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REVISION BDS > dx in endodontics p149 > Flashcards

dx in endodontics p149 Flashcards

1
Q

issue with vitality/sensibility tests

A

not 100% fullproof as in teeth with multiple canals there is the possibility one canal maybe diseased and another healthy

tests neurological function as opposed to vascularity which is better measure of tooth vitality

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2
Q

types of sensibility tests

A

electric pulp test

cold/ethyl chloride (thermal)

heat (thermal)

cutting as test cavity

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3
Q

electric pulp test

A
  • Patient holds on to the metal as dentists gloves interfere with the conduction of the electrical stimulus
  • Patient lets go once sensation has been established
  • Lower electrical level = greater ‘vitality’
  • up to 80
  • test contra-lateral tooth
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4
Q

heat (thermal) test

A

heated HP stick

apply vaseline to enamel as heated GP will stick to enamel readily

not commonly used as can injur pulp

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5
Q

cold/ethyl chloride test

A

ethyl chloride is at -50oC

applied onto cotton pledget

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6
Q

cutting a test cavity

A

can be good in eliciting nerve response

however nerves can synapse in pulpal tissue long after the blood supply has diminshed and the pulp has become necrotic

last resort test

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7
Q

7 possibe pulpal dx

A
  1. normal pulp
  2. reversible pulpitis
  3. symptomatic irreversible pulpitis
  4. asymptomatic irreversible pulpitis
  5. pulp necrosis
  6. previously treated
  7. previously initiated therapy
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8
Q

normal pulp

A

symptom free

resposive to testing

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9
Q

reversible pulpitis

A

inflammation

clinical findings suggesst it should return to normal

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10
Q

symptomatic irreversible pulpitis

A

vital inflammed pulp incapable of healing

thermal pain, spontaneous pain and referred pain

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11
Q

asymptomatic irreversible pulpitis

A

vital inflamed pulp incapable of healing

no clinical symptoms but inflammation triggered by caries/caries excavation/trauma

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12
Q

pulp necrosis

A

indicatins that pulp is dead

non-responsive to pulp testing

neurvascularity is nil

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13
Q

previously initiated pulp therapy

A

previously undergone partial therapy e.g. pulpotomy/pulpectomy

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14
Q

6 apical dx

A

normal apical tissues

symptomatic apical periodontitis

asymptomatic apical periodontitis

acute apical abscess

chronic apical abscess

condensing osteitis

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15
Q

normal apical tissues

A

normal periradicular tissue

lamina dura intact

PDL space uniform

not sensitive to percussion or palpation

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16
Q

symptomatic apical periodontitis

A

inflamed apicla periodontium

associated periapical radiolucency

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17
Q

aymptomatic apical periodontitis

A

destruction and inflammation of periodontium of endodontic origin

associated periapical radiolucency

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18
Q

acute apical abscess

A

rapid onset of pain often spontaneous, tenderness of tooth to pressure

pus formation

swelling of associated tissues

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19
Q

chronic apical abscess

A

gradual onset, little to no discomfort

intermittent discharge of pus through sinus tract

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20
Q

condensing osteitis

A

diffuse radiopaque lesion

represents a localised bony reaction to low grade inflammatory stimulus

usually seen at the apex of the tooth

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21
Q

indication for endo tx (4)

A
  • overdenture - decoronated teeth retained in the arch to preseve alveolar bone
  • crowns - prophylactic treatment of pulp before crown added to reduce complications
  • preiodontal disaese - root resection may merit elective devitalisation
  • pulpal sclerosis following trauma - small proportion of teeth can suffer pulpal problems following trauma, may indicate RCT
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22
Q

contraindications for endodontic tx (6)

A
  • poor OH
  • insufficient PD support
  • root fracture
  • bizarre anatomy
  • internal resorption - resorption of pulp chamber/canal = radiolucent
  • external resorption - intiated in periodontium and affecting external surfaces of the tooth
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23
Q

principles of endodontic access

A

all caries and defective restorations must be removed

tooth should be capabale of isolation

periodontal status shuld be sound or capable of resolution

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24
Q

design objectives of endo access

A
  • create a continuouly tapering funnel shape
  • maintain apical foramen in orignial position
  • keep apical opening as small as possible
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25
Q

objectives of endo access

A

entire roof of pulp chamber removed so chamber can be debrided

provide a straight line access to apical 1/3 of the canal to allow proper instrumentation

to allow temporary seal to be applied

conserver as much sound tissue as possible

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26
Q

stages of endo access

A
  1. initial entry made with tungsten carbide/diamond bur
  2. outline form completed as required
  3. advance bur towards roof of the pulp chamber until pulp roof just penetrated
  4. apply rubber dam at this stage
  5. removal of the pulp chamber and tapering of the walls done by safe tipped endodontic access bur
  6. *if pulp stones elicited from pre-op radiograph these are to be dissected out at this stage
  7. gently flare out the walls of the pulp chamber to improve access, this will result in a gentle funnel shape - the safe tip should be felt passively working along the floor of the pulp chamber
  8. clear any remaining pulpal debris from the floor of the pulp chamber and canal orifices with an excavator
  9. the access cavity should then be flushed with sodium hypochlorite to remove residual debris
  10. the canal orifices may be located with the DG16 endo probe
  11. outline form modification to ensure straight line access may be carried out at this point
  12. Using a CT4 tip for an ultrasonic clear any sclerotic or secondary dentine away
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27
Q

upper central incisor

access and av length

A

triangle

23mm

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28
Q

upper lateral incisor

access and av length

A

triangle

21-22mm

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29
Q

upper canine

access and av length

A

ovoid

26.5mm

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30
Q

lower central incisor

access and av length

A

ovoid

21mm

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31
Q

lower lateral incisor

access and av length

A

21mm

ovoid

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32
Q

lower canine

access and av length

A

22.5mm ovoid

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33
Q

upper 1st premolar

access

A

oval

2 roots

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34
Q

upper 2nd premolar

access

A

oval

1 central root canal

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35
Q

watch winding technique

A
  • back and forward oscillation of 30-60o
  • light apical pressure
  • Effective with K- files
  • useful for passing small files through canals
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36
Q

balanced force technique

A
  • clockwise 1/4 turn
  • continued apical pressure
  • 1/2 turn counterclockwise
  • dentine should ‘click/snap’
  • repeat 1/3 times to remove debris and check file
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37
Q

coronal flaring

A

modified double flare technique

WATCH WINDING

  • Gates-Glidden burs - use brushing motion 4, 3, 2 sizes (STRAIGHT PORTION OF CANAL ONLY)
  • create funnel shape
  • take a size 10 file to EWL (from pre-op radiograph) then another radiograph for CWL
38
Q

apical flaring

A

modified double flare technique

BALANCED FORCE TECHNIQUE

  • Established corrected working length with diagnostic radiograph and no. 10 file at working length
  • from that either advance further or reduce WL slightly
  • Take no. 10 file to WL
  • increase at WL using 15 and 20, 25, 30 (in larger canals)
  • Use 10 file to recapitulate along with irrigation as normal
39
Q

mid canal preparation

A

step back technqiue (middle stage)

Use Master apical file (i.e last file used in apical flaring) - 30/35 depending on canal size (i.e one up from the last one used in apical flare

Move back 1mm each time you move up a file size

e.g

  • no. 30 - 23mm
  • no. 35 - 22mm
  • no. 40 - 21mm etc etc
40
Q

ProTaper Process of Instrumentation

A
  1. Establish CWL with ISO 08 and 10
  2. Instrument to ISO 25
  3. S1 to CWL
  4. Sx for Coronal Flaring
  5. Use 10 for patency
  6. S1(again) S2, F1, F2, F3, F4, F5 as needed
  7. Obturate with Protaper Cone equivalent to file size
41
Q

reciproc process of instrumentation

A
  1. Insert blue rotary file into orifice
  2. Start roation
  3. Use light pressure and a in and out pecking motion with oscillations not exceeding 3mm, one in and out movement = 1 peck
  4. Remove the instrument after 3 pecks
  5. clean the file itself extra-orally using the stand
  6. Irrigate
  7. Re-establish patency using an ISO 10
  8. Gently instrument Coronal 2/3 with this instrument
  9. Finish with R25 for apical 1/3
42
Q

Protaper Rotary process of instrumentation

A

Create glide path using ISO 10, 15

S1 and S2 coronal 2/3 shaping

10, 15 to rescout

Finish apical 1/3 with S1, S2 and F1 to length

If no apical binding at F1 then go to F2 if still not then use up to ISO 25 to achieve binding

If still none then use ISO 30, and then F3 rotary

43
Q

endodontic obturation

A
  1. Irrigate canal with EDTA to remove smear layer
  2. Dry with paper points
  3. final irrigation with Sodium hypochlorite
  4. Select Master Cone and dry fit
  5. MAKE SURE it goes to working length - take Radiograph if unsure
  6. if suitable, coat with sealer (do not leave on bench as it will deform as the sealer and GP react)
  7. Use in and out motion with coated point to butter the canal with sealer
  8. fully seat master point at working length
  9. use ‘A’ finger spreader at working length and displace master cone laterally for 30 seconds and have an accessory cone ready of equivalent size coated in sealer (must all happen very quickly) to insert into the space upon withdrawal of the spreader
  10. repeat consectutively using larger and larger spreaders and points! (A,B,C,D)
  11. Trim excess GP using heated instrument or dedicated GP trimmer
  12. Condense material into the orifice with an amalgam plugger (slighlty larger than orifice)
  13. Place RMGI over the orifice to complete coronal seal
  14. Take post operative periapical radiograph
44
Q

apical limit

A

dentinocemental juction

  • histological landmark
  • impossible to determine clinically
  • irregular

0 - 2.5mm from apex of root

varing constriction anatomy

increases with age

root resorption is a complicating factor

45
Q

accessory anatomy

A

Number of apical foramina 1-16

lateral canals can be associated w/ pathology

accessory canals are common but not important in pathology

only treat main canal

46
Q

Gutta Percha is

A

isoprene monomer can give rise to GP and natural rubber

exists in two crystalline forms α and β

  • β used comercially in dentistry

Can be ISO, non standard and size matched

  • can be deformed by sealer
47
Q

GP cones constituents

A

20% GP

65% Zinc Oxide

10% Radiopacifiers

5% Plasticisers

48
Q

removal of obturation material

A
  1. Removal of Coronal GP using Gates-Glidden burs
  2. Use solvent to dissolve GP
  • Chloroform - v. good at dissolving GP but potential carcinogen
  • Eucalyptus Oil - not great at dissolving GP but antibacterial and non-irritant
  1. Use ISO or Hedström file to remove GP from there
  2. EDTA to remove smear layer

Protaper Retreatment kit
D1 (16mm) - Coronal 1/3
D2 (18mm) - Middle 1/3
D3 (22mm) - Apical 1/3

49
Q

7 possible clinical endodontic problems

A

acute periapical abscess

pain following instrumentation

sclerosed canals

pulp stones

broken file

removing old root fillings

perforations

50
Q

how to manage

acute periapical abscess after endo

A

rubber dam

open up tooth with a bur

drain and irrigate with sodium hypochlorite

51
Q

how to manage sclerosed canals

A

canal orifice may be undefined

use ultrasonic instrument or bur to negotiate and reopen then traet conventionally

52
Q

how to manage pulp stones

A

can be flicked out with a small file

53
Q

how to manage broken file

A

fine mosquito tweezers

use a small file adj to dislodge it

ulstrasonic instrument on low power

54
Q

how to manage removing old root filings

A

GG burs or NiTI rotary files can be used to remove GP points

chemicals (chloroform, eucalyptus oil) can be used but leave a smaer on the pulp canal wall

55
Q

how to manage perforations and possible causes

A

can be iatrogenic

can be due to resorption

treated by adding non setting CaOH to lesion

56
Q

4 types of root canal instruments

A

barbed broach

hedstrom file

k-reamers

k-files/k-flex

57
Q

barbed broach files

A

used for extirpating pulp not enlarging

formed from a tapered round shaft like a finger spreader then lifting staggered portions of metal from the shaft to almost right angles to the shaft

use a narrower broach than the previous engaging file, but select the largest broach that will sit freely

helps to eliminate the possibility of engaging the canal walls

extremely fragile

58
Q

hedstrom file

A

machined steel blank

used in a filing motion - cuts upon withdrawal

good cutting efficiency but can result in iatrogenic damage

no longer used in canal prep

used for removing GP or fractured instruments incases of retreatment

*Identified by black circle below file number on the side and around the top*

59
Q

k reamers

A

manufactured by twisting a triangular shaft

cutting edges nearly parallel to long axis

roated 1/4 - 1/2 turn clockwise to cut as advanced to length must be in contact with the walls of the canal in order to be effective

*must not bind or it will break

60
Q

k-files/k-flex

A

distinguishable by the colour or the square on the handle #

  • K file = black square
  • K flex = white square

manufactured by twisting a sqaure shaft

cutting edges almost perpendicular to the long axis of the instrument

can be used in a filing mtion - advanced to working length (rotated 1/4 - 1/2 turn CW)

withdrawn with concurrent lateral pressure

repeated cicrcumferentially until canal enlarged

*do not use a larger instrument too quickly*

61
Q

4 problems assocaited with conventional hand instruments

A

canal blockage

ledging

apical zipping/transportation

perforation

62
Q

canal blockage

A

caused by dentine debris getting packed into apical portion of the root

when packed tightly it can be as hard as surrounding dentine

attempts to remove it can result in a false canal being cut and possible perforation

63
Q

ledging

A

internal transportation of the canal

occurs when working short of WL

can be bypassed but with difficulty

solution:

  • place rubber stop marker in the vector of the curve
  • place apical curve in the file to remove the ledging

note that if the curved canals are instrumented as they were straight they will create ledges and the last few mms of canal will remain diseased and infected and uninstrumentated

64
Q

apical zipping / transportation

A

occurs with the tendency of the instrument to straighten inside a curved canal

consequences

  • over enlargment of outer side of canal curvature
  • under preparation of the inner aspect at apical end point
  • main axis of the canal is transported
    • results in teardrop of hour glass shape

avoidance

  • always pre-curve the inital small sized hand instruments
  • do not skip instruments in the sequence
  • never rotate the instruments in curved canals

transportation of the apical foramen results in poor resistance for the packing of GP

cases tend to be overextended and poorly filled

65
Q

perforation

dx

A
  • perisitent bleeding into canal
  • multiple radiographs
  • electronic apex locator
  • dental operating microscope
66
Q

prognosis for perforation dependent on

A
  • location
  • time elapsed
  • size
  • perio instrumentation
  • material used for repair
67
Q

NiTi instruments

key adv property

A

superelasticity

  • NiTi can be strained more than other alloys before deformation
  • allows NiTi files to be placed in curved canals with less lateral forces exerted
    • less ledging, zipping, transportation
    • central perparation in harmony with canal shape
68
Q

NiTi vs SS

A

pros

  • increased flexibilty in larger sizes and tapers
  • increased cutting efficiency
  • if used apporpriately good safety in use
  • can be more user friendly with instruments and simple sequence

cons

  • instrument fracture
  • expense
  • access can be difficult with posterior teeth
  • unsuitable for complex canal anatomy
69
Q

function of endodontic sealers

A

seals space between dentine wall and core

fills voids and irregularitis in canal, lateral canals and between GP points used in lateral condensation

lubricates during obturation

70
Q

properties of an ideal endodontic sealer

A

tackiness to provide good adhesion

hermetic seal (airtight)

radiopacity

easily mixed

no shrinkage on setting/no staining

bacteriostatic

slow set

insoluble in tissue fluids

tissue tolerant

soluble on retreatment

71
Q

types of endo sealers (2)

A

resin sealers

bioceramic sealers

72
Q

resin sealers

A

long history of use (AH26)

epoxy resin

paste-paste mixing 50/50

slow setting 8hrs

good sealing ability

good flow

inital toxicitiy declines after 24hrs

73
Q

bioceramic sealers

A

calcium silicate, calcium phophate

dimensionally stable

non-resorbable

early high pH antibacterial

prolonged set time

74
Q

properties of an ideal obturation

A
  • easily manipulated with ample working time
  • dimensinonally unaffected by tissue fluids
  • seals tha canal laterally and apically
  • non irritant
  • impervious to moisture
  • unaffected by tissue fluids
  • inhibits bacterial growth
  • radiopaque
  • does not discolour tooth
  • sterile
  • easily removed if needed
75
Q

issues with silver points

A

very rigid so couldn’t conform to irregularities in anatomy

produced cytotoxic corrosion products

76
Q

law of centrality

A

floor of pulp chamber is always located in the centre of the tooth at the level of the ACJ

77
Q

law of concentricity

A

walls of the pulp chamber are always concentric to the external surface of the tooth at the level of the ACJ

78
Q

law of ACJ

A

ACJ is the most consistent repeatable landmark for locating the position of the pulp chamber

79
Q

law of symmetry

A

except for maxillary molars

the orifices of the canal are equidistant from a line drawn mesio-distally through the pulp chamber floor

the orificies of the canals lie on a line perpendicular to the line drawn mesio-distally along the pulp chamber floor centrally

80
Q

law of colour change

A

the colour of the pulp chamber floor is alway darker than the walls

81
Q

law of orific location

A

orifices of RCs are located

  • at the junction between the walls and floor
  • angles of the junction
  • terminus of the root development fusion lines
82
Q

apical preparation and irrigation

A

ISO 30 or larger to allow irrigation

canal curvature and apical size will determine whcih is safe

83
Q

gold standard irrigant

A

NaOCl

2.5% or above will disturb biofilm

84
Q

manual dynamic irrigatioon

A

irrigate

in and out with GP point

v effective at removing biofilm

85
Q

management of NaOCl extrusion into tissues

A

LA for pain relief

canals irrigated with copious amount of physiologic saline

relax the pt and assure him or her that this complication can be controlled

dress tooth with non-setting CaOH

priorty must be given to pain relief, reduction of swelling and prevention of secondary infection

  • cold compresses during the first few days
  • warm compresses for resolution of soft tissue swelling and elimination haemotoma
  • analgesics (ibuprofen, paracetamol)
  • review in 24hr
  • prescription of antibiotics - case specific
  • refer if severe
86
Q

symptoms of NaOCl extrusion

A
  • pain
  • swelling
  • ecchymosis
  • hemorrhage
  • neurological complications

airway onstruction

87
Q

penultimate irrigation with

A

EDTA 17%

remove smear layer of biofilm and debris inside root anatomy

allows sealer and irrigant to penetrate tubules

88
Q

NaOCl and EDTA

A

do not mix

dry canal thoroughly between chemicals with paper points

89
Q

sequence of chemical irrigantion

A
  1. NaOCl
  2. Dry w/ points
  3. 1 minute with EDTA
  4. Dry w/ points
  5. Final rinse with NaOCl

*CHX can’t be used in Endodontics

  • Poor antifungal
  • Doesn’t disrupt biofilm well enough
90
Q

single vs multi appointments

A

vital teeth - single visit usually but case by case decision

non-vital cases are more complex with greater resistance to tx

91
Q

interappointment disinfection

A

Appropriate to use medicament between visits which will reduce and prevent multiplication of any bacteria that do remain

Odontopaste - ZnO based endo dressing contains Corticosteroid and Tetracycline antibiotic

Effective for 5-7 days

canal not obturated between visits, instead non-setting calcium hydroxide should be used must come into contact w/ bacterial cell wall to be therapeutic

Surface seal with one of the following

  • Cavit
  • IRM
  • polycarboxylate
  • GIC

REVISION BDS (43 decks)

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