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ENDO > Written Exam > Flashcards

Written Exam Flashcards

1
Q

What is caries ?

A

Pathological demin of tooth tissues by fermenting bacteria

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2
Q

What is aim of vital pulp therapy?

A

Treats reversible pulpal injury

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3
Q

What are the two subcategories of vital pulp therapy ?

A

Direct

Indirect

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4
Q

What are the types of direct pulp therapy?

A

Pulp cap
Partial pulpotomy ➡️ Cvek pulpotomy
Full pulpotomy

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5
Q

What are the types of indirect pulp therapy?

A

Stepwise (2 steps)
Direct complete (one step)
ART

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6
Q

What are the requirements for successful vital pulp therapy ?

A

Pre op: signs/ symps of reversible pulpitis and radiographically involving more than 3/4 of dentine
Intra-op: haemorrhage controlled, rubber dam caries removal and non toxic materials
Post op: prevention of microbial leakage

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7
Q

What study is the process of stepwise caries removal based upon and what did they find with regards to caries removal?

A

-Murray 2000 and Shovelton 1968
- Deepest layer of softened dentine not infected
- inner layer of softened caries contained collagen NOT affected by bacterial proteases and once protected it can be preserved and remineralised

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8
Q

What are the four procedural requirements of vital pulp therapy

A
  • sterile conditions (rubber dam, sterile burs and water
  • irrigate dentine chips with sterile saline
  • rinse with hypo
  • haemorrhage controlled in healthy pulp
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9
Q

What type of cells are odontoblasts ?

A

They are post mitotic which means they will survive for life of the tooth if damage not too extensive

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10
Q

Which embryonic tooth development structure gives rise to dentine?

A

Dental papilla

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11
Q

If there is a mild injury to the PDC what type of Dentine would be expected to be laid down?

A

Tertiary dentine of the Reactionary type

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12
Q

What molecules are involved in formation of odontoblast like cells following a severe injury ?

A

Growth factors
TGF beta
BMP’s

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13
Q

Which dentine is faster to lay down between reactionary and reparative denting ?

A

Reactionary as you are stimulating the already present cells

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14
Q

What effect does EDTA and CaOH have on growth factors?

A

Can stimulate their release from the dentine matrix

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15
Q

What action does EDTA specifically have on tertiary dentine formation?

A

When cavity conditioned with EDTA it can intensify the response from dentine by solubising the bio active growth factors

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16
Q

What is the critical depth of remaining dentine prevent severe pulpal inflammation?

A

0.5mm

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17
Q

What is critical pH of dentine?

A

6.7

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18
Q

What is the downside of using caries detector dyes?

A

Does not discriminate infected vs affected so can end up over prepping this increased risk of pulpal exposure

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19
Q

What is hard dentine?

A

Resistant to probe penetration

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20
Q

What is firm dentine

A

Can be probed but not removed with hand instrumentation

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21
Q

What is ART and describe when it is used

A

Atraumatic Resto treatment

Cares removed only with hand instrumentation in circumstances where resources are limited

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22
Q

What is the most important factor with regards to ART?

A

A good seal is achieved

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23
Q

What is direct complete/one stage pulp therapy?

A
  • All caries is removed along walls
  • Leave behind hard dentine only leaving residual caries
  • Once caries removed condition with NaOCl or ETDA
  • CaOH/Biodentine or MTA and then definitely
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24
Q

With vital pulp therapy what is the risk of placing comp if less than 0.5mm dentine left?

A
  • increased risk of inflammation response

- etch also opens up dentinal tubules facilitating bacterial penetration

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25
Q

What is benefit of biodentine over MTA

A

Biodentine does not contain bismuth oxide so reduces risk of discolouring teeth

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26
Q

How does two stage caries removal work?

A
  • removal of bulk of soft superficial caries and leave avoid excavation close to pulp
  • soft discoloured dentine left overlying pulp
  • Layer of CaOH/MTA placed and then GIC
  • Re enter in 8-12 weeks remove fills and remainder of dentine until hard dement found
  • Defin restn
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27
Q

What is the benefit of two stage vs one stage during VPT and stepwise caries removal ?

A

Reduced risk of pulpal exposure and can re enter and re-assess the situation

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28
Q

In which clinical circumstances is a pulp cap more reliable in?

A

DTI over carious exposure

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29
Q

What are the disadvantages of pulp therapy?

A
  • Obliteration can occur
  • Resorption can be seen in cases with trauma
  • Can get discolouration with MTA
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30
Q

What effect does age have on success of VPT?

A

Young patients do better due to

  1. increased blood supply
  2. Open root apices
  3. Pulp free of age related changes
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31
Q

What size of pulp exposure reduces chance of success of VPT?

A

5mm

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32
Q

List 5 ideal properties of materials used for pulp capping

A 
stimulate tertiary dentine formation
maintain pulp vitality
bacteriostatic or cidal
radiopaque
non toxic
bacterial seal provided
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33
Q

What is the need for mechanical preparation of root canal system according to Hulsman et al 2005?

A
  • Remove nectrotic tissue
  • Creates access and space for irrigation to root canal system
  • Preserve integrity of apical canal anatomy
  • Facilitate obturation
  • Preserve sound root dentine
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34
Q

Pulpal and periapical disease is driven by?

A

microbes!!

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35
Q

What are schilders 1974 5 mechanical objectives?

A
  • Cont tapering funnel from apex to access
  • Cross sectional diameter should be narrower at every point apically
  • Root canal should follow original anatomy
  • Apical foramen remain in original location
  • Apical opening kept as small as practical
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36
Q

Benefit of coronal flare?

A

Less likely to extrude material

Working length less likely to change throughout

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37
Q

Risks of prepping apically first?

A

Do not know where the file is binding-could be binding in mid part or apically

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38
Q

What are the principles of cutting your access cavity?

A
  • Remove ensure pulp root
  • Do not touch floor
  • Provide straighline access
  • Resistance and retention form which will retain temp restn
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39
Q

What features will affect determining size of apical preparation?

A
  • Taper: if taper is 0.05 then prep needs to be ISO 30
  • Resorption present
  • Acute apical curvatures
  • Thin roots-risk of fracture
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40
Q

What is gauging?

A

This is a degree of tightness or looseness of a given instrument

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41
Q

What are the biological aims of root canal medicament use?

A

-Effect on microbes: Kill remaining bacteria and prevent re growth of bacteria
-Effect on host: Eliminate exudate, Induce hard tissue genesis and Enti inflammation and analgesic effect
-

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42
Q

which paper showed empty canals had bacterial re growth?

A

Bystrom et al 1981

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43
Q

What did Strogen et al 1991 show?

A

The use of CaOH reduced bacterial load inter visa medicament

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44
Q

What are the ideal features of inter-visit canal medicaments?

A 
Biological:
-Broad spectrum activity
-Tissue dissolution
-Bicompatible
Physical:
-no detrimental effect on dentine
-no detrimental effet on root filling material
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45
Q

What is the pH of CaOH?

A

12.8

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46
Q

Does CaOH have a low or high solubility in water?

A

LOW

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47
Q

What are the types of root canal prep?

A 
HULSMAN et al 2005
Manual
Automated
Sonic
UltraSonic
Laser
Non instrumented technique (NIT)
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48
Q

According to Peters 2004 what are the benefits of NiTI vs SS files?

A
  • NiTi has less material removal than SS
  • Flexural fracture happens after more cycles in NiTi compared to SS
  • Canal transportation with acute curves due to greater restoring force with SS
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49
Q

What are Schilders 1974 4 biological objectives?

A
  • Confine instruments to roots
  • Do not force necrotic debris apically
  • removal of all tissue from within root space
  • Create space of canal medicaments
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50
Q

What is the aim of obturation?

A

Sealing of the root canal system to incarcerate residual bacteria and prevent recontamination

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51
Q

Why is it not a hermetic seal?

A

there is micro and nano leakage occurring

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52
Q

What is microleakage?

A

seepage of fluids debris and microorganisms along the interface between the restoration and walls of cavity

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53
Q

Name some of the commonly used root canal filling materials

A 
GP
Silver points
Resilon
MTA
Pastes
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54
Q

What is a sealer?

A

Radiopaque luting agent used in combination with a solid or semi solid core material to fill voids during obturation

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55
Q

Who set out 11 properties of ideal sealer?

A

Grossman 1981

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56
Q

According to Schiller 2006 what are the three solvent techniques available ?

A

Chlorpercha: GP is dissolved in solvents and a paste is created
Callahan-Johnson diffusion : canal is flooded with chloroform and GP placed into the canals allowing GP to be forced into inaccessible areas
Nygaard -Ostby technqiue: Chlorpercha paste used in combination with GP preventing excess being forced apically

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57
Q

What is the downside of the Callahan Johnson diffusion tech according to Schiller 2006?

A

Lots of shrinkage

GP may be extruded

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58
Q

What is the 3 D strategy for treating endo pain

A

Diagnosis-effective treatment starts with an accurate diagnoses
Definitive dental treatment
Drugs

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59
Q

Differential diagnosis of dental pain according to seltzer and Hargreaves’s 2002?

A 
Musculoskeletal 
Neuropathic
Nero vascular (Headaches)
System disorders
Psychogenic
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60
Q

What is convergence ?

A

The central terminal of different Nociceptors will convergence or synapse on the same location in the brain. When site of pain perception is different from the origin of nociceptor activation

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61
Q

How to identify origin in cases of convergence?

A
  • By using LA which can block one area

- local palpating may increase intensity of the pain to help distinguish origin from site

62
Q

Wright 2000 showed what regarding referred pain?

A

Masseter muscle is a common orofacial site refers oral pain to teeth
Molars and premolars are more dominant for pain compared to incisors

63
Q

Central sensitisation is?

A

Concept that central neurones in pain system can become sensitised after peripheral injury

64
Q

What is the risk with endo on chronic pain patients ?

A

This may increase risk of post op pain severity as they are predisposed to increased risk of pain

65
Q

What is the most common type of orofacial pain?

A

Odontalgia (Lipton et Al 1993)

66
Q

What are the positive predictors for post endo pain?

A

Hargreaves’s and Hutter 2002

  • pre op pain or TTP - strongest predictor
  • females more than males
  • the higher the number of appts the more risk
  • apical perio
  • necrotic pulp
67
Q

What are the two main points regarding pre op pain on post op pain ?

A

Torbinejad 1994

  • pre op pain good predictor for post op pain
  • pain is maximal for first 24-48 hours
68
Q

What are the strategies for definitively treating Endodontic pain?

A

Pulpotomy
Extraction
incision and drainage
Adjust occlusion

69
Q

How long after performing a pulpotomy would you expect to see reduction in pain?

A

After 1 day dramatic reduction irrespective of the medicaments used
Hasselgren & Reit 1989

70
Q

Why are pulpotomies so effective in pain management ?

A
  • It is a peripheral axonomy
  • The axons have extensive number of nocicpetors receptors and ion channels in the pulp and dentinal tubules making extirpation very effective
71
Q

In necrotic pain where does pain originate?

A

Periapical tissues hence pain with mechanical allodynia rather than temperature

72
Q

Why does debridement help in pain management ?

A

Because you are removing bacteria and their antigens which activate peripheral nociceptors

73
Q

What is the importance of endotoxin on toll like 4 receptors ?

A

Trigeminal neurones express toll like receptors (Toll 4) therefore bacteria can communicate to patient neurones by endotoxin activating toll 4 receptor thus causing pain

74
Q

What is the effect on occlusal adjustment on pain management?

A

Rosenburg et al 1998
80% had no pain after adjustment
50% had no pain after placebo adjustment (not removing cusp tissue)

75
Q

Which patients would best benefit from occlusal adjustments for pain management?

A
  • Pre op pain
  • TTP
  • No PARL
  • Vital cases
76
Q

How does incision and drainage help with pain?

A
  • reduces pressure

- removes bacterial products and cytokines

77
Q

What orientation should you incise for D and I?

A

A vertical direction to reduce number of blood vessels that are transected

78
Q

What three methods do we have for Drugs management for pain relief?

A
  • Pre treat with NSAID or paracetamol
  • Use of long acting LA
  • Flexible prescription plan
79
Q

Which group of drugs are most effective in dental pain?

A

Nsaids 800mg or 600mg and then paracetamol

80
Q

How do NSAIDS work?

A

Peripheral hypothesis : inhibition of COX-strongest general acceptance
Central hypothesis: inhibition of COX

81
Q

What is COX1 enzyme and where is it found?

A

(COX-1 and COX-2) catalyze the conversion of arachidonic acid to prostaglandin (PG) H2, the precursor of PGs and thromboxane. These lipid mediators play important roles in inflammation and pain and in normal physiological functions

COX 1 Present in stomach kidneys and platelets
Traditional NSAIDS e.g aspirin preferentially inhibit Cox1

82
Q

What is Cox 2 enzyme ?

A

COX 2 is inducible and is synthesised in inflamed tissues and cox 2 inhibitors have less GI and renal side effects

83
Q

Name some COX1 NSAIDs?

A

aspirin
indomethacin
ibuprofen

84
Q

Name some COX 2 NSAIDS

A

Etodolac

85
Q

What is the risk with COX 2 inhibitor ?

A

Increased CV risks

86
Q

What are the main risks of COX 1 inhibitors ?

A

Increased GI risk

87
Q

What are the advantages of NSAID drugs?

A

Effective for pain of inflammation origin
Less adverse side effects compared wit opioids
Less addictive potential
No tolerance
Possible protection fro Alzheimers disease

88
Q

What are the disadvantages of NSAIDS?

A
  • Ceiling effect therefore would need to add a separate drug class
  • Adverse side effects e.g GI/Renal/Allergic type
  • Cannot be used in some patients e.g peptic ulcers/asthma/liver dysfunction
89
Q

What effect do NSAIDs have on patients?

A

Analgesic
Antipyretic
inhibition of osteoclasts

90
Q

What type of drug is paracetamol?

A

Acetaminophen

91
Q

Where is paracetemol converted?

A

Paracetamol is converted by enzyme FAAH in liver into AM404

92
Q

Where is AM404 mainly made?

A

In the brain

93
Q

What type of receptor is AM404 similar to?

A

Canabinoids

94
Q

Paracetamol method of actions are?

A

Absorbed into CNS and converted into AM404
Inhibits COX 1 splice variant
Inhibits prostaglandin production

95
Q

What is the benefit of LA?

A

Pain management during and after treatment by blocking the development of central sensitisation

96
Q

What is periapcial disease?

A

reaction between periradicular tissues and noxious stimuli caused by interaction between bacteria and host immune response

97
Q

What is a periapical lesion?

A

Retreat of bone away from source of infection creating space for body’s immune cells to migrate the immediate vicinity

98
Q

What type of tissue is present in a chronic lesion?

A

Granulomatous tissue-co-existance of healing and inflammation

99
Q

Name some cells found in granulomas

A 
PMNS and macrophages
T and B cells
Eosiniphils and mast cells
Endothelial cells and fibroblasts
Viral cells
100
Q

In cysts are T or B cells more dominant?

A

B cells

101
Q

Where there are sinus tracts what additional cells are present other than immune cells?

A

Epithelial cells

102
Q

What is the name for zones of which cells are organised in periapical granulomas?

A

Zones of fish

103
Q

What are the zones of FISH from external to internal layer

A 
Zone of:
Stimulation
Irritation
Contamination
Infection
104
Q

Which land mark study showed root canal infection is caused by bacteria?

A

Kakehashi et al 1965

105
Q

What type of organisms cause periapical disease?

A

Eubacteria
Bacterial products e.g LPS and M Protein
Viruses
Archaea (no nucleus and this prokaryotes)

106
Q

Describe the model of periapical disease?

A

Bacterial invasion of root canals
Non specific inflammation response with fluid exudate
PMns and Macrophasges recruited
Phagocytosis of bacteria
Adaptive immune response with B and T cells in an attempt to wall of the oncoming infection

107
Q

In cases where the infection is new how would this appear radiographically?

A

Diffuse area as there is no pre existing immunity but chronic lesions the host immune response manages this well resulting in a circumscribed area on the xray

108
Q

What is AAP so TTP?

A

When the onslaught of pulpal and periapcial inflammation occurs faster than bone resorption can occur creating an accumulation of PMNS and oedema around apical tissues

109
Q

What additional factors are seen in chronic lesions other than immune cells and bacteria?

A

Cytokines which include interleukins

110
Q

What are cytokines?

A

These are secreted proteins released by cells in attempt to regulate inflammation - they can be pro or anti inflammation

111
Q

Name some anti inflammatory cytokines

A

IL4 IL10 IL11

112
Q

Name some pro inflammatory cytokines

A

IL1 IL2 and TNF alpha

113
Q

How would you describe the variety of microbes in periapical disease?

A

Polymicrobial

114
Q

What does diversity in PA disease consist of?

A

Species richness: number of unique species

Species evenness: abundance of each taxa

115
Q

What type of bacteria are more common in acute exacerbations?

A

Fusobacteria

116
Q

How does the species variety shift as time goes on with periapcial disease?

A

Lesion becomes

more anaerobic and more gram -ve

117
Q

Between the main canal dentine and apical region which are has the greatest site of bacteria?

A

Main canal

118
Q

Between the main canal dentine and apical region which are has the greatest impact on periapcial tissues?

A

Apical region due to its proximity

119
Q

How do facultative anaerobes make ATP?

A

Either by oxygen or by fermentation in absence of oxygen

120
Q

List ways bacteria can gain entry into the pulp system?

A

Caries- MOST common
Cracks
Exposed dentine tubules eg lateral canals
Less commonly anachoresis - bacteria from another site

121
Q

Why does internal resorption generally have a better long term prognosis compared with external?

A

Because there is no communication with PDL in internal

122
Q

What problems do retreatment pose compared with primary treatment?

A
  • Bacteria present more difficult to eradicate with more gram pos present
  • Iatrogenic errors from primary treatment may hinder access
  • Tactile sensation of canal altered due to prev treatment
123
Q

Outline the 6 stages of retreatment

A
  1. removal of existing coronal restoration
  2. assess restorability using restorability index
  3. remove all the root filling but avoid instrumentation
  4. Guage canal to understand shape and missed anatomy
  5. rectify and modify shape and irrigate
  6. obturate
124
Q

Name a restorability index we can use

A

McDonald and Setchell 2005

125
Q

What are the three main causes of root canal failure?

A

Infection
Non microbial
Cyst

126
Q

What are the two types of infection that can cause root canal failure?

A

Intraradicular and extradicular

127
Q

Between intra and extraradicular infection which is the most common cause of failure?

A

Intra

128
Q

What type of non microbial causes of failure are there

A

Foreign body reaction

129
Q

What type of cysts can cause failure

A

True or bay cysts

130
Q

What happens on a cellular level in foreign body reactions?

A

Acute inflammation: with present of monocytes and neutrophils
Proliferative phase: Fibroblasts and macrophages
Fibrotic encapsulation with foreign body giant cells

131
Q

with regards to the bacterial species why are retreamtent more difficult?

A

-Presence of facultative anarobes eg actinomycete and e faecalis

132
Q

What does e faecalis possess that makes it difficult to eradicate?

A

Proton pump inhibitor acting against calcium in CaOH

133
Q

What are the success rates for retreatment success rates?

A

78-85%

134
Q

What are the common causes of RCT failure?

A
  • Leaking restorations
  • Root fractures
  • Untreated canals
  • Inadequately cleaned canals
  • Iatrogenic errors
135
Q

How can RCT failure be assessed clinically?

A

Presence of pain
Cracks
Sinus
Mobility

136
Q

What are the options for surgical re endo

A

Perradicualr sugery e.g apicetomy
Corrective surgery e.g root resection
Fistulatative surgery e.g I and D or decompress

137
Q

According to Ng et al 2011 , what are the 11 prognostic factors indicative for RCT failure?

A
  1. Presence of pre op lesion
  2. Size of pre op lesion
  3. Presence of sinus tract
  4. Patency
  5. Prep as close to apical terminus
  6. Extrusion
  7. Perforation
  8. Flare up
  9. coronal sela
  10. Not using CXD 2%
  11. Re RCT use of EDTA as penultimate rinse
138
Q

Classify iatrogenic errors

A
  1. Access
  2. Instrumentation
  3. Obturation
  4. Other e.g. hypochlorite accident/inhalation
139
Q

How can root peforations be classified

A

Cause: iatrogenic or pathological
Position: Coronal middle apical

140
Q

What three things affect prognosis of root perforations

A

Size
Location: exposure to mouth poorer porngosis
Time: the longer between closing perf then the worse

141
Q

What materials do we have for repairing perforations in bone?

A

MTA which is osteogenic and biocompatible

142
Q

What materials do we have for repairing perforations in the mouth?

A

GIC

143
Q

If the perforation is in the apical third how would you manage this?

A

Treat this as a canal and obturate with GP

144
Q

Why don’t we use MTA in lesions exposed to saliva?

A

It will be washed out since long setting time and dissolvable

145
Q

What are the components of dentine?

A

Inorganic mineralised tissue HAP
Collagen mainly type 1
Water

146
Q

What function does water perform in dentine?

A

Stress absorbing and visco-elastic properties

147
Q

What function does the inorganic mineral content provide to dentine?

A

rigidity and stregth

148
Q

What function does collagen play ind dentine?

A

toughness and flexibility

149
Q

Why does dehydrated dentine fracture quicker than hydrated dentine?

A

Unable to undergo plastic strain

150
Q

What are the three main principles to consider when restoring teeth?

A
  1. Preserve remaining tooth structure
  2. Reduce stress and ensure favourably distributed in the remaining tooth
  3. Provide a seal against coronal leakage
151
Q

What is a bay/pocket cyst?

A

Huumonen 2002

Lumen of the cyst is cont with the infectious source-one the tooth is removed then the cyst will go

152
Q

What is a True/self sustained cyst?

A

Hummonen 2002

Cyst is completely lined by epithelium -once tooth removed then cyst will need removal separately

ENDO (22 decks)

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