Endo - ABGD Flashcards
What are the dental history questions when asking regarding a tooth that may need endo?
Localization
commencement
intensity
provocation
relief
duration
What is the opening of a sinus tract called?
Stoma
What are the grades of mobility?
+1= >normal, +2= </= 1mm, 3+ = >1mm, rotation and/or depression
When testing percussion, what methods do you use?
Pressue–>tap–>B/L tap
When heat testing a tooth, at what temperature should the water be?
150 degrees
Histology: What the the types of cells in the pulp and which is the most numerous?
Odontoblast, Fibroblast (most numerous), undifferential mesenchymal, inflammatory (such as lymph, macrophages, plasma, mast cells)
Histology: What are types of tissue are in the pulp?
CT, collagen: I, III, IV, vascular and neural tissue
What are the pulp zones?
Dentin–>predentin–>odotoblasts–>cell rich–>pulp proper
Types of dentin?
secondary: after root development
tertiary: reaction or reparative
Mantle: the first formed
Where are undifferentiated mesenchymal cells located within the pulp zones, and what do they help do to dentin?
Cell Rich Zone
Replace Odontoblasts when damaged which allows for reactionary/reparative dentin
How does the size of dentin tubules change as you approach the pulp?
increase in number and diameter
1-2 micron–>3-4 micron
10-25k –>30-52k/mm2
What size are bacteria?
<1 μm
Dentin is made up of?
45% inorganix, hydroxiapitits
33% organic: collagen and ground
22% H20
What is the theory of tooth sensitivity?
Brannstrom/hydrodynamic theory
What does the hydrodynamic theory describe?
nerve cells are “tugged” as a result of the moving liquid in the tubules.
Which nerves are stimulated during sensitivity?
A-Delta
Which way does liquid flow (per hydrodynamic theory) with heat?
In
Which way does liquid flow (per hydrodynamic theory) with COLD or AIR?
out
Is the in pull or the out pull in sensitivity a stronger response?
OUT = cold, air
What are the two broad types of innervation in the pulp?
Afferent(sensory) and Efferent
What are the names of the nerve fibers?
Afferent: A-Delta, A Beta, C
Efferent: C
Describe A-Delta nerves
large, mylenated, pain is quick sharp, shooting. They are fully formed at ~3-5 years,
Describe A-Beta Nerves
large, mylenated, few in #, transmit-awareness of light touch
Described C fibers (afferent)
Small UNmylenated. Transmit dull, delayed, ache, burning sensations
Describe Efferent C nerves
sympathetic, vasoconstriction
Does a pulp have proprioception?
no
For endo xrays, what kVp should you have it on?
63-70 kVp - low which produces a high contrast,
To increase the density on a radiograph….?
increase time
To increase contrast on a radiograph…?
decrease kVp
Can you have a apical pathosis without bacteria?
No, Kakehashi (1965)
What are the signs of multiple canals?
fast break (disappear), decreased density, uncrease ouline of the root, canal not centered
Internal resorption looks like ….. on xray?
enlarged vanal, canal not seen through lesion, symmetrical, well defined, centered with shift shot
External resorption looks like ….. on xray?
canal seen through lesion, asymetrical, poorly defined, shifts with shift shot.
What inhibits root resorption?
Osteoprotegerin (OPG)
Which inflammatory cells are blamed for resorption?
macrophage, osteoclast, IL-1
What kind of bacteria are found in symptomatic teeth?
Bacteriodes
What bacteria is found in Asymptomatic teeth?
Streptococci
A PARL or
Radicular Cyst arises from what cells?
Rests of malassez
If you take multiple angles of the same tooth, how does it change the diagnostic accuracy?
Up to 90% (Brynolf)
What is the only appropriate time to take a CBCT in endo?
per AAE/AAOMR, anatomical variations, evaluating non-healing, trauma, or resorptions
What are the laws of endo?
C3S2 CO3
Centrality, CEJ, Concentricity
Symmetry x2 (equidistance, and perpendicular from M-D line)
Color Change
Orifice Location x3 (junction of wall and floor, angles of floor wall junction, terminus of root development fusion lines)
What is the Weine classification?
I: 1:1
II: 2:1
III: 2:2
IV: 1:2
Canal %: MAX Ant
1 canal
Canal %: MAX 1stPM
*2: 85%,
3: 6%,
2 roots: 57%
Canal %: MAX 2ndPM
50/50
Canal %: MAX1M MB
1: 20%
*2: 77%-99
3: 3%
MB2: 65% weine II
*35% weine III
Canal %: MAX 2M MB
1: 65%
*2: 37% - weine II
Canal %: MAND Incisor
*1: 57%
*2: 43% = 1 foramen: 97-99% weine II
Most often L canal is missed
Canal %: MAND Canine
*2: 22%
Canal %: MAND 1PM
1: 75%
*2: 25%
3: 1% (often splits in apical 3rd) weine IV
Canal %: MAND 2PM
*1: 97%
2: 3%
Canal %: MAND 1M
2: 7%
3: 64%
*4: 29 %
Canal %: MAND 2M
2: 4%
3: 81%
*4: 11%
Cshape: 3%
How to determine WL?
estimate 0.5-1mm from radiograph. Mino contstiction. Using tactile, apex locator, paperpoint, patient sensation
What % is there a deviation from major foramina from the radiographic apex
92%
How does an apex locator work?
impedance of two frequencies, calculates the quotiont of the impedances, and expresses this quotient as a position of the files inside of the RC
resistence in file and lip clip/body become equal when the tip touches the PDL
At what distance is most deviations from the apex
0.59mm
What are the goals of cleaning and shaping?
total removal of pulp contents, develop straight line access, maintain central axis of canal, keep apical constriction small and in original position, continuously tapering smooth, funnel shaped preparations
What are the colors of files form 06-40
PGP - WYRBGBl
pink -6
gray -08
purple -10
white 15
yellow 20
red 25
blue 30
green 35
black 40
typical distance MB2 is from Mb2
1.8mm
the further the distance from MB2 the greater the chance it will be a Weine class III
Where is MB2 typically located
Slightly mesial to the line drawn between MB1 and P.
K file: material, shape, cut vs safe?
SS, Triangular/square, cutting
K flex: material, shape, cut vs safe?
SS, rhombiod, cut
Flex-R: material, shape, cut vs safe?
SS, triangular, safe
Sureflex: material, shape, cut vs safe?
niTi, square, safe
Hedstrom: material hape,
SS or NiTi, flute like design,cuts when pulling out
What does a negative rake angle do?
scrape
what does a positive rake angle do?
cut
Types of orifice shapers? What do they do?
Radicular access, coronal flaring
GatesL sie 1 = #50, size 2= 70
Peeso ReamersL size 1 = 70, size 2 =90
at what % should NaOCl be?
8%
What does 8%NaOCl do?
LD3OG-B
Lubricant,
Dissolves tissue,
Deodorizer,
Detoxifies endotoxins,
Organic portion of the smear layer,
Germicide,
Bleaching
At what concentration should EDTA be?
17%
17% EDTA - What does it do?
LIC:
Lubricant
Inorganic portion of the smear layer
chelating agent
For a 30G Maxiprobe, what size do you need to file the canal?
35/40 or 0.32mm- must go to Medium in Wave 1
What does Calcium hydroxide do?
High pH (alters environment), antimicrobial, dissolves, tissue, favors calcification, favors osteogenesis, causes limited tissue necrosis, helps dry. “weeping” canals, halts or slows resorptive process, effective for 1 week.
What do you use to judge obturation?
ALTD
Apical Width
Length
Taper
Density
GP is made up of what?
56-75% Zinc Oxide
19-22% GP
2-17: metal sufites
1-4%: waxes/resins
What technique for obturation endo?
continuous wave warm vertical
When a file breaks what kind of fatigue occured?
Cyclic- because of use, bending back and forth, one rotation = one tension-compression cycle.
Torsional: tip locks, files turns. often due to too much apical pressure, and it is locking or dragging in the canal. Warning signs are a clicking noises.
When using Bioceramic sealer- what is the advantage?
pH12, decreased contact angle
calcium silicates
can bond to ceramic filled GP (like activ GP)
When to finish endo in 1 visit
pt availability
medical complex
vital tooth
esthetics
negative for pathosis
(no change in success rate or pain levels)
When to use multivisits for endo?
canal system is infected, acute apical sympm sinus tract
Things that go wrong in endo
separation, perforation, ledges, over fills, voids, VRF, NaOCl accidents.
What does it look like and what to do about an NaOCl extrusion
Symp: swelling, hematoma, extreme pain
Tx: calm patient, anesthesia, cold compress for x6 hours, warm compress for 2 days, analgesics, antibiotics, daily recall
immediate referral if airway compromise
How to I&D
incise in biggest area, blunt dissect, irrigate. place drain for 2-5 days. daily f/u
What to prescribe for moderate pain?
IBU 96-800) +APAP (650-1000mg)/Codeine equivilant of 60mg
if no aspirin, 600-1000 APAP and 60mg codiene
What to give for mild pain?
2-400mg IBU or 650 Aspirin
650-1000mg APAP
What to give for severe pain?
IBU and/or APAP with 10mg oxy equivalant
Local anesthetic works by…?
inhibiting nerve depolarization by blocking Na. LA cation dissociates into the base and H ions, the base molecule diffuses through the lipid nerve sheath, then binds with H to form a cation which then blocks the Na receptor channel thus blocking Na penetration in the nerve sheath and preventing depolarization.
What happens if it has a more acidic environment with regards to LA?
More acidic environment means more H ions so there will be less base form present there for less base to diffuse across the membrane
Why can the Base ion (RN) dissociate then cross the membrane?
because it is lipophilic
How to have more base available in more acidic environments regarding LA?
lower the pKa/ use the one that has the lowest pKa (carbo)
Normal pH of tissue
7.4
What is it called when normal percussion becomes extreme pain?
hyperalgesia
What is it called when a patient has pain when they should have zero?
Allodynia
What are the resorption types in trauma?
SIR
Surface (self limiting) inflammatory (infection) replacement (ankylosis)
Gow gates is given how?
while pt is open, to the ant neck of the condyle to hit V2 when it exits the foramen ovale.
Lower Pka does what for onset?
faster onset
Most cracked tooth?
mand 2M then 1M
Pulp canal obliteration is also known as:
calcific metamorphosis
How often does pulp obliteration happen following an injury? Does it need tx?
25% of luxation injuries- causes yellow coronal discoloration,
Tx: routine intervention is NOT needed.
What does internal resorption look like and what to do?
VITAL pulp, asymptomatic, pink tooth.
tx: ENDO ASAP
Root fractures: where to fx for best outcomes
middle and apical 1/3
How do root fractures health with %?
Hard tissue: 33%
CT: 36%
Bone and CT: 8%
Non-healing (needs endo): 23%
Best to worse injuries to a tooth
Concussion<subluxation<extrusive luxation<lateral luxation<intrusive luxation
If the tooth is in an infraposition after injury in a growing patient, what should you do?
decoronate to save bone.
Avulsion: whats the best solutions
Hanks balanced (24-96),
Milk (6hrs)
Saline, saran wrap, saliva (2hrs)
What to do with an avulsion of an adult tooth with a closed apex and immature?
<60 min, replant, splint, for 2 weeks pulp in 7-10
immature: soak in doxy, replant, splint, monitor
> 60min: remove tissue tages, saok in NaF fro 20 min, replant, splint, pulp in 7-10 days.
If immature splint for 4 weeks
When a rt is fractured how long should you splint?
4 weeks to 4 months if near the cervical
Alveoloar fx- how long to splint?
4 weeks
What size is a flexible sploint
0.016” or 0.4 mm
Frequency to follow up with trauma?
1-2 weeks, 4weeks, 3-6 months, 1 year, and annually
Goals and procedure of apexification
induce calcified apical barrier, in a tooth with a necrotic pulp. Long term CaOH vs short term(best prognosis) 4weeks-4hrs
same day- debride, clean, MTA barrier
can strengthen by filling with composite
Apexogensis- goals and procedure
maintain pulp vitality- cvek pulpotomy. development of root end, thickening of dentin walls,
do this for asymptomatic, immature roots, with a vital pulp that have a carious exposure or traumatic exposure
Regen/revasculatization: goals and procedure
regenerate pulp. disinfect canal/chamber in a non-vital tooth with 1.5% naOCL and 17% EDTA.
minimal instrumentation to 1mm of apex.
triple ABX paste or caOH in place for 1-4 weeks, temporize
after 104 weeks, 3% mepivi plain, create bleeding with instrumentation, then stop bleeding
place collaplug, white MTA, and GI or composite coronal.
- close f/u
What is in the triple antibiotic paste?
1:1:1 cipro/ metronidazole/ minocycline
What causes staining with regen?
MTA and minocycline
What are the goals of regeneration?
- eliminate symptoms and create bony healing
- increased root wall thickness and length
- positive response to vitality testing
Why is there minimal instrumentation with regen?
walls are thin and fragile, avoid damage. rely on irrigation.
Endo success rates:
-overall
-No PA pathosis
-With Pathosis
-retx with no PA
-retreat with PA
Sojogren, 1991
overall: 91%
No PA pathosis: 96%
With Pathosis: 86%
retx with no PA: 98%
retreat with PA: 62%
Etiology of endo failure
POOR PAST AM
Perforation
obturation incomplete
overextension
root canal missed,
periodontal involvement
Another tooth
Split tooth
Trauma
Anatomic variation
Microleakage
How to remove GP?
gates, NiTi rotary, heat, handfiles (like hedstrom, solvents (endosolv, chloroform, halothane)
Steiglitz forceps
How to remove a post?
ultrasonics, Gonon, Ruddle
GP exposure to oral cavity
30 days is the accepted limit if obturation was of good quality
Indications for periradicular sx
inability to debride apical canal, gross over extension, perforation, progressive root resorption, persistant post op disease, if a biopsy is necessary (ie periapical granuloma, periapical cyst, OKC)
What kind of flap to use or root end sx
triangular flap- single release between eminences
Internal Bleaching- what does it require to be successful?
adequate obtruation, 2mm thick protective barrier at the level of the CEJ, removal of all discolored dentin, Sodium perborate and h20 with temp filling
How often does cervical resorption happen with bleaching?
minimal- and only if you dont place protective barrier (2-7%)
What should you def not use for bleaching?
superoxol (30-35% hydrogen peroxide)
what is endo ice and how cold does it get?
tetrofluorethane
-26.2* C
or -14 F
What are the fibers that are stimulated when exposed dentin in cold, hot, air or probing?
A delta
What are the diagnoses for pulp?
normal
Reverse pulp
Symp Irr Pulp
Aysmp Irr pulp
pulpal necrosis
previously initated
previously tx
What are the apical dx?
normal
SAP
AAP
CAA
AAA
condensing osteitis
What are the signs of SIP?
spontaneous pain
pain that wakes them up
throbbing pain
lingering >15 secs esp to temp
deep dull ache
radiating pain
CC may be reproduced
may refer
pain decreases with necrosis
What is the law of centrality
pulpal floor is located in the center of the tooth at the level of the CEJ
What is the law of concentricity?
the roots are equidistance from the pulp chamber walls, form of pulp follows form of tooth
pulp walls of chamber are concentric to the external surface of the tooth at the level of the CEJ
Explain the law of CEJ
Pulp chamber is at level of CEJ- most consistent and repeatable landmark
How much can the actual apical foramen deviate from the radiograph apex
0.59mm (Burch 1972)
What happens to the canal if the rake angle is postitive?
cutting the wall
What is EDTA?
-ethylene diamine tetra acetic acid
What is the ellis classification?
1: enamel only
II: enamel and dentin
III: dentin and pulp
IV: root
generally which teeth are the most cracked and at what percent?
mandibular molars- 70% of cracked teeth
What endo rotary system and technique do you use?
Vortex Blue- .04, and .06 tapers. #15-50 size. NiTi, blunted triangular cross section (less agressive)
Technique: establish straight line access, establish WL to #15 with apex locator and xrays
use crown down technique- larger file first to resistance or WL, then irrigate, recapituate with #10-15 hand file, then proceed with smaller files until WL is established at a minimum of #35 (so that irrigant can reach the apex)
What is passive ultrasonic irrigation? How is it done and do you use it?
excellent auxiliary in the process of final cleaning of the RC system.
it increases the efficiency of irrigant solutions and tissue/debris removal.
*insert the tip to 1-2 mm of WL and remain in the position for 2 period of 20 secs each.
creates accosting micro streaming along the length of the instrument that forms irrigant jets directed to the canal wall to remove debris
signs of external cervical resorption
clinical- cervical reagion has a pink spot, normal vitality testing, spontaneous BOP, sharp/thinned edges aroudn cavity
xray: varies, possible asymptomatic RL, mottled, RC is visible and intact. moves with shift shots
What are common causes to external cervical resorption?
ortho
trauma
OS
perio therapy
bruxism
intracoronal restorations
delayed eruption
DO to eliminate internal restoration process?
remove blood supply, kill osteoclasts- ENDO
What is the classification of external cervical resorption?
Heithersay classification: class 1-4. based on the depth and extent of the damage with decreasing prognosis
What conditions increase tooth survival after RCT?
crown within 90 days
M or D contact
not an abutment
tooth type ( decreased rate for 2nd molars)
3D obturation (no voids)
How long do you wait for an endo lesion to heal and why?
2-4 years
(friedman)
1 yr- 50% healed
2yr 90% healed
4-5: healed or not
What sized needle do you use in endo? and what is the tip at the apex?
30 gauge, side vent, 0.32 needle
What is the perforation prognosis dependent upon?
location, size and time of repair
GOOD: small, near apical or coronal, fresh
BAD: old, large, sulcular or crestal
