lDstrumerts/Materials/

Techniques

Access Preparations,

ENDODONTICS

Imagine the access preparation for a maxillary cntral incisor.

Copyrigh

e l0ll-2011-

Dental Decks

IIarillary Central Incisor

Maxillary Lateral Incisor

Maxillary Canine

Access Opening

Access Opening

Access Opening

Reprinted liom liglc.

l,

dd

B ak1^nd

LK. Endodontics Fourth E.litian O I 99i1. s irh pennission from Williams & Wilkins.

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Mandibular Central
Incisor

Nlandibular Lateral

Nlandibular Canine

Incisor

Access Opening

Access Opening

Access Opening

One canal

Reprirted arorn lngle. JI. a.d Bakllnd LK

End.,lanti.s Fat h E.lition .t l1)t)1, *\th
lennisron ftinn \\rllams & Wilkins

Maxillary First Premolar

Maxillary Second Premolar

Access Opening

Access Opening

One canal

Onc canal
One fbnmen

One

foramen

Two canals
Two lbramens
Three
Rctrin!.d tion fngle.

199.1,

Jt-

ca.als

15%
21o
1Yo

ind B^ll^..1l,K E,l.)tldnns. Fottth

wilh lremission tionr $illiam\ & $llklns

4
Cop)'right O 20 I I -20 l2 - Denhl Decks

Cop).righr O 201l-2012 - Dental Decks


pre m 20 -22

Mandibular First Premolar

Mandibular Second Premolar

Access Opening

Access Opening

all prem the most percentage one canal one foramer except max 4
2 canal 2 foramen 70%

One canal
One foramen

One canal

Two canals

Two canals

One fommen

One foramen

One foramen

Two canals
'I
wo foramens
R.pn n'ed

riofr

Two canals

lngle. Jl. and Btkland LK. Lrtlodontu s. Fourli

td,rt,, q

Maxillary First Molar

994. wnh pemission from u illiams &

Access Opening

19.9 mm 20
19.4 rnm

Palatal

willins

Maxillary Second Molar

Access Opening 3 roots mb db palatal

MB
DB

MB
DB

20.2

3roots mb db palatal

mn

20.6 mm

Three
Fused

mb root

Reprinred frcrn Ingle, Jl. and aakl^ndLK. Etulo.lontns.

I9.4 mm
Palatal- 20.8 mm

mb root

r'auth Etlition A

1994. vith penission

rion willians & willins

54%

46%

Coprighr O

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. A persistent periodontal defect

. A radiolucent halo surrounding the root ofthe fracture
. A radiopaque lesion at the sight ofthe fracture

. A visible fracture when transillumination is used

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Mandibular Second Molar

Mandibular First Molar

Access Opening 2roots m & d

root 21

Access Opening 2roos m & d

Mesial 20.9 mm
Distal 20.9 mm

Mesial 20.9 mm
Distal 20.8 mm
foramina

Two canals
Three canals
Four canals

Ong canal

One

fommen l3Yo

92%

Two canals

]lesial
One

canal
Two canals
One

foramen 4l%

Two canals
T\r'o foramens

One

Distal

Two canals

72%
28%

foramen 49vo

Two canals
Two foramens

38%

590

l',,

Two canals
59olo

fommen

62%

Two canals
Two foramens

38olo

One

Repnnred

fdt!,, g

|Ion fngle.Jf.and B nkt^nC,I K. End.danti.s Fnurth

199.1, silh pe.misstu. fion Willilns & Nilklns

Often times transillumination is used to see the defect, but ofcourse, this cannot be diagnostic on tooth structure that is under bone. Also, persistent periodontal defects are often
caused by vertical root fractures; however, this is not radiographic (read the question
carefu I I1') .

Important: Radiographs lwltlrout.lirst wedging the lootiT rarely will show veftical fractures.

Vertical fractures will often be recognized radiographically by their effect on the bony
attacirment apparatus that is seen as a diffhse radiolucency or "halo" surrounding the
root. This can be differentiated from other periapical radiolucencies because it surrounds
the tooth uniformly ratherthan being located at the portal ofexit ofthe apical foramen or
lateral canal.

\otes

l. A tooth with

vertical fracture through root structure has a poor progno-

sis.

';q:.:,.r', 2. Studies have indicated that most vertical root fractures are caused by too
much condensation force during obturation with gutta-percha.
Therapy for horizontal fractures of the root always involves considerable difficulty.
Root canal treatment is not indicated if the fracture sites remain in close proximity and
ifthe pulp retains its vitality. However, ilclinical symptoms develop or the segments appear to be separating according to the x-ray, some treatment is necessary.
Remember: Root fracture can only be visualized on a radiograph if the x-ray beam passes
through the fracture line. As the fracture line could extend diagonally, an additional radiograph is taken with a 45" (steep) vertical angulation in addition to the conventional 90".

. #19 - virgin
. #15 - primary cavitation on occlusal

. #3 - fulI gold crown

. #30 - occlusal amalgam

8
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Same

. Opposite

coplrighr O 201l-2012 - Denral Decks

EPT checks the sensibility of a tooth by stimulating ncrvc cndings with a low current and high
potential difference in voltage. Although manufacturers ofthis device give normal relerence valucs ofcurrent, the best way to check "nolmal,/baseline" values is to use it on adjacant t"ron-pathoiogicai) teeth. This is then compared with the values obtained on the looth being questioned. The
EPT uses electrical excitation to stimulate the A-delta sensory fibers in the pulp. A positive response does not provide any information about the health or intcgrity of the pulp: it simply indicates that therc are yital sensory fibers present. lmportant: The EPT fails to provide any
informalion about the vascular supply to the pulp, which is the truc determinant ofpulp vitality.
Note: EPT is not considered reliable in the following conditions.
1. A pus-fillcd canal
t'alse positivc

- false positive
.1. Recent dental trauma
lalse negatire
4. hsulating rcstoration - false negative
5. Sccondary dentin deposits
falsc negative
- [alsc positir c
6. Moisturc (ontaminalion
7. lmmature tooth t'open apex)
false negative
8. Patient who has taken analgesics
false negative
2. A nervous patient

lmportant: Never wear gloves while using the EPT as this impcdes conrpletion and results in a
false-negative response. Also, ifa paticnt's medical history reveals that a cardiac pacemaker has
been implanted, the use

ofan electric pulp tester is contraindicated.

Response to EPT:

. Acute pulpitis: lower than normal current,

as acute

inflammation mediators lowcr the pain

thrcshold

. Hlperemia: lower than normal, but higher than that seen in

. Pulp necrosis/abscess: no response at any currenGlevel

acute

pulpitis

ln other words, wc can say that the cone image shift technique separates and idenlifies thc facial
and lingual structures. Noter The cone shif-t technique is also known as thc buccal object rule,
SLOB rufe (Saae Lhgual, Opposite Buccaf, Clark's rule or Walton's Projection.
As the conc position moves lrom parallel either towards horizonlal or vertical, the objcct on the film
shifts away from the dircction ofthc cone (i.e., in the direction ol the central beatt).

Note: ln order to apply this rule, you must have

reference object.

Important: A disadvantage of the cone shili technique is that it results in blurring of the object
uhich is directly proportional to cone angle. The clearest radiograph is achieved by thc paralleling
tcchnique so when thc central beam changes direction rclativc to thc object and the film, the object becones blurry.
\\'hen trearing multicanaled bicuspids and molars. it is ol'ten difficult to ascertain on the
radiograph $hich canal is more toward thc buccal. When a straight-on exposure is taken ofa bicanaled tooth. thc canals become supe mposed on the filnl, and visualization of each canal is impossible. Ifthe x-ray cone is moved to give an angled exposure, the roots will bc separate on the

film.
By'applying the cone image technique you will be able to determine which canal is thc buccal
and rvhich is the lingual.

Explanation of SLOB (Same Lingual, Opposite Buccal) rule; the object toward the lingual
side (closer to the liln) will appear to shift on the film to the same direction as the repositioned x-ray cone. For example, ifthe x-ray cone is mesially angulated, the lingual/palatal object (root) will shilt toward the same (nesiql) side in the resultant radiograph film, and thus
will be easily visualized.
Note: Uring this technique you can determine:
l Working length of superimposed canals.
2. Curvatures of root/canals.

3. Facial-Lingual orientation ofinstrumnts, or other anatomical objects.

. Soft tissue exam

. Hard tissue exam
. Radioglaph
. vitality

test

. Percussion test

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. Mandibular first molars, maxillary first molars

. Mandibular first molars, maxillary second molars
. Maxillary second molars, mandibular first molars

. Maxillary first molars, mandibular first molars

'11

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*** This test is contraindicated. The pcrcussion test is usually not performed bccause ofits paini
however the vitality test will givc you a truly falsc reading, bccause oftcmporary paresthesia in the
area-

For teeth that have becn recently traumatized the dental examination should include:
. Soft tissue exam: observc the lips, face, tongue, etc.
. Hard tissue exam: visually look and then palpate thc injured tooth and alveolus to reveal thc
extent oftooth mobility as well as alveolar fractures and area of inllammation. check for occlusal
disharmonies to hclp detcct tooth displacements andjaw fractures
. Radiographic examination; x-rays reveal tooth displacsment and root fracturcs as well as
other important facts (previous rc,ot canal, periapical radioluce cies, elc.).
. Observe the adjacent and opposing tceth for injury'
Teeth that have been traumatized n,lay bc fine for a long tine. however, nany rvill develop radiolucencies. Do not indiscriminately do root canals without first checking pulp vitality' and perform
root canal thcrapy only in those teeth that do not rcspond to pulp testing Example: Trauma to
maxillary anterior tcclh. A fcw years latcr x-rays rcveal radiolucencics around the region of thc
apices ofthe incisors. Check the pulp vitality ofall anterior teeth before performin-q root canals'
Note: Trauma tc4r., iry deep intnrsion) to a permancnt tooth will most likely result in necrosis of
the pulp and conventional root canal therapy will be necessary.
Pulpal necrosis: ifcaused by inflammation that started in the pr.rlp /e 81., cdrie.t/, it most probably
will spread to the periradicular tissues; ifcaused by trauma that severs the blood supply to the tooth,
partial or total:
a dry necrosis rnay result that may not spread to the pcriradicular tissues. [t rnay be
partial necrosis may present with somc of the symptoms associated with ireversiblc pulpitis
(e.g., a fito-.anale.l tooth could hare an inJlamed pulp in one canal and a necrotic pulp itl the
otrer. Total necrosis is asymptomatic before it affects the PDL, and there is no rcsponse to thcrmal or clectric pulp tests. Note: The inflammation will eventually spread beyond the apical foramen. which rvill lcad to thickening of the PDL. The clinical manifestation of this presents as
tendemess to percussion and biting

Mandibular molars are characterized by a trapezoidal outline of the pulp chamber. This
outline is formed by two canals in the mesial root and one oval canal in the distal root. ln
approximately 287o (offrst molars) ofthe cases the distal root may have a second canal
(burth canal overal1). The pulp chamber is located in the mesial two-thirds olthe crown.
Important: You must look for the fourth canal ifthe first-found canal in the distal root
lies more toward the buccal, instead ofbeing located in the center
The lingual wall ofmandibular teeth is most easily perforated when preparing an access opening due to the lingual inclination ofthese teeth.
2. The mandibular first molar requires endodontic treatment more frequently
than any other tooth in the oral cavity.
I.

Maxillary molars have a triangle outline of the chamber:

. The base of it is formed by the buccal canals, the apex by tlte palatal canal
. The line connecting the mesial with the palatal canal is the longest
. Ifa fourth canal is present, it is usually located lingual to the orifice ofthe mesiobuccal canal. and in the mesiobuccal root. lt is much more common than previously
thought.

. ,. 1. The mesiobuccal of the maxitlary molars is the most complex root in the
/l\odr entire dentition because 90o% have either second canals or major fins leading off
.:

.a4,^

of the mesiobuccal cana..

2. The maxillary first molar is the posterior tooth with the highest endodontic failure rate. The lingual or palatal root is the longest, has the largest diameter, and offers the easiest access. The clinician should always assume there are
two canals in the mesiobuccal root until it is proven there is only one.

most oftn refer prin to the temporal region,

. Maxillary

second premolars, mandibular molars

. Maxillary molars, mandibular molars

. Maxillary

second premolars, mandibular premolars

. Maxillary molars, mandibular premolars

12

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Which of the following teeth is most likely to hsve two canals,

in facL it has two canals most of the tlme?

Tooth

Tooth #12

/14

. Tooth #20
. Tooth #28

Coprighr O 2011-2012 - Denlal Decks

Ifcaref'ul diagnosis does not reveal the afl'ected tooth, other teeth and related anatomic structures become suspect. Pulpitis in one tooth may cause pain in other areas
the pain is re-

ferred.
Slte of Prin

Referril

Pulp ofTooth Causing Prin

Vcrillrry

canincs, rrcrnolJ6

Maxillary sccond prcmola.s

Ear. angle ofjaw, or postelior

Mtrl3l

rc8ion ofmandiblc

ZygoMtic, par'cral,

and

Mrndrbular incisors, canrncs. and prcmolr6

occipir.l

Opposing quadmnl or 10 olher

tect) in tle sarne quadranl

Maxillary and mandibuhr molari

Important: The nerve endings of cranial neryes Vll, lX, and X are widely distributed
within the subnucleus caudalis ofthe trigeminal (V) newe. A profuse intenningling ofthese
nerve fibers creates the potential fbr the referral ofdental pain to many sites.
Orofacial pain can be the clinical manifestation of a variety of diseases involving the head
and neck region. The cause ofthe pain must be differentiated between odontogenic and nonodontogenic. Characteristics of nonodontogenic involvement:

. Fpi:udrc pain with pain free

remissions

. Tdgger points
. Pain travels and crosses the midline ofthe face
. Pain that surfaces with increasinq stress
. Pain that is seasonal ar cyclic

Pain accompanied by paresthesia

Maxiffary first premolars: Approximately 78oh have two roots, one buccal and the other
palatal, each rvith a single canal. The two roots rnay be completely separate or merely twin
projections rising from the middle third ofthe root to the apex (this is nore comrD,?). The two
roots are usually equal in iength from apex to cusp. However, the lingual root and canal may
be wider.
ln approximately 229lo of maxillary first premolars, only one root is present. there may either
be one or trlo canals with one foramen. A cross section at the cervical line shows a canal
shaped like a figure eight /e//rpse). The access opening is a thin oval. Be careful not to perforate on the mesial (the concavii, on the mesial makes perforation reD'conmon).
The apical foramen ofthe maxillary first premolar is usually close to the anatomic apex, and
rhe apical ponion ofthe roots often taper rapidly, ending in extremely narrou and curved root
rips. The buccal root can fenestrate through the bone, leading to problems such as inaccurate
aper location. chronic post-operative sensitivity to palpation over the apex, and increased risk
ofan irrigation accident. This tooth is also prone to mesiodistal root fractures and fiactures at
rhe base ofthe cusps, especially the buccal cusp.

Nlarillary second premolars: The most common configuration in this tooth is a single root,
occurring approximately 75%o ofthe time. Approximately 25%o ofthe time, two separate roots
are present, each \\,ith a single canal. The access opening is exactly the same as that for maxillary first premolars (thin oval).
Remember: Maxillary second premolars have a higher incidence ofaccessory canals (60'%),
than do maxillary first premolars.

, .. f. When onlyonecanal is present (frst or secotld premolar), it is usually found in

rNolce.i fis center ofthe access preparation. lfonly one canal is found, but it is not in the
'*i4d;i center ofthe tooth, it is probable that another canal is present
2. Overfilling either tooth may force materials directly into the maxillary sinus.

. You failed to locate

calal

a second mesiobuccal

. You failed to locate a second distobuccal canal

. You failed to locate

a second palatal canal

. Nothing, it takes more than

12 months for the bone to heal

14
Cop)'right O 20ll-2012 - Dnhl Decks

. \{axillary central incisor

. Vandibular central incisor
. \{axillary lateral incisor
. \{andibular lateral incisor

Coptrighl C 20t 1,2012 - Lrntat Decks

*** Not only

is the mesiobuccal canal the hardest canal to find on tooth #3 and # 1.1, but

it also olten splits into t\,'o.

Canal orifices ofa maxillary first molar are arranged in the shape ofa triangle. Tlie orifice to the mesiobuccal canal is usually the most difficult to locate, since it is under the
mesiobuccal cusp and must be entered frorn a distolingual position. This canal is the
small canal and often splits into two canals. lt may be calcified and difficult to instrument. The palatal canal is the straightest, widest, and most tapering canal. The most common curvature ofthe nalatal root is to the facial. The distobuccal canal is also small and
tapering. The orifice to this canal has no direct relation to its cusp. The distobuccal orifice is usually located by means of its relation to the mesiobuccal orifice, t\.'ith the distobuccal found approxinately 2 to 3 mm to the distal and slightly to the palatal aspect of
the mesiobuccal orifice.

Note: In approximately 587o ofmaxillary first molar teeth, a fourth canal is present with
its orifice being just lingual to the orifice ofthe mesiobuccal canal. The canal is located
in the rlesiobuccal root and may join the mesiobuccal canal or exit through a separate
fbramen. lf a lesion is present on the mesiobuccal root pior to root canal therapy and
doesn't heal in the usual amount of time (6-12 month.s) following treatrnent, il is rnost

likely due to

a missed canal

(nesiolingual).

Fracture ofthe maxillary first molar is usually through the central groove or at the base
ofthe buccal cusp. These fractures can extend into the furcation, creating an untreatable
periodontal det'ect.
Remember: The U-shaped radiopacity commonly seen overlying the apex ofthe palatal
root of the maxillary first molar is most likely the zygomatic process ofthe maxilla.

The base ofthe triangle lvill be the f'acial. The apex

oval,

will

be the

lingual.

llit

is not

triangular, then rtwill be

Over 607o olmaxillary ccntril incisors show accessory canals, and thc apical foramen is found
the apex in .157o of$ese tecth.

apa11

flonr

ldeal access preparation ofnlaxillary central incisors is ovxl-triangulrr on rhe lingual surface oflhe tooth
a sli!ht cune lingually to avoid reducing the incisal edge.

\\'ilh

The cenical cross sections below olthe maxillar] permanent teeth

sho\r the relationship ofthe crown outline to the
pulp chamber and the root canal.

@@@
/7-\ \,\0
,6,

\\0\l
'a\l/ \r' )l

Firn

Prcmohr

Second Prcmolar

./=-\ F:l

nl\ll
/1 ll
utl u
l) U U
il

\-/ \r'
First

luolar

S.cond

ltol.r

.5%
.20%

.45%
.65%

t5
CopFighr O 20ll-2012 - Dent.l Decks

. The first statement is true, the second is false

. The first statement

is false, the second is true

. Both statements are true

. Both statements are false

17
Copyrighr O 201 l-2012 - Dntal Decks

*** Almost

one fourth

ofall mandibular first oremolars mav

have two canals with two foram-

ina.
The treatment of mandibular first premolars can really be tricky! At least 27oA may have
two canals with either one or two fommen. This is quite different from the mandibular second
premolar
are found to have one canal with one foramen.

-867o

The second premolar has fewer variations than the fimt premolar, usually having one root and
one well-centered canal. The access opening is oval. Consideration must be given to the mental foramen which lies in close proximity to the apex. Avoid overinstrumentation and overfill. When viewing an x-ray ofthis area, the mental foramen is sometimes misdiagnosed as a
premolar abscess. Therefore, before performing root canal therapy, make sure all diagnostic
tests confirm your finding.

Note: Ifa straight-on preoperative radiograph ofa mandibular first premolar shows the pulp
canal disappearing (or goingfrom dark lo /r'g@ in midroot, this is an important indication
that two canals are present

Other diagnostic tests:

. Slective anesthesia test:

can be used when other tests have not determined which tooth
is the source ofpain.
. Test cavity: only done in cases where a strcng suspicion ofpulp necrosis is present and
confirmed with other tests and radiographic findings, but a definitive test is requircd.

Remember: A radiolucency will not begin to manifest until demineralization ofbone extends
point: You should not rely exclusively on x-rays
through the cortical plate ofthe bone
in an anempt to anir e at a diagnosis. -Key
Because an x-ray is only a two-dimensional image, two films ofthe tooth or teeth
in question should be taken at the same vertical angulation but with a 10- to l5-degree change
in horizontal ansulation.

lmportant:

Mandibular canines usually have only one root but in rare

cases may have two separate

roots. The access opening is a large oval with the greatest width placed incisogingivally.

This tooth usually has a slightly labial axial inclination of the crown, therefore the access opening needs to be directed towards the lingual surface.
The canal ofthe mandibular canine is somewhat ovoid at the cervical area but it becomes
rounder at the apex.

\ote:

The root canal for a mandibular canine is thin mesiodistallv but wide labiolinguall)'.

. Maxillary central incisor

. Maxillary lateral incisor

. Maxillary canine
. Mandibular central incisor

18
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. Control the hemonhage with hemostatic agents

. Apply formocresol with cotton pellets at the amputation site

. Irrigate the canal with sodium hypochlorite then apply calcium hydroxide
. Perform the amputation at a more apical level

. Stop the procedure and close the tooth with

an interim restoration

. All of the above

19
Coplright O 20ll-2012 - Denral Decfts

The maxiiJary lateral incisor ahvays h{s f99.9Zo) one root with one canal. The root is more slender than
in the maxillary central incisorand frequently 1557,y' has a distal and/or lingual curvature or dilaceration.
The access opening is oval.

Maxillary central incisor: The maxillary central incisor always has one root and one canal. The root
is bulky, with a slight distal axial inclination but rarely has a dilaccration. The access opening is oval-

triartgular.

Maxillary canine: The maxillary

canine always has one root and one canal. This tooth is the longest

in the arch. The access opening is o\al.

Note: The maxillary central, lateral, and caninc roots and hence, canals all have a distal axial inclination. This mcans in pcnetrating along thc long axjs ofthe tooth, the bur must be slightly angled toward
the distal surface. Failure to do this may lead to perforation ofthe mesial portion ofthe root.
Remember: The mandibular incisors (latemls and centrals) ha're only one root which is narrow
mesjodistally but relatively wide labiolingually and may have a distal and/or lingual curvature. Two
canals may be present. When there are two canals, the labial canal is the straighter one. The access
opening for a orandibular central or lateral is a long oval, with the greatest width placed incisogingivally
and the incisal extent very close to the incisal edge.

Perforation: Although many errors can potentially occur during acccss preparations, the most deictcrious is perforation ofthe pulp chamber space into the oral cavify or periodontal tissues. Ifthe perforation
occurs above the osseous crest in the gingival sulcus or above the free gingival margin, consider the
following measures: (l) Control hemorrhage with a dry cotton pellet or some hemostatic agent, do not
use formocrcosol (2) Scalwidl a temporary cement, such as Cavit orZOE, (3) Procccd with RCT (4) Plan
to restore perforated area separately or make such restoration part of the final tooth preparation. Ifthe
pedoration is at or below the osseous crest or into the furcation region, thc following steps can bc considered; horvever, the prognosis for thcse cases is very poor (l) Seal the perforation immediately (2) If
the pcrforation is close to a canal orifice, place a file, gutta-percha cone! or silver cone into thc canal to
prcvcnt the placement ofmaterial in the canal during the repair (3) Control the hemorrhage, if it can not
be controlled due to size the[ use a pulp capping agcnt, such as Dycal, if it is controllable, use Cavit or
ZOE to seal perforation (4) Try to avoid pushing any sealing materials into the periradicular tissues.

*** Uncontrolled

bleeding is a sign ofinflamed pulp tissue. The radicular pulp must be

uninflamed for the success ofthis procedure. It is not uncommon to find uninflamed pulp
at a more apical level, especially in cariously exposed teeth. If bleeding does not stop

even after more apical amputation, hemostatic agents are used as a compromise
treatment. These are closely monitored and
procedures should be instituted.

if vitality is lost, apexificatiorr (pulpectomy)

Pulpotomy is the surgical removal of the coronal portion of a vital pulp to preserve the
vitality ofthe remaining radicular pulp. The common indications include:
. Cariously exposed deciduous teth
healthy radicular pulps
-with teeth with undeveloped roots
. Traumatic or carious exposure ofpermanent
. An alternative to extraclion when endodontic treatment is not available
. Emergncy treatment in permanent teeth with acute pulpitis
Unfortunately, pulpotomy procedures performed in fully developed permanent teeth
are not found to be successful. For this reason it is regarded as a temporary procedure in
these teeth.

. Accidental exposue of the pulp

. Pulp ofa middle-aged person

. Carious exposure ofthe pulp
. Pulp ofa young child

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20
201l-2012, Dnral Deck

. Lack ofan apical stop

. An abnormally large apical portion of the canal
. An inegular apical portion of the canal

. After

an apexifrcation procedure

. All of the above

21

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Pulp capping is the placing of a sedative and antiseptic dressing on an exposed healthy pulp in
order to allow it to recover and maintain normal function and vitalit),. The dressing most commonly used is CaOH2 (Dycal). Pulp capping is overuscd in dcntistry today. ln reality it has only
very l-ew indications for its use. Young pulps are morc vascularized and. therefore, more amenable
to repair. Pulp cappjngs are more successful if the exposure was acc idental (trduma or \r ith a de la1Dr, as opposed to carious. ln addition, the exposure should only be pinpoint lo expecl succcss.
Repair is accomplishcd by the formation ofa dentin bridge at the site ofexposure. Evcn a snall
carious cxposurc should have root canal therapy for thc best long-term prognosis.

Note: Direct pulp capping is indicated ifthere is a small mechanical exposure for.snall traLtmatic
expo.\ure), an asymptomatic vital pulp, and no coronal or periapical pathology. A hard tissuc barricf (repuratlw dentin bridge) may be visualized as early as 6 weeks postoperative.

Atooth may stay asymptomatic for scveralweeks after pulp capping has bccn pcrformcd. However,
this may be only tenrporary. Unfortunatcly, if pulp capping I'ails and the tooth becomes symptomatic, it may be difficult, ifnot impossible, to treat with routine endodontics because oflhe severc
calcifications in the root canal. Perforations may occur during attempts to follow the obliterated
canal to gain palency to the apex. Note: Perfo.ations into lurcations ofmulti-rooted tecth havc the
poorest prognosis.

Indirect pulp capping involves removing infccted dentin almost up to the point ofpulpal exposure. Calcium hydroxide is placcd and then a resin modified glass ionomer cement is placed over
a final restomtion is placed alicr rcmoval
ofthc internlediate restoration and rcsidual carics. Thc goal ofindirect pulp capping is to havc thc
tooth participale in ils own recovery. Indications for indirect pulp capping include deep carious
lesions that encroach but are not actually in the pulp, no history ofchronic pain, no radiographic
pathology'. r'ital pulp. and normal looth mobility and color

that. Formation of secondary dentin should occur and then

Ifthe preparation is properly flared, fitting the master cone is not a time-consuming procedure. A gutta-percha cone the same size as the file used last durin gpreparation (MAF)
is selected and placed as far as possible into the canal, but not beyond the working length.
Once satisfactory tugback and apical positioning appear to be obtained, a radiograph is
taken to verify cone positioning. If an accurate determination and careful enlargement
have been performed, the x-ray will show that the master cone reaches the most apical
position of the preparation or extends to a point just short of that ( I nm). When the
cone is slightly short, the pressure ofcondensation plus the lubricating action ofthe sealer
* ill be sufficient to produce complete seating of the cone.

\rl3es

L If the cone is more than I mm from the radiographic apex, discard the cone
and fit a smaller one or instrurnent more in the apical third.
2. Remember: The main reason for recapitulation lirirgl,our MAF after eqcll
inct euse in .;file size) during instrumentation of the canal is to clean the apical
segment ofthe canal ofany dentin filings that lrere not removed by irrigation.
3. Common solvents used to soften gutta percha are chloroform, methylchloro-

formate, halothane, rectified white turpentine, and eucalyptol.

4. Studies show that solvent softening does not ultimately result in a better apical seal.
5. Slight resistance to dislodgement is refened to as 'itugback.r'
6. The cone should also have a delinite apical seal
it should not be able to
be pushed further apicall,.

. Continue with obturation, the anesthetic is simply wearing off

. Continue with obturation, this is a normal complaint during this part ofthe procedure
. Consider looking for an accessory canal

and re-filing, there is

likely pulpal tissue that

has not been properly debrided

. Inigate furtheq the Sodium Hlpochlorite should take care ofthis problem
. Temoorize the tooth and obturate at a later date

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Coplrighr O 2011-2012 - Dmial Decks

. Urea peroxide (Gly-Oxide)

. Hydrogen Peroxide

Sodium Hypochlorite

. Calcium Hydroxide

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***

This indicates inadequate debridement, as a pulpless tooth should not respond to any
stimuli.
The most important consideration before filling a root canai is propr cleaning (debridener, and shaping (instrumentin&) ofthe canal. Once the canal is obturated, any organisms
that have entered the periapical tissues from the canal are eliminated by the natunl defenses
ofthe body.

Objectives of root canal obturation:

. To develop a fluid-tight seal at the apical foramen

. Complete filling ofthe root canal space
. To create a favorable biologic environment for the process oftissue healing
ln endodontic treatment the importance ofcanal obturation (/i//,rg) is second only to canal
debridement friic h is the ke! to succe$. Approximately 40% offailures are believed to be
caused by incomplete obturation ofthe root canal. lfthe canal is not filled, tissue flr,rid and microorganisms from the periapical tissues are able to enter the voids, with failure as the ultimate
result. Howeyer, if an accessory canal is not totally filled during obturation, the appropriate treatment is to observe the tooth and evaluate every three months.

Remember: The presence of a periapical lesion before root canal treatment will reduce the
success rate of the treatment by 10%-20%.
Note: After endodontic therapy is completed on a tooth with a periapical radiolucency, it nsually takes 6-12 months before marked reduction in the size ofthe radiolucency is evident on
an x-ra.v. Desired periapical tissue changes include regenention ofalveolar bone, deposition
of aoical cementum. and re-establishment ofthe PDL.

***

Calcium hydroxide is not an irrigant.

Sodium Hypochlorite is the most widely used irrigant and has effectively aided canal
preparation for many years. A 5.25olo solution provides excellent germicidal solvent action, but is dilute enough to cause only mild irritation when contacting periapical tissue.
NaOCI is a good tissue solvent as well as having some antimicrobial effect. It also acts as
a lubricant for root canal instrumentation. Note: lt is toxic to vital tissue; always use rubber dam. Note: To date there is no agreement on any single concentration-value of
sodium hypochlorite Q"taOCl) as being the most effective while being the safest.
H"vdrogen peroxide (396 solution) is also widely used in endodontics with two modes of
action. The bubbling of the solution when in contact with tissue and certain chemicals
physically foams debris from the canal (efJbnescent eflbcf. In addition, the liberation of
oxygen uill destroy strictly anaerobic microorganisms. The solvent action of hydrogen
peroxide is much less than that ofNaOCl. However, many cljnicians use the solutions altemately during treatment.

Urea peroxide is available in an anhydrous glycerol base, as Gly-Oxide, to prevent

decomposition and is a useful irrigant. It is better tolerated by periapical tissue than
NaOCl. yet has greater solvent action and is more germicidal than hydrogen peroxide.
Therefore, it is an excellent iffigant for treating canals with normal periapical tissue and
ri,'ide apices. The best use for Gly-Oxide is in narrow and/or curved canals, utilizing the
slippery effect of the glycerol.
Note: Irrigants perform the important biologic function of destroying bacteria during
endodontic therapy. Their action is unquestionably more significant than that supplied by
the use ofintracanal medicaments. Irrigants should be used copiously throughout the instrumentation phase ofroot canal procedures.

. Rotary files
. Chloroform
. Glass bead sterilizer
. Ultrasonic
. Heated instruments

24
Coplrighr O

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De

al

Deks

. It is a chelating agent with the capability to remove the mineralized portion ofthe smear
layer

. It

can decalcifu up to a 50 pm thin layer

. Normally it is used in

a concentration

of

ofthe root canal wall

l7o/o

. RC-Prep and EDTAC are other preparations of EDTA

. The decalcifying process induced by EDTA is selfJimiting

. It

is also an excellent irrigation solution

25
Coplrighr C 201l-2012 - Dental Dcks

Techniques to remove gutta-percha include:

. Rotary removal
. Ultrasonic removal
. Heat removal
. Heat and instrument removal
. File and chemical removal
Chloroform is the reagent of choice to dissolve gutta-percha. [t is very effective but
should be used with caution. Its vapor is potentially hazardous, so it is dripped directly in
the canal avoiding excessive flooding.
Other chemicals which can dissolve gutta-percha to a varying degree include: xylol,
halothane, benzene, carbon disulfide, essential oils, rrethyl chloroform and white rectified
turpentine.

If

a gutta-percha cone has passed beyond the apx then a file must be used beyond the
apex in order to avoid breakage ofthe cone. A broken cone in the periapical area may result in an orthograde re-treatment lailure.

,'Notes,

l. Gutta-percha points may be disinfected by placing them in a 5.25% NaOCI

solution for one minute.
2. A glass bead sterilizer can sterilize endodontic files in l5 seconds at 220'

c u2n

F).

***

This is false; it has a limited value as irrigation solution. The decalcifying process induced by EDTA is selfJimiting and stops as soon as the chelator is used up.

Chelating agents are used to aid and simplify preparation for very sclerotic canals after
the apex has already been reached with a fine instrument. These agents act on calcified
tissues only and have little effect on periapical tissue. Their action is to substitute sodium
ions, which combine with the dentin to give soluble salts for the calcium ions that are
bound in less soluble combination. The edges of the canal are thus softer, and canal enlargement is facilitated.

EDTA will remain active in the canal for 5 days if not inactivated. For this reason, at the
completion ofthe appointment the canal must be irrigated with a sodium hypochlorite
(NTOCl) containing solution. Note: Rinsing for I minute with EDTA eliminates the
smear laver, opens dentinal tubules, and provides a cleaner surface for gutta-percha
and sealer to adapt.

EDTAC is EDTA with the addition of Cetavlon, a quatemary ammonium compound. lt

has greater antimicrobial action than EDTA. However, it has greater inflammatory potential to tissue as well. The inactivator for EDTAC is NaOCl.
RC-PREP combines the functions ofEDTA plus urea peroxide to provide both chelation and irrigation. The foamy solution has a natural effervescence that is increased by irrigation with NaOCI to aid in the removal oldebris.

. To obtain clean shavings of the canal

. To attain a clean irrigating solution

To achieve glassy smooth walls of the canal

. All ofthe above criteria are reliable

. None ofthe above criteria is acceptable

26

cop)righr O 20ll-2012 - Dental Decks

While cleaning and shaping the canal, an instrument seperat$ in the canal.
As you rttempt to retrieve it, the broken instrument passes partially
through the rpex, tbus partly protruding into the periapical lesion.
How do you manage this case?

. Use a smaller H file to bypass it and try retrieving it

. Use Gates Glidden drills to widen the canal and then try retrieving it
. Raise a flap and remove the instrument surgically followed by gutta-percha filling the
canal

. Extract the tooth

as irreparable damage has occurred to the apex

. Just inform the patient, fill the canal with gutta-percha and monitor

27
Coplright O 20l l-2012 - Dental Decks

***

Clean shavings are difficult to see on a file. The attainment of a clean irrigating solution is considered an inaccurate way to determine the end point ofdebridement.

Debridement is defined

as the removal offoreign material and contaminated or devitalized tissue from or adjacent to a traumatic infected lesion until surounded healthy tissue
is exposed. Chemomechanical debridement of the root canal system is the most crucial
aspect ofroot canal treatment.

Complete debridement of the canal is the most effective means to reduce root canal
microorganisms. It can be carried out in various ways as the case demands, and may include instrumentation ofthe canal, placement ofmedicaments and irrigants antVor surgery

Remember:
. The most common cause ofroot canal failure is incompletely and inadequately disinfected root canal systems.

. The second most common cause of failures ol root canals is leakage from a poorly
filled canal. This is common even after apical curettage. Example: Root canal treatment performed on a tooth with apical curettage ofa lesion that was found to be a cyst.
Three years later the lesion is even bigger than it was before. The most likely cause of
this lailure is leakage from a poorly filled canal.
. A ledge is an artificially created irregularity on the surface ofthe root canal wall which
prevents the placement ol instruments at the apex ofan otherwise patent canal. Ledging
is caused by insertion ofuncurved instruments sl'lort ofthe working length with excessive
amounts ofapical pressure. The canal wall is gouged or a false canal is created which results in ledge formation. The effective use ofcircumferential filing, especially with Hedstrom files, will ensure smoothness and occlusal flaring ofthe canal walls and prevent the
derelopment of steps or irregularities.

Cenerally, when a broken instrument protrudes past the apex, surgery should be
performed. This constant iritant must be removed.

Note: It is relatively easier to retrieve an instrument if it is wedged coronal to the

curvature or at the curvature ofthe canal but verv difficult if it has Dassed the curvature.
When an instrument breaks off anrvhere in the canal and a periapical radiolucency is
present and rninimal canal enlargement has been performed before the accident, surgery
is indicated since the periapical tissues have had little opportunity for haling to be
stimulated. You would prepare and obturate to the point of blockage and then perform
an apicoectomy and retrofilling.
However, rvhen an instrument is broken off in the apical third and is lodged tightly with
no periapical radiolucency evident, the remaining root canal space can be filled. The
patient should be informed ofthis and placed on a 3-6 month recall.

Important: Prognosis ofa tooth with

pulp and no periapical lesion.

broken instrument is best if the tooth had a vital

Push and pull stroke

. Reaming motion

. Engine-driven rotary motion

. All ofthe above

2a

Coplriglt

@ 201 1,201 2

- Dmral

Deck

. Non-staining property

Fast setting time

. Adhesion

. lnsolubility
. Long history ofsuccessful

usage

29
Cop)'ri8hr

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***

The engine driven instruments, however, use only the reaming motion. Nickel titanium instruments can be both hand operated and engine-driven.
Generally, hand instrumentation is done by either filing (push and pull) or reaming 6epeated rotqtions).

Filing is a push-pull action with emphasis on the withdrawal stroke. Its efficiency is greatest with fils than with reamers for removing dentin because of the greater number of
flutes in contact with the canal walls during the rasping motion of removing the instrument. Filing action produces an irregularly shaped canal and therefore must be filled
with gutta-percha in a condensation procedure.
Reaming is defined as the repeated clockwise rotation of the instrument, particularly
during insertion. Reaming produces a canal that is round. Reaming is recommended
using a silver cone to fill canals.

if

Circumferential filing is a push-pull action with emphasis on scraping the canal walls
to create a smooth, tapered preparation. It is a method of filing whereby the instrument
is moved first towards the buccal side ofthe canal, then reinserted, and removed slightly
mesially. This is done all the way around the tooth until all the dentin walls have been
planed. This technique enhances preparation when a flaring method is used.

Remember: The primary function ofa root canal sealer is to fill in the discrepancies
between the core-filling material and the dentin wall. In fact it is said that it is more im-

portant than the core filling material.

Other purposes or functions ola root canal scalcr includc:
. To act as a lubricant, facilitating placement ofthc gutta-pcrcha
. To form a bond between the filling material and the dentin walls

. To exert antibacterial activity

(some exert more than others). This activity is the

highest in the period of time immediately aftr its placement.

Most root canal scalers are some type ofzinc oxide-eugenol cement and are capablc
producing a seal whilc bcing well-tolerated by periapical tissues.

of

All sealers display some degree of radiopacity (caused by metollic sahs in the sealer);
thus are visiblc on a radiograph. This helps disclose the presence of accessory canals, resorptivc arcas, root fracturcs, and thc shapc ofthc apical foramen and other structurcs of
lnterest.
Note: After filling a tooth with gutta-percha, if you see a horizontal line of firaterial
(gutta-percha or sealer) extending both mesially and distally from thc canal to thc pcriodontal ligament space, this is indicative of a root fracture.
ZOE disadvantages: staining, slow setting time, non-adhesion, solubility.

. Maxillary first premolar - mesial concavity

. Maxillary molar - proximity of canals to mesio-buccal line angle

. Mandibular molar - mesioJingual tilt of tooth

. Mandibular incisor - small buccal-lingual dimension

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. The first statement is true, the second is false

. The first statement

. Both

is false, the second is true

statements are true

. Both statements are false

31

Coplright O

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Major objectives ofthe access preparation:

l. StraighGline access
2. Conservation of tooth structur
3. Unroofing ofthe chamber and to remove pulp horns
Access to the root canal is the initial step in canal preparation. It is necessary to estabIish straight-line access to the apical foramen to ensure free movement ofthe instrument
during debridement and preparation ofthe canal. A1l the treatment that follows hinges on
the correctness ofthe access preparation. All access cavities are made through the lingual
on anterior teeth and through the occlusal on posterior teeth.

Note: A facial approach is recommended for an access opening on maxillary primary

incisors.
Remember: Mandibular incisors and maxillary first premolars require the most care
to avoid perforation during preparation ofthe access opening. This is due to the narrow
mesio-distal dimension ofthe rnandibular incisors and the mesial concavitv ofthe max-

illary first premolars.

Important: During access preparation on mandibular molars, lhe following two regions tend to be "overcut" which results in the undesirable over preparation ofthe tooth:
. The mesial aspect under the marginal ridge
. The lingual surface under the lingual cusps
*** Mandibular molars tip mesially and lingually. Ifa bur is directed straight inferior

it may cause unnecessary loss oftooth structure ftom the these

areas.

Studies have shown that the action of using thc instrunent, rather than the instrument used, determines the general shape ofthc canal preparation. Therefore, a reaming action produces a canal
thal is relatively round in shape while a filing action produces a canal that is irregular in shape.

Important: A canal should be instrumented and shaped so that it has a continuously tapering funnel shape. The widest diameter would be at the canal opening and the narrowest at the dentinocemental j unction aJ I o L0 mm from the radiographic aper). This is where all teeth should be filed
to and fillcd to fideal/r.
The common methods for sterilization uscd in cndodontics are:

. 2 1/o Glutaraldehyde:
- Cold or heat-labile instruments such as rubber dam frames. etc.
- Generally, 24 hours are required to achieve cold sterilization.
- Least desirable mcthod.
. Autoclave:
- Instrurnents should be wrapped and autoclaved for 20-30 minutes at 250' F ( I 2
psi.

- This

I'

C) and

15

*ill kill all bactcria, sporcs and viruscs.

. Dr-v heat sterilization:

- Is supcrior for sterilizing sharp-edged insltruments (hand instruments, fles, reamers, broaches,
D&ri. etc.l to best preserve their cutting edges.
- Temperature is 320" F (160" C) fbr a minimum of I hour
- Dry heat is effectivc as a stcrilizing agcnt becausc the resistancc ofproteins to heat denatF
ration decreases as they dry.

. Hot salt {or beads):

- Bead sterilizers are receptacles that heat contents to approximately 45O" F (232" C).
- lntracanal instruments (iles, reamers, broaches, etc.) shouldbe stcrilized by immersion in the
salt for 5 seconds.

. Both the statement and the reason are correct and related
. Both the statement and the reason are correct but NOT related
. The stalement is correct, but the reason is NOT
. The statement is NOT correct, but the reason is correct
. NEITHER the statement NOR the reason is correct

32
CopFight C20ll-2012 - Dental Dcks

. Plasma cells
. Vacrophages
. Lymphocyes
. Polymorphonuclear (PMN) Leukocytes

Copj,right O 20ll-2012 - Dnral Decks

***

The rcason broaches are not used for canal cnlargcmcnt is not becaus they are made ofstainless stccl.

it is lheir design.The barbs are notchcd out of the instrument shaft and rcpresent a weakend point. If the
broach is not used with the utmost of car or il it is forced apically, the barbs will be bent and will engage
the walls, making removal difficult. It is not used for canal enlargemenf.
K-type instruments:

. Files are lhe most uscful instruments in eDdodontics fbr the removal ofhard tissue in canal enlargements.
They arc manufactured by t$isting a blank, which is a square rod. producing a series ofcutting fluies. The
action uscd for placing this type offile into a canal should rescmble a clock \1 ise-counierc lock*,ise motion
with pressure dircctcd apically (tan he a.filing or reaning action). Note: These files are the strongest of
all files ancl cut the least aggressivll. A modification to this tlpe oftlle is the K-fli file.

. Ramerc are manut'actured in a manncr similar to files. only they have fe*er flutes. They are used in
canal preparation to shave dentin and enlarge cmals \r,ith a rcaming action only, They remove intracanal
dcbris with clockrvise reaming action. They arc also uscd to place materials into the apical ponion of the
canal by using a counierclocklr'is(] rotatlon.
H-type instruments:

. Hdstrom files are manufactured by using a sharp, rotating cutter to gauge triangular sgments our ofa
round blank shaft. This produces a very sharp edge and thereforc an cffective cuiting insrument. Ifused caretully, lvith filing action only, it \\'ill successtully planc rhc deniin *alls much faster than K-rype files or
reamcrs. A modification oflhis filc is the S-file.
\ote: All ofthe

above are made ofsteinless stel.

File dimenrions: The position at which the cutting bladcs begin on an instrument is called Dl, aDd thc flutcs
.\tcnd up rhc shafl fbr 16 mm to stop at D2. The remaining portion ofthe shaft extendiig io the handle has no
llutes. and its length is the difference between 16 mm. and the lotal lcngth from lhe tip to the handlc. The
leneth of cunin.e edgcs lthe distance beteee D t a d Dt remains l6 mm, regardless ofthe lcngth or style of
Ihc i:sirument. The numbcring svstem for instrument identification is based on the diameter at Dl, stated in
hurdredths of millimeters. Therefore the name ofeach instrumcnt givcs considerable inlormation about its dimerioni Asjzel0fleisindicatedtobe0.l0mminwidthatDt and . l0 mm plus 0.30 mm (or 0.10 mn) ar
3 lornt 16 mm f'arther up the shaft fDr, etc.

The onset ofpulpal inflammation is an insidious process and is characterized by a chronic celfufar response fplasmq cells, macrophages and l,vmphoq'tes). There is no direct exposure of
the pulp to dental caries and the response, therefbre, is not acute. After pulp exposure, the
acute inflammatory cells (nainly PMN celA, are chemotactically attracted to the area. Histologicalh, the tissue is likely to show signs ofacute inflammation near the site ofthe exposure
and a band ofchronic inflammatory cells between the acute inflammation and the underlying

normal pulp.
The response ofvital pulp to microbial invasion is very resistant. Based on the observation
IhaI e\ en alier t$,o weeks of tmumatic pulp exposure, only 2 mm of coronal pulp may "give
in" to microorganisms. Non-yital pulp, in contrast, is a "fertile ground" for the growth of microorganisms.

Remember: Carious exposures in permanent teeth generally require root canal treatment. Immatld(e (open qper) pennanent teeth with carious exposures can be treated by pulp capping
or pulpotomv procedures.

Important: Pulp capping is not recommended in primary teeth with carious exposures due
to its high failure rate and because pulpotomy, having similar time requirements. has shown
to be very successful. Pulp capping can be done, however, in mechanical exposures.
1. Calcium hydroxide has a high pH of 12.5 which cauterizes tissue and causes
superficial necrosis.
2. This necrotic zone encourages the pulp to induce hard tissue repair with secondary odontoblasts laying down reparative dentin.

. Condensing osteitis
. A vertical fracture ofthe tooth

. Periodontal abscess

. Secondary occlusal trauma

CopFigh O

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. The first statement is true, the second is false

. The first statement is false, the second is true
. Both statements are true
. Both statements are false

35
Copltighi o 20l l-2012 - Dental Decks

Radiographic examination seldom reyeals the fracture because the crack is usually parallel
to the x-ray film. One of the most puzzling and frustrating dental conditions involving the
possible need for endodontic treatment is the cracked tooth syndrome. Symptoms from this
condition usually are characterized by a sharp but brief pain occurring unexpectedly only
when the patient is chewing. Having a patient bite forcefr.rlly on a bite stick and noticing the
cusps that occlude when the pain occurs will aid in the location ofthe olTending tooth.
In most cases there is an isolated probing defect at the site offracture. An important diagnos-

tic sign is a radiolucency from the apical region to the midline of the root (J-shaped or
teardrop-shaped). Vertical fractures through rcot structure, however, have an almost hopeless
prognosis. lfthe fractured segment can be removed and gingivoplasty and alveoloplasty perfbrmed, treatment can be successful. However, unrealistic or overambitious case selection
leads to a high degree

offailure.

When an anterior tooth fractures, it generally occurs in a more horizontal plane and may
show up on the x-ray. The cause is usually accidental tnuma such as a blow to the jaw or
teeth. If the fracture line is not too far down the root ofthe tooth. it mav be able to be saved
with a root canal and a crown.

lmportant: Inlays have

been shown to be a cause offractures. lfa patient complains ofpain

on mastication since the placement ofan inlay, suspect a fractured cusp /asltg n b ite stick will

help detemtine v'hiclt cusp may be fracnred).

Itiote: Chronic focal sclerosing osteomyebtrs (condensing oJleillt is excessive bone mineralization around the apex ofan asymptomatic, vital tooth. This radiopacity may be caused by a
lo$.erade puip initation. This process is asymptomatic and benign and does not require root
canal therap!.

*** Hydrogen peroxide

is the most effective bleaching agent; used in concentrations

of

30-50%. lt is best delivered in an alkaline medium.

Superoxol is a 307o aqueous solution by weight ofhydrogen peroxide in distilled water.
It is potent oxidizing agent whose bleaching effect results from direct oxidation ofstain-

producing substances.

Chairside technique: Application of heat to Superoxol-saturated cotton pellets in the

tooth chamber Repeat until tooth is lighter Note: The heat liberates the oxygen in the
bleaching agent.

Important:
. Cervical root resorption relating to bleaching is a potential side effect; usually it
does not manifest for at least 6 months. This is a reason why recall appointments are

lmponant.

. The most probable postoperative complication of bleaching

a tooth that has not

been adequately obturated is an acute apical periodontitis.

. Tooth bleaching causes a color change in both enamel and dentin.

\lalking

bleach technique: uses a mixture ofsodium perborate and water and may be
utilized ifthe chairside results are inadequate or ifyou prefer to avoid the possibility ofa
higher chance ofcervical root resorption. Place a thick paste in the tooth chamber with a
temporary restoration for four to seven days. Several repetitions of this procedure can
work quite well. The sodium perborate when fresh is 95olo perborate giving off 9.9% of
available oxygen. This material is more easily controlled and safer than Superoxol; therefore, it is the material ofchoice.

Tooth # 9 requires root-end surgery. Which

llap design is generally lr'Ol indicated?

. A submarginal curved flap (semilunar)

. A submarginal scalloped flap (Ochsenbein-Luebke)

. A fulI mucoperiosteal flap (triangular, rectangular, trapezoidal, horizontal)
. None of the above

Copyrighr Q 2011'2012 - Dmral Decks

In which of the following cases could a dentist choose not to

perform root canal thrtpy rlthough it is advised?

. On a non-restorable tooth
. On a periodontally insufiicient tooth
. On a tooth with a vertical root fracture
. On

a asymptomatic tooth

. On

a tooth that is not in occlusion

. On

a tooth that has massive extemal resorption

with

a calcified chamber

Cop)right O 20ll-2012 - DentalDecks

This half-moon shaped flap is raised with a curved horizontal incision in the mucosa or attached gingival with the concavity towards the apex. Although it's simpie and does not impinge on the surrounding tissuc, thc disadvantages outweigh its advantages. These include:

. Limited access and visibility

. Tcaring of comeN ofthe incisions when an attempt is made to improve accessibility by stretching
the flap

. Ifsomehow

a lesion is found to be bigger than anticipated, the incisions come to lie over the bony
defect
. Its extent is also lirnited by anachments 1/e.g.,.fienum, muscles etc.)
*** Tlterefo.e, this tcchnique is not used for anlerior root end surgery.

Surgical flaps on the basis ofhorizontal incision can bc classificd into tr}o major typesi
L Full mucoperiosteal flaps:

. Triangular (one vertical releasing inci.sion) . Trapezoidal (brctal hased rcctanguldr)

. Rectangular /ano t,erlical reledsing incisior.t . Horizontal /ro rcfiical rcleasing incisions)
2.

Limited mucoperiosteal flaps:

. Strbmarginal cuned (Senihnar)

. Submarginal scallopcl

Oc hsenbei n- Luebke)

The submarginaf scalloped (Ochsenbein-Le!6te, tlap requires at least 3-5 mm ofattached gingiva and
a hcalthy periodontium. It is raised by a scalloped incision in the aftached gingiva with onc or two vertical incisions. Less risk ofincising over bony defects and no post-surgical recession ofgingiva. Its disadvantages includc hcmorrhagc from the cut margins and scarring. Access and visibility is better fdrd
acceptoblel than semrlunar flap but not as good as full mucoperiosteal flap.

Full mucoperiosteal flaps allorv maximal access and visibility. They are raised from the gingival sulc\rs (ele\!ting gingirdl crest and interdental glrg,?,/. This wide outliI1e ofthe flap prccludes any incisions o\'cr bonv defects and allows various periodontal procedures including curettage. root pianing and
bone re-shaping. A large flap may be difficult to reposition, suftrrc and makc alterations. Posr surgical ginsi\ al recession is also a oossibilitv.

*** ln all thc

othcr sccnarios. root canal therapy is contraindicated.

Other contraindications include:

. A non-strategic tooth

tooth not in occlusion

-a or external resorption
. A tooth with massive internal
.A tooth that has a canal unsuitable for instnlmentation or forsurgery /i.e., broken instnrnents,
dentina l sc lerosi|;, s hat p d[l a. erations, etc..)
A medical condition such as hcmophilia is not a contraindication to convcntional endodontic therapy. However, it is strongly recommended that a dcntist obtain clcarance from the patient's physi-

cian prior to trcatmcnt. Thc only systemic conlraindications to endodontic thcrapy

are

uncontroffed diabetes or a very recent myocardial infarction (v,ithin tlte post 6 months).
Note: Example of a special case: A previously traumatizcd looth may show complcte
obliteration ofthe pulp chamber and canal. The periodontal ligament may appear non'nal. The patient will be asymptomatic and the tooth will not respond to pulp vitality testing. The trcatment of
choice is to obsene as long as the tooth remains asymptomatic and no periapical changes arc cvrdent.

Fracture injuries:

. Infraction: an incomplctc crack ofenamel wilhout thc loss oftooth structluc

. Enamel fracture frIis Class I)t involves enamel only: no pulpal involvemcnt
. Enamel and dentin fraeture (Ellis Cla.t,r 1/): involves enamel and dentin; no pulpal involvctnent

. Enamel and dentin fracture with pulpal involvement ft1lr.r Class III): pulpal trcatment de-

pcnds on stage of developrnent oi' tooth (immatrre $ msture) and ti]me after traumatic injury
/lfter 21 hours the chances ol direct bacterial contdmii.ttion increase)
. Root fractures: prognosis dcpcnds on location; coronal root liactures ha!c a poor prognosis,
n]idroot fracturcs havc guarded prognosis and apical root fractures havc the bcst prognosis
Important: Prognosis improves as liacturc approaches apex: horizontal is better than vertical;
nondisplaced is bctter than a displaced fracturei and oblique is bettcr than transversc.

. A conical shaped probing

. A narrow sinus tract type probing
. A blow-out type probing

. None ofthe above

38

CoDriglr

O 201 I -20 12 - Dental Decks

. A major disadvantage of posts/dowels is that it does not reinforce the tooth structure,
in fact, it weakens

it

. All post designs are predisposed to leakage

. At least 4 mm ofgutta-percha must remain to prserve the apical seal

. Threaded screw posts are preferred over parallel sided and tapered posts

. Pins add to stresses and microfractures in dentin and should not be used
. Cusps adjacent to lost marginal ridges should be restored with an onlay
39
Coplai8hr o 201 l-2012 - Dental Dcks

***

In "blow-out type" and "sinus tract type" probings, another clue for diagnosis is a nonthese two lesions can completely heal after root canal treatment.

vital (necrosed) pulp

Acute or blow-out lesions:

a tooth

with this type oflesion will show normal sulcus depth all

the way around the tooth until the area ofthe swelling is probed. At this point, the probe drops
suddenly, to a level near the apex. The probing depths in all other areas are within normal limrts.

Periodontal lesions characteristically show bone loss which begins at the crestal bone level
and progresses apically. Hence probing defect would be conical in shape. This type of lesion
may not be amenable to root canal treatment alone even if it is associated with a pulpless tooth.
However, endodontic treatment must be completed prior to tackling the periodontal problem.
A narrow sinus tract type lesion: the probing reveals nomra) depths al) around the tooth except at one very narrow area. Here, the probe can pass down the root surface to some distance
and sometimes even to the apex. The tooth is pulpless (non-itel.). Once the root canal treatment is completed, the lesion heals within one week. i'r"ote; All sinus tracts should be traced
rvith a gutta-percha point by radiograph.
Remember: A perio-endo abscess is a combined lesion. The lesion usually demonstrutes radioeraphic involvement ofthe periodontium and the apex ofthe involved tooth.

Important: To distinguish a periodontal lesion lrom an endodontic lesion, pulp

alLrng $ ith periodontal probing are essential.

vitality

tests

\ote: A common clinical finding ofa periodontal problem is pain to lateral percussion on a
tooth rrith a wide sulcular Docket.

***

Thesc may actually increase the chance offracture. The parallel-sided posts are prefened.

Options availablc whcn restoring endodontically treated posterior teeth:

. Rstoration ofocclusal opening only: in rare instances thc

access opcning and ca es destnrction

do not encroach on the cusps and marginal ridges. These teeth may be restored with an occlusal amalgarr; however, a cuspal coverage restoration would provide protection from fracture.

. Onlay restoration: in most cases it is imperative that root canal treated teth b protected from
fracture by a cusp-coverage qpe ofrcstoration. The minimum (ra ost conserwtiv) preparation should
be for an onlay' covering the cusps and marginal ridges.

. Cro$n:

a full-coveragc crorvn is prcfcrred whcn the rcmaining coronal tooth strucrurc does not afford sull'icicnt tooth structure for an onlay.

. Cro$n $ith post and core: to reinforce the treated tooth and provide suitable coronal tooth strxcmre for an optimum crown prcparation, thc usc of a post and corc is often indicared. Be very careful
$ hen placing posts. Perforations and vertical root fractures can occur. Important: The primary
purpose ol the post is to rctain a corc in a tooth whcn thcrc is an cxtcnsivc loss ofcoronal tooth strucrure Posrs do not reinforce the tooth, but further weaken it. At least 4 to 5 mm ofremaining guna-percha is recomnended.
1.

Ifyou

arc performing a pulp chamber-retained amalgam, you need to placc amalgam 3

\otes mm inro each canal for retention.

.., l. Endodontically trcatcd postcrior tccth arc morc pronc to fracturc than Llntreated postedor
_i::!_':
mainly to the destruction
tooth
have reduced structeeth due

ofthe coronal

structure

-they
tural integrity.
3. More endodontically treated teeth are lost because ofrestorative factors than failure ofthe
root canal treatment itsclf.
4. Pemanent restorations arc bcst placcd ASAP after obturation to seal the intemal aspeot
of thc tooth from contamination.
5. Endodontically heated teeth do not become brittle. The moisture content ofcndodontically treated teeth is not reduced even after l0 years. Key pointi Tccth are weakened by thc
loss of tooth structure.

Misc.

Retreating a tooth with a post is the most common reason for an

apicoectomy and retrograde filling,
Whenever a reverse lilling procedure is to be used, apicoectomy is mandatory to
provide a table into which the preparation and filling will be placed.

. The first statement is true, the second is false

. The first statement is false, the second is true
. Bolh statements are true
. Both statements are false

40
CopFight C 20ll'2012 - Denral Decks

Misc.

ENDODONTICS

Endodontic procedures involve taking multiple radiographs. How should

)ou protect yourself or your staffwhile taking radiographs if there is
no barrler available to stand behind?

Stand at least 4 feet away anywhere around the patient

Stand at least 5 feet away exactly opposite the x-ray bearn source

Stand at least 6 feet away and in the area that lies between 90 to 135 degrees to x-ray
Deam

Stand at least 7 feet away and in the area that lies between 60 to 90 degrees to x-ray
beam

. Never take an x-ray without

a barner

41

copyright () 2011-l0l: - Denrll Decls

An apicoectomy is thc prcparatior ofa llat surfacc by thc cxcision ofthc apical portion ofthc root and any subscqucnt rcmoval ofattached soft tissucs.
Ifa toolh has had previorrs endodonlic lherapy and becomes reinfectcd, il is usually bcst lo try and .etreat it con'
vcntionally remove filling marerial, debride the canals, and rcfill. However, iltbe tooth has bccn restorcd $ith a
post, corc. and crown thcn apical curcttagc, apicocctomy, and a rclrotill should bc pcrformcd. Note: Rctrcaling a
tooth with a post is the most common rerson for an apicoectomy and retrograde fllling.
Indications for apicoecaomy (root-e n d

rc se c tion ) |

. A rcvcrsc filling nccds to bc placcd

. ll is ncccssary to gain acccss to an area ofpathosis
. Thc poorly fillcd apical ponion oflhc root is to be rcmoved to the levcl ofcanal obliteration
. Non-ncgotiablc canal, blockagc or scvcrc root curvaturc in wbich non-surgical trcatrnc t is impossiblc
. Complications arising fiom proccdumi accidcnts (e.9., separat ion of instrumentt, ledsingai /or pertrrruliot$)
$hich cannot bc handlcd withoul surgical cxposurc ofthe sitc
. Failcd rcatmcnt duc to inetricvablc posts or root fillings
. Horizontal apical liacturcs in which apical cnd ofthc pulp bccomcs necrotic
. Biopsy . to diagnosc non-odontogcnic causcs of symptoms &.9., p.rlient *ilh a histotr 4 pre|ious nalignancr, Iip paresthesid or anesthpsia)

Contrsindications for api.oectomy (rcol-end rcsection):

. Anatomic factors that limit acccss . Mcdical or systcmic complications . Toolh is nonrcstorablc or

has a

poor

crown/root ratlo

Procedure:
. Radiographs are taken to determine the length ofthe root and ils proximity to adjacent structurcs
. Administer anesthesia
. On th labial surfacc ofthe tooth, witb the help ofa pcriostcal elcvator. locatc the root apex, so that an incision
can bc madc
. Flap designs used: submarginal scallopcd fO. ltsenbein- l,uehke) ,
t! I I m ucoperiosteal flaps t ? r"Jr/
^nd
. Reflect the flap
. Root apex is exposed, thcn apcx is cut olf with a lissure bur about one-third of its lcngth
. Curette the surrounding pathologic tissucs and round ollthc end of thc cut rool
. For retrograde filling, a bevel of0-10 dcgrccs is grvcn
. Retrograde filling to I mm is donc
. Irrigate the wound Nnd ruture the llap in position

Notes rclated to radiation safety and diagnostic radiographs:

1 . A fast (se sitive) filfir, lor example E-speed (Ektaspeed or Ektaspeed phts) film is preferred
o|cr D ltlm (Ultraspee.l) as laster films require less radiation faboal /rallJ exposure while providing quality image. r-ote: A newer F-spced. (Insigh, filrnhas been recently introduced that requires 20% to 25% lcss cxposure than E-speed film but more studies need to be donc to access
lhe usefulness ofthis new filrn type
l. Dental units should operate at 70kV or higher. The higher the kV, the lower the patient's skin
doses. \ote: The optimal setting formaximal contrast between radiopaque and radioluccnt structurcs is 70 kV.
L Collimation fi.e., restfiction ofthe x-rq) beam size so that iL does not exceed 2.5 inches at the
purient! skin, reduces exposure).
J. Patient should be protectcd with a lead apron and a thyroid collar for each exposure.

5. If there is no barrier for thc clinician to stand behind while exposing films,

hc/shc
should stand in an area of minimal scatter r^diztiorr ( i.e., 6.feet otrat and
the area thot lies
b, n'een 9(P to 135" to x-ray beam)
6. DeIltal personnel who may gct exposed to occupational x-radiation must wear fiLn badges
to record exposurc and must never exceed the maximum permissible dose IMPD) of50 mSv per

year/whole body.
7. An operator should never remain in the room holding an x-ray packet in place for a patient.
lffilm must be held in place by somcone else (i.e.,lor a child.1, drape the patient and have him,/her
hold the film.
8. The most accurate radiographs for endodontics are made using the paralleling technique.
Remember: When using the paralleling technique, you must ccntcr the X-ray film packet
behind, and parallel with the long axis ofthe tooth bcing X-rayed. The tube head must be positioned so that the ccntral X-ray beam is projected perpendicular to the tooth and the lilm
Packet.

. Porphyromonas species and Bacteroides melaninogenica

. Eubacterium and Fusobacterium
. Actinomycetes and Spirochetes

. Wolinella and Veillonella species

12
copyrighr O 201l-2012 - Detual Decks

the cemento-enamel junction

reYeals that probing depths are

. Extensive periodontal treatment followed by vitality re-assessment

. Endodontic treatment only
. Endodontic treatment followed by periodontic treatment

. Root

end surgery

. Periodontic treatment followed by endodontic treatment

43
copyrighr O

201

l-2012 - Dental Decks

Predominant bacterial species isolated from infected root canals include:

. Porphyromonas species
. Bacteroides melaninogenica
. Eubacterium species
. Peptostreptococcus species
. Fusobacterium species

. Prevotella species

***

Note: Strict anearobes predominate

Virulence factors which play a role in periradicular pathosis include:

. Lipopolysaccharide (LPS): found on the surface ofgram negative bacteria

. Enzymes: neutralize antibodies and complenent components
. Extracellular vesicles: involved in bacterial adhesion, proteolytic activities, hemagglutination and hemolysis
. Fatty acids: affect chemotaxis and phagocytosis

A vital pulp resists bacterial invasion. Even ifthe pulp is exposed to microorganisns for
2 weeks, the penetration ofbacteria may extend no more than 2 mm into the pulp. In contrast, a non-vital pulp is a fertile ground for the growth of microorganisms and leads to

necrosis.

Remember: Streptococcus species may be more important in the initiation ofrather than
the progress of a carious lesion leading to a pulp exposure. Strict anaerobes are found
to play a significant role in periapical pathoses.

***

In a combined perio-endo lesion, endodontic treatment generally takes precedence

over periodontal management.

Combined endodontic-periodontal therapy is widely used because the anatomic and

clinical connections between the pulp and periodontal structures are close and numerous.
In most cases ofthis nature, endodontic procedures are preformed first and, when necessary, are followed by periodontal measures.

olthe vitality
of the pulp is crucial. In some doubtful cases, the better part of wisdom is to wait until
after the completion ol the root canal therapy to see whether spontaneous resolution
lpocket closure and osseous ./ill-in) will occur before surgical periodontal procedures are

In these cases, the value ofprecise pocket probing

and correct appraisal

begun.
Periodontal therapy should be initiated first only in the case ofa primary periodontal lesion rvith subsequent secondary endodontic involvement.

Remember: A common clinical finding ofa periodontal problem is pain to lateral percussion on a tooth with a wide sulcular pocket.
Note: The combination lesion (perio-endo) is dorninated by gram-negative anearobic
bacteria

. Reticulin fibers
. Collagen fibers
. Unmyelinated nerve fibers

. Myelinated nerve fibers

. Proprioceptor nerve fibers

44
Coplright O 2011,2012 - Dmral Decls

. Mantle dentin
. Circumpulpal dentin
. Predentin

Secondary dentin

. Tertiary dentin

45
Copfight O

201

1-2012 -

Dfrlal Deck

*** Proprioceptors

fwhich respond to stimuli regarding mot'ement, are not found in the pulp.

The pulp contains both myelinated and unmyelinated nerve fibers. They are afferent and sympathetic.
The myelinated fibers are sensory and the unmyelinated fibers are motor
play a role in the reg-they
ulation ofthe lumen size ofthe blood vessels.

Important: The only type ofnerve ending found in the pulp is the free nerve ending, which is a specific rcceptor for pain. Regardless ofthe sourcc of stimulation fl,eat, cold, pressurc), the onl,v rerponse

will

be pain.

Afferent Nrve Fibers found in the Dental Pulp:

. Large myelinated A-delta tibers: enter at tl')e apical foramcn, follow thc path ofthe blood vessels,
and then branch to form tl,c Plexus ofRaschkorv beneath the cell rich zone. Within thc plexus, the
fibers lose their myclin shcath and proceed to the cell-free zone where they form a subodontoblastic
plexus. The free ne e endings then pass into thc odontoblastic layer and the predentin. A-delta fiber
pain is immediately pcrceived as a quick, shar?, momcntary pain that dissipatcs quickly on removal
ofthe stimulus. Note: The intimate association ofA-delta fibers with thc odontoblastic ccll layer and
dentin is rcfcned to as thc pulpo-dentinal complex.
. Small unmyelinated C fibers: enter at the apical foramen within thc A dclta fibcr bundlcs; distributed throughout the pulp. They are associated with burning, aching, throbbing q?cs ofpain. Characterized by having a high threshold of stimulation. These fibers are true nociceptive
fibers pain-conducting fibers that respond to stimuli capable of injuring tissuc. They rcmain cxcilable even in necrotic tissue. Nole: These fibers are stimulated by hot liquids or foods.
Important: When C fiber pain dominates, it significs irreversible local tissue damage.pain e hot

trote*:

i. As the pulp ages there is a decrease in rettc.ulin f$ers (the pulp becomes less cellular and
more fibrous).
2. The sizc ofthe pulp also decreases because ofthe conrinued deposition ofdentin.
3. As thc pulp ages thcrc is an increase in the number ofcollagen fibers and calcifications
within the pulp (ca11ed denticles or pulp stones).
4. Pulp stones are associated with chronic pulpal discasc - tiom advanccd carious Icsions or
larce restorations.

Immediately adjacent to the odontoblast layer in the pulp, l0-47 pm ofthe dentin matrix
remain unmineralized. Ifthis unmineralized layer ofdentin is lost 1e.g., due to taLtmct or
infectious process) it predisposes the dentin to internal resorption by odontoclasts.

. Mantle dentin: is first-formed

dentin which is laid before odontoblast layer gets

organized. Hence the pattern ofdeposition and size ofcollagen fibers is different from

cjrcumpulpal dentin.

. Circumpulpal dentin: represents most of the dentin which is formed.

. Secondary dentin lorms

after eruption of a tooth and throughout life resulting in a

Sradual but asymmetric reduction in pulp size.

. Tertiary dentin or reparative dentin: is an irregular and disorganized layer ofdentin

laid dorvn in response to any injurious/irritant stimuli.
Note: Dentin lormation is the primary function ofpulp.

Other functions include:

. Induction: forms dentin which in turn induces enamel formation

. Nutrition: dentinal tubules are linked to the pulp which maintains its hydration and
formation of peritubular dentin

..

.. l. Once bacteria

,/Noq:

?&i

enter the pulp with sufficient quantity or virulence, complete

pulpal necrosis is imminent and ireversible.
Z. Bacteria from dental caries are the main cause of more serious pulpal injury,
and the main cause ofpulpitis.

:'

.:

,.,.,r,..
N.

The

. Collagen, pulpectomy
. Network ofcapillaries and nerves, pulpectomy
. Collagen, pulpotomy
. Network ofcapillaries and nerves, pulpotomy

46
Coplright

@ ?01

1,2012 - Denlal

Deck

. The permanent maxillary right first molar

. The permanent maxillary right second molar
. The permanent maxillary right third molar

. The permanent maxillary right first premolar

Reprinred

frm

Bdh Balogh. Mary

and Ma.garet J. F.hrcnbach..

D""tal

Enbdoloe;, Hislolog, and Anotontt

Second e.litionA 2006. wit\ pennission frcm Elsevie. Saundes.

17
Coplright O 201 l-2012 - Dental Decks

III collagen is present in the pulp in a ratio of557o : 45%. Type

V is found in small amounts. In dentin, Type I collagen predominates. Odontoblasts synthesize Type I while fibroblasts in the pulp synthesize both Type I and Il.
Mainly, Type I and Type

The central zone or pulp proper contains large nerves and blood vessels. This area is
lined peripherally by a specialized odontogenic area which has three layers (from innermost to outermosl).

l. Cell rich zone: innermost pulp layer which contain fibroblasts.

Cell-free zone or zone of Weil: is rich in both capillaries and nerve networks. The

2.

nerve plexus ofRaschkow is located here.

3. Odontoblastic layer: outermost pulp Iayer rl,hich contains odonroblasts and lies
next to the Dredentin and mature dentin.

Cells found in the dental pulp include fibroblasts (the principal cell). odontoblasts, histrocyles (mocrop haset, and lymphocytes.
a diseased pulp, the following cells are present: PMN's, plasma cells, basophils,
eosinophils. lymphocltes, and m ast cells (contain histantine and heparin).

Note: In

Important: The pulp lacks collateral circulation, which severely limits its ability to
copc rr ith bacteria. necrotic tissue. and inflammation.

M]
/(Fryl\

ea2
$:rodlt3l

a0

Bll

tt

jwi
\A'
A

{tw

fr) 0

Pulp cavity of the permanent maxillary

Pulp cayity of the permanent maxillary

risht first molar

risht second molar

Retirlnred

iion B.tl}B.lo8h, Mrrt

mi$ron liom Ekevier SaundeF

and

Margar.l J F.htcnb^cb Dolal Enh\ ol/4r, Hisloln$ .h,l ,lnd1o,tr

5..a,1.d/to,

:o 2006-

lrh per

. The permanent maxillary right first premolar

. The permanent maxillary right second premolar
.

The permanent maxillary right first molar

The permanent maxillary right third molar

Reprinted from B8rhBalosh, M6ry and MaF

garei

J.

Fehrcnbach..
Dental Enbryologr, Hn'

toloEr, ahd Anolon,

Second edition @ 2006.

wnhpemission from EI-

4E

coplright O20ll-2012

- Dental Decks

i secti(

. The permanent marillary right first premolar

. The permanent maxillary right canine
. The permanent maxillary right lateral incisor
. The permanent maxillary right second premolar
Reprinted

fron

BdloSh, Mary ard

garet

J.

Bath-

Mar

febrenhch.
DentalEnbryolog, Hk
tolog,, ond Arcto8r,

Second etlition @ 2006.

wiih pemission from El'

,t9
Cop]'isht O 201l-2012 - Dental Decks

&e.@ &e*&
llaalodletal

Brrccolingrrel

Pulp cavity of the permanent

maxillarf- right first premolar

l*aalodblrl

Pulp cavity of the prmanent

maxillary right second premolar

R::rl.'n]n.ttJl1jBiogh'v.rand\,argar.t.]F.h|!nbaclrDe,/rl/E,lna,l'9'}|i'kn.g'ant1:1hlltont|:St.
r .. ..r :i.I FL.\re. SaLnder

/\

\1//
Csrvleal
croea aectlon

Mesiodi3lal
sectlon

Lablollnguol
sectlon

\il/

\l

Meslodistal
agcllon

Cervtcal
crosa Secllon

(rt\
t\tl

\y

Loblollngual
aoclloB

Pulp cavity of the permanent

Pulp cavif"v of the permanent

maxillary right canine

mandibular right canine

Repnnred froD BadlRalogh. Vary and Nrargarel J. Fehrenbach D.hkn

m,$'on frenr tts!ier Srundes

Fhbtlolo*:

Hinnlo'at: tnJ

lntbht) 5..ot1.tlitn'n a.r2006,*irhr

. The permanent mandibular right third molar

.

The permanent mandibular right second molar

. The permanent mandibular right second premolar

. The permanent mandibular right first molar

Rep.inted from Bqth-Balogh,

Mdry 6nd Ma!rci J. Fcbrenbeh.. Deabl Enht?ologr', Htttolos, and Analoity. Secon.l
@ 2006, with pemiv
"dtor
sion frcm El*viq Saddls.

50
Cop,riSht O

201

l-2012 -

De d

Decks

. The permanent mandibular right camne

. The permanent mandibular right lateral incisor

.

The permanent mandibular right first premolar

The permanent mandibular right second premolar

R?nnted from Bath-Baloeh

Mary and Margarci

Fehc.beL. D.u ral

olosr', Histolog,

drd

Andtoh!, Second edition

2006. with pe.nission

51

CopFiehr O 201l-2012 - Dental Decks

J.

t'rlr@

fiofr

P-'?\
tr--1/

\ffij
uo3Lglrt l

F^r
\\

/r-\l

\ffi/
\q

TWI
\qf/
\V

H/

ArA
\-/

@]l

U=:

tg]

Pulp caYirJ* of the permanent

mandibular right first molar

W
@

'::lls*'

/-\a)

tlj ty

Pulp cavity ofthe permanent

mandibular right second molar

Re|nntc.jti.n]B3th-B3L.8h.\larlndN1argarelJ,Fehrenbtc\'DentllEh1ht|.bg'HisbI.e\'a"1l.1hdant's..a"d..L
i;.'r hr) llie\rersaunde^

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\t]I/
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tny
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W
L.slodlrt.l

rn
\Bi

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\/wr
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Euccollngurl

tuerollngual

Pulp cavity of the permanent

Pulp cavity of the permanent

mandibular right first premolar

mandibular right second premolar

(three-cusp \'pe)

Rqrrint.d fron Brth-Brbgh, Mary and VargareiJ. Fchrcnbacn D.ntal l:nh\.artEr, H5lDlo.i, an,l A"atanr, S..an.l

ftrsno. lionr Ehevier

Saunden

.drbh

a,2006.

{nh

aJeF

The permanent maxillary right canme

. The permanent maxillary right first premolar

. The permanent maxillary right central incisor
. The permanent maxillary right second premolar

52
copyrighr O 20ll-2012 - Dental De.ks

The permanent maxillary right third molar

. The permanent maxillary right second molar

. The permanent maxillary right first premolar

. The permanent maxillary right first molar
Reprinied frcn BathBaloeh. Mary and Mar

garet J.

Fchenbach..

Dertal EhbrloloAu l-listologr', dad Arolon!, sec-

A 2006, wnh
pmission fro'n Elsevier
on.l e.lition

53
Coplrighr O 20ll-2012 - Dental Dcks

A 4Nml A
/ll\ @ /A\ 1r1 q fil\
I
tP/
r=J v \l tU
A i\",.:T::xl""

Meslodistal
aoclion

\ltl ",*"I

Lablollogual
seciion

Moslodlstal
iici6n-

Lablotingusl
sectton

Pulp cavity of the permanent

Pulp cavity of the permanent

marillary right central incisor

mandibular right central incisor

.....|l:.::;.[I3]l1]t]]trah'\J!rmdV!rga'elJ.Fehrenblch'D.n|dlEh|h|v|ap'||^1o
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\a,

@
Svc.ollngt al

A1\

v
(t

)\| Iiltl

W @
'ffi.x'"'

(I,lq
l0l

/F^\
t{

@)

Pulp cavity ofthe permanent

Pulp cavity of the permanent

maxillary right third molar

mandibular right third molar

Reprinted lionr Bath-Baloeh. Maryand Vargarel J Fehrenbrcla

mbsio. fio'n Ehevier S.uide^

D.,r"/ E r/,1,h lt, HtttolDir, d,d

.1ad

t.ntt,

5..,,a .drr., !

:006. $rh ncF

The permanent maxillary right central incisor

. The permanent maxillary right lateral incisor

. The permanent maxillary right canme
. The permanent maxillary right first premolar
Rep.inred ft om Bath-Balogh.

M.ry and M$garet

J.

FehrcnbetL Dentot Enbd-

ologl Histologj lnrl

Anatory', Second edition <)
2006. with pmission rroD

54
Cop)'right O 201l-2012 - Denral Decks

. \{ilk
. \later

. Saliva
. Saline

Copltighr O20ll-2012 - Dental Dcks

/l\

l.1l

/u\

lYr

t\\\
lltt
tnl

Iil\

til/

Csrvlcal

/&i

cr0s9 Secllon

b:J
Mesiodlstal
secllon

Lsblolingual
Ssctlon

A
ItI

Celvlcat
caoss

secllon

\il1

\t

\ili

Meslodlstql
sct,on

Lablollngual
section

The pulp cavity of the permanent

maxillary right lateral incisor

The pulp cavitl of the permanent

mandibular right lateral incisor

!:]l.::.::i.,J:BJd]BJl.gh'\hr]ndva.ea|.tJF.hrnbrchD.,l.lE'ln,r,14]r

- .. r i.ri:

Flr.lre.

SaLnders

Important: Thc first priority oftrcatmcnt ofavulsion irturics is

1o prorecr

thc viabilir)--. of thc pcriodontal ligamcnt.

Five factors thnt arc critical lo Ihc managcnrcnl oftraumatic avulsion injurics lo tccthl

L Timei thc time intcnal from injury ro rcplacemcnt ofrhc looth is a major lactor in rhc maintc|ancc of ligamcnt \ irbility and subscqucDl rft)t rcsorption. Tccth rcplantcd \l ilhin l0 mimurcs have been rcportcd ro cxhibil vcry
littlc rcsorpiion, u hcrcas most oflhe tccth rcplantcd aficr 2 hours sho* a lot ofcxtcmat roor rcsorprion ,,r,r,(, r,
Ih" nail uus? ol fui1uft 4 rcpla r?d teeth).
L Storage mcdia: ii thc toolh cannot bc immdiatcly rcplanlcd, thc prcpcr sloragc ofthc ioolh c?n favorablv
influence thc viabilitv ofPDLcells. Milk is considcrcd bcst fbrlhis purposc bccausc ofils ncarnutralpH /6 j6 lr rnd osrrolality. conducilc ibr the sur,"jval otcclls. Othcr storagc mcdia.rre physiologic salinc and snliva.
I -lboth socket: should not bc dam.rgcd by curctlttgc or fbrccful rcplantarion. Replanl slowly $i1h slight

d:!rta nr.sLrrc

.l Splint stabilization:

a splint that

allo\rs drc physiologic movcment is placcd fbr

a maximum

of

\\,ccks /Z n

-'l,.L/r.irxl.rr.Thistimcpcriodallowslbrthcinitialrcarrachnrcntofrhcpcriodontat tigamcnt ilbcrs.

Root surfacci should not bc sc.apcd. dricd. or manipulatcd with causlic chcmicals.

Imporianti
. T.n drvs ro n\o *ccks rtlcr rcplartation. tbc roor canal is prcparcd (Lleunrd utkl rr.rp././ and
dro\ide paste is placcd into rhc cdnals
. This rastc

rs replaced evrv

. If after one tear, it appcars

\ote:

catcium

ht,

three montbs for onc ycar

that rcsorption has rcvcrscd or stoppcd. a pcrmancnt gurta-pcrcha Ulling can bc

The abovc informalion changes *hcn a tooth has bccn oul of thc mouth
mainly the trcahcnt ofthc looth sockct and root surf-aces. Changcs rrc as follows:

for more than 2 hours --

. Ankvlosis and erternal root resorption x'ill probably resulr withln hvo vcars. Ank]lojis rcsuhing iiom rcplaccrrcnt would give a bcttcr prognosis than external resorption, which u ill lcad ro farture.
. Root canal thcrapy is pcrlbrmed in irs cntircty prior to rcplantatjon
. Thc looth is soaked in a 2.470 fluoride solution acidulatd at pII 5.5lbr t0 minutcs or nrorc. Thc fluoridc \ri
slow the resorpli\c proccss.
. Gentll curctte blood clot out ofthc alveolar sockc( and irrigate with saline
. RcplaDt slo*4y wi(h slighl digital pressuru
. Stabilizc wjlh splint for a maxin]um of2 wccks (7 b lA ddrs is irteal)

VIP

. Both the statement

and the reason are correct and related

. Both the statement

and the reason are correct but NOT related

. The statement is correct, but the reason

is NOT

. The statement is NOT correct, but the re:rson is correct

. NEITHER

the statement NOR the reason is correct

56

copltisht

O 20ll-2012 - Denhl Dcks

. Vaintenance ofa normal anterior dentition

. To relieve parental guilt
. To maintain child's self-esteem

To maintain child's social acceptance

57
CoDright O 20ll-2012 - Dental Decks

Intentional replartation implies that a tooth requiring cndodontic therapy is purposcly removed
ftom its socket, son]e type ofcanal or apical preparation and/or filling is perfonned, and thc tooth
is returned to its original socket.
Indications lbr intentional replantation falso called replant vugery);
. When routine endodontic therapy of a tooth is impractical or impossible
. When an obstruction of a canal is prcscnt. such as a broken instrument or a calcification, and
periapical surgery is impractical (e.g-, a lower molar w'ith the mandibular canal in close pro*

inin
. When perforating internal or external resorption is present, yet surgery is impractical
. When a previous lreatment has failed but nonsurgical treatment or surgery is impractical
Note: lntentional replantation should be considered only when there's no other alternative treatment to maintain a "strategic" tooth. Long term follow up is required to monitor for complications
including periodontal defccts and ankylosis with replacemcnt rcsorption.
Other surgical endodontic procedurcs.
. Bicuspidization: is a process in which a tooth is divided into mesial and distal halves without
removal ofany. Endodontic treatment is done and two separate crowns are fixed on both halves.
It is perfomred on mandibular molars with furcation involvement. Better stability ofthe tooth
is achieved when their roots are divergent.
. Hemisectioni is the division of a mandibular molar buccolingually into two single-rooted
tceth: the defective root is extracted. Hemisection requircs root canal therapy on all rctained
root sesments. Note: When possible, it is prefcrablc to complete the root canal trcatment and
place a pemranent restoration into the canai odlices prior to the hemisection.
. Root amputation: ref'ers to the removal ofa rcot from any molar without sectioning through
thc crown. Root amputation requires root canal therapy on all retained root segments.
. Surgical removal of the apical segment of a fractured root: performed on a tooth when a
root fractwe occurs in the apical portion and pulpal necrosis results. Note; The coronal looth segment must be restomble and functional or else this procedure is worthless.

***

The question ofwhether to replant primary teeth has been a focus of debate and controversy in the dental literaturc. However, most dental textbooks uniformly recommend that primary teeth not be replanted. Replantation ofa primary tooth is not recommended because of
the potential danger to the permanent successor from sequels of trauma fe.&, infection, anlg
losis, or damage dtrc to uqnipulqtion during procedure itselfl.

Proper management of an avulsed permanent tooth that has been replanted within two

hours ofthe accident:

. Ten days to two weeks after replantation, the rcot canal is preparcd (cleaned qnd.\hqped)
and a calcium hydroxide paste is placed into the canals
. This paste is rplaced every three months for one year
. Ifafter one year, it appears that resorption has reversed or stopped, a permanent gutta-percha filling can be placed

lmportant: Ifa tooth is out ofthe mouth for more than two hours:
. Ank)"losis and external root resorption will probably result within two years. Ankylosis resulting from replacement would give a better prognosis than external resorption,
u hich

rvill

lead to failure.

. Root canal therapy is performed in its entirety prior to replantation.

. The tooth is soaked in a 2.47o fluoride solution acidulated at pH 5.5 for 20 minutes or
more. The 0uoride

will slow the resorptive process.

. Gently curette blood clot out ofthe alveolar socket and irrigate with saline.
. Rinse tooth with saline, replant into socket, and splint for a maximum of2 weeks.
Note: Resorption is the most frequent sequela to replantation. Three different types of resorption have been identified: surface, inllammatory and replacement (qnlg'lotic resorption).
Replacement resorption refers to resorption ofthe roat surface and its substitution by bone,
resulting in ankylosis.

Internal resorption of a tooth is generally believed to be caused by

inllammation due to an infscted coronal pulp.

. The first statement

is true, the second is false

. The first statement

is false, the second is true

. Both

statements are true

. Both

statements are false

58
l-2012 - Dental Decks

CopFighr C

201

Coplrighl

20ll-2012 - Denhl Deck

Surface resorption

. Infl ammatory resorption

. Replacement resorption

59
@

lnternal (in;flammalory) resorption is usually asymptomatic and is discovered on routine

radiographic evaluation. The anatomic configuration of the root canal is altered and increases in size with intemal resorplion. It will appear as an inegular radiolucency anywhere along the canal space. The tooth involved may respond to pulp vitality tests. When
intemal resorption is detected, a pulpectomy should be performed. Once the pulp tissue
responsible is removed, all resorption ceases. To "wait and see" may result in sufficient
destruction ofthe tooth to create a Derforation ofthe root.

Internal resorption of maxillary

right lateral incisor.

\ote: Although, intemal resorption can occur only when some of the pulp tissue is still
lital. a negative sensitivity test does not rule out this etiology. Also remember that sometimes on a radiograph, an extemal resorptive lesion can superimpose the canal space to
mimic intemal resorption. In such cases, another radiograph should be exposed at an
angle to the tooth. The radiolucent lesion inside the canal space will not shift.

Bowl-shaped areas ofresorption involving cementum and dentin characterize external inllammatory
root resorption. This type ofresorption is rapidly progressive and will continue iftreatment is not instituted. Since both a necrotic pulp and the presence ofbacteda are necessary components ofinflammatory
rcsorption, the process can be arrested by jmmediate root canal beatment. The tooth is opened and the
canal is cleaned and shaped. A calcium hydroxide paste is placed in the canal. This is replaced every
three months for one year If after one year, it appears that the resorption has stopped, a permanent root
c nal filling (gutta-percia) can be placed. A calcium hydroxide-based root canal sealer is strongly recommended.

Surface resorption is caused by acute injury to the periodontal ligament and root sulface. It is very
common, self-limiting, and reversible. Ifinjury is not repeated, healing takes place with new cementum
and PDL. Root surface resorption is limited to cementum, may heal itself, and is not radiographically visible.
Replacement resorption refers to resorption ofthe root surface and its substitution by bone, resulting
in ankylosis. Replacement absorption accompanies dentoalveolar ankylosis due to extensive hauma to
(peliodontal ligament damage).The tooth is often in infraocclusion due
the tooths aftachment
^ppafifis
to progressive submergence
with growth. There is a metallic sound on percussion.
Rememberi This is often seen in unsuccessful replant cases.
Remember the etiology ofextemal and intemal resorption:
. Erternaf resorption: periradicular inflammation, dental trauma (/erultihg in dafiage b attachhent
apparatut), excessive orthodontic forces, impacted teeth, intemal bleaching ofnon-vital teeth.
. Internal resorption: dental trauma (resulting in loss of vitalit)' and subsequent i fection), dental
caries, pulp capping with calcium hydroxide, cracked tooth.

Note: Invasive cervical resorption is a clinical term used to describe a relatively uncommon, insidious
and often aggressive form ofextemal tooth resorption. Cha.acterized by its cervical location and invasive nature, this resorptive process leads to progressive and usually destructive loss oftooth structure.
Resorption of coronal dentin and enamel often creates a clinically obvious pinkish color in the tooth
crown as highly vascular resorptive tissue becomes visible through thin residual enamel.

ImportantiThe majority ofmisdiagnoses ofresorptive defects are made between intemal root resorptions. cervical caries. and cervical resomtion.

. Lack of mobility
. Lack ofPDL on x-ray
. Pinl Appearance

. Infra-occlusion

60
Copyright O 20ll-2012 - Dcnlal Decks

. Apical scar

. Cementoma
. Traumatic bone cyst

. Globulomaxillary cyst
. Radicular cyst

. Cfuonic dental

abscess

. Chronic periapical granuloma

61

CoplriShr O 201 l -20

12

- Detrtal Dcks

*** Traditionally pink tooth

has been considered pathognomonic ofinternal resorption

and is sometimes a feature ofcervical root resorption. lt is characterized by a pinkish ap-

pearance of the tooth due to the

dentin.

grofih of granulation

tissue undermining the coronal

Replacement resorption, which accompanies dentoalveolar ankylosis resulting from extensive trauma to the attachment apparatus ofthe tooth is characterized by progressive replacement ofthe root by the bone. Note: Histologically, it shows direct contact befween
dentin and bone with no intervening PDL or cemental layer.

Remember: Replacement resorption's pathognomonic signs are:

1. Lack of

mobility

2. Metallic sound to percussion

3. lnfra-occlusion of the involved tooth in the developing dentition

Important: Tooth mobility is directly proportional to the integrity of the attachment

apparatus or to the extent of inflammation of the PDL. Other causes oftooth mobility inc Iude:

. Horizontal root fracture

. Recent trauma
. Bruxism

. Ovezealous orthodontic treatment

An apical scar is represcntcd by a periapical granuloma. cyst, or abscess that heals with scar tissuc.
Well-circumscribed radiolucency resembling a granuloma. Tooth is non-vital.

A radicular cyst usually occurs in a pre-cxisting granuloma. Scldom is painful. Radiolucency at apcx

ofnon-vital tooth.
A chronic dental abscess is often a result of a periapical granuloma. Radiolucent area at apex ofnonIital tooth. Fistula is often found leading from an abscess caviry Once drainage is establishcd, thc tooth
stops being painful. Note: A chronic periapical abscess is often the cause of a sinus tract in the gingi-

ral trssucs of childrcn.

-\ chronic periapical granuloma
iLrcialed wiih a non-vital tooth.

is the most common sequelae

ofpulpitis. It is asymptomatic

and as-

.\ cementoma

occurs most frequently in the antrior region ofthe mandible. It starts as a radiolucent
leritrn and then calcifies. The cementoma does not affect pulp vitality. Also called periapical cemental dlsplasia.
.q, traumatic bone cyst is not a truc cyst sincc thcrc is no epithclial lining. Found mostly in young pcople. asymptomatic. Radiolucency which appears to scallop around the roots ofteeth. Teeth are usuallv

\itel.
A gfobulomaxillary cyst (developmental cys, is found at the junction of
processcs

the globular and maxillary

ofthc maxilla, between thc lateral incisor and the canine roots. Teeth are vital.

Alateral periodontal cyst occurs on a lateral periodontal location and it

is ofdcvclopmental origin arising fiom cystic degeneration ofclear cells ofthe dental lamina. Tooth is vital.
An ameloblastoma is a benign, locally aggressive tumor arising from the odontogenic ectodem.Lesions
occur as multilocular radiolucencics and frequently cause extensive root resorption. Thc mandible is affected four times more frequently than the maxilla.

A cementoblastoma is an odontogenic tumor characterized by the proliferation offunctional cementoblasts that folm a large mass ofcemennrm or cementum-like tissue on the tooth root.

. Radiopaque

Easy to manipulate

. Hydrophilic
. Biocompatible
. Not toxic

. Short setting time

. Induction ofhard tissue formation
62

coplri8ht o 20ll-2012 - Dental Decks

. A dull thobbing pain on masticatlon

. Sensitivity to hot, and/or cold stimuli

. A persistent feeling ofdiscomfort

. Vild bleeding
. Pail on percussion

Coplrigh O 20ll-2012

- Dental Decks

The main ions found in MTA are calcium and phosphorus. MTA has a high pH so it induces
hard tissue formation. MTA has superior sealing ability and is not adversely affected by biood
contaminants. [t also causes only low levels of inflammation because it forms fibrous connective tissue and cementum when in contact with the pe odontium. Note: MTA is difficult
to manipulate and has a long settilg time. Despite these disadvantages, it's the material of
choice today.

A retrofif ling falso called a reverse f lling or retrograde qmalgam.filling) rs placed to seal the
apical portion ofthe root canal. This procedure is used when an apicoectomv alone will not
yield a good result. Whenever there is any chance whatsoever that an apical seal may be
faulty, a reverse filling material must be placed. For example, if the root canal appears calcified. it would be impossible to obturate most ofthe canal and get a seal. Ifjust the root apex
were cut off faplcoectoatl, the incompletely filled canal might act as a source ofreinfection.
To prevent this after the root tip is resected, the foramen is found, enlarged, and filled with a
zinc-ftee amalgam to create a seal.

An apicoectomy lro ot-end rcsection) is a procedure where the buccal tissue is flapped back,
the buccal bone about the apex is removed, the root apex is removed, and the area is curetted out. Indications for apicoectomy: l) A reverse filling needs to be placed 2) It is necessar] ro gain access to an area ofpathosis 3) The poorly filled apical portion ofthe root is to
be removed to the level ofcanal obliteration. Note: A retrograde amalgam hlling should al$ a1s be done after an apicoectomy. Teeth that have posts in them and need to be retreated are
rhe most common reason for an apicoectomy and a retrograde filling.
Remember: Periapical curettage is the same procedure as an apicoectomy (as far os fap and
remotal ofbuccal hor) but without removing the root apex. Removal and examination ofthe
diseased tissue and determination ofthe extent ofthe lesion are the objectives ofapical curetIace.

*** Thermal sensitivity

is thc earliest and most common symptom

ofan inflamcd pulp.

As caries entcrs thc dcntin it bcgins with a lateral sprcad al thc DEJ. This is duc 1o thc incrcascd orSanic conlcnt and
the involvcmcnt ofmany dcntinal tubulcs. Thc Tomcs fibcrs rcact, causirg fa(y dcgencnttion, thcn latcr dccalcification /.!.'/.,forrt. As caries progrcsses. destruction ofdentin is followcd by rhc bactcrial invasion ofrhe hrbules and com
plclc destruction ofdcntin. Once odontoblasts arc involvcd, pulpal changcs occur. Initially thcrc is vascrlar dilation
and local cdcma. Tlc carliesa common slmptom ofthis edema fz./rreprlrth.) is thcrmrl sensitivity (us ullr it1o?used and persistent puin on upplirution oJ rcld).

Rememberr Thc only rcliablc clinical cvidcncc thal sccondary dcntin has formcd is decreased tooth sensitivitl_
tuvnllr seen a lev vteel.s dlter place e t oIa li ing. whcn dcntinal tubulcs bccomc complctcly calcifrcd. thc dcntin
is ins.nsitivc
L Thcrmal tcsts arc cspccially valuablcwhcn thc paticnt dcsc.ibcs fic pain as dillusc. Thc cold test can
bc Lionc w irh cold r s ter bal h s, sticks of icc, thyl ch loridc, dich lorod ifluo rcnerharc / DDM , Eh.lo k e )

\trtes

:. Thc heat test can bc donc wilh wann slicks oflutla

pcrcha, using a rubbcr whecl mountcd on a mandrcl revolving at a polishing speed io gcncratc hcat, or a hot rvatcr bath.
3. Thc bcst mclhod to clicit a most sccurute thcrmal rcsponsc is to individually isolatc thc suspcctcd
tccth \r'ith a rubbcr dam and thcn balhc cach toolh in hol or cold water This is donc bccausc all other
mcthods mav stinulate the iooth at only onc scction ofonc surfacc.
ResDonses to thermal tests:

. \o response: indicates a nonvital pulp or a false negative responsc

. Mild-fo-mode.ate response: slight pain that subsides within I to 2 scconds; }1ithin normal limits
. Strong, momentaay painful response: subsidcs within I to 2 scconds; indicates reversible

pulpitis

. Moderate-to-strong painful response: lingers for scvcral scconds or longer; indicalcs irreversible pulpitis
Thermal tcsls may be falsc-ncgativc in immature, recently traumatized lccth or bccausc ofpremcdicstion with an analgcsic.
5. Although the percussion test docs not indicatc thc hcalth oflhe pulp, thc scnsitivity ofthc proprioccptivc tlbcrs does reveal inflammation ofthe apical PDL.
6. A positive response to pcrcussion indicatcs not only thc prcscncc of inflammation ofthc PDL. bu!
also thc cxlcnt ofthc inflamrratorv Droccss.
,1.

. An acute apical periodontitis

. A suppurative apical periodontitis

. An asymptomatic periapical granuloma

. An acute exacerbation ofa chronic apical periodontitis
. A chronic state ofan acute apical periodontitis

64
Copyrighr O 201 I -20 l2 - Dental Decks

. CAA is asymptomatic

' CAA

is s;.rnPtomatic

. Only histological examination can differentiate

. The border ofthe radiolucent lesion

65
Cop)'righr @ 201| -2012 - Denial

Dcks

A phoenix abscess is also known as a recrudescent abscess. lt develops as the granulomatous zone becomes contaminated or infected by elements from the root canal. Diagnosis
is based on the acute symptoms fparn /o perc'ussion) plus radiographic examination, which
reveals a large periapical radiolucency. Note: A phoenix abscess is always preceded by

chronic apical periodontitis. Signs and symptoms are identical to those of an acute periradicular abscess, but a radiograph will show a periapical radiolucency that indicates the
presence ofa chronic disease. Not: The term "Phoenix Abscess" is becoming obsolete.
The term replacing it seems to be "an acute exacerbation ofchronic apical periodontitis"
(yes, the delinition is no\r the term).

A granuloma is defined

of granulomatous tissue continuous with the peri

odontal ligament resulting from pulpal death with diffusion oftoxic products into the periapical area. ln most cases a granuloma is symptomless. Radiographically, one sees a
well-defined area ofrarefaction with some inegularities, while clinically the tooth is not
sensitive. A massive invasion of pulpal contaminants will result in the formation of an
as a growth

acute abscess (Phoenix abscess).

A cl st is an inflammatory response of the periapex, which develops from preexisting

granulomatous tissue (granuloma). It is characterized by a central, fluid-filled, epithelium-lined cavity, surrounded by granulomatous tissue and peripheral fibrous encapsulation. It is often associated with a chronically infected tooth. The tooth may be
mobile. On radiographs. one will see a well-defined area of rarefaction (radiolucency)
ivhich is limited by

continuous radiopaque, sclerotic border olbone. It is usually asymp-

tomatic.

Important: A granuloma or a cyst can only be diffrentially diagnosed by histological

eramination.

The chronic apical abscess (also calletl suppuralire apical periodonltlr,/ is somctimes so painlcss that it nray
go undetected for years until revealed by an x-ray. It is a long-standing, low-grade infection ofthe periapical
bone with the root canal bing the source ofthe inf'ection. This condition may follow an acule alveolar abscess
or unsatisfactory root canal lherapy. Radiographs will reveal a diffusc radiolucency and PDL thickening. The
tooth may be slighlly loose or tender to percussion. The chronic absccss may be differentitted fiom cysts and
granulomas by the tact thatboth cysts andgranulomas have 1,ell'defincd radiolucencics associated with them.

The trertment is conventional root crnrl treatment.

Rmember: 309/o ro 5070 ofbone calcium must bc altered before radiographic evidence ofperiapical breakdo\rn occurs flrls .r//e/dtion takes place at tlrc junction beireen the cortical dnd cancellous hone).
The acute apical abscess (AAA) is a localized collection ofpus in the rlveolar bone at the root apex following death ofthe pulp $ith extension ofthe infection into ihc pcriapical tissue. The first symptom may be a slight
tendemess ofthe tooth. This later develops into a severe throbbing pain to percussion rdth swelling ofthe
o|erhing mucosa. The tooth becomes more painful, elongalcd and loose. At timcs thc pain may dccrcase or
disappcar complctcly. Thc paticnt may appcar wcakcned. irritable and present with a fever. Thc dirgnosis is
bascd on lhe history. exam, and radiogmphs. The tooth \\,ill not rspond to the EPT or cold test but may respond to heal The best treatmnt ofan acute alveolar abscess includes establishing drainage and debriding the canal s\ stem ofnecrotic fissue which will relieve the acute sy:nptoms. This is followed at a later date
b\ con\ entional root canal therapy.\ote: Ifthe abscess rupores through the periosteum into thc soli tissue, the

lrtic.fs

svmproms

*,ill

subsidc.

lncision and drainag of solt tissues in indicated;

.lfa

plthway is needed in soft tissues with localized fluctuant swelling that can provide necessary drainage.

\ote:

It should be emphasized that, rhenever possible, lhe acute periapical abscess should be incised and
drained through the root canal system.
. When pain is caused by thc accunrulatjon ofexudat in tissues.
. wren it is necessary to obtain a cultr:re ofthc cxudatc
Apical trep hin ation is accorr pl ished by aggress ively p lacing a No. I 5 to 2 5 K-fi lc bcyond the confincs of the
apex. Surgical trephination is a perforation of thc alveolar cortical bone to release accumulatcd tissue exudates. A small /J-lr/r/ horizontal inc ision is made with a No- I 5 scapel bl ade at ihe I e! el sl ightly apical to the
root apex. ANo. 6 or 8 round bur is uscd on a stmight handpiece to penetrate the conical plate above the root
apex. Iftherc is diffusc swclling f.e11 /irrt, antibiotics are usually indicated.

. Eventually the

acute nature

ofthe lesion will progress into a chronic, and non-painful

lesion

. This lesion can progress into the bone causing osteomyelitis,

. The apical lesion

a more severe condition

has been there for years and the tooth needs treatment immediately

55
Coprighl C201l-2012 - De alDecks

. EPT
. Cold test
. Heat test

67

coptriglt

@ 201

l-20l2 - Dmral Decks

Osteomyelitis is not a particularly common disease. It is a serious sequela of periapical infection that often results in a diffuse spread of infection throughout the medullary
spaces, with subsequent necrosis ofa variable amount ofbone.

Acute or subacute osteomyelitis may involve either the maxilla or the mandible. In the
maxilla, the disease usually remains fairly wellJocalized to the area of initial infection.
In the mandible, bone involvement tends to be more diffuse and widespread.

Clinically, the person afllicted with acute osteomyelitis is usually in rather severe pain
and manifests an elevation of temperature with regional lymphadenopathy. The teeth in
the area of involvement are loose and sore so that eating is difficult, if not irnpossible.
Note: Another clinical symptom ofacute osteomyelitis is leukocytosis, an elevated number of white cells in the blood.

Radiographically, acute osteomyelitis progresses rapidly and demonstrates little radiographic evidence of its presence until the disease has developed for at least one to two
u eeks. At that time, diffuse lytic changes in the bone begin to appear Note: A "motheaten" radiolucent aooearance is evident.
The general principles of treatment demand that drainage be established and maintained and that the infection be fteated with antibiotics to prevent further spread and complications.

***

The tooth

will not respond

to the EPT or cold tests but may respond to heat

Ofall

the denral abscesses. the periapical is the most common t?e. It is a localized colleclion ofpus in thc
alveolar bone at the root apex following death ofthe pulp with extension ofthe infection into the periapical
tissue. The first symptom may be a slight tendemess ofth(r tooth. This later develops into a severe throbbing
pair. (ac te abscess) with swelling ofthe overlying mucosa. Reducing thc irrilant, reduction ofprcssurc. or
thc removal ofthe inflamed pulp is the immediate goal. Ofthese, pressure relcase is the most effective in re-

lie\ ing the patient's pain. Emergency treatment includes establishingdqinage (ideall! throlryh the cana[)
and prescribing antibiotics lonlv il indicated hv s)'stemic signs dnd elewted tenlrera ture ) and ni alges ics. This
!\ ill relie\ e ihe acute symptoms followed by conventional endodonric thcrapy at a latcr datc. Note: Complete
cleaning and shaping ofthe root canals is the preferred treatment. Horvever, iffor some reason this is not pos:ible. a pulporomv is usually effective in the absence ofpcrcussion sensitivity.

Important:\\hen diffuse swelling exists, the swelling

has disscctcd into fascial spaccs. The most important

removal ofthe irritant via canal debridement or extraction ofthe offcnding tooth. Swclling may
be incised and drained followed by drain insenion and systcmic antibiotics.

objecti\

e is the

\ote: For endodontic infections that do not respond to penicillin VK, clindamycin is olien recommended. It
produces high blood levels and is eflective against anaerobic bacteria but must be used with caution bccause
of the polenlral for p.cudomembranou. colrtis.

:Nol3*'
'
,-

l. A history ofpre-opcrative pain and s*'eiling is the best predictor of interappointment cmcrgencres.
2. No relationship exists between flare-ups and treatment procedures /i.e.. rirgle ormultiple|isperiodontal abscess is an acute abscess lhat devclops through thc periodontal pocket. Alveolar bone loss, pocket formation and pe odontal pathologic conditions are suggestive ofthe periodontal abscess. The tooth \rill usually be palpation and percussion positive. lt will respond to the
electric pulp tester frrlike the periapical abscert. Bactria associated with this abscess include
gftm-negative rods sucb as Capnocytophaga species, Vibrio-corroding organisms and Fusobaclenum spccles,
4. The gingival abscss is a relative rarity rhat occurs whn the bacteria iDvade through some
break in th gingival surface. Such abrasions may be the result ofmastication, oral hygien proccdurcs. or dcntal trcalmcnt.
3. The

. Reversible pulpitis

. Irreversible pulpitis

68
Cop}'ighr

r'\. A
.

\')

20l

l'2012'

Dntal Decks

central incisor
with a complaint thrt tooth #8 is
draining pus into his mouth, The tooth had been traumrtized earlien
The vitality tesh reved no response. What is the treatment ofchoice?
seven year old boy arrives at the ollice

. Extraction
. Apexogenesis / pulpotomy
. Root canal treatment

. Periodontal surgery to remove sinus tract

. It

is only necessary to give the child analgesics and antibiotics for pain and infection

. Apexification
69
CoplriShr O 20ll-2012 - Dental Dcks

The severity ofthe clinical symptoms will vary as the inflammatory response increases. Pain $ ill vary liom a
mild and readily tolerated discomfort to a severe, throbbing and excruciating pain. The pain is spontaneous!
unprovoked! and is intrmittent or continuous in naturc. Thc pain lingers after the removal ofthe irritant.
The pain is usually not readily localized by the patient but is difuse in character Lying down or bcnding over
intensifies the pain ofineversible pulpitis because the overall increase in cephalic blood pressure is relayed to
thc confined pulp tissue. The tooth may be tenderto percussion, heat may intensit the pain response while cold
m y relieve it (in ad|anced s/dgerl. Usually they both will cause severe and lasring pain. Thc radiographs will
usually disclose no periapical patholog!. Treatment is root canaltherapy. Note: In cases ofirrevrsible pulpitis, an acutcly inflamed pulp is symptomatic whercas a chronically inflnmed pulp is rs) mptomatic in most
cases. The end result is necrosis ofthe pulp.

. Asymptomatic irreversible pulpitis- possible consequences:

- Hyperplastic pulpitis: a rcddish, cauliflower-like growrh ofpulp tissue through and around a carious

ofa grossly decayed tooth.

-Internal resorptioni is a pathological process initiated *,ithin the pulp
exposure

often

is described as an oval-shaped enlargement

space uith the loss ofdentin. k

ofthe root canal space and usually is asymptomatic and

detectable by routine radioSraphs.

. Sr"mptomatic irrerersible pulpitis: as dcscribcd above, the pain is spontrneous, unprovoked! and is intermittnt or continuous in nature- Pain will vary liom a mild and readily tolerared discomfoft to a severe,
throbbing and excruciating pain.

Relersible pulpitis /h\'percniaI the pain associated with hlperemia does not occur spontaneously.

I1 requires an extemal irritant to evoke a painful response /i.{,., .o/d. srt?ctr). Thc pains are sharp and ofbrief duration. ceasing \\'hen the irrilant is removed. Radiographs appear normtl lnat'shov,deep caries or catiq
/,r1'l,1,"drirr. The tooth is usuirlly percussion negativc. In thcrmal tests. the pulp rcsponds more readily to cold
itrmuli fian to hot 1t respo se laaws shortlv after rcnotal olthe stirrrlfur). Treatment usually is a seda-

tire filling or nell restoration lvith a base.

Caus.\ ofrel ersible pulpitis inchde early carics, priodonl1l scaling, root planing. microleakage, and restoraronj placcd $ithout a base. Remember: Reversible pulpitis is not a diseasc, rather it is a symptom. Ifthe irritanl ii removed, the pulp will revert to a healthy slatc. If the irritant rcmains, the symptoms may lead to
irre|ersiblc pulpi!is.

\otei

Pulpaf intlrmm^tion (h.r'perenia) is most commonly caused by bacteria.

Apxification is a technique whose goal is to induce further root development in a pulpless

tooth by stimulating the formation of a hard substance at the apex, so as to allow obturation
ofthe root canal space. Apexification may be rcquired afler pulpectomy as at seven years of
age the apex ofthis tooth must be open. Remember: Apex closes 2-3 years after emption.
The technique consists ofisolation ofthe field with a rubber dam, making an access cavity and
removing all pulpal tissue by the use ofreamers and files. A premixed syringe of a calcium
hydroxide-methyfcellulose paste (/or erample, a Pulpdent s.vrlrge/ is injected into the canal
until it is filled to the cervical level. The paste must reach the apical pofiion ofthe canal to
stimulate the tissues to form a calcific barrier. A double seal ofcement is made to close offthe
access cavity. The patient is recalled after three months to see ifapexification has taken place.
Ifnot. a liesh supply ofpaste is placed. lfapexification has occurred, conventional root canal

therapv is instituted.
The action of calcium hydroxide in promoting formation ofa hard substance at the apex is
best erplained by the fact that calcium hydroxide creates an alkaline environment that prornoles hard tissue deposition. Note: Its high pH (pH-12.5) also causes an antibacterial ellect

rnd it inacli\ ate: lipopolysacchande.

\ote: Ifa

permanent tooth fractures and has a fully formed root and the pulp is exposerJ, (large
erpasure). the ffeatment of choice is complete root canal therapy. Apexification is not
needed because the root is fully fonned. lf the exposure is small and the length of time is
short ( I /2 hour to I hour), then a direct pulp cap with CaOH lbllowed by a restoration is the
ireatment (|fchoice.

Remember: Apexogenesis is the process of maintaining pulp vitality during pulp treatment
to allow continued development of the entire root. As opposed to apexification, this procedure relates to teeth with retained viable pulp tissue in which this pulp tissue rs protected,
treated, or encounged to permit the process ofnormal root maturation.

. Transplanted teeth with partial root development have a better prognosis than those
with developed roots

. Orthodontic extrusion

is a common indication prior to implant placement

Intentional replantation is a viable altemative to endodontic surgery

A major disadvantage of endodontic implants is the lack ofan apical seal

70
Coptaighr O 20ll-2012 - Dental Dcks

*** Intentional replantation is not a substitute

for endodontic surgery

if it can be un-

dertaken.

Transplantation is the transfer ofa tooth from one alveolar socket to another either in the
same person or in another person.

Orthodontic extrusion is defined

as force-controlled vertical tooth movement occlusally

in the socket. Indications include untreatable subgingival pathoses e.9., cervical caries, cervical fracture, periodontal defects, resorptive lesions and perforations in the cervical
atea.

Crown lengthening is a procedure used to apically position the gingival margin and./or
to reduce the cervical bone. It is employed during the treatment of subgingival caries,
perforations and resorption.

Root submersion involves resection of tooth roots 3 mm below the alveolar crest. The
coronal portion ofthe tooth is removed and the roots are covered with a mucoperiosteal
flap. Indications include rampant caries, adverse periodontal conditions and in cases that
have had repeated prosthetic failures. The submerged roots will prevent alveolar resorption and maintain better proprioception. This is especially useful in medically compromised or handicapped patients requiring better denture control- Sometimes, this is also
done to avoid formation of an esthetic defect that may result after extraction.