Endodontics Notes with photos


Pulp Biology
• Contains loose fibrous connective tissue with nerves, blood vessels, and lymphatics
• Contains fibroblasts
• Contains odontoblasts
– Primary dentin
– Secondary dentin
• Contains undifferentiated mesenchymal cells
– Tertiary dentin

Pulp Biology
• Surrounded by hard dentin which limits its ability to expand
• Lacks collateral circulation which limits its ability to cope with infection

Dentin and Pulp Defense
• Sclerotic dentin= calcification of tubules in response to slowly advancing caries or aging
• Reactionary dentin= reaction to minor damage
• Reparative dentin= repair for major damage
• Pulpal necrosis= response to rapidly advancing caries or other severe damage

Histologic Zones of Pulp
• Predentin
• Odontoblastic layer
• Cell-free zone of Weil
• Cell-rich zone
• Pulp core

Dentinal Pain (Aδ fibers)
• Large myelinated afferent nerve
• Course coronally through pulp
• Sharp transient “first pain”
• Cold

Pulpitis Pain (C fibers)
• Small unmyelinated afferent nerve
• Course centrally in the pulp stroma
• Dull throbbing “second pain”
• Heat

Pain Sensitization
• Hyperalgesia= heighted response to pain
• Allodynia= reduced pain threshold, pain due to stimulus that does not normally provoke pain

sunburnt skin is an example of aloe-dynia

Referred Pain
• Preauricular pain often refers from mandibular molars since both share V3 innervation

Endodontic Diagnosis
• Pulpal Diagnosis
• Periapical Diagnosis

Pulpal Diagnosis
• Normal Pulp
• Reversible Pulpitis
• Symptomatic Irreversible Pulpitis
• Asymptomatic Irreversible Pulpitis
• Pulp Necrosis
• Previously Treated Pulp

Normal Pulp
• Asymptomatic
• Mild to moderate transient response to thermal and electrical stimuli

Cold Test
• Endo Ice= dichlorodifluoromethane, -30˚C
• Chilled pellet is applied immediately to middle third of facial surface of crown for 5 seconds
• Intensity and duration of response provide information about pulpal diagnosis

Electrical Pulp Test (EPT)
• Least reliable pulp vitality testing
• Indicates if there are vital sensory fibers present in the pulp, but does not provide any information about vascular supply to the pulp
• False positives & negatives
• Contraindicated if cardiac pacemaker

Reversible Pulpitis
• Symptomatic
• Thermal (usually cold) stimulus causes quick, sharp, hypersensitive, transient response
• No complaints of spontaneous pain
• Caused by an irritant that affects the pulp
• Symptom, not a disease

Symptomatic Irreversible Pulpitis
• Symptomatic
• Pulp has been irreversibly damaged beyond repair; even with removal of the irritant it will not fully heal
• Characterized by spontaneous intermittent or continuous pain
• Thermal (often cold) stimulus causes lingering pain
• Postural changes like bending over or lying down increases blood pressure to the head and may exacerbate dental pain
• Radiographs are generally insufficient; EPT is of little value for diagnosis

Asymptomatic Irreversible Pulpitis
• Asymptomatic
• Microscopically similar to previous, but no clinical symptoms

Pulp Necrosis
• Usually asymptomatic but not always
• Can be partial or total
• Due to long-term interruption of blood supply to the pulp
• Crown discoloration may accompany pulp necrosis in anterior teeth

Pulpal Diagnosis
• Normal Pulp
• Reversible Pulpitis
• Symptomatic Irreversible Pulpitis
• Asymptomatic Irreversible Pulpitis
• Pulp Necrosis

Periapical Diagnosis
• Normal Apical Tissues
• Symptomatic Apical Periodontitis
• Asymptomatic Apical Periodontitis
• Acute Apical Abscess
• Chronic Apical Abscess

Normal Apical Tissues
• Asymptomatic
• No pain on percussion or palpation

Percussion & Palpation
• Percussion= tapping on teeth with a mirror handle
• Palpation= feeling on gums around apex of the root

Symptomatic Apical Periodontitis
• Painful inflammation around the apex
• Characterized by painful percussion and intense throbbing pain
• Localized inflammatory infiltrate within the PDL

Asymptomatic Apical Periodontitis
• Asymptomatic
• Apical radiolucency
• Confirmation of pulpal necrosis

Acute Apical Abscess
• Rapid swelling
• Severe pain
• Purulent exudate (liquefaction necrosis) around apex

Chronic Apical Abscess
• Draining sinus tract usually without discomfort

Periapical Diagnosis
• Acute Apical Abscess
• Chronic Apical Abscess
• Symptomatic Apical Periodontitis
• Asymptomatic Apical Periodontitis
• Normal Apical Tissues


Access Preparation
• Most important technical aspect of RCT
• Conservation of tooth structure
• Deroof chamber to expose pulp horns and orifices
• Straight-line access to orifice and apex

Access Preparation
• Incisors

Access Preparation
• Canines

Access Preparation
• Premolars

Access Preparation
• Maxillary molars

Access Preparation
• Mandibular molars

• SS hand files= .02 taper
– K-file (Kerr)= twisted square, watch winding method
– H-file (Hedstrom)= spiral cone, only cuts in retraction
• NiTi rotary instruments= .04 or .06 taper

File Dimensions
• D1= diameter at tip
– Size 15 file à 0.15mm
• D2 or D16= diameter 16mm from tip where cutting flutes end
– Size 15 K-file à 0.15mm + .02(16mm) = 0.47mm

• Gates-Glidden drills= to open orifice for straight-line access
• Barbed broaches= entangle and remove
• Reamer= twisted triangle

Cleaning and Shaping
• Crown-down= big to small
• Step-back= small to big

Irrigation and Medicaments
• Sodium hypochlorite (NaOCl)= irrigant, dissolves organic material
• Ethylenediamine tetraacetic acid (EDTA)= lubricant, dissolves inorganic material
• Chloroform= dissolves GP in retreatment

Endodontic Microbiology
• Primary endodontic infection à Bacteroides
• Failed endodontic treatment à Enterococcus faecalis

• To seal canal system
• Gutta-percha and sealer= ZOE
• Warm vertical and cold lateral

Endodontic Treatment Planning
1. RCT
2. Retreatment== canal
3. Surgical RCT ==apex

Incision & Drainage
• Surgical opening in soft tissue to release exudate and pressure
• Best for localized and fluctuant swelling

• Surgical opening in hard tissue to release exudate and pressure

Periapical Microsurgery

Ledge Formation

• Artificial irregularity created on surface of root canal wall
• Why do ledges occur?
• Flexible NiTi files are less likely to ledge
• Use smaller instrument to bypass ledge

Instrument Separation
• Breakage of an instrument within the confines of a canal
• Why do instruments separate?
• Flexible NiTi files are more likely to fracture
• Use smaller instrument to bypass instrument

• Coronal perforation= through the crown
• Furcal perforation= through pulpal floor
• Strip perforation= due to excessive coronal flaring

• Root perforation= more apical has better prognosis
• Immediate hemorrhage or sudden pain are signs of a perforation

• Internal repair with MTA

Trauma Protocol
• Tetanus booster (avulsions only)
• Radiographs
• Antibiotics (avulsions only)
• Vitality testing
• More
• Appointments

Ellis Classification
• Class I enamel only
• Class II enamel and dentin
• Class III enamel, dentin, and pulp
• Class IV traumatized tooth that has become non-vital
• Class V luxation
• Class VI avulsion

Uncomplicated Fracture
• Without pulp involvement
• Enamel only à smooth edges
• Enamel and dentin à restore

Complicated Fracture
• With pulp involvement
• Less than 24 hours ==DPC
• More than or equal to 24 hours ==Cvek
• More than or equal to 72 hours ==PPTY

Horizontal Root Fracture
• Coronal segment displaced, apical segment not displaced
• Should take 3 PAs and 1 occlusal
• Ideal healing is calcific healing at the fracture site—calcific metamorphosis can reattach fragments in close proximity via calcification
• Vital == splint ASAP
– Coronal fracture ==rigid splint for 6-12 weeks
– Midroot fracture == flexible splint for 3 weeks
– Apical fracture == flexible splint for 2 weeks maximum to avoid ankylosis
• Necrotic ==RCT
• 25% chance of necrosis of coronal segment, necrosis of apical segment is very rare

• No displacement, no mobility, PDL sore
• Concussion à let the tooth rest

• No displacement, increased mobility
• PDL rips and bleeds
• Subluxation == flexible splint for 1-2 weeks
• 6% chance of necrosis with closed apices, more favorable with open apices

• Partially extruded from socket
• Open apex == reposition, flexible splint, monitor
• Closed apex == reposition, flexible splint, RCT if needed
• 65% chance of necrosis with closed apices

Lateral Luxation
• Displacement of tooth in any direction except axially
• Usually crown is displaced palatally and root apex is displaced labially
• Same treatment options as extrusion
• 80% chance of necrosis with closed apices

• Apical displacement of tooth
• Open apex à allow to reerupt
• Closed apex à reposition, flexible splint, RCT
• 96% chance of necrosis with closed apices

• Complete separation of tooth from its alveolus
• Extraalveolar dry time (EADT)= amount of time a tooth has been out of the mouth while dry
• Avulsion à reimplant ASAP, flexible splint for 1-2 weeks

• Closed apex, EADT < 60 minutes ==reimplant, splint
• Open apex, EADT < 60 minutes == reimplant, splint, no RCT but apexification at first sign of infected pulp
• Closed apex, EADT > 60 minutes == reimplant, splint, RCT
• Open apex, EADT > 60 minutes == may or may not reimplant, splint, RCT, plan for implant

Storage Media
• Hank’s Balanced Salt Solution (HBSS)
• Milk
• Saline
• Saliva
• Water is least desirable

External Resorption
• Initiates in the periodontium, due to damage to cementoblastic layer
• Replacement resorption (RR)= ankylosis, replaces PDL with bone
• Cervical resorption (CR)= subepithelial sulcular infection from trauma or nonvital bleaching
• Inflammatory root resorption (IRR)= bacteria and byproducts from necrotic pulp travel through dentinal tubules to affect periodontium
• Margins are ragged and poorly defined
• Moves with angled radiographs

Internal Resorption
• Initiates in the root canal system, due to damage to odontoblastic layer
• Inflammation due again to necrotic pulp from caries or trauma but this time causes resorption from within
• Better prognosis/easier to treat than external resorption
• Internal resorption à RCT
• Margins are sharp and well-defined
• Does not move with angled radiographs

Calcific Metamorphosis
• Trauma induces odontoblasts to rapidly form extensive amounts of reparative dentin within the pulp space
• More likely with open apices, intrusions, and severe crown fractures
• Yellow-orange color
• Canal obliteration

Calcium Hydroxide (CaOH2)
• Stimulates secondary odontoblasts to repair with dentinal bridge formation
• High pH of 12.5 cauterizes tissue and kills bacteria

Mineral Trioxide Aggregate (MTA)
• Stimulates cementoblasts to produce hard tissue
• Three minerals= calcium, silicon, aluminum
• Bismuth oxide= opacifier
• Long 3-hour setting time
• Sets in the presence of moisture
• Antimicrobial
• Nonresorbable—great sealing agent

Vital Pulp Therapy
• Indirect Pulp Cap (IPC)
• Direct Pulp Cap (DPC)
• Cvek Pulpotomy
• Pulpotomy (PPTY)
• Pulpectomy (PCTY)
• Root Canal Therapy (RCT)
• Extraction
• Apexogenesis
• Apexification

Indirect Pulp Cap
• CaOH or RMGI is placed on thin partition of remaining dentin that if removed, might expose the healthy pulp
• Deep caries approximating pulp

Direct Pulp Cap
• CaOH is placed directly on otherwise healthy pulp exposure
• Traumatic exposure <24 hours
• Carious or mechanical exposure <2mm
• Hard tissue barrier will hopefully form within 6 weeks

Cvek Pulpotomy
• Also known as partial or shallow pulpotomy
• Removal of small portion of coronal diseased pulp
• Traumatic exposure ≥24 hours
• Carious or mechanical exposure >2mm

• Removal of coronal diseased pulp
• Traumatic exposure ≥72 hours
• For primary—vital and restorable primary tooth with pulp exposure (asymptomatic)
• ZOE in crown, formocresol to attain hemostasis

Buckley’s Formocresol
• 19% formaldehyde
• 35% cresol
• 15% glycerine
• 31% water
• Bactericidal + “fixative”

• Removal of coronal and radicular dead or dying pulp
• Often as temporary pain relief on teeth with irreversible pulpitis until full RCT can be done
• For primary—nonvital and restorable primary tooth with pulp exposure (asymptomatic)
• ZOE in crown, CaOH in root (can be resorbed by underlying permanent tooth)

• Removal of tooth with a dead or dying pulp
• For primary—primary first molars, nonrestorable, root resorption (symptomatic)

Root Canal Treatment
• Pulp can be diseased or dead
• PCTY + cleaning, shaping, and filling

• Maintain pulp vitality in order to stimulate root development and allow the body to make a stronger root
• CaOH or MTA is placed on healthy or diseased pulp
• Includes any IPC, DPC, Cvek, or PPTY performed in an immature permanent tooth
• Contraindicated in avulsed, nonrestorable, severe horizontal fracture, and necrotic teeth

• Disinfection of root canal followed by induction of an acceptable apical barrier
• CaOH or MTA is placed at base of canal after dead or dying pulp is removed
• Includes any PCTY performed in an immature permanent tooth

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