Endodontics Chapter 54 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

Dental Specialties Preassessment  What specialty deals with injuries and diseases of the nerve tissues of the teeth? List as many causes of nerve tissue damage as you can think of? List as many registry functions you can think of that would be frequently performed in this type of office? State the proper name of the dentist who specializes in treatment of nerve injury. Give a lay term for this treatment. Write a short paragraph stating what you already know about this specialty.  

Endodontics defined: Endodontics is the specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the periradicular tissues surrounding the root of the tooth. General dentists are able to perform endodontic treatment. Endodontists have 3 years of continued training in endodontics. What is another name for endodontics? What is the name for the specialist who deals with the diseases of the pulp? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3

How can pulpal tissue be damaged? Decay Trauma Mechanical irritation Idiopathic Mechanical injury Avulsed Radiation Symptoms: pain on occlusion, pain during mastication, sensitivity to temperature, and facial swelling Who has had a root canal? What was the source of the nerve damage? What were the symptoms? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4

How can pulpal tissue be damaged? Here is a picture of living pulp tissue extending out from a broken tooth. This is the artery, vein & nerve which is what extends down the root of the tooth. This is what is removed during a root canal, also known as endodontic therapy.

Define Pulpitis? Inflammation of pulpal tissues Two types of pulpitis: Reversible Pulpal tissue is vital (alive) but inflamed, the tissue may be able to heal itself Irreversible Pulpal tissue is non-vital (dead) (necrotic) Tissue can not heal itself

Signs and Symptoms of Irreversible Pulpitis Percussion sensitive Palpation sensitive Extreme heat sensitivity Mobility Discoloration Pain during mastication Facial swelling X-ray pathology Symptoms differ from patient to patient. Other symptoms include a dull ache in a tooth that lasts over a period of time. How would we put these symptoms in lay terms? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7

Diagnostic tests to determine pulpal damage Subjective examination (patients perception) Chief complaint Character and duration of pain Painful stimuli Sensitivity to biting and pressure Objective examination (Doctor’s gathering) Extent of decay Periodontal conditions Extensive restoration Tooth mobility Swelling or discoloration Pulp exposure The subjective examination includes an evaluation of all symptoms the patient describes. All symptoms should be documented in the patient’s chart. What may be a patient’s chief complaint? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8

Fig. 54-1 Radiograph showing extensive decay into the pulp Fig. 54-1 Radiograph showing extensive decay into the pulp. (From Johnson W: Color atlas of endodontics, StLouis, 2002, Saunders.) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9

Fig. 54-2 Radiograph of a necrotic tooth resulting from trauma Fig. 54-2 Radiograph of a necrotic tooth resulting from trauma. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.) What can we see on this radiograph? Which teeth are involved? What was the probable cause of pulpal damage? What may be the No. 1 symptom this patient is experiencing? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10

Tests to determine pulpal damage Percussion (tapping) Palpating buccal vestibule area Heat test Cold test Electronic pulp test (vitalometer) Radiograph The objective examination includes all findings by the dentist in the oral cavity. All findings must be documented in the patient’s chart. Control tooth: What is it? How is it selected? Students: If tooth 14 is hurting, which tooth would be the control tooth? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11

Fig. 54-3 Percussion test. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.) Which tooth is the dentist testing? Which tooth would be the control tooth? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12

Fig. 54-4 Palpation test. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.) Which area is the dentist palpating? What is the dentist looking for? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13

Fig. 54-5 Ice used for testing thermal sensitivity Fig. 54-5 Ice used for testing thermal sensitivity. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders.) Ice is applied to the cervical area of the tooth only. What would be the control tooth for this photograph? All findings must be documented in the patient’s chart. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14

Procedure 54-1 Placement of a pulp tester. All findings must be documented in the patient’s chart. Explain to patient that he or she may feel a tingling or warm sensation during this test. Toothpaste is used as a conductor. Testing should only be done on the facial surface of the cervical third of the tooth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15

Endodontic Procedures Pulp capping Direct pulp capping Small exposure of pulp An attempt to allow the pulp tissue to heal A medication (calcium hydroxide) is placed directly on top of exposure Indirect pulp capping Thin layer of dentin still present (but blushing) To promote pulpal healing and build up 2˚ dentin A medication (calcium hydroxide) is placed on over the blushing dentin

Pulp Capping

Endodontic Procedures Pulpotomy Removal of pulpal tissue in the coronal portion of the tooth leaving vital tissue in roots Done regularly on primary teeth 1st phase of pulpectomy Pulpectomy AKA Root Canal Treatment Complete removal of dental pulp

Pulpotomy

Pulpectomy

Sequence of a Pulpectomy Access Extirpation Debridement Obturation Close

Access Gaining entry to the pulpal chamber

Extirpation Removal of pulp tissue: removed diseased pulp issue.

Debridement Clean and shape the canal Locate the apex or bottom portion of the canal In the debridement step, the dentist will use a variety of instruments, irrigants like Sodium Hypochlorite. To find working length, the dentist will put a hand file in the canal, set the stopper at the cusp of the tooth, and take an x-ray. The comparison of the x-ray with the known length of the file will allow the dentist to determine the working length. At the apex, or bottom of the tooth, the canal narrows.

Debridement Drying - Remove all moisture from the canal During and after cleaning and shaping the canal in the debridement step, the funnel shaped canal space is flooded with an irrigant to ease removal of the contents. This is done with paper points. The dentist places one or more paper point in the canal and uses them to absorb all the moisture. This continues until the last paper point comes back dry.

Obturation Fill the canal to avoid bacterial growth The obturation or filling of the canal is done with gutta-percha. Gutta-percha is a very bio-compatible material. It is pink, firm, waxy and somewhat rubbery.

Close A temporary filling is placed to close the opening. The temporary filling will be removed by your before the tooth is restored and prepared for a crown..

Common numbers of pulp canals: Incisors: 1 Canines: 1 Premolars: 1 or 2 Molars: 3 to 5

Endodontic Instruments What is used to remove tissue and debris remaining in pulp chamber? Endodontic excavator What is used to locate the orifice of the canals? Endodontic explorer What is used to remove bulk pieces of pulpal tissue from canals? Barbed broach What is used to enlarge opening of orifice before using files? Gates Glidden burs

Determining working length of canal: What is used to determine length of root canal? Instrument of known length with stopper Preoperative film as a reference X-ray taken with instrument in canal to compare length Millimeter ruler What is another tool used to confirm length of root canal? Apex locator Instrument with stopper

Debridement Instruments What is used to shape and cleanse nerve canals prior to filling with GP? Initial debridement: K-files Enlargement of canal: Hedstrom Cut and enlarge canals: Reamer What is used to remove debris and prevent blockages from forming during debridement? Irrigation serves as a disinfectant and solvent within the canal Irrigation solution using a Luer-lock (lok) syringe Sodium hypochlorite Hydrogen peroxide Parachlorophenol –(par″ah-klo″ro-fe´nol)

Obturation Instruments What is used to remove moisture from canal prior to closing or fitting GP? Paper points/ cotton pliers (locking) What is used fill canal permanently? Gutta Percha What instrument is used to adapt GP into the canal vertically? Endodontic spreader What instrument is used to condense GP into the canal horizontally? Endodontic plugger What instruments can be used to coat the internal walls of the canal with sealer prior to filling the canal with GP? Paper points, GP, lentulo spiral

Obturation instruments What is used to remove heated gutta percha? Glick 1 What is used in addition to gutta percha cones to fill canal? Softened, flowable gutta percha What is used to heat the instrument or gutta percha in order to remove the excess? Touch n Heat Flame

Closing Instruments What is used to place material in tooth prior to final restorative work? Plastic filling instrument (Woodson) What materials can be used as temporary fillings? ZOE Cavit

Temporary Restoration Purpose: A short term material placed to seal an opening in a tooth Filling placed to sedate a hyperemic pulp Equipment: Basic set up Plastic instrument Cement spatula Cotton pellets/ cotton tipped applicators/ gauze Articulating paper/ forceps IRM/ ZOE/ glass slab/ paper pad Cavit

Extensive Endodontic Ailments and Procedures Fistula Abnormal tract, leading from a pathologic cavity to the surface Example: drainage tract from a periapical abscess to the surface of mucosa Appears like a blister on the tissue

Extensive Endodontic Ailments and Procedures Periapical abscess Progression of a periapical infection into the bone Localized collection of exudate (pus) All tissue in area is destroyed Osteomyelitis Progression of periapical infection into the bone

Extensive Endodontic Ailments and Procedures Apexification Induced root development or apical closure by hard tissue deposition on a non-vital tooth Apexigenesis Treatment of vital pulp to continue development

Extensive Endodontic Ailments and Procedures Hemisection Complete sectioning through the crown of a tooth through furcation region

Extensive Endodontic Ailments and Procedures Root amputation Removal of a root of a multi-rooted tooth

Extensive Endodontic Ailments and Procedures Apicoectomy Surgical removal of apex or apical portion of root; alternative when conventional root canal fails Apical curettage Removal of infected tissue in the periapical area without removal of root tip Incise and drain Cutting a fluctuant mucosal lesion to allow for the release of pressure and drainage of fluid exudate

Retrograde Restoration This procedure is undertaken when an apical seal is not adequate. A small class I preparation is made at the apex and sealed with filling materials such as gutta-percha, amalgam, or composite. Used in conjunction with apicoectomy, apical curettage, or both. Commonly referred to as “root-end filling.” Amalgam is most commonly used filling material. Why would this procedure be done by an endodontist rather than a general dentist? Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42

Endodontic terms Pulpal hyperemia Recapitulaton Excessive blood in the pulpal tissue Reaction to inflammation and irritation Recapitulaton Procedure used during debridement of root canal To repeat; using smaller file to confirm that there are no blockages within the canal Going from larger to smaller

Surgical Endodontics Indications for surgical intervention Endodontic failure Persistent infection, severely curved roots, perforation of the canal, fractured roots, extensive root resorption, pulp stones, or accessory canals that cannot be treated Exploratory surgery To determine why healing did not occur Biopsy Root canals have a 10% to 15% chance of failure. Used to save a tooth from extraction. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved. 44