INBDE High-Yield Endodontics
.pdf
School
Dental Assistant Academy of Chicago**We aren't endorsed by this school
Course
DENTAL ASS 1182727
Subject
Biology
Date
Dec 22, 2024
Pages
10
Uploaded by ProfTapirMaster1192
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comBasics and flowchartsAn endodontic diagnosis consists of apulpal diagnosisand aperiapical diagnosis, which are determined separately.
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comPulpal diagnosisDiagnosisClinical presentationPulp testingRadiographic presentationRadiographTreatmentNormal pulp●Asymptomatic●May havemild,transientresponse to tothermal, cold or electricalstimuli● Vital●EPT: +●Cold test: +,non-lingering● Normal apical anatomy● Intact lamina dura●No treatmentReversible pulpitis● Symptomatic● Irritant (i.e. caries,defective restoration)causesreversibleinflammation● Short, sharp painthatsubsides when stimulus isremoved★Pain from A-deltafibers● Vital● EPT: +● Cold test: ++,non-lingering●Normal apical anatomy,no evidence of resorptionor caries close to pulp●Remove irritant → pulpreverts to normal● AnalgesicsSymptomatic irreversiblepulpitis● Pulp isirreversiblydamaged due to an irritant●Pain is spontaneous,lingering, or referred,wakes patient up at night(postural changes)★Pain from C fibers● Vital● EPT: +● Cold test: ++ or +++,lingering●Deep caries or largerestorationapproximatingthe pulp●No or minimal periapicalchanges, thickening ofPDL space may beevident●Root canal treatment● AnalgesicsAsymptomatic irreversiblepulpitis● Pulp isirreversiblydamaged due to an irritant●No pain, evidence ofpulpal involvement must bepresent (i.e. caries, trauma)● Vital● EPT: +● Cold test: +,non-lingering● Deep cariesapproximating the pulp●No or minimal periapicalchanges, thickening ofPDL space may beevident●Root canal treatment
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comPulpal diagnosisDiagnosisClinical presentationPulp testingRadiographic presentationRadiographTreatmentPulp necrosis●Death of pulp tissue(partial or total) due tointerruption of pulpal bloodsupply●Asymptomatic pulpbutmay have history ofsymptoms● Crown discoloration canoccur● Necrotic● EPT: -● Cold test: -●Normal or widened PDL,periapical radiolucency(PARL) may be present●Root canal treatmentPreviously initiatedtherapy●Partial or incompleteprevious endodontictreatment(pulpotomy,pulpectomy)●EPT: -● Cold test: -●Intracanal medicamentpresent in canals and/orpulp chamber● Complete root canaltreatmentPreviously treated● Canalspreviouslyobturated●EPT: -● Cold test: -●Obturation materialpresentDependent on apicaldiagnosis:●Normal apex: notreatment●Persisting apical lesion:retreatment or endodonticmicrosurgery
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comApical diagnosisDiagnosisClinical presentationRadiographic presentationRadiographTreatmentNormal apical tissues●Asymptomaticapices●Normalapical anatomy● Lamina dura intact● Determine pulpal statusand treat accordinglySymptomatic apicalperiodontitis● Inflammation around apex of the tooth with inflammatoryinfiltrate within the PDL● May or may not respond to pulp testing● Pain to palpation and/or percussion●Normal or widened PDL,PARLmay be present● Determine pulpal statusand cause (which mayinclude caries, trauma, orhigh occlusion) and treataccordingly● AnalgesicsAsymptomatic apicalperiodontitis● Inflammation around apex of tooth due to pulpal necrosis,negativeresponse to pulp testing● Asymptomaticapices● PARLDependent on pulpaldiagnosis:● Pulp necrosis: root canaltreatment● Previously treated:retreatment or endodonticmicrosurgeryAcute apical abscess● Rapid swelling and/or fluctuance● Pain to biting pressure, percussion and/or palpation● Pus formation and swelling of associated tissues●Normal or widened PDL,PARLmay be present● Since an acute abscesshappens quickly, usuallyno PARL is presentDependent on pulpaldiagnosis:● Pulp necrosis: root canaltreatment● Previously treated:retreatment or endodonticmicrosurgery● Antibiotics and analgesics
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comApical diagnosisDiagnosisClinical presentationRadiographic presentationRadiographTreatmentChronic apical abscess● Asymptomatic apices with no swelling● Drainingsinus tract●PARL(can betraced withgutta-percha)Dependent on pulpaldiagnosis:● Pulp necrosis: root canaltreatment● Previously treated:retreatment or endodonticsurgery● Antibiotics if evidence ofsystemic symptomsCondensing osteitis●Localized bony reaction to low-gradeinflammatorystimulus● Asymptomatic apices● Periapicalradiopacityofsurrounding bone● Determine pulpal statusand cause and treataccordingly○ Cause may includecaries, trauma, orother sources ofinflammationTooth biologyDentin and pulp biologyTypes of tooth painDentin● Primary dentin: outer layer of dentin that forms before root formation● Secondary dentin: inner layer of dentin that forms after root formation● Tertiary dentin: forms in response to a stimulus (i.e. caries) in order to protect pulp● Sclerotic dentin: dentin calcified tubules that form in response to caries or aging● Reactionary dentin: tertiary dentin that is secreted by original odontoblasts, in responseto minor damage● Reparative: tertiary dentin that is secreted by odontoblast-like cells, in response tomajor damagePulp● Consists of connective tissue, nerves, blood vessels, and lymph● Contains fibroblasts, odontoblasts, undifferentiated mesenchymal cells●No collateral circulation→ affects ability to fight infectionA delta fibers● Responsible for dentinal pain● Sharp, transient, “first pain”● Responds to cold temperaturesC fibers● Responsible for pulpitis pain● Dull, throbbing, “second pain”● Responds to heat temperaturesHyperalgesia: increasedresponseto painAllodynia: decreased painthreshold, which causes pain to a normally non-painful stimulusReferred pain: pain that spreads to another region separate from the site of stimulation○ I.e. pain in mandibular molars can refer to the preauricular area due to shared V3innervation
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comRoot canal treatmentAccessInstrumentsGoals of pulp access● Conserve tooth structure● Deroof pulp chamber● Expose pulp horns and orifices● Straight line access to the orifices and apexHand files● 0.02 mm taper● Stainless steel or nickel titanium● Every 1 mm away from the file tip, the file diameter increases 0.02 mmDx= D0+ (Taper)*(X)Dx= file diameter at X distanceD0= file size/100Taper = 0.02X = distance from file tipExample: size 40 hand file, diameter 16 mm from tipD0= 0.4, Taper = 0.02, X = 16Dx= 0.4 + (0.02)*(16) = 0.72 mmRotary files● 0.04 or 0.06 mm taper● Nickel titanium (more flexible)● Fits into latch handpieceUniversal color scheme:ColorFile NumberFile NumberPink6Gray8Purple10White1545Yellow2050Red2555Blue3060Green3570Black4080
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comPercentage of canalsMaxillary tooth# of canals (%)Mandibular tooth# of canals (%)Central1C - 100Central1C - 752C - 25Lateral1C - 100Lateral1C - 852C -15Canine1C - 100Canine1C - 902C - 101st premolar1C - 82C - 853C - 71st premolar1C - 702C - 302nd premolar1C - 552C - 452nd premolar1C - 902C - 101st molar3C - 354C - 65Mesiobuccal root: 1C - 302C - 60Distobuccal root: 1C - 100Palatal root: 1C - 1001st molar2C - 103C - 554C - 35Mesial root: 1C - 32C - 97Distal root: 1C - 702C - 302nd molar3C - 654C - 35Mesiobuccal root: 1C - 652C - 35Distobuccal root: 1C - 100Palatal root: 1C - 1002nd molar2C - 153C - 754C - 10Mesial root: 1C - 102C - 90Distal root: 1C - 902C - 10Reference percentages in the table above vary based on the source. Use the percentages in the table when answering canal percentage questions for the INBDE. Note that percentageswill not always add up to 100%.InstrumentationNumber of canalsGoal of instrumentation is tofile, shape, and cleaneach canal of the tooth until it is toworking lengthWorking length = 0 to 2 mm from the apex of the tooth (ideally 1 mm)Crown down technique● Done withrotaryfiles● Coronal ⅓ of canal is shaped with largest file● Use smaller file for the middle ⅓● Use even smaller for the apical ⅓, to working lengthStep back technique● Done withhandfiles● Coronal ⅓ shaped with larger file to achieve coronal flaring● Smaller file is inserted and filed to working length● Larger files are used sequentially to slightly shorter than working lengthMaxillary toothMost likely # ofcanalsMandibular toothMost likely # ofcanalsCentral1Central1Lateral1Lateral1Canine1Canine11st premolar21st premolar12nd premolar12nd premolar11st molar4 (2 mesiobuccal)1st molar3 (2 mesial, 1 distal)2nd molar3 (1 mesiobuccal)2nd molar3 (2 mesial, 1 distal)
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comRoot canal treatmentIrrigationObturationCanals should beirrigatedbetween each fileSodium hypochlorite (NaOCl)● Also known as bleach● Dissolves theorganicmaterial (bacteria)Ethylenediaminetetraacetic acid (EDTA)● Lubricant that dissolvesinorganicmaterial (dentin smear layer)●ChelatingagentChloroform● No longer in use● Historically used to dissolve gutta-percha in endodontic retreatmentSealsthe root canal and prevents entrance ofbacteriaFilling material: gutta-percha and sealerSealer: zinc oxide eugenol or bioceramic sealerWarm vertical condensation● Seat gutta-percha to working length● Heated plugger instrument condenses the gutta-perchaCold lateral condensation● Seat gutta-percha to working length● Finger spreader creates room in the canal to place accessory conesAtemporary restoration(i.e., Cavit) is then placed on top of the gutta-percha until thetooth can be restored with a final restoration.Treatment planningTypes of endodontic treatmentSurgical treatment1. Root canal treatment● First line treatment for irreversible pulpitis, pulp necrosis, apical periodontitis● Orthograde → accesses canal from coronal part of tooth2. Retreatment● Indicated when root canal treatment has failed and there is a persistent infection● Re-access canal, remove previous materials, re-instrument, and re-obturate3. Surgical endodontics (apicoectomy)● Indicated when root canal treatment has failed and the infection is limited to the apex ofthe tooth● Microsurgical procedure that removes infected tissue at the apex of the tooth● Retrograde → access from the apex of the tooth, instrumentation, and fillingIncision & drainage● Indicated when an infection isfluctuantandlocalizedto one area● Incision of the soft tissue, drainage ofpurulence, release ofpressure● Drain can be placed for severe infectionPeriapical microsurgery● Also known asapicoectomy●Resect~ 3 mm of a diseased root tip● Instrumentation of the apex● Retrofill with mineral trioxide aggregate (MTA)Adjunctive materialsPostsCalcium hydroxide (CaOH)● Kept in place between root canal appointments as amedicament● Stimulates secondary odontoblasts to formtertiary dentin● High pHkills bacteria, cauterizes tissue● Resorbs over timeMineral trioxide aggregate (MTA)● Stimulatescementoblaststo form cementum● Sets in moist environments, long setting time● Nonresorbable● Antimicrobial● Used torestore endodontically-treated teethwhen coronaltooth structure is lost○ Post extends into root canal to help retain a core○ After root canal therapy, gutta-percha is removed until 5mm remains → then a post is placed in the canal● Ideal length is⅔ the lengthof the tooth root● Ideal diameter is up to⅓ the diameterof the tooth● Post failure○ Ceramic posts may decement or debond○ Metal posts can cause root fracture
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comTreatment planningVital pulp therapyNon-vital pulp therapyIndirect pulp cap● Fordeep cariesclose to pulp, butno pulp exposure● Placement of CaOH or resin modified glass ionomer (RMGI) on carious dentin < 1 mmfrom pulpDirect pulp cap● Forsmall pulp exposure< 24 hours, carious or mechanical exposure < 1 mm● Placement of CaOH over exposed pulp, to form tertiary dentinPartial (Cvek) pulpotomy● Removal of smallportionof thecoronal diseased pulp● Traumatic pulp exposure >/= 24 hours, carious or mechanical exposure < 4 mm in size● Standard treatment for immature permanent teeth with traumatic exposurePulpotomy● Removal of deep caries and inflamed pulp fromcoronal pulp chamber● For teeth withpulp exposurethat arevitaland restorable● Traumatic exposure >/= 72 hours● Generally only done in primary teethApexogenesis● Done on exposed or diseased pulp tomaintain pulp vitalityin immature teeththat do not have fully formed roots● Placement of CaOH or MTA on the pulpPulpectomy● Removal ofall pulp tissuein a tooth, both coronal and radicular● For teeth withpulp exposurethat arenon vitaland restorable● Primary second molars for space maintenance● Helpful in permanent teeth as temporary pain relief for irreversible pulpitis, until full RCTcan be doneRoot canal therapy● Removal ofall pulp tissuein tooth, both coronal and radicular, with a canalfilling● Pulpectomy + cleaning, shaping, filling the canalApexification● Performed on immature teeth withdead or dying pulpafter the pulp hasbeen removed● Goal is to allow the roots to finishforming, to obtain an apical barrierafter a root canal or pulpectomyEndodontic complicationsLedge formationInstrument separationPerforation●Ledge irregularitythat has been instrumented into thewall of a root canal● Occurs due to:○ Lack of straight line access○ Narrow, long, or curved canals○ Insufficient irrigation or lubrication●Transportationmay occur when files straighten out acurved canal○ Due to tendency of file to return to original linearshape● Treatment○ Use a smaller file to bypass the ledge●File breaksinside a root canal● Occurs due to:○ Force○ Too large of a file○ Lack of irrigation, lubrication○ Old files that are weak and prone to fracture● Treatment○ Broken file may be left in place, and the canal isfilled around it● The later the breakage occurs, the better the prognosis○ More instrumentation leads to more bacteriaremovedCoronal perforation● Crown is perforated duringaccesspreparation● Occurs due to inaccurate bur angulationFurcal perforation● Furcation of tooth is perforated● Occurs during the search for pulpalorificesStrip perforation●Stripping the dentinof a canal due to too muchcoronal flaring of a canal while filing● Often occurs inmandibular molarsRoot perforation● Perforation of the root, making anartificial apicalforamenor lateral perforation● Causeshemorrhageandpain● Treatment: repair with MTA
INBDE Bootcamp High-Yield Endodontics | Bootcamp.comTraumaEllis classificationCracked tooth syndromeUncomplicated fracture● Class I: simple fracture (enamel)● Class II: crown fracture (enamel, dentin)● Class III: crown fracture (enamel, dentin, pulp)● Class IV: non-vital tooth, with or without crown involvement● Class V: avulsion● Class VI: root fracture, with or without crown fracture● Class VII: displacement of tooth, no crown fracture● Symptoms: can be asymptomatic, pain withbitingandrelease,sensitivityto hot and cold● Typically amesiodistalcrack in posterior teeth● Detect with dye, transillumination, bite stick● Treatment○Healthy pulp→ splint, observe, or crown○Diseased pulp→ RCT and crown● No pulp involvement● Treatment○Enamel fracture→ smooth edges○Enamel and dentin fracture→ restorationComplicated fractureHorizontal root fractureVertical root fracture● Pulp involvement● Treatment○< 24 hours→ direct pulp cap○≥ 24 hours→ partial pulpotomy○≥ 72 hours→ pulpotomy● Fracture of the root, in which apical segment is notdisplaced but thecoronal segmentisdisplaced● Treatment○Vital tooth→ splint■Coronal fracture: splint 6-12 weeks■Mid-root fracture: splint 3 weeks■Apical fracture: splint 2 weeks○Necrotic tooth→ RCT● Typicallystarts at apexand travelscoronally● May be due topostorover-condensationduring RCT● Common sign isJ-shapedorteardropradiolucency● Hopeless prognosis● Treatment○Single root→ extract○Multiple roots→ extract or resect the fractured rootCalcific metamorphosisExternal root resorption● Response to trauma● Odontoblasts formreparative dentininside the pulpchamber● Tooth appearsyellowororangeclinically● Pulp canal shrinks due to dentin deposition● Response totraumaand damage tocementoblasts● Replacement resorption○ Also called ankylosis○ Replacement of PDL with bone● Cervical resorption○ Resorption at the CEJ due to a subepithelial sulcularinfection○ Tooth appearspinkclinically (pink tooth ofMummery) due to granulation tissue in coronal pulp● Inflammatory root resorption○ Products of necrotic pulp cause resorption○ Ragged, poorly defined margins on radiograph○ Travels from inside the pulp to the outsideInternal root resorption● Response totraumaand damage toodontoblasts● Products of necrotic pulp causeresorption within the tooth● Margins will be sharp, well-defined● Can be treated with RCT● Can present aspink tooth ofMummery:crown has pink hue dueto granulation tissue in the coronalpulp (pictured in external root resorption)