Copyright 2003, Elsevier Science (USA). All rights reserved. Endodontics Chapter 54 Copyright 2003, Elsevier Science (USA). All rights reserved. No part of this product may be reproduced or transmitted in any form or by any means, electronic or mechanical, including input into or storage in any information system, without permission in writing from the publisher. PowerPoint ® presentation slides may be displayed and may be reproduced in print form for instructional purposes only, provided a proper copyright notice appears on the last page of each print-out. Produced in the United States of America ISBN

Copyright 2003, Elsevier Science (USA). All rights reserved. Endodontics is the specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the periradicular tissues that surround the root of the tooth. Introduction

Copyright 2003, Elsevier Science (USA). All rights reserved.  Physical irritation Most generally brought on by extensive decay.  Trauma Blow to a tooth or the jaw.  Physical irritation Most generally brought on by extensive decay.  Trauma Blow to a tooth or the jaw. Causes of Pulpal Nerve Damage

Copyright 2003, Elsevier Science (USA). All rights reserved.  Pain when biting down.  Pain when chewing.  Sensitivity with hot or cold beverages.  Facial swelling.  Pain when biting down.  Pain when chewing.  Sensitivity with hot or cold beverages.  Facial swelling. Signs and Symptoms of Pulpal Nerve Damage

Copyright 2003, Elsevier Science (USA). All rights reserved.  Subjective examination Chief complaint Character and duration of pain Painful stimuli Sensitivity to biting and pressure  Subjective examination Chief complaint Character and duration of pain Painful stimuli Sensitivity to biting and pressure Endodontic Diagnosis

Copyright 2003, Elsevier Science (USA). All rights reserved.  Objective examination Extent of decay Periodontal conditions surrounding the tooth in question Presence of an extensive restoration Tooth mobility Swelling or discoloration Pulp exposure  Objective examination Extent of decay Periodontal conditions surrounding the tooth in question Presence of an extensive restoration Tooth mobility Swelling or discoloration Pulp exposure Endodontic Diagnosis  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Percussion tests Used to determine whether the inflammatory process has extended into the periapical tissues. Completed by the dentist tapping on the incisal or occlusal surface of the tooth in question with the end of the mouth mirror handle held parallel to the long axis of the tooth.  Percussion tests Used to determine whether the inflammatory process has extended into the periapical tissues. Completed by the dentist tapping on the incisal or occlusal surface of the tooth in question with the end of the mouth mirror handle held parallel to the long axis of the tooth. Diagnostic Testing

Copyright 2003, Elsevier Science (USA). All rights reserved.  Palpation tests Used to determine whether the inflammatory process has extended into the periapical tissues. The dentist applies firm pressure to the mucosa above the apex of the root.  Palpation tests Used to determine whether the inflammatory process has extended into the periapical tissues. The dentist applies firm pressure to the mucosa above the apex of the root. Diagnostic Testing  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Thermal sensitivity Necrotic pulp will not respond to cold or hot.  Cold test Ice, dry ice, or ethyl chloride used to determine the response of a tooth to cold.  Heat test Piece of gutta-percha or instrument handle heated and applied to the facial surface of the tooth.  Thermal sensitivity Necrotic pulp will not respond to cold or hot.  Cold test Ice, dry ice, or ethyl chloride used to determine the response of a tooth to cold.  Heat test Piece of gutta-percha or instrument handle heated and applied to the facial surface of the tooth. Diagnostic Testing  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Electric pulp testing Delivers a small electrical stimulus to the pulp.  Factors that may influence readings: Teeth with extensive restorations. Teeth with more than one canal. Failing pulp can produce a variety of responses. Control teeth may not respond as anticipated. Moisture on the tooth during testing. Batteries in the tester may be weak.  Electric pulp testing Delivers a small electrical stimulus to the pulp.  Factors that may influence readings: Teeth with extensive restorations. Teeth with more than one canal. Failing pulp can produce a variety of responses. Control teeth may not respond as anticipated. Moisture on the tooth during testing. Batteries in the tester may be weak. Diagnostic Testing  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Placement of a pulp tester.

Copyright 2003, Elsevier Science (USA). All rights reserved.  Initial radiograph Diagnosis.  Working length film Used to determine the length of the canal.  Final instrumentation film Taken with the final size files in all canals.  Root canal completion film Taken after the tooth as been temporized.  Recall films Taken at evaluations.  Initial radiograph Diagnosis.  Working length film Used to determine the length of the canal.  Final instrumentation film Taken with the final size files in all canals.  Root canal completion film Taken after the tooth as been temporized.  Recall films Taken at evaluations. Radiographs in Endodontics

Copyright 2003, Elsevier Science (USA). All rights reserved.  Show 4-5 mm beyond the apex of the tooth and the surrounding bone or pathologic condition.  Present an accurate image of the tooth without elongation or fore-shortening.  Exhibit good contrast so all pertinent structures are readily identifiable.  Show 4-5 mm beyond the apex of the tooth and the surrounding bone or pathologic condition.  Present an accurate image of the tooth without elongation or fore-shortening.  Exhibit good contrast so all pertinent structures are readily identifiable. Requirements of Endodontic Films

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Quality radiograph in endodontics.

Copyright 2003, Elsevier Science (USA). All rights reserved.  Normal pulp There are no subjective symptoms or objective signs. The tooth responds normally to sensory stimuli, and a healthy layer of dentin surrounds the pulp.  Normal pulp There are no subjective symptoms or objective signs. The tooth responds normally to sensory stimuli, and a healthy layer of dentin surrounds the pulp. Diagnostic Conclusions

Copyright 2003, Elsevier Science (USA). All rights reserved.  Pulpitis The pulp tissues have become inflamed.  Reversible pulpitis The pulp is irritated, and the patient is experiencing pain to thermal stimuli.  Irreversible pulpitis The tooth will display symptoms of lingering pain.  Pulpitis The pulp tissues have become inflamed.  Reversible pulpitis The pulp is irritated, and the patient is experiencing pain to thermal stimuli.  Irreversible pulpitis The tooth will display symptoms of lingering pain. Diagnostic Conclusions  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Periradicular abscess An inflammatory reaction to pulpal infection that can be chronic or have rapid onset with pain, tenderness of the tooth to pressure, pus formation, and swelling of the tissues.  Periradicular abscess An inflammatory reaction to pulpal infection that can be chronic or have rapid onset with pain, tenderness of the tooth to pressure, pus formation, and swelling of the tissues. Diagnostic Conclusions  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Periodontal abscess An inflammatory reaction frequently caused by bacteria entrapped in the periodontal sulcus. A patient will experience rapid onset, pain, tenderness of the tooth to pressure, pus formation, and swelling.  Periodontal abscess An inflammatory reaction frequently caused by bacteria entrapped in the periodontal sulcus. A patient will experience rapid onset, pain, tenderness of the tooth to pressure, pus formation, and swelling. Diagnostic Conclusions  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Periradicular cyst A cyst that develops at or near the root of a necrotic tooth. These types of cysts develop as an inflammatory response to pulpal infection and necrosis of the pulp.  Periradicular cyst A cyst that develops at or near the root of a necrotic tooth. These types of cysts develop as an inflammatory response to pulpal infection and necrosis of the pulp. Diagnostic Conclusions  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Pulp fibrosis The decrease of living cells within the pulp causing fibrous tissue to take over the pulpal canal.  Pulp fibrosis The decrease of living cells within the pulp causing fibrous tissue to take over the pulpal canal. Diagnostic Conclusions  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Necrotic tooth Also referred to as nonvital. Used to describe a tooth that does not respond to sensory stimulus.  Necrotic tooth Also referred to as nonvital. Used to describe a tooth that does not respond to sensory stimulus. Diagnostic Conclusions  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Pulp capping A covering of calcium hydroxide is placed over an exposed or nearly exposed pulp to encourage the formation of irritated dentin at the site of injury.  Indirect pulp cap is indicated when a thin partition of dentin is still intact.  Direct pulp cap is indicated when the pulp has been slightly exposed.  Pulp capping A covering of calcium hydroxide is placed over an exposed or nearly exposed pulp to encourage the formation of irritated dentin at the site of injury.  Indirect pulp cap is indicated when a thin partition of dentin is still intact.  Direct pulp cap is indicated when the pulp has been slightly exposed. Endodontic Procedures

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Spreader and plunger.

Copyright 2003, Elsevier Science (USA). All rights reserved.  Pulpotomy Involves the removal of the coronal portion of an exposed vital pulp. Completed to preserve the vitality of the remaining portion of the pulp within the root of the tooth. This procedure is commonly indicated for vital primary teeth, teeth with deep carious lesions, and emergency situations.  Pulpotomy Involves the removal of the coronal portion of an exposed vital pulp. Completed to preserve the vitality of the remaining portion of the pulp within the root of the tooth. This procedure is commonly indicated for vital primary teeth, teeth with deep carious lesions, and emergency situations. Endodontic Procedures  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Example of a pulpotomy.

Copyright 2003, Elsevier Science (USA). All rights reserved.  Pulpectomy Also referred to as root canal therapy; procedure involves the complete removal of the dental pulp.  Pulpectomy Also referred to as root canal therapy; procedure involves the complete removal of the dental pulp. Endodontic Procedures  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig A diagram of a pulpectomy.

Copyright 2003, Elsevier Science (USA). All rights reserved.  Endodontic explorer  Endodontic spoon excavator  Broaches  Endodontic files K-type Hedstrom  Endodontic explorer  Endodontic spoon excavator  Broaches  Endodontic files K-type Hedstrom Instruments and Accessories for Endodontic Procedures

Copyright 2003, Elsevier Science (USA). All rights reserved. Table 54 ‑ 1 Colors and Sizes of Endodontic Files

Copyright 2003, Elsevier Science (USA). All rights reserved.  Rubber stops  Paper points  Spreaders  Pluggers  Glick No. 1  Millimeter ruler  Rubber stops  Paper points  Spreaders  Pluggers  Glick No. 1  Millimeter ruler Instruments and Accessories for Endodontic Procedures  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Rotary instruments Gates-Glidden bur Pesso reamer Lentulo spiral  Rotary instruments Gates-Glidden bur Pesso reamer Lentulo spiral Instruments and Accessories for Endodontic Procedures  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Irrigation solution Sodium hypochlorite Hydrogen peroxide Parachlorophenol (PCP)  Irrigation solution Sodium hypochlorite Hydrogen peroxide Parachlorophenol (PCP) Medicaments and Dental Materials in Endodontics

Copyright 2003, Elsevier Science (USA). All rights reserved.  Gutta-percha points  Formocresol  Root canal sealer  Gutta-percha points  Formocresol  Root canal sealer Medicaments and Dental Materials in Endodontics  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Anesthesia and pain control  Isolation and disinfection of the site  Access preparation  Debridement and shaping the canal  Obturation  Anesthesia and pain control  Isolation and disinfection of the site  Access preparation  Debridement and shaping the canal  Obturation Overview of Root Canal Therapy

Copyright 2003, Elsevier Science (USA). All rights reserved.  Indications for surgical intervention Endodontic failure caused by 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 has not occurred. Biopsy  Indications for surgical intervention Endodontic failure caused by 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 has not occurred. Biopsy Surgical Endodontics

Copyright 2003, Elsevier Science (USA). All rights reserved.  To surgically remove the apical portion of the root with the use of a high ‑ speed handpiece and bur.  To evaluate: Inadequate sealing of the canal. Accessory canals. Fractures of the root. Pathological tissue around the root apex.  To surgically remove the apical portion of the root with the use of a high ‑ speed handpiece and bur.  To evaluate: Inadequate sealing of the canal. Accessory canals. Fractures of the root. Pathological tissue around the root apex. Apicoectomy and Apical Curettage

Copyright 2003, Elsevier Science (USA). All rights reserved.  Completed 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. Retrograde Restoration

Copyright 2003, Elsevier Science (USA). All rights reserved.  Root amputation A surgery performed to remove one or more roots of a multirooted tooth without removing the crown.  Hemisection A procedure in which the root and the crown are cut lengthwise and removed.  Root amputation A surgery performed to remove one or more roots of a multirooted tooth without removing the crown.  Hemisection A procedure in which the root and the crown are cut lengthwise and removed. Root Amputation and Hemisection