Introduction, Scope, History, Rationale HISTORY

Dr Louis Grossman, published an excellent history on

and Principles of Endodontics endodontics in July 1976
Prelims: Endodontics (1)

Objectives of the Subject: Pre-Science • Skull dating from 2nd & 3rd century BC
1. Know the Importance & signi cance of Endo Therapy (1776-1826) found in Negev Desert in Israel had bronxe
2. Know di erent ways of assessing success and failure in wire in one of its teeth
endodontic tx. • Abscess tx w Leeches
3. Recognize the importance of px recall • Pulp horn cauterized w red hot cauteries
4. Know how endodontic therapy has evolved into what is • Entire root canals lled w gold foil.
today
5. De ne each principle in Endo therapy and give an overview Age of • Development of anesthesia & barbed
of its signi cance in endo therapy Discovery broaches
(1826-1876) • Introduced gutta percha points in 1847 by
ENDODONTICS Edwin Truman
Endo: inside | Odont: tooth [Greek] • 1867, Bowman used gutta-percha cones
as sole mat’l for obturating root canals
• Branch of dentistry associated w prevention, diagnosis, tx of • Medications were created for tx pulpal
pathosis of the dental pulp and its sequelae. infections
• Cements & pastes to ll them
Includes but isn’t limited to Dark Age • Discovery of x-ray
1. Di erential Diagnosis (1876-1926) • Dr. Edmund Kells: used radiograohs for
2. Tx of oral pains &/ periapical origin diagnosis & during RCT
3. Vital Pulp Therapy • Advancement of gen. anesthesia fr. LA
a. Pulp Capping • Wholesale extraction of teeth & v little endo
b. Pulpotomy was practice
4. Non-surgocal tx of RC systems w or w/out periradicular • Hardly any innovation took place
pathosis of pulpal origin
5. Selective surgical removal of pathological tissues resulting
from pulpal pathosis FOCAL INFECTION THEORY
6. Intetntional replantation and replacement • Bacteria from an in amed part could migrate & metastasize to
7. Surgical removal of tooth structure other parts of the body
a. Root-end resection/apicoectomy
b. Bicuspidization The • Golden period of endodontics
c. Hemisection Renaissance • Better anesthesia & radiographs
8. Bleaching of discolored dentin and enamel (1926-1976) • Host of RC medicaments appeared on
9. Retreatment of teeth scene
10. Tx procedures related to coronal restoration= • Focal infection theory started dying out
• 1st RC Book “Root Canal Therapy”: Dr.
Objectives of RCT: Grossman
1. To retain tooth inside o. cavity w/ch may otherwise require • RC instrument got standardized & became
extraction readily available
2. Relief of pain, if present • Est. of American Association of Endo, 1943
3. Removal of pulp from roots of tooth • Est. of numerous dental schools worldwide
4. Disinfection of root and surroundign bone by cleaining and • Teaching science of endo as dental
shaping root canal walls specialty
5. Complete lling of canal • Est. of # of journal solely devoted to
6. Placement of nal resto specialty.
7. Main contraindication: Non-Restorable tooth • Huge # research projects for post grad.
curriculum

Innovation • Tremendous advancements at v fast rates

Era (1977 • Better vission, better techniques of
Onwards) biomechanical prep & obturations
• Simpler, easier, faster endo w better results
• Single visit endo now globally accepted in
contrast to multiple visits.
• DR. ANGELO SARGENTI: 1st to introduce
single visit endo
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 MODERN ENDODONTICS Will antibiotics cure a NO!
• Single visit endo therapy globally accepted by all school of root canal infection? Bc thesource of infections is in the
thoughts tooth where there’s no blood supply
• Improvised visibilty w advent of endodontic microscope & antibiotcs cannot get to. The cure
• Newer, more better apex locator is complete cleaning, shaping, &
• Improve better forms of biomechanical cleaning & shaping obturations of the contaminated
• Esier, simpler, faster obturation canal. Antibiotics are useful in tx RC
infections bc they help relieve
sympoms assoc. w teeth that have
non-vital pathology. Antibiotics are
indicated when there’s swelling, an
increased in temp/oth systemic signs
of infections.

Will I feel pain during/ • None —better techniques & better

after RCT? understanding of anesthesia
• Sensation might feel if pain &
infections was present prior to the
procedure —can be relieved by
medication
• Continuous severe pain & pressure
—consult endodontist!

Will I have a dead NO

tooth after RCT? Tooth is supplies by blood vessels
Who performs All dentist recieve basic education in present in periodontal ligament. It
endodontic therapy? endo tx but an ENDODONTIST is continues to recieve nutrition &
preferred for endo therapy remains healthy. It only becomes
numb.
How does pulp - Tooth Decay
become damaged? - Gum Diseases Will the tooth need - Not chew/bite on treated tooth
- Trauma any special care/ until haven’t restored
additional tx after - Practice good oral hygiene
When to RCT? • When pulp becomes in amed/ endo tx? - Retx for failed RCT
infected
• Abscess forms at the end of the Can all teeth be - Mostly, YES
root bc of damageed pulp treated
endodontically? Contraindications:
Most Common 1. Pain - Not accessible
Symptoms for teeth a. Painful tooth waking you up at - Root severly fractured
w damaged pulp night - Tooth can’t be restored
b. Sensitivity to hot/cold - Tooth doesn’t have bony support
c. Biting sensitivity - Anomalies
d. Apparent tooth pain that
radiated into ear &/causes
headaches
2. Infection Principles of Endodontics
3. Pain & Infection 1. ASEPSIS • Rubber Dam
4. Sometimes, no symptoms

Once the pulp of the - Save tooth by RCT Uses:

tooth is damaged: - Extract tooth a. Protection
- Do nothing b. E ciency
c. Cross Infection Risk
d. Legal Consideration
BASIC PHASES OF THERAPY
a. Diagnostic Phase 2. CORRECT • Improper diagnosis leads to
b. Preparatory Phase DIAGNOSIS & TX imporoper tx
c. Filling/bliteration of Canal PLANNING • Improper tx may a ect px systemic
condition
• Proper tx may alleviate systemic
conditions not though rel. to dental
problem.
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 3. ATRAUMATIC • Great respect due to periapical
HANDLING OF tissue dur. tx
THE TISSUE • All tx should be carried out w/in
canal
• Overinstrumentation causes pain
• Caustic drugs shouldn’t be used
• Work w/in working length

4. CLEANING OF Endo therapy is essentially a

CANAL debridement proced. that req. removal
of the irritants of the canal periapical
tissue if success is to be gaines.

Debridement may be:

1. Insrumentation of Canal
2. Placement of Medicametns &
Irrigants
3. Electrolysis/Surgery

5. SHAPING OF - Biomechanical prep of canal

CANAL - Crown down technique

6. OBTURATION Filling the entire canal w gutta percha

points

7. RESTORATION • Proper resto after tx & must be

explained to px
• Fracture, 2ndary caries after RCT —
disheartening & discouraging

8. RECALL OF PX • Postobservation necessary

• Despite high success, failures may
occur
• Some may be retreated successfully,
many heal after surgery
• Recall necessary

CONCLUSION: To appreciate Endo, all scope, history,

rationale, & principles must be fully understood.
Endodontics: PULPAL DISEASE
1. NORMAL Pulp
Pain x Doesn’t exhibit
spontaneous symptom
x Mild pain to pulp vitality
test w/ch don’t distress
Radiograph May have degree of
calcification, but no
evidence of resorption,
caries,/mechanical
exposure of pulp
Percussion
Palpation
Thermal T.
EPT
Treatment No RCT
3.a. SYMPTOMATIC 3.b. ASYMPTOMATIC
2. REVERSIBLE Pulpitis 4. NECROSIS
IRREVERSIBLE Pulpitis IRREVERSIBLE Pulpitis
x Doesn’t occur • Sharp/Dull, Localized/Referred Absent Absent, or may come from
spontaneously • Intermittent/Spontaneous Pain If present, pain may be dull periradicular area
• Stimulus evokes sharp pain of short to temp. changes (esp. Cold)
duration • Pain lingers even after removal
• Pain ceases upon removal of of stimulus
stimulus • Lying down of bending may
intensify pain
CAUSES: Irritants, Early Caries, Perio
Scaling, Root Planing, Microleakage,
Unbased Resto.
• PDL Space: Normal • PDL: Normal • Caries may be well into Normal unless
• Lamina Dura: Intact • May have thickening of PDL in the pulp accompanied by Apical
• May reveal depth of caries/resto advanced stage periodontitis
• Periapical area shows normal appear. • May reveal depth of caries/
but a slight widening may be evident resto
in advanced stages of pulpitis.
Usually (-) May be tender (-) (-)
(-) (-) (-) (-)
(+) to cold/heat (+) (+) (-); may present mixed
resp. in multi-rooted tooth
(+) (+) (+) (-); may present mixed
resp. in multi-rooted tooth
- Excavation of Caries RCT RCT RCT
- Extensive Caries: observation for
sev. weeks w temporary resto
- Placement of insulation in deep
caries
CLASSIFICATION/DIAGNOSIS OF
PERIRADICULAR DISEASES PULP PERIODONTAL TISSUE
Endodontology (Prelims)
• Not always Localized. • Always localized to an area
1. ACUTE Periradicular Peridontitis Often difficult to locate easily located.
• V painful resp. to biting pressure/percussion
• (-) to any vitality test • Pain: sharp, lancinating, • Dull, steady, continuous.
• May exhibit varying degree of mobility intermittent, throbbing. Not affected by body
• Result of an extension of pulpal inflammation into the Usually worse dur. fatigue & position/time of day.
periapical tissue, mechanical,/chemical trauma by endo at night when in reclining
instruments/materials, hyperocclusion,/trauma position
• Widened periodontal ligament space, but NO periradicular
radiolucency. • V sensitive to thermal • Usually unaffected by
• Swelling in mucobuccal fold & facial tissues adj. to tooth changes & oth irritants thermal changes/chem.
• Px may be febrile irritants
• Cervical & subseq. lymph nodes may be present. • Slightly tender to
percussion if there’s • In early stages, pressure
2. CHRONIC Periradicular Peridontitis beginning of periapical inv. relieves & later intensifies
• Asymptomatic pain
• Doesn’t respond to any vitality tests
• Exhibits periradicular radiolucency on apical 3rd of root • Tooth doesn’t seem • Tooth is raised to its socket
• Not sensitive to biting pressure but “feels diff.” to pax upin elongated & doesn’t & strikes first in occlusion
percussion interfere w occlusion unless
there’s periapical involvem.
Chronic Periradicular ABSCESS
(SUPPURATIVE Periradicular Perio) • Tooth usually shows • Regional lymph nodes
• Asymptomatic extensive caries/large resto usually enlarged & tender to
• Periapical radiolucency (Large/Small, Diffuse/Circumscribed) regional lymph nodes in palpation
• Shows sinus tract = Chronic suppurative perirad. perio. submax. area are usually
• RCT unaffected.
• Body temp. is unaffected • Body temp. is usually
unless there’s periapical elevated
PHOENIX —Acute Exacerbation of the Chronic Lesion involvement.
ABSCESS
• Rapid Onset
• Pain may be severe Site of Pain Referral Tooth Pulp Initiating Pain
• May present swelling
• (+++) Percussion & Palpation • Frontal (Forehead) reg. - Mx Incisor
• Periapical Radiolucency • Nasiolabial area - Mx C & PM
• Tx: RCT; Antibiotics may be req. if px • Mx. reg. above Mx. Molars - Mx 2PM
presents w systematic signs & symptoms. • Temporal reg. - Mx 1PM
• Md. area below Md. Molar - Mx 2PM
CELLULITIS • Pain may be severe • Ear - Md. M; Mx 2M,3M (occassional)
• Px may be febrile • Mental reg. of Md. - Md. I, C, PM
• Extraoral/Intraoral swelling
• May/may not present radiograpic change
• Tx: RCT; Incision & Drainage, Extraction if
not restorable, Antibiotics

CONDENSING • Asymptomatic
OSTEITIS • Periapical Radiopacity
• RCT, only if assoc. w irreversible pulpitis

Phoenix Abscess
PERIAPICAL • Excessive bone mineralization around
OSTEO apex that’s asymptomatic, vital pulp
-SCLEROSIS • Caused by low-grade pulp irritation
• Asymptomatic & benign; RCT not req.

Cellulitis
INFECTION CONTROL FAQS concerning Endo Treatment
Endodontology (Prelims)
1. What is
Endodontic (Root
Infectious Diseases:
Canal) Treatment?
1. Influenza
2. Upper Respiratory Disease
3. Tubercolosis 2. What causes pulp When pulp is injured/diseased &
4. Herpes to die/become unable to repair, it becomes stable &
5. Hepatitis B, C, D diseased? eventally die
6. AIDS
3. What are the Momentary to prolonged, Mild to
INFECTION CONTROL symptoms of a severe pain on exposure to hot/cold
• Minimize risk of cross-contamination in work environment diseased pulp? or on chewing/biting.
• ADA recommends that each px be considered “potentially
infectious”
• Use equipment & protective clothing, training, signs & labels,
& hepa vax.

Recommended ICON Guidelines by ADA, CDC, OSHA

1. All dentist & Staff who have px contact be vax against Hepa
B.
2. Thorough medical history be taken & updated
- Screen for allergy
3. Dental personnel must wear protective attire & use proper
barrier technique.
a. Disposable Latex/Vinyl gloves must be worn
b. Hands, wrist, & lower forearms must be washed w
soap
c. Px clothing should be protected w waistlenght
coverings overlaid w disposable px bib.
d. Use rubber dam
4. Contaminated disposable sharps & contaminated reusable
sharps must be placed in separate, leakproof, closable,
puncture resistant containers.
- Containers should be colored red/labeled
“BIOHAZARD” w symbol
5. Countertops & operatory surfaces can either be covered/
disinfected.
6. Contaminated radiographic film packets must be handled
properly to prevent cross contamination.
- “OVERGLOVES” should be placed over
contaminated gloves to prevent cross
contamination.
7. Mouthrinse bfore tx —0.12% Chlorhexidine Gluconate
8. All burs & Instruments must be sterilized after tx.

Treatment Planning
- Immediate attention to emergencies
- Any asympt. but irreversible pulpal & periradicular problems
are managed bfore they bcome symptomatic & more difficult
to handle.
- Ensure sound, healthy foundation exist bfore further tx.
- Explain nature of tx & inform any risks, the prognosis & oth
pertinent facts
- Establish effective communication
- Present simple but informative case that answers all
questions that reduces px anxiety & solidifies px trust.