1. Therapeutic dentistry department Lecturer: as. Yavors’ka-Skrabut I.M.
Treatment of pulpitis with biological, vital amputational and extirpation methods. Testimony, sequence and features of the stages. Efficiency of methods, complication and methods of its prevention.
Therapeutic dentistry department
Lecturer: as. Yavors’ka-Skrabut I.M.

3. Introduction
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.

4. Causes of Pulpal Nerve Damage
Physical irritation
Most generally brought on by extensive decay.
Trauma
Blow to a tooth or the jaw.

5. Signs and Symptoms of Pulpal Nerve Damage
Pain when biting down.
Pain when chewing.
Sensitivity with hot or cold beverages.
Facial swelling.

6. Endodontic Diagnosis Subjective examination Chief complaint
Character and duration of pain
Painful stimuli
Sensitivity to biting and pressure

7. Endodontic Diagnosis Objective examination Extent of decay
Periodontal conditions surrounding the tooth in question
Presence of an extensive restoration
Tooth mobility
Swelling or discoloration
Pulp exposure

8. Diagnostic Testing 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.

9. Diagnostic Testing- cont’d
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.

10. Diagnostic Testing- cont’d
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.

11. Diagnostic Testing- cont’d
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.

12. Fig. 54-4 Placement of a pulp tester.

13. Radiographs in Endodontics
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.

14. Requirements of Endodontic Films
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.

15. Fig. 54-5 Quality radiograph in endodontics.

16. Diagnostic Conclusions
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.

17. Diagnostic Conclusions
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.

18. Diagnostic Conclusions
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.

19. Diagnostic Conclusions-
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.

20. Diagnostic Conclusions
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.

21. Diagnostic Conclusions
Pulp fibrosis
The decrease of living cells within the pulp causing fibrous tissue to take over the pulpal canal.

22. Diagnostic Conclusions
Necrotic tooth
Also referred to as nonvital. Used to describe a tooth that does not respond to sensory stimulus.

23. Endodontic Procedures
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.

24. Fig. 54-11 Spreader and plugger.

25. Endodontic Procedures
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.

26. Fig. 54-13 Example of a pulpotomy.

27. Endodontic Procedures
Pulpectomy
Also referred to as root canal therapy; procedure involves the complete removal of the dental pulp.

28. Fig. 54-14 A diagram of a pulpectomy.

29. Instruments and Accessories for Endodontic Procedures
Endodontic explorer
Endodontic spoon excavator
Broaches
Endodontic files
K-type
Hedstrom

30. Table 54‑1 Colors and Sizes of Endodontic Files

31. Instruments and Accessories for Endodontic Procedures
Rubber stops
Paper points
Spreaders
Pluggers
Glick No. 1
Millimeter ruler

32. Instruments and Accessories for Endodontic Procedures
Rotary instruments
Gates-Glidden bur
Pesso reamer
Lentulo spiral

33. Medicaments and Dental Materials in Endodontics
Irrigation solution
Sodium hypochlorite
Hydrogen peroxide
Parachlorophenol (PCP)

34. Medicaments and Dental Materials in Endodontics
Gutta-percha points
Formocresol
Root canal sealer

35. Overview of Root Canal Therapy
Anesthesia and pain control
Isolation and disinfection of the site
Access preparation
Debridement and shaping the canal
Obturation

36. Surgical Endodontics 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

37. Apicoectomy and Apical Curettage
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.

38. Retrograde Restoration
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.

39. Root Amputation and Hemisection
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.

40. Treatment of Reversible Pulpitis

41. Remove irritant if present (caries; fracture; exposed dentinal tubules).
If no pulp exposure: CaOH, restore, monitor
If pulp exposure:
Carious: initiate RCT
Mechanical: >1 mm: initiate RCT
<1 mm crown planned: initiate RCT
<1 mm: direct cap or RCT
If recent operative or trauma – postpone additional treatment and monitor.

42. Pulpal inflamation and degeneration not expected to improve.
A physiologically older pulp has less ability to recover due to decrease in vascularity and reparative cells.
As inflammation spreads apically, cellular organization begins to break down.
Localized pressure slows venous return, resulting in buildup of toxins and lower pH that causes widespread cellular destruction.

43. Endodontic Materials 43

44. The main objectives of root canal therapy are:
Removal of the pathologic pulp.
Cleaning and shaping of the root canal system.
Three dimensional obturation to prevent reinfection.

45. Functions of irrigants
Irrigants are used to clean the root canal and are used in association with the shaping instruments.
Functions of irrigants include:
Lubrication of instruments used to shape the canal.
Flushing out of gross debris.
Dissolution of organic and inorganic tissue.
Antimicrobial effect. 45

46. Irrigants Ideal properties: Lubricant Antimicrobial
Dissolve organic debris
Flushing
Biocompatible
Cheap 46

47. Classification of irrigants
Chemically inactive irrigants
Water
Saline
Local anaesthetic solution
Chemically active irrigants
Sodium hypochlorite (NaOCl).
Oxidizing agents as Hydrogen peroxide (H2O2)
Chelating agents as EDTA. 47

48. Irrigants Use Adequate volume required
Stays within the confines of root canal
Never deliver with excessive force
Apical extrusion results in pain and possible swelling.
Use luer-lok 27 gauge endodontic needle
Efficiency enhanced with ultrasonic, sonic and mechanical instruments 48

49. Sodium hypochlorite 0.5-5.25 % Antibacterial Dissolve organic matter
Corrosive/caustic
Low toxicity
Apical reaction
Rubber dam 49

50. Production of O2 eliminate anaerobes
Hydrogen peroxide
3% +/- NaOCl
Production of O2 eliminate anaerobes
Bubbles may prevent adequate contact of irrigant with debris
Limited shelf life 50

51. Chlorhexidine
Hibisrcub(HIBISCRUB is an antimicrobial preparation for pre-operative surgical hand disinfection, antiseptic handwashing
Usually used in 0.2% concentration
Antibacterial, Substantivity.
Flushing
Lubricant
Does not dissolve organic debris 51

52. Chelating agent
Ethylene Diamine Tetracetic Acid “EDTA” (File-eze, RC Prep)
Remove smear layer allowing
cleaning of tubules
Soften dentine
Not antibacterial
File-eze is water soluble unlike RC Prep which contains carbowax and is difficult to remove 52

53. They only provide lubrication and gross debris removal functions.
Irrigants
Sterile water
Local anaesthetic
Saline (0.9%)
They only provide lubrication and gross debris removal functions. 53

54. Intracanal medicamanets
If root canal treatment can’t be finished in a single visit, root canals are dressed with medicaments.
Functions of intracanal medicaments:
Primary function: antimicrobial activity
Antisepsis(is the destruction or inhibition of (slowing the growth of) microorganisms )
Disinfection(Cleaning an article of some or all of the pathogenic organisms which may cause infection )
Secondary functions
Hard-tissue formation
Pain control
Exudation control
Resorption control 54

55. Intracanal medicament
Ideal properties
Antibacterial
Penetrates dentinal tubules
Control exudation or bleeding
Biocompatibile.
Eliminates pain
Induce calcific barrier
No effect on temporary
Radio-opaque
Does not stain tooth 55

56. Calcium hydroxide
Hypocal(contains calcium hydroxide and barium sulfate)
Ca(OH)2, 34-50% Ba SO4,5-15% Methylcellulose.
Antibacterial (pH>12)
Denatures protein
Synergestic with NaOCL
Cytotoxic-local necrosis, calcific barrier
Cheap
Dries weeping canals 56

57. Combination of drugs required to be effective
Antibiotics
Combination of drugs required to be effective
Resistant strains becoming more difficult to treat
Allergies 57

58. Steroids Triamicinolone, prednisolone
Pain relief but no evidence of more effective than Ca(OH)2
?use in root resorption by inhibiting odontoclasts
?depresses the host inflammatory response
Not antibacterial but can be mixed with Ca(OH)2
Ledermix= triamicinolone+ tetracycline 58

59. Phenol based agents, Aldehydes and Halidyes
Phenol, parachlorophenol(PCP), camphorated mono PCP, cresol, creosote, formacresol and chlorine.
Antibacterial agents.
Highly toxic agents.
Possible mutagenic and carcinogenic effect. 59

60. Obturating materials Ideal properties of root canal filling materials:
Antimicrobial
Biocompatible.
Good flow
Adhesive in nature
Dimensionally stable
Not affected by moisture
Radio-opaque
Good handling
Easily removed, post prep or retreat
Does not stain dentine
Cheap 60

61. Gutta Percha
Gutta percha “ Isoprene” (C5H8) is one of the oldest and most common root filling material in use today.
A natural latex produced from a genus of tropical trees
Polymers of isoprene:
Cis-natural rubber
Trans-gutta percha. 61

62. Gutta percha points used in clinic consists of:
Zinc oxide 60-75%
Metal sulphides, waxes, resin, opacifiers
Gutta percha is available in 2 phases; Alpha and Beta. 62 62

63. Gutta percha taken from trees is in Alpha phase.
Gutta percha in points used in the clinic is in Beta phase.
Both phases differ in Melting temperature, volumetric changes and flow characteristics when molten. 63

64. 64

65. Gutta percha Advantages of gutta percha: Biocompatible
Dimensionally stable
Compactable
Easily removed
Cheap
Disadvantages of gutta percha:
Does not adhere to dentine
Lacks rigidity 65

66. Metal points Silver (gold, tin, lead and titanium have been used)
Introduced in 1930’s
Silver preferred due to antibacterial effect
Rigid, unyielding
Impossible to adapt to canals
Poor seal as canal not commonly circular in shape
Corrosion
Difficult to remove for post
Titanium- biocompatible and avoids corrosion 66

67. Functions of sealer Sealers
Sealers are used in association with Gutta percha.
Functions of sealer
Cementing (luting, binding) the core material (gutta percha) into the canal.
Filling the discrepancies between the canal walls and core material
Acting as a lubricant to enhance the positioning of the core filling material
Acting as a bactericidal agent 67

68. Root canal sealers Most sealers are toxic when freshly mixed
Toxicity substantially reduced when set
Most sealers are absorbable to some extent when exposed to tissue fluid
Ideally sealer should flow backwards out of the canal
However, no evidence that apical extrusion reduces success rate providing preparation and obturation are meticulous 68

69. Zinc-oxide eugenol Grossmans, Tubliseal Antibacterial Radio-opaque
Slightly toxic when freshly mixed.
Good flow and working time
Does not adhere
soluble 69

70. Calcium hydroxide based sealers
Sealapex, Apexit
Radio-opaque
Soluble
Biocompatible
Preserve vitality of pulp stump and promote healing
Does not adhere 70

71. Resin based sealers AH26, AH Plus, Endorez, Epiphany, RealSeal.
Adhesive
Antibacterial
Toxic when freshly mixed
Show setting shrinkage when set 71

72. Glass-ionomer based sealers
Ketac Endo and ActiV GP.
Mildly antibacterial
Adheres to dentine
Slightly soluble
Unset GIC is cytotoxic but when set this reduces with time
Very difficult to be removed 72

73. Silicone based sealers
Roekoseal sealer.
Slightly expands when set.
Addition type silicone.
GuttaFlow is Roekoseal sealer with added gutta percha particles.
Does not adhere to root canal. 73

74. New root canal filling materials
Resilon: resin-based cones. Similar in appearance and handling to gutta percha cones. Used with any resin-based sealer.
Endorez cones: resin-coated gutta percha. Used with endorez sealer or any other resin-based sealer.
ActiV GP: glass ionomer coated gutta percha. Used with glass ionomer based sealers. 74

75. Retrograde root filling materials
Ideal properties
Seals apex
Biocompatible
Ease of handling
Moisture and blood tolerant
Low solubility
Radio-opaque
Good tissue response
Bonds to dentine 75

76. Amalgam Corrosion Apical inflammation Poor sealing ability
Mercury toxicity 76

77. IRM Modified zinc oxide-eugenol Seals better than amalgam
Need high powder to liquid ratio to decrease toxicity and solubility
Short working time 77

78. Super EBA Modified zinc oxide-eugenol
High compressive and tensile strength
Neutral pH
Low solubilty
Not affected by blood
Good tissue response 78

79. Composite Problems with moisture control
Some good results in sealing ability but further work required 79

80. Glass Ionomer Cements Bonds to tooth substance
Biocompatibilty (Toxicity reduces when set)
Some antibacterial properties
Seal superior to amalgam 80

81. New materials Diaket (Tricalcium phosphate paste)
Polyvinyl resin
Good tissue response
?cementum forming
Mineral Trioxide aggregates (MTA)
Seals better than amalgam or super EPA
Not adversly affected by blood
Marginal adaptation better than amalgam, IRM or super EBA
?cytotoxicity
Laser
Hydroxyapatite 81

82. Mineral trioxide aggregate: Pulp capping Nonsurgical apical closure
MTA
Mineral trioxide aggregate:
Pulp capping
Nonsurgical apical closure
Perforation repair
Surgical root end filling 82

83. ACCESS CAVITIES

84. Despite advances there is always a chance of error in endodontic therapy, and diligence in the involved procedures is necessary.

85. it is important that the access preparation be precise
Entering a tooth without an adequate radiograph is a “fool’s errand.”

86. Preoperative radiographs are essential because they tell us where pulp chambers are located in relationship to coronal surfaces, and at what angles canals enter pulp chambers

87. Gaining access to root canals, wherein the root canal instruments can be slipped easily into the canals to reach the apical portion, is the most important starting point of the root canal treatment. Before you lift that hand piece to start access cavity preparation, stop and think about the following three points:

88. Have you refreshed the knowledge of the morphology and anatomy of the tooth you are going to treat?
Have you taken a good look at the tooth in the oral cavity? Its shape, size, tilt and morphology need careful consideration.
Have you spent sufficient time studying the radiograph?

89. When the access preparation is cut too small, it is often impossible to find all the canals in the tooth.
Even if all the canals are located, it sets the stage for negotiation difficulties, file breakage, and unnecessary frustration during obturation procedures.

91. Conversely, access cavities that are cut too big are a betrayal of the clinician’s first admonishment to do no harm, increasing the short-term possibility of perforation and the long-term probability of tooth and root fracture.

92. CHOOSE SAFE, EFFECTIVE BURS
choosing the wrong bur can presage a poor access result
burs that are too large will inevitably increase the size of the final cavity preparation as well as significantly increase the potential for tooth perforation

93. #2 round is ideal for anterior and premolar access
a #4 is optimal for molar access

94. As soon as the author drops into the chamber, the round bur has accomplished its purpose and is replaced with a tapered diamond bur.

95. In anterior and premolar teeth, the convenience form is afforded by extending the preparation from buccal to lingual; the conservation form is accomplished by preserving tooth structure in the mesial to distal dimension

96. Anterior - Triangular

97. Canines - ovoid

98. Premolar - Round

99. In posterior teeth, the line-angle extensions are cut to the working cusps and stop 1 mm to 2 mm short of the idling cusps.

100. In maxillary premolars and molars, the line angle extensions are taken to the palatal cusps (working) and are short of the buccal cusps (idling)

101. Molar - Rhomboid

102. Conversely, in mandibular premolars and molars the line angle extensions are taken to the buccal and are short of the lingual cusps

104. Straight-line access
Success in modern endodontic treatment may be dependent upon a well-designed access cavity to permit straight-line access to all the main root canals

107. Flexural stress will be increased if the instrument must negotiate past an overhang; arrow A indicates overhang preventing continuous straight line access; arrow B indicates point of greatest curvature on outside wall of canal.

108. Showing a canal opened to the apex to a No
Showing a canal opened to the apex to a No. 20 reamer or file; arrow indicates the thickest, most engaged part of NiTi, most prone to fracture