Endodontics final.pdf

Intro to Endodontics What is Endodontics? Who do we do it for? (indications) It’s a RCT ○ Where we mechanically expand RCs after removing pulp tissue from crown + root, purifying them from microorganisms by irrigation, and fi...

Intro to Endodontics What is Endodontics? Who do we do it for? (indications) It’s a RCT ○ Where we mechanically expand RCs after removing pulp tissue from crown + root, purifying them from microorganisms by irrigation, and filling them completely To perform a successful RCT, dentists must make sure they provide the Correct diagnosis. They must also make sure they perform a complete cleaning + enlargement of the pulp cavity, and obturate it sufficiently RCT is done to Acute/Chronic Pulpitis and Necrotic or Gangrenous pulp, where pulp is necrotic due to obstruction or inflammation ○ Other indications: ○ When Post-core is needed ○ In prosthetic treatments, if there’s an abnormal too elongated root or tilted, we have to prepare these teeth ↑↑ to get them to normal levels ○ If Repetitive treatments ○ Periradicular inflammation ○ Perforated pulp iatrogenic reasons 0 ○ In internal resorptions where there’s NO large lesion opening up to periodontium ○ If there’s pulp exposure due to caries, attrition, erosion, abrasion, or trauma + Direct capping or Amputation NOT INDICATED ○ If capping or amputation fail What are the factors you might consider to NOT do RCT? What are the Contradictions? If there's inadequate periodontal support If RC expansion can’t be done 5 000 ○ Like Tooth fracture, ↑ Dilase canals, Calcifications present, Periapical lesions Vertical fractures Wide resoptions If its a tooth that CAN'T be repaired 3 ○ Deep rot root, Furcation caries, or Internally-weak teeth Contraindications: ○ If patient is ↑old: 12 There will be ↓ Repair ability of tissues 00 Narrowing + Occlusion of Pulp chamber, RC, and Apical foramen ○ If patient has a disease that ↓ Repair ability of tissues Cancer, Leukemia, Syphilis Inflammatory rheumatic disease, Diabetes, Tuberculosis CLS DIR Test cavity Invasive irreversible pulp vitality test NOT routinely used Used only when all other methods are deemed imp or Inconclusive results Ex: ○ Full coverage crown has suspected pulp disease ○ A small class 1 cavity prep is made on occlusal surface of crown to reach sound tooth structure data PMSing Manatee What kinds of Radiographs are used in Endodontics? Conventional intraoral 2D radiographs ○ Can visualize most of the structures in 1 image ○ Panorama ○ Periapical ○ Bitewing Digital radiographs ○ RVG ○ ↓ Radiation by 40% ○ Measures the distance b/w 2 points in the digital image using software ○ Disadvantages I Correct reference points cant always be det due to anatomical variations Superpositions + Distortions in 2D images Patient’s exposure to X-rays Advanced imaging ○ CBCT 3D imaging Used as a diagnostic adjunct to conventional dental imaging Show great details in many planes of vision, but can also leave out IMP details if the slice is not in the area of existing pathosis ○ MRI Offers simultaneous 3D + ST imaging of teeth W/o ionizing radiation Its use is still limited in endo II te What is a Diagnosis and How do you approach it? 00 Diagnosis is basically detecting and distinguishing WHAT the problem is patient is having and WHY he’s 0 having it It's the first step to a successful endo treatment = directly affects treatment We use a Planned, methodical + systematic approach to Data gathering process ○ Its divided into 5 stages Patient tells clinician the reason he is seeking advice Clinician questions patient about the symptoms + history that led him to visit 0 Chief complaint – Documented using patient’ own words Medical history – Questioned at each treatment to see if there are any changes or medications that might affect anesthetics, drug choices, etc Dental history – see 0 Localization: Can you point to the concerned toth Commencement: When did the symptoms start Intensity: How intense pain is on pain scale Provocation + attenuation: What produced or reduced symptoms Duration: Do these symptoms subside shortly; or linger after provoked? Clinician performs Objective clinical tests Dead 0 Intraoral radiograph: To interpret actually a potential endodontic pathosis; NOT used alone Extra oral exam: starts from the moment patient comes in ○ Check gait, physical limitations, asymmetry, palpate for any swellings Intra oral exam: check for any abnormalities Percussion test: indicates if there’s anAlive inflammation of PDL ○ Done by gently tapping on incisal or Occlusal surface of tooth in Vertical + Horizontal axis using a blunt end of an instrument Palpation: indicates an Active periradicular inflammation ○ Done by applying firm digital pressure to mucosa covering Roots ○ You press mucosa against cortical bone under it Mobility: Indicated compromised PD attachment apparatus EPT method Pulp tests: Indicates pulp vitality ain't too tooth Bite test ○ Helps localize pain. w/ Percussion at incisal third or occlusal of Studies ○ Used show there'stip whenplacing Labially pain on biting Bilge ○ Positive crown 9Accurate results or 2° sensitivity due to Crack in tooth = PDL inflammation Agy Cracks in tooth = pain on percussion + bite test only when applied to a certain cusp or section PDL inflammation = pain everywhere Selective anesthesia ○ When patient CANT localized symptoms + inconclusive pulp test results ○ Start w/ maxilla if he cant determine arch Clinician correlates Objective findings w/ Subjective details = Creates preliminary list of differential diagnosis Clinician formulas a definitive diagnosis  Importance of Medical history in Diagnosis Oral ST changes are usually due to the meds used to treat the medical condition, not the condition itself. What are some common side effects of medications that affect the Oral cavity? Stomatitis – sore Xerostomia Double ended No 5 Petechiae Ecchymosis — Discoloration due to underlying bleeding Lichenoid mucosal lesions — Amalgam reaction Bleeding of oral ST 4What areTuberculosis glick No I the 2 diseases that cause the enlargement of Cervical and Submandibular L.ns? Lymphomas ➔ Both lead to a misdiagnosis of a Ln enlargement 2° to odontogenic infection What are the diseases that cause paresthesia of Oral ST? Iron deficiency anemia Pernicious anemia Ii Leukemia Sickle cell anemia g What are the diseases that mimic dental pain? ○ Bone pain that mimics dental pain needle Trigeminal neuralgia Multiple sclerosis Referred pain from cardiac angina Acute maxillary sinusitis I ○ In Posterior maxilla ○ Mimics signs + symptoms of Pulpitis = ↑↑ Sensitivity to Cold + Percussion 7 no What disease results in loss of Trabecular bone pattern on radiographs? 5 7 Sickle cell anemia pluggers ○ = Misdiagnosed w/ radiographic lesions of endodontic origin What disease causes unexplained tooth mobility? Multiple myeloma J yWhat are the complications of Radiation therapy? 3 ↑ Sensitivity of Teeth Osteoradionecrosis What helps in determining whether there’s a crack in the surface of a tooth? Transillumination and staining Percussion and Bite test  show pics What are the Pulp testing methods? What do they Probably indicate? Pulp testing checks the responsiveness of sensory neurons found in pulp = Vitality Thermal methods — Frozen CO2 + Heated GP ○ Applied to surface of tooth ○ Normal response: Sensation is felt + immediately disappears after stimulus’ removal ○ Abnormal: Lack or response, Lingering or intensification after stimulus’ removal, or Immediate excruciating pain upon placement Electric methods ○ Determines vitality by Intactness + Health status of Vascular supply Other non-invasive testings: ○ Laser doppler flowmetry: Assess BF in RC A diode projects infrared light beam → crown → Pulp chamber If vital = Moving RBCs = Light beam’s fq changes as it hits them If static BF = fq remain stable ○ Pulse Oximetry: Assess O2 concentration in blood Explain potential False-negative or False-positive response interpretations in Electric pulp testing False-positive ○ ↑ Anxiety ○ Failed tooth isolation ○ Contact w/ Metal restoration ○ Only partially necrotic pulp False-negative G ○ Calcifications in RC 0 ○ Immature apex ○ Recently traumatized teeth area ah flat land L ○ Drugs that ↑ Threshold for pain ○ Poor contact of Pulp tester to tooth onward 8 we mightbreak or lock hasmetaltags  Instruments used in Endodontics tospiral If Examination kit Mouth mirror Periodontal probe Double-ended No. 5 explorer Glick No. 1 Cotton forceps in a Emergency kit Examination kit Shaping + cleaning kit Easier GG Incision for drainage kit Anesthetic armamentarium Shaping + cleaning kit: 5 mL Luer-Lok syringe w/ 27-gauge needle Cotton forceps Glick No.1 Gates-glidden drills Lentulo spiral drill Broaches + files A mm rule Incision for drainage kit Scalpel handle + Blade Periosteal elevator Suction tip Irrigating syringe w/ 18-gauge needle Needle holder Sterile saline Rubber dam Instruments used for obturation Spreaders or Pluggers 5/7 pluggers or Pluggers for vertical condensation Glock No.1 for Heat transfer Cotton forceps What are the instruments used in Endodontics Hand-operated ○ K-type Files + Reamers ○ H-type Files ○ Barbed Broaches: Stainless steel that has a metal tag. They entangle + Remove pulp Engine-driven Rotary ○ Insert into Slow-speed handpiece 0 ○ (Gates-glidden + Peeso) Reamers + Files O Both for Straight-line access GG: Non-Cutting tip + Elliptical shape PR: Non-cutting tip + Parallel sides = ↑ Aggressive Lentulo spiral drills ○ Insert into Slow-speed handpiece ○ They spin Pastes, Sealers, or Cements into canal (usually used to place CaOH) ○ Used w/ care to not screw itself = lock + separate Ultrasonic + Sonic ○ Broaches + files that insert into vibratory hand-piece that energize instrument Nickel titanium instruments ○ For both Hand-operating + Engine-driven applications ○ ↑ Flexible = Allows file to follow canal curvature = ↓ Apical transport But also means inability to precurve canal before inserting esp in posterior teeth where there's ↓ Interocclusal opening ofee ↑Elasticity = ↓Cutting efficiency compared to Stainless steel ○ To utilize it, Engine-driven type of U-shaped groove w/ flat land area To As it rotates, flutes will lane the RC wal + Land area keeps it centered esp in fine curved canals Intracanal usage of Files and Reamers K-type Files + Reamers ○ Reaming: Rotating-pushing instrument clockwise Rotations = scribing an arc from 1 Cutting edge to the Next Triangular reamer — 3 60° Cutting edges = Rotational 120° before each edge = ⅓ turn then withdraw RI 90° Cutting edge = 90° = ¼ turn + withdraw ○ Filing: Push-pull motion Q File inserted to full length using Passive rotation of file File is then rotated ¼ and withdrawn while tip is pushed firmly against RC wall Circumferential filing = Passive rotation, Reaming, then Withdrawing on each RC wall until all walls have been planed H-type Files Seen w Pag O ○ Filing motion only Barbed Broaches: For pulp removal WatchIkent winding: Reciprocated back + forth clockwise + counterclockwise motions, then retract to remove debris i 3 MR  Sizes of Files + Reamers used: 21, 25, 31 mm ○ Shorter = ↑ operator control Posterior teeth ○ 25 and 31= longer roots Dimensions of K-file D0: Diameter at tip of point D16: Diameter at end of cutting edge ○ Spiral cutting edge must be at least 16 mm long File diameter increases 0.02 mm/ Running mm of length Helix: Angle b/w Cutting edge + Long axis of file Flute: the groove on the Working surface that removes ST + Debris from RC Radial area: it reduces the tendency of File to screw into canal by supporting the Cutting edges so it Limits depth of cut Explain how to determine Working length? What are some methods that are used? WL must be ideal for a Hermetic RC filling Working length is the distance b/w the point in Coronal region + Minor foramen Step back ○ This is the ideal endpoint for RC filling = Cemento-Dentinal junction = point where Pulp ends and PD membrane starts it's where○weIt'sfirst the apical prepare point the narrowest b/w Pulp portion + Periapical RC up of tissue to WL = Minor foramen ○ w/ ↑ Age, ↑Cement deposition = ↑ Narrowing then use stepwise reduction using larger files in o s 1mm steps flared shape To determine WL — RC shaping + filling procedures should terminate 05.-1mm behind Full apical Enables us to create a Proper apical stop before middle coronal third prep narrowing Advantages And that is determined using: Limitations Loss of WL tendency to straightenout canal Extrusion of Debris into Periapicaltissues ○ Radiographic method – Determined Radiological apex, and we terminate 0.5-1 mm behind it ○ Digital radiograph — Reduces radiation by 40% ○ Electronic Apex locators step down 1 side of EAL connected to Oral mucosa via a lip clip, and the other side connected to a Conducting canal file. It uses the body to complete an electrical circuit. It's where we prepare the coronal third first then middle thenApical thirds Currently most Optimal + Accurate 4 basic Advantages Elimination B of generations: 1.Resistance, before 5th + 6th more developed 2.Impedance, apical shaping 3.Frequency, minimize 4.Proportionality blockage risk debris extrusion Easier shaping Betteraccess False readings in EAL control over Apical enlargement Contact w/ Saliva Limitations Gaugingtheapical third is the last step of technique Contact w/ Metal restoration ↑ Bleeding or Exudate Open apex Non-conductive canal files  Shaping RCs What are the phases of an Endodontic treatment? What are the objectives to keep in mind? Proper Straight-line access preparation into pulp space Shaping + Cleaning RCs ○ Remove all Vital + Necrotic pulp tissue ○ Eliminate microorganisms in canal by irrigation ○ Create space for obturation ○ Preserve WL A ○ Preserve sound Root dentin = allows Long-term function ○ Avoid further irritation of periradicular tissues ○ Avoid iatrogenic damage Hermetic obturation What are the techniques used to shape RCs? hating Standardized technique ○ Starting w/ small instruments to bigger instruments all inserted to WL Step-back technique ○ Apical preparation is done first with MAF ○ Then, stepwise reduction of the WL for larger files, in 0.5-1 mm steps = ↑ Flared shapes Step-down technique 5 ○ Its where we instrument the coronal third of RC before apical shaping Explain the Shaping + Cleaning guidelines Anatomical considerations ○ Most critical area for disinfection is apical 3-4 mm ○ = Enlarge it enough to allow flow of irrigants 0 Restricting instruments + irrigants within RC space 000 ○ They should be confined to RC space and not damage periradicular tissues Precurving D ○ Precurving a stainless steel instrument before we insert it into canals ○ Facilitates its insertion to WL + Prevents ledging into walls Recapitulation for Patency E faecalis ○ We must regularly go back to a smaller instrument to prevent Dentin packing ○ This ensures Patency = Keeping Apical foramen free of debris Candida Albicans Removal of Dentinal debris from used instruments ○ During shaping, dentinal debris clogs the flutes of files is ÉᵗÉ ○ They must be removed by squeezing the blading b/w a wet gauze while turning counterclockwise commonendo more patron Anticurvature filing: ○ By inserting a precurved file at outer side of curvature ○ It helps keeps flies away from furcational zones of curved RCs = Prevents strip perforations Watch-winding: Reciprocated back + forth clockwise + counterclockwise motions then retract Filing: Push-pull Circumferential filing: Passive rotation, Reaming, then Withdrawing on each M D B L walls Reaming: Rotating clockwise + pushing motion  2 nmc multisoni technology n in infrared EMS mintada Q latilir  Irrigation in Endodontics Why do we use irrigants in Endodontics? What are the ideal requirements of an irrigant? Remove debris creating during shaping Dissolve Organic + Inorganic tissues Remove + Prevent Smear layer Lubricate RC Ideal requirements: ○ Mechanically flushed out debris from RC ○ Dissolved Vital + Necrotic tissues ○ Removes smear layer hem meditament hem sealed ○ Serves as a lubricant ○ Antimicrobial ○ NON-toxic and NON-irritating to Periapical tissues ○ NO adverse effects on Physical properties of dentin ○ Does NOT interact w/ Sealing ability of RC sealer or obturating material ○ LOW surface tension What are the types of Irrigants used in Endodontics? Explain. 1. Sodium Hypochlorite ○ Most effective at 5.2% At ↓ concentrations, we must ↑ Volume, exposure time We can also heat it up = more efficient in removing organic dentin I ○ Properties Antimicrobial When NaOCl ionizes, it produces Hypochlorous acid + Hypochlorite ion Dissolves Vital + Necrotic tissues Dissolves Organic component of dentin + biofilms faster ○ NaOCl accidents are Cytotoxic To prevent, Insert needle passively in Apical third RC 2. Chlorhexidine Digluconate ○ 2% ○ Broad-spectrum antibacterial against most common endo pathogens Bacteriostatic + Bactericidal ○ Lacks tissue-dissolving abilities of NaOCl But isn't cytotoxic nor bleaches clothes CAN'T REMOVE SMEAR LAYER yay = use w/ other irrigants host NaOCl + CHX should NOT interact endo They will produce an orange precipitate patho If you wanna use in same appointment, use NaOCl first, flush canals w/ saline, then use CHX Has pH Explain 12.5 used the techniques Neutralizes acids for Irrigation Manual So it causterizes tissues kills bacteria ○ Syringe irrigation w/ Needles used as a broad spectrum antibiotic ○ Brushed ○ Manual dynamic Agitation maintains antibiotic effect for a longtime Machine-assisted ○ Sonic: low fq Sonic waves help in irrigant activation stimulates stemcells to produce secondary odontoblasts to form Dentinal bridge formations ○ Ultrasonic: Higher fq waves that set up Transverse vibrations w/ Nodes and Antinodes ○ Laser-activated irrigation: Photon-induced photoacoustic streaming ○ Wide-spectrum sound energy Disadvantages Explain the different types of Calcifying agents weak marginal adaptation to Dentin 1. EDTA — EthyleneDiAmineTetraAcetic Acid Removal ○ 17%is hard incomplete even after irrigation w Nacl or EDTA ○ Removes inorganic component of smear layer Primary rootresorption Ineffective alone It degrades dissolutes So usually used as a final irrigant overtime after using NaOCl, which dissolves the organic part microleakage thru defective calcifi bridges But don't mix them, because EDTA makes NaOCl lose its tissue-dissolving capacity Pulpal degeneration necrosis So 5.25% NaOCl as irrigation, then 17% EDTA as final rinse before obturation 2. QMIX ○ Has CHX-analog, Triclosan, and EDTA as a decalcifying agent ○ Used as a Final rinse 3. MTAD ○ 3% doxycycline, Tween 80 detergent, and 4.25% Citric acid as demineralizing agent 4. Tetraclean ○ Similar to MTAD but ↓ Doxycycline concentration 5. Hydrogen Peroxide ○ Biocide for sterilization 6. Etidronic Acid ○ Weak chelator that’s a potential alternative to EDTA  Intracanal Medicaments 7 Tubit seal 1. CaOH 2. CHX Digluconate Roth Eugenol USP Y 3. Antibiotics mmation a. Double antibiotic paste b. Triple antibiotic paste 4. Steroids a. Ledermix Nz Paste Sargenti sealer Calcium Hydroxide ○ Stimulates Secondary odontoblasts repair w/ Dentinal bridge formation By stimulating Undifferentiated mesenchymal cells ( stem cells) to form Secondary odontoblasts → Tertiary dentin Roellosed fits ○ Does this bya its version 12.5 pHof= High = neutralizes acids ○ Causterizes tissues + Kills bacteria Sustains antimicrobial effects for a long period for Usedvitalas apull them antimicrobial agent broad-spectrum ○ Disadvantages Weak marginal adaptation to dentin desiredhere 2 its so Degradation + it dissolution can over be time released which Notis Allowspeg microleakage of microbes thru calcific bridge defects ○ = Pulpal degeneration = Dystrophic calcification + Pulpal necrosis Primary tooth resorption Absorbable = dimensionally unstable NOT effective against some endo pathogens like E. faecalis + Candida albicans Removal is hard + incomplete Even after irrigation w/ NaOCL, saline, or EDTA CHX Digluconate ○ Used as Irrigant Intracanal medicament 2% CHX gel Mix of CHX + CaOH ○ Effective against E. faecalis + Candida albicans in MTA  Antibiotics ○ No antibiotic can actually completely eradicate the complex polymicrobial flora in an infected RC ○ They have a limited role cuz: Most antibiotics are bacteriostatic + depend on host resistance for dealing w/ infection Effects are limited cuz NO blood supply in RC ○ Types: TAP – Minocycline + Ciprofloxacin + Metronidazole (1:1:1) in a Macrogol/Propylene Olabiliv glycol vehicle Minocycline causes Tooth discoloration Q DAP – Ciprofloxacin + Metronidazole Steroids ○ Rapid pain relief + anti-inflammatory ○ Ledermix Non-setting water-soluble paste Olabilir Made up of: Q Corticosteroid: 1% Triamcinolone acetonide Antibiotic: Demeclocycline Used as Intra canal medicament ○ In Internal resorption cases ○ In traumatic injuries of tooth Direct or indirect pulp-capping agent Away for filling  Canal Sealers ZOE sealer Antimicrobial Overflows into periradicular tissues + Resorbed Slow curing time Teeth discoloration Formaldehyde-containing pastes Ex: Endomethasone Toxic due to Paraformaldehyde Silicone-based sealers RoekoSeal ○ Expands during curing reaction GuttaFlow ○ Cold flowing gutta-percha filling technique CaOH sealer Therapeutic effect Thought to be Antimicrobial + Cementogenic + Osteogenic (no proof yet) Resorbable Ex: Vitapex, sealapex GI pastes Good bonding to dentin Difficult to remove from canal when needed Ex: Ketac-endo, Active Gp Resin- based sealers Advantages ○ Easy manipulation ○ Tightness ○ Periapical tissue compliance ○ Anti-microbial ○ Binds to dentin ○ NO eugenol 2 types – Epoxy resin + Methacrylate resin ○ Epoxy resin ex: AH 26, AH plus ○ Methacrylate resin ex: Realseal, Endorez, Epiphany Calcium Silicate Pastes Tricalcium + Dicalcium silicate – hardens when reacts w/ water = highly alkaline hard structure pH 12 ○ Consisting of Ca silicate hydrate + CaOH Zirconium dioxide for Radiopacity ○ Bismuth oxide stains teeth Ex: Bioaggregate, MTA Fillapex, iROOT SP, iROOTBP  Filling the Root canals check if thereare any Why? Remove all entrances b/w the Periodontium + RC When? If the tooth is Asymptomatic ○ Must be by 2. Session if there's no Exudate If the RC is dry using absorbent paper + NO bad odor ○ Bad odor = infection Properties of RC filling material Must be dimensionally stable + NOT resorbable ○ Most imp ○ Done by Good condensation Biocompatible, Radiopaque Easily manipulated + sufficient Working time Easily removed when needed Shouldn't discolor teeth Solid Substances: Gutta percha, Silver cone, Resilon For adhesion = using Sealers Silver cone Unsuccessful ○ Rigid = don't fully adapt to RC walls = usually filled w/ canal sealer ○ Dissolves in saliva + periradicular fluid + corrosive products are toxic Resilon High performance Polyurethane; alternative to Gutta percha Contains Methacrylate resin, Bioactive glass, Bismuth, Barium salts Used w/ Resin sealant Smear layer is removed using Self-etch primer, the monoblock structure is created Gutta Percha From rubber base of Genus Sapotaceae Contents: ○ 18-22% Gutta percha as Matrix ○ 59-76% Zinc Oxide for Binding ○ 1-4% Wax + Resin for Manipulation ○ 1-18% metal-sulfate for Radiopacity Exists in 2 crystalline phases ○ Unheated beta phase – Incompressible + solid ○ When heat is applied, Beta → Alpha phase — Flexible, soft, sticky Both phases have the same mechanical properties Alpha phase techniques are preferred cuz ↑Stable + ↓shrinkage when heated + cooled Advantages of Gutta Percha Due to wax + resin content = Easily manipulated ↓ Toxicity Easily removed from duct when heat or solvent is applied Dimensionally stable + NO teeth discoloration Easily disinfected Disadvantages of Gutta Percha redo endo treatment Needs paste cuz NO adhesion to dentin Shrinks when heated + cooled = easily protrude thru apical foramen under pressure f  RC Filling Technique 1. Cold lateral compaction ○ Master GP is placed in the canal, then thinner gutta are added by compression 2. Warm lateral compaction ○ Heated GP spreader to prevent the gaps formed in the Cold LC method 3. Vertical compaction ○ Main cone is placed in the canal, then GP is softened using a heated spreader ○ The soft Gutta is then removed from the canal + compressed vertically line ○ Indications: Internal resorption, Wide lateral canal, Apical filling of Post-core teeth alcess straight Got PR for 4. Chemically softened techniques We use ○ Dissolving GP w/ Chloroform + Eucalyptol creating a paste ○ Applying this paste w/ a main cone well adapted to the canal ○ Loses integrity during freezing ○ Uncontrollable canal filling → Overflow 5. Thermomechanical compaction ○ Mcspadden’s ○ His tool softens the Gutta by making 10k revolutions and canal is filled 6. Thermoplasiticed Gutta percha injection ○ GP is heated to 160 in injector, becomes fluid, and applied into canal w/ Mechanical pressure ○ Systems: Obtura (High temp 160) = Destroys periodontal tissues Ultrafil (Low temp 70) = Hard usage + ↑Time 7. Thermoplasticized core techniques ○ Core-bearing GP is softened by heating + placed in canal at WL ○ Ex: Thermafil, AlphaSeal, SuccessFil 8. Obturation w/ Continuous heat ○ Condensation by applying pressure in both Lateral + Vertical directions, while heat is applied to GP ○ Down-packing phase Fills the apical 4-5 mm After the main cone is aligned to canal, appropriate taper is selected Main cone applied in canal w/ cement Heat is applied for a few seconds, 5-10 secs to press vertically ○ Back-filling phase Using cartridges of GP a Filling in 2-3 movements towards the coronal  RCT Failures Operator-related causes Inadequate cleaning = Persistent infection Missed RC = reinfection Improper isolation Improper shaping – Ledge formation Improper postendo coronal seal – Microleakage Improper management of perforations Instrument separation Inadequate sterilization Non-operator causes persistent periradicular infection Extraradicular cysts Vertical root fractures Clinical management of RCT failures 1. If patient is asymptomatic + isn’t convinced he needs treatment ○ Keep patient under observation 2. If clinically symptomatic endo-treated tooth ○ Non-surgical endo treatment 3. When nonsurgical endo treatment is technically difficult; or if teeth have complex anatomy = difficulty reaching Apical third of root ○ Surgical endo treatment (preferably w/operating dental microscope) 4. When Surgical + Non-surgical treatments not possible + CANT be restored prosthodontically ○ Extraction Also when patients aren't interested in saving tooth Last treatment option plan – always try to save dentition first Non-surgical endo retreatment To remove RC filling from tooth, reshape, and obturate Aim ○ Achieve adequate access opening If crown = Remove crown ○ Ensure complete removal of all restorative + obturating material previously inserted To remove GP: Rotary instruments, Solvents, Heat-carrier instruments, Ultrasonics, or COMBO ○ Rotary like ProTaper universal retreatment file ○ Ultrasonic to penetrate hard-set pastes; sensitive = Dont use ↑force ○ Solvent to soften the Coronal third of obturating agent ○ Disinfect RC ○ Shape, Clean, Obturate, + Create optimal seal  P task Steps for Retreatment 5h Ipkf 1. Solvent to dissolve coronal third of GP During preparation 2. Stiff + smaller hand instrument used to create a glide path inside obturated canal of RC 3. Rotary or retreatment file are then used to remove remaining GP → WL 4. Frequent irrigation to not block canal 5. Sequential radiographs help clinician process apically till WL For infected retreatment cases: Multiple sessions is preferred ○ Cuz 2° endo infections are ↑ resistant to therapy Instrument separation Causes + Tips Inadequate access opening ○ Straight-line access No glide path ○ Create a glide path w/ small hand files Excessive apical pressure during shaping ○ Don't push hard on file Overuse of instruments ○ Immediately replace files inserted into small + curved canals ○ Most common cause of instrument separation ○ Hedstrom files are NO LONGER indicated for RC shaping due to ↑ shaping errors Operator inexperienced Using instrument w/ improper speed Other tips: ○ Examine files regularly ○ Regularly irrigate canal w/ NaClO ○ Avoid keeping file in 1 spot Esp in curved canals How to remove separated instruments? 1. Retrieve instrument thru Ultrasonic or Wire loop + tube technique 2. Bypass the instrument by a smaller file + make it apart of the obturation (keep it there) ○ If cleaning and shaping completed till apex ○ Cuz by this step, most of the microbes if not all are already cleaned 3. Surgical intervention (hemisection/ Root resection)  RCT Complications Loss of WL To maintain WL: 5 3 points ○ Intact + reusable reference ○ Fixed safe rubber stopper should be used ○ Use fixed radiograph angles “Zip” formation at Apex swelling Its the transport of the apical portion of RC (hourglass shape) ↑ Common if RC has ↑ curvation If RC is not enlarged properly = inadequate prep ○ Gaps will form + cant be properly filled Stripping The thinning + perforation of Lateral root wall Due to ↑ prep ○ Esp in middle part of molars Blockage of RCS To avoid Q ○ Remove all carious, weak, unsupported structures before opening access cavity ○ Walls of access cavity toward the occlusal ○ Straight-line access after stimulusis removed ○ Effective irrigation goesaway ○ Clean materials used during treatments before each use ○ Don’t skip file sizes ○ Recapitulation should be performed in all procedures Recapitulation is the sequential reentry and reuse of each previous instrument Ledge formation Artificially created irregularity the RC wall that prevents the instrument from being inserted up tp the apex Reasons: ○ Failure to est straight-line access ○ Using straight tools in curved canals ○ ↑ apical pressure + ↑ sized files e Suspected when we cant reach WL ○ Take radiograph to determine pain Night Use smaller sized file to bypass the ledge to reach Apical region Perforation Q Creating an artificial opening that causes a cont rs b/w Pulp cavity + Periodontium Created during: ○ Exploration ○ Enlargement / Prep of RC Reasons: ○ Insufficient determination of WL ○ Inadequate opening of access cavity ○ Using a straight file in a curved canal ○ Using larger files in smaller canals Management: ○ Use a new apical stop created within the RC 1-2 mm inside the radiographic apex Called “back-up apex” w Apical So always Ingestion + aspiration of foreign objects If swallowed object is sharp, like a canal instrument = Risk of perforation ○ If not sharp, it will pass thru digestive system + passed w/ stool Aspirated foreign objects may cause Partial/total airway obstruction, Brain damage, Pulmonary infection, or Death Just use a Rubber dam Periodontit s  Causes of Pulp disease Physical ○ Mechanical Trauma Pathological wear by Attrition, Abrasion, Abfraction, Bruxism Crack or fracture origination from crown Iatrogenic causes Accidental exposure of Pulp during deepen dentin caries removal Too rapid movement of teeth in Ortho treatment ○ Thermal Exothermic heat from setting of cement Conduction of heat from deep fillings w/ pulp liner Frictional heat during Tooth prep or Polishing ○ Electrical Galvanic current from amalgam Chemical ○ Least common ○ Pulpal reaction due to Resto material inserted in deep cavities Bacterial microleakage ○ Most common cause of Pulp injury Q ads 1 due to dev of Acute inflammation in terivodimler mechanild Eating beyond RC system QI  Types of Periapical pain BUS N of Major Is up made Acute periapical pain fdftht veact.ggDentin odonto Acute apical periodontitis Pentin wh Acute apical abscess Nextto reparativeDent oafe Chronic periapical pain — Usually painless but may progress to Acute stage Chronic apical periodontitis Chronic apical abscess Apical cyst Acute apical periodontitis pain Acute inflammation of PD membrane around apex Severe, Continuous, Pulsating pain Sensitivity to Vertical percussion + Palpation Tooth mobility Reparative Dentine Q Heat aggravates pain Cold relieves pain Acute apical abscess Pulp necrosis = Spread of infection to periapical tissues = Localized pus in Alveolar bone around apex As swelling ↑ = pain ↑ Feeling of elongation in tooth Tooth mobility Chronic apical periodontitis = Granuloma Detected by radio Chronic apical abscess Long-term severe inf of periapical alveolar bone due to spread of inf of pulpal necrosis eversiblepulpit's or Hyperemia Likely Fistula formation is seen or detected by radio Apical cyst Detected by radio When cyst grows = ↑ Pressure Mobility may occur Q Hyperemia  Endodontic Pain What is pain? Highly unpleasant physical sensation caused by illness or injury What are the factors considered in pain control? Understanding the pain system Good endodontic procedure Use of appropriate analgesics What’s the diff between the pain of Odontogenic origin from pain of Non-odontogenic origin? Pain description 00 ○ Odontogenic: Throbbing, Pulsating, Pressure, Sharp ○ Non-odontogenic: Tingling, Burning, Electrical, Combustion Q Effect of LA ○ Odontogenic: Relieves pain ○ Non-odontogenic: Does NOT relieve pain reparativebridges by odo like stemcells Area of pain ○ Odontogenic: Unilateral ○ Non-odontogenic: May exceed midline Radiographic + Clinical exams ○ Odontogenic: Clinical exam: source of pain is noticed during exam like Rotten, Broken, or Defective resto Radio: Caries, High filling, Periapical lesion Symptoms: Thermal sensitivity, Pain during chewing ○ Non-odontogenic: Normal Radio + Clinical exams NO sig history to cause pain Pain May be associated w/ Headache May be caused by Stress May occur during Palpation of Joint or Muscle area Endodontic pain is a symptom of what types of inflammation? Pulpal and Periapical Inflammation What does the formation of Peripheral and Central Hyperalgesia depend on? Depends on Severity of Inflammation + Body response, from Mild to Extreme Explain the types of peripheral neuron fibers of Trigeminal system Aα Aβ Aγ ○ These have Large diameter, Thick myelinated fibers ○ Motor, Touch, Pressure, functions Smaller and Less myelinated Aδ fibers 1-4 u, 5-15 m/sec Thinner and Unmyelinated C fibers 0.5-1 u, 0.5-2 m/sec add the last 2 as resp for pain causes toothdiscoloration Classification of Oral and Facial pain Regional pain ○ Periodontal pain ○ Pulpal pain Hyperactive pulpalgia Hypersensitivity Hyperemia Traditional Acute pulpalgia — Incipient, Moderate, Advanced Chronic pulpalgia traditionalRCT Pulp polyp pain frequency Necrosis Pulp pain — Total or Partial Internal resorption pain Occlusal trauma pain – Bruxism or High restorations Incomplete fracture or Tooth crack pain ○ Periapical pain Acute Acute apical periodontitis pain Acute apical abscess pain Chronic Chronic apical periodontitis pain (Granuloma) Chronic apical abscess pain Apical cyst pain ○ TMJ Pain Dysfunction Syndrome Neural pain ○ Trigeminus neuralgia ○ Trigeminus neuritis ○ Herpes Zoster Neuritis + Post-herpetic Neuralgia Reflected pain ○ Pain reflected from Pulp ○ Pain reflected from Nasal + Paranasal tissues ○ Pain reflected from MI, Coronary thrombosis, + Angina pectoris Atypical facial pain ○ Mental facial pain ○ Facial pain due to Vasodilation Periodontal pain Pain of perio origin Pulsating + Throbbing pain Mild to severe mobility Redness + Swelling of gums Pulp is Vital In acute phase— Pain becomes severe + Fever  Types of Pulpal pain Hyperactive pulpalgia Reasons ○ Restoration of dentin ○ PD operation that exposes the Root ○ Bruxism ○ Incomplete fracture ○ Sinusitis in upper jaw (affects Upper molars) Types ○ Hypersensitivity Sensitive to Cold f + d and Air Pulpagia is caused by Sweet, Sour, Salt, and diff metals Felt as an Electric current formed b/w OC + Pulp ○ Hyperemia Vasodilation Neuropeptide release → Prostaglandin degradation → Tissue degranulation + Mast cells destruction → Histamine release → Vasodilation ↑ of Temp in tooth = ↑ BP Acute pulpalgia Intrapulpal pressure ↑ due to inflammation Painful pulpitis develops spontaneously + related to activation of Nociceptive C fibers Types ○ Incipient Pulpitis in initial stage can heal after taking precautions Cavity prep Sensitive to cold + sweet Occlusal trauma Greatest danger: leakage of microorganisms thru open dentinal tubules b/w Filling material + Cavity wall ○ Moderate Pain description: First localized, then widespread Headache + Prolonged pain, Night pain ↑ with cold Does NOT go away when factor is removed ○ Advanced Cold relaxed patient Easier to localize tooth Chronic pulpalgia Diffuse pain Pain on pressure or When Lying down Sensitivity to heat Pulp polyp pain If no direct pressure = Painless Necrosis pulp pain Total: Painless Partial: Chronic pulpalgia pain-like Internal resorption pain Mild pain Pink coloration in Coronal area Resorption zone seen on radio Occlusal trauma pain Due to Bruxism or High restorations aott MTA ○ If wakes up in morning w/ pain = bruxism Sensitivity to Cold + Chewing Incomplete fracture or Tooth crack pain Tenderness while chewing Risks: ○ If crack extends to pulp ○ Leakage of microorganisms to pulp ○ Pulpitis MTA  Reflected Pain Feeling pain in an area away from the tissues causing it Lower jaw ↔ Upper jaw Tooth on 1 side → Neighboring lodges in the same area Pain is Unilateral = doesn't pass midline 1. Pain reflecting from Pulp Pain from tooth → tooth ○ U3 → all posterior ○ L45 → Upper Molars ○ Lower molars → L45 ○ L45 ↔ U45 ○ L12 → L34 or Mental area ○ L5 → Mental area or Middle ramus Pain from tooth → Adjacent tissues ○ Upper incisors = Forehead ○ U34 = Nasolabial + Orbital ○ U56 = Maxilla + Temporal ○ L67 = Ear + Gonion ○ L8 = Upper area of ear + larynx 2. Pain reflecting from Nasal + Paranasal tissues Sinusitis ○ Inflammation + swelling of Mucous membrane of Maxillary sinus ○ Symptoms Severe headache Unilateral pain of all upper molars Moderate pain that feels deep Pain spreads to face, Temple, and Nose regions Feeling of elongation in teeth Sensitivity to cold ○ Clinical exam Teeth adjacent to diseased sinus are usually mobile Sensitivity to Percussion + Cold test Produce a very soft sound during percussion Produce hard sound on the normal side ○ Radio exam In RVG = NO caries In Panorama = Full sinus gives a ↑RO image ○ Questions to ask patient Whether there is discharge from Nose to throat Location of pain in head (Frontal = sinusitis) Does the pain ↑ when chewing, coughing, bending, or jumping?  Local Anesthetics Endodontic emergencies Pain or swelling caused by various stages of inflammation of pulpal or periradicular tissues 85% ofof Mechanism effect dental of L.A emergencies = Pulpal or periradicular disease their effects by Reducing permeability of Nat canals CA exertemergencies: Endodontic interrupting N conductio Symptomatic irreversible pulpitis w/ Normal apical tissues sothey prevent generation transmission of impulses creating a chemical block 61 Symptomatic irreversible pulpitis + Symptomatic Apical Periodontitis Necrotic impulse sourcepulpbrain + Symptomatic Apical Periodontitis Necrotic pulp + Fluctuant intraoral swelling Ionic of +L.A forms pulp Necrotic Diffuse1facialSimple swellingion form RN Both block Na channels 2 Charged acidic form Rna Traumatic dental injuries Nachannels they Previously are Voltage endodontic teeth + gated channels Symptomatic Apical Periodontitis or Acute Apical abscess Endodontic flare-ups b/w sessions Types 1 Toxin blocked TTX 2 Toxin Resistant TTX R Surgical principles Remove cause of pain If fluid exudatemostly on Pain receptors = Drainage Prescribe analgesic sensitized Resistance to I A Adjust occlusionif by prostaglandins if.AM uffffe This pain threshold Presentations of Vital pulp: 1. Normal + Asymptomatic explains why tooth sensitive in inflammation 2. Reversible pulpitis ex of situation Early sensitivity w EPT ○ Reversible sensitivity to cold or osmotic changes ○ Treatment: Conservative removal of caries To Prostaglandin sensitivity Protect Dentin anesthesiaefficiency in painful teeth adminster NSAID Proper beforerestoration procedure 3. Irreversible pulpitis ○ ↑ sensitivity + ↑duration even after stimulus removal (esp. cold) ○ Intermittent or Spontaneous pain ○ Treatment: Initiate RCT Complete pulp removal Total debridement of Root canal system Structure of L.A consist of Lipophilia Hydraulic part Lipophilic Allows drug to reach thearea Hydraulic Allows drug to disperse in the tissue Types Ester Procaine Amide Lidocaine jetocaine calgel xyloraine Articaine Ultracain DS Mepivacaine Isocaine Carbocaine HCl Prilocaine Citanest octopressin 1 Procain 1ˢᵗsynthetic IA Toxic than estergroup Toxin than amidegroup Based on their chemical structure Ester of Benzoic acid Cocaine Tetracaine Benzocaine Ester of ParaaminoBenzoicacid Procaine clorprocaine Propoxycaine 1 Lidocaine Tefficacy than Procaine suitable for topical use one rapidly absorbed from mucosa 1ˢᵗ L.A in Dentistry 2 Articaine UltracaineDS suitable for ppl w allergies cuz low risk contraindicated in Anemia Heart disease Methemoglobinemia Respiratory disease  3 Mepiracaine vasodilator effect than Lidocaine Adrenaline free form used in kids Elderly patient's whose system is Not suitable 4 Prilocaine shows least systemic toxicity in Amide group Risk of methemoglobinemia due to its metabolite 0 Toluidine limiting its usage L.A according to their Duration of effect 1 Short term Aug30 min Lidocaine 21 Mepivalaine 31 Prilocaine 41 infiltrative techniques 2 Mediumterm Aug Gomin Procaine 21 Levanordetrin 1120k Lidocaine 21 Adrenaline 1 50k I look Articaine 41 Adrenaline 1 200k Mepivaraine 2.1 Adrenaline 1 200k Pritocaine 41 Adrenaline 1 200k 3 Longterm 90 min Bupivaraine 0.51 Adrenaline 1 20 K ftidocaine 1.51 Adrenaline 11200 k vasoconstrictors in Dentistry All anesthetics affect vascular smooth muscles cause vasodilation so get eliminatedfrom tissues in a short time exc for Mepivaraine vasodilator effect why do we use it To Duration Depth of effect to Dosage of anesthetic its toxicity to BF control bleeding at operation site for pain control throughout procedure Types used in Dentistry Adrenaline Noradrenaline Levanoudefrin Flipressin Coctapressin concentrations 1150k 11200k octopressin has least systemic toxicity that's why used w Prilocaine Usage of L.A in systemi conditions In patients w Heart diseases 1mi to control Pain stress Treated in morning given shortterm procedures Non vasoconstrictor L.A or Low dosage I A preferred consultation obtained before procedure Hypertension Non vasoconstrictor L.A or Low dosage I A preferred consultation obtained before procedure 3.1 mepiracaine used cuz they already take B blockers Diabetes if its well tontrolled we can still use vasoconstrictors if theyhave an additional Heart disease vasoconstrictors contraindicated  Pregnancy of Non-vital pulp: Presentations 1. Pulpal necrosis + Symptomatic Apical Periodontitis Articaine Ultracain DS must be used ○ AP often due to infection of Root canal system 80 90○ of Prilocaine mepivacaine cross the placenta Treatment: Methemoglobinemia Remove pulp remnants from RC space Procaine causes contractions in uterus Irrigate w/ NaOCL Dry canals + seal w/ CaOH (intracanal medicamentl) + Restore 2. Pulpal necrosis + Acute apical abscess ○ Tissue swelling w/ AAA When? Systemic complications of AtL.A initial emergency visit Overdose reactions Inter-appointment flare-up Post-endo complication caused by amountLocalized of Adrenaline or Diffused; anesthesia in or Fluctuant Firm ○ Acute Periapical abscess may occurs as: Patient's BP HRto Acute Sequel Arrhythmia Dysuhythmia collapse apical periodontitis may occur Acute phase of Chronic apical periodontitis Allergic reactions ○ Provide drainage + Remove source of infection mostly ○ when using If Fever + Malaise Ester antibiotics an = administer Procaine must be questioned when taking medical history ➔Allergy Acute lesions don't show on radiographs cuz visible only after bone resorbs small dose mustbe applied waited Localized swelling Methemoglobinemia Drain thru the root canal A metabolite is In eieis + disinfection Complete canal debridement L.A as they getmetabolized causing methemoglobinemia swelling Benzocaine Articaine and rarely lidocaine Pvilocaine Persistent Apply gentle finger pressure to mucosa overlying the swelling = Facilitates drainage thru canal causes Clean + dry carrying capacity of Blood to 02canals Cyanosis Headache vomiting Dyspnea Apply CaOH as intracanal medicament + Seal access cavity fainting○ vaso vagal attack If ↑ Exudate discharge is present: may be due to canPsychological You factors leave the tooth w/ lanxiety temporary orNONon filling for psycho MORE THAN 24 hrs Poorphysicalconditio Hunger nauseated skin is Patient becomes + Cellulitis Management of Abscess dizzy pale cold slow pulse Treatment = remove cause of inflammation Drug interactions = Endodontic treatment preferred if we ○ use L.A w vasoconstrictor Chemo-mechanical on RCPatients prep of infected + incisionusing Tricyclic for drainage for fluctuant periradicular even the antidepressants swelling immediately improve signs + symptoms smallest doses will cause variable degrees of potentiations of BP in response to Adrenaline Usually treated w/o systemic antibiotics Local complications of L.A Painful injection anxiety sudden movement needle breakage Burning during injection pHof solution rapid injection of CA Needle breakage sudden unexpected movement of patient Trismus due to usage of infested needle causing infection in masticatory space Hematoma formation By penetrating needle Paresthesia due to trauma to any N wh jiffy infffen ST injuries like trauma to lips or tongue Infection contamination of needle or improper handeling of anesthetic equipment complementary Anesthesia methods 1 Intraseptal very thin needle applied to interdental septum in verythin applied for a short time inconvenient to repeat Septum may become Necrotic 2 Intraosseous a move apical application into spongybonecavity Not used as much these days 3 Intralignmentary Anestheti administered directly into PD membrane at Pressure 4 Intrapulpal injected directly to pulp chamber used when mandibular anesthesia is insufficient in irreversible pulpitis why do we Antibiotic isolate teeth administration indications: (adjunct to RC debridement) Fever (over 37) To protect operation area from salivation Malaise instruments dental parts or irrigation solutions from escaping into patient's system Cellulitis Preventing Lymphadenopathy To protect STorfrom Progressive instruments persistent swelling Unexplained Trismus To retract cheeks tongue to are These prevent patientor from all Progressive Persistent their infections closing w/mouth Systemic signs + symptoms To protect Dentist assistant from saliva Aerosols NOT indicators Irreversible pulpitis Symptomatic apical periodontitis Draining sinus tract Prophylaxis for flare-ups After endo surgery, after incision for exudate drainage ➔ Analgesics NOT antibiotics are administered for pain management ➔ This is due to Risk : Benefit ◆ Risk for side effects + Resistance of microorganisms Any infection marked by Cellulitis — Aggressive incision for drainage Incision for drainage Provides a pathway of drainage to prevent further spread of abscess or cellulitis Allows for: ○ Decompression of ↑tissue pressure due to edema + Significant pain relief ○ Draining pathway for Bacteria, their products, + inflammatory mediators Endodontic Flare-ups (also swelling) Acute exacerbation of Periradicular pathosis after initiation or continuation of Non-surgical RCT Reasons: ○ Prepping beyond apical terminus ○ Over-instrumentation ○ Pushing Dentinal + Pulpal debris into Periapical area ○ Incomplete removal of pulp tissue ○ Overextension of RC filling material ○ Root fractures ○ Microbiologic factors ○ Hyper occlusion ○ Chemical irritants — Irrigants, Intracanal medicaments, Sealers Management ○ Periapical surgery ○ Reentry into tooth ○ Providing drainage thru tooth ○ Adjust occlusion Factors affecting Anesthesia failure 1 Individual reaction of Patient to anesthetic anxiety Pain threshold Alcohol Drug addicted tolerance for stress pain 2 Methodof anesthesia applied usuallydue to Poor techniques esp in IANBlock 3 Region anatomy close proximityto BVs injection into BV Noanesthetit obtained 5 Tissue iii inflammation thiscauses pit in area sensitive to pain iii  Vital Pulp Therapy Treatment to preserve + maintain pulpal health in teeth exposed to trauma, caries, resto procedures. ○ Preserves immature = young pulp Initiates formation of Tertiary dentin or Calcific bridges Indications: Reversible pulpitis or Partially inflamed pulps ○ Remaining healthy tissue can be conserved to generate a Hard tissue barrier (3. Dentin or calcific bridges) that would seal + protect pulp Treatment outcome depends on: Patient’s history to determine rational prognosis Radiograph evaluation Clinical evaluating Pulp testing Hemostatic agents Choice of pulp capping material Integrity of the sealed permanent resto Local factors ○ Area of exposure ○ Carious or Mechanical exposure ○ Size of exposure ○ Duration of exposure before treatment ○ Microleakage ○ Bacterial contamination Pathophysiology of Pulpal inflammation Due to invading microorganisms Acidogenic Gram + bacteria ( Oral streptococci + Lactobacilli) produce metabolic byproducts during active caries that demineralize Enamel + Dentin ↑ Bac challenge = ↑ inflammation + edema (immune cell response) Pulpal pain ↑ Prolonged inflammation = Pulp disintegration + Apical pathosis The caries invasion is initially blocked by protective immune responses = Microbes first encounter a positive outward flow of dentinal fluid w/ depositions of Igs + serum proteins = Slow down bacterial antigens Pulp is a highly vascularized LCT enclosed w/ w rigid envelope consisting of Enamel, Dentin, + Cementum Together = Dentin-pulp complex Functions = Defense (immune cell), Surveillance, Nutrition, Dentinogenesis, Proprioceptor recognition Dental pulp can generate reparative hard tissue, Peritubular, + 2. Dentin Dentin pulp structural zones: 1. Cell-rich layer 2. Core sth here 3. Cell-free zone 4. Odontoblastic layer – Lines pulp periphery Caries excavation The 2nd demineralized carious layer proximal to pulp has degraded HA crystals but contains Collagen w/ intact cross-links = unaffected by cariogenic acids = Not stained w/ caries detector dyes If this layer can be identified + preserved in caries excavation, then the remaining pulp + odontoblast subjacent to carious zone will be subjected to less trauma = ↑ Pulp protection This layer has a stronger capacity to remineralize when paired w/ bonded composite restorations to prevent bacteria microleakage What’s the objective in vital pulp therapy? — Encourage hard tissue barrier formation after injury Reparative bridge formation Initiated when regenerated odontoblast-like cells (stem cells) recruited from the Cell-rich zone + Subodontoblastic layer advance the repair of Pulpodental defects after migration of high vascularized tissue to the site Process: 1. Moderate inflammation 2. Recruitment + advancement of Stem cells (Progenitor cells) 3. Proliferation of Stem cells 4. Terminal differentiation In Primary dentition: Direct pulp capping – Vital tooth w/ pulp exposure Indirect pulp capping – vital tooth w/ deep carious lesion approximating pulp ○ In both NO signs of pulpitis or Reversible pulpitis Pulpotomy Possible complication in Indirect pulp capping Determining the exact point where Caries excavation should be terminated ○ Based on operator’s skill Presence of potential voids under the provisional restoration Rapid reactivation of dormant lesions after resto failure Indirect pulp capping indications: Immature permanent teeth w/ ○ Large apical foramen ○ Thin canal walls ○ ↑ Pulp vascularization Pulpotomy Pulp amputation = removal of coronal portion of vital pulp to preserve the vitality of the remaining radicular portion Recommended for: Primary teeth w/ favorable short-term outcomes Procedure: 1. Complete amputation of coronal pulp 2. Capping material placed over pulp floor + remaining exposed tissue in canal orifices ○ Formocresol was the accepted standard capping agent Research shows its Carcinogenic + Genotoxic Int. Resorption in nonhuman models ○ MTA and CSCs replaced it Primary molar pulpotomy = MTA Permanent teeth pulpotomy = MTA and CSCs Pulp capping agent’s specification: Radiopaque Maintain pulp vitality Stimulate reparative dentin formation Bactericidal, Bacteriostatic, Provides bacterial seal Sterile Well adherence to Dentin + Resto material Resist forces under resto for lifetime Material for Vital pulp therapy: Calcium Hydroxide MTA Calcium Silicate-based cements Resin-modified GIC + Hydrophilic resins Calcium Hydroxide Stimulates Secondary odontoblasts repair w/ Dentinal bridge formation ○ By stimulating Undifferentiated mesenchymal cells ( stem cells) to form Secondary odontoblasts → Tertiary dentin Does this by its 12.5 pH = High = neutralizes acids Causterizes tissues + Kills bacteria Disadvantages ○ Weak marginal adaptation to dentin ○ Degradation + dissolution over time Allows microleakage of microbes thru calcific bridge defects = Pulpal degeneration = Dystrophic calcification + Pulpal necrosis ○ Primary tooth resorption ○ Absorbable = dimensionally unstable MTA = Mineral Trioxide Aggregate Aggregates of Ca, Silicon, Aluminum Stimulates cementoblasts to produce Hard tissue = Reparative dentinogenesis = Matrix formation + Mineralization Advantages ○ Has bismuth oxide → Radiopaque ○ Sets in moisture ○ Antimicrobial ○ Nonresorbable = Great sealing agent ○ Superior Long setting time = 3 hours Indications: ○ Pulp cap, Pulpotomy, Pulp regeneration ○ Furcation + Lateral perforation repair, Root resorption repair ○ Apexification + Apicoectomy Calcium Silicate-based cements Physicochemical + Bioinductive properties similar to those of MTA BioAggregate, Biodentine, MTA-Angelus Resin-modified GI Cements + Hydrophilic Resins Excellent seals when combined w/ Light-cured composites Placed directly over pulp capping materials like MTA or CaOH Hemostatic agents — To control bleeding pulp exposure NaOCL ○ 1.5 - 6 % as the Most effective + safest 2% CHX MTAD 30% Hydrogen Peroxide Ferric sulfate Epinephrine Lasers Direct pressure w/ cotton pellets soaked w/ saline of sterile water Importance: Hemostasis + disinfection of Dentin-pulp interface Chemical amputation of Blood clot + Fibrin Biofilm removal Clearance of dentinal chips Removal of damaged cells ➔ If hemorrhage can’t be arrested after 5-10 min after exposure to NaOCL = Irreversible Coronal pulp inflammation  Endodontic outcomes What are the methods used to evaluate endodontic treatment outcomes? What are the limitations? Clinical examination Radiological examination of Periapical tissues Histopathological findings of Biopsies Successful endo treatment = Absence of Clinical symptoms + Periapical RL ○ Symptoms must decrease to min levels 7 days after RCT Spontaneous pain, Pain on percussion, palpation or chewing If pain persists = due to Nonodontogenic cause or Persistent infection Limitations of Radiographic exam ○ If the lesion is limited to cancellous bone, then normal radiographs we use won’t show it. Adequate demineralization of bone + cortical plates must occur for lesions to show on radio. ○ They’re Subjective + Observer biases affect the conclusion Periapical Index measurement system A scoring system for Classifying radiographic features of Apical periodontitis Its based on a Visual scale of Severity of Periapical periodontitis + builds on Histo-radio correlations = basically depends on Operator’s skill CHECK w/ BILGE HOCA CBCT-PAI PAI used w/ CBCT ○ Implements standardization in approaches to assessing severity of Apical periodontitis Assesses the expansion + destruction of cortical bone ○ = ↑ Sensitivity to detect periapical disease ○ But its NOT recommended to use as a Routine diagnostic tool due to ↑ Radiation exposure Its a 6-point scale index w/ 0-5 + 2 variables Toronto Study Introduced terms for evaluating Endo treatment outcomes If PAI less than 3 = Healed If PAI is 3 or more = Disease Asymptomatic teeth regardless of PAI = Functional Fill in the blanks: 1. Radiographs provide a static view of degree of mineralization of Tooth + Periodontium 2. Endo treatment outcomes have evolved from Disease-centered values by Strindberg to Patient-centered criteria 3. Disease-independent treatment outcome must always be the goal of ALL endo treatments 4. Strindberg determined outcomes for: Conventional endo treatments + Endo Treatments on Preoperative periapical diagnosis Difference b/w Strindberg criteria and AAE results criteria AAE-approved Endo outcome definitions — Alternative to the Strict Strindberg criteria Healed: Functional + Asymptomatic radiographically W/O or MIN Periradicular patho Unhealed: Nonfunctional + Symptomatic regardless of periradicular patho presence Teeth in Healing: ○ Functional + Asymptomatic w/ periradicular pathology ○ Symptomatic but performing its function regardless of periradicular patho Functional: Treated tooth thats’ performing its intended task Strindberg criteria Success ○ Teeth w/o any clinical signs of symptoms ○ Intact lamina dura ○ Borders of PDL are enlarged around overhanging root filling ○ Normal PDL contours ○ If there's root resorption but NO periradicular patho Failure ○ Symptomatic teeth ○ Unchanged periradicular patho, or not complete resolution ○ Increased size of RL, or New RL ○ Impaired continuity of Lamina dura Uncertain ○ Inadequate radiographs that are unclear ○ Irregular or Indistinct LD + less than 1 mm of Periradicular patho ○ Cases of tooth extraction due to NON-endo related reasons Treatments for Underdeveloped permanent teeth = Open apex Vital pulp therapy ○ Preserves vitality + functionality of Dentin-pulp complex ○ Ultimate goal = Stimulate growth + maturation of immature root = preserving natural dentition of young patients ○ Success criteria Clinical findings: Regression of symptoms Preservation of Pulp vitality Radiographic findings: Continuity of Root elongation Maturation of apex Thickening of RC walls ○ Failure Clinical findings: Persistent or recurrent symptoms - Pulp vitality test Radiographic findings: Root growth arrest Interruption of apex maturation NO thickening of RC walls What are the Factors that Affect the Outcome of Vital pulp therapy in immature teeth? Age of patient Microleakage of capping material ○ Infection control is MOST imp Tooth development Severity of pulp damage + Regenerative potential of Pulp  Non-vital pulp treatments ○ Regenerative endodontics by Revascularization First treatment option for immature permanent teeth w/ Necrotic pulp + treats Apical periodontitis Immature = Open apex This favors repair not true regeneration Primary goal (essential): Elimination of symptoms + Evidence of bone healing Secondary goal (desirable): ↑ Width of RC walls ± ↑ Root length Tertiary goal: Positive response to vitality testing Tooth discoloration is a risk Procedure: In 1st session, we irrigate the RC, apply a medicament, then a temporary seal In 2nd session, We stimulate bleeding by overinstrumentation, which would cause a blood clot formation. This blood clot is sealed w/ MTA, which stimulates cementoblasts to produce Hard tissue = Reparative dentinogenesis ○ Success Clinical findings: NO pain, ST swelling, or Sinus tract obstruction Positive results to Vitality tests Radiological findings: Resolution of Apical RL ↑ Width of RC walls ↑ Root length ○ Failure = Failure to achieve Primary goal If this treatment fails, then we can try Apexification ○ Apexification Apexogeesis = Creates a calcific bridge barrier or continues the continuity of a Necrotic immature tooth = Open apex usually by applying MTA We don't want to do RCT cuz RC walls are fragile + Apex is wide open Success criteria Clinical findings: ○ Regression of symptoms Radiographic findings: ○ Resolution of Apical RL Failure Clinical findings: ○ Persistent or recurrent symptoms Radiographic findings: ○ No change or ↑ of Periapical RL  Success Trauma case Periapical - Partial resolution in - Reduction in - 4 years follow-up: (6 months ago): radiograph taken periapical periapical and Closure at the apex after the end of radiolucency peripheral - Complaint of without periapical Regenerative radiolucency toothache and - Reduction in clinical rarefaction Endodontic discoloration on the symptoms - Healing and Treatment - Thickening of the crown regeneration of the - Healing of periapical wall in the MTA placed pdl border around the - Vitality: (-) inflammation is area of the canal apex, lamina dura, and monitored - Open apex and bone - Ectopic calcifications periapical radiolucency scattered along its - Minimal changes in apical ⅔ apical foramen width ❖ The upper incisors were restored with composite as a result of a crown fracture, and 6 months later, the patient presented to the clinic with pain and swelling in the maxillary left central incisor. Regenerative endodontic treatment was successfully applied. Diagnosis Postoperative radiography 18-month follow-up: Radicular dentin deposition occurs more slowly. However, the MTA was placed on the blood clot at apex is closing and the the cementoenamel border. periapical structures are Perceptible narrowing of the apical being re-established. foramen - suggesting that post- traumatic necrosis does not develop immediately.  Apexification with MTA application - success Diagnosis 3-month follow-up 11 months follow-up 8-year follow-up