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What are the 3 Cases where conventional Endodontic treatment is NOT suitable?
- Unfavorable restoration
- Persistent/Extra-Radicular infection
- Lateral/Accessory canals
Predentin Odontoblast Layer Sub-Odontoblast layer (Cell-Poor Zone Cell-Rich Zone) Pulp Proper
What are the functions of Odontoblast Layer?
- Smaller/Flattened morphology
- Content: (1) Fibroblasts, (2) Blood vessels, (3) Neural Network (Plexus of Raschkow) – innervate into
odontoblast layer/dentine
- Content: (1) Fibroblast, (2) Blood vessels, (3) Immune Cells (Macrophage/Lymphocyte), (4) Nerves, (5)
Pluripotent (stem) cells
Central Pulp
- Fibroblast
- Defence cells
- Collagen
Parietal Pulp
Odontoblast, Fibroblast, Pluripotent (stem) cells, Defence Cells (Macrophage, Lymphocyte, Dendritic Cells)
- Macrophage
Mostly @ Peri-Vascular Portion (Inner Pulp) & Odontoblastic Region (Outside Pulp)
Phagocytic ability
Secrete IL-1, IL-6, TNF, Growth Factors inflammatory response & Tissue regeneration
- Dendritic Cell
Activate T-Lymphocytes
Release of Neuropeptides in Pulp Increased vascular permeability and Vasodilation Affect activity of
inflammatory cells (macrophage) Amplified neurogenic inflammation
Collagen
- Mostly TYPE I
- Glyco-aminoglycans
- Glyco-proteins
- Proteo-glycans
- Arterioles (afferent)
Infraorbital Artery
- Venules (effert) drain through Facial Vein (anterior) & Maxillary Vein (posterior)
How does vascular changes occur?
Sympathetic Nerve
- Control pre-capillary sphincter (smooth muscle) alter blood pressure, flow, distribution
Sensory Nerve
- Afferent nerves from Trigeminal Nerve CN5 Maxillary Branch and Mandibular Branch
Sensory receptor (eg. Nociceptor) Sensory nuclei (spinal cord) Thalamus Cortex
- Nerves converge @ Spinal Tract Nucleus Difficulty locating pulpal pain (leads to referred pain)
What is Sub-Odontoblastic Plexus of Raschwkow?
Odontoblast layer
Dentinal tubules
- Mostly Aα, Aδ & C fibers sensory perception (some C fibers for sympathetic efferent for BV smooth
muscles)
No direct pathway between stimuli and nerve endings so it’s the MOST accepted theory
- Stimulus Fluid movement within tubules Activate Nociceptors in Inner Dentine/Peripheral Pulp
Dentine:
Pulp:
- Pulp Stones
Location where pulp communicates with periapical tissues (narrows w/ age = Decreased in
vascularity)
How are types of cementum defined by?
- Contains cementocytes
- Features: Cementocytes, Laminated appearance, Cementoid on surface (new cementum layer less calcified)
What is PDL?
Cribiform Plate:
- Different microorganisms expected as they survived through irrigation and mechanical removal
- As diverse bacterial community as Primary Infection (w/ some key species found)
Enterococcus Faecalis:
Due to ability to enter dentinal tubules, bind to dentine, withstand starvation and Calcium Hydroxide,
and form biofilm
- Conservative outline
Concentricity: pulp chamber walls are concentric to external outline of the tooth @ CEJ level
What are 3 Guidelines for canal orifice location?
Orifice location:
Symmetry: mesio-distal midline along the chamber floor (mandibular molar ONLY)
Creates an electronic circuit from lip hook (mucosa) to Periapical tissue via file
What are Local Anaesthesia technique for Maxillary Teeth for ENDO?
Posterior: Additional palatal infiltration (for soft tissue – especially tooth on rubber dam)
Anterior: Buccal infiltration (IAN block not predictable for anterior teeth)
Posterior: IAN Block + Long Buccal Nerve Block (LB nerve – for soft tissues)
Why is the failure rate high for Irreversible Pulpitis? And which teeth are hardest to anaesthetize?
“Hot Pulp” syndrome: extenstively inflamed pulp (8 times higher failure rate)
- Anatomical Factor
- Effect of Inflammation
- Central Sensitisation
- Psychological factors
- Supplemental LA
Patient Protection:
- Improved Access
- Improved Visibility
- Reduce floording
- Unpleasant taste/odour
Bleach
- EDTA (15-17%)
3 Different Needles: (1) Side-Vented Needles, (2) Closed-Ended Needles, (3) Standard
Intracanal Medicament:
Temporary Restoration:
Bacteria reach apical foramen in contact with peri-radicular (around root) tissue
1) Cleaning:
- Remove all organic debris and microorganisms from the root canal system
2) Shaping
- Shape the walls of root canal for cleaning and shaping for obturation (mildly tapered)
Larger apical size & Moderate tapering >>>> Small apical size & Large tapering
WHY?
What is the average diameter of root canals? Which instrument should we use as result? Why is it important?
- Important because there are different shapes of apical construction but as long as it’s cleaned with
greatest diameter, it should be fine
- Overfilling (0-1mm) is okay but must be compacted well within root canals regardless
H- Files K- Files
Positive Rake angle Efficient cutting Negative Rake angle Reaming action (widen hole)
Cut “push-pull” action Cut “turning” action
Very flexible flute pattern/cross section Not flexible triangle/square cross section
- Most pulp tissue& bacteria removed prior to apical third minimize risk of
extruding debris through apex
- Transportation
- Ledging
- Apical perforation
Torsional failure tip locks and file begins to unwind repeat of unwinding and re-winding file breaks
Flexural failure files rotate around a sharp curve break without distortion
1) Number of uses
2) Canal Curvature
- Increased flexibility
- Flooded canal
- Established patency
- Kill bacteria & Dissolve Organic Matter (dentine collagen, pulp tissues, biofilm)
** All irrigant must reach the microbes (if NaOCL can’t get there, neither can anything else)
Time longer it stays, more bacteria it kills (Both 1% and 4% are effective just need to stay longer)
Canal Dimension 40/0.4 better than 20/0.4 (apical size >> tapering)
Always:
- “gently” jiggle
2. Ecchymosis involving periorbital region and angle of mouth (eye and mouth)
- Ecchymosis
- Explain to patient
- Pain Control
- Lubricant
- Method:
Final flush with 3ml of 15% EDTA, then 5ml NaOCl solution
- Reduce microbial load to a very low level so immune system can respond
Flat paste-fillers:
Double seal:
- Cavit G or W
What are the differences between Interim Restoration vs. Temporary Restoration?
- Improved compressive strength & Good sealing ability (less than Cavit)
- Easy to use
Disadvantages:
- Cost, slow setting, seal deteriorate over time, not easy to use, difficulty in differentiating from tooth
structure
LECTURE 10: Root Canal Filling
- Physical barrier between root canal and oral environment prevent nutrient supply and re-infection
- Entomb residual bacteria within root canal space prevent communication with peri-radicular tissues
- Biofilm formation
- Resistance to antimicrobials
-Ca(OH)2 based
-ZOE based
-Silicone based
-Bioceramic based
What are the advantages and disadvantages of Lateral Compaction (root fillings)?
Advantages Disadvantages
Good Length Difficult technique
Deficiency can be easily corrected during Lots of Time
root filling
Lots of accessory cones
Poor compaction is common
High Fracture risk (spreader had to go
deep)
- Heated GP systems
Advantages Disadvantages
Fill accessory canals Extrusion of GP and sealer
Adapt to canal shape Carrier remains in canal (maybe a problem for
retreatment)
Sealer thickness: avg 2mm
GP may penetrate tubules
Less extrusion (빠져나온다)
- BUT can’t always control placement (hard to see leakage & shrinkage is a
problem)
Compounds present:
Di-Calcium Silicate
Tri-Calcium Silicate
Tri-Calcium Aluminate
Gypsum
Tetra-Calcium Alumnino-Ferrite
Release of calcium and hydroxyl ions interact with phosphate from body fluids form apatite-like
deposits
Deposits fill gaps from shrinkage and improve frictional resistance of MTA to canal walls
- Perforation
- Periapical surgery
If Short, (1) Measure/Revise WL again OR (2) Use rotary instrument to clear obstruction and refine
apical portion
Size 40 because you don’t want it to reach apex – only put it half way and master cone will push it
down apically
- Insert D11TS (Root Canal Spreader) with minimal force & compact accessory cones
LECTURE 11:
- Percussion
Tenderness to Percussion a sign of abnormality; doesn’t mean it requires treatment right away
- Palpation
Gingiva, Sulcus
- Occlusion
Restoration, Pain on Biting, Fracfinder testing, Occlusal Interferences, Bruxism, Plunger Cusps
- Periodontal
- Transillumination
Identify crack
- Pulp Testing
Heat Test
Use Rubber Dam and Boiling Water in Syringe for 30s See if patient responds in 2 mins
- TMJ
Age:
Trauma:
Orthodontics:
Healthy Pulp:
- Vital
- No Inflammation
- Asymptomatic
- Normal Response
Reversible Pulpitis:
- Mild Inflammation
- Thermal Pain
Irreversible Pulpitis:
- Severe inflammation
- CAN’T heal
- Spontaneous pain
Necrotic Pulp:
- Total/Partial Necrosis
Previous Initiated Treatment RCT has been started but not completed
Hyperplastic Pulpitis Development of granulation tissue from pulp causing low-grade chronic
inflammation
Internal Resorption
What are different Periapical Diagnosis?
- Normal Tissue
- Not Tender
Apical Periodontitis:
- Symptomatic
- Asymptomatic
No symptoms
Necrotic
Radiolucency at Apex
- Rapid onset
- Tenderness
- Swelling
- Localized swelling causing pressure (from pus) and pain – may need drainage
- Little/No Discomfort
- Sinus Tract
Condensing Osteitis
- May be tender
Pre-Operative
Mid-Treatment X-rays:
- Working Length
- Cone-Fit
- Mid-Obturation
Post-Treatment X-rays
- Good angulation
- Children
- Pregnant ladies
Distance
Wrong tooth:
Perforation:
Gouging: Excessive removal of tooth structure during access and coronal flaring
- Good vision, Illumination and Access, Locate canals using DG16 Probe
Transportation: File cuts more on external surface and straighten curved canal
Ledge: Iatrogenically (by dentist) created irregular platform in the root cananl
system
Elbow and Zip: Straightening out of the working file within canal
Fractured Instruments
Extrusion of medicament
Tissue necerosis
- Temperature increase of > 10 C may cause irreversible bone and PDL damage
Dentine thickness, Application duration, Obturation technique
- Recognize: pain during Tx, tenderness to percussion, mobility, periodontal/alveolar bone necrosis
- Potential complication: nerve damage when over-extend into mandibular canal/mental foramen
** BUT usually overfilling is okay – often complication w/ lower molars with IAN
Nerve Injury:
Management: Refer to OMFS, Regular review, Antibiotics, Analgesics, Corticosteroids, Proteolytic Enzymes, Vit C
- Cause: compressed air during restoration (EXO, Periodontal Tx, Endodontic Tx)
- Recognition: rapid face swelling, erythema (redness), crepitus (friction sound/sensation), dysphagia and
dyspnea (trouble swallowing and breathing)
- Management: Reassurance (resolve in 3-4 days), Analgesics, Medical referral if (dyspnea or dysphagia)
- Cause: Iatrogenic (caused by medical tx/exam), us NaOCl as LA by accident, Open Apex, Close proximity
to tissue spaces
- Location: Maxillary teeth > Mandibular (70% maxillary premolars and molars, 30% anteriors)
LECTURE 16: Aseptic Technique
- Eliminate microorganisms
- Protect Operator
- Gamma Radiation
Gloves Contamination: “Propionibacterium acnes” number increases on gloves during endodontic treatment
- At initial, after acess, after working length, before removing rubber dam
- Can contaminate sterile GP with P. Acnes, S. Epidermidis 1 min of 5% NaOCl to remove bacteria
KEY: variations in the inorganic structure & organic components different optical properties
KEY: deciduous teeth are more opaque white (less translucency); less-dense and less-organised
enamel crystalline structure
Extrinsic Discolouration:
- Chromogen lies NOT on dental hard tissue but in surface deposits (areas of thicker acquired pellicle
and reduced cleaning)
Interaction between pellicle & chromogen may just act like a sponge to enhance uptake of
chromogen
Intrinsic Discolouration:
Different Causes:
Dental Trauma:
Blood components penetrating into dentinal tubules Pink Hue (disappear once pulp recovers)
Delayed discolouration (if pulp is not vital) from pulp necrosis and infection
Further discolouration as Iron (from blood product) react with bacterially derived Hydrogen Sulphide
Endodontic Material:
- Breakdown molecules = “free radicals” + “reactive oxygen molecules & hydrogen perioxide anions”
Mechanism of Action:
- Oxidation breakdown products “cleave double bonds of large pigmented molecules to form NON-
PIGMENTED smaller molecules”
- Carbamide Peroxide
- Sodium Perborate
Common Complications:
- Tooth Sensitivity
- Mucosal Irritation
Intracoronal application of bleaching agent following endodontic treatment to chemically eliminate discolouration
from internal surface
Favourable responses expected: Younger TEETH Less predictable responses expected: Older Teeth
Larger tubules Narrow tubules
Short-Term Discolouration Long-Term Discolouration
Cases where discolouration due to Trauma and Cases where discolouration due to metallic ion &
Necrosis endodontic and restorative materials
Key factors “Sound Coronal Restoration” is an important factor to ensure longevity of internal bleaching result
(re-leakage)
Unknown mechanism
Instrumentation
Obturation
Restoration
PATIENT CENTRED:
Tooth factors
- Cost effective
- Patient-centred
- Loss of Proprioception
Lose the protective feedback mechanism when pulp is removed (2 times more force required to feel
discomfort)
Lose stiffness by 5% with conservative access (used to be @ roof of pulp, after endo more @ CEJ)
Fail to:
- Retain Crown
Why do endo-treated teeth fail?
- Loss of Structure
- Failure to resist initiation and propagation of cracks by dental tissues (age related changes)
- Restorative Margin
- Calcification
- Anatomical variations
- Root Curvature
- Number of roots
- Tooth Angulation
- Armamentarium
Laws of Centrality: floor of pulp chamber located always @ center of tooth @ CEJ level
Laws of Concentricity: walls of pulp chamber are concentric to external surface of tooth @ CEJ level
Laws of Colour Change: floor of pulp chamber darker than surrounding walls
Laws of Symmetry: orifices are Equi-Distant and Perpendicular to a line drown from
Mesio-Distal direction
Laws of Orifice location: orifices located at the JUNCTION of walls and floor
Advantages:
Access restorability
Eliminate leakage/caries
Crack detection
Anatomical Orientation
Strength (or fracture resistance) of tooth determined by amount of remaining dentine after tooth
prep
- Coronal microleakage
Post Spaces must be blocked (Suckdown Splint, Bonded temporary crown, Intracanal barrier)
- Cuspal Coverage
Bite Forces
Posterior Teeth – axial forces (molars & mandibular premolars), lateral forces (maxillary premolars)
- Aesthetics
- Occlusal forces
Post
DO NOT STRENGTHEN TOOTH (remaining tooth structure strengthen the root not metal)
5mm of apical GP for seal (immediate prep required for post space)
Biological Width (from Alveolar Bone to Epithelial Junction/Base of Sulcus – minimum 3mm required)