussion – inflammation in the PDL
• Periodontal probing
o Defects originating from a perio lesion – usually wide
and do not extend to the apices of the involved teeth
o Defects of pulpal origin – narrow, extend to either the
openings of lateral canal or to the apical foramen
Classification and Differential Diagnosis
• Pulpal (endodontic) origin
• Periodontal (periodontic) origin
• Endodontic-periodontic origin (true combined lesions)
Pulpal Origin • R: generalized vertical and horizontal bone loss along the
• Usually associated with a single-rooted tooth, with a necrotic root surfaces, and periapical lesions isolated to that tooth
pulp, r a multi-rooted tooth with a partially necrotic pulp • Unresponsive to cold, heat, electricity, cavity tests
• Patient may or may not have any discomfort • Wide and V-shaped defects
• Evidence of localized abscess with some swelling on some • Presence of plaque, calculus, periodontitis, wide and conical
occasions pockets
• Visually: Caries and/or extensive restoration • Tx: endodontic and periodontal treatments
• Radiographically: Periapical lesion isolated to a single tooth • Overall prognosis for the affected tooth depends on the
• Absence of response to thermal or electric stimuli prognosis for each individual lesion
• May or may not test positive on palpation or percussion • If periapical and periodontal lesions communicate, successful
sensitivity tests RCT eliminate the continuation of the lesion of pulpal origin
• Normal probing around the tooth except in one area with a and converts combined lesion into a defect of periodontal
narrow defect origin
• GP tracing into the sinus tract defect is deep, usually to the • Prognosis for the tooth depends primarily on the outcome of
apex or possibly to the opening of a lateral canal periodontal therapy – generally guarded
• Should be considered a coronally extended periradicular
lesion
• Not a true periodontal pocket
• Tx: adequate cleaning and shaping, and obturation of the
RCS
• Does not require any adjunctive periodontal treatment,
disappears quickly, excellent prognosis
Primary Periodontal Defects of Periodontal Origin
• Usually associated with generalized gingivitis and/or
periodontitis resulting from the accumulation of plaque
and/or periodontitis resulting from the accumulation of
plaque and/or calculus formation
• Patients have no significant symptoms
• Affected tooth may or may not have undergone extensive
restorative procedures
• Associated with varying degrees of mobility
• R: generalized vertical and horizontal bone loss along the
root surfaces
• Pulp testing: within normal limits
• Wide and V-shaped defects
• Crest is WNL, pocket depth decreases in a “step-up” manner
and reaches normal depth on the opposite side of the pocket

• Periodontal treatment indicated

• Occasionally, RCT is needed for a multirooted tooth that has
undergoen amputation or hemisection (adjunct)
Primary Periodontal Defects of Endodontic- Periodontic Origin
(True Combined Lesions)
• Occurs less often than previou 2 types
• Independent perioapical lesion originating froma necrotic
pulp; independent periodontal lesion that has progresses
apically toward the periapical lesion

• Lesions may or may not communicate with one another

(depending on stage of development
• Usually associated with clinical signs and symptoms of
generalized gingivitis and/or periodontitis with little or no
discomfort
• Affected tooth may or may not have undergone extensive
operative procedures; often mobile
 FINAL TOPIC FINALLY!! RATIONALE
Preserving the lifespan of the primary teeth in the arch Procedure would result in:
Preserving the vitality of the young permanent teeth to Deposition of tertiary dentin = increases between the
permit complete development of the root affected dentin and the pulp
Procedures Deposition of sclerotic dentin = decreases dentin
Pulp protection/base placement permeability
o Base placement as a protective barrier
o To minimize further injury to the pulp
Indirect pulp capping
Direct pulp capping
Pulpotomy
PRIMARY VS. PERMANENT TOOTH MORPHOLOGY
Primary teeth
o are smaller in all dimensions
o wider MD compared with crown length
o narrower and longer roots, compared to crown length
and width
o more prominent facial and lingual cervical thirds of the
crown primary anterior teeth
o moreconstricted at the CEJ
o Facial and lingual molars converge occlusally = narrow
faciolingual (than cervical) occlusal surface
o Primary molar roots are more slender and longer
o Primary molar roots flare out nearer the cervical area and
more at the apex
o Thinner enamel (approx. 1 mm) and more consistent
depth
STEP WISE/INTERMITTENT EXCAVATION
o Lesser thickness of dentin between the pulp chamber and
Tooth is re-entered, caries appears arrested
enamel
Remove the remaining caries
o Larger pulp chambers in primary teeth
Tooth is permanently restored
o Higher pulp horns (especially the mesial) in primary
Recall the patient after 6-8 weeks
molars
Take a radiograph
INDIRECT PULP CAPPING
Need good case selection and sealing of the cavity
Removal of caries to leave layer of stained dentin at the
Unsuitable candidates for the technique
cavity floor
o Cases with deep caries with unbearable pain, PDL
Objectives:
widening, sensitivity to thermal stimuli and percussion
o Promote dentin sclerosis (reduce permeability
o Stimulate formation of tertiary dentin (put calcium
hydroxide)
o Remineralize carious dentin
o Prevent microleakage
Indications:
Deep carious lesions approximating the pulp, but no signs
and symptoms of pulp degeneration
Symptom-free vital tooth, where the complete removal of
softened dentin on the pulpal floor is likely to result in pulp
exposure HALL TECHNIQUE
Tooth with reversible pulpitis Minimally invasive restorative option for primary teeth with
Technique: severe decay and/or hypomineralization
Anesthetize the tooth No anesthesia and no preparation required
Rubber dam isolation Indications:
Caries removal at the DEJ of the cavity Carious primary teeth
Judicious removal of soft, deep carious dentin Reversible pulpitis
Place thin layer of calcium hydroxide, then ZOE or GIC as Clear band of dentin between the carious lesion and the pulp
base on a radiograph
Place definitive restoration (adhesive restoration/performed Newly erupted first permanent molars with severe minor-
SSC) incisor hypomineralization
Best clinical marker to indicate how much caries to leave: Contraindications:
quality of dentin Caries extension into the pulp
o Soft and mushy – should be removed Irreversible pulpitis
o Hard and discolored – can be indirectly capped Unrestorable teeth
Patients where the airways cannot be protected due to very
poor cooperation
DIRECT PULP CAPPING Inability to control radicular pulp hemorrhage following a
For smaller traumatic exposures in primary teeth coronal pulp amputation
o Accidental pulp exposure during cavity preparation A pulp with serous or purulent drainage
o Pulp is exposed during removal of healthy dentin Presence of a sinus tract
Not for carious pulpal exposures PARTIAL/CVEK PULPOTOMY
Likelihood of successful pulp capping diminishes with age Permanent teeth with an open apex – to promote
Materials: apexogenesis
Calcium hydroxide +ZOE/GIC Remove inflamed pulp with a round bur
MTA Control bleeding with a moistened cotton pellet and irrigate
GI base + amalgam/composite restoration with NSS
Technique: Place calcium hydroxide powder paste
Anesthetize the tooth Top with IRM or any hard cement
Isolate with the rubber dam TECHNIQUE OF CORONAL PULP AMPUTATION
Remove any remaining caries peripheral to the pulp Diagnosis
exposure Anesthetize the tooth and isolate with a rubber dam
Control bleeding with sterile moistened cotton pellets Remove all caries
o do not insert any instrument into the exposure Unroot the pulp using a high-speed non-end cutting bur and
o do not blast air into the site abundant water spray
place calcium hydroxide over the exposure Amputate the coronal pulp with a low-speed #6/#8 round
top with composite or amalgam bur or spoon excavator
recall the patient after 1-4 weeks and monitor the pulp Wash the pulp chamber thoroughly (sterile water/NSS)
response Control hemorrhage using wetted and blotted almost dry
6-month recall intervals up to 4 years cotton pellets placed against the stumps of the pulp (within 3
FACTORS AFFECTING PROGNOSIS minutes)
Size If bleeding continues from one of the canals, re-enter with a
Location small round bur to amputate the inflamed tissue
Manner of exposure Wound management with any of the following:
o Dilute formocresol solution for 5 minutes
o 15% ferric sulfate solution for 15 seconds
o Permanent placement of MTA
o Electrosurgical manipulation of the wound surfaces
o Laser manipulation of the wound surface

PULPOTOMY
Amputation of the affected/infected coronal portion of the
pulp, preserving the vitality and function of all or part of the
remaining radicular pulp (AAPD)
Evidence of Successful Pulp Therapy
Vitality of the majority of the radicular pulp
No prolonged adverse clinical signs or symptoms (e.g.,
sensitivity, pain, or sensitivity, pain, or swelling)
No radiographic evidence of internal resorption reaching the
alveolar bone
No breakdown of periradicular tissue
No harm to permanent successor teeth Hemostasis and maintenance of vital tissue – ferric sulfate,
Pulp canal obliteration (abnormal calcification): not electrosurgery, laser
considered a failure Dentin bridge formation and maintenance of vital tissue –
INDICATIONS & CONTRAINDICATIONS MTA
Pulp exposure of primary teeth in which the Superficial or partial pulp tissue fixation and maintenance of
inflammation/infection is judged to be confined to the vital tissue – formocresol, glutaraldehyde
coronal pulp FORMOCRESOL PULPOTOMY TECHNIQUE
Contraindications for Pulpotomy in a Primary Tooth Put 1/5 dilution formocresol solution on a cotton pellet (blot
A history of spontaneous toothache (not caused by pulpitis excess) and place in direct contact with pulp stumps for 5
resulting from food impaction) minutes
A non restorable tooth where postpulpotomy coronal seal o 1 part Buckley’s formocresol solution mixed with 1 part
would be inadequate distilled water and 3 parts glycerin
A tooth near to exfoliation or if no bon overlies the crown of o Tissue appears brown and no hemorrhage is seen
the permanent successor tooth If any area of the pulp was not in contact, repeat procedures
Evidence of periapical or furcal pathosis for that tissue
Evidence of pathologic root resorption Place ZOE cement base over the pulp stumps and allow it to
 SSC preferred restoration of choice for primary molars, Teeth with mechanical or carious perforations of the floor of
tooth-colored composite restoration for anterior primary the pulp chamber
teeth (or crown if tooth is badly broken down) Excessive pathologic root resorption involving more than
Restore with composite, GIC, amalgam third of the root
Recall after 6 weeks Excessive pathologic loss of bone support, with loss of the
If pulp pathosis develops, partial pulpectomy must be normal periodontal attachment
considered with right away or until root development is Presence of a dentigerous or follicular cyst
completed Periapical or interradicular lesion involving the crypt of the
developing permanent successor
Technique:
Anesthetize the tooth, if the pulp is vital
Isolate with rubber dam
Access preparation
Cleaning and shaping
o Ni-Ti files are preferred
o Avoid over instrumentation
Obturation – filling material is different than in permanent
teeth
IDEAL FILLING MATERIAL IN PRIMARY TEETH
Resorb at a similar rate as the primary root
Be harmless to the periapical tissues and the permanent
tooth germs
Resorb readily if pressed beyond the apex
Be antiseptic
FERRIC SULFATE PULPOTOMY Fill the root canals easily
Complete coronal pulp amputation and achieve hemostasis Adhere to the walls of the root canal
15.5% solution of ferric sulfate is applied to radicular pulp Not shrink
stumpsfor10-15 seconds Be easily removed if necessary
Wound should appear brown and no bleeding is seen Radiopaque
ZOE cement base Not discolor the tooth
Permanent restoration as for formacresol pulpotomy Most commonly used filling materials:
MINERAL TRIOXIDE AGGREGATE (MTA) PULPOTOMY ZOE paste
Complete coronal pulp amputation and achieve homeostasis Iodoform paste
MTA powder mixed with sterile water Calcium hydroxide
Apply MTA to pulp tissue using an excavator or amalgam Restorations:
carrier to cover exposed pulp tissue to a depth of 3-4 mm SSC
Gently pack MTA mixture over pulp tissue Composite restoration
ZOE/GIC cement base Amalgam restoration
Restore tooth permanently
MTA
Setting time: 3-4 hours
pH 12.5 (similar to calcium hydroxide)
Compressive strength + 70 MPa (comparable to IRM)
Amtimicrobial
Promotes hard tissue formation
Biocompatible
Expensive
ELECTROSURGICAL PULPOTOMY
Electrode is placed 1-2 mm above the pulpal stump
Procedure may be repeated up to a maximum 3 times, then
transfer to the next stump
Pulpal stumps appear dry and completely blackened
Fill chamber with ZOE placed directly against the stumps * leave 2 mm space sa file
Restore with SSC APEXOGENESIS
LASER PULPOTOMY Designed to preserve vital pulp tissue in the apical part of a
Carbon dioxide laser root canal in order to complete formation of the root apex
Too expensive – not cost-effective Deep resection of pulp tissue, usually in single rooted
NONVITAL PULP THERAPY – PULPECTOMY IN PRIMARY TEETH anterior teeth, with small endodontic spoon excavator or
Indications: Teeth with pulpal involvement that has spread round diamond bur
beyond the coronal pulp, whether vital or not o Posterior teeth: files/reamers
Contraindications for Pulpectomy in the Primary Dentition Control bleeding with saline-soaked cotton pellets or NaOCl
An unrestorable tooth Cover with dressing material
Internal resorption in the roots visible on radiographs Restore with crown
 Working length determination
Canal cleaning and shaping
Slurry of calcium hydroxide mixture is introduced into the
canal and sealed
When the tooth is free of signs and symptoms of infection, it
is re-isolated with a rubber dam and the canal is re-entered
Canal is flushed and cleaned of calcium hydroxide
medicament
Canal is then dried and a plug of MTA is compacted into the
apical 4-5 mm using amalgam carrier and large paper points
(measured 1-2 mm short of the apex)
Take a radiograph to verify the adequacy of the apical plug
Remove excess MTA from the canal walls
Place cotton pellets and seal
APEXIFICATION Re-appoint the patient and check if the MTA is set
• Root end closure Root canal filling is done
• Process whereby a nonvital, immature, permanent tooth Final restoration
which has lost the capacity for further root development, is CONCLUSION
induced to form a calcified barrier at the root terminus Prevention of RCT or extraction is done to preserve the
• Uses calcium hydroxide paste vitality of the tooth, both for the primary and permanent
• Apical barrier technique has now become the accepted teeth
treatment of choice using MTA Every attempt should be made to maintain the vitality of
• Objective: stimulate apical closure of pulpless permanent these teeth before resorting to the more radical
tooth with an incomplete formed apex management, such as pulpectomy or extraction.
• Indication: pulpless young permanent tooth with a TRAUMATIC INJURIES TO THE PRIMARY DENTITION
blunderbuss apex (wide open apex) Most injuries caused by falls or accidents
• Material: calcium hydroxide powder + distilled water Maxillary incisors most frequently injured teeth in primary
• Diagnosis: vitality tests, radiographic evaluation dentition
• Isolate tooth with rubber dam Most common injury: luxation/displacement injuries (crown
• Access preparation fractures)
• Working length determination (avoid overinstrumentation) 2-4 y/o: peak age of injuries
• Canal debridement using NaOCl Children with protruding incisors 2x-3x more likely to suffer
• Canal Cleaning and shaping dental trauma
• Dry the canal Other causes of injuries: automobile accidents, chronic
• Slurry of calcium hydroxide mixture is introduced into the seizure disorders, child abuse
canal and sealed In the primary dentition, the prevalence of injuries ranges
• Recall at 3 monthly intervals from 31 to 40% in boys and from 16 to 30% in girls.
• Followed by completefillinf of the canal with gutta percha In the permanent dentition; the prevalence of dental trauma
in boys ranges from 12 to 33% as opposed to 4 to 19% in girls
Classification of Injuries
WHO
Andreasen
Garcia and Godoy
Ellis and Davey
WHO (1994)
A. Injuries to the hard dental tissues and the pulp
1) Enamel infarction
2) Enamel fracture (uncomplicated crown fracture)
3) Enamel Dentin Fracture (uncomplicated Crown fracture)
4) Complicated crown fracture
5) Uncomplicated Crown-Root Fracture
6) Complicated Crown-Root Fracture
7) Root Fracture
B. Injuries to the Periodontal Tissues
1) Concussion
2) Subluxation (Loosening)
3) Extrusive Luxation (Peripheral Dislocation, Peripheral
APICAL BARRIER TECHNIQUE Avulsion)
Alternative treatment which allows immediate obturation of 4) Lateral Luxation
the canal with an open apex 5) Intrusive Luxation (Central dislocation)
Technique: 6) Avulsion (Exorticulation)
Rubber dam isolation
Access opening
 C. Injuries to the Supporting Bone
1) Comminution of the mandibular or maxillary alveolar
socket
2) Fracture of the mandibular or maxillary alveolar socket
wall
3) Fracture of the mandibular or maxillary alveolar process
4) A fracture involving the base of the mandible or maxilla
and often the alveolar process (jaw fracture)
D. Injuries to the Gingiva or Oral Mucosa
1) Laceration of gingival or oral mucosa
2) Contusion of gingiva or oral mucosa
3) Abrasion of gingival or oral mucosa
Andreasen (1981)
A. Injuries to the hard dental tissues and pulp
1) Crown infarction
2) Uncomplicated crown fracture
3) Complicated crown fracture
4) Uncomplicated crown root fracture
5) Complicated crown root fracture
6) Root fracture
B. Injuries to the periodontal tissues
1) Concussion
2) Subluxation
3) Intrusive Luxation (central dislocation)
4) Extrusive luxation (peripheral dislocation partial avulsion)
5) Lateral Luxation
6) Exorticulation (complete avulsion)
C. Injuries of the Supporting Bone
1) Comminution of alveolar socket (mandible and Maxilla)
2) Fracture of the alveolar socket wall (Mandible and
Maxilla)
3) Fracture of the alveolar process (Mandibular and Maxilla)
4) Fracture of the Mandible and Maxilla
D. Injuries to gingiva or oral mucosa
1) Laceration of gingiva or oral mucosa
2) Contusion of gingiva or oral mucosa
3) Abrasion of gingiva or oral mucosa
Garcia and Gadoy (1981)
Enamel crack
Enamel fracture
Enamel Dentine fracture without pulp exposures
Enamel Dentine cementum fracture without pulp exposure
Enamel Dentine cementum fracture with pulp exposure
Root fracture
Concussion
Luxation
Lateral displacement
Intrusion
Extrusion
Avulsion
Ellis and Davey (1970)
Class 1 – simple fracture of the crown involving little or no
dentin
Class 2 – extensive fracture of the crown – involving
considerable dentin, but not the pulp
Class 3 – extensive fracture of the crown – involving
considerable dentin, and exposing the dental pulp
Class 4 – traumatized tooth which becomes nonvital – with
or without loss of crown structure
Class 5 – teeth lost as a trauma
Class 6 – fracture of the root – with or without fracture of
crown or root
Class 7 – displacement of the tooth-without fracture of
crown or root
Class 8 - fracture of the crown en masse and its replacement
Ellis (1970)
 I – simple crown fracture involving little or no dentin
 II – extensive crown fracture with considerable loss of
dentin, but with pulp not affected
 III – extensive crown fracture with considerable loss of
dentin and pulp exposure
 IV – a tooth devitalized by trauma with or without loss of
tooth structure
 V – Teeth lost as a result of trauma
 VI – root fracture with or without the loss of crown structure
 VII – displacement of the tooth with neither root nor crown
fracture
 VIII – complex crown fracture and its replacement
 IX – traumatic injuries of primary teeth
“Many classifications have been suggested for dental injuries
with some classifications were excessively complex. As
suggested earlier, there is a need for reappraisal of tooth
fractures and any such classification should be applicable to
both primary and permanent dentition”
Crown, root or both
Crown fractures: limited to enamel, extend up to dentin,
includes pulp (most complicated and demanding to manage)
Classification
Concussion – tooth not mobile and not displaced
Subluxation – tooth loosened, but not displaced
Intrusion – central dislocation of tooth from socket
Extrusion – central dislocation of tooth from socket
Lateral luxation – tooth displaced in a labial, lingual or lateral
direction
Avulsion – tooth completely displaced from alveolus
History of the Dental Injury
When, where, how did the accident occur?
o When: time elapsed since injury can determine type of
treatment to be provided
o Where: severity; need for tetanus prophylaxis, rule out
more serious injury
o How: more info on severity: ask if px lost consciousness,
vomited, or was disoriented at time of accident
  Tecklenburg & Wright: significant head injuries can
lead to symptoms many hours after initial trauma:
parents are cautioned to monitor previously-noted
signs for 24 hours.
Thermal change with sweet/sour foods = dentin/pulp
exposure
Tender to touch or while chewing? Change in occlusion? =
luxation injury or alveolar fracture
Clinical Examination-Extraoral
Palpate facial skeleton (discontinuation of facial bones). TMJ
(note any swelling, crepitus, clicking)
Check for wounds and bruises
Check mandibular function in all excursive movements
Stiffness or pain in neck = immediate referral to a physician
Clinical Examination-Intraoral
Examine soft tissues and record any injuries
o Note presence of foreign matter and remove at initial
appointment
Examine tooth for fractures, pulp exposure, dislocation
Record displacement, horizontal and vertical tooth mobility;
reaction to percussion and palpation
Pulp vitality testing not done
Radiographic Examination
Baseline documentation, subsequent evidence of
radiographic evidence compared with initial films
Root fractures
Extent of root development
Size of pulp chambers
Periapical radiolucencies
Extent and type of root resorption
Degree of tooth displacement
Position of unerupted teeth
Relationship between injured primary teeth and their
permanent successors
Jaw fractures
Presence of tooth fragments and other foreign bodies in soft
tissues
No "standard series" of radiographs for dental injuries
Clearly show apical areas
Suspected root fractures: 2nd/3rd radiograph made at
slightly different angles (vertical and horizontal)
EMERGENCY CARE
INJURIES TO THE HARD DENTAL TISSUES
Cracks and Fractures of the Enamel and Dentin without Pulp
Exposure
Smoothen sharp edges at fracture line with abrasive disks
Tooth fracture associated with wounded lip: take radiograph
of lip
Fractures of the Enamel and Dentin with Pulp Exposure
Pulpotomy, RCT, extraction
Vitality of tissue and time elapsed since injury
o Vital pulp: cervical pulpotomy
o Ram and Holan: Partial pulpotomy
Pulp exposure overlooked/neglected, no tx rendered =
necrotic and infected pulp, with swelling or fistula
Extract ASAP: massive external inflammatory root resorption
(EIRR), follicle of underlying tooth bud involved
Crown-Root Fractures
Rare
Teeth usually split into 2 or more fragments, one remaining
firm and the other loose
Separate fragments to determine pulp exposure; remove
loose fragment
Suggested tx: Pulpectomy and reconstruction of crown
Extract both fragments if fracture goes deep into alveolus
and creates a perio pocket in space previously occupied by
loose fragment
Root Fractures
Rare
Slight mobility and sensitivity to percussion
Extract coronal fragment if it is pushed away from apical part
of root and assumes a lingual inclination
Avoid attempts to remove apical fragment
No disturbance to occlusion: no tx, provide parents with
instructions for thorough OH and soft diet for a limited time
No need for immobilization
Splinting only recommended to alleviate sensitivity during
function
Injuries to the Chin
Minor enamel fractures, fractures with dentin exposure
imitating a carious lesion on radiograph, crown-root
fractures with/without pulp exposure, PDL injuries
Fracture of Md mainly in symphysis, mental, and subcondylar
areas
Exposed dentin in fractured posterior teeth = increases risk
of pulp imitation and may become carious
o Small exposure: composite resin
o Large fracture or extends beyond gum line: SSC
o Pulp exposure but crown restorable: pulpotomy and
SSC
INJURIES TO THE SUPPORTING TISSUES
Concussion and Subluxation
Concussion: sensitive to percussion
Subluxation: increased mobility, widening of PDL space
Signs of bleeding seen initially after injury
No tx, soft diet (limited time), thorough OH
Intrusion
One of the most complicated injuries to primary incisors
Occurs during first 3 years of life
Clinical: tooth disappears completely into surrounding
tissues/incisal part visible with crown shorter than adjacent
teeth
PDL compressed, root surface tightly pressed against alveolar
bone = reduced mobility
Metallic sound on percussion, no pain provoked
Bleeding from gingival sulcus initially after injury
Swollen upper lip
Root of primary incisor close to labial surface of permanent
tooth
Immediate removal of primary tooth if it is pushing against
crown of permanent incisor
Determine ASAP after injury if primary contacts the
permanent, or pushed labially and away from labial surface
of permanent
Intruded teeth that do not risk permanent teeth left to re-
erupt spontaneously
Estimate of re-eruption: measure distance between incisal
angle of partially intruded tooth and tongue depressor
placed between permanent teeth on either side of intruded
tooth
o Repeat measurements at recall visits
Extrusion
Clinically elongated relative to adjacent unaffected teeth
Increased mobility and sensitivity to percussion
Bleeding from gingival sulcus seen initially after injury
Widening of PDL space esp. around apex
 Greater chances of disruption of blood supply and
development of pulp necrosis the more tooth moves out of
socket
Resembles lingual luxation - approach to both injuries should
be similar
Lingual Luxation
Crown moves in a palatal direction, apex pushed labially
Increased mobility and sensitivity to percussion
Signs of bleeding
Upper lip often swollen
Radiograph: RL gap between apex and alveolar bone,
shortened and more opaque image compared to adjacent
teeth
Extraction, but some parents insists on retention of tooth
o Tooth can be repositioned before formation of coagulum
o Splint for 7-14 days
o Perform RCT
Cases of open bite without occlusal interference: functional
forces of tongue pushes crown into labial position
o Eliminate interferences by creating intentional open bite
= composite "buttons" on Mx/Md molars
o When luxated teeth are seen after formation of blood
clot several hours after injury
Strict instructions for good OH provided for parents
Avulsion
Common outcome of dental trauma
Contributing factors = high crown:root ratio, bone resilience
75% of cases have damage to permanent successor
Avoid replantation
If tooth already replanted by parents: splint and do RCT with
resorbable paste
o Inform parents of risks, and costs vs. benefits of keeping
tooth
Account for all avulsed teeth; if tooth/teeth not found, refer
to a pediatrician
Information and Instructions for Parents
Do not base diagnosis solely on information given by parents
over the phone
o Serious injury = child should be seen ASAP
Inform parents about possible complications of injury,
prognosis of injury, likelihood of damage to permanent
successor
Instructions are given to prevent late complications and
detecting complications ASAP to allow appropriate tx
Thorough cleaning and plaque removal
Chlorhexidine gluconate (0.2%) as antiseptic medicament:
repeat several times/day, esp. after meals, for 1 week
Soft diet
Antibiotics for severe tooth luxation and heavy damage to
soft tissues
Timing of follow-up based on type of injury
Pulpal necrosis and IRR detected radiographically in 1 month
If parents notice swelling, redness, fistula in gums,
discoloration, increased mobility or sensitivity, bring child in
earlier
INJURIES TO PERMANENT ANTERIOR TEETH
Class I and II Crown Fractures
If dentin is exposed, place adequate dentinal protection and
follow with composite "band-aid" restoration.
Allow up to four weeks of recovery, then restore the tooth
with esthetic resin restoration.
Class III Crown Fractures
Evaluate the size of pulp exposure to determine whether
pulp capping or pulp therapy is necessary.
If exposure is less than 1mm, perform a direct pulp cap.
If exposure is 2mm or greater, pulpectomy is recommended
Concussion
Percussion or pressure produces sensitivity
Relieve occlusion
Perform vitality tests
Observe periodically with radiographs for up to a year
Advise soft diet for two weeks
Subluxation
If minimal, leave alone, monitor teeth with vitality tests, and
adjust occlusion if necessary.
If extensive, place a flexible splint (monofilament fiber or
light orthodontic wire) bonded to the tooth with acid-etch
resin for one to two weeks.
Evaluate the tooth for clinical signs of pulpal degeneration
using vitality tests and radiographic follow-up.
Intrusion
Optimal treatment not yet been determined
Treatment of choice is orthodontic repositioning over a
period of three to four weeks
Orthodontic extrusion should be performed as soon as
possible
Pulp necrosis will occur
Begin orthodontic extrusion within two weeks
Access root canal within three to four days and perform
endodontic treatment
Monitor with radiographs for up to five years
Extrusion
Assess the position of the tooth radiographically
Reposition tooth to normal position and splint with a non-
rigid, acid-etch splint for two to three weeks
Monitor pulp vitality every few weeks. If pulp necrosis
occurs, perform endodontic therapy.
Choice of root canal filling material depends on the maturity
of the tooth.
Avulsion
Stage of root development
Physiologic status of the periodontal ligament
Length of extra-oral time
If parents call the dental office to report that their child's
tooth has been avulsed:
o place the tooth in a moist environment if they cannot
replant the tooth into its socket
o stored in milk, HBSS, saline, or saliva until replacement
o Storage in tap water or saliva is not recommended
The extra-oral time (EOT) the tooth is out of its socket is
critical to the success of the replantation procedure.
Success compared with time shows:
o less than 30 minutes - 90% success
o 30 to 90 minutes - 43% success
o more than 90 minutes - 7 % success
Treatment Protocol
Gently rinse tooth in a steady stream of saline. Do not
manipulate root surface.
Place tooth in OSE (optimal storage environment) for 30
minutes while obtaining medical history, injury history,
neurologic assessment, and radiographic assessment.
Flush socket and replant tooth with light pressure.
Splint tooth with a flexible, passive splint for two to three
weeks.
If apical foramen is closed, perform root canal therapy (RCT)
one week following the trauma.
Root Fractures
More common after age 10 years.
Change radiograph angulation 10° to 15° apically or coronally
to see the fracture
Tx: application of a rigid splint for up to six weeks
Careful monitoring with radiographs and pulp vitality tests
are important
PATHOLOGICAL SEQUELAE OF TRAUMA TO THE TEETH
Reversible Pulpitis
Infection of the PDL
o Irreversible Pulpitis
o Pulp Necrosis
Coronal Discoloration
Inflammatory Resorption
Replacement Resorption
Pulp Canal Obliteration
Complications following Intrusion
Complications following Avulsion