Classic Endodontic Training

Treatment Rationale

• Endodontic residency encompasses comprehensive literature reviews and clinical skill development
• Endodontic residents complete 300 cases and are trained consistently by board-certified endodontists
• Continuing education attendance and practice are crucial components

Clinical Treatment

• Restorability is determined collaboratively by oneself and faculty, not solely the endodontist
• Root canal treatments can be performed on any tooth when deemed appropriate
• Posts are used only to retain the core structure of the tooth
• An average of six cases is completed per student, a standard maintained since 1975

Instruction Philosophy: Classic Endodontic Training

• Classic endodontic training involves stainless steel hand files, specifically K files and Hedstrom files
• K files are used with a quarter-turn-and-pull motion instead of a corkscrewing motion
• Hedstrom files employ a pull motion for effective shaping
• Cold lateral compaction obturation and NaOCl irrigation are integral

Instruction Philosophy: Modern Endodontic Training

• Modern endodontic training incorporates Nickel-Titanium rotary instrumentation, which poses a risk of breakage
• Warm vertical compaction is utilized
• Adjuncts to treatment include EDTA, activation of irrigants using sonic devices, and CBCT imaging

Transition to Clinical Practice

• The clinic is where educational experiences are uniquely applied
• Dentistry blends art and science
• Patient interviews are essential for gathering information to aid in diagnosis

Transition to Patient Care

• The move from preclinical exercises to real patient care is significant
• Requires consideration of the patient's medical status
• Diagnosis and prognosis are provided to obtain informed consent
• Tooth anatomy varies and impacts case management
• Anesthetic choice is tailored to the case and technique
• Managing the patient includes bathroom breaks, bite blocks, and proper dental dam placement to expose the nose
• Multi-visit procedures are common and typically require 2-3 appointments

Treatment Verification Steps

• Verification steps include reviewing medical history, radiographs, and testing results
• Critical steps are diagnosis, prognosis, obtaining informed consent, administering anesthesia, isolation, and access
• Canal identification and electronic apex locator (EAL) use are essential, along with glide path evaluation
• Other steps include orifice opening, recapitulation, radiographic estimation of working length
• Crown-down NiTi rotary shaping, master cone radiograph, and obturation evaluation
• Final steps include placing an interim restoration and taking a final radiograph

Case Complexity Assessment

• General dentists complete 80% of root canal treatments
• An easy endo case is a misnomer
• Factors to consider include difficulty level, patient management, and long-term prognosis
• An AAE case selection form may be used

Clinical Protocol

• Prior to treatment obtain a medical history
• Elicit the chief complaint via direct quote, such as "My front tooth hurts"
• Evaluate pain using a 0-10 VAS scale
• Have patients point to the specific area of concern
• Radiographs should be taken on the same day if there are changes since the last visit
• Radiographs should be straight and shift periapical, extending 2 mm past the apex, with the alveolar crest visible

Sensitivity Testing

• Testing procedures include transillumination and electric pulp testing (EPT)
• Use a water bath with cold or hot water, verifying temperature with a thermometer
• Soft tissue findings may reveal a parulis or swelling that can be intraoral or extraoral
• Tooth assessment includes checking for cracks and assessing remaining structure

Pulpal Diagnosis

• Diagnostic categories include normal pulp, reversible pulpitis, and irreversible pulpitis (symptomatic and asymptomatic)
• Additional diagnoses include pulp necrosis, previously initiated therapy, and previously treated conditions
• Further diagnostic considerations are normal periapical tissue, symptomatic and asymptomatic apical periodontitis
• Other applicable diagnoses are chronic and acute apical abscess and condensing osteitis

Layman’s Prognosis

• Prognosis can be described as excellent, good, fair, poor, or hopeless
• It can also be classified as favorable or unfavorable

Prognosis: Healing Rates

• Vital teeth have a 90-95% chance of healing
• Non-vital teeth with a lesion have an 80-85% chance of healing
• Retreatment without a lesion has a 70-90% chance of healing
• Retreatment with a lesion has a 70-75% chance of healing

Apicoectomy

• Apicoectomy with retreatment has a 90% healing rate
• Apicoectomy without retreatment has a 50% healing rate

Root Canal: Layman's Explanation

• The tooth's interior is cleaned out, and a filling material is placed inside, resembling rubber

PARL: Layman's Explanation

• A dark area in the bone usually implies nothing serious
• PARL is bone defect and breakdown, often caused by infection that may present as a granuloma or cyst
• PARLs can heal with a root canal
• Biopsies are not always needed
• Radiographic improvement may takes six months to a year
• Rarely indicates a different type of pathology like a tumor

Case Presentation Summary

• Case presentations should include: medical history, sensitivity test results, diagnosis, proposed treatment, and anticipated challenges

Nitrous Oxide

• Nitrous oxide may be needed because the idea of a root canal can be anxiety-provoking
• It can reduce blood pressure and aid anesthesia

Clinical Treatment Considerations

• Preparation and organization reduce stress during clinical treatment
• Chaos can increase patients' stress and reduce their confidence

Anesthesia: Topical Anesthetics

• Consider possible allergens, dyes, and sweeteners in topical anesthetics
• Be aware of benzocaine/topical anesthetic concerns and methemoglobinemia
• Lollicaine is generally well-tolerated but should not be used in children under 2 years old

Anesthesia: Injectable

• The initial anesthetic of choice is 2% lidocaine with 1:100,000 epinephrine because it is safer
• Readministration for pulpal anesthesia is common
• Secondary anesthetics include 4% articaine, limited to buccal infiltration due to paresthesia risk
• Other choices are 3% mepivacaine, which has no epinephrine and is Class C for pregnancy
• Bupivacaine 0.5% with 1:200k epinephrine is for symptomatic patients
• Confirm profound anesthesia with cold testing prior to isolation

Anesthesia: Pregnancy

• The FDA classifies drugs based on risk to pregnant women and fetuses
• Lidocaine is considered a safe, Category B drug
• Mepivacaine and bupivacaine are Category C drugs to be used with caution
• During the first trimester and lactation, local anesthesia should be administered without a vasoconstrictor
• Avoid idiosyncratic reactions in the fetus or neonate
• Prilocaine is contraindicated due to the risk of the fetus developing methemoglobinemia

Pulpal Anesthesia

• Pulpal anesthesia onset typically takes 10-30 minutes
• Success in inflamed teeth can be between 25-40% in the MN posterior with an IANB block

Adjunct Anesthetic Techniques

• Intraligamentary injections involve using 2% lidocaine or 3% mepivacaine
• Do not use articaine or bupivacaine
• Intraosseous injections provide a 70-90% chance of profound anesthesia
• Heat generation during intraosseous injections can cause tissue necrosis
• Separating the alveolus can occur if the port is not carefully removed

Anesthesia Duration

• Lidocaine 2% with 1:100k epi lasts about 60 minutes in non-inflamed tissues
• Bupivacaine 0.5% with 1:200k epi lasts up to 6 hours
• Carbocaine 3% without epi lasts 20-40 minutes
• Septocaine with 1:100k epi lasts about 60 minutes in non-inflamed tissues

Isolation

• Single-tooth isolation is most often used
• Rubber dam should stay in place until access is sealed to prevent bacterial leakage
• Remove the frame only for radiographs

Access

• Do not blow air once access is started to avoid air embolism
• Use a 557 or 245 bur for efficient removal of decay and restoration
• Switch to a low-speed #6 round bur for refining access (small round bur not recommended)
• Caries removal to sound tooth structure often locates the chamber and canals
• Remove amalgam to sound tooth structure, but avoid getting the amalgam entering canals
• Interim restoration may be necessary before entering the canal to seal it

Endo Z Bur

• Used after the chamber is located
• It has a non-cutting tip

Radiographs

• Frequent radiographs are needed in endo
• Evaluate progress with radiographs during treatment

Cleaning and Shaping

• There is no magic file system

Irrigation

• Use NaOCl, saline, chlorhexidine gluconate, and/or EDTA
• Use constant motion with irrigants
• Use an up-and-down motion with slow flow rate and keep moving
• Do not engage the tip in the canal or it will cause extrusion out of the apex or cause a fracture of the irrigation tip

Length Determination

• Use accessed teeth, EAL, and radiographs to establish working length
• Trends show files may be longer than assessed
• Better to be in than out, thus better to be short than long

Two-Step Canal Protocol

• Place CaOH in the canal with a file, not a metal tip, to avoid extrusion beyond the apex
• Medicate the chamber/canal between appointments for 7-10 days
• Use a sterile foam or Teflon tape spacer in the chamber

Obturation

• Coat gutta-percha with sealer without pumping it in
• Goal to avoid extrusion of sealer beyond the apex
• Use 1mm short of radiograhic apex, as this is realistic
• Adapt gutta-percha points with a gutta guage as they are inconsistent in stated sizes
• Carrier-based obturation is not recommended due to poor results

Interim Restoration

• Glass ionomer seals well
• IRM needs mechanical lock
• Duotemp is similar to GI but light cure
• Cavit seals well but is for short term use
• Composite is uncommon

Advanced Endodontic Techniques for residency

• Include retreatment, second molar endo, post removal, and seperated file management
• Also includes apicoectomy, microscope use, perforation repair, and intraosseous injections
• Includes activation of irrigants through sonic or ultrasonic methods and the use of a rationale notebook

Practice Philosophy

• Each dentist may have differing opinions and philosophies
• Clinical experience should be supported by evidence-based rationale
• Evidence-based practice is encouraged

Clinical Competency

• Steps must be completed without assistance
• Clinicians will be held to standard following graduation
• Steps must be completed and verified by staff

Cracked tooth

• If a cracked tooth is identified, it should be checked with a tooth slooth
• Cracked teeth are usually not visible but may need to be extracted
• Conduct a CBCT to check for defect
• Diagnosis may take multiple visits to locate