Overview Of
Endodontics
What is Endo?
Study and treatment
of the dental pulp
General dentist can
perform RCT but
Endo:
Use
microscopes
Assigned difficult
& complicated
cases
Microsurgery
Why is Endo awesome?
Save teeth!!
Help relieve a patient of excrutiation pain
Become very specialized; Focus on one
specific area of dentistry
Deail focused
Cool technology
Microscopes
Electronic Apex Locator
3D Imaging
Top 5 Reasons for Endo Therapy
(In order of Prevalence)
Caries
Iatrogenic Treatment
Trauma and Resorption
Perio Endo Etiology
Orthodontic Tooth Movement
Trauma, Resorption, and Ortho: Necrosis
precedes infection
Questions for Patient
History of pain is very important!
Stimulated or Spontaneous pain?
Localized or Referred pain?
Pain when you bend or lie down?
Pain with hot or cold food and drinks?
Pain when eating certain foods?
Pain keeps you up at night or wakes you
up?
Take any medication for pain?
Interpretations
Spontaneous + sensitivity cold/ hot + lots of pain =
irreversible pulpitis
Pain bending over, + sinus pressure, inflammed sinuses =
sinusitis
Tooth mobility, thermal sensitivity, pain chewing, widened
PDL? Occlusal trauma: high restoration, abnormal biting
or habits
Pain upon waking in jaw and neck? Bruxism
Cant find cause of pain? Chronic Oral Facial Pain
Always check adjacent and contralateral teeth, especially
with referred pain!
Testing Methods
Palpation
Use finger tips to
apply light pressure
to mucobuccal fold
+ infection broken out
of bone
Percussion
Use handle of
instrument to tap
tooth
+ response =
inflammation of PDL
Patient Interview
Visual Inspection
Mobility
Perio probing
Sinus Tract testing
Anesthesia Test
Bite Test
Vitality Tests
Electric Pulp Test
Test neurons in pulp are
functioning
Cold Test
Put endo ice on cotton pellete.
Apply to tooth
Painful response?
Lingers 1-2 seconds
Sensitivitiy
Seceral secondsminute
Heat Tests
Apply heat to tooth.
+ advanced stage pulpal
inflammation
Irreversible
pulppitis
No response
Necrotic pulp
Periapical Radiolucency: larger =
greater # bacteria in root canal
Resorption
External
Internal
Review of Endodontic
Procedures
Karishma Sitapara
uni: kbs2137
Presentation Adapted from Mikes
Master Files and Anshuls Endo
Study Guide
Procedures
Pulpotomy
Pulpectomy/RCT
Pulp Cap (Direct & Indirect)
Apexogenesis
Apexif ication
Apicoectomy
Pulpotomy
What?
Make access opening, remove all pulp tissues in the pulp
chamber only, place cotton pellet and IRM
When?
In emergencies to relieve pain
In immature teeth in children (apexogenesis)
Why?
Opening the tooth vents the pressure build up and
relieves the pain
Pulpectomy/Root Canal Therapy
What?
When?
Make access opening, remove all pulpal tissue in
chamber and canals, clean and shape, medicament,
obturate (f ill) with gutta percha
Irreversible pulpitis, pulp exposure (carious), necrosis
Why?
Remove bacteria causing the inf lammation/pathology,
create hermetic seal
*90-95% success rate in vital teeth, 80% in non-vital
teeth
Direct Pulp Cap
What?
When?
The bleeding is stopped by irrigation w/ sterile, isotonic
saline, calcium hydroxide placed on exposed pulp, glass
ionomer cement, and permanent f illing placed. Check
radiographically and clinically for 4-5 years.
Non-carious or iatrogenic pin-point pulp exposure
Why?
To prevent bacteria from invading pulp
Indirect Pulp Cap
What?
Excavate deep carious lesion, but do not remove the
layer of carious dentin closest to the pulp. Place calcium
hydroxide, followed by GI, and then a temporary
restoration. *Temporary procedure
Wait few months for reparative dentin formation to act as
barrier between remaining carious lesion and pulp
Remove temporary restoration, excavate the remaining
carious dentin. If no pulp exposure, then f inal restoration
is placed.
When?
Deep carious lesion that will likely result in pulp exposure
Apexogenesis
What?
Exposed tissue is covered with calcium hydroxide in an
attempt to keep the pulp healthy while the root apex fully
forms
Procedure: Pulpotomy, pulp cap, or partial pulpectomy
When?
For an immature vital tooth with a pulpal exposure
Why?
To allow for continued root formation, while keeping the
pulp healthy/vital
Apexif ication
What?
Clean the root canal, place calcium hydroxide inside
canal, replace every few months (induces formation of
biological calcif ic barrier closure of apex with periapical
healing)
Or use MTA as apical barrier
Once closure has taken place, RCT can be performed.
When?
For an immature non-vital tooth with an open/not fully
formed apex
Why?
Procedure Overview
Procedures that can be used on vital teeth:
Pulpectomy
Pulpotomy
Pulp Capping
Apexogenesis
Procedures that can be used on non-vital teeth:
Pulpectomy
Apexif ication
Apicoectomy
What?
Drill through bone to apex, surgical resection of the end of
the root, f illed with MTA
Microsurgery > traditional approach
When?
After RCT re-treatment has failed
Why?
Eliminate infection (possible reinfection by bacteria in
accessory canals in apical third)
Access Opening &
Basics of Cleaning & Shaping
(Step Back/Crown Down Techniques)
Misun Chun
Class of 2017
Maxillary Access Opening
Mandibular Access Opening
Basics of Cleaning and Shaping
After the access opening is created, we need to remove
non-vital/necrotic pulp tissue from pulp chamber/canals.
Must reach to the apical constriction
1) Find the working length
2) Instrument the canal
1) Find the Working Length
Working length
Anatomic length - 1mm = Working length
Anatomic length: distance measured on a radiograph from root apex
to cusp tip
.5~1.5mm above the apex
The location of apical constriction
In pre-clinic, use a ruler and subtract 1
In clinic, apex locator/radiograph
Write it down so you dont forget!
2) Instrument the Canal
Clean the sick pulp tissue and shape it.
We want a long tapered canal to ensure no voids and gain
the convenience form for obturation.
2 techniques we learn at CDM:
Step-back
Crown-down
Step-up Rotary
Step Back Technique
Find the smallest file that binds at the working length (tug
back)
You take 3 files larger than this.
Ex) If the tug-back file is 20k, you work it up to 25, 30, 35k and
file them at the working length (lets say hypothetically 20mm)
Now that your canal is clean, its time to shape it.
You take the next file, 40k, and shape it to 19mm.
Keep going- 45k to 18mm, 50k to 17mm, etc.
Step Back Technique
Find the smallest file that binds at the working length (tug
back)
You take 3 files larger than this.
Ex) If the tug-back file is 20k, you work it up to 25, 30, 35k and
file them at the working length (lets say hypothetically 20mm)
Now that your canal is clean, its time to shape it.
You take the next file, 40k, and shape it to 19mm.
Keep going- 45k to 18mm, 50k to 17mm, etc.
Crown Down Technique
Start with a hand file and find the first K-file that gives you
a tug-back.
After hand-filing with 2 K-files at the working length, use
the largest rotary file and insert with gentle pressure for a
count of 3 until you feel the resistance.
If you reached the working length, you are done!
(If not use the next smallest rotary file until you reach the
working length.)
Instruments and Materials
Disclaimer:
The following information is not comprehensive but just an overview
of some of the instruments and materials you will hear about in your
introduction to preclinical Endo
All information is from Koteckis Master Files and Anshuls Endo
Study Guide: Read them! They are very helpful!
Endodontic Explorer
(aka: Stewart Probe)
Used for probing and exploring root canals
Used to find canals when you are in the pulp chamber
Endo Files
K files (what we use)
Made of either stainless steel or nickel titanium
Hand files used to shape and smooth the pulpal canals
All have a taper of .02 (.02 mm increase in diameter with every
1mm in length
Each file is labeled with a number (10, 15, 20) which represent
the diameter of the tip in hundredths of a mm (#15=.15 mm in
diameter at the tip of that instrument)
Color coded based on that number
Stoppers are used to mark a measurement on a file. Stoppers
should be measured to a reproducible landmark such as a
cusp/incisal tip.
K-Files
Hand files made of either stainless steel or nickel titanium
Nickel titanium is more flexible and better to use for curved canals
Stainless steel files are more rigid and need to pre-bend when
working on a curved canal to prevent perforation (making your own
new canal).
Reaming and Filing- two ways to clean and shape RC with K File:
Reaming= active in, passive out . - turn actively engaging in
dentinal wall on the instroke, then passively out
Filing= passive in, active out
Rotary Instruments
Nickel- titanium rotary instruments
Used with latch-type slow speed hand piece
Has a taper of 4 (in preclinic)
Advantages:
Less time needed
Fewer instruments required
Allows for better vision of the canal
Evenly tapered canals prepared that facilitate obturation (filling)
Disadvantages:
Expensive
Unexpected fractures
Navigating curved canals without first using hand instruments can cause
Gutta Percha
Material used to obturate (fill) root canals
Made mainly of Zinc Oxide
Coated with cement and inserted into the canal space to make up a
root canal filling
Gutta percha used in preclinic are non-standardized and come in
five sizes: fine-fine<medium-fine<fine<fine-medium<medium
As many cones as possible should be squeezed into the canal
space for a dense and air- tight fill
Lateral Condenser / Endodontic
Spreader
During obturation, the canal is filled with gutta percha and this
instrument is used to laterally condense the gutta percha
Glick #1
A double- ended instrument
Paddle shaped end: used to place temporary restorative materials
such as IRM and cavit
Plugger end: heated and then used to trim the end of the gutta
percha. Can also be used to condense the material.
Gates Glidden and Peeso Reamer
Burs used with slow speed latch- type hand piece
Both are used for creating taper and enlarging the coronal portion of
root canal
Can be used to remove gutta percha for post space preparation
The Peezo has cutting edges on its tip and side so it is more
dangerous and can cause perforations
Apex Locator
Used to determine position of apical foramen
It beeps when the file hits the apical constriction
IRM (zinc oxide eugenol)
Used as a temporary restoration in between RCT appointments
Soothing to the pulp because of the eugenol
Cavit
Another temporary restoration
Provides a good seal- expansion upon setting
Easier to use sets easy and fast
Removal of the smear layer after
mechanical instrumentation of the
Smear layer= organic and inorganic debris
canals
Organic debris= bacteria and pulp tissue
Inorganic debris= dentin slurry
Mechanical instrumentation of the canal does not get rid of the
bacteria in accessory canals and dentinal tubules. The smear layer
coats the walls and prevents chemical disinfectants from entering
the accessory canals and dentinal tubules
Chemicals that remove organic
component:
Sodium hypochlorite (Chlorox bleach): antibacterial and dissolves
necrotic and vital tissues
Calcium hydroxide: antibacterial (due to high pH) and dissolves
organic material
Chlorhexidine: broad-spectrum antimicrobial agent against gram
negative and gram positive bacteria
Calcium Hydroxide vs. Dycal
Calcium hydroxide= a powder mixed with a sterile solution to create
a paste placed into the root canal with a file
Dycal: a cement that has calcium hydroxide in it and used in deep
cavities for direct pulp capping
Chemicals that remove inorganic
component:
EDTA= a chelating agent (removes inorganic part of smear layer by
causing dimineralization. EDTA causes dimineralization by binding
to calcium)
Citric acid= also a chelating agent
RC Prep
A combination of EDTA (for chelation), urea peroxide (antibacterial
activity), and carbowax (for lubrication)
Used as a canal lubricant
Used to facilitate the mechanical action of the endodontic hand or
rotary files by removing debris
Post and Core
Lauren Chiang
All pictures were taken
from Dr. Zemnicks
slides!
Indications
When there is
insufficient coronal
structure for the
retention of a
restoration
Need to use a post
which holds in place
the core, which is
used to build up
tooth structure
Post preparation
After RCT, remove all but 5 mm of gutta percha
from the canal using a gates glidden, then use a
peezo reamer to ensure no undercuts are present
Width of the post should be as narrow as possible,
but fill the entire post prep space
If using multirooted teeth, choose the straightest root
Cut post to desired length before cementing it in to
the post space
Post placement has disadvantages
Requires an additional operative procedure
Placing a post does NOT strengthen the tooth
Post preparation weakens the tooth, and makes it more likely to fracture
The thinner the post space is, the better!
You need a minimum of 1 mm of surrounding axial width
Endodontic re-treatment may be complicated with the placement of a
post
Pre-fabricated post & core
Ready made dowels which you can immediately insert into the prepped
post space can be completed in one visit, vs. two for custom
Can be used in multirooted teeth, where you place two non-parallel to
each other to lock it in place
Custom fabricated or
cast post & core
Custom made for that specific tooth
Used in cases where insufficient tooth structure (2 or less axial walls) is
remaining after excavation and tooth prep
Accurately fills shape, and post & core is one structure
Add self-curing/dual curing cement directly into
the canal before inserting the post
Insert the post into the space,
and hold it down as it cures
Trim the post to the proper
height if you havent already
Core build-up
Add core material to remaining tooth structure
(e.g. FluoroCore)
Cure core material
Prepare tooth for a crown
Ferrule Effect
A ferrule is a ring of metal encircling the end of a wooden pole to
prevent it from splitting
E.g. if you hammered a nail into the end of the stick, the ferrule protects the
sides and prevents it from splitting
A tooth needs the same protection from the post, which acts as the nail in
this situation
The apical most portion of the crown acts as this ferrule (you need at
least 1.5 2 mm as a ferrule)
So the crown has to end at least 1.5 mm apical to where the core ends!
Ferrule vs. no ferrule
What if there isnt sufficient
crown length for a ferrule?
Ways to ensure sufficient ferrule:
Curettage
Crown lengthening procedure
Orthodontic extrusion
