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

EndodonticsEndodontics

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

Chapter 54Chapter 54

Lesson 54.1Lesson 54.1


Learning ObjectivesLearning Objectives

Pronounce, define, and spell the Key Terms.Pronounce, define, and spell the Key Terms. Describe the diagnostic testing performed for Describe the diagnostic testing performed for

endodontic diagnosis.endodontic diagnosis. List the conclusions of the subjective and List the conclusions of the subjective and

objective tests in the endodontic diagnosis.objective tests in the endodontic diagnosis. Assist in an electric pulp-vitality test.Assist in an electric pulp-vitality test. Describe diagnostic conclusions for Describe diagnostic conclusions for

endodontic therapy.endodontic therapy.


IntroductionIntroduction

Endodontics is the specialty of dentistry Endodontics is the specialty of dentistry

that manages the prevention, that manages the prevention,

diagnosis, and treatment of the dental diagnosis, and treatment of the dental

pulp and the periradicular tissues pulp and the periradicular tissues

surrounding the root of the tooth. surrounding the root of the tooth.


Causes of Pulpal Nerve Damage Causes of Pulpal Nerve Damage

Physical irritation Physical irritation Extensive decay moving into the pulpExtensive decay moving into the pulp

Trauma Trauma Blow to a tooth or the jawBlow to a tooth or the jaw


Signs and Symptoms of Signs and Symptoms of Pulpal Nerve Damage Pulpal Nerve Damage

Pain on occlusionPain on occlusion Pain during masticationPain during mastication Sensitivity to hot or cold beverages Sensitivity to hot or cold beverages Facial swelling Facial swelling


Endodontic Diagnosis Endodontic Diagnosis

Subjective examinationSubjective examination Chief complaint Chief complaint Character and duration of pain Character and duration of pain Painful stimuli Painful stimuli Sensitivity to biting and pressureSensitivity to biting and pressure

(Cont’d)(Cont’d)


Endodontic DiagnosisEndodontic Diagnosis


Objective examinationObjective examination Extent of decay Extent of decay Periodontal conditions Periodontal conditions Extensive restoration Extensive restoration Tooth mobility Tooth mobility Swelling or discoloration Swelling or discoloration Pulp exposure Pulp exposure


Fig. 54-1 Radiograph showing extensive decay into the pulp. Fig. 54-1 Radiograph showing extensive decay into the pulp. (From Johnson W: (From Johnson W: Color atlas of endodonticsColor atlas of endodontics, StLouis, 2002, Saunders.), StLouis, 2002, Saunders.)


Fig. 54-2 Radiograph of a necrotic tooth resulting Fig. 54-2 Radiograph of a necrotic tooth resulting from trauma. from trauma.

(From Johnson W: (From Johnson W: Color atlas of endodonticsColor atlas of endodontics, St Louis, 2002, Saunders.), St Louis, 2002, Saunders.)


Diagnostic Testing Diagnostic Testing

Percussion tests Percussion tests These tests are used to determine whether the These tests are used to determine whether the

inflammatory process has extended into the inflammatory process has extended into the periapical tissues. periapical tissues.

The dentist taps on the incisal or occlusal surface The dentist taps on the incisal or occlusal surface with the end of the mouth-mirror handle held with the end of the mouth-mirror handle held parallel to the long axis of the tooth. parallel to the long axis of the tooth.



Fig. 54-3 Percussion test. Fig. 54-3 Percussion test. (From Johnson W: (From Johnson W: Color atlas of endodonticsColor atlas of endodontics, St Louis, 2002, Saunders.), St Louis, 2002, Saunders.)


Diagnostic Testing Diagnostic Testing


Palpation TestsPalpation Tests These tests are used to determine whether the These tests are used to determine whether the

inflammatory process has extended into the inflammatory process has extended into the periapical tissues.periapical tissues.

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



Fig. 54-4 Palpation test. Fig. 54-4 Palpation test. (From Johnson W: (From Johnson W: Color atlas of endodonticsColor atlas of endodontics, St Louis, 2002, Saunders.), St Louis, 2002, Saunders.)


Diagnostic TestingDiagnostic Testing


Thermal sensitivityThermal sensitivity Necrotic pulp will not respond to cold or heat.Necrotic pulp will not respond to cold or heat.

Cold testCold test Ice, dry ice, or ethyl chloride is used to determine Ice, dry ice, or ethyl chloride is used to determine

the response of a tooth to cold.the response of a tooth to cold. Heat testHeat test

A piece of gutta-percha or an instrument handle is A piece of gutta-percha or an instrument handle is heated and applied to the facial surface of the heated and applied to the facial surface of the tooth. tooth.



Fig. 54-5 Ice used for testing thermal sensitivity.Fig. 54-5 Ice used for testing thermal sensitivity. (From Johnson W: (From Johnson W: Color atlas of endodonticsColor atlas of endodontics, St Louis, 2002, Saunders.), St Louis, 2002, Saunders.)


Diagnostic TestingDiagnostic Testing


Electric pulp testingElectric pulp testing A small electrical stimulus is delivered to the pulp.A small electrical stimulus is delivered to the pulp.

Factors that may influence readings:Factors that may influence readings: The patient has extensive restorations.The patient has extensive restorations. The patient has teeth with more than one canal. The patient has teeth with more than one canal. Failing pulp produces a variety of responses. Failing pulp produces a variety of responses. Control teeth don’t respond as anticipated.Control teeth don’t respond as anticipated. There is moisture on the tooth during testing.There is moisture on the tooth during testing. The batteries in the tester are weak.The batteries in the tester are weak.


Procedure 54-1 Placement of a pulp tester.Procedure 54-1 Placement of a pulp tester.


Radiographs in Endodontics Radiographs in Endodontics

Initial radiograph Initial radiograph DiagnosisDiagnosis

Working-length film Working-length film To determine the length of the canal To determine the length of the canal

Final-instrumentation film Final-instrumentation film Final-size files in all canals Final-size files in all canals

Root canal completion film Root canal completion film Taken after the tooth has been temporized Taken after the tooth has been temporized

Recall films Recall films Taken at evaluations Taken at evaluations


Requirements of Endodontic Films Requirements of Endodontic Films

Must show 4 to 5 mm beyond the apex of the Must show 4 to 5 mm beyond the apex of the tooth and the surrounding bone or pathologic tooth and the surrounding bone or pathologic condition condition

Must present an accurate image of the tooth Must present an accurate image of the tooth without elongation or foreshorteningwithout elongation or foreshortening

Must exhibit good contrast so that all Must exhibit good contrast so that all pertinent structures are readily identifiable pertinent structures are readily identifiable


Fig. 54-6 Good-quality radiograph in endodontics.Fig. 54-6 Good-quality radiograph in endodontics.


Diagnostic Conclusions Diagnostic Conclusions

Normal pulpNormal pulp No subjective symptoms or objective signs are No subjective symptoms or objective signs are

noted. The tooth responds normally to sensory noted. The tooth responds normally to sensory stimuli, and a healthy layer of dentin surrounds the stimuli, and a healthy layer of dentin surrounds the pulp.pulp.



Diagnostic ConclusionsDiagnostic Conclusions


Pulpitis Pulpitis The pulp tissues have become inflamed.The pulp tissues have become inflamed.

Reversible pulpitisReversible pulpitis The pulp is irritated, and the patient is The pulp is irritated, and the patient is

experiencing pain in response to thermal stimuli.experiencing pain in response to thermal stimuli. Irreversible pulpitisIrreversible pulpitis

The tooth displays symptoms of lingering pain.The tooth displays symptoms of lingering pain.(Cont’d)(Cont’d)




Periradicular abscessPeriradicular abscess This inflammatory reaction to pulpal infection may This inflammatory reaction to pulpal infection may

be of chronic or acute onset with pain, tenderness be of chronic or acute onset with pain, tenderness of the tooth in response to pressure, pus of the tooth in response to pressure, pus formation, and swelling of the tissues. formation, and swelling of the tissues.





Periodontal abscess Periodontal abscess This inflammatory reaction is frequently caused by This inflammatory reaction is frequently caused by

bacteria trapped in the periodontal sulcus. A bacteria trapped in the periodontal sulcus. A patient will experience rapid onset of pain, patient will experience rapid onset of pain, tenderness of the tooth in response to pressure, tenderness of the tooth in response to pressure, pus formation, and swelling. pus formation, and swelling.





Periradicular cystPeriradicular cyst This type of cyst develops at or near the root of a This type of cyst develops at or near the root of a

necrotic tooth. They develop as an inflammatory necrotic tooth. They develop as an inflammatory response to pulpal infection and necrosis of the response to pulpal infection and necrosis of the pulp. pulp.





Pulp fibrosisPulp fibrosis A decrease in living cells within the pulp causes A decrease in living cells within the pulp causes

fibrous tissue to take over the pulpal canal. fibrous tissue to take over the pulpal canal. (Cont’d)(Cont’d)




Necrotic toothNecrotic tooth The tooth may also be referred to as nonvital. The The tooth may also be referred to as nonvital. The

term is used to describe a tooth that does not term is used to describe a tooth that does not respond to sensory stimulus. respond to sensory stimulus.


Chapter 54Chapter 54

Lesson 54.2Lesson 54.2


Learning ObjectivesLearning Objectives

List the types of endodontic procedures.List the types of endodontic procedures. Discuss the medicaments and dental Discuss the medicaments and dental

materials used in endodontics.materials used in endodontics. Provide an overview of root canal therapy.Provide an overview of root canal therapy. Assist in root canal therapy.Assist in root canal therapy. Describe surgical endodontics and how it Describe surgical endodontics and how it

affects treatment.affects treatment.


Endodontic Procedures Endodontic Procedures

Pulp cappingPulp capping Calcium hydroxide is placed over an exposed or Calcium hydroxide is placed over an exposed or

nearly exposed pulp to encourage the formation of nearly exposed pulp to encourage the formation of dentin at the site of injury. dentin at the site of injury.

Indirect pulp capping is indicated when a thin Indirect pulp capping is indicated when a thin partition of dentin is still intact.partition of dentin is still intact.

Direct pulp capping is indicated when the Direct pulp capping is indicated when the pulp has been slightly exposed. pulp has been slightly exposed.



Endodontic ProceduresEndodontic Procedures


Pulpotomy Pulpotomy This procedure involves removal of the coronal This procedure involves removal of the coronal

portion of an exposed vital pulp.portion of an exposed vital pulp. It is used to preserve the vitality of the remaining It is used to preserve the vitality of the remaining

portion of the pulp within the root of the tooth. portion of the pulp within the root of the tooth. The procedure is commonly indicated for vital The procedure is commonly indicated for vital

primary teeth, teeth with deep carious lesions, and primary teeth, teeth with deep carious lesions, and emergency situations. emergency situations.



Endodontic ProceduresEndodontic Procedures


Pulpectomy Pulpectomy Also referred to as root canal therapy, this Also referred to as root canal therapy, this

procedure involves the complete removal of the procedure involves the complete removal of the dental pulp. dental pulp.


Instruments and Accessories for Instruments and Accessories for Endodontic Procedures Endodontic Procedures

Hand instrumentsHand instruments Instruments for pulp preparationInstruments for pulp preparation

Hand- and finger-operated filesHand- and finger-operated files Instruments attached to a low-speed handpieceInstruments attached to a low-speed handpiece Rotary filesRotary files

Ancillary instruments Ancillary instruments Rubber stopsRubber stops Paper pointsPaper points


Table 54-1 Colors and Sizes of Endodontic FilesTable 54-1 Colors and Sizes of Endodontic Files


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

Irrigation solution Irrigation solution Sodium hypochlorite Sodium hypochlorite Hydrogen peroxide Hydrogen peroxide Parachlorophenol, or PCPParachlorophenol, or PCP

Root canal–filling materialsRoot canal–filling materials Gutta-percha pointsGutta-percha points

Root canal sealersRoot canal sealers


Overview of Root Canal Therapy Overview of Root Canal Therapy

Anesthesia and pain controlAnesthesia and pain control Isolation and disinfection of the siteIsolation and disinfection of the site Access preparationAccess preparation Débridement and shaping of the canal Débridement and shaping of the canal Obturation Obturation


Surgical Endodontics Surgical Endodontics

Indications for surgical interventionIndications for surgical intervention Endodontic failureEndodontic failure

• Persistent infection, severely curved roots, perforation of Persistent infection, severely curved roots, perforation of the canal, fractured roots, extensive root resorption, pulp the canal, fractured roots, extensive root resorption, pulp stones, or accessory canals that cannot be treatedstones, or accessory canals that cannot be treated

Exploratory surgery Exploratory surgery • To determine why healing did not occurTo determine why healing did not occur

Biopsy Biopsy


Apicoectomy and Apical Curettage Apicoectomy and Apical Curettage

To surgically remove the apical portion of the To surgically remove the apical portion of the root with the use of a high-speed handpiece root with the use of a high-speed handpiece and burand bur

To evaluate:To evaluate: Inadequate sealing of the canal Inadequate sealing of the canal Accessory canals Accessory canals Fractures of the root Fractures of the root Pathologic tissue around the root apex Pathologic tissue around the root apex


Retrograde Restoration Retrograde Restoration

This procedure is undertaken when an apical This procedure is undertaken when an apical seal is not adequate. seal is not adequate. A small class I preparation is made at the apex A small class I preparation is made at the apex

and sealed with filling materials such as gutta-and sealed with filling materials such as gutta-percha, amalgam, or composite. percha, amalgam, or composite.


Root Amputation and Hemisection Root Amputation and Hemisection

Root amputationRoot amputation This surgery is performed to remove one or more This surgery is performed to remove one or more

roots of a multirooted tooth without removing the roots of a multirooted tooth without removing the crown. crown.

HemisectionHemisection The root and the crown are sectioned lengthwise The root and the crown are sectioned lengthwise

and removed.and removed.


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

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