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BDS3 Endodontics > Clinical Skills > Flashcards

Clinical Skills Flashcards

1
Q

aetiology of endo disease

A
  • Bacterial invasion bacteria and fungi
  • Development of bacterial ecosystem
  • Biofilm formation
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2
Q

clinical objectives of RCT

A
  • Removing canal contents
  • Eliminating infection
  • Spectrum of possibilities exist from Non-instrument technique to Extraction
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3
Q

chemomechanical disinfection

A
  • Used to manage RCS complexity
  • Use of mechanical means of shaping and debriding root canal space and chemical means to further disrupt biofilm and disinfect RCS

Dr Herbert Schider

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4
Q

design objectives (3)

A
  • Create a continuously tapering funnel shape
  • Maintain apical foramen in original position
  • Keep apical opening as small as possible

Create space for introduction irrigants whilst maintaining sufficient structure

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5
Q

pre endo tx need

A

An undistorted peri-apical radiograph must be taken to show all the root and 2-3mm of surrounding peri-radicular tissue

Use light box and magnifier in dark room to view X-ray

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6
Q

what to look for in a pre-endo tx radiograph?

(6)

A
  • Is there peri-radicular pathology and how far does it extend?
  • The anatomy of the root canal system
  • Canal calcifications – is pulp chamber compressed, due to layer down of tertiary dentine
  • Check angulation of root in relation to adjacent teeth
  • Number, length and morphology of roots
  • Proximity of vital structures
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7
Q

before deciding on endo tx definitely what must be done to the tooth in Q

A

All caries and defective restorations must be removed from the crown

  • Allows assessment of restorability and creates an environment suitable for obtaining adequate isolation
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8
Q

pre-endo build up when

A

Assess restorability

  • Clamp placement good
  • Four walled access cavity
  • Control irrigant
  • Control saliva
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9
Q

dental dam needed in endo?

A

Mandatory for all procedures involving the pulp

  • To eliminate bacterial contamination
  • To prevent inhalation of instruments etc
  • Retracts and protects soft tissues and tongue
  • Prevents patient from rinsing, chatting
  • Reduces chairside time and operator stress
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10
Q

5 reasons for dental dam use in endo

A
  • to eliminate bacterial contamination
  • To prevent inhalation of instruments etc
  • Retracts and protects soft tissues and tongue
  • Prevents patient from rinsing, chatting
  • Reduces chairside time and operator stress
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11
Q

when to place your dental dam in regards to cutting access cavity

A

can place your dental dam after cutting most of your access cavity to avoid losing orientation

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12
Q

7 instruments in endo kit

A
  • Mirror – front facing, single shot to improve visulisation
  • Locking tweezers
  • Probe
  • DG 16
  • Excavator
  • Flat plastic
  • Burnisher
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13
Q

DG16

A

dull ended probe, long tip to allow exploration of pulp chamber and orifices/access RCS

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14
Q

equipment needed for endo access cavity prep

A

endo kit

local anaesthetic equipment

examination kit

handpieces and burs

  • air rotor, fissure burm Endo-Z or similar
  • slow speed - long shanked round bur

basic armentarium

  • file holders (clean K files)
  • rulers
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15
Q

slow speed bur type used in endo

A

long shanked round bur

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16
Q

root of upper central incisor

A

23mm

little apical curvature

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17
Q

root of uppper lateral incisor

A

21-22mm

1 canal inclined palatally

distal apical curvature

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18
Q

root upper canine

A

26.5mm

distal and labial curvature

narrow apex

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19
Q

root lower central incisor

A

21mm

41% hhhave 2 canals

distal apical curvature

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20
Q

root of lower lateral incisor

A

21mm

41% have 2 canals

distal apical curvature

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21
Q

root lower canine

A

22.5mm

14% have 2 canals

distal and sometimes labial apical curvature

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22
Q

access cavity driven by

A

need to gain access – roof of pulp chamber.

Instrument needs to be able to pass unhindered into root canal – to reduce chance of instrument fatigue and failure.

Can be variation in shape/position depending on what you are aiming to achieve

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23
Q

why is a good access cavity important

A

Instrument needs to be able to pass unhindered into root canal – to reduce chance of instrument fatigue and failure.

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24
Q

access cavity maxillary central

A

2 pulp horns – triangular access cavity,

  • start with single point of access until drop into pulp chamber then shape into triangle,
  • long flat end tapered bur

(Middle third of tooth)

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25
Q

access cavity maxillary lateral

A

smaller triangular access for smaller 2 pulp horns

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26
Q

access cavity maxillary canine

A

single pulp horn - oval shape access cavity

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27
Q

access cavity mandibular incisors (central and lateral)

A

Single canal – ovoid access,

can be moved more incisal – more mid crown and slightly up.

Too lingual access will only be able to instrument labial area and not all of canal system

(lower incisors often fail as not properly irrigated

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28
Q

care needed in access cavity prep to ensure

A

not go beyond pulp chamber - perforation

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29
Q

objectives of access cavity preparation (4)

A
  • Remove entire roof allowing complete removal of pulpal tissue
  • Allow visualisation of root canal entrance
  • Produce smooth walled preparation with no overhangs
  • Allow unimpeded straight-line access of instruments
    • If severely curved whilst working, risk will start to fatigue and failure or damage root canal along walls -> ledge formation, perforation
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30
Q

initial access cavity prep with

A

long tapered high speed flat ended diamond bur

extends working distance improvng visualisation

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31
Q

when to switch from high to slow speed handpiece in access cavity prep

A

when breach pulp

chamber switch to long neck round bur on slow speed

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32
Q

with the long neck round slow speed bur - aim to

A

de roof pulp chamber

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33
Q

once de roofed the pulp chamber with slow speed

switch to

A

ultrasonic

safely remove remainder of pulp chamber roof so can see full access

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34
Q

good straigh line access enables

A

dropping into RCS from access cavity

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35
Q

conventional instruments for developing canal shape

A
  • Made from stainless steel
  • The lengths of ISO instruments, (International Organisation for Standardisation) are 21, 25 or 31mm
  • The handles of ISO instruments are colour-coded according to file tip size
  • 02 Taper or 2% Taper
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36
Q

ISO tools shape

A

tapered with flutes along (02 taper/2%)

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37
Q

ISO colour code

A

handles colour coded to file tip size

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38
Q

ISO-sized instruments

A

stainless steel

  • All have 16mm cutting flutes
  • Each file is named according to its diameter at the first rake angle – D1
  • Taper is 0.32mm over the 16mm, or 0.02mm per millimetre from tip (2%)

Diameter at D2 = apical size + 0.32mm

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39
Q

hand instrumentation by (2)

A

K files

  • Flexible therefore useful in curved canals
  • Available in stainless steel
  • Cut when used in rotation

Flexible K Files (Flexofiles)

  • Cross-sectional shape allows greater flexibility
  • Stainless steel or nickel titanium
  • Used in rotation or filing motion
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40
Q

4 types of file motion

A
  • Filing
  • Reaming
  • Watch-winding
  • Balanced Forced Motion
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41
Q

watch winding motion

A
  • Back and Forward Oscillation of 30°-60 °
  • Light apical pressure

Effective with K files

Useful for passing small files through canals

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42
Q

balanced forced techniques

A
  • insert file and engage clockwise into the dentine 1/4 turn
  • with continued pressure, go counter-clockwise 1/2 turn to strip the dentine away
  • do this 1-3 times before removig the file to remove debris and check the file
    • remove, clean, reintroduce, working way to working length
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43
Q

root canal preparation needs

A

to be undertaken with copious irrigation

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44
Q

objectives of irrigants (5)

A
  • To disinfect root canal
  • Dissolve organic debris
  • Flush out debris
  • Lubricate root canal instruments
  • Remove endodontic smear layer
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45
Q

luer lock syringe

A
  • 27 gauge endodontic-tipped needle
  • Ensure needle is tightly screwed onto syringe
    • But should be loose and free to move inside canal
  • Always placed short of working length

Get NaOCl from galley pot (1/2 -2/3 full)

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46
Q

reason for coronal flaring (3)

A
  • Avoids hydrostatic pressure in canal
  • Early removal of heavily contaminated contents
  • Improved straight line access to apical 1/3
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47
Q

3 methods for coronal flaring

A

step down technique

double flare technique

crown done pressureless technique

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48
Q

modified double flare technique for coronal flaring

A

Uses the balanced force technique

  • to enlarge/flare the coronal part of root canal
  • to negotiate the narrower apical part of canal
  • to flare the apical part of canal by step-back technique

The aim is to create a continuously tapering, funnelled root canal without forcing debris apically whilst respecting original canal anatomy

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49
Q

gates glidden bur

A

bur with tear drop, long shank placed in motor

  • too small – fragile
  • too large – remove too much
  • break just below shank to allow tip to be retrieved

run at relatively low level (1000rpm)

only in coronal portion

50
Q

series of instruments for coronal prep (straigh portion of canal only)

A
  • NaOCl
  • # 10 K file
  • GG4 (too big)
  • GG3
  • NaOCl
  • GG2

light pressure and brushing movements - irrigate between sizes

51
Q

working length characteristics

A
  • Preparation should end at the junction of pulpal and periapical tissue
    • just shy of apical constriction
  • WL should be as close as possible to CDJ
  • This is usually the narrowest part of the canal – apical constriction
52
Q

Corrected working length
CWL

A

instrument and radiographic interpretation

  • K file and with rubber stop at landmark (incisal cusp)

Go into to EWL (from pre-op radiograph)

  • 1-2mm of radiographic apex
  • But due to potential curvature of root canal need to confirm the length

Put file in at EWL and then take another radiograph to determine CWL

53
Q

how to determine CWL

A

Radiographically

  • Length should be 1mm from radiographic apex
  • Use a sound and reproducible reference point
    • Usually the incisal edge or a cusp tip
  • Use paralleling technique with film holder

electronic apex locator

54
Q

radiographic apex -> apical constriction distance

A

varies

greater in older teeth with secondary cementum - can lead to over extension of preparation

55
Q

electronic apex locator

A

Allows better determination of working length, more reliable

  • Place instrument in canal with apex locator attached, and to lip of pt
  • Current passed through, instrument able to determine when instrument enters PDL
  • Reach 0 is the true length from coronal reference point to apex constriction

Want to go 1mm short of where you reach 0 (first red band)

56
Q

paper point length determination

A

Determine interface between wet and dry

  • Dry canal using paper points
  • Place paper point into canal and as it touched PDL, see blood or tissue fluid

Coronal reference point to this point (1mm short of)

57
Q

apical preparation

A
  • Determine working length with K files, electronic apex locator, paper point
  • Use watch winding and balanced force technique working up files to size 20
  • Irrigate
  • Back to size 10 (lift debris from canal to ensure not packing debris in)
  • Then take size 10 just beyond CWL to work as patency file
    • Prevents collection of debris at apical portion
  • Balanced force technique with next size up file (25) to expand apical preparation
  • Want to reach at least size 25
    • But in order to ensure sufficient preparation may want to expand to size 30
      • Until reach appropriate diameter
      • Master apical file
58
Q

apical gauging

A

Get feedback from canal

  • Loose feeling – starting diameter wider (greater than point diameter)
59
Q

apical size determined by

A

initial size of root canal apex

use apical gauging

Usually at least ISO size 25 (to CWL)

  • Want to go at least 2 sizes bigger than initial size of just gauging

Some advocate 30 and larger to allow irrigation (to CWL)

  • Canal curvature impacts upon what is achievable safely
60
Q

apical size aim

A

Want to go at least 2 sizes bigger than initial size of just gauging

61
Q

mid root preparation technique

A

step back

62
Q

step back technique

A

mid root preparation

  • 25 file taken to CWL
  • Insert K files 1 size greater 1mm short of CWL
    • 30 at 1mm short
    • 35 at 2mm short
    • 40 at 3mm short
  • Create steps
  • Extend coronal and so will join coronal taper that created initially
  • Then take master apical file (25) and make filing motions circumferentially in canal to smooth out steps, to create taper from apical to coronal portion
63
Q

estimated working length

A

Estimated length at which instrumentation should be limited. Obtained by measuring pre-operative radiograph to determine distance between coronal reference point and radiographic apex then subtracting 1mm.

64
Q

corrected working length

A

Length at which instrumentation and subsequent obturation should be limited. Obtained by the use of an electronic apex locator and/or working length radiograph.

65
Q

master apical file

A

The largest diameter file taken to working length and therefore represents the final prepared size of the apical portion of the canal at the working length

66
Q

resin sealer

A
  • Epoxy Resin
  • Paste-Paste mixing
  • Slow setting - 8 hours
  • Good sealing ability
  • Good flow
  • Initial toxicity declining after 24 hours
67
Q

GP cones

A
  • 20% Gutta-percha
  • 65% Zinc Oxide
  • 10% Radiopacifiers
  • 5% Plasticizers
  • Standardised, non-standardised and size-matched
68
Q

cold lateral compaction

A

Common method for filling root canals in 3D

  • Can be used in most clinical situations

Good length control – GP is semi-solid

Does not allow good adaptation to canal irregularities

69
Q

cold lateral compaction materials and equipment

A
  • GP points
    • size correspond to master apical file
  • finger spreaders (A, B, C, D)
    • not hand spreaders - too great a force
70
Q

cold lateral compaction inital step

A

Get master point (correspond to master apical file)

  • grasp cone at CWL – compress GP cone
  • place into damp canal – should go to CWL

Check for “Tug Back” with Master Cone

Take a “cone fit” radiograph

  • place master cone into RCS and take radiograph, should reach approximately the CWL
    • Too short – modify so goes to CWL
    • Too long
      • Either increase size of cone
      • Trim off excess GP

Needs to sit snuggly

71
Q

accessory points

A

Cones that fit around the master cone

  • A, B, C, D correspond to space left by finger spreaders
72
Q

how to dry canal

A

paper points

73
Q

cold lateral compaction cycles

A

Master cone that goes to CWL

  • Coat with thin layer of sealer

Place finger spreader alongside master cone

  • Insert apically and apply apical pressure – create space for accessory cone

Go through rounds of compaction and additions of accessory cones

Each addition will go to a shorter length

Until fill RCS

74
Q

what to do once fill pulp chamber with GP points

A

remove excess

DON’T FILL PULP CHAMBER

NO NEED TO PUT ACCESSORY CONES IN PULP CHAMBER

  • Traverse it

Cut using a heater cutter, sever off GP

  • Compact GP into the space

Finish obturation at level of ADJ

75
Q

issue here

A

Not appropriate

  • GP should reach orifice but should not coat the walls of pulp chamber
  • Sealer – white substance

Pulp chamber space needs to be cleaned

Circle of GP evident in the orifice

76
Q

what goes on top of the orifice

A

a secondary sealer (vitrebond, RMGI)

  • protect thr orifice from ingress of bacteria
77
Q

summary of obturation

A
  1. Complete preparation
  2. Try finger spreader in, should go to CWL (just shy 1-2mm)
  3. Master apical cone
  4. Accessory cone
  5. Spread laterally
  6. Additional rounds of adding accessory cones
  7. Compaction with accessory cone placement
  8. Sever off at level of ACJ, allow thin layer of vitrebond/RMGI and opportunity to place definitive restoration (amalgam, composite or GIC until it can be done if no time)
78
Q

manual dynamic irrigation

A
  • Introduction of GP cone towards CWL, with inward and outward movement
    • Agitate hypochlorite
    • Lift debris

Go through rounds of manual dynamic irrigation and irrigation until 10 mins up

79
Q

what should be used before the final rinse of NaOCl before GP placement

A

EDTA for 1 min

80
Q

maxillary 1st premolar acccess cavity

A

2-3 canals

ovoid access cavity

81
Q

maxillary 2nd premolar access cavity

A

1-3 (mostly single rooted)

oval

82
Q

maxillary 1st molar access cavity

A

3-4 canals

mesial quadrangle

83
Q

maxillary 2nd molar access cavity

A

3 canals

mesial quadrangle

84
Q

mandibular first premolar access cavity

A

1 root (73%)

oval

85
Q

mandibular 2nd premolar access cavity

A

1 root (85%)

oval

86
Q

mandibular 1st premolar access cavity

A

2-3 roots

3 canals

central quadrangle

87
Q

mandibular 2nd molar access cavity

A

2 roots

2-4 canals (3 most common)

central quadrangle

88
Q

how to determine access cavity for posterior teeth

A

look at radiograph - where likely to find root canal

fissure bur to most easy access

89
Q

pre op assessment before initial access cavity cut

A

consider

  • angle of bur
  • size of pulp chamber
  • pulp horns
90
Q

reason to have a pre op assessment and have a plan

A

to try and avoid problems - perforation

and ID them if they occur

(bur penetration too deep, angulation wrong)

91
Q

additional possible step in access prep

A

may need deconstruct tooth to ensure gaining access to correct area

  • remove crowns, restorative materials
92
Q

how to safely de roof pulp chamber

A

safe ended bur (not damage floor of pulp)

  • diamond coated
  • tungsten carbide

tip of instrument is not cutting

  • insert into hole made in pulp chamber roof and it will cut laterally to remove the roof
    e. g. EndoZ
93
Q

dentine below pulp chamber roof is

A

very homogenous

Anatomical features – developmental fusion lines

94
Q

what to ensure before completing access cavity stage and moving onto prep

A
  • Check that roof of pulp chamber has been removed
  • Complete and direct vision of canal openings
95
Q

straight line access

A

often lip of dentine at opening of orifice, will interfere with endodontic straight line access

  • Need to modify dentinal wall so can get straight line access to first point of curvature or apex (whichever is first)

If don’t have

  • Additional stress on instrument – risk perforation, fracture, mishaps in canal shaping
96
Q

gates glidden bur role

A
  • To improve straight line access
  • Don’t use gates 1
  • Ensure don’t go too deep into canal, otherwise get Coke bottle appearance (over expanded coronal preparation, narrow taper)
97
Q

GG 2 diameter

A

0.9

98
Q

GG3 diameter

A

1.10

99
Q

GG bur action

A
  • Dipping into coronal aspect of root canal to improve straight line access
    • Remove mesial portion of orifices
    • Work away from furcation
      • Not into – risk perforation
100
Q

GG X

A
  • Combination on gates glidden burs
    • Tip of gates 1 (0.7)
    • Max diameter of gates 4 (1.30)

Create the shape with single instrument

101
Q

ProTaper Handfiles

A
  • Series of files made from nickle titanium
  • Superelasticity – significant flexibility in RCS
  • Variable Taper
    • Variations in coronal to apical taper with files
102
Q

ProTaper handfiles allow

A

Create shape in RCS that would otherwise be very complex to attain

103
Q

S1 ProTaper

A

Wide coronally and significant taper to apex

104
Q

S2 protaper

A
  • Slightly larger tip size
  • Taper leads to enhanced diameter of instrument at middle cutting section
  • Slightly smaller diameter at coronal portion
105
Q

Sx ProTaper

A
  • Very short cutting blade
  • Significantly increases from apex to coronal portion over short period
  • Not typically used in routine endo, can be used in pre-flaring
106
Q

how to intial create coronal flare with protaper files

A

Initially pass 10 or 15 file 2/3 of working length

S1 to 2/3 of working length – creating coronal flare due to rapidly increasing taper

Can use Sx but not common place

107
Q

when to confirm working length

A

after creating coronal flare (with S1)

108
Q

glide path

A

preparation of root canal that allows subsequent instruments to be able to move more freely and safely in the RCS

109
Q

once establish guide path

A

Once established Glide Path, use S1 with advanced force to CWL

  • Irrigate and recapitulate and patency check

Repeat with S2 file to CWL

Continue till comfortably reach CWL with S1 and S2 file

  • create root flare
110
Q

once created coronal flare and root flare with ProTaper files, then

A

need to finish preparation using finishing F files

111
Q

F files

A

finishing

  • colours for different diameters
  • apical taper of 3mm slightly differs

use F1 with advanced force and continue until achieve apical diameter wanted

112
Q

apical diameter needs to reflect

A

Original size of Root canal

  • 2-3 sizes bigger to first file that bites

Dentine looks like

  • Needs to be bright and white – clean thus sufficient

Ability to irrigate

  • Larger the apical diameter the more efficient irrigation
    • F files have wide diameter, F2 does provide sufficient irrigation if provides control
113
Q

how to know you have control of apical area

A

apical gauging

Take a file to CWL

It won’t advance any deeper into Root canal

  • However F2 can bind more coronal due to taper
    • Thus put in equivalent K file, with light apical pressure – should not advance beyond CWL
    • F2 = 25 K file
      • K file will only bind apically due to tapering made by S and F files (only 2% taper)

get control with 25 K then decide F2 is sufficiently large enough, thus obturation material less likely to lose control when placed

114
Q

ProTaper tx sequence

A

use 10 and 15 file for scouting

S1 (and SX) to shape coronally

  • Balanced force motion

Irrigate

10 file to EWL and with electronic apex locator determine 0 reading

  • May need to go to larger file if apical diameter is large

Establish CWL (0-5-1mm short of 0 reading)

Take S1 to CWL, followed by irrigation, recapitulation and patency filing

  • Balanced force
  • Repeat several times (irrigation etc in between) to get to CWL

S2 (same process)

F1

  • Balanced force to CWL

Bigger – determined by apical gauging

If canal exceptionally curved may only be able to expand to an F2

115
Q

if master cone is short

A

consider debris and shape

116
Q

if master cone is long

A

cut with scalpel blade (precisely 0.5mm etc)

keep taper the same

117
Q

multi rooted obturation

A

Issue for access

Treat one root at a time, unless roots fused

  • Place one cone in a canal and another in the second canal and establish if both go to CWL
    • Withdraw the one that has reached CWL
    • And try to navigate the other deeper
      • Indication of level of interaction
118
Q

how to determine level of interaction of multi rooted teeth

A

Place one cone in a canal and another in the second canal and establish if both go to CWL

  • Withdraw the one that has reached CWL
  • And try to navigate the other deeper
    • Indication of level of interaction

If they interact, Place master cone in primary and cut the cone for the secondary canal

  • So 2 GPs
  • Then accessory cones as needed

Typically treat one canal at a time, unless they interact

119
Q

restoration impact of endo tx

A

good endo + good restoration = 91%

poor endo + good restoration = 69%

120
Q

endo impact on final restoration tx

A

good endo + good restoration = 91%

poor endo + good restoration = 69%

good endo + poor restoration = 44%

poor endo + poor restoration = 18%

BDS3 Endodontics (10 decks)

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