Endodontics Flashcards
1
Q
How will lack of planning affect endodontic treatment?
A
Difficulties during treatment or failure of the procedure.
2
Q
What are the indications for endodontic treatment?
A
- Irreversible pulpitis
- Periapical pathology
- Post retained restoration
- Overdenture
- Teeth with doubtful prognosis
- Periodontal disease
- Pulp sclerosis following trauma
3
Q
What are the features of irreversible pulpitis?
A
The patient history shows:
- Lingering pain
- Spontaneous
- Kept awake
The clinical exam shows:
- Exaggerated response to sensibility testing
- May be difficult to locate the tooth responsible
Placing a sedative dressing may relieve the symptoms but the diagnosis stays. Endodontic treatment should be scheduled.
4
Q
What can the diagnoses be for periapical pathology?
A
- Acute/chronic periapical periodontitis
- Acute/chronic apical abscess
Early presentations of chronic disease may be difficult to diagnose.
5
Q
What planning is required for a post-retained restoration?
A
This is where a tooth has lost too much tooth structure to retain an indirect restoration without the use of an endodontic post. There needs to be careful assessment of the remaining tooth structure. Ask: can a direct composite core be used?
6
Q
What is the exception to root treating roots for an overdenture?
A
Teeth may be decoronated to provide support as an overdenture abutment. These teeth should undergo endodontic treatment and the only exception is if the canal is highly sclerosed with no periapical pathology.
7
Q
Why are teeth with doubtful pulps sometimes root treated?
A
Consideration should be given to root treating teeth with a doubtful prognosis especially if the tooth is to be crowned or be a bridge abutment. If endodontic treatment is undertaken at this age it will be easier to undertake and have a better prognosis. Research has shwon that a significant number of vital teeth will become non-vital following crown/bridge preparation.
8
Q
When are teeth root treated in periodontal disease?
A
This may be done for perio-endo lesions. In multi-rooted teeth one root may have significant pathology and this is an indication for root resection. If root resection is planned then endodontic treatment should be undertaken prior to resection.
9
Q
When is root treatment used to treat pulp sclerosis following trauma?
A
Teeth which retain vitality after trauma may respond by laying down secondary dentine resulting in gradual narrowing of the pulp space. This is not an indication for root treatment in isolation. However it will be easier if undertaken prior to complete pulp sclerosis. The patient may also be concerned regarding yellow discolouration which can only be reliably treated with elective endodontics and internal bleaching.
10
Q
What are the contraindications to root canal treatment?
A
General: - Inadequate access - Poor-oral hygiene/status/attitude - General medical condition Local: - Tooth not restorable - Insufficient periodontal support - Non-strategic tooth - Root fractures - Root resorption - Bizarre anatomy
11
Q
Why might a patient have inadequate access and how can this be managed?
A
Patients with limited mouth opening may not be suitable for endodontic treatment. The reasons for limited access are:
- Microstomia
- TMD
- Previous radiotherapy
- Overeruption of lower anterior teeth
- Scleroderma
A general rule is that it should be possible to place 2 fingers between the patients incisors. Consider using mouth props if the patient finds wide mouth opening challenging.
12
Q
Why does poor oral hygiene/status/attitude affect whether endodontic treatment can be done?
A
Endodontic treatment should not be carried out if a patient is not able to maintain a healthy oral status. Medically compromised patients may be an exception to this. Think about the long term outcome. Patients with poor motivation towards dental treatment are unlikely to complete the treatment.
13
Q
How can medical conditions affect endodontic treatment?
A
There are no specific medical contraindications to endodontic treatment. However the patient has to be well enough to undergo a relatively long dental procedure possibly for multiple appointments. If the patient is older this will be compounded by the endodontic treatment itself being more complex due to canal sclerosis.
14
Q
Why is root canal treatment not done on an unrestorable tooth?
A
It must be possible following root canal treatment to restore the tooth to health and function. The finishing line of the restoration must be supracrestal and preferably subgingival. Don’t start endodontics on a tooth with questionable restorability as you are not doing yourself or the patient any favours.
15
Q
Why is insufficient periodontal support a contraindication for root treatment?
A
The tooth should have periodontal support to ensure the medium to long term survival of the tooth. Endodontics is difficult enough without having to work on a moving tooth. Teeth with significant periapical infection/acute abscess may be mobile due to the pathology but this will hopefully heal following the endodontic treatment.
16
Q
Why might you not carry out root canal treatment on a non-strategic tooth?
A
If a tooth is unopposed and non-functional the benefit of endodontic treatment versus extraction should be considered. A reason to save an unopposed tooth may be to maintain a distal abutment for a partial denture.
17
Q
What is the treatment for a root fracture and what are the signs?
A
Sub-crestal/vertical root fractures have a very poor prognosis and extraction is the only option. Clinical signs include an isolated, narrow, deep periodontal pocket. Radiographic signs include a J shaped radiolucency around the tooth or obvious displacement of the root fragments.
18
Q
What are the types of root resorption that can affect endodontic treatment?
A
- External root resorption
- External cervical resorption
- External replacement resorption
- Internal root resorption
19
Q
What is external cervical root resorption?
A
It has unknown aetiology and may be associated with previous trauma. Resorption usually starts subgingivally in the cervical region. The pulp is usually vital and only becomes involved when the lesion has progressed extensively. It is often asymptomatic.
20
Q
How is external cervical root resorption diagnosed and treated?
A
Diagnosis is based on clinical and radiographic findings. CBCT may be useful to assess the extent of the lesion. Treatment involves surgical exploration of the lesion followed by repair. Endodontic treatment may or may not be required. This is specialist treatment and referral should be instigated as soon as diagnosis is suspected.
21
Q
What is external replacement resorption?
A
The root surface is gradually replaced with bone and this is also known as ankylosis. It often has a traumatic origin. It can be transient and self-limiting but will often progress until complete root replacement occurs. The rate of replacement is often faster in children.
22
Q
How is external replacement resorption diagnosed and treated?
A
Diagnosis is based on radiological appearance and clinical examination which will show a high pitched, metallic sound on percussion. The tooth will be non-mobile and may become infra-occluded in children who are still growing. There is no treatment which can stop the ankylosing process.
23
Q
What is internal root resorption?
A
It occurs entirely within the canal system and results in an ovoid expansion of the root canal. The outline of the canal will be lost around the area of resorption. The pulp will likely be chronically inflamed. A ‘pink spot lesion’ may be visible through the enamel. The tooth is usually partially vital and there may be symptoms of pulpitis.
24
Q
What is the treatment for internal root resorption
A
Endodontic treatment is required. Obturation can be difficult due to the unusual canal anatomy. Thermal obturation techniques (involving backfill with molten GP) is required.
25
What bizarre anatomy could make endodontics difficult?
Features may include:
- Exceptionally curved roots
- Dilacerated teeth
A pre-treatment assessment should identify any unusual features that will increase the complexity of the endodontic treatment. Referral to a specialist would be recommended for a further opinion and treatment is possible.
26
How does radiotherapy affect bone tissue?
It is often used for the treatment of cancers, either as the sole treatment modality or as an adjunct to surgery/chemotherapy. The mandible and/or maxilla is often involved in the radiotherapy beam in head and neck cancer. The effect on bone tissue is to reduce its vascularity (end arteritis obliterans).
27
What are osteoclast inhibitors?
Bisphosphonates are a class of drug which are used to inhibit bone resorption. They are used to treat diseases which present with increased bone resorption such as osteoporosis, Paget's disease and bone cancers/metastases. Examples include alendronate (Fosamax) and zolendronic acid. They can be delivered orally or IV depending on the dose and aetiology. New drugs such as denosumab have a similar effect but are not part of the bisphosphonate group.
28
What affect do osteoclast inhibitors and radiotherapy on root treatment?
Patients who have undergone radiotherapy in the head or neck region or who have taken osteoclast inhibitors are at increased risk of osteonecrosis of the jaw. This is a serious and painful condition which is difficult to treat and can result in significant disfigurement. The causes of osteonecrosis include dental extractions. For this reason, people who are risk of osteonecrosis should be strongly considered for endodontic treatment rather than extraction. This may mean trying to endodontically treat a tooth which would otherwise be considered unrestorable. In this case the tooth can be de-coronated and left as a root face with an appropriate restoration covering the root.
29
What are the arguments for implants versus endodontic treatment?
Endodontics has an 80-90% success rate whereas with implants it can be 95%. However the success rate of implants is actually more correctly a 'survival' rate ie the implant is still in situ. Success depends on certain factors for example is the implant still functional and has it suffered complications or pathology. When strict success criteria are applied to implants the success rate declines dramatically. Implants are still a very successful treatment option but patients should be aware of all associated complications and limitations. Implants should not be considered an alternative for endodontics. They are an option for certain patients to replace a missing tooth once a tooth has failed and is deemed unrestorable.
30
When should endodontics be referred?
The GDC state that you should only perform treatment which you feel adequately trained and confident to perform.
You can refer to a dental hospital/department with an endodontic service nearby but many will have acceptance criteria. The alternative is to refer to a local endodontist but they will charge.
31
What are the tricalcium silicates in dentistry?
- MTA
| - Biodentine
32
What is portland cement?
It is a hydralic cement that not only hardens by reacting with water but also forms a water-resistant product. Portland cement clinkers are comprised of:
- Tricalcium silicate (CaO)3.SiO2 45-75%
- Dicalcium silicate (CaO)2.SiO2 7-32%
- Tricalcium aluminate (CaO)3.Al2O3 0-13%
- Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3 0-18%
- Gypsum CaSo4.2H2O 2-10%
- Clinkers are pulverized to form a powder
33
What is the composition of portland cement?
Powdered clinkers make up over 90% of he final powder. Calcium sulphate is added which controls setting over time. There are up to 5% other contituents (fillers).
34
What are the typical constituents of Portland cement?
- Calcium oxide CaO 61-67%
- Silicone dioxide SiO2 19-23%
- Aluminium oxide Al2O3 2.5-6%
- Ferric oxide Fe2O3 0-6%
- Sulphate 1.5-4.5%
35
What is the composition of MTA?
It is the same as portland cement but without traces of arsenic and lead. There is the additional of bismuth oxide 20% for radiopacity. It has smaller and more uniform particle size. It contains less gypsum which is an inhibitor to control working time. It is medical grade Portland cement. Approval was given for its use in dentistry in 1998. It is expensive and there is grey and white.
36
What are the properties of MTA?
- Biocompatible
- Non-toxic
- Non-resorbable
- No leakage around margins
- Very alkaline when mixed with water
- Compressive strength equal to IRM - cannot be used for direct restorative material
- Bactericidal
- Histological analysis showed that cementum can form over the surface of MTA - biocompatible
37
What are the uses of MTA?
- Root end restorations following apical surgery
- Repair of lateral/furcation root perforations
- Pulp capping (primary and secondary dentition)
- Apexification in immature roots
- Repair of resorption defects
38
How do you use MTA?
- Mix powder with sterile water in a 3:1 ratio on a glass slab
- Add small amounts of water to keep the handling properties correct
- Deliver MTA using appropriate instrument
- If using internally place a cotton wool pellet in contact with the MTA to allow it to set
- If using external to the tooth e.g. RRF moisture will be taken from the surrounding tissues
39
What happens with MTA after placement?
Upon hydration MTA forms a colloidal gel that solidifies to a hard structure in 3-4 hours. The initial ph of 10.2 rises to 12.5 after 3 hours. The strength increases in the presence of moisture for up to 21 days.
40
How can MTA be used in perforation?
Clean and flush it out. Dry the area and place MTA using a plugger over the perforation. Pack with some GP or paper point (80 or 90).
41
How do MTA and dycal compare as a pulp capping material?
Research has shown favourable results for MTA. Results from a study show iatrogenic pulpal wounds treated with MTA were mostly free from inflammation after 1 week and became covered with a compact hard tissue barrier of steadily increasing length and thickness within 3 months following capping. Control teeth treated with dycal revealed less consistent formation of a hard tissue barrier that had numerous tunnel defects at 3 months and at 1 week there is still inflammation. So with MTA better hard tissue healing and reducing inflammation. MTA has a higher success rate, results in less pulpal inflammatory response and a more predictable hard dentine bridge formation.
42
What are the inadequacies of MTA?
- Takes several hours to set
- Can be washed away before its set
- Handling properties
- Acidic environment will interfere with the setting process - placement site needs to be infection free
- Cost
43
What does the liquid and powder in Biodentine?
Powder:
- Tricalcium silicate C3S (main core material)
- Di-calcium silicate C2S (second core material)
- Calcium carbonate and oxide (filler)
- Iron oxide (shade)
- Zirconium oxide (radio-opacifier)
Liquid:
- Calcium chloride (accelerator)
- Hydrosoluble polymer (water reducing agent)
44
What are the properties of Biodentine?
The setting period is 9-12 minutes (initial set). Compressive strength during setting remains high and is comparable to GIC. Biodentines compressive strength reaches the same level as human dentine after 28 days. Biodentine shows a similar flexural modulus as dentine, ensuring similar mechanical behaviour. Biodentine cuts like dentine giving a similar sensation under the bur. Its ivory shade and opacity allow easy differentiation from tooth structure. Biodentine enters dentinal tubules so there is micromechanical bonding. It won't leak much as there is a really good seal with natural tooth structure. Biodentine is the first all in one biocompatible and bioactive crown-root dentine substitute to use wherever dentine is damaged. There is tooth vitality preservation thanks to reactionary dentine genesis and reduction of therapeutic failures thanks to its microleakage resistance. It has both endo and restorative indications thanks to physical properties similar to human dentine.
45
What are the uses of biodentine?
They are similar to MTA. However dentine can be used as a bulk restorative material for permanent dentinal restorations, temporary enamel restorations and endodontic repairs.
46
How is biodentine used?
It comes as a capsule. You add liquid to the capsule and place in an amalgamator. It can be used as a pulp cap and to rebuild the tooth. After 24 hours it can be prepared for a permanent restoration.
47
What is the aim of obturation?
The establishment of a fluid tight barrier with the aim of protecting the periradicular tissues from microorganisms which reside in the oral cavity. A hermetic seal is required from the coronal orifice of the canal to the apical foramen at the cemento-dentinal junction.
48
What three main functions are served by a well obturated system?
- Prevent coronal leakage of microorganisms or potential nutrients to support their growth into the dead space of the root canal system
- Prevent periapical or periodontal fluids percolating into the root canals and feeding microorganisms
- Entomb any residual microorganisms that have survived the debridement and disinfection stages of treatment in order to prevent their proliferation and pathogenicity
49
What are the ideal properties of a root filling material?
- Easy handling and ample working time
- Seal the canal laterally and apically conforming to the complex internal anatomy
- Dimensionally stable
- Non-irritant
- Does not stain tooth structure
- Anti-microbial
- Impervious and non-porous
- Unaffected by tissue fluid
- Radiopaque
- Easily removed
50
What is gutta percha?
It is a naturally occurring rubber. Traditional GP contains:
- Zinc oxide 65%
- Gutta percha 20%
- Radio opacifier (metal sulphate) 10%
- Plasticiser 5%
It is produced in a variety of cone sizes.
51
What are the phases of GP?
GP occurs in 2 crystalline forms which are the alpha and beta phases. Below 42 degrees it is in the beta phase and between 42-49 it is in the alpha phase. Above 49 GP becomes amorphous. Upon cooling it returns to the beta phase.
52
What is the role of an endodontic sealer?
- Seal the space between the obturating core material and the internal root surface
- Fill the space between core and accessory filling materials in lateral condensation
- Seal the irregularities of the complex anatomy (lateral canals, tubules etc)
- Lubricate and facilitate seating of the core and accessory filling material
53
What are the types of endodontic sealers?
- Zinc-oxide/eugenol-based (most popular with long track record e.g. tubliseal)
- Calcium hydroxide based (less antimicrobial but also less toxic than zinc oxide eugenol e.g. sealapex)
- Glass ionomer based (not commonly used, difficult to remove e.g. Ketac-endo)
- Resin based (superior sealing ability, adheres to dentine and antimicrobial e.g. AHPlus)
- Calcium silicate based (e.g. smartphase bio, MTA fillpex - limited research at this stage)
- Silicone based (e.g. Roekoseal - limited research at this stage)
54
What are the obturation techniques?
- Lateral compaction (cold and warm)
- Single cone
- Thermomechanical compaction
- Warm vertical compaction (continuous and interrupted wave)
- Carrier based
- Apical barrier
55
What is cold lateral compaction?
Choose an ISO master GP point that fits snugly with tug-back, coat with sealer and place to working length. Place a finger spreader down to 1mm from the working length. Place an accessory point where the finger spreader was removed, ensuring it extends to 1mm from the working length. Continue the process and the finger spreader will get further from the working length. After placing 2/3 accessory points consider taking a mid-fill radiograph. Continue until all the accessory points fill to just below the canal orifice. Once complete, sear the cones off at orifice level and compact vertically.
56
What is warm lateral compaction?
It is a modification of cold lateral compaction. It uses 'energised spreading'. The technique:
- A k type file is inserted into the piezoelectric ultrasonic unit
- The file is activated and introduced into the GP generating heat to soften it
- A finger spreader is then placed followed by an accessory point as in the cold lateral technique
It may have an advantage over cold lateral as the thermoplasticised GP may flow into accessory anatomy.
57
What is single cone?
This is when only the master GP point with sealer is used to obturate. It is only applicable with greater taper GP points matched to the preparation file e.g. F1, 2, 3 GP points for protaper. It does not provide a good 3 dimensional seal and it not recommended. A newer material 'smartseal' uses a single cone which expands when coated in a hydrophilic polymer. It is a resin based system with a calcium silicate based cement 'smartpastebio'. There is not enough evidence yet to assess its effectiveness.
58
What is thermomechanical compaction?
It uses heat generated from a reverse Hedstrom file which is driven with a slow handpiece into the GP. A master point is placed with sealer and the instrument placed 3-4mm from the working length. The GP is driven apically and laterally and the file driven coronally. It can cause extrusion from the apex and its possible for the instrument to fracture in the canal.
59
What is warm vertical compaction?
It is a modification of Schilder technique introduced in 1967 and can be divided into:
- Continuous wave compaction
- Interrupted wave compaction
60
What are the two stages of continuous wave compaction?
- Downpack - aims to create an apical 'plug' of GP which seals and fills the apical 3-4mm of the canal thereby providing apical control
- Backfilling - aims to fill the remainder of the canal by squirting molten GP through a GP 'gun'
61
What are the steps of continuous wave compaction?
1 - choose a GP point which fits the apical preparation and displays tug back just before the apical constriction
2 - choose a plugger which extends to approx 4mm from the apex and binds. Adjust the rubber stop to this length
3 - turn on the heat source and plunge the plugger through the GP point
4 - continue to apply pressure towards the pre-determined binding point. This should be done in one movement and only take 1-2 seconds
5 - the plugger will slow its apical movement and stop just short of the predetermined binding point. Stop the heat source and maintain apical pressure for 10 seconds to prevent cooling shrinkage of the mass
6 - activate the heat source again and complete the pressure until the binding point is reached. Then wiggle the plugger tip and remove it from the canal
7 - as the plugger is removed any GP coronal to the tip is also removed leaving a plug of GP sealing the apical third
8 - place the tip of the injectable GP gun against the plug of apical GP and extrude GP in bursts of 3-4mm
8 - after each application of GP use a condenser to compact the GP which has just been placed, then continue placing further GP in this manner until the canal orifice is reached
10 - completed obturation
62
What are the advantages of continuous wave compaction?
- Has been shown to provide improved 3D obturation compared to cold lateral condensation
- The canal is filled with a homogenous mass of GP with no carrier
- Good for filling internal resorption defects and other anomalous anatomy
63
What are the disadvantages of continous wave compaction?
- Technique sensitive and takes time to master
| - Requires relatively expensive material
64
What is interrupted wave compaction?
It is very similar to continuous wave technique. However, the downpack is carried out in multiple waves rather than one continuous wave. It is recommended for wider canals.
65
What is carrier based obturation?
It consists in a carrier coated in GP. Thermafil is the market leader. It utilises a plastic carrier surrounded by heated GP which is inserted into the canal. The carrier is then cut at the entrance of the canal leaving the remaining carrier and GP in the canal.
66
What is the technique for carrier based obturation?
- Choose a thermafil carrier which matches the size of canal preparation undertaken
- Use a verifier or a carrier with the GP stripped off to check it can be inserted to the full working length
- Take a radiograph if required
- Modify the thermafil point to achieve better length control and reduce the amount of excess GP
- Place the rubber stopped at the correct length
- Dry the canal
- Apply sealer (extra working time) to the entrance of the canal using a probe
- Place thermafil point into the oven
- Press the correct button according to the size and then press start
- The oven will beep when the GP is heated correctly
- Remove the thermafil point from the oven
- Insert the point into the canal up to the rubber stopper
- Use a plugger to condense the GP in the coronal portion of the canal
- Use a thermacut bur to remove the carrier and any excess GP at the entrance to the canal
67
What are the advantages for carrier based obturation?
It has been shown to provide improved 3D obturation compared to cold lateral condensation. It is quick and relatively easy to learn.
68
What are the disadvantages for carrier based obturation?
- Length control can be an issue
- Increased post-operative pain has been reported
- The plastic carrier can be an issue when removing it during a retreatment case or preparing for an endodontic post
- Cannot fill internal resorption defects as well as warm vertical compaction
69
What are the developments in obturation?
Recently a cross-linked GP core has been developed. This has the advantage of being easier to remove during retreatment and post preparations. The technique used is the same as for the plastic cores.
70
What is an apical barrier?
When the apex is immature (pulp death before root formation completed) or has been damaged (iatrogenic/resorption etc) then apical control becomes more difficult. If the apical size is 0.7mm (ISO 70) or greater then an apical plug should be considered which is a specialist technique. The material of choice for an apical plug is MTA (calcium silicate).
71
What is the technique for an apical plug?
Undertake endo conventionally however there will be minimal need to prepare the walls/apex. Be careful or irrigant extrusion. Dry the canal. Use a delivery system to place a plug of MTA in the apical region. Continue to place plugs of MTA, using a paper point to compact it, until a plug of 3-5mm has been achieved. MTA needs moisture to set, therefore a damp cotton wool pledget is placed in the canal next to the MTA. At the next appointment the MTA will have set and the remainder of the canal can be filled with heated GP.
72
What is Realseal?
It looks similar to GP but is actually resin based. The intention is to bond to the internal structure of the root. It can be used for either lateral or warm vertical compaction. It can be problematic for removal during retreatment.
73
How is obturation assessed?
Obturation becomes a surrogate marker for quality of canal preparation as it is difficult to assess this clinically and radiographically prior to obturation. The root filling is judged by taper, condensation and length. The aim is to provide a well condensed root filling ending just coronal to the apical foramen without extrusion of GP into the apical tissues. A recent systematic review (Ng et al 2007) showed that root fillings without voids, extending to within 2mm of the radiographic apex had a significantly improved outcome.
74
What is the aim of endodontic treatment?
It is to prevent or cure periapical periodontitis. Ideally the outcome should be the absence or resolution of periapical periodontitis after endodontic treatment.
75
How can endodontic outcome be categorised?
It can be categorised into strict or loose. Strict outcome criteria:
- Ideal so may be unrealistic
- Requires no symptoms
- No clinical signs of disease
- No periapical radiolucencies
- For endodontic treatment to be deemed a sucess
Loose outcome criteria:
- Realistic approach
- No symptoms
- No clinical signs of disease
- Decrease in size of periapical radiolucency
76
How can survival be used as outcome criteria for endodontic treatment?
It may be a more pragmatic approach. The tooth is still present in the arch, asymptomatic and functional. There may still be clinical and radiographic signs of pathology which may even be worsening. It is useful for comparing to the survival rate of implants (to level the playing field). Use the words favourable, uncertain or unfavourable instead of success or failure which mean different things to different people. As per the European society of endodontology guidelines.
77
What is the success rate of endodontic treatment?
Many studies have been undertaken to assess the outcome of endodontic treatment. Depending on the outcome criteria and type of study, success rates of around 85% were reported. Depending on the case outcomes of up to 95% can be achieved.
78
What three main factors affect endodontic treatment outcome?
- Preoperative status of the PA tissues
- Quality of the root canal filling
- Quality of the coronal restoration
79
How does preoperative status of periapical tissues affect outcome?
The outcome is likely to be more favourable when the pulp is vital, has pulpitis or is necrotic but uninfected. Probability of success is about 95% in these cases. For teeth with signs of PA periodontitis the success is reduced to 85% probably because the root canal is more heavily infected. The success is reduced further if the PA radiolucency is larger than 5mm in diameter.
80
How does the quality of the root canal filling affect the outcome of endodontic treatment?
Endodontic treatment is more likely to be successful when root canal filling is satisfactory - within 2mm of the radiographic apex and well compacted. Success decreases when the root filling is overextended, underextended or contains voids.
81
How does the quality of the coronal restoration affect the outcome of endodontic treatment?
Endodontic treatment is more likely to be successful when the quality of the coronal restoration is satisfactory. The restoration should have no marginal deficiencies, defects or recurrent caries which can act as routes for bacteria to reinfect the root canal. Some studies have indicated an increased success rate when a full coverage coronal restoration is placed e.g. a crown following endodontic treatment. Whilst placing a crown is often desirable following completion of endodontic treatment to improve coronal seal and structural durability, each tooth should be assessed on its own merits regarding whether to place a crown or direct restoration.
82
When should completed endodontic treatment be reviewed?
The patient should be assessed 9-12 months following completion of endodontic treatment for a clinical and radiographic assessment. The patient may be reviewed earlier if symptomatic but radiographs are not taken unless there are suspected developments e.g. root fracture. Depending on the outcome at review patients may need to be reviewed for up to 4 years.
83
What should be assessed in a review appointment?
- Assess symptoms
- Clinical exam
- Radiographic exam
- Favourable outcome - no further treatment
- Uncertain outcome - review for up to 4 years
- Unfavourable outcome - further treatment required
84
What patient symptoms should you ask about in a review?
Ask about pain, swelling and loss of function. Lack of symptoms does not always prove favourable outcome so you still need a clinical and radiographic exam.
85
What can continued pain/discomfort after RCT be due to?
It may be due to persistent periapical infection but also due to:
- Occlusal interferences
- Food trapping in the area
- Tooth fracture
- Neurogenic pain
- Non-odontogenic pain - sinusitis, TMD, atypical facial pain
86
What should be assessed in a clinical examination in a review?
The following outcomes should be assessed and compared to the preclinical situation:
- Presence/absence of sinus tract or swelling
- Tenderness to palpation in the sulcus and soft tissues
- Tenderness to percussion of the tooth
- Presence of tooth fractures
- Presence of dental caries
- Periodontal status - probing depths and mobility
- Quality of the coronal restoration
87
What should be assessed in the radiographic exam in the review?
Compare review and post-op radiograph to assess:
- Quality of root filling
- Presence/absence of PA radiolucency
- Size of PA radiolucency and comparison to the preoperative PA lesion (increase, decrease, no change in size)
- Quality of coronal restoration
- Presence of caries
- Periodontal condition
- CBCT is more accurate to detect PA pathology but only indicated in specific situations e.g. if persistent pain with no signs on conventional radiograph
88
How can the outcome of the RCT be defined after review?
It depends on the results of patient symptoms, clinical examination and radiographic examination. It may be defined as:
- Favourable
- Uncertain
- Unfavourable
89
What is a favourable outcome?
- Asymptomatic
- Tooth is functional
- Associated tissues are healthy clinically
- Associated PA tissues appear healthy on x-ray
90
What is an unfavourable outcome?
- Symptomatic e.g. pain, swelling
- Tooth not functional e.g. patient avoids eating on it
- Clinical signs of infection - sinus tract, swelling
- Radiographic signs: new periapical radiolucency has developed, increased in size, PA radiolucency has persistent (remained the same or reduced in size) at or after the four year assessment period
91
What is an uncertain outcome?
- No signs or symptoms
| - PA radiolucency is still there on radiograph within 4 year assessment period - same size or reduced in size
92
When should a definitive restoration be placed?
- Placing soon after completion of endo treatment will improve the coronal seal and structural durability
- Indirect restoration increases prognosis of tooth, however each tooth should be assessed on its own merits
- Clinical signs and symptoms must be resolved - not necessarily radiographic signs
93
What are the reasons for endo failure?
- Intraradicular infection
- Extraradicular infection
- True cysts (apical true cysts are self sustaining and do not heal following satisfactory endo
- Foreign body reaction (foreign bodies can compromise healing e.g. GP
94
What types of intraradicular infection are there?
- Persistent infection - residual microbes left within root canal following endo treatment
- Secondary infection - microbes which have re-entered the canal after endo (coronal leakage, fractures etc)
95
What extraradicular infection may occur after RCT?
- PA actinomycosis
| - Displacement of infected dentine
96
If you did not undertake endo treatment yourself what history should you ascertain?
- Where was it performed
- When was it done
- What was the original diagnosis
- Did the original treatment remove the symptoms initially
- What techniques were used and how long did it take
97
How can endo failures be managed?
- No treatment - monitor
- Extraction
- Endodontic retreatment
- Apical surgery
98
When can you monitor a tooth with failed endo?
If a tooth has an unfavourable outcome according to strict criteria but the tooth is stable enough to warrant review rather than intervention e.g. asymptomatic but non-healing PA radiolucency. Monitor to reduce the risks of reintervention. Advice for the patient:
- Regular review
- Return if signs/symptoms develop
- Acute flair up may occur at any time
99
When should a failed endo tooth be extracted?
It is the quickest solution and can be done when monitoring isn't an option. Consider when the patient doesn't want further treatment, monitoring isn't an option, doubtful restorability, non-functional tooth with no strategic value, tooth with untreatable disease - root fracture, advanced perio bone loss.
100
When can endodontic retreatment be done?
It can be done if the patient is keen to save the tooth. The tooth must be restorable. Even if previous obturation looks adequate you do not know how well the tooth was disinfected, whether rubber dam was used etc. The goal of retreatment is to eradicate microbes and provide a good apical and coronal seal. When undertaken properly the success rates can be nearly as high as primary treatment (83/80%).
101
What advice should be given to the patient with regards to RCT retreatment?
- During treatment the tooth may be deemed unrestorable e.g. discovery of a catastrophic fracture, gross caries etc
- Root canal retreatment is complex and there are risks e.g. perforation which may render the tooth unrestorable or at least reduce the prognosis
- It may not be possible to fully instrument canals if they are blocked etc and this will affect the prognosis
102
When is apical surgery appropriate in endo failure?
Surgical endodontics is only carried out when it is not possible to carry out root canal retreatment. The indications are:
- Endo retreatment would have unfavourable outcome
- Obstructions within canal that cannot be removed/negotiated with orthograde treatment
- Teeth with long/wide posts which risk root fracture if removal is attempted
- Perforations which require surgical repair
- Investigative procedures e.g. biopsies, confirmation of root fractures etc
- Extraradicular infection and true cysts
103
What canal contents may require removal during endo retreatment?
In endo retreatment you need to remove contents of the root canal prior to thorough disinfection and cleansing. Canal contents which require removal:
- GP
- Endodontic posts
- Thermafil carriers
- Silver points
- Fractured instruments etc
- In addition repair of iatrogenic perforations may be required as part of endodontic retreatment
104
What equipment and materials can be used to remove GP?
- GG burs for coronal GP and hand files for apical GP. Hedstrom files are useful for gripping GP by engaging it in its cutting flutes. Check files regularly for distortion. Ideally GP should always be visible to ensure you remain centred within the canal. Tactile sensation of GP feels more rubbery compared to dentine
- Retreatment rotary NiTi files - some systems e.g. protaper produce files specially designed to remove GP, they are more resistant to fracture, designed to remove dislodged GP in a coronal direction. Never use SX, S1, S2 files as they are too fragile at tip
- Solvents soften GP such as chloroform xylol, eucalyptus oil and orange oil. Use chloroform in hospital, sparingly, ideally following bulk removal with other instruments due to tendency for it to become smeared everywhere
- Combinations of above
105
How can endo posts be removed?
Metal endodontic posts can be removed using a number of techniques:
- Trephining around the post using an ultrasonic tip or specialised kit (Masserann)
- Ultrasonic to break cement lute
- Grab post with fine forceps
- Specialised endo post removal kit e.g. Ruddle, Egler etc
- Combinations of above
106
What are the stages of removing an endo post?
The first stage is to remove the crown on the tooth and then remove the core material, leaving only the post sticking out from the canal. Cast cores need to be reduced carefully so the core is reduced to the post width extending out of the canal to give something to grip to. The appropriate technique or combination of techniques can then be used to loosen the post. Threaded posts can often simply be unscrewed. Fibre posts are usually bonded in and are difficult to loosen. The most effective way to remove them is to use a diamond bur or ultrasonic to remove the post by drilling down through the middle of the post.
107
How are thermafil carriers removed?
They are difficult to remove. They have a groove down them which is meant to be engaged in a file prior to removal however this is often ineffective. Use hand files/rotary files to remove coronal GP (maybe using a solvent) then try to grab the carrier. The braiding technique can be very effective - braid 2 hand files around the carrier and exert a pull in the coronal direction. Once the carrier is removed the remaining GP can be removed using the previously described methods. Thermafil have recently released new carriers made from GP which are easier to remove.
108
How are silver points removed?
Not commonly found these days but it is important to recognise on a radiograph. They are found to corrode over time and disintegrate during removal. To remove - troughing around them with ultrasonics, tephining with Masserann kit, removal with fine forceps and braiding technique.
109
How are fractured instruments removed?
They can be very challenging to remove. Success depends on where the instrument has fractured, the type of instrument, how long the fragment is, how accessible it is. If the instrument cannot be removed you can try to bypass it. Removal is attempted by first achieving good access and vision (microscope). Ultrasonics or modified GG bur can be used to create a staging platform. A combination of techniques (ultrasonics, hand files, Massernn kit etc) can be used to attempt to loosen and remove fragment. If successfully removed the remainder of the endodontic treatment can be completed conventionally.
110
How do perforations affect prognosis and how can they be repaired?
Perforations indicate a poor prognosis for the tooth. Poor prognosis depends on:
- Size of perforation
- Location of perforation
- Condition of remaining tooth
- How infected it is
It can be repaired internally or externally. MTA or biodentine are best for repairing.
111
What is the objective of restoration of a root filled tooth?
It is to create a mechanical system which mimics an unrestored tooth. It should withstand impact loads, resist wear and distributes and dissipates stresses throughout the radicular dentine and the supporting periodontal structures. Restoring a root filled tooth is to avoid bacterial leakage, restore coronal structure and to restore aesthetics.
112
What are the endodontic considerations when restoring a root filled tooth?
- Adequacy of root filling
- Preserving apical seal
- Potential for coronal disassembly if it is necessary to re-navigate the canal system
- Why was the endodontic procedure performed?
- Was the endodontic procedure uneventful?
- Is the resultant root filling technically excellent?
- Is the tooth asymptomatic?
- Can I disassemble the coronal reconstruction?
113
When should a root filled tooth be restored?
Restore the tooth when history, symptoms and radiographic findings point towards healing of periapical tissues. You would not expect to see any noticeable radiographic changes for 9-12 months. If everything seems fine it can be restored. If there are symptoms then you wait the 9 months. Restore RFT as soon as possible, there is no magical time frame. When the combined evidence from the operative outcome, history, presenting symptoms, clinical findings and radiographic findings point to a resolution of infection.
114
What can coronal leakage be due to?
- A breakdown of the temporary restoration
- A delay in placing the definitive coronal restoration
- A fracture or cracks of the existing coronal restoration
- Exposed dentine tubules
- Presence of pre-existing or secondary caries
- Contamination of the pulpal space during post-hole preparation and temporisation
Look at notes on studies.
115
What does Khayat et al 1993 say about saliva contamination?
100% of root canals of root filled teeth exposed to saliva became contaminated within 30 days, regardless of the obturation technique.
116
What is the weak link in a root filled tooth?
The GP-dentine interface is the weak link. The sealer offers limited protection. Avoid packing excess GP across the floor of the pulp chamber – molars. Ensure an effective seal of the pulp chamber with a GIC or RMGIC and restore and definitive restoration. A root filled tooth has compromised architecture, changes in physical properties and changes in loading.
117
What are the challenges of a root filled tooth?
- Severe or total coronal damage
- Compromised mechanical integrity of remaining tooth
- Reduced capability for stress distribution
- Greater potential for bacterial leakage
- Possible damage to the periodontal supporting structures
- Possible change in physical properties of dentine
- Loss of proprio-reception from the pulp
Root filled teeth may be placed under greater occlusal loads than vital teeth but are less able to withstand these forces.
118
What factors should be considered when deciding whether to restore a root filled tooth?
- Previous pulpal/apical history (elective, non-symptomatic, periapical abscess, periradicular cyst)
- Radiographic history
- Symptoms history
- Effectiveness of RCT procedure
- Age
119
What are the biomechanical principles of restoring a root filled tooth?
- To restore the structural integrity of the radicular mass
- To aid retention of the coronal component
- To restore the crown with a material adhesively united to the radicular mass
- Retain as much tooth structure as possible
- Consider the need for cuspal protection of posterior teeth:
- Cuspal protection required if more than 2 surfaces (e.g. buccal and mesial) lost or under large occlusal forces
- Cuspal protection does not always mean a crown. Crown preparations will remove remaining cusps and weaken the tooth irreversibly
120
What are the desirable properties for dentine replacement?
- Adequate compressive, tensile and flexural strengths to perform under load
- Matches elastic moduli
- Matches coefficient of thermal expansion
- Cariostatic chemistry
- Potential for bonding
- Radiopacity greater than dentine/enamel
- Ease of mixing, manipulation and placement
- Cariostatic chemistry
121
What materials can be used to replace dentine?
- Microfilled/hybrid composites in combination with a dentine bonding system
- Amalgam
- Materials to be used in limited circumstances
- Glass ionomers
- Intracoronal restorations - amalgam, composite, gold, ceramics
122
What is the elastic modulus, fracture strength and compressive strength of enamel and dentine?
```
Enamel:
- Elastic modulus 85GPa
- Fracture strength 10MPa
- Compressive strength 400MPa
Dentine:
- Elastic modulus 15GPa
- Fracture strength 50MPa
- Compressive strength 300MPa
```
123
What is the elastic modulus, fracture strength and compressive strength of amalgam and composite?
```
Composite:
- Elastic modulus 20GPa
- Fracture strength 60MPa
- Compressive strength 100MPa
Amalgam:
- Elastic modulus 35GPa
- Fracture strength 100MPa
- Compressive strength 400 MPa
```
124
What materials can provide cuspal protection and what are the properties?
Large posterior restorations may benefit from cuspal protection. For onlays gold is probably the best. Gold requires cuspal coverage and provides cuspal bracing. It is technically and clinically challenging. It can be cemented adhesively. Ceramic has adhesive cementiation. It has same adhesive limitations as composite. It has a high elastic modulus – brittle. It has a higher incidence of tooth fracture. For small intra-coronal it is ok.
125
What are the challenges of total crown replacement?
- The restoration needs to be retained by the root
- It must allow stress distribution
- It must not cause root fracture
- It must be durable
126
What are the principles in crown retention?
- Retain as much dentine mass as possible
- Restore dentine mass with a suitable material if necessary
- Use an intra-radicular post in combination the above only if retention is compromised
127
What materials can be used for the core?
- Amalgam (strong, reliable, successful, ?adhesion)
- Core composite (strong, adhesive, ?predictable, mismatch in thermal expansion)
- Glass ionomers
- Compomers
(for core build-up)
128
What are the properties of glass ionomer for core build-up?
- Low tensile strength – brittle
- Unreliable
- Poor adhesion
- Excellent thermal match to tooth
- Dimensionally stable
- Reserve for patches only
129
What is an intraradicular post?
They retain and support the core and coronal restoration. They aid in transferring functional loads to as wide an area as possible. Posts do not increase tooth fracture strength. Ideally the post should be a rigid material or elastic with a ferrule. It needs to have appropriate dimensions (width and length). It can be prefabricated or cast. It needs to be integrated with an appropriate core material.
130
What are the intra-radicular post considerations?
- Parallel sided or tapered
- Surface configuration
- Active or passive fit
- Length, width
- Ferrule
- Anti-rotation
- Cast or prefabricated
- Choice of material
Ideal is parallel sided. Tapered one will cause root to split as it is pushed into the root. Parallel sided has resistance to axial forces so no root fracture.
131
What is the surface configuration of intra-radicular posts?
- Casting roughness
- Sandblasted
- Etched
- Grooved
- Fluted
This is important as we want to increase the surface area of the post for bonding. The best way is to accept casting roughness or sandblast it.
132
How are intra-radicular posts retained?
- Active system (not a good idea) - a thread cuts into the post hole wall to aid post retention, this introduces great stresses into the system
- Passive system - the post is retained in the hole by the means of an adhesive lute, the surface of the post may be configured to aid adhesion
133
How does the length of the post affect retention?
Deeper post holes distribute stress better. Deeper post holes increase retention but deeper post holes disturb apical seals and destroy tooth substance. Post design:
- 3-4mm short of apex or
- 2/3 of total root length or
- 1/2 greater than crown height
The greater the crown to root ratio the poorer the prognosis - x(clinical crown)/y(clinical root)
134
How does the width affect the post?
Strength is more dependent upon the outer perimeter of the root. Post should be as narrow as possible but within the strength limits of the material. Narrow posts are conservative of tooth substance but narrow posts are weak and easily rotated.
Prefabricated stainless steel post can be used for narrow canals. Otherwise cast posts e.g. NiCr.
135
What is a ferrule?
The distance between the crown margin and the interface between the core and the dentin is called the ferrule. The greater the ferrule, the greater the resistance to breakage of the crown. If the ferrule is not present there will be fracture. Dentin ferrule: the retention of >1.5mm of vertical sound tooth structure between the crown margin and the dentine core interface that wraps around 360 degrees around the tooth.
136
How do you prevent rotation of the post?
In most clinical cases, the irregular shape of the access cavity will provide the required anti-rotation. There can be an anti-rotational device as part of the core which has an anti-rotation pin as part of it.
137
What are prefabricated and cast posts used for?
```
Prefabricated:
- Circular post holes
- Divergent roots
- Narrow post holes SS
Cast:
- Non-circular root canals
- Direct or indirect
- Choice of alloy
- Path of withdrawal and insertion
Can't have undercut. You want to adhesively bond whenever possible.
```
138
What are the two choices for elasticity for a post?
- Iso-elastic - same elasticity as dentine
| - Gradient of elasticity - increasing gradient from the low dentine outside to a stiff (post) core inside
139
What metal alloys are used for post.
They are strong and corrosion resistant. Prefabricated is stainless steel and TiVAl. Cast is gold alloys and nickel chrome.
140
What are the other prefabricated materials used for posts?
- Resin-reinforced carbon fibre - difficult to see and therefore remove
- Ceramics
- Composite fibre - only one we use out of these
141
What are the rigid and elastic post materials?
```
Rigid:
- Stainless steel
- Gold alloys
- Ni-Cr alloys
- Zirconium ceramics
Elastic:
- Titanium
- Titanium alloys
- Carbon-fibre
- Composite fibre
```
142
What are the different post systems?
- Parapost
- Composipost – carbon fibre – low modulus of elasticity, very difficult to remove
- Cosmopost – zirconia – high modulus of elasticity (extreme stiffness), acceptable strength
- Radix anker
- Kurer
143
What is the Parapost system?
The parapost system is a complete integrated system using parallel posts. There are matching instruments and posts with anti-rotational pins. There are multiple clinical techniques and multiple materials and combinations. ParapostXP has a one visit technique. It has traditional parapost head design with X pattern. It is indicated for amalgam cores and multi-rooted teeth where space is limited. It is titanium or stainless steel and 19mm long. It is parallel sided so evenly distributes functional forces, eliminating the wedging effect of a tapered post. It has a passive fit which eliminates stress in the dentin compared to a screw post.
144
What extracoronal restorations can be used for root filled teeth?
Extracoronal restorations can be gold, ceramic or porcelain fused to metal. A full veneer gold crown provides a strong protective veneer over vulnerable underlying structure. The margin of safety is far greater than for ceramic or composite materials. It is durable but unaesthetic. Aesthetic crowns for anterior teeth are all ceramic and ceramic bonded to metal.
145
What should be done if there is no ferrule?
If no ferrule you must use a rigid material. Composite fibre is not very rigid but if you have a ferrule this will be ok.
146
How can a post fail?
- Fatigue disintegration of labial margins
- Opening of palatal margins
- Bending of post
- Rotation of post
- Dislodgement of post
- Fracture of post
- Fracture of root
147
How can a root filling fail mechanically or biologically?
```
Biological:
- Periapical abscess
- Periodontal disease
- Recurrent caries
Mechanical:
- Inappropriate coronal retention
- Unfavourable displacing forces
- Loss of structural integrity
- Inappropriate use of materials and techniques
```
148
How can success be achieved with post-core crowns?
- Keep to reliable methods (simple and established)
- Lateral/vertical condensation with gutta percha and a bland root sealer
- Leave 3-5mm GP at apical root terminus
- Use a passive adhesively retained custom post
- Use a ferrule design for the overlying crown prep
149
What does surgical endodontics include?
- Emergency procedures e.g. incision and drainage
- Biopsy/EUA
- Peri-radicular surgery (micro-surgical endodontics)
- Corrective surgery (perforation repair/root resection/hemi-section)
- Surgical retreatment
- Regenerative procedures
- Decompression (large cysts)
150
What is the aim of surgical endodontics?
The aim of surgical endodontics is elimination of apical periodontitis where this cannot be achieved by non-surgical means.
151
What are the causes of persistent apical periodontitis?
- Persistent intra-radicular infection
- Persistent extra-radicular infection
- Foreign body reaction to exogenous materials in peri-apical tissues
- Cholesterol crystal accumulation leading to peri-apical irritation
- True cystic lesions
- Scar tissue formation
152
What are the indications for surgical endodontics?
- Persistent disease when non-surgical RCT or re-RCT cannot be undertaken, is not feasible or has failed e.g. post-crown where dismantling carries significant risk of root fracture
- Correction of iatrogenic errors not amenable to a non-surgical approach e.g. apically extruded filling material or fractured instrument removal
- Where direct visual examination EUA or corrective measures require a surgical approach e.g. suspected root fracture or perforation repair
- As a combined approach with non-surgical treatment or re-treatment (e.g. persistent exudate/open apex) or in conjunction with procedures such as root amputation or hemi-section
- Where patient factors dictate that surgical treatment would be more expedient than non-surgical treatment
153
What are the contraindications to surgical endodontics?
- When no-surgical endodontic treatment or re-treatment is feasible
- Tooth with inadequate periodontal support
- Non-restorable tooth (including root fractures)
- Poor surgical access
- Serious underlying medical conditions e.g. bleeding disorders/GA risk or psychological problems
- Limited ability/skill of operator
154
What is the success rate of non-surgical endodontic re-treatment?
86% 4 year success rate.
155
What is the success rate of endodontic surgery?
5 years:
- Traditional root end surgery TRS 59%
- Modern micro-surgical techniques 94%
156
What are the objectives of surgery?
- Remove diseased peri-radicular tissue
- Debride canal system as far as possible (retro-grade approach)
- Seal the root end cavity (prevent possible egress of microorganisms into the peri-radicular tissues)
- Allow healing/regeneration of normal PDL apparatus around apical portion of tooth
157
What are the prerequisites of surgery?
- Patients informed consent
- Skilled operator/nurse
- Detailed knowledge of anatomy of surgical site
- Check medical history carefully (care with anticoagulants/bleeding disorders)
- Correct equipment/materials
- Light and magnification
158
What are the stages of endodontic surgery?
- Pre-op NSAIAs/Corsodyl mouth rinse
- Local analgesia
- Incision/flap reflection
- Osteotomy/90 degree root end resection
- Curettage of peri-radicular lesion
- Ultra-sonic preparation of root end cavity
- Haemostasis (moisture control of bony crypt)
- Inspection, drying and filling root end cavity
- Suturing
- Post-operative instructions and aftercare
159
What are the types of incisions?
| Look at pics in notes.
- Semi-lunar - not done due to lots of scarring, bleeding, cannot see root.
- Intra-sulcular (2 sided triangular) - if patient has veneers or crowns this may not be suitable as there will be recession which will expose margins
- Intra-sulcular (three sided rectangular)
- Sub-marginal - if patient has adequate width of attached gingivae this is good for crowns etc as there is no recession. There will be a faint white scar.
- Papilla base - this is also used for aesthetics
160
What is used to make the incisions?
SM63 blade.
161
What instrument is used to remove bone?
Bone removal is done with a surgical air rotor. Normal air rotor uses air, water and oil which could cause contamination of site.
162
What is used to prepare the root end cavity?
The root end cavity is prepared with ultrasonic handpiece and KiS microsurgical ultra-sonic tips. Moisture control is done with adrenaline impregnated cotton wool pellets packed into the base of the cavity.
163
What filling materials are used in endodontic surgery?
- Amalgam – historic
- Ethoxy benzoic acid cement (super EBA)
- Intermediate restorative material IRM
- Mineral Tri-oxide aggregate MTA
- GIC/Composite resin
- Biodentine
164
What materials can be used for suturing?
- 4-0 polyglactin (resorbable)
- 5-0 PTFE (non-resorbable)
- 6-0 polypropylene (non-resorbable)
165
What is the post-operative care for endodontic surgery?
- Post operative instructions
- Ice pack
- NSAIDs – ibuprofen, paracetamol
- Antibiotics
- OHI – Corsodyl mouthrinses
- Review/suture removal 48-96 hours post op
