Endodontics Flashcards
What is the root canal procedure steps?
Prerprocedural checks
Chief concern and history taking
Taking the PA
Consultation with the patient and tutor
EPI calculation
Procedural
Step 1: Initial acess
Apply anaesthetic and isolate the appropriate tooth using single clamp
Using a high speed, end cutting bur such as 838 to gain initial access to the pulp chamber – always refer back to the PA
Switch to the non-end cutting endo-z bur in order to expand the access cavity
Use endoprobe to locate the canal
Pre-curve size 10 file and insert it a few mm into the canal
Take a PA
Irrigate the canal with a pre-bent hypochlore 1%
Step 2: Expansion of the coronal aspect
Using size 2 and 3 gate glitten bur, brush it a few mm into the canal coronally to expand the access
Irrigate
Step 3: Working length determination
Determine the working length using electronic apex locator, attach the device, advance to 1mm away from apex and have a good refrence point, take a PA to confirm
When confirmed chart as correct working length
Irrigate
Step 4:
Pre-cruve files and set them to the correct working length
Starting with the smallest file (size 10) instrument using clokc winding technique
Irrigate
Ensure canal is very loose for the smallest file – move to file that is 1 size larger
Irrigate and recapitulate and irrigate again
Ensure canal is very loose for the size up file – move to the file that is 1 size larger
Continue until you reach file 30 – take a PA of master apical file at 25 to confirm
Step 5: Step back
Pre-cruve file 30 and 35, set to correct working length
Create a stepback of 1mm with file 30
Irrigate
Create a stepback of 2mm with file 35
Irrigate
Step 6: Medicaments
Use calcium hydroxide for non-symptomatic and odontopaste for symptomatic
Apply using a file or a lentulo spiral at low rpm
Step 7. Interim restoration
- Put a nice layer of cavit in the pulp chamber – use a small cotton pallet with water to engae it
Use RMGIC to restore – check occlusion and recall the patient in 4 weeks
Why is endodontics important?
1.Treatment of pain is the main factor in patient
2.Stopping the propagation of infections
How do you write a diagnostic statement in endodontics?
1.Pulp and root canal condition – necrotic pulp/irreversible pulpitis
2.Periapical status – chronic/acute apical periodontitis evident radiographically
What aspects should we consider for endodontic treatment?
1.Strategic value of the tooth
2.Periodontal factor – if the tooth is grade III mobility what si the point of endodontically treating it?
3.Patient factors – MHx, motivation, age, compliance with treatments
4.Restorability options – consider the entire mouth
What clinical test should you do during endo examination?
1.Percussion of tooth
2.Palpation around the soft tissue
3.Periodontal examination – cracks and fractures
4.Pulp sensibility tests – cold, hot or electric
5.Radiographs – PAs and BWs with or without use of GP with fistula
6.Special test – removal of restoration, selective LA, transillumination oe fracture finder on each cusp
7.Full data analysis and appropriate diagnosis presented to patient with options – two component diagnosis pulp+root canal AND periapical status – IT IS SEEN ON MY UNI REMMEBER IT
8.Patient need to be informed about the time, cost, step-by-step of each procedure, risks and need to consider a crown restoration
9.Ask the patient “is there anything you want to ask me, your opinion is essential for your own wellbeing”
10.Accurate record keeping
What is considered to be moderate diffuclty in the AAE classifications?
One or two of the following:
1. ASA class 3 patient
2. Vasoconstrictors intolerance
3. Anxiety
4. Limitation in opening
5. Gagging
6. Moderate pain or swelling
7. extensive differential diagnosis
8. Difficulty in obtaining radiographs
9. 1st molar
10. Moderate inclination - 10-30 degress
11. Soem trouble with rubber dam
12. Coronal distruction or complex restoration
13. Canal morphology is slightly more complex
14. Pulp stones
15. 3-5 mm near the IAN
16. Minimal apical resorption
17. Crown fracture
18. Previous access without complications
19. Endo-perio lesion
What is considered to be high diffuclty in the AAE classifications?
3 or more in moderate difficulty and at least one in the high diffuculty such as?
1. ASA 4
2. Can’t get anaesthesia
3. Uncooperative
4. Significant limitation in opening
5. Extreme gaggin
6. Sever pain
7. History of orofacial pain
8.2nd or 3rd molar
9. Extreme inclanation
10. Extreme rotation
11. Significant deviation from normal tooth/root form
12. C-shape morphology, extreme curvature or S-shape curve, rare root morphology, very long teeth
13. Pulp chaber not visible
14. extremly close to IAN (<3mm)
15. Extreme resopriton
14. Root fractures
15. Previous endo
What is the classification of cracked teeth according to severity from low to high?
1.Craze line – very common and only in enamel – use transillumination
2.Fracture cusp – usually from insufficient cusp support from deepest point of restorative material – sharp pain on biting usually on non-funcitonal cusps
3.Cracked tooth – centered, vertical crack that has pulpal symptoms and can be in none restored teeth – typically mandibular second mollars
4.Split tooth – progression of cracked tooth – hopeless prognosis
5.Veritcal root fracture – a longitudinally oriented fracture extending from the root canal to the periodontium – hopeless prognosis
What are pre-disposing factors from cracked teeth?
1.Occlusal factors – posterior buccal crossbites, anterior open bites, steep cusps
2.Parafunction
3.Age
4.Width and depth of cavity
5.Use of rotary instrumental – common in vertical root fractures
How do we diagnose coronal cracks?
1.Patient symptomatology
2.Vision enhancers
3.Symptom reproducers – Very important
4.Radiographs
What is the mechanisms of pain in cracked teeth?
Due to peripheral location and low excitability threshold of A-beta and A-delta fibers, rapid sharp pain is generated. In cracked teeth, the increased rapid movement of dentine fluid in dentinal tubules during relaxation after prolonged biting result in such symptom. When bacterial toxins infiltrate the pulp, hyperalgesia can result. This is a state of pulpal inflammation, which lowers the threshold of stimulation of A-delta fibers. Thus patient feels pain easier. A second type of pulpal stimulation is occurs through activation of C-fibers. C-fibers have a higher threshold of excitability thus only respond to prolonged inflammation of pulpal tissues. C-fibers activation means more than likely, pulp treatment is needed.
What is the treatment of cracked tooth + symptoms of reversible pulpitis?
1.Removal of restoration + invastigate crack + remove or reduce any cracked cusps + restore
2.Provisional restoration and review in 3 months to confirm diagnosis
3.Consider crown
4.Reduce caueses of the crack
What is the treatment of a cracked tooth + symptoms of irreversible pulpitis?
1.Endodontic access + investigate crack
2.Temporize with ortho band and proceed with RCT or extract
3.Consider causes of this and try to reduce them
What is the prognosis from poor-to-good for cracked teeth?
1.Poor – segment separation, crack crossing pulpal floor, periodontal pocketing at fracture line, damaging habits not amenable to change
2.Guarded – crack extends to the floor of the pulp chamber
3.Good – crack into roof of the pulp chamber, does not reach pulpal floor
What is a clinical presentation of a vertical root fracture?
1.Broad-based soft tissue swelling in the mid-root
2.Sinus tract bilaterally on 2 aspects
3.Depp pockets on 2 bilateraly surface (eg buccal-lingual)
4.J-shapped lesion/defect on the radiographs
5.Presents of isolated horizontal/angular bone loss
6.Visual confirmation through raising the flap
What are the 3 main avenues of communication between periodontium and the pulp?
1.Dentinal tubules – only through patent dentinal tubules due to loss of cementum
2.Lateral and accessory canals – seen in 30-40% of the teeth usually around the apical 1/3 of the tooth
3.Apical foramen – possibly the main avenue – acts as entry and exit
