ENDO Flashcards
The Pulp contains
- Loose fibrous CT w/nerves, BVs, and Lymphatics
- Fibroblasts
- Odontoblasts
- Undifferentiated Mesenchymal Cells
Primary vs Secondary vs Tertiary Dentin
Primary Dentin:
* before complete root formation
Secondary Dentin: (aka Reactionary Dentin)
* after complete root formation
* reaction to minor damage
* ex: Chronic Attrition
Tertiary Dentin: (aka Reparative Dentin)
* repair major damage
* ex: pulp exposure
Fibroblasts
secrete fibrous CT
Odontoblasts
Secrete Dentin
Undifferentiated Mesenchymal Cells
Stem cells-> become new cells (secondary Odontoblasts)-> Tertiary Dentin–>protect pulp from injury
Pulp properties
Surrounded by hard dentin
* limits ability to expand
Lacks collateral circulation
* limited ability to deal w/infection
Scelortic Dentin
Calcification of tubules in respose to:
* slow advancing caries
* aging
Hardened Dentin
Histologic Zones of Pulp
Predentin: not mineralized
Odontoblastic layer: where nuclei are laying down dentin
Cell free zone of Weil: 0 nuclei/no cells
Cell-rich zone
Pulp core
Dentinal Pain Vs Pulpitis Pain:
Dentinal Pain=A delta Fibers
* large myelinated afferent nerve
* course coronally through pulp
* Sharp transient “First Pain”
* associate w/Cold
Pulpitis Pain=C fibers
* small unmyelinated afferent nerve
* course centrally in the pulp stroma
* Dull throbbing “Second pain”
* Heat
Pain Sensitization
Hyperalgesia
* heightened response to pain
Allodynia:
* reduced pain threshold, stimulus that usually doesn’t cause pain
* sunburnt skin is an example of aloe-dynia
Referred Pain
Preauricular pain(in front of ear)
* refers from mandibular molars
* both share V3 innervation
Endo Pulpal Diagnosis
- Normal Pulp
- Reversible Pulpitis
- Symptomatic Irreversible Pulpitis
- Asymptomatic Irreversible Pulpitis
- Pulp Necrosis
- Previously Treated Pulp
Endo Periapical Diagnosis
- Normal Apical Tissues
- Symptomatic Apical Periodontitis
- Asymptomatic Apical Periodontitis
- Acute Apical Absscess
- Chronic Apical Abscess
Cold Test
Endo Ice: dichlorodifluoromethane, -30 C
chilled pellet applied to middle 1/3 of facial surface for 5 seconds
Intensity & Duration=pulp diagnosis
Pulp Capping
Place CaOH liner
* irritates odontoblasts to form Secondary/Tertiary dentin (depends on distance from pulp)
* forms dentin wall/barrier
Normal Pulp
Asymptomatic
Thermal & Electrical Stimuli=Mild to moderate transient response
Electrical Pulp Test (EPT)
Least reliable pulp vitality testing
Indicates: vital sensory fibers in pulp
* no info about vascular supply to pulp (Vascular supply=true determinant of pulp vitality)
Contraindicated: Pacemaker
What is the true determinant of pulp vitality?
Vasculary supply to pulp
Reversible Pulpitis
Symptomatic–>symptom NOT disease
Thermal (cold) stimulus causes:
* quick, sharp, hypersensitive, transient response
* Heightened but NOT NLINGERING
* No Spontaneous pain
Caused by:
* an irritant that affects the pulp
Symptomatic Irreversible Pulpitis
Symptomatic:
* Spontaneous intermittent or continuous pain
* Cold stimulus= Lingering pain
Postural changes (Bending over or lying down)
* exacerbate dental pain
Radiographs are insufficient
* EPT not valuable
Asymptomatic Irreversible Pulpitis
Asymptomatic
microscopically similar to sympatomatic irrervsible pulitis but NO Clinical Symptoms (normal)
* micro abscesses of pulp
Pulp Necrosis
Asymptomatic, but not always
Can be partial or total
* due to long term interuption of blood supply to pulp
Anterior Teeth=Crown discoloration
* tx w/RCT or internal bleaching
What happens if a necrotic pulp is left untreated?
Toxins spread beyond the apical formaen and leads to:
* thickened PDL
* tenderness to percussion/palpation
* Apical Disease
Normal Apical Tissues
Asymptomatic
No pain on percussion or palpation
Symptomatic Apical Periodontitis
Symptomatic:
* painful percussion-inflammation around apex
* intense throbbing pain
If vital tooth + symptomatic= occlusal adjustment
If Nonvital tooth=RCT
Asymptomatic Apical Periodontitis
Asymptomatic
Apical Radiolucency=Confirms pulp necrosis
Acute Apical Abscess
Rapid Swelling
Severe Pain
Purulent exudate around apex
Chronic Apical Abscess
Draining SINUS TRACT/Fistula (Neutrophils)
* no discomfort/swelliing
Acess Preparation
Most important part of RCT
* conserve tooth structure
* Deroof chamber to expose pulp horns & orifices
* Straight-line acess
* Standard of care=RUBBER DAM
Access Prep for Incisors
Triangular
* always 1 canal
* ensures removal of pulp horns (Deroofing(
* helps prevent marginal ridges
* helps attain straight line access
Access Prep for Canines
Oval
* 1 canal
Acces Prep for Premolars
Oval
* 1 or 2 canals
* Maxillary 1st premolar=2 roots
Access Prep for Max Molars
Blunted Triangle or Rhomboidal
* 3 roots
* 4 canals, MB root has 2 canals
Access Prep for Mandibular Molars
Trapezoidal
* 3 roots
* 4 canals, D root has 2 canals
SS Hand Files
.02 taper
K File (Kerr)
* twisted square
* watching winding method
H File (Hedstrom)
* spiral cone
* only cuts in retraction (pulling out)
NiTi Rotary Instruments
0.04 to 0.06 taper
Universal Color Code system
White (15)
Yellow
Red
Blue
Green
Black
Gates-Glidden Drills
Enlarge coronal canal area
* Open orifice for straight line access
Barbed Broaches
entangle and remove vital pulp or materials from canals
Reamer
twisted triangle
File Dimensions
D1: Diameter at tip
* size 15= 0.15 mm
D2 or D16: Diameter 16mm from tip
* cutting flutes end
* Sze 15 K file: 0.15 mm + 0.02(16mm)=0.47mm
Cleaning and Shaping
Crown-down: Big to small
Step-Back: Small to big
Irrigation and Medicaments used in Endo
Sodium Hypochlorite (NaOCl)
EDTA
Chloroform
Sodium Hypochlorite (NaOCl)
Irrigant
* dissolves organic material (Bacteria)
* Disinfects canals
Medicament of choice for RCT
Achieve Hemostasis in Vital Pulp Therapy
EDTA
Lubricant
* dissolves inorganic material (Smear layer of dentin)
* Chelating agent (decalcifies dentin)
Chloroform
dissolves GP in retreatment
Endo Microbiology: Primary vs Failed Endo Infection/treatment
Primary Endo Infection: Bacteriodes
* gram negative obligate anaerobes bacteria (No o2)
Failed Endo Treatment: Enterococcus Faecalis
* gram positive facultative anerobic bacteria
Obturation
To fill & seal canal system
* GP and Sealer= ZOE (main ingredient)
Warm vertical and Cold Lateral Condensation
* Warm Vertical: GP + Pluggers
* Cold Lateral: Using finger spreader to move GP and pack in accessory cones
End Treatment PLanning
- RCT
- Retreatment–> CANAL (IF problem is in)
- Surgical RCT (Aka microsurgery) –> APEX
Incision & Drainage
Surgical opening in SOFT TISSUE
* to release exudate and pressure
* Best for localized and fluctuant swelling
Trephination
Surgical opening in HARD TISSUE to release exudate and pressury
* Periapical surgery then Apicoectomy
Endo Procedure Complications
Ledge Formation
Instrument Seperation
Perforation
Ledge Formation
Flexible NiTi files are less likely to ledge
To bypass ledge:
* Renegotiation: use a smaller file to explore and discover anatomy
* Put a small bend in the file
Why do ledges occur?
No straightline access
Inadequate irrigation/lubrication
Happens in longer canals, smaller diameter, or curved canals
Instrument Seperation
Flexible NiTi are more likely to fracture
To Bypass-Us smaller instrument
Better prognosis=The later the instrument breaks
* if sufficiently disinfected=can leave instrument and seal canal
Why do instruments seperate?
- Using Excessive Force
- Jumping up in a file size
- Inadequate irrigation/lubrication
- Not replacing files often enough
Perforation
Coronal Perforation: Through the crown
Furcal Perforation: Through the pulp floor
Strip Perforation: due to excessive coronal flaring
* mandibular molars: Always favor M side of M root (THICKER DENTIN)
Root Perforation: more apical=better prognosis
Internal Repair with MTA
Later in tx process=better prognosis
What are signs of perforation?
Immediate Hemmorhage
Sudden Pain
Trauma Protocol
TRAVMA
* Tetanus booster (Avulsions only)
* Radiographs
* Antibiotics (Avulsions only)
* Vitality testing: False positives are common for 2-8 wks after trauma due to damaged sensory nerves, vascular suppy may be intact
* More
* Appointments: 3 wks, 3 mos, 6 mos, 12 mos
Ellis Classification
- Class 1: Enamel only
- Class 2: Enamel & Dentin
- Class 3: Enamel, Dentin, & pulp
- Class 4: Nonvital tooth
- Class 5: Avulsion
- Class 6: Root Fracture
- Class 7:Displacement of tooth
Uncomplicated Fracture
W/o pulp involvement
* Enamel Only: Smooth Edges
* Enamel & Dentin: Restore
Complicated Fracture
w/pulp involvement
< 24 hrs: DPC (Direct Pulp Cap)
24-71 hrs: Cvek
* partial pulpotomy 1-2 mm below exposure
72+ hrs: PPTY (pulpotomy)
Horizontal Root Fracture
Take 3 PAs and 1 occlusal
* at different angles to view fracture line
Ideal Healing: Calcific metamorphisis
Vital: Splint ASAP, Oblique (/) is better than transverse (–)
* coronal fracture: rigid splint for 6-12 wks
* midroot fracture: flexibile splint for 3 wks
* apical fracture (BEST): flexible splint for 2 wks max to avoid ankylosis.
Necrotic: RCT
* 25% chance of necrosis in coronal segment
* apical segment=rare, if it does=extract/surgically treat
Concussion
Bumped your tooth
* no displacement, no mobility, PDL Sore
Monitor & LET THE TOOTH REST
* avoid chewing w/it
* soft foods
Subluxation
Bumped tooth and saw some bleeding around sulcus
* no displacement, increased mobility
* PDL Rips and bleeds
Flexilble splint for 1-2 wks
* 6% chance of necrosis w/closed apices, more favorable w/open apices
Extrusion
Open Apex (Most favorable):
* Reposition
* flexible splint (1-2 wks)
* monitor
Closed Apex:
* Reposition
* flexible splint
* RCT if needed (if it becomes necrotic)
* 65% chance of necrosis
Lateral Luxation
Displacement of tooth in any direction but axially
* usually crown displace palatally, and root apex labial
Same tx options as extrusion
Open Apex: Reposition, flexible splint (1-2 wks), monitor
Closed APex: Repositioin, Flexibile Splint, RCT If neeeded (Necrotic)
* 80% chance of necrosis
Intrusion
Apical displacement of tooth
Open Apex: Allow to reerupt
Closed Apex: Reposition, flexible splint, RCT
* 96% chance of necrosis
Avulsion
Extraalveolar dry time (EADT): amount of time a tooth has been out of the mouth while dry
Reimplant ASAP, flexible splint for 1-2 weeks (Not for primary teeth)
EADT<60 mins
Closed Apex: Reimplant, splint
Open Apex: Reimplant, splint, Apexification at first sign of infected pulp (No RCT)
EADT> 60 mins
Closed Apex: Reimplant, splint, RCT
Open Apex: May or may not reimplant, splint, RCT, plan for implant
Avulsion: Storage Media
- Hank’s Balanced Salt Solution (HBSS)=BEST
- Milk
- Saline
- Saliva
- Water (least desirabe bc hypotonic)
What are the possible long term responses to trauma
External Resorption
Internal Resorption
External Resorption
starts in the periodontium
* due to damage to cementoblastic layer (Cementoblasts)
Margins: Ragged & poorly defined
* Moves w/angled radiographs
Types:
Replacement Resorption (RR)
Cervical Resorption (CR)
Inflammatory ROot Resorption (IRR)
Internal Resorption
Initiates in the root canal system
* due to damage to odontoblastic layer (Odontoblasts)
Better prognosis/esier to tx
* RCT
Margins: Sharp and well defined
* does not move w/angled radiographs
Calcific metamorphasis
Truma–> stimulate odontoblasts–> reparative dentin w/in the pulp
Results in:
* Yellow-orange tooth color
* Canal Obliteration
Calcium Hydroxide (CaOH2)
Stimulates
1. secondary odontoblasts: Form dentin bridge
2: mesenchymal cells–> tertiary dentin to protect pulp
High pH=12.5
* cautterizes tissue
* kills bacteria
MTA
Mineral Trioxide Aggregate
Stimulates cementoblasts–>Cementum
* 3 minerals: Calcium, silicon, aluminum
MTA: Pros & Cons
Pros:
* sets in the presence of moisture
* Antimicrobial
* Nonresorbable=great sealing agent
Cons:
* Bismuth oxide=opacifer (Radioopaque on x-ray)
* Long 3 hr setting time
Vital vs Non-Vital Pulp Therapy Procedures
Vital Pulp Therapy:
* Indirect Pulp Cap (IPC)
* Direct Pulp Cap (DPC)
* Cvek Pulpotomy
* Pulpotomy (PPTY)
* Apexogenesis
Nonvital Pulp Therapy:
* Pulpectomy (PCTY)
* RCT
* Extraction
* Apexification
Indirect Pulp cap
Indication:Deep caries approximating pulp
CaOH or RMGI
* if removed, might expose HEALTHY PULP
Direct Pulp Cap
CaOH
healthy pulp expsoure
* Traumatic Exposure<24 hrs
* Carious or mechanical exposure < 2mm
Hard tissue barrier forms in 6 weeks
Cvek Pulpotomy
Aka partial or shallow pulpotomy
* remove coronal DISEASED PULP
* 1-2 mm below exposure
Used for:
* Traumatic exposure: 24+ hrs
* Carious or mechanical exposure > 2mm
Pulpotomy
Remove coronal DISEASED PULP
Uses:
* Truamatitc exposure 72+ hrs
* vital and restorable primary tooth w/pulp exposure (Asymptomatic)
ZOE in crown
* formocresol to obtain hemostasis
Formocresol:
*General
* Contains
Contains:
* 19% formaldehyde
* 35% cresol
* 15% glycerine
* 31% water
Bactericidal & Fixative (fixates the pulp tissue)
Used for Vital Primary teeth Pulpotomy
Pulpectomy
Remove ALL dead or dying pulp
* temporary relief for irreversible pulpitis until a RCT can be done
nonvital + restorable primary tooth w/pulp exposure (Asymptomatic)
* ZOE in crown
* CaOH in root (resorbed by underlying permanent tooth
Extraction
Symptomatic root resorption
Nonrestorable
Primary 1st molars
* a lot of accessory canals, RCT=difficult
* higher success with ext
Root Canal Therapy
Diseased or Dead Pulp
Pulpectomy + Cleaning, shaping, and filling
Apexogenesis
stimulate root development=stronger root
CaOh or MTA placed on Healthy or diseased pulp
On immature permanent tooth, includes
* IPC
* DPC
* Cvek
* PPTY
Contraindication:
* Alvulsed
* norestorable
* severe horizontal fracture
* necrotic teeth
When is Apexogenesis Contraindicated?
Avulsed
Nonrestorable
Severe Horizontal Fracture
Necrotic Tooth
Apexification
Non Vital Pulp therapy- close root apex
Steps:
* remove dead or dying pulp
* CaOh or MTA placed at base of canal==apical barrier to prevent retrograde infection
immature permanent tooth, includes:
* pulpectomy
Pulp Necrosis
Response to rapid advancing caries or other severe damage
Replacement Resorption
External Resorption type
Replacement Resorption (RR)
* ankylosis
* replaces PDL w/bone
Cervical Resorption
External Resorption type
Cervical Resorption (CR)
* subepithelial sulcular infection
* due to trauma or nonvital bleaching
Inflammatory Root Resorption
Type of External Resorption
Inflammatory ROot Resorption (IRR)
Necrotic Pulp–> Bacteria & Byproducts–>Dentin tubules–>Affect periodontium
Calcific metamorphosis is more likely to occur in?
- open apices
- intrustions
- severe crown fractures
How long does it take a periodical radiolucency to resolve after RCT?
1 year
* if < 1 year=monitor
Silver Points
Obturation material
* More radiopaque than GP
Corrode spontaneously in serum & blood
* stain tooth and surrounding tissue
* Periradicular inflammation & pain
Tx: retreatment (replace silver points)
Bioceramic Sealer
Goal: Fill small gaps b/w core obturation material & canals walls to MINIMIZE VOIDS
- Radiopaque
- slow setting time
- Antimicrobial
Bonds to root dentin
* helps seal cananl
* makes pretreatment harder
MTA: Uses
Dental root repair
Sealing root perforation
Root end filling after apicoectomy
Apical barrier for open apex
Post-Endodontic Flare Up
After RCT=Severe Pain & swelling in periapical region
* 5% of pts
Due to:
* extrusion of bacteria past apical foramen=most common
* overinstrumentation
* Extrusion of irritants & dental material into periapex (least common)
Primary Endo Infection
Bacterriodes
* Gram Negative Bacteria (Lipopolysaccharides in cell wall)
* Obligate Anerobes
Gram Negative Bacteria: Virulence
Gram Negative Bacteria: Virulence Factor
Lipopolysaccharides in cell wall
Sealer Extruded from apex:
Radioopaque puff
Due to:
* overinstrumentation
* lose apical stop
Internal Bleaching: increased Risk?
Risk=external cervical resorption
* pink spot along gingiva
What should a general dentist do if a file breaks during a RCT?
Tell the pt what happened and refer to endodontist
Silver Point
Corrosion in presence of Blood and serum
* Stain tooth & surrounding tissue
* periradicular pain & inflammation
Result: Failed ENDO
Tx: retreatment (remove silver point)–> Clean canal system–> Replace w/GP
Post
Extends into root canal
* Retain the core
Cast Post:
Ideal Post length: 2/3 length of tooth root
Ideal Post diameter: 1/3 diameter of tooth–>Rigidity
What is the radiolucency b/w obturation material and Post?
Empty space
Hardest tooth to treat with endo therapy?
Maxillary 1st molar
What tooth is most susceptible to GP overflowing into maxillary sinus?
Maxillary 1st molar
What tooth is most difficult to access bc of mesial surface?
Max 1st premolar:
* developmental depression on M surface=concavity: Increase perforation
What does Bleeding After instrumentation indicate?
Vital tissue remnants at apex
*occur in teeth w/apical infection
What should you do if a file separated in apical 1/3 during endo tx?
1.Do not attempt to remove
* cannot bypass
2.Obturate up to separated instrument
- Place on recall to further eval
* obtain apical seal=can remain asymptomatic
Rubber Dam: primary goal
patient protection
* prevents aspiration of instruments/materials
What irritant is most likely to cause reversible pulpitis?
Restorative tx
Recommended obturation material
Ceramic Based Obturation material:
* Guttacore
* BIoceramic
* Thermoplasticized injectable
Not recommended: Paraformaldehyde paste
What is a good alternative to NaOCl?
Chlorhexidine:
* antimicrobial
Acute Apical Abscess vs acute periodontal abscess
Acute Apical Abcess:
* Purulent Swelling
* Infection in root canal
* always NONVITAL
Acute Periodontal Abscess:
* Purulent swelling
* DEEPER perio pocket
* does not affect tooth vitality
What is most useful in differentiating an acute apical abscess from acute periodontal abscess
EPT: Electric Pulp Test
Acute Apical Abcess:
* Purulent Swelling
* Infection in root canal
* always NONVITAL
Acute Periodontal Abscess:
* Purulent swelling
* DEEPER perio pocket
* does not affect tooth vitality
SLOB
Buccal Object Rule
*Same Lingual Opposite Buccal
Object moves in same direction as x-ray machine=Lingual
Object moves in opposite direction as x-ray machine=Buccal
Internal Bleaching: Options
Carbamide Peroxide
Sodium perboxate
Hydrogen peroxide w/o heat
Pulp Vitality Tests: Most reliable to least reliable
- Cold (most reliable)
- EPT
- Heat (least reliable)
