Endodontics PDF
Endodontics PDF
Endodontics PDF
As a general rule, when a broken instrument protrudes past the apex , surgery should
be performed to remove the constant irritation.
When an instrument breaks off anywhere in the canal and a periapica l radiolucency
is present and minimal canal enlargement has been performed before the accident ,
surgery is indicated since the periapical tissues have had little opportunity for
healing to be stimulated. You would prepare and obturate to the point of blockage and
then perform apicoectomy and retrofilling.
However, when an instrument is broken off in the apical third and is lodged tightly with
no periapical radiolucency evident , the canal can be filled in the remaining root canal
space. The patient should be informed of this and placed on a 3-6 month recall.
The prognosis of a tooth with a broken instrument is best if the tooth had a vital pulp
and no periapical lesion.
Ind Tth
ENDODONTICS
Which tooth below will almost always have two canals?
Approximately 60% have two roots, one buccal and the other palatal , each with a single
canal. The two roots may be completely separate or merely twin projections rising from the mid-
dle third of the root to the apex (this is more common). The two roots are usually equal in length
from apex to cusp. However, the palatal root and canal may be wider.
In approximately 40% of maxillary first premolars, only one root is present, usually with
two separate canals. A cross section at the cervical line shows a canal shaped like a figure eight
(ellipse). The access opening is a thin oval. Be careful not to perforate on the mesial (the con -
cavity on the mesial makes pe rforation vel)' common ).
Maxillary second premolars : The most common configuration in this tooth is a single root,
occurring approximately 85% of the time. Approximately 15% of the time, two separate roots are
present, each with a single canal. The access opening is exactly the same as that for maxil-
lary first bicuspids (thin oval).
Notes :
• When only one canal is present (first or second premolars), it is usually found in the center
of the access preparation. If only one canal is found, but it is not in the center of the tooth, it
is probable that another cana l is presen t.
• Overfill ing either tooth may force materials directly into the maxillary sinus.
Ind Tth
ENDODONTICS
Which tooth listed below may have a pulp chamber that is somewhat triangular as
opposed to oval?
The base of the triangle will be the facial. The apex will be the lingual. If it is not tri-
angular, then it will be oval.
Max 00(@
@ @ 0
Central Lateral Canine
Mand.
Mandibular molars
• Trapezoidal outline, formed by the two canals in the mesial root and the oval canal
in the distal root.
Remember: The distal root has a second canal approximately 30% of the time.
L
Ind Tth
ENDODONTICS
Which of the following canals in a maxillary first molar is usually the most difficult
to locate?
• Palatal
• Distobuccal
• Mesiobuccal
• All of the canals are relatively easy to find
Canal orifices of a maxillary fi rst molar are arranged in the shape of a triangle. The orifice to
the mesiobuccal canal is usually the most difficult to locate, since it is under the
mesiobuccal cusp and must be entered from a distolingual position. This canal is the small-
est canal and often splits into two canals. It maybe calcified and difficult to instrument. The
palatal canal is the straightest, widest and most tapering canal. The most common curvature of
the palatal root is to the facial. The distobuccal canal is also small and tapering. The orifice to
this canal has no direct relation to its cusp. The distobuccal orifice is usually located by means
of its relation to the mesiobuccal orifice, with the distobuccal found approximately 2 to 3 mm to
the distal and slightly to the palatal aspect of the mesiobuccal orifice.
Note: In approximately 59% of maxillary first molar teeth, a fourth canal is present with its ori-
fice being just lingual to orifice to the mesiobuccal canal. The canal is located in the
mesiobuccal root and may join the mesiobuccal canal or exit through a separate foramen. If a
lesion is present on the mesiobuccal root prior to root canal therapy and doesn't heal in the usual
amount of time (6-12 months) following treatment, it is most likely due to a missed canal (mesio-
lingual).
Remember : The U-shaped radiopacity commonly seen overlying the apex of the palatal root
of the maxillary first molar is most likely the zygomatic process of the maxilla.
Ind Tth
ENDODONTICS
The root canal for a mandibular canine is:
The root canal for a mandibular canine is thin mesiodistally but wide labiolingually.
Mandibul ar canines usually have only one root but in rare cases may have two sep-
arate roots. The access opening is a large oval with the greatest width placed
incisogingivally.
This tooth usually has a slightly labial axial inclination of the crown, therefore the
access opening needs to be directed towards the lingual surface.
Ind Tth
ENDODONTICS
Which mandibular premolar presents with more variations in root canal anatomy?
• First premolar
• Second premolar
The mandibular first premolar may cause problems during treatment because of the
relatively frequent ( 15%) existence of a bifurcated canal dividing in the middle or apical
third into a buccal and a lingual branch. The shape of the access opening is oval. When
divided canals are present, the entry must be widened buccolingually.
The second premolar has fewer variations than the first premolar, usually having one
root and one well-centered canal. The access opening is oval. Consideration must be
given to the mental foramen which lies in close proximity to the apex. Avoid over-
instrumentation and overfill. When viewing an x-ray of this area, the mental foramen is
sometimes misdiagnosed as a premolar abscess. Therefore, before performing root
canal therapy, make sure all diagnostic tests confirm your finding.
• Ether
• Superoxol
• Chloroform
• Sodium hypochlor ite
Important:
• The most probable postoperative complication of bleaching a tooth that has not
been adequately obturated is an acute apical periodontitis.
• Tooth bleaching causes a color change in both enamel and dentin.
Walking bleach technique: Place a thick paste consisting of sodium perborate and
2-3 drops of Superoxol in the tooth chamber with a temporary restoration. Several
repetitions of this procedure can work quite well.
Ind Tth
ENDODONTICS
Which tooth below is most likely to have a curved root?
The maxillary lateral incisor always has one root with one canal. The root is more slender than
the maxillary central incisor, and frequently (55%) has a distal and/or lingual curvature or dilac-
eration. The access opening is oval.
Maxilla ry cent ral inc isor: The maxillary central incisor always has one root and one canal.
The root is bulky with a slight distal axial inclination, but rarely has a dilaceration. The access
opening is ova l-triangular.
Maxilla ry canine: The maxillary canine always has one root and one canal. This tooth is the
longest in the arch. The access opening is oval.
Note: The maxillary central, lateral and canine roots and, hence, canals all have a distal axial
inclination . This means in penetrating along the long axis of the tooth, the bur must be slightly
angled toward the distal surface. Failure to do this may lead to perforation of the mesial por-
tion of the root.
Mandibular central incisor : The mandibular incisors (laterals and centra ls) have only one root
which is narrow mesiodistally but relatively wide labiolingually and may have a distal and/or
lingual curvature. Two canals may be present. When there are two canals, the labial canal is
the stra ighter one. The access opening for a mandibular central or lateral is a long oval , with
the greatest width placed inciosogingivally and the incisal extent very close to the incisal edge.
Ind Tth
ENDODONTICS
Which of the following teeth most often refer pain to the tempo ral region?
• Mandibular molars
• Maxillary incisors
• Maxillary second premolars
• Maxillary molars
If carefu l diagnosis does not reveal the affected tooth, other teeth and related
anatomic structures become suspect. Pulpitus in one tooth may cause pain in other
areas. The pain is referred.
Important: The nerve endings of cranial nerves VII, IX, and X are widely distributed
within the subnucleus caudalis of the trigeminal (V) nerve. A profuse intermingling of
these nerve fibers creates the potential for the referral of dental pain to many
sites.
Ind Tth
ENDODONTICS
Which tooth listed below requires endodontic treatment most frequently?
The most common morphology for the access opening in mandibular first molars is a trape-
zoid formed by the two canals in the mesial root and the oval canal in the distal root. Both the
mesial and distal canals lie in the mesial two-thirds of the crown. The mesiolingual canal lies
beneath the mesiolingual cusp. The mesiobuccal canal Is the most difficult to locate but is
usually found on a straight line to the buccal from the mesiolingual orifice and is tucked deeply
beneath the mesiobuccal cusp. The distal canal is the largest and easiest to find. Therefore,
it should be located first, lying slightly distal to the buccal groove, closer to the buccal than the
lingual wall.
Note: If the distal canal is more buccal (not in center of tooth), there will usually be a fourth canal
(towards the lingual). This occurs in approximately 30% of mandibular first molars.
The lingual wall of mandibular molars is most easily perforated when preparing the access
opening (compared to maxillary molars). Perforations into furcation areas have the poorest
prognosis. When instrumenting the mesial canals of mandibular molars, be careful not to
strip-perforate the distal surface of the root (this can happ en if you are too aggress ive).
Remember: The mesiobuccal roots of maxillary molars and the mesial and distal roots of
mandibular molars often have two root canals. Make sure you look for them.
Diag Meth
ENDODONTICS
Which of the following are con tra indications to the use of the electric pulp tester?
Note: The EPT (also called vitalometer) is the most popular and most debated diag-
nostic method.
The clinician dries off the tooth to be tested. Normally the tooth in question, the tooth
adjacent to it and the contralateral tooth are tested . On a dry enamel surface, one
places some toothpaste (conductive medium) on the tip of the tester, which is then
applied to sound tooth structure. The operator then delivers various electrical currents
to the tooth and the patient will respond to these. This indicates to some people
whether there is pulp vitality or not. To others, the degree of response can be correlat-
ed to a different pupal state of health. Not all clinicians agree about this, but everyone
seems to be in agreement that the EPT is not always reliable.
Note: The EPT should be applied first to at least one tooth other than the tooth in ques-
tion. This will determine a normal response for the patient.
Diag Meth
ENDODONTICS
According to the buccal object rule, when the x-ray tube is repositioned either at a
more mesialor at a more distal angulation and a film is exposed, the root or canal far-
ther from the film (the buccal) will:
Therefore, when the cone is aimed to the distal (angled from the medial direction)
the buccal root or canal moves to the distal and appears distal to the lingual or
palatal root (or canal).
Note: In order to apply this rule, you must have a reference object.
By applying the buccal object rule you will be able to determine which canal is the
buccal and which is the lingual.
Diag Meth
ENDODONTICS
What diagnostic tests are indicated for teeth that have recently been traumatized?
• False-positive response
• False-negative response
To some people, the electric pulp tester (EPT) only suggests whether the tooth is vital or non -
vit al. To others, the degree of response can be correlated to a different pulpal state of health.
Importa nt: The electric pulp tester alone is not sufficient to allow a diagnosis of the pulp and
must be combined with other tests.
Other test s that need to be done for a diagnosis:
o Percussion - this test is a valuable diagnostic tool. It is performed by tapping the surface of
the tooth with an instrument (mirror handle). Once the infection has extended through the api-
cal oramen into th P.D pace and apica tissue Rai ts localized wi the percussio ts t.
o Palpation - isolation of an inflamed or swollen area. It is performed by manipulating the tis-
sue or applying pressure on an area with the fingers or hand.
Radiograph - the most important diagnosis aid. X-rays can reveal deviations from the nor-
mal that cannot be detected by any other method.
o Hot and cold tests - how tooth responds is a clue to the status of the pulp.
Response to EPT:
Hy remi oot - tooth will respond to less current than normal
o A ul i ' - tooth will respond to even less current than hyperemia
C I "s - tooth will respond to higher current than normal
o P. ros ' - tooth will not respond to any current
Diag Math
ENDODONTICS
Which of the following are useful diagnostic aids that can be used to determine if a
tooth has a vertical crown-root fractur e?
Impo rtant: Radiographs (without first wedging the tooth) rarely will show vertical frac-
tures.
Notes :
1. A tooth with a vertical fracture through root structure has a poor prognosis.
2. Studies have indicated that most vertical root fractures are caused by too much
condensation force during obturation with gutta-percha.
Therapy for horizontal fractures of the root always involves considerable difficulty.
Root canal treatment is not indicated if the fracture sites remain in close proximity and
if the pulp retains its vitality. However, if clinical symptoms develop or the segments
appear to be separating according to the x-ray, some treatment is necessary.
Terms/Cond
ENDODONTICS
The chronic apical abscess (CAA) is gen erally:
• Very painful
• Asymptomatic
• Mildly painful
The chron ic apical abscess (also called suppurative apical pe riodon titis) is sometimes so painless that
it may go undetected for years until revealed by an x-ray. It is a long-standing, low-grade infection of the
periapical bone with the root canal being the source of the infection. This condition may follow an acute
alveolar abscess or unsatisfactory root canal therapy. RadlograRh will ell a diffuse radiplucency and
eo hickening. The tooth may e lightly loose on tender t percussion. The chronic abscess may be
differentiated from cysts and granulomas by the fact that both cysts and granulomas have well-defined
radiolucencies associated with them. The treatment is conventional root canal treatment.
Remember : 3 00 to 500 0 bona calcium must be altered befor ra diographic idence of periapical
braakdo (this alteration takes place at the j unction between the cortical and cancellous bone).
The acute apical abscess (MA) is a localized collection of pus in the alveolar bone at the root apex fol-
lowing death of the pulp with extension of the infection into the periapical tissue. The first symptom may
be a slight tenderness of the tooth. This later develops into a severe throbbing pain to percussion with
swelling of the overlying mucosa. The tooth becomes more painful, elongated and loose. At times the
pain may decrease or disappear completely. The patient may appear weakened, irritable and present with
a fever. The diagnosis is based on the history, exam, and radiographs. The tooth will not respond to
the EPT or cold test but may respond to heat. Treatment of an acute alveolar abscess includes
establishing drainage and debriding the canal system of necrotic tissue which will relieve the
acute symptoms. This is followed at a later date by conventional root canal therapy.
Note: if the abscess ruptures through the periosteum into the salt tissue, the patient's symptoms will sub-
side.
Terms/Cond
ENDODONTICS
In which of the following conditions are the pulps of the involved teeth likely to be non-
vital?
• Apical scar
• Cementoma
• Radicular cyst
• Traumatic bone cyst
• Chronic dental abscess
• . Globulomaxillary cyst
• Chronic periapical granuloma
• Gutta-percha
• Calcium hydroxide
• Zinc oxide
• Eugenol
Apex if ication is a technique whose goal is to induce further root development in a pulpless
tooth by stimulating the formation of a hard substance at the apex, so as to allow obturation of
the root canal space.
The technique consists of isolation of the field with a rubber dam , making an access cavity and
removing all pulpal tissue by the use of reamers and files. A premixed syringe of a calcium
hydroxide-methylcellulose paste (for example, a Pulpdent syringe) is injected into the canal
until it is filled to the cervical level. The paste must reach the apical portion of the caOSll1Q...§tirn:
ulate the tissues to form a calcific barrier. A double seal of cement is made to close off the access
cavity. The patient is recalled after three months to see if apexification has taken place. If not, a
fresh supply of paste is placed. If apexification has occurred , convent ional root canal therapy is
instituted.
The action of calcium hydroxide in promoting formation of a hard substance at the apex is
best explained by the fact that calcium hydroxide creates an alkaline environment that promotes
~rd tissue deposition
Note: If a permanent tooth fractures and has a fully formed root and the pulp is exposed (large
exposure), the treatment of choice is complete root canal therapy. Apexification is not need-
ed because the root is fully formed. If the exposure is small and the length of time is short (1/2
hour to 1 hour) , then a direct pulp cap with CaOH followed by a restoratioD is the treatment of
choice. --
Terms/Cond
ENDODONTICS
The most common cause of acute osteomyelitis of the jaws is:
• Unknown
• Iatrogenic
• Dental infection
• Radiation
It is not a particularly common disease. It is a serious sequela of periapical infection that often
results in a diffuse spread of infection throughout the medullary spaces, with subsequent necro-
sis of a variable amount of bone.
Acute or subacute osteo myelitis may involve either the maxilla or the mandible. In th e max-
ill a, the disease usually remains fairly we ll- localized to the area of initial infection. In the
mandible, bone involvement tends to be mo re diffuse and w idespread.
Clin icall y, the person afflicted with acute osteomyelitis is usually in rather severe pain and man-
ifests an elevation of temperature with regional lymphadenopat hy. The teeth in the area of
involvement are loose and sore so that eating is difficult, if not impossible.
Radiographi cally, acu te osteomyelitis progresses rapidly and demonstrates little radiographic
evidence of its presence until the disease has developed for at least one to two weeks. At that
time, diffuse lytic changes in the bone begin to appear. A "moth-eaten" radiolucent appearance
is evident.
The general principles of treatment demand that drainage be established and maintained and
that the infection be treated with antibiotics to prevent further spread and complications.
Terms/Cond
ENDODONTICS
Which material listed below has historically been the retrofilling material of choice?
• Compos ite
• Zinc-free amalgam
• Gutta-percha
• Methyl methacrylate
"·The best argument for the use of zinc-free amalgam is the lack of expansion found when con-
taminated with moisture.
A retrofilling (also called a reverse filling or retrograde amalgam filling) is placed to seal the apical
portion of the root canal. This procedure is used wh en an ap icoe ctom y alone will not y ield a good
result. Whenever there is any chance whatsoever that an apical seal may be faulty, a reverse filling
material must be pl aced. For example, if the root canal appears calcified, it would be impossible to
obturate most of the canal and get a seal. If just the root apex were cut off (apicoectomy), the incom-
pletely filled canal might act as a source of reinfection. To prevent this after the root tip is resected, the
foramen is found, enlarged, and filled with a zinc-free amalgam to create a seal.
An apicoectomy (root resection, root amputation) is a procedure where the buccal tissue is flapped
back, the buccal bone about the apex is removed, th e root apex is remo ved , and the area is curet-
I ted out. Indication s for apicoe ctomy: 1) A rever se fil ling needs to be placed. 2) It Is necessary to
gain access to an area of pathosis. 3) The poorly filled apical portion of the root is to be removed to
the level of canal obliteration. Note: A retrograde amalgam filling should always be done after an api-
coectomy. Teeth that have posts in them and need to be retreated are the most common reason for
an apicoecto my and a retrograde filling.
Remember: Periapical curettage is the same procedure as an apicoectomy (as far as flap and
removal of buccal bone), but witho ut removing the root apex. Removal and examination of the dis-
eased tissue and determination of the extent of the lesion are the objectives of apical curettage.
Terms/Cond
ENDODONTICS
Which condition listed below is characterized by pain that is spontaneous and has
periods of cessation (intermittent in nature)?
• Reversible pulpitis
• Irreversible pulpitis
The severity of the clinical symptoms will vary as the inflammatory response increases. Pain will
vary from a mild and readily tolerated discomfort to a severe, throbbing and excruciating pain.
The pain is spontaneous and is intermittent In nature. The pain lingers after the removal of
the irritant. The pain is usually not readily localized by the patient but is diffuse in character.
Lying down or bending over intensifies the pain of irreversible pulpitis because the overall
increase in cephalic blood pressure is relayed to the confined pulp tissue. The tooth may be ten-
der to percussion, heat may intensify the pain response while cold may relieve it (in advanced
stages). Usually they both will cause seve re and lasting pain. The radiographs will usually dis-
close ~riap lcal pathologY.. Treatment is root canal therapy.
• Reversible pul pitis (hyperemia): The pain associated with hyperemia does not occur spon-
taneously. It requires an external irritant to evoke a painful response (i.e., cold, sweets). The
pains are sha rp and of brief duration, ceas ing whe n the irri tant Is removed. Radiographs
appear normal (may show deep caries or cavity preparation). The tooth is usually percussion
negative. In thermal tests, the pulp responds more readily to cold stimuli than to hot (the
response leaves shortly after removal of stimulus). Treatment usually is a sedative filling
or new restoration with a base .
• Cyst
• Phoenix abscess
• Granuloma
• None of the above
It is also known as a recr udescent abscess. It develops as the granulomatous zone becomes
contaminated or infected by elements from the root canal. Diagnosis is based on the acute symp-
toms (pain to percussion) plus radiographic examination, which reveals a large periapical radi-
olucency.
A granuloma is defined as a growth of granulomatous tissue continuous with the periodontal lig-
ament resulting from pulpal death with diffusion of toxic products into the periapical area. In most
cases a granuloma is symptomless. Radiographically, one sees a well-defined area of rar-
efaction with some irregularities, while clinically the tooth is not sensitive. A massive Invasion
of pulpal contaminan ts will result In the formation of an acute abscess (Phoenix abscess) .
A cyst is an inflammatory response of the periapex, which develops from preexisting granu-
lomatous tissue (granuloma ). It is characterized by a central, fluid-filled, epithelium-lined
cavity , surrounded by granulomatous tissue and peripheral fibrous encapsulation. It is often
associated with a chronically infected tooth. The tooth may be mobile. On radiographs, one will
see a well -defined area of rarefaction (radiolucency), which is limited by a continuous
radiopaque, sclerotic border of bone. It is usually asymptomatic .
Remember: A granuloma or a cyst can only be differentially diagnosed by histological
examination .
Terms/Cond
ENDODONTICS
The earliest and most common symptom of an acute pulpltls is:
As caries enters the dentin it begins with a lateral spread at the DEJ. This is due to
the increased organic content and the involvement of many dentinal tubules. The
Tomes fibers react, causing fatty degeneration, then later decalcification (sclerosis). As
caries progresses, destruction of dentin is followed by bacterial invasion of the tubules
and complete destruction of dentin. Once odontoblasts are involved, pulpal
changes occur. Initially there is vascular dilation and local edema. The earliest com-
mon symptom of this edema (acute pulpitis) is thermal sensitivity (usually increased
and persistent pain on application of cold).
Remember: The only reliable clinical evidence that secondary dentin has formed is
decreased tooth sensitivity (usually seen a few weeks after placement of a filling).
When dentinal tubules become completely calcified, the dentin is insensitive.
Terms/Cond
ENDODONTICS
Which condition listed below is the result of a pulpal infection that extends through
the apical foramen to the periapical tissues?
• Periodontal abscess
• Gingival abscess
• Periapical abscess
Of all the dental abscesses, the periapical is the most common type. It is a localized collec-
tion of pus in the alveolar bone at the root apex following death of the pulp with extension of the
infection into the periapical tissue. The first symptom may be a slight tenderness of the tooth.
This later develops into severe throbbing pain (acute abscess) with swelling of the overlying
mucosa. The tooth w ill not res pond to the EPT or cold test but may respond to heat.
Emergency treatment includes establishing drainage (ideally through the canal) and prescribing
antibiotics and analgesics. This will relieve the acute symptoms followed by conventional
endodontic therapy at a later date. For dodo tic iote ti s tha 0 not respon 1 Renici in,
c1iodamycin i of en recomm nded. It produce igb bone e)/els an 's ettacH e gains aer-
obic bacteria bu must be used with caution because of th pote ti I f ~ s udo e branous coli-
tis.
The periodontal abscess is an acute abscess that develops through the periodontal pocket.
Alveolar bone loss, Rocket formation and lJ,eriodontal pathologic conditions are suggestive of the
periodontal abscess: The tooth will usually be palpation and percussion positive. It will respond
1<\0 the electric pulp tester (unlike the periapical abscess ). Bacteria associated with this abscess
include gram-negative rods such as Capnocytophaga species. Vibrio-corroding organisms and
Fusobacterium species.
The gingival abscess is a relative rarity that occurs when the bacteria invade through some
break in the gingival surface. Such abrasions may be the result of mastication, oral hygiene pro-
cedures or dental treatment.
Misc.
ENDODONTICS
All of the following cells would be found in a hyperemic pulp after an exposure during
caries removal, except
• Plasma cells
• Lymphocytes
• Goblet cells
• Mast cells
• Neutrophils (PMN's)
···Plasma cells, lymphocytes, mast cells and neutrophils (PMN 's) are all chronic
inflammatory cells.
The increased blood volume associated with hyperemia ("reversible pulpitis") also
increases the intrapulpal pressure in the involved area, which may be limited to a pulp
horn or include the entire coronal chamber. Histologically, the tissue is likely to show
signs of acute inflammation near the site of exposure and a band of chronic inflamma-
tory cells (plasma cells, Iympocytes , PMN 's and mast cells) between the acute inflam-
mation and the underlying normal pulp.
Remember: Most clinicians agree that carious exposure of a permanent tooth gen-
erally requires root canal treatment. Bacterial invasion of the pulp has already taken
place. An exception would be a carious exposure in a tooth with an immature apex.
Performing a partial pulpotomy and pulp capping may have a higher chance of suc-
cess.
Misc.
ENDODONTICS
In most cases where there is endodontic-periodontic therapy indicated on a tooth,
which is performed first?
• Endodontic therapy
• Periodontic therapy
• A non-restorable tooth
• A tooth with insuffi ci ent periodontal support
• A tooth with a vertical root fracture
• All of the above
" ' An apicoectomy is best accomp lished by obliquely resecting the most apical
portion of the involved root.
If a tooth has had previous endodontic therapy and becomes reinfected , it is usu-
ally best to try and retreat it conventionally (remove filling material, debride the canals
and refill). However , if the tooth has been restored with a post, core and crown then
apical curettage, apicoectomy and a retrofill should be performed.
• Condensing osteitis
• A vertical fracture of the tooth
• Periodontal abscess
• Secondary occlusal trauma
Radiographic examination seldom reveals the fracture because the crack is usually parallel to
the x-ray film. One of the most puzzling and frustrating dental conditions involving the possible
need for endodontic treatment is the cracked tooth syndrome. Symptoms from this condi-
tion usually are characterized by a sharp but brief pain occurring unexpectedly only when
the patient is chewing . Having a patient bite forcefully on a bite stick and noticing the cusps that
occlude when the pain occurs will aid in the location of the offending tooth.
Vertical fractures through root structure, however, have an almost hopeless prognosis . If the
fractured segment can be removed and gingivoplasty and alveoloplasty performed, treatment
can be successful. However, unrealistic or overambitious case selection leads to a high degree
of failure.
When an anterior tooth fractures, it generally occurs in a more horizontal plane and may show
up on the x-ray. The cause is usually accidental trauma such as a blow to the jaw or teeth. If the
fracture line is not too far down the root of the tooth, it may be able to be saved with a root canal
and a crown.
Inlays have been shown to be a cause of fractures. If a patient complains of pain on mastica-
tion since the placement of an inlay, suspect a fractured cusp (using a bite stick will help deter-
mine which cusp may be fractured).
Misc.
ENDODONTICS
Which of the following flap designs is preferred when performing endodontic surgery
in the maxillary anterior region?
This flap is a modified double vertical flap. It has the advantage of being able to be
sutured into the dense attached gingiva, thus causing less scarring.
The curved (semilunar) flap was at one time the most commonly used flap, however,
it is not used much today due to excessive shrinkage and the formation of an
obv ious, uns ightly collagen scar.
The palatal flap is used around the gingival margins of maxillary bicuspids and molars
to expose the palatal roots.
. Replant
ENDODONTICS
Which of the following appears to be the ideal storage media for a tooth that has been
traumatically avulsed and will be out of its socke t for more than an hour?
• Soda
• Sodium hypochlorite
• Milk
• Hydroge n peroxide
Five fact ors that are critical to the management of traumatic avulsion injuries to teeth:
1. Time : The time interval from injury to replacement of the tooth is a rnalor factor in the main-
tenance of ligament viability and subsequent root resorption. Teeth replanted within 30 min-
utes have been reported to exhibit very little resorption, whereas most of the teeth replanted
after 2 hours show a lot of external root resorption (which is the main cause of failure of
replanted teeth).
2. Storage media : If the tooth cannot be immediately replanted, proper storage of the tooth
can favorably influence periodontal ligament viability. The preferred storage media
seems to be saliva, physiologic saline or milk. The root that is allowed to dry will show the
maximum amount of resorption. If the footH will e 0 t 0 tfi e soc et for mor t an an our,
milk appear to be th Ideal storage mellia.
3. Tooth socket: Should not be damaged by curettage or forceful replantation
4. Splint stabilization: A splint that allows the physiologic movement is placed for a maximum
of 2 weeks. This time period allows for the initial reattachment of the periodontal ligament
fibers.
5. Root surface: Should not be scraped, dried or manipulated with caustic chemicals.
Note: The above information changes when a tooth has been out of the mouth for more
than 2 hours (mainly the treatment of the tooth socket and root surfaces as well as the time for
splint stabilization).
Replant
ENDODONTICS
Which of the following factors are important to the success of intentional replantat ion?
• A short extraoral time period (to maintain the viability of the periodontal ligament)
• A healthy periodontium
• A skillful extraction technique
• All of the above
• Should be cleaned very well and replanted if within five hours of the injury
• Are usually not replanted
• Should be replanted immediately
• Should have a pulpotomy performed on them prior to replantation
"·Most clinicians advise against replantation of primary avulsed teeth unless ideal conditions exist to pre-
vent trauma to the permanent succedaneous tooth.
Proper management of an avulsed permanent tooth that has been rep lanted w ith in two hours of the
acci dent:
Ten days to two weeks after replantation, the root canal is prepared (cleaned and shaped) and a calci-
um hydr oxi de pas te is placed into the canals
This paste is rep laced every three months for one year
If after one year , it appears that resorption has reversed or stopped, a permanent gutta-percha filling can
be placed
Important: If a tooth Is out of the mouth for more than two hours :
Anky losis and external root resorption will probably result within two years. Ankylosis resulting from
replacement would give a better prognosis than external resorption, which would lead to failure.
Root canal therapy is performed in its entirety pr ior to replantati on.
The tooth is soaked In a 2.4% fluoride so lution acidulated at pH 5.5 for 20 minutes or more. (The flu-
oride will slow the resorptive p rocess .)
Gentl y curette blood clot out of the alveolar socket and irrigate with saline.
Rinse tooth with saline, replant into socket and splint for 4-6 weeks.
Note: Resorption is the most frequent sequela to replantation. Three different types of resorption have been iden-
tified: surface, inflammatory and replacement (ankylotic resorption). Replacement resorption refers to resorption
of the root surface and its substitution by bone, resulting In ankylosis.
Resorp
ENDODONTICS
Which of the following is generally believed to be the cause of internal resorption of
a tooth?
• Orthodontic treatment
• Tooth fracture
• The presence of a chronic pulpitis
• Periodontal disease
• Surface resorption
• Inflammatory resorption
• Replacement resorption
Surface resorption is caused by acute injury to the periodontal ligament and root sur-
face. If injury is not repeated, healing takes place with new cementum and PDL.
Replacement resorption refers to resorption of the root surface and its substitution by
bone, resulting in ankylosis. Remember: This is often seen in unsuccessful replant
cases.
Pulp
ENDODONTICS
Anatomically, the dental pulp is divided into two portions, the coronal and radicular
pulp. Which portion is located in the pulp chamber and pulp horns?
• Coronal pulp
• Radicular pulp
Portions of pulp
1. Coronal pulp - located in the pulp chamber and pulp horns (crown portion of tooth).
2. Radicular pulp - located in the pulp canals (root portion of tooth)..
•••Accessory canals extend from the pulp canals through the root dentin to the PDL. An abrupt
change in the radi olu cent appearance of a canal in the middle third of the root is most likely
due to a bifurcation of the cana l.
The central zone or pu lp proper contains large nerves and blood vessels. This area is lined
peripherally by a specialized odontogenic area which has three layers (from innermost to out-
ermost):
1. Cell-rich zone which contains fibroblasts.
2. Cell-free zone or zone of Weil which is rich in both capillaries and nerve networks. The
nerve plexus of Rashkow is located in this zone.
3. Odontoblastic layer which contains odontoblasts and lies next to the predentin and mature
dentin.
Cells found in th e denta l pulp include fibroblasts (the principal cell), odontoblasts, histiocytes
(macrophages), and lymphocytes.
Note: In a diseased pulp, the following cells are present: PMN's , plasma cells, basophils,
eosinophils, lymphocytes and mast cells (contain histamin e and heparin).
Pulp
ENDODONTICS
Which of the following is the main function of the dental pulp?
• Nutritive
• Sensory
• Protective
• Formative
' --The primary function of the dental pulp is to form dentin (by the odontoblasts)
As the pulp ages there is a decrease in reticulin fibers (the pulp becomes less cel-
lular and more fibrous). The size of the pulp also decreases because of the contin-
ued deposition of dentin. r ~\ 612o LJ S Put-(='
As the pulp ages there is an increase in the number of collagen fibers and calci-
fications within the pulp (called denticles or pulp stones).
The pulp contains both myelinated and unmyelinated nerve fibers. They are affer-
ent and sympathetic. The myelinated fibers are sensory and the unmyelinated fibers
are motor (they playa role in the regulation of the lumen size of the blood vessels).
Note: Proprioceptors (which respond to stimuli regarding movement) are not found
in the pulp.
The only type of nerve ending found in the pulp is the free nerve ending, which is a
specific receptor for pain. Regardless of the source of stimulation (heat, cold, pres-
sure), the only response will be pain.
Note: Pulp stones are associated with chronic pulpal disease (from advanced carious
lesions or large restorations).
Inst/Mat/Tech
ENDODONTICS
Which of the following methods for using endodontic instruments involves no rotation
of the instrument whatsoever and relies on hard tissue removal on the outstroke
only?
• Filing
• Reaming
• Circumferential filing
• All of the above
Filing is a push-pull action with emphasis on the withdrawal stroke. Its efficiency is
greater with files than with reamers for removing dentin because of the greater num-
ber of flutes in contact with the canal walls during the rasping motion of removing the
instrument. The appearance of the canal is irregular and for this reason a canal pre-
pared with this action must be filled with gutta-percha in a condensation procedure.
• Square in shape
• Irregular in shape
• Round in shape
• Triangular in shape
Studies have shown that the action of using the instrument, rather than the instrument
used, determines the general shape of the canal preparation. Therefore, a reaming
action produces a canal that is relatively round in shape while a filing action pro-
duces a canal that is irregular in shape.
This slight resistance to dislodgement is referred to as "tugback". The cone should also have
a definite apical seat (it should not be able to be pushed further apically).
If the preparation is properly flared , fitting the master cone is not a time-consuming proce-
dure. A gutta-percha cone the same size as the file used last during preparation (MAF) is select-
ed and placed as far as possible into the canal, but not beyond the working length. Once satis-
factory tugback and apical positioning appear to be obtained, a radiograph is taken to verify cone
positioning. If an accurate determination and careful enlargement have been performed, the x-
ray will show that the master cone reaches the most apical position of the preparation or
extends to a point just short of that (1 mm). When the cone is slightly short, the pressure of
condensation plus the lubricating action of the sealer will be sufficient to produce complete seat-
ing of the cone.
If the cone is more than 1 mm from the radiographic apex, discard the cone and fit a smaller one
or instrument more in the apical third.
Remember: The main reason for recapitulation (using your MAF after each increase in file size)
during instrumentation of the canal is to clean the apical segment of the canal of any dentin
filings that were not removed by irrigation.
Inst/MatlTech
ENDODONTICS
The primary function of root canal sealers is:
Most root canal sealers are some type of zinc oxide-eugenol cement and are capa-
ble of producing a seal while being well-tolerated by periapical tissues.
All sealers display some degree of radiopacity (caused by metallic salts in the sealer) ;
therefore their presence can be demonstrated on a radiograph. This is an important
property, since it may disclose the presence of accessory canals. resorptive areas, root
fractures. and the shape of the apical foramen and other structures of interest.
Note: After filling a tooth with gutta-percha, if you see a horizontal line of material
(gutta-percha or sealer) extending both mesially and distally from the canal to the
periodontal ligament space, this is indicative of a root fracture.
Inst/Mat/Tech
ENDODONTICS
Which of the following intracanal instruments is designed for the removal of pulp tis-
sue, cotton pellet absorbent points and other soft materials, but not for canal enlarge-
ment?
• Files
• Reamers
• Broaches
• None of the above
K-type instruments:
• File s are the most useful instruments in endodontics for the removal of hard tissue in canal
enlargement. They are manufactured by twisting a blank, which is a square rod, producing a
series of cutting flutes. The action used for placing this type of file into a canal should resem-
ble a clockwise-counterclockwise motion with pressure directed apically (can be a filing or
reaming action). Note: These files are the strongest of all files and cut the least aggres-
sively. A modification to this type of file is the K-f1ex file.
• Reamers are manufactured in a manner similar to files, only they have fewer flutes. They are
used in canal preparations to shave dentin with a reaming action only. They remove intra-
canal debris with clockwise reaming action. They are also used to place materials into the api-
cal portion of the canal by using a countercl ockwise rotation.
H-type instruments:
• Hedstrom files are manufactured by using a sharp, rotating cutter to gauge triangular seg-
ments out of a round blank shaft. This produces a very sharp edge and therefore an effective
cutting instrument. If used carefully, with a filing action only, it will successfully plane the
dentin walls much faster than K-type files or reamers. A modification of this file is the S-
file.
t Note: All of the above are made of stainless steel.
InstiMatITech
ENDODONTICS
Which two of the following situations offer better success for pulp capping?
Pulp capping is the placing of a sedative and antiseptic dressing on an exposed healt!}}' pulp
in order to allow it to recover and maintain normal function and vitality. The dressing most com-
monly used is CaOH2 (Oyca~ . Pulp capping is overused in dentistry today. In reality it has only
very few indications for its use. Young pulps are more vascularized and, therefore, more
amenable to repair. Pulp cappings are more successful if the exposure was accidental
(trauma or with a dental bur) as opposed to carious. In addition, the exposure should only be
pinpoint to expect success. Repair is accomplished by the formation of a dentin bridge at the
site of exposure. Even a small carious exposure should have root canal therapy for the best
long-term prognosis.
A tooth may stay asymptomatic for several weeks after pulpcapping has been performed.
However, this may be only temporary. Unfortunately, if pulp capping fails and the tooth
becomes symptomatic, it may be difficult, if not impossible, to treat with routine endodontics
because of the severe calcifications in the root canal. Perforations may occur during attempts to
follow the obliterated canal to gain patency to the apex. Perforations into furcations of multi-root-
ed teeth have the poorest prognosis.
Traumatic blows to teeth are also a cause for calcification of the pulp space sometimes to a
point where locating the canal is very difficult. With primary teeth, trauma may cause calcifica-
tions in the pulp chamber, which in turn cause a yellowish discoloration of the tooth.
Inst/Mat/Tech
ENDODONTICS
Which of the following are chelating agents?
• EDTA
• RC-Prep
• EDTAC
• All of the above
"'Important: These agents all contain ethylene diam ine tetra-acetic acid as the active ingre-
dient.
Chelat ing agents are used to aid and simplify preparation for very sclerotic canals after the apex
has already been reached with a fine instrument. These agents act on calcified tissues only
and have little effect on periapical tissue. Their action is to substitute sodium ions, which com-
bine with the dentin to give soluble salts for the calcium ions that are bound in less soluble com-
bination. The edges of the canal are thus softer, and canal enlargement is facilitated.
EDTA will remain active in the canal for 5 days if not inactivated. For this reason, at the com-
pletion of the appointment, the canal must be irrigated with a sodium hypochlorite (NaOe L)-
containing solution.
EDTAC is EDTA with the addition of Cetavlon, a quaternary ammonium compound. It has
greater antimicrobial action than EDTA. However, it has greater inflammatory potential to tissue
as well. The inactivator for EDTAC Is NaOCL.
@C.~R~mbines the functions of EDTA Ius urea rovide both chelation and
~ngaIon. The foam solution has a natural efferve irn ation with
NaDeL to aid in the removal of debrig:
Inst/MatlTech
ENDODONTICS
No endodontic cases lend themselves to successful treatment without some degree
of:
• Irrigation
• Debridement
• Obturation
• Medication
Debridement is defined as the removal of foreign material and contaminated or devitalized tis-
sue from or adjacent to a traumatic infected lesion until surrounded healthy tissue is exposed.
Chemomechanical debridement of the root canal system is the most crucial aspect of root
canal treatment.
Complete debridement of the cana l is the most effective means to reduce root canal microor-
ganisms. It can be carried out in various ways as the case demands , and may include instru-
mentation of the canal, placement of medicaments and irrigants andlor surgery.
Remember:
• The most common cause of root canal failure is incompletely and inadequately disinfec-
ted root canal systems.
The second most common cauOse of failures of root canals is leakage from a poorly filled
canal. This is common even after apical curettage. Example: Root canal treatment performed
on a tooth with apical curettage of a lesion that was found to be a cyst. Three years later the
lesion is even bigger than it was before. The most likely cause of this failure is leakage from
a poorly filled canal .
• When a canal is properly prepared, any of the accepted methods of filling will almost cer-
tainly produce a successful result (as long as canal is completely filled).
InstlMatlTech
ENDODONTICS
Gutta-percha is freely soluble in which two solvents listed below?
• Alcohol
• Chloroform
• Xylol
• Eugenol
The simplest method of removing gutta-percha from a root canal is by softening the
gutta-percha with a solvent , such as chloroform, xylol, or euca lyptol. Once the orifice of
the canal has been uncovered , the access cavity is filled with solvent. After 1 to 2 min-
utes, the solvent in the pulp chamber will dissolve the gutta-percha to the extent that a
small file will easily negotiate the canal. Be careful not to use any solvent at or near
the apical foramen. Passage of these chemicals past the end of the root may result in
severe postoperative discomfort.
Notes:
1. Gutta-percha points may be disinfected by placing them in 5.25% NaOCl (sodi-
um hypochlorite) solution for one minute .
2. Endodontic files should be immersed in a bead sterilizer at 220° C (428 ° F) for
15 seconds for sterilization.
Inst/MatlTech
ENDODONTICS
Which of the following are indi cations for performing a pulpotomy?
A pulpotomy is the removal of a portion of the pulp. Usually the injured or infected
coronal pulp is removed in an attempt to preserve the health of the radicular pulp. Note:
If there is a radiolucency, draining sinus tract present, internal resorption, or pain
in percussion, a pulpectomy is the treatment of choice.
Important: The success of a pulpotomy for a primary tooth is dependent upon vital
pulp tissue in the root.
Inst/MatlTech
ENDODONTICS
Which of the following irrigants is the most widely used in endodontics?
• Sodium hypochlorite
• Urea peroxide
• Hydrogen peroxide
• Saline
It is the most widely used irrigant and has effectively aided canal preparation for many years.
A .25% soltitian p vides e cellen germicidal Iven action, ut is dilute enough to cause
only mild irritation when contacting periapical tissue. NaOCl is a good tissue solvent as well as
having some antimicrobial effect. It also acts as a lubricant for root canal instrumentation. Note:
It is toxic to vital tissue; always use rubber dam.
Hydrogen peroxide 3°0 soJution)a is also widely used in endodontics with two modes of action.
The bubbling of the solution when in contact with tissue and certain chemicals physically foams
debris from the canal (effervescent effect). In addition, the libecatio f oxyge(l will destroy strict-
Iy anaerobic icroorganis . The solve t action of hydrogen peroxide is much les b that of
NaeC . However, many clinicians use the solutions alternately during treatment.
[ r ide is available in an anhydrous glycerol base, as y,. to prevent decompo-
sition and is a useful irrigant. It is better tolerated by periapical tissue than NaOCl, yet has
greater solvent action and is more germicidal than hydrogen peroxide. Therefore, it is an excel-
lent irrigant for treating canals with normal periapical tissue and wide apices. The best use for
Gly-Oxide is in nan w an L r c c , utilizing the Iippery ff of the lv.ce I.
Note: Irrigants perform the important biologic function of destroying bacteria during endodontic
therapy. Their action is unquestionably more significant than that supplied by the use of
intracanal medicaments. Irrigants should be used copiously throughout the instrumentation
phase of root canal procedures.
Inst/MatlTech
ENDODONTICS
Which of the following are cons idered to be the two object ives of the access opening?
Access to the root canal is the initial step in canal preparation. It is necessary to
establish straight-line access to the apical foramen to ensure free movement of the
instrument during debridement and preparation of the canal. All the treatment that fol-
lows hinges on the correctness of the access preparation. All access cavities are
made through the lingual on anterior teeth and through the occlusal on posterior
teeth (see note below).
Remember:..Mandibular incisors and maxillary first premolars are the easiest teeth
to perforate during preparation of the access opening due to the limited access mesio-
distally. Therefore care must be taken when initiating treatment on these teeth.
• The canal must be prepared in a manner that ensures optimum debridement and
access to the apical area so that the filling material can be condensed to obliterate
the entire preparation
• The tooth must be asymptomatic
• At the time of fill, the canal must be dry
• If a bacteriologic culture test is being used, a negative culture must be obtained
• All of the above
The most important consideration before filling a root canal is proper cleaning (debridement)
and shaping (instrumenting) of the canal. Once the canal is obturated, any organisms that have
entered the periapical tissues from the canal are eliminated by the natural defenses of the body.
Objectives of root canal obt uratio n:
To develop a fluid-tight seal at the apical foramen
• Complete filling of the root canal space
• To create a favorable biologic environment for the process of tissue healing
In endodontic treatment the importance of canal obliteration (filling) is second only to canal
debrid ement. A proximately 40% of failures ar belie ed to be caused b incom lete a Iitera-
tio 0 h to ca al. If the canal is not filled, tissue fluid and microorganisms from the periapi-
cal tissues are able to enter the voids, with failure as the ultimate result. However, if an acces-
sory canal is not tot ally fill ed during obturation, the appropriate treatment is to observe
the tooth and ~va l u ate every three months .
Note: Atter endodontic therapy is completed on a tooth with a periapical radiolucency, it usually
takes 2 a a con e ize ut radioltJcency ' evident on an x-
ray. ir a i 9 e n 'on 0 bo , deposition of
apical cementum and re-establishment of the PDL.