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

2. 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.

3. 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?
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4. 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?
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5. 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.

6. 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

7. 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?
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8. 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?
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9. Fig. 54-1 Radiograph showing extensive decay into the pulp
Fig Radiograph showing extensive decay into the pulp. (From Johnson W: Color atlas of endodontics, StLouis, 2002, Saunders.)
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10. Fig. 54-2 Radiograph of a necrotic tooth resulting from trauma
Fig 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?
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11. 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?
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12. 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?
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13. 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?
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14. Fig. 54-5 Ice used for testing thermal sensitivity
Fig 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.
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15. 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.
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16. 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

17. Pulp Capping

18. 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

19. Pulpotomy

20. Pulpectomy

21. Sequence of a Pulpectomy
Access
Extirpation
Debridement
Obturation
Close

22. Access
Gaining entry to the pulpal chamber

23. Extirpation
Removal of pulp tissue: removed diseased pulp issue.

24. 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.

25. 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.

26. 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.

27. 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..

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

29. 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

30. 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

31. 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)

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

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

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

41. 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

42. 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?
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43. 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

44. 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.
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