Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Techniques
Access Preparations,
ENDODONTICS
Copyrigh
e l0ll-2011-
Dental Decks
Maxillary Canine
Access Opening
Access Opening
Access Opening
l,
dd
B ak1^nd
LK. Endodontics Fourth E.litian O I 99i1. s irh pennission from Williams & Wilkins.
Cop:/right O
2
ml l-412 - Dcd.l D.ct8
3
Cogyrigh O 201 l-2012 -
D.dl Drck
Mandibular Central
Incisor
Nlandibular Lateral
Nlandibular Canine
Incisor
Access Opening
Access Opening
Access Opening
One canal
Access Opening
Access Opening
One canal
Onc canal
One fbnmen
One
foramen
Two canals
Two lbramens
Three
Rctrin!.d tion fngle.
199.1,
Jt-
ca.als
15%
21o
1Yo
4
Cop)'right O 20 I I -20 l2 - Denhl Decks
pre m 20 -22
Access Opening
Access Opening
all prem the most percentage one canal one foramer except max 4
2 canal 2 foramen 70%
One canal
One foramen
One canal
Two canals
Two canals
One fommen
One foramen
One foramen
Two canals
'I
wo foramens
R.pn n'ed
riofr
Two canals
td,rt,, q
Access Opening
19.9 mm 20
19.4 rnm
Palatal
willins
MB
DB
MB
DB
20.2
3roots mb db palatal
mn
20.6 mm
Three
Fused
mb root
I9.4 mm
Palatal- 20.8 mm
mb root
r'auth Etlition A
54%
46%
Coprighr O
201
7
Coplrigh O
201
root 21
Mesial 20.9 mm
Distal 20.9 mm
Mesial 20.9 mm
Distal 20.8 mm
foramina
Two canals
Three canals
Four canals
Ong canal
One
fommen l3Yo
92%
Two canals
]lesial
One
canal
Two canals
One
foramen 4l%
Two canals
T\r'o foramens
One
Distal
Two canals
72%
28%
foramen 49vo
Two canals
Two foramens
38%
590
l',,
Two canals
59olo
fommen
62%
Two canals
Two foramens
38olo
One
Repnnred
fdt!,, g
Often times transillumination is used to see the defect, but ofcourse, this cannot be diagnostic on tooth structure that is under bone. Also, persistent periodontal defects are often
caused by vertical root fractures; however, this is not radiographic (read the question
carefu I I1') .
Important: Radiographs lwltlrout.lirst wedging the lootiT rarely will show veftical fractures.
Vertical fractures will often be recognized radiographically by their effect on the bony
attacirment apparatus that is seen as a diffhse radiolucency or "halo" surrounding the
root. This can be differentiated from other periapical radiolucencies because it surrounds
the tooth uniformly ratherthan being located at the portal ofexit ofthe apical foramen or
lateral canal.
\otes
l. A tooth with
sis.
';q:.:,.r', 2. Studies have indicated that most vertical root fractures are caused by too
much condensation force during obturation with gutta-percha.
Therapy for horizontal fractures of the root always involves considerable difficulty.
Root canal treatment is not indicated if the fracture sites remain in close proximity and
ifthe pulp retains its vitality. However, ilclinical symptoms develop or the segments appear to be separating according to the x-ray, some treatment is necessary.
Remember: Root fracture can only be visualized on a radiograph if the x-ray beam passes
through the fracture line. As the fracture line could extend diagonally, an additional radiograph is taken with a 45" (steep) vertical angulation in addition to the conventional 90".
. #19 - virgin
. #15 - primary cavitation on occlusal
8
Copyrigbr O 201l-2012 - Dental Dcks
Same
. Opposite
EPT checks the sensibility of a tooth by stimulating ncrvc cndings with a low current and high
potential difference in voltage. Although manufacturers ofthis device give normal relerence valucs ofcurrent, the best way to check "nolmal,/baseline" values is to use it on adjacant t"ron-pathoiogicai) teeth. This is then compared with the values obtained on the looth being questioned. The
EPT uses electrical excitation to stimulate the A-delta sensory fibers in the pulp. A positive response does not provide any information about the health or intcgrity of the pulp: it simply indicates that therc are yital sensory fibers present. lmportant: The EPT fails to provide any
informalion about the vascular supply to the pulp, which is the truc determinant ofpulp vitality.
Note: EPT is not considered reliable in the following conditions.
1. A pus-fillcd canal
t'alse positivc
- false positive
.1. Recent dental trauma
lalse negatire
4. hsulating rcstoration - false negative
5. Sccondary dentin deposits
falsc negative
- [alsc positir c
6. Moisturc (ontaminalion
7. lmmature tooth t'open apex)
false negative
8. Patient who has taken analgesics
false negative
2. A nervous patient
lmportant: Never wear gloves while using the EPT as this impcdes conrpletion and results in a
false-negative response. Also, ifa paticnt's medical history reveals that a cardiac pacemaker has
been implanted, the use
Response to EPT:
as acute
thrcshold
acute
pulpitis
ln other words, wc can say that the cone image shift technique separates and idenlifies thc facial
and lingual structures. Noter The cone shif-t technique is also known as thc buccal object rule,
SLOB rufe (Saae Lhgual, Opposite Buccaf, Clark's rule or Walton's Projection.
As the conc position moves lrom parallel either towards horizonlal or vertical, the objcct on the film
shifts away from the dircction ofthc cone (i.e., in the direction ol the central beatt).
reference object.
Important: A disadvantage of the cone shili technique is that it results in blurring of the object
uhich is directly proportional to cone angle. The clearest radiograph is achieved by thc paralleling
tcchnique so when thc central beam changes direction rclativc to thc object and the film, the object becones blurry.
\\'hen trearing multicanaled bicuspids and molars. it is ol'ten difficult to ascertain on the
radiograph $hich canal is more toward thc buccal. When a straight-on exposure is taken ofa bicanaled tooth. thc canals become supe mposed on the filnl, and visualization of each canal is impossible. Ifthe x-ray cone is moved to give an angled exposure, the roots will bc separate on the
film.
By'applying the cone image technique you will be able to determine which canal is thc buccal
and rvhich is the lingual.
Explanation of SLOB (Same Lingual, Opposite Buccal) rule; the object toward the lingual
side (closer to the liln) will appear to shift on the film to the same direction as the repositioned x-ray cone. For example, ifthe x-ray cone is mesially angulated, the lingual/palatal object (root) will shilt toward the same (nesiql) side in the resultant radiograph film, and thus
will be easily visualized.
Note: Uring this technique you can determine:
l Working length of superimposed canals.
2. Curvatures of root/canals.
test
. Percussion test
10
Copyrighi O
201
'11
Cop"iShr O
201
Dek
*** This test is contraindicated. The pcrcussion test is usually not performed bccause ofits paini
however the vitality test will givc you a truly falsc reading, bccause oftcmporary paresthesia in the
area-
For teeth that have becn recently traumatized the dental examination should include:
. Soft tissue exam: observc the lips, face, tongue, etc.
. Hard tissue exam: visually look and then palpate thc injured tooth and alveolus to reveal thc
extent oftooth mobility as well as alveolar fractures and area of inllammation. check for occlusal
disharmonies to hclp detcct tooth displacements andjaw fractures
. Radiographic examination; x-rays reveal tooth displacsment and root fracturcs as well as
other important facts (previous rc,ot canal, periapical radioluce cies, elc.).
. Observe the adjacent and opposing tceth for injury'
Teeth that have been traumatized n,lay bc fine for a long tine. however, nany rvill develop radiolucencies. Do not indiscriminately do root canals without first checking pulp vitality' and perform
root canal thcrapy only in those teeth that do not rcspond to pulp testing Example: Trauma to
maxillary anterior tcclh. A fcw years latcr x-rays rcveal radiolucencics around the region of thc
apices ofthe incisors. Check the pulp vitality ofall anterior teeth before performin-q root canals'
Note: Trauma tc4r., iry deep intnrsion) to a permancnt tooth will most likely result in necrosis of
the pulp and conventional root canal therapy will be necessary.
Pulpal necrosis: ifcaused by inflammation that started in the pr.rlp /e 81., cdrie.t/, it most probably
will spread to the periradicular tissues; ifcaused by trauma that severs the blood supply to the tooth,
partial or total:
a dry necrosis rnay result that may not spread to the pcriradicular tissues. [t rnay be
partial necrosis may present with somc of the symptoms associated with ireversiblc pulpitis
(e.g., a fito-.anale.l tooth could hare an inJlamed pulp in one canal and a necrotic pulp itl the
otrer. Total necrosis is asymptomatic before it affects the PDL, and there is no rcsponse to thcrmal or clectric pulp tests. Note: The inflammation will eventually spread beyond the apical foramen. which rvill lcad to thickening of the PDL. The clinical manifestation of this presents as
tendemess to percussion and biting
Mandibular molars are characterized by a trapezoidal outline of the pulp chamber. This
outline is formed by two canals in the mesial root and one oval canal in the distal root. ln
approximately 287o (offrst molars) ofthe cases the distal root may have a second canal
(burth canal overal1). The pulp chamber is located in the mesial two-thirds olthe crown.
Important: You must look for the fourth canal ifthe first-found canal in the distal root
lies more toward the buccal, instead ofbeing located in the center
The lingual wall ofmandibular teeth is most easily perforated when preparing an access opening due to the lingual inclination ofthese teeth.
2. The mandibular first molar requires endodontic treatment more frequently
than any other tooth in the oral cavity.
I.
. ,. 1. The mesiobuccal of the maxitlary molars is the most complex root in the
/l\odr entire dentition because 90o% have either second canals or major fins leading off
.:
.a4,^
. Maxillary
12
coptright
2011-201? -
Ddlal Deck
Tooth
Tooth #12
/14
. Tooth #20
. Tooth #28
Ifcaref'ul diagnosis does not reveal the afl'ected tooth, other teeth and related anatomic structures become suspect. Pulpitis in one tooth may cause pain in other areas
the pain is re-
ferred.
Slte of Prin
Referril
Vcrillrry
canincs, rrcrnolJ6
Mtrl3l
rc8ion ofmandiblc
ZygoMtic, par'cral,
and
occipir.l
Important: The nerve endings of cranial neryes Vll, lX, and X are widely distributed
within the subnucleus caudalis ofthe trigeminal (V) newe. A profuse intenningling ofthese
nerve fibers creates the potential fbr the referral ofdental pain to many sites.
Orofacial pain can be the clinical manifestation of a variety of diseases involving the head
and neck region. The cause ofthe pain must be differentiated between odontogenic and nonodontogenic. Characteristics of nonodontogenic involvement:
remissions
. Tdgger points
. Pain travels and crosses the midline ofthe face
. Pain that surfaces with increasinq stress
. Pain that is seasonal ar cyclic
Maxiffary first premolars: Approximately 78oh have two roots, one buccal and the other
palatal, each rvith a single canal. The two roots rnay be completely separate or merely twin
projections rising from the middle third ofthe root to the apex (this is nore comrD,?). The two
roots are usually equal in iength from apex to cusp. However, the lingual root and canal may
be wider.
ln approximately 229lo of maxillary first premolars, only one root is present. there may either
be one or trlo canals with one foramen. A cross section at the cervical line shows a canal
shaped like a figure eight /e//rpse). The access opening is a thin oval. Be careful not to perforate on the mesial (the concavii, on the mesial makes perforation reD'conmon).
The apical foramen ofthe maxillary first premolar is usually close to the anatomic apex, and
rhe apical ponion ofthe roots often taper rapidly, ending in extremely narrou and curved root
rips. The buccal root can fenestrate through the bone, leading to problems such as inaccurate
aper location. chronic post-operative sensitivity to palpation over the apex, and increased risk
ofan irrigation accident. This tooth is also prone to mesiodistal root fractures and fiactures at
rhe base ofthe cusps, especially the buccal cusp.
Nlarillary second premolars: The most common configuration in this tooth is a single root,
occurring approximately 75%o ofthe time. Approximately 25%o ofthe time, two separate roots
are present, each \\,ith a single canal. The access opening is exactly the same as that for maxillary first premolars (thin oval).
Remember: Maxillary second premolars have a higher incidence ofaccessory canals (60'%),
than do maxillary first premolars.
calal
a second mesiobuccal
14
Cop)'right O 20ll-2012 - Dnhl Decks
is the mesiobuccal canal the hardest canal to find on tooth #3 and # 1.1, but
Note: In approximately 587o ofmaxillary first molar teeth, a fourth canal is present with
its orifice being just lingual to the orifice ofthe mesiobuccal canal. The canal is located
in the rlesiobuccal root and may join the mesiobuccal canal or exit through a separate
fbramen. lf a lesion is present on the mesiobuccal root pior to root canal therapy and
doesn't heal in the usual amount of time (6-12 month.s) following treatrnent, il is rnost
likely due to
a missed canal
(nesiolingual).
Fracture ofthe maxillary first molar is usually through the central groove or at the base
ofthe buccal cusp. These fractures can extend into the furcation, creating an untreatable
periodontal det'ect.
Remember: The U-shaped radiopacity commonly seen overlying the apex ofthe palatal
root of the maxillary first molar is most likely the zygomatic process ofthe maxilla.
will
be the
lingual.
llit
is not
Over 607o olmaxillary ccntril incisors show accessory canals, and thc apical foramen is found
the apex in .157o of$ese tecth.
apa11
flonr
ldeal access preparation ofnlaxillary central incisors is ovxl-triangulrr on rhe lingual surface oflhe tooth
a sli!ht cune lingually to avoid reducing the incisal edge.
\\'ilh
@@@
/7-\ \,\0
,6,
\\0\l
'a\l/ \r' )l
Firn
Prcmohr
Second Prcmolar
./=-\ F:l
nl\ll
/1 ll
utl u
l) U U
il
\-/ \r'
First
luolar
S.cond
ltol.r
.5%
.20%
.45%
.65%
t5
CopFighr O 20ll-2012 - Dent.l Decks
17
Copyrighr O 201 l-2012 - Dntal Decks
*** Almost
one fourth
ina.
The treatment of mandibular first premolars can really be tricky! At least 27oA may have
two canals with either one or two fommen. This is quite different from the mandibular second
premolar
are found to have one canal with one foramen.
-867o
The second premolar has fewer variations than the fimt premolar, usually having one root and
one well-centered canal. The access opening is oval. Consideration must be given to the mental foramen which lies in close proximity to the apex. Avoid overinstrumentation and overfill. When viewing an x-ray ofthis area, the mental foramen is sometimes misdiagnosed as a
premolar abscess. Therefore, before performing root canal therapy, make sure all diagnostic
tests confirm your finding.
Note: Ifa straight-on preoperative radiograph ofa mandibular first premolar shows the pulp
canal disappearing (or goingfrom dark lo /r'g@ in midroot, this is an important indication
that two canals are present
can be used when other tests have not determined which tooth
is the source ofpain.
. Test cavity: only done in cases where a strcng suspicion ofpulp necrosis is present and
confirmed with other tests and radiographic findings, but a definitive test is requircd.
Remember: A radiolucency will not begin to manifest until demineralization ofbone extends
point: You should not rely exclusively on x-rays
through the cortical plate ofthe bone
in an anempt to anir e at a diagnosis. -Key
Because an x-ray is only a two-dimensional image, two films ofthe tooth or teeth
in question should be taken at the same vertical angulation but with a 10- to l5-degree change
in horizontal ansulation.
lmportant:
roots. The access opening is a large oval with the greatest width placed incisogingivally.
This tooth usually has a slightly labial axial inclination of the crown, therefore the access opening needs to be directed towards the lingual surface.
The canal ofthe mandibular canine is somewhat ovoid at the cervical area but it becomes
rounder at the apex.
\ote:
The root canal for a mandibular canine is thin mesiodistallv but wide labiolinguall)'.
18
Coplright
@ ?01
. Irrigate the canal with sodium hypochlorite then apply calcium hydroxide
. Perform the amputation at a more apical level
an interim restoration
The maxiiJary lateral incisor ahvays h{s f99.9Zo) one root with one canal. The root is more slender than
in the maxillary central incisorand frequently 1557,y' has a distal and/or lingual curvature or dilaceration.
The access opening is oval.
Maxillary central incisor: The maxillary central incisor always has one root and one canal. The root
is bulky, with a slight distal axial inclination but rarely has a dilaccration. The access opening is oval-
triartgular.
canine always has one root and one canal. This tooth is the longest
Perforation: Although many errors can potentially occur during acccss preparations, the most deictcrious is perforation ofthe pulp chamber space into the oral cavify or periodontal tissues. Ifthe perforation
occurs above the osseous crest in the gingival sulcus or above the free gingival margin, consider the
following measures: (l) Control hemorrhage with a dry cotton pellet or some hemostatic agent, do not
use formocrcosol (2) Scalwidl a temporary cement, such as Cavit orZOE, (3) Procccd with RCT (4) Plan
to restore perforated area separately or make such restoration part of the final tooth preparation. Ifthe
pedoration is at or below the osseous crest or into the furcation region, thc following steps can bc considered; horvever, the prognosis for thcse cases is very poor (l) Seal the perforation immediately (2) If
the pcrforation is close to a canal orifice, place a file, gutta-percha cone! or silver cone into thc canal to
prcvcnt the placement ofmaterial in the canal during the repair (3) Control the hemorrhage, if it can not
be controlled due to size the[ use a pulp capping agcnt, such as Dycal, if it is controllable, use Cavit or
ZOE to seal perforation (4) Try to avoid pushing any sealing materials into the periradicular tissues.
*** Uncontrolled
even after more apical amputation, hemostatic agents are used as a compromise
treatment. These are closely monitored and
procedures should be instituted.
Pulpotomy is the surgical removal of the coronal portion of a vital pulp to preserve the
vitality ofthe remaining radicular pulp. The common indications include:
. Cariously exposed deciduous teth
healthy radicular pulps
-with teeth with undeveloped roots
. Traumatic or carious exposure ofpermanent
. An alternative to extraclion when endodontic treatment is not available
. Emergncy treatment in permanent teeth with acute pulpitis
Unfortunately, pulpotomy procedures performed in fully developed permanent teeth
are not found to be successful. For this reason it is regarded as a temporary procedure in
these teeth.
Coptriglt
20
201l-2012, Dnral Deck
. After
an apexifrcation procedure
21
Pulp capping is the placing of a sedative and antiseptic dressing on an exposed healthy pulp in
order to allow it to recover and maintain normal function and vitalit),. The dressing most commonly used is CaOH2 (Dycal). Pulp capping is overuscd in dcntistry today. ln reality it has only
very l-ew indications for its use. Young pulps are morc vascularized and. therefore, more amenable
to repair. Pulp cappjngs are more successful if the exposure was acc idental (trduma or \r ith a de la1Dr, as opposed to carious. ln addition, the exposure should only be pinpoint lo expecl succcss.
Repair is accomplishcd by the formation ofa dentin bridge at the site ofexposure. Evcn a snall
carious cxposurc should have root canal therapy for thc best long-term prognosis.
Note: Direct pulp capping is indicated ifthere is a small mechanical exposure for.snall traLtmatic
expo.\ure), an asymptomatic vital pulp, and no coronal or periapical pathology. A hard tissuc barricf (repuratlw dentin bridge) may be visualized as early as 6 weeks postoperative.
Atooth may stay asymptomatic for scveralweeks after pulp capping has bccn pcrformcd. However,
this may be only tenrporary. Unfortunatcly, if pulp capping I'ails and the tooth becomes symptomatic, it may be difficult, ifnot impossible, to treat with routine endodontics because oflhe severc
calcifications in the root canal. Perforations may occur during attempts to follow the obliterated
canal to gain palency to the apex. Note: Perfo.ations into lurcations ofmulti-rooted tecth havc the
poorest prognosis.
Indirect pulp capping involves removing infccted dentin almost up to the point ofpulpal exposure. Calcium hydroxide is placcd and then a resin modified glass ionomer cement is placed over
a final restomtion is placed alicr rcmoval
ofthc internlediate restoration and rcsidual carics. Thc goal ofindirect pulp capping is to havc thc
tooth participale in ils own recovery. Indications for indirect pulp capping include deep carious
lesions that encroach but are not actually in the pulp, no history ofchronic pain, no radiographic
pathology'. r'ital pulp. and normal looth mobility and color
Ifthe preparation is properly flared, fitting the master cone is not a time-consuming procedure. A gutta-percha cone the same size as the file used last durin gpreparation (MAF)
is selected and placed as far as possible into the canal, but not beyond the working length.
Once satisfactory tugback and apical positioning appear to be obtained, a radiograph is
taken to verify cone positioning. If an accurate determination and careful enlargement
have been performed, the x-ray will show that the master cone reaches the most apical
position of the preparation or extends to a point just short of that ( I nm). When the
cone is slightly short, the pressure ofcondensation plus the lubricating action ofthe sealer
* ill be sufficient to produce complete seating of the cone.
\rl3es
L If the cone is more than I mm from the radiographic apex, discard the cone
and fit a smaller one or instrurnent more in the apical third.
2. Remember: The main reason for recapitulation lirirgl,our MAF after eqcll
inct euse in .;file size) during instrumentation of the canal is to clean the apical
segment ofthe canal ofany dentin filings that lrere not removed by irrigation.
3. Common solvents used to soften gutta percha are chloroform, methylchloro-
. Inigate furtheq the Sodium Hlpochlorite should take care ofthis problem
. Temoorize the tooth and obturate at a later date
22
Coplrighr O 2011-2012 - Dmial Decks
Sodium Hypochlorite
. Calcium Hydroxide
Coplright C
201
23
I-2012 - Dental Decks
***
This indicates inadequate debridement, as a pulpless tooth should not respond to any
stimuli.
The most important consideration before filling a root canai is propr cleaning (debridener, and shaping (instrumentin&) ofthe canal. Once the canal is obturated, any organisms
that have entered the periapical tissues from the canal are eliminated by the natunl defenses
ofthe body.
Remember: The presence of a periapical lesion before root canal treatment will reduce the
success rate of the treatment by 10%-20%.
Note: After endodontic therapy is completed on a tooth with a periapical radiolucency, it nsually takes 6-12 months before marked reduction in the size ofthe radiolucency is evident on
an x-ra.v. Desired periapical tissue changes include regenention ofalveolar bone, deposition
of aoical cementum. and re-establishment ofthe PDL.
***
Sodium Hypochlorite is the most widely used irrigant and has effectively aided canal
preparation for many years. A 5.25olo solution provides excellent germicidal solvent action, but is dilute enough to cause only mild irritation when contacting periapical tissue.
NaOCI is a good tissue solvent as well as having some antimicrobial effect. It also acts as
a lubricant for root canal instrumentation. Note: lt is toxic to vital tissue; always use rubber dam. Note: To date there is no agreement on any single concentration-value of
sodium hypochlorite Q"taOCl) as being the most effective while being the safest.
H"vdrogen peroxide (396 solution) is also widely used in endodontics with two modes of
action. The bubbling of the solution when in contact with tissue and certain chemicals
physically foams debris from the canal (efJbnescent eflbcf. In addition, the liberation of
oxygen uill destroy strictly anaerobic microorganisms. The solvent action of hydrogen
peroxide is much less than that ofNaOCl. However, many cljnicians use the solutions altemately during treatment.
. Rotary files
. Chloroform
. Glass bead sterilizer
. Ultrasonic
. Heated instruments
24
Coplrighr O
201
l-2012 -
De
al
Deks
. It is a chelating agent with the capability to remove the mineralized portion ofthe smear
layer
. It
. Normally it is used in
a concentration
of
. It
25
Coplrighr C 201l-2012 - Dental Dcks
. Rotary removal
. Ultrasonic removal
. Heat removal
. Heat and instrument removal
. File and chemical removal
Chloroform is the reagent of choice to dissolve gutta-percha. [t is very effective but
should be used with caution. Its vapor is potentially hazardous, so it is dripped directly in
the canal avoiding excessive flooding.
Other chemicals which can dissolve gutta-percha to a varying degree include: xylol,
halothane, benzene, carbon disulfide, essential oils, rrethyl chloroform and white rectified
turpentine.
If
a gutta-percha cone has passed beyond the apx then a file must be used beyond the
apex in order to avoid breakage ofthe cone. A broken cone in the periapical area may result in an orthograde re-treatment lailure.
,'Notes,
c u2n
F).
***
This is false; it has a limited value as irrigation solution. The decalcifying process induced by EDTA is selfJimiting and stops as soon as the chelator is used up.
Chelating agents are used to aid and simplify preparation for very sclerotic canals after
the apex has already been reached with a fine instrument. These agents act on calcified
tissues only and have little effect on periapical tissue. Their action is to substitute sodium
ions, which combine with the dentin to give soluble salts for the calcium ions that are
bound in less soluble combination. The edges of the canal are thus softer, and canal enlargement is facilitated.
EDTA will remain active in the canal for 5 days if not inactivated. For this reason, at the
completion ofthe appointment the canal must be irrigated with a sodium hypochlorite
(NTOCl) containing solution. Note: Rinsing for I minute with EDTA eliminates the
smear laver, opens dentinal tubules, and provides a cleaner surface for gutta-percha
and sealer to adapt.
26
While cleaning and shaping the canal, an instrument seperat$ in the canal.
As you rttempt to retrieve it, the broken instrument passes partially
through the rpex, tbus partly protruding into the periapical lesion.
How do you manage this case?
. Just inform the patient, fill the canal with gutta-percha and monitor
27
Coplright O 20l l-2012 - Dental Decks
***
Clean shavings are difficult to see on a file. The attainment of a clean irrigating solution is considered an inaccurate way to determine the end point ofdebridement.
Debridement is defined
as the removal offoreign material and contaminated or devitalized tissue from or adjacent to a traumatic infected lesion until surounded healthy tissue
is exposed. Chemomechanical debridement of the root canal system is the most crucial
aspect ofroot canal treatment.
Complete debridement of the canal is the most effective means to reduce root canal
microorganisms. It can be carried out in various ways as the case demands, and may include instrumentation ofthe canal, placement ofmedicaments and irrigants antVor surgery
Remember:
. The most common cause ofroot canal failure is incompletely and inadequately disinfected root canal systems.
. The second most common cause of failures ol root canals is leakage from a poorly
filled canal. This is common even after apical curettage. Example: Root canal treatment performed on a tooth with apical curettage ofa lesion that was found to be a cyst.
Three years later the lesion is even bigger than it was before. The most likely cause of
this lailure is leakage from a poorly filled canal.
. A ledge is an artificially created irregularity on the surface ofthe root canal wall which
prevents the placement ol instruments at the apex ofan otherwise patent canal. Ledging
is caused by insertion ofuncurved instruments sl'lort ofthe working length with excessive
amounts ofapical pressure. The canal wall is gouged or a false canal is created which results in ledge formation. The effective use ofcircumferential filing, especially with Hedstrom files, will ensure smoothness and occlusal flaring ofthe canal walls and prevent the
derelopment of steps or irregularities.
Cenerally, when a broken instrument protrudes past the apex, surgery should be
performed. This constant iritant must be removed.
. Reaming motion
2a
Coplriglt
@ 201 1,201 2
- Dmral
Deck
. Non-staining property
. Adhesion
. lnsolubility
. Long history ofsuccessful
usage
29
Cop)'ri8hr
201 I
***
The engine driven instruments, however, use only the reaming motion. Nickel titanium instruments can be both hand operated and engine-driven.
Generally, hand instrumentation is done by either filing (push and pull) or reaming 6epeated rotqtions).
Filing is a push-pull action with emphasis on the withdrawal stroke. Its efficiency is greatest with fils than with reamers for removing dentin because of the greater number of
flutes in contact with the canal walls during the rasping motion of removing the instrument. Filing action produces an irregularly shaped canal and therefore must be filled
with gutta-percha in a condensation procedure.
Reaming is defined as the repeated clockwise rotation of the instrument, particularly
during insertion. Reaming produces a canal that is round. Reaming is recommended
using a silver cone to fill canals.
if
Circumferential filing is a push-pull action with emphasis on scraping the canal walls
to create a smooth, tapered preparation. It is a method of filing whereby the instrument
is moved first towards the buccal side ofthe canal, then reinserted, and removed slightly
mesially. This is done all the way around the tooth until all the dentin walls have been
planed. This technique enhances preparation when a flaring method is used.
Remember: The primary function ofa root canal sealer is to fill in the discrepancies
between the core-filling material and the dentin wall. In fact it is said that it is more im-
Most root canal scalers are some type ofzinc oxide-eugenol cement and are capablc
producing a seal whilc bcing well-tolerated by periapical tissues.
of
All sealers display some degree of radiopacity (caused by metollic sahs in the sealer);
thus are visiblc on a radiograph. This helps disclose the presence of accessory canals, resorptivc arcas, root fracturcs, and thc shapc ofthc apical foramen and other structurcs of
lnterest.
Note: After filling a tooth with gutta-percha, if you see a horizontal line of firaterial
(gutta-percha or sealer) extending both mesially and distally from thc canal to thc pcriodontal ligament space, this is indicative of a root fracture.
ZOE disadvantages: staining, slow setting time, non-adhesion, solubility.
30
Cop)'righr
201
31
Coplright O
201
l. StraighGline access
2. Conservation of tooth structur
3. Unroofing ofthe chamber and to remove pulp horns
Access to the root canal is the initial step in canal preparation. It is necessary to estabIish straight-line access to the apical foramen to ensure free movement ofthe instrument
during debridement and preparation ofthe canal. A1l the treatment that follows hinges on
the correctness ofthe access preparation. All access cavities are made through the lingual
on anterior teeth and through the occlusal on posterior teeth.
incisors.
Remember: Mandibular incisors and maxillary first premolars require the most care
to avoid perforation during preparation ofthe access opening. This is due to the narrow
mesio-distal dimension ofthe rnandibular incisors and the mesial concavitv ofthe max-
areas.
Studies have shown that the action of using thc instrunent, rather than the instrument used, determines the general shape ofthc canal preparation. Therefore, a reaming action produces a canal
thal is relatively round in shape while a filing action produces a canal that is irregular in shape.
Important: A canal should be instrumented and shaped so that it has a continuously tapering funnel shape. The widest diameter would be at the canal opening and the narrowest at the dentinocemental j unction aJ I o L0 mm from the radiographic aper). This is where all teeth should be filed
to and fillcd to fideal/r.
The common methods for sterilization uscd in cndodontics are:
. 2 1/o Glutaraldehyde:
- Cold or heat-labile instruments such as rubber dam frames. etc.
- Generally, 24 hours are required to achieve cold sterilization.
- Least desirable mcthod.
. Autoclave:
- Instrurnents should be wrapped and autoclaved for 20-30 minutes at 250' F ( I 2
psi.
- This
I'
C) and
15
. Both the statement and the reason are correct and related
. Both the statement and the reason are correct but NOT related
. The stalement is correct, but the reason is NOT
. The statement is NOT correct, but the reason is correct
. NEITHER the statement NOR the reason is correct
32
CopFight C20ll-2012 - Dental Dcks
. Plasma cells
. Vacrophages
. Lymphocyes
. Polymorphonuclear (PMN) Leukocytes
***
The rcason broaches are not used for canal cnlargcmcnt is not becaus they are made ofstainless stccl.
it is lheir design.The barbs are notchcd out of the instrument shaft and rcpresent a weakend point. If the
broach is not used with the utmost of car or il it is forced apically, the barbs will be bent and will engage
the walls, making removal difficult. It is not used for canal enlargemenf.
K-type instruments:
. Files are lhe most uscful instruments in eDdodontics fbr the removal ofhard tissue in canal enlargements.
They arc manufactured by t$isting a blank, which is a square rod. producing a series ofcutting fluies. The
action uscd for placing this type offile into a canal should rescmble a clock \1 ise-counierc lock*,ise motion
with pressure dircctcd apically (tan he a.filing or reaning action). Note: These files are the strongest of
all files ancl cut the least aggressivll. A modification to this tlpe oftlle is the K-fli file.
. Ramerc are manut'actured in a manncr similar to files. only they have fe*er flutes. They are used in
canal preparation to shave dentin and enlarge cmals \r,ith a rcaming action only, They remove intracanal
dcbris with clockrvise reaming action. They arc also uscd to place materials into the apical ponion of the
canal by using a counierclocklr'is(] rotatlon.
H-type instruments:
. Hdstrom files are manufactured by using a sharp, rotating cutter to gauge triangular sgments our ofa
round blank shaft. This produces a very sharp edge and thereforc an cffective cuiting insrument. Ifused caretully, lvith filing action only, it \\'ill successtully planc rhc deniin *alls much faster than K-rype files or
reamcrs. A modification oflhis filc is the S-file.
\ote: All ofthe
File dimenrions: The position at which the cutting bladcs begin on an instrument is called Dl, aDd thc flutcs
.\tcnd up rhc shafl fbr 16 mm to stop at D2. The remaining portion ofthe shaft extendiig io the handle has no
llutes. and its length is the difference between 16 mm. and the lotal lcngth from lhe tip to the handlc. The
leneth of cunin.e edgcs lthe distance beteee D t a d Dt remains l6 mm, regardless ofthe lcngth or style of
Ihc i:sirument. The numbcring svstem for instrument identification is based on the diameter at Dl, stated in
hurdredths of millimeters. Therefore the name ofeach instrumcnt givcs considerable inlormation about its dimerioni Asjzel0fleisindicatedtobe0.l0mminwidthatDt and . l0 mm plus 0.30 mm (or 0.10 mn) ar
3 lornt 16 mm f'arther up the shaft fDr, etc.
The onset ofpulpal inflammation is an insidious process and is characterized by a chronic celfufar response fplasmq cells, macrophages and l,vmphoq'tes). There is no direct exposure of
the pulp to dental caries and the response, therefbre, is not acute. After pulp exposure, the
acute inflammatory cells (nainly PMN celA, are chemotactically attracted to the area. Histologicalh, the tissue is likely to show signs ofacute inflammation near the site ofthe exposure
and a band ofchronic inflammatory cells between the acute inflammation and the underlying
normal pulp.
The response ofvital pulp to microbial invasion is very resistant. Based on the observation
IhaI e\ en alier t$,o weeks of tmumatic pulp exposure, only 2 mm of coronal pulp may "give
in" to microorganisms. Non-yital pulp, in contrast, is a "fertile ground" for the growth of microorganisms.
Remember: Carious exposures in permanent teeth generally require root canal treatment. Immatld(e (open qper) pennanent teeth with carious exposures can be treated by pulp capping
or pulpotomv procedures.
Important: Pulp capping is not recommended in primary teeth with carious exposures due
to its high failure rate and because pulpotomy, having similar time requirements. has shown
to be very successful. Pulp capping can be done, however, in mechanical exposures.
1. Calcium hydroxide has a high pH of 12.5 which cauterizes tissue and causes
superficial necrosis.
2. This necrotic zone encourages the pulp to induce hard tissue repair with secondary odontoblasts laying down reparative dentin.
. Condensing osteitis
. A vertical fracture ofthe tooth
. Periodontal abscess
CopFigh O
201
34
l'2012 - Dental Decks
35
Copltighi o 20l l-2012 - Dental Decks
Radiographic examination seldom reyeals the fracture because the crack is usually parallel
to the x-ray film. One of the most puzzling and frustrating dental conditions involving the
possible need for endodontic treatment is the cracked tooth syndrome. Symptoms from this
condition usually are characterized by a sharp but brief pain occurring unexpectedly only
when the patient is chewing. Having a patient bite forcefr.rlly on a bite stick and noticing the
cusps that occlude when the pain occurs will aid in the location ofthe olTending tooth.
In most cases there is an isolated probing defect at the site offracture. An important diagnos-
tic sign is a radiolucency from the apical region to the midline of the root (J-shaped or
teardrop-shaped). Vertical fractures through rcot structure, however, have an almost hopeless
prognosis. lfthe fractured segment can be removed and gingivoplasty and alveoloplasty perfbrmed, treatment can be successful. However, unrealistic or overambitious case selection
leads to a high degree
offailure.
When an anterior tooth fractures, it generally occurs in a more horizontal plane and may
show up on the x-ray. The cause is usually accidental tnuma such as a blow to the jaw or
teeth. If the fracture line is not too far down the root ofthe tooth. it mav be able to be saved
with a root canal and a crown.
Itiote: Chronic focal sclerosing osteomyebtrs (condensing oJleillt is excessive bone mineralization around the apex ofan asymptomatic, vital tooth. This radiopacity may be caused by a
lo$.erade puip initation. This process is asymptomatic and benign and does not require root
canal therap!.
of
producing substances.
Important:
. Cervical root resorption relating to bleaching is a potential side effect; usually it
does not manifest for at least 6 months. This is a reason why recall appointments are
lmponant.
\lalking
bleach technique: uses a mixture ofsodium perborate and water and may be
utilized ifthe chairside results are inadequate or ifyou prefer to avoid the possibility ofa
higher chance ofcervical root resorption. Place a thick paste in the tooth chamber with a
temporary restoration for four to seven days. Several repetitions of this procedure can
work quite well. The sodium perborate when fresh is 95olo perborate giving off 9.9% of
available oxygen. This material is more easily controlled and safer than Superoxol; therefore, it is the material ofchoice.
. On a non-restorable tooth
. On a periodontally insufiicient tooth
. On a tooth with a vertical root fracture
. On
a asymptomatic tooth
. On
. On
with
a calcified chamber
This half-moon shaped flap is raised with a curved horizontal incision in the mucosa or attached gingival with the concavity towards the apex. Although it's simpie and does not impinge on the surrounding tissuc, thc disadvantages outweigh its advantages. These include:
. Ifsomehow
a lesion is found to be bigger than anticipated, the incisions come to lie over the bony
defect
. Its extent is also lirnited by anachments 1/e.g.,.fienum, muscles etc.)
*** Tlterefo.e, this tcchnique is not used for anlerior root end surgery.
Surgical flaps on the basis ofhorizontal incision can bc classificd into tr}o major typesi
L Full mucoperiosteal flaps:
. Submarginal scallopcl
Oc hsenbei n- Luebke)
The submarginaf scalloped (Ochsenbein-Le!6te, tlap requires at least 3-5 mm ofattached gingiva and
a hcalthy periodontium. It is raised by a scalloped incision in the aftached gingiva with onc or two vertical incisions. Less risk ofincising over bony defects and no post-surgical recession ofgingiva. Its disadvantages includc hcmorrhagc from the cut margins and scarring. Access and visibility is better fdrd
acceptoblel than semrlunar flap but not as good as full mucoperiosteal flap.
Full mucoperiosteal flaps allorv maximal access and visibility. They are raised from the gingival sulc\rs (ele\!ting gingirdl crest and interdental glrg,?,/. This wide outliI1e ofthe flap prccludes any incisions o\'cr bonv defects and allows various periodontal procedures including curettage. root pianing and
bone re-shaping. A large flap may be difficult to reposition, suftrrc and makc alterations. Posr surgical ginsi\ al recession is also a oossibilitv.
. A non-strategic tooth
-a or external resorption
. A tooth with massive internal
.A tooth that has a canal unsuitable for instnlmentation or forsurgery /i.e., broken instnrnents,
dentina l sc lerosi|;, s hat p d[l a. erations, etc..)
A medical condition such as hcmophilia is not a contraindication to convcntional endodontic therapy. However, it is strongly recommended that a dcntist obtain clcarance from the patient's physi-
are
uncontroffed diabetes or a very recent myocardial infarction (v,ithin tlte post 6 months).
Note: Example of a special case: A previously traumatizcd looth may show complcte
obliteration ofthe pulp chamber and canal. The periodontal ligament may appear non'nal. The patient will be asymptomatic and the tooth will not respond to pulp vitality testing. The trcatment of
choice is to obsene as long as the tooth remains asymptomatic and no periapical changes arc cvrdent.
Fracture injuries:
. Enamel and dentin fracture with pulpal involvement ft1lr.r Class III): pulpal trcatment de-
pcnds on stage of developrnent oi' tooth (immatrre $ msture) and ti]me after traumatic injury
/lfter 21 hours the chances ol direct bacterial contdmii.ttion increase)
. Root fractures: prognosis dcpcnds on location; coronal root liactures ha!c a poor prognosis,
n]idroot fracturcs havc guarded prognosis and apical root fractures havc the bcst prognosis
Important: Prognosis improves as liacturc approaches apex: horizontal is better than vertical;
nondisplaced is bctter than a displaced fracturei and oblique is bettcr than transversc.
38
CoDriglr
. A major disadvantage of posts/dowels is that it does not reinforce the tooth structure,
in fact, it weakens
it
. Threaded screw posts are preferred over parallel sided and tapered posts
. Pins add to stresses and microfractures in dentin and should not be used
. Cusps adjacent to lost marginal ridges should be restored with an onlay
39
Coplai8hr o 201 l-2012 - Dental Dcks
***
In "blow-out type" and "sinus tract type" probings, another clue for diagnosis is a nonthese two lesions can completely heal after root canal treatment.
a tooth
with this type oflesion will show normal sulcus depth all
the way around the tooth until the area ofthe swelling is probed. At this point, the probe drops
suddenly, to a level near the apex. The probing depths in all other areas are within normal limrts.
Periodontal lesions characteristically show bone loss which begins at the crestal bone level
and progresses apically. Hence probing defect would be conical in shape. This type of lesion
may not be amenable to root canal treatment alone even if it is associated with a pulpless tooth.
However, endodontic treatment must be completed prior to tackling the periodontal problem.
A narrow sinus tract type lesion: the probing reveals nomra) depths al) around the tooth except at one very narrow area. Here, the probe can pass down the root surface to some distance
and sometimes even to the apex. The tooth is pulpless (non-itel.). Once the root canal treatment is completed, the lesion heals within one week. i'r"ote; All sinus tracts should be traced
rvith a gutta-percha point by radiograph.
Remember: A perio-endo abscess is a combined lesion. The lesion usually demonstrutes radioeraphic involvement ofthe periodontium and the apex ofthe involved tooth.
vitality
tests
\ote: A common clinical finding ofa periodontal problem is pain to lateral percussion on a
tooth rrith a wide sulcular Docket.
***
Thesc may actually increase the chance offracture. The parallel-sided posts are prefened.
. Onlay restoration: in most cases it is imperative that root canal treated teth b protected from
fracture by a cusp-coverage qpe ofrcstoration. The minimum (ra ost conserwtiv) preparation should
be for an onlay' covering the cusps and marginal ridges.
. Cro$n:
a full-coveragc crorvn is prcfcrred whcn the rcmaining coronal tooth strucrurc does not afford sull'icicnt tooth structure for an onlay.
. Cro$n $ith post and core: to reinforce the treated tooth and provide suitable coronal tooth strxcmre for an optimum crown prcparation, thc usc of a post and corc is often indicared. Be very careful
$ hen placing posts. Perforations and vertical root fractures can occur. Important: The primary
purpose ol the post is to rctain a corc in a tooth whcn thcrc is an cxtcnsivc loss ofcoronal tooth strucrure Posrs do not reinforce the tooth, but further weaken it. At least 4 to 5 mm ofremaining guna-percha is recomnended.
1.
Ifyou
ofthe coronal
structure
-they
tural integrity.
3. More endodontically treated teeth are lost because ofrestorative factors than failure ofthe
root canal treatment itsclf.
4. Pemanent restorations arc bcst placcd ASAP after obturation to seal the intemal aspeot
of thc tooth from contamination.
5. Endodontically heated teeth do not become brittle. The moisture content ofcndodontically treated teeth is not reduced even after l0 years. Key pointi Tccth are weakened by thc
loss of tooth structure.
Misc.
40
CopFight C 20ll'2012 - Denral Decks
Misc.
ENDODONTICS
Stand at least 5 feet away exactly opposite the x-ray bearn source
Stand at least 6 feet away and in the area that lies between 90 to 135 degrees to x-ray
Deam
Stand at least 7 feet away and in the area that lies between 60 to 90 degrees to x-ray
beam
a barner
41
An apicoectomy is thc prcparatior ofa llat surfacc by thc cxcision ofthc apical portion ofthc root and any subscqucnt rcmoval ofattached soft tissucs.
Ifa toolh has had previorrs endodonlic lherapy and becomes reinfectcd, il is usually bcst lo try and .etreat it con'
vcntionally remove filling marerial, debride the canals, and rcfill. However, iltbe tooth has bccn restorcd $ith a
post, corc. and crown thcn apical curcttagc, apicocctomy, and a rclrotill should bc pcrformcd. Note: Rctrcaling a
tooth with a post is the most common rerson for an apicoectomy and retrograde fllling.
Indications for apicoecaomy (root-e n d
rc se c tion ) |
has a
poor
crown/root ratlo
Procedure:
. Radiographs are taken to determine the length ofthe root and ils proximity to adjacent structurcs
. Administer anesthesia
. On th labial surfacc ofthe tooth, witb the help ofa pcriostcal elcvator. locatc the root apex, so that an incision
can bc madc
. Flap designs used: submarginal scallopcd fO. ltsenbein- l,uehke) ,
t! I I m ucoperiosteal flaps t ? r"Jr/
^nd
. Reflect the flap
. Root apex is exposed, thcn apcx is cut olf with a lissure bur about one-third of its lcngth
. Curette the surrounding pathologic tissucs and round ollthc end of thc cut rool
. For retrograde filling, a bevel of0-10 dcgrccs is grvcn
. Retrograde filling to I mm is donc
. Irrigate the wound Nnd ruture the llap in position
5. If there is no barrier for thc clinician to stand behind while exposing films,
hc/shc
should stand in an area of minimal scatter r^diztiorr ( i.e., 6.feet otrat and
the area thot lies
b, n'een 9(P to 135" to x-ray beam)
6. DeIltal personnel who may gct exposed to occupational x-radiation must wear fiLn badges
to record exposurc and must never exceed the maximum permissible dose IMPD) of50 mSv per
year/whole body.
7. An operator should never remain in the room holding an x-ray packet in place for a patient.
lffilm must be held in place by somcone else (i.e.,lor a child.1, drape the patient and have him,/her
hold the film.
8. The most accurate radiographs for endodontics are made using the paralleling technique.
Remember: When using the paralleling technique, you must ccntcr the X-ray film packet
behind, and parallel with the long axis ofthe tooth bcing X-rayed. The tube head must be positioned so that the ccntral X-ray beam is projected perpendicular to the tooth and the lilm
Packet.
12
copyrighr O 201l-2012 - Detual Decks
. Root
end surgery
201
. Prevotella species
***
A vital pulp resists bacterial invasion. Even ifthe pulp is exposed to microorganisns for
2 weeks, the penetration ofbacteria may extend no more than 2 mm into the pulp. In contrast, a non-vital pulp is a fertile ground for the growth of microorganisms and leads to
necrosis.
Remember: Streptococcus species may be more important in the initiation ofrather than
the progress of a carious lesion leading to a pulp exposure. Strict anaerobes are found
to play a significant role in periapical pathoses.
***
olthe vitality
of the pulp is crucial. In some doubtful cases, the better part of wisdom is to wait until
after the completion ol the root canal therapy to see whether spontaneous resolution
lpocket closure and osseous ./ill-in) will occur before surgical periodontal procedures are
begun.
Periodontal therapy should be initiated first only in the case ofa primary periodontal lesion rvith subsequent secondary endodontic involvement.
Remember: A common clinical finding ofa periodontal problem is pain to lateral percussion on a tooth with a wide sulcular pocket.
Note: The combination lesion (perio-endo) is dorninated by gram-negative anearobic
bacteria
. Reticulin fibers
. Collagen fibers
. Unmyelinated nerve fibers
44
Coplright O 2011,2012 - Dmral Decls
. Mantle dentin
. Circumpulpal dentin
. Predentin
Secondary dentin
. Tertiary dentin
45
Copfight O
201
1-2012 -
Dfrlal Deck
*** Proprioceptors
fwhich respond to stimuli regarding mot'ement, are not found in the pulp.
The pulp contains both myelinated and unmyelinated nerve fibers. They are afferent and sympathetic.
The myelinated fibers are sensory and the unmyelinated fibers are motor
play a role in the reg-they
ulation ofthe lumen size ofthe blood vessels.
Important: The only type ofnerve ending found in the pulp is the free nerve ending, which is a specific rcceptor for pain. Regardless ofthe sourcc of stimulation fl,eat, cold, pressurc), the onl,v rerponse
will
be pain.
trote*:
i. As the pulp ages there is a decrease in rettc.ulin f$ers (the pulp becomes less cellular and
more fibrous).
2. The sizc ofthe pulp also decreases because ofthe conrinued deposition ofdentin.
3. As thc pulp ages thcrc is an increase in the number ofcollagen fibers and calcifications
within the pulp (ca11ed denticles or pulp stones).
4. Pulp stones are associated with chronic pulpal discasc - tiom advanccd carious Icsions or
larce restorations.
Immediately adjacent to the odontoblast layer in the pulp, l0-47 pm ofthe dentin matrix
remain unmineralized. Ifthis unmineralized layer ofdentin is lost 1e.g., due to taLtmct or
infectious process) it predisposes the dentin to internal resorption by odontoclasts.
organized. Hence the pattern ofdeposition and size ofcollagen fibers is different from
cjrcumpulpal dentin.
..
.. l. Once bacteria
,/Noq:
?&i
:'
.:
,.,.,r,..
N.
The
. Collagen, pulpectomy
. Network ofcapillaries and nerves, pulpectomy
. Collagen, pulpotomy
. Network ofcapillaries and nerves, pulpotomy
46
Coplright
@ ?01
1,2012 - Denlal
Deck
frm
D""tal
17
Coplright O 201 l-2012 - Dental Decks
The central zone or pulp proper contains large nerves and blood vessels. This area is
lined peripherally by a specialized odontogenic area which has three layers (from innermost to outermosl).
2.
3. Odontoblastic layer: outermost pulp Iayer rl,hich contains odonroblasts and lies
next to the Dredentin and mature dentin.
Cells found in the dental pulp include fibroblasts (the principal cell). odontoblasts, histrocyles (mocrop haset, and lymphocytes.
a diseased pulp, the following cells are present: PMN's, plasma cells, basophils,
eosinophils. lymphocltes, and m ast cells (contain histantine and heparin).
Note: In
Important: The pulp lacks collateral circulation, which severely limits its ability to
copc rr ith bacteria. necrotic tissue. and inflammation.
M]
/(Fryl\
ea2
$:rodlt3l
a0
Bll
tt
jwi
\A'
A
{tw
fr) 0
Retirlnred
and
5..a,1.d/to,
:o 2006-
lrh per
garei
J.
Fehrcnbach..
Dental Enbryologr, Hn'
4E
coplright O20ll-2012
- Dental Decks
i secti(
fron
garet
J.
Bath-
Mar
febrenhch.
DentalEnbryolog, Hk
tolog,, ond Arcto8r,
,t9
Cop]'isht O 201l-2012 - Dental Decks
&e.@ &e*&
llaalodletal
Brrccolingrrel
l*aalodblrl
R::rl.'n]n.ttJl1jBiogh'v.rand\,argar.t.]F.h|!nbaclrDe,/rl/E,lna,l'9'}|i'kn.g'ant1:1hlltont|:St.
r .. ..r :i.I FL.\re. SaLnder
/\
\1//
Csrvleal
croea aectlon
Mesiodi3lal
sectlon
Lablollnguol
sectlon
\il/
\l
Meslodistal
agcllon
Cervtcal
crosa Secllon
(rt\
t\tl
\y
Loblollngual
aoclloB
Fhbtlolo*:
Hinnlo'at: tnJ
50
Cop,riSht O
201
l-2012 -
De d
Decks
olosr', Histolog,
drd
51
J.
t'rlr@
fiofr
P-'?\
tr--1/
\ffij
uo3Lglrt l
F^r
\\
/r-\l
\ffi/
\q
TWI
\qf/
\V
H/
ArA
\-/
@]l
U=:
tg]
W
@
'::lls*'
/-\a)
tlj ty
Re|nntc.jti.n]B3th-B3L.8h.\larlndN1argarelJ,Fehrenbtc\'DentllEh1ht|.bg'HisbI.e\'a"1l.1hdant's..a"d..L
i;.'r hr) llie\rersaunde^
.A
\t]I/
\\l/
Crvical
tny
\HI
W
W
L.slodlrt.l
rn
\Bi
/A-.)
\/wr
IWI
\H/
\H/
\[i
\d)
Euccollngurl
tuerollngual
Rqrrint.d fron Brth-Brbgh, Mary and VargareiJ. Fchrcnbacn D.ntal l:nh\.artEr, H5lDlo.i, an,l A"atanr, S..an.l
Saunden
.drbh
a,2006.
{nh
aJeF
52
copyrighr O 20ll-2012 - Dental De.ks
garet J.
Fchenbach..
A 2006, wnh
pmission fro'n Elsevier
on.l e.lition
53
Coplrighr O 20ll-2012 - Dental Dcks
A 4Nml A
/ll\ @ /A\ 1r1 q fil\
I
tP/
r=J v \l tU
A i\",.:T::xl""
Meslodistal
aoclion
\ltl ",*"I
Lablollogual
seciion
Moslodlstal
iici6n-
Lablotingusl
sectton
.....|l:.::;.[I3]l1]t]]trah'\J!rmdV!rga'elJ.Fehrenblch'D.n|dlEh|h|v|ap'||^1o
'r :. r -. r Fli.lre. SrLrdcrs
m\
i\w/)
\a,
@
Svc.ollngt al
A1\
v
(t
)\| Iiltl
W @
'ffi.x'"'
(I,lq
l0l
/F^\
t{
@)
.1ad
t.ntt,
5..,,a .drr., !
J.
54
Cop)'right O 201l-2012 - Denral Decks
. \{ilk
. \later
. Saliva
. Saline
/l\
l.1l
/u\
lYr
t\\\
lltt
tnl
Iil\
til/
Csrvlcal
/&i
cr0s9 Secllon
b:J
Mesiodlstal
secllon
Lsblolingual
Ssctlon
A
ItI
Celvlcat
caoss
secllon
\il1
\t
\ili
Meslodlstql
sct,on
Lablollngual
section
!:]l.::.::i.,J:BJd]BJl.gh'\hr]ndva.ea|.tJF.hrnbrchD.,l.lE'ln,r,14]r
- .. r i.ri:
Flr.lre.
SaLnders
1o prorecr
Five factors thnt arc critical lo Ihc managcnrcnl oftraumatic avulsion injurics lo tccthl
L Timei thc time intcnal from injury ro rcplacemcnt ofrhc looth is a major lactor in rhc maintc|ancc of ligamcnt \ irbility and subscqucDl rft)t rcsorption. Tccth rcplantcd \l ilhin l0 mimurcs have been rcportcd ro cxhibil vcry
littlc rcsorpiion, u hcrcas most oflhe tccth rcplantcd aficr 2 hours sho* a lot ofcxtcmat roor rcsorprion ,,r,r,(, r,
Ih" nail uus? ol fui1uft 4 rcpla r?d teeth).
L Storage mcdia: ii thc toolh cannot bc immdiatcly rcplanlcd, thc prcpcr sloragc ofthc ioolh c?n favorablv
influence thc viabilitv ofPDLcells. Milk is considcrcd bcst fbrlhis purposc bccausc ofils ncarnutralpH /6 j6 lr rnd osrrolality. conducilc ibr the sur,"jval otcclls. Othcr storagc mcdia.rre physiologic salinc and snliva.
I -lboth socket: should not bc dam.rgcd by curctlttgc or fbrccful rcplantarion. Replanl slowly $i1h slight
d:!rta nr.sLrrc
.l Splint stabilization:
a splint that
a maximum
of
\\,ccks /Z n
Root surfacci should not bc sc.apcd. dricd. or manipulatcd with causlic chcmicals.
Imporianti
. T.n drvs ro n\o *ccks rtlcr rcplartation. tbc roor canal is prcparcd (Lleunrd utkl rr.rp././ and
dro\ide paste is placcd into rhc cdnals
. This rastc
rs replaced evrv
catcium
ht,
The abovc informalion changes *hcn a tooth has bccn oul of thc mouth
mainly the trcahcnt ofthc looth sockct and root surf-aces. Changcs rrc as follows:
. Ankvlosis and erternal root resorption x'ill probably resulr withln hvo vcars. Ank]lojis rcsuhing iiom rcplaccrrcnt would give a bcttcr prognosis than external resorption, which u ill lcad ro farture.
. Root canal thcrapy is pcrlbrmed in irs cntircty prior to rcplantatjon
. Thc looth is soaked in a 2.470 fluoride solution acidulatd at pII 5.5lbr t0 minutcs or nrorc. Thc fluoridc \ri
slow the resorpli\c proccss.
. Gentll curctte blood clot out ofthc alveolar sockc( and irrigate with saline
. RcplaDt slo*4y wi(h slighl digital pressuru
. Stabilizc wjlh splint for a maxin]um of2 wccks (7 b lA ddrs is irteal)
VIP
is NOT
. NEITHER
56
copltisht
57
CoDright O 20ll-2012 - Dental Decks
Intentional replartation implies that a tooth requiring cndodontic therapy is purposcly removed
ftom its socket, son]e type ofcanal or apical preparation and/or filling is perfonned, and thc tooth
is returned to its original socket.
Indications lbr intentional replantation falso called replant vugery);
. When routine endodontic therapy of a tooth is impractical or impossible
. When an obstruction of a canal is prcscnt. such as a broken instrument or a calcification, and
periapical surgery is impractical (e.g-, a lower molar w'ith the mandibular canal in close pro*
inin
. When perforating internal or external resorption is present, yet surgery is impractical
. When a previous lreatment has failed but nonsurgical treatment or surgery is impractical
Note: lntentional replantation should be considered only when there's no other alternative treatment to maintain a "strategic" tooth. Long term follow up is required to monitor for complications
including periodontal defccts and ankylosis with replacemcnt rcsorption.
Other surgical endodontic procedurcs.
. Bicuspidization: is a process in which a tooth is divided into mesial and distal halves without
removal ofany. Endodontic treatment is done and two separate crowns are fixed on both halves.
It is perfomred on mandibular molars with furcation involvement. Better stability ofthe tooth
is achieved when their roots are divergent.
. Hemisectioni is the division of a mandibular molar buccolingually into two single-rooted
tceth: the defective root is extracted. Hemisection requircs root canal therapy on all rctained
root sesments. Note: When possible, it is prefcrablc to complete the root canal trcatment and
place a pemranent restoration into the canai odlices prior to the hemisection.
. Root amputation: ref'ers to the removal ofa rcot from any molar without sectioning through
thc crown. Root amputation requires root canal therapy on all retained root segments.
. Surgical removal of the apical segment of a fractured root: performed on a tooth when a
root fractwe occurs in the apical portion and pulpal necrosis results. Note; The coronal looth segment must be restomble and functional or else this procedure is worthless.
***
The question ofwhether to replant primary teeth has been a focus of debate and controversy in the dental literaturc. However, most dental textbooks uniformly recommend that primary teeth not be replanted. Replantation ofa primary tooth is not recommended because of
the potential danger to the permanent successor from sequels of trauma fe.&, infection, anlg
losis, or damage dtrc to uqnipulqtion during procedure itselfl.
Proper management of an avulsed permanent tooth that has been replanted within two
lmportant: Ifa tooth is out ofthe mouth for more than two hours:
. Ank)"losis and external root resorption will probably result within two years. Ankylosis resulting from replacement would give a better prognosis than external resorption,
u hich
rvill
lead to failure.
. Gently curette blood clot out ofthe alveolar socket and irrigate with saline.
. Rinse tooth with saline, replant into socket, and splint for a maximum of2 weeks.
Note: Resorption is the most frequent sequela to replantation. Three different types of resorption have been identified: surface, inllammatory and replacement (qnlg'lotic resorption).
Replacement resorption refers to resorption ofthe roat surface and its substitution by bone,
resulting in ankylosis.
. Both
. Both
58
l-2012 - Dental Decks
CopFighr C
201
Coplrighl
Surface resorption
59
@
\ote: Although, intemal resorption can occur only when some of the pulp tissue is still
lital. a negative sensitivity test does not rule out this etiology. Also remember that sometimes on a radiograph, an extemal resorptive lesion can superimpose the canal space to
mimic intemal resorption. In such cases, another radiograph should be exposed at an
angle to the tooth. The radiolucent lesion inside the canal space will not shift.
Bowl-shaped areas ofresorption involving cementum and dentin characterize external inllammatory
root resorption. This type ofresorption is rapidly progressive and will continue iftreatment is not instituted. Since both a necrotic pulp and the presence ofbacteda are necessary components ofinflammatory
rcsorption, the process can be arrested by jmmediate root canal beatment. The tooth is opened and the
canal is cleaned and shaped. A calcium hydroxide paste is placed in the canal. This is replaced every
three months for one year If after one year, it appears that the resorption has stopped, a permanent root
c nal filling (gutta-percia) can be placed. A calcium hydroxide-based root canal sealer is strongly recommended.
Surface resorption is caused by acute injury to the periodontal ligament and root sulface. It is very
common, self-limiting, and reversible. Ifinjury is not repeated, healing takes place with new cementum
and PDL. Root surface resorption is limited to cementum, may heal itself, and is not radiographically visible.
Replacement resorption refers to resorption ofthe root surface and its substitution by bone, resulting
in ankylosis. Replacement absorption accompanies dentoalveolar ankylosis due to extensive hauma to
(peliodontal ligament damage).The tooth is often in infraocclusion due
the tooths aftachment
^ppafifis
to progressive submergence
with growth. There is a metallic sound on percussion.
Rememberi This is often seen in unsuccessful replant cases.
Remember the etiology ofextemal and intemal resorption:
. Erternaf resorption: periradicular inflammation, dental trauma (/erultihg in dafiage b attachhent
apparatut), excessive orthodontic forces, impacted teeth, intemal bleaching ofnon-vital teeth.
. Internal resorption: dental trauma (resulting in loss of vitalit)' and subsequent i fection), dental
caries, pulp capping with calcium hydroxide, cracked tooth.
Note: Invasive cervical resorption is a clinical term used to describe a relatively uncommon, insidious
and often aggressive form ofextemal tooth resorption. Cha.acterized by its cervical location and invasive nature, this resorptive process leads to progressive and usually destructive loss oftooth structure.
Resorption of coronal dentin and enamel often creates a clinically obvious pinkish color in the tooth
crown as highly vascular resorptive tissue becomes visible through thin residual enamel.
ImportantiThe majority ofmisdiagnoses ofresorptive defects are made between intemal root resorptions. cervical caries. and cervical resomtion.
. Lack of mobility
. Lack ofPDL on x-ray
. Pinl Appearance
. Infra-occlusion
60
Copyright O 20ll-2012 - Dcnlal Decks
. Apical scar
. Cementoma
. Traumatic bone cyst
. Globulomaxillary cyst
. Radicular cyst
. Cfuonic dental
abscess
12
- Detrtal Dcks
grofih of granulation
Replacement resorption, which accompanies dentoalveolar ankylosis resulting from extensive trauma to the attachment apparatus ofthe tooth is characterized by progressive replacement ofthe root by the bone. Note: Histologically, it shows direct contact befween
dentin and bone with no intervening PDL or cemental layer.
mobility
An apical scar is represcntcd by a periapical granuloma. cyst, or abscess that heals with scar tissuc.
Well-circumscribed radiolucency resembling a granuloma. Tooth is non-vital.
A radicular cyst usually occurs in a pre-cxisting granuloma. Scldom is painful. Radiolucency at apcx
ofnon-vital tooth.
A chronic dental abscess is often a result of a periapical granuloma. Radiolucent area at apex ofnonIital tooth. Fistula is often found leading from an abscess caviry Once drainage is establishcd, thc tooth
stops being painful. Note: A chronic periapical abscess is often the cause of a sinus tract in the gingi-
ofpulpitis. It is asymptomatic
and as-
.\ cementoma
occurs most frequently in the antrior region ofthe mandible. It starts as a radiolucent
leritrn and then calcifies. The cementoma does not affect pulp vitality. Also called periapical cemental dlsplasia.
.q, traumatic bone cyst is not a truc cyst sincc thcrc is no epithclial lining. Found mostly in young pcople. asymptomatic. Radiolucency which appears to scallop around the roots ofteeth. Teeth are usuallv
\itel.
A gfobulomaxillary cyst (developmental cys, is found at the junction of
processcs
ofthc maxilla, between thc lateral incisor and the canine roots. Teeth are vital.
is ofdcvclopmental origin arising fiom cystic degeneration ofclear cells ofthe dental lamina. Tooth is vital.
An ameloblastoma is a benign, locally aggressive tumor arising from the odontogenic ectodem.Lesions
occur as multilocular radiolucencics and frequently cause extensive root resorption. Thc mandible is affected four times more frequently than the maxilla.
A cementoblastoma is an odontogenic tumor characterized by the proliferation offunctional cementoblasts that folm a large mass ofcemennrm or cementum-like tissue on the tooth root.
. Radiopaque
Easy to manipulate
. Hydrophilic
. Biocompatible
. Not toxic
. Vild bleeding
. Pail on percussion
Coplrigh O 20ll-2012
- Dental Decks
The main ions found in MTA are calcium and phosphorus. MTA has a high pH so it induces
hard tissue formation. MTA has superior sealing ability and is not adversely affected by biood
contaminants. [t also causes only low levels of inflammation because it forms fibrous connective tissue and cementum when in contact with the pe odontium. Note: MTA is difficult
to manipulate and has a long settilg time. Despite these disadvantages, it's the material of
choice today.
A retrofif ling falso called a reverse f lling or retrograde qmalgam.filling) rs placed to seal the
apical portion ofthe root canal. This procedure is used when an apicoectomv alone will not
yield a good result. Whenever there is any chance whatsoever that an apical seal may be
faulty, a reverse filling material must be placed. For example, if the root canal appears calcified. it would be impossible to obturate most ofthe canal and get a seal. Ifjust the root apex
were cut off faplcoectoatl, the incompletely filled canal might act as a source ofreinfection.
To prevent this after the root tip is resected, the foramen is found, enlarged, and filled with a
zinc-ftee amalgam to create a seal.
An apicoectomy lro ot-end rcsection) is a procedure where the buccal tissue is flapped back,
the buccal bone about the apex is removed, the root apex is removed, and the area is curetted out. Indications for apicoectomy: l) A reverse filling needs to be placed 2) It is necessar] ro gain access to an area ofpathosis 3) The poorly filled apical portion ofthe root is to
be removed to the level ofcanal obliteration. Note: A retrograde amalgam hlling should al$ a1s be done after an apicoectomy. Teeth that have posts in them and need to be retreated are
rhe most common reason for an apicoectomy and a retrograde filling.
Remember: Periapical curettage is the same procedure as an apicoectomy (as far os fap and
remotal ofbuccal hor) but without removing the root apex. Removal and examination ofthe
diseased tissue and determination ofthe extent ofthe lesion are the objectives ofapical curetIace.
As caries entcrs thc dcntin it bcgins with a lateral sprcad al thc DEJ. This is duc 1o thc incrcascd orSanic conlcnt and
the involvcmcnt ofmany dcntinal tubulcs. Thc Tomcs fibcrs rcact, causirg fa(y dcgencnttion, thcn latcr dccalcification /.!.'/.,forrt. As caries progrcsses. destruction ofdentin is followcd by rhc bactcrial invasion ofrhe hrbules and com
plclc destruction ofdcntin. Once odontoblasts arc involvcd, pulpal changcs occur. Initially thcrc is vascrlar dilation
and local cdcma. Tlc carliesa common slmptom ofthis edema fz./rreprlrth.) is thcrmrl sensitivity (us ullr it1o?used and persistent puin on upplirution oJ rcld).
Rememberr Thc only rcliablc clinical cvidcncc thal sccondary dcntin has formcd is decreased tooth sensitivitl_
tuvnllr seen a lev vteel.s dlter place e t oIa li ing. whcn dcntinal tubulcs bccomc complctcly calcifrcd. thc dcntin
is ins.nsitivc
L Thcrmal tcsts arc cspccially valuablcwhcn thc paticnt dcsc.ibcs fic pain as dillusc. Thc cold test can
bc Lionc w irh cold r s ter bal h s, sticks of icc, thyl ch loridc, dich lorod ifluo rcnerharc / DDM , Eh.lo k e )
\trtes
pcrcha, using a rubbcr whecl mountcd on a mandrcl revolving at a polishing speed io gcncratc hcat, or a hot rvatcr bath.
3. Thc bcst mclhod to clicit a most sccurute thcrmal rcsponsc is to individually isolatc thc suspcctcd
tccth \r'ith a rubbcr dam and thcn balhc cach toolh in hol or cold water This is donc bccausc all other
mcthods mav stinulate the iooth at only onc scction ofonc surfacc.
ResDonses to thermal tests:
pulpitis
. Moderate-to-strong painful response: lingers for scvcral scconds or longer; indicalcs irreversible pulpitis
Thermal tcsls may be falsc-ncgativc in immature, recently traumatized lccth or bccausc ofpremcdicstion with an analgcsic.
5. Although the percussion test docs not indicatc thc hcalth oflhe pulp, thc scnsitivity ofthc proprioccptivc tlbcrs does reveal inflammation ofthe apical PDL.
6. A positive response to pcrcussion indicatcs not only thc prcscncc of inflammation ofthc PDL. bu!
also thc cxlcnt ofthc inflamrratorv Droccss.
,1.
64
Copyrighr O 201 I -20 l2 - Dental Decks
. CAA is asymptomatic
' CAA
is s;.rnPtomatic
65
Cop)'righr @ 201| -2012 - Denial
Dcks
A phoenix abscess is also known as a recrudescent abscess. lt develops as the granulomatous zone becomes contaminated or infected by elements from the root canal. Diagnosis
is based on the acute symptoms fparn /o perc'ussion) plus radiographic examination, which
reveals a large periapical radiolucency. Note: A phoenix abscess is always preceded by
chronic apical periodontitis. Signs and symptoms are identical to those of an acute periradicular abscess, but a radiograph will show a periapical radiolucency that indicates the
presence ofa chronic disease. Not: The term "Phoenix Abscess" is becoming obsolete.
The term replacing it seems to be "an acute exacerbation ofchronic apical periodontitis"
(yes, the delinition is no\r the term).
A granuloma is defined
tomatic.
The chronic apical abscess (also calletl suppuralire apical periodonltlr,/ is somctimes so painlcss that it nray
go undetected for years until revealed by an x-ray. It is a long-standing, low-grade infection ofthe periapical
bone with the root canal bing the source ofthe inf'ection. This condition may follow an acule alveolar abscess
or unsatisfactory root canal lherapy. Radiographs will reveal a diffusc radiolucency and PDL thickening. The
tooth may be slighlly loose or tender to percussion. The chronic absccss may be differentitted fiom cysts and
granulomas by the tact thatboth cysts andgranulomas have 1,ell'defincd radiolucencics associated with them.
lrtic.fs
svmproms
*,ill
subsidc.
.lfa
plthway is needed in soft tissues with localized fluctuant swelling that can provide necessary drainage.
\ote:
It should be emphasized that, rhenever possible, lhe acute periapical abscess should be incised and
drained through the root canal system.
. When pain is caused by thc accunrulatjon ofexudat in tissues.
. wren it is necessary to obtain a cultr:re ofthc cxudatc
Apical trep hin ation is accorr pl ished by aggress ively p lacing a No. I 5 to 2 5 K-fi lc bcyond the confincs of the
apex. Surgical trephination is a perforation of thc alveolar cortical bone to release accumulatcd tissue exudates. A small /J-lr/r/ horizontal inc ision is made with a No- I 5 scapel bl ade at ihe I e! el sl ightly apical to the
root apex. ANo. 6 or 8 round bur is uscd on a stmight handpiece to penetrate the conical plate above the root
apex. Iftherc is diffusc swclling f.e11 /irrt, antibiotics are usually indicated.
. Eventually the
acute nature
lesion
has been there for years and the tooth needs treatment immediately
55
Coprighl C201l-2012 - De alDecks
. EPT
. Cold test
. Heat test
67
coptriglt
@ 201
Osteomyelitis is not a particularly common disease. It is a serious sequela of periapical infection that often results in a diffuse spread of infection throughout the medullary
spaces, with subsequent necrosis ofa variable amount ofbone.
Acute or subacute osteomyelitis may involve either the maxilla or the mandible. In the
maxilla, the disease usually remains fairly wellJocalized to the area of initial infection.
In the mandible, bone involvement tends to be more diffuse and widespread.
Clinically, the person afllicted with acute osteomyelitis is usually in rather severe pain
and manifests an elevation of temperature with regional lymphadenopathy. The teeth in
the area of involvement are loose and sore so that eating is difficult, if not irnpossible.
Note: Another clinical symptom ofacute osteomyelitis is leukocytosis, an elevated number of white cells in the blood.
Radiographically, acute osteomyelitis progresses rapidly and demonstrates little radiographic evidence of its presence until the disease has developed for at least one to two
u eeks. At that time, diffuse lytic changes in the bone begin to appear Note: A "motheaten" radiolucent aooearance is evident.
The general principles of treatment demand that drainage be established and maintained and that the infection be fteated with antibiotics to prevent further spread and complications.
***
The tooth
Ofall
the denral abscesses. the periapical is the most common t?e. It is a localized colleclion ofpus in thc
alveolar bone at the root apex following death ofthe pulp with extension ofthe infection into the periapical
tissue. The first symptom may be a slight tendemess ofth(r tooth. This later develops into a severe throbbing
pair. (ac te abscess) with swelling ofthe overlying mucosa. Reducing thc irrilant, reduction ofprcssurc. or
thc removal ofthe inflamed pulp is the immediate goal. Ofthese, pressure relcase is the most effective in re-
lie\ ing the patient's pain. Emergency treatment includes establishingdqinage (ideall! throlryh the cana[)
and prescribing antibiotics lonlv il indicated hv s)'stemic signs dnd elewted tenlrera ture ) and ni alges ics. This
!\ ill relie\ e ihe acute symptoms followed by conventional endodonric thcrapy at a latcr datc. Note: Complete
cleaning and shaping ofthe root canals is the preferred treatment. Horvever, iffor some reason this is not pos:ible. a pulporomv is usually effective in the absence ofpcrcussion sensitivity.
objecti\
e is the
\ote: For endodontic infections that do not respond to penicillin VK, clindamycin is olien recommended. It
produces high blood levels and is eflective against anaerobic bacteria but must be used with caution bccause
of the polenlral for p.cudomembranou. colrtis.
:Nol3*'
'
,-
l. A history ofpre-opcrative pain and s*'eiling is the best predictor of interappointment cmcrgencres.
2. No relationship exists between flare-ups and treatment procedures /i.e.. rirgle ormultiple|isperiodontal abscess is an acute abscess lhat devclops through thc periodontal pocket. Alveolar bone loss, pocket formation and pe odontal pathologic conditions are suggestive ofthe periodontal abscess. The tooth \rill usually be palpation and percussion positive. lt will respond to the
electric pulp tester frrlike the periapical abscert. Bactria associated with this abscess include
gftm-negative rods sucb as Capnocytophaga species, Vibrio-corroding organisms and Fusobaclenum spccles,
4. The gingival abscss is a relative rarity rhat occurs whn the bacteria iDvade through some
break in th gingival surface. Such abrasions may be the result ofmastication, oral hygien proccdurcs. or dcntal trcalmcnt.
3. The
. Reversible pulpitis
. Irreversible pulpitis
68
Cop}'ighr
r'\. A
.
\')
20l
l'2012'
Dntal Decks
central incisor
with a complaint thrt tooth #8 is
draining pus into his mouth, The tooth had been traumrtized earlien
The vitality tesh reved no response. What is the treatment ofchoice?
seven year old boy arrives at the ollice
. Extraction
. Apexogenesis / pulpotomy
. Root canal treatment
is only necessary to give the child analgesics and antibiotics for pain and infection
. Apexification
69
CoplriShr O 20ll-2012 - Dental Dcks
The severity ofthe clinical symptoms will vary as the inflammatory response increases. Pain $ ill vary liom a
mild and readily tolerated discomfort to a severe, throbbing and excruciating pain. The pain is spontaneous!
unprovoked! and is intrmittent or continuous in naturc. Thc pain lingers after the removal ofthe irritant.
The pain is usually not readily localized by the patient but is difuse in character Lying down or bcnding over
intensifies the pain ofineversible pulpitis because the overall increase in cephalic blood pressure is relayed to
thc confined pulp tissue. The tooth may be tenderto percussion, heat may intensit the pain response while cold
m y relieve it (in ad|anced s/dgerl. Usually they both will cause severe and lasring pain. Thc radiographs will
usually disclose no periapical patholog!. Treatment is root canaltherapy. Note: In cases ofirrevrsible pulpitis, an acutcly inflamed pulp is symptomatic whercas a chronically inflnmed pulp is rs) mptomatic in most
cases. The end result is necrosis ofthe pulp.
often
Relersible pulpitis /h\'percniaI the pain associated with hlperemia does not occur spontaneously.
I1 requires an extemal irritant to evoke a painful response /i.{,., .o/d. srt?ctr). Thc pains are sharp and ofbrief duration. ceasing \\'hen the irrilant is removed. Radiographs appear normtl lnat'shov,deep caries or catiq
/,r1'l,1,"drirr. The tooth is usuirlly percussion negativc. In thcrmal tests. the pulp rcsponds more readily to cold
itrmuli fian to hot 1t respo se laaws shortlv after rcnotal olthe stirrrlfur). Treatment usually is a seda-
\otei
therapv is instituted.
The action of calcium hydroxide in promoting formation ofa hard substance at the apex is
best erplained by the fact that calcium hydroxide creates an alkaline environment that prornoles hard tissue deposition. Note: Its high pH (pH-12.5) also causes an antibacterial ellect
\ote: Ifa
permanent tooth fractures and has a fully formed root and the pulp is exposerJ, (large
erpasure). the ffeatment of choice is complete root canal therapy. Apexification is not
needed because the root is fully fonned. lf the exposure is small and the length of time is
short ( I /2 hour to I hour), then a direct pulp cap with CaOH lbllowed by a restoration is the
ireatment (|fchoice.
Remember: Apexogenesis is the process of maintaining pulp vitality during pulp treatment
to allow continued development of the entire root. As opposed to apexification, this procedure relates to teeth with retained viable pulp tissue in which this pulp tissue rs protected,
treated, or encounged to permit the process ofnormal root maturation.
. Transplanted teeth with partial root development have a better prognosis than those
with developed roots
. Orthodontic extrusion
70
Coptaighr O 20ll-2012 - Dental Dcks
if it can be un-
dertaken.
Transplantation is the transfer ofa tooth from one alveolar socket to another either in the
same person or in another person.
Crown lengthening is a procedure used to apically position the gingival margin and./or
to reduce the cervical bone. It is employed during the treatment of subgingival caries,
perforations and resorption.
Root submersion involves resection of tooth roots 3 mm below the alveolar crest. The
coronal portion ofthe tooth is removed and the roots are covered with a mucoperiosteal
flap. Indications include rampant caries, adverse periodontal conditions and in cases that
have had repeated prosthetic failures. The submerged roots will prevent alveolar resorption and maintain better proprioception. This is especially useful in medically compromised or handicapped patients requiring better denture control- Sometimes, this is also
done to avoid formation of an esthetic defect that may result after extraction.