ENDODONTICS Part 1: Pulpal/Periradicular Diseases Pulp -made of loose, fibrous CT and contains ner es, blood essels, and

l!mp"atics -almost completel! surrounded b! dentin, #"ic" limits room for e$pansion and restricts abilit! to tolerate edema -lac%s collateral circulation, #"ic" limits abilit! to cope #/ bacteria, necrosis, and inflammation -possesses uni&ue, "ard-tissue secretin' cells (odontoblasts) as #ell as mesenc"!mal cells t"at differentiate into osteoblasts to form more dentin to protect pulp from in*ur! Functions of Pulp 1) Dentin formation (primar! f$n) +) Induction: forms dentin #"ic" induces enamel formation ,) Nutrition t"rou'" dentinal tubules Zones of Pulp 1) Central -one (pulp proper): contains lar'e ner es and blood essels +) Cell ric" -one: innermost la!er containin' fibroblasts ,) Cell free -one (-one of .eil): ric" in capillaries and ner es -ple$us of /as"%o# located "ere 0) Odontoblastic la!er: outermost pulp la!er containin' odontoblasts Cells of Pulp 1) 1ibroblasts (primar! pulp cell) +) Odontoblasts ,) 2istioc!tes/macrop"a'es 0) 3!mp"oc!tes4 Aging of Pulp -as pulp a'es, t"ere is: 1) decrease in reticulin fibers +) decrease in pulp si-e ,) increase in colla'en fibers and calcifications Reparative Dentin (Tertiary Dentin) -follo#in' in*ur!/irritation, primar! odontoblasts die, resultin' in formation of secondar! odontoblasts t"at produce reparati e dentin as defense at site of irritant -pulp uses t"is as defense a'ainst most nonmicrobial irritants -if irritant is too 'reat and deposition of reparati e dentin insufficient, pulp defenses become o er#"elmed and lead to imminent and irre ersible pulp necrosis -bacteria from dental caries is main cause of main pulpal in*ur! and pulpitis

Physiology of Pulpal Pain -controlled b! 5-delta and C-afferent fibers 1) 5-delta fibers: responsible for dentinal pain -lar'er, m!elinated ner es t"at enter root canal and di ide into smaller branc"es coronall! in pulp -5-delta fiber pain immediatel! percei ed as &uic%, s"arp, momentar! pain t"at dissipates &uic%l! on remo al of stimulus -pulpodentinal comple$: association of 5-delta fibers #/ odontoblastic cell la!er and dentin +) C-afferent fibers: responsible for pulpitis pain -smaller, unm!elinated ner es t"at course centrall! in pulp -pro'ression of pulpal inflammation c"an'es pain response from s"arp 5-delta fiber pain to dull, t"robbin' C-afferent fiber pain (#/ increasin' inflammation, onl! Cfiber pain remains) -C-afferent fibers not in ol ed in pulpodentinal comple$ and not easil! pro o%ed -C-fiber pain occurs #/ pulp in*ur! and mediated b! inflammation, blood flo#, and pressure increase -"ot li&uids can raise intrapulpal pressure to le els t"at e$cite C-fibers -#"en C-fiber pain dominates, it si'nifies irre ersible local tissue dama'e -pulpitis pain is diffuse and can refer to ot"er sites/teet" -a sustained inflammator! c!cle in"ibits pulpal reco er! and leads to tissue necrosis Normal Pulpal Response -as!mptomatic #/ mild-moderate transient response to t"ermal/electrical stimuli t"at subsides almost immediatel! #"en stimulus is remo ed -does not cause painful response on percussion or palpation Reversible Pulpitis -t"ermal stimuli cause &uic%, s"arp, "!persensiti e response t"at subsides as soon as stimulus is remo ed -can be caused b! caries, S/P, or deep restorations #/o a base -if irritant is remo ed, can re ert to "ealt"! state but if not, s!mptoms can lead to irre ersible pulpitis -does NOT in ol e complaint of spontaneous/unpro o%ed pain -penetration of bacteria into pulp is #"en crosso er to irre ersible pulpitis occurs rreversible Pulpitis -pulp is dama'ed be!ond repair e en #/ remo al of irritant -micro-abscesses #it"in pulp be'in to form as tin! -ones of necrosis #it"in acute inflammator! cells -leads to e entual necrosis of pulp -ma! be s!mptomatic or as!mptomatic !ymptomatic rreversible Pulpitis -spontaneous, unpro o%ed, intermittent or continuous pain -t"ermal stimuli elicit prolon'ed pain t"at lin'ers after stimulus is remo ed -ma! "a e pain on postural c"an'es -EPT and radio'rap"s of little alue in dia'nosis (radio'rap" ma! s"o# #idened PD3 in ad anced sta'e) Asymptomatic rreversible Pulpitis 1) 2!perplastic pulpitis: reddis" 'ro#t" of pulp tissue t"rou'"/around a carious e$posure -pulp proliferates due to lo#-'rade c"ronic irritation +) Internal resorption: can e entuall! perforate t"e root -appears as c"ronic pulpitis #/ c"ronic inflammator! cells, 'iant cells, and necrotic pulp cells -onl! prompt /CT #ill stop process and pre ent furt"er toot" destruction

nternal Resorption -caused b! inflammation from infected coronal pulp -often caused b! trauma -undifferentiated CT cells of pulp acti ated to form dentinoclasts, #"ic" resorb portion of root in contact #/ pulp -absence of pre"entin (unminerali-ed dentin) predisposes toot" to internal resorption b! pulp cells -usuall! as!mptomatic and detected b! radio'rap" s"o#in' increased sei-e (bulb) of pulp an!#"ere alon' len't" of canal -must be treated #/ /CT to remo e pulp tissue, #"ic" #ill stop resorption Pulp Necrosis -deat" of pulp resultin' from untreated irre ersible pulpitis, trauma, or interruption of pulpal blood suppl! -necrosis ma! be partial or total 1) Partial necrosis: ma! occur #/ some s!mptoms of irre ersible pulpitis (multi-canaled teet") +) Total necrosis: as!mptomatic so no response to t"ermal/electrical tests -ma! cause discoloration of cro#n -protein brea%do#n products and bacterial to$ins #ill spread be!ond apical foramen, causin' #idened PD3 t"at leads to sensiti it! to percussion and palpation -#/ increasin' inflammation and necrotic b!-products, tissue pressure builds to cause percussion sensiti it! -bacteria can penetrate dentinal tubules, ma%in' it necessar! to remo e superficial la!ers of dentin durin' cleanin'/s"apin' of canals !igns of Perira"icular Disease -are inflammator! responses to irritants from root canal s!stem -s!mptoms ran'e from as!mptomatic to sensiti it! to c"e#in', s#ellin', fe er, malaise, and intense pain -radio'rap"icall!, "as loss of lamina dura apicall! -if radiolucenc! is assoc6 #/ ital pulp, it can7t be of pulpal ori'in and #ill eit"er be a normal structure or ot"er t!pe of pat"osis Acute Perira"icular#Apical Perio"ontitis (AAP) -locali-ed inflammation of PD3 in periradicular re'ion -caused b! e$tension of pulpal disease into periapical re'ion, o erinstrumentation/o erfillin' of canal, or occlusal trauma/bru$ism -can occur around ital and non ital teet", so pulp testin' is onl! #a! to determine need for /CT -if ital, occlusal ad*ustment can relie e pain -if non ital, needs /CT -toot" ma! be sensiti e to percussion -radio'rap"icall!, ma! appear .N3 or #idened PD3 -"istolo'icall! appears as locali-ed inflammator! infiltrate #it"in PD3 Acute Perira"icular#Apical Abscess (AAA) -painful, purulent e$udate around ape$ as result of e$acerbation of 55P from necrotic pulp -can also result from infection from C5P (called a phoeni$ abscess) -s!mptoms of 55P and p"oeni$ abscess are same, but p"oeni$ abscess "as periapical radiolucenc! -ma! "a e s#ellin', pain on percussion and palpation, toot" mobilit!, and can lead to cellulitis -radio'rap"icall!, can "a e normal or #idened PD3 and normal or #idened lamina dura -"istolo'icall!, is central area of li&uefacti e necrosis #/ neutrop"ils, macrop"a'es, and some l!mp"oc!tes -bacteria not al#a!s present -can be differentiated from lateral periodontal abscess b! pulp testin' (#on7t be ital) and probin' (no poc%etin')

Chronic Perira"icular#Apical Perio"ontitis (CAP) -lon'-standin', as!mptomatic or mildl! s!mptomatic lesion -ma! "a e sli'"t tenderness to palpation or percussion -bacteria and endoto$ins cascade out of periapical re'ion from necrotic pulp and cause deminerali-ation of bone, leadin' to radio'rap"icall! isible apical resorption/radiolucenc! -dia'nosis confirmed b! absence of s!mptoms, periapical radiolucenc!, and ne'ati e pulp test -onl! #a! to distin'uis" from periradicular c!st or periradicular 'ranuloma is b! "istopat"olo'ical e$am -acute e$acerbation of C5P "as painful response to bitin'/percussion #/ periapical radiolucenc! (necrotic pulp) !uppurative Perira"icular Perio"ontitis -c"ronic periapical abscess t"at "as continuousl! or intermittentl! drained ia sinus tract #/o discomfort -can also drain t"rou'" sulcus, mimic%in' perio lesion -ne'ati e pulp tests b/c necrotic pulp -radio'rap"icall! appears as periapical radiolucenc! -sinus tracts resol e spontaneousl! after /CT Chronic Focal !clerosing %steomyelitis (Con"ensing %steitis) -e$cessi e bone minerali-ation around ape$ of as!mptomatic ital toot" -caused b! lo#-'rade pulp irritation -is beni'n and re&uires no endo t"erap! Part +: Endo Dia'nosis, E$amination, and Testin' %"ontogenic vs Nono"ontogenic Pain -man! orofacial diseases can mimic endodontic pain -si'ns of nonodonto'enic pain include: 1) episodic pain #/ pain free remissions +) tri''er points ,) pain crosses midline 0) pain increases #/ mental stress 8) pain is c!clic/seasonal 9) parest"esia Contrain"ications to &n"o Therapy -onl! s!stemic conditions t"at conflict #/ endo t"erap! are uncontrolled diabetes and m!ocardial infarction in past 9 mont"s Referre" Pain 1) :a$6 molars: refer pain to -!'omatic, parietal, and occipital re'ions +) :and6 molars: refer pain to ear, an'le of mandible, or posterior nec% ,) :a$6 incisors: fore"ead 0) :a$6 canines, P:: nasolabial re'ion 8) :a$6 +nd P:: temporal re'ion 9) :and6 anteriors and P:: mental re'ion of mandible 'uality of Pain 1) ;on! ori'in: dull, dra#in', ac"in' +) <ascular: t"robbin', poundin', pulsatin' ,) Ner e pat"osis: s"arp, electric, stabbin' 0) Pulpal/Periapical pat"oses: ac"in', pulsin', t"robbin', dull, radiatin', stabbin', *oltin' Palpation Testing -periapical inflammation from pulp necrosis burro#s into facial cortical bone and affects mucoperiosteum -before s#ellin' is e ident, sensiti it! to fin'er pressure #ill be e ident

Percussion Testing -inflammation of apical PD3 causes sensiti it! of propriocepti e fibers -indicates not onl! presence of inflammation of PD3, but e$tent of inflammation -ot"er conditions t"at periapical infection cause percussion sensiti it!: ort"o, "i'" restoration, and lateral periodontal abscess Thermal Testing 1) Cold test: cold #ater bat", ice stic%, et"!l c"loride, dic"loromet"ane (EndoIce), CO+ ice stic%s -appl! cold test to middle t"ird of facial surface +) 2eat test: #armed temporar! fillin'/'utta perc"a, dr! prop"! cup, or "ot #ater bat" #/ rubber dam (most accurate test) -responses to t"ermal testin': 1) No response: non ital pulp or ne'ati e response of ital pulp from calcified canal, trauma, pre ious pulpotom!, premedication, partiall! necrotic pulp or immature ape$ +) :ild/:oderate response t"at subsides in 1-+ seconds: normal, ital pulp ,) Stron', momentar! response t"at subsides in 1-+ seconds: re ersible pulpitis 0) :oderate-stron' response t"at lin'ers: irre ersible pulpitis -pulp italit!/t"ermal testin' contraindicated in recentl! traumati-ed teet" b/c trauma usuall! causes temporar! parest"esia and 'i es false readin' &lectric Pulp Testing -uses electric current to stimulate sensor! ner es of pulp -stimulates 5-delta fibers -doesn7t indicate "ealt" of pulp, *ust t"at pulp "as ital sensor! fibers (must be combined #/ ot"er tests) -EPT readin' of 1-=> is ital, EPT readin' of ?@ is necrotic -doesn7t pro ide an! info about ascular suppl! to pulp, #"ic" is true determinant of italit! -"as "i'" incidence of false positi es and false ne'ati es -don7t use 'lo es #/ EPT b/c impedes response -tec"ni&ue: 1) isolate and dr! toot" +) coat electrode #/ conductor (toot"paste) ,) appl! electrode to middle t"ird of facial surface and increase current flo# slo#l! -electrode s"ould not be applied to restorations (false readin') -t"ic%er enamel #ill cause dela!ed response -if patient "as cardiac pacema%er, t"en EPT is contraindicated Responses to &PT 1) C"ronic pulpitis: elicits response at "i'"er t"an normal current +) 5cute pulpitis: elicits response at lo#er t"an normal current ,) 2!peremia: elicits response at lo#er t"an normal current, but current "i'"er t"an acute pulpitis 0) Pulp necrosis/abscess: no response elicited at an! current Causes of False Rea"ings on &PT 1) 1alse positi e a) electrode contacts metal restoration or 'in'i a b) patient an$iet!/ner ous pt c) li&uefacti e necrosis (pus) d) failure to isolate/dr! teet" +) 1alse ne'ati e a) premedicated #/ anal'esics, narcotics, alco"ol, or tran&uili-ers b) inade&uate contact bt# electrode and enamel c) recent trauma to toot" d) e$cessi e calcification of canal e) immature ape$ f) partial necrosis ') insulatin' restoration

Pulpal Diagnosis Chart Complaint Reversible pulpitis cold sensitivity hot/cold Irreversible sensitivity pulpitis w/ lingering pain Necrotic variable

Radiograph normal or widened PDL normal or widened PDL, apical radiolucency normal or widened PDL, apical radiolucency

EPT responds responds no response

Cold exaggerated w/o lingering exaggerated w/ lingering no response

Perio &$am -if si'nificant isolated poc%et is found in absence of perio d$, li%el! a ertical root fracture -to distin'uis" from perio and pulpal ori'in, must italit! test and probe %ther Pulpal Tests 1) Selecti e anest"esia: onl! done #"en no ot"er test "as !ielded determinati e resultsA anest"etic diffuses to numb ad*acent teet" so not er! reliable +) Test ca it!: onl! in cases #"ere stron' suspicion of necrotic pulpA not a definiti e test (uccal %b)ect Rule (!*%( Rule) -used to decip"er place of superimposed ima'es on radio'rap" -mo in' $-ra! cone to one direction #ill cause ob*ect to mo e to same side if lin'ual and opposite side if buccal Ra"iographic Differential Diagnosis of Periapical Ra"iolucencies 1) <ertical root fracture +) 3ateral periodontal c!st: lamina dura isible and normal italit! tests ,) Osteom!elitis 0) De elopmental c!sts: e$6 Nasopalatine/incisi e canal c!stA use italit! tests to differentiate 8) Traumatic bone c!st: italit! testin' usuall! .N3 9) 5meloblastoma: usuall! multilocular and can resorb roots =) Cemental d!splasia: mi$ed radiolucent/radiopa&ueA teet" are ital (mandibular anteriors) ?) Cementoblastoma: radiopa&ue, #ell-circumscribed >) Normal anatom!: mental foramen, submand6 fossa, ma$6 sinus, incisi e foramen, marro# spaces Periapical Diagnosis Chart Complaint AAP biting sensitivity AAA CAP SAP Focal sclerosing osteitis pain w/ swelling no symptoms sinus tract asymptomatic Radiograph normal or widened PDL normal or widened PDL, apical radiolucency apical radiolucency apical radiolucency apical radiopacity Percussion mild-mod sensitivity mild-mod sensitivity no response no response no or mild response

Crac+e" Tooth !yn"rome 1) Clinical features -pain on bitin' (onl! upon release of bitin') -occasional, momentar!, s"arp, diffuse pain t"at is "ard to reproduce -t"ermal sensiti it!, as #ell as sensiti it! to s#eet or acidic foods +) /adio'rap" -mesiodistal crac% is impossible to see on radio'rap" ,) Incidence: most in lo#er molars #/ sli'"t preference for 1st molar o er +nd molar 0) Dia'nosis a) transillumination b) Toot" Sloot" (test eac" cusp tip separatel!) c) Stain (met"!lene blue) d) Stream of air if dentin is e$posed e) #ed'in' toot" and ta%in' $-ra! 8) Treatment a) 2ealt"! pulp/re ersible pulpitis: splint #/ ort"o band and obser e or place cro#n (place temp6 cro#n and obser e before placin' permt6 cro#n) b) Irre ersible pulpitis/necrosis #/ 55P: /CT, restoration, and cro#n 9) Pro'nosis a) Presence of deep poc%et: 'uarded pro'nosis b) Crac% e$tends to floor of pulp c"amber: 'uarded pro'nosis c) 1racture e$tends entire mesiodistal surface: poor pro'nosis ,ertical Root Fracture 1) Clinical 1indin's -starts apicall! and e$tends coronall!, usuall! in buccal-lin'ual plane -endo treated teet" most susceptible -isolated probin' defect -B-s"aped/tear-s"aped radiolucenc! from apical to middle 1/, of root +) Etiolo'! a) "ea ! enlar'ement of canal durin' /CT b) stress from obturation (most common cause) c) unfa orable post placement ,) Dia'nosis -onl! b! sur'ical e$ploration b! flap sur'er! 0) Treatment a) Sin'le-rooted teet": e$traction b) :ulti-rooted teet": "emisection #/ remo al of affected root or e$traction 8) Pro'nosis: "opeless &n"o-Perio Relationships -pulp and periodontium communicate ia: a) tubules c) furcation canals b) accessor!/lateral canals d) apical foramen -endo d$ can cause perio d$, but perio d$ usuall! doesn7t cause endo d$ (unless it reac"es ape$ of toot") -perio t$t can cause endo problems b/c it can force bacteria into e$posed dentin tubules Primary &n"o vs Primary Perio *esions 1) Primar! endo lesion: toot" is non ital -treated b! /CT or e$traction +) Primar! perio lesion: poc%et formation and ital teet" -treated b! perio t"erap! Primary Perio *esion .# !econ"ary &n"o nvolvement -deep poc%etin' #/ "$ of e$tensi e perio d$ or possible past t$t of perio d$ -treated b! endo t"erap! and t"en perio t$t

True Combine" Perio-&n"o *esion -once perio and endo lesions coalesce, it ma! be impossible to distin'uis" t"e t#o -t$t re&uires correction of bot" endo and perio problems -endo t$t s"ould occur before perio t$t Part ,: Nonsur'ical Endodontics Access Preparation -represents t"e most important p"ase of tec"nical aspect of /CT, b/c proper access prep ma$imi-es cleanin', s"apin', and obturation -ob*ecti es: 1) strai'"t line access +) conser ation of toot" structure ,) unroofin' of c"amber to e$pose orifices and pulp "orns /or+ing *ength Determination -select a reference point t"at is stable and easil! isuali-ed -tec"ni&ues: 1) Estimate .3 #/ dia'nostic film usin' parallelin' tec"ni&ue and 1@ or 18 C-fileA correct for .3 b! measurin' discrepanc! bt# tip of file and ape$ (ad*ust 1mm s"ort of radio'rap"ic ape$) +) use ape$ locator (operates on principles of resistance, fre&uenc!, or impedance) ,) feel for apical constriction (ma! be unreliable) Cleaning an" !haping -best indicator of clean #alls is le el of smoot"ness obtained -best to precur e files in s"apin' b/c nearl! all canals are cur ed -taper of canal s"ould be ade&uate to prepare canal for obturation and allo# insertion of spreader -most acceptable met"od to ac"ie e ade&uate root canal debridement is to ac"ie e 'lass! smoot" #alls of canal -not b! obtainin' clean s"a in's or clean irri'ant solution Apical Preparation -apical stops "elp confine instruments, materials, and c"emicals to canal space and create barrier a'ainst #"ic" 'utta perc"a can be condensed File Dimensions 1) D@: file si-e at tip of file (6@?mm for D? fileA 618mm for D18 file, etc6) +) D19: diameter of file #"ere cuttin' flutes end (usuall! 19mm for "and files) ,) Taper: amount t"e file diameter increases eac" mm from tip to#ard "andle -e$6 1or 6@+ taper file, t"e diameter at D19 is D@E(19$6@+) !o"ium 0ypochlorite (NaCl%) -used to disinfect root canal b! "!poc"lorite ion (ClO-) -proteol!tic material dissol es organic matter -does not remo e smear la!er -is irri'atin' solution of c"oice in /CT -alternati e is c"lor"e$idine b/c it is less to$ic, but lac%s sol ent action -ot"er alternati es: urea pero$ide (Fl!-O$ide) and ,G "!dro'en pero$ide -no sin'le conc6 best suited and ones used are 1G, +69G, 8, +8G (86+8G pro ides e$cellent 'ermicidal action and dilute enou'" to not be se erel! irritatin') -al#a!s use rubber dam as it is to$ic to tissues

!o"ium 0ypochlorite Acci"ent 1) Si'ns a) instant, e$treme pain b) e$cessi e bleedin' from toot" c) rapid s#ellin' d) rapid spread of er!t"ema e) later on, "a e bruisin' and sensor!/motor ner e deficits +) Treatment a) lon'-lastin' local anest"etic b) encoura'e draina'e c) steroids, anal'esics, and antibiotics d) cold compresses e) dail! follo#-up &thylene"iaminetetraacetic aci" (&DTA) -a&ueous solution of 1=G EDT5 -acti e in'redient in /C-Prep -remo es inorganic material and smear la!er -is c"elatin' a'ent t"at remo es CaE+ to deminerali-e and soften dentin (facilitates ne'otiatin' calcified canals) -onl! #or%s on calcified tissues and little effect on periapical tissues -poor irri'ant solution -remains acti e in canal for 8 da!s if not inacti ated b! sodium "!poc"lorite at end of procedure ,ariants of &DTA 1) EDT5C: EDT5 plus ceta lon, a &uaternar! ammonium compound -"as 'reater antimicrobial action t"an EDT5 alone +) /C-Prep: EDT5 plus urea pero$ide to pro ide bot" c"elation and irri'ation Calcium 0y"ro$i"e -is best intracanal medicament a ailable -"i'" p2 (1+68) causes antibacterial effect -also encoura'es calcification and in"ibits resorption -inacti ates lipopol!sacc"aride (3PS) and "as tissue-dissol in' capacit! Purposes of %bturation 1) Eliminate all a enues of lea%a'e from oral ca it! or periradicular tissues into root canal s!stem +) To seal #it"in t"e s!stem an! irritants t"at can7t be full! remo ed durin' cleanin' and s"apin' 1utta Percha -is pliable at room temp and becomes plastic at 10@ de'rees 1 -can be dissol ed in c"loroform, $!lol, and eucal!ptol 1) 5d anta'es a) plasticit! (adapts #/ compaction to irre'ularities) d) eas! to remo e b) eas! to mana'e e) self-sterili-in' (doesn7t support bacterial c) lo# to$icit! 'ro#t") +) Disad anta'es a) does not seal #/o sealer d) s"rin%a'e after coolin' b) lac% of dentin ad"esion c) elasticit! causes rebound from dentin

!ealers -used to fill discrepancies bt# canal #alls and 'utta perc"a -0 'roups based on constituents a) HOE b) CaO2 c) resin d) 'lass ionomer -c"aracteristics of ideal sealers: 1) nonirritatin' 0) "ermetic sealin' =) 'ood ad"esion to canal #alls +) insoluble 8) radiopa&ue ?) nonstainin' to dentin ,) dimensionall! stable 9) bacteriostatic >) readil! remo able if needed -f$n of sealer: 1) act as lubricant for 'utta perc"a +) form bond bt# 'utta perc"a and canal #all ,) e$ert antimicrobial acti it! !olvent-!oftene" Custom Cones -to be used in follo#in' situations: 1) lac% of apical stop +) abnormall! lar'e apical portion of canal ,) irre'ular apical portion of canal 0) after ape$ification procedure -not to be used if tu'bac% #it"in 1mm of ape$ ac"ie ed -is more time-consumin' and does not pro ide better apical seal -common sol ents used to soften 'utta perc"a: 1) c"loroform ,) "alot"ane 8) eucal!ptol +) met"!lc"loroformate 0) #"ite turpentine Root Canal Therapy in Primary Teeth -if a permt6 successor toot" is present, t"e canal is obturated #/ a resorbable material suc" as HOE -if no permt6 successor is present, an acceptable nonresorbable material can be used ('utta perc"a) &n"o"ontic Re-Treats -c"loroform is best rea'ent to dissol e 'utta perc"a -cro#n do#n se&uence (lar'e-to-small) of instrumentation used from coronal to apical -rotar! instruments faster and impro e access better t"an "eated instruments - er! li'"t apical pressure used #/ rotar! files -o er-e$tended 'utta perc"a cones can be remo ed b! e$tendin' file periapicall!

Part 0: Sur'ical Endodontics ncision an" Drainage -ob*ecti es are to e acuate e$udates, purulence, and to$ic irritants -remo al speeds "ealin' and reduces discomfort from irritants and pressure -best treatment for s#ellin' from 555 is to establis" draina'e and to clean/s"ape canal -incision and draina'e indicated #"en: a) pat"#a! is needed in soft tissue #/ locali-ed fluctuant s#ellin' to establis" draina'e b) pain is caused b! accumulation of e$udates in tissues c) needed to obtain samples for bacteriolo'ic anal!sis -trep"ination of "ard tissues indicated #"en: a) pat"#a! is needed from "ard tissue to obtain draina'e b) pain is caused b! accumulation of e$udate #it"in al eolar bone c) to obtain samples for bacteriolo'ic anal!sis -procedure: 1) incision and draina'e is sur'ical openin' created in soft tissue for purpose of releasin' e$udates or decompressin' an area of s#ellin' +) trep"ination is sur'ical perforation of al eolar cortical bone to release accumulated tissue e$udates ,) profound anest"esia is difficult to ac"ie e in presence of infection due to acidic p2 of abscess and "!peral'esia 0) incision s"ould be made firml! t"rou'" periosteum to bone - ertical incisions are parallel #/ ma*or blood essels and ner es and lea e little scarrin' 8) ma! include placement of a drain 9) antibiotics ma! be indicated if t"ere is diffuse s#ellin' (cellulitis), s!stemic s!mptoms, or immunocompromised Root &n" Resection (Apicoectomy) - is preparation of a flat surface b! e$cision of apical portion of root and an! subse&uent remo al of attac"ed soft tissues 1) Procedure a) a mucoperiosteal flap is ele ated and, if needed, bone remo ed to allo# direct isuali-ation and access to affected area b) diseased root tip is remo ed c) traditional 08 de'ree be el "as been replaced #/ lesser be els (@-+@ de'rees) -use of ultrasonics "as allo#ed for less be el d) remo e ,mm of root tip if possible and lea e ,mm for root end ca it! prep and fillin' e) increasin' dept" of root end fillin' si'nificantl! decreases apical lea%a'e f) after retrofillin' of canal #/ biolo'icall! acceptable material (:T5), primar! closure of site obtained +) Indications a) persistent or enlar'in' periapical pat"osis follo#in' nonsur'ical /CT b) nonsur'ical endo t$t unfeasible -o ere$tension of obturatin' materials interferin' #/ "ealin' -biops! necessar! -access for root-end preparation and root end fillin' needed -apical portion of root canal can7t be cleaned, s"aper, and obturated ,) Contraindications a) anatomic factors b) medical complications c) nonrestorable toot" d) poor cro#n/root ratio

0emisection -is sur'ical di ision of a multi-rooted toot" into e&ual "al es b! ma%in' ertical cut t"rou'" cro#n into furcation and defecti e "alf of toot" is e$tracted -usuall! in mandibular molars - re&uires /CT on all retained root se'ments -#"en possible, preferable to complete /CT and place permanent restoration into canal orifices prior to "emisection -indications: 1) class III or I< perio furcation defect +) infrabon! defect of one root of multi-rooted toot" t"at can7t be treated periodontall! ,) coronal fracture e$tendin' into furcation 0) ertical root fracture confined to root to be e$tracted 8) carious, resorpti e root or perforation defects t"at are inoperable or can7t be corrected #/o root remo al 9) persistent periapical pat"osis #"ere nonsur'ical t$t isn7t possible and problem confined to one root (icuspi"i2ation -is sur'ical di ision of multi-rooted toot" (usuall! mand6 molar), but unli%e "emisection, t"e cro#n and root of bot" "al es are retained -procedure results in complete separation of roots and creation of t#o separate cro#ns Root Resection (Root Amputation) -is remo al of one or more roots of multi-rooted toot" -entire root(s) remo ed, lea in' cro#n of toot" intact -re&uires /CT on all retained root fra'ments -#"en possible, is preferable to complete /CT and place permt6 restoration into canal orifices -indications: 1) class III or I< perio furcation defect +) infrabon! defect of one root of multi-rooted toot" t"at can7t be treated periodontall! ,) e$istin' fi$ed prost"esis 0) ertical root fracture confined to root to be resected 8) carious, resorpti e root or perforation defects t"at are inoperable 9) persistent periapical pat"osis #"ere nonsur'ical endo not possible =) at least one root is structurall! sound ntentional Replantation -is insertion of a toot" into its al eolus after it "as been e$tracted for purpose of root-end fillin' procedure -stabili-ation of replanted toot" ma! or ma! not be needed -#"en possible, /CT performed prior to replantation -indications: 1) persistent periapical pat"osis follo#in' /CT +) nonsur'ical t$t not possible or unfa orable pro'nosis ,) periapical sur'er! not possible or "i'" ris% of iolatin' anatomic structures 0) toot" "as reasonable c"ance of remo al #/o fracture 8) toot" "as acceptable perio status !urgical Removal of Apical !egment of Fracture" Root -is sur'ical remo al of apical se'ment of fractured root #"en coronal se'ment is restorable and functional -root fracture must be onl! in apical portion of root and pulp is necrotic in apical se'ment

Root !ubmersion -in ol es resection of root ,mm belo# al eolar crest and co erin' #/ mucoperiosteal flap -pre ents bone resorption in area Transplantation -transfer of toot" from one soc%et to anot"er -can be in same person or bt# ppl -#or%s better #"en roots are partiall! de eloped, rat"er t"an full! de eloped Part 8: Endodontic Emer'encies/:icrobiolo'! &n"o &mergencies -usuall! associated #/ pain and/or s#ellin' and re&uire immediate dia'nosis and t$t -can include lu$ation, a ulsion, or fractures as #ell -a true emer'enc! is one in #"ic" onl! one toot" is causin' pain and identified -for t$t, relie in' pressure is most effecti e #a! of reducin' pain -complete cleanin'/s"apin' of canal is preferred, but pulpotom! can be effecti e in absence of percussion sensiti it! -c"emical medicaments sealed in c"ambers don7t "elp control or pre ent pain -antibiotics not indicated -reducin' occlusion s"o#n to aid in relief of s!mptoms if 55P e$ists -if locali-ed s#ellin' e$ists, abscess "as in aded soft tissues and re&uires complete debridement of canal, draina'e, but no antibiotics b/c rarel! "a e s!stemic si'ns or ele ated temps -if diffuse s#ellin' e$ists, t"e abscess "as dissected into fascial spaces and re&uires canal debridement or e$traction of toot", incision and draina'e #/ drain insertion for 1-+ da!s, and s!stemic antibiotics -for interappointment flare-ups, treatment 'enerall! in ol es complete cleanin' of canals, placement of intracanal medicament, and prescribin' anal'esic (antibiotics not indicated e$cept if s!stemic s!mptoms/cellulitis e$ist) -no relations"ip e$ists bet#een flare-ups and number of isits Portals of &ntry of (acteria into Pulp 1) Caries +) Permeable tubules a) ca it! prep b) dentin e$posed c) lea%in' restorations d) in necrotic pulps, t"ere are no more odontoblastic processes or dentinal fluid ,) Crac%s/trauma 0) Pulp e$posure Nature an" Dynamics of Root Canal nfection 1) Pol!microbial +) Positi e correlation bt# number of bacteria in infected canal and si-e of periapical radiolucenc! ,) Difference bt# primar! infection and infection resultin' from unsuccessful /CT a) Primar! infection: strict anaerobes i) Fram- anaerobes: Porphyromonas and Bacteroides melaninogenica most common ii) FramE anaerobes: 5ctinom!ces (root caries) b) 1ailed /CT: Enterococcus faecalis and facultati e anaerobes *ipopolysacchari"es (*P!) -found on surface of 'ram- bacteria -#"en released from cell #all, are %no#n as endoto$ins -endoto$ins capable of diffusin' across dentin -relations"ip establis"ed bt# presence of endoto$ins and periapical inflammation

Antibiotics in &n"o"ontics 1) Pen <C (first c"oice) -effecti e a'ainst most strict anaerobes and facultati e anaerobes (Strep, Enterococci) +) Clindam!cin -effecti e a'ainst 'ram- and 'ramE bacteria (strict and facultati e anaerobes) ,) :etronida-ole -effecti e a'ainst strict anaerobes (not for facultati e anaerobes and aerobes) Part 9: Sterili-ation 1lutaral"ehy"e -cold or "eat-labile instruments (rubber dam frame) ma! be immersed for period of +0 "ours for cold sterili-ation -immersion ma! disinfect, but #ill not %ill all or'anisms -is least desirable sterili-ation procedure in office and reser ed for instruments t"at can7t tolerate "eat Pressure !terili2ation -instruments autocla ed for 1+1 de'rees C and 18 psi -%ills all bacteria, iruses, and spores -can use steam or c"emicals (c"emicals #ill cause less rustin' t"at #ater/steam) -bot" steam and c"emical autocla in' #ill dull ed'es of cuttin' instruments caused b! e$pansion from "eat t"en contraction #/ coolin' Dry 0eat !terili2ation -superior for s"arp-ed'ed instruments to preser e cuttin' ed'es -c!cle is temperature dependent -temp6 s"ould be at 19@ C for 9@ minutes (if temp6 falls belo# t"is before 9@ minutes, c!cle must be repeated) -disad anta'e is lon' time re&uired Disinfection -surface disinfection of "and files durin' canal instrumentation is done b! usin' =@G isoprop!l alco"ol or &uaternar! ammonium on 'au-e -t"is cleans but doesn7t disinfect t"e files Part =: /adio'rap"ic Tec"ni&ues Angulation Techni3ues 1) Parallelin' tec"ni&ue: most accurate met"odA film is parallel to toot" -less distortion, more clarit!, and better reproducibilit! +) :odified parallelin' tec"ni&ue: ne$t best tec"ni&ueA used if can7t use parallelin' tec"ni&ue due to lo# palatal ault, ma$illar! tori, lon'er roots, etc6 -film isn7t parallel to toot" but central beam oriented at ri'"t an'les to film ,) ;isectin' an'le tec"ni&ue: least accurate tec"ni&ue /or+ing Films 1) .or%in' len't": distance from reference point to point #"ere canal prep and obturation #ill end +) :aster cone/point: lar'est 'utta perc"a point t"at can be placed to full .3 prior to obturation Types of Film 1) D film (Iltraspeed): better contrast t"an E film, but re&uires "i'"er radiation e$posure +) E film (E%taspeed): ade&uate clarit! compared to D film, but re&uires onl! "alf radiation e$posure ,) 1 film: re&uires +@-+8G less e$posure t"an E film -optimal settin' for E speed film for ma$ contrast bt# radiolucent and radiopa&ue structures is =@ %<

Cone mage !hifting -re eals ,rd dimension of structures -indications: 1) separation/identification of superimposed canals +) mo ement/identification of superimposed structures (-!'oma o erl!in' root ape$) ,) determinin' .3 0) determinin' cur atures of roots (facial or lin'ual b! usin' S3O; rule) 8) determinin' facio-lin'ual location 9) identification of undisco ered canals (if root contains onl! one canal, it s"ould be closer to center of root t"an if t"ere is more t"an one canal)A must ta%e $-ra! at mesial or distal an'le =) 3ocation of calcified canals Characteristics of Ra"iolucent &n"o"ontic *esions 1) 5pical lamina dura is absent +) :ost often radiolucenc! is circular around ape$ ,) /adiolucenc! sta!s a ape$ re'ardless of an'ulation 0) Cause of pulpal necrosis usuall! e ident Characteristics of Ra"iopa3ue &n"o"ontic *esions (Con"ensing osteitis#Focal !clerosing %steomyelitis) 1) Opa&ue, diffuse appearance +) /epresent an increase in trabecular bone ,) 2a e diffuse borders and concentric arran'ement around ape$ 0) Pulp often ital and inflamed 8) Often appears to'et"er #/ apical periodontitis Part ?: Procedural Complications *e"ge Formation -a led'e is an artificial irre'ularit! created in surface on root canal t"at impedes placement of instruments to ape$ -.3 can7t be ac"ie ed and instrumentation and obturation #ill be s"ort of ape$ and no lon'er follo#s true cur ature of root -causes: 1) 3ac% of strai'"t line access (improper access prep) +) 3en't" of canal (lon'er canals "a e "i'"er potential for led'in'A s"ould recapitulate lon'er canals to c"ec% patenc!) ,) Canal diameter (smaller diameter canals "a e "i'"er c"ance of led'in') 0) De'ree of cur ature (as cur ature increases, c"ance of led'in' increases) 8) Inade&uate irri'ation/lubrication (lubricants allo# for ease of file insertion, decrease stress on instruments, and ease of debris remo al) -NaClO is 'ood irri'ant, but additional lubricant is needed 9) E$cessi e enlar'ement of cur ed canals #/ files -files "a e tendenc! to strai'"ten out and cut strai'"t a"ead instead of bendin' #/ canal -files cut dentin to#ard outside of root at ape$ and create ne# JcanalK, called transportation -can be a oided b! usin' eac" successi e file in order (don7t *ump file si-es) -correction of led'e: 1) relocate canal and rene'otiate +) use precur ed small file to re-establis" .3 #/ plent! of lubricant and a Jpic%in'K motion ,) once locate ori'inal canal, use reamin' motion and occasionall! an up-do#n mo ement to debride canal 0) 'oin' bac% and flarin' !our access prep can also "elp impro e access to apical 1/, of canal 8) if unable to correct led'e, *ust clean and s"ape at ne# led'ed .3 -pro'nosis better if led'e formation occurs after most of debris "as been cleaned

nstrument !eparation 1) Causes a) limited stren't" and fle$ibilit! of instruments b) o eruse or e$cessi e force applied to instrument c) manufacturin' defects (rare) +) 2o# to 5 oid a) reco'ni-e stress limitations on instruments b) use copious lubrication and irri'ation c) e$amine instruments before placin' into canal -steel instruments s"o# flutin' distortions, but Ni-Ti files don7t and s"ould be discarded before isual si'ns are seen d) replace files often e) don7t proceed to lar'er files until smaller ones ft loosel! #it"in t"e canal ,) 2o# to Treat a) tr! to b!pass t"e instrument (*ust li%e b!passin' a led'e) b) remo e instrument (often unsuccessful and need to refer to endodontist) c) prepare and obdurate to point of separated instrument d) if pus" separated instrument past ape$, must raise flap and remo e instrument sur'icall! 0) Pro'nosis -depends on e$tent of debris remainin' in re'ion apical to separated instrument (pro'nosis impro es if separation occurred durin' later sta'es of cleanin' -if in apical 1/, and no radiolucenc! present, t"en fill remainin' canal space and "a e on ,-9 mont" recalls -poorer pro'nosis in teet" #"ere smaller si-e instruments "a e separated -easier to remo e if it is #ed'ed coronal to cur ature or at cur ature -if belo# cur ature it is er! difficult to remo e -o erall, as lon' as mana'ed properl!, it "as a fa orable pro'nosis -if patient ends up "a in' residual s!mptoms, must treat toot" sur'icall! (root end resection) Perforation -is iatro'enic communication of toot" pulp c"amber #/ outside en ironment 1) T!pes a) Coronal perforation: caused b! failure to direct bur to#ard lon' a$is of toot" durin' access prep -pre ent b! usin' ma'nification, transillumination, or radio'rap"s b) 1urcal perforation: occurs durin' searc" for canal orifices and must be immediately repaired c) Strip perforation: in ol es furcation side of coronal root surface -caused b! e$cessi e flarin' of coronal +/, of canal d) /oot perforation: can occur at ape$ (transportation) or midroot (from led'e formation) +) /eco'ni-in' perforation a) "emorr"a'e (from PD3 or bone)-doesn7t al#a!s occur b) sudden pain (can "a e burnin' pain from NaClO seepin' out) c) radio'rap"ic e idence d) ape$ locator readin's #ell s"ort of %no#n .3 e) file de iates from pre ious pat" f) se ere post-op pain ,) Pro'nosis a) Perforation into PD3 causes &uestionable pro'nosis b) If located abo e crestal bone, "as fa orable pro'nosisA if belo# crest of bone, "as poor pro'nosis (causes recession of attac"ment and permt6 perio poc%et formation) c) perforation smaller t"an 1mm are easier to repair and cause less tissue destruction d) perforations occurrin' after most of canal debridement is completed "a e better pro'nosis e) sooner t"e repair is made, better pro'nosis due to less dama'e to periodontal tissues f) 'ood isolation of toot" at time of perforation leads to better pro'nosis ') 'ood accessibilit!, 'ood pt oral "!'iene, and 'ood dentist capabilit! impro e pro'nosis ") usin' restorati e material #/ 'ood sealin' capabilit! increases pro'nosis

i) coronal perforations "a e 'ood pro'nosis, furcal perforations are 'ood if repaired immediatel!, root perforation pro'nosis depends on si-e/s"ape and ma! need sur'ical t$t, strip perforations are "ard to access and "a e #orst pro'nosis 0) 2o# to /epair (a oid usin' NaClO b/c it can be e$truded and inflame periodontium) a) Sur'ical repair: tr! to position apical portion of defect abo e crestal bone t"rou'": -ort"o e$trusion -root amputation -cro#n len't"enin' -intentional replantation -"emisection b) nonsur'ical internal repair #/ :T5 (is er! biocompatible and promotes cementum-li%e material deposition) ,ertical Root Fractures -is fracture alon' lon' a$is of rootA often assoc6 #/ isolated se ere perio poc%et and lateral root radiolucenc! -can occur after post cementation or e$cessi e condensation forces -can onl! be confirmed b! isuali-in' fracture t"rou'" sur'er! -treated b! remo in' in ol ed root in multi-rooted teet" or e$traction Part >: Traumatic In*uries &$amination of Teeth .# Trauma -teet" are sensiti e to percussion -apical displacement causin' in*ur! to blood essels enterin' apical foramen can cause pulpal necrosis -pulp testin' often leads to false ne'ati e responses and ma! be unreliable for 9-1+ mont"s - italit! is actuall! determined b! ascular suppl!, #"ic" ma! be intact durin' in*ur! but neural response be impaired -pulp tests s"ould be repeated at , #ee%s, , mont"s, 9 mont"s, 1 !ear, and !earl! inter als 4ncomplicate" Fractures -fracture #/o pulpal in ol ement 1) Infraction: incomplete crac% of enamel #/o loss of toot" structure +) Ellis Class I: fracture in ol in' onl! enamel -treated b! smoot"in' rou'" ed'e or restorin' toot" if needed ('ood pro'nosis) ,) Ellis Class II: cro#n fracture in ol in' enamel and dentin, but no pulp -treated #/ restoration usin' bonded tec"ni&ue ('ood pro'nosis unless lu$ated) Complicate" Fractures -fracture t"at in ol es enamel, dentin, and pulp (Ellis class III) -treated ia ital pulp t"erap! or /CT dependin' on se eral factors a) sta'e of toot" de elopment: immature teet" s"ould use ital pulp t"erap! if possible b) time bt# accident and t$t: if #it"in +0"rs, s"ould use ital pulp t"erap! b/c s"ould be limited contamination and less t"en +mm pulp inflammationA after +0 "rs can do /CT c) concomitant perio in*ur!: compromises nutritional suppl! of pulp and s"ould do /CT d) restorati e t$t plan: if comple$ restoration to be placed, /CT recommended

0ori2ontal Root Fracture -fracture limited to root onl! (cementum, dentin, and pulp in ol ement) -ma! "a e bleedin' from sulcus 1) Conse&uences a) coronal se'ment of toot" is usuall! displaced but apical portion is usuall! not b) pulp necrosis of coronal se'ment ma! result (+8G) c) pulp necrosis in apical se'ment is rare b/c blood suppl! is not disrupted +) Dia'nosis a) ma! be missed on a P5 radio'rap" b/c fracture usuall! obli&ue from facial to palatal b) radio'rap"ic e$am s"ould include 1 occlusal and , Pas (at @ de'rees, E18, and -18 de'rees) ,) 2ealin' Patterns (0 t!pes) a) 2ealin' #/ calcified tissue: ideal "ealin' t!peA calcified callus forms at f$ site on root surface and inside canal (successful) b) 2ealin' #/ interpro$imal connecti e tissue (successful) c) 2ealin' #/ bone and CT (successful) d) Interpro$imal inflammator! tissue #/o "ealin' (unsuccessful) 0) Treatment a) Coronal root fracture: stabili-e coronal se'ment #/ ri'id splint for 9-1+ #%s -if reattac"ment of coronal se'ment not possible, e$tract coronal se'ment and if possible tr! to restore apical se'ment b! ort"o e$trusion or perio sur'er! -coronal fractures "a e poor pro'nosis b) :idroot fracture: stabili-e for , #ee%s -pulp necrosis occurs in +8G of cases (often limited to coronal se'ment) -in rare cases #"ere bot" coronal and apical se'ments are necrotic, /CT t"rou'" fracture is difficult and bot" portions s"ould be remo ed c) 5pical root fracture: "a e best pro'nosis b/c pulp #ill mostl! be ital and "a e little mobilit! 8) Pro'nosis a) Impro es as fracture e$tends apicall! b) 2ori-ontal fracture is better t"an ertical c) Nondisplaced better t"an displaced d) Obli&ue better t"an trans erse *u$ation (Ellis Class <) -effect on toot" t"at tends to dislocate toot" from al eolus -concussion: no displacement or mobilit!, normal cold response but sensiti e to percussion -pulp blood suppl! li%el! to reco er -treatment: occlusal ad*ustment possible, but no immediate t$t neededA s"ould let toot" rest (a oid bite) t"en follo#-up -s"ould ta%e baseline radio'rap"s and italit! tests !ublu$ation -toot" "as been loosened, but not displaced -treatment: baseline italit! tests/radio'rap"s, occlusal ad*ustment, splint for , #ee%s -rarel! results in pulpal necrosis &$trusive#*ateral *u$ation -toot" is partiall! e$truded from soc%et, occasionall! accompanied b! al eolar fracture -usuall!, cro#n is displaced palatall! and root ape$ labiall! (e$trusi e lu$ation) -lateral lu$ation is displacement in an! direction ot"er t"an a$iall! -treatment: radio'rap", reposition toot" and splintA /CT ma! be necessar! -pulpal outcome: 98G rate of necrosis in e$trusi e lu$ationA ?8G rate in lateral lu$ation

ntrusive *u$ation -apical displacement of toot" (pus"ed into soc%et) -treatment: a) immature teet" #/ open ape$: allo# to re-erupt b) ort"o repositionin' c) sur'ical repositionin' d) /CT -"a e er! "i'" rate (>9G) of pulpal necrosis Avulsion (&$articulation) -complete separation of toot" from al eolus b! traumatic in*ur! (Ellis Class <I) 1) Treatment: first priorit! is to protect iabilit! of PD3 a) /eimplant immediatel! if possible -immediate implantation impro es PD3 "ealin' and pre ents root resorption b) If can7t reimplant immediatel!, t"en store in media and ta%e to dentist -success rates of e$traoral dr!-time: i) less t"an 18 mins: >@G success ii) ,@ minutes: 8@G success iii) o er 9@ mins: less t"an 1@G success -stora'e media: i) optimal stora'e en ironment (OSE): maintains and reconstitutes metabolites -<iaspan, 2an%7s balanced salt solution (best) ii) ot"er #et en ironment: *ust maintains iabilit! of PD3 -mil%LsalineL sali aL #ater (least desirable-as bad as dr! stora'e) -sali a and #ater are "!potonic and cause cell l!sis and inflam6 +) Treatment in dental office a) Closed ape$, e$traoral dr!-time less t"an 9@ mins or stored in OSE, mil%, or sali a -don7t "andle root surface or curette soc%et -remo e coa'ulum from soc%et #/ saline -replant toot" slo#l! -stabili-e #/ p"!siolo'ic (semi-ri'id) splint for =-1@ da!s -s!stemic antibiotic for = da!s (Pen <C) -refer to :D for need for tetanus booster b) Closed ape$, e$traoral dr!-time o er 9@ mins -remo e debris and necrotic PD3, coa'ulum from soc%et -immerse toot" in +60G Na1 solution (p2 868) for 8 mins, replant, splint =-1@ da!s -s!stemic antibiotic (Pen <C) for = da!s and refer to :D for tetanus booster c) Open ape$ #/ e$traoral dr!-time less t"an 9@ mins or stored in OSE, mil%, sali a -clean root surface and apical foramen #/ saline -place toot" in do$!c!cline/saline solution -remo e coa'ulum from soc%et #/ saline -replant toot" and stabili-e #/ p"!siolo'ic splint for =-1@ da!s -s!stemic antibiotic and tetanus booster d) Open ape$ and e$traoral dr!-time o er 9@ mins -replantation not recommended ,) Endo t$t after =-1@ da!s reimplanted a) Closed ape$ -/CT initiated =-1@ da!s after reimplantation -if /CT is dela!ed for lon'er period t"an t"is or si'ns of resorption present, s"ould 'i e lon'-term CaO2 t$t before doin' /CT b) Open ape$, less t"an 9@ mins dr!-time -/CT s"ould be a oided and si'ns of re asculari-ation s"ould be c"ec%ed -at first si'n of infected pulp, ape$ification procedure s"ould be'in c) Open ape$, o er 9@ mins dr!-time -if /CT not performed on toot" out of mout", t"e ape$ification procedure is initiated

&$ternal Resorption -destructi e process initiated in periodontium -0 t!pes: 1) Surface resorption +) /eplacement resorption (an%!losis) ,) Cer ical resorption 0) Inflammator! root resorption -e$ternal resorption al#a!s accompanied b! bone resorption !urface Resorption -transient p"enomenon t"at is common, re ersible, and self-limitin' -due to mec"anical dama'e to cementum surface and PD3 #"ic" causes spontaneous destruction and repair -repair occurs #it"in + #ee%s and is not clinicall! si'nificant Replacement Resorption (An+ylosis) -caused b! PD3 dama'e/trauma, resultin' in non iable PD3 -occurs in 9@G of replanted teet" -t"ere is loss of root as it is replaced b! bone, causin' loss of cementum, dentin, and PD3 as bone fuses to root defect -clinicall!, causes pro'ressi e submer'ence of toot" leadin' to infraocclusion, lac% of p"!siolo'ic mobilit!, as #ell as metallic sound on percussion -is irre ersible process #/ no real feasible t$t Cervical Resorption -also called e$tracanal in asi e resorption or subepit"elial e$ternal root resorption -caused b! a sulcular infection from trauma, ort"o, perio t$t, c"emical in*ur! (non ital bleac"in'), or idiopat"ic -radio'rap"icall!, appears similar to cer ical caries or radiolucenc! around canal #/ irre'ular mot"-eaten appearance around root -clinicall!, see crestal bone defect and possibl! pin% spot due to 'ranulation tissue underminin' enamel -pulp testin' is .N3 -usuall! be'ins at CEB -treated b! sur'ical remo al of 'ranulation tissue and repaired #/ restoration nflammatory Root Resorption -caused b! necrotic pulp from trauma #"ere bacteria initiate and follo# ports of e$it to affect periodontium -occurs at apical and lateral aspects of root, appearin' similarl! to cer ical resorption radio'rap"icall! -is a necrotic pulp, so treated b! immediate /CT -CaO2 fillin' placed in canal and c"ec%ed e er! , mont"s for 1 !earA if after !ear t"e resorption "as stopped, 'utta perc"a placed nternal Resorption -destructi e process initiated #it"in root canal s!stem -caused b! inflammation from caries, attrition/abrasion, crac%ed toot", trauma, pulpotom!, cro#n prep -can occur an!#"ere alon' root canal, but mainl! in primar! teet" -is 'enerall! as!mptomatic, but can manifest as pin% toot" from 'ranulation tissue in coronal dentin underminin' t"e enamel (can be misdia'nosed as cer ical resorption) -radio'rap"icall!, mar'ins of canal are smoot" but balloon out -usuall! tests ital, but ma! 'et ne'ati e italit! test if resorption "as been lon'standin' and pulp is necrotic -treated b! prompt /CT Calcific 5etamorphosis -pulp canal obliteration -occurs from sublu$ation -also increased li%eli"ood from immature teet", intrusions, and se ere cro#n fractures

Pulpal Necrosis from Trauma 1) Intrusion (>9G) +) 3ateral lu$ation (?@G) ,) E$trusion (98G) 0) Sublu$ation (9G) 8) Concussion (+G) -muc" less c"ance of necrosis in immature teet" t"an mature/closed ape$ teet" Part 1@: 5d*uncti e Endo T"erap! ,ital Pulp Therapy Techni3ues 1) Indirect pulp cappin' +) Direct pulp cappin' ,) Partial pulpotom! 0) Pulpotom! 8) 5pe$o'enesis 5aterials 4se" in ,ital Pulp Therapy -attempt to stimulate dentinal brid'e formation and maintain ital pulp 1) Calcium "!dro$ide: used since 1>,@s as pulp cappin' material and er! reliable -"as p" of 1+68 #"ic" cauteri-es tissue and causes superficial necrosis, #"ic" encoura'es pulp to induce production of reparati e dentin +) :ineral trio$ide a''re'ate: deri ati e of Portland cement -consists of calcium p"osp"ate and calcium o$ide ("!drop"ilic) #"ic" set in presence of moisture -nonresorbable, so ma%es 'reat sealin' a'ent and also not ad ersel! affected b! blood contamination -"as "i'" p2 to induce "ard tissue formation -also used for retrofillin' of canals A"vantages#Disa"vantages of 5TA 1) 5d anta'es a) radiopa&ue d) non-to$ic b) "!drop"ilic e) induces "ard tissue formation c) biocompatible +) Disad anta'es a) "ard to manipulate b) lon' settin' time n"irect Pulp Capping -material is placed on t"in piece of remainin' carious dentin t"at, if remo ed, #ould result in pulp e$posure -indicated in teet" #/ deep carious lesion near pulp, but no si'ns of pulpal or periapical disease -done on permt6 teet" #/ immature ape$ -ob*ecti e is to arrest t"e caries and allo# reminerali-ation/reparati e dentin formation -#ait 9-? #ee%s for reparati e dentin to form, t"en 'o bac% and remo e remainin' caries Direct Pulp Capping -material placed directl! o er mec"anical/traumatic pulp e$posure -indicated if pulp "as been e$posed for under +0 "rs, pulp is "ealt"!/as!mptomatic, and e$posure is small -t"in la!er of CaO2 or :T5 placed directl! o er e$posure, t"en base, and final restoration -durin' follo#-up isits, do pulp testin' and ta%e periapicals to isuali-e "ard tissue barrier formation -sur i al of pulp depends on &ualit! of seal of restoration a'ainst bacteria, de'ree of bleedin', and elimination of an! inflamed pulp -indirect or direct pulp caps done onl! on permt6 teet" b/c "i'" p2 of CaO2 or :T5 can induce internal resorption in primar! teet" -better results of pulp cappin' if e$posure is accidental (non-carious) and of !oun' c"ild (not older adult)

Partial Pulpotomy (Cve+ Pulpotomy) -sur'ical remo al of small portion of coronal pulp tissue to preser e remainin' coronal and radicular pulp tissue -indicated in teet" #"ere inflammation less t"an +mm into pulp c"amber and not into root orifices, traumatic e$posures less t"an +0 "rs, or immature permt6 teet" -follo# up #/ pulp testin' and radio'rap"s -'ood pro'nosis, dependin' on ade&uate remo al of inflamed pulp, disinfection of dentin/pulp, a oidance of clot formation, and 'ood seal on restoration Pulpotomy -sur'ical remo al of coronal portion of ital pulp to preser e italit! of radicular pulp -pulp usuall! remo ed to le el of root orifices, but is arbitrar! -indicated in teet" #/ ital pulp e$posure after =+ "ours, no pain, and no abscesses -done in primar! teet" #/ ital pulp or irre ersible pulpitis or permt teet" #/ incomplete root formation or as emer'enc! procedure until /CT can be done -pulpotomies not used as permt6 t$t in permt6 teet" b/c can result in pulp obliteration, internal resorption, or necrosis and ma%e canals inoperable to future /CT -primar! teet" #/ less t"an +/, remainin' root structure, internal resorption, furcation perforation, sinus tract, or periapical pat"olo'! contraindicated for pulpotom! -if "emorr"a'e can7t be controlled, ma! need to complete o er t#o appts -ma! need to remo e more tissue apicall!, as all uninflamed tissue must be remo ed -if "emorr"a'e still #on7t stop, use "emostatic a'ents of full /CT can be initiated -problem is dentist can7t determine e$actl! if all diseased pulp "as been remo ed Ape$ogenesis -process of maintainin' pulp italit! durin' pulp t$t to allo# for continued de elopment of entire root -toot" "as open ape$ still (apical closure occurs , !rs after eruption) -indicated in immature teet" #/ incomplete root formation and dama'ed coronal pulp but "ealt" radicular pulp -procedure: 1) 5ccess prep and pulp amputation +) Control "emorr"a'in' ,) Place CaO2 o er radicular pulp stump and place coronal fillin' 0) /ecall e er! , mont"s and perform /CT #"en root de elopment completed -'ood pro'nosis in pulp cap or partial pulpotom!A con entional pulpotom! "as sli'"tl! less success -contraindicated in a ulsed, nonrestorable, necrotic, or "ori-ontall! fractured teet" Nonvital Pulp Therapy 1) Pulpectom! +) 5pe$ification Ape$ification -met"od used to stimulate formation of calcified tissue at open ape$ of pulpless toot" -creation of calcified barrier in ol es cleanin' debris/bacteria from canal and placin' material at ape$ to induce apical closure -+ met"ods: 1) place dense CaO2 paste into canal after instrumentation and t"en obturate in ,-9 mont"s +) Place artificial barrier (:T5) at open ape$ prior to obturation (obturate in 1-+ da!s) -indicated in teet" #/ open ape$ and standard tec"ni&ues can7t create apical stop to facilitate obturation

Nonvital ( nternal) (leaching -indicated in teet" t"at "a e discoloration from internal source and "a e been treated endodonticall! -must place cement barrier (I/: or Ca it) to pre ent cer ical resorption from bleac" penetratin' into dentinal tubules -procedure: 1) Place rubber dam and remo e coronal portion of 'utta perc"a to place cement base +) ;leac"in' a'ent placed in facial surfaces of access prep and temporar! restoration placed ,) Toot" monitored for color c"an'e e er! ,-0 da!s, and bleac"in' a'ent remo ed #"en satisfactor! results obtained Nonvital ( nternal) (leaching Techni3ues 1) T"ermocatal!tic tec"ni&ue: place o$idi-in' a'ent (678 09%9#!upero$ol) into pulp c"amber and appl! "eat (+mm cement barrier needed #"en Supero$ol used) -complications: cer ical resorption as bleac"/"eat dama'e cementum and PD3 +) .al%in' bleac" tec"ni&ue: place mi$ of sodium perborate and #ater in c"amber and return in +-9 #%s -se eral repetitions performed Causes of Discoloration 1) Necrotic pulp +) Intrapulpal "emorr"a'e ,) Calcific metamorp"osis 0) 5'e 8) 1luorosis 9) S!stemic dru's =) Toot" defects ?) ;lood d!scrasias >) Obturation materials Part 11: Post-Treatment E aluation Coronal *ea+age -ma*or cause of endo failures -more endo treated teet" are lost b/c of restorati e factors t"an endo factors -after /CT, internal c"ambers of toot" ma! become reinfected if coronal lea%a'e occurs (sali a contaminated #/ bacteria can cause endo failure #"ic" increases #/ duration of sali a e$posure) -temporar! restorations #ill not pro ide complete protection a'ainst occlusion forces, so #"en an immediate restoration isn7t possible, a bonded temporar! restoration at canal orifice s"ould be used -permt6 restorations are best placed as soon as possible to seal toot" from contamination -#"en root canal space "as been 'rossl! recontaminated, retreatment s"ould be considered !tructural Consi"erations -endo treated teet" do not become brittleA t"e moisture content of endo treated teet" isn7t reduced e en after 1@ !rs -teet" are #ea%ened b! loss of toot" structure -loss of mar'inal rid'es is ma*or contributor to reduced cuspal stren't" -it is loss of structural inte'rit! #/ access prep, rat"er t"an c"an'es in dentin, t"at lead to "i'"er occurrence of fractures -most impt part of restored toot" is t"e toot" structure itselfA no restoration can substitute for toot" structure

Ferrule -#"en a cro#n is needed, t"e a$ial #alls of cro#n en'a'e a$ial #alls of prepped toot", formin' t"e ferrule -t"e ferrule is a band t"at encircles t"e e$ternal dimension of t"e residual toot", similar to metal bands around a barrelA it is formed b! t"e #alls and mar'ins of t"e cro#n -a lon'er ferrule increases resistance to fracture -fracture resistance increases #it" an increasin' amount of toot" structure -a lon'er ferrule also resists lateral forces from posts and le era'e from t"e cro#n in f$n -cro#n preps #/ 1mm coronal e$tension of dentin abo e mar'in of restoration "a e double t"e fracture resistance compared to #"en dentin core ends immediatel! abo e t"e mar'in -t"e ferrule must encircle a ertical #all of sound toot"! structure abo e mar'in and can7t end on restorati e material -insufficient toot" structure to construct a ferrule s"ould be e aluated for cro#n len't"enin' or ort"o e$trusion to 'ain additional root surface Post Preparation -primar! purpose of post is to retain a core -need for post is dictated b! amount of remainin' coronal toot" structure -posts #ea%en toot" b! additional remo al of dentin and b! creatin' stress t"at predisposes t"e root to f$ -at least 0-8mm of remainin' 'utta perc"a is recommended -all post dei'ns are predisposed to lea%a'e -t"readed scre# posts increase li%eli"ood of fracture compared to parallel/tapered posts Causes of &n"o Failures 1) Inade&uate seal of root canal s!stem -coronal seal more important t"an apical seal -obturation reported as most critical step to /CT success +) Poor access ,) Inade&uate debridement 0) :issed canals 8) <ertical f$ 9) Procedure errors (perforation, led'e, etc6) =) 3ea%in' restoration ?) Perio in ol ement >) /esorption 1@) Compromised "ost factors (s!stemic conditions) 11) :isdia'nosis Factors nfluencing &n"o !uccess 1) Periradicular Pat"osis (presence of P5 lesion before t$t reduces success rate b! 1@-+@G +) ;acterial status of canal: presence of bacteria in canal before obturation decreases success ,) Mualit! of endo #or% 0) Mualit! of coronal seal Classic Tria" of !uccessful &n"o"ontics 1) Sterili-ation (microbe disinfection) +) Debridement (%e! to success) ,) Obturation

Part 1+: /oot Canal 5natom! Number of Canals for 5a$illary Teeth 1) Central incisor: 1 root, 1 canal (1@@G) +) 3ateral incisor: 1 root, 1 canal (1@@G) -root cur es distall! at ape$ ,) Canine: 1 root, 1 canal (1@@G) -lon'est tooth in arc" 0) 1st premolar: + roots, + canals (=8G) -1 root, 1 canal (+@G) -, roots, , canals (8G) 8) +nd premolar: 1 root, 1 canal (=8G) -1 root, + canals (+8G) 9) 1st molar: most often , roots, 0 canals (+ in :; root) (9@G) -can "a e , roots, , canals (0@G) -0 roots, 0 canals (rare) =) +nd molar: , roots, , canals (9@G) -, roots, 0 canals (+ in :; root) (0@G) -can also "a e + roots #/ +-, canals or 1 root, 1 canal Number of Canals for 5an"ibular Teeth 1) Central incisor: 1 root, 1 canal (>8G) -1 root, + canals (8G) +) 3ateral incisor: 1 root, 1 canal (=@G) -1 root, + canals (,@G) ,) Canine: 1 root, 1 canal (>8G) -1 root, + canals (8G) 0) 1st premolar: 1 root, 1 canal (?@G) -1 root, + canals (+@G) 8) +nd premolar: 1 root, 1 canal (>@G) -1 root, + canals (1@G) 9) 1st molar: + roots, , canals (+ in : root) (=@G) -+ roots, 0 canals (+ in : and D roots) (,@G) -can "a e , roots and 0 canals (+:, 1D;, 1 D3) =) +nd molar: + roots, , canals (+:, 1 D) (>@G) -+ roots, 0 canals (+:, +D) (8G) -C-s"aped sin'le orifice #/ , canals (8G) Access Preparation !hapes 1) :a$illar! a) CI: trian'ular b) 3I: narro# trian'le to o oid c) Canine: narro# trian'le to o oid d) 1P:, +P:: o oid e) 1:, +:: trian'le + :andibular a) CI, 3I: narro# trian'le to o oid b) Canine, 1P:, +P:: o oid c) 1:, +:: trape-oid 5a$illary 5olar Facts -:; root of ma$6 molars is most comple$ root in entire dentition b/c >@G "a e + canals or ma*or fins -s"ould al#a!s assume + :; canals until pro en t"ere is onl! one -:; canal "ardest to locate and located under :; cusp -:;+ located *ust lin'ual to orifice of :;1 canal

-ma$6 1st molar is posterior toot" #/ "i'"est endo failure rate -palatal root is lon'est, "as lar'est diameter, and easiest access of , roots 5an"ibular 5olar Facts -in 0@G of cases, mand6 molars "a e + canals is distal root (al#a!s + in mesial) -lin'ual #all of mand6 teet" most easil! perforated due to lin'ual inclination of teet" -mesial #all also fre&uentl! o ercut -mand6 1st molar is toot" most fre&uentl! re&uirin' /CT in #"ole mout" 5a$illary First Premolar -P: most li%el! to "a e + canals, #/ 9@G "a in' + roots -ot"er 0@G "a e one root #/ + separate canals -easil! perforated on mesial due to conca it! on mesial side of cro#n 5a$illary Anteriors -all "a e distal a$ial inclination, so bur s"ould be an'led sli'"tl! to distal #"en accessin' to pre ent mesial perforation 5an"ibular Anteriors -roots/accesses are al#a!s #ider labiolin'uall! and t"in mesiodistall! Apical Terminology 1) 5natomic ape$: most apical end of root (also %no#n as radio'rap"ic ape$) +) 5pical foramen: rarel! coincides #/ anatomic ape$ and usuall! about @68mm s"ort of it ,) 5pical constriction: located about @68mm from apical foramen -is a natural stop in /CT and is detected b! ape$ locator -/CT and obturation s"ould stop about 1mm s"ort of radio'rap"ic ape$ (apical constriction is @68mm s"ort of ape$ and apical foramen is @68mm s"ort of constriction) Part 1,: 2and and /otar! Instruments 0an" nstruments 1) ;roac": t"in, fle$ible, tapered and pointed metal instrument #/ s"arp pro*ections/barbs alon' len't" of instrument -used to remo e pulp tissue from #ide canals -not meant to be used for canal enlar'ement -must be used #/ e$treme care not to fracture +) /eamer: made b! t#istin' a tapered trian'ular or s&uare #ire for form instrument #/ s"arp cuttin' ed'es -used #/ reaming action only to enlar'e canals -differs from C-files in "a in' fe#er spirals/flutes per unit len't" ,) C-file: "as ti'"tl! spiraled cuttin' ed'es t"at cut #it"er in reamin' or filin' motion -cross-sectional confi'urations include diamond, s&uare, and trian'ular -most useful instruments for remo in' "ard tissue -stron'est of all instruments and cut least a''ressi el! 0) 2edstrom file: made b! cuttin' spiral flutes into s"aft of tapered #ire to produce ele ated cuttin' ed'es t"at appear to form a series of intersectin' cones -cuttin' occurs onl! on pullin' stro%es (onl! to be used in filing motion) -cuts more a''ressi el! t"an C-file, but more prone to brea%a'e Nall abo e instruments made of stainless steel Rotary nstruments 1) NiTi files: made b! cuttin' spiral flutes into round #ire composed of superelastic nic%el-titanium allo! -remain better centered, produce less transportation, and instrument faster t"an stainless steel files due to better fle$ibilit! and resistance to fracture +) Fates-Flidden burs: composed of stainless steel s"an% #/ cuttin' bulb and pilot-tip -desi'ned so t"at a fracture occurs near "ub t"an bt# s"an% and cuttin' bulb