Endodontics Chapter 54

Copyright 2003, Elsevier Science (USA). All rights reserved.

EndodonticsEndodonticsChapter 54Chapter 54

Copyright 2003, Elsevier Science (USA).

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ISBN 0-7216-9770-4


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.

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.

IntroductionIntroduction


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 Causes of Pulpal Nerve Damage


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 Signs and Symptoms of Pulpal Nerve Damage


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 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

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 Endodontic Diagnosis cont’d


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


• 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 Diagnostic Testing


Palpation tests• Used to determine whether the


• The dentist applies firm pressure to the mucosa above the apex of the root.

Palpation tests• Used to determine whether the


• The dentist applies firm pressure to the mucosa above the apex of the root.

Diagnostic Testing cont’d 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.

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.



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.



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


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 Radiographs in Endodontics


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 Requirements of Endodontic Films


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


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 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.

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 Diagnostic Conclusions cont’d


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.



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.



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.



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.



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.



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 Endodontic Procedures


Fig. 54-11 Spreader and plunger. Fig. 54-11 Spreader and plunger.


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 Endodontic Procedures cont’d


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


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 Endodontic Procedures cont’d


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


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 Instruments and Accessories for Endodontic Procedures


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


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 Instruments and Accessories for Endodontic Procedures cont’d


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 Instruments and Accessories for Endodontic Procedures cont’d


Irrigation solution • Sodium hypochlorite • Hydrogen peroxide • Parachlorophenol (PCP)

Irrigation solution • Sodium hypochlorite • Hydrogen peroxide • Parachlorophenol (PCP)

Medicaments and Dental Materials in Endodontics Medicaments and Dental Materials in Endodontics


Gutta-percha points Formocresol Root canal sealer

Gutta-percha points Formocresol Root canal sealer

Medicaments and Dental Materials in Endodontics cont’d Medicaments and Dental Materials in Endodontics cont’d


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 Overview of Root Canal Therapy


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 Surgical Endodontics


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 Apicoectomy and Apical Curettage


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.

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 Retrograde Restoration


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 Root Amputation and Hemisection

Endodontics Chapter 54

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