Endodontics: Recent Episodes

DrMayakha Mariam

These are lectures of The Gulfie Dentist Coaching

MICROBIOLOGY IN ENDODONTICS

STREPTOCOCCUS SALIVARIS
 Aerobic
 Most abundant
 At birth
 Mainly in saliva
 1st organism to invade the oral cavity
 Seen in aeroter

STREPTOCOCCUS MUTANTS
 Aerobic
 Seen 1st at 6 months age
 Appears after tooth eruption only
 Associated with teeth mostly
 Caries initiator – because enamel contains 95% inorganic content – mutants demineralize inorganic substances
 Examples – nursing bottle caries, smooth surface caries, incipient caries

LACTOBACILLUS
 Aerobic
 Caries progression
 Attacks dentine – because dentine contains 65% inorganic & 35% organic – lactobacillus demineralize organic component easily

ACTINOMYCES
 Strictly anaerobic
 Gram +ve
 Root / senile caries
 Also seen in root canal as part of mixed flora in it

E-FECALIS
 Re-infection in RC treated teeth
 Most persistent organism in root canals
 Can be killed by MTAD / CHX only

OTHER BACTERIAL SPECIES SEEN IN INFECTED ROOT CANALS
 Porphyromonas gingivalis
 Bacteroids melaninogenicus
 Eubacteria species
 Fusobacterium species
 Prevotella special
(Strict and obligate anaerobes are predominant) ( Collagenase & toxins from bacteria &
spirochetes are seen in canals )

PULPAL PAIN
Nerve Trunk – 5th cranial nerve i.e. TRIGEMINAL NERVE

A-delta fibres:

Dentinal pain
Quick, sharp, momentary pain, which disappears quickly on removal of the stimulus
Large myelinated nerves
Joins with the odontoblastic cell layer and dentin to form the pulpodentinal complex—dentinal hypersensitivity reason- reversible pulpitis
Reason for acute pain
Found only in mature / permanent / closed apex tooth
EPT detects this type fibre only

C nerve fibers:

Pulpal pain
Dull, throbbing ache
Small, unmyelinated nerves that course centrally in the pulp
In irreversible cases
Chronic pulpitis
Diffuse pain, may be referred to other tooth also
Provoked by hot liquids or food

NOTE: VIEW PICTURE BELOW

VIEW PICTURE BELOW

PULPAL DISEASES

Normal Pulp
Thermal test- Mild to moderate transient pain that subsides almost immediately when stimulus is removed.

REVERSIBLE PULPITIS
1. Another name- Hyperemia / Focal reversible pulpitis
2. Quick sharp hypersensitive response that subsides as soon as stimulus is removed.
3. Causes: caries, scaling, deep restorations w/o base, after crown preparation.
4. Aggravating factor- cold
5. Relieving factor- heat
6. Vital tooth
7. A delta fibers involved
8. Thermal response- painful response that disappears after stimulus.
9. Something has invaded our dentine !!

Reversible pulpitis 1 : DENTINAL HYPERSENSITIVITY
 Symptom: spontaneous sharp lancinating pain
 Tooth is Vital
 Theory – Hydrodynamic Theory
Treatment options:
- Unfilled acrylic soln.- dentine bonding agents
- Fluoride gels / varnishes
- Desensitizing pastes – Potassium Nitrate salts, Strontium salts, 33% NaF salts
- ( use twice daily for 6 months > review > once in a week > once in 2 weeks )
- Crown placement

Example 2: CRACKED TOOTH SYNDROME (CTS)
 Continuous pain
 Pain on releasing the bite.
 Best diagnosed by subjective symptoms & horizontal percussion

 DIAGNOSIS:
1. Bite test- best test
2. Transillumination test - DFOTI
3. Die test- Please correct what I said Propyl glycol to Methylene Blue**

NB : CTS is reversible if pulp crack doesn’t involve the pulp. Treatment- crown. CTS is
irreversible pulpitis if crack involves the pulp. Treatment - RCT + crown

SYMPTOMATIC IRREVERSIBLE PULPITIS
1. Pulp damaged beyond repair. Cannot reverse or save the tooth.
2. Symptom- Unprovoked continuous or intermittent pain without any stimuli.
3. Symptom -Pain at night, sleeplessness
4. Aggravates more on hot drinks or food
5. So Aggravating factor –both heat & cold
6. Flight, high altitude pain. Pain on postural changes
7. Vital / non-vital

PULP NECROSIS
1. Pulp becomes non-vital
2. Cause- traumatic injury, progression of irreversible pulpitis
3. EPT test –ve
4. Discolouration - if it happens in anterior teeth

HYPERPLASTIC PULP
1. Pulp polyp
2. Reddish cauliflower-like growth
3. Cause: Low grade, chronic irritation to pulp
4. A type of irreversible pulpitis
5. Young pulp - due to generous vascular supply

INTERNAL RESORPTION
1. Identified accidentally during routine examination
2. Cause : chronic pulpitis, idiopathic,
3. Histologic appearance- Multinucleated giant cells adjacent to granulation tissue*
4. Necrotic pulp seen coronal to resorbtive defect
5. Partial pulp vitality is necessary for active resorption. (So EPT might show +ve)
6. The only treatment : Immediate single sitting RCT.

APICAL DISEASES
PULP NECROSIS >> APICAL PERIODONTITIS >> PERAPICAL ABSCESS >> PERIAPICAL GRANULOMA >> PERIAPICAL CYST

SYMPTOMATIC / ACUTE APICAL PERIODONTITIS
a. Intense pain, slight sensitivity-like feel on chewing.
b. TOP +ve
c. No radiographic changes seen
d. Vital AAP & non-vital AAP is differentiated only by pulp tests.

I. Vital AAP
o Post-restoration high point for 2 days
o TFO, bruxism, Pericoronitis
o Ortho PDL tear
o Abutment tooth in prostho FPD, RPD clasps, etc
o Treatment: simple occlusal adjustments only needed.

II. Non-Vital AAP
o Fully infected / necrosed pulp progression
o Over instrumentation in BMP ( piercing the PDL membranes beyond the apex >>> inflammation >>> post BMP pain
o GP extrusion post OBT pain

Nb: pulp vitality test…to know if endo treatment is req

SYMPTOMATIC / ACUTE APICAL PERIODONTITIS
a. Intense pain, slight sensitivity-like feel on chewing.
b. TOP +ve
c. No radiographic changes seen
d. Vital AAP & non-vital AAP is differentiated only by pulp tests.

I. Vital AAP
o Post-restoration high point for 2 days
o TFO, bruxism, Pericoronitis
o Ortho PDL tear
o Abutment tooth in prostho FPD, RPD clasps,etc
o Treatment: simple occlusal adjustments only needed.

II. Non-Vital AAP
o Fully infected / necrosed pulp progression
o Over instrumentation in BMP ( piercing the PDL membranes beyond the apex >>>
inflammation >>> post BMP pain
o GP extrusion post OBT pain

Nb: pulp vitality test…to know if endo treatment is required

ASYMPTOMATIC / CHRONIC APICAL PERIODONTITIS

a. Radiographic changes present
 Widening of PDL space
 Thickening of lamina dura
 Apical bone resorption

b. Pain – maybe slightly present or no pain at all.

c. In chronic cases, the cell rests of Malassez that was asleep down there, due to chronic irritation, it will start proliferating thus leading to granuloma, abscess n cyst.

d. So the origin of abscess, granuloma etc is cell rests of Malassez

UNDERSTANDING HOW TO ANSWER QUESTIONS.

APICAL ABCESS
Also known as PERIAPICAL / RADICULAR ABSCESS

ACUTE
 Spontaneous & Severe pain
 Rapid onset of pain, overnight
 Rapid swelling
 Purulent exudate at apex- ie. pus
 TOP +ve
 Slight tooth mobility
 No radiographic findings or slightly widened PDL

NB : Acute apical abscess can be differentiated from lateral periodontal abscess by pulp
vitality test

Vital >>>>>>>>> Periodontal abscess
Non-vital >>>>>>>> Periapical

CHRONIC
 Sinus tract may be present
 Pus discharging
 Halitosis
 Radiographically ill-defined radiolucency seen
 Swelling absent generally
 No pain due to draining pus
 Acute chronic apical abscess can be differentiated from lateral periodontal abscess by sinus tracing

Sinus Tract
 Periapical abscess :- self healing, no treatment required for that will heal when endo done
 Periodontal abscess :- needs perio treatments
 GP TRACING is the test done to detect the origin of the sinus, to diagnose if perio or endo origin
 GINGIVAL DRAINING SULCUS :- mimicking pockets
But it’s not gingival pocket. Could be perio or endo origin

CONDENSING OSTEITIS
1. Excessive mineralization of the bone around apex
2. Radiopacity
3. Rct not necessary.

PHOENIX / RECRUDISSANT ABCESS

a. Another names: ACUTE EXACERBATION OF CHRONIC PERIODONTITIS, RECRUDISSANT ABCESS
b. Pain present
c. Pus discharge maybe seen
d. Swelling seen
e. Radiographic changes present
f. Partially healing old sinus tract may be seen

ENDODONTIC DIAGNOSTIC TESTS

Percussion
Percussion- doesn’t indicate the health of the pulp, instead any inflammation to the pdl makes the proprioceptive fibers sensitive…..causing top +ve
Causes- apical periodontitis, High points in recent restoration, rapid ortho movt, lateral abscess.

VITALITY TESTS

I. THERMAL TESTS
o Always isolate using rubber dam or at least dry
o Always check contra-lateral tooth – because they have exact similar composition of enamel dentine, pulp nerves, etc. tooth no- 7, 10
o Wait for an appropriate amount of time, 5 secs to avoid misinterpretation, or until the pt begins to feel pain
o Crown & bridge cases – only cold test under rubber dam isolation
o Cold test is the best vitality test than heat test and EPT

A. Cold test
 Cold water bath
 Ethyl chloride ( -5 °C )
 Endo ice – Please correct "dichloro difluoro methane" to tetrafluoroethane ( -30 °C, -21 °F )
 Dry ice – CO2 ice – ice sticks – ice blocks - frozen CO2 ( -77.7 °C, -108 °F )
B. Heat test
 Rotating dry prophy cup
 Heated – warm gp point
 Hot water bath- most accurate

4 RESPONSES
1. No response- non-vital, or recent trauma.
2.Mild to moderate pain, subsides on removal- normal pulp
3. Strong, spontaneous pain, subsides on removal- reversible
4. Moderate to strong pain, lingers after removal of stimulus- irreversible

PULSE OXIMETRY TEST
o Best vitality test ( if available in options )
o Because vascular supply is detected here – which is the true determinant of pulpal vitality

LASER DOPPLER FLOWMETRY
o A type of pulse oximetry

ELECTRONIC PULP TEST –

 Least reliable test
 Here vitality is determined by nerve fibres not by the vascular supply, which is the true determinant of vitality.
 Isolate >> coat electrode with viscous conductor >> apply on dried enamel only
 Contra indicated in pacemaker cases
 False(lying that) negative maybe seen in:
o Immature / open-apex / young permanent teeth ( because of poor A-delta fibre innervation )
o Patient under alcohol / analgesics
o Calcified tooth
o Recent trauma cases ( because the nerve fibres may be hyper-polarised / numb )

Always wait n watch  recall after 3 days >> if EPT no response >> Then go for RCT

SELECTIVE ANESTHESIA TEST
o To determine which jaw or quadrant pain
o IANB
o Cannot find out the exact tooth.

TEST CAVITY
o Definitive / confirmatory test
o Pain felt if vital

TRANSILLUMINATION TEST
o FOTI – Fibre Optic Trans Illumination
o Under light- caries appears opaque
o QUALITATIVE assessment
o Detects Cracked Tooth Syndrome
o Detects initial caries, smooth surface caries
o DFOTI – Digital Foti
o Disadv – a) misinterprets stains, b) cant detect pit & fissures

LASER FLUORESENCE
o For pit & fissure sealants
o Also detects smooth surface caries
o DIAGNODENT – best for pit & fissure caries detection
o QUANTITATIVE assessment

DENTINE
 The dental structure that is similar to bone
 65% inorganic 35% organic by volume
 45% inorganic 55% organic by weight

PRIMARY
 Mantle dentine- 1st formed dentine*
 Physiologic dentine occurring before root completion

CIRCUMPULPAL DENTINE
Represents most of the dentine formed.

SECONDARY
1. Physiologic dentine formed after root completion-naturally formed.
2. Gradually formed throughout life time.
3. Formation starts after root formation
4. Increases with age.

TERTIARY
1. Other names: REACTIONARY / REPARATIVE / SCLEROTIC DENTINE
2. Formed as pathologic response to irritation / trauma
3. Eg: DPC, IPC,TFO, Bruxism, Attrition, Erosion, Caries

PULPAL THERAPY

VITAL PULP THERAPIES- IPC, DPC, PULPOTOMY, PARTIAL PULPOTOMY, APEXOGENESIS

NONVITAL PULP THERAPIES- PULPECTOMY, APEXIFICATION, RCT

IPC – INDIRECT PULP CAPPING

 Material placed after excavating the last layer of infected dentine, leaving thin partition of affected dentine.
 No pulpal exposure here
 Can do on both primary & permanent teeth
 Apply MTA (Mineral Trioxide Aggregate )
 Material of choice – MTA or Ca(OH)
 No time limit.

DPC – DIRECT OULP CAPPING

 0.5-1mm pulp exposed cases ( pin-point exposure )
 Exposure time – within 24 hrs post trauma
 Only on iatrogenically / traumatically exposed tooth
 Contra-indicated in cariously exposed teeth
 Only on Young permanent / permanent tooth
 Contra-indicated in deciduous tooth
 Age must be above 6 years (tricking qn )

NB: ( DPC in primary tooth causes internal resorption due to hyperactive young pulp –
instead go for pulpotomy )

CVEK PULPOTOMY
 Shallow / partial pulpotomy
 Surgical removal – small position of coronal pulp
 Ojective- Preserve remaining coronal + radicular pulp
 Indi- Non- carious exposure cases more than 1mm, iatrogenic, inflammation greater than 2mm but not until root orifice, trauma within 24hrs.
 in pedo
 Also done in Young permanent to promote apexogenesis

PULPOTOMY
 In Primary teeth /
 Also in Young permanent tooth to facilitate APEXOGENESIS
 If more than 1mm pulp is exposed
 Exposure time :- 48 to 72 hrs i.e. within 2days post trauma
 Tooth should be vital
 Excavate & remove coronal pulp only
 Preserve radicular pulp – essential for natural apex closure i.e. Apexogenesis &
natural exfoliation

 Materials of choice:
MTA / Ferric Sulphate > CaOH > Formocresol
Best > better > least
 Formocresol PULPOTOMY(2 drops ) – numification / fixation
 Ferric Sulphate PULPOTOMY (2 drops ) – fixation
 Filling materials of choice– GIC / Temporary filling i.e. ZnOE
 Restoration to be done immediately

PULPAL HEAMORRHAGE
 Saline
 Ferric Sulphate
 Iodoform
 CMCP
 Epinephrine 1 : 1000
 Formocresol
 Cresatin
 Never use NaOCl

APEXOGENISIS
 Naturally happening process of apex closure
 Not manually done by dentist
 Tooth should be vital
 IPC, DPC & Pulpotomy stimulates Apexogenesis
 In young Permanent Teeth – to promote root closure

APEXIFICATION
 In young permanent teeth
 Exposure time:- if crosses 72 hrs / 2 days
 Tooth becomes non-vital
 Trauma / caries cases
 Removal of entire pulp – both coronal and radicular
 Create MTA plug at the apex
 Wait for 1 year approx.
 Root length remains the same
 The periodontal tissues near or around the root end becomes hardened / calcified – hence closure of apex
 After 1year, check if calcific barrier is formed at the apex with radiographic diagnosis

MATERIALS USED IN VITAL PULP THERAPY

CALCIUM HYDROXIDE
 Has a pH of 11.5 - 12.5
 Highly basic
 Mild irritant to tissues
 Function – irritates tissues thus inducing formation of tertiary dentine
 For DPC, IPC , Apexification, perforation repair, & weeping canals

MINERAL TRIOXIDE AGGREGATE
 Calcium Phosphate + calcium oxide
 Has a pH of 12.5 – 13
 Disadvantage- very long Setting time – 2 hrs 45mins
 Non-resorbable quality makes it the best sealing material.-superior than CaOH
 For Apexification, perforation repair, & Apicocetomy

GREY MTA –
o Ferric Oxide
o Prevents moisture sensitivity
o So no change in properties
o Best used for Apicocetomy

WHITE MTA –
o No iron content
o Therefore sensitive to moisture
NB : MTA is preferred than CaOH. But choose both if such option available

OTHER CASES WHERE THESE MATERIALS ARE USED:

WEEPING CANALS:-
Irrigants to be used is NaOCl + Iodide Potassium – IRRIGANT
Here the bleeding spot at the apex has to be arrested, hence we place CaOH for 2-3 weeks.

CaOH acts as disinfectant, Helps neutralize acidic exudate, medicament - OBT MATERIAL

USES OF MTA / CaOH
 IPC
 DPC
 Pulpotomy
 Pulpectomy
 Apexogenesis
 Apexification
 Perforation repair
 Internal resorption

ROOT CANAL TREATMENT

ROOT CANAL ANATOMY & ACCESS OPENING

ACCES OPENING – MAXILLARY
1-MAXILLARY ANTERIORS – THEY ALWAYS HAVE ONLY SINGLE ROOT
CENTRAL INCISOR -OVAL
LATERAL INCISOR -OVAL
CANINE -OVAL

2- MAXILLARY PMS

1ST PREMOLAR - OVAL
78% TWO ROOTS
22% SINGLE ROOT
72% TWO CANALS WITH SAME FORAMEN
13% TWO CANALS WITH SEPARATE FORAMENS
6% THREE CANALS WITH 3 FORAMENS

2ND PREMOLAR- OVAL
75% SINGLE CANAL
25% TWO ROOTS

3- MAXILLARY MOLARS

1ST MOLAR- TRIANGULAR
56% FOUR CANALS ie MB2 – WILL BE DISTOPALATAL TO MB1
42% THREE CANALS
2% FIVE CANALS ie DB2
MB canal is most difficult to locate- its very narrow

2ND MOLAR TRIANGULAR
54% THREE SEPARATE ROOTS
46% FUSED ROOTS

ACCES OPENING – MANDIBULAR

MANDIBULAR ANTERIORS

CENTRAL INCISOR - OVAL
70% SINGLE CANAL
30% TWO CANALS / BIFURCATION
 24% TWO CANALS WITH SAME FORAMEN
 6% TWO CANALS WITH SEPARATE FORAMENS

LATERAL INCISOR- OVAL
56% SINGLE CANAL
44% 2ND CANAL PALATAL TO 1ST ONE*

CANINE- OVAL
94% SINGLE CANAL
6% TWO CANALS WITH SEPARATE FORAMENS ie 2 roots

MANDIBULAR PMS

1ST PREMOLAR - OVAL
73% SINGLE CANAL
7% TWO CANALS WITH SAME FORAMEN
20% TWO CANALS WITH SEPARATE FORAMENS*

2ND PREMOLAR - OVAL
86% SINGLE CANAL
2% TWO CANALS WITH SAME FORAMEN
12% TWO CANALS WITH SEPARATE FORAMENS

MANDIBULAR MOLARS

1ST MOLAR – TRIANGULAR / TRAPEZOIDAL
98% TWO ROOTS
2% THREE ROOTS
72% SINGLE CANAL IN DISTAL ROOT
28% TWO CANALS IN DISTAL ROOT*
MB canal is most difficult to locate- its very narrow

2ND MOLAR
87% TWO CANALS IN MESIAL ROOTS
13% SINGLE CANAL IN MESIAL ROOT
92% SINGLE CANAL IN DISTAL ROOT
8% TWO CANALS IN DISTAL ROOT

 THE TOOTH THAT REQUIRES ENDO TREATMENT MORE OFTEN THAN ANY OTHER – MAND 1ST MOLAR (MISSED 2ND DISTAL CANAL)

 TOOTH THAT HAS HIGHEST ENDO FAILURE – MAX 1ST MOLAR

 LINGUAL WALL OF THE MAND TEETH THAT IS MOST PERFORATED DURING AO- DUE TO
LINGUAL INCLINATION - MAND 1ST PM

 THE ONLY MAND TEETH THAT IS SLIHTLY LABIALLY INCLINED – MAND CANINE

 MB ROOT IN MAX MOLARS IS THE MOST COMPLX ROOT AMONG ALL TEETH- - EITHER HAS MB2 OR ACCESSORY CANALS

 HIGHEST INCIDENCE OF ACCESSORY CANALS – MAX 2ND PMs with 60%

 TEETH WITH CLOSEST PROXIMITY WITH MAX SINUS - PMs & 1st MOLAR

 U-SHAPED RADIOLUCENCY SEEN ABOVE MAX 1ST MOLAR – ZYGOMATIC PROCESS

 CURVED ROOT – MAXILLARY LATERAL INCISOR

BMP INSTRUMENTS

K FILES
1. All files are made of SS
2. Twisting a blank that is a Square cross section
3. More +ve rake angle
4. High no. of flutes per mm length
5. Therefore less cutting efficiency- least aggressive.
6. But high fracture resistance, strongest of all files
7. Used for – orifice locating , pulp extirpation
8. Technique – push inside & pull outside in clockwise-anticlockwise motion
9. Can use filing and reaming action.
10. To remove hard tissue in canal enlargement.
11. 1st instrument to introduce in the canal

K REAMERS
 Twisting Triangle cross section rod
 -ve rake angle
 Better cutting efficiency than K file
 Technique – push, rotate only to one side, pull motion
 Can use only reaming motion-repeated clockwise motion
 To shave dentine & to enlarge canals
 Flexible files

H FILES
 Not twisting, but by using a sharp rotating cutter to create triangular segments out of a Round cross section blank.
 +ve rake angle
 Less no. of flutes per mm length
 Very sharp edges
 Therefore high cutting efficiency
 Poor fracture resistance
 Use carefully with filing action only=push-pull action

GATES GLIDDEN DRILL
 Long shaft- short cutting head- side cutting surface with safety tip.
 Tip diameter = 0.5-1.5
50 – 150 size K file
 For enlarging coronal 1/3rd of canal
 Coronal enlargement –50 size
 GG#1 FILE LENGTH – 20mm*
 Removes lingual shoulder

FILE SIZE EXPALANTION
6 8 10 Difference is 2
10 – 60 Difference is 5
60 – 130 Difference is 10

STANDARDIZATION OF INSTRUMENT IS- Width Tip
Diameter,
Do = file size / 100 I.e. One by hundredth of the file no.

PROTAPERS
Sx – S1 – S2 – F1 – F2 – F3
Triangular cross-section
Orange-Purple-White-Yellow-Red-Blue
DR.MAYAKHA MARIAM;THE GULFIE DENTIST 27
Engine driven files use only reaming action

BMP TECHNIQUE
 Reaming action- round canal shape
 Filing action causes irregular canal shape
 Widest diameter at canal opening & narrowest at the apex ie. dentino-cemental junc

BM PREP :-

PATENCY FILING – 10K file – Creating a gliding path first

INITIAL APICAL FILE- should get snug fit at the apex
MOLARS AND PMs – 10 K
INCISORS & CANINES - 25 K

MASTOR APICAL FILE- 3 consecutive files after IAF – till full working length
MOLARS -15, 20, 25K
INCISORS & CANINES - 30, 35, 40K

Recapitulation – Re-entering the canal using the smallest file after each file preparation- purpose-to clean the apical portion of any dentine scrapping that was not removed by irrigation – go beyond apex to avoid clogging of debris at apex – push file apically

Continue with hand files – START STEP-BACK AFTER MAF
1MM LESS FOLLOW STEP-BACK – 45, 50
Continue with rotary – CROWN DOWN TECHNIQUE

MASTER CONE
CORESSPONDING TO MAF
MOLARS – 25 SIZE GP
INCISORS – 40 SIZE GP

Recapitulation – Re-entering the canal using the smallest file after each file
preparation- purpose-to clean the apical portion of any dentine scrapping that was not
removed by irrigation – go beyond apex to avoid clogging of debris at apex – push file
apically

Continue with hand files – START STEP-BACK AFTER MAF
1MM LESS FOLLOW STEP-BACK – 45, 50
Continue with rotary – CROWN DOWN TECHNIQUE

MASTER CONE
CORESSPONDING TO MAF
MOLARS – 25 SIZE GP
INCISORS – 40 SIZE GP

Working Length Determination-
 Major constriction / diameter also known as radiographic diameter
 Should always end at minor constriction / diameter i.e. our working length - dentinocemental junc.
 0.5 -1mm from the radiographic apex
 Bmp & obt to be done till there
 This is Grossman method – best method

MODIFICATIONS:-
 If bone resorption at apex – 1.5mm short
 If external root resorption – 2mm short
 If open apex – put paper points & take radiograph of WLD
 If file goes beyond apex – correct it to 1mm short – retake the xray – then only do BMP

IRRIGANTS
Volume of irrigation – must be used in copious amount - most important factor
Irrigants reduce the surface tension in the canal.
NaOCl, EDTA, H2O2, CHX, MTAD, Urea Peroxide

SODIUM HYPOCHLORITE
¤ Most widely used irrigant
¤ Most effective irrigant
¤ 5.25% conc. – market 5% available
¤ Adv / properties
it has disinfectant & effervescent*
Tissue dissolvent – coagulation of protein
Antimicrobial properties
¤ Disadv – does not remove smear layer
¤ NaOCl Accident- toxic to vital tissue- always use rubber dam
¤ Don’t push apically- Periapical damage due to the tissue dissolving property

SMEAR LAYER –
- Layer seen on the dentinal walls after cavity prep or BMP
- Contains salivary proteins from mouth, fresh–cut dentine debris from debridement, bacteria in the infected canal
- It closes the open dentinal tubules – occluding them thereby
- It is protective in restoration to reduce sensitivity from the chemicals in the restorative material
- But for RCT, composite, retention of the material will be affected.

HYDROGEN PEROXIDE
¤ Irrigant – 3%
DR.MAYAKHA MARIAM;THE GULFIE DENTIST 29
¤ Effervescent action has two benefits
¤ One – the bubbling of soln when in contact with tissues will form debris – which is easier
to identify & thus clean out.
¤ Two - Anti microbial – the liberation of oxygen will kill the strictly anaerobic organisms
¤ Used alternatively with NaOCl.
CHLORHEXIDINE
¤ Daily use mouthwash – 0.12%
¤ Perio cases / gingivitis cases – 0.2%
¤ RCT cases as irrigant – 2% - highest conc.
¤ Advantages
Anti-microbial property
Substantivity*
¤ Disadvantage
Stain causing
Chance of occlude / obstruct salivary gland mainly Stenson’s duct (parotid )
Metallic taste
Caution – never mix CHX + NaOCl –CARCINOGENIC – dangerous & contraindicated (So how we use is after full saline irrigation – last u do CHX maybe.)

CHLORHEXIDINE
¤ Daily use mouthwash – 0.12%
¤ Perio cases / gingivitis cases – 0.2%
¤ RCT cases as irrigant – 2% - highest conc.
¤ Advantages
Anti-microbial property
Substantivity*
¤ Disadvantage
Stain causing
Chance of occlude / obstruct salivary gland mainly Stenson’s duct
(parotid )
Metallic taste
Caution – never mix CHX + NaOCl –CARCINOGENIC – dangerous & contraindicated (So
how we use is after full saline irrigation – last u do CHX maybe.)
EDTA
¤ Ethylene Diamine Tetra cyclic Acid
¤ Conc. of 17%
¤ Removes smear layer
¤ Decreases surface tension
¤ After apicocectomy – as root conditioning agent*
¤ It is more of a lubricant(smoothens canal) than fluid (than irrigant)
¤ Action stays for 5 days only
¤ Therefore always use in adjunct with NaOCl, which has longer effect.
¤ Chelating property- 5 mm of surface decalcifies. Therefore smoothening the wall after
BMP
UREA PEROXIDE / GLY OXIDE
¤ Recently developed irrigant & has all the properties
¤ Anyhydrous glycerol- because of glycerol’s slippery effect - best useful in narrow or curved canals.
¤ Smear layer removal- that NaOCl don’t have & EDTA has
¤ Anti microbial
¤ Effervescent – that H2O2 has
¤ Disinfection
¤ Can use in open apex & intentional RCT– as it is better tolerated by the periapical tissue than NaOCl
MTAD
¤ Mixture of tetracycline & detergent
¤ Best irrigant* that is generally available in clinic
¤ Can kill E-fecalis- that is the causative agent for re-infection - therefore the best so far.
¤ Re-RCT - MTAD is best irrigating fluid or the CHX to kill E-feacalis

ENOSONIC IRRIGATOR MACHINE
¤ Increase the efficiency of the canal irrigation to accept GP
¤ Sodium hypochlorite into canal
¤ Tip into canal
¤ Endosonic vibration + hypo effervescence

Re-RCT : MTAD / CHX
Weeping canal : NaOCl + Iodide Potassium
Curved canals : Urea peroxide
RC Prep content – EDTA + Urea peroxide

Q. What is the rationale of BMP?
For apex closure & GP filling till apex

Q. What determines the success of RCT?
BMP & proper irrigation, whereby the entire bacteria is removed thereby making the canal
bacteria-free zone

Q. Which is best for wld- ?
Apex locator-
R/f- slanting orifice opening- false apex- over instrumentation & obt

Q. What is TUGBACK EFFECT?
A GP cone is placed same as the file lastly used (MAF) is placed until the wl
Need to get tug back
Confirm with R/FGP
Cone should have proper apical seal- should not push further….if so take out-cut it and
place to get tug back effect- yaaani perfect seal without leakage.

Q. Formocresol used – 1/5th saturated

LASER IN ENDO:
 LASER ENDODONTICS – Nd YAG
 LASER PERIODONTICS – Nd YAG
 COMPOSITE LAYER – ARGON, 475nm wavelength, because it has more depth penetration.

RC SEALANTS
 Primary Function –fill all the voids btwn GP pts and between GP pts and walls.
 Other funtions- lubricant action, antibacterial activity (high immediately after obt – short lived though)
 Imp property - viscosity / condensation (that’s helps to give proper seal ok! )
 Lentospiral instrument is used to apply sealant*

EUGENOL BASED
1. Grossman
2. Tubli sealer
3. Endomethasone
4. Watch sealer

NON-EUGENOL BASED
1. Diaket (ketone based)
2. AH-26 (epoxy sealer )
Disadv- poor colour stability
Formaldehyde gas release
3. AH-26 PLUS

ENDOMETHASONE
 Most common
 Eugenol based
 Adv – has steroids, thus soothing the canal
 Disadvantageso
Soluble in tissue fluid
o Releases formaldehyde
o Staining- no colour stability
o Slow setting time

AH-26 PLUS
 Made to overcome the Disadv of AH-26
 No formaldehyde & has colour stability

REAL SEAL
 Biocompatible
 Nontoxic
 Leak resistant
 Removable with heat / chloroform
 Real Seal has lesser reaction than ZnOE & Epoxy resin
 ZnOE & AH-plus will be more irritating than real seal

NB: - Best or most superior material - AH-26 PLUS OR
INTRACANAL MEDICAMNT – CaOH common, ZnOE – no much qns

OBTURATION MATERIALS

GUTTA PERCHA
 66% Zinc Oxide*
 20% GP content
 Barium sulphate- radio opacifier
 Property - inertness
 Available alpha α & beta β forms, but most commonly used is beta form clinically
 Sterilization-best option is NaOCl, Secondary option is CHX & Hydrogen peroxide
 Alpha α GP – 42 to 49 °C, Thermoplasticised is the transition temperature of alpha GP.
This technique is called Thermoplasticised Tech.

SILVER POINTS
 Best indicated in straight canals / fine canals
 Instrument to hold silver pts – Stiglitz plier
 This plier – extraction of fractured root tip

RESILION
 Resin based obturating material
 REAL SEAL cone
 EPIPHANY sealer
 SYBRON ENDO machine
 New material that replaces the traditional GP+SEALER combination
 Overcomes 2 drawbacks of traditional method:
o Shrinkage of GP on cooling
o Gap formation that occurs due to the inability of GP to bind physically with the sealer

All three – GP, resilion & silver pts are contraindicated in primary teeth
Most common obturation material in pedo – ZnOE
Whereas ideal pedo obturation – is METAPEX, VETAPEX, KRI Paste ( iodoform + CaOH )

Q. What are the objectives of obt?
 To get fluid tight deal at the apex
 Void free filling of root canal
 To allow proper tissue healing at the apex by creating a favourable biological environment

Q. Key to rct sucees?
Proper irrigation & debridement

OBTURATION TECHNIQUES

LATERAL CONDENSATION / COLD GP TECHNIQUE
 Place master GP pt.
 Lateral condense with spreader
 Add on GPs
 No heating
 Commonly used on clinics
 Temp related

VERTICAL CONDENSATION / WARM GP TECHNIQUE
 Place GP – warm slightly, temp related
 Warm instrument & condense downward
 Disadv – vertical root fracture

THERMOPLASTICIZED GP TECHNIQUE
 Alpha form GP – 42 to 49 °C melting
 A gun is used
 Pallet / gun / capsule
 Temp related
 Technique – Obtura II technique
o Curved / accessory canals – indication
o Complication by doctors –voids formations
o Mistake by PG students – periapical extrusion

THERMO-MECHANICAL / MC SPADDEN TECHNIQUE
 Using inverted H file – mechanical
 Disadv – can’t use in curved canals
 High chances of instrument fracture / separation
 Heat GP slightly - thermal

CONTINUOUS WAVE / SECTIONAL GP TECHNIQUE
 System B device used
 Post & core cases
 Obturating apical portion – apical 3rd
 Continuous condensation technique
 Disadv – more time consuming

CHEMICALLY PLASTICIZED / CUSTOM-MADE GP
 Indication – young permanent tooth – open apex ones- 1year after apexificatiion
 Roll 2-3 GPs on a glass slab & make one thick GP

ENDO MISHAPS

PAIN
a) During RCT (same day ) – over-instrumentation, due to pdl damage
b) After 2 days – secondary apical periodontitis**
c) After RCT (1 week or 1 yr also) – secondary apical periodontitis
- Should do re-RCT
- But wait 1 month, because patient with stress will have bacteriemia more.
- Give antibiotics till then

INSTRUMENT SEPARATION ( Common in rotary files )
a) At apex
 Can leave it there if BMP almost done – if its tightly sealed at apex – if no periapical lesion – Good prognosis
 Cant leave – if did only minimal canal enlargement ie. BMP had only started – then complete RCT up to the file breakage – then do apicocectomy + retrograde filling.
b) At furcation / middle / coronal 3rd
 Poor prognosis

LEDGE FORMATION
 Ledge is a nick formed on the wall surface of a root canal, especially at the curves that prevent the instrument going further towards the apex- because it gets stuck there.
 Caused when instrument that is not pre-curved is inserted into the canal with excessive pressure
 Take a small size file – apply EDTA & do circumferential filing for long time- it will help smoothen out the ledge by cutting away excessive dentine.
 Thereby bypass the ledge
 EDTA helps dissolve & soften the area - chelation property
 After correction of ledge & bypass, the wall becomes very thin, therefore chances of perforation - most important complication

 Correction at furcation
a) Stop RCT
b) Place MTA / CaOH / GIC
c) Thus the form of a barrier
d) Continue with RCT
e) Or OBT only after healing
 Management of perforation is done after BMP & before OBT

PERFORATION
a. At furcation / coronal 3rd – good prognosis
b. At middle 3rd / apical 3rd – poor prognosis
c. If perforation at apical 3rd – poor prognosis
d. If at furcation – best prognosis

LEDGE FORMATION
 Ledge is a nick formed on the wall surface of a root canal, especially at the curves that prevent the instrument going further towards the apex- because it gets stuck there.
 Caused when instrument that is not pre-curved is inserted into the canal with excessive pressure
 Take a small size file – apply EDTA & do circumferential filing for long time- it will help
smoothen out the ledge by cutting away excessive dentine.
 Thereby bypass the ledge
 EDTA helps dissolve & soften the area - chelation property
 After correction of ledge & bypass, the wall becomes very thin, therefore chances of perforation - most important complication

 Correction at furcation
a) Stop RCT
b) Place MTA / CaOH / GIC
c) Thus the form of a barrier
d) Continue with RCT
e) Or OBT only after healing
 Management of perforation is done after BMP & before OBT

PERFORATION
a. At furcation / coronal 3rd – good prognosis
b. At middle 3rd / apical 3rd – poor prognosis
c. If perforation at apical 3rd – poor prognosis
d. If at furcation – best prognosis

STRIPPING
 Danger zone
 Mand – mesial aspect of distal root canal- inside aspect
of the curved area
 Treated with MTA
 Rotary instruments
 Due to excessive flaring of canals

POST & CORE

 When there isn’t enough crown structure
 Can put on same day as OBT
 Depends on the remaining coronal structure of the nature tooth – indication
 Function – retention of core
 PIEZO REAMER is used to make post space inside the canal
 Continuous wave / sectional GP / system B technique
 Resin – modified GIC is ideal to cement post
 Factors that affect its efficiency:-
a. Length :-
 2/3rd of the canal – most imp
 4-5mm length from apex
 4mm- minimum GP to be left
 5mm- ideal GP to be left in the canal
b. Diameter :-
 Greater the diameter, more the efficiency
c. Surface Texture :-
 Rough surface is preferable than smooth ones. Roughened / serrated
d. Post material :-
 Pre-fabricated posts such as fibre posts & metallic posts
 Custom made posts such as casted posts
e. Post shape :-
 Parallel is preferred than tapered ones
 More retention

CASTED POSTS
 Indicated in anteriors & flared canals

FIBRE POSTS
 Can absorb shock
 Best in posteriors
 Can withstand masticatory forces

METAL POSTS
 Least preferred
 May fracture the tooth

CORE BUILD-UP
 Core should take the shape of natural tooth
 Should extend to contra-bevel to produce ferrule effect
NB: Management of re-infected post & core treated tooth:

Apicocectomy
If not possible go for extraction
Can’t do re-RCT here usually

APICOCECTOMY

 Apex removal
 RETROGRADE FILLING / ROOT END FILLING
 Done if re-infection seen even after re-RCT
 Indication
o To gain access to are of pathosis – like say a cyst
o Poorly filled apical portion
o Severe root curvature / non- negotiable canal ends / blockage
o Infection after post & core cases – most common cause of opting for apicocectomy
o cyst formation cases
o Complications happened during RCT –
Instrument separation / ledging /
perforation
o Biopsy
 Method: raise flap – curette the apical area – root end resection – condition with EDTA – fill with MTA – then place flap – suture tightly
 Grey MTA ( with ferric content, as its not moisture sensitive ) is the material of choice
 Success lies in
o proper placement of flap
o type of flap

 Root end resection:
o Can cut up to middle 3rd
o Flap-- full mucoperiosteal – best flap
o 3mm retrograde filling into canal
o Usually ideal measurement is about 3-4mm
o Ideal angulation is 10° or acute angle
o Commonly cut at 45°
o Condition – clean – MTA pack – flap – suture

ELLIS CLASSIFICATION OF FRACTURE

CLASS I – ENAMEL FRACTURE

CLASS II – ENAMEL + DENTINE FRACTURE
 Treatment – Re-attachment of fractured fragment
 Or CaOH base (if sensitivity present) + composite build-up

CLASS III – ENAMEL + DENTINE FRACTURE + PULP EXPOSURE
a) Within 24 hrs
o Or if only pin-point exposure (less than 0.5mm) - DPC
b) More than 48 hrs / 2 days
o Or if exposure more than 0.5- 3mm - Pulpotomy
o Consider the age also i.e. young permanent tooth
c) More than 72 hrs / 3 days
o If young permanent tooth - Apexification
o If fully formed permanent tooth - RCT
NB: No IPC in fractured / trauma cases

CLASS IV – NON-VITAL DISCOLOURED TOOTH
a. If young permanent tooth - Apexification
b. If fully formed permanent tooth – RCT

CALSS V – AVULSION
FIVE FACTORS THAT DETERMINE THE SUCCESS
a. TIME
i. 30 MINS-1 HOUR – best prognosis
ii. MORE THAN 1 HOUR - ERR
b. STORAGE MEDIA (NB : Never use tap water)
iii. Viaspan - best option ( used in heart transplantation )
iv. HBBS - best option in clinical setup
v. Cold milk – most commonly used & readily available
vi. Physiologic saliva and saline
c. TOOTH SOCKET
vii. Should not be curetted or disrupted

Q. Should you irrigate the socket?
Ans. No irrigation required, but if necessary only mild irrigation acceptable. Vigorous irrigation is contraindicated.
d. SPLINT STABILIZATION
viii. Splint type – flexible splint – that will allow physiologic movement.
ix. Splint time – 2 weeks or 1-2 weeks – 7-10 days is ideal*
e. ROOT SURFACE
x. Should not be dried
xi. Should not be scrapped or manipulated with any chemicals

Q. How should the tooth be held?
Ans. Only at the crown portion. Never touch the root – might hamper the natural PDL.

Within 60mins
- Viability of PDL cells stays max up to 60mins only – that is the 1st priority of the treatment, re-implantation
- If dried beyond that time, pdl dies off
- Success rate depends on pdl viability i.e. extra-oral dry time
1. Rinse in tetracycline
2. Replace in socket & splint with adjacent teeth
3. Splint type – flexible splint
4. Splint time – 2 weeks or 1-2 weeks – 7-10 days
5. Start RCT after 2 weeks – if not external root resorption may happen
6. Here we expect normal PDL attachment over a period of 1 year
7. Until then CaOH is placed into the canals, which is replaced every 3 months for 1 year.
8. Possible complication here –– ankyloses or replacement resorption
9. But usually good prognosis

After 60 mins
1. Rinse/soak in 2.4% acidulated fluoride solution at pH 5.5 (citric acid + sodium fluoride) (helps prevent root resorption )
2. Extra-oral RCT is performed by holding the tooth in fluoride soaked gauze.
3. The socket clot is suctioned and irrigated with saline to remove the clot.
4. Replant with digital pressure, the Splint with flexible splint for 4 weeks
5. Possible complications –
a. Here we expect either ankyloses or replacemental root resorption – which will happen within 2 years
b. inflammatory external root resorption (IERR) – which is the main reason for failure of reimplantation Therefore can displace the tooth i.e. possibility of avulsion again
c. Ankyloses will give better prognosis than ERR, which will lead to failure.
Once ankylosed, chances for IERR decreases over time.

CLASS VI – ROOT FRACTURE

Vertical Root Fracture
Causes
- Post & core cases
- Warm GP / vertical condensation cases
- Bite / chewing
- Accidental trauma
Diagnosis
- J-shaped radiographic appearance
- Tear-drop shape
- Isolated PDL pocket
[Other causes for isolated pockets
o Endoperio lesion – pathological
o Developmental groove (max LI) – normal variant ]

Horizontal Root Fracture
Apical 1/3rd
- Treatment is wait & watch
- Small fragment may get resorbed by cementoblasts & odontoblasts
- Later do RCT
- Best prognosis
Middle 2/3rd
- Wait & watch
- May get resorbed
- Then go for RCT for rest of the coronal root
- Lesser prognosis
Cervical 3rd
- Prognosis is very poor
- Splint to adjacent teeth with rigid splint such as metallic band / wire
- Wait & watch
- Extraction if no re-attachment seen

CLASS VII – LUXATION
INTRUSION - Chances of cut-off of blood supply is seen in intrusion – in 6 months – revascularization should happen – therefore the wait & watch scheme

a. PERMANENT
- Wait & watch for 6 months for natural extrusion / eruption
- If not orthodontic extrusion
b. PRIMARY
- Radiograph is must 1st
- If tooth is impinging underlying tooth follicle – Extract
- If no impingement – wait & watch for 6 months
- If impingement on follicle – leads to Turner’s Hypoplasia
- Never extract tooth normally – open flap, split the tooth, the extract

EXTRUSION / LATERAL LUXATION
- Replace into normal position
- Followed by flexible splinting for 2 weeks

SUBLUXATION
- Tooth that is mobile without displacement. Here tooth supporting structure is affected, hence the mobility.
- Place back into normal position
- Flexible splint for 2 weeks
- Wait & watch, then decide if RCT required

CLASS VIII – CROWN-EN-MASSE FRACTURE
- Treatment – RCT + Post & core build-up of crown

CLASS IX – PRIMARY TOOTH FRACTURE
- Avulsion in pedo
- Never place it back, Discard the tooth
- Give space maintainer if needed

DISCOLOURATIONS

YELLOWISH- WHITE
- Pulp is inflammed & calcified, non-necrotic
- It is calcific metamorphosis
- No infection here. Tertiary dentine in formed extensively
- Dystrophic calcification, pulp stones may be seen
- If asymptomatic – RCT not required – give crown directly

YELLOWISH GREY TO BROWN / RED
- Pulp is dead & undergoing necrotic changes
- Do RCT, some bleach ( GP up to middle 3rd only then rest fill up with GIC – tight seal, because hydrogen peroxide must not fall into the canal
- Go for crown if needed

TETRACYCLINE STAINS
- Yellow brown stain seen in adults
- If pregnant mothers take tetracycline – child’s primary teeth will be affected
- If child takes tetracycline during early ages – permanent dentition will be affected
- Mechanism – during the stage of tooth formation, tetracycline bonds to teeth instead of Calcium
- Treatment :– if mild  bleaching ; if severe  veneer / crown

PINK TOOTH OF MURMERY
- Internal resorption
- Pulp is enlarged & hyperactive
- Enamel shell shows off the pulp ( because dentine is resorbed here )
- 90% seen in primary teeth
- Cause is unknown ……….. Due to inflammatory reaction?
- This the reason why DPC is contra-indicated in primary teeth. CaOH is of 12Ph, which will irritate the pulp thus initiating the inflammation
- Irreversible type of pulpitis
- Radiograph – isolated radiolucency, & not moth-eaten appearance
- If asymptomatic, thus usually found during routine radiographs
Treatment – single sitting pulpectomy / RCT
- If symptomatic, pulp extirpation – followed by CaOH
(Pulp chamber which is highly acidic will be neutralized by CaOH)

CYSTIC FIBROSIS
- They are on tetracycline, thus the stains
- They always have a variety of infections
- Key feature - thick secretions

ERYTHROBLASTOSIS FETALIS
- Yellow molars
- Bleaching is the treatment, if required only
- Treatment not necessary

PORPHYRINE STAINS
- Red stains

AMALGAM BLUEING
- Blueish black discoloration due to amalgam

BLEACHING
Bleaching is the removal of stains that has been formed on the organic content of the tooth.

A. NONVITAL TOOTH

THERMOCATALYTIC TECHNIQUE
 Material used – hydrogen peroxide – 30%
 After RCT – remove GP from the coronal top – place GIC filling – about 2mm as protective
cement barrier – Place the oxiding agent – 30% hydrogen peroxide- SUPEROXOL – inside the
chamber & apply heat
 Done in office set up
 Done intracoronally – because its more effective.
 Dangerous – must not fall into the canal, in the oral mucosa, due to high concentration of
hydrogen peroxide
WALKING BLEACHING
 Material used – sodium perborate
 Place mixuture of sodium perborate + water inside the chamber
 Changed every 4-7 days
 Finish in 2-6 weeks.
 In-home bleaching technique
 Safer than superoxol

B. VITAL TOOTH
 IMMEDIATELY AFTER BLEACHING, COMPOSITE IS CONTRAINDICATED – because the content of bleaching agent will hinder the polymerization of composite – therefore always delay the composite restoration by 1 week – by placing temporary restoration for that time period

CONTRAINDICATIONS OF RCT
 Non-restorable tooth
 Vertical root fracture
 Tooth with insufficient periodontal support / periodontally weak ones

FILE CALCULATION :-

Length of files available: 21, 25, 31

ISO INSTRUMENTATION IS BY WIDTH OF FILE TIP- Do

TO FILE SIZE 34 CUT 2MM FROM FILE 30