No lesion (%)

Success (%)

0
0

20
40
60
80
20
40
60
80

100
100
De Cleen et al. 1993 Strindberg 1956

Petersson 1993 Kerekes & Tronstad 1979

Ray & Trope 1995 rstavik et al. 1987

Buckley & Spangberg 1995

Bystrm et al. 1987

Eriksen et al. 1995

Molven et al. 1988
Saunders 1997
Sjgren et al. 1990
Weiger 1997
Cvek et al. 1992
Marques et al. 1998
Smith et al. 1993.
Sidaravicius et al. 1999
Zeldow & Ingle 1994
De Moor et al. 2000
rstavik et al. 1996
Kirkevang 2000

Caliskan et al. 1996.

Cross-sectional studies
Tronstad et al. 2000

University Settings (78%-97%)

Trope et al. 1999.
Theory to Practice

Dugas et al. 2002

of Endodontic Therapy
Hommez et al. 2002 Peters et al. 2002.

Lupi-Pegurier et al. 2002 Friedmann et al. 2003

General Population
jhupp@roseman.edu
James G. Hupp, DMD, MS
Modern Endodontics - From

PREDICTABLE, CONSISTENT AND EFFICIENT

Treatment Outcome and Prognosis

> 80%
Diplomate, American Board of Endodontics
2/26/2017

1
 2/26/2017

OUTCOMES

1. State reasons and describe strategies for enlarging the cervical portion of the canal to promote straight-line access.
2. Define how to determine the appropriate size of the master apical file.
3. Describe objectives for both cleaning and shaping and explain how to determine when these have been achieved.
4. Describe appropriate techniques for removing the pulp.
5. Characterize the difficulties of preparation in the presence of anatomic aberrations that make complete debridement difficult.
6. List properties of suitable irrigants and identify which irrigant meets most of the criteria.
7. Describe the techniques that provide the maximal irrigant effect.
8. Discuss the properties and role of chelating and decalcifying agents.
9. Explain how to minimize preparation errors in small, curved canals.
10. Describe techniques for negotiating severely curved, blocked, ledged, or constricted canals.
11. Discuss the properties and role of intracanal, interappointment medicaments.
12. List the principal temporary filling materials and describe techniques for their placement and removal.
13. Describe temporization of extensively damaged teeth.
14. Outline techniques and materials used for long-term temporization.

CODA STANDARDS: 2-9, 2-10, 2-21, 2-22, 2-23j

CODM Competencies: 2, 3, 4, 5, 6, 9, 15, 17

Success with vs. without Radiolucency

No Radiolucency Radiolucency

Strindberg (1956) 89% 68%

Seltzer et al (1963) 92% 76%

Kerekes & Tronstad (1979) 94% 84%

Sjgren et al. (1990) 96% 86%

Friedman et al. (2003) 92% 74%

Farzaneh et al. (2004) 93% 79%

2
 2/26/2017

The Goal of Endodontics:

The Prevention of
Apical Periodontitis

The Prevention of Apical

Periodontitis

Treatment of a vital
(non-infected) pulp

Pathogenisis

Oral microorganisms

Kakehashi et al. - 1965

Sundqvist - 1976

3
 2/26/2017

Irreversible pulpitis

The Goal of Endodontics:

The Prevention or Treatment of
Apical Periodontitis

12

Pulp and Periapical Disease

Oral microorganisms

Kakehashi et al. - 1965

Sundqvist - 1976

4
 2/26/2017

The significance of filling

the canal without or with
cultivable bacteria

Bacteria and Prognosis

Success by Culturing Results
Presence of Bacteria No Bacteria

Engstrom et al (1964) 76% 89%

Primary infection

Zeldkow & Ingle (1963) 83% 93%

Sjgren et al (1997) 68% 94%
Molander et al (2007) 44% 80%
Sundqvist et al (1998) 33% 80%
Retx.

Fabricius et al (2006) 21% 72%

Tx of Teeth with Apical

Periodontitis
< microbes
=
> healing
> prognosis

5
 2/26/2017

The Healing of Apical Periodontitis

Canal Disinfection

Microbiological Goals
Tx Vital pulps - prophylactic
treatment (pulp free of infection) -
prevent apical periodontitis -
ASEPSIS
Tx Apical periodontitis - infectious
disease that should be treated with
elimination of microorganisms -
ANTISEPSIS
Kievit TR Infect Immuno 2000
Smith T. textbook1934

Diagnosis

Root Canal Treatment

Mechanical Antimicrobial
Instrumentation Irrigation

Intra-canal
medication

Microbial Control Phase

Filling Phase
R.C. is Root canal
R.C. Filling
Top Filling

6
 2/26/2017

APICAL SIZE

Treatment of the Vital (non-infected) Canal

Canal free of infection

Asepsis!
Chemo-Mechanical
R.C. Filling
Instrumentation

UPPER JAW
ISO 50 or 60 ISO 50 ISO 50 or 60 B: ISO 35 or 40 B: ISO 35 or 40 MBs: ISO 35 or 40 MBs: ISO 35 or 40
ISO 35- 40 P: ISO 40 P: ISO 40 DB: ISO 35 or 40 DB: ISO 35 or 40
(if curved) P: ISO 50 or 60 P: ISO 50 or 60
1 canal: 1 canal:
ISO 50 or 60 ISO 50 or 60

B: ISO 40 B: ISO 40 B: ISO 40 B: ISO 40 MB: ISO 35 or 40 MB: ISO 35 or 40

L: ISO 40 L: ISO 40 P: ISO 40 P: ISO 40 ML: ISO 35 or 40 ML: ISO 35 or 40

1 canal: 1 canal: 1 canal: 1 canal: D: ISO 50 or 60 D: ISO 50 or 60

ISO 50 ISO 50 ISO 50 or 60 ISO 50 or 60 2 Ds: ISO 40 or 50 2 Ds: ISO 40 or 50

LOWER JAW

7
 2/26/2017

THE APICAL REGION

Minor
Foramen

Dentin

Cementum

0.5 to 1.0 mm
Radiographic
apex

Controlling the infection by mechanical instrumentation

D M

B
1 mm - 0.35/0.37 mm
2 mm - 0.41/0.55 mm
3 mm - 0.49/0.54 mm
4 mm - 0.54/0.60 mm

1 mm - 0.22/0.23 mm L
2 mm - 0.27/0.27 mm
D #25 M 3 mm#25
- 0.30/0.30 mm
4 mm - 0.35/0.36 mm

Courtesy Dr. Richard Walton

8
 2/26/2017

IRRIGATION

LARGER APICAL SIZES TO... FACILITATE IRRIGATION

Bacterial Reduction With Progressive Filing

Saline (Dalton 1998)
Control
(Shupping 2000)
NaOCl 1.25%
6 NaOCl 5.25%

5
20% neg.
culture
40% neg.
Log10 CFU means

4
culture
3

2
61.8% neg.
1
40% neg. culture culture
#20 #25 #35
0
S1 S2 S3 S4

samples
McGurkin et al. 2005

9
 2/26/2017

Intracanal Irrigation
Needle penetration and diameter

FlexiGlide Tips Navi Tips

Vista Dental Ultradent

Root Canal Anatomy

Weng et al. JOE 2009

10
 2/26/2017

Intracanal Irrigation

IRRIGATION PROTOCOL

*Your endodontic set-up will have a 30g side-vented needle (for final irrigation) and a 23g needle
(for bulk irrigation).

30 g side-vented irrigation needle

1 mm from WL- PASSIVE NEEDLE PLACEMENT (NO BINDING)
NO FORCERFUL EXTRUSION

Copious amount of Sodium Hypochlorite (NaOCL) between files using a 23 g needle

AFTER FINAL FILE (FAF):
5-10 ml NaOCL per canal (over 1 minute) 30 g needle

3-5 ml EDTA (Smear Clear) per canal (over 1 minute) This is a flush not a soak! 30 g needle
3 ml 2% CHX per canal as a final rinse 30 g needle

If obturation; fit BC GP and take radiograph PRIOR TO DRYING CHX

If Ca(OH)2; dry and place w/ paste filler (lentulo spiral)
At second visit, same irrigation protocol

ICM

11
 2/26/2017

Ca(OH)2

Ca(OH)2
1-4 weeks

12
 2/26/2017

Effect of Ca(OH)2 on Microorganisms

and their by-products

Direct killing: OH-

Block of nutrients

Neutralize bacterial

products - LPS

Disrupt Biofilms
Safavi KE, Nichols FC. Effect of calcium hydroxide on bacterial lipo- polysaccharide. J Endodon 1993;19:768.
Safavi KE, Nichols FC. Alteration of biological properties of bacterial lipopolysaccharide by calcium hydroxide treatment. J Endodon

No differences between
1994;20:1279

alone or combine with CHX

OBTURATION

13
 2/26/2017

MATRIX AND WEDGE

...OTHER TECHNIQUES RELY ON

FRICTION

Goal of
Penn
Endo Obturation

Bergenholtz, Textbook of Endodontology

2nd Ed 2010

Penn
Endo

The Gutta- percha sandwich!!!!!

Orstavik ET 2005 Sealer/GP interface, Eldeniz et al. in press

14
 2/26/2017

BioCeramics
Ceramic materials that are specially
developed for use as medical
(orthopedic joint replacement -
framework for tissue replacement)
and dental implants

BioCeramics
Alumina and zirconia
Ceramic materials that
Calcium silicate
are specially developed
Calcium oxides
for use as medical
Calcium phosphates
(orthopedic joint
Calcium carbonate
replacement - framework
Bioactive glasses
for tissue replacement)
Glass-ceramics
and dental implants
Hydroxyapatite

BIOCERAMIC TECHNOLOGY
DEFINITION
Ceramics used for the repair and reconstruction of diseased or damaged parts of
the musculo-skeletal system, termed bioceramics, may be bio-inert (alumina,
zirconia), resorbable (tricalcium phosphate), bioactive (hydroxyapatite, bioactive
glasses, and glass-ceramics), or porous for tissue ingrowth (hydroxyapatite-coated
metals, alumina).

MTA

BIODENTIN
E
NANOTECHNOLOGY
PARTICLE SIZE

CALCIUM SILICATES
SETTING REACTION PRODUCES HYDROXYAPATITE
creates the monoblock or chemical bond

15
 2/26/2017

BioCeramics in Endo
1st generation

MTA (mineral trioxide aggregate)

Loma Linda University, 1990 - M. Torabinejad

New Generation
of BioCeramics in
Endodontics
48

BioCeramics in Endo
Powder Liquid Time Use
Tricalcium silicate (CaSiO4)
Tricalcium aluminate (CaAl 2O4)
Tricalcium oxide (CaSO4) Distilled water 15 min to 4 Mix before
hours use
MTA Silicate oxide
Bismuth oxide for radiopacity
(BiO3)
pH = 12.8

Bio Tricalcium silicate (CaSiO4) Calcium chloride 12 min

30 s
amalgam
Calcium carbonate (CaCO3) Water reducing agent
Dentin Zirconium dioxide (ZrO2) Water
triturator

pH = 12.9
e
Tricalcium silicate (CaSiO4) Moisture from 2-4 hours
periapical and root Ready mixed

BC Calcium phosphate (CaHPO4)

Zirconium dioxide (ZrO2)
canal tissues

Calcium hydroxide (Ca(OH)2)

pH= 12.7

16
 2/26/2017

Tricalcium Biosilicate
Technology

17
 2/26/2017

Bioceramic Points /
Bioceramic sealer

BioCeramics in Endo
Powder Liquid Time Use
Tricalcium silicate (CaSiO4)
Distilled water 15 min to 24 Mix before

MTA Tricalcium aluminate (CaAl 2O4)

Tricalcium oxide (CaSO4)
hours use

Silicate oxide
Bismuth oxide for radiopacity
(BiO3)
pH = 12.8

EndoSequence BC -
Research
More than 40 scientific studies from 2008-2012

Antimicrobial effect
Cytotoxicity
Biocompatibility
Sealability
Adhesion
Clinical
55

18
 2/26/2017

Hydraulic Condensation with

Bioceramic Sealers
Adequate BMI and chemical
debridement
Fit snug cone appropriate taper and
size, to working length
Apply sealer directly into canal
Coat apical 4mm of cone
Insert cone slowly to 4mm, then insert
with force to express sealer into
irregularities
Use additional points if necessary
Cut at orifices and apply gentle apical
pressure

The sealer does the

work!!!!!

Penn
Endo

BC SEALER
BioACTIVE
material during
hydration process

BioSTABLE upon
setting

19
 2/26/2017

Penn
Endo BioACTIVE material during hydration
process
Bioactive glass requires an aqueous environment to set
Hydration reactions of calcium silicates: Is this chemical or physical rxn? (assess)
(A) 2[CaOSiO2] + 4H2O 3CaO2SiO23H2O + Ca(OH)2
(B) 3[CaOSiO2] + 6H2O 3CaO2SiO23H2O + 3Ca(OH)2

Precipitation reaction of hydroxyapatite:

(C) 7Ca(OH)2 + 3Ca(H2PO4) Ca10(PO4)6(OH)2 + 12H2O

Preview: the moisture naturally present in the root canal and

dentinal tubules initiates and completes the setting reaction

Koch and Brave 2009

BIOCERAMIC OBTURATION
1. ANTIBACTERIAL - PH

2. HYDROPHILIC

3. EXPANDS SLIGHTLY
4. DIMENSIONALLY STABLE
5. BIOCOMPATIBLE-0STEOGENIC

6. SEALER BONDS TO DENTINE (HYDROXYAPATITE) AND GP

7. BIOCERAMIC WITH 3 DIFFERENT PARTICLE SIZES -

SEALER, ROOT REPAIR, PUTTY
8. PREMIXED - NO WASTE
9. GP POINT ACTS LIKE A PLUGGER/SPEADER
SINGLE CONE TECHNIQUE

10. RETX NOT DIFFICULT DUE TO GP PATHWAY

11. STRENGTHENS ROOT

20
 2/26/2017

BioCeramics in Endodontics
Conclusions
Excellent sealing properties (seal in wet environment)
Potent antibacterial activity (pH - 12.5)
Biocompatible material
Chemical bond with dentine
Insoluble in tissue fluids
Easy handling (last generations)
Can be used on retrograde, orthograde fashoin and as a
obturation material combined with gutta-percha

62

Hydraulic Condensation with

Bioceramic Sealers
Adequate BMI and chemical
debridement
Fit snug cone appropriate taper and
size, to working length
Apply sealer directly into canal
Coat apical 4mm of cone
Insert cone slowly to 4mm, then insert
with force to express sealer into
irregularities
Cut at orifices and apply gentle apical
pressure

21
 2/26/2017

NEW SYSTEM CASES

22
 2/26/2017

Penn
Endo

Endodontic Treatment vs Coronal Restoration

Success (%)
Endodonti Hommez et
Coronal al
Ray & Tronstad
c
restoration (Radiographic and Trope et al
treatment clinical)

Good Good 77.5 91.4 81

Poor Good 65.6 67.6 56

Good Poor 75.7 44.1 71

Poor Poor 56.8 18.1 57

Experimental Procedure

Instrumentation/ Removal of G/S Placement of Orifice Plug

R.C. filling
Plug (IRM or Composite)
~2 mm

Histology

Results
Inflammation rates

With Plug Without plug (G+S)

G + NS + Comp
89% (n= 16/18)
58% (n=7/12)
M=7, S=9
M= 5, S= 2
G + S + IRM
38% (n=5/13)
M=5

G + S + Comp
39% (n=7/18)
M=6, S=1

23
 2/26/2017

BIORACE

24
 2/26/2017

Taper can be defined as the rate of change of cross-sectional diameter. A file with a taper of 0.02 (2%) increases in diameter at a rate of 0.02mm per running millimeter of leng

Cyclic
Fatigue
Torsional
Fatigue

Tip locks

Cyclic Torsional
Flute deformation
Flexibility Fatigue Fatigue

Taper

Flexibiltiy

Apical Sizes

25
 2/26/2017

VARIABLE TAPER ON NITIs

D1(0.25mm)
+ 0.02mm per mm

D16(0.57mm)
Flexible

0.27mm
0.29mm
0.31mm
0.02 25/0.02

0.32 mm diameter increase

D1(0.25mm)
+ 0.06mm per mm

Flexible

0.43mm
0.37mm
0.31mm
D16(1.21mm)

0.06 25/0.06

0.96 mm diameter increase

NiTi ROTARY INSTRUMENTATION

Crown-Down Technique

0.10 Taper

0.08 Taper

0.06 Taper

Coronal 1/3 Preparation

NiTi ROTARY INSTRUMENTATION

Crown-Down Technique

0.04 Taper

Middle 1/3 Preparation

26
 2/26/2017

NiTi ROTARY INSTRUMENTATION

Apical 1/3 Preparation

0.04 Taper

# 25

# 30

# 35

# 40

The effect of Instruments Tapers

Variable Tapers

0.06 0.04 0.02

The effect of Instruments Tapers

Same Taper

15/0.02
20/0.02
25/0.02
30/0.02
35/0.02
40/0.02

27
 2/26/2017

The effect of Instruments Tapers

ONE FILE

25/0.08

Micro Cracks

Before Instrumentation After Instrumentation

4X gentle
movements
600 rpm

28
 2/26/2017

Basic Sequence 19/14mm

25/0.08
Coronal BR0

25/16mm
15/0.05
BR1

General 25/0.04
Shape BR2
Full Length

25/0.06
BR3

35/0.04
BR4
Apical
Prep.
Full Length 40/0.04
BR5

25/0.08 15/0.05 25/0.04 25/0.06 35/0.04 40/0.04

> Zones BR0 BR1 BR2 BR3 BR4 BR5
of
< Contact EAL EAL

21 mm
8 mm

81
41 73 80 77 103 85 92
13 65 75 81 88
39 73 97
12 57 70 79 84
37 69 91
11 49 65 75 80
35 65 85
10 41 60 71 76
33 61 79
09 33 55 67 72
31 57 73
13 mm

08 25 50 63 68
29 53 67
07 45 59 64
27 49 61
06 40 55 60
25 45 55
05 35 51 56
23 41 49
04 30 47 52
21 37 43
03 25 43 48
19 33 37
02 20 39 44
17 29 31
01 15 35 40
15* 25 25
00

mm

* 1/100 mm Bio RaCe - Basic Set

25/0.08 15/0.05 25/0.04 25/0.06 35/0.04 40/0.04

> Zones BR0 BR1 BR2 BR3 BR4 BR5
of
< Contact EAL EAL

21 mm
8 mm

81
41 73 80 77 103 85 92
13 65 75 81 88
39 73 97
12 57 70 79 84
37 69 91
11 49 65 75 80
35 65 85
10 41 60 71 76
33 61 79
09 33 55 67 72
31 57 73
13 mm

08 25 50 63 68
29 53 67
07 45 59 64
27 49 61
06 40 55 60
25 45 55
05 35 51 56
23 41 49
04 30 47 52
21 37 43
03 25 43 48
19 33 37
02 20 39 44
17 29 31
01 15 35 40
15* 25 25
00

mm

* 1/100 mm Bio RaCe - Basic Set

29
 2/26/2017

Bio RaCe Basic Set

BR0 - 25/0.08
19mm BR1 BR2BR3BR4BR5 25/0.06
15/0.05

25/0.04

35/0.04

40/0.04

Bio RaCe Basic Set

BR1 - 15/0.05
BR0 BR2BR3BR4BR5
25/0.06
25/0.08

25/0.04

35/0.04

40/0.04

Bio RaCe Basic Set

BR2 - 25/0.04
BR0BR1 BR3BR4BR5
25/0.06
15/0.05
25/0.08

35/0.04

40/0.04

30
 2/26/2017

Bio RaCe Basic Set

BR3 - 25/0.06
BR0BR1 BR2 BR4BR5
15/0.05
25/0.08

25/0.04

35/0.04

40/0.04

BR3
.06 taper

If it doesnt go to WL after first cycle(4x insertions), flush canal, wipe file and repeat cycle

If it doesnt go to length, move to BR4 (35.04) and gently try

for WL..cycle (4x insertions), one attempt only

if BR4 does not go to length, stop and get assistance!

all this information is telling you there is a hidden curve

Bio RaCe Basic Set

BR4 - 35/0.04
BR0BR1 BR2BR3 BR5
25/0.06
15/0.05
25/0.08

25/0.04

40/0.04

31
 2/26/2017

Bio RaCe Basic Set

BR5 - 40/0.04
BR0BR1 BR2BR3BR4 25/0.06
15/0.05
25/0.08

25/0.04

35/0.04

Bio RaCe Basic Set

Bio RaCe
Extended Set
Large apical
preparation

BR6 - 50/0.04 BR7 - 60/0.02

Bio RaCe Basic Set

Bio RaCe
Extended Set
Large apical
preparation

BR7 - 60/0.02
BR6 - 50/0.04

32
 2/26/2017

Bio RaCe Basic Set

Bio RaCe
Extended Set
Large apical
preparation

BR6 - 50/0.04
BR7 - 60/0.02

7-8 mm
Apical Box

DB:40/0.04

33
 2/26/2017

Bio RaCe - Extended Set BR4C BR5C

If BR3 - Short of WL (-2mm)

Severe and apical curvature
Short apical radius
Instrument to
WL BR3
BR0

Extended Set
35/0.02 40/0.02
BR4 BR5
BR0
19 mm

BR6 BR7
to BR3
as for
the Basic
set
Additional large
apical sizes

25/0.08 25/0.06

35/0.04 40/0.04 50/0.04 60/0.02

34
 2/26/2017

B-L orientation

35
 2/26/2017

Select a Reference Point

Using your pre-operative radiograph

apex

measure the
radiographic length

reference point

36
 2/26/2017

22mm

Compute the Estimated WL

Estimated WL is the
radiographic length minus
1mm

Ex. 22mm - 1mm = 21mm

TREATMENT RECORD

incisal edge 21mm

37
 2/26/2017

Set #15 file to estimated WL

working length radiograph

Working Length Radiograph

* File appears to end 1mm short of

radiographic apex

* No need to adjust

38
 2/26/2017

Working Length Radiograph

* In this case, estimated

working length is equal to the
final (actual) working length

* EWL = FWL
* record FWL

TREATMENT RECORD

incisal edge 21mm 21mm

39