Endodontics Lecture Notes 2024 PDF

Lec 1 Endodontics Introduction and Scope of Endodontics By: Meelad Joffrey Dr.Cube I Fourth Stage I 2024 Introduction and Scope of Endodontics “En” is a Greek word for “Inside” and Odont is the Greek word for “Tooth”. Endodontic treatment...

Lec 1 Endodontics Introduction and Scope of Endodontics By: Meelad Joffrey Dr.Cube I Fourth Stage I 2024 Introduction and Scope of Endodontics “En” is a Greek word for “Inside” and Odont is the Greek word for “Tooth”. Endodontic treatment treats the inside of the tooth. Endodontics is the branch of clinical dentistry that deals with the prevention, diagnosis and treatment of the pathosis of the dental pulp and peri-radicular tissue and their morphology. Studying Endodontics need you to understand pulp biology, etiology, diagnosis, treatment, and prevention of the diseases and injuries of the pulp and associated periradicular tissues. Figure 1: Anatomy of the root canal system www.drcube.org The main aim of endodontic therapy involves the prevention and treatment of periapical pathosis through the following processes: i. Maintain the vitality of the compromised pulp in vital teeth. www.drcube.org The main aim of endodontic therapy involves the prevention and treatment of periapical pathosis through the following processes: ii. Preserve and restore the tooth with a necrotic pulp. iii. Preserve and restore the tooth with a periapical lesion. www.drcube.org The main aim of endodontic therapy involves the prevention and treatment of periapical pathosis through the following processes: iv. Preserve and restore the teeth which have failed the previous endodontic therapy (endodontic retreatment option), to allow the tooth to remain functional in the dental arch. www.drcube.org Objective of Endodontic Treatment The primary objective of endodontic therapy is to create a biologically acceptable environment within the root canal system which allows the healing and continued maintenance of the health of the peri- radicular tissue. This objective can be achieved by eliminating the bacteria (the source of infection) from within the root canal system (in the coronal pulp chamber and radicular part of the root canal system), and by sealing the root canal and tooth to prevent re- infection. www.drcube.org The source of bacteria usually (in most cases) is from dental caries initially which penetrate deep by deep carious lesions until they reach the pulp chamber resulting in infection of the pulp. If the infection was not treated it will result in necrosis of the pulp and infection of the whole root canal spaces which will progress (if not treated) into the periapical tissue resulting in infection of the bone in the periapical area which is called apical periodontitis. Endodontics has been defined as an art as well as the science of clinical dentistry because despite all Figure 2: Source of infection the factual scientific foundation on which endodontics is based, providing an ideal endodontic treatment is an art by itself. www.drcube.org Endodontic treatment encompasses procedures that are designed to maintain the health of all or part of the dental pulp and periapical tissue. When the dental pulp is diseased or injured, treatment is aimed at preserving normal peri- radicular tissues. When apical periodontitis has occurred, treatment is aimed at restoring the peri-radicular tissues to health: this is usually carried out by root canal treatment, occasionally in combination with surgical endodontics. www.drcube.org Scope of Endodontics Scope of endodontics includes the following procedures: 1. Vital pulp therapy (pulp capping, pulpotomy). 2. Diagnosis and differential diagnosis of oro-facial pain. 3. Non-surgical root canal treatment of teeth with or without periradicular pathology of pulpal origin. 4. Surgical root canal treatment of teeth with or without periradicular pathology of pulpal origin. 5. Regenerative endodontic. 6. Apexogenesis, and apecification. 7. Management of avulsed teeth (replantation). 8. Endodontic implants. 9. Root end resections, hemisections and root sections. 10.Retreatment of teeth previously treated endodontically. 11.Bleaching of non-vital discolored teeth. 12.Coronal restorations of endodontically treated teeth using post and cores. www.drcube.org Indications for Root Canal Treatment Root canal treatment may be carried out on all patients where other dental procedures may be undertaken. Specific indications include: 1 Teeth that have irreversibly infected or necrotic pulp with or without apical periodontitis. 2 Elective devitalization, e.g., to provide post space, before construction of overdenture, doubtful pulp health before restorative procedures, the likelihood of pulpal exposure when restoring a (misaligned) tooth and before root resection or hemisection. www.drcube.org  Contraindications for Root Canal Treatment 1 Teeth that cannot be made functional nor restored. 2 Teeth with insufficient periodontal support (loss of supporting bone due to periodontal infection). 3 Teeth with poor prognosis, uncooperative patients, or patients where dental treatment procedures cannot be undertaken. 4 Teeth of patients with a poor oral condition that cannot be improved within a reasonable period. www.drcube.org Histology of Dental Pulp The dental pulp is the soft tissue of mesenchymal origin located in the center of the tooth. It consists of specialized cells, and odontoblasts arranged peripherally in direct contact with the dentin matrix. This close relationship between odontoblasts and dentin is known as the “pulp-dentine complex”. The pulp is a connective tissue system composed of cells, ground substances, fibers, interstitial fluid, odontoblasts, fibroblasts and other cellular components. www.drcube.org The pulp is a microcirculatory system consisting of arterioles and venules as the largest vascular component. When pulp is examined histologically, it can be distinguished into four distinct zones from the periphery to the center of the pulp as shown in the Figure. www.drcube.org The zones are as follows: A. The Odontoblastic Layer at the Pulp Periphery: Odontoblasts consist of cell bodies and cytoplasmic processes. B. Cell-Free Zone of Weil: Central to odontoblasts is sub-odontoblastic layer, which contains plexuses of capillaries and small nerve fibers C. Cell-Rich Zone: It contains fibroblasts, undifferentiated cells which maintain the number of odontoblasts by proliferation and differentiation D. Pulp Core: It contains large vessels and nerves from which branches extend to peripheral layers. www.drcube.org Anatomy of Dental PULP The pulp lies in the center of the tooth and shapes itself into a miniature form of the tooth. This space is called the pulp cavity which is divided into a pulp chamber and root canal/a starting from the orifice to the apical foramen. There are also accessory and lateral canals. The roof of the pulp chamber consists of dentin covering the pulp chamber occlusally. Canal orifices are openings in the floor of the pulp chamber leading into the root canals. The shape of the root canal varies with the size, shape, and number of the roots in different teeth. www.drcube.org  Function of the Pulp The pulp performs four basic functions: 1. Formation of dentine 2. Nutrition of dentine 3. Innervation of tooth 4. Defense of tooth www.drcube.org  Root Canal Configuration The configuration of root canals is divided into four types: Type 1 A single canal leaving the pulp chamber and continuing as a single canal to the root apex and opening in a single apical foramen. It refers to 1-1. Type 2 Two canals leave the pulp chamber and then join each other at the apical third to open in a single apical foramen. It refers to 2-1. www.drcube.org  Type 3 Two canals leave the pulp chamber and continue as two canals to be opened in two separate apical foramina. It refers to 2-2. Type 4 A single canal leaving the pulp chamber, bifurcating at the apical third into two canals and opening in two apical foramina. It refers to 1-2. www.drcube.org  Basic Phases of Treatment There are three basic phases of treatment: 1 The Diagnostic phase in which the disease to be treated is “determined“ and the treatment plan developed. 2 The Preparatory phase in which the contents of the root canal are removed, and the canal is prepared to receive a filling material. 3 The Obliteration Phase in which the canal is filled or obliterated with an inert material to obtain an adequate seal as close as possible to C.D.J. (cemento-dentinal junction). If there is a defect in any phase, the endodontic treatment will not be succeeded. www.drcube.org Pulp and Peri-Radicular Pathology The etiology of pulpal diseases can be broadly classified into: I. Bacterial Irritant Bacteria, usually from dental caries, are the main source of injury to the pulpal and periradicular tissues and they enter either directly or through dentine tubules. www.drcube.org Modes of entry for bacteria to the pulp are as follows: 1. Through the carious cavity. 2. Through the dentinal tubules as in contamination during cavity preparation, through exposed root surfaces, and surfaces with erosion, abrasion and attrition. 3. Through the apical foramen as in advanced periodontitis where microorganisms reach the apical foramen and then the pulp. 4. Through the bloodstream (anachoresis: it is a process by which microorganisms get carried by the bloodstream from another source and localize on inflamed tissue). 5. Through faulty tooth restoration. 6. Through the extension of a periapical infection from the adjacent infected tooth. www.drcube.org Bacteria most often recovered from infected vital pulps are: Streptococci Lactobacillus Fusibacterium, etc. www.drcube.org II. Mechanical Irritants Examples of mechanical irritation include trauma, operative procedures, excessive orthodontic forces, subgingival scaling, and over-instrumentation using root canal instruments. III. Chemical Irritants Pulpal irritation may result from bacterial toxins or some restorative materials/conditioning agents. Peri- radicular irritation may occur from irrigating solutions, phenol-based intra-canal medicaments, or extrusion of root canal filling materials. www.drcube.org IV. Radiation Iinjury to the pulp Radiation therapy affects the pulps of fully formed teeth in patients exposed to radiation therapy. The pulp cells exposed to ionizing radiation may become necrotic, and there may occur vascular damage and the interference in mitosis of cells. www.drcube.org Classification of Pulp and Periapical Diseases Diagnosis of pulp and periapical disease is usually based on patient symptoms and clinical findings. Pulpal Disease Pathological conditions of the pulp can be classified into the following: 1- Reversible pulpitis (Pulpal Hyperaemia) 2- Irreversible pulpitis 3- Pulp necrosis 4- Pulp calcification www.drcube.org 1 Reversible Pulpitis (Pulpal Hyperaemia) A mild-to-moderate inflammatory condition of pulp caused by noxious stimuli in which the pulp is capable of returning to a normal state following removal of stimuli. Determination of reversibility is the clinical judgment that is influenced by the history of the patient and clinical evaluation. Etiology includes dental caries, trauma, after deep restoration, thermal and chemical injuries. www.drcube.org Symptoms:  Sharp momentary pain caused by cold.  Pain is not a spontaneous pain and needs an external stimulus and it subsides immediately after the removal of the stimulus.  Normal periradicular radiographic appearance on X-ray radiograph.  Teeth are not tender to percussion but sensitive to a cold stimulus. Treatment involves covering up exposed dentine, removing the stimulus, or dressing the tooth. www.drcube.org 2 Irreversible Pulpitis It is a persistent inflammatory condition of the pulp, symptomatic or asymptomatic, caused by a noxious stimulus. It has both symptomatic and asymptomatic stages in pulp. Irreversible pulpitis usually occurs as a result of more severe insults than reversible pulpitis. It may develop as a progression from a reversible state. Histologically pulp with irreversible inflammation is characterized by the presence of an area of liquefaction necrosis compared to a pulp with reversible inflammation. www.drcube.org Irreversible Pulpitis is Divided into: a) Symptomatic Irreversible Pulpitis (previously known as acute irreversible pulpitis) This condition is usually associated with acute symptoms which include:  Severe pain develops spontaneously or from stimuli that may last from minutes to hours after exposure to cold or hot stimuli, which is sharp, throbbing, intermittent, or continuous.  Pain exacerbated on bending down or lying down due to a change in intrapulpal pressure from stand to supine.  Pain is so severe that it keeps the patient awake at the night. www.drcube.org  Presence of referred pain.  In later stage, Heat stimulus increases pain due to the expansion of blood vessels, therefore, increasing pressure in the pulp.  Cold stimulus decreases pain due to contractile action on the blood vessels, therefore, lowering intrapulpal pressure.  Not tender to percussion and normal radiographic apical region in early stage.  A widened periodontal ligament may be seen radiographically in the later stages. Treatment involves either pulpectomy (removal of the infected pulp) followed by a root canal filling or extraction of the tooth. www.drcube.org b) Asymptomatic Irreversible (previously known as chronic irreversible pulpitis) After the acute phase, the pulp might enter the chronic phase. The symptoms experienced are:  Mild to moderate intermittent pain may be tolerated by the patient for a long period.  Thermal tests are of little value.  Tenderness to percussion and radiographic changes are not seen until infection reaches the periapical region. Treatment involves either root canal therapy or extraction of the tooth. www.drcube.org c) Hyperplastic Pulpitis Hyperplastic pulpitis is a form of irreversible chronic pulpitis and is also known as a pulp polyp. It is an inflammatory response of pulpal connective tissue due to extensive carious exposure to young pulp. It shows the overgrowth of granulomatous tissue into the carious cavity. It is commonly seen in the teeth of children and adolescents because this pulp tissue has high resistance and large carious lesion permits a free proliferation of hyperplastic tissue. www.drcube.org Symptoms include: It is usually asymptomatic, Fleshy pulpal tissue fills the pulp chamber. It is less sensitive than normal pulp but bleeds easily due to a rich network of blood vessels. Sometimes this pulpal growth interferes with chewing. www.drcube.org d) Internal Resorption Internal resorption is initiated within the pulp cavity and results in the loss of substance from dentinal tissue. Etiology is unknown but occasionally, pulpal inflammation may cause changes that result in dentinoclastic activity. Such changes result in resorption of dentine; clinically, it is asymptomatic unless perforation of the root occurs, a pink spot may be seen in the later stages if the lesion is in the crown. www.drcube.org Radiographic examination reveals a radiolucency that is seen to be continuous with the rest of the pulp cavity. Root canal therapy will result in the arrest of the resorptive process; however, if destruction is very advanced extraction may be required. www.drcube.org 3 Pulp Necrosis Pulp necrosis or death is a condition following untreated pulpitis. Pulpal tissue becomes non vital and if the condition is not treated, noxious materials will leak from pulp space forming a lesion of endodontic origin. Symptoms include: Tooth might be asymptomatic, Discoloration of the tooth due to extravasation of pulpal blood into the dentin. Radiograph shows a large cavity or restoration or normal appearance unless there is concomitant apical periodontitis or condensing osteitis. Treatment involves root canal therapy or extraction. www.drcube.org 3 Pulp Calcification In which part of the pulp tissue is replaced by calcific material, Mainly three types of calcifications are seen in pulp: Dystrophic calcifications: the foci of these calcifications can begin in dead and degenerated tissue, blood clots, connective tissue walls of blood vessels and nerves of the pulp because of the inflammation Diffuse calcifications: these are usually linear calcification present in the root canal. Denticles/pulp stones: they are present in the pulp chamber and can be classified according to location as either a free stone, embedded stone in dentin, or an attached stone. www.drcube.org Also, pulp stones can be classified according to structure into: True Denticle It is composed of dentin formed from detached odontoblasts or fragments of Hertwig’s enamel root sheath which stimulates the undifferentiated cells to assume dentinoblastic activity. False Denticle Here degenerated tissue structures act as a nidus for deposition of concentric layers of calcified tissues. www.drcube.org Who performs an endodontic therapy? Generally, all dentists receive basic education in endodontic treatment, but an endodontist is preferred for endodontic therapy. General dentists often refer patients needing endodontic treatment to endodontists. Why does patient Feel Pain? When pulp becomes infected, it causes increased blood flow and cellular activity, and pressure cannot be relieved from inside the tooth. This causes pain. Pulp can even die without causing significant pain; it may depend on pain threshold and pain reaction of the patient. www.drcube.org How can You Tell if Pulp is infected? When pulp gets inflamed, it may cause toothache on taking hot or cold, spontaneous pain, pain on biting or on lying down. On occasion a damaged pulp is noticed by drainage, swelling, and abscess at the root end. Sometimes, however, there are no symptoms. www.drcube.org Why does the patient need root canal therapy? Because the tooth will not heal by itself, the infection may spread around the tissues destroying bone and supporting tissue. This may cause the tooth to fall out. Root canal treatment is done to save the damaged pulp by thoroughly cleaning and shaping the root canal system and then filling it with gutta-percha (rubber-like) material to prevent recontamination of the tooth. The tooth is permanently restored with a crown with or without a post. What are Alternatives to Root Canal Therapy? If the tooth is seriously damaged and its support is compromised, then extraction is the only alternative. www.drcube.org What is the Root Canal Treatment Procedure? Once the endodontic therapy is recommended, your endodontist will numb the area by injecting a local anesthetic. After this, a rubber sheet is placed around the tooth to isolate it. Then the opening is made in the crown of the tooth and very small-sized instruments are used to clean the pulp from the pulp chamber and root canals. After thorough cleaning and shaping of root canals, they are filled with rubber-like material called gutta-percha, which will prevent the bacteria from entering this space again. After completion of endodontic therapy, the endodontist places the crown or other restoration so as to restore the tooth to full function. www.drcube.org Will the Tooth Need Any Special Care or Additional Treatment after Endodontic Treatment? The patient should not chew or bite on the treated tooth until the patient has had a tooth restored by the dentist. The non-restored tooth is susceptible to fracture, so the patient should visit the dentist for a full restoration as soon as possible not more than one month. Most endodontically treated teeth last as long as other natural teeth. In a few cases, a tooth that has undergone endodontic treatment does not heal or the pain continues. Occasionally, the tooth may become painful or diseased months or even years after successful treatment. Often when this occurs, re-treating the endodontic procedure can save. www.drcube.org Can All Teeth be Treated Endodontically? Most of the teeth can be treated endodontically. But sometimes when root canals are not accessible, the root is severely fractured, the tooth cannot be restored or the tooth doesn’t have sufficient bone support, it becomes difficult to treat the tooth endodontically. However, advances in endodontics are making it possible to save the teeth that even a few years ago would have been lost. Newer research, techniques and materials have helped us to perform endodontic therapy in a better way with more efficiency. Since the introduction of rotary instruments and other technologies reduce the treatment time, the concept of the single visit is gaining popularity nowadays. It has been shown that the success of endodontic therapy depends on the quality of root canal treatment and not the number of visits. In the modern world, single-visit endodontics is becoming quite popular. www.drcube.org Thank You For Your Attention ‫‏‬The First and Largest Educational Platform for Students of The Medical Group in Iraq www.drcube.org