ENDODONTICS • Most

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#DMDDECEMBER2022
I. PULP- DENTIN
COMPLEX
• Derived from ectomesenchyme
• Pulp is composed of cells, extracellular
matrix and connective tissue fibers.
• It is a loose connective tissue
A. PULP
Zones of the Pulp (Outermost to innermost
layer)
1. Odontoblast Layer
• Single layer of odontoblasts that produce
dentin
• Odontoblastic Processes- extensions
which pass into the dentinal tubules
• Also contains capillaries and nerve fibers
• Crown- More dentinal tubules + larger
diameter;
Root- Less dentinal tubules + smaller
diameter
2. Cell-poor Zone of Weil
• Contains capillaries and myelinated
nerve fibers
• Plexus of Raschkow
3. Cell- rich Zone
• Contains fibroblasts, macrophages and
dendritic cells, mesenchymal
stem cells
4. Pulp proper
(Innermost pulp)
• Central part of the canal
Cells of the Pulp
1. Fibroblasts
• Most numerous cell type
• Synthesizes Types I and III collagen
• Produces extracellular matrix
2. Macrophages
• Functions for phagocytosis, antigen
presenting, production of pro-
inflammatory cytokines
3. Dendritic cells
immune cells
• Acts as antigen-presenting cells
4. Lymphocytes
• T- Lymphocytes: play a role in immunity
with macrophages and dendritic cells
• B-Lymphocytes: only seen in inflamed
pulp
5. Mast cells
• Mainly found in chronically inflamed pulp
around blood vessels
• Release Heparin & Histamine which play
a role in inflammation
* Normal Pulp: Dendritic cells (most common),
macrophages, some T-cells
Inflamed Pulp: Acute- Neutrophils; Chronic-
B-cells and mast cells
Extracellular Matrix of the Pulp
• Functions: Support cells of the pulp,
holds H2O, and mediates cell- to- cell
interactions
• Made up of glycoproteins,
proteoglycans, glycosaminoglycans
(Hyaluronin)
Connective Tissue Fibers of the Pulp
• Type 1 (55%) Collagen, Type III (45%)
Collagen & Type V (minute amounts)
Collagen
Innervation of the Pulp
• Pulp is innervated by:
1. Afferent Neurons
2. Autonomic (Efferent) Neurons
• Sensory innervation to the pulp is
composed of mainly two types of
neurons: A-delta & C fibers
• Dentin above the pulp horns: most nerve
fibers
• Radicular dentin: has the least nerve
fibers
Blood Flow to the Pulp
 • Arterioles enter the pulp through the
apical foramen and the accessory
foramina
• Plexus of capillaries
• Lymphatic drainage

B. DENTIN
• 70% inorganic material (Calcium
hydroxyapatite), 20% organic material
(proteins most commonly Type I collagen
with small amounts of Type III and Type
V), 10% water Age Changes of the Pulp---Dentin Complex
• Elasticity of dentin provides flexibility 1. Decrease in:
allowing the impact of mastication to • Size of pulp chamber and root canals due
occur without fracturing the enamel to secondary dentin formation
• Cellularity of the pulp
Types of Dentin • Number of nerves and blood vessels
1. Primary Dentin • Dentin permeability
• Formed before the root has been • Sensitivity
completed 2. Increase in:
• Mantle dentin is the dentin that forms • Number and thickness of collagen fibers
first and is the Closest to the enamel/ • Deposition of Peritubular dentin
cementum (Different from the rest of
primary dentin) II. MORPHOLOGY OF THE ROOT CANAL
2. Secondary Dentin SYSTEM
• Dentin formed after root completion and • Major anatomic components of the root
throughout life canal system:
• Found between the predentin and the
primary (circumpulpal) dentin
3. Tertiary Dentin
• Produced in reaction to attrition, caries,
restorative procedures
• Further classified into: Reactionary
Dentin & Reparative Dentin
4. Sclerotic Dentin
• Dentin in which the dentinal tubules have
• Important structures:
been completely occluded
Accessory canals – common in the floor of
Dentin Hypersensitivity the chamber and in apical third of the
1. Hydrodynamic Theory root
• Most accepted Isthmus – connection between 2 canals
• When dentin is stimulated, the fluid in located within 1 root
the tubules will move and will stimulate Pulp Chamber
the free nerve endings (A-Delta nerve Maxillary Mandibular
fibers) Central Triangular Ovoid
2. Odontoblastic Transduction Theory incisors (base: incisal
3. Direct Conduction Theory area, apex:
cervical area)
 Lateral Triangular
incisors (pulp horns)
or ovoid Root canals
(if pulp MAXILLARY MANDIBULAR
horns are MAIN VARIATIO MAIN VARIATION
receded) # N #
Canines Ovoid (wider CANAL CANAL
buccopalatally 1 1 1 2
than MD) (100% (70%)
Premolars Ovoid (wider )
buccopalatally 2 1 2 1 2
than MD) 3 1 2 1 (70- 2
Molars Triangular or Trapezoidal (95%) 89%)
rhomboid (wider 4 2 1 1 (70- 2
(MB2) mesiodistally (85%) 75%)
than BL) 5 2 1 (50%) 1 2
(50%) (85%)
* The pulp chamber shape will dictate the shape 6 4 3 3 4
of the access preparation. (60%) (Asians (Caucasian
Root Apex ) s)
1. Anatomic apex – most apical portion of the 7 3 4 3 2
root determined morphologically
2. Radiographic apex- most apical portion of the III. DIAGNOSTIC TESTING
root determined radiographically • Characterize pain by evoking
3. Apical foramen – also major apical diameter; reproducible symptoms (subjective
located 0.5 mm from the anatomic apex symptoms to a more objective data)
4. Apical constriction – also dentinocemental • Test the adjacent and contralateral teeth
junction (DCJ) or minor apical diameter; Located
prior to testing the involved/suspected
0.5 mm from the apical foramen
tooth
• Narrowest part of the canal
• Marks the junction of the pulp and the
A. VITALITY TEST
periodontal ligament
1. Thermal test- determines vascular supply
• The point at which canal instrumentation
• suggests whether the pulp is reversibly
and obturation should stop
inflamed, irreversibly inflamed, or necrotic
in nature
• Cold test – dichlorodifluoromethane (Endo
Ice refrigerant spray −26.2° C), ethyl
chloride (−5˚ C), ice sticks, cold water
bath
• Heat test – heated gutta percha, hot
water bath
• Vital: (+), note the severity and duration
of pain/discomfort
• Non-vital: (-), no response
2. Electric Pulp Test- detects presence of viable
nerves
• Conduction medium: toothpaste
 • Bridging Technique is done when the -
tooth has a crown or an extensive “precipitously”
restoration
drops
Place the toothpaste-coated tip of the
explorer on the exposed tooth surface, Broad-based Periodontal in
then place the probe tip on the explorer pocket nature
• Contraindicated in patients with -conical
pacemakers
Mobility Grade Amount of mobility
FALSE NEGATIVE FALSE POSITIVE
Multiple canals with Probe contacting a 1 <1mm
partial necrosis metallic restoration
Probe contacting a Nervous patient 2 >1mm
large restoration 3 Can be depressed
Recently traumatized Patient in severe vertically
tooth pain
Immature tooth with Poor tooth isolation C. SPECIAL TESTS
open apices
1. Bite test
Obliterated pulp Liquefactive necrosis • Tooth Slooth
chamber or calcified • Pain on biting - inflammation of the
canal periapical tissues
Anesthetized tooth • Pain on release- Cracked Tooth Syndrome
Patients who have 2. Transillumination – uses a fiberoptic light
recently taken source to detect fracture and caries
analgesics 3. Anesthetic test – localizes which arch the
No conductive diffuse or referred pain is coming from
medium placed 4. Test cavity – done when all other tests yield
inconclusive results; tooth is prepared up to the
B. PERIODONTAL EXAMINATION DEJ (sensitivity means pulp is vital)
1. Percussion- presence of inflammation in the
periapical area D. RADIOGRAPHIC EXAM
• Pain is localized due to the presence of SLOB RULE- When you move the cone distally,
proprioceptive nerve fibers in the PDL the lingual canal will also seem to move distally.
• (+) = physical trauma, occlusal The buccal canal will move to the opposite
prematurity, periodontal disease, directions (towards the mesial)
extension of pulpal disease into PDL
space
2. Palpation- helps characterize intraoral swelling
• (+)= pulp disease has communicated
with adjacent soft tissue
3. Probing and mobility- detects amount of
periodontal ligament and bone destruction
• Probing aids in differentiating pulpal from
periodontal disease:
Narrow Deep Endodontic in
Pocket nature/ Vertical
-sinus fracture
-blowout
 Dentinal Hypersensitivity
IV. PULPAL DIAGNOSES • Application of cold on enamel triggers

Reversible Acute Chronic Necrotic

Pulpitis Irreversible Irreversible
Pulpitis Pulpitis
Chief Complaint “Nangingilo ang “Hindi ako “May butas ang “Maitim ang
ngipin ko” makatulog sa ngipin ko” ngipin ko”
gabi sa sakit ng
ngipin ko”
History of MILD to “Hot tooth” Tooth was Tooth may be
Present Illness MODERATE SEVERE previously previously
PROVOKED UNPROVOKED/ painful painful or was
EASILY SUBSIDES SPONTANEOUS traumatized
PROLONGED
Intensified by
changes in
postural position
May be referred 1
Clinical Usually Tooth caries, Deep carious Grayish color
condition of accompanied with extensive lesion, pulp
Tooth deep carious restorations, polyp in open
lesion, large fractures cavities, internal
restoration exposing the resorption
pulp (pink)2
Radiographic - -/+ (no to -/+ (no to -/+ (no to
Exam minimal) minimal) minimal,
pronounced RL)
EPT + (low current) +++ (lower + (high current) -
current)
Thermal test + (easily subsides) +++ (prolonged) + (prolonged) -
Percussion - +/- -/+ -/+
Palpation - - - -/+
Treatment Restoration RCT or Extract
normal response but on exposed root/
dentin
Normal Pulp • triggers sharp painful response that lasts
• Pulp is symptom- free for 1-2 seconds after stimulus is removed
• Responds normally to pulp vitality tests: • may be confused with reversible pulpitis
Mild/transient response on cold test (1-2 so you have to correlate with clinical
seconds) exam
Previously Initiated 2 Chronic Irreversible Pulpitis
• This indicates that the tooth has been • Chronic hyperplastic pulpitis (pulp polyp) -
treated by partial endodontic treatment reddish mass of reparative pulp tissue
Previously Treated extruding through a large cavity usually in
• Diagnostic term indicating that a tooth molars of children; proliferating capillaries
has been endodontically treated and the and granulation tissue
pulp canals have been obturated with root
canal filling
 • Internal Resorption- from chronic irritation
leading to irreversible inflammation;
Asymptomatic
ovoid or irregular radiolucency within
canal;
Prompt RCT is required to stop resorptive
process

1 Sites of Pain Referral

Histologic Appearance:
V. PERIAPICAL DIAGNOSIS
Symptomatic Asymptomatic Condensing Chronic Acute Apical
AP AP Osteitis3 Apical Abscess
Abscess
Chief “Masakit ang NONE NONE “May pimple “May nana po ako
complaint ngipin ko po ako sa sa gilagid”
kapag gilagid”
ngumunguya”
Pain Significant None to mild Symptomatic If pain is Rapid onset of
symptom pain on (Histologically, or present, due pain,
mastication may have asymptomatic to occasional spontaneous
and pressure, granuloma or closing of moderate to
severe cyst1) sinus tract; severe
spontaneous metallic discomfort,
discomfort taste in the swelling with pus,
mouth extreme
tenderness to
biting; may be
associated with
elevated temp,
lymphadenopathy,
malaise,
leukocytosis
Pulp status -reversible Necrotic Necrotic or Necrotic Necrotic pulp
pulpitis2 irreversibly pulp
-irreversible inflamed pulp
pulpitis
-necrotic
Treatment RCT or RCT or exo RCT or exo RCT or exo IND, RCT or exo
management
of etiology

Normal Periapical Tissues Malassez (Remnants

• Teeth are not sensitive to percussion and of
palpation test HERS)
1Asymptomatic Apical Periodontitis
6. Surrounded by
Granuloma Cyst fibrous
1. Chronic 1. Filled with fluid capsule
inflammation and
2. Neutrophils, cellular debris
plasma cells, 2. Lined by stratified 2 Symptomatic Apical Periodontitis
histiocytes, mast squamous epithelium • Only periapical disease wherein the pulp
cells, (Source: Rests of may have reversible pulpitis only due to
eosinophils Malassez) trauma or premature contact. If this
3. Multinucleated 3. Surrounded by happens, treatment is management of the
giant cells fibrous etiology.
4. Cholesterol capsule
5. Epithelial Rests of 3 Condensing osteitis also focal sclerosing
osteomyelitis
 • Response to low grade inflammation
• Only periapical diagnosis that will appear
radiographically as radiopacity because of
bone formation
Phoenix abscess, also “recrudescent
abscess”
• Acute exacerbation of a chronic periapical
lesion such as a cyst or a granuloma
• Associated with initiation of RCT in an
asymptomatic tooth with CAP
• Percussion and palpation suddenly
becomes positive
• Radiographic finding: periapical
radiolucency on a root canal-treated tooth
Apical scar
• Healing of periapical disease by repair
rather than regeneration
• Bone is replaced with dense fibrous
connective tissue
• Commonly seen in asymptomatic root
canal-treated teeth
• Radiographic finding: periapical
radiolucency which does not need
treatment
Other radiolucencies associated with vital teeth,
not requiring endodontic therapy:
• Cementoma
• Traumatic Bone Cyst
• Globulomaxillary cyst
• Lateral Periodontal cyst
• Nasopalatine Duct cyst
• Gingival abscess- lesion only on the
gingiva; relative rarity that occurs
when the bacteria invade through
some break in the gingival surface

V. PULPAL THERAPY PROCEDURES

VITAL PULP THERAPY

Indirect Pulp Direct Pulp Pulpotomy Partial (Cvek)
Capping capping Pulpotomy
Goal To preserve vital pulp tissue & promote apexogenesis in young permanent
teeth
Prerequisites Pulp should be normal or at most, reversible pulpitis
Indications deep carious pinpoint Usually performed Traumatic or carious
lesion with (<0.5mm) on deciduous molars exposure of
imminent pulp exposure due w/ carious pulp immature
exposure to mechanical exposure provided permanent teeth
or traumatic that: (<2mm)
injury -pulp is normal/ with
reversible pulpitis
only
-root length at least
2/3 of original
length
-pulpal hemorrhage
can be controlled
Procedure Excavate Apply CaOH Amputate coronal Remove 1-2mm of
infected dentin, liner to the pulp, control superficial pulp
leave affected pulp exposure bleeding, medicate tissue and control
dentin1 then then restore w/ Formocresol/ bleeding, apply
place CaOH MTA2, seal w/ ZOE CaOH to promote
liner
 apexogenesis, seal
and restore

NON-VITAL PULP THERAPY

Apexification Pulpectomy Root Canal
Treatment
Goal To induce root apex Complete removal of Retain mature
closure by hard tissue irreversibly inflamed/ permanent tooth with
deposition necrotic pulp tissue to fully developed root
retain the tooth in and apex
function
Prerequisites Irreversible Pulpitis & Necrotic pulp
Indications Immature Permanent -Canals accessible -irreversible pulpitis
teeth prior to RCT -Roots at least 2/3 -pulpal necrosis with
original length or without periapical
disease
-intentional RCT
Procedure File and irrigate, File and irrigate, fill
CaOH / MTA3 placed with resorbable ZOE
to promote hard paste
tissue deposition

1 Infected Dentin Affected Dentin

• Bacteria present
• Collagen is irreversibly denatured
• Not mineralizable and must be removed
• Zone 4 (turbid) & Zone 5 (Infected Zone)
• Yellow, soft, mushy, cheese/curd-like
• No bacteria
• Collagen is irreversibly denatured
• Remineralizable and should be preserved
• Zone 2 (Subtransparent Dentin) & Zone 3
(transparent dentin)
• Black, hard, leathery dentin

2Pulpotomy is usually done in primary and young permanent teeth. Prognosis is not very favorable in
permanent teeth but it can be done in emergency cases of acute irreversible pulpitis but must always
be followed by RCT.
Calcium hydroxide cannot be used in pulpotomy of primary teeth because of risks of internal
resorption.

3Calcium hydroxide for apexification is used for long term root end closure through biologic process.
MTA is used for short term artificial plug., but the problem with MTA is that it is very difficult to
manipulate.
VI. ROOT CANAL TREATMENT
Contraindications:
• Non-restorable tooth
• Vertical Root Fracture
• Insufficient Periodontal Support
• Massive Internal/ External Resorption
• Tooth unsuitable for instrumentation
*Single-visit RCT: vital teeth only
Multiple appointments for necrotic teeth
Goals:
• Caries removal
• Unroof Pulp Chamber
• Straight Line Access up to the apical
foramen
• Pulp Tissue Removal
• Conserve Sound Tooth Structure
• Orifices location
• Restorability Check

A. Access Preparation
- MB2 difficult to
ANATOMIC CONSIDERATIONS FOR locate reason
MAXILLARY TEETH why Max 1st
Roo Orific Can SPECIAL molar has
t e al CONSIDERATIO highest
NS endodontic
Centr 1 1 1 ALL MAXI failure rate
al ANTERIORS
have a slight -Palatal -
distal axial widest, has
angulation buccal curvature
Latera 1 1 1 Distopalatal -Cross-section of
l canal curvature all maxi molar
near the apex canals:
Canin 1 1 1 Longest root in Oval-shaped
e the arch with
1st 2 2 2 Roots: buccal, buccopalatal
PM palatal (usually diameter greater
equal in length) than mesiodistal
Mesial diameter
developmental EXCEPT
depression PALATAL
(prone to CANALS (still
perforation) oval but wider
2nd 1 or 1 or 1 or Canal/s tend to mesiodistally)
PM 2 2 2 divide/fuse
midroot 2nd 3 4 4
1st 3 4 4 -Roots: Molar
Molar mesiobuccal,
distobuccal, ANATOMIC CONSIDERATIONS FOR
palatal MANDIBULAR TEETH
MB root always Roo Orific Can SPECIAL
has 2 canals t e al CONSIDERATIO
(MB2 canal is NS
located palatal Centr 1 1 1 Pulp chamber is
to MB1) al mesiodistally
 narrow = prone
to perforation
Some have 2
canals
Latera 1 1 or 1 or Most common
l 2 2 anterior tooth
with 2 orifices
and 2 canals
Canin 1 1 1 Most common
e bi-rooted
anterior tooth
1st 1 1 1 Crown is tilted
PM lingually (prone
to access prep
errors);
may be
bifurcated
2nd 1 1 1 Apex lies in
PM close proximity
to the mental
foramen
1st 2 3 3 Mesial root
Molar always has 2
canals
Canals: MB, ML,
Distal
Distal canal is
the widest and
straightest
Distolingual root
is common in
Asians
2nd 2 C-shaped canal;
Molar highly variable

*Locate canal orifices with Endodontic explorer

Flare with Gates Glidden burs
Explore with #12 file / canal probe

*Temporization prevents bacterial ingress in

between appointments
Quality of coronal seal depends on the thickness
of the material
• Anterior teeth – At least 3.0 mm of
temporary filling material
• Posterior teeth – At least 4.0 mm (to
allow for wear)
B. Chemomechanical Instrumentation

• Systematic procedure of removing pulp tissue, debris, and bacteria with the use of files to
shape and irrigants to disinfect the canal

STEPS GOAL INSTRUMENT PROCESS

1. Pup Remove vital pulp Appropriate sized barb Insert to TWL, should not
Extirpation broach engage walls, twist & pull
2. Canal Evaluate #12, #6, #8, #10 Scout
Patency/ Glide diameter and
Path/ Canal patency of canal
Scouting
3. Radicular Enlarge and flare Largest to smallest files -file, irrigate, recapitulate
Preparation/ coronal 2/3 of per 1mm increment w/ #10, irrigate
Crown Down canal to remove Start: Rx CL + cervical -use smaller size per 1mm
Technique/ bulk of third increment until end of
Pre-flaring microorganisms & End: Rx CL+ cervical + crown down length
ensure straight middle third of root
line access to
apical region
4. Final To know the File that will bind at -Slightly tap, should not
Working desired end point estimated working length go beyond estimated
Length of apical working length
Determination preparation/ to -rx: 0.5 to 1mm from
locate apical radiographic apex
constriction
5.Apical Enlarge the apical IAF to MAF contained at -file, irrigate, recapitulate
Preparation/ third of canal to FWL w/ IAF, irrigate
Serial Filing remove bacteria IAF: measures
and debris from uninstrumented width of
apical third & apical constriction
create apical MAF: 3-4x size larger than
stop/ matrix IAF
6. Patency prevent blockage #10, FWL + 1mm Push file gently
Check of apical foramen
7. Stepback/ Flare the canals MAF at FWL, then 3-4x -file, irrigate, recapitulate
Double Flaring to optimum level smaller files per 1mm w/ MAF, irrigate
to properly length withdraw
receive the
obturating
material
8. Ensure that MAF at FWL Go around canal to file
Circumferential debridement & away ledges and ensure
Filing flaring is optimal glass like feel of the walls
and obturation
will be done
properly
9. Spreader To test if canal is MAF at FWL, #3 spreader Insert MAF at FWL, insert
reach test optimally flared at FWL-1mm spreader at FWL-1mm
 to receive
obturation
• The most common cause of root canal failure is incomplete and inadequate disinfection of the
root canal system

ADA Specification No. 28

• Length of Cutting edge: 16mm

• FILE # = DIAMETER AT ITS TIP e.g. #30= 0.3mm at its tip
• 0.02 degree taper means +0.02mm in diameter every 1mm
File Nomenclature • Milled to different file designs
STAINEL Manufactu Motion Notes • Shape memory and superior elasticity so
ESS red from maintains original curvature of the canal
STEEL • flexes when it encounters obstruction like
K File SQUARE Watch Stronges ledges or calcifications
ROD winding t, can be • Used in rotary instrumentation
or filing pre- ➢ Faster and more centered canal
curved; preparation compared to manual
more ➢ Reduced likelihood of procedural
flutes errors
than ➢ Ideal tapering of canal for
reamers obturation
so less ➢ Less extrusion of debris apically
aggressi
ve
H files ROUND Filing Sharp Endodontic Microbiology
ROD (impossi and • Caries: Predominance of Gram (+)
ble to efficient Facultative Aerobes
withdra cutting • Primary Infection: predominance of Gram
w in edge, (-) anaerobes because root canal is
reaming cuts conducive to bacterial growth (warm,
motion) more moist, protected from environment)
aggressi • Secondary Infection/ Persistent Infection:
ve than Gram (+)
K-files ➢ Enterococcus faecalis is the most
and commonly present in secondary
reamers infection
Reamers TRIANGULA Clockwis Less
R ROD e flutes, Irrigants
reaming more • Tip: 1-2mm from FWL, not engaging
only aggressi walls, no pressure (to prevent
ve; also Hypochlorite accident)
used to • Irrigate with distilled water and dry before
remove every change in irrigant
obturati
on Sodiu Hydro Chlorhe EDTA
material m gen xidine
Hypoc Peroxi
Motions of Instrumentation hlorite de
1. Filing Push & pull Conc. 0.5- 3-5% 2% for 17%
(Circumferential or 5.25% RCT
Anticurvature) Use Most Traditio Used in Chelat
2. Reaming/ Rotary CW ¼, pull commo nally retreatm or/
3. Watchwind CW/ CCW (30- n used in ent dentin
90°) while conjun procedu soften
advancing down ction res er
4. Balanced Force CW ¼, CCW ¾ with
NaOCl
NiTi Files
 Adv. - efferve - - • Useful when used with irreversible pulpitis
dissolve scence excellent dissolv and symptomatic apical periodontitis
s - broad es 3. Chlorhexidine
organic bleachi spectru inorga • 2% gel may be used as a medicament
content ng m nic • Mixed with Calcium Hydroxide
- agent antibact debris • More effective than CaOH alone
hemost erial (enlar • Does not usually reduce pain
atic agent ge
- narro Antibiotics
effectiv w • ONLY indicated for:
e canals a. Persistent exudation after RCT
antibact & final b. Replantation of avulsed teeth
erial flush c. Systemic signs of infection (fever,
agent for malaise and lymphadenopathy)
-good remov d. Cellulitis
intracan al of e. Trismus
al smear
lubrican layer)
t
- 3. Obturation
afforda • Total obliteration of canal space; sealing
ble the apical constriction to prevent
Disadv -does -weak -does -no reinfection of the canal
antage not antibac not antiba
dissolve terial dissolve cterial Criteria for Obturation
inorgani effect organic activit 1. Asymptomatic
c only and y 2. Temporary filling intact
tissues inorgani -does 3. Dryable
-caustic c tissues not 4. Odorless
to soft -elicits dissolv 5. Cleaned and shaped to optimum level
tissues chemical e
interacti organi Core Materials
on w/ c • Should seal the canal apically and laterally
NaOCl tissue 1. Silver Points
and • Not used anymore
EDTA • Rigid, very radiopaque, permits leakage
2. Resilon
Intracanal Medicaments • Resin based core material
• Reduce inter---appointment pains • Require etching the root surface and a
• Help disinfect the canals resin sealer
1. Calcium Hydroxide • No long-term clinical data
• Antimicrobial activity 3. Gutta Percha
• Recommended for teeth with necrotic • Advantages
pulps a. Plasticity (conforms to canal shape)
• No pain reduction b. Ease of manipulation
• Little benefit with vital teeth c. Minimal toxicity
2. Corticosteroids d. Radiopaque
• Anti-inflammatory agents e. Ease of removal with heat or solvents
• Useful for reducing post-operative pain (Xylene)
 f. Can be sterilized (5.25% NaOCl for 1 • Accessory cones are used to fill the rest of
minute) the canal
• Disadvantages • Steps:
a. Does not adhere to dentin a. Coat canals with sealer
b. Shrinks on cooling b. With a pumping motion, slowly
• Components: Eugenol, Gutta percha advance MAC to FWL
polymer, metal sulfates c. Using spreader, MAC is compacted
• Disinfection: immerse in full strength laterally to make room for accessory
(5.25%) NaOCl for 1 minute canals (minimum spreader size: #25)
• Solvents used during retreatment: d. Add accessory cones until coronal third
Eucalyptol, Xylol, Chloroform & of canal is reached (apical 2/3 has been
Turpentine obturated)
e. Sear off GP below the orifice level with
Sealers heated instrument
• Fill spaces between Gutta Percha points f. Vertical compaction with plugger to
and between GP and canal walls and prevent voids in coronal segment of
provide a good hermetic seal obturation
1. Zinc Oxide Eugenol 2. Warm Vertical Compaction
• Long history of use • Fills in canals with irregularities and
• Slow-setting abberations
• Stains teeth • Poor working length control
• Do not adhere to dentin • Gutta Percha is heated to become soft
• Resorbable and is inserted into the canal
2. Epoxy Resin • Pluggers are used to apply vertical
• Adhesive pressure to the warm GP
• Insoluble
• Antimicrobial action Process of Sterilization and Disinfection
• Good sealing 1. Autoclave/ Pressure Steam- 120°C for 20-30
• Long working time and easy to mix mins, 15 psi
• Stains teeth 2. Glassbead Sterilizer- 218°C- 232°C
3. Calcium Hydroxide Files: 10-15 seconds
• Antimicrobial properties Paperpoints/ Cotton: 5 seconds
• May stimulate calcific barrier formation at 3. 2% Glutaraldehyde- 6-10 hrs for heat-
the apex sensitive materials
4. Glass Ionomer 4. Full strength (5.25%) Sodium Hypochlorite
• Adheres to dentin Gutta percha: 1 minute
• Provides adequate seal 5. Dry heat- 160°C > 1 hr for sharp-edged
• Biocompatible instruments
• Hard and Insoluble (difficulty in
retreatment and post-space preparation) 4. Restoration
5. Ceramic-based • Coronal Seal is needed to prevent entry of
• Insoluble bacteria into the obturated root canal and
• Radiopaque subsequent reinfection.
• Non-shrinking • Minimum restoration for endodontically
teated posterior tooth is onlay, the most
Techniques recommended is crown.
1.Cold Lateral Compaction • Endodontically treated teeth are more
• A master cone is coated with sealer then prone to fracture than sound teeth mainly
it is fitted to the working length
 due to the destruction of coronal tooth
structure
• Core replaces missing coronal structure to
replace the crown, post is to retain the
core
Post placement
1. Minimum: 4-5mm gutta percha
VII. ENDONDONTIC ERRORS
ACCESS PREP Definition
ERRORS
1. Gouging Removal of sound dentin
on walls of pulp chamber
2. Perforation Iatrogenic communication
between the root canal
system and the external
tooth surface
CANAL PREP DEFINITION
ERRORS
1. Ledge formation Iatrogenically created
step in the canal wall
impeding placement of
file in canal
2. Strip perforation Linear perforation of
canal wall due to
excessive lateral tooth
structure removal
3. Zipping Iatrogenic widening of
the apex
4. Apical Moving the position of
transportation the canal’s physiologic
terminus to a new
iatrogenic location
5. Apical perforation Transportation extends
further creating an
artificial opening
6. Instrumentation beyond
Overinstrumentation apical foramen
7. Instrument Fracture of instrument
Fragmentation within canal
2. Length: at least equal to crown length, >1/2-
2/3 of remaining root, extends ½ length of
root supported by bone
3. < 1/3 of root width at its narrowest
dimension, should have 1mm remaining
dentin thickness
4. Mx molar- palatal canal, Md molar-distal
canal
Management
Do not smoothen, restore properly
Control bleeding if present, locate original
canals first, apply MTA, apply tin mix of CaOH
and water, temporize
MANAGEMENT
Smoothen ledge with pre-curved file or just
obturate until new working length
Control bleeding w/ paper point then
obturate immediately. If bleeding cannot be
controlled, place CaOH on the side for 2-6
weeks. Remove CaOH, obturate or apply
MTA
Obturate the best way possible
Locate the original canal, debride and
obturate the original canal. Just fill the
iatrogenically created canal with sealer
Control bleeding, shorten working length,
CaOH therapy or obturate ASAP.
Control bleeding. Pack with dentinal chips if
large perforation, or go back to working
length, create an artificial seat by creating
ledge where MAC can seat if small
perforation only
-Best prognosis: Vital & no periapical lesion
 -General rule: TRY TO RETRIEVE OR
BYPASS
-File anywhere in the canal +Periapical
radiolucency + Minimal canal enlargement
= Periapical tissues have little opportunity
for healing= obturate to point of blockade,
apicoectomy & retrofilling

OBTURATION MANAGEMENT
ERRORS
1. Underfill Re-obturate
2. Overfill Observe. If symptoms develop, surgical endodontics
3. Void Re-obturate if middle & apical third; add more accessory cones prior
to sear off if coronal
VIII. ENDODONTIC SURGERY
1. Surgical drainage
• To eliminate pus and release pressure
buildup within tissues
• Incision and drainage (I&D): surgical
opening created in soft tissue
• Cortical trephination: surgical perforation
of the alveolar bone (surgical window)
2. Periapical surgery
• To gain access to the affected area
• Apical curettage
• Apicoectomy
➢ Removal of unclean/infected apical
portion of the root
➢ Post-restored tooth that needs
retreatment
➢ Broken instrument at the
coronal/middle third of the canal
where in retrieval and bypass are
not possible
➢ Root amputation: 3mm
➢ Retropreparation: 3mm, 0- 10°
➢ Retrofilling: Zn free Am, SuperEBA,
MTA (to establish apical seal)
3. Corrective surgery
• Manage procedural errors and resorptive
defects
• Root amputation/ Resection
• Biscuspidization
• Hemisection
IX. DENTOALVEOLAR INJURIES
Ellis Classification of Dental Injuries
* Ellis class 7- displacement only; Class IX-
primary teeth
Treatment considerations
• Stage of tooth development:
Vital immature- promote apexogenesis,
vital immature- promote apexification
•Time between accident and treatment
•With periodontal injury= high possibility
of necrosis
• Need for complex restoration requires
RCT
• Treatment of injuries of primary teeth
will depend on vitality and life
expectancy
Reminders
• EPT is unreliable for recent trauma cases
• Mobile segments- reattach and stabilize
with a splint
• Pain upon biting/ positive to percussion-
disocclude
A. Infraction
• without loss of tooth structure
• incomplete crack of enamel
• craze lines in enamel that do not extend
into dentin
B. Uncomplicated Fracture
• with loss of tooth structure but without
pulp involvement
• prognosis is good
• Treatment is smoothening the rough
edges or restoring lost structure
C. Complicated Fracture
• With pulp involvement (Involves enamel,
dentin, and exposure of the pulp)
D. Crown-Root Fracture
E. Root Fracture
• Involves cementum, dentin, and pulp
• May arise from a physical traumatic
injury, occlusal prematurities,
parafunctional habits, resorption-induced
pathologies, or extensive dental
procedures
• Treatment depends on position of fracture
line, mobility of tooth, and pulpal status
• The more apical the horizontal fracture is,
the better prognosis because no or little
mobility
• Vertical Root Fracture:
➢ Single-rooted teeth: extraction
➢ Multirooted teeth: hemisection
(removal of involved root) or
extraction
F. Luxation
• Movement of a tooth within the alveolus
due to trauma, without complete
dislodgment from the socket
• Minor luxation injuries – concussion &
subluxation
• Major luxation injuries- Extrusive, lateral
& intrusive luxation
• Intrusive luxation- poorest prognosis
because highest probability of pulp
necrosis of replacement resorption
(ankylosis)
Concussion Subluxation Luxation
Percussion + + +
Mobility - + +
(except
lateral)
Displacement - - +

G. Avulsion
• Complete dislodgment of a tooth from the
alveolus due to trauma
• Factors to consider: Extraoral dry time,
stage of root development, type of
storage medium
• Hank’s Balanced Salt Solution - preserves
viability of PDL cells for 3 to 72 hrs , milk-
3 hrs, saliva/ saline-2 hrs, tap water is
equally damaging as dry storage
 COMPLICATED CROWN- ROOT LUXATION AVULSION
CROWN ROOT FRACTURE
FRACTURE FRACTURE
Immature, Vital: w/o pulp w/o Concussion & Extraoral Drytime
<2 days- DPC/ exposure: displacement Subluxation: <1hr
CaOH pulpotomy Stabilize of coronal splint for 2 Immature:
depending on coronal part: weeks for Attempt
pulp exposure fragment to Disocclude comfort revascularization
size adjacent (Minocycline + saline),
>2 days- tooth part w/ Extrusive & Rinse, replant, splint
Pulpotomy or restore displacement: Lateral: for 2 wks, Recall if
Immature tooth, Splint (4 wks to Splint then revascularization is
Necrotic: w/ pulp 4 months) then follow up if for successful. If not,
Apexification/ exposure: follow up if for RCT apexification for RCT
Revascularization Immature, RCT
Vital: partial . Intrusive: Mature: Saline, replant,
pulpotomy Immature: splint for 2 wk, Start
Immature, <7mm- w/in a week RCT, CaoH
Necrotic: spontaneous for 4 wks before
Apexification eruption; if not, obturation
& ortho Extraoral Drytime
Pulpectomy >7mm- >1hr
Mature, Vital: surgical/ortho Immature: remove
<24 hrs, simple dead PDL cells w/
resto: DPC Mature: gauze, RCT
<24 hrs, PCC: <3mm, extraorally, replant,
RCT Mature: <17y/o- splint for 4 wks
>24 hrs: RCT RCT, PCC spontaneous Mature: remove dead
Mature, euption w/in 2- PDL cells w/ gauze,
Necrotic: RCT 3 weeks; if not, immerse in 2% NaF,
ortho/surgery RCT prior to
3-7mm- replantation, splint,
reposition w/in CaOH for 4 wks before
3 weeks obturation
ortho/surg Prepare socket: Anes &
>7mm- surgery irrigate
Recall if needs
RCT after
repositioning

H. Alveolar process fracture *Rigid splint (composite)- tooth to tooth or

• Clinical sign: malocclusion, multiple (metal plates) bone to bone
adjacent teeth move as one unit
• Management is by reduction and fixation IX. ENDO-PERIO LESIONS
(rigid splint) Periodontic---Endodontic Lesion
• Routes of communication between PDL
* Flexible Splint (0.17 x 0.25 SS or Monofilament and pulp:
Nylon)- for tooth to bone splinting ➢ Apical Foramen
➢ Lateral Canals
 ➢ Exposed Dentinal Tubules
• May be classified as: IX. BLEACHING AGENT
➢ Primary Endodontic with Secondary • Main component of any bleaching agent
Periondontal Involvement is Hydrogen Peroxide
➢ Primary Periodontal with Secondary ➢ Superoxol: 30%
Endodontic involvement ➢ Sodium perborate: 3-7.5%
➢ True Combined lesions ➢ Carbamide peroxide: 10-22%
• Endodontic therapy is always completed
FIRST Intracoronal Extra-
➢ This allows healing of the endodontic (Non-Vital) coronal
component of the bone loss (Vital)
➢ The periodontal component of the bone Chair-side Superoxol Superoxol
loss is then more easily assessed and (in-office) (i.e.
then treated thermocatalytic)
At-home Sodium Carbamide
A. Primary Endodontic with Secondary perborate peroxide
Periodontal Involvement (i.e. walking (i.e.
• Etiology: Pulp Necrosis bleach custom
• Vitality Tests: Negative Cold, Heat, and technique) tray
EPT technique)
Complications External Transient
B. Primary Periodontal with Secondary Cervical sensitivity
Endodontic involvement resorption,
• Etiology: Extensive Periodontal acute apical
Destruction periodontitis
• Generalized Periodontitis is common *To prevent complications from intracoronal
• Pulp Testing: bleaching, there should be base material of at
➢ Early stages: Positive and exaggerated least 4mm before the obturation
pulpitis
➢ Late stages: Negative pulp eventually Thermocatalytic technique
becomes necrotic • Chairside intracoronal bleaching
• Probing: Wide apex extending apically but • Place Superoxol-saturated cotton pellets
doesn’t really reach the apex, subgingival in the tooth chamber then apply heat via
plaque and calculus electric heating devices/designated lamps
• Radiographic Appearance: • Risk: external cervical root resorption
➢ Generalized Periodontal Destruction caused by diffusion of bleaching agent
➢ Horizontal Bone Loss through dentinal tubules
➢ Periapical Radiolucency if pulpal
necrosis has occurred Walking bleach technique
• Management: Endodontic Therapy then • At-home intracoronal bleaching
Periodontal Therapy • Prepare a thick paste of sodium perborate
+ inert liquid (water, saline, anesthetic
C. True Combined lesions solution) or Superoxol
• Etiology: Pulp necrosis causes a periapical • Place the mixture inside the pulp
lesion. At the same time, there is a chamber, temporize, and dismiss. Recall
periodontal bone loss around the tooth. in 2 wks.
• Separate Endo and Perio lesions will • Advantage: less chair time; safer
eventually join together technique
 • May be done in conjunction with chairside
bleaching -Very
Acute injury common,
to PDL and self-
Replaceme root surface limiting,
nt reversible

Resorption Rationale Result Bone -Ankylosis

replaces
1. Internal Chronic -PINK Invasive dentin
Resorption irreversible tooth due Cervical
pulpitis, to growth Resorption -
trauma, of unknown Uncommon
caries, pulp granulation , insidious,
capping w/ tissue aggressive
CaOH, underminin form
cracked g coronal
tooth dentin
2. External trauma,
Resorption periradicular
inflammatio
n, excessive
ortho
forces,
Prepared by:
impacted
Dr. Nica Jeorgia P. Salazar
teeth,
internal
bleaching of
nonvital -
Inflammato teeth Progressive
ry bowl
Due to the shaped
infected/ area of
necrotic resorption
pulp involving
cementum
and
Surface dentin