Our lecture today about endodontic material and bleaching systems , In terms of definition its the science that

deals whatever concern root canal system in terms of morphology, physiology ,treatment and pathology of the dental pulp and periradicular tissue ( tissues around the root ) . the dental material can be used to treat the pulp in case of injury during cavity preparation , to remove the pulp tissue from the root canal , to clean the canal system and then place any sort of medication and fill it . Now Why do we need root canal treatment : -Clean the canal properly - establish Apical seal so that the bacteria wont be able to go in again and cause an infection
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establish Coronal seal so there will be no any leakage on the coronal part and on the apical part of the tooth and this is done by proper cleaning and removing the disease tissue and then placing either a coronal restoration or a restoration at the root canal ( should be no empty spaces inside the tooth ) .

slide 3 pic : this is a lower molar . we dont have just one straight canal , there ll be some small lateral ( accessory ) canals .

now we enter to the pulp , in some cases the pulp ll be exposed because of : - Caries ( deep caries ) -During cavity preparation -Trauma and fracture Now Two procedures can be done either : - Indirect pulp capping : in this way the caries usually very deep as a dentist you remove caries but there is a remaining discolored layer will stay and its hard not soft , if you remove it the pulp ll be exposed , so we can leave it since its hard( not active ) and we put some medications on the top of it ( liner or base ), so if there is any bacteria it wont be allowed to have any nutrition then it will die and the caries ll stop . Now the success depend on sealing the cavity very well by a good permanent restoration with no micro leakage if there is micro leakage the food , saliva will go in and the bacteria will get access to it , the bacteria ll become active and the caries start to occur and youll have a current caries and this ll lead to expose the pulp and must do RCT , and seal the pulp and save its vitality is better than doing RCT . And this procedure it can be succeed or not . Now the figures in slide 6 : this is an example of a deep carious cavity in a lower molar , the dentist have removed most of the caries and leave the discolored layer on the pulpal floor ( not all the walls , the walls should be clean especially the DEJ walls because if there is any caries at this area it ll spread very quickly and recurrent caries ll occur ). So usually we start cleaning the walls and then go to the pulpal floor or axial wall .

So we remove most of the carious lesion and leave that discolored layer and then we put calcium hydroxide as a liner because of its properties ( its alkaline ph so it can kill the bacteria ) . but even we place other liners (like RMGIC and ZOU) the important thing that we care about is inhibiting the nutrient from reaching the bacteria. So there is other liners but traditionally we use calcium hydroxide . Now after that the cavity was restored with composite not temporary filling because it wont provide a good seal like permanent filling ( its weaker and more voids inside it ) . Using bonding agent isnt really preferable because we need to do acid itching before it and doing acid itching near the pulp can cause irritation to the pulp. So its indirect because we dont expose the pulpal tissue . - Direct pulp capping : here caries is deep and we excavate all caries both on the wall and the floor and after that we notice a pin point pulp exposure ( very small ). So when we do direct method we should have very small pulpal exposure , no blood is coming from the exposure place because if bleeding is continuous this is mean the pulp is inflamed , then we should do RCT . and we should have clean environment a round it so we always start with cleaning the walls then the floor then exposure occur and we need to isolate the area Completely by suction, cotton nodes should be no saliva at all , then we do pulp capping . In this procedure we need to disinfect the area first by using sodium hypochlorite on a small cotton pellet and put it for 2 min , then we need to dry it with another cotton pellet , then we put calcium hydroxide which ll kill any bacteria and it ll stimulate calcified tissue formation to close the exposure place like a wall and isolate it from the cavity and thats what we want . After we place a calcium hydroxide we need to put another liner or base to protect it because its a weak material then permanent filling . To success we should follow these steps .

Figures in slide 9 : a trauma cause incisal fracture and pulp exposure ( the red line ) , now if the patient is a young so the there is a good chance to heal ( more than mature tooth) so we need just to cap the pulp although its not a pin point exposure . the material that well use should kill the bacteria , stimulate hard tissue formation , shouldnt have any harm effect on the pulp and protect the pulp from bacteria . Now failure of direct pulp capping can occur if there is chronic inflammation of the pulp , pulpal blood clot (prevent contact between cement and healthy pulpal tissue, Restoration failure ( break off ) so there will be a gaps so in these cases we need to go through RCT. Now once you removed the pulpal tissue from the coronal part and root canal you need to clean the canal before you place any filling inside . when we do a regular cavity (class 1 or 2 ) we clean it by 3 in one syringe air and water , or by cotton pellet. But in case of canals we cant access to it so we need to irrigate it by certain materials and the instrument that we use is a syringe with a needle attach to it , we insert it to apart of the canal and flush it by the irrigant of choice . the irrigation is important to disinfection and remove the deprees . The irrigant should be : -Able to dissolve and disturb debris -Non toxic -Low surface tension which means able to spread in the surface of the canal ( dentin) -Able to lubricate -Able to sterilize -Able to remove smear layer We cant find all of these properties in one material but the irrigant of choice usually is sodium hypochlorite 2-10% .

Disadvantage: irritant material if in contact with living tissue , so we need to use it carefully and isolate the tooth from the rest of the cavity so its tissue wont become in contact with this irrigant material ( its used only inside the canal by the needle ). We can use another irrigant called chlorhexidine gluconate 0.2% its a mouth wash and antibacterial . Another solution that we can use is called EDTA (ethylene diamine tetra acetic acid): maybe used as a lubricant , and this solution can solve (capture) Ca( inorganic depree) , so if the canal is obstructed by a calcified material due to continuous irritation by inflamed pulp we can use this irrigant . Ideally we should use sodium hypochlorite throughout RCT without water or any thing else. If you dont have enough time to finish your treatment and you need to send the patient to home with temporary filling , you ll use some sort of medication to prevent the infection(Intracanal medicaments) like : -Paramonochlorophenol (PMCP): no clinical indication for itsuse. Acts as a disinfectant -Non-setting calcium hydroxide: high pH. Induces closure of apex (in immature teeth) and arrests root resorption -Poly-antimicrobial pasts: mixture of steroids, tetracycline, sulphonamide And the most useful one and we use it between visits is Non setting calcium hydroxide , we need it non setting because if it set it ll close the canal . it has the same properties of regular calicium hydroxide ( alkaline ph , anti bacterial and stimulate hard tissue formation at the apex , like in young patient the apex isnt closed yet we use it to close it , but in adults apex was closed we use it mainly for anti bacterial and alkaline ph ) .

We apply it by asyringe with disposable tip or we can use a special instrument that called file to fill up the canal . next visit we remove by simple irrigating be Na hypochlorite . Now root canals is ready to filling and we use certain material to this . previously they use : -Silver: corrosion, cannot be adapted well, hard to retrieve( because sometimes the filling could fail and we need to retrieve it) and staining the teeth . -Amalgam: technically hard, retreatment is hard -Medicated pastes: antibacterial Paraformaldehyde based: sets hard, toxic Iodoform based: resorbable Because of these disadvantages these materials are replaced by Contemporary material: -Gutta percha -Polyester resin Now Gutta percha : The most commonly used and it contain rubber Zinc oxide as a filler to make it stronger Metal salts for radiopacity ( to see it in radiograph to tell this is good filling or not inside the root) Wax or resin as plasticizer to make it flexable Antioxidants to prevent brittleness Now Handling characteristics and properties: -Thermoplastic material softens at 60-65C and melts at 100C , when its cold its like rubber and when we heat it its like a paste so we can use it cold or heated. -Oxidizes upon exposure to light and hardens we cant use it by this. -Dissolved in chloroform to remove it .

-Maybe disinfected by Na Hypochlorite -Solvents such as acetone may cause it to swell then as the solvent evaporates GP shrinks which ll cause space around it . -No chemical bond with dentine Its shape similar to the shape of the canal like a cone , and different sizes are a valuable . we use a finger spreader ( slide 19) to condense it one by one (GP then condense then GP ) inside the root canal ( for lateral condensation not vertical) . we know its full by dont find any space to condense . when its cold or hot we ll have different structures : -Cold packing (-phase GP): GP points (cold lateral condensation technique) -Thermal packing (-phase GP): Softening a material prior to insertion Heat application on GP after insertion then condensation Available systems: Thermafil (plastic carrier), Obtura (injection gun) Heat maybe applied using a rotary instrument, clockwise rotation next to GP in canal Now if you inject melted GP by using a gun we ll call the system obtura . another sys to inject heated GP is thermafil which ll make It soft by putting it In oven then place it in the canal . so obtura melts GP and thermafil soften it . Another material like GP is Polyester resin: based on thermoplastic synthetic polyester , barium sulphate, bismuth chlorate, bioactive glass (claimed to release calcium and phosphate inducing bone growth) ( doctor said this component not for memorization ). This material is available for

cold and hot applications. It has similar properties to GP but different composition and its based on resin . We said these material cant bond chemically to dentin so if we put it alone well have a lot of voids , so we need something to close these voids between GP itself and GP and the wall of the root . this material is a sealer : its a paste that we use to seal any voids or spaces , and it should have the following properties : Easy to use Good seal Free of air bubbles, homogenous when mixed Flow to thin film thickness Insoluble Biocompatible Radiopaque slow setting time and long working time some of these sealers are based on : Zinc oxide eugenol Resins Calcium hydroxide cements (sealapex) Glass ionomer cements Polydimethyl siloxane Now Zinc oxide-eugenol-based cements Three formulations available: -Rickets (silver caused discoloration): 15 minute working time, good flow, but has thick film

-Grossman (contains barium for radiopacity instead of silver): 1 hour working time, good flow, lower solubility -Tubliseal (paste-paste system to produce smooth mix): low film thickness, good flow, 20 minutes working time Its paste and catalyst we mix them until we have a homogenous color then we use them in root canal filling

Calcium hydroxide-containing cements : its very famous but it was widely replaced by resin material . the proplem in calcium hydroxide its soluble so it washes out easily 2 paste system, base and catalyst ( famous product seal apex ) Long working time Antibacterial and alkaline Biocompatible Can induce hard tissue formation Disadvantage: high solubility

Resins : it has low solubility compared to GIC and calicium hydroxide System available: Commercial systems: AH plus, 2 paste system: (long working time, better flow & film thickness, low solubility ), based on previous product Ah 26 its the first product and the disadvantage of it is it release formaldehyde which is toxic material but the AH plus is better because it doesnt have formaldehyde.

ADSEAL Excellent : biocompatibility, Easy to dispense and mix, insoluble in tissue fluids and it has one container not two Problem: silver content, shrinkage (depends on the product) Newer products may be silver free with minimal shrinkage

Glass ionomer sealants New formulation have filler sizes < 25 m to improve handling and add radiopacity Advantages: Bonds to enamel and dentine Low shrinkage Disadvantages: Short working time Difficulty in re-treatment ( set very hard )

Polydimethyl siloxane Composition: Polydimethyl siloxane Paraffin oil Silicon oil Zirconium dioxide Advantages: insoluble, dimensionally stable, biocompatible

Disadvantages: dose not bond o dentine, no antibacterial ability

Material for root canal repair and peri-radicular surgery MTA: Mineral trioxide aggregate, it is highly alkaline, sets when exposed to water. Its better than calicium hydroxide because it has lower solubility but its expensive material . When exposed to water, setting reaction starts, material remains plastic for some time which facilitates insertion for repair or root end filling material. Final setting occurs when the material crystallizes to form a hard mass with slight expansion Characteristics: induces cementogenesis, antimicrobial, biocompatible Slide 37 : an example of a material that is called pro root , its grey and some versions are white .

Post and core systems : if we want to do a post and core restorations we must have good RCT because you want something to make apical seal to prevent infection To restore endodontically treated-badly broken don teeth. Post system provides support and retention for the coronal restoration Desirable properties: Maximum retention with minimal preparation Aesthetically acceptable Post is retrievable Post can transfer stress to remaining tooth structure

Types of post systems ( the dr said that we talked about them in metals lec) Prefabricated (core is made from composite, amalgam, GIC, etc.): Metal posts Fiber reinforced resin posts Ceramic posts: esthetic, strong, tough, rely on mechanical retention Cast posts

Fiber reinforced resin post Two types: Carbon fiber reinforced ( stained black, unaesthetic) Glass fiber reinforced its better choice These posts may allow even stress distribution and reduce chance of tooth fracture Teeth bleaching ( whitening) : it ll break up the stains and allow it to dissolve and get out from enamel and dentin How bleaching works: bleaching agent (hydrogen peroxide or nonperoxide agents) penetrate enamel and reach dentine then oxidizes pigments and lightens tooth color. This action is enhanced by low intensity heat or high intensity light. Composition Hydrogen peroxide, carbamide peroxide, urea peroxide

Non-hydrogen peroxide system containing: Sodium chloride Oxygen Natrium fluoride Additives such as potassium nitrate and fluoride to reduce sensitivity Types of stains Many things can cause staining and some of these staining : Intrinsic (medication like tetracycline as we know-, trauma, disease conditions during or after tooth development) Extrinsic: coffee, tea, tobacco ( easier to treat than intrinsic ) Combination The materials that we use in bleaching are based on H2O2 ( hydrogen peroxide ) and in different percentage . the problem with H2O2 is its irritant and it can cause burning so we need to isolate the teeth and protect the gingiva , mucosa , palate . and it can cause : Sensitivity Irritation of the gingiva Soreness of the muscles of mastication from wearing night guards overnight Roughness of composite restoration surfaces *** But its temporary and after a period the patient ll have a nice teeth . ***the doctor didnt talk about these two slides : Bleaching of vital teeth: -35% hydrogen peroxide liquid + heat: time consuming for multiple teeth and technique sensitive -Powder and liquid system: hydrogen peroxide liquid + powder containing light/ chemical activators -35% carbamide peroxide gel system: better control than liquid system

Bleaching of non-vital teeth: staining maybe caused due to necrotic breakdown products of the pulp, or hemoglobin from blood in the pulp. -Bleaching is done internally through the access cavity -Bleaching solution: 30% hydrogen peroxide on a saturated cotton pellet in pulp chamber then activated by a heating instrument -Walking bleach: sodium peroxyborate paste or gel mixed with hydrogen peroxide then placed in access cavity.

So it can cause sensitivity, but it's temporary, later on it's going to subside. So this is a picture of before and after:

Another material which can be used which is a version of hydrogen peroxide which is called carbamide peroxide, now the difference is: hydrogen peroxide is used by you as a dentist in the clinic, because you cannot give it to the patient to use it by himself, while carbamide peroxide is a like a gel material that is available in home bleaching kits, which means that the person can use it on his own at home, so he can place it using a tray on his upper and lower teeth, once it's broken down it's going to release hydrogen peroxide in small percentages, so it will not cause a lot of irritation, it's manageable by the patient himself, but pure hydrogen peroxide (35%) must be used only be used by the dentist because it needs careful control. Now other systems have been suggested and they don't contain hydrogen peroxide (but they are not use commonly) and they contain: (sodium chloride, oxygen, natrium fluoride). Some additives are add to hydrogen peroxide paste or gel to minimize sensitivity and irritation like fluoride and potassium nitrate, so some companies add them to minimize the side effects. Types of stains Stains can be Intrinsic (medication, trauma, disease conditions during or after tooth development) or Extrinsic (coffee, tea, tobacco) or combination of both.

These was pictures extrinsic stained teeth, now after the bleaching if the patient get back to the cause of the staining again (like smoking) the teeth will be stained again, so after bleaching the teeth need high maintenance, so we should minimize intake of coffee, tea and smoking, because all of these stain teeth very easily. (I already said that the bleaching can be activated by heat using warm instrument or by light (makes the process quicker) so they place the gel then they use the light to activate the material, and all of this should be done after isolation, which can be done by Vaseline to protect the gingiva) So the type of bleaching that I talked about earlier is called vital tooth bleaching (the teeth are vital): 35% hydrogen peroxide liquid + heat: time consuming for multiple teeth and technique sensitive. Powder and liquid system: hydrogen peroxide liquid + powder containing light/ chemical activators.

35% carbamide peroxide gel system: better control than liquid system.

Now there's another type of bleaching that's the non-vital teeth bleaching (for root canal treated teeth that have stained with time), staining maybe caused due to: Necrotic breakdown products of the pulp, bacteria, dead tissue. Hemoglobin from blood in the pulp.

 If you don't remove gatta perca from the coronal part of the tooth it can cause staining with time. So all of these can be remove and then bleaching is done internally through the access cavity, for a week or two weeks until the teeth become lighter in color and then it's removed and permanent filling is placed. Bleaching solution: 30% hydrogen peroxide on a saturated cotton pellet in pulp chamber then activated by a heating instrument Walking bleach (for non-vital, they call it so cause after you place the bleaching agent and the temporary filling the patient walks away for the clinic) : sodium peroxyborate paste or gel mixed with hydrogen peroxide (or sometimes with water) to form a paste that is placed in access cavity and then close by temporary filling until the patient is happy with the shade, or if it's not enough (because hydrogen peroxide after some time become inactive) then we remove the filling and place another amount of the bleaching agent and close it again until we get the proper shade. One of side effect of walking bleaching is cervical resorption (and root resorption), because you are placing the bleaching in the pulp chamber, close to the cervical area of the tooth, and that occurs if you don't take care of the percentage of the hydrogen peroxide that you are using.

so this is an example of a discolored tooth (it was necrotic) and it became grayish in color, and it can be treated with bleaching. Home bleaching Chemical used 10-16% (20% is also available) carbamide peroxideat a near neutral pH in a viscous gel. Composition: Carbamide peroxide: hydrogen peroxide + urea. Gel: propylene glycol or glycerin. Carbopol: thickener. Flavoring agents. It can cause temporary sensitivity.

So it's provided as kit that you buy, these syringes contain the gel, and there is a tray here either with the kit or you need to go to dentist and he'll take an impression to make a tray for you then you put the gel inside the tray and wear it. Duration of treatment 30 minutes twice daily-overnight: or maybe for 1 hour or 2 hours or overnight depending on how quickly you wants that results 2 (maybe 3) weeks depending on results.

The choice of the percentage of bleaching (10% or 20% or whatever) can be determined be the sensitivity of the patient, so if a patient came and said that he has sensitive teeth then you'll choose 10% to minimize side effects, and vice versa. Other products named as over-the-counter products like Crest white strips (or whitening tooth paste) worn for 30 minutes twice that contain 5.3% hydrogen peroxide. Home bleaching products containing preformed trays or thermoplastic trays heated in water then shaped on the dental arch (10% carbamide peroxide). The most difficult area is the cervical area because it's usually the yellowish part of the tooth, so the patient need to be careful that when he place the gel to cover the entire labial surface. The cause of staining is different like aging (tertiary dentine) smoking, genetic, tetracycline, most of them can be resolved with bleaching.

Side effects of bleaching:

Sensitivity. Irritation of the gingiva. Soreness of the muscles of mastication from wearing night guards overnight. Roughness of composite restoration surfaces.

Contraindications for bleaching:

Allergy to bleaching agent. Patients with very sensitive teeth. Patients with multiple composites who do not wish to replace them.

So before the bleaching you need to examine the patient, tell him about the cost, about the consequences and the side effects.

Restorative considerations Before bleaching: Carious teeth should be restored Leaky and bad restorations replaced because it'll cause damage. After bleaching: Esthetic restorations (composite and veneers) may need to be replaced but after 2 weeks period is for teeth color to stabilize, because teeth after bleaching will be white, and after 2 weeks the shade will slightly become darker and stabilize, and also that's why when we bleach the teeth we bleach to a higher degree than that we want because it will slightly darken afterward.

Forgive us if there is any mistake Best wishes for all Done by : Yahya al Omary Ammar al Dawoodyeh