Endodontology

The study of the form, function and health of, injuries to, and diseases of the dental pulp and periradicular region, their prevention and treatment.

( European Society of Endodontology 1992 )

Pulp space anatomy

Pulp chamber Root canal Pulp horns Apical foramen Accessory canals Periradicular tissues

Functions of dental pulp

Formation of dentine (dentinogenesis) Sensation (pain only?) First line of defense to injuries and infection of dentine
Tertiary dentine Immuno-competent Clearance of toxic substances

Components of dental pulp

Cells + (extracellular) Matrix Ground substance

Fiber

Structural Adhesive GAG

Collagen Elastin Fibronectin Laminin HS DS CS

Proteoglycan
Decorin Versican

Components of dental pulp

y

CELLS (odontoblast, fibroblast, undifferentiated cell, macrophage, dendritic cell) FIBERS AND GLYCOPROTEIN (collagen type I, III, no elastic fiber, fibronectin) GROUND SUBSTANCES (glycosaminoglycans, chondroitin sulfate proteoglycan) BLOOD VESSELS, NERVES, LYMPH VESSELS

Types and properties of pulpal sensory nerve fibe

A-beta fibers


C fibers
   

A-delta fibers
y y y y y y

Conduction velocity 30-70 m/s Very low threshold, nonnoxious sensation 50% of myelinated fibers in pulp Functions not fully known Conduction velocity 2-30 m/s Lower threshold Involved in fast, sharp pain Stimulated by hydrodynamic stimuli Sensitive to ischemia Sharp pain

 

Conduction velocity 0-2 m/s Higher threshold Involved in slow, dull pain Stimulated by direct pulp damage Sensitive to anesthetics Dull pain

Non-myelinated sympathetic fibers

 

Conduction velocity 0-2 m/s Post-ganglionic fibers of superior cervical ganglion Vasoconstriction

Diagnosis
Medical history Dental history Chief complaint Examination Clinical tests Radiographs

Medical history
Cardiovascular diseases : Recent MI Congenital HD Valve replacement Rheumatic HD Bleeding disorders : Dialysis patients Alcoholic abusers Patients taking Aspirin Diabetes : Uncontrolled DM (Insulin shock OR Diabetic coma )

Allergy : Latex rubber ( use Vinyl instead ) Sodium hypochlorite Physical disabilities Parkinsons disease Spinal cord injuries Stroke Steroid therapy Susceptibility to infection Cancer, AIDS & Pregnant patients

Dental history
 Chief complaint As expressed in patients own words  Location Pointing with one finger  Chronology When symptoms were initially perceived Spontaneous OR provoked Immediate OR delayed Persistent OR intermittent Momentary OR lingering

 Description Dull, drawing OR aching ~ pain of bony origin Throbbing OR pulsing ~ vascular response to inflam. Electric, recurrent OR stabbing ~ nerve pathosis Aching, pulsing, throbbing, dull, radiating, flashing OR stabbing ~ pulpal & periapical pathosis  Intensity Mild, Moderate OR Severe  Affecting factors Aggravating factors Relieving factors

Examination
Extraoral  Facial asymmetry
    Presence & extent of swelling in head & neck region Lymphadenopathy Presence of fistula Presence of TMJ dysfunction

Intraoral  Oral hygiene  Presence of swelling & sinus tract

 Condition of teeth present  Periodontal condition

Clinical tests
Palpation Mobility test Percussion Periodontal examination Pulp sensitivity tests Selective local anesthesia Sinus tract exploration

Palpation
Gently using the index finger Rolling motion Bidigital OR bimanual palpation

Mobility test
The blunt handle of two metal instruments Lateral force D Facial-lingual direction Vertical movement DDegree of depressibility

Percussion
Biting on a cotton roll OR a low speed suction tip

Periodontal examination
 Recording the depth of all pockets  Determination of any furcation involvement

Pulp sensitivity tests

 Isolation with a rubber dam & bathing in hot OR iced water  Response : No response Moderate Severe  Electric pulp testing : Pulp vital OR nonvital

Selective local anesthesia

Selective infiltration Intraligamentous Inferior alveolar nerve block

Radiographs
Two dimensional Periapical lesions : Loss of lamina dura Radiolucency remains at root apex Hanging drop appearance Degenerative pulp changes : Pulp stones Extensive canal calcification Root resorption

Pulp status
1. 2. 3. 4. 5. 6. 7. Normal pulp Reversible pulpitis Irreversible pulpitis Necrosis Acute apical abscess Acute apical periodontitis Chronic apical periodontitis

Normal pulp
Asymptomatic with normal response to thermal and electrical stimuli Intact lamina dura with no resorption No painful response to palpation & percussion

Reversible pulpitis
Asymptomatic with quick, sharp response that subsides immediately after stimuli removal No spontaneous pain

Irreversible pulpitis
Sensitivity to thermal stimuli of long duration Previous history of pain severe spontaneous pain Tenderness to percussion ( Not always )

Necrosis
No response to thermal OR electric stimuli Tenderness to percussion ( Not always ) Crown darkening ( In anterior teeth )

Acute apical abscess

Painful, purulent exudate around the apex Normal radiographs OR slight widening in PDL Slight to severe pain and swelling Pain on percussion & palpation

Acute apical periodontitis

 Inflammation around the apex of vital OR nonvital tooth  Over instrumentation OR occlusal trauma  Tooth is tender to percussion

Chronic apical periododntitis

 Long standing asymptomatic inflammation around the apex  Sinus tract ( Pus discharge )

Description

Symptoms

Treatment

Reversible Pulpitis

Tooth is sensitive to cold. Pain disappears when the triggering factor is removed.

Removing decay, restoring tooth structure.

Irreversible Pulpitis

Tooth sensitivity remains after the triggering factor is removed. Or pain could be spontaneous, happening without a triggering factor such as throbbing pain at night.

Root Canal Treatment. Sleeping on high pillows might temporarily work as a remedy to reduce toothache usually aggravated by increased blood flow from low head position.

Periapical Infection

Tooth becomes tender for bite pressure. At this stage the bacterial infection has traveled through the root canal and reached the jaw bone surrounding the tooth.

Root Canal Treatment.

Abcess / Swelling

Bacterial infection spreads to the tissue around the jaw bone and causes a swelling, which will have general systemic reactions and implications.

Antibiotics. Possibly Root Canal Treatment and possibly extraction

Indications for RCT

 An irreversibly damaged or necrotic pulp with or without clinical and/or radiological findings of periradicular involvement  Elective devitalisation : To provide post space Prior to construction of an overdenture

Why we need Root Canal Treatment ?

1- Due to deep Caries

2- Due to Leaked Restoration

3- Due to Trauma

4- Excessive force during ortho. treatment

Contraindications for RCT

     Teeth that can not be made functional or restored Teeth with insufficient periodontal support Teeth with poor prognosis Uncooperative patient Poor oral hygiene

Basic principles of Endodontic Treatment 1- Endodontic Diagnosis 2- Patient Education 3- Local Anesthesia 4- Rubber Dam Isolation (single isolation) 5- Access Cavity 6- Working length 7- Instrumentation 8- Obturation 9- Final restoration

Steps of RCT
1. 2. 3. 4. 5. 6. 7. 8. Local anesthesia Preparation of tooth Isolation of tooth Access cavity preparation Working length determination Preparation of root canal system Irrigation Obturation of root canal system

Local anesthesia
 Infiltration  Block  Intraligamentous  Intrapulpal

Preparation of tooth
 All caries & defective restorations should be removed  Tooth protected against fracture  Tooth should be capable of being restored & isolated

Isolation of tooth
Using the rubber dam Gauze pack to protect the pharynx Safety chain or dental floss

Access cavity preparation

Complete removal of the roof of pulp chamber Minimise binding of instruments (Straight line access ) Avoid damage to pulp chamber Introduce instruments into root canals with undue binding The occlusal projection should be larger than the base Access should be a two- stage procedure Conserve as much sound tooth structure as possible

Maxillary incisors & canines

 Triangle with mesial and distal extension to include the pulp horns  Should extend far enough incisally to allow straight line access to the apical foramen

Maxillary premolars
Through occlusal surface Ovoid in bucco-lingual direction

Maxillary molars
 Triangle with the base towards the buccal, and the apex palatally  Oblique ridge must be intact

Mandibular incisors & canines

Triangle with incisal edge involvement Avoid labial perforation

Mandibular premolars
Through occlusal surface Ovoid in bucco-lingual direction

Mandibular molars
Rectangular outline Preserve the marginal ridge

Working length determination

      From preoperative radiographs Use file No. 15 OR larger Use film holder As close to the CEJ as possible Between 0.5-2.0 mm from the radiographic apex Use rubber stopper to establish a reproducible reference point

Preparation of the root canal system

       Remove remaining pulp tissue Eliminate microorganisms and debris Shape the root canal so that it can be obturated A continuous tapering canal preparation Maintaining the original anatomy of RC system Maintaining the position of apical foramen Apical foramen as small as possible

Debridement of the root canal system.

Enlarging the radicular pulp space to receive an obturating material.

1. Elimination of microorganisms. 2. Remove pulpal tissues and debris. 3. Allowing placement of a three dimensional root filling.

1. A continuous tapering, funnel

shaped canal preparation. 2. The original anatomy maintained. 3. Position of the apical foramen maintained. 4. Foramen as small as possible.

Forms of apical third RC preparation :

1. Apical dentine matrix ( Retention ) form : Standardised gutta percha points are fitted in the apical 2 3 mm of the canal. 2. Continuously tapering ( Resistance ) form : Non standardised gutta percha points are fitted.

Patency :
Def. : Absence of soft or hard tissue blockage in the apical third of the canal. File used : A small flexible k-file ( not H file )which will passively move through the apical constriction without widening it ( Buchanan, 1989 ). Size of file : # 10 , # 15 and # 20 .

1. Always work in a wet canal. 2. Irrigation is done frequently and copiously. 3. Explore the canal with a small file. 4. Gradual enlargement of canal using successively larger files ( DO NOT SKIP !!). 5. Remove debris and dentine using a circumferential filing at or close to WL. 6. Avoid forcing or continuing to rotate the instrument that binds on insertion. 7. Keep away from the danger zone. 8. Do not perforate the apical foramen.

Initial apical preparation :

1. Working length determination. 2. Enlargement of apical 1-2 mm of the canal one or two sizes larger than the the first file that demonstrates any binding. 3. Tapering of the remaining canal by shortening the WL of each successively larger instrument by 0.5 mm. 4. Recapitulation : Returning to MAF after using each step-back file. 5. Size of preparation : size 60 or 70 is usually necessary.

Final apical enlargement :

Instruments 2-4 sizes larger than the MAF are carefully reamed in a clockwise at the WL in wet canal to remove dentine chips that pack apically during drying.

Limitations :
1. It has a tendency to straighten the severely curved canals. 2. Debris frequently collects at the apical region and either becomes extruded through the apex or blocks the canal. 3. Loss in WL is noticed because of the reduction of curvature of the canals during mid-root flaring.

Coronal & mid-root flaring

1. Enlarge to a depth where # 15 file starts to bind. 2. Circumferential and anticurvature filing ( with # 15- # 25 ). 3. Gates glidden drills # 2 & 3 with a very light pressure.

WL determination

Apical preparation
1. Serially enlarge to MAF at WL. 2. Step-back for 4 instruments. 3. Circumferential & anticurvature filing. 4. Recapitulate.

Advantages
1. Removing most of infected materials and bacteria from coronal third of the canal. 2. Reduce the chance of extrusion of debris from the apical foramen. 3. Most of the resistance & obstacles encountered during preparation of curved canals originate from the coronal portion of the canal are removed.

Early coronal flaring with GG burs.

Incremental removal of dentine from a coronal to apical direction. Straight k- type files are used in a large to small sequence with a clockwise rotation motion without apical pressure until the WL is reached.

Advantages
1. It produces less apical extrusion of debris. 2. It prevents excessive amount of bacteria and / or other debris coronally. 3. It allows irrigation to be effective to the complete depth that the cleaning & shaping instruments reach.

Flex-R file ( with a triangular CS and modified non-cutting tip ) is used in a reaming action. Clockwise rotation of file no more than 180 degrees. Anticlockwise rotation of file 120 degrees or greater with digital apical pressure until the desired WL is obtained.

Advantages :
1. Can be used in severe curved canals without transportation or ledge formation. 2. Can open calcified canals rapidly.

Concern :
1. Possibility of apical blockage. 2. Possibility of instrument fracture.

Profile series 29 % Quantic series 2000 Hero 642 Protaper Greater taper ( GT ) Light speed

1. Pulp tissues must be removed before any rotary shaping can be used. 2. Working time of each instrument in the canal should not be longer than 5 seconds. 3. Rotation should never be stopped in the canal. 4. Gentle apical pressure with a light in and out movement while working must be applied at all times. 5. Instrument should be cleaned and checked each time they are removed from the canal. 6. Copiously irrigated throughout the preparation. 7. Check files often for stress or deformation, and discard them frequently.

Piezoelectric
Low frequency ultrasonic vibrations ( 20 42 kHz ).

Generation of multiple low velocity currents of liquid ( 2.6 % NaOCl ) around the vibrating file. Violent agitation of irrigation solution allows cleaning of root canal walls. The file should be used in a gentle up and down motion. Useful in heavily infected canals.

Micro

Mega 1500

Frequency below 20 kHz.

Transmit oscillation to the tip of a file.

Should be accompanied by irrigation ( NaOCl )

Step-back technique ( Clem 1969 )

Serial preparation: Use of a series of progressively larger instruments which fit successively further away from the apical foramen A small file is reused at working length to ensure canal patency Master apical file is inserted to full working length

Points to remember
The canal should retain its preoperative shape Keep instruments & irrigants within the confines of root canal system Sequential usage of instruments Copious irrigation during preparation

Irrigation
      Eliminate microorganisms Flush out debris lubricate root canal instruments Dissolve organic debris Sodium hypochlorite is the most commonly used Chlorhexidine, saline, water, anesthetic solution and EDTA

1. Dissolution of debris : Concentration of solution, volume, time of contact, temperature, mechanical action, surface area and the structural integrity of pulpal tissues can affect the dissolving ability of an endodontic irrigant. 2. Antibacterial activity. 3. Non toxicity to periapical tissues. 4. Flushing out organic and inorganic debris : volume of irrigant solution, size of canal, needle size and the depth of penetration into the root canal can affect the ability of any solution physically to flush out loose debris. 5. Low surface tension : ST : Forces between molecules that produces a tendency for the surface area of a liquid to decrease.

6. Removal of smear layer : SL : A layer of debris, composed of both organic and inorganic materials, remaining on canal walls after endodontic instrumentation. 7. Lubrication of endodontic instruments.

Sodium hypochlorite ( NaOCl )

1. Broad spectrum antimicrobial activity. 2. Solvent ability for both necrotic & vital tissues. 3. Concentration ranges between 0.5 % - 5.25% . 4. Can be extremely cytotoxic & should be used with caution.

Chlorhexidine ( CHX )
1. Significant antibacterial activity. 2. Low toxicity to periapical tissues. 3. Can be used in teeth with patent apices. 4. No tissue dissolving ability. 5. Concentration ranges between 0.2% - 2.0% .

Ethylenediaminetertraacetic acid ( EDTA )

1. Chelating agent. 2. Soften dentine and remove smear layer. 3. Not efficient in dissolving pulpal remnants. 4. Not effective on Gram positive species. 5. Variations : REDTA : 17% EDTA + sodium hydroxide + water. RC Prep : 15% EDTA + 10% urea peroxide + carbowax. EDTAC : 17% EDTA + cetrimide.

Hydrogen peroxide
1. Foaming action helps debris removal. 2. The nascent oxygen released can destroy some bacteria. 3. Bleaching action on discolored teeth. 4. Low ability to dissolve necrotic tissues. 5. Very limited antimicrobial activity. 6. Concentration : 3% .

Other types
1. Isotonic saline solution ( 0.9% NaCl ). 2. Sterile distilled water. 3. Glyoxide ( 10% carbamid peroxide in an anhydrous glycerine base. 4. Castor oil based irrigants. 5. Bis dequalinium acetate ( BDA ). 6. Electro chemically activated water ( ECA ).

1. Effective infection control procedures before RCT. 2. Flushing of pulpal chamber with NaOCl. 3. Irrigation should be performed slowly without undue pressure. 4. Needle is bent at angle that allows easy access. 5. Frequent exchange of irrigant & use of large quantities.

1. Eliminate any remaining bacteria after canal instrumentation. 2. Reduce inflammation of periapical tissues & pulpal remnants. 3. Render canal contents inert & neutralise tissue debris. 4. Act as a barrier against leakage from temporary filling. 5. Help to dry persistently wet canals.

1. Phenolics. 2. Aldehydes. 3. Halogens. 4. Calcium hydroxide. 5. Antibiotics.

1. CMCP, thymols, eugenol, creosate, cresol. 2. High toxicity to efficacy ratio. 3. Limited antibacterial effect.

1. Formocresol, gluteraldehyde, formaldehyde. 2. Have mutagenic & carcinogenic potential.

1. NaOCl, iodine potassium iodide. 2. Potent oxidising agents with rapid bactericidal effects. 3. Dissolve necrotic tissue & debris. 4. Toxicity, staining, allergy.

1. Calasept, vitapex, hypocal, reogan. 2. Creation of an environment for healing of pulpal or periapical tissues. 3. Antimicrobial effect. 4. Elimination of apical seepage ( weeping ). 5. Induction of calcified tissue formation.

1. Penicillin, sulpha preparations, metronidazol, tetracycline clindamycin. 2. Sensitization, drug resistance & limited spectrum.

1. Intracanal environment. 2. Duration. 3. Toxicity. 4. Distribution. 5. Taste & smell.

Obturation of RC system
Objectives: 1. To prevent the passage of microorganisms and fluid along the root canal 2. To fill the whole root canal to block the portals of exit to the periapex, dentinal tubules and the accessory canals When to fill ? 1. Asymptomatic tooth ( No pain, swelling OR tenderness ) 2. Dry canals 3. Intact temporary filling

Gutta percha
Is an unsaturated polymer of isoprene Rigid at ordinary temperature It becomes pliable at 25-30 C, soften at 60 C and melts at 100 C with partial decomposition Soluble in chloroform, eucalyptol, benzene & xylene When exposed to light and air, it undergoes degenerative oxidation and becomes brittle

Advantages of GP
1. It is compactable and has good adaptability to root canal walls 2. It can be softened by heat OR organic solvents 3. It is inert, non-allergic and bio-compatible 4. It is radio opaque 5. Doesnt discolor the tooth structure 6. It has dimensional stability 7. It can be easily removed from the canal

Disadvantages
1. It lacks rigidity 2. It lacks adhesiveness 3. It can be stretched

Root canal sealers

Zinc oxide eugenol- based Rickerts Tubliseal Grosmans Endomethasone Calcium hydroxide- based Apexit Sealapex Resin- based AH26 Diaket

Hydron

Glass ionomer- based Ketac- endo

Lateral condensation ( Callahan 1914 )

Placing a master gutta percha point, coated with sealer, to the predetermined canal length Accessory gutta percha points are then condensed laterally into the canal using lateral spreaders until the canal is fully obturated Cone fit : 1. Guided by MAF 2. Having good tug-back 3. Fit to the full working length of the canal 4. Impossible to be forced beyond the apical foramen

Disadvantages of LC technique
1. Time consuming 2. Difficult in fine, curved canals 3. Pressure exerted can deform the root canal and create micro- fractures within dentin 4. Can cause vertical root fracture 5. It creates non- homogeneous mass with void formation