ENDODONTICS – REVISION

What are the 3 Cases where conventional Endodontic treatment is NOT suitable?

- Unfavorable restoration

- Unfavorable anatomical or Expected procedural error

- Persistent/Extra-Radicular infection

What are the structures of Roots

Through which structures do pulp communicate with Periapical tissues?

- Apical foramen (open @ apex)  made of Minor Apical Diameter (apical

construction or Cemento-Dentinal Junction) + Major Apical Diameter

- Lateral/Accessory canals

- Apical Delta/Ramification (branching pattern of accessory canal near apex)

Tell me the structures of dental pulp from Dentin

Predentin  Odontoblast Layer  Sub-Odontoblast layer (Cell-Poor Zone  Cell-Rich Zone)  Pulp Proper
What are the functions of Odontoblast Layer?

Odontoblastic cell body processes projecting into dentinal tubules

- Tall Columnar morphology

 Secretory – secrete collagen & ground substance (involved in dentine mineralization)

- Smaller/Flattened morphology

 Quiescent – means Dormancy

Odontoblasts – terminally differentiated cells

- No more cell division

- Are from Pluripotent (stem) cells @ sub-odontoblast layer

What is “Cell-Free Zone” of Sub-Odontoblast Layer?

- Right beneath odontoblast layer

- Bulk of coronal pulp

- Content: (1) Fibroblasts, (2) Blood vessels, (3) Neural Network (Plexus of Raschkow) – innervate into
odontoblast layer/dentine

What is “Cell-Rich Zone” of Sub-Odontoblast Layer?

- Beneath “Cell-Free Zone”

- Bulk of coronal pulp

- Content: (1) Fibroblast, (2) Blood vessels, (3) Immune Cells (Macrophage/Lymphocyte), (4) Nerves, (5)
Pluripotent (stem) cells

What is Pulp Proper?

Central Pulp

- Major blood vessels and nerves

- Fibroblast

- Pluripotent (stem) cells

- Defence cells
 - Collagen

Parietal Pulp

- Small blood vessels and nerves

What are the cells of dental pulp?

Odontoblast, Fibroblast, Pluripotent (stem) cells, Defence Cells (Macrophage, Lymphocyte, Dendritic Cells)

What is fibroblast? What are its function?

- Spindle-shaped, Most abundant in Cell-Rich Zone

 Young: stellate shape, plump nucleus

 Old: flatten shape, condensed nucleus

- Function: Produce collagen and ground substance for ECM

 Involved in collagen turnover

What are the pulpal defence mechanisms?

Physical barrier - Surrounded by dental hard tissues (rigid barrier)

Innate & Immune Systems – defence cells & inflammatory response

- Macrophage

 Mostly @ Peri-Vascular Portion (Inner Pulp) & Odontoblastic Region (Outside Pulp)

 Phagocytic ability

 Secrete IL-1, IL-6, TNF, Growth Factors  inflammatory response & Tissue regeneration

- Dendritic Cell

 Antigen Presenting Cell (APC) –

immunosurveillance

 Detect & Capture antigen

 Activate T-Lymphocytes

 Mostly @ Peri-Vascular Portion

& Para-Odontoblastic Region
(outer pulp – beyond
odontoblastic region)
What do T- and B- Lymphocytes do in dental pulp?

T-Lymphocyte  mostly in normal pulp; MORE CD8 (cytotoxic) cells

B-Lymphocyte  mostly in inflamed pulp

How does Neurogenic Inflammation work for Pulpal Defence?

Release of Neuropeptides in Pulp  Increased vascular permeability and Vasodilation  Affect activity of
inflammatory cells (macrophage)  Amplified neurogenic inflammation

What are the Extracellular Components of Pulp?

Collagen

- Mostly TYPE I

- Irregular arrangement in pulp BUT perpendicular to predentine @ Periophery

- More collagen in radicular pulp (occupying canals) than coronal pulp

Ground Substance (NON-COLLAGEN)

- Glyco-aminoglycans

- Glyco-proteins

- Proteo-glycans

- Function: helps w/ ECM integrity (hydration and adhesion)

How do blood vessels work in pulpal area?

- Arterioles (afferent)

 Branches of Maxillary artery:

 Inferior Alveolar artery

 Posterior Superior Alveolar artery

 Infraorbital Artery

 Branches @ periopheral coronal pulp  sub-

odontoblastic capillary plexus

- Venules (effert)  drain through Facial Vein (anterior) & Maxillary Vein (posterior)
How does vascular changes occur?

Local nerve changes:

Sympathetic Nerve

- Control pre-capillary sphincter (smooth muscle)  alter blood pressure, flow, distribution

Sensory Nerve

- Response to inflammation (release of neuropeptides)

Where are lymphatic vessels located? What do they do?

- Start @ Periphery of Pulp  Exit as 1 or 2 large vessels via. Apical foramen

- Function: Removal of cellular debris and inflammatory exudates/transudates

- ISSUE!: spread of endodontic infection!

Where is pulpal innervation coming from?

- Afferent nerves from Trigeminal Nerve CN5  Maxillary Branch and Mandibular Branch

Radicular pulp: centrally close to blood vessels

Coronal pulp: branches around odontoblast - sub-odontoblast layers

How does afferent nerve of Trigeminal nerve travel?

Sensory receptor (eg. Nociceptor)  Sensory nuclei (spinal cord)  Thalamus  Cortex

- Nerves converge @ Spinal Tract Nucleus  Difficulty locating pulpal pain (leads to referred pain)
What is Sub-Odontoblastic Plexus of Raschwkow?

- Branching of afferent nerves in coronal pulp

 Odontoblast layer

 Dentinal tubules

- Unmyelinated nerve endings

- Mostly Aα, Aδ & C fibers  sensory perception (some C fibers for sympathetic efferent for BV smooth
muscles)

What is Hydrodynamic Theory?

No direct pathway between stimuli and nerve endings so it’s the MOST accepted theory

- Stimulus  Fluid movement within tubules  Activate Nociceptors in Inner Dentine/Peripheral Pulp

What are changes in pulp w. AGE?

Dentine:

- Increase in Secondary/Tertiary Dentine  Smaller Pulp Chamber

- Occluded tubules  Reduced permeability

Pulp:

- Decrease in Cell content, BV, Innervation & Increase in Fibrous content

- Pulp Stones

What is Cementum? What does it do?

- Physical barrier that covers root dentine

 Attachment site for periodontal fibers (PDL)

 Prevent root resorption

 Stop harmful products to reach periodontal tissues

What is Minor Apical Foramen?

- Apical constriction = CDJ (Cemento-Dentinal Junction)

 Location where pulp communicates with periapical tissues (narrows w/ age = Decreased in
vascularity)
How are types of cementum defined by?

- Formed Pre- / Post- Eruption (Primary vs. Secondary)

- Cellular Content (Cellular vs. Acellular)

- Origin (Intrinsic - Cementoblast vs. Extrinsic – PDL

fibroblast)

Primary Acellular Intrinsic Cementum: first cementum formed

Primary Acellular Extrinsic Cementum:

- From CEJ to Apical 2/3 or more

- Important for Attachment/Support (Sharpey’s fibres insert!)

Secondary Cellular Intrinsic Cementum:

- @ Apical 1/3 and Furcation

- NOT for support

- Contains cementocytes

Secondary Mixed Fibre Cementum:

- Both cellular/acellular & Intrinsic/Extrinsic

- Features: Cementocytes, Laminated appearance, Cementoid on surface (new cementum layer less calcified)

What is PDL?

- Specialised connective tissue – attaches tooth to alveolar bone

 Absorb occlusal forces  transmit force to bone

 Provide nutrients to bone and cememntum

 2 Sensory: Nociceptor – pain, Mechanoreceptor – position & pressure

- Mean width 0.2 mm

- Lined by: Cementoblasts (Cementum) and Osteoblast (Alveolar Bone)

What are 2 types of Alveolar Bone?

Bundle Bone and Cribiform Plate

Bundle Bone:

- Similar to Cortical Bone (compact bone)

 = Laminda Dura in radiograph

- Attachments of Periodontal Fibres (Sharpey’s fibres)

- More dense than surrounding bone

Cribiform Plate:

- Perforations along Alveolar Bone (Volkmann canals)

 Allow blood vessels and nerves to reach tooth

What issues can be caused by pulpal inflammatory response?

- Incompressible cellular/connective tissue encased in hard tissue

 Change in pulpal fluid volume affect pressure

What are the causes of pulpitis? MMCT

Microbial, Thermal, Mechanical, Chemical

Why different clinical responses between Reversible vs. Irreversible Pulpitis?

- Depends on degree of inflammation and damage to pulp tissue

 2 Types of Nerve Fibers:

 Alpha Delta fibers: thick diameter and myelinated

 C fibers: thin diameter and non-myelinated

What are different types of infection of root canal?

Primary – initial infection

Secondary – infection during treatment OR between appointments

Persistent (Recurrent) – remnants of primary or secondary infection

- Different microorganisms expected as they survived through irrigation and mechanical removal

- As diverse bacterial community as Primary Infection (w/ some key species found)
Enterococcus Faecalis:

- Consider to be MAJOR agent for persistent/recurrent apical periodontitis

 BUT not the only cause

 Due to ability to enter dentinal tubules, bind to dentine, withstand starvation and Calcium Hydroxide,
and form biofilm

Which one is better? 1-Visit vs. 2-Visit Endodontic Treatment?

- Both had residual bacterial communities in canals

 More in 1-Visit than 2-Visit

 Not enough evidence to say: 2-Visit > 1-Visit

What are the requirements of Acess?

- Unroof pulp chamber

- Get ‘Straight-Line’ and Visibility

- Conservative outline

What are 2 Guidelines for pulp chamber location?

Centrality: always in the center of tooth @ CEJ level

Concentricity: pulp chamber walls are concentric to external outline of the tooth @ CEJ level
What are 3 Guidelines for canal orifice location?

Color: pulp chamber floor is always DARKER than walls

Orifice location:

- Always @ junction of walls and floor

- Corners of floor-wall junction

Symmetry: mesio-distal midline along the chamber floor (mandibular molar ONLY)

- Orifices are equi-distant from midline

- Orifices line perpendicular to midline

What is working length?

- The distance from coronal landmark (reference point) to root apex

What is Electronic Apex Locator (EAL) and what does it do?

- A device to locate the apical extent of canal

 Creates an electronic circuit from lip hook (mucosa) to Periapical tissue via file

 Uses math algorithm to estimate how far file is from apex

What are Local Anaesthesia technique for Maxillary Teeth for ENDO?

ALL: Buccal Infiltration

Posterior: Additional palatal infiltration (for soft tissue – especially tooth on rubber dam)

What are LA technique for Mandbile Teeth for ENDO?

Anterior: Buccal infiltration (IAN block not predictable for anterior teeth)

Posterior: IAN Block + Long Buccal Nerve Block (LB nerve – for soft tissues)

Why is the failure rate high for Irreversible Pulpitis? And which teeth are hardest to anaesthetize?

“Hot Pulp” syndrome: extenstively inflamed pulp (8 times higher failure rate)

 Mandibular Molars are hardest

What are theories for failure?

- Central Core Theory

- Anatomical Factor

- Effect of Inflammation

 pH, Bloodflow, TTX-resistant NA channels, Nociceptors

- Central Sensitisation

- Psychological factors

How to manage LA failures?

- Supplemental LA

 Intraligamentary – inserted into sulculus to PDL and inject

 Intraosseous – force a needle through cortical plate into alveolar bone

 Intrapulpal – into the pulp chamber directly

- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

Advantages of Rubber Dam in ENDO

Patient Protection:

- Protect Oropharynx: aspiration/swelling of instruments, medicaments, irrgants

- Retract and Potect oral soft tissues

Improve Treatment Efficiency:

- Improved Access

- Improved Visibility

- Reduce floording

What are clinical considerations of Rubber Dam?

Sodium Hypochlrite Irrigant (“Bleach” – 0.5~5%)

- Broad antimicrobial spectrum and tissue dissolving properties

- Unpleasant taste/odour

Patient Safety – swallowing & inhaling small instruments avoided

Endodontic Outcome:

- Rubber dam produces “aspetic field”

What are 2 different irrigants for Canal Preparation?

- Sodium Hypochlorite (0.5-5%)

 Bleach

 Strong antimicrobial action

 Dissolve organic tissue

- EDTA (15-17%)

 Chelating agent to facilitate smear layer removal (inorganic component)

3 Different Needles: (1) Side-Vented Needles, (2) Closed-Ended Needles, (3) Standard

Why do ENDO treatments need more than 1 appointment?

Intracanal Medicament & Temporary Restoration

Intracanal Medicament:

- Calcium Hydroxide [Pulpdent Paste] / Steroid-Based (steroid +

antibiotic) [Odontopaste, Ledermix]

 Paste filler / Lentulo-Spiral used

Temporary Restoration:

Cavit & GIC

Orthodontic Band: reduce cusptal flexure

What are 2 Obturation Materials?

Gutta-Percha: fills bulk of the canal

Sealer: seals by filling the gap between canal wall and GP

- Epoxy Resin based

Paper Points: dry canals before obturation

LECTURE 7 – Rotary NiTi – Biological Principles

What’s the cause of apical periodontitis?

- Polymicrobial biofilm infection of the root canal space

 Bacteria reach apical foramen in contact with peri-radicular (around root) tissue

What are the objectives of Canal Preparation?

1) Cleaning:

- Chemical – Mechanical cleaning

- Remove all organic debris and microorganisms from the root canal system

2) Shaping

- Shape the walls of root canal for cleaning and shaping for obturation (mildly tapered)

Which Canal Preparation Philosophies do we prefer?

Larger apical size & Moderate tapering >>>> Small apical size & Large tapering

How much do we need to clean – canal preparation?

- A layer of dentine must be removed to eliminate microorganisms in dentinal tubules

 WHY?

 Bacteria penetrate up to 300 um, Irrigants penetrate up to 100um

What is the average diameter of root canals? Which instrument should we use as result? Why is it important?

Diameter of root canal: 350-400 um  ISO 35 or larger required as result!

- Important because there are different shapes of apical construction  but as long as it’s cleaned with
greatest diameter, it should be fine

What are 3 Factors that affect Microbial control of root canals?

Effectiveness of Canal cleaning, Irrigant, Medicament

Where should root filling end?

0-0.5mm of radiographic apex

- Overfilling (0-1mm) is okay but must be compacted well within root canals regardless

LECTURE 8: Rotary NiTi Root Canal Preparation

What are the differences between H-files vs. K-files

H- Files K- Files
Positive Rake angle  Efficient cutting Negative Rake angle  Reaming action (widen hole)
Cut “push-pull” action Cut “turning” action
Very flexible  flute pattern/cross section Not flexible  triangle/square cross section

What is “Crown-Done” technique?

- Enlarge coronal part of the canal

- Progress towards apex

 Decreasing instrument sizes cutting short lengths of dentine

- Complete apical enlargement

What are the 3 advantages of Crown-Down technique?

- Most pulp tissue& bacteria removed prior to apical third  minimize risk of
extruding debris through apex

- Enhance irrigation efficiency

- Eliminate constriction of coronal aspect to reduce canal curvature

What are the possible procedural errors of canal preparation?

- Transportation

- Ledging

- Apical perforation

- Zipping (larger towards apex)

- Excessive dentine removal

What are 3 advantages of using Rotary NiTi canal preparations?

- Conservative coronal flaring

- Smoothly tapered canal shape

- No apical transportation (still possible if you are bad)

** Easier, Faster, Better healing overall

What are 2 main types of failures?

Torsional failure  tip locks and file begins to unwind  repeat of unwinding and re-winding  file breaks

Flexural failure  files rotate around a sharp curve  break without distortion

What are 2 factors you consider to prevent fracture?

1) Number of uses

A. Up to 10 times or 4 molar teeth (9-12 canals)

B. Single overloading event

2) Canal Curvature

A. Small radius curvature  more likely to

fracture (reduce rotary NiTi lifespan)
Flowchart for managing fractured instrument:

How does tapers work on rotary file?

Ex. 0.02 Taper  every 1 mm from apex, taper increases by 0.02 mm

What is M-Two System?

- Two blades with a large groove (Reduced core diameter)

- Increased flexibility

** Very effective  risk of excessive dentine removal

** M- TWO 25/.07 and 30/.05  perform bulk of prep

- Choose apical size

How to create the glide path

- H-file more efficient

- Watch-winding motion (push, turn, pull)

 1/8 – 1/4 turn

 Advance with each entry

- Flooded canal

- Established patency

Circumferential filing  push-pull filing against all walls

- File until “loose”

Apical size of Rotary NiTi depends on ____, ____, _____

Canal size, Shape, and Curvature

LECTURE 9: Root Canal Preparation – Irrigation, Medication, Temporary Restoration

What are desired functions of irrigating solutions?

- Kill bacteria & Dissolve Organic Matter (dentine collagen, pulp tissues, biofilm)

- Penetrate canal periphery and anatomical irregularities

- Flushing (remove debris)

- Lubricant (reduce instrument friction, help dentine removal)

WHAT NOT TO DO:

- Do not damage vital periapical tissue or dissolve inorganic tissue (dentine)

- Do not weaken tooth structure

What are 2 most commonly used solutions for irrigation?

NaOCL – Sodium Hypo-Chlorite

EDTA – Ethylene Diamine Tetra-Acetic Acid

** All irrigant must reach the microbes (if NaOCL can’t get there, neither can anything else)

What are the characteristics of NaOCL?

- Powerful bactericidal agent (0.5-6%)

- Remain in dentinal tubules after drying w/ paper points

- Dissolve organic matter

- Dentalife “EndoSure Hypochlor” product

 1% (pH: 11-12), 4% solutions (pH: 11-13)

What are important factors of irrigant solution? TCCPV

Time  longer it stays, more bacteria it kills (Both 1% and 4% are effective just need to stay longer)

- 1% NaOCL active for ~ 1 hour, >4% NaOCL active for ~ 4 hours

Pre-Heating Solution  No point because of rapid cooling

Corono-Apical level of needle  Ideally 3mm away from working length

- Different needle types to prevent apical pressure (“side vent”)

- Dynamic irrigation “jiggling” to prevent needle pushing deeper

 into apex (passive ultrasonics/sonic)

Canal Dimension  40/0.4 better than 20/0.4 (apical size >> tapering)

Volume of Irrigant  More the better; “flooding”

How effective is irrigation?

Chemo-Mechanical instrumentation (NaOCL)  decrease microbial load by 100-1,000 fold

What are 4 rules of Irrigation

Always:

- Use Side-venting needle

- “gently” jiggle

- Keep needle loose in canal

- Use gentle pressure on syringe (< 4ml / min)

Which vein is affected by NaOCL-induced ecchymosis (discoloration of skin from bleeding)?

Superficial facial vein

What are 4 categories of NaOCL accidents?

1. Oedema w/o ecchymosis

2. Ecchymosis involving periorbital region and angle of mouth (eye and mouth)

3. Ecchymosis above & neck region

4. Ecchymosis above & chest  lead to mediastinal ecchymosis

What are signs of NaOCL incidents?

- Immediate swelling/intense pain

- Ecchymosis

- Profuse bleeding from pulp chamber

How do you manage NaOCL incidents?

- Explain to patient

- Pain Control

 More LA (BLOCK! No infiltration, No vasoconstrictor – no adrenaline)

 Ibuprofen (NSAID) + Paracetamol (+/- Codeine)

- Systemic antibiotics (Amoxicillin + Clavulanate)

- Cold pack first 24 hours  Warm pack 2nd day

- May require systemic steroid medication to control inflammation if severe

What are characteristics of EDTA?

- 15% w/v Di-Sodium EDTA Salt (pH: 7.2)

- Lubricant

- Remove smear layer (dentine, pulp, bacteria etc.)

- Method:

 Only after instrumentation

 Final flush with 3ml of 15% EDTA, then 5ml NaOCl solution

Is intracanal medicament effective?

Decrease microbacterial load BUT doesn’t change outcome

- Compete removal of microorganisms is nearly impossible SO

- Reduce microbial load to a very low level so immune system can respond

What are 2 contemporary intracanal medicaments?

Calcium Hydroxide (Pulpdent/UltraCal XS) Steriod/Antibiotic Paste (Odontopaste)

Antibacterial Consist of “Triamcinolone (1%) and Clindamycin (5%)”
-from HIGH pH (12.5-12.8) – destroy bacterial cell
walls and protein structures
- hydrolyze lipid moiety of bacterial lipopolysaccharide
Slow acting; takes 7 days to eliminate bacteria Improved zone of inhibition against E. Faecalis
No discoloration of teeth
Effective pain relief
How are medicament placed?

Flat paste-fillers:

- Slow “pumping” action

- Minimum 4mm away from WL

- Moderate speed handpiece

- Don’t bind in the canal

- Avoid small sizes (#40 preferred)

** AVOID traditional spiral bur  very fragile

How do you do Temporary Seal?

Double seal:

- Cavit G or W

- GIC / IRM (Intermediate Restorative Material)

What are the differences between Interim Restoration vs. Temporary Restoration?

Interim  Restore the tooth after removal of caries/existing restoration

Temporary  Seal the access cavity cut through interm restoration

What is GIC Dome?

- Interim Restoration in between endodontic appointments to avoid using

“Orthodontic Band”

 Ortho Band  create periodontal problem as band often sits around

periodontal areas

- No difference in risk of fracture between SS band, GIC-O, and GIC-IRM

What are the characteristics of Cavit Cement?

- Contain Zinc Oxide, Calcium Sulphate, Zinc Sulphate….

- High coefficient of linear expansion (w/ water)

What are characteristics of IRM (Intermediate Restorative Material)?

- ZOE cement reinforced with Polymethyl Methacrylate

- Improved compressive strength & Good sealing ability (less than Cavit)

- Easy to use

- Double Seal (inner – cavit, outter – IRM) recommeneded

What are characteristics of GIC Cement?

- Good physical properties

- Decent sealing from adhesion (dentine)

- Antibacterial activity (release of fluoride)

Disadvantages:

- Cost, slow setting, seal deteriorate over time, not easy to use, difficulty in differentiating from tooth
structure
LECTURE 10: Root Canal Filling

What is the role of root filling?

- Physical barrier between root canal and oral environment  prevent nutrient supply and re-infection

- Prevent supply of periapically derived fluids providing nutrient to residual bacteria

- Antimicrobial effect of GP/Sealer Cement

- Entomb residual bacteria within root canal space  prevent communication with peri-radicular tissues

Why is entombment important?

Bacteria survive by:

- Biofilm formation

- Invasion into dentinal tubules

- Resistance to antimicrobials

- Survival in starvation state

- Remain in isthmus, canal ramifications, fins

Contemporary Root Filling Materials are:

Core materials (GP), Sealers, Root filling systems

What are the different types of root canal sealers?

-Resin-based (Epoxy, Methacrylate, Polymer)  AH26 one we use at clinic

-Ca(OH)2 based

-ZOE based

-Silicone based

-Bioceramic based

Advantages of Epoxy-Resin-Based Sealers

- AH 26  Antimicrobial effect due to Formaldehyde release (first 24 hours)

- Biocompatible once set

 - Gold standard: sealing ability and biocompatibility

- History of good outcome

What are the advantages and disadvantages of Lateral Compaction (root fillings)?

Advantages Disadvantages
Good Length Difficult technique
Deficiency can be easily corrected during Lots of Time
root filling
Lots of accessory cones
Poor compaction is common
High Fracture risk (spreader had to go
deep)

What are 3 ‘Thermoplastic Root Filling’ Systems?

- Vertical compaction system B

- Carrier-based (Thermafill, GuttaCore, GuttaMaster, GuttaFusion)

- Heated GP systems

What are the advantages and disadvantages of Carrier-based System?

Advantages Disadvantages
Fill accessory canals Extrusion of GP and sealer
Adapt to canal shape Carrier remains in canal (maybe a problem for
retreatment)
Sealer thickness: avg 2mm
GP may penetrate tubules
Less extrusion (빠져나온다)

What is the potential problem with Carrier-based system?

- Stripping of GP from Carrier

 Due to under-prep of canals

Heated GP-delivery system is good for filling irregular canal spaces very
effectively

- BUT can’t always control placement (hard to see leakage & shrinkage is a
problem)

What is Minteral Trioxide Aggregate (MTA)?

- Mixture of Portland’s cement and bismuth oxide

 Compounds present:

 Di-Calcium Silicate

 Tri-Calcium Silicate

 Tri-Calcium Aluminate

 Gypsum

 Tetra-Calcium Alumnino-Ferrite

- Set by “Hydration reaction of Tri-Calcium Silicate” and “Di-Calcium Silicate”

- Form colloidal gel that solidify in 3-4 hours

- Moisture from surrounding tissues assist setting reaction

How does MTA work?

- Doesn’t bond to Dentine DIRECTLY BUT

 Release of calcium and hydroxyl ions interact with phosphate from body fluids  form apatite-like
deposits

 Deposits  fill gaps from shrinkage and improve frictional resistance of MTA to canal walls

- Formation of “non-bonding, gap-filling” apatite deposits  account for seal of MTA

MTA used for:

 - Apexification (inducing apical closure through formation of mineralized tissue)

- Perforation

- Filling wide/irregular canals

- Vital pulp therapy

- Periapical surgery

What are the steps of Root Fillings?

- Match GP point to MAF size/taper

 Check for length and resistance in a WET canal (NaOCl)

- Make GP cone adjustments:

 If Long, (1) Go up a size OR (2) Trim 1mm if ~1mm short

 If Short, (1) Measure/Revise WL again OR (2) Use rotary instrument to clear obstruction and refine
apical portion

- Place sealer via. “#40 FLAT PASTE-FILLER” NOT lentulo-spiral

 Size 40 because you don’t want it to reach apex – only put it half way and master cone will push it
down apically

 You don’t want sealers @ Inferior Alveolar Canal

- Insert/Rotate Master Cone SLOWLY to minimize apical pressure

 Firm pressure ONLY @ WL

 Go up-down as you push down

- Insert D11TS (Root Canal Spreader) with minimal force & compact accessory cones

Compare Traditional Lateral Compaction vs. Modified Technique

Traditional Lateral Compaction Modified Technique

Voids common Excellent Adaptation
Poor compaction Uniform and thing sealer
Excessive sealer Minimum accessory cones

LECTURE 11:

What are the clinical examinations for Endodontics?

- Percussion
  Tenderness to Percussion  a sign of abnormality; doesn’t mean it requires treatment right away

- Palpation

 Gingiva, Sulcus

- Occlusion

 Restoration, Pain on Biting, Fracfinder testing, Occlusal Interferences, Bruxism, Plunger Cusps

- Periodontal

 Periodontal Health, Cracks, Drainage

- Transillumination

 Identify crack

- Pulp Testing

 Cold Test (GOLD STANDARD)

 CO2 (-72 C) vs. Spray (-20 ~ -55 C)

 Heat Test

 Use Rubber Dam and Boiling Water in Syringe for 30s  See if patient responds in 2 mins

 Electronic Pulp Test

 No response  High chance it’s necrotic (0-80)

- TMJ

What factors affect pulpal testing? TAO

Age:

- Immature Teeth: Less responsive to EPT, More responsive to Cold

- Older Teeth: High Calcification  Respond better to EPT

Trauma:

- Disrupted nerve supply NOT blood supply

Orthodontics:

- Impaired blood flow

What are different Pulpal Diagnosis?

Healthy Pulp:
 - Vital

- No Inflammation

- Asymptomatic

- Normal Response

Reversible Pulpitis:

- Vital (can heal)

- Mild Inflammation

- Thermal Pain

- Not Spontaneous pain

Irreversible Pulpitis:

- Severe inflammation

- CAN’T heal

- Exaggerated response (@Start: extreme pain  @end: dull pain)

- Spontaneous pain

KEY: Antibiotics are USELESS for Irreversible Pulpitis

Necrotic Pulp:

- Total/Partial Necrosis

- No response to pulpal testings

- Symptoms vary (from 0 to VERY severe)

Previous Initiated Treatment  RCT has been started but not completed

Previously Treated  RCT has been completed

Hyperplastic Pulpitis  Development of granulation tissue from pulp causing low-grade chronic
inflammation

Internal Resorption
What are different Periapical Diagnosis?

Normal Apical Tissue

- Normal Tissue

- Not Tender

- Intact Lamina Dura

Apical Periodontitis:

- Symptomatic

 Inflammation of Peri-Radicular Tissues

 Pain on Percussion / Radiolucency

- Asymptomatic

 No symptoms

 Necrotic

 Radiolucency at Apex

Acute Apical Abscess

- Rapid onset

- Tenderness

- Swelling

- Localized swelling  causing pressure (from pus) and pain – may need drainage

Chronic Apical Abscess

- “Suppurative Apical Periodontitis” (body found its drainage so no pain)

- Gradual onset of infection

- Little/No Discomfort

- Sinus Tract
Condensing Osteitis

- Diffuse radiopaque lesion

- Localized bony reaction

- Low-grade inflammatory stimulus

- May be tender

- Pulp testing inconclusive

What are 2 factors to consider after Completing Endodontic Treatment?

- Good quality Coronal Restoration

- Full Cuspal Coverage

LECTURE 13: Radiology

What are the minimum number of X-rays you need to take?

Pre-Operative

Mid-Treatment X-rays:

- Working Length

- Cone-Fit

- Mid-Obturation

Post-Treatment X-rays

What are different X-ray Film options?

Analog X-ray Films Digital (Phosphor Plate) Digital CMOS Sensor

Thin & Easier to tolerate Quality similar to conventional film Instant Image
Ample holders Reusable Last long time (+10 years)
Long exposure time Slower than CMOS sensor Bulky, Difficult to tolerate
Not reusable Poor Angle

How to take Mid-Treatment X-rays?

Film & Artery forcep

Key features of Mid-Treament X-rays

- Film should be against the palate or in lingual sulcus

- Edge of the film should be close to occlusal plane

- Radiographic cone should be perpendicular to film

How do you judge Diagnostic Value of endodontic X-rays?

- Able to see APEX of tooth and BONE

- Able to see END of instrument or root filling

- Good angulation

- Minima cone cut, correct exposure and contrast

Is lead apron needed?

Not required unless:

- Children

- Pregnant ladies

How to reduce radiation

Distance

X-ray Holders to prevent retake

Good technique (Reproducible, Consistent, Inexpensive)

L15: Intracanal Procedural Accidents:

How to manage “Access-Related Procedural Errors”?

Wrong tooth:

- Identify tooth clinically/radiographically, recognize different restoration and morphology

Crown fracture

- Composite resin repair OR new crown

- TO PREVENT: HS diamond bur to cut ceramic &

Tungsten Carbide bur to cut metal

Perforation:

- Management depends on size and location (MTA might work)

- Prevent by knowing canal/pulp chamber anatomy

How to prevent “Instrument-Related Procedural Errors”?

Gouging: Excessive removal of tooth structure during access and coronal flaring

- Good vision, Illumination and Access, Locate canals using DG16 Probe

Transportation: File cuts more on external surface and straighten curved canal

- Incremental use of files, pre-curve, NiTi instrumentation

Ledge: Iatrogenically (by dentist) created irregular platform in the root cananl
system

- Straight-line access, incremental use of files, tactile sensation

Elbow and Zip: Straightening out of the working file within canal

- Incremental use of file, avoid large hand files, NiTi instrumentation

Canal Blockage: due to compaction of debris or hardened mass

- Irrigation in between, maintain canal patency

Fractured Instruments

- Clinical: loss of WL, shortened instrument, visual confirmation

- Radiographic: presence of file on PA

Extrusion of medicament

- Careful usage of calcium hydroxide

How to prevent “Obturation-Related Procedural Errors”?

Tissue necerosis

- Temperature increase of > 10 C may cause irreversible bone and PDL damage
  Dentine thickness, Application duration, Obturation technique

- Recognize: pain during Tx, tenderness to percussion, mobility, periodontal/alveolar bone necrosis

- Management: Analgesic, Antibiotics, OH, Refer to OMFS(Surgeon)

- Prevent: Intermittent heating, water coolant, keep heat as low as possible

Over/Under-Filling and Sealers

- Recongize: pain DURING tx or pain or paraesthesia AFTER obturation

- Potential complication: nerve damage when over-extend into mandibular canal/mental foramen

** BUT usually overfilling is okay – often complication w/ lower molars with IAN

** Overfilling of GP  Not as okay; doesn’t get resorbed easily by the body

** Overfilling of Sealer  Okay  gets resorbed

Nerve Injury:

- From Intracanal procedures, Over-Instrumentation, Medicament Extrusion, Rootfilling overextension

Recognition: sudden pain during TX and persistent pain or localized anaesthesia

Management: Refer to OMFS, Regular review, Antibiotics, Analgesics, Corticosteroids, Proteolytic Enzymes, Vit C

- Surgical management: over 90% IAN improved after microsurgical repair

Prevention: Preo-Op assessment, RCT within root canal system

What are other procedural errors?

Tissue Emphysema – passage and collection of air into tissue space

- Cause: compressed air during restoration (EXO, Periodontal Tx, Endodontic Tx)

 Endo  Blast of air into access/during treatment

- Recognition: rapid face swelling, erythema (redness), crepitus (friction sound/sensation), dysphagia and
dyspnea (trouble swallowing and breathing)

- Potential Complications: spread to neck, respiratory difficulty

- Management: Reassurance (resolve in 3-4 days), Analgesics, Medical referral if (dyspnea or dysphagia)

Sodium Hypochlorite Accident – tissue injury

- Cause: Iatrogenic (caused by medical tx/exam), us NaOCl as LA by accident, Open Apex, Close proximity
to tissue spaces

- Location: Maxillary teeth > Mandibular (70% maxillary premolars and molars, 30% anteriors)
LECTURE 16: Aseptic Technique

What are 4 Aseptic Concepts in Endodontics?

- Eliminate microorganisms

- Prevent cross-contamination between patients

 File management during Tx, Sterilisation of Rotary Instrument, Clinical Zoning

- Prevent introducing new microorganisms

 Rubber Dam, Sterile Instruments, Clean working area

- Protect Operator

 Remove RD carefully (clamp first, be area of overflown saliva and blood)

What are criteria for “Sterile” instruments?

- 121 C degree, 30 minutes, 15 psi

- Gamma Radiation

- Pouched less than 6 months

What are different clinical zonings?

- Sterile, Clean, Dirty, LA & RD, Access & Endo Tx,

What are steps to sterilize rotary instrument?

What are different Endodontic outcome with aseptic measures?

Rubber Dam: Higher survival rate

Gloves Contamination: “Propionibacterium acnes” number increases on gloves during endodontic treatment

- At initial, after acess, after working length, before removing rubber dam

- Can contaminate sterile GP with P. Acnes, S. Epidermidis  1 min of 5% NaOCl to remove bacteria

BUT will require more research to see if it improves outcome!

LECTURE 17: Discolouration & Internal Bleaching

Where do you get the color of the tooth?

- Enamel: translucent (consist of blue, green, pink)

- Dentine: less translucent (yellow-brown)

KEY: variations in the inorganic structure & organic components  different optical properties

KEY: deciduous teeth are more opaque white (less translucency); less-dense and less-organised
enamel crystalline structure

How to describe colour?

Hue  families of colour

Value  relative lightness and darkness of a colour (along black-white scale)

Chroma  degree of colour saturation (intensity, strength of colour)

What are the 2 different discolouration? How are they different?

Extrinsic Discolouration:

- Chromogen lies NOT on dental hard tissue but in surface deposits (areas of thicker acquired pellicle
and reduced cleaning)

 Critical role of Pellicle  mechanism unknown

 Interaction between pellicle & chromogen  may just act like a sponge to enhance uptake of
chromogen

Intrinsic Discolouration:

- Interact chemically to produce a stain (usually colourless compounds)

Different Causes:

- Metabolic, Inherited, Idiopathic (MI hypomineralisation), Traumatic (dental trauma), Iatrogenic

(tetracycline +endo/ restorative material)

 Dental Trauma:

 Induce pulpal haemorrhage  immediate discolouration (in a few days)

 Blood components penetrating into dentinal tubules  Pink Hue (disappear once pulp recovers)

 Delayed discolouration (if pulp is not vital)  from pulp necrosis and infection

Further discolouration as Iron (from blood product) react with bacterially derived Hydrogen Sulphide

 IF goes more YELLOW  pulp space calcification follow trauma

 Endodontic Material:

 From Sealer in pulp chamber & Use of Tetracycline-containing Intracanal Medicaments

 Obturation materials should be limited to root canal & Tetracycline-containing medicaments

should be avoided

What is the internal bleaching agent available?

Hydrogen Perioxide (H2O2)

- Strong oxidizing / Colourless agent

- Breakdown molecules = “free radicals” + “reactive oxygen molecules & hydrogen perioxide anions”
 Mechanism of Action:

- Oxidation  breakdown products “cleave double bonds of large pigmented molecules to form NON-
PIGMENTED smaller molecules”

 Accelerated by HEAT, LIGHT, and ELECTRONIC CURRENT

What are some Hydrogen Perioxide creating chemicals?

- Carbamide Peroxide

- Sodium Perborate

What are 4 methods of External bleaching?

KEY: Whether at HOME or OFFICE  time and concentration dependent procedure

Common Complications:

- Unpleasant taste & Burning Sensation

- Tooth Sensitivity

- Mucosal Irritation

What is the “Walking Bleach Technique”?

Intracoronal application of bleaching agent following endodontic treatment to chemically eliminate discolouration
from internal surface

- Most widely practiced technique: uses “Sodium Perborate”

What are some Internal Bleaching Technique?

- Mix with hydrogen peroxide  Conflicting result

- Cotton Pellet?  leads to COLOR REGRESSION (losing colour)

- How long should I leave it  1-4 weeks (ideally 4 weeks)

When are difference effectiveness of internal bleaching?

Favourable responses expected: Younger TEETH Less predictable responses expected: Older Teeth
Larger tubules Narrow tubules
Short-Term Discolouration Long-Term Discolouration
Cases where discolouration due to Trauma and Cases where discolouration due to metallic ion &
Necrosis endodontic and restorative materials
Key factors  “Sound Coronal Restoration” is an important factor to ensure longevity of internal bleaching result
(re-leakage)

What are possible complications?

- Invasive cervical resorption

 Unknown mechanism

 Risk Factor  High concentration of Hydrogen Perioxide +/- HEAT

 TOOTH w/ history of trauma  still @ risk of Invasive Cervical Resorption

- Sodium Perborate & Water  Internal bleaching is safe

LECTURE 18: RESTORATION of ENDODONTICALLY TREATED TEETH

What is treatment outcome in Endo?

DISEASE SPECIFIC: Prevent/Cure Apical Periodontitis  manage as BACTERIAL infection

PROCESS CENTRED: Quality of Treatment determined by:

 Instrumentation

 Obturation

 Restoration

PATIENT CENTRED:

- Function, Aesthetics, Pain Free, Long Term Retention

What are the factors that affect Endodontic Treatment Planning?

Tooth factors

Operator experience and judgement

Patient’s needs and expectations

What do ideal treatment plan target?

- Solve chief complaint

- Provide long-term solution

- Cost effective

- Meet/Exceed patient expectations

- Patient-centred

How do Endo-Treated Teeth differ compared to real teeth?

- Change in moisture content (9%)

- Effects of medicaments/irrigants on root dentine

- Loss of Proprioception

 Lose the protective feedback mechanism when pulp is removed (2 times more force required to feel
discomfort)

- Loss of tooth structure

 Lose stiffness by 5% with conservative access (used to be @ roof of pulp, after endo  more @ CEJ)

 20% loss of strength with EACH surface lost (marginal ridges)

 Cuspal flexure increase with INCREASED FORCE and LENGTH

How do endo-treated teeth fail?

Fail to:

- Resolve infection, Carives/Periodontal Involvement

- Protect crown/root from fracture and stress

- Give a good seal, and Appropriate Occlusion

- Retain Crown
Why do endo-treated teeth fail?

Degree of Stress under load

Biomechanical Properties on remaining structure

- Loss of Structure

- Fatigue over time

- Failure to resist initiation and propagation of cracks by dental tissues (age related changes)

Why Minimally Invasive Endodontic is required?

Maintain Strength & Stiffness & Resist Structural Deformation

- Minimal Access Cavity  preserve structural integrity

How do we practice conservative dentistry?

Well-aligned & GOOD QUALITY radiographs

 Gives you useful information that affect diagnosis

- Pathology & Caries

- Restorative Margin

- Calcification

- Anatomical variations

- Root Curvature

- Number of roots

- Tooth Angulation

- Distance from Restoration to Pulp, Furcation to Pulp

Preserve structural integrity

- Armamentarium

- Rotary NiTi instruments

 Conservative Prep, Centred, Less Straightening, Safer Radicular

- Know dental anatomy

 Laws of Centrality: floor of pulp chamber located always @ center of tooth @ CEJ level

 Laws of Concentricity: walls of pulp chamber are concentric to external surface of tooth @ CEJ level
  Laws of Colour Change: floor of pulp chamber  darker than surrounding walls

 Laws of Symmetry: orifices are Equi-Distant and Perpendicular to a line drown from
Mesio-Distal direction

 Laws of Orifice location: orifices located at the JUNCTION of walls and floor

- Remove Exisiting Restoration

 Advantages:

 Access restorability

 Eliminate leakage/caries

 Crack detection

 Anatomical Orientation

 Location of Pulp chamber

- Minimize loss of tooth structure

 Strength (or fracture resistance) of tooth determined by amount of remaining dentine after tooth
prep

 Consequences: Tooth fracture, Secondary Caries, Loss of Retention

What are restorative factors that can affect endodontic prognosis?

- Coronal microleakage

 Quality of permanent coronal restoration (and temporary)

 Post Spaces must be blocked (Suckdown Splint, Bonded temporary crown, Intracanal barrier)

- Cuspal Coverage

 Loss of marginal ridge  weaken all cusp

 Selective cusp capping  leaves uncapped cusps weakened

 Complete occlusal coverage w/ Amalgam or GOLD  Strength all cusps

How do occlusion defer?

Bite Forces

- Variations among genders (male stronger than female; incisor/molar)

- Destructive Enviroment (Sharp cusp, Plunger cusp)

 - Parafunction: increased load levels, prolonged loading times, increase in loading cycles

Anterior Teeth - shearing & Lateral forces

Posterior Teeth – axial forces (molars & mandibular premolars), lateral forces (maxillary premolars)

Which 3 factors affect restorative options?

- Amount of Coronal Structure left

- Aesthetics

- Occlusal forces

What are restorative options for Anterior and Posterior Teeth?

Anterior Teeth Posterior Teeth

Composite Resin Direct Restoration
- Cheap
- Minimal-moderate size
- Immature root (good seal & aesthetics)
- Yonger patients
Veneers Direct Overlay
- Conservative option
PFM Indirect Overlay
- Extensive restoration
Ceramic Crown Crown (indirect)
- Extensive restoration - Increased retention
- Good long-term outcome
- Able to improve aesthetics
- Able to modify coronal form of tooth

Anterior Teeth affected by 3 factors:

Ferrule Effect (ideal 1.5-2mm – each 1mm double fracture resistance)

 Increase in fracture resistance

 Resist functional lever forces

 Resist wedging effect of post

Post

 Core in a tooth that has extensive coronal structure loss

 DO NOT STRENGTHEN TOOTH (remaining tooth structure strengthen the root not metal)
  5mm of apical GP for seal (immediate prep required for post space)

Biological Width (from Alveolar Bone to Epithelial Junction/Base of Sulcus – minimum 3mm required)

 Response to invasion (inflammation, loss of cystal bone, gingival recession, hyperplasia)

What are principles of Post?

- NOT indicated for molar teeth (but

largest/straightest canal might need)

- Premolars (might be required for

crown)