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ENDODONTIC MANUAL
SEVENTH EDITION, 2006; EDITOR: DR. SAMUEL W. OGLESBY

The objectives of this laboratory course in endodontics are for the dental student to be able
to instrument and to obturate teeth. Knowledge of both external and internal dental
anatomy is important. The student is to follow the instructions as closely as possible. When
instructions are unclear, ask for clarification. Please bring any problems to the attention of
the faculty especially Dr. Oglesby.

References:
Walton, R., Torabinejad, M.: Principles and Practice of Endodontics. 2002
Cohen, S., Hargreaves, K.: Pathways of the Pulp, Ninth Edition. 2006
Ingle, J ., Bakland, L.: Endodontics, Fifth Edition. 2002
Gutmann, J ., and others: Problem Solving in Endodontics, Fourth Edition. 2005
Bergenholtz, G., and others: Textbook of Endodontology. 2003
Pitt Ford, T.R.: Endodontics in Clinical Practice. 2004
Dumsha, T., Gutmann, J .: Clinicians Endodontic Handbook. 2005
Ingle, J .: PDQ Endodontics. 2005

S. Davi s, DDS; M. Kar i mi pour , DMD; B. Shoust ar i , DMD; T. Levy, DDS;
D. Sc hec ht er , DDS; S. Ogl esby, DDS - USC Sc hool of Dent i st r y.


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USC ENDODONTICS

COURSE DIRECTOR SAMUEL W. OGLESBY, MA, DDS
LABORATORY DIRECTOR THOMAS A. LEVY, DDS, MS
LABORATORY FACULTY DANIEL W. SCHECHTER, DDS
WAYNE G. BEMIS, DDS
MARK E. WHALEN, DDS

RESIDENTS MICHAEL ALFANDARI, DDS
RAMBOD ALIREZAEI, DDS
ROHIT BATHEJA, DDS
DREW BRUECKNER, DDS
DEBRA EDSON, DDS
PEDRO GONZALEZ, DDS
SAMANTHA HAAS, DDS
EDON HIRT, DDS
KHANG LE, DDS
LESLIE WANG, DDS
PUBLISHER USC SCHOOL OF DENTISTRY




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T A BL E OF CONT ENT S
REFERENCES PAGE 1
FACULTY PAGE 2
USCSD COMPETENCIES - ENDODONTIC PAGE 4
THE EXPECTED OUTCOMES OF THIS COURSE PAGE 4
ENDODONTIC INSTRUMENT ARMMENTARIUM PAGE 5
MOUNTING TEETH, INSTRUCTIONS PAGE 11
TYPEODONT INSTRUCTIONS PAGE 13
ROOT CANAL SCHEMATIC PAGE 17
DEFINITIONS PAGE 18
ACCESS PAGE 20
INSTRUMENTATION OUTCOMES PAGE 22
CLEANING AND SHAPING, OUTCOMES PAGE 23
MANIPULATION OF FILES PAGE 24
ANTICURVATURE FILING PAGE 25
BALANCED FORCES TECHNIQUE PAGE 25
OPPOSITE FORCE TECHNIQUE PAGE 26
WATCH-WIND FILING PAGE 26
ROTARY INSTRUMENTATION PAGE 27
BUILDUP PAGE 28
IRRIGATION PAGE 28
TEMPORARY RESTORATIONS PAGE 28
CALCIUM HYDROXIDE PAGE 29
ANTERIOR ANATOMY, OUTCOMES PAGE 31
ANATOMY PAGE 32
ACCESS PAGE 39
CLEANING AND SHAPING: GATES GLIDDEN drills PAGE 40
REQUIRED RECORDED DATA PAGE 44
TREATMENT RADIOGRAPHS PAGE 44
LABORATORY RADIOGRAPHS PAGE 44
RADIOGRAPHIC PROCESSING PAGE 45
OBTURATION, OUTCOMES PAGE 46
CHARACTERISTICS PAGE 46
PRINCIPLES OF OBTURATION PAGE 46
OBTURATION OF A SINGLE CANAL PAGE 47
PREMOLAR ANATOMY, OUTCOMES PAGE 49
ANATOMY PAGE 50
ACCESS PAGE 56
CLEANING AND SHAPING: ROTARY INSTRUMENTATION PAGE 57
MANDIBULAR MOLAR, OUTCOMES PAGE 61
ANATOMY PAGE 61
ACCESS PAGE 66
MAXILLARY MOLAR, OUTCOMES PAGE 68
ANATOMY PAGE 69
ACCESS PAGE 73
OBTURATION OF MULTIOROOTED TEETH PAGE 75
PROCEEDURAL ACCIDENTS PAGE 77
PERFORATION DURING ACCESS PAGE 77
ACCIDENTS DURING CLEANING AND SHAPING PAGE 79
SODIUM HYPOCHLORITE ACCIDENT PAGE 82
ACCIDENTS DURING OBTURATION PAGE 83
PRECLINICAL GRADING SHEET (BROWN SHEET) PAGE 85
GRADING PROCEEDURES PAGE 87
INTEGRITY PAGE 87
GRADING CRITERIA PAGE 89
VOCABULARY PAGE 90
ELECTRONIC APEX LOCATOR PAGE 91
SYSTEMATIC ENDODONTIC DIAGNOSIS PAGE 92
SOAP NOTES PROBLEM ORIENTED DENTAL RECORD____________________ PAGE 94
REQUIRED RADIOGRAPHS PAGE 96
10 STEPS TO ENDODONTIC HEAVEN PAGE 98
CLINICAL ENDODONTIC DIAGNOSIS PAGE 99


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USCSD Competencies specifically addressed in Endodontics all competencies are important for
a competent professional.


17. Recognize pulpal and periradicular disease, treating uncomplicated conditions and referring
complicated endodontic procedures.


08. Perform a comprehensive diagnostic evaluation based upon the application of scientific
principles, and current literature, with consultations as appropriate.

10. Combine clinical and supporting data, with individual patients goals and values, and
integrate multiple disciplines into individual, comprehensive, sequenced treatment plans with
appropriate diagnoses, prognoses, and treatment alternatives.

11. Recognize the normal range of clinical findings and significant deviations that reflect oral
pathology and that require monitoring, treatment or management.

22. Recognize and manage pain, hemorrhage, trauma and infection of the orofacial complex.

23. Select and administer or prescribe pharmacological agents in the treatment of dental
patients.

24. Manage patients with pain and/or anxiety using non-pharmacological methods.


04. Regularly assess ones knowledge and skills, and seek additional information to correct
deficiencies and enhance performance.

07. Implement and monitor infection control and environmental safety programs according to current
standards.

09. Assess patient goals, values and concerns to establish rapport, guide patient care, maintain oral
health and monitor therapeutic outcomes.

THE EXPECTED OUTCOMES OF THIS COURSE ARE:

At the end of this course students will be able to:

1. Diagnose Pulpal and Periradicular Pathology
2. Evaluate the case for treatment or referral
3. Expose and interpret radiographs used in endodontics
4. Know the composition of materials used in endodontics
5. Safely make an endodontic access preparation
6. Accurately determine working length for canal preparation
7. Correctly clean and shape root canals
8. Correctly prepare and place root canal sealer
9. Completely obturate root canals by lateral condensation of gutta-percha
10. Accurately evaluate rendered treatment
11. Thoroughly complete endodontic records


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ENDODONTIC INSTRUMENT ARMMENTARIUM

Endodontic hand files
Hand files come in sizes 6-140, and in lengths of 21mm, 25mm and 30mm. Longer files designed
for veterinary use are manufactured. These are used for cleaning and shaping of root canal
systems. Stainless steel files size #8-20 as well as nickel-titanium (NiTi) files #25-60 are available
for use in the lab and the clinic.


21mm stainless steel hand files 25mm NiTi hand files

Endodontic rotary files
Rotary files are made from nickel-titanium and are more flexible than stainless steel.

ProFiles K3 Files

The K3 and ProFiles are sizes 30-0.06, 30-0.04, 25-0.06, 25-0.04.

Silicone Stoppers Used to set working length on files and spreaders.





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Gutta-percha
Moldable material used to obturate prepared canals. Gutta-percha comes in various sizes and
shapes. We will use standardized .02 taper cones in sizes 25-80 and accessory cones FF and MF.



#2 and #4 round, #557 straight fissure, Endo-Z, friction-grip burs
These burs are used to outline access preparation and to penetrate into the pulp chamber. Non-end
cutting burs such as Endo-Z are used to smooth the axial walls and refine the access preparation.



#2, #4, #6 right angle latch-type round bur
These burs are used to expand the deep part of the access preparation when necessary. They may
be used for preparation into the pulp chamber after the initial access is made with high speed round
or diamond burs




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Endodontic Explorer EXDG16/17
A sharp endodontic explorer is used to locate canal orifices and for chipping through calcifications.


Endodontic Excavator EXC 1, 2, 3
Long-shanked spoon excavator designed to remove debris and other materials from the pulp
chamber.


Iris scissors
Either straight or curved are, on rare occasions, used for cutting the tips of gutta-percha cones
when fitting a master cone.



Endodontic ruler (metal)
Sterilizable finger rulers are used to set lengths on files, gutta percha points, and paper points, flat
ruler is used to make measurements from radiographs.




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Gates-Glidden Drills
Latch-type Gates-Glidden drills are used to open the coronal 1/2 to 2/3 of the canal. Gates-
Glidden drills are intended to cut upon withdrawal from the canal. The cutting flutes are on the
back of the instrument head rather than the tip. 2=0.70mm; 3=0.90mm; 4=1.1mm


Plastic pipettes
Pipettes are used to deliver irrigants into the chamber and coronal portion of canals.
DO NOT USE A SYRINGE AND NEEDLE TO DELIVER MEDICAMENTS INTO A CANAL.



Paper points
Paper points come in many sizes and are used to dry fluids from canals.




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Hand spreader, D-11T
This instrument is used to laterally condense gutta percha during obturation of the prepared root
canal system. Place a rubber stopper on the spreader as a guide for insertion depth.
DO NOT HEAT THE SPREADER!

Glick #1
The paddle end of the Glick is used to carry and place temporary filling material while the plugger
end is used to compact the temporary filling material. Both ends may be heated and used to sear
off and remove excess gutta-percha and to soften gutta-percha as needed.



Plugger
Flat-ended instrument used for vertical compaction of heat-softened Gutta-percha as is done when
excess Gutta-percha seared off at the canal orifice at the end of completion of lateral condensation.
It is also used for the entire compaction of the heat-softened gutta-percha with the vertical
compaction technique. DO NOT USE AS A HEAT CARRIER!





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Film clip
It is mandatory that you use film clips. YOU MUST BUY AT LEAST 4. They are used to
hold radiographic films during processing, viewing, and air-drying. A hemostat or other pliers
should not be used to hold the film. If you loose your clips, buy more.

Cavit
This temporary material is used to the fill access opening. It is a thick putty-like requiring no
mixing and sets upon contact with water (saliva). It has better sealing ability but less strength than
IRM.


IRM
This material is used to fill an access opening. Powder and liquid must be mixed to make a
thick putty-like paste. IRM also comes in capsules for ease of mixing.


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MOUNTING TEETH-

Materials Needed
1. Paper cups
2. Tongue blades
3. Acrylic monomer and polymer
4. Dental stone
5. Boxing wax
6. Laboratory knife
7. Bunsen burner
8. Wax spatula
9. Ruler

For each tooth to be mounted:

1. Cut a piece of boxing wax 2 cm wide and 8.3 cm long.






2. Make shallow score marks at 2 cm intervals along the length of the wax strip.



3. Fold the wax strip with the score marks toward the outside to form a box. The score marks
will be the fold lines. The 4 mm excess at one end of the original strip will extend out from the side
of the box.


4. Fold over the flap of excess wax and weld the box together with a heated wax spatula.







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5. Cut a 2.5 cm square of boxing wax and weld onto one open end of the box to seal that end.



6. Roll up a 4-5 mm ball of wax and place at the end of each root.



7. Place 20 cc of acrylic polymer in a plastic cup. Add just enough stone (approximately one
gram or 1/4th teaspoon) to very thinly cover the surface of the polymer.

8. Add monomer and mix until runny and pour acrylic into the box.

9. With the box held on the laboratory vibrator, seat the tooth into the acrylic to the level of
the cervical line. Keep any caries or restorations at least 2mm above the acrylic and do not let
the apical wax touch the bottom of the box. Align the buccal, lingual, mesial, and distal surfaces
of the tooth parallel with the sides of the box, move the tooth out of the box slightly, if necessary to
keep the apical wax from touching the bottom of the box. Remove the box from the vibrator and
place it on a table remote from the vibrator.



10. Hold the tooth in place until the acrylic is at a consistency that will prevent the tooth sinking
into the mix.

11. Allow the acrylic to set and cool, then strip away the wax with a lab knife.

DO NOT TRIM THE ACRYLIC BLOCKS ON THE MODEL TRIMMER.

The acrylic will damage the trimmer disc.
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Ret ent i ve gr oove
Pr eoper at i ve r adi ogr aph
of unmount ed t oot h
Apex put t y ar ound
t he apex and c over
of t he r oot


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Pl ac e t oot h i n soc k et t o get i t i n
oc c l usi on wi t h opposi ng t eet h
Pl ac e f i x i ng gel ar ound t oot h t o
c over put t y and hol d t oot h i n pl ac e
Set t i ng t i me i s about 30 mi nut es
Tak e 2 r adi ogr aphi c vi ews
of t he mount ed t oot h
Use r ope wax t o hol d
t he f i l m i n pl ac e


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Mount t ypodont on mani k i n
Pl ac e r od (or hi gh vac suc t i on t i p) t o hol d t he mandi bl e i n pl ac e


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Rubber dam i nst r ument s

Rubber dam c l amps
Rubber dam wi t h
hol e punc hed
Det er mi ne pr oper c l amp si ze and pl ac e sec ur el y on t he t oot h
Pl ac e t he r ubber dam sheet over t he c l amp and posi t i on
t he f r ame, t i e f l oss t o t he c l amp f or pat i ent saf et y.


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ROOT CA NAL SCHEMA T I C
Foramen
Main Canal

Accessory Canal
Apical Bifurcation


Lateral Canal





Canal Orifice
Pulp Chamber


Major Foramen
Minor Foramen
Apical constriction


Q





Instrumentation and filling materials should terminate at the apical constriction (minor
foramen, cementodentinal junction), the narrowest width of the canal, and its termination at
the foramen. This point is often 0.5 to 1.0mm from the radiographic apex or 0.5mm from the
major foramen.
APICAL CONSTRICTION
APICAL STOP PREPARATION


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ENDODONTIC TREATMENT is also called conventional endodontic treatment, root canal therapy,
root canal treatment, and endodontic therapy or orthograde endodontic treatment.

DEFINITIONS: Refer to page 17 for illustrations
Access
This is the opening prepared in a tooth to gain entrance to the pulp canal system for the purpose of
cleaning, shaping and obturating. The access should reflect the anatomy of the pulp chamber and allow
straight access to each canal; this usually involves removal of the roof of the pulp chamber. This
opening needs to be large enough for convenience without undue sacrifice of tooth structure.

Apical constriction
It is the narrowing of the canal near its terminus. It is typically about 1/2mm from the major foramen.
Often it is the junction of dentin and apical cementum. This is the histological transition from pulp to
periapical tissue (PDL). This is the point at which cleaning, shaping and obturation ideally terminate.

Apical Foramen
The apical foramen is the exit of the canal usually near the radiographic apex. It consists of a major
foramen and a minor foramen. The Major Foramen is the opening on the surface of the root. The Minor
Foramen is generally mm short of the major foramen. It is also know as the apical constriction.

Apical Stop
The matrix of dentin or other materials at the apical end of a root canal preparation that prevents further
advancement of both endodontic instruments and obturating materials.

Apical Stop Preparation: THIS IS THE PREPARATION YOU SHALL DO!
The preparation design whereby a ledge is created within the canal at approximately the apical
constriction. The canal is enlarged while the constriction is left intact. This creates a barrier or
retention form against which to compact gutta-percha.

Deep Shape
This is the convenience form created in the canal to facilitate obturation of the canal space.

First File to Bind
This is the smallest file that engages the dentin (binds in the canal) at the Apical Stop.

Instrumentation
Cleaning is done to remove vital and necrotic tissue and infected dentin. This is accomplished with
files, Gates-Glidden drills, sodium hypochlorite (NaOCl, 5.25% or bleach), chelating agents and
lubricants such as EDTA (16-20%) and RC-Prep.
Shaping is done to aid in irrigation, disinfection and obturation, accomplished with files, and Gates-
Glidden drills. This is similar to convenience form in operative dentistry.

Lateral Condensation, Obturation
The complete filling and closing of a cleaned and shaped root canal using a root canal sealer and core
filing material with Lateral compaction (condensation). A sealer is placed in the canal followed by a
fitted gutta-percha master point compacted laterally by a tapering spreader to make room for additional
accessory points. The master cone is usually the same size as the MAF.
Master apical file (MAF)
This is the largest file that reaches WL.


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Master cone (MC)
The largest gutta percha cone that fits to WL with slight tug-back.

Patency file
A small (usually #10-15) file that extends past WL to RL, it is used to clear the canal of debris to
prevent blockage of the canal. The file is only manipulated in a gentle watch winding or opposite force
motion - not in a filing motion (filing will over-enlarge the foramen and inoculate debris into the
periapical tissues). Blockage of the canal with debris could result in misdirection of files and ultimately
perforation.

Radiographic length (RL)
The length of the root from the corresponding occlusal/incisal reference point (usually a cusp tip) to the
apex as measured on the radiograph with a straight metal ruler.

Reference point (Ref pt)
The occlusal anatomic feature from which a canals length is measured, e.g. cusp tip, marginal ridge.














Recapitulation
Recapitulation is the reintroduction of small files during canal preparation to keep the apical area clean
and patent (apical patency).

Step-back
The sequential use of files, in order from smallest to largest with each file being used incrementally 0.5-
1.0 mm shorter in length than the preceding file, for example, if #45 is the MAF at WL 20 mm, then #50
is used at 19.5 mm, #55 at 19 mm, #60 at 18.5 mm. The effect is to create a tapered, cone-shaped
preparation that blends the apical preparation with the deep shape preparation, for size 60 and above use
1mm increments.

Trial length (TL)
An estimated working length calculated by subtracting 1mm from the radiographic length.

Working length (WL)
It is the most apical extent of canal preparation and measured from a corresponding occlusal landmark
toward the apex of the given root; generally 0.5-1.0mm from the radiographic apex unless otherwise
dictated by the root anatomy. Ideally working length terminates at the apical constriction.
The working length is the length at which the apical stop is created. .


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ACCESS

Access into the pulp chamber and root canal system is the initial step in root canal therapy
and the most critical factor in determining the ease or difficulty of properly treating the case.
The access must be large enough to facilitate instrumentation but not so large as to
compromise the structural integrity of the tooth. Most of the procedural errors that occur
during root canal therapy are directly or indirectly related to the access opening made into
the tooth.


The OUTCOMES of the access preparation are to BE ABLE TO:

1. Provide unobstructed visibility into all canals.
2. Allow files to be passed into each canal without binding on the walls of the access
preparation (straight line access).
3. Allow obturation instruments to fully enter each canal without binding on the walls
of the access preparation.
4. Include removal of all caries and defective restorations.
5. Make possible the removal of all pulp tissue.
6. Removal of the roof of the pulp chamber.
7. Not unnecessarily remove tooth structure.

In order to accomplish these objectives, adequate enlargement of the access must be made.
The most common error in making endodontic access is making it too small. The most
critical error is making the endodontic access in the wrong place. Of course, we do not want
to needlessly weaken the tooth by removing excessive amounts of tooth structure. Over-extending
the access where it is not necessary will make the tooth more susceptible to fracture. However,
saving tooth structure at the expense of properly performing the endodontic treatment could result
in failure of the treatment and complete loss of the tooth.


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Some points to remember in making access into the pulp chamber:

1. Measure the initial radiograph for the distance from the occlusal or incisal surface to the
roof and to the floor of the pulp chamber (usually 4-6 mm to the roof of the chamber and 8-
10 mm to the floor). Record the measurements. Stay within these dimensions when making
the access preparation.

2. Remove all caries and defective restorations before entering the pulp chamber.

3. Reduce occlusion on a posterior tooth prior to entering the pulp chamber unless it has an
existing serviceable crown.

4. Make an outline of the access preparation about 2 mm into tooth structure with a #557, #2 or
#4 F.G. bur.

5. Pulp horns are almost directly under the corresponding cusp tips - a little toward the central pit
of the tooth. Review tooth anatomy prior to starting access.

6. Make initial penetration into the pulp chamber with the same bur (or a similar sized bur in the
slow speed handpiece) toward the most prominent part of the chamber. The

normal pulp
chamber in all teeth (those without excessive calcification) is usually encountered within 4-6 mm
of the tooth surface.
If the pulp is not entered within this depth, radiographs must be taken and the angle and
direction of approach must be re-assessed and corrected or perforation of the tooth may
occur.

7. Once initial penetration into the pulp chamber has been made, the remainder of the roof of the
chamber is removed by withdrawal strokes with the latch type slow speed round bur, cutting with
the edges on the top of the bur. The key to remember here is that the access is not completed by
cutting in an apical direction, but rather by removing the roof by cutting in a horizontal and
coronal direction. The concept is intended to prevent ledging of the canal or perforation of the root
surface during the access preparation.


8. The walls of the preparation may be smoothed and refined with the Endo-Z or diamond
bur.

9. Once the access is completed in a clinical case, it should be possible to view the orifice of
every canal with minimal movement of the mirror (straight-line access).







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The properly performed access preparation provides for visual straight-line access into every
canal of the tooth. The final straight-line approach may require the use of some other instruments
to remove dentin overhangs obstructing the orifices of some teeth. The treatment required for
these situations will be discussed when the individual teeth are addressed. Do not remove tooth
structure from the walls or floor of the pulp chamber unless specifically instructed to do so
by an instructor.
There are only two basic outline shapes of access preparations that encompass all teeth -
oval and triangular. A round preparation is never correct. A small, round access opening is
under-extended in at least one dimension, and a large, round opening is overextended in at least
one dimension. Maxillary incisors and all molars have triangular preparations, the molars
sometimes having modifications of the triangular form (trapezoid). All canines, premolars, and
mandibular incisors have oval outlines in a facial-lingual direction.
These preparation outlines are not arbitrary but are dictated by the internal anatomy of
the given tooth.



Do not remove tooth structure from the walls or floor of the pulp chamber unless specifically
instructed to do so by an instructor.

INSTRUMENTATION

Outcomes: Be able to:

1. List the two aspects of instrumentation and describe their functions.
2. Define the following terms: radiographic length, trial length, working length, foramen, reference
point, master apical file, patency file, step-back, recapitulation, master cone, and tug-back.
3. Discuss the objectives of cleaning and shaping.
4. Distinguish between stainless steel and nickel-titanium K-files.
5. Discuss the intended use of the above instruments.
6. Explain the significance of the numbering system of endodontic files.
7. Give the general dimensions of endodontic files.
8. Describe watch wind motion.
9. Describe reaming motion.
10.Describe balanced forces instrumentation.
11.Describe opposite force instrumentation.
12.Discuss a proper, systematic sequence of instrumentation of a straight canal.
13.Discuss how instrumentation techniques can lead to canal preparation errors.


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OUTCOMES OF CLEANING AND SHAPING: BE ABLE TO:

1. Create an apical stop within the tooth 1/2mm to 1mm from the radiographic apex or
from the major foramen when it can be located.

2. Keep the foramen in its original location to prevent zipping or perforation.

3. Keep the minor foramen (apical constriction) as small as possible to prevent zipping,
perforation, and to aid obturation.

4. Maintain the original canal shape to perform thorough cleaning and to prevent
transportation or stripping through the side of the root.

5. Create a continuously tapering, cone-shaped preparation from the orifice to the apical
stop to aid in irrigation and obturation.

6. The shape of the preparation should tend to duplicate or follow the shape of the root.

7. Remove organic material from the tooth and disinfect the tooth

8. THE MESIAL-DISTAL WIDTH OF THE PREPARATION SHOULD NOT EXCEED 1/3
THE WIDTH OF THE TOOTH.



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The Washington Monument has been
described by Dr. Dudley Glick as the
perfect shape for a root canal filling.




MANIPULATION OF FILES

Instrumentation techniques include reaming, watch
winding, circumferential filing,
Anti-Curvature Filing, Balanced Forces Technique
and Opposite Force Filing
.




Always inspect your files and other instruments
for cleanliness and defects, e.g. unwinding, before
you place them in a canal and after you withdraw them. All your instruments work better
when cleaned of debris. The file you do not inspect is the one that will break.

Reaming is a continuous clockwise rotation of the instrument.

Filing is simply an in-and-out motion of the file with amplitude of 2-3 mm. When a strictly filing
motion is done, the file is not tightly bound in the canal. With circumferential filing tooth
structure is removed uniformly from the canal walls. Do not use in the apical 1/3 of the canal.












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Anti-curvature filing instruments the walls of the canal away from DANGER AREAS such as
the furcations or root concavities to minimize the chance of a stripping perforation.

DANGER AREAS:
Lower Molar Upper Molar













Large Arrows Show Danger Areas

BALANCED FORCES TECHNIQUE
Balanced Forces should be the primary instrumentation technique used for all canals. The
technique uses a clock-wise motion of no more than 45 degrees with apical pressure to engage
the file flutes into the dentin followed by a counter clock-wise motion of 120 degrees or more
with apical pressure to break off the engaged dentin. Then a clock-wise motion of up to 360
degrees without apical pressure is used to pick up the created debris. The file is then
removed from the canal cleaned and inspected. The file is then reinserted into the canal and the
Balanced Forces Technique is repeated as needed. The degree of rotation is dictated by the
curvature of the canal. With severely curved canals the rotation may be only a few degrees in each
direction. Balanced forces technique was developed by Dr. Jim Roane to help instrument to larger
sizes in curved canals without ledging, perforating, stripping or zipping. The technique can be
viewed as a modification of watch wind.
























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OPPOSITE FORCE TECHNIQUE
Instrumentation of canals with even the slightest curve can be very difficult. Five factors influence
our ability to keep a file centered within the canal: Curvature of the canal, hardness of the dentin,
flexibility of the file, sharpness of the file and how much force is used to advance the file. A dull,
flexible file pushed gently in a slightly curved, hard tooth will keep the curve better than a sharp,
stiff file shoved forcefully into a severely curved, soft tooth.

Counter-clockwise rotation is the dull way to use a file and can be referred to as Opposite Force
(O-FORCE) Technique. This is a modification of the Balanced Forces Technique. Apical
pressure is exerted on the file as it is rotated counter-clockwise. The more curved the root
the more gentle the apical pressure and less the rotation, it may only be a few degrees in a
severely curved root. Then with no apical pressure the file is rotated clockwise to pick up
debris on its flutes, withdrawn from the canal and cleaned. This is repeated until the file
reaches its working length. O-FORCE instrumentation can be used as part of step-back or crown
down instrumentation.

The latter two may be used in crown down or step back techniques. Combinations of crown down
and step back may also be used to handle difficult curves or narrow canals, the greater the
curvature the smaller the increment of work done with each file.
.
Watch-Winding:
Watch winding is a back-and-forth movement of the file while it is gently being advanced
apically. The amplitude of the motion in a straight canal is 30-60 degrees right and left from the
center point, with a curved canal the rotation may be only a few degrees in each direction. It is
much like the file handle is being rolled back and forth between the thumb and forefinger while a
slight apical pressure is applied. Generally a Balanced Forces or Opposite Force technique is
preferred IN ALL CANALS. Almost all canals have some curvature and thus a curved canal
instrumentation technique should be used in ALL canals.

Watch-wind, Balanced Forces and O-Force are all successive modifications of reaming

For curved canals Balanced Forces Technique or Opposite Force Technique are
usually more appropriate to better maintain the curve.
The enclosing circle represents dentin as it contacts the
cutting edges of a file. R represents the internal force
applied by dentinal hardness as it is vectored toward the
center of the instrument. S is a restoring force applied
against the curvature by the file attempting to return to
its original straight condition. S remains stationary as
the instrument is rotated while R rotates with the blades.
As long as R remains greater than S, the instrument will
not transport the canal; however, should the file be
pulled out rather than rotated this formula fails and S
applies the primary cutting load. Transportation will
frequently occur under such conditions.


27
27



.
ROTARY INSTRUMENTATION

All Rotary instrumentation begins with handfiles. The operator should have a radiographic
knowledge of canal morphology and an established working length. When instrumenting with
nickel-titanium rotary files use a light touch, do not force the instrument. Go down the canal in
small increments using the same pressure that advanced the file into the canal 1mm in 1 second.
This has been described as a light pecking force. The smaller the diameter of the rotary file, the
less pressure the file can withstand before deforming or separating. The greater the curvature of
the canal, the less pressure the rotary file can withstand before separation. BE GENTLE. If the
rotary file gets stuck and does not advance go to a smaller size or hand files. Ledging and then
perforation occurs when files are used for an extended period at the same position in the canal.

Rotary commandments:

1. The Rotary electric motor is set at 275 RPM-torque control is set at midrange
2. Rotary working length is RL-2mm or to the curve of the root
3. Keep the canal wet-EDTA
4. Frequently clean and inspect the rotary files-use the files on 4 cases or less
5. Always work with straight line access
6. Never force rotary files - avoid the BEEP!
7. KNOW THE EXACT WORKING LENGTH BEFORE TOUCHING A ROTARY FILE
8. Clean files after each use-
9. Look to see the area on the rotary file that is picking up dentin, this tells you where the
file is working in the canal
10. No more than 1 second at any length
11. Respect the nickel-titanium rotary and it will be good to you


NEGOTIATING THE CURVE: The 6 factors that facilitate negotiation of the curve are:
Gentile instrumentation (light touch), precurved files, flexible files, dull files (counter-
clockwise rotation), minimal curve of the tooth, and having hard tooth structure.



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28
BUILDUP
A provisional buildup must be done to replace any missing pulp chamber walls prior to
beginning instrumentation. This will facilitate isolation of the pulp space from saliva and to help
confine irrigants to inside the tooth. Provisional buildups may be done with Cavit, zinc phosphate
cement, IRM, composite, glass ionomer and other appropriate materials.

IRRIGATION
Endodontic irrigation is an extremely important aspect of endodontic therapy. Irrigants
should be used at all times during canal instrumentation. Files are rarely used in a dry canal.
Sodium hypochlorite, 5.25%, is a mainstay of modern endodontics; it is an excellent
disinfectant, tissue solvent and lubricant. As a tissue solvent it works best full strength, 5.25%
(and heated), its efficacy, as a disinfectant seems to be as good diluted as full strength. Care must
be taken with the use of sodium hypochlorite, 5.25%; its unpleasant taste can disturb patients and
forceful injection into or through the tooth can be catastrophic. When using sodium hypochlorite,
5.25%, a well fitting (sealed) rubber dam should be in place and the solution should be gently
placed into the pulp chamber not injected into a canal. Do not use sodium hypochlorite, 5.25%,
in the SIM LAB!
EDTA, 16-20%, is a useful irrigant and its chelating properties facilitate instrumentation
especially in narrow canals. It is not particularly useful as an aid in searching for canals.
Sometimes for debridement purposes it is desirable to flush material from the canal; the easiest
method is to use local anesthetic (remember to use a new needle).
Generally NaOCl, 5.25%, is alternated with EDTA, 16-20%, during treatment. After
access the pulp chamber is irrigated with NaOCl, 5.25%, which is allowed to soak for a few
minutes. Then EDTA, 16-20%, is placed into the pulp chamber and the coronal flare is performed.
NaOCl, 5.25%, is again placed for length determination. GGD, rotary and hand instrumentation
are done with EDTA, 16-20%, while NaOCl, 5.25%, is used for soaking while radiographs are
taken or during other non-instrumentation periods. Do not use sodium hypochlorite in the SIM
LAB!

TEMPORARY RESTORATIONS
Sealing of the access preparation between appointments and after final obturation is
absolutely necessary to prevent microorganisms from contaminating the root canal system.
A number of recent studies have demonstrated contamination even of an obturated root canal as a
result of an open access cavity or an access with a deficient restoration. This leakage into the root
canal system, therefore, has the potential to be an etiologic factor for failure of a completed root
canal treatment. A well-sealed temporary restoration has the ability to prevent coronal leakage and
subsequent recontamination of the root canal.

Many different materials have been used or recommended as endodontic temporary restorations.
Two of the more common materials are Cavit and IRM.
Once endodontic treatment is completed, place a temporary filling of Cavit or IRM. This filling
should be at least 3mm in thickness.

IF A COTTON PELLET IS PLACED TO FACILITATE REENTRY INTO THE PULP
CHAMBER THEN IRM MUST BE USED.
CAVIT MAY BE USED AS A TEMPORARY RESTORATION AFTER ENDODONTIC
OBTURATION ONLY IF IT FILLS THE ENTIRE PULP CHAMBER.


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29
CALCIUM HYDROXIDE-INTRACANAL MEDICATION
Once endodontic treatment is started will be calcium hydroxide will be used as an interim
antimicrobial intracanal medication (temporary root canal filling) in all canals and Cavit or IRM
placed as a temporary restoration.
The preferred intracanal medication is calcium hydroxide. This is placed with a spiral
filler. Powered Ca(OH)2 is mixed with sterile water or anesthetic solution to a creamy
consistency, picked up on the spiral filler and spun into the canal. When the slow speed handpiece
is set in the forward (normal) position the spiral will spin the medication into the canal, when set in
reverse it will bind in the canal and break. Always check that the spiral filler spins clockwise in
the correct direction before placing it into a canal. Calcium hydroxide may also be placed with
a file one size smaller that the last size taken to length and rotating it counter-clockwise or placed
and packed with the blunt (big) end of a paper point.

Set a rubber stop on the spiral filler 2mm short of working length. Coat the filler, place it into the
canal and slowly spin it until it reaches the stopper lever. Allow the spiral filler to rotate for 5
seconds and then slowly withdraw. If the canal does not appear full, repeat the process. When the
canal is full, remove the excess Ca(OH)2 from the chamber, place a cotton pellet into the pulp
chamber and then place Cavit or IRM as a temporary access filling. This filling should be at
least 3mm in thickness.

30
TEMPORARY RESTORATION WITH Ca(OH)2 IN the CANAL




TEMPORARY RESTORATION PLACED AFTER COMPLETION OF ENDODONTIC
THERAPY

GUTTA PERCHA
COTTON
PELLET
CAVIT
IRM




PLACE Ca(OH)2
WITH A
LENTULO
SPIRAL
FILLER
(check placement
with a
radiograph in
the preclinical
course)
PLACE COTTON
&
PLACE CAVIT or
IRM
Ca(OH)2
COTTON PELLET
CAVIT or IRM


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31
ANTERIOR ANATOMY, ACCESS, AND INSTRUMENTATION


Outcomes


1. Discuss the internal anatomy of all anterior teeth.
2. Describe the access outline and process for making access into all anterior teeth.
3. Explain the objectives of endodontic access.
4. Cite the most common error in making endodontic access.
5. Discuss procedures to avoid making errors in endodontic access.
6. Discuss general principles in controlling the depth of access.
7. Describe the two basic outline shapes of access and give the reason for their shapes.
8. Demonstrate proper processing of radiographs.
9. Describe and demonstrate a complete and systematic sequence for instrumenting
anterior teeth.







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ANATOMY OF ANTERIOR TEETH
Maxillary Central Incisor
The maxillary central incisor has a roughly triangular shaped crown with its pulp chamber
reflecting that same shape. The triangular shape of the pulp chamber creates two pulp horns,
mesial and distal. During endodontic treatment, all tissue must be removed from the pulp horns.
If tissue is left behind in the pulp horn extensions, pigments from the breakdown of the tissue can
cause discoloration of the tooth.
The average length of the maxillary central is 22.5mm. Maxillary centrals very rarely have
multiple canals. They often have accessory canals, though, which are not visible on a radiograph
before endodontic treatment. Accessory canals may be implied on the radiograph of a tooth with
necrotic pulp by the location of a radiolucency in the bone adjacent to an accessory canal a
radiolucency is usually centered on its source. Accessory canals can often be visualized after
obturation of the root by the presence of radiopaque sealer in the accessory canals. Approximately
45% of maxillary centrals have the foramen located away from the anatomic terminus (apex) of the
root, usually to the buccal or lingual.
Access into the maxillary central is triangular in shape, reflecting the triangular form of the pulp
chamber. It is made by first cutting the triangular outline into tooth structure to a depth of 2mm.
Initial penetration into the pulp chamber is made with the bur at the cingulum area of the
preparation. After penetration is made, the chamber is unroofed with withdrawal strokes, cutting
with the top of the round bur. The preparation may be smoothed using the Endo-Z bur. There may
be alingual overhang of dentin partially obstructing the orifice of the canal. This is removed
using a long shank #2 or #4 round bur or Gates-Glidden drills creating straight-line access into the
canal.

Maxillary Lateral Incisor
The maxillary lateral has a coronal shape similar to the central but with smaller dimensions.
The average length is 22mm, almost the same as the central. The shape of the pulp chamber in the
lateral is triangular like the central. Due to the smaller dimensions of the lateral, though, the
access is usually oval. If the lateral incisor is larger, with a corresponding larger pulp chamber, the
outline may be triangular.
Maxillary lateral incisors very often have a moderate to severe distal curvature in the
apical 1/3 of the root with the foramen most often corresponding to the anatomic apex. The
curve may also have a palatal aspect to it. Mishandling of the apical curvature during
instrumentation can result in failure of the endodontic treatment (the maxillary lateral incisor has
one of the highest failure rates).
Access is accomplished similarly to the maxillary central incisor. The outline is made to be
oval instead of triangular if the pulp chamber is found to be of average size.

Maxillary Canine
The maxillary canine is the longest tooth in the dental arch with an average length of 26.5mm.
The coronal pulp is ovoid in cross-section and the access preparation reflects this shape. The root
may have mild to moderate apical curvature and the foramen is usually close to the anatomic apex.
Accessory canals occur less frequently than in maxillary incisors. The root apex may have a disto-
labial curvature.
Access is made in a manner similar to the central and lateral, keeping the outline oval in shape.
The incisal extension is about 2/3 of the distance to the cusp tip.


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33
Mandibular Central and Lateral Incisor
Mandibular incisors have their greatest cross-sectional dimension in the facial-lingual direction
and are very narrow mesio-distally. The pulp space is, therefore, ribbon shaped reflecting the
same dimensional proportions as the exterior root surface. Average length of mandibular incisors
is 20.7mm. Two canals or a dumbbell shaped canal occur in 40% of mandibular incisors,
however, two separate foramina occur less than 5% of the time. The second canal (or second lobe
of the dumbbell shaped canal) is usually located toward the lingual after initial access is made. It
is very often obscured from view by an overhang of dentin that must be removed to make complete
access. The oval shaped access preparation is made very carefully and is not expanded at all
mesio-distally beyond the width of the #557 or #4 round bur. A #2 round bur may be used to make
the access preparation to prevent overextension. Access extends from the cingulum 2/3 the
distance to the incisal edge or, sometimes, even to the incisal edge. Severely rotated mandibular
incisors or those with lingually tipped crowns may require access on the labial surface. This
access is easily restored with bonded composite.
Instrumentation is done in mandibular incisors at the expense of the facial and lingual surfaces of
the canal, sparing the mesial and distal surfaces. After obturation, the clinical radiographic view
may not reveal much taper in the shape of the canal, but if a view were taken from the proximal, a
significant taper would be seen. A mandibular incisor should usually be treated as if it has 2 canals.


Mandibular Canine

The mandibular canine has an average length of 25.6mm. It is a fairly straightforward tooth
with minimal complications, similar to the maxillary canine. The mandibular canine, though, may
on occasion have two canals or two roots evidenced on the radiograph by an apparent termination
of the visible canal somewhere at mid-root level. Where two canals are present, it is usually easier
to gain access into one than the other. Nonetheless, both must be located and treated. Frequently
the foramen exits to the buccal or mesial (35%-50%).
The access preparation is oval as in the maxillary canine.

SUMMARY: The most common error made in accessing anterior teeth is perforation of the
facial crown or root surface. If the canal is not easily encountered within the confines of the
crown of the tooth, an instructor must be consulted. Remember to estimate the location of the
pulp chamber and if you do not find it there take a radiograph and ask for help

In order to minimize perforations you must evaluate the radiographs and estimate where the pulp
chamber will be found and determine if you are comfortable with this search.
If so, then go to this predetermined location. If you do not find the pulp chamber at this point,
take at least 2 radiographs (at different angles) to help guide you along with faculty consultation.
Always have an objective when you cut on a tooth. When in doubt, ASK FOR HELP!!








34
34
MAXILLARY CENTRAL INCISOR










35
35
MAXILLARY LATERAL INCISOR











36
36
MAXILLARY CANINE





37
37
MANDIBULAR CENTRAL AND LATERAL INCISOR




38
38
MANDIBULAR CANINE

















39
39
ANTERIOR ACCESS

1. Use a #2 F.G. round bur for mandibular incisors or a #4
F.G. round bur for all other anterior teeth. A fissure bur such as
the 557 may also be used for access. Hold the bur
perpendicular to the lingual surface and make an outline of the
access preparation 2 mm into tooth structure. The preparation
extends from the cingulum to 2/3 of the cusp height. Mandibular
incisors may extend all the way to the incisal edge.

2. Change the angle of the bur so it is parallel to the long axis
of the tooth and place the tip of the bur in the most cervical part of
the access outline (cingulum area). Make initial penetration into
the pulp chamber. Do not penetrate more than 4 mm from the
lingual surface - there is a risk of perforating the buccal
surface. Get help if you have not found the pulp chamber at this
point.
. Do not remove tooth structure from the walls or floor of the
pulp chamber unless specifically instructed to do so by an
instructor.

3. Locate the opening into the chamber with the DG16
endodontic explorer.

4. Enter the pulp chamber with a round, then with the bur
parallel to the long axis of the tooth, sweep it incisally, unroofing
the rest of the pulp chamber.

5. Probe for the orifice(s) with a sharp endodontic explorer.

6. If the canal is large, remove the lingual overhang with
Gates-Glidden drills,
7. Explore and clean any remaining pulp horns with a
DG16-17 explorer.





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40
CLEANING AND SHAPING USING HAND FILES
AND GATES GLIDDEN DRILLS anterior tooth
RECOMMENDED INSTRUMENT SEQUENCING FOR AN APICAL STOP PREPERATION
We want to create an apical stop at the apical constriction (minor foramen). The apical constriction
is generally about 0.5-1mm from the major foramen. When we cannot identify the major foramen we
measure from the radiographic apex.
1. Take diagnostic radiographs, 2 periradicular (and bite-wing for posterior teeth in the clinic).
--Radiograph--
2. Observe external and internal tooth anatomy, measure and record the radiographic length (RL)
and the distance from the incisal edge to the pulp chamber [roof of pulp chamber (RPC)]
--Record
3. With a sharp #2 pencil, draw the access outline on the lingual surface of the tooth.
--Check Point, steps 1-3--
4. Make access outline 2 mm into tooth structure.
--Check Point--
5. Continue access to the RPC measurement point.
--Check Point--
6. Complete access as described in Anterior Access

and irrigate the pulp chamber with 2 ml of
water. Ensure that the roof is off the pulp chamber. Do not remove tooth structure from the walls
or floor of the pulp chamber unless specifically instructed to do so by an instructor.
7. Locate the orifice(s) or canal(s) with a sharp endodontic explorer (only). Do not use a bur.
--Check Point-
8. Estimate working length (RL minus 1 mm). This is the trial length (TL).
--RECORD
9. Set the silicone stopper on a #15 file at the TL, measurement from the tip.


41
41
NOTE: IN THE CLINIC INSTRUMENTATION IS DONE WITH EDTA IN THE TOOTH
AND A SODIUM HYPOCHLORITE SOAK IS DONE DURING NON-
INSTRUMENTATION PERIODS SUCH AS TAKING RADIOGRAPHS.
NaOCl IS NOT USED IN THE LAB.
AS FILE SIZE INCREASES, ITS STIFFNESS INCREASES MAKING A LARGE FILE
LESS ABLE TO INSTRUMENT AROUND A CURVE.

10. Using EDTA as a chelating agent and lubricant, insert a #15 tile to TL (RL-1mm) using a
balanced forces or opposite force filing several times until TL (silicone stopper touches the incisal
edge) is reached. [If TL is not reached easily with the #15 file, then try #10 (or even a #8 file) until it
reaches TL and then work up to the larger size. If the #15 file is loose at estimated TL, increase the
file size until a file is selected that binds slightly at TL.]. The #15 file is the minimal file size to use
while making a length determination radiograph. (The tip of a file smaller than #15 is too
difficult to distinguish on radiographs.)
--Radiograph-Record (Trial length)-

11. Confirm that the file has not moved. If the silicone stopper is not still in contact with the
reference point, with the file held firmly in place, move the silicone stopper until is touches the
reference point (generally the incisal edge for an anterior tooth and a convenient occlusal reference
point for a posterior tooth). Remove the file from the canal and measure the distance from the tip to
the silicone stopper. If nothing shifted position during the radiographic process then this
measurement will be the same as your TL, if it is not then this new length is to be used as the TL.
12. Calculate the working length (WL). Using the new radiograph measure and record the distance
from the tip of the file to the major foramen or radiographic apex; Calculate the correction
necessary to place the file tip within the tooth at a point 0.5-1mm from the major foramen or from
the radiographic apex (closer is not better). This new length is your Working Length. Do not
position the file at the WL until after initial coronal flare.
13. Place #10 file to full length (radiographic length) with EDTA in the canal, rotate turn
clockwise and withdraw to remove debris and maintain patency (apical clearing with a patency file).
14. INITIAL CORONAL FLARE: Initial coronal flare should go no deeper into the tooth than
1/2 of the working length. On the GG drills (4, 3, 2), set the silicone stoppers at 1/2 the estimated
working length. The coronal flare will be created in a CROWN DOWN manner-larger to smaller
instruments.
15. Rotating at moderate rpm, slowly and carefully insert the head of the #4 GG drill into the wet
canal. Maintain a tight grip on the tooth block. Move the drill once or twice, maintaining a moderate
RPM, into the canal with careful in-and-out strokes without any or only very slight apical pressure.
Remove the drill and wipe off debris with gauze. If the drill has reached the depth set by the stopper
use of GG drills is complete.
16. Irrigate into orifice and use patency file as in step #13. If midroot has been reached skip to
step #19.
17. If midroot has not been reached REPEAT STEPS #15-#16 using the #3 GG drill.
18. If midroot has not been reached REPEAT STEPS #15-#16 using the #2 GG drill.
19. Place the WL file into the tooth at working length and take a radiograph.
--Radiograph-Record (Trial working length)-




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42
20. Determine Working Length: Working length is the distance from the reference point to the
apical stop. The Apical Stop should be created within the tooth at a distance of 0.5-1.0mm from the
Major foramen or Radiographic Apex. This is about the location of the Minor Foramen or apical
constriction. Determine and record the amount of length adjustment of the WL file for a correct
WL. (If it is correct at the working length, then no further correction is necessary). Record the
amount of the change and the correct WL, if adjustment is 1mm or less, continue instrumentation at
the corrected working length. If the adjustment is greater than 1 mm, make the adjustment and take a
new radiograph to confirm proper WL.
--RecordCheckpoint--
21. Determine and record the first file to bind. The first file to bind is smallest size file that
fits tightly in the canal at working length.
--Record
22. The master apical file is usually 3-5 file sizes larger than the FIRST FILE TO BIND
at WL. Optimal enlargement will usually be 5 sizes; minimal enlargement will be 3 sizes. For
example, if the FIRST FILE TO BIND is #20, MAF will be at least #35 with an optimal size of
45. If the FIRST FILE TO BIND is #40 (possible in young maxillary anterior teeth), the optimal
MAF is at least #70. Minimal MAF is #30 for very narrow or curved roots and #40 for straight
roots, most MAFs fall into the range of #30-#80.
23. Hand instrument using balanced forces or opposite force technique to a size 20 with
stainless steel files (unless the first file to bind is size 20 or larger). Using nickel-titanium hand
files, hand instrument using balanced forces or opposite force technique to the appropriate
MAF. The MAF should be at least size 30 on curved canals and size 40 on straight canals and at
least 3-5 sizes larger than the first file to bind at working length.
24. Once the apical preparation has been completed with the MAF at WL, place the MAF into the
canal at WL and take a radiograph.
--Radiograph-Record-Check Point-

NOTE: INSTRUMENTATION IS NEVER DONE IN A DRY CANAL, ALWAYS
INSTRUMENT IN A WET, LUBRICATED CANAL. In lab, we use water and RC-Prep or
EDTA; in clinic, we use sodium hypochlorite and RC-Prep or EDTA.
INSTRUMENTATION IS NEVER DONE IN A CURVED CANAL WITH A STRAIGHT
STAINLESS STEEL FILE.

25. Dry canal with paper points, place Ca(OH)2 with Lentulo spiral filler, place cotton pellet and
Cavit or IRM. This step is done, in the clinic, at every appointment when endodontic treatment
is not completed.
--RadiographCheck Point
26. Remove temporary with a round bur, remove the cotton pellet and flush canal with water.
WE WILL USE MAF #40 ARBITURARY TO CONTINUE WITH STEP-BY-STEP
PREPARATION we will step back to size #60.
27. At the beginning of every subsequent treatment visit for a tooth, start the visit with a
radiograph on the last (largest) file to working length. This will reorient you to the tooth and
confirm that you are where you think you are.
28. Set silicone stopper on #45 file (white) 0.5 mm shorter than WL.
29. Insert #45 file into canal and instrument using balanced forces or opposite force technique to
the set length.


43
43
30. Irrigate into orifice and use patency file as in Step #13.
31. Set silicone stopper on #50 file (yellow) 0.5 mm shorter than the length for #45 (1.0mm shorter
than working length).
32. Insert #50 file into canal and instrument using balanced forces or opposite force technique to
the set length.
33. Irrigate into orifice and use patency file as in Step #13.
34. Set silicone stopper on #55 file (red) 0.5 mm shorter than the length for #50 (1.5 mm shorter
than working length).
35. Insert #55 file into canal and instrument using balanced forces or opposite force technique to
the set length.
36. Irrigate into orifice and use patency file as in Step #13.
37. Set silicone stopper on #60 file (blue) 0.5 mm shorter than the length for #55 (2.0 mm shorter
than working length).
38. Insert #60 file into canal and instrument using balanced forces or opposite force technique to
the set length.
DO ALL STEP BACK AT 1/2MM INCREMENTS TO AT LEAST A SIZE 60 REGARDLESS
OF THE SIZE OF THE MAF.
39. Irrigate into orifice and use patency file as in Step #13.
40. Use #4 Gates Glidden Drill (4 GG) 2-3mm into the orifice (past the CEJ) or 7-9mm short of
working length (this depends on MAF). Irrigate and use patency file.
41. Use #3 GG 4-5mm into the canal (orifice, past the CEJ), 5-7mm short of the working length but
not around a curve. Irrigate and use patency file.
42. Use #2 GG 6-7mm into the canal (orifice, past the CEJ), 3-5mm short of the working length.
Irrigate and use patency file.
43 Place #35 file (one size smaller that the MAF) into canal and gently watch-wind to WL. Rotate
turn clockwise and withdraw to remove debris. (APICAL CLEARING with file 1 size smaller
than MAF.)
44 Place #40 file (MAF) into canal and gently watch-wind to WL. Rotate turn clockwise and
withdraw to remove debris. (APICAL CLEARING with MAF.)
45 Irrigate with 2cc of water and use patency file.
46. Place the MAF into the canal at WL and take a radiograph. IT IS CRITICAL THAT THE
MAF IS IN THE CORRECT POSITION (0.5-1mm from the major foramen or radiographic
apex). If the MAF/apical stop is in an incorrect position a new apical stop needs to be created.
47. CONFIRMATION OF APICAL STOP: mark at working length a gutta-percha point 2
sizes smaller than the MAF. Place it into the canal and confirm that even with firm pressure it will
not go beyond the apical stop. If it does the apical stop is inadequate and the MAF is in the correct
position then the MAF needs to be larger. The gutta-percha point may bend in the canal and appear
to go long. This bending is observed upon removal of the point from the canal.
-Radiograph-Record-Check point-
48. To check for adequate flare, place a gutta point the same size as the MAF into the canal to
working length then gently insert a spreader along side, measure and record the depth of spreader
penetration. If the spreader does not go to within 5mm of the apical stop the flare of the preparation
is inadequate for filling and additional flaring needs to be accomplished, consult with your instructor.
--Checkpoint--
49. Dry the canal with paper points, first using coarse then medium or fine.




44
44
Required recorded data for all teeth in the clinic as well as preclinical endodontic block.
Radiographic length
Depth to pulp chamber
Estimated tooth length/Trial file length
Correction to determine working length
Additional corrections as necessary
Working length
First file to bind at working length
Rotary working length
Master apical file size
Master cone size

TREATMENT RADIOGRAPHS for preclinical* block and Clinic**, mounted
Required Radiographs-
1. Initial* (periapical and bite-wing for posterior teeth)**
2. Trial length (TL)* **
3. Working length (WL)* (may be multiple radiographs)**
4. Working Length Correction (if needed)*
5. Calcium hydroxide placement in the canal*
6. Master apical file (MAF) at WL* **
7. Master cone (MC)* **
8. Initial condensation (MC & 1-3 accessories)* **
9. Final fill with temporary* **
*In the Preclinical Course: Take both Facial and Proximal views on a single film
**In the clinic: Take straight parallel as well as an angled periapical radiographs.

PRECLINICAL LABORATORY RADIOGRAPHS



45
45
PROCESSING RADIOGRAPHS

The film is oriented with the dimple toward the occlusal or incisal side of the tooth. This is to
keep the dimple away from the apex of the root. If the dimple falls close to or overlaps the apex of
the root, it will distort the image and make it unreadable.
The main problem students have with radiographs in the preclinical course is under fixation.

Developing Radiographs
The liquids in the portable dark rooms are arranged as follows:

Developer Water Fixer Water
1 2 3 4
15 sec 3sec 30 sec 3 sec

1. Be sure the cover on the developing box is properly in place obstructing leakage of light.
2. Holding the film packet with the dimple in the upper right hand corner (away from you), peel
back the tab and partially unfold the black paper liner.
3.Attach the film clip at this upper right corner. this will prevent clamping the film near the image
of the apex of the root. (Remember, the film was oriented with the dimple toward the occlusal, or
incisal of the tooth).
4. Dip the film for 3 seconds into the water in the second cup to moisten the emulsion.
5. Gently agitate the film in the developer (first cup) for 15 seconds. A distinct image will appear
on the film.
6. Remove film from the developer and rinse in the water in the cup for only 3-5 seconds.
7. Gently agitate the film in the fixer (third cup) for at least 30 seconds.
The image will appear to darken.
8. Remove film from the fixer and rinse in the water in the fourth cup.
9. After removing the film from the developing box, rinse it again under running tap water,
Photographic fixer will leave a brown stain if it drips onto clothing.
10. The film may be viewed and kept at the work area if needed for reference at this point.
However, the image is not permanently fixed until the film has been fixed for 3-4 minutes,
then rinsed for 5 minutes [rub the surface gently with fingertips to help remove any residual film
(on the film)], and allowed to dry. Radiographic films are the only permanent visible record of
endodontic treatment and must be of archival quality.
11. Proper radiograph criteria are:
a. No fixer stains
b. No scratches
c. Tooth centered mesial-distal
d. Radiographic apex at least 4mm from the edge of the film
e. Proper exposure/contrast
f. Long axis of tooth parallel to side of the film
g. All required radiographs present





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OBTURATION
Outcomes

1. Be able to list the characteristics of an ideal obturation material.
2. Be able to discuss the composition of endodontic gutta-percha.
3. Be able to give the general characteristics of gutta-percha.
4. Be able to explain the sizing of gutta-percha cones.
5. Be able to List the basic ingredients of the most commonly used sealers.
6. Be able to discuss the purpose of obturation.

Characteristics of Ideal Obturation Material

1. Hermetic seal
2. Non-irritating to vital tissue
3. Radiopaque
4. Easy to handle
5. Non-absorbable
6. Bacteriostatic
7. Nonstaining
8. Removable

PRINCIPLES OF OBTURATION

Preparation is the first step in obturation. The tooth and canal should be prepared in a
manner to facilitate obturation. Generally we want a smooth even taper decreasing in
diameter from orifice to apical stop. As the canal is being filled we must maintain our access
to the unfilled portion of the canal. Often during lateral compaction a blockage occurs at the
level of the CEJ or canal orifice. It is important to remove this blockage as it develops and
before it leads to a midroot void in the filling.
The Initial Condensation Radiograph, after placement of sealer, master cone, and not
more than 3 accessory cones, is important for evaluation of the apical third fill. If the apical
fill is good (to the apical stop and without voids) we can proceed to fill the midroot portion of
the canal.
But we must be able to get to the midroot and to do so we usually need to remove the
gutta-percha to the level of the CEJ or orifice. This removal is accomplished with a heated
Glick. The heated paddle end is used to remove the gutta-percha as it emerges from the
tooth and the heated (red hot) plugger end is used to remove the gutta-percha to the level of
the orifice or facial CEJ. This helps to prevent a midroot blockage and allows a void free fill.
We then add several (1-3) more accessory gutta-percha points periodically melting them
off to ensure access to the canal and slowly backing out of the canal. Always monitor the
position of the spreader and see that the accessory point goes to the same level as the
spreader it is replacing.
When the mid-root is densely filled the gutta-percha is melted off at the CEJ or orifice
and condensed vertically with the Glick or a plugger. If additional softening is needed the
Glick may be heated and dipped into sealer powder (to prevent sticking) prior to
condensation.



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HAPPINESS IS A WELL FILLED ROOT


Obturation of a Si ngle Canal

1. Insert a D11T spreader into canal and ensure it reaches WL. This is a test for adequate flare.
Another test is to try the spreader along side the Master Cone placed at working length. The
spreader should go passively to within 3-5mm. As a learning tool it is good to do both tests.
2. Select a standardized master cone the same size as the MAF and 1-3 medium-fine or
fine-fine accessory cones.
3. Irrigate the canal. The canal is irrigated to provide lubrication for the master cone during try-in
similar to when sealer is placed into the canal for final obturation.
4. Assure canal patency with an #10 file. Then apically clear, first with a file one size smaller
than the MAF, then with the MAF.
5. Grasp the master cone at working length and try it in the canal checking for tug-back.
If the master cone has no tug-back or folds up upon insertion, cut it back 1 mm and try in
again. If it does not fit properly, cut back again. The cone can be cut back 2 1/2 mm in
length before the tip is the same diameter as the next larger cone (0.02 taper results in 0.05
mm change in diameter per 2.5 mm in length.) If the master cone does not go to working
length, use a smaller size and adjust for tug back.

If the master cone goes long, i.e. past the apical stop, redetermine the working length and a
new apical stop must be created within the tooth (at least 2 sizes larger than the previous size).

CHECK POINTRADIOGRAPH--

6.If the master cone is properly sized, remove it and dry the canal using coarse, then medium or
fine paper points.
7. As the last step before filling the canal, insert the MAF to WL, gently turn clockwise 1/4 turn in
a straight canal, less in a curved canal, withdraw and clean the file with gauze to clear the apex of
dried debris. Repeat until no debris remains.
This is the only time a file is used in a dry canal.
8. Pick up sealer with the file one size smaller than MAF (minimum #25 file). Insert the file into
the canal and gently rotate the file counter-clockwise to spin the sealer off the file and onto the
wal1s of the canal.
9. Repeat step #8 several times.
10. Coat the apical 1/3 of the MC with a layer of sealer.
11. Grasp the master cone at working length and insert it into the canal fully seating into the
apical 1/3.
12. Set the silicone stop at 1 mm short of working length on the D11T hand spreader. Insert the
spreader into the canal alongside the gutta-percha and work it to length with a steady apical
pressure. Ideally the spreader will go to within 1mm of the working length and should get to
at least within 3mm.
13. After the spreader has reached length, leave it in place briefly so the gutta-percha will distort
and leave a track for an accessory cone.
14. Slowly withdraw the spreader from the canal while rotating it in back and forth to prevent it
from sticking to the gutta-percha and pulling out the master cone.



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15. Insert a fine-fine or medium-fine accessory to length in the pathway left by the spreader. A
thin coat of sealer may be placed on the accessory cones, be sure the accessory cone inserts to
the same length as the spreader. As an alternative, place sealer on the spreader if more sealer is
desired in the canal.
After 1-3 accessory cones have been placed in the canal, take a radiograph. This INITIAL
CONDENSATION radiograph allows the evaluation of the apical gutta-percha fill in the canal,
and if not acceptable, the gutta-percha can be grasped by the extended ends of the cones and
removed from the poorly filled canal. The canal can then be properly re-filled.
--CHECK POINTRADIOGRAPH--
16. Heat the paddle end of the Glick instrument and sear off the gutta percha protruding from the
access (at the cavo-surface margin).
17. Heat the plugger end of the Glick (red hot) and remove the gutta percha to the most apical
level of the CEJ (or the canal orifice in a posterior tooth.)
Often a gutta-percha blockage develops at about the level of the CEJ and must be removed
in order to adequately fill the midroot.
A midroot void is avoided by insuring adequate sealer in the canal, by insuring that the
accessory point is placed to the depth achieved by the spreader and using the heated Glick to
periodically remove gutta-percha at the CEJ level before a block occurs. Clean the Glick
after each use.
18. Add additional accessory points until the spreader will not penetrate more than 2-3mm past
the CEJ level. Periodically remove the gutta-percha after every 2-5 points as described in steps
#16& #17. Further radiographs are not required unless midfilling checks are needed.
20. Condense the gutta-percha apically with a cooled Glick plugger.
21. Place the appropriate temporary restoration. Gutta-percha should be to the CEJ in single
rooted teeth and only to the canal orifice in multi-rooted teeth.
--Radiograph




















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PREMOLAR ANATOMY, ACCESS, AND INSTRUMENTATION

OUTCOMES
1. Be able to discuss the internal anatomy of maxillary premolars including the relative
incidence of two canals.

2. Be able to discuss the importance of occlusal reduction.

3. Be able to describe the access outline and process of making access into premolars.

4. Be able to discuss the internal anatomy of mandibular premolars including the relative
incidence of two canals.

5. Be able to discuss the apical anatomy of mandibular premolars.

6. Be able to discuss and demonstrate a complete and systematic sequence for
instrumentation of premolars.







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ANATOMY OF PREMOLARS

Maxillary First Premolar

The maxillary first premolar has two canals frequently enough that it must always be assumed
there are two canals until proven otherwise. Studies have revealed two separate canals and
foramina in 75% of first premolars. There is even a chance the first premolar may have three
canals - a very difficult treatment situation.
The root structure may be a single bi-canalled root, a common trunk with apical separation of
two root apices, or two separate roots for their full length. Average length of the first premolar is
20.6 mm. The premolar has significant coronal mass but a relatively small cervical diameter so;
care must be taken in making the access preparation. Along with mandibular incisors, the
maxillary first premolar is the most likely tooth to be perforated during access.
The access preparation is oval in shape with the largest dimension in the buccal-lingual
direction. Buccal and lingual extensions are 2/3 the distance up the cusp tips. Mesial-distal
extension need be no greater than the width of the #4 round bur.


Maxillary Second Premolar

The average length of the maxillary second premolar at 21.5 mm is slightly greater than that of the
first premolar. The incidence of two canals is just the opposite of the first premolar - 24% with
two canals and 75% with one canal. There is a 1% occurrence of three foramina. Two orifices do
not always correspond with two foramina - there may be two orifices with the canals joining to exit
through one foramen. In this instance, the lingual canal is usually straighter and treated as the
primary canal, and the buccal canal is treated as the secondary canal. Lateral canals may occur
but less often than incisors. The crown is wider mesio-distally and narrower bucco-lingually than
the first premolar. Apical accessory canals are common (60%). The apical foramen is often on the
lateral surface of the root (78%). The average distance of the foramen from the apex is 0.62 mm.
Access is oval in shape like the first premolar and with similar extensions.





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Mandibular First Premolar

For a tooth that almost always has a single root, the mandibular first premolar has a great
variety in canal anatomy. The anatomy can be as simple as a single orifice and single foramen or
as complex as a single cervical orifice dividing in the mid-root into three canals terminating in
three orifices. Single-canal first premolars may have an apical arborization that divides into
multiple apical foramina. The single canal form occurs 70% of the time and two canals combining
to exit in one foramen 4% totaling 74% of first premolars with a single foramen.
The most common deviation from the single canal form is a single orifice dividing mid-root into
two canals with two foramina. This condition must be anticipated since it accounts for 24% of
mandibular first premolars. The radiographic appearance of a canal disappearing mid-root is
indicative of a bifurcation of the canal. Delicate probing into the canal with a small file can also
reveal much of the internal anatomy and can confirm the presence or absence of a canal
bifurcation.
Average length of the first premolar is 21.6 mm. The foramen very often deviates from the
apex (85%-90%) - 1/3 of deviations are toward the distal.
Access in the mandibular first premolar, like all other premolars, is oval to encompass the oval
shape of the pulp and to aid the search for divisions in the canal, extension to the buccal and
lingual is 2/3 the distance to the cusp tips.

Mandibular Second Premolar

In contrast to all the potential complexities of the mandibular first premolar, the second
premolar is relatively simple. Up to 95% of second premolars have a single foramen at the apex. It
must be kept in mind; however, the remaining percentage of teeth may have any of the anatomic
forms seen in mandibular first premolars. The average length of the second premolar is 22.3 mm.
Access is oval in shape, with dimensions and extensions similar to the first premolar. Frequently
there are deviations of the foramen from the root apex, most often to distal.
An important consideration with both mandibular premolars is their proximity to the mental
nerve. Inflammation from these teeth can affect the mental nerve resulting in some degree of
paresthesia of the lip. Occasionally, even permanent paresthesia may result if gross over--
instrumentation or over-filling occurs. Also, inter-appointment and post-treatment sensitivity
associated with endodontic treatment in these teeth can be greater than other teeth because of their
proximity to the nerve.




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MAXILLARY FIRST PREMOLAR





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MAXILLARY SECOND PREMOLAR






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MANDIBULAR FIRST PREMOLAR





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MANDIBULAR SECOND PREMOLAR






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PREMOLAR ACCESS

1. Measure, on a bitewing radiograph, the distance from
the occlusal surface to the roof of the chamber and to the
floor of the chamber. Subtract 1mm to allow for occlusal
reduction. This gives you an estimate of where you
should first encounter the pulp chamber and at what level
you should find the orifices of the canals. If you do not
find the pulp chamber where you expect it, take a
radiograph and get help.

2. Using a #557 F.G. bur, reduce the occlusion 1mm, and
then make an outline of the access preparation 2mm into
tooth structure. The preparation is centered mesio-distally
and is no wider than the diameter of the bur. Buccal-lingual
extension is 2/3 the way up the buccal and lingual cusps.

3. In the center of the outline, make initial penetration into the pulp
chamber - it should be encountered within 4-6 mm from the
occlusal surface. In order to avoid furcal perforation in a multi-
rooted premolar, do not exceed 8 mm in penetration. Take
radiographs if pulp chamber is not found. Evaluate location of
access and pulp chamber and adjust appropriately.

4. Locate the opening into the chamber with the endodontic
explorer.

5. With light horizontal and outward (occlusal) motions, unroof
the rest of the chamber extending buccally and lingually.

6. Smooth the walls with the Endo-Z bur and create the occlusal
reference point(s).

7. Locate the canal orifice(s) with the DG16 endodontic explorer.




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CLEANING AND SHAPING THE MAXILLARY PREMOLAR WITH ROTARY
INSTRUMENTATION

1. Take initial diagnostic radiographs, periapical (and bite-wing in the clinic).
--RADIOGRAPH--
2. Observe root and pulpal anatomy, measure and record radiographic length. Measure and
record, (using a bite-wing radiograph in the clinic), the distance from the occlusal surface to the
roof and to the floor of the pulp chamber. Subtract 1mm from pulp chamber measurements (to
correct for future occlusal reduction, unless the tooth has a to be maintained cast restoration).
--RECORD--3 MEASUREMENTS--CHECKPOINT--
3. Using a #557, #2 or #4 F.G. round bur, reduce occlusion 1mm, create occlusal reference points.
--CHECK POINT--
4. Draw the outline of the access on the tooth with a sharp #2 pencil
--CHECKPOINT
5. Make an access outline 2mm into tooth structure with a fissure or round bur.
--CHECK POINT--
6. Complete access as described in Premolar Access and RINSE with water. Do not remove
tooth structure from the walls or floor of the pulp chamber unless specifically instructed to
do so by an instructor. If you do not find the pulp chamber where you expect, take
radiographs and get help.
Locate the canal orifice(s) with the DG16-17 endodontic explorer. Ensure the roof is off the pulp
chamber. Remember straight-line access.
--CHECK POINT--
7. Determine TL for all canals TL=RL-1mm
--RECORDCHECKPOINT--.
8. With RC-Prep or EDTA as a lubricant, negotiate, using the balanced forces or opposite force, a
#15 file into each canal to TL. The #15 file is the minimal file size to use while making a length
determination radiograph. [If TL is not reached easily with the #15 file, then try #10 (or even a #8
file) until it reaches TL and then work up to the larger size. If the #15 file is loose at the TL,
increase the file size until a file is selected that binds slightly at TL.] With a file in each canal at
TL, take 2 trial radiographs to confirm that the file is within a canal and to make changes to the
TL. Do not be fooled into interpreting this radiograph as showing one root in front of the other.
Radiographs are purely two-dimensional and any sense of three-dimensionality is false. To
determine which root outline on the radiograph is buccal and which is lingual, multiple-angled
radiographs may be taken and the SLOB rule applied, or different sizes or types of files may be
placed into each canal so they can be distinguished on the radiograph.
--RADIOGRAPH--RECORD--CHECKPOINT--
9. Determine the amount of length adjustment of each file for a correct WL for each canal. (If it
is correct at the trial length, then TL =WL. Record the amount of the change and the correct WL
for each canal. Working length is the location at which we wish to create an apical stop, 0.5-
1mm from the radiographic apex or from the greater foramen. Do not reposition the files
until after initial coronal flare
--RECORD--CHECKPOINT--
10. Canals should be instrumented separately.
11. Place #10 file to full length (TWL+1mm) rotate turn clockwise and withdraw to remove
debris and maintain patency (patency file).


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NOTES: IN THE CLINIC INSTRUMENTATION IS DONE WITH EDTA IN THE
TOOTH AND A SODIUM HYPOCHLORITE SOAK IS DONE DURING NON-
INSTRUMENTATION PERIODS SUCH AS TAKING RADIOGRAPHS. NaOCl IS NOT
USED IN THE LAB.
AS FILE SIZE INCREASES, ITS STIFFNESS INCREASES MAKING A LARGE FILE
LESS ABLE TO INSTRUMENT AROUND A CURVE.
12. INITIAL CORONAL FLARE: Initial coronal flare should go no deeper into the tooth
than 1/2 of the WL. Set the silicone stoppers at 1/2 the WL on a set of rotary files (either the 4
K3 or the 4 Profiles). Use the rotary files from largest to smallest in a CROWN DOWN manner
in the following order:
a. 30-.06, b. 30-.04, c. 25-.06, d. 25-.04, e. 30-.06 Place the file in the electric contra
angle with a speed setting of 275. Rotating at slow speed, slowly and carefully insert the 30-.06
file into the lubricated canal. Maintain a tight grip on the tooth block. Note that only light
pressure is to be used. Pressure that would break a sharp #2 pencil point is too much.
Use these instruments with a light touch, do not force them and allow the file to do the
work.
Do one or two passes with each file in order or until mid root (silicone stopper) is reached with
the 30-.06 rotary file. Ledging and the perforation occur when the files are used for an extended
period at the same length.
13. If midroot has not been reached REPEAT STEPS #11 & #12 (at this point take what you get).
14. Place a #15 file at TWL and in each canal take two radiographs (if this file does not fit tightly
increase in file size until one does).
--Radiograph-Record-Check Point-(Trial working length)-
15. Determine the amount of length adjustment of the file for a correct WL. Working length is
the location at which we wish to create an apical stop. Record the amount of the change and the
correct WL. Take a radiograph to confirm the correct working length. Make additional
adjustments until the file tip is at the proper position within the canal as confirmed by a
radiograph. The apical stop should be 0.5mm-1.0mm from the radiographic apex or from the
greater foramen.
16. Determine and record the size of the first file to bind (fit tightly) at working length.
--Radiograph-Record-Check Point (Working length)
17. Place a #10 file to WL +1mm, rotate turn clockwise and withdraw to remove debris and
maintain patency. This is a patency file. Get help if you cannot accomplish this step.
18. Instrument to a size #20 at working length if the canal is not already to at least that size. Use
the patency file as in step #17.
19. DEEP SHAPE (CONVENIENCE FORM): Set a silicone stopper on the set of K3 or the
set of PROFILE rotary files at a length 2mm less than WL.
This is ROTARY WORKING LENGTH (RWL). RWL=WL-2mm
Use the rotary files from largest to smallest in a CROWN DOWN manner in the following order:
a. 30-.06, b. 30-.04, c. 25-.06, d. 25-.04, e. 30-.06
Use these instruments with a light touch, do not force them. Allow the file to do the work.
If the rotary file is not long enough to reach RWL take what you can get (gently) and
proceed.
Do one or two passes with each file. Ledging and the perforation occur when the files are used
for an extended period at the same length. Use the patency file as in step #17. You do not
necessarily need to reach RWL at this point. Take what you get and proceed to step 20.


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20. If more than 2mm from the working length use balanced forces or opposite force filing, with
nickel titanium hand files, to increase the canal 1 file size at working length.
21. Repeat steps #19 & #20 until the 30.06 rotary nickel-titanium file reaches RWL.
22. Determine the size file that will be the probable master apical file (MAF); this is usually; at
least, 3 file sizes larger than the first file to bind at WL. For example, if the first file to bind is
#20, MAF will be at least #35. If the first tile to bind is #40 (possible in young maxillary anterior
teeth), the MAF is at least #55. In the clinic the minimal MAF is #30 for very narrow or curved
roots and #40 for straight roots, most MAFs fall into the range of #30-#80. IN THE
LABORATORY WE WILL USE A MINIMUM MAF OF #40 we will then create the
apical flare by stepping back to size #60. Use nickel-titanium hand files #s 25-60 whenever
possible for apical enlargement.

23. Use #4 Gates Glidden Drill (4 GG) 2-3mm into the orifice (past the CEJ) or 7-9mm short of
working length (this depends on MAF). Irrigate and use patency file.
24. Use #3 GG 4-5mm into the canal (orifice, past the CEJ), 5-7mm short of the working length but
not around a curve. Irrigate and use patency file.
25. Use #2 GG 6-7mm into the canal (orifice, past the CEJ), 3-5mm short of the working length.
Irrigate and use patency file.
26. Hand instrument using balanced forces or opposite force technique to the appropriate
apical size. The MAF should be at least size 30 on curved canals and size 40 on straight canals.
APICAL FLARE: Apical flare is created by step back. This involves using increasingly larger
files at lengths short of the working length.
27. Use a file 1 size larger the MAF to instrument to 1/2mm less than WL, then the next larger
file is instrumented to 1mm less than WL and so on, stepping back in mm intervals with larger
files, until step back is completed-usually at least 3 sizes and to at least a size 60, though may be
more. Remember to use only Balanced Forces or Opposite Force instrumentation.
28. Once the apical preparation has been completed, place the MAF into the canal at WL and
take a radiograph.
--Radiograph--Record--Check Point--
NOTE: INSTRUMENTATION IS NEVER DONE IN A DRY CANAL.
ALWAYS INSTRUMENT IN A WET, LUBRICATED CANAL.
In lab, we use water or EDTA; in clinic, we use EDTA, sodium hypochlorite and/or.
29. Dry the canal with paper points, place Ca(OH)2 with a spiral filler (place a stopper on the
spiral filler 2mm short of working length) , place cotton pellet and Cavit or IRM. This step is
done, in the clinic, at every appointment when endodontic treatment is not completed. (Be
careful to check that your handpiece is turning clockwise.) This is done here in the lab to
learn the skill.
--Radiograph--Check Point--
30. Remove the temporary filling with a bur, remove the cotton pellet and irrigate canal with
water.
31. Irrigate with EDTA into the pulp chamber and use a patency file as in Step #11.
32. Place a #35 file into the canal and gently watch-wind to WL. Rotate the file turn
clockwise and withdraw to remove debris. (APICAL CLEARING with file 1 size smaller than
MAF.)
33. Place a #40 file (MAF) into the canal and gently watch-wind to WL. Rotate the file turn
clockwise and withdraw to remove debris. (APICAL CLEARING with MAF.)


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34. Irrigate with 2cc of water.
35. Place the MAF into the canal at WL and take a radiograph. Verify that the MAF is in the
correct position in the root.
--Radiograph--Record--Checkpoint--
36. TO CHECK FOR ADEQUATE FLARE, PLACE A GUTTA-PERCHA POINT THE
SAME SIZE AS THE MAF INTO THE CANAL THEN GENTLY INSERT A SPREADER
ALONG SIDE, THE SPREADER SHOULD GO TO WITHIN 5MM OF THE APICAL
STOP. THIS WILL INSURE ADEQUATE FLARE FOR FILLING. BY PLACING
APICAL PRESSURE ON THE GUTTA-PERCHA POINT WE ALSO ARE CHECKING
FOR ADEQUACY OF THE APICAL STOP.
37. Dry the canal with paper points, first using coarse then medium or fine.
There are three more radiographs to be taken to complete the mounted set of radiographs, but
they will be taken at the time of obturation.

Review Required Recorded Data
Review Required Radiographs



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MANDIBULAR MOLAR ANATOMY, ACCESS AND INSTRUMENTATION

OUTCOMES
1. Be able to discuss the internal anatomy of mandibular molars.

2. Be able to discuss the importance of Occlusal Adjustment.

3. Be able to describe and demonstrate proper access preparation for mandibular molars.

4. Be able to describe the various canal configurations in mesial and distal canals.

5. Be able to discuss apical anatomy of mandibular molars.

6. Be able to discuss and demonstrate a complete and systematic sequence for
instrumentation and obturation of mandibular molars.




ANATOMY OF MANDIBULAR MOLARS

Mandibular First Molar
The mandibular first molar is usually a two-rooted tooth with three canals. The average
configuration is two canals in the bilobed mesial root and one broad oval-shaped canal in the distal
root. One third of first molars, though, have two distal canals, sometimes with the second canal in
a separate second root. Occasionally there may be three canals in the mesial root or the mesial
may be divided into two separate roots.
It is not unusual for the canal in the distal root to have a sharp distal curve in the apical 2-3 mm.
This is evidenced on the radiograph by a

fish hook or bulb-like appearance of the end of the root.

Much like the mandibular first premolar, the canal in the distal root may begin as a single broad
orifice then divide mid-root into two separate canals. The broader the orifice in the buccal-lingual
direction, the more likely this happens. With a 33% incidence of two canals in the distal root, the
second canal must always be searched for during endodontic treatment. It is generally best to
instrument the distal canal as if it was 2 separate canals, DB & DL.
It is quite common that the two mesial canals join in the apical 1/3 of the root to form a
single foramen exiting the tooth. These mesial canals sharing a common root also often have
anastomoses throughout their length, which may be seen filled with sealer when a radiograph is
exposed at an angle. The mesial canal usually has more curvature than the distal. Average tooth
length is 21 mm.
Access is triangular. However, the distal orifice must be completely exposed, and if it is broad
buccal-lingually, the access is made more like a trapezoid.







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Mandibular Second Molar
All the same characteristics and variants of the first molar can occur in the second molar but
usually to a lesser degree. The second molar anatomy may be so simple as to have a single high-
volume canal. A unique anatomic variant that most often occurs in the mandibular second molar is
the C-shaped canal. This occurs by a fusion of the mesio-buccal root lobe with the distal root.
The canal orifice is a continuous C-shaped swath starting at the mesio-lingual, sweeping to the
mesio-buccal, then curving distally to the distal root. The most common canal anatomy found
beyond the orifice is a separate mesio-lingual canal and orifice, and a curtain-like connection
between mesio-buccal and distal exiting the tooth as a single foramen in the location of a normal
distal foramen. Rarely, the curtain-like anatomy extends to the mesio-lingual and the foramen
reflects the same form a very difficult situation to treat endodontically.
Average tooth length is 19.8 mm. Access is triangular in shape. The mandibular second
molar is the most frequent tooth to suffer a mesial-distal fracture.


Mandibular Third Molar
The mandibular third molar is unpredictable in its morphology. It may appear much like a
straightforward second molar or it may have severely curved or malformed roots. When assessing
a mandibular third molar for endodontic treatment, the primary consideration is not the ease of
treatment - almost any tooth can be treated endodontically with enough effort - but the ability of
the tooth to withstand occlusal loads. The tooth is usually quite short (average tooth length 18.5
mm). Often the crown is tipped mesially, because first and/or second molars are missing (the best
reason to consider doing endodontic treatment on a third molar).
Access is triangular in shape as in other molars.




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MANDIBULAR FIRST MOLAR









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MANDIBULAR SECOND MOLAR



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C SHAPED CANAL





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MOLAR ACCESS

1. Measure, on a bitewing radiograph, the distance on the
radiograph from the occlusal surface to the roof of the pulp
chamber (average 4-6 mm) and to the floor of the chamber
(average 8-10 mm). Subtract 1mm to allow for change caused by
occlusal reduction. If you do not find the pulp chamber where you
expect, take a radiograph and get help. Do not continue to remove
dentin unless you are orientated and know what direction
you need to go. Unneeded removal of tooth structure will
weaken the tooth, increase the possibility of fracture and
may leave it unrestorable.




2. Using a #557 F.G. bur, reduce the occlusion 1mm then
make an outline of the access preparation 2 mm into tooth
structure. The outline is triangular for both mandibular and maxillary molars.


Mandibular molars:

a) The base of the triangle is on the mesial side of the
occlusal surface of the tooth paralleling the mesial marginal
ridge. It extends 2/3 of the way up the cusp tips.

b) The apex of the triangle is just distal to the central pit.

c) The apex angle may need to be expanded into a straight
side forming a trapezium if the distal canal is broad bucco-
lingually or there are two distal canals.

3. Holding the handpiece at a slight angle so the bur parallels the mesial surface of the
crown; make initial penetration into the pulp chamber, staying within the above limits.
4-6mm


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67

4. Locate the opening into the chamber
with the DG16 endodontic explorer.

5. With outward sweeping motions,
unroof the rest of the chamber.

6. Smooth the walls of the preparation
with the Endo-Z bur and create the
occlusal reference point(s).

7. Locate the canal orifices with the
DG16 endodontic explorer.

















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CLEANING AND SHAPING THE MANDIBULAR MOLAR (see pages 41 & 58)
The completed preparation should generally duplicate or follow the outline on
the tooth, but should not be greater than one third (1/3) the width of the tooth.

Review Required Recorded Data/Review Required Radiographs

MAXILLARY MOLAR ANATOMY, ACCESS, AND INSTRUMENTATION

Outcomes

1. Be able to discuss the internal anatomy of maxillary molars.
2. Be able to discuss the importance of Occlusal Adjustment.
3. Be able to describe the various canal configurations in mesio-buccal, disto-buccal and
lingual roots.
4. Be able to describe and demonstrate proper access preparation for maxillary molars.
5. Be able to completely instrument a maxillary molar, avoiding procedural errors.
6. Be able to keep thorough and accurate treatment records.




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ANATOMY OF MAXILLARY MOLARS

Maxi1lary First Molar
The maxillary first molar has the most complex root canal anatomy of all teeth in the mouth.
The three principle roots of the tooth have markedly different anatomic features. The mesio-buccal
root is the most complex of the three roots and if it stood alone as a single root it would be one of
the most varied roots in the mouth. The mesio-buccal root almost always has some apical
curvature, sometimes as great as 90 or more. The most enigmatic feature of the mesio-buccal root
is the occurrence of a second canal (and sometimes a separate second root). The principle mesio-
buccal canal is often referred to as the MB1. The MB1 orifice is relatively easy to locate after
access is made, it being located at one of the angles of the base of the triangle formed by the three
major orifices. The mesial lingual or MB
2
orifice is significantly smaller than the MB
1
and is
located lingual to it. The MB
2
may be found to be on the line connecting the MB
1
with the lingual
orifice or mesial to that line. An overhang of dentin frequently obscures the orifice necessitating
removal of the overhang before the orifice can be identified. The incidence of a MB
2
canal has
been reported to be from 75-95% by various investigators. Whatever the true percentage of
maxillary first molars with two separate foramina in the mesio-buccal root, the percentage with
two separate orifices, MB
1
and MB
2
, is greater. So, the MB
2
must always be assumed to be
present, sought out, and treated unless found not to exist.
The disto-buccal root of the maxillary first molar is a relief after dealing with the mesio-buccal
root. It usually has a single canal. The disto-buccal and mesio-buccal roots are about the same
length with the mesio-buccal sometimes being slightly longer.
The lingual root is also fairly straightforward. The primary anatomic variation of the lingual
root is a curve toward the buccal in the apical 1/3 of the root. This curve is very common but is
not detectable radiographically unless the curve is extreme. Then the apex may have a knob-like or
bulls-eye appearance on the radiograph. Occasionally, the curve may project more to the distal
than to the buccal, which will be visible on the radiograph.
The second anatomic variation of the lingual root, although rare, is the presence of a second
canal. Variations of the maxillary first molar may go so far as to present four separate roots with
evenly spaced orifices forming the corners of a square or even five roots, each with a separate
canal. The lingual root is usually 1.5-2 mm longer than the buccal roots and average length for the
tooth is 20.8 mm.
Access for the maxillary molar as for all molars is triangular. For maxillary molars, the base of
the triangle is toward the buccal and a nearly right angle is formed between the base and the line
connecting to the lingual orifice. The preparation is positioned mesial to the transverse ridge.
Variations from the three-sided form may be made when searching for the MB
2
by adding a fourth
short side, if necessary, forming a trapezoid.



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70

Maxillary Second Molar
The most striking differences in morphology of the maxillary second molar compared to the
first molar are the closer grouping of the relatively straighter roots, and slightly shorter length
(average 20 mm). All of the anatomic variants of the first molar can occur in the second molar but
generally to a lesser degree. The location of orifices of mesio-buccal and disto-buccal canals can
be quite different from the first molar with the disto-buccal positioned more toward the lingual
than the mesio-buccal orifice. The more the occlusal surface of the tooth is shaped like a triangle,
the more likely the disto-buccal orifice will be located toward the lingual. When in this location,
the orifice may be mistaken for a perforation through the floor of the chamber into the furcation.
Access form is triangular like the first molar, but the triangle may be flatter if the disto-buccal
orifice is located toward the lingual.

Maxillary Third Molar
Root canal morphology of the maxillary third molar is highly unpredictable. It may be much
like a shorter version of the second molar, it may have two canals, or it even may have just one
conical root with a high volume canal. Radiographic review of the anatomy should be made
before commencing endodontic treatment. The average length is 17 mm.
Access is similar to the other two molars. If a single canal is present, the access may take on a
more oval shape.



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71

MAXILLARY FIRST MOLAR



72
72



MAXILLARY SECOND MOLAR

4 canals, 75-95%
2 canals 75-95%
3 canals. 5-25%


73
73

ACCESS MAXILLARY MOLARS


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MOLAR ACCESS

1. Measure, on a bitewing radiograph, the distance on
the radiograph from the occlusal surface to the roof of the
pulp chamber (average 4-6 mm) and to the floor of the
chamber (average 8-10 mm). Subtract 1mm to allow for
occlusal reduction. If you do not find the pulp chamber where you expect, take a
radiograph and get help. Do not continue to remove
dentin unless you are orientated and know what
direction you need to go. Unneeded removal of tooth
structure will weaken the tooth, increase the possibility
of fracture and may leave it unrestorable.




2. Using a #557 F.G. bur reduce the occlusion by
1mm and make an outline of the access preparation 2 mm into tooth structure. The
outline is triangular for both mandibular and maxillary molars.



Maxillary molar:

a) The base of the triangle is on the buccal side of
the occlusal surface of the tooth roughly parallel to the
buccal surface. It extends 2/3 of the way up the
mesio-buccal cusp tip and distally just past the buccal
groove.


b) The apex of the triangle is 1/2 the way up the
lingual cusp. The triangle formed is not equilateral - it
is almost 90 degrees at the distal angle.
c) A short fourth side might be added to the mesial line of the triangle forming a
trapezium in order to locate the MB
2
orifice.
4-6mm


75
75
3. Holding the handpiece at a slight angle so the bur parallels the mesial surface of the
crown, make initial penetration into the pulp chamber, staying within the above limits. If
you do not find the pulp chamber where you expect, take a radiograph and get help. If
you do not find the pulp chamber where you expect, take a radiograph and get help. Do
not continue to remove dentin unless you are orientated and know what direction you
need to go. Unneeded removal of tooth structure will weaken the tooth, increase the
possibility of fracture and may leave it unrestorable.

4. Locate the opening into the chamber with the DG16 endodontic explorer.

5. With outward sweeping motions, unroof the rest of the chamber.

6. Smooth the walls of the preparation with the Endo-Z bur and create the occlusal
reference point(s).

7. Locate the canal orifices with the DG16 endodontic explorer.






16mm
D
o
D
16
=
D
o
+ 0.32mm
16
D


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76
CLEANING AND SHAPING THE MAXILLARY MOLAR (see pages 41 & 58)
The completed preparation should generally duplicate or follow the outline on
the tooth, but should not be greater than one third (1/3) the width of the tooth.

Review Required Recorded Data
Review Required Radiographs




OBTURATION OF MULTI-ROOTED TEETH
Outcomes
1. Be able to densely obturate all roots on a multi-rooted tooth.
2. Be able to present completed cases with thorough treatment records.

OBTURATION OF MOLARS

1. Select standardized master cones the same size as the MAF for each canal
2. Irrigate the chamber and canal orifices.
3. Check patency of each canal with a #10 file at WL+1mm. Gently do apical clearing with a
file one size smaller than the MAF and then the MAF.
4. Grasp a master cone at WL and try it in its corresponding canal, checking for tug-back. Repeat
for each canal.
5. Adjust the master cones as needed.
--RADIOGRAPH--CHECK POINT--
6. Place the master cones on a paper with a label for each canal i.e. MB, DB, B, L, etc.
7. Dry the canals first using coarse, then medium or fine paper points. If there is a large amount
of liquid in the chamber, dry it first with cotton pellets.
8. As the last step before filling the canals, insert the MAF to WL, turn clockwise turn,
withdraw and clean the file with gauze to clear the apex of dried debris. Repeat until no debris
remains.
This isthe only time a file is used in a dry canal.
9. Place sealer into the canal(s).
10. Place a Master Cone into its canal.


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77
11. Place 1-3 accessory cones.
In a curved canal, insert the D11T spreader between the gutta-percha and the convex side of the
curve to avoid gouging the tip of the spreader into the gutta percha, which may prevent the
spreader from advancing to full length (e.g. in the mesial root of a mandibular molar, which has a
curve toward the distal, the spreader is inserted along the mesial side of the gutta-percha so the tip
of the spreader contacts dentin as it passes around the curve.)

--RADIOGRAPHCHECKPOINT--if apical fill is good (no voids and at the apical stop)
proceed, if not pull out and redo steps #9-#11.
12. Melt off gutta-percha with the Glick.
13. Continue filling the canal using the spreader and accessory cones to the canal orifice.
14. Repeat steps #10-#13 for each canal until all canals are filled.
15. Mandibular Molar: Obturate the distal canal (or canals) first; take a radiograph, sear off the
excess gutta-percha and pack into the orifice(s). Then fill the two mesial canals concurrently. Take
a radiograph, and then sear off and down pack the excess gutta percha.
--RADIOGRAPH--CHECK POINT--
16. Maxillary Molar: Obturate the Palatal (lingual) and DB canals concurrently (or separately if
desired). Take a radiograph, then sear off the excess gutta percha and pack into the orifice(s).
Then obturate the MB
1
and MB
2
canals concurrently. Take a radiograph, then sear off and down
pack the excess gutta percha.
17. Place a temporary restoration.

--RADIOGRAPH--CHECK POINT





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78
PROCEDURAL ACCIDENTS
OUTCOMES:

The student will be able to:

1. List dental and restorative characteristics that may result in perforation during
access preparation.
2. Describe various ways to avoid perforation during access preparation.
3. Discuss the prognosis of a tooth with a perforation made during access
preparation.
4. Explain how blockage can lead to ledge and perforation formation.
5. Discuss the prevention of blockage, ledging, and perforation.
6. Describe the treatment and prognosis of blockage, ledging, and perforation.
7. Explain the cause, prevention, and treatment of file breakage.
8. Tell how a sodium hypochlorite accident can be avoided.
9. Discuss the causes and treatment of underfill and overfill.
10. Describe how vertical root fracture can be avoided.

PROCEDURAL ACCIDENTS

I. Perforation during access preparation

Accidents can occur in endodontic treatment as early as making access - the principle
problem being lateral perforation of the crown or root, or perforation into the furcation.
This problem can best be avoided by thoughtful case selection and referral. In reality,
any case, even an easy case, has potential for perforation if access is not done carefully
and cautiously.

Causes:
Tipped or crowded tooth with abnormal orientation of its long axis.
Beware the tipped posterior tooth that has a restoration recreating a normal occlusal table
but with the long axis of the crown not parallel to the long axis of the roots.
This situation is most often encountered when a mandibular bridge has been placed on a
mesially tipped distal abutment tooth.



Full-coverage restoration obliterating the outline of the
pulp chamber.



Calcified pulp, partially or completely obstructing the
radiographic outline of the chamber.



long axis o
crown
long axis of roots


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79
Prevention of perforation
Case Selection! - let someone else struggle with it.
Remember, the average distance from occlusal surface to roof of chamber is 4-6 mm and
to floor of chamber is 8-10 mm.
Study the radiographs and measure the distance to roof and floor of the chamber on the
particular tooth you are treating.
Measure bur length and stay within the dimensions measured above.

In clinic, never extend a bur past the alveolar crest in search of the chamber or
canals. Get an instructor for help.

Canals are located with an endo explorer not with a bur
High and slow speed burs are used only to carve out the internal anatomy of a tooth to
allow the operator to locate the canals with the explorer
Burs are not probes - they are not used to locate canals
Begin access with the rubber dam off.

This allows visibility of the whole exposed part of the tooth and orientation on the long
axis of the roots as the crown emerges from the alveolus - the long axis of the crown may
not be parallel to the long axis of the roots. The ultimate goal is to gain straight-line
access to the canals within the roots. Visibility of the cervical outline of the tooth helps
keep orientation on the true long axis of the roots.
Or, clamp a more distal tooth, eliminating the rubber dam clamp as an obstacle to seeing
all of the tooth structure.
Recreate the normal shape and volume of the chamber within the crown.

Progress slowly
Periodically take bitewing radiographs (perpendicular to the buccal crown surface i.e. bite-
wing) to observe orientation.

Prognosis
Lateral perforation coronal to the attachment level can be included within the preparation
of the restoration.
Lateral perforation at or just apical to the attachment level, and furcal perforation do not
have a good prognosis.
Periodontal defect will usually form Better prognosis if treated promptly
If a perforation occurs, inform the patient and make proper, prompt referral for treatment
(may necessitate hemisection or extraction)




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80
II. Accidents during cleaning and shaping

Even when all of the above precautions are taken, perforation may still occur during
access preparation, especially in the case of severe calcification. Unfortunately, if access
is successfully completed, the potential for intra-operative problems does not cease.
Several types of accidents can occur during cleaning and shaping. The difference here,
though, is that all accidents that may occur during instrumentation are avoidable.
Blockage
By far the most common problem seen during instrumentation is blockage. This is often
noticed at the time of fitting the master cone when it will not extend to working length.
Debris has accumulated at the apical end of the preparation preventing complete seating
of the master cone.

Prevention
This can be avoided by frequent irrigation and use of a patency file.

Treatment
Irrigate the canal, carefully work a small file (#10-20) to working length, then follow with
subsequent files to remove debris and regain the MAF at WL. Keep the canal flooded
with irrigant.
Use RC Prep or other chelating agent as irrigant and proceed as described above.

Ledge formation
Ledge formation is a frequent sequel to canal blockage in a curved canal. The apical
canal becomes blocked with debris because of inadequate use of irrigation and patency
file. Subsequent files, then, are prevented from following the path of the canal and are
diverted off-axis forming a ledge. If large files are forced, this misadventure continues,
and creation of a new canal and perforation of the root can occur. Ledge formation is
most likely to happen in narrow, curved, and long roots.
Ledge formation can also occur by overfiling with a given file. All files have elastic
memory - if confined in a curved space, they want to straighten out. If a file is used
repeatedly at a certain length in a curved canal, it will try to straighten out, and the tip of
the file will begin to cut preferentially on the outside of the curve, thus creating a ledge.
Excessive use of chelating agents (RC Prep, EDTA) can result in ledge formation or
perforation in curved canals. Chelating agents are not selective in the type of dentin they
affect - all dentin is softened by chelating agents.
If a ledge is created, it might be possible to bypass and eliminate the ledge by precurving
stainless steel files and re-entering the original canal path. If this is not possible, the
canal is filled to the point of the ledge, and the case observed for development of
pathology. A tooth that had a vital pulp at the start of treatment, and a tooth with a
necrotic pulp that had already been well debrided before the ledge was formed have the
best prognosis if the ledge cannot be passed.
Blockage or aggressive use of files (especially in an exaggerated filing motion) in the
apical 1/3 of a canal with an apical curve can result in a tearing perforation of the
foramen often referred to as an apical strip or apical zip. The outcome of this mishap is
a foramen that has been changed from essentially round to a long slot extending from the
original position of the foramen coronally along the outer surface of the curve.


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Cause
Blockage
Forcing files to length
Over-use of a given file at a given length
Misuse of chelating agent
Prevention
Repeated recapitulation through the series of files from small to large creating a tapered
shape that is carried to the apex rather than forcing files to their assumed final lengths
helps prevent ledge formation.
Do not use a particular file for a long time at a specific length. Keep moving through the
sequence of files repeatedly. Each file should be used for only 20-30 seconds before
proceeding to the next-size file.
Do not use chelating agents (RC Prep, REDTA) with a file larger than #25.
Perform apical preparation with just watch-winding and minimal filing motion.

Perforation
There are other situations in which perforation can occur during instrumentation besides
that described above. In two cases, the perforation penetrates to the furcation.
Perforation can occur while using the Gates-Glidden drills during coronal flaring. Gates-
Glidden drills are not intended to be used as flexible instruments and pass around a
curve. They are meant to be used only in the straight, coronal portion of the canal. The
diameter of the canal preparation should never be larger than 1/3 the diameter of the root.
The largest Gates-Glidden drill we routinely use is a #4, which is 1-1.1 mm in diameter.
This must be kept in mind when performing the coronal flare. If a root is observed on a
radiograph to be unusually narrow, the depth of each Gates-Glidden drill must be
adjusted accordingly.
The second situation when perforation may occur on the furcal side of the root is during
preparation of the middle 1/3 of a severely curved canal. Over-aggressive filing motion
in a sharply curved canal will preferentially remove material from the inside of the curve in
the mid-root area similar to the preferential removal on the outside of the curve in the
apical 1/3 due to the tendency of a file to straighten out. This is referred to as a strip
perforation and is very difficult to adequately obturate due to its linear nature.
Poor determination of working length and lack of length control with overextended
instrumentation will result in an apical perforation. Irritation to periapical tissue and
difficulty in controlling gutta percha during obturation due to the lack of an apical stop
create problems similar to those associated with a perforation in any other part of the root.
Whereas an apical zip occurs in a root with an apical curve, an apical perforation can
occur with a curved or a straight canal.
Prevention
Study the dimensions, curvature, and emergence of roots from the crown on radiograph
and foresee possible problems due to curvature.
Remember, canals curve buccal-lingually as often as mesial-distally this curvature is not
visible radiographically.
Establish proper working length, use repeatable, stable reference points and control the
depth of penetration of instruments.
If significant resistance is felt with any instrument, do not force it. Adjust depth of
instruments accordingly.


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Treatment
Furcal perforations of any cause have a poor prognosis but prompt referral for treatment
before periodontal breakdown occurs may improve the prognosis.
Strip perforations are hard to obturate because there is no resistance form for the gutta-
percha.
If on the furcal side, mid-root, the prognosis may not be good because surgical access for
repair is very difficult.
Apical zips may have a less than good prognosis following orthograde treatment but are
more easily accessed surgically than mid-root strips.
An apical perforation is treated by shortening working length, creating an apical
stop with a newly determined, larger MAF and obturating to the new length.
Even these cases may have some long-term chronic inflammation.
The sooner a perforation is treated, the better.

The prognosis for a perforation changes, according to location - best prognosis for a
perforation in the apical 1/3, and worst prognosis for a perforation in the coronal 1/3.
Gates-Glidden drills are never extended into a curve.



File breakage
Though file breakage can happen due to manufacturing flaws, it usually is due to overuse
or misuse of files. Failures to notice signs of excessive wear (kinking, tightening or
unwinding of flutes or other deformation-sometimes these show up as a shiny spot in the
flute area) and continued use of an overused file will likely result in its breakage. Inspect
each file for cleanliness and defects before you place it in a canal and after you
remove it. When in doubt, throw it out. Regular disposal of files will greatly reduce the
incidence of file breakage. At MUSC, we discard files #10-25 (stainless steel) after each
case if these files were involved in the instrumentation performed on that day. Files sized
#30-50 (nickel-titanium) are discarded after 5 cases. Those files numbered 55-80 are
discarded when they show wear or seem to cut inefficiently.
The most common cause of file breakage is using it too aggressively. The confusing
thing about file breakage is having it occur when the file is being used relatively gently or
even during recapitulation after larger files have already been used. This happens all too
often, and the breakage is wrongly attributed to a manufacturing flaw. In reality, the file
had already been overstressed, probably showing some signs of deformation, and the
reinsertion into the canal was done in a manner that was sufficient to separate a segment
of the file. The one fortunate aspect of breakage with this nonaggressive use is that the
file segment is not tightly bound in the canal and might be removed or, more likely,
bypassed and full treatment of the canal completed.
Lubricant (i.e., irrigation solution) makes the files cut more efficiently without gouging and
binding, and should always be used during instrumentation.

Prevention
Always instrument a wet canal.
Never instrument a dry canal.


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83
Apply apical pressure on a given file no greater than the pressure you can apply with your
fingertip directly to the point of the file without causing pain.
Do not force files to predetermined lengths.
Recapitulate multiple times, if necessary, to progress a file to its expected, eventual
length.
If a file becomes bound in a canal, gently manipulate it in a watch-winding motion of small
amplitude and with light withdrawal pressure.
Inspect each file for cleanliness and defects before you place it in a canal and after
you remove it. If in doubt, throw it out.
Treatment
Inform the patient. Having an instrument break during treatment is not malpractice but
failure to inform the patient is. Use the phrase separated instrument
Attempt to bypass the fragment using RC-Prep and small (#8, 10, 15) files, then complete
instrumentation. The file segment becomes embedded within the gutta percha when
obturated.
If the fragment cannot be bypassed, complete instrumentation to the fragment, fill to this
length, inform the patient and follow for an extended time.
Or, explain the presence of the separated instrument and refer.




SODIUM HYPOCHLORITE ACCIDENT
It is a matter of fact that material is extruded into periapical tissues during instrumentation.
This debris can include bacteria, infected dentin shavings, and irrigating fluids. All of
these materials are toxic to periapical tissues. It is imperative, then, to minimize the
amount of extruded debris. This is the reason for preparing the apical 1/3 of the canal
less
aggressively than the middle and coronal 1/3s.
Sodium hypochlorite, which we use almost exclusively as our irrigating/disinfecting agent,
is a very strong protein denaturant. It is nonspecific in its action, that is, it attacks normal,
vital tissue as well as it bacteria or necrotic tissue. Sodium hypochlorite that is
expressed
through the foramen under pressure will immediately cause tissue damage resulting in an
acute, ballooning swelling and excruciating pain. The swelling will probably increase over
the next couple days accompanied by extensive ecchymosis. The pain will steadily
decrease after the initial episode although swelling may be increasing. This misadventure
is completely avoidable with proper care and handling of sodium hypochlorite.

Prevention
Never wedge the irrigating syringe needle into the canal. There must be space for fluid to
back-flow out of the canal. Keep the irrigating needle in motion, going in and out of the
canal.
Never express the irrigant rapidly out of the syringe. It is not being injected into the
canal - it is being deposited slowly into the pulp chamber. The files carry the sodium
hypochlorite into the canal.


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84


Treatment
Re-anesthetize
Oral steroid
Antibiotic
Ice pack
Reassure the patient and have daily monitoring of symptoms.
Advise the patient of likely severe increase in swelling and severe ecchymosis.
Unlike other procedural mishaps that have higher potential to occur due to anatomic or
restorative conditions, a sodium hypochlorite accident is totally avoidable.

III. Accidents during obturation

Under-extended fill
One of the most frequent mishaps during endodontic therapy is to underextend the fill of a
canal, i.e., fill it short of working length. The sequence of events is as follows: proper
length has been determined and verified radiographically, instrumentation has been
completed, the canal obturated, but when a radiograph is made, the fill is clearly short of
working length. There are two reasons for a short fill. First, and unfortunately much too
common, is a short fill due to accumulation of dentin filings in the apical portion of the
canal preventing full seating of the master cone. The canal has not been kept irrigated
and debris has not been removed from the apical part of the canal by recapitulation.
The second situation of a short fill occurs after proper fitting of the master cone at correct
working length. It is noted after obturation that length has been lost. In this case, cement
has been placed into the canal, the master cone seated to working length, and the
spreader inserted alongside the master cone. The tip of the spreader, though, either has
become imbedded into the master cone, or dried sealer on the spreader (the spreader
was not properly cleaned after prior use) has adhered to the sealer and master cone
pulling it back when the spreader is removed from the canal. This pullback usually occurs
when placing the first or second accessory cone. After 2-3 accessory cones have been
placed and laterally condensed, the master cone is usually locked in place and will not
pull back.

Prevention
At the end of instrumentation, irrigate and recapitulate through the files, inserting each file
to its length, rotating clockwise 1/2 turn and removing debris. Inspect the spreader before
use and clean sealer off of the spreader after use. Insert the spreader along the side of
the master cone toward the outside of the curve so the tip of the spreader runs along the
dentin wall. Insert the spreader using a watch-winding motion; continuing the watch
winding while the spreader is left in place for 30 seconds and during withdrawal.

Treatment
Irrigate; starting with #10-15 file, pick through debris regaining working length;
recapitulate through the whole series of files in a debris-removal manner. Always take a
radiograph before searing off excess gutta percha to evaluate proper fill - if short (or
long), grasp and remove gutta percha, and refill.


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Over-extended fill
Over-extended filling (filling longer than working length) is attributable to one cause - lack
of length control. Part of the design of root canal preparation is to provide resistance form
to prevent extrusion of filling material into periapical tissues. Lack of an apical stop and
proper taper to the preparation will allow gutta percha to be pushed through the foramen
into periapical tissues.

Prevention
Establish correct length determination.
Check stopper position on files throughout instrumentation to be sure they have not
moved.
Expect effective working length to shorten slightly on a curved canal as the canal is
widened and the curve straightened out
If there is question about length at completion of cleaning and shaping, check with paper
points for the consistent drying length - the length at which paper points come back dry
and at which, if the paper point were inserted further, it would come out with the tip wetted
with blood or tissue fluid (tan or straw colored). This is accomplished by first drying the
bulk of irrigant out of the canal with large paper points. Then, the largest sized paper
point that will fit to length is grasped with the cotton pliers at WL, placed into the canal to
the reference point, withdrawn, and the tip of the paper point examined.

Treatment
If the canal has not yet been filled, determine a shorter working length, and establish an
apical stop with a new, larger master apical file.
Fit a master cone 1/2 mm short of the new working length (when condensed, it will slide
apically to working length)
If the canal has already been obturated, grasp the extensions of gutta percha and pull the
mass out of the canal and then follow the above steps.

Root fracture
Although it is not an everyday occurrence, a vertical root fracture can be created during
obturation by the wedging action of the spreader. This is more likely to occur with a hand
spreader than with a finger spreader because of the greater taper of the hand spreader
and the ability to generate more force. This is the most common cause of vertical root
fracture.

Prevention
Properly shape the canal with
adequate taper.
Do not make the master apical
file larger than necessary.
Slowly advance the spreader apically.
If significant resistance is felt,
do not force the spreader.

Treatment
Extraction



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The endodontic preclinical laboratory-grading sheet must be filled out and signed by an instructor
in a contemporaneous manner. Each step must be checked and graded prior to progressing to the
next step. Note the box at the bottom of the 2
nd
page for measurement recording-FILL THIS OUT
AS YOU GO!










































Suitability of tooth
Removal of caries
and restorations
Provisional
build-up
Occlusal
reduction
RadiographEvaluation
RL, PC, TL
Mounted tooth
Access outline
evaluation --
Access
Evaluation
2mm check --
completed --
Set up Evaluation
PRECLINICAL GRADING SHEET
ONE FOR EACH TOOTH
RL=
RPC=
FPC=
TL=
TL=

WL= TL WL


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Oglesby, 2003
preclinical lab
TOOTH # CANAL SINGLE B L/P M D MB ML/MB2 DB DL


RADIOGRAPHIC LENGTH

TRIAL LENGTH


WORKING LENGTH

ROTARY WORKING LENGTH



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GRADING PROCEEDURES 08 CLASS
ENDODONTIC LABORATORY

DR OGLESBY
DR LEVY
DR SCHECHTER
DR BEMIS
DR WHALEN

Practical Procedures

Each natural practical tooth is to be turned in two weeks prior to the examination. Please turn teeth
in to your T.A. in a baggie.
1. Tooth embedded in plaster/resin with student number.
2. Preoperative radiographs with 2 views: facial-lingual and mesial-distal.
3. Grade sheetLabel with name and student number.
4. Turn in to your endodontic resident teaching assistant.

Practical teeth will be checked and returned the day of the practical. All teeth will be marked
only teeth that are pre-checked will receive a grade.
Three Independent graders will grade all Practical Teeth. An average of the 3 grades will be the
final grade you receive.

Grading:
Please bring the following:
1. Completed tooth, in a baggie, labeled with student #.
2. Mounted radiographs labeled with student #.
3. Grading sheetcompletely filled out with name, student #, and checked by the
Endodontic Resident Teaching Assistant.
Staple these together in the upper right corner, #1 on top and #3 on the bottom.

Grading Scale:
3 Above clinical standard clinical excellence competent
2 At clinical standard clinical acceptability beginner
1 Below clinical standard unacceptable novice

All ones will need to be redone before proceeding to the next exercise.


STUDENTS ARE EXPECTED TO DO THEIR OWN WORK
CHEATING IS NOT ACCEPTABLE BEHAVIOR

INTEGRITY IS PARAMONT IN A PROFESSIONAL



Maliwada Human Development Training School ON INTEGRITY


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We are going to visit the arena of Profound Humanness called "Integrity". Sometimes "integrity is reduced to
mean a kind of moral uprightness and steadfastness, in the sense of saying, "He has too much integrity to
ever take a bribe."

But profound integrity goes far beyond this. Sometimes, in order to distinguish it from more limited popular usage,
it is called "secondary integrity". This is the integrity, which is not constrained by limited moralities, however well
intentioned. The integrity that is profound living is the singularity of thrust of a life committed and ordering every dimension
of the self towards that commitment. Thus the self is in fact shaped by the self, and focused towards
that commitment. You can say that an audacious creation of the self takes place in integrity, without which you
are simply the creation of the various forces impacting you in your society.

Thus the basis of integrity is a destinal resolve - a resolve that chooses and sets your destiny and out of which your whole life
is ordered. The object of that resolve is the ultimate decision of each person, and each person makes that choice, consciously or
unconsciously. To do so with awareness is the height of man's responsibility. It is incarnate freedom. It is what real freedom
looks like. When man has thus exercised his freedom he realizes that to be true to himself ever thereafter he has a unique
position to look at the values of his society. He is no longer bound by the opinions and codes of his fellow man, but
reevaluates then on the basis of their impact on his destinal resolve.

Thus the man of integrity is continuously engaged in a societal trans-valuation, a moving across the values of society and
reinterpreting them in line with his life's thrust. It does not give him the liberty of ignoring his society,
but his obligation transcends the conformity of living within the codes and mores of his society. Thus the man of profound
integrity always seems to not quite fit with his fellow men, but his actions always are appropriate for
him, even to those who oppose him.

No matter how odd the man of profound integrity appears to his neighbors, he experiences himself as securely anchored. While
he is very clear that this world is not his home, nevertheless he experiences himself as having found his native vale. He
experiences an eternal at-one-ness, not so much with the currents and waves of activity around him, but with the deeper trends
of history itself. Amid the flux of wavering to and fro that is so evident in others, he experiences an inexplicable rootedness, as
though he has sunk a taproot deep into the foundations of the earth itself. Though he experiences his life as a long journey,
even an endless journey, towards the object
of his resolve, yet he never senses himself as a stranger on the journey. Its as if hed been there before.
Original integrity is experienced primarily by this sense of at-one-ness.

Kierkegaard once wrote a book about this kind of integrity that he titled, "Purity of Heart is to Will One Thing".
An ancient philosopher focused his wisdom around this integrity with the advice, "Know yourself, and to your
own self, be true."





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Minimum (Not
Maximum) vocabulary
and phrases for
Endodontics

Anatomic

Roof of the pulp chamber
Pulp horn
Pulp chamber
Floor of the pulp chamber
Canal
GRADING CRITERIA: PRECLINICAL ENDODONTIC LABORATORY
3 Outstanding performance demonstrated excellence clinical excellence
- Paperwork completed and concise
- Extracted teeth mounted cleanly and placed esthetically
- Pre-operative radiographs are clean, well fixed and dried
- Access cavity well oriented and refined
- Cleaning and shaping: Maintenance of the canal(s) configuration(s),
determination of working length is correct, final size and shape ideal
- Obturation: Canal filled to apical stop, obturation complete, no voids and
good density
- Access cavity properly filled
- Treatment radiographs well presented, radiographic technique excellent
- Excellent work habits, neat work area
- Sterile technique observed
- Demonstrates an understanding of the procedures

2 Acceptable performance adequate, average, clinically acceptable
- Paperwork complete
- Extracted teeth mounted cleanly
- All radiographs clean, well fixed and dried
- Radiographic technique good with minimal repetitions
- Access cavities adequate and need minimal refinement
- Cleaning and shaping: Canals well cleaned and shaped, apical stop in the
correct position and patency maintained, minor changes necessary
- Obturation: Filled to the apical stop, no apical voids, generally good density
- Student exhibited adequate work habits
- Demonstrates adequate understanding of the procedures

1 Poor Will require repeating the exercise clinically unacceptable
- Paperwork incomplete
- Extracted teeth mounted unacceptably
- Radiographs of fair to poor quality (nondiagnostic), technique poor
- Access cavities inadequate, require major modifications, perforated
- Cleaning and shaping: Insufficiently prepared, over prepared, inadequate
maintenance of the apical stop, unacceptable transportation of the canal
- Obturation: Apical third of the canal poorly filled, voids in the apical third, or
gross or multiple voids in the middle and/or coronal thirds, filling beyond the
apical stop or short of the apical stop
- Poor work habits demonstrated, messy work space
- Demonstrates a lack of understanding of the procedures



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Canal orifice
Main canal
Lateral canal
Accessory canal
Apical foreman
Major foreman
Minor foreman ==
apical constriction
Round canal
Elliptical canal
Dumbbell shaped canal
C-shaped canal
Curved canal
Straight canal
Bifurcated canal
Calcified canal

Root Canal Preparation
Vocabulary

Access
Straight-line access
Mechanical
preparation (cleaning)
Chemical preparation
(cleaning)
Crown down
preparation
Balance forces
technique
Stepback-apical flare
Coronal flare
Taper
Deep shape
Apical stop- apical
stop preparation
Irrigants
Sterile saline
EDTA
Sodium Hypochlorite
Anesthetic solution
with sterile needle
Short fill
Long fill
Ledge
Transportation
Perforation
Gouge
Danger area

Measurement vocabulary

Radiographic length
Trial length
Working length
Working width

Obturation vocabulary

Gutta percha
Accessory points
Sealer
Initial condensation
Dense fill
Seal
Coronal
Apical

Build-up
Post
Core
Calcium hydroxide
Lentulo-spiral
Temporary restoration
materials

Radiograph vocabulary

Under exposed
Overexposed
KVP`s in milliamps
Exposure time
Fixer stain
Contrast
Radio-opaque
Radiolucent
Fixed
Developed

SLOB rule
Lamina dura
PDL space

Instruments and supplies



Files
Hand files
Length
Stainless steel
Nickel titanium
Rotary files
K3
Taper
Size
Length

Burs
Sizes, types and
numbers

Drills
Gates gladdens- #`s 1,
2, 3,4 (know maximum
diameter of each size)

Rulers
Straight
Endo ruler

Endo spoon

Pipette
Paper points
Hand spreader D-11T
Endo explorer
Glick #1 ( know what
each end is called and
used for)
Plugger




Electronic Apex Locators (EAL)


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Steps prior to use:
1. Read the instruction manual!!
2. Power: Make sure you have fresh batteries or a fully charged rechargeable battery pack. Do not
wait for your alkaline batteries to get low. Change them monthly or whenever you experience the
EAL "not working normally."
3. Check that an electrical signal is traveling thru the cord by placing the lip-clip and file-clip into
the cord and touching them together. Some EALs automatically turn on when a connection is
made. The screen should read "past the apex".
4. Contacts: The EAL is an electrical device that depends on good electrical contacts. Make sure
the lip-clip is touching the oral mucosa. The EAL will read long if the lip-clip is only touching the
skin. If you are using a bite-block, you can place the lip-clip between the mucosa and the bite-
block. If the mucosa is dry, moisten the interface between the lip-clip and the mucosa with saline
or water.
5. Dry the pulp chamber floor and walls to make sure there is no electrical connection between the
canals or between a canal and a metal restoration; this will give false and erratic readings if not
done. If the tooth has a metal restoration, do not touch the restoration with the file while
attempting to get a length.
Taking a length measurement: Be sure the unit is turned on.
1. Begin with a #1 0 file and proceed into the canal. Advance the file towards the apex
until the EAL reads "past apex". Then back up until the EAL reads "at the apex". Record the
length. Do not believe the EAL when it tells you how far you are from the apex and settle being
.2mm or .1mm short because you think you are close enough and stop trying to go thru. Always
go long and then back up. With a Root ZX skip to step #3.
2. Now take an EAL reading with a #15 file. Go past the apex and back up to the apex.
Record the length. Skip to step #4.
3. With the Root ZX, using a #15 file go past the apex and back up to the half millimeter short
line, use this for the trial length. Skip to step #5.
4. Subtract 1/2mm from length from step #2; this is your trial length.
5. Determine the first file to bind at the working length, place it into the tooth at the trial
length and take a radiograph.
6. False reading are possible, these readings are a guide. Radiographs are still needed to
observe canal anatomy and verify apex locator readings.




Systematic Endodontic Diagnosis
~Published as an insert to the Fall/Winter 1996 edition of ENDODONTICS: Colleagues for Excellence~



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I. Chief Complaint-Record symptoms or problems expressed by the
patient in his or her own words.
It Health History
A. Medical history
I. Take a complete medical history for each new patient. 2.
Update the medical history of each patient of record.
B. Dental history
1. Summarize present and past dental treatment
2. May provide subtle clinical findings or identify source of
patient's complaint
3. Attitudes toward dental health and treahnent may affect
treatment planning.
C. Present signs and symptoms
III. Diagnostic Evaluations
A. Subjective Examination-obtain information by question and
answer regarding history of the present illness and symptoms.
1. Location-In some cases the patient may be able to identify
2. Intensity-The more the pain disrupts the patient's lifestyle,
the more likely it is caused by irreversible pathosis.
3. Duration-Does pain linger after the stimulus is removed?
4. Stimulus-Pulp tests should be chosen based upon what
provokes the patient's chief complaint.
5. Relief-Medications or actions (such as sipping ice water)
taken to relieve pain.
6. Spontaneity-Pain occurring without stimulus.
B. Objective Examination
1. Extraoral Examination
a. Check general appearance, skin tone, and facial
asymmetry.
b. Note any swelling, redness, sinus tracts, tender or enlarged
lymph nodes, or tenderness or discomfort upon palpation
or movement of the TMJ.
2. Soft Tissue-Examine the mucosa and gingiva visually and
digitally for discoloration, inflammation, ulceration,
swelling, and sinus tract formation.
3. Dentition-Examine teeth for discoloration, fracture, abrasion,
erosion, caries, large restorations, discoloration or other
abnormalities.
4. Clinical Tests-Most tests have inherent lirnitations. They
require care on application and interpretation. The
objective is to discover which tooth is different from the
patient's other teeth. Always test healthy control teeth
first.
a. Periodontal Examination-periodontal probing cannot be
overemphasized, since pulpal and periodontal pathosis
sometimes mimic each other and must be differentiated.
b. Periradicular Tests
(1) Percussion-a painful response is an indicator of
periradicular inflammation.
(2) Palpation-same as above
c. Pulp Vitality Tests- These determine response to stimuli
and may identify the offending tooth with an
abnormal\al response. Always include stimuli similar
to those that provoke the patient's chief complaint.
(1) Cold Test
(a) Intense, prolonged pain indicates an irreversible
pulpitis.
(b) Necrotic pulps do not respond.
(c) A false negative response may occur with
constricted canals.
(2) Heat Test-same as for cold test

Electric Pulp Testing
Contrary to popular opinion and persistent notion, different
response levels in electric pulp testing do not indicate
different stages of pulp degeneration. Electric pulp testers
do not measure the degree of health or disease of a pulp. A
"yes or no" response is merely a rough indicator of the
presence or absence of vital nerve tissue in the root canal system.
(3) Electric Pulp Testing
(a) Before testing, clean, dry, and isolate the teeth,
then place a small amount of tooth- paste or other
conductor on the electrode. Be sure to follow
your manufacturer's instructions for establishing
an electrical circuit and to ensure accurate
measurement with your instrument.
(b ) Sensation may be described as tingling, stinging,
or a feeling of heat, "fullness," or pressure.
(4) Test cavity-may be helpful, especially for a tooth
with a porcelain-fused-to-metal crown (PFM),
Sudden, sharp sensation when the bur cuts dentin
indicates that the pulp contains vital tissue.

The following outline provides a quick review of the steps taken in endodontic diagnosis:

Tentative Diagnosis
After taking histories and identifying signs and symptoms,
The practitioner may reach a tentative diagnosis. The
Objective examination will gather the information necessary to
confirm this diagnosis.


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SOAP notes: Purpose of the Problem Oriented Dental Record

C. Radiographic Examination
I. Limitations
a. Pathologic vital pulps are not visible on radiographs.
b. Necrotic pulps may not produce radiographic changes in
early stages.
c. To be visible, the inflammatory process must spread to
cortical bone.
2. Periradicular
a. Periradicular lesions of pulpal origin tend to have thn.'e
characteristics:
(1) Loss of lamina dura apically
(2) Radiolucency remaining at the apex regardless of
cone angle
{3) Radiolucency resembling a "hanging-drop"
b. [f a radiolucency is in the periradicular region of a tooth
with a vital pulp, it cannot be of pulpal origin and will be
either a normal structure or another type of pathosis.
c. Follow up or biopsy may be required with radiolucencies
not of pulpal origin.
3. Pulpal
a. Radiographically visible pulpal pathoses are only rarely
related to irreversible pulpitis.
b. Internal resorption or extensive diffuse calcification in
the chamber may indicate long-term, low-grade
irritation.
c. "Obliteration" of canals (usually with history of trauma)
does not, in itself, indicate need for treatment.

D. Special Tests-if special circumstances prevent making a
definitive diagnosis, additional tests may be indicated.
1. Caries Removal-in an asymptomatic vital case, caries is
removed as a final test. Penetration into the pulp indicates
an irreversible pulpitis requiring root canal treatment.
2, Selective Anesthesia-useful in painful teeth particularly
when the patient cannot isolate the offender to a specific
arch.
3. Transillumination-for identification of vertical crown
fractures, since fractured segments do not transmit the light
similarly. Dark and light shadows appear at the fracture
sire.
IV; Analyze the data you have obtained-Findings may not always
be consistent, and the process of arriving at a final diagnosis
depends heavily on the practitioner's critical evaluation of the
findings.
V: Formulate an appropriate diagnosis and treatment plan-
In addition to diagnosing pathoses and their indicated treatments,
the practitioner must take into account the patient's overall needs,
know the indications and contraindications for root canal therapy
and recognize those conditions that make treatment difficult.
The American Association of Endodontists cannot guarantee success in every case. Practitioners must always use their best
professional judgment in individual situations. The AAE neither expressly nor implicitly warrants any positive results nor
expressly nor implicitly warrants against any negative results associated with the application of this information.
If you would like more information on endodontic diagnostic considerations, call your local endodontist or write to the American
Association of Endodontists, 211 E. Chicago Ave., Ste. 1100, Chicago, IL60611-2691, 312/266-7255, fax 312/266-9867.
References are available upon request.
\Copyright 1996 American Association of Endodontists. 211 East Chicago Avenue, Suite 1100. Chicago. JL 60611-2691. The Association
grants a limited license to members of the Association to copy Systemic Endodontic Diagnosis for their own person use, for educational
purposes with patients and among dental/medical professionals,. and for no other purpose. Systemic Endodontic Diagnosis may not be
reprinted for sale and may not be amended or altered in any manner. This; license is not assignable.


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1.. To improve communication among all those caring for the patient.
2.. To display the assessment, problems and plans in an organized format to facilitate the
care of the patient and for use in record review and quality control

S: SUBJ ECTIVE DATA:
Presents the problem from the patient's point of view - feels. It may include the chief complaint,
present illness, past history, current medications, diet and appetite, and allergies.

O. OBJ ECTIVE DATA
This is a record of the physical examination and includes the specific objective and
reproducible findings gathered by:
1.. Observation of the patient
2.. Physical examination
3.. Laboratory results
4.. X-rays
5.. Pulp tests

A. ASSESSMENT:
This is a short tentative working diagnosis for each problem.

P: PLAN:
This describes your plans for the care and management of each problem. What are you going
to do to treat the patient? It may include one or all of the following:
1.. A plan for collecting further information like blood tests or X-rays.
2.. A plan for initial treatment with specific procedures or medications.
3.. A plan for educating the patient
4.. Referral and / or consultations
5.. Plan for follow up.


SOAP NOTE FORMAT IN DETAIL:

S: SUBJ ECTIVE - what the patient tells you.
1.. Chief Complaint (CC) - The patient's reason for coming to the clinic today. The CC is
usually a single statement. Example: CC/"My tooth hurts."
2.. Associated symptoms - ex: thermal sensitivity, tenderness to touch, spontaneous pain.
3.. Duration of symptoms - ex: times 3 days.
4.. Any new symptoms which have appeared or prior symptoms noted. Ex: chills 3 days ago
associated with runny nose, which cleared.
5.. Anything that makes the symptoms better or worse, aggravates or relieves the problem.
Ex: going up stairs aggravates the pain, better with rest.
6.. Frequency of symptoms - ex: constant pain, increasing with swallowing, headaches every
other day.
7.. Remedies tried already - ex: ASA, salt water gargles - effective or ineffective.
8.. Antecedent events - ex: tooth broke, traumatic injury, recent restoration.
9.. Severity of symptoms - particularly pain (rate on a scale of 1 - 10), quality of pain -
burning, aching.
10.. Location of symptoms - ex: right posterior mandible, radiating to ear.
11.. Significant negatives - ex: no cough, no ear pain, no sinus problem


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12.. Medications being taken currently - VERY IMPORTANT, especially for women.
Always ask if they are on the pill as many medications are affected. Pregnancy may also be a
consideration for treatment.
13.. Allergies - If the patient is allergic to something, note both the allergy and the effect when
the patient is exposed ex: penicillin allergy - hives.
14.. Immunization status (Tet., Tox., MMR, etc.) Should always check for tetanus immunity if
patient has a wound. Check the shot record if possible.
15.. Serious - medical history - ex: surgeries, history of rheumatic fever, etc review the chart!


O: OBJ ECTIVE - what you observe. Consists of two parts: physical findings and lab/ X-ray
1.. Physical findings This should begin with your impression of the patient, what he looks like
- his general appearance Is he alert and orientated or in any apparent distress? Look for any
signs of alcohol or drug abuse. Then begin your complete Head, Neck, Oral examination of the
patient. If symptoms are restricted to a specific body system or region, a more limited
examination may be appropriate. Document only what you carefully examine and only the
things that are pertinent.
Ex Pt. is alert and oriented x 3 no apparent distress.
Ex Pt is alert and oriented x 3, with alcohol noted on breath.
Ex Swelling right mandible, db cusp fracture #30.
PA lesion noted radiograph #30.
Pulp test (CO2) no response #30, #19 respond 3 seconds.
#30 tender to percussion, #19 no tenderness to percussion.
2.. STAT laboratory and X-ray results may be important in making the diagnosis.


A.: ASSESSMENT - This is where you think through the results of the history and physical
examination. It calls for your interpretation and evaluation of the problem, the data, possible
implications and the prognosis.
Ex Necrotic Pulp, Acute Periradicular Abscess.


P: PLAN
1.. Further diagnostic studies needed. Ex: Throat Culture, Urine Culture, Chest X-ray, and
CBC.
2.. Therapeutic regimen including medications given, treatments prescribed. Specify dosage,
how they are to be taken, and how often.
3.. Patient education: What the patient has been told about his sore throat what he should
know and understand about his medications and therapy, as well as self care for the future.
Note any educational printed material given. Patient's response to education i.e. states
understanding; questions answered or needs further education.
4.. Disposition - home, or back to limited or full duty. Follow-up must be specified.
Ex Endodontic therapy
Every SOAP note should include what arrangements were made for follow-up.

from Dr. G M Heir, modified by Dr. S W Oglesby













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Required Radiographs
All lab radiographs have two views

Suitability radiograph: unmounted tooth. Check suitability for lab exercise. Pulp
chamber should be readily seen. Canal should be straight from orifice to foramen. Major
foramen should easily be identified. This radiograph is not needed in the clinic.

1. Diagnostic radiograph: Tooth mounted in resin-stone. All the landmarks seen in
the suitability radiograph should readily be seen. Use different exposure times and
KVP until a radiograph with contrast is produced. Write down the values for
exposure time and KVP and which machine you used. All to following
radiographs should be of the same quality as this one.

2. Trial working length (TL) radiograph: Radiographic length minus 3mm. Use this
to estimate the working length (WL). When you can identify the major foramen
(which should be the case for all the teeth selected for lab), the working length
should be .5 to .75mm short of it. If you cant see the major foramen, the WL
should be .5 to 1.0 mm from the radiographic length. Use at least a #15 file.

3. Working length (WL) radiograph: Adjusted WL file (at least a #15 file) is within
1mm of where you want to be. If it is not exactly where you want it, it is all right
to place another file and take another radiograph, but we dont require it.

4. Master Apical File radiograph (MAF): Shows largest file taken to WL. Done
after you have completed the root canal preparation including step back and deep
shape.

5. Master gutta percha cone radiograph: Evaluate fit and length. Should appear to
fill up the apical 2-3mm of canal. No greater than .5 mm from WL. At WL (with
slight tugback) is preferable.

6. Initial condensation radiograph: Evaluate fit and length after sealer is placed and
two accessory gutta cones are placed. Should fill up apical 2-3mm and be exactly
where you want it.

7. Final radiograph: Evaluate gutta percha condensation from buccal CEJ to apical
stop. Temporary fill should be in place from where the gutta percha stops to the
cavo-surface margin.

The numbered radiographs are also necessary for patient treatment in the clinic.


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10 Steps To Endodontic Heaven Or how I succeeded in endo without really trying.
1. PROPER PREPARATION:
Take appropriate high quality preoperative radiographs.
Treatment Plan & Restorability Check.
Examine, pulp test, record.
SOAP notes.
Measure and record RL, calculate and record TL, RPC, FPC.
2. PROPER ACCESS:
Isolation,
Rubber dam
Buildup.
Occlusal reduction.
Straight line.
3. INITIAL INSTRUMENTATION
#15 file to TL
Radiograph
Calculate working length
4. Coronal Flare
GG to WL
Maintain patency/irrigate
5. Confirm WL with radiograph
First File to Bind
6. Apical Stop Preparation Nickel-Titanium Hand Files
Balanced forces/opposite force
3-5 sizes larger then the First File to Bind
Irrigate/patency
7. Deep Shape
Rotary Length and/or GGs
Step-back
8. MAF radiograph
Correct as necessary
Irrigate/patency
9. Master cone
Apical stop verification
Tugback
Flare check
Radiograph
10. Obturation
Sealer/Master Cone
Initial Condensation
Radiograph/evaluate
GP removal to CEJ/orifice
Complete Obturation
Temporary
Final Radiograph
Remove Rubber Dam






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Clinical Endodontic Diagnosis

...
Other Relevant definitions:
1. Periodontium: the tissues that surround and support teeth, attaching them to alveolar
bone; includes bone, connective tissue, vascular, and neuronal element
2. Abscess: a localized collection of pus within a tissue or a confined space
3. Periodontitis: inflammation of periodontium
4. Pulpitis: a clinical and histological term denoting inflammation of the dental pulp;
clinically described as reversible or irreversible and histologically described as
acute, chronic or hyperplastic
* Above terms and definitions are current as of 2004-2005 according to the Glossary of
Endodontic Terms published by American Association of Endodontics.
Pulpal Diagnosis
1. Normal
2. Reversible Pulpitis
3. Irreversible Pulpitis
4. Necrotic
A.
B. Periradicular Diagnosis
1. Normal
2. Subacute Periradicular Periodontitis
Inflammation usually of the apical periodontium producing mild clinical
symptoms; not as severe as acute periradicular periodontitis
3. Acute Periradicular Periodontitis (=Acute Apjcal Periodontitis) Inflammation
usually of the apical periodontium producing clinical symptoms including
painful response to biting and percussion
4. Chronic Periradicular Periodontitis (=Chronic apical Periodontitis) Inflammation
and destruction of apical periodontium producing that is pulpal origin,
appearing as periradicular radiolucent area and does not produce clinical
symptoms
5. Acute Periradicular Abscess (=Acute Apical Abscess)
An inflammatory reaction to pulpal infection and necrosis characterized by
rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus
formation and eventual swelling of associated tissues
Other terms used historically): acute periapical abscess, acute alveolar
abscess, dentoalveolar abscess, phoenix abscess, recrudescent
abscess, secondary apical abscess)
6. Chronic Periradicular Abscess (=Suppurative Periradicular Periodontitis,
Chronic Apical Abscess, Chronic Periapical Abscess)
An inflammatory reaction to pulpal infection and necrosis characterized by
gradual onset, little or no discomfort, and the intermittent discharge of pus
through an associated sinus tract
January 2005 Esther Cho

101

Chief
Complaint

History
Radiographic
Findings
Electronic
Pulp Test
Thermal
Testing

Percussion

Palpation

Mobility

Treatment

DDx
Normal Pulp None Normal Responsive Mild none

Reversible
Pulpitis
Hot &/or Cold
Sensitivity
Thermal
sensitivity
(cold is most
common)

Normal

Response
Exaggerated,
Non-lingering


Removal of
stimulus

Irreversible
Pulpitis
Lingering Hot &/or
Cold Sensitivity
Spontaneous
Pain
Normal,
Periradicular
Radiolucency, or
Widened PDL

Response
Exaggerated,
Lingering


Root canal
treatment (RCT)
Necrotic
Pulp
Variable
Variable
Normal,
Periradicular
Radiolucency, or
Widened PDL

No
Response

No Response


Root canal
treatment (RCT)

Caries,
Cracks,
Restorative
Procedures, or
Trauma

Periradicular
Diagnosis
Chief
Complaint

History
Radiographic
Findings

EPT
Thermal
Testing

Percussion

Palpation

Mobility

Treatment

DDx
Normal


None

Normal

Response
Response,
Non-lingering
Not
sensitive
Not
sensitive

WNL

none

Acute
Periradicular
Periodontitis
Discomfort
When Biting or
Chewing
Recent
Restoration?
Normal,
Widened PDL
or Periradicular
Radiolucency

Response /
No
Response

Variable

Moderately
Sensitive

Sensitive or
Not
sensitive

+/ -
RCT. If
occlusal trauma,
occlusal
adjustment will
relieve the pain

Occlusal
Trauma?
Acute
Periradicular
Abscess
Pain usually with
Slight to Large
Swelling

Coronal
Microleakage
?
Normal,
Widened PDL
or Periradicular
Radiolucency


No
Response


No Response


Exquisitely
Sensitive


Sensitive


+/ -
Open for
drainage, I & D
through bone
and mucosa and
RCT


Necrotic or
Pulpless
Chronic
Periradicular
Periodontitis

None

Asymptomatic

Periradicular
Radiolucency
No
Response
No Response Not
sensitive
Not
sensitive

WNL

RCT
Necrotic or
Pulpless
Subacute
Periradicular
Periodontitis

Slight or Mild
Spontaneous or
Discomfort
When
Biting/Chewing

Coronal
Microleakage
?
Normal,
Widened PDL
or Periradicular
Radiolucency

Response /
No
Response

Variable

Mildly
Sensitive

Sensitive or
Not
sensitive


+/ -

RCT

Occlusal
Trauma?
Chronic
Periradicular
Abscess
Bad Taste
or
Gum Bump

Asymptomatic

Periradicular
Radiolucency
No
Response
No Response Not
sensitive
Not
sensitive

WNL

RCT
Necrotic or
Pulpless with
Sinus Tract
Focal Sclerosing
Osteomyelitis
(Condensing
Osteitis)
Asymptomatic or
Variable Pulpal
Symptoms
Extensive
Restorative
History /
Opacity
Increased
Radiodensity /
Opacity
Response /
No
Response
Variable Sensitive or
Not
sensitive
Sensitive or
Not
sensitive
WNL ? Condition due
to pulpal
inflammation
Focal
Osteopetrosis /
Periapical
Osteosclerosis
Asymptomatic Virgin Tooth
of Normal
Pulp
Increased
Radiodensity /
Opacity
Response Normal
Response
Not
sensitive
Not
sensitive
WNL No Endo
Treatment