MIDTERMS going on & we want to treat the infection.
We don’t
ENDODONTICS (LECTURE)
Branch of dentistry concerned with the morphology,
physiology and pathology of the human dental pulp &
periradicular tissues. Morphology is the anatomy & forms.
Physiology deals with function. Pathology deals with diseases
of the human dental pulp & periradicular tissues.
Endodontics doesn’t only concern the inner structures but also
the periradicular (peri; around, radicular; root) tissues.
Its study and practice encompass the basic and clinical
sciences including the biology of the normal pulp & the
etiology, diagnosis, prevention & treatment of diseases &
injuries of the pulp & associated periradicular conditions.
Etiology means cause. Again, pulp & periradicular conditions.
Laging partner yan sa endo. When you study endo, your study
is just confined to the root canal or inner structures of the
tooth, NO. Kasama yan lagi is the periradicular tissues & the
periradicular conditions. Endodontics - pulp & periradicular
tissues.
( 3 ) MAIN RATIONALE FOR ENDODONTIC
TREATMENT
1. Retain Tooth, Retain Function
Why do we do RCT? What’s its importance /
significance? Because we don’t want the tooth to be
extracted. We want to retain the tooth as much as
possible. Ngayon, pag na-retain yung tooth, it should
function. The retain on function is more on posterior.
2. Preserve Occlusion
No normal occlusion affects mastication, digestion,
and overall health of the patient.
3. Preserve Esthetics - Particularly for Anteriors
( 6 ) PRINCIPLES IN RCT
1. Aseptic Technique
Sterilization, RDI, proper rubber dam isolation.
Asepsis yan. So, all instruments used for rct should
be sterile, autoclaved properly. Another way of
observing aseptic technique is application of your
rubber dam or rubber dam isolation. It should always
be in place & it has to be done properly or else
maddefeat yung purpose.
2. Gentle Handling of Tissues (Periradicular Tissues)
All instrumentation must be within the root canal
only. All instruments whenever we insert those files,
those obturating materials inside the canal, should be
confined to the canal & not go over the periradicular
tissues & you should not induce damage or injury to
your periodontal ligament. Kasi once na lumabas na
yung instrument mo, then you’ll damage the
periradicular tissue. That could be irritated, could
cause inflammation & infection.
3. Adequate Disinfection
Use of irrigants & medicaments to prevent any
reinfection. We want to reduce the microorganisms
present inside the canals. How? By placing irrigants
& medicaments to prevent any re-infection. Kaya ka
gagawa ng endo sa ngipin na yan kasi may infection
want to add more infection into the root canal.
4. Complete Obturation
Goal is to seal off the apical end of the canal.
Kailangan ma-seal yung opening na yon para hindi
na magkaroon ng reinfection ang iyong canal.
5. Proper Restoration
To seal the coronal part by the restoration.I always
tell my students, obturation is not the final phase in
rct. It is the restoration. Without putting a good
restoration on an endodontically treated tooth, then
it’s bound to fail.
6. Recall
To monitor healing. It could be after a month, after 6
months, after 2 years. That’s the basic recall.
Why is there a need to recall? To monitor healing.
Especially for those cases that started with periapical
infection. You want to monitor if there are signs of
healing or maybe you weren’t able to disinfect it
correctly that's why there is tooth pain.
Note: You can only say that you’ve done a successful
endodontic treatment when you do a recall after 2
years & everything was okay. After 2 years, if there’s
no infection, the patient is satisfied,, tooth is
functioning, that’s the only time for you to say that
you did a successful endodontic treatment, doon mo
palang siya pwedeng i-claim na successful.
( 10 ) PROCEDURES INVOLVED IN ROOT CANAL
TREATMENT
1. Diagnosis & TR. First we begin with proper history
taking & examination of the involved tooth to be able
to arrive at a correct diagnosis & subsequently be
able to provide the appropriate treatment plan.
Note: Always remember, you cannot give a proper
treatment without proper diagnosis. Ganon ka-
significant ang proper diagnosis.
2. Anesthesia. To provide local anesthetic if necessary.
For each diagnosis available, there is a specific
administration of local anesthesia depending on
the vitality of the tooth being treated. Hindi naman
lahat ng cases ni endo is vital. Pag vital lang, that’s
the only time you need to put anesthesia pero kung
may mga cases na necrotic, anesthesia may not be
required anymore. But make sure when the patient is
in pain, make sure that your anesthesia is effective
enough kasi kung in pain si patient, he/she wouldn’t
cooperate.
3. Rubber Dam Isolation. Essential to endodontic
treatment. This is done to achieve a clean & dry
environment during treatment & also to prevent
ingestion or aspiration of the medications /
medications & instruments. Irrigants like Sodium
Hypochlorite “Zonrox” could be prevented.
There have been cases na nalunok yung file and nakita sa
radiograph. Endodontic files and instruments are sharp and
fine. Ingatan niyo nakakasugat yan. Kahit yung clamp, pag di
kayo nag-iingat sa paglalagay pag di mo pa nalalagay yung
rubber dam, possible na tumalsik, baka malunok ng pasyente
niyo, kaya kayo maglalagay ng dental floss sa clamp para pag
nahulog sa oral cavity or malunok ng patient niyo (wag naman
sana), you can easily pull it out. Some irrigants in endo can be
irritating. For example, sodium hypochlorite ( Zonrox ). It
doesn’t have a pleasing smell mas lalo na taste. Imagine
working with that sa bibig ng pasyente. You have to be careful
na wag tumulo sa oral cavity or malunok ng pasyente. Kaya
tayo may rubber dam isolation.
4. Access Preparation. We gain access through the
pulp chamber by means of drilling through the crown
5. Removal of Vital Pulp. Some use files, broaches.
6. Canal Cleaning, Irrigated & Shaping. The canals
are then cleaned, irrigated and shaped. We shape the
canal into a form that can be easily obturated & filled
up. The main purpose of Canal Shaping is for us to
perform a good obturation.
7. Medications. We just don’t use files & these
instruments, we also use some medications. The
antiseptic medicines can be placed into the canal & it
should have an antibacterial property because an
endodontically treated tooth is a tooth with an
infection inside. Kaya I mentioned that most of the
cases in endodontics are accompanied with infection
that’s why we have to use a disinfectant to reduce the
amount of microorganisms that are present & those
medications are placed in your canal hopefully
eliminating the infection after the treatment.
8. Temporary Filling. Then, we put a temporary filling
also which is placed in the access opening to protect
the root canals from infection in between
appointments especially if you’re not doing a one
sitting endo.
One-sitting Endo / Single Visit Endo - no need for
temporary filling kasi pagbukas mo, obturate then close edi
final na yung restoration mo. Multiple Visit Endo -
temporary filling is a must).
9. Obturation
Then, when completely clean & free from infection,
then the root canal is filled & obturated with gutta
percha points & sealants.
10. Crown Restoration
It should have an adequate seal with a protective
filling material to cover the crown & satisfy the
functional & aesthetic demands of the patient
especially if it is an anterior tooth. Anterior tooth
sometimes, even before you start your endo,
discolored na yan pag necrotic yan.
( 10 ) SCOPE OF ENDODONTICS
1. Diagnosis (Pulpal / Apical Origin). Diagnosis,
differential diagnosis and treatment of oral pain.
Symptoms either: Pulpal / Periapical Origin
2. Vital Pulp Therapy (Pulp Capping, Pulpotomy,
Pulpectomy, Apexogenesis, Apexification)
3. Non-surgical Treatment (Obturation). You will
only fill the canal & you don’t have to make a flap.
Wala masyadong complicated procedure na involved.
4. Surgical Treatment (Root End Resection,
Hemisection, Bicuspidization). All of these
procedures are scope of study of endodontics.
5. Root Repair (for Root Perforation). This is related
to pathologic or iatrogenic damage.
6. Replantation (for Avulsed Tooth). If you replant
the avulsed tooth, high chances are it will become
necrotic later on. Only a very slim chance of a
reimplanted avulsed tooth remains vital. It is very
time sensitive. The shorter the time, the better the
prognosis. It may reattach but since the blood supply
is cut, pulp could lead to necrosis. No other treatment
but only root canal.
7. Endo-Perio Interrelationship. Check if bone
support is still fine. Mobility & all.
8. Bleaching. Usually intracoronal bleaching is done
because most of the endodontically treated tooth’s
problem is discoloration. So, bleaching is an option.
9. Re-treatment. Mga previously treated the root canal
system. Ito yung mga ginawa previously tapos
nagkaroon ng problema, nagkaroon ng re-infection.
So, kahit na root canal na yan basta nagkaroon ng re-
infection.
10. Restoration. Involves root canal space & access
opening.
( 1 ) MAIN CONTRAINDICATION
A non-restorable tooth. An endodontically treated
tooth that is not properly restored is bound to fail. You have to
restore the function.
What to Assess:
● Pulpal involvement?
● Periapical involvement?
● Condition of the crown?
● Possible crown restorations after endodontics?
( 1 ) PRIMARY OBJECTIVE / GOAL
To create an environment within the root canal
system which allows the healing and continued maintenance
of the health of the periradicular tissue. Healing will only take
place once you get to address the source of infection. (e.g.,
necrotic pulp causing infection).
( 2 ) SPECIFIC OBJECTIVES
1. To bring the tooth back to a healthy state. It can be
even if there’s no pulp anymore. Pero needless to say,
meron pa rin dapat yang bone support, gingiva, and
the needs to be able to function
2. To relieve pain. Because endodontically involved
teeth are usually accompanied by pain like for
example root canal treatment.
( 1 ) ULTIMATE OBJECTIVE / GOAL
Restoration of the treated tooth to its proper form &
function (in the masticatory apparatus, in a healthy state). Root
canal treatment will not be successful if the restoration is
poorly made because the only thing that would increase the
longevity of the tooth is a sealed restoration. No matter how
good the root canal treatment was, if not sealed properly, it is
bound to fail. Appreciate & understand the value of what
you’re doing for you to do it properly.
May link sa Canvas about sa history ng endo, check it out. I
will not elaborate on that anymore.
DIAGNOSIS
When you diagnose, it’s not enough to just know the
pulpal diseases. You should match it with the result of the
diagnostic test. Diagnosis is similar to matching types. You
shouldn’t just just run some tests without knowing the type of
pulpal disease. You need to know the different diseases & you
should make a diagnostic test & you should have data with the
result. Then, that result will be matched in the characteristics
of the different diseases that you know. That’s how you
diagnose.
(5) PULPAL DIAGNOSIS
1. Reversible Pulpitis
A normal pulp is symptom free & it will give a
normal response to testing. Like for example a
Thermal Test, a normal pulp would react because it’s
normal but without the stimulus, it wouldn’t be
possible.
Hyperemia is the old term of Reversible Pulpitis. It
also means sensitivity to cold. Now, the response is
provoked or stimulated by the cold.
Kapag Reversible Pulpitis, sumasakit siya kapag may
cold stimulus. There’s discomfort or sensitivity to
sharp pain but pain doesn’t linger kasi nga stimulus
dependent siya. So, kapag nandon ang cold stimulus
atsaka lang siya masakit.
Common Chief Complaint:
“Doc, kumain ako ng ice cream eh. Grabe sobra ngilo ng
ngipin ko.” Then ask mo how long sumakit; “mabilis lang,
nung tumigil ako kumain ng ice cream, nawala naman na
siya”. So ibig sabihin, na-trigger lang siya ng stimulus. Nung
wala ng stimulus, wala na yung pain.
Reversible pulpitis indicates that it can return to normal.
There’s a chance for the pulp to heal.
If the pulp can heal, can we do an RCT to a Reversible
Pulpitis?
No. RCT is not indicated in REVERSIBLE PULPITIS
cases. All you need to do is remove the cause of RP which is
caries (frequent cause of RP).
All you have to do is clean the open cavity - clean it & put in
a restoration.
Placing a permanent restoration provides a seal that would
prevent microorganisms entering the dentinal tubules therefore
it will create a stable environment for the pulp.
There are cases na kapag medyo malaki ang caries, naglalagay
muna ng temporary filling. If a temporary filling is placed,
then you observe the case. It is more prone to failure &
leakage which will allow bacteria to enter kaya hindi din dapat
masyadong matagal ang filling and you should also inform the
patient na “Pag na natanggal ang filling, you have to come
back to me asap”. Kasi pag nagkaroon ng leakage yun,
papasukan ng bacteria and magkaroon ng chance to progress
to irreversible pulpitis.
2. Irreversible Pulpitis
A. Symptomatic ( Symptomatic Irreversible Pulpitis)
aka “Acute Irreversible Pulpitis” but we don’t use
the term ‘acute’ for this anymore.
Pain is spontaneous
Does not need a stimulus but can be triggered by
stimulus. For example, uminom ng malamig and after
uminom, andun pa rin yung pain, lingering for hours.
Pain is lingering & spontaneous, pulsating & throbbing &
is usually affected by postural change because this is due to
the increase of blood pressure in the head which increases
intrapulpal pressure in the pulp. Inflamed na nga yung pulp eh
tas dadagdagan mo pa ng pressure, sasakit talaga yon.
Usual Complaints of a Patient: “di makatulog sa gabi”.
Often they wouldn’t say it na “Doc tuwing humihiga po ako,
sumasakit” Di nila maoobserve yun. Ang maoobserve nila, di
sila makatulog sa gabi. Mapapansin nila yun kapag nakahiga
na sila bago matulog. It’s not because of the time. Nighttime
has nothing to do with it but it’s the postural change, the
bending position.
In SIP, pain may be referred
Referred Pain - actual source of infection is different from
where the patient perceives the pain
Anterior teeth seldom suffer from referred pain, madalas
posterior yan. Pain is a prominent feature of SIP kasi nga
symptomatic.
Pag nasa advanced stage na and SIP, sometimes the cold
stimulus can relieve the pain because it causes constriction
of blood vessels which decreases the intrapulpal pressure,
chances are there would be less pain. You can advise them to
put cold compress to the affected area to relieve the pain.
 B. Asymptomatic ( Asymptomatic Irreversible
Pulpitis)
No clinical symptoms, no pain, Kung meron mang
pain, mild to moderate lang yan, short-lasting,
occasional. Could have a history of spontaneous pain
but don’t have anymore at present. Pwede ganun ang
HPI ng patient.
Clinical Variations:
● Internal root resorption (indicates that pulp is
irreversible, inflamed - and the only way that the
resorption can be stopped is via RCT) Di naman kasi
to symptomatic, walang nararamdaman ang pasyente.
● Pulp Polyp / Pulp Hyperplasia / Chronic
Hyperplastic Pulpitis - common in young patients,
young adolescents. low intensity and pain niya. Long
term irritation of pulp, has red pulpal mass in the
cavity, common in 1st permanent molar.
3. Necrosis. Asymptomatic. May have a history of pain
na nawala na in the present. May be discolored if
long-standing (brownish or grayish in color).
Indicated for RCT.
4. Previously Treated (exclusive for endo only).
Tooth that has undergone treatment but has failed.
RCT, obturated, re-treated. As such RCT should be
done again, if possible. Is it re-treatable? If yes, you
need to have the diagnosis that it is. This would be
cases na inobturate, tapos nagkaroon ng re-infection.
5. Previously Initiated Therapy (exclusive for endo,
additional diagnosis). Partial treatment was done
due to an emergency. Pulpotomy and pulpectomy are
initial treatments. This would be cases na in-open tas
treatment was not final.
Sa lahat ng pulpal diseases, Reversible Pulpitis ang hindi
indicated for RCT. The rest indicated for RCT or extraction.
Normal Diagnosis
- You can diagnose as normal.
- Normal pulp
- Normal periapex
- There is little pressure when you do
percussion but there is no pain, tenderness or
If the sinus tract is seen on 22, do not assume that it is the
discomfort
source of infection because it can be the adjacent tooth (23).
- Radiographically, the PDL space and lamina
dura is intact, uniform and continuous
- Lamina dura - thin radioopaque line that
surrounds the root of the tooth right next to
PDL space.
( 5 ) PERIAPICAL DISEASES
1. Symptomatic Apical Periodontitis
Radiograph either meron or wala with pain. Need for
RCT/only tx? You will only do RCT if the partner of
pulpal diagnosis is necrosis. THE TREATMENT
DEPENDS ON THE PULPAL DIAGNOSIS.
POSSIBLE CAUSE COULD BE PREMATURE
CONTACT (1-2 DAYS MAWAWALA YUNG
PAIN).
● Presence of inflamed periodontal tissue
● Pain on biting, use your finger to test so that
the test wouldn’t be too much for the patient
compared to butt end of the mouth mirror.
● When percussed, oops masakit. Positive to
percussion.
● If the patient doesn’t respond, you may
switch to a mouth mirror & then you do a
palpation test it will help you determine if
there is swelling or bony expansion.
● Radiographic findings could be normal or
not.
● Diagnosis could be reversible or irreversible
etc.
● You can do RCT IF THE PULPAL
DIAGNOSIS IS IRREVERSIBLE
PULPITIS AND NECROSIS.
● BUT IF THE PULP IS NORMAL and there
is pain upon biting, check if there is
premature contact due to overfill restoration.
Upon removal of this premature contact, in
1-2 days mawawala ang pain
2. Asymptomatic Apical Periodontitis
● Associated with necrotic pulp. Percussion &
palpation is negative. Radiograph will
always have radiolucencies pero walang
pain
3. Chronic Apical Abscess
● Associated with necrotic pulp. There’s little
or no discomfort since there is a long-
standing lesion.
● There are radiolucencies.
● There's a pathognomonic sign - sinus tract
opening (pus usually comes out. Bavarian
cream).
● They put gutta percha to show where the
pain on the tooth is, usually there’s no pain
but you can put topical anesthesia
● There is no pain because there is no pressure
build-up because the pus is able to exit
through the sinus tract.
4. Acute Apical Abscess
● Associated with necrotic pulp. Rapid onset
of severe pain and swelling & long-standing
● Talagang maghahanap ng dentista nag
patient kasi namamaga, super sakit,
sometimes with fever pa. Sobrang masakit
ito.
● Minsan may lymphadenopathy, inflamed
ang lymph nodes (ito ang indications niya)
● Radiograph sometimes has no
radiolucencies, loss of continuity of lamina
dura “disrupted”
 ● There can be periapical radiolucency or
none
5. Condensing Osteitis
● Localized bony reaction to a low grade
stimulus. Asymptomatic.
● Radiographic appearance is radiopaque seen
at the apex of the tooth but usually is
asymptomatic.
● Instead of radiolucency, radiopacity.
● Common in molars & usually involves the
mesial roots
QUESTION: IS RADIOGRAPH SIGNIFICANT TEST IN
PULPAL DIAGNOSIS? CAN YOU SEE THE PULP ON
THE RADIOGRAPH?
ANSWER: NO. WHEN YOU ARE DIAGNOSING THE
PULP, WE CAN’T SEE THE PULP IN THE
RADIOGRAPH, YOU’LL ONLY SEE THE PULP SPACE,
TISSUE. WHAT IS IMPORTANT IS THE SYMPTOM.
ALWAYS LISTEN TO YOUR PATIENT. THEN DO A
CONFIRMATORY TEST BECAUSE A PULP IS
DEPENDENT ON THE STIMULUS. SA PULPAL
DISEASE, MAKINIG KA LANG SA PATIENT, MAY
INITIAL DIAGNOSIS KA NA PERO HINDI KASAMA
DOON ANG RADIOGRAPH.
QUESTION: PERCUSSION, IS IT SIGNIFICANT IN
DIAGNOSING PULPAL DISEASE?
ANSWER: NO. PERCUSSION IS A PERIAPICAL TEST,
NOT FOR PULPAL CONDITION.
CASE SELECTION & TREATMENT PLANNING
Why Do Case Selection?
Because not all painful teeth are for endo. Success of endo tx
depends on how you choose your case.
1. To determine if root canal treatment (RCT) should be
performed.
Example:
- Symptomatic Irreversible Pulpitis + periodontal support then retain the other half
Asymptomatic Apical Periodontitis
2. To determine if RCT can be performed.
Factors:
- Itsura ng canal
- Curvature ng root manageable ba
- Patient mo ba highly motivated
- Do you have enough instruments
- Do you have the skill
- Etc. mamaya madiscuss
( 6 ) INDICATIONS FOR RCT
● Teeth with irreversible pulp disease or with necrotic
pulp with or without periapical disease.
● Teeth with pulps that would be compromised during
dental procedures (we call this intentional / elective
root canal treatment)
1. Overdenture Abutments
2. Limited Correction of Alignment
For example, your central incisors are
labioverted but the patient cannot afford
ortho treatment.
Now studying all the possible course of
action, you and the patient have agreed that
you will be crowning the two central
incisors with the correct alignment given
that the labioversion is minimal.
Kaso kapag naglabial reduction ka, pwede
mo ma-expose ang pulp. So, if that is the
case, you can do RCT and there would be no
limit as to how much tooth preparation you
can do labially because you already did
RCT.
3. Restorative Needs. The patient presents a
tooth with an extensive cavity, you assume
there’s no pulp exposure.
After removing all the undermined tooth
enamel, the tooth may not be able to retain
the restoration.
Anlala na pala to do point na need mo
maglagay ng reinforcement, na need mo na
maglagay ng post so mag-r-Rct ka talaga.
4. Complexion + Questionable Pulp Status.
But medyo leaning to pulpal inflammation,
it’s safe to do RCT rather than putting a
crown & later on patients would complain of
pain edi sisirain mo rin, what a waste of
money, time and effort.
5. Root Resection, Hemisection,
Bicuspidization. You can do RCT to those
with good support, just remove the poor
by performing RCT on this half.
6. Traumatically Displaced or Avulsed
Teeth E.g., boxers, you could reimplant
right away but it is time bound. It could
reattach but no assurance that pulp could
regain its vitality.
(4) CONSIDERATIONS WHEN THE CASE IS
INDICATED
1. The tooth should be restorable
2. Does it have adequate periodontal support - take into
consideration the periodontal support of the tooth.
3. Presence of a pathologic condition - there’s internal
root resorption. RCT not indicated.
 4. Whether or not the tooth has strategic value.
(diagnosis is previously treated).
With pictures:
1. The tooth should be restorable
CAN IT BE DONE BY YOU?
● If not restorable, you can opt for extraction then
implant.
2. Does it have adequate periodontal support - take into
consideration the periodontal support of the tooth.
● The previous treatment has not been done properly,
yung canal preparation and obturation not done
properly so nagkaroon ng infection sa periapex.
● Retreatment is needed in this case as it is a valuable
tooth.
1. Patient Considerations
a. Medical conditions
b. Local Anesthesia considerations - allergy
c. Personal factors - e.g., limited mouth
opening, motivation to preserve dentition
(who would rather have the tooth extracted,
pero still try to educate them), physical
impairment
2. Objective Clinical Findings
a. Difficulty in obtaining films of diagnostic
value
b. Malpositioned teeth
c. Pulp space
d. Root morphology - dilaceration
e. Apical morphology

Others:
a. Problem with isolation
3. Presence of a pathologic condition - there’s internal b. Existing restorations (example: mga
root resorption. RCT not indicated. pasyenteng ayaw ipagalaw yung fixed
bridge)
In this case, the walls have already resorbed and is c. Fracture resorption
not an ordinary case of open apex. d. Trauma
e. Previous RCT
Internal root resorption is usually progressive so this f. Procedural errors
will resorb overtime. So, RCT will not be applicable
anymore as this is through and through already. 3. Clinician’s Level of Expertise

If yung resorption hindi pa connected sa outside of 4. Availability of Necessary Equipment &

the root, pwede pa i-RCT pero kung ganto ka- Instruments
aggressive, di na to kaya ng RCT. - If 27mm yung haba ng canal mo tas 25mm lang mga
files mo, di pwede yun.

TREATMENT PLANNING
Treatment Objective: To restore health, function & esthetics

Treatment Planning Objective: To achieve treatment goals

efficiently

TREATMENT PLAN
● Personalized
○ No two patients are the same in terms of
4. Whether or not the tooth has strategic value. dentition so for each patient, there is an
(diagnosis is previously treated). individual treatment plan
● Flexible
○ The patient has the final say on the choice of
treatment
○ We cannot force a patient to undergo
treatment that he/she doesn’t want.

( 3 ) TREATMENT PHASES
A. PRE-TREATMENT PHASE
● Prepare the field to facilitate performance of
treatment proper
● When a tooth will be used as an abutment
● OHI, S/P, caries control
● Previously treated - pulpal diagnosis.
 ○ Never start a treatment without
giving proper education on proper
oral hygiene kasi kahit i-RCT mo
yan tas di nya ittoothbrush, edi
wala rin yung treatment mo
3. Cotton pliers (locking)
○ Make sure that the patient knows
how to maintain proper oral - Para hindi continuous yung finger pressure
hygiene - Without a lock, when you pick up a paper
point, continuous yung pressure mo and it
B. TREATMENT PHASE would stress your finger right away
● Chief complaint - address chief complaint 4. Endodontics spoon excavator
before anything else especially pain, relieve - The neck of ordinary is shorter
pain first on treatment plan
- Unlike ESE, a longer shaft can reach the
● Other possible procedures you might need
● Extraction, RCT chamber in molar and premolar
● Restoration 5. Woodson plastic filling instrument
● Prosthetic rehabilitation - Common mistake of clinicians: not plastic.
● Orthodontic treatment - Actually made of metal
● Periodontal therapy - We use this for loading temporary filling,
compressing cavities into preparation.
C. MAINTENANCE PHASE
● To monitor healing
● To detect new disease
● Recall radiographs

SINGLE VISIT VS. MULTIPLE VISIT RCT

(5) Factors To Consider
1. Diagnosis
● Vital cases with normal apical tissues -
pwedeng single visit
● Cases with pulp necrosis & apical
periodontitis - multiple visits because mas
maraming bacteria and need a lot of time to
reduce and to improve the patient’s
periapical condition
2. Severity of the Patient’s Symptoms
- Kapag in pain ang pasyente, may lagnat,
probably multiple visit yan
3. Anatomy of the Pulp Cavity - if may dilaceration,
tignan mo kung kaya mo
4. Clinician’s Skill
5. Retreatment Cases - are problematic that’s why
multiple visits to
** Kapag challenging, probably multiple visit yan
ISOLATION
( 4 ) Reasons for using rubber dam:
1. Protects the patient from aspiration. ( aspiration of
instruments, clamps, files, solutions)
2. Prevents infection from fluids (saliva, blood) once
you have opened an access preparation which
prevents increase in microbial load.
3. It allows retraction of the soft tissues tissues and
tongue.
4. Enhances access so bacteria will not be introduced
into the canals. As I mentioned before, the oral cavity
has a lot of bacteria, there are a lot of teeth with
cavities. That's why part of the pre-treatment phase is
restoration of the carious tooth.
That's why we restore to minimize the amount of bacteria. One
way to help prevent bacteria from entering into the tooth being
treated RCT, is through rubber dam isolation.

( 5 ) BASIC HAND INSTRUMENTS

( 6 ) MATERIALS OF RUBBER DAM ISOLATION (pls
50% skill in dentists, 50% materials. If you’re not using
insert pics)
proper instruments, it’ll affect your performance. Understand
1. Rubber dam sheet - it is used to retract & cover soft
the principles, theories and techniques.
tissues that are supposed to be protected & retracted.
1. Mouth mirror
It comes in different colors, thickness, and scent.
2. Rubber dam frame - could either be Young,
nygaard-Osby, metal. It is used to stretch the rubber
dam sheet in place.
2. Endodontic explorer (DG16)
- Explore floor of pulp chamber
- Path finder for orifices
- Also checks chamber roof & cervical ledges
 3. Rubber dam clamps - it also comes from different measure the exact what is only between .5. We don’t
designs and sizes. It functions to hold the rubber dam measure .3, .4, etc.
sheets in place around the tooth.

HOW DO YOU KNOW WHICH PROPER CLAMP TO

USE?
You check on the cervical diameter of the tooth you’re going
2. Rubber stops / stoppers - it designates working
to isolate & check the pinaka-mouth nung clamp mo & it
length. E.g, a 25 file, you put the stopper in the
should fit on the cervical area of the tooth. You don’t measure
middle of the file & then insert it into the hole then
the crown, kasi hindi mo naman sa pinakang crow i-adapt eh.
push it down. Now, pag nag stop, yun na yon - you
4. Rubber dam forceps - it carries the clamp into the
have the exact measurement of the tooth. When you
tooth.
put it inside the tooth, make sure it is touching or
5. Rubber dam stamps / template - it serves as a guide
resting on the reference point (cusp tip of molar or
on the correct area on where you are supposed to
incisal edge).
punch the hole.
6. Rubber dam punch - it creates the exact size of the
hole into the rubber dam sheet.
( 2 ) ORGANIZATION SYSTEM (pls insert pics)
1. Endodontic sterilizing box / endodontic organizer
- this is the simplest organizer you can buy just make
sure that it should be autoclavable. Ito yung
tambayan ng files. ( 2 ) ACCESS PREPARATION (pls insert pics)
1. High speed and low speed handpieces
2. Endodontic access burs
a. Round bur #2, #4. Round burs is for the
initial access. Especially if i’m working on
mandibular incisors, I use #1 round bur.

2. Clean stand - After you use the file, you clean it

here. Maraming debris na galing sa canal.
Tatanggalin mo yung debris by putting it here on
your clean stand which has a gauze or sponge with b. Fissure burs. To finish & smoothen the
antiseptic. Wala dapat tumatambay na files sa clean walls of your preparation.
stand. Should be autoclavable. Be particular with c. Special endodontic burs (Diamendo,
asepsis. Make sure you replace the gauze every Howard Martin, Endo 2 Bur). We usually
appointment use this for access prep of posteriors & if
you notice, most of them especially its tip is
non-end cutting (not damage it severely only
scratches but at least you wouldn’t burn out
the floor), but the purpose is to - in molar, it
has a floor right? If you use end-cutting, it’ll
damage the floor. Mortal sin yan kasi next to
( 2 ) MEASURING DEVICE (pls insert pics)
damaging is perforation na.
Every instrument that you put inside the canal should be
properly measured because if you will not measure it & just
insert it inside the canal, there’s a tendency that you would
perforate the apical area of the tooth which could cause further
( 3 ) CANAL IRRIGATION (pls insert pics)
infection. You have to carefully measure the instrument that
HOW MANY IRRIGATING SYRINGE DO YOU NEED?
you will put inside the canal, it has to have its measurement
2 or 3. 1 for loading of solution & 1 for aspiration.
before you put it inside.

1. Endodontic measuring block - each hole is

measured already to its length. The holes in the
middle represent point 5. In endodontics, we only
 3. K files
- #6 (pink), #8 (gray), #10 (violet) -
commonly used as the first instrument that
1. Irrigating syringe - if you will buy the plain one, should enter into your canal. Used if you
you will have to label it. 1 for irrigating & 1 for need to enlarge the canal
aspirating because you should not interchange them. - After probing the canal, use #10 to enlarge
2. Irrigating needle - you have to make use of the side the narrow canal since it is more rigid.
vented needle; yung butas wala sa dulo, nasa side
yung butas kasi kapag nasa side, it would flow evenly
in the walls not on the end. Pag ang butas nasa tip,
lalabas ang solution mo sa apex which we don’t want
to happen kasi pwedeng ma-irritate, lumabas yung
irrigant sa apex at ma-irritate ang periapical tissue.
Your irrigant should backflow. Pag masikip si needle,
you have to retract a little bit, make it lose para may
space for the solution to flow back and that is what
we want to happen. Gusto lang natin iwash ang canal BIOMECHANICAL PREPARATION / CANAL
at ayaw natin lumabas ang solution sa apex. ENLARGEMENT
3. Irrigating solution (5.25% NaOCl) - some would
use EDTA. We use it as a lubricant and for narrow
canals. If the case is non-vital we combine EDTA &
sodium hypochlorite “zonrox” - EDTA it helps
remove smear layer of dentin. Zonrox is plainly just
to disinfect the root canal.

Other patients would think that you’re trying to poison them,

you should be willing to explain to them what that is for. “We
use this po as an antibacterial agent, I will try my very best na STANDARD FILES SIZES
hindi niyo malasahan or malunok. Ayan po ay plainly just to
disinfect your root canal.” #6-#10 Increase of 2 units (6, 8, 10)

( 3 ) CANAL EXPLORATION (pls insert pics) #10-#60 Increase of 5 units (10,15, 20)
After mo mag-access ng canal you would have to explore. #60-#140 Increase of 10 units (60, 70, 80)
Ang RCT is like you’re going to a place you’re not familiar
with, you cannot see. Ganun ka-exciting ang RCT. If-feel mo
lang siya. You will try to explore a certain area. Color-coded
Color coding of files
Sa exploration, ffeel mo lang loob ng canal mo. #6 - pink
Dito mo malalaman if umaabot ba ko sa length ng canal ko, #8 - gray
may nagbblock ba sa canal ko, masikip ba canal ko, curved #10 - purple
canal ba to? #15 - white
1. Endodontic explorer (DG16) #20 - yellow
2. Canal probe #25 - red
● #12 (orange). It is used to locate small #30 - blue
canals not visible to the naked eye. A non- #35 - green
cutting and has adequate size to be inserted #40 - black
in narrow and unprepared canals. Ginagamit
sa super liit na canals.
Files
Standard length
● Posterior teeth - 21 & 25 mm. we use shorter files in
posterior teeth kasi kung sobrang haba nyan,
mahihirapan ka na maipapasok yan.
● Anterior teeth - 28 & 31 mm. ( 3 ) STERILIZATION FOR ENDO. PROCEDURE

( 2 ) Types of file material Techniques Description

a. Stainless steel - less expensive. More rigid. Limited
1. Sterilization Use of physical or
use only. You cannot use it on curved canals chemical procedure to
because it is rigid and hard, not bending. You may destroy all microbial
pre-bend it, but you cannot use it again, it should be life including bacterial
disposed of after use. Ito madalas na napuputol. endospores inside the
b. NiTi (Nickel Titanium) - mas mahal, more flexible. root canal and area of
You can use it on curved canals, it can curve by operation.
itself. You can use it more times than the stainless 2. Disinfection Elimination of virtually
steel files. all pathogenic
vegetative
ROTARY INSTRUMENTS / ENGINE DRIVEN: ProFile, microorganisms but
Quantec, Hero, PropTaper - is usually used in the clinic. does not eliminate
endospores.
( 5 ) OBTURATION (pls insert pics)
3. Barrier Technique Use of headcap, face
1. Lentulo spiral - we use this to load the sealer or to mask, rubber gloves,
spread, coat the walls of the canal with the sealer. eye wear, plastic
barriers.

SOME STERILIZING EQUIPMENTS: (INSERT PIC)

2. Spreader - used to do lateral compaction during Autoclave or pressure steam - sterilize the majority of
obturation. There is a hand spreader where we use instruments.
our hands; it is usually used for lateral compaction of
anterior teeth. Finger spreader is used for lateral
compaction on the posterior tooth.

Glass bead sterilizer - chairside means of sterilization.

Should be beside your working area.

3. Plugger - used for vertical compaction during

obturation.
Glutaraldehyde solution - commonly used if there is no
means of sterilization.

4. Gutta percha points - seal the major foramen of

your canal during obturation. Same color coding with
paper points
Full strength 5.25% NaOCl - sterilize only the gutta percha
points.

5. Paper points - it can be used during biomechanical

preparations too. It is used to dry the canals to absorb
the excess irrigant inside the canal and used to dry
the canal completely. It also comes with the same ACCESS PREPARATION
sizes as our files. Same color coding Access Cavity - the initial stage.
 ● It is the opening in the dental crown that permits 2. Law of Concentricity
localization, cleaning, shaping, disinfection, and
obturation of the root canal system.
● A properly prepared access cavity creates a smooth,
straight-line path to the canal system & ultimately to 3. Law of CEJ
the apex or position of the first curvature.
A proper access preparation can give you a non-problematic
experience. Smooth access from the opening, the orifice up to
the apex or up to the first curvature.

( 6 ) OBJECTIVES OF ACP 4. Law of Symmetry 1

1. Remove all caries when present
- to lessen or minimize presence of bacteria,
- for us to realize the sound tooth structure
remaining,
- for us to prevent any microleakage in 5. Law of Symmetry 2
between appointments kasi pag hindi mo 6. Law of Color Change - the floor is darker than the
tinanggal yung caries, dito mag leak yung walls.
fluid.
- Do not remove sound tooth structure as well
as overextend preparation as it can weaken
the tooth
2. Conserve sound tooth structure - when we access
prep, we have to be able to prepare the ideal 7. Law of Orifice Location 1
preparation only. We don't remove sound tooth 8. Law of Orifice Location 2
structure that is not supposed to be removed because 9. Law of Orifice Location 3
it will weaken the tooth.
3. Unroof the pulp chamber completely - you have to
remove the entire roof to expose the entire floor.
4. Remove all coronal pulp tissue (vital or necrotic) -
if it's removal of vital pulp, “Pulp extirpation” & here
we use a barbed broach. We just do “debridement”
which is similar to irrigation - this is a procedure 1.) REMOVAL OF ALL DEFECTIVE
where we flush out all the non-vital or necrotic debris RESTORATION AND CARIES BEFORE
through irrigation. ENTRY INTO THE PULP CHAMBER To
5. Locate all canal orifice - because canal orifice is the prevent further leakage.
opening to the root canal. If you can’t see the
opening, di mo mapapasok yan. All canal orifices
should be visible.
6. Achieve straight - or - direct-line access to the
apical foramen or to the initial curvature of the
canal. This is the main goal for access
preparation. 2.) REMOVAL OF UNSUPPORTED TOOTH
STRUCTURE To preserve sound tooth structure.
( 9 ) KRASNER AND RANKOW LAWS OF PULP Stable tooth structure is your reference point.
CHAMBER ANATOMY (pls insert pics)
With access preparation, you could use this as your guide. I
will not elaborate on this anymore, just check and read it on
canvas so you would be guided on your access preparation.
1. Law of Centrality

PROCEDURE (pls insert pics)
ANTERIOR
1. External Outline Form
Removal of caries & Determine the access start
restorations as necessary to
establish sound tooth margins.
The initial external outline
opening is on the lingual
surface. Whether it is
maxillary or mandibular, you
start at the lingual surface.
Penetrate the enamel &
slightly (1 mm) into dentin
using #2 or #4 round bur (or a
tapered fissure bur) on a high
speed handpiece. If your lower
incisor is too small, you will
need #1 round bur. You may
use low speed for a beginner at
baka ma-overwhelm ka sa
high speed.
_________________
2. Penetration of the Pulp
Chamber Roof
For anterior: with no. 2 or no.
4 round bur: penetrate into the
tooth to the roof until a drop
into the chamber is felt in an
angle that is perpendicular to
parallel to the long axis of the
root.
Drop is reaching the chamber.
POSTERIOR
1. External Outline Form
location:
The pulp chamber of posterior
teeth is positioned in the center
of the tooth at the level of the
CEJ. You have to locate the
pulp chamber.
Maxillary premolar - point of
entry is on the central groove
between the cusp tips.
Mandibular premolar -
adjust starting location to
compensate for the lingual tilt
of the crown.
Molars - correct starting
location is on the central
groove halfway between the
mesial and distal boundaries.
Always start on the central
groove.
#2 or #4 round bur (premolars)
and #4 or #6 round bur
(molars) on a high speed
handpiece may be used to
penetrate the enamel &
slightly (1 mm) into dentin.
Bur is directed perpendicular
to the occlusal table.
_________________
2. Penetration of the Pulp
Chamber Roof
After initial penetration, the
angle of penetration changes
from perpendicular to the
occlusal table to an angle
appropriate for penetration
through the roof of the pulp
chamber.
– Premolars: angle is parallel
to the long axis of the root/s
both in the mesiodistal &
_________________
3. Removal of the Chamber
Roof (Deroofing)
The remaining roof is removed
by catching the end of a round
bur under the lip of the dentin
roof and cutting on the bur’s
withdrawal stroke. Pag nag
drop ka sa chamber, outward
stroke na lahat. Hindi na
palalim kasi kung ganon,
papunta ka sa ilalim ng orifice
mo which is pwede kang mag
gauge sa pinakang orifice.
This enables the internal pulp
anatomy to dictate the external
outline from the access
opening Tanggalin mo lahat
ng roof. The goal. Kaya
movement of round bur is
sweeping out.
How many times should you
drop in an anterior or
posterior? 1 drop only
because we only have 1
buccolingual directions.
– Molars: angle is towards the
largest canal because the pulp
chamber space is usually
largest just occlusal to the
orifice of this canal; maxillary
- toward palatal orifice;
mandibular - toward distal
orifice.
Penetrate into the tooth to the
roof until a drop into the
chamber is felt.
An endodontic explorer is
used to probe the depth of the
access.
_________________
3. Removal of the Chamber
Roof (Deroofing)
The remaining roof is removed
by catching the end of a round
bur under the lip of the pulp
horn and cutting on the bur’s
occlusal withdrawal stroke.
Funnel the corners of the
access cavity directly into the
orifices using a safety tip
diamond or carbide bur.
chamber. We do not create
the orifice because the orifice
is already there & will come
out by itself.
You can use a non-end cutting
bur to avoid damaging the
floor.
_________________
4. Removal of the Lingual
Shoulder & Coronal Flaring
of the Orifice
Remove the shelf of dentin
that extends from the
cingulum to a point
approximately 2mm apical to
the orifice.
Safety-tip diamond or carbide
bur - tip is placed 2mm apical
to the canal orifice and
inclined to the lingual during
rotation to slope the lingual
shoulder.
In anterior, you have to bevel
the margin in the incisal but
don’t flatten the incisal
because nothing now will hold
your temporary filling & will
cause dislodgement of
temporary filling.
Frequent dislodgment of
temporary filling - kaya hindi
ito finflatten ang incisal
margin
_________________
5. Straight Line Access
Determination
Using a small intracanal file
that can reach the apical
foramen or the first portion of
canal curvature with no
deflections.
Anterior tooth with big canal:
#10.
If small or laterals: #6 or #8
depending on the initial size of
the canal.
_________________
4. Identification of all canal
orifices
Orifices are located at the
corners of the final preparation
(junction of the floor and the
wall).
The access cavity should have
all orifices positioned entirely
on the pulp floor not into the
axial wall. Pag naghahanap ka
ng orifice, it should be entirely
on the floor.
“Mouse hole” effect is the
extension of an orifice into the
axial wall which indicates that
your access prep is still
underextended. Meaning, you
have to bawas sa wall para
maging ideal orifice mo,
entirely on the floor.
_________________
5. Removal of Cervical
Dentin Bulges & Orifice &
Coronal Flaring
Cervical bulges are shelves of
dentin that frequently
overhang orifices restricting
access into root canal and
accentuating existing canal
curvatures. You will check if
there's a need to lessen to
achieve the straight access.
Removes bulges safely with
burs or ultrasonic instruments
placed at orifice level and with
light pressure cut laterally
toward the dentin bulge to
remove overhanging ledges.
You are going to clear the
_________________
6. Visual Inspection of the
Access Cavity
Inspect for grooves that might
indicate an additional canal.
Evaluate orifice and coronal
portion of the canal for a
bifurcation. Remember, not all
anterior teeth are mono rooted.
The anatomy is highly
variable.
7. Refinement & 7. Visual Inspection of the
Smoothening of Restorative
Margins
Final step is to refine &
smooth cavosurface margins.
Smoothen walls using fissure
burs.
ACCESS OUTLINE FOR INDIVIDUAL TEETH
Maxillary Central & Lateral
Incisors (triangular)
Maxillary Canines (ovoid to
triangular kasi depende sa
shape ng roof ng pulp
chamber) always remember
what dictates the external
orifices to check if something
is blocking.
_________________
6. Straight Line Access
Determination
Files must have unimpeded
access to the apical foramen or
the first point of canal
curvature to perform properly.
Maglalagay ka na ng #10 na
file. Check mo dapat straight
at hindi nag bend kasi ibig
sabihin may nakaharang diyan
na tooth structure.
Pulp Chamber Floor
Ensure all canal orifices are
visible & no roof overhangs
are present.
_____________________
8. Refinement &
Smoothening of Restorative
Margins
Restorative margins should be
refined & smoothened to
minimize potential for coronal
leakage.
Maxillary Premolars
(extended ovoid
buccolingually) extended
ovoid na buccolingual, ha.
BAKA MAGPREP KAYO
NG MESIODISTAL, ANG
CANAL NIYAN AY
BUCCAL AT
PALATAL.Oki? It should be
extended ovoid
buccolingually.
Maxillary Molars (triangular)
Always remember that you
seldom would find a maxillary
molar with only 3 canals.
More frequent yung 4 canals.
 So, ganun rin sa internal anatomy ng ngipin. Pag nakita mo ng
outline of your access
preparation. It is always ang orifice mo ay nasa gitna, wag ka na maghanap ng iba pa.
dictated by the shape of the Mag-isa lang yan kasi it’s at the center. But if you have it at
roof of the pulp chamber kasi the side, nasa lateral yan, asahan mo meron pa sa kabila yan
pag natanggal mo ng buo yung kasi it is always symmetrical. That’s applicable only to
roof, that is the correct access mandibular molars.
outline. Your access outline is
always dictated by the shape
I would suggest, if you have extra natural tooth/specimen, mag
of the roof of your pulp
chamber. practice kayo, Kahit hand held na muna kung meron kayong
mga ngipin diyan na sira or ginagamit niyo na dati. If you
want to seek comments from me before Thursday, you can do
so. Kunan niyo ng picture then send it to my inbox, i’ll try to
make some comments if it needs to improve.

SCOUTING, EXPLORATION & IRRIGATION ( insert

Mandibular Central &
Lateral Incisors
(always triangular.
Misan ovoid din)
depende. How will you
know if it is triangular
or ovoid? Check it with
your explorer.
Mandibular Premolars
(usually mono rooted kaya round
lang, minsan ovoid kapag malaki
yung canal niya)
pics)
The following are procedures and guidelines in scouting &
exploration:
1. Probe the canal orifice with an endodontic
explorer (pathfinder/Stewart probe) to determine
the direction of the canal at the cervical third.

2. Establish the Trial Working Length (TWL).

Mandibular Canines Mandibular Molars (rhomboidal:4 a. Using the endo tooth model specimen
(usually ovoid or pwede / triangular: 3) will depend on how (JChenny), measure the tooth length (TL)
rin triangular kung many orifices you will have
from the reference point (incisal; anterior or
bata pa ang pasyente at
meron pang pulp horns) cusp tip/occlusal; posterior) to the apex or
end of the root. Whatever the measurement,
.YUNG subtract 2 mm as a safety factor to get the
GITNA, IT’S WRONG TWL.
OVEREXTENDED NA SIYA.

The Law of Symmetry applies on mandibular molars. Ang

galing kasi ni Lord eh, isipin mo - even the internal anatomy
of our tooth talagang na-design niya yun na may ganong
configuration na kahit ang loob ng anatomy ng ngipin, should
be symmetrical o pantay. It is very true on the mandibular
molar. Pag ang orifice mo nasa gitna kagaya nito, ibig sabihin
isa lang yan. Pag ang orifice mo nasa side, dalawa yan kasi
dapat meron siya laging partner sa kabilang side. Okay?
Parang mukha lang natin yan. Ilang nose ba ang meron ka,
Rochelle? 1 po. Oh diba kaya isa lang yan kasi nasa gitna yan.
How many eyes do you have Alfred? 2 po. Oh diba dalawa
yan isa sa kanan isa sa kaliwa.
How many heads do we have? Only one. Kaya nasa gitna.
How many hands do we have? Dalawa. Kaya both sides.
NOTE: TLI means Tooth Length Image applies to
radiographs. Wala naman tayong x-ray. So, TL lang.
Example ang measurement ng central mo is 25 edi minus 2 =
23 mm TWL mo.
Sa molar naman, ito palatal ha, make sure natatandaan mo
anong cusp tip ang ginamit mo for reference point kasi sa
molar, maraming cusp tip ang laman isa lang yan and every
cusp tip, iba ang height.
Halimbawa sa palatal, ito ang ginamit mong reference point -
tandaan mo, na ito ang ginamit mong cusp tip kasi dapat
consistent ka para hindi ka mamali sa measurement mo.
Okay?
 b. Record the measurement on your printed
portfolio.
I think the portfolio I have posted is on canvas. You may print
or download it for you to fill it up. Your final grade will be
based on the completion of your portfolio. As we go with
the procedure, you will be able to fill that portfolio with the
information that is needed depending on the exercise that
we’re about to be doing.
There’s one portfolio for central, one for premolar and one for
molar.
3. Mark on the scouting instruments of the TWL.
a. Mark the TWL on SS K-type files #8 and
#10 with rubber or silicone instrument stop.
b. Select which from the two files can glide
freely through the canal. The file that glided
through will be referred to as the scouting
instrument.
4. Confirm the canal morphology as the scouting
instrument was inserted apically.
a. Feel the patency of the root canal using the
scouting instrument. I-fill mo ngayon.
Pumapasok ba? Nag-glide ba ng canal yung
instrument mo.
b. Taking note of any abrupt changes in the
canal anatomy. At this point, you have to
identify what is blocking the canal.
c. Interpret the tactile information and take
note of the probable direction or location of
resistance and curvatures. Baka kailangan
mo lang i-redirect or di mo na-irrigate
properly kaya na-block ang canal mo ng
debris, need mo i-irrigate more. There is
some information that you have to observe
to do this procedure.
PROCEDURE AND GUIDELINES IN IRRIGATION
1. Prepare two (2) disposable hypodermic syringes.
Color code or label each of the syringes for easy
identification. One will be used to introduce the
irrigation solution & the other to aspirate excess
solution when the oral cavity is ready for sealing.
2. Prepare the irrigation solution.
a. In a clear & clean container, dilute 1 part of
5.25% Sodium hypochlorite (NAOCl) with
5 parts distilled water (1:5 ratio). If full
concentration is preferred, simply transfer
the commercially prepared 5.25% solution
in another container to conceal the brand. Ito
yung sinasabi ko na hindi dapat nakikita ng
patient mo yung Zonrox.
b. Fill up one syringe with the solution. Lift the
syringe with the needle in an upward
direction and tap the barrel to remove the
bubbles toward the surface of the solution.
Tap mo para kung may air, bubble, space.
Dapat walang empty space doon sa top at
walang bubbles kaya pinipitik yun.
c. Push the plunger & express out the trapped
air. Minsan may lumalabas na konting
solution, that’s fine.
That’s how you prepare your irrigating solution. It should be
freshly mixed every appointment kasi nag contaminate rin yan
pag matagal nang naka prepare, it precipitates under. Prepare
just enough for today. If there's an irrigating solution left,
dispose of it.
3. Irrigation of the canal.
a. Position the needle into the widest portion of
the canal allowing an adequate space for the
backflow of the solution. For narrow canals,
simply flood the pulp chamber with NAOCl.
b. Place a cotton ball next to the access
preparation to catch the backflow of the
solution.
c. Very slowly and without pressure, push the
syringe plunger to introduce at least 1 cc of
the solution into the canal. For narrow
canals, simply flood the chamber with the
solution.
d. Place a drop of lubricant.
e. File the canal once it’s ready.
f. Leave the solution inside the canal while
filling. Constantly irrigate before changing
the file size.
g. At the end of the instrumentation, and as a
final rinse before sealing the canal either
temporarily or permanently, repeat the
 procedure, except for the application of the How long? Seconds? Minutes? Hours?
lubricant (step d), until all dentin shavings Days?
or debris are flushed out of the canal. Intensity of pain? (rate the patient to rate the
pain, 10 being the most).
4. Aspirate the excess solution when the canal is
What provokes it, hold cold?
ready for drying & sealing. Is there something that relieves the pain?
a. With the second syringe, express out the air Other symptoms?
from the barrel by pushing the plunger to the 3. Medical & Dental History
fullest before insertion into the orifice.  Systemic conditions
b. Position the tip of the needle inside the root  Ask, “Naospital na po ba kayo?”
canal. “May iniinom na po ba kayo?”
c. Pull the plunger to aspirate the access “Why are you taking it?”
“Do you know why you’re taking it?”
irrigation solution & air.
 Your knowledge in pharmacology is
d. Repeat the procedure when necessary. necessary.
5. Dry the canal with sterile absorbent paper points.

EXTRACTION
a. Sterilize the absorbent paper points in an
autoclave. Paper points must have the same
size as the MAF. PHYSICAL EXAMINATION
b. Mark the WL on the paper points.
c. Pass the paper point over the flame of an
alcohol lamp 3x or immerse in glass beads
sterilizer for a few seconds.
d. Insert the sterilized absorbent paper into the
canal & swab the walls to the full WL
marker to absorb the fluids from the canal.
e. Repeat the procedure until the canal is “bone
dry”
6. Seal the canal either temporarily with Calcium
hydroxide (only when canal shaping was
completely done) or with final root canal
obturation materials.
ENDODONTIC (LABORATORY)
DIAGNOSIS
These diagnostic procedures will help you arrive at a diagnosis
with confirmatory tests to your tentative diagnosis and arrive
at a definitive diagnosis.
You need to record and analyze the results.
INTERVIEW
1. Chief Complaint
 “Doc, masakit po ipin ko.”
2. History of Present Illness You can use this data later on when you try to diagnose.
 Ask questions
 History of present condition DIAGNOSTIC TESTS
 Try to dig in the background of pain
 Does the px experience pain? When?
 More invasive than RCT.
 If a patient has a medical condition, ask yourself kaya
mo ba i-manage? If yes, go with RCT
 Always seek for doctor’s clearance if patient is
medically compromised for him or her to undergo
any dental procedure
1. General appearance
 Gait
 Physical deformity
 Special needs
 Limp
 Swollen parts of body
 Skin color (Unusual, black and blue)
2. Extraoral examination
 Check for swellings, lesions around the
mouth.
3. Intraoral examination
 Don’t go agad to the suspected tooth.
 Check the oral health muna of the patient.
Dami ba calcular deposits, caries?
 Oral Health Status is an important factor in
Endodontics dahil kahit gano kaganda yang
pagka-RCT mo, kung di marunong mag-
alaga yung patient ng oral hygiene, balewala
rin.
Clinical condition of suspected tooth:
 WNL “within normal limit”,
 pulp exposure,
 discoloration,
 prior access “e.g., in attempt in-root canal”,
 caries, restoration).
 Soft tissue exam: sinus tract, swelling
 These tests are done to be able to diagnose
what the problem is.
  This will help you arrive at a right diagnosis.
 Before doing anything to the patient, explain
it.
 Perform more than one test on one tooth.
 There should be a controlled tooth for your
comparison.
 Know what the normal response of the
patient is by using the response of the
control tooth
Controlled vs. Suspected Tooth
 There is no single test that will tell you
everything you need to know, you need to
do several tests.
 Know when the normal response is of a
normal tooth.
 Don't use controlled teeth with restorations.
Use the one within normal.
 You can use adjacent tooth or contralateral
tooth as long as they are normal
Vitality Test - determine blood supply if normal, intact.
Pulp Test
 We depend on stimulus
1. Thermal
“common, reliable.”
1.1 Cold Test
Tetrafluoroethane (Endo Ice)
ALTERNATIVE: sterile anesthesia empty carpule with water
then refrigerate
Procedure:
1. Give instructions to the patient.
 “May ilalagay po ako na malamig sa ngipin niyo”. -
IMPORTANT.
 “Pag may ngilo or sakit, taas kamay. Pag wala,
baba.”
 Pag taas kamay, start counting, pagbaba ng kamay
stop counting.
2. Isolate the area of the CT with cotton rolls & saliva ejector.
Dry the tooth with a small cotton ball/gauze. (Do not use
compressed air to dry! Bc may mga ngipin na nangingilo pag
nahahanginan)
3. Spray the refrigerant on an approximately-sized cotton
pellet.
4. Apply the cotton pellet on the labial/buccal surface,
approximating the middle or cervical third of the tooth. Not on
the incisal edge. If you’re applying on the cervical third, make
sure you do not come in contact with the gingiva. You’re
supposed to put it on an area that has the thinnest enamel,
manipis sa cervical kaso ayun nga malapit sa gingiva. Kaya
mas safe sa middle third. Kung sa middle third ka, dapat both
control and suspected tooth sa middle third lang.
5. When the patient raises his/her hand, withdraws the cold
stimulus then starts counting in seconds, until the patient puts
down his/her hand. (Count 1001, 1002, 1003….)
6. Record the duration of time from stimulus removal until the
time the patient puts down his or her hand. Also not the
intensity of the response of the patient.
a. Mild sensation = record as (+)
b. Moderate pain = record (++)
c. Severe pain = record as (+++)
If you’re going to give out a rating:
1-4 = mild
5-6 = moderate
10 = severe pain
It’s better to do control tooth first as to avoid bias on pain.
7. Do steps 1-6 on the Suspected Tooth
8. Do steps 1-6 on another Control Tooth (CT - CT may mean
contralateral tooth)
1.2 Heat Test
Has gutta percha wall
Procedure:
1. Give instructions to the patient
 “Pag may ngilo or sakit, taas kamay. Pag wala,
baba.”
 Pag taas kamay, start counting, pagbaba ng kamay
stop counting.
2. Isolate the area of the CT with cotton rolls and saliva
ejector. Dry the tooth with cotton/gauze.
3. Apply petroleum jelly to the labial/buccal surface of the CT.
Why? Because gutta percha is rubber medyo sticky pag
uminit, pwede siya dumikit sa ngipin
4. Heat the gutta percha ball in an open flame until warm, soft
and start to glisten or kintab.
5. Apply the GP ball to the labial/buccal surface,
approximating the middle or cervical third of the tooth.
6. When the patient raises his/her hand,withdraws the hot
stimulus then starts counting in seconds until the patient puts
down his or her hand
7. When the patient raises his/her hand, withdraws the cold po ang kamay kapag may nararamdaman po
stimulus then starts counting in seconds, until the patient puts kayong kakaiba”
down his/her hand. (Count 1001, 1002, 1003….)  EPT has a fast mode & slow mode. Should
8. Record the duration of time from stimulus removal until the always be slow mode
time the patient puts down his or her hand. Also not the  Put a blob of toothpaste on the tip of the
intensity of the response of the patient. EPT
a. Mild sensation = record as (+)  Complete the circuit by letting the patient
b. Moderate pain = record (++) touch the metal part of the EPT with the
c. Severe pain = record as (+++) pointer and middle finger, then turn the EPT
on
9. Do steps 1-6 on the Suspected Tooth o There are also EPT’s with “lip-
10. Do steps 1-6 on another Control Tooth (CT - CT may clip” that may be attached to the
mean contralateral tooth) lower lip (no need to touch metal
part)
 Different response levels DO NOT indicate
different stages of pulp degeneration
 It’s just a rough indicator of presence or
absence of vital nerve tissue
 YES or NO only (vital or not)
Procedure when using EPT:
2.) Test Cavity

1. Make sure the patient does not have a pacemaker, or fixed

orthodontic appliance. Remove RPD’s with metal framework -
not allowed
“Real test for vitality” 2. Give instructions to the patient
Pwedeng wag na gawin if satisfied ka sa cold & heat test. 3. Isolate the area of the CT with cotton rolls and saliva
ejector. Dry the tooth with cotton/gauze.
Procedure: 4. Put the setting of the EPT to slow mode
You drill until dentin * you will know the pulp is vital if there
is sensitivity felt by the patient.
 Not routinely done, because it is irreversible, invasive METHOD A METHOD B
& destructive.
5. Hang the lip clip on the 5. Apply toothpaste
 Sometimes if the previous tests mentioned are all
side of the patient’s mouth to (conductor) on tip of tester
inconclusive, there is no choice but to do a test
complete the circuit 6. Apply the electrode lip to
cavity. Pag mahirap i-interpret yung cold or heat test
6. Apply toothpaste dry tooth enamel on the
mo or inconclusive ang results, you can do this test
(conductor) on tip of tester labial/buccal surface,
cavity.
7. Apply the electrode lip to approximating the middle or
dry tooth enamel on the cervical third of the tooth
3.) Electric Pulp Test
labial/buccal surface, 7. Have the patient touch the
approximating the middle or EPT with the pointer and
cervical third of the tooth middle finger tot complete
the circuit

Isolation of the teeth is very critical
 Saliva is a conductor of electricity
 Isolate, then dry with a piece of gauze
 Always warn px about procedure
o “Gagamitin ko lang po itong gadge na ito sa
inyong ngipin. Medyo may mararamdaman
po kayong pain tingling sensation. Pakitaas
8. Press the button and observe while the reading on the EPT
increases (one unit increase per second)
***NOTE: For Method A, inform the patient that when he/she
feels something, the EPT will stio the tingling sensation
Pag hindi gumagalaw, ibig sabihin tooth is non responsive
Note: Among the 3, the thermal test is the easiest.
Periapical Test
1. Percussion
 When you give instruction, tell patient they will feel
something removing contact of the fingers from the
EPT wall
 For the condition of the periapex/periapical area.
 Even if +++ pain, pulp isn’t the related cause here.
 Ask them if they feel tenderness or pain?
 If it's different from what the control teeth
felt? Don’t be suggestive. Just extract on the
narrative of the patient
 Controlled > suspected > contralateral tooth
 You can change the sequence to prevent bias
 IS THE TOOTH VITAL WHEN YOU
PERCUSS IT?
 WHAT IS THE GOAL WHEN WE
PERCUSS THE TEETH?
 Goal of percussion: To test the condition
of the periapical.
 If positive, something is wrong with the
periapex but not with the pulp.
 Anterior teeth: percuss from the incisal & labial
surfaces
 Posterior: percuss from the occlusal, buccal & lingual
surfaces
 Do not tell the patient if you're percussing the
suspected tooth, to prevent bias.
Note the intensity of the response of the patient:
a. Mild sensation = record as (+)
b. Moderate pain = record as (++)
c. Severe pain = record as (+++)
2. Palpation
Procedure
 Apply the pressure, approximating the apex of the
tooth
 Aside from telling you if the inflammation has
extended the periapical area, you will also be able to
feel if there is a very soft or hard swelling.
 Make sure that your gloves don’t have excess rubber
at end of fingertips
 Palpate the mucosa, vestibule and the lingual
3. Radiographic
One of the most common basic necessity tests.
Not necessary in pulp.
You can see in this case that this has disrupted lamina dura,
less bone support, and the extent of caries.
#1 indication of a non-restorable tooth.is loss of bone support
and extensive caries
NOTE: Radiograph is insignificant to pulpal test. Only for
periapical area.
Tells you about the anatomy of the tooth, continuity of lamina
dura & periapical radiolucencies.
 Gum boil: if there’s sinus tract, ALWAYS TRACE
 Gum boil / parulis / open sinus tract
 Gum boil manifests in chronic apical periodontitis
 Using a #20 or #25 GP - because soft and flexible
Use thin Gutta Percha. Do not use expired Gutta
Percha, they are brittle when bended.
 Insert GP gently in the opening (the pus follows the
path of least resistance) there is no pain but you can
use topical anesthesia
 Stop if you can’t insert the GP anymore
 Then take a radiograph to know the source of
infection
 Be careful of some errors like using the wider end of
the GP or using a different size
 Can also tell if there is a possible endo-perio lesion
affecting the tooth
 Can tell you if the tooth can undergo RCT
(sometimes the tooth is not restorable anymore)
 If it is indicated, prescribed doing a CBCT.
Especially if it will help you understand the complex
anatomy of the tooth you will work on.
4. Periodontal Probing
 Useful in knowing if there is an endo-perio lesion
involved
 6 Sites to probe: mesial, mid-labial, distal,
mesiolingual, mid-lingual, distolingual
 Normal pocket depth : 2-3 mm
5. Mobility Test
 Determine the periodontal support
 Usee butt ends of 2 instruments (don’t use your
finger).
 Grade 1 , Grade 2 , Grade 3
 3 is severe mobility
SUPPLEMENTARY TESTS
1. Transillumination  Used when you cannot localize the location of the
pain.
Done if you suspect a presence of fracture  It is easier to anesthetize the maxillary area.
Could give you an idea whether the tooth is vital or not.  For example, you anesthetize an area, then the pain
Additional test if there is history of trauma or fracture suddenly disappears, then probably the pain comes
You can use light curing system or a strong light from that area.
Fractures can be seen in radiographs but it does not offer
definitive diagnosis for fracture. Better do transillumination to Record your data for every test and match it with pulpal and
confirm. periapical diagnosis.
Limited only fractures to the crown. If suspected root fracture,
do staining test Radiographic: destruction of lamina dura, periapical
radiolucency

Among the periapical diseases, alin doon may periapical

May fracture to. If wala tong fracture, dapat nailawan or
tumagos yung light hanggang lingual. Kaso hindi, so may
fracture to.
 Light will not traverse the fracture line
 Part beyond the fracture will be dark
 If there is no fracture, the entire tooth will be bright
Transillumination can also determine is the pulp is still vital or
not. Reddish or pinkish color indicates blood supply hence
vital. Black or brown color indicates no blood supply hence
not vital anymore.
2. Staining
Test for a suspected crown fracture using methylene dye.
Could show you the exact fracture line. Additional test if there
is history of trauma or fracture. Dye seeps through the crack
so when washed, the fracture can be seen.
3. Bite Test.
radiolucency
You cannot give proper treatment without proper diagnosis.
FINALS
SLIDE #1.
CANAL PREPARATION
other terms:
- biomechanical preparation,
- canal cleaning & shaping,
- canal enlargement.
Question: Why do we do canal preparation?
Answer: In order for the canal to receive a good obturation.
We clean & shape the canal so that it would be able to receive
a good obturation. We clean the canal to disinfect and remove
all the debris, smear layer, and bacteria inside the root canal.
Clean and shape magkasama yan.
Ako, I always compare this with cleaning the bathroom.
Imagine that the bathroom is the root canal. It isn’t enough to
clean your bathroom by just scrubbing (equivalent to shaping)
it. Ang partner ng scrubbing involves soap, water, detergent
(cleaning). Or how about the other way around? It isn’t
enough to just brush detergent and water without scrubbing.

They must come in pairs, you have the detergent and water as
well as you must do the scrubbing.
Additional test if there is history of trauma or fracture. This
can determine if the fracture has reached the pulp manifesting
through sharp pain when releasing from a bite. SLIDE #2.
First procedure
ORIFICE OPENING
 Tooth slooth is used (place the concave part of it on Objectives:
the cusp, then ask the patient to bite). 1. To enhance canal orifice.
There are some orifices that are too small. You need to make the
4. Selective Anesthesia Test size of the orifice a little bigger for accessibility.
2. Provide direct insertion of instrument to the apical third
of the root canal.
This is one of the goals in access preparation of the teeth. In
order for us to gain a straight line access from the opening, from
the chamber, or from the crown up to the apical third of the
canal.
 Anesthesia by elimination, when pain cannot be
identified.
1st photo: the instrument is deflected because there’s an area
in the wall called the Dentin shelf that wasn’t removed yet.
So, you have to remove it - this one is a Gates Glidden Drill.
You may use a rotary system (has orifice shaper) or a file. If
you have a rotary system, you may not use GGD or a file
anymore; orifice shaper is enough.
When removing the dentin shelf manually, using a file, it is a
bit difficult as you will have to really exert effort.
You see now the difference of the orientation of the file from
the 1st photo to the 2nd photo when the dentin shelf was
removed, now your file is a little bit straight. So, that’s the
purpose of orifice opening.
SLIDE #3.
ORIFICE OPENING
Procedure
This procedure is applicable only if we have an x-ray. I will
be skipping this part.
1. Estimate the trial working distance for trial working
length.
a. Determine TLI & approximate length of crown
from the radiograph.
Once you measure the incisal edge (reference point) up to
the apex of the tooth, we call this Tooth Length Image
only if we used an xray because there’s an image. But since
it’s only a specimen, we call this Tooth Length because
there’s no image. It’s just the tooth itself that we’re
measuring.
REFERENCE POINTS:
● Incisor - Incisal Edge
● Premolars / Molars - Cusp Tip
Measuring the specimen,
remember the cusp tip you used as your reference point
because you’ll be using the same reference point when you
insert your instrument.
b. Subtract 2 mm from TLI as a safe factor for errors
in radiograph.
E.g. TL: 27 mm
Once you measure the TL, you will now Subtract 2 mm
from the tooth length as a safety factor because there might
be a discrepancy (image is elongated or shortened) in the
radiograph. Others subtract 2 mm because the curvature of
the canal is there & we don’t necessarily need to reach the
end of the canal assuming that there’s a possible curvature.
TL: 27 mm - 2 = 25 mm
TWL: 25 mm
The radiograph will be referred to as TWL.
TWL becomes the basis of all the instruments that will be
inserted into the canal. All instruments inserted should be
measured.
In access preparation, you only irrigate the chamber.
After establishing the TWL you have to;
c. Approximate the cervical third of the root canal by
subtracting 8 mm from the TWL.
You have to approximate the cervical third or coronal ⅔ of
the canal. Pag orifice opening, you should only reach the
cervical third.
E.g. TWL: 22 mm
TL: 24 mm - 2 mm
TWL = 22 mm
22 mm - 8 mm = 14 mm is the length goal you should be
able to reach to open your orifice.
SLIDE #4. (pls insert pics)
ORIFICE OPENING
Procedure (cont…)
2. Orifice opening
a. Use of gates glidden drills. If you’re going to use
GGD, you need at least 3 consecutive sizes. This is to be

operated by a low speed handpiece. You first have to use
the biggest, next smaller size then the smallest. When using
the GGD, it should be rotating once you insert it &
sweeping out 3x. Drill, out, drill, out, drill, out then done. It
has to be continuously rotating as you put it in & out.
SLIDE #5. (pls insert pics)
ORIFICE OPENING
Procedure (cont…)
2. Orifice opening
b. Use of orifice shapers. One drill is only used to shape.
SLIDE #6. (pls insert pics)
ORIFICE OPENING
Procedure (cont…)
2. Orifice opening
c. Use of K-type files. In mono rooted (central incisors
having big orifices), you may start with file #80 because this
is the biggest file that you have.
Now, the ones with small orifices like molars especially
MB1, MB2 & sometimes the DB canal has small orifice, you
shouldn’t start at #80. You may start with #60 or #70.
Kung anong file ka nag uumpisa depends on the size of the
orifices. Big orifices = big file. Small orifices = tiny file.
On Thursday, you’ll be working on a CI, begin with #80. How
are you gonna do it? First, irrigate. Don’t insert it first ,
especially molars. Irrigate first. With the JChenny CI, I don’t
think you need EDTA or lubricant because the canal is big
enough. With the CI, irrigation is enough.
SLIDE #7. (pls insert pics)
IRRIGATION / DISINFECTION / LUBRICATION
● Ensure that the chamber and canal is full or
irrigant (2.5 - 5.25% Sodium Hypochlorite).
● Use a chelating agent / EDTA (liquid or paste).
Once you’re done irrigating, you may check the patency of
the canal if you wish to. In big canals, you may use #15. In
smaller canals, you may use #10.
Q: How are you gonna do it?
A: Get file #15, put a stopper then measure it on your TWL 22
mm & insert it inside your canal & make sure papasok siya
until 22 mm
Q:Doc, paano po kung 22 mm yung TWL pero hanggang 20
mm lang siya at ayaw na pumasok?
A: There could be a curvature, there could be a blockage
meaning you should irrigate more or there’s a calcification
blocking. If so, take a radiograph to see what’s blocking the
canal. You have to feel if it's hard or soft, if soft it could be a
pulp tissue.
SLIDE #8. (pls insert pics)
PATENCY CHECK
Objective: To check if your canal is patent. If there’s nothing
blocking the way. Once done, now you’re ready for an
orifice opening.

ORIFICE OPENING
● Get file #80
● Note: Coronal ⅔ is 14 mm
● Measure mo sa 14 mm
● Put a stopper until 14 mm only
● Insert it inside the canal
● Pag umabot siya sa 14 mm length mo na loose, it
means that your orifice is big enough. So, hindi ka
pwedeng mag orifice opening. If you can insert it
straight at umabot siya sa length mo na 14 mm, not
deflected - it means that your orifice is big enough.
Wait lang ah I have to answer this call xD
Going back, if your file #80 reached 14 mm, it means that
your orifice is open and big enough.
Q: How about you out file #80 & bitin yung stopper? Kasi
yung stopper mo hindi siya magttouch sa reference point mo
ibig sabihin hindi ka umabot sa 14 mm mo. What to do?
A: Push the stopper, it should touch the reference point & then
measure it using your measuring device.
Lets say your goal is 14 mm & you only got 12 mm. It’s fine.
Then you just tabulate. In the portfolio, there’s a tabulation
that you need to fill up.
In the coronal ⅔, file #80 reached 14 mm, then tapos na. Pero
halimbawa hindi. File #80 mo, 12 mm. Edi file #80 and the
length 12 mm.
Lagay mo yung file mo hanggang sa 12 mm & then you do
passive filing - when you turn your file ¼ turn only, pull,
insert again, ¼ turn, pull, insert again, ¼ turn, pull, insert
again for 3x. You will stop pag loose na yung file but make
sure you stay at 12 mm kung ano lang ang measurement niya
do not push on that kasi pag pinush mo gagalaw na yung
stopper mo, mali na yung length mo non. You have to stay to
your length until the file becomes loose. Kapag loose na, take
it out and put it on your clean stand, linisin mo because there’s
debris, dentin shavings.. Linisin mo sa clean stand mo and
ibalik mo sa organizer mo & the irrigate. Pagka-irrigate mo,
napansin mong short ka pa ng 2 mo, so after file #80 you now
proceed to #70 and do the same procedure. Halimbawa ang
file #70 nagreach na ng 14 mm. Measure mo file #70 mo,
lagyan mo ng stopper and measure it at 14 mm, lagay mo na
sa canal at pag lagay mo oops nag touch na stopper mo doon
sa reference point mo. Ibig sabihin yun na yun. All you have
to do is to file it. Passive file, passive file until it becomes
loose, irrigate your canal then tapos ka na sa orifice opening.
What if yung file #70 is 13 mm lang umabot. Osige, file mo
siya, tabulate. Yung #70 mo only 13 mm, okay? Then file
your canal. Do passive filing and then irrigate and then
proceed to the next file size which is #60. Check mo naman
ngayon ang file that would reach your computed length.
Kailangan mong mareach yung computed length.
Q: Doc, ano po yung 14 mm?
A: That’s your coronal 1/3 length. The one that you minus
from the TWL.
After mong ma-reach yung cervical third length mo. If you
want, you can do a patency checking again. Kasi mamaya
baka hindi ka naka-irrigate enough, nablock yan ng degree at
hindi na-patent canal mo. At least early at this point, mac-
correct mo. So, irrigate mo lang. Basta make sure before you
proceed, patent parin ang canal mo. Basta pag medyo duda ka,
patency check.
SLIDE #9. (pls insert pics)
CROWNDOWN
Subtract 4mm from the TWL to get the WD for the
coronal ⅔.
Q: How are you going to estimate the coronal ⅔ of your
canal?
A: You subtract 4 mm t o your TWL “22”.
TWL - 4 = 18 mm is your coronal ⅔ length and ito na yung
goal mo na kailangan mong i-reach.
Yung crown down technique, we start at the opening /
orifice going down. From the crown pababa.
We open first the taas, ibabaw bago natin i-touch the
narrowest portion of our root canal.
18 mm is our coronal’s ⅔ length. To reach this length, this is
what you’re going to do; (kindly refer to the next slide)
A higher file size is used at the cervical third and
progressively moves apically up to the cervical ⅔ of the
canal in a sequence from big to small size files.
● You will start with the biggest file #80.
● Measure it to your coronal ⅔ length which is 18
mm
● Then put it inside the canal
● Tignan mo kung hanggang saan maabot niya;
check mo where is that point where the file can fit
snuggly. Yung snug fitting lang yung hindi mo
kailangang i-push yung kung saan siya papasok na
may snug fitting hindi maluwag na maluwag at
hindi rin masikip na masikip.
● Pag na ipasok mo na siya doon, nandun yung
length na naabot ng file #80 & then move the
stopper.
● Kailangan yung stopper mo magreach or touch sa
reference point. Kailangan ganyan ang position
(kindly refer to the right photo).
● Then take it out, tabulate ka ng file #80. Iba iba
kasi ang tabulation, meron for orifice opening or
coronal ⅓ meron din sa coronal ⅔, iba rin yun.
Dito ka na sa tabulation ng coronal ⅔.
● So, file #80 ilang mm ang nareach niya.
Halimbawa ang nareach niya is 13 mm. Edi 13
mm lang. So most likely andito (cursor) lang file
#80 mo:
● Then, balik mo yung file, passive file until it
becomes loose. Kasi kanina diba may snug fitting?
Medyo masikip lang ng konti so ngayon
ipapaloosen mo konti by doing passive filling, the
¼ turn and pull until it becomes loose and then
clean the file, put it in your organizer then irrigate
your canal.
● When do you irrigate? Every time you finish
one filing before you proceed to the next file,
make sure you already have irrigated your canal.
● Then proceed, #70. Measure, fit inside the canal &
if it doesn't reach, move mo lang yung stopper
magtouch lang sa reference point mo & then
measure, tabulate, file, passive file, irrigate.
● Then proceed ka nanaman sa next file until
mareach mo yung coronal ⅔ length mo which is in
our example, 18 mm hanggang mareach mo itong
point na ito (refer to cursor) the cervical ⅔.
Naintindihan kung paano mag prepare ng coronal ⅔? So,
from big to small files yun hanggang mareach mo yung
point na to (refer to cursor).
● Pano mo malalaman na nareach mo na yung poit
na yun? Pag umabot ka na, di ba nagmeasure ka ng
18 mm naglagay ka ng file yung stopper ganyan na
itsura sa pic, walang space on top. Ibig sabihin
umabot ka na nga.
● Pero kapag pinasok mo and measured na 18 mm,
ayaw na pumasok nung file, may space in between
the reference point and rubber stopper, ibig sabihin
di mo pa narreach length mo. that’s why you have
to measure, push down the stopper para makapag
tabulate ka kung anong length lang nareach nya.
Hanggang mareach mo 18 mm.
● By th way, kung makikita niyo dun sa materials,
meron dun materials for rubber dam isolation.
● You will be working on it with a rubber dam
isolation. Yung access prep di kailangan na naka
rubber dam yun. Minsan kasi naooverlook yung
perforation kapag naka rubber dam agad. When
you will irrigate kelangan isolate yung tooth.
● Never irrigate na hindi nakarubber dam. Sa access,
pagkadrop and deroofing pwdeng di naka access
yun. Pag may initial checking na and okay na
outline, tyaka lang nagpapalagay ng rubber dam.
● During canal preparation dapat naka rubber dam
all the time.
Before you touch the apical portion or the apical preparation,
you have to establish your final working length. Kasi what we
have is just the trial working length minus 2. So, this time,
after you open and prepare the coronal ⅔, then you will now
proceed to the apical portion - this is when we establish our
final working length.
Now, paano mag establish ng final working length? Maraming
method, ways to determine. (kindly refer to the slide below);
WORKING LENGTH REGISTRATION
Ways to Determine the Working Length
 Yung picture sa right is a picture pag x-ray. But if you want to
1. Ingle’s Method (Add-Minus)
learn this meron sa canvas. Itong pic sa baba yung finafollow
2. Grossman’s Method (Mathematical equation)
pag may available na radiograph.
3. Weine’s Method (Subtract 1 mm from WL)
4. Tactile sense
Pag may radiograph and actial patient di no pwede bunutin
5. Paper point method
yung ngipin sa patient. We all base the measurement sa
6. Electronic devices (Apex locator, Root ZX, etc).
radiograph. Ito (sa baba) yung procedure which i will SKIP
KASI WALA TAYONG RADIOGRAPH.
We cannot do the add-minus because we don’t have the
radiograph. In the clinic, in actual patients, pag may x-ray,
what we do is either the add-minus or the mathematical
equation by Grossman. Now since wala tayong x-ray, we are
using a model, we can directly subtract .5 mm not from the
WL but from the Tooth Length. Let’s say your TL is 24 mm,
we will just subtract .5 mm & the final working length would
be 23.5 di na ginagamit yung 1 mm kasi mas gutso nila na
nasa dulo ka, 0.5 from the terminus.

But as a beginner, mas gusto namin na may safety factor dun.

Pang pro and pang endodontist na yung exact apical position
or apical terminus. PROCEDURE

Sa beginner dun tayo sa safest, we subtract not 1 mm, but
0.5. Dun tayo sa middle, hindi 1 mm kasi we believe na that 1
mm could still harbor bacteria. Hindi rin yung wala na,
eksatong eksakto kasi the fear that u might extrude kaya dun
tayo sa 0.5 na gitna.
With your model tooth, you don’t take out the tooth.
Nameasure mo na yan e. So kung ang tooth length mo ay 24
mm, magmaminus ka lang ng 0.5 mm. Your final working
length is now 23.5.
Itong final working length mo andito (cursor) ka na ngayon:
Use the Grossman’s method - mathematical equation.
TWL = AFL X TLI / SF - 1 mm
FWL (Final Working Length)
AFL (Actual Final Length) measurement of actual file
from the tip to the rubber stopper.
TLI (Tooth Length Image) measurement of the tooth on
the radiograph from the radiographic apex to the reference
point or rubber stopper.
SF (Shadow of File) measurement of the file on the
radiograph from the rubber stopper.

So, from 18 mm kanina sa coronal ⅔, yung final working SLIDE #13.

length mo ngayon is 23.5 dito sa apical portion.
FWL = AFL X TLI / SF - 1 mm
FWL = 23 mm X 25 mm / 23 mm - 1mm
FWL = 25 mm - 1 mm
FWL = 24 mm

Kung walang radiograph, just measure the model tooth. Yung

measurement mo ng tooth length minus 0.5

Now, sa apical preparation, meron ka nang FWL. After

coronal ⅔ preparation, FWL determination, apical preparation
na kasunod.

Sa portfolio niyo meron na naman ulit dun ng tabulation.

Here in apical preparation, iccanal, clean and shape na natin
yung apical portion kaya apical preparation;
APICAL PREPARATION
Procedure:
● Identify the IAF (#25) “Initial Apical File” This
is the first thing that you need to establish.
1. You may start with file #15. Put a
stopper, measure the FWL which is 23.5
then insert it in the canal & see if file #15
will snuggly fit in 23.5 mm na length & if
it’s snug fitted, then file #15 could be
your IAF.
Q: Pano pag very loose? Then you get
the next bigger file. Gamitin mo #25
Q: Paano kung masyadong masikip or
hindi umaabot? 23.5 mm ang FWL pero
23 mm lang, hindi eksakto? Edi you use
#10.
Pag masikip, go to maliit. Pag maluwag,
go to malaki. Logical diba.
Once you are established with IAF, you do a passive file. ¼
turn lang, ¼ turn, pull 3x.
Ngayon, kung mayroong curvature ang iyong canal, you
cannot do passive filing on a curved canal. Pag inikot mo
yan kahit ¼ lang, putol yan. What you should do here is an
anticurvature filing.
Anticurvature filing is done by inserting the file then
ihahagod mo siya kung saan may mas thicker na dentin.
Ang mas thicker na dentin is always on the outer. Never
file on the inner curve kasi on the inner curve, mas manipis
ang dentin diyan, pwede kang magkaroon ng stripping. So,
you should always file doon sa may outer curve where you
have a thicker dentin. So, ang hagod ng file mo is insert out,
hagod mo palabas, palabas, palabas. That is anticurvature
filing when you have a curved canal. Again, on a curved
canal you don’t do passive filing, you do anticurvature
filing.
Q: How will you know kung may curvature ang canal mo?
A: Pag sa actual patient makikita mo yun, you could have
examined the radiograph beforehand. So, alam mo na may
curve ka on a certain canal.
Now, doon naman sa mga specimen ninyo, check ninyo
kung may curvature. Next, file mo. So, passive filing.
Anticurvature filing kung may curve ang canal mo with
IAF.
Q: When do you stop?
A: Kapag lose na.
& then don't forget to irrigate. After IAF, there’s another
table for the identification of the MAF or Master Apical
File.
● Identify the MAF (#40)
Purpose of MAF is to prepare the apical third of
your canal, 3 sizes bigger.
Diba kanina ang IAF is 25? After 25, you will use 30. Your
30 should be measured based on your FWL which is 23.5
So, the file #30 should be 23.5. Measure it, put a stopper
then insert it inside your canal.
Sa umpisa masikip yan kasi ang pumasok lang na maluwag
is 25, that’s why you have to passive file (straight) or
anticurvature filing if curved, ¼ turn, ¼ turn hanggang
malose ang #30 mo at magreach siya sa 23.5 and then
tabulate it.
So, file #30 at length 23.5.
Hanggat hindi abot ng #30 mo ang FWL, don't proceed with
file #35 kasi pag nagproceed ka, baka magcreate ka pa ng
ledge so make sure na yung #30 nareach yung FWL before
ka mag #35. Then use the next file, #40.
The 4th file from the IAF is your MAF which is file #40.
From IAF to MAF, ang mga length niya should be your
FWL, pare pareho sila ng length.
● Prepare the apical third 3 sizes bigger
Another purpose of IAF to MAF is we want to create a
dentin matrix or apical matrix. Sa apical portion, you’re
trying to create a ledge sa pinakang apical constricture mo.
Diba, 25, 30 eh mas malaki diameter ng 30. Tapos gumamit
ka naman ng 35. Parang nag ccreate ka ng step doon sa
apical constricture. We call that the apical matrix or the
apical stop.
Significance of Apical Stop: everytime maglalagay ka ng
instrument or material that is same size with your MAF,
hindi siya lalabas kahit ipush mo siya kasi meron siyang
stopper don basta same size ng MAF ha and that is the
purpose why we file from IAF to MAF.

Apical Constricture is the narrowest portion of your canal
where all of your instrumentation should stop & if you go
beyond it, there are blood vess els that might cause severe
bleeding or hemorrhage kasi ibig sabihin, naperforate mo na.
Lumagpas ka na. Pwedeng mag continuous bleeding si patient.
IAF is #25. To get the MAF, kunin natin yung susunod na 3
sizes. 40 is the MAF.
On Thursday, pagka established mo ng IAF mo, you have to
take a photo of your IAF. Pwede mong tanggalin sa pagkaka
mount and take a photo. Labial or lingual nakalagay sa
portfolio pero I will not allow labial only lingual. Why?
Because nandoon ang inyong engraving. Then proceed ka sa
MAF.
SLIDE #15. (pls insert pics)
TAKE A RADIOGRAPH WITH MAF IN PLACE,
THIS CONFIRMS
A. Length
B. Placement
So, after apical preparation, naprepare mo na yung apex. You
have to take a step back preparation.
STEP-BACK PREPARATION
Objective: To create a taper at apical third after
establishing the MAF.
SLIDE #17 (pls insert pics)
From MAF, identify succeeding four bigger sizes.
Subtract 1mm from the WL every increase in file size. As
the file goes bigger, the WL becomes shorter
Diba kanina ang MAF natin kanina ay 40?
● So, you have to identify four bigger sizes.
● So, 45, 50, 55, 60.
● Pagkatapos mong gamitin ang 40, diba ang 40
ginamit mo to sa 23.5 na FWL?
● Paano mo ngayon gagamitin ang 45? You will
subtract 1 mm for every increasing file size as the
file goes bigger, the working length becomes
shorter. So lagi, minus 1 to 45, 50, 55, 60.
● Kung minus 1 sa 45, 23.5 - 1 = 22.5 ang length.
Insert it now to your canal then do a passive file,
make it loose, then irrigate. Then proceed to the
next file which is #50.
● Anong length ng 50? 22.5 - 1 = 21.5, measure mo,
insert it inside the canal, then file, passive file,
 irrigate your canal.
● Next file. 21.5 - 1 = 20.5, itong file #55. Then
passive file, irrigate. Then proceed to the last one;
● 20.5 - 1 = 19.5, file #60 mo is 19.5, passive file,
irrigate, make sure na kumpleto ang tabulation mo
for stepback.
Kaya ang canal preparation natin is a combination of crown
down and stepback technique. Because this is the crown
down, and this is the step back portion.
So, after step back.. Have you realized that filing na ginawa
natin is passive filing? Pwera nalang kung curved ang canal
mo, pwedeng mag anticurvature filing ka.
So, the passive filing that you’ve done, lahat yon mag create
ng cuts. Nagkaroon ng cuts sa canal everytime na
magppassive file ka kasi nilalaki mo yung canal mo.
Q: Ano na kayang itsurang canals mo? Is it smooth or rough
after all the filing you did?
A: Rough. Kasi you have cuts all over every time you passive
file
Q: How will you smoothen it?
A: You do that by doing final flaring.
FINAL FLARING
CIRCUMFERENTIAL FILING
Objective:
1. To file out irregularities on the canal walls
created by passive filing. So, lahat ng roughness,
irregularities doon, tatanggalin.
2. To finish the walls in a “glassy feel”. A glassy feel
is like a glass slab with water then try to run your
file in there, that should be the feeling inside your
canal.
The common misconception of clinicians, kasi they always
think of the word “circumferential” meaning pabilog. So ang
thinking nila, ang movement ng file sa loob ng canal is
paikot kasi nga circumferential filing.
Now, isipin niyo yung logic. Pag ginawa mo ang paikot na
yon, yung file na yon puro floops yan sa paligid kaya nga
siya pacut eh. Tapos, pag nilagay mo yan sa canal mo at
hinagod mo ng paikot, nasmoothen mo kaya yung canal mo
or mas lalo kang nagcut? Mas lalong nag cut.
In passive filing, ang file is at the center ip-push mo lang
doon sa pinakang constricted na part and then you turn it, ¼
turn, ¼ turn kaya masshape mo yung area na yon, magc-cut
siya.
But with circumferential filing, ang file mo nasa side. Nagt-
touch sa wall, sharp yan. Pag inikot mo to, eh diba mas
maraming kang cuts na ginawa?
Kaya sabi ko, kung ganyan ang thinking niyo of the
circumferential filing, mas aggressive ito. Kasi it’s not just
the tip of the cuts, it’s the entire file. Basta naka attach sa
wall at inikot mo, magccut yan.So, you’ve created more cuts
on the walls rather than making it smooth.
So, yung circumferential filing, ang file nakadikit siya
dapat sa wall. Don't turn the file because it will cut more.
Ang movement ngayon ng file mo is in & out but you don't
turn kasi nandito yung roughness or irregularities. Yung
buong circumference, you need to smoothen it.
The file we use in circumferential filing is only your
MAF.
Doon sa iba, dito sa step back, pagkatapos ng isang file..
e.g., #45 it recapitulates sa MAF para whatever irregularity
was created by #45, massmoothen out agad ng #40; meaning
babalikan mo. may babalikan ka. So, after ng #45, file #40.
Pagkatapos ng #50, file #40. #55 then #40 ulit. & pagkatapos
ng file #60, MAF, file #40 ulit. Just to make sure that you’re
not deviating from your final working length nar reach parin
siya even if you’re using bigger files. Pag ginawa niyo yon,
then you have lesser ledges na sa circumferential filing.
Pwedeng mag recapitulate, pwede ring hindi. Sakin pwedeng
hindi na basta maayos ang circumferential filing mo, you’ll be
able to achieve that glassy smooth walls.
Make sure when you do circumferential filing, your canal is
irrigated properly. Wet ang iyong canal with irrigant.
During canal preparation, diba lagi kayong mag irrigate?
Every time you change a file, irrigate. It’s enough to
magflowback or flush out lang yung debris but you don't have
to dry out your canal, no need to aspirate because if you dry
yung canal mo & we don’t file on a dry canal because we will
produce heat, there could be friction inside and heat is
something not friendly to the periodontium. So, never file on a
dry canal.. It should always be wet & irrigated para walang
maproduce na heat. Just irrigate then hayaan mo mag flow
back yung mga debris then file. Hindi dapat aabot ng apical
portion ang needle, okay? The farthest that your needle can
must be intact, rinse the Ca(OH)2 from the canal
reach is the middle third of your canal.
with NaOCl and proceed with the obturation
after canal evaluation.
Sodium hypochlorite may not be enough to remove the smear
layer. EDTA is effective. You don’t use EDTA as your final
irrigant, it’s always sodium hypochlorite because EDTA is a
SLIDE #20 (pls insert pics)
chelating agent (like a dentin softener), when it stays in your
canal for too long, pwedeng malusaw dentin walls mo.
Disinfection during multiple-visit RCT with necrotic
Combination lagi yan.
pulp:
1. Clean and shape with NaOCl and EDTA.
Ngayon may EDTA na gel type, you can place a portion, just
2. Place Ca(OH)2 in the canal.
drop it in the orifice & then insert your file but still you have
3. Seal the access opening well with temporary
to irrigate that out after kasi hindi pwedeng maiwan ang
filling.
EDTA sa loob ng canal. How long? Just a few minutes. Kasi
4. Upon reentry (after 7 days), temporary filling
paglagay mo naman it will take effect na agad.
must be intact, rinse the Ca(OH)2 from the canal
with NaOCl and proceed with the obturation
IAF
after canal evaluation. Necrotic pulp has much
Photo
more bacteria than inflamed.
MAF
Ca(OH)2 will act as an antibacterial agent. Then
Photo
finish. That’s the end.
Your photo should be after circumferential filing
Pag labial or lingual, lingual lang.
Q: Pag anticurvature, insert then labas?
After Final Flaring, your final procedure would be A: Yes. Ang hagod mo lang, you have to identify the direction
disinfection & temporarization after dismissing your patient; of the canal, nasaan ba yung curvature niya? Kailangan mong
i-identify saan banda yung curvature. Kasi dapat, ang hagod
ng file mo don is outer thicker portion. Dapat alam mo yung
curvature ng iyong canal when you do curvature filing. Tapos
in out in out lang yon. You don’t turn out the file kasi kapag
tinurn mo yung file, eh curve yung canal mo eh edi putol yan.
Alam niyo sa endo, very important ang tactile sense. Never
SLIDE #19 (pls insert pics)
force a file inside the canal. Wag niyong ipipilit kasi
mapuputulan kayo ng file.
DISINFECTION & TEMPORIZATION
Q: Paano kapag naputulan kami ng file?
Disinfection during multiple-visit RCT with inflamed
A: Then you have to retrieve it. There are a lot of techniques
pulp:
to retrieve a file but again, it’s easier said than done.
Pag inflamed pulp, ang diagnosis mo when you start is
irreversible pulpitis whether it’s symptomatic or
Q: Paano kapag hindi namin natanggal yung broken file
asymptomatic irreversible pulpitis. Basta kapag nag umpisa
inside the canal?
ka na vital ang pulp, inflamed lang.
A: If you’re working on a model tooth, then you have to work
1. Clean and shape with NaOCl and EDTA.
on another one. You have to repeat.
2. Place Ca(OH)2 in the canal. Calcium hydroxide.
You will mix it with distilled water. The mixture
Q: Paano kapag hindi namin natanggal yung broken file
should be mayonnaise-like. It shouldn’t be watery,
inside the canal sa actual patient?
so medyo thick ng konti.
A: You inform the patient that you have such an incident.
After mixing, you will put it inside the canal using
Exert all effort to retrieve. If not, well it depends kasi sa
your lentulo filler by coating it with Ca(OH)2,
location. Pag nasa apical portion yung broken instruments &
insert it inside the canal & then wiggle the lentulo
somehow medyo nalinis mo naman na yung canal, if really
filler para mag spread lang all over the canal.
unretrievable siya, we make it part of the material but we
Punuin mo yung canal mo with Ca(OH)2.
observe the case kasi pwedeng i-reject yon ng tissue.
Kailangan puno yung canal hanggang orifice lang.
Syempre hindi maiiwasan na malalagyan ng
A lot of cases naman sa clinic, minsan may broken instrument
chamber so remove it with your excavator na
but several years na nandon. Nir-recall naman yung patient,
napunta doon sa chamber - it should be clean at
wala namang symptom, so fine lang yun ibig sabihin inaccept
hanggang orifice lang. After that, put a sterile cotton
siya. Pero kasi pwedeng i-reject lalo na kung hindi sterile
pellet on the orifice, then take a photo of the
yung naputol na file kahit gawin mo yang part ng filling mo, it
position of the cotton., then the rest of the chamber
will harbor bacteria and it will grow.
will be placed with IRM.
3. Seal the access opening well with temporary
Q: Paano kung naging symptomatic? Namaga?
filling.
A: Then you have to do some surgery. Either you remove the
4. Upon reentry (after 3-4 days), temporary filling
entire tooth or you do apicoectomy wherein binubuksan ang
pinakang root at nir-retrieve from there yung broken
instrument. See how complicated it will be if you commit such
an error.
Q: Sa passive filing po, ¼ turn, ilalabas po ba muna?
A: Hindi mo siya ilalabas totally. Insert it in your canal, ¼
turn, just pull it a little, retract lang a little. Nasa loob yung file
all through out, retract mo lang a bit. Until mafeel mo siya na
loose, that’s the time for you to pull it out.
Q: Since naiwan po yung file sa loob, gaano katagal po
bago malaman if ni-reject po ng tissue?
A: Well, it depends on the patient and it depends on the
location of the broken instrument. Minsan, yung broken
instrument kasi lumalabas sa apical foramen minsan yung
kalahati nakabaon & when that happens, minsan may reaction
agad. A day after, masakit na agad or minsan after 2 days,
masakit na masakit na. Ibig sabihin, hindi accepted nung
tissue. Kasi foreign body yan eh so malalaman mo kaagad kasi
magkakaroon ng symptom. Minsan naman sa loob ng canal,
wala na agad reaction yan kasi kung may bacteria man, hindi
naman kaagad lalabas yung bacteria. It will still take time. The
bacteria may break the filling material then after that atsaka
palang siya lalabas sa apex and after atsaka palang
nararamdaman ng patient ang symptom.
May mga times naman na hindi, accepted siya. Pwedeng yung
naputol mo na instrument is sterile enough. Isa yun sa mga
advantage why we want all your instruments to be sterilized to
lessen the bacteria. If you have broken instruments but they
are sterile, it is possible that bacteria will not grow.
There’s a case where the tip of the file is left and the bone just
grew around the file. It was accepted. So, that happens.
On Thursday, we will do from rubber dam, to orifice opening,
coronal 1/3 preparation HANGGANG temporization.
Manufacturers recommend that the maximum times of use for
Stainless Steel Files is for 3-4 canals only. But if you have
already pre-curved the file, you can only use it once. Di mo
pwedeng ipilit yung straight sa file sa curved canal because
you will create another canal kapag ginawa mo yun. Di mo na
pwede hilutin yung curved na file kasi may tension na yan and
magweweaken na so may tendency na maputol. So, use pre-
curved files and then dispose.
With NiTi Files, no need to pre-curve anymore. They advise
NiTi files for curved canals. They can also be used more times
than stainless steel files.
Place Calcium Hydroxide into the whole pulp canals until the
orifice only by loading it to the Lentulo Fillers. Then place
cotton pellets, plug it into the orifice. Then place your IRM
covering the access preparation. Make sure it is not overfilled
or underfilled.
With regards to loading of Calcium Hydroxide, you can also
use your MAF. You have to coat MAF with Calcium
Hydroxide, insert into the canal and turn counter clockwise to
dislodge the Calcium Hydroxide and leave it in the canal. This
is because the flutes of the MAF are clockwise.
● Calcium up to orifice of canal
● Clean up floor of chamber because wala dapat
Calcium hydroxide sa floor of chamber
● Plug cotton pellet into the orifice
● Place IRM, do not overfill or underfill
Common error: placing large cotton pellets
Placing large cotton pellets will take up space in the chamber
and the tendency is that there will be thin space for the IRM.
What will happen is that the IRM will be easily dislodged.
Your patient will go home and the IRM might break or
dislodge. If there is no more IRM, the cotton pellet will be left.
The cotton pellet will be contaminated with saliva and
eventually, your calcium hydroxide will also be affected.
Remember, this procedure is for disinfection and
temporization. If the cotton pellet is saturated with fluid and
calcium hydroxide is affected then no disinfection will occur.
This will introduce infection and may worsen the previous
infection.
With dislodged IRM, obturation will not be allowed because
your canal is now again infected. What you will do is remove
the cotton pellet, re-file the canal removing the calcium
hydroxide, irrigate, re-file and re-do the procedure again.
—------END—------
Canvas (Lecture)
MODULE 1: INTRODUCTION
Endodontics is the branch of Dentistry concerned
with the human dental pulp and periradicular tissues. This
module will introduce you to the field of Endodontics, its
scope, its general objectives and its interrelationship with the
other disciplines of Dentistry. As you will be doing
independent learning, this module will involve tasks and
activities that require you to immediately apply what you
learned in your reading assignments. Your involvement in
your learning is expected to facilitate retention of the concepts
for your future use as clinicians.
ENDODONTICS
● is the branch of dentistry concerned with the
morphology, physiology and pathology of the human
dental pulp and periradicular tissues.
● Its study and practice encompass the basic and
clinical sciences including the biology of the normal
pulp and the etiology, diagnosis, prevention and
treatment of diseases and injuries of the pulp and
associated periradicular conditions.
The scope of endodontics includes, but is not limited to,
the:
 ● differential diagnosis and treatment of oral pains of
pulpal and/or periapical origin;
● vital pulp therapy such as pulp capping and
pulpotomy;
● nonsurgical treatment of root canal systems with or
without periradicular pathosis of pulpal origin, and
the obturation of these root canal systems;
● selective surgical removal of pathological tissues
resulting from pulpal pathosis;
● intentional replantation and replantation of avulsed
teeth;
● surgical removal of tooth structure such as in:
○ root-end resection
○ hemisection
○ root resection
● endodontic implants;
● bleaching of discolored dentin and enamel (teeth);
● retreatment of teeth previously treated
endodontically;
● treatment procedures related to coronal restorations
by means of post and/or cores involving the root
canal space
General Objectives of Endodontics
The following are the primary objectives of Endodontic
Treatment:
● Prevent pulpal/periradicular pathosis
● Intercept pulpal/periradicular pathosis
● Preserve the natural dentition when affected by
pathosis
That is, the dentist should be able to relieve pain (if present),
bring the tooth back to a healthy state in order to retain the
tooth and prevent re-infection. Retaining the tooth in the oral
cavity not only preserves aesthetics but also preserves
occlusion which results in proper function and mastication.
The primary cause of pulpal and periradicular pathosis are the
microorganisms. Through cleaning of the root canal system,
endodontic treatment reduces the volume of microorganisms
in a pathosis to a level compatible with healing. It is important
that the root canal system is filled (obturated) to prevent re-
infectionS
Significance of Endodontic in other field of Dentistry
This module presents an overview of the interrelationship of
Endodontics with other fields of Dentistry. For a more detailed
discussion, please refer to pp. 82-86 of Cohen's Pathways of
the Pulp
1. Endodontics and Periodontics
● The interrelationships between pulpal and periodontal
disease primarily occur by way of the intimate
anatomic and vascular connections between the pulp
and the periodontium.
● Extensive periodontal lesions may complicate
endodontic prognosis.
● Lesions with endodontic and periodontal components
may necessitate consultation with an endodontist or
periodontist in order to gather more information
about the tooth’s prognosis.
2. Endodontics, Restorative Dentistry and Prosthodontics
● The quality of the coronal restoration is as important
as the quality of the root canal treatment.
● Therefore, to increase the success of the treatment, it
is strongly suggested that the clinician discuss the
restorative plan of the tooth with both the patient and
the referring dentists (if referred patient) before
initiation of treatment.
● Some teeth may be endodontically treatable but non-
restorable, or they may represent a potential
restorative complication because of a large
prosthesis.
● Whenever possible, restorations should be removed
before endodontic treatment.
Full coverage restorations are usually suggested after
endodontic treatment. A systematic review on tooth survival
following non-surgical root canal treatment, four factors
were found to be of significance in tooth survival:
● A crown restoration after root canal treatment
● Tooth having both mesial and distal proximal
contacts
● Tooth not functioning as an abutment for removable
or fixed prosthesis
● Tooth type or specifically non-molar teeth
Problems with restoration must be recognized before
endodontic treatment is initiated. For complex cases, a
restorative treatment plan should be in place before initiating
endodontic treatment
3. Endodontics and Surgery
● Surgical evaluation is particularly valuable in the
diagnosis of lesions that may be nonodontogenic.
 ● When retreatment is being considered, the clinician
2. The clinician questions the patient about the
must determine whether nonsurgical, surgical, or
symptoms and history that led to the visit.
combined treatment is appropriate
3. The clinician performs objective clinical tests.
● Endodontic surgery is most often performed in an
4. The clinician correlates the objective findings with the
attempt to improve the apical seal and correct failure
subjective details and creates a tentative list of
of nonsurgical therapy. Bacteria are the essential
differential diagnoses.
cause of failure.
5. The clinician formulates a definitive diagnosis.
● Endodontic surgery may also be performed as a
● No appropriate treatment recommendation can be
primary procedure when there are complications such
made until the clinician has arrived on a definitive
as calcific metamorphosis.
diagnosis. (Hargreaves, et. al, 2011).
MODULE 2: M2 Objectives and Basic Principles of Root
Canal Treatment (Introduction)
As with all other disciplines of Dentistry, there are principles 3. BIOMECHANICAL PREPARATION
governing Endodontic Treatments. This module will briefly
The clinical management of infected root canals undergoing
discuss those principles and provide an overview of concepts
nonsurgical root canal treatment involves instrumentation and
that will be discussed in detail in the succeeding modules. As
disinfection. Instrumentation disrupts biofilms which colonize
you will be doing independent learning, this module will
infected soft and hard tissues, and provides access for irrigation
involve tasks and activities that require you to immediately
and exposure to antimicrobial solutions for disinfection of the
apply what you learned in your reading assignments. Your
root canal system.
involvement in your learning is expected to facilitate retention
Instrumentation also shapes the root canal system. The purpose
of the concepts for your future use as clinicians.
of shaping is to facilitate debridement and disinfection and to
provide space for the placement of obturation materials. The
( 7 ) STEPS
main technical objectives of shaping are to maintain the apical
foramen in its original position, allowing it to remain as small
1. ASEPSIS
as possible, and to develop a continuously tapering funneled
The primary etiologic agents of pulpal and periapical pathosis preparation from the canal orifice to the apex allowing the
are microorganisms and their byproducts Biofilms are involved tapered shape to provide apical resistance during obturation.
in all stages of root canal infection and can be found on root ● Only a well-prepared canal system can provide ideal
canals walls, in dentinal tubules, and on extra-radicular conditions for appropriate obturation. A well shaped
surfaces (AAE, 2018). and well-debrided canal system will potentially create
Successful endodontic treatment depends on effective measures the conditions for healing periapical tissues (AAE,
to eliminate and prevent infection of root canals. Initially 2018).
treatment should start with isolation and disinfection of the
operating field (Malmberg, Bjökner, Bergenholtz, 2016).
4. DISINFECTION
● This simply means using a rubber dam during the Disinfection is achieved by the use of both antimicrobial agents
duration of endodontic treatment. No endodontic and the mechanical flushing action of irrigation, with the goal
treatment must be done without placing a rubber dam. being the disruption, displacement and removal of pulpal
Additionally, all of the armamentaria must be remnants, microorganisms, metabolic byproducts, debris and
sterilized or disinfected to prevent microbial infection. the smear layer created during instrumentation. When
treatment is provided over multiple appointments,
interappointment intracanal medicaments provide additional
2. DIAGNOSIS
opportunities for disinfection (AAE, 2018)
Diagnosis is the art and science of detecting and distinguishing
deviations from health and the cause and nature thereof. The
5. OBTURATION
process of determining the existence of an oral pathosis is the
culmination of the art and science of making an accurate
In general, canals should only be filled when the patient is
diagnosis.
asymptomatic, there are no signs or symptoms of pathosis,
The process of making a diagnosis can be divided into five
and the canal can be dried. A good primary fit with apical
stages:
tug-back of a master cone is one adjusted to fit both the
1. The patient tells the clinician the reasons for seeking
apical size and the taper of the preparation. This is critical to
advice.

promote a good obturation.
● Prepared and filled canals should demonstrate a
homogenous radiopaque appearance, free of voids
and filled to working length (AAE, 2018).
6. CROWN RESTORATION AFTER ROOT CANAL
TREATMENT
As per the discussion in the previous module, the quality of
the coronal restoration is as important as the quality of the
root canal treatment.
● Root canal treatment should not be considered
finished until the tooth in question is restored in a
timely and adequate fashion. It is clear from the
literature that any delay between endodontic
treatment and tooth restoration should be as brief as
possible, since numerous studies report that there is
notably reduced survival after endodontic treatment
for teeth restored with temporary restorations,
compared to those receiving a permanent
restoration. Providing a fluid-tight seal, preventing
bacterial leakage, and protecting the remaining
tooth structure will provide long-term stability
following the root canal treatment. (AAE, 2018)
7. RECALL
It is necessary to recall ALL completed cases in order to
detect the small percentage of failures and re-treat them
(Riley, 1974). This is the only way to monitor if you were
successful in controlling the pulpal/periapical pathosis
M3 LEC
MODULE 3: DIAGNOSIS, CASE SELECTION, AND
TREATMENT PLANNING
Introduction
● Historically, there have been a variety of diagnostic
classification systems advocated for determining
endodontic disease.
● Unfortunately, the majority of them have been based
upon histopathological findings rather than clinical
findings, often leading to confusion, misleading
terminology, and incorrect diagnoses.
● A key purpose of establishing a proper pulpal and
periapical diagnosis is to determine what clinical
treatment is needed.
● For example, if an incorrect assessment is made, then
improper management may result.
● This could include performing endodontic treatment
when it is not needed or providing no treatment or
some other therapy when root canal treatment is truly
indicated.
● Another important purpose of establishing a universal
classification system is to allow for communication
between educators, clinicians, students and
researchers.
● A simple and practical system which uses terms
related to clinical findings is essential and will help
clinicians understand the progressive nature of pulpal
and periapical disease, directing them to the most
appropriate treatment approach for each condition.
PULPAL DIAGNOSIS
● Normal Pulp
● Reversible Pulpitis
● Symptomatic Irreversible Pulpitis
● Asymptomatic Irreversible Pulpitis
● Pulp Necrosis
● Previously Treated
● Previously Initiated Therapy
1. NORMAL PULP
● Normal Pulp is a clinical diagnostic category in
which the pulp is symptom-free and normally
responsive to pulp testing.
● Although the pulp may not be histologically normal,
a “clinically” normal pulp results in a mild or
transient response to thermal cold testing, lasting no
more than one to two seconds after the stimulus is
removed.
● One cannot arrive at a probable diagnosis without
comparing the tooth in question with adjacent and
contralateral teeth.
● It is best to test the adjacent teeth and contralateral
teeth first so that the patient is familiar with the
experience of a normal response to cold.
2. REVERSIBLE PULPITIS
● Reversible Pulpitis is based upon subjective and
objective findings indicating that the inflammation
should resolve and the pulp return to normal
following appropriate management of the etiology.
● Discomfort is experienced when a stimulus such as
cold or sweet is applied and goes away within a
couple of seconds following the removal of the
stimulus.
Typical etiologies may include:
● exposed dentin (dentinal sensitivity)
● Caries
● deep restorations
● There are no significant radiographic changes in the
periapical region of the suspect tooth and the pain
experienced is not spontaneous.
 ● Following the management of the etiology (e.g.
caries removal plus restoration; covering the exposed
dentin), the tooth requires further evaluation to
determine whether the “reversible pulpitis” has
returned to a normal status.
● Although dentinal sensitivity per se is not an
inflammatory process, all of the symptoms of this
entity mimic those of a reversible pulpitis.
3. SYMPTOMATIC IRREVERSIBLE PULPITIS
● Symptomatic Irreversible Pulpitis is based on
subjective and objective findings that the vital
inflamed pulp is incapable of healing and that root
canal treatment is indicated.
Characteristics may include:
● sharp pain upon thermal stimulus
● lingering pain (often 30 seconds or longer after
stimulus removal)
● spontaneity (unprovoked pain)
● referred pain.
● Sometimes the pain may be accentuated by postural
changes such as lying down or bending over
● over-the-counter analgesics are typically ineffective.
Common etiologies may include:
● deep caries
● extensive restorations, or
● fractures exposing the pulpal tissues.
Teeth with symptomatic irreversible pulpitis may be difficult
to diagnose because the inflammation has not yet reached the
periapical tissues, thus resulting in no pain or discomfort to
percussion. In such cases, dental history and thermal testing
are the primary tools for assessing pulpal status.
4. ASYMPTOMATIC IRREVERSIBLE PULPITIS
● Asymptomatic Irreversible Pulpitis is a clinical
diagnosis based on subjective and objective findings
indicating that the vital inflamed pulp is incapable of
healing and that root canal treatment is indicated.
● These cases have no clinical symptoms and usually
respond normally to thermal testing but may have
had trauma or deep caries that would likely result in
exposure following removal.
5. PULP NECROSIS
● Pulp Necrosis is a clinical diagnostic category
indicating death of the dental pulp, necessitating root
canal treatment.
● The pulp is non-responsive to pulp testing and is
asymptomatic.
● Pulp necrosis by itself does not cause apical
periodontitis (pain to percussion or radiographic
evidence of osseous breakdown) unless the canal is
infected.
● Some teeth may be unresponsive to pulp testing
because of calcification, recent history of trauma, or
simply the tooth is just not responding.
● As stated previously, this is why all testing must be
of a comparative nature (e.g. patient may not respond
to thermal testing on any teeth).
6. PREVIOUSLY TREATED
● Previously Treated is a clinical diagnostic category
indicating that the tooth has been endodontically
treated and the canals are obturated with various
filling materials other than intracanal medicaments.
● The tooth typically does not respond to thermal or
electric pulp testing.
7. PREVIOUSLY INITIATED THERAPY
● Previously Initiated Therapy is a clinical diagnostic
category indicating that the tooth has been previously
treated by partial endodontic therapy such as
pulpotomy or pulpectomy.
● Depending on the level of therapy, the tooth may or
may not respond to pulp testing modalities.
APICAL DIAGNOSIS
● Normal Apical Tissues
● Symptomatic Apical Periodontitis
● Asymptomatic Apical Periodontitis
● Chronic Apical Abscess
● Condensing Osteitis
1. NORMAL APICAL TISSUES
● Normal Apical Tissues are not sensitive to percussion
or palpation testing and radiographically, the lamina
dura surrounding the root is intact and the periodontal
ligament space is uniform.
● As with pulp testing, comparative testing for
percussion and palpation should always begin with
normal teeth as a baseline for the patient.
2. SYMPTOMATIC APICAL PERIODONTITIS
● Symptomatic Apical Periodontitis represents
inflammation, usually of the apical periodontium,
producing clinical symptoms involving a painful
response to biting and/or percussion or palpation.
● This may or may not be accompanied by
radiographic changes (i.e. depending upon the stage
of the disease, there may be normal width of the
periodontal ligament or there may be a periapical
radiolucency).
● Severe pain to percussion and/or palpation is highly
indicative of a degenerating pulp and root canal
treatment is needed.
3. ASYMPTOMATIC APICAL PERIODONTITIS
 ● Asymptomatic Apical Periodontitis is inflammation
and destruction of the apical periodontium that is of
pulpal origin.
● It appears as an apical radiolucency and does not
present clinical symptoms (no pain on percussion or
palpation).
4. CHRONIC APICAL ABSCESS
● Chronic Apical Abscess is an inflammatory reaction
to pulpal infection and necrosis characterized by
gradual onset, little or no discomfort and an
intermittent discharge of pus through an associated
sinus tract.
● Radiographically, there are typically signs of osseous
destruction such as a radiolucency.
● To identify the source of a draining sinus tract when
present, a gutta percha cone is carefully placed
through the stoma or opening until it stops and a
radiograph is taken.
5. ACUTE APICAL ABSCESS
● Acute Apical Abscess is an inflammatory reaction to
pulpal infection and necrosis characterized by:
○ rapid onset
○ spontaneous pain
○ extreme tenderness of the tooth to pressure
○ pus formation and
○ swelling of associated tissues.
● There may be no radiographic signs of destruction
and the patient often experiences:
○ Malaise
○ fever
○ lymphadenopathy
6. CONDENSING OSTEITIS
● Condensing Osteitis is a diffuse radiopaque lesion
representing a localized bony reaction to a low-grade
inflammatory stimulus usually seen at the apex of the
tooth.
M3 LESSON 3 Treatment Planning and Case Selection
Contemporary Endodontic Treatment Recent
technological advances in endodontic treatment have resulted
in the retention of teeth that were previously deemed
untreatable. However, technology, instruments and materials
are not a replacement for clinical skill and experience, but
rather adjuncts that a practitioner can employ to reach a
desired goal. With that in mind, it is imperative that a careful
sequence of case selection and treatment planning is carried
out based on clinical factors and the dentist’s own knowledge
of his or her abilities and limitations. A recent ADA survey
estimates that some 15.8 million endodontic procedures were
performed in the United States alone in 1999. This number has
climbed from an estimated six million root canal procedures
30 years prior. With demand as high as it is for the treatment
of pulpal disease, general practitioners should at a minimum
be comfortable with diagnosis of pulpal and periradicular
pathosis, and endodontic treatment planning.
Treatment Planning
The first step in treating the patient is planning the
case in full. This initially involves a comprehensive medical
review to predict any conditions that may require modification
of the usual treatment regimens. The identification of medical
conditions that may complicate endodontic treatment will help
the dentist avoid potential medical emergencies during
treatment. In addition, consideration of complicating patient
factors such as anxiety, limited opening or gag reflex will
allow the dentist to avoid situations that may compromise
treatment outcomes. Following the medical evaluation, a
subjective examination and a radiographic survey should be
completed. The practitioner should then be able to perform
and interpret diagnostic tests to arrive at a diagnosis and high-
quality treatment plan that addresses the patient’s needs and
desires. Collection of this data makes it possible to avoid
misdiagnosing and therefore mistreating a patient—actions
that could lead to a loss of the patient’s confidence in the
practitioner, the prescribed treatment and ultimately the dental
profession. Proper treatment planning not only helps the
practitioner avoid procedural shortcomings (e.g., missed
canals, excessive removal of dentin, perforations, ledges,
separated instruments or over/underfill of the canal space), but
also allows the dentist to choose cases based upon his or her
experience, skill set and comfort level. Every clinician must
constantly evaluate his or her diagnostic and technical skills.
The practitioner then has a legal and ethical obligation to
determine, based on the case at hand, whether he or she
possesses the skills necessary to predictably manage the
patient’s endodontic needs, and assure the delivery of timely
and effective care. Practitioners electing to perform
endodontic treatment are held to the same standard of care as
endodontists. Cases that exceed the comfort level or skill set
of the dentist should be referred to a specialist with the
requisite skills and experience to manage the patient.
Case Selection Using AAE’s Case Difficulty Assessment
Forms and
M3 LESSON 3 CONTINUATION
The American Association of Endodontists has
developed a practical tool that makes case selection more
efficient, more consistent and easier to document. The
Endodontic Case Difficulty Assessment Form is intended to
assist practitioners with endodontic treatment planning, but
can also be used to help with referral decisions and record
keeping. The assessment form identifies three categories of
considerations which may affect treatment complexity: patient
considerations, diagnostic and treatment considerations, and
additional considerations. Within each category, levels of
difficulty are assigned based upon potential risk factors. The
levels of difficulty are sets of conditions that may not be
controllable by the dentist. Each of the risk factors can
influence the practitioner’s ability to provide care at a
consistently predictable level. This may impact the appropriate
provision of care and quality assurance. For each level of
difficulty, guidelines are given to aid the dentist in
determining whether the complexity of the case is appropriate
for his or her experience or comfort level.
* Dentists should be familiar with the information in the form,
and be able to assess each case to determine its level of
difficulty 1
Please click and study carefully the following:
Patient Difficulty AssessmAssessmentForm.pdf (Links to an
external site.) (Links to an external site.)
Extra Readings:
https://f3f142zs0k2w1kg84k5p9i1o-wpengine.netdna-
ssl.com/specialty/wp-content/uploads/sites/
2/2017/06/2014treatmentoptionsguidefinalweb.pdf
https://f3f142zs0k2w1kg84k5p9i1o-wpengine.netdna-
ssl.com/specialty/wp-content/uploads/sites/
2/2019/02/19_TraumaGuidelines.pdf
M3 LESSON 3 CONTINUATION-2
If Referral is Necessary
If the level of difficulty exceeds the practitioner’s experience
and comfort, referral to an endodontist is appropriate. There
are several components to an effective referral that make the
process a positive experience for the patient, referring to the
dentist and endodontist.
1. Develop a referral relationship with an endodontist
prior to the need for referral. Endodontists and
general dentists are part of the same team and
reinforce each other’s value. Establishing a
relationship with an endodontist will allow the
endodontist to serve as a consultant and a resource,
and will encourage communication, which will better
serve the patient. 2. When it becomes apparent that a
referral is necessary, make the referral in a timely
manner. An efficient referral minimizes the
possibility of potential complications such as pain or
swelling associated with untreated endodontic
pathosis. 3. Explain the reason for referral to the
patient. If possible, the referral should be made with
the patient in the office, so that any literature, maps
and preoperative instructions may be provided at that
time.
2. Discuss your diagnosis with the endodontist, and tell
him/her exactly what you have explained to the
patient. If applicable, discuss the treatment plan and
the desired outcome with the endodontist. It is
appropriate to include information regarding the
planned restoration—if a post and core is necessary,
describe how much post space is desired so that it can
be prepared at the time of treatment. If verbal
communication is not convenient, information can be
provided by written referral.
3. If possible, schedule the restorative appointment
within one month of the endodontic treatment. For
example, if a buildup and crown are planned
following endodontic therapy, this should be
scheduled with the referring dentist in advance to
avoid lengthy delays between completion of the
endodontic treatment and placement of the final
restoration. Significant delays in the placement of the
final restoration can lead to coronal microleakage and
nonhealing. 6. Following endodontic treatment, a
report including pre- and post-treatment radiographs
should be returned to the patient’s general dental
office. The prognosis and additional treatment needs
should also be clearly stated. For example, if a canal
is previously blocked and the endodontist believes
that a root end resection may be necessary, this
should be communicated in the report.
Conclusion
In today’s society, patients are better educated and
have higher expectations regarding the dental care they
receive. Dental professionals have the technology,
methodology and scientific rationale to repair damage to the
dentition that was viewed as irreversible only years ago. These
advances allow patients to keep their natural dentition, with a
few exceptions, for a lifetime. Teeth that have had surgical
and nonsurgical endodontic treatment that has not allowed
healing can often be disassembled and “re-engineered” to
allow healing, preservation and function of the tooth. Any of
the treatment options offered to the patient must have the
patient’s best interests and health as a primary goal. The
treatment must be delivered in a predictable manner by the
treating practitioner to optimize the healing potential.
Nonsurgical root canal therapy results in one of the highest
retention rates of any dental procedure when completed under
optimal conditions. As clinicians, we can ensure the highest
quality treatment with our ability to plan a treatment plan for
the patient in such a way that we honestly assess the difficulty
of the case and our personal skill levels, and then determine
whether to treat or refer. In the final analysis, when the
treatment proceeds without complication and healing occurs,
the patient and the dentist benefit
M4 Armamentarium and Pre-treatment
(INTRODUCTION)
Before initiation of a nonsurgical root canal
treatment, a number of treatment, clinician, and patient needs
must be addressed. These include proper infection control and
occupational safety procedures for the entire health care team
and treatment environment; appropriate communication with
the patient, including case presentation and informed consent;
pre-medication, if necessary, followed by effective ● Smooth broach
administration of local anesthesia; a quality radiographic ● Barbed nerve broach
survey; and thorough isolation of the treatment site. ● Irrigating syringe
● Sodium hypochlorite solution
M4 Objectives ● Aspirating syringe
● Identify the different instruments used in C. Cleaning and Shaping
Endodontics ● Endodontic files
● Categorize the instruments as to its function. ● Irrigating syringe
● Explain the importance of Disinfection and ● Sodium hypochlorite solution
Sterilization in Endodontics ● Aspirating syringe
● Recognize the significance of Preparatory Phase in ● Paper points / absorbent points
Endodontic Treatment. D. Disinfection & Temporization - a procedure done
● Understand the benefits of good asepsis through good after root canal cleaning and shaping to ensure the
oral hygiene and properly isolated, disinfected field reduction of bacteria inside the root canal.
of operation during treatment. ● Intracanal medicaments
- Calcium hydroxide intertreatment
M4 LESSON 1 Classification of Armamentarium dressing / eugenol / camphorated
According to Procedure monochlorophenol
1. Basic Instruments for Endodontic Treatment - Temporary filling material /
● Mouth mirror hydrophilic cement
● Endodontic explorer E. Obturation - is the placement of root canal filling
● Endodontic excavator material inside the canal to ensure sealing of all
● Endodontic locking pliers portals of entry of bacteria.
● Woodson plastic filling instruments ● Gutta percha points
2. Rubber Dam Isolation - a procedure where to be treated is ● Root canal sealer
isolated from saliva and other structures in the oral cavity. ● Lentulo filler / lentulo spiral
● Rubber dam sheet ● Finger plugger
● Rubber dam clamp ● Finger spreader
● Rubber dam template
● Rubber dam clamp forcep M4 LESSON 2 Sterilization of Instruments
● Rubber dam puncher
● Rubber dam frame Sterilization – is the process of making something /
● Rubber dam napkin instruments free from bacteria or other living microorganisms.
● Disposable saliva ejector tip
3. Access Preparation - a procedure done to gain an opening Methods of Sterilization
to the internal structure of the tooth.
● High handpiece with burs 1. Steam Sterilization / Steam Under Pressure
- Round bur no. 2 or no. 4 2. Dry Heat Sterilization
- Safe tip tapered fissure bur ● Static-air type
● Gates glidden drill ● Forced-air type
● Basic instruments for endodontics 3. Cold Sterilization/ Chemical Sterilization
● Irrigating syringe
Steam Sterilization / Steam Under Pressure
● Irrigating solution
● Aspirating syringe
(Autoclave) a strong heated container used for chemical
● Sterile cotton pellet
reactions and other processes using high pressures and
4. Exploration, Cleaning & Shaping of Root Canal -
temperatures, e.g. steam sterilization.
procedure done to clean and shape the root canal in
preparation for obturation.
Dry Heat Sterilization
A. Work Length Registration
● Smooth broach / path finder he high heat and extended time are major factors in achieving
● Rubber stopper sterilization.
● Endodontic ruler
● Periapical x-ray film Dry heat may be used to sterilize patient-care items that might
B. Pulp Extirpation be damaged by moist heat (e.g., burs and certain orthodontic
instruments). Although dry heat has the advantages of low
operating cost and being noncorrosive, it is a prolonged
process and the high temperatures required are not suitable for
the sterilization of many instruments and devices.
There are two types of dry-heat sterilizers used in
dentistry: static-air and forced-air types.
1. The static-air type is commonly called an oven-type
sterilizer. Heating coils in the bottom or sides of the
unit cause hot air to rise inside the chamber through
natural convection.
2. The forced-air type is also known as a rapid heat-
transfer sterilizer. Heated air is circulated throughout
the chamber at a high velocity, which permits more
rapid transfer of energy from the air to the
instruments, thereby reducing the time needed for
sterilization.
Cold Sterilization/ Chemical Sterilization
Chemical sterilization is a method used for the
decontamination of thermosensitive instruments, which cannot
withstand cycles of autoclaving. For the rest, autoclave
sterilization should be considered the elected procedure
Pitfalls in achieving sterilization
● Interrupting the sterilization cycle, or inadequate
time, temperature, or pressure
● Inadequate pre-cleaning of instruments
● Overloading of sterilizer
● Inadequate drying cycle (autoclaves)
● Faulty gaskets or seals
● Improper packaging
● Bulky packaging
● Inadequate spacing of instruments
● Improper operation of unit
M4 LESSON 3 Pre-treatment Phase
1. Preparation of operatory (Infection Control)
2. Patient Preparation (Treatment Planning)
● Case presentation
● Informed consent
3. Pain Management
4. Preparation of tooth for access
5. Oral Prophylaxis and Rehabilitation
● Caries control and Crown build up
● Tooth Isolation
PREPARATION OF OPERATORY (INFECTION
CONTROL)
All dental personnel are at risk of exposure to a host
of infectious organisms that may cause a number of infections,
including influenza, upper respiratory tract disease,
tuberculosis, herpes, hepatitis B, and AIDS, it is essential that
effective infection control procedures be used to minimize the
risk of cross-contamination in the work environment.
These infection control programs must not only protect
patients and the dental team from contracting infections during
dental procedures but also must reduce the numbers of
microorganisms in the immediate dental environment to the
lowest level possible.
PATIENT PREPARATION (TREATMENT PLANNING)
Aside from emergency situations that require
immediate attention, endodontic treatment usually occurs early
in the total treatment plan for the patient, so that any
asymptomatic but irreversible pulpal and periradicular
problems are managed before they become symptomatic and
more difficult to handle.
The most important rationale for the high priority of
endodontics, however, is to ensure that a sound, healthy
foundation exists before further treatment is undertaken. A
stable root canal system within sound periradicular and
periodontal tissues is paramount for the placement of
definitive restorations.
Regardless of the specifics of the case, it is the
responsibility of the clinician to explain effectively the nature
of the treatment as well as inform the patient of any risks, the
prognosis, and other pertinent facts.
As a result of bad publicity and hear say, root canal
treatment is reputed to be a horrifying experience.
Consequently, some patients may be reluctant, anxious, or
even fearful of undergoing root canal treatment. Thus it is
imperative that the dentist educate the patient before treatment
(i.e., informing before performing) to allay concerns and
minimize misconceptions about it.
Case Presentation
Good dentist-patient relations are built on effective
communication. There is sufficient evidence to suggest that
dentists who establish warm, caring relationships with their
patients through effective case presentation are perceived
more favorably and have a more positive impact on the
patient's anxiety, knowledge, and compliance than those who
maintain impersonal, noncommunicative relationships.
Most patients also experience an increase in anxiety
while in the dental chair; a simple but informative case
presentation that leaves no question unanswered not only
reduces patient anxiety but also solidifies the patient's trust in
the dentist.
The American Association of Endodontists (AAE)
and the ADA publish brochures such as "Your Teeth Can Be
Saved by Endodontic (Root Canal) Treatment"1 to help
patients understand root canal treatment. Valuable educational
aids of this nature should be available to the patient, either
before or immediately after the case presentation. This
supportive information addresses the most frequently asked
questions concerning endodontic treatment. These questions
are now reviewed. Accompanying each question is an example
of an explanation that patients should be able to understand. In
addition, the dentist will find it useful to have a set of
illustrations or drawings at hand to help explain the procedure.
Informed Consent
A great deal of controversy surrounds the legal
aspects of informed consent. The current thinking of the courts
holds that, in order for consent to be valid, it must be freely
given; that all terms must be presented in language that the
patient understands; and that the consent must be "informed."
for consent to be informed, the following conditions must be
included in the presentation to the patient: the procedure and
prognosis must be described (this includes prognosis in the
absence of treatment); alternatives to the recommended
treatment must be presented along with their respective
prognoses; foreseeable and material risks must be described;
and patients must have the opportunity to have questions
answered. It is probably in the best interests of the dentist-
patient relationship to have the patient sign a valid informed
consent form. With today's continuous rise in dental practice
litigation, a good rule to follow is to realize that "no amount of
documentation is too much and no amount of detail is too
little”.
A critical portion of the endodontic case presentation
and informed consent is educating the patient about the
requirement for radiographs as part of the treatment. The
dentist must communicate to the patient that the benefits of
radiographs in endodontics far outweigh the risks of receiving
the small doses of ionizing radiation, as long as techniques and
necessary precautions are properly executed. Although levels
of radiation in endodontic radiography range from only 1/100
to 1/1000 of the levels needed to sustain injury, it is still best
to keep ionizing radiation to a minimum, for the protection of
both the patient and dental delivery team. A simple analogy
can be used to help the patient conceptualize the minimal risk
levels with dental radiographs. A patient would have to
receive 25 complete full-mouth series (450 exposures) within
a very short time frame to significantly increase the risk of
skin cancer. Nevertheless, the principles of ALARA (as low as
reasonably achievable), which are essentially ways to reduce
radiation exposure, should be followed as closely as possible
to minimize the amount of radiation that both patient and
treatment team receive. ALARA also implies the possibility
that no matter how small the radiation dose, there still may be
some deleterious effects.
PAIN MANAGEMENT
It is paramount to obtain a high level of pain control
when performing root canal treatment, and in no other
specialty is this task as challenging or as demanding. The
clinician must strive for "painless" local anesthetic injection
technique with relatively rapid onset of analgesia.
The problem of managing pain and anxiety in the
practice of dentistry is a significant one. Studies have
demonstrated that the major reason that over 50% of adult
Americans do not seek routine dental care is fear of pain.
Interviews with patients indicate that although they may
not be in pain when they visit their dentist, the overwhelming
majority truly believe that at some time during a dental
appointment they will experience pain. The person most
frequently cited as being responsible for this discomfort is the
dentist.
Pain and anxiety are entirely different problems, yet
at the same time they are closely related. Pain produced by
dental treatment can usually be minimized or entirely
prevented through thoughtful patient management and the
judicious use of the techniques of pain control, especially local
anesthesia. Anxiety, too, can usually be managed effectively;
however, before anxiety can be managed, it must be
recognized. Discovery of the cause of a patient's anxiety is the
major factor in managing the problem. Once aware of a
patient's fears, the dentist has many techniques available with
which to care for the patient.
In most areas of dental treatment, the problem of
anxiety control is greater than the management of pain. Pain
control is usually readily obtained with a local anesthetic.
Once effective pain control is established, anxiety control
usually is more readily achievable. In endodontics more than
in any other specialty of dentistry, pain control often proves to
be more of a difficult problem than the management of
anxiety. Because of this difficulty in achieving effective pain
control, the patient undergoing endodontic treatment often
anticipates the experience with a great deal of apprehension.
Although achieving adequate pain control for
endodontic care is not usually difficult, there appear to be all
too many instances when a satisfactory result eludes the
doctor. The most likely explanation for the greater percentage
of anesthetic failures in endodontics than in other areas of
dental care lies in the tissue changes that commonly develop
in and around pulpally involved teeth
 Although this procedure is somewhat effective,
injection of anesthetic solutions into infected areas is
undesirable because of the possibility of the spread of
infection to a previously uncontaminated area. Deposition of
the anesthetic into an area at a distance from the involved
tooth is more likely to provide adequate pain control, because
of the normal tissue conditions that exist there. Regional nerve
block anesthesia is therefore a major factor in pain control for
pulpally involved teeth.
There are also occasions, fortunately rare, when even
regional block anesthesia at a distance from the infected tooth
fails to produce adequate pain control. Omitting for a moment
the most likely cause of this situation, faulty injection
technique, has proposed that inadequate pain control may be
due to the fact that morphologic changes (e.g.,
neurodegenerative changes in the axon or the presence of
inflammatory mediators) are developing.
Yet another unfortunate situation in endodontic pain
control relates to the inflamed tooth that when anesthetized
becomes asymptomatic but, on attempts to gain access to the
pulp chamber and canals, becomes exquisitely sensitive to
manipulation. Although no entirely satisfactory explanation
exists for this circumstance, it may be explainable on the basis
of an increase in the rate of stimulation to the nerve endings
that occurs with use of the high or low-speed handpiece. The
degree of neural blockade may be adequate for a lower level
of stimulation prior to preparation yet prove inadequate to
block completely the rapid flood of impulses arising with use
of the handpiece. This is equivalent to the so-called anesthetic
window noted in obstetric anesthesia following epidural nerve
block during delivery: The degree of pain control is quite
adequate except during the most intense uterine contractions.
The same intense increase in the rate of neural stimulation is
thought to be responsible for this phenomenon in endodontics.
The tissue changes and their possible actions on the
effectiveness of local anesthetics influence the choice of local
anesthetic technique used in attempting to prevent discomfort
during treatment. A variety of techniques are available in the
maxilla and mandible.
PREPARATION OF TOOTH FOR ACCESS
Oral Prophylaxis and Rehabilitation
Elimination of sources of infection is essential in Endodontics.
Prior to Endodontic treatment removal of plaque and calcular
deposits is required. Carious teeth must be restored and
severely carious teeth must be removed.
Caries control and Crown build up
The tooth to be treated endodontically must be cleaned and
freed of carious lesion as part of the preparatory phase.
Tooth Isolation
The use of the rubber dam is mandatory in root canal
treatment.
The best way to prevent seepage through the rubber
dam is meticulous placement of the entire system. Proper
selection and placement of the clamp, sharply punched,
correctly positioned holes, use of a dam of adequate thickness,
and inversion of the dam around the tooth all help reduce
leakage through the dam and into the root canal system.
Nevertheless, there are clinical situations in which small tears,
holes, or continuous minor leaks may occur. These often can
be patched or blocked with Cavit, Orabase, rubber base
adhesive, "liquid" rubber dam, or periodontal packing. If
leakage continues, the dam should be replaced with a new one.
LOSS OF TOOTH STRUCTURE
If insufficient tooth structure prevents the placement
of a clamp, the clinician must first determine whether the tooth
is periodontally sound and restorable. Meticulous and
thorough treatment planning often can prevent embarrassing
situations for both doctor and patient. One example is the not
uncommon case in which the endodontic treatment is
completed before restorability is determined and it is then
discovered that the tooth cannot be restored.
Once a tooth is deemed restorable but the margin of
sound tooth structure is subgingival, a number of methods
should be considered. Less invasive methods, such as using a
clamp with prongs inclined apically or using an Ivory no. 21
clamp, should be attempted first. If neither of these techniques
effectively isolates the tooth, the dentist may consider the
clamping of the attached gingiva and alveolar process. In this
situation, it is imperative that profound soft tissue anesthesia
be induced before the clamp is placed. Although the procedure
may cause some minor postoperative discomfort, the
periodontal tissues recover quickiy with minimal
postoperative care.
RESTORATIVE PROCEDURES
If none of the techniques mentioned above is
desirable, a variety of restorative methods may be considered
to build up the tooth so that a retainer can be placed properly.
A preformed copper band, a temporary crown, or an
orthodontic band may be cemented over the remaining natural
crown. This band or crown not only enables the clamp to be
retained successfully; it also serves as a seal for the retention
of intracanal medicaments and the temporary filling between
appointments.
MODULE 5 ACCESS PREPARATION M5 Lesson 1.1: Pulp Chamber

Access preparation focuses on the tooth crown. It is
the first step in root canal treatment. It exposes the inner core
of the tooth through the pulp cavity. The pulp cavity is made
up of 2 parts, the pulp chamber located at the crown area of
the tooth and the root canal found within the root portion. By
removing the roof of the pulp chamber, the pulp cavity is
opened allowing entry for endodontic instruments to reach the
entire root canal system. This step will help facilitate an
effective cleaning and shaping of the pulp cavity to eliminate
infection throughout its length.
The tooth is divided into the crown and the root demarcated by
a cervical line. The crown is further divided into 3 parts:
● Incisal/Occlusal third: which is the functioning
surface of the tooth during mastication
● Middle third: beneath the occlusal third and between
the mesial and distal third
● Cervical third: is the base of the crown located at the
border between the crown and the root at the area of
the cervical line.
● Mesial Third: is the mesial side of the crown from the
incisal/occlusal to the cervical
● Distal third: is the distal side of the crown from the
incisal/occlusal to the cervical

And the root into:

● Cervical third: at the cervical line area
● Middle third
● Apical third or 3-4 mm from the tip of the root
M5 Lesson 1: Morphology of the Pulp Cavity
In the study of Anatomy, it has been emphasized that
the external shape and form of structures compliments its
internal shape and form. Since Endodontics is involved with
structures within the tooth, the external anatomy can provide
clues or guides as to the morphology of the inside of the tooth
particularly the pulp cavity. Tooth’s external anatomy will
provide a three-dimension mental image of the approximate
location of the center of the chamber and its bounderies. This
is essential in establishing the location of the initial
penetration of the roof of the pulp chamber as you drill
through the solid tooth crown during actual access preparation.

In an outward sweeping motion of the bur, the pulp

chamber is completely "deroofed" up to the limitation of the
walls, and only then will the true size, shape and form of the
pulp chamber will be established. Therefore, it is the anatomy
of the pulp chamber that will dictate the final outline form of
the access preparation.

The pulp chamber, on the other hand, is a cavity

located within the center of the tooth crown starting from the
middle third extending to the cervical third. It is bounded by
the roof of the pulp chamber, floor of the pulp chamber and
the 4 lateral walls (Labial, Lingual, Mesial and Distal walls).
On the floor of the pulp chamber located at the cervical third
Youtube vid:
of the tooth, slightly below the cervical line, is where the canal
https://www.youtube.com/watch?
orifices are found. These are the openings of the root canals.
time_continue=5&v=itpO3ns4Phw&feature=emb_title
According to the 9 Laws of the Cervical third, this area has the
most consistent anatomy unaffected by physiologic changes.
Exposure of these orifices is the objective of access
preparation. To expose them correctly will help facilitate
success in succeeding steps of root canal treatment.
Since the pulp chamber is enclosed within the solid
external tooth structures, correct preparation is dependent on
the external anatomy of the occlusal third particularly the
occlusal table, where important land marks guide the extent
and possible location of the pulp chamber without unduly
removing crown tissue during preparation thus preserving and
maintaining the strength and integrity of the tooth crown
structures.
For further discussion on the 9 Law of the Anatomy of the
Pulp Chamber, click the link below:
https://www.juniordentist.com/krasner-and-rankow-
guidelines-or-laws-of-pulp-chamber-anatomy-to-help-in-
access-opening.html
a line drawn in a mesial-distal direction across the
center of the floor of the pulp chamber
6. Law of Color Change: The color of the pulp
chamber floor is always darker in comparison to the
vertical surrounding dentin walls
7. Law of Orifice location 1: The orifices of the root
canals are always located at the junction of the dentin
walls and the floor of the pulp chamber
8. Law of Orifice location 2: The orifices of the root
canals are located at the angles of the junction of
dentin wall to the pulpal floor
9. Law of Orifice location 3: The orifices of the root
canals are located at the terminus of the root
developmental fusion lines.
M5 Lesson 2: Coronal Access
Access preparation is the initial entry into the root
canal system. This lesson will focus more on understanding
the significance and principles of each step of preparation
rather than the technical aspect to help arrive at a correct
coronal access preparation. Guidelines and pointers will be
emphasized in order to avoid errors. Appreciating the
importance of the preservation of the remaining tooth tissue by
starting with correct access preparation is a very significant
factor in the success of root canal treatment.

KRASNER AND RANKOW LAWS OF PULP

CHAMBER ANATOMY
1. Law of Centrality: The floor of the pulp is always
located in the center of the tooth at the level of CEJ
(cementoenamel junction). This law helps in
determining the depth to which you can go without
causing any perforation. You can use an IOPA X-ray
or just place the bur against against the tooth and
measure it against the Bur length to have an idea of
the depth to which you can extend in search of the
pulp orifice
2. Law of concentricity: The walls of pulp chamber are
always concentric (or around the pulp chamber
following its shape) to the external surface of the
tooth at the level of CEJ.
3. Law of CEJ: It should be used as a landmark to
locate the pulp chamber as it is repeatable and
consistent in its position in any tooth.
4. Law of Symmetry 1: Except for maxillary molars,
the orifices of the canals are equidistant from a line
drawn in a mesial distal direction through the pulp- Guidelines:
chamber floor. ● Develop a mental image of the pulp cavity in three
5. Law of Symmetry 2: Except for maxillary molars, dimension with the aid of the radiograph and
the orifices of the canals lie on a line perpendicular to knowledge of canal anatomy
 ● Know the possible morphology of the root canal Rules of Access Preparation:
system 1. Remove the roof of the pulp chamber.
● Determine the point of penetration ○ After the "drop" remove the remainder of
● Assess the occlusal and external root form the roof in an outward sweeping motion.
● Radiograph measurement of the depth of the pulp ○ Check the location of the ledge after initial
chamber roof from the occlusal table access using the basic explorer.
● Assessment of complicating factors
● Develop a mental image of possible positions of the
canal orifices
● Be guided by the 9 Laws of Anatomy at the cervical
third of the tooth according to Krasner and Ranskow

Youtube vid link:

https://www.youtube.com/watch?v=6G7a-
1cPE2s&feature=emb_title

M5 Lesson 2.1: Objectives, Rules and Principles

Coronal Access Opening:

Provides a convenient entrance to the root canal/s via the
canal orifice/s to facilitate cleaning and shaping.

Objectives of Entries:
● To provide visualization (location) of all canal
orifices.
2. Create a straight line access (SLA)
● SLA to the apical portion of the canal

With straight line access

● To provide direct insertion of instruments to the

apical third of the Root Canal System (RCS)

No straight line access

 M5 Lesson 2.2: Common Errors in Access Preparation

Common Errors in Access Preparation

1. Intact roof of pulp chamber

3. Avoid damage to the floor of the pulp chamber

Presence of intact roof of the pulp chamber

4. Conserve tooth substance

5. Establish a resistance form

The Access Preparation is Completed when it is:

1. Chamber walls are smooth and continuous with the
radicular portion of the pulp canal
2. When it provides direct access to the apical third of
the root canal
A completely deroofed pulp chamber will expose its floor
The Outline form of the Access: showing the fusion lines of the dentin map
1. Reflects the shape of the internal anatomic structure
of the chamber 2. Intact dentin shelf
2. Limited to the walls of the chamber
3. Confined within the marginal ridges

3. Perforation at the furcation

 ● Hippocrates
- “”First, Do No Harm”.
- From (what is) to their harm or injustice, I
will keep (them)

Hippocratic Oath: DO NO HARM.

It is acceptable and even ethically required that a clinician
not guess at the diagnosis when you need to refer or ask your
endodontist.

Standard Diagnostic Framework: SOAP format

4. Crown Perforation ● Subjective information
- What the patient tells you
- Chief complaint
● Objective findings
- What is seen by clinicians
- Results of tests
● Assessment
- Information are put together to come up
with a formula of diagnosis
● Plan of treatment
- Follows the diagnosis

We want to know if things match up to what the patient tells us

and what we see matched up and backed up by the results
from the tests.

Canvas (Laboratory)
Step 1: HISTORY
CLINICAL ENDODONTIC DIAGNOSIS - Medical History Form
- Completed by patient
Diagnosis and treatment planning are two of the most - Signed and dated
important facets of endodontics. - Reviewed completely
Without accurate diagnosis and proper treatment planning, - Follow-up questions
all other aspects become of little importance. - Highlight significant conditions
A clinician can perform the most skillful treatment but if it is
on the wrong tooth, then you may find yourself drowning in Example: a patient takes an arthritic drug which may or may
those difficult waters. not mask the symptoms that they are complaining about or
There have been a lot of changes in the last several years due results of your testing on that day.
to the developments in science, technology, and
understanding. CHIEF COMPLAINT
- Must be written in the patient's own words.
PRIMARY DIAGNOSTIC OBJECTIVES - Reason for visiting the dentist
● Reproduce chief complaint - Problem that urged the patient to have a dental
● Determine the cause check up
● Eliminate the cause - It is not uncommon for patients to have multiple
● Address patient symptoms problems.
● Prevention of endodontic disease - Identify problems that are endodontic in nature and
problems which may be related to something else.
If the first two can’t be done then the astute clinician does not
proceed with treatment. It is where the process starts. a. SUBJECTIVE INFORMATION
● History of pain
Ultimate Goal: help patient symptoms, and prevent & - When did it start? How has it
eliminate endodontic disease. progressed?
- Was the pain related to a specific
Despite a thorough assessment, the clinician may or may not experience?
be able to determine the exact nature of the patient's chief - Recent dental treatment, trauma,
complaint. or no specific incident
● Location of pain
NOTE: DO NOT TREAT UNLESS YOU KNOW THE CAUSE - Localized to one tooth
OF THE CHIEF COMPLAINT. - Poorly localized to one quadrant
 - Poorly localized to one side of the ● Radiographic assessment
face (may or may not be
endodontic problem)
- Poorly localized to both sides of Get that and the tell us we’re gonna figure out the rest out in
the midline (NOT an endodontic our testing specifically but we want to know what they think
problem) and what they are feeling on a day to day basis in terms of the
● Severity of pain pain when they’re having episodes how long does it last, in
- Scale of 1 to 10 particular with the cold we want to know when you had drink
- 1 = NO pain a cold glass of water, does that pain last 30 seconds, less than
- 10= WORST pain imaginable that just well the colds on there or is it something that lingers
- Subjective patient judgment that persist on when cold sensitivity persists greater than 30
● Nature of pain seconds or minutes or hours we know that that’s indication of
- Throbbing, burning, shooting, reversible pulpitis
dull,sharp
- Very subjective descriptors CLINICAL EXAMINATION EXAM:
- Different types of pain in
endodontic: Extra-oral exam
Neuralgic, Muscle
● Frequency of pain
- Intermittent or continuous?
- How often do episodes occur? And
for how long?
● Spontaneity of pain
- SPONTANEOUS: no stimulus
related to it, wakes patient up at
night.
- TRIGGERED: always needs a
stimulus, does the stimulus cause
the pain?
● Stimulus of pain
● Duration of pain Approach the patient with 12 oclock position, it give you a
chance to palpate the neck nodes, submandibular nodes,
Severe spontaneous pain is an indication of irreversible submental nodes, we know that of course if somebody has
pulpitis. pain to palpation of the muscles, and mastication we may not
dealing with an endodontic problem at all , and on the other
Chewing can act as a stimulus (aggravating factor). hand if they are have tender or enlarged nodes in the neck or
under the jaw, the of course we may be dealing with spreading
Triggered pain could be an indication of pulpitis or something infection and something that is definitely endodontic in nature.
non endodontic. It could be a biting sensitivity from
malocclusion or bruxism or a periodontal problem. - Intra-oral examination (oral cancer screening)

- we want to collect all this information and get it together to

make diagnosis

Subjective Information

Stimulus of the pain

- Cold/heat
- Biting/chewing/ touching/ pressure
- Pushing on the gums

Duration of the pain

Looking for asymmetries swelling areas of redness or
- How long does it persist after removing the stimulus? inflammation, i like to compare the right and the left sides of
- 0 to 30 seconds >30 seconds. the mouth and at the same time while we’re examining these
- Persists minutes to hours after stimulation. soft tissues now is the time to check the palate and tongue and
do our oral cancer screening as well.
● Clinical examination
○ Extraoral As for soft tissue findings, one important sign to look for is a
○ Intraoral draining sinus tract, if a sinus tract is present must be traced
● Comparative testing with a gutta percha points and a radiograph taken you will be
surprised how often the draining sinus tract does not arise
from the tooth that you think it should be arising from in other
words the draining sinus tract may not be right the side of the
tooth.

- Gingival recession
- Exposed dentin

Another thing to know is gingival recession, exposed dentin

can be quite sensitive to cold and it may be an indication of
- Soft tissue findings reversible pulpitis and if it is reversible then it is something
- Redness, swelling draining sinus tract. where endodontics not needed and there may be a more simple
solution.

General conditions:

- Caries - a sign of bacterial invasion of the tooth and if

the caries and the bacteria are getting into the pulpal
tissue then we’re dealing with an irreversible pulpitis
which will eventually lead to necrosis.

- Wearing facets - may be indicating the present of

strong occlusal forces and perhaps a pair of
functional habits such as bruxism and occlusal
trauma is frequently misdiagnosed endodontic
disease so this finding is very relevant

- Extensive restoration or leakage.


- Tooth fractures.
Areas of recession may be also associated with tooth fractures
and tooth fractures is another that the bacteria get into the pulp
where there’s recession check carefully using magnification
and a perio probe to examine and see if there may be a fracture
present on roots especially below crown fractures.
- transillumination of a fractured tooth.
I turn off the operating lights and sometimes turn off my
overhead lights and I'm shining the light through the dentin of
the crown and where there is a crack that light transmission
will be disrupted and you will be able to see that crack.
So now that we look at the general oral conditions we want to
move on to our clinical testing of the suspected tooth and its
entire quadrant, we’re often going to find secondary problems
or that symptoms are related to more than one thing, it could
be endodontics and periodontics for example.
Comparative Testing
I like to consider the periodontal probe as the first instrument
of my endodontic testing. It's a critically important step.
PERIODONTAL PROBING, MOBILITY
Here we have a case, the patient was sent for endodontic
treatment for a toothache. It’s a good idea to consider
measuring at least 6 points around the tooth and we also want
to look for things such as are we dealing with an isolated
pocket where we’ve got normal periodontal probing and then
all of a sudden, the probe drops into a 10 mm depth. This
could be an indication of a fracture perhaps this tooth isn’t
savable if we’re probing at those 6 points and we find a broad
area of bone loss, then that can be something that is
periodontal bone loss. We want to refer for that or be looking
at periodontal support to determine whether or not prognosis
for long-term outcome is good for this tooth.
PALPATION
Palpation is done in the quadrant and it’s done to detect
periapical inflammation that spreads to the surface of the
mucosa and it may indicate an underlying problem.
I think it’s useful also to note the precise area of the mucosa
that may be sensitive, for example, if your patients are finding
that they’re sensitive but it;s along the gingival margin, we
may be dealing again with a periodontal problem not an an
endodontic problem. This is quite different from when they’re
sensitive to palpation at the root ends. Note the area and
location of that sensitivity to palpation. To be aware with
upper molars particularly that there’s muscle insertion in this
area at the root apices and patients will often say that this area
is sensitive to palpation. Compare the right side and left side
in these areas to make sure there is a difference.
PERCUSSION
Percussion testing is used to more specifically examine for
inflammation at the root ends. One should bear in mind,
however that this is in fact a periodontal test, periodontal
inflammation can be caused by endodontic infection certainly
if it’s spreading to the apical tissues from the pylp space going
to get sensitivity to percussion but also things such as bruxism,
malocclusion, pair of functional habits, these can also stretch
and traumatize those periodontal fibers causings sensitivity to
percussion.
THERMAL TESTS
Every tooth that’s considered for endodontic therapy should
have a cold test. Cold testing is an essential element of our
tests. There are several ways that we can do it so you can use
water. Water is ice so to do this, you take your cleaned and
disinfected empty anesthetic cartridges, you fill them with
water put them in a little plastic cup upright and freeze them
and then when you want to take them out for your cold testing
then you make a little ice pencils which you can hold in a 2x2
gauze. When you’re using this method, it is important to start
with teeth distal and then move mesially because as you are
testing the ice will melt onto the adjacent teeth and we don’t
want to get any false positives.
COLD (H20, CO2, ENDO ICE)
I would like to use endo ice spray, it’s a tetra fluoro ethane
spray and it’;s very convenient and easy to use. It comes out of
a can, you spray it onto a cotton pellet or a cotton swab and
then you can test the teeth very specifically and individually
without having melting where cold is transferring from one
tooth to another. Be aware that as you’re using the can, a
temperature can vary so give it a really good shake before you
spray it onto your cotton pellet. CO2 snow which is dry ice
can be used as well but the temperature is very extreme and
also you need a lot of armamentarium, a big canister in your
office to be able to have that available.
THERMAL TESTS
● COLD (H2O, CO2, Endo Ice)
● HEAT (Warm Gutta-Percha)
A heat test, so if someone complains of hot sensitivity then we
should be doing a heat test and there are several ways to do
that. One of the ways that you can do this, is by using a rubber
cup and creating friction on the tooth to create heat. I don’t
find this works as well as safe for example as using warm
gutta-percha on a tooth and a heated instrument or using a
rubber dam test in hot water.
HEAT (Warm Gutta Percha)
The heat test when we’re using a heated instrument or warm
gutta-percha is used similar to the way we would do the cold
test where we hold that hot or cold stimulus on the tooth for
about a second or until the patient feels that stimulus and then
remove it right away.
So when we’re doing the heat test, with a hot gutta-percha and
heated instrument, what we want to remember is to put a little
vaseline on the tooth first to prevent gutta percha from
sticking.
CLINICAL EXAMINATION - SEPARATION MEDIUM
What we want to remember is to put a little vaseline on the
tooth first to prevent gutta percha from sticking.
When we are doing the rubber dam test, what we are doing is
placing rubber dam and flowing hot water onto one specific
tooth at a time.
So while rubber dam placement is not comfortable for
everyone you'd be surprised at how often you can get that on
comfortably to be able to do a nice accurate hot test .
CLINICAL EXAMINATION - HEAT TESTING
There is equipment available as well that will have the ability
to heat test. for example the
calamus tool has a specific heat desk tip and you can apply
that to teeth as well for heat testing.
So we've used our thermal tests for vitality testing the pulp.
Objective findings - comparative testing
Another vitality test is the electric pulp test and it's
unfortunately of limited value if you've got teeth that are
heavily restored which is often the case when we're testing for
endodontic problems. So it's not all that frequently used but it
does become very important with trauma cases and in trauma
cases we want to establish a baseline of what our electric pulp
tests say and then follow that through over the weeks or
months of follow-up assessments that we're doing.
Bite tests are performed using a tooth sleuth or a similar
instrument a wooden stick or a cotton swab again and a
positive test result here may indicate periapical inflammation
but it may also indicate something like a crack for example in
the tooth.
So with the bite test as well to establish your baseline of what
is normal and where a patient may be specifically bite
sensitive it's a good
idea to test all the cusps of all the teeth in that quadrant and
again doing that in a random order.
So do be aware with all of these testing the percussion, the bite
testingm, and our temperature testing it's a good idea not to go
in order. We want to establish what's normal around the tooth
before moving to the tooth in question and we don't want the
patient to necessarily anticipate the test result.
With the bite test also we have the advantage of being even
more specific than that because these tooth sleuths allow us to
place forces on specific cusps and we can document exactly
where that sensitivity may be coming from.

Selective anesthesia is not used often but can be used where
we have patients that are complaining of pain to the entire side
of the face where they can't tell if the pain is coming from a
top or a bottom tooth. In this case what you can do is
anesthetize the arch that you think the pain is in and if the
patient's pain goes away entirely then at least you know that
that is the area from where the pain is coming.
Now if you're not only able to eliminate the pain then you may
be dealing with pain from the opposite arch of course but also
you may very well be dealing with a non endodontic pain or a
non dental pain which of course we can't anesthetize away.
● Cold
○ Blowing air is inaccurate
○ Use endo ice, ice stick, or CO2 snow
● Heat
○ Use dab of petroleum jelly to keep gutta
percha from sticking to tooth
● Anesthetic test - anesthetizes adjacent teeth, useful to
elucidate upper vs lower pain, or non-endodontic
pain.
So to review some of the clinical tips just to note that blowing
air is very inaccurate for cold testing as can be the ice stick if
you're not careful about it and letting the melted water drip. So
use endo is something that you can use specifically to touch
the tooth in question and remove immediately.
When doing the hot test do put some petroleum jelly on the
tooth to prevent the gutta-percha from sticking and be aware
that anesthetic tests are not able to anesthetize just one tooth
but they are very useful when you can't tell whether pain is
coming from an upper versus a lower arch.
So moving on to our radiographic assessments when exposing
radiographs it's a great idea to use some form of film device
and this way you can get reproducible angulations. It's also
good
because we're able to get a better view for endodontic
purposes when we compare to using a bisecting angle
technique for example. So here's an example of a radiograph
that was taken using a bisecting angle technique which is on
the left and a radiograph taken by the endodontists on the right
using a Rin device.
So the suspected tooth is tooth number three and we note that
on the radiograph on the left the zygomatic arch covers the
palatal root end and the buccal roots are quite foreshortened so
not as clear as I'd like to see to determine whether or not this is
the tooth in question whether this has a tooth that has difficult
anatomy. when I take look at the radiograph on the right
which is the one that was taken by an endodontist at the
corrected angulation we can see that there's extensive caries
it's approaching the furcation.
There’s a severe distal periodontal defect there's quite a
curvature of those mesiobuccal roots and the palatal roof is of
course easier to see and can see that the amount of
calcification there the corrected angulation on the image on
the right hand side has enhanced clarity and this may be a
tooth that i want to think twice about what I'm going to do in
my treatment my endodontic treatment here.
so we can also see how two different types of images can
show two different types of information and it's for this reason
that in my office I always take two views of every tooth and we
take a straight-on view and then a distal angulated view now
this also reminds us of something we may have learnt in
dental school which is the buccal object rule
so here's an example of a previously treated tooth and we're
seeing a periapical lesion on the medial roots and we're
suspecting that there may or may not be a miss canal either
way we want to see more information about this tooth the
image on the right is a distal angulated view of that tooth
so the tube head is moved distally to take the image of the
tooth what that will do is it will move all the objects that are
closest to the tube head away so my analogy for this is if
you're driving down the highway the trees in the front move
quickly and they move by you fast they but the moon which is
far away it stays relatively still
so in this second view on the right what we see is the mesial
root which is filled is closer to the distal aspect of that mesial
root it's not centered in that root anymore so my suspicion is
that there may be canal anatomy unfilled which is centered in
that mesial root and that would be to that right side of that
image to the mesial side
so knowing that that has now moved away in my distal and
angulation I know that that must be the mesial-buccal root
end
here in our post-operative view of that radiograph we can see
now both the mesial-lingual and the mesial-buccal roots are
both filled
we can use the same concept to move other objects away from
root end
so here we've had an orthographic surgery and some pins and
retention devices which are covering the root apices in our
straight-on view
i want to move those elements which are on the front face
away from root ends so by moving the tube head down I can
get those elements to move up away from the root ends and
there we can see the root apices
now where we have foreign objects that we can remove which
is more common these days as well nose piercings and lip
piercings do have patients remove them so that we can just see
what we need to see in the image without it being obstructed
reviewing some of our clinical tips:
● Perio probe- record your depths measurements at 6
points at least also take an assessment of the
● Mobility- of the tooth whether it's slight moderate or
extensive remember that grade three mobility always
refers to a tooth that can be compressed in an apical
direction
● Percussion and palpation testing and temperature
testing start with the uninvolved teeth and be random
working towards the of all involve tooth get the
patient accustomed to normal perhaps test the right
side versus the left side
● Images- for your imaging remember you must
always have a current image and you should show
both the tooth and all its surrounding tissues if there's
a lesion present you want to show the entire lesion in
your radiograph
so we've gathered all the information from our patient and
we've gathered all the information for ourselves so now it's
time to put everything together into our diagnosis
● Pulpal diagnosis
● Periradicular diagnosis
● Non-endodontic pathology
the diagnosis actually separated up into two areas and then
non endodontic pathology meaning there's something else
going on but the endodontic diagnosis we want to look at the
pulpal diagnosis and the perioradicular diagnosis
so there are six classifications for Pulpal diagnosis and these
are the first three:
● Reversible pulpitis
- Non-lingerinng (thermal tests)
- Not spontaneous
They have to do with vital pulp, pulp that is still alive but may
or may not be bacterial II infected so in a reversible pulpitis
we have sensitivity usually to thermal but it's not lingering and
it's not spontaneous this is an inflammation of the pulp.
Irreversible pulpitis (symptomatic)
● A bacterial infection usually of the pulp and it’s
causing pain for the patient
● Symptomatic
 ● Spontaneous pain be needed in theses cases.)
● Pain lingers after stimulus (lingers after cold usually Irreversible Pulpitis (symptomatic)
a very severe type of pain)
● Usually severe

Irreversible pulpitis (asymptomatic)

● The bacteria have infected the pulp tissue but there
are no symptoms and it’s quite common as we’ll see
when there are deep caries and sometimes in trauma
cases.

(So our pulp test would elucidate that there is an in-depth

indeed and irreversible pulpitis even though the patient may
not complain of that.)
Findings:
Pulp necrosis
● No response to thermal or electrical stimuli Percussion + or -
Bite + or -
Previously root canal therapy Cold +++
● Canals are obturated (linger > 30 sec)
Previously initiated therapy Heat +++ or -
● Start to do some sort of emergency treatment such as Radiograph usually unremarkable
pulpotomy or pulp ectomy
● Parital endodontic treatment (We start to get percussion sensitivity perhaps and bite
sensitivity perhaps. Our cold sensitivity would be more severe
Case Examples: and then we start to get that lingering quality. Patients may
also have or not have heat sensitivity associated. When
Reversible pulpitis looking at a radiograph of a tooth that has irreversible pulpitis,
we may or may not see some small signs in the x-ray. In this
radiograph, there may be a sign of some condensing osteitis, a
little widen PDL space so be aware of those changes as well.

Irreversible Pulpitis (Asymptomatic)

Findings:

Percussion -
Bite -
Cold ++ Findings:
(non-lingering)
Percussion -
Radiograph <-really?? Bite -
Cold + or -
(No sensitivity to percussion, no sensitivity to bite because (may linger)
there is no periapical inflammation at this point. We’ve got a
pulp tissue that’s inflamed and it could have some cold Heat + or -
sensitivity. Maybe if it’s more severe sensitivity or starting to Radiograph caries approaching pulp
linger, we may start to think well is it moving to revert
irreversible pulpitis but if it’s just sensitive for a short time (The patient is not complaining of any symptoms but here
without percussion or bite sensitivity we’re probably dealing we’re seeing quite a large carious lesion. It’s very close to the
with a reversible pulpitis and no endodontic treatment would pulp space and our testing may either find that there’s a
lingering response same with the thermal testing of hot or cold
and again we want to look for those radiographic signs
perhaps we will also see small signs of condensing osteitis or
widened PDL space in a case like this.
Pulp Necrosis
Findings:
Percussion - to +++
Bite - to +++
Cold -
(non-lingering)
Heat -
Radiograph evidence of apical periodontitis frequently
(Once the infection progresses to pulp necrosis, now we’re
gonna start seeing more signs of periapical inflammation.
We’re going to see bite sensitivity, and percussion and
sometimes that can be fairly minimal but sometimes quite
severe. Since there’s no live tissue, we’re going to have a
negative response to both hot and cold testing. In the
radiograph, we see the sign of that periapical inflammation
and periapical bone changes associated with infected as that
darkness forms around the ends of the root)
Previously Treated
Findings:
Percussion - to +++
Bite - to +++
Cold -
Heat -
Radiograph appearance variable (root filling evident)
(There is no percussion or bite sensitivity, it may be minor,
severe. Again we’re gonna have no response to thermal test
because there is no living tissue in this tooth but
radiographically we start to see signs of disease, signs of
endodontic infection. We’ve got periapical radiolucency. With
previously treated teeth, we also want to look for other types
of elements like caries, where are the post, are there signs of
fracture, are there untreated canals. Going back to what I said
before about the radiographs here’s a really great time to have
more than one view of a tooth.
Periapical diagnosis
Normal apical tissues
● Asymptomatic, intact lamina dura
Symptomatic apical periodontitis
● Pain to biting and percussion
● May or may not have associated PA radiolucency
Asymptomatic apical periodontitis
● Cannot elicit pain or altered sensation (By tapping or
palpation)
● Apical radiolucent area
Acute apical abscess
● Localized swelling, pain, pus formation
● Tender to pressure
● fever ? Lymphadenopathy?
● PA radiolucency?
Chronic apical abscess
● Minimal or no pain
● Pus drains from a sinus tract
● getting that same pressure build up like we do with
the acute apical abscess here we've got pass and it
may be draining from a sinus tract and now we're
looking for draining sinus tracts
●
Facial cellulitis
● Extraoral spread of infection
● Dangerous- treat aggressively
● want to treat this aggressively we're going to see
swelling of the face there may be redness tenderness.
There are other things that can mimic endodontic symptoms
and we want to be very aware not to create any misset
diagnosis, so here are some of those entities. We can have
● periodontal abscesses or other periodontal
problems even food impaction can mimic and
endodontic symptoms
● vertical root fractures
● Acute/chronic sinusitis- sinusitis so pressure in the
sinuses causing pressure on the ends of the roots and
upper molars will sometimes cause a dental pain we
can have
● Muscular pain, TMD/MPD (inc. occlusal trauma) -
TMJ pain or muscular pain and this can include
occlusal trauma or pair of functional habits
● Neuropathic pain- pain that's not actually occurring
in the dental structures themselves but in the nerves
and in the in the blood vessels around up around the
dental tissues and then we can have
● Atypical facial pains - so pain that's associated with
nothing dental a little
All of those conditions listed on the previous slide can mimic
endodontic disease and you have to rule those out prior to
instituting root canal therapy. If you're not sure refer or ask
many misadventures have occurred and thousands of
unnecessary treatments performed because of misdiagnosis of Case #1 - Pulpal diagnosis?
non dental pain ● Spontaneous pain - severe
● Lingering pain after heat
Plan of treatment ● Relieved by cold
● Endodontic therapy ● Heat sensitivity reproduced with tests
○ Emergency treatment
○ Elective treatment Symptomatic irreversible pulpitis
● Extraction
● Referral

The treatment planning part of this presentation we've got our

subjective findings. We've got our objective findings. We've
made our assessment in our diagnosis so we're looking at
endodontic therapy. If we've assessed that we've got a tooth
that needs it then we can go ahead and do that endodontic
therapy. If the tooth is restorable and the periodontal condition
is sound the tooths not restorable or we don't have a good
periodontal prognosis and we may want to consider extraction
and in cases where either you think the tooth is a child is
presents a challenging case or you have any doubts about the
diagnosis that you've made then this may be a good time to
refer.
We know that that the pain was severe, we know that there
Case #1 was lingering pain after heat that was relieved by cold and our
● 28 y.o female heat sensitivity and testing reproduced what the patient had as
● Caucasian their complaint
● Office worker
● She is obviously in pain So based on all of this we know we have a symptomatic
● She is holding a cup of ice water irreversible pulpitis. Bacteria is invading that pulp and killing
● She doesn’t look as if she’s slept well that nerve and we need to get rid of it

Medical history Case #1 - Periradicular Diagnosis?

● Generally good health
● Mitral valve prolapse with regurgitation
● Allergic to penicillin
Subjective information
● Pain started on its own three days ago- worsening
● Pain is a spontaneous, constant throbbing
● Pain worsens when ingesting hot substances, lingers
● Pain is relieved by cold
● Pain is slightly worsened by biting pain
● Pain feels like 9 out of 10 - wakes patient up at night
Document everything!
● Mild bite sensitivity
● Mild percussion sensitivity - reproduced with tests
Symptomatic apical periodontitis
We’ve got bite sensitivity we've got mild percussion
sensitivity and it's again reproduced with the test. the patient
knows that when you tap on that two thoughts the one so we
have a symptomatic apical periodontitis
Case #1 - Plan of treatment
Non surgical root canal therapy

Our radiographic analysis we've see a pulp exposure carious

lesion under an existing restoration and possibly some
condensing osteitis and some PDL thickening.

And our treatment plan for this tooth is non-surgical root canal
therapy and elimination of the carries on top getting rid of the
source of the infection and getting rid of the symptoms by
getting rid of the bacterial

For case number two..

Case #2

34 y.o. Male
● Asymptomatic “bump” on gums
● Recent crown replacement
● Perioprobing WNL
○ Percussion - +
○ Palpation - -
○ Bite - -
○ Cold - -
● Dx: Pulp necrosis
Cold positive response indicates that there is indeed vital and
● Chronic apical abscess
healthy nerve tissue in that tooth so our diagnosis in this case
● Tx: NSRCT
is a normal pulp and a periodontal abscess

In this case endodontic treatment is not indicated but the

question becomes is the tooth savable from periodontal
perspective

Case #4
48 y.o. Female
● Caucasian
● Malpractice litigation attorney
● Medical history (non-contributory)
● “There’s a sore lump on my gums”
● “My dentist tried root canal… it hasn’t helped”

Case#4 - Subjective history

● Tender swelling on gums
We Trace that sinus tract and our radiographic image shows ● Present two months
that that sinus tract just draining from the mesial-buccal root ● Dentist attempted NSRCT #21 - unsuccessful
of that tooth so based on our negative cold response we know ● Referred
that the tooth has no vital nerve tissue to feel anything we're ● Paresthesia - mild
dealing with pulp necrosis draining sinus tract meaning it's got ● No other pain
a chronic apical abscess

So our treatment in this case is non-surgical root canal therapy

and in this case within days or weeks the draining sinus tract
will heal

Case #3
64 y.o. Male
● Asymptomatic “bump” on the gums
● Perio probing 10+ mm - broad pocket
○ Percussion - +
○ Palpation - +
○ Bite - -
○ Cold - +
Now is that important and you know the dentist may be
● Dx: Normal pulp
thinking while I should refer this patient and I need to take
● Chronic periodontal abscess
better records but the truth of the matter is that every patient
● Tx: Likely extraction
should be treated exactly the same and those records should be
the same for every patient document everything it's always
really important and it will help you for your treatment and
patient management moving forward always

So for this patient her medical history was non-contributory

she said there was a sore lump on her gums and her dentist
tried to do a root canal treatment but it hasn't helped the
clinical exam showed a tender swelling on the gum being
there for two months despite the previously attempted non-
surgical root canal treatment she describes that she's got a
paresthesia meaning she's got altered sensation of the chin but
no other pain
Dynamic Diagnosis
● Develop diagnostic findings
● Derive a “provisional diagnosis”
● Continue observation
● Continue collection of significant data
● Derive a final diagnosis
○ After treatment
○ After outcome
So I'd like to introduce with this case the idea of dynamic
diagnosis it's a concept that's very important to note in that
diagnosis is an ongoing state it doesn't just stop when the
dentist picks up the handpiece it's got to be continually
verified and modified throughout the procedure since
sometimes findings and observation during treatment can
cause the Stute practitioner to change their diagnosis and that's
the concept of dynamic diagnosis it's fluid and it's changeable
you want to follow the procedure until it's completed and
healing has occurred and this way we're taking our provisional
initial diagnosis to its endpoint
So going back to the case, the dent the patient has this
gingival swelling and the paresthesia so here it's a nice idea to
outline with a skin pencil the area she describes as having
altered sensation and you want to record that so as that area
diminishes over time which are hopefully will you've got a
record of that
And you want to record that so as that area diminishes over
time which are hopefully will you've got a record of that
so though it's rare also just bear in mind that paresthesia in this
area can result from endodontic infection and swelling that
presses on the mental nerve, but that's not all that common
so looking at our standardized form here we've got our dental
findings and our test results and we see that everything is
consistent with a persistent endodontic disease
radiographically the significant findings include:
● we've got a leaking temporary restoration so
recontamination of that canal space bacteria is getting
in there
● we've got thickened cervical level periodontal
ligament space and that's consistent with a clue cell
trauma or root fracture or loosen the loosening of the
tooth
● we've got a periodontal ligament thickening around
the end of the root that's consistent with the
endodontic infection
Pulpal Diagnosis:
● No pain
● No response to pulp tests
● Dentist started NSRCT
PREVIOUSLY INITIATED THERAPY
so creating our Popple diagnosis she has no pain, no response
to pulp tests and the dentist started the non-surgical root canal
therapy so we have previously initiated therapy
Periradicular Diagnosis
● Tender to palpate alveolus
 ● Negative periradicular tests
● Drainage from gingival sulcus
● Apical periodontal ligament thickening
the tooth is tender to palpate, it's negative period radicular
tests, there's drainage from the gingival sulcus and the apical
periodontal ligament thickening indicates that we have a
chronic apical abscess
Instrumentation:
● Crown-down and rotary
● Two appointment
○ High level disinfection
Obturation:
● Hybrid lateral/ warm vertical compaction
so based on the pulpal and the periradicular diagnosis, the
endodontic treatment was completed by the endodontist. It
was done in two appointments with a high level of
disinfection. the coronal seal was maintained throughout and a
good temporary well fitting well sealed temporary was put on
the tooth afterward. no fractures were seen using the general
operating microscope and no other canals were detected
so despite our treatment the lesion never healed and this is
where the idea of dynamic diagnosis concept comes in.
reevaluation and performing another diagnostic sense
sampling with reformation of a treatment plan is indicated
here
Options:
● Do nothing
● Non-surgical retreatment
● Extraction
● Surgical endodontic therapy
so what are the patient's options they were discussed and they
are: do nothing non-surgical retreatment, extraction, or
surgical endodontic therapy, and the patient here chose
surgical endodontic therapy.
flap was reflected and an unexpectedly large lesion was filled
with necrotic bony sequester was found. It was curated and
the route and resection and filling of the first premolar was
done. just note here also that the cuspid root is hanging within
this lesion resulting in its pulp losing vitality. so that material
that granulation tissue and bode sequester that was sent to a
qualified oral pathology service
Change the diagnosis:
● Lesion was too large
● Bony sequestra found and removed
○ Does not occur with LEO
● Biopsy performed
● Pre-existing paresthesia
here's our new information for our changing diagnosis. the
lesion was very very large, there's bony sequester found and
they were removed and that doesn't usually occur with lesions
of endodontic origin. we've got our biopsy we're waiting for
that information and now that idea of that pre-existing
paresthesia we're starting to think of how that may not have
just been swelling pressing on a mental nerve in the area
Final diagnosis: central giant cell granuloma
so the final diagnosis was a central giant cell granuloma, a non
endodontic pathology that in this case truly mimicked an
endodontic infection
Re-evaluation:
 M2 OBJECTIVES

Identify functions of each of the armamentarium for rubber

dam isolation
Use the different armamentarium for rubber dam tooth
isolation
Understand the disadvantages and advantages of rubber dam
isolation
Describe the different methods of rubber dam isolation
Perform rubber dam isolation on a mounted jaw
so following through on the dynamic diagnosis right to its
endpoint, here, twenty six months later we've got complete M2 LESSON 1. Armamentarium for rubber dam tooth
healing following that surgical debridement and the non- isolation
surgical root canal therapy was done on the on the cuspid
tooth it was the one that was devitalized during the surgery ● Basic Instruments for Endodontics
● Mouth Mirror
you may also note here that the patient unfortunately hasn't got ● Endodontic Locking Plier
their final restoration replaced and it's 26 months later. so this ● Endodontic Excavator
tooth is definitely subject to coronal leakage and ultimately the ● Woodson plastic filling instrument
potential for post endodontic infection in these teeth is really ● Rubber Dam Sheet
great. we may not be at the end of the story here ● Rubber Dam Template
● Rubber Dam Clamps
so as you can see diagnosis can be an area that can be really ● Rubber Dam Clamp Forcep
complex but there are ways that we can simplify it. take great ● Rubber dam Punch
notes and do things systematically and consistently the same. ● Rubber Dam Frame
do your testing and clinical examinations covering all bases ● Floss
from the general to the specific. gather that information and
put it together in a way that makes sense for an accurate Additional Requirement for Virtual Rubber Dam Isolation:
diagnosis. if you're not sure call your local endodontists, ask
1. Table top
questions. but where you know the diagnosis the treatment
plan follows and from a great treatment plan comes. great 2. Metal jaw or any type of jaw (with complete upper and
treatment and great treatment makes a happy patient lower natural or typodont tooth specimen) that will fit in your
chosen table top.
MODULE 2 – TOOTH ISOLATION (Introduction)
INTRODUCTION To view the details of each material and instrument and to
know their function, please click the link below and view the
In Dentistry, to work under dry conditions, free of powerpoint presentation.
saliva is essential. That need has been recognized for
centuries, and the idea of using a sheet of rubber to isolate the https://cden.tu.edu.iq/images/New/2016/Lectures/Dr.Ahmed/
tooth. 5/Tooth-isolation.pdf

The introduction of this notion was attributed to a
young American dentist from New York, Dr. Sanford Christie
Barnum, who in 1864 demonstrated for the first time the
advantages of isolating the tooth with a rubber sheet. At that
time, keeping the rubber in place around the tooth was a
problem, but things soon improved a few years later, in 1882
S.S.White introduced a rubber dam punch similar to that being
used now. In the same year, Dr. Delous Palmer introduced a
set of metal clamps which could be used for different teeth.
The Quality Assurance Guidelines of the American
Association of Endodontists says that “Cleaning, shaping,
disinfection and obturation of all canals are accomplished
using an aseptic technique with dental dam isolation whenever
possible”
According to Dr. Arnaldo Castelluci, “When it is
not possible, the clinician has two options: one is to make it
possible and the other is to extract the tooth.”
M2 LESSON 2.Advantages and disadvantages of rubber
dam isolation
The advantages of using a rubber dam:
enhances visibility of the treatment site since the dam retracts
the cheeks and lips
reduces the risk of the patient swallowing instruments or
debris
reduces the risk of contamination of oral microorganisms in
the blood and/or saliva
provides a clean and dry operating field that is free of saliva,
blood, and debris from the procedure, as well as achieves
maximum bond strength when using restorative materials and
cements
reduces mercury exposure when using amalgam materials in
the mouth;
reduces aerosol splatters in the oral cavity from dental
procedures;
protects dentists, hygienists, and patients from possible
exposure to HIV, hepatitis, and other infectious diseases or
blood-borne pathogens during procedures

The disadvantages of using a rubber dam:

additional application time, which can be difficult and time-

consuming
additional cost of materials: stamp, dental clamps, rubber dam,
frame
rubber dam could break in the patient’s mouth, thus floss is
placed around the clamp as a precaution for retrieval
could cause damage to the oral mucosa during placement and
removal of the dam
patient may have discomfort or difficulty breathing due to Step 2. Select the appropriate clamp and check its fit on the
blockage of the airway tooth to be isolated.
if the rubber dam is latex, it could cause a latex allergy or
episode to occur
may decrease communication between patient and operator
may increase patient anxiety
many patients refuse the rubber dam
For more information on rubber dam isolation, click the link
below:

https://www.rdhmag.com/patient-care/article/16408220/
dammed-if-you-do-dammed-if-you-dont

M2 LESSON 3.Different methods of rubber dam isolation

Method 1- Clamp and Rubber Dam Sheet Together

Step 3. Designate the area to punch hole on the rubber dam

sheet using rubber dam stamp or template.

Method 2- Clamp first followed by Rubber Dam Sheet

Step 4. Punch a hole on the rubber dam sheet, appropriate for

the size and location of the tooth.
Method 3-Rubber dam Sheet followed by Clamp

Step 5. Lubricate the inner surface of the rubber dam sheet

with Vaseline to allow it to slide better over the contours of
the tooth and contact areas closely and tightly around the
cervix.
M2 LESSON 3 CONTINUATION

Rubber Dam Isolation Procedure:

Step 1. Remove calcular deposits on tooth surfaces.
 5. After placement of clamp and rubber dam sheet, a
dental floss may be used to draw the sheet through
the proximal contact area.

Step 6. Choose what Method of Isolation you like to use.

Method 2 - Clamp first followed by Rubber Dam Sheet

Method 1- Clamp and Rubber Dam Sheet together. 1. Place the clamp on the tooth crown using the clamp
forcep.
1. Attach the wings of the clamp to rubber dam sheet
over the area of the punched hole.

2. Slide and stretch the rubber dam sheet over the bow
of the clamp.
2. With the clamp forcep , place the clamp with rubber
dam sheet beyond the greatest contour of the crown.

3. Release the clamp from the forcep and adapt the 3. Slide and stretch the rubber dam sheet over the under
rubber dam sheet around the cervix of the tooth. jaw and prong of the clamp.

4. After placement of clamp and rubber dam sheet, a

4. With a hand instrument release the rubber dam sheet dental floss may be used to draw the sheet through
from the wing of the clamp to allow the sheet to the proximal contact area.
constrict around the cervix of the tooth.

Method 3 - Rubber dam Sheet followed by Clamp

 1. Slide the rubber dam sheet over the contours of the
tooth.
2. With the forcep , place the clamp beyond the greatest
contour of the crown.
3. Release the clamp from the forcep and adapt the
rubber dam sheet around the cervix of the tooth.
4. After placement of clamp and rubber dam sheet, a
dental floss may be used to draw the sheet through
the proximal contact area.
Step 5. Place the frame over the rubber dam sheet, and stretch
out the sheet on the frame to provide soft tissue retraction.
Step 6. Swab with disinfectant the isolated tooth and the
adjacent structures .
(12) Cross check for missing pictures and details and M1
MODULE 4 SCOUTING, EXPLORATION, PULP
EXTIRPATION AND IRRIGATION
Canal scouting is the first phase of canal instrumentation,
during which procedural difficulties or errors might more
frequently occur.
As a first step, the negotiation is most often essential.
Negotiation might be thought of as the process of exploration
and discovery to determine the individual canal anatomy noted
previously using small K-files(6-10s).
Therefore, canal scouting and exploration is necessary prior to
canal cleaning and shaping. Another equally important
procedure is pulp extirpation, it is the complete removal of
vital dental pulp, which is also called pulpectomy.
Irrigation on the other hand facilitates the physical removal of
materials from the canal and introduction of chemicals for
antimicrobial activity, deodorizing and hemorrhage control.
M4 Lesson 1:Armamentarium for Scouting, Exploration,
Pulp Extirpation and Irrigation:
1. SS K-type files #6,#8 and #10
2. Rubber stop
3. Specimens: Maxillary Central Incisor, Maxillary First
Premolar and Maxillary First Molar
4. 5.25% Sodium Hypochlorite
5. Lubricant (EDTA)
6. 2-3 pieces of 3 cc or 5 cc hypodermic syringes
7. 2-3 pieces side vented or side port needles
8. Absorbent paper points size #15 to #40
9. Lamp with denatured alcohol and match or lighter
10. Distilled water for dilution
M4 Lesson 2: Procedure and Guidelines in Scouting,
Exploration, Pulp Extirpation and Irrigation
A normal pulp tissue as in the case of intentional root canal
treatment or a diseased pulp tissue with an irreversible pulpitis
case is removed during canal cleaning and shaping with the
use of endodontic files and irrigating solutions. However, in
cases where canal cleaning and shaping is not possible on the
same treatment appointment pulp extirpation is recommended.
Click the link below to view a case of pulp extirpation using
photoacoustic irrigant streaming.
The following are Procedures and Guidelines in Scouting
and Exploration:
1. Probe the canal orifice with endodontic explorer
(pathfinder/Stewart probe) to determine the direction of the
canal at the cervical third.
2. Establish the Trial Working Length (TWL).
a. Using the endo tooth model specimen
(JChenny), measure the tooth length (TL)
from the reference point (incisal or occlusal)
to the apex or end of the root. Whatever the
measurement, subtract 2mm as a safety
factor to get the TWL.
b. Record the measurement on your
printed portfolio.
3. Mark on the scouting instruments the TWL.
a. Mark the TWL on SS K-type files #8
and #10 with rubber or silicone instrument
stop.
b. Select which from the two files can
glide freely through the canal. The file that
glided through will be referred to as the
scouting instrument.
4. Confirm the canal morphology as the scouting
instrument was inserted apically.
a. Feel the patency of the root canal
using the scouting instrument.
b. Take note of any abrupt changes in
the canal anatomy.
c. Interpret the tactile information and
take note of the probable direction or
location of resistance and curvatures.
Procedure and Guidelines in Irrigation:
1. Prepare two (2) disposable hypodermic syringes.
a. Color code or label each of the
syringes for easy identification. One will be
used to introduce the irrigation solution and
the other to aspirate excess solution when
the canal is ready for sealing.
2. Prepare the irrigation solution.
a. In a clear and clean container, dilute 1
part of 5.25% Sodium hypochlorite
(NAOCl) with 5 parts distilled water (1:5
ratio). If full concentration is preferred,
simply transfer the commercially prepared
5.25% solution in another container to
conceal the brand.
b. Fill up one syringe with the
solution. Lift the syringe with the needle in
an upward direction and tap the barrel to
remove the bubbles toward the surface of
the solution.
c. Push the plunger and express out the
trapped air.
3. Irrigation of the canal.
a. Position the needle into the widest
portion of the canal allowing an adequate
space for the backflow of the solution. For
narrow canals, simply flood the pulp
chamber with NaOCl.
b. Place a cotton ball next to the
access preparation to catch the backflow of
the solution.
c. Very slowly and without pressure,
push the syringe plunger to introduce, at
least,
4. 1 cc of the solution into the canal. For narrow
canals, simply flood the chamber with the solution.
d. Place a drop of lubricant.
e. File the canal once it’s ready.
f. Leave the solution inside the canal
while filing. Constantly irrigate before
changing the file size.
g. At the end of instrumentation and as a
final rinse before sealing the canal either
temporarily or permanently, repeat the
procedure, except for the application of
lubricant (step d), until all dentin shavings or
debris are flushed out of the canal.
5. Aspirate the excess solution when the canal is
ready for drying and sealing.
a. With the second syringe, express out
the air from the barrel by pushing the
plunger to the fullest before insertion into
the orifice.
b. Position the tip of the needle inside
the root canal.
c. Pull the plunger to aspirate the excess
irrigation solution and air.
d. Repeat the procedure when
necessary.
6. Dry the canal with sterile absorbent paper points.
a. Sterilize the absorbent paper points in
an autoclave. Paper points must have the
same size as the MAF.
b. Mark the WL on the paper points.
c. Pass the paper point over the flame of
an alcohol lamp 3x or immerse in glass
beads sterilizer for a few seconds.
d. Insert the sterilized absorbent paper
point into the canal and swab the walls to
the full WL marker to absorb the fluids from
the canal.
e. Repeat the procedure until the
canal is "bone dry".
7. Seal the canal either temporarily with Calcium
hydroxide or with final root canal obturation materials.
M4 Lesson 3: Procedure in Handling Chemical Adjuncts
Irrigation performed with mechanical cleaning and shaping of
root canals constitutes one of the most important stages of root
canal treatment. The antibacterial effects of current irrigation
solutions have been reported to be enhanced by increasing the
concentration, temperature and amount of solution and by
agitation.
Sodium hypochlorite is currently the most commonly used
irrigating solution due to its pronounced antimicrobial effects
and the capacity for organic tissue dissolution. Decreasing the
concentration of the solution reduces its toxicity, antibacterial
effect and ability to dissolve tissues. Increasing its volume or
warming it increases its effectiveness as a root canal irrigant.
However, due to its (NaOCl) limited effects on inorganic
component of the smear layer, ethylene diamine tetraacetic
acid (EDTA) is used which acts on the inorganic part of the
smear layer. NaOCl is an adjunct solution for removal of the
remaining organic components. Irrigation with 17% EDTA for
1 minute followed by a final rinse with NaOCl is the most
commonly recommended method to remove the smear layer.
EDTA has little or no antibacterial effect.
Chlorhexidine has broad-spectrum antibacterial action,
sustained action and low toxicity. Because of this properties it
has also been recommended as a potential root canal irrigant.
The major advantages of chlorhexidine over NaOCl are its
lower cytotoxicity and lack of foul smell and bad taste.
However, like NaOCl, it is unable to kill all bacteria and
cannot remove the smear layer.
An alternative solution to EDTA for removing the smear layer
is the use of MTAD, a mixture of a tetracycline isomer, an
acid (citric acid) and a detergent. MTAD was developed as a
final rinse to disinfect the root canal system and remove the
smear layer. The effectiveness of MTAD to completely
remove the smear layer is enhanced when a low concentration
of NaOCl (1.3%) is used as an intracanal irrigant before
placing 1 ml of MTAD in a canal for 5 minutes and rinsing it
with additional 4 ml of MTAD as the final rinse. it appears to
be superior to chlorhexidine in antimicrobial activity. In
addition, it has sustained antibacterial activity, is
biocompatible and enhances bond strength.
M4 Lesson 4: Errors in Scouting, Exploration, Pulp
Extirpation and Irrigation as Well as its Management
Sodium hypochlorite is generally not utilized in its most
active form in a clinical setting. For proper antimicrobial
activity, it must be prepared freshly just before its use.
Exposure of the solution to oxygen, room temperature and
light can inactivate it significantly. Extrusion of NaOCl into
periapical tissues can cause severe injury to the patient. To
minimize NaOCl accidents, the irrigating needle should be
placed short of the WL, fit loosely in the canal and the
solution must be injected using a gentle flow rate. Constantly
moving the needle up and down during irrigation prevents
wedging of the needle in the canal and provides better
irrigation. The use of irrigation tips with side venting reduces
the possibility of forcing solutions into the periapical tissues.
Treatment of NaOCl accidents is palliative and consists of
observation of the patient as well as prescribing antibiotics and
analgesics.
(Video from Canvas-https://youtu.be/PX3tezaj1ns)
ENDODONTIC DISINFECTION
- Debridement
- Smear Layer
- Biofilm
There's been a variety of methods that our profession has
utilized to better appreciate root canal system anatomy but
what we all agree upon is that well shaped canals have the
potential to be clean canals regardless of the method utilized
in the night disinfection is comprised of removing all the pulp
the byproduct of our instrumentation the smear layer and
finally communities of bacteria biofilms.
Many clinicians relate to a block canal is the inability to pass
a ten file to the full working length but in reality especially
with the advent of nickel titanium instruments and with
particular emphasis on the cross section of the file many
blocked canals are in turned blocked laterally rotary nickel
titanium instruments especially the radial landed variety tend
to burnish more debris into the lateral canals eccentricities off
the rounder canals and dentinal tubules than cutting
instruments these blocked anatomical spaces need to be
cleansed so we can encourage and promote our irritants to
move laterally into the deep anatomy
There has been tremendous interest in the endodontic
marketplace on how to improve clinical disinfection there's a
variety of methods that are either to market or are emerging
rapidly for clinical practice let's quickly take a look at some of
the more popular methods:
DISINFECTION METHODS
- EndoVac
- RinsEndo
- Ultrasonic fluid delivery
- Photo activating Disinfection
- Plastic endo File
- Irrisafe file vibringe
- Endobrushes
- EndoActivator
The endo vac is nothing more than placing a suction device in
a well shaped canal to the full working length this method is
quite interesting sucking out debris or livering it through
vacuassin procedures is useful and helps us have less flare-ups
and potentially allows us to pack better
The Rinsendo is a german device that is made by the Durr
company and in this method they use pulsating positive
irrigation and suction to better enhance disinfecting
Yet another method that has proven to be quite interesting as
based on the evidence presented in the Journal of endodontics
is ultrasonic fluid delivery in this method a cannula is attached
to a ultrasonic handpiece the power setting is going to move
the tip between 25 and 40 thousand Hertz and dispense the
reagent of your choice into a well
Shaped canal as per usual with ultrasonic activation one has to
be concerned about internal ledges transportations and broken
instruments
Photo activating disinfection is a very interesting method that
it was born primarily in Western Europe in this method of
disinfection a low diode laser is used the preferable
wavelength is 980 nanometers of light in this method a
solution such as tellurium chloride can be flushed liberally
into a well shaped canal and presumably the solution will
move out and enter The cell wall of a microorganism this is
called tagging the bacteria when the diode laser is placed in use and finally is there evidence or science behind it to
the canal and activated the light seeks out the tagged bacteria show that it actually
it implodes the microorganism rendering it non virulent plastic disinfects a root canal system
end o file is
nothing more than a plastic instrument that's impregnated with
a diamond coating as this instrument turns clockwise in a
canal the diamond grit tends to sand and continue to prepare
and already optimally shaped canal this
instrument is actually producing its own smear layer although
some evidence has been produced to show its efficacy the

Erie safe file is a non cutting instrument that attaches to an

ultrasonic handpiece and I've already given the cautionary
remarks about
vibrating metallic instruments below the orifice
the vibrance is one of the newer devices that has recently
come to market and it's basically like a handheld anesthetic
syringe except in this case the operator is dispensing reagent
as the cannula again being metal is vibrated we've seen some
movement towards endo brushes not as quickly as I would
have anticipated but we now see some brushes on the market
the problem with the current market version brushes
is the d0 diameters are quite large on the order of about 50 or
60 which means

they don't often get all the way to length on smaller diameter
canals stay tuned though we don't know the final verdict on
brushes because technology always drives new innovations the
one that you're probably familiar that I've been involved with
and our group and team built is the endoactivator in this
method of activation

we use a polymer which is highly flexible and strong and it

goes into a fluid-filled chamber is
introduced into a canal and through activation we use sonic
energy to kindly activate the tip the polymer tips are not
subject to a diminishing return on their vibration they can
write on thewalls of prepared dentin and still activate a
solution to length and around multiplanar curvatures there is
plenty of emerging evidence on the endoactivator and I'll
show you just

three images that were produced at Paris

by a postgraduate residence named korone and you can see
in that low magnification 500x a bifida T both branches
have been cleaned one presumably with the instrument and
with reagents and the other one the lateral canal is where
the instruments never went in a higher magnification you
can begin to see the potential for the reagent to move as
much as three to four hundred microns back through the
dentinal tubules to enhance deep lateral cleaning and finally
a 2000 X you can
see open Patent dentinal tubules in the apical one third of
this specimen and this was
around the curvature if we're ever going
to bond obturation materials against

Dentin we must divide remove the smear layer and finally

all the bacteria when present my final remark would be
when you look at this rather lengthy list of devices one
must assess the cost to get into the technology to the ease of