Solutions to common endo problems

Question 1

Common endo problems

Answer 1

Question 2

Access to pulp chamber

Answer 2

1. remove all decay and restore with stable restoration

2.

Question 3

Access to pulp chamber

Answer 3

1. remove all decay and restore with stable restoration
2. direction of access:
   - know the anatomy
   - always have radiograph visible***
   - want straight line access
3. determine tooth axis before placing rubber dam
4. First search for big roots

Question 4

Why is GIC not stable?

Answer 4

NOT stable

can be used temporarily as endo is $ and time consuming, the only thing that can create a long lasting seal is comp

Question 5

What to do when getting access through crown?

Answer 5

dont trust visible anatomy

trust the radiograph, if necessary get another w cone shift

Question 6

You should clean the floor of the pulp chamber to see better but what should you avoid?

Answer 6

Do not flatten the floor or you will lose all hints the anatomy gives in regards to where the canals are

Question 7

What can you do when locating fine or calcified canals?

Answer 7

• know the anatomy and where to find the canal entrances
• SOM or high magnification loupes
• clean the floor of the pulp chamber
• small files #8-10
• special pathfinder instruments (stiffer)
• sonotrodes for digging
• rinse with lots of hypo
• move files slowly
• clean files frequently, if a file is bent, replace it
• if the canal is not accessible, leave it and fill accessible ones, then reconsider the case

Question 8

What should you do before cleaning/shaping?

Answer 8

• after EAL, recheck lengths after initial shaping
• if unsure, always reconfirm WL with silver points + radiograph
• always have a stable and reproducible reference points
• apex and reference point must be visible in radiograph

Question 9

What can you do to make access easier before shaping?

Answer 9

shape the canal entrances

with Gates Gliddens burs or circumferential filing with Hedstrom file (sharp)

Question 10

How can you prevent ledges? (4)

Answer 10

• prebend steel files
• use small Hedstroem files
• use NiTi rotary systems (for more curved canals)
• rinse

Question 11

How can you prevent file fractures? (4)

Answer 11

• do not push
• lubricate
• use only for a short time
• if the file does not want to work go back to a smaller one

Question 12

What are the issues with overshaping/undershaping

Answer 12

overshaping - strip perforation (dont use oversized instruments)
undershape - difficulty in cleaning and obturation

Question 13

Rinsing. 3 things to do.

Answer 13

• 5ml per canal
• solution needs time to clean, 10-20mins overall (should add up if you rinse alot during tx)
• preheated solutions and ultrasonic activation are recommended

Question 14

What should you do if the master cone is too short, too long or no tug back?

Answer 14

too short: reshape (preferred) or smaller cone
too long: cut the tip
tug back: cut the tip (tug back allows better control during condensation

Question 15

What to do after fitting master cone?

Answer 15

• always check with x-ray

Question 16

What does it mean if you pull out the master cone during condensation?

Answer 16

• tug back insufficient (no friction)
• condensation force too small

->but dont over condense (apply low force)

Question 17

What to do when doing re-treatment? (4)

Answer 17

• use Hedstrom files >#20 (dont go lower as they fracture)
• frequently check file and replace if damaged
• do not use choloform
• dont use NiTi rotary files

Question 17

What to do when doing re-treatment? (4)

Answer 17

• use Hedstrom files >#20 (dont go lower as they fracture)
• frequently check file and replace if damaged
• do not use choloform
• dont use NiTi rotary files (can fracture)

Question 18

When should you place post/core and crown after RCT?

Answer 18

post/core

• if no problems expected (low bacterial load e.g. pulpitis w no PA inflammation) you can do it right away
• if problems expected, wait atleast 1-2 weeks

crown

• apply stable adhesive resto RIGHT after obturation
• if crown needed, do asap (2-4 weeks)

Question 19

If someone comes in with endodontic pain, what must you achieve (5)

Answer 19

• sound diagnosis
• sufficient LA
• do RCT if needed (quickly and well, could be just extirpation)
• nothing else will help the pain (e.g. NSAIDS dont work for pulpitis or acute apical perio, likely opioids wont either)
• no special indication for abx, they dont remove pain

Question 19

If someone comes in with endodontic pain (emergency), what must you achieve (5)

Answer 19

1. sound diagnosis
2. sufficient LA
3. do RCT if needed (quickly and well*, could be just extirpation)
4. nothing else will help the pain (e.g. NSAIDS dont work for pulpitis or acute apical perio, likely opioids wont either)
5. no special indication for abx, they dont remove pain

• not ethical to just send patient home with pain

Question 20

What should you inform you patient when treating a tooth with resorption?

Answer 20

You can remove the cause (infection?) and the resorption may stop but no lost tissue will redevelop

Inform pt of limited success - normal RCT is about 80-90%, therefore 10-20% failure, root resorption further decreases this

Question 21

How do we deal with lateral root resorptions?

Answer 21

same as apical -

remove the cause (infection?) and resorption has a chance to stop

take PA with tube shift to make sure its not internal resorption

use ledermix (research shows)

inform pt about limited success and in SOME cases, leave and monitor

Question 22

How to deal with perio-endo lesions?

Answer 22

1. confirm diagnosis
2. RCT and initial perio tx
3. reconsider case after 3-6 months

basic idea: both inside and outside must be sufficiently cleaned

Question 23

How to treat root perforations?

Answer 23

after general cleaning and shaping, close with MTA*

microscope is highly beneficial

*if below bone level or in bifurcation –> MTA, if higher –> can use GIC