INBDE Bootcamp High-Yield Endodontics PDF

INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Basics and flowcharts An endodontic diagnosis consists of a pulpal diagnosis and a periapical diagnosis, which are determined separately.  INBDE Bootcamp...

INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Basics and flowcharts An endodontic diagnosis consists of a pulpal diagnosis and a periapical diagnosis, which are determined separately.  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Pulpal diagnosis Diagnosis Clinical presentation Pulp testing Radiographic presentation Radiograph Treatment Normal pulp Asymptomatic Vital Normal apical anatomy No treatment May have mild, EPT: + Intact lamina dura transient response to to Cold test: +, thermal, cold or electrical non-lingering stimuli Reversible pulpitis Symptomatic Vital Normal apical anatomy, Remove irritant → pulp Irritant (i.e. caries, EPT: + no evidence of resorption reverts to normal defective restoration) Cold test: ++, or caries close to pulp Analgesics causes reversible non-lingering inflammation Short, sharp pain that subsides when stimulus is removed ★ Pain from A-delta fibers Symptomatic irreversible Pulp is irreversibly Vital Deep caries or large Root canal treatment pulpitis damaged due to an irritant EPT: + restoration approximating Analgesics Pain is spontaneous, Cold test: ++ or +++, the pulp lingering, or referred, lingering No or minimal periapical wakes patient up at night changes, thickening of (postural changes) PDL space may be ★ Pain from C fibers evident Asymptomatic irreversible Pulp is irreversibly Vital Deep caries Root canal treatment pulpitis damaged due to an irritant EPT: + approximating the pulp No pain, evidence of Cold test: +, No or minimal periapical pulpal involvement must be non-lingering changes, thickening of present (i.e. caries, trauma) PDL space may be evident  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Pulpal diagnosis Diagnosis Clinical presentation Pulp testing Radiographic presentation Radiograph Treatment Pulp necrosis Death of pulp tissue Necrotic Normal or widened PDL, Root canal treatment (partial or total) due to EPT: - periapical radiolucency interruption of pulpal blood Cold test: - (PARL) may be present supply Asymptomatic pulp but may have history of symptoms Crown discoloration can occur Previously initiated Partial or incomplete EPT: - Intracanal medicament Complete root canal therapy previous endodontic Cold test: - present in canals and/or treatment treatment (pulpotomy, pulp chamber pulpectomy) Previously treated Canals previously EPT: - Obturation material Dependent on apical obturated Cold test: - present diagnosis: Normal apex: no treatment Persisting apical lesion: retreatment or endodontic microsurgery  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Apical diagnosis Diagnosis Clinical presentation Radiographic presentation Radiograph Treatment Normal apical tissues Asymptomatic apices Normal apical anatomy Determine pulpal status Lamina dura intact and treat accordingly Symptomatic apical Inflammation around apex of the tooth with inflammatory Normal or widened PDL, Determine pulpal status periodontitis infiltrate within the PDL PARL may be present and cause (which may May or may not respond to pulp testing include caries, trauma, or Pain to palpation and/or percussion high occlusion) and treat accordingly Analgesics Asymptomatic apical Inflammation around apex of tooth due to pulpal necrosis, PARL Dependent on pulpal periodontitis negative response to pulp testing diagnosis: Asymptomatic apices Pulp necrosis: root canal treatment Previously treated: retreatment or endodontic microsurgery Acute apical abscess Rapid swelling and/or fluctuance Normal or widened PDL, Dependent on pulpal Pain to biting pressure, percussion and/or palpation PARL may be present diagnosis: Pus formation and swelling of associated tissues Since an acute abscess Pulp necrosis: root canal happens quickly, usually treatment no PARL is present Previously treated: retreatment or endodontic microsurgery Antibiotics and analgesics  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Apical diagnosis Diagnosis Clinical presentation Radiographic presentation Radiograph Treatment Chronic apical abscess Asymptomatic apices with no swelling PARL (can be traced with Dependent on pulpal Draining sinus tract gutta-percha) diagnosis: Pulp necrosis: root canal treatment Previously treated: retreatment or endodontic surgery Antibiotics if evidence of systemic symptoms Condensing osteitis Localized bony reaction to low-grade inflammatory Periapical radiopacity of Determine pulpal status stimulus surrounding bone and cause and treat Asymptomatic apices accordingly ○ Cause may include caries, trauma, or other sources of inflammation Tooth biology Dentin and pulp biology Types of tooth pain Dentin A delta fibers Primary dentin: outer layer of dentin that forms before root formation Responsible for dentinal pain Secondary dentin: inner layer of dentin that forms after root formation Sharp, transient, “first pain” Tertiary dentin: forms in response to a stimulus (i.e. caries) in order to protect pulp Responds to cold temperatures Sclerotic dentin: dentin calcified tubules that form in response to caries or aging Reactionary dentin: tertiary dentin that is secreted by original odontoblasts, in response C fibers to minor damage Responsible for pulpitis pain Reparative: tertiary dentin that is secreted by odontoblast-like cells, in response to Dull, throbbing, “second pain” major damage Responds to heat temperatures Hyperalgesia: increased response to pain Pulp Consists of connective tissue, nerves, blood vessels, and lymph Allodynia: decreased pain threshold, which causes pain to a normally non-painful stimulus Contains fibroblasts, odontoblasts, undifferentiated mesenchymal cells No collateral circulation → affects ability to fight infection Referred pain: pain that spreads to another region separate from the site of stimulation ○ I.e. pain in mandibular molars can refer to the preauricular area due to shared V3 innervation  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Root canal treatment Access Instruments Goals of pulp access Hand files Conserve tooth structure 0.02 mm taper Deroof pulp chamber Stainless steel or nickel titanium Expose pulp horns and orifices Every 1 mm away from the file tip, the file diameter increases 0.02 mm Straight line access to the orifices and apex Dx = D0 + (Taper)*(X) Dx = file diameter at X distance D0 = file size/100 Taper = 0.02 X = distance from file tip Example: size 40 hand file, diameter 16 mm from tip D0 = 0.4, Taper = 0.02, X = 16 Dx = 0.4 + (0.02)*(16) = 0.72 mm Rotary files 0.04 or 0.06 mm taper Nickel titanium (more flexible) Fits into latch handpiece Universal color scheme: Color File Number File Number Pink 6 Gray 8 Purple 10 White 15 45 Yellow 20 50 Red 25 55 Blue 30 60 Green 35 70 Black 40 80  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Percentage of canals Maxillary tooth # of canals (%) Mandibular tooth # of canals (%) Central 1C - 100 Central 1C - 75 2C - 25 Lateral 1C - 100 Lateral 1C - 85 2C -15 Canine 1C - 100 Canine 1C - 90 2C - 10 1st premolar 1C - 8 2C - 85 3C - 7 1st premolar 1C - 70 2C - 30 2nd premolar 1C - 55 2C - 45 2nd premolar 1C - 90 2C - 10 1st molar 3C - 35 4C - 65 1st molar 2C - 10 3C - 55 4C - 35 Mesiobuccal root: 1C - 30 2C - 60 Mesial root: 1C - 3 2C - 97 Distobuccal root: 1C - 100 Distal root: 1C - 70 2C - 30 Palatal root: 1C - 100 2nd molar 3C - 65 4C - 35 2nd molar 2C - 15 3C - 75 4C - 10 Mesiobuccal root: 1C - 65 2C - 35 Mesial root: 1C - 10 2C - 90 Distobuccal root: 1C - 100 Distal root: 1C - 90 2C - 10 Palatal root: 1C - 100 Reference percentages in the table above vary based on the source. Use the percentages in the table when answering canal percentage questions for the INBDE. Note that percentages will not always add up to 100%. Instrumentation Number of canals Goal of instrumentation is to file, shape, and clean each canal of the tooth until it is to Maxillary tooth Most likely # of Mandibular tooth Most likely # of working length canals canals Working length = 0 to 2 mm from the apex of the tooth (ideally 1 mm) Central 1 Central 1 Crown down technique Done with rotary files Lateral 1 Lateral 1 Coronal ⅓ of canal is shaped with largest file Use smaller file for the middle ⅓ Canine 1 Canine 1 Use even smaller for the apical ⅓, to working length Step back technique 1st premolar 2 1st premolar 1 Done with hand files Coronal ⅓ shaped with larger file to achieve coronal flaring 2nd premolar 1 2nd premolar 1 Smaller file is inserted and filed to working length Larger files are used sequentially to slightly shorter than working length 1st molar 4 (2 mesiobuccal) 1st molar 3 (2 mesial, 1 distal) 2nd molar 3 (1 mesiobuccal) 2nd molar 3 (2 mesial, 1 distal)  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Root canal treatment Irrigation Obturation Canals should be irrigated between each file Seals the root canal and prevents entrance of bacteria Sodium hypochlorite (NaOCl) Filling material: gutta-percha and sealer Also known as bleach Sealer: zinc oxide eugenol or bioceramic sealer Dissolves the organic material (bacteria) Warm vertical condensation Ethylenediaminetetraacetic acid (EDTA) Seat gutta-percha to working length Lubricant that dissolves inorganic material (dentin smear layer) Heated plugger instrument condenses the gutta-percha Chelating agent Cold lateral condensation Chloroform Seat gutta-percha to working length No longer in use Finger spreader creates room in the canal to place accessory cones Historically used to dissolve gutta-percha in endodontic retreatment A temporary restoration (i.e., Cavit) is then placed on top of the gutta-percha until the tooth can be restored with a final restoration. Treatment planning Types of endodontic treatment Surgical treatment 1. Root canal treatment Incision & drainage First line treatment for irreversible pulpitis, pulp necrosis, apical periodontitis Indicated when an infection is fluctuant and localized to one area Orthograde → accesses canal from coronal part of tooth Incision of the soft tissue, drainage of purulence, release of pressure Drain can be placed for severe infection 2. Retreatment Indicated when root canal treatment has failed and there is a persistent infection Periapical microsurgery Re-access canal, remove previous materials, re-instrument, and re-obturate Also known as apicoectomy Resect ~ 3 mm of a diseased root tip 3. Surgical endodontics (apicoectomy) Instrumentation of the apex Indicated when root canal treatment has failed and the infection is limited to the apex of Retrofill with mineral trioxide aggregate (MTA) the tooth Microsurgical procedure that removes infected tissue at the apex of the tooth Retrograde → access from the apex of the tooth, instrumentation, and filling Adjunctive materials Posts Calcium hydroxide (CaOH) Used to restore endodontically-treated teeth when coronal Kept in place between root canal appointments as a medicament tooth structure is lost Stimulates secondary odontoblasts to form tertiary dentin ○ Post extends into root canal to help retain a core High pH kills bacteria, cauterizes tissue ○ After root canal therapy, gutta-percha is removed until 5 Resorbs over time mm remains → then a post is placed in the canal Ideal length is ⅔ the length of the tooth root Mineral trioxide aggregate (MTA) Ideal diameter is up to ⅓ the diameter of the tooth Stimulates cementoblasts to form cementum Post failure Sets in moist environments, long setting time ○ Ceramic posts may decement or debond Nonresorbable ○ Metal posts can cause root fracture Antimicrobial  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Treatment planning Vital pulp therapy Non-vital pulp therapy Indirect pulp cap Pulpectomy For deep caries close to pulp, but no pulp exposure Removal of all pulp tissue in a tooth, both coronal and radicular Placement of CaOH or resin modified glass ionomer (RMGI) on carious dentin < 1 mm For teeth with pulp exposure that are non vital and restorable from pulp Primary second molars for space maintenance Helpful in permanent teeth as temporary pain relief for irreversible pulpitis, until full RCT Direct pulp cap can be done For small pulp exposure < 24 hours, carious or mechanical exposure < 1 mm Placement of CaOH over exposed pulp, to form tertiary dentin Root canal therapy Removal of all pulp tissue in tooth, both coronal and radicular, with a canal filling Partial (Cvek) pulpotomy Pulpectomy + cleaning, shaping, filling the canal Removal of small portion of the coronal diseased pulp Traumatic pulp exposure >/= 24 hours, carious or mechanical exposure < 4 mm in size Apexification Standard treatment for immature permanent teeth with traumatic exposure Performed on immature teeth with dead or dying pulp after the pulp has Pulpotomy been removed Removal of deep caries and inflamed pulp from coronal pulp chamber Goal is to allow the roots to finish For teeth with pulp exposure that are forming, to obtain an apical barrier vital and restorable after a root canal or pulpectomy Traumatic exposure >/= 72 hours Generally only done in primary teeth Apexogenesis Done on exposed or diseased pulp to maintain pulp vitality in immature teeth that do not have fully formed roots Placement of CaOH or MTA on the pulp Endodontic complications Ledge formation Instrument separation Perforation Ledge irregularity that has been instrumented into the File breaks inside a root canal Coronal perforation wall of a root canal Occurs due to: Crown is perforated during access preparation Occurs due to: ○ Force Occurs due to inaccurate bur angulation ○ Lack of straight line access ○ Too large of a file Furcal perforation ○ Narrow, long, or curved canals ○ Lack of irrigation, lubrication Furcation of tooth is perforated ○ Insufficient irrigation or lubrication ○ Old files that are weak and prone to fracture Occurs during the search for pulpal orifices Transportation may occur when files straighten out a Treatment curved canal ○ Broken file may be left in place, and the canal is Strip perforation ○ Due to tendency of file to return to original linear filled around it Stripping the dentin of a canal due to too much shape The later the breakage occurs, the better the prognosis coronal flaring of a canal while filing Treatment ○ More instrumentation leads to more bacteria Often occurs in mandibular molars ○ Use a smaller file to bypass the ledge removed Root perforation Perforation of the root, making an artificial apical foramen or lateral perforation Causes hemorrhage and pain Treatment: repair with MTA  INBDE Bootcamp High-Yield Endodontics | Bootcamp.com Trauma Ellis classification Cracked tooth syndrome Uncomplicated fracture Class I: simple fracture (enamel) Symptoms: can be asymptomatic, pain with biting and No pulp involvement Class II: crown fracture (enamel, dentin) release, sensitivity to hot and cold Treatment Class III: crown fracture (enamel, dentin, pulp) Typically a mesiodistal crack in posterior teeth ○ Enamel fracture → smooth edges Class IV: non-vital tooth, with or without crown involvement Detect with dye, transillumination, bite stick ○ Enamel and dentin fracture → restoration Class V: avulsion Treatment Class VI: root fracture, with or without crown fracture ○ Healthy pulp → splint, observe, or crown Class VII: displacement of tooth, no crown fracture ○ Diseased pulp → RCT and crown Complicated fracture Horizontal root fracture Vertical root fracture Pulp involvement Fracture of the root, in which apical segment is not Typically starts at apex and travels Treatment displaced but the coronal segment is displaced coronally ○ < 24 hours → direct pulp cap Treatment May be due to post or ○ ≥ 24 hours → partial pulpotomy ○ Vital tooth → splint over-condensation during RCT ○ ≥ 72 hours → pulpotomy Coronal fracture: splint 6-12 weeks Common sign is J-shaped or Mid-root fracture: splint 3 weeks teardrop radiolucency Apical fracture: splint 2 weeks Hopeless prognosis ○ Necrotic tooth → RCT Treatment ○ Single root → extract ○ Multiple roots → extract or resect the fractured root Calcific metamorphosis External root resorption Response to trauma Response to trauma and damage to cementoblasts Odontoblasts form reparative dentin inside the pulp Replacement resorption chamber ○ Also called ankylosis Tooth appears yellow or orange clinically ○ Replacement of PDL with bone Pulp canal shrinks due to dentin deposition Cervical resorption Internal root resorption ○ Resorption at the CEJ due to a subepithelial sulcular infection Response to trauma and damage to ○ Tooth appears pink clinically (pink tooth of odontoblasts Mummery) due to granulation tissue in coronal pulp Products of necrotic pulp cause Inflammatory root resorption resorption within the tooth ○ Products of necrotic pulp cause resorption Margins will be sharp, well-defined ○ Ragged, poorly defined margins on radiograph Can be treated with RCT Can present as pink tooth of ○ Travels from inside the pulp to the outside Mummery: crown has pink hue due to granulation tissue in the coronal pulp (pictured in external root resorption)