ENDODONTICS FINAL REVIEWER

ENDODONTICS

Branch of dentistry concerned with the :o Morphology – shape of the pulp cavityo Physiology – reversible or irreversible stateo Pathology of the human dental pulp and periradicular

tissues Its study and practice encompass the basic and clinical sciences

including the biology of the normal pulp and the etiology, diagnosis, prevention and the treatment of diseases and injuries of the pulp and associated periradicular conditions

REVERSIBLE PULPITIS – diagnosis of class 1 to 5 restoration

IRREVERSIBLE PULPITIS – do root canal therapy

SCOPE OF ENDODONTICS

1. Differential diagnosis2. Treatment of oral pains of pulpal and/or periapical origin

(orthograde/conventional RCT)3. Vital pulp therapy

a. Pulp cappingb. Pulpotomy

4. Non-surgical treatment of root canal systems with or without periradicular pathosis of pulpal origin

5. Selective surgical removal of pathological tissues resulting from pulpal pathosis (e.g. cyst)

6. Intentional replantation and replantation of avulsed teeth7. Surgical removal of tooth structure

a. Root-end rsectionb. Bicuspidization – cut molar to form 2 bicuspidsc. Hemisection - 1 root only for RCTd. Apicoectomy (retrograde/conventional endodontics)

8. Bleaching of discolored dentin9. Retreatment of teeth10. Treatment procedures related to coronal restorations

OBJECTIVES

1. To be able to retain a tooth inside the oral cavity which may otherwise require extraction (ex. For extraction: no bone support anymore; horizontal fracture or root fracture)

2. Relief of pain, if present3. Removal of pulp from root/s of tooth4. Disinfection of root and surrounding bone by cleaning and

shaping of the root canal walls (use of irrigate sodium hypochlorite)

5. Complete filling of root canal (obturation)6. Placement of final restoration (if not restorable, extract)7. Main contraindication: non-restorable tooth

HISTORY (1977 to PRESENT)

Improved visibility is now available with the advent of the endodontic microscope

The single visit endodontic therapy globally accepted by all school taught

Newer and better

BASIC PRINCIPLES

1. Chain of asepsisa. Paper points = 5 secs in glass beadsb. Gutta percha = 1 min in chloroxc. Rubber dam = alcohold. Instruments = sterilize (autoclave)e. Files = autoclave or glass beads

2. Correct diagnosis and treatment planning3. Atraumatic holding of tissues4. Cleaning of the canal – debridement and removal of biofilm

sticking on the canal walls5. Shaping of the canal6. Complete obturation7. Restoration8. Recall

RATIONALE

1. Saving the natural teeth to health2. Restore efficient mastication3. Control pain and swelling4. Speech and phonation5. Preserved occlusion6. Esthetics

BASIC CONCEPT OF ROOT CANAL THERAPY

If bacteria and byproduct of pulpal inflammation has been reduced to a non-critical level of infection, it will effect a cure allowing resolution and repair of damaged depends on the virulence

APPLIED ANATOMY OF THE ROOT CANAL SYSTEM

1. ROOT CANAL SYSTEM2. SIGNIFICANCE OF STUDYING THE ROOT CANAL SYSTEM3. FACTORS AFFECTING ROOT CANAL MORPHOLOGY

SPECIFIC OBJECTIVES

1. To review the individual root canal morphology of human teeth and relate it to endodontic treatment

2. To know the factors that alter root canal morphology3. To understand the effect of root canal system complexities to

endodontic treatment4. To be familiar with other variations in the canal systems5. To recognize the relationship of internal anatomy to endodontic

procedures

Maxillary molar

3 roots (MB, DB and palatal) 4 canals (MB, DB, MP and palatal)

ROOT CANAL MORPHOLOGY AND ITS SIGNIFICANCE

1. DIAGNOSIS – to know indication and case selection for root canal2. TREATMENT – to guide us in all treatment procedures3. PROGNOSIS – to predict the outcome of the treatment

ROOT CANAL SYSTEM

1

Pulp is located and found at the center of the tooth Unique for every tooth and is highly variable

SCHEMATIC SECTION (CROSS SECTION) OF THE TEETH

The shape of the pulp chamber and the outline of the canals are a reflection of the outline of the surface of the crown and root

DIFFERENCE BETWEEN ROOF AND FLOOR

ROOF FLOORLOCATION C3rd of crown C3rd of root

COLOR Yellowish DarkerDENTINAL MAP Absent Present

TEXTURE Rough; no definite shape

Smooth; convex

DENTINAL MAP – line that connects the orifice of the canal

METHODS OF STUDYING THE ANATOMY OF THE ROOT CANAL

1. Ground section (cross or lingual)2. Histologic3. Radiograph4. Clearing technique5. Acrylic cast6. Silicone injection

FACTORS AFFECTING ROOT CANAL MORPHOLOGY

1. Age2. Caries3. Developmental anomalies

a. Dilacerations – severe bend or distortion 45 - 90°b. Taurodontism – bull or prism teethc. Dens en dented. Microdontiae. Macrodontia

4. Irritatnts – pulp stones, internal resorption5. Attrition6. Abrasion7. Erosion

a. Internal resorption (thermoplastic gutta percha)b. External resorption

8. Trauma9. Clinical procedures

ROOT CANAL CONFIGURATION

TYPE CONFIGURATIONI 1-1II 2-1III 1-2-1IV 2-2V 1-2VI 2-1-2VII 1-2-1-2VIII 3-3

Maxillary Second Premolar

The only tooth that showed all 8 possible configurations

ACCESS CAVITY PREPRARATION

Cavity prepared on crown of teeth fro endodontic instruments and materials to gain direct path towards the apex for biomechanical preparation and obturation

OBJECTIVES

1. To create a smooth, straight line path to the canal system up to the apex

2. To remove caries and debris from the chamber3. To allow for complete irrigation4. To establish maximum visibility to gain access up to the end of the

canal (apical foramen)

IDEAL ACCESS RESULTS IN

1. Straight entry into the canal orifices, with the line angles forming a funnel drops smoothly into the canal or canals

2. Quality endodontic result

“Variation of rooth canal anatomy is more of a rule rather than an exception.”

ANATOMY OF THE TEETH

Center (x-ray) Create imaginary line to know how many orifice are there Maxillary second premolar

o 1 root = 1 canal (canal is at the center)o Variations:

2 roots = 2 canals 3 roots = 3 canals

Maxillary first molaro 3 roots = 4 canals (MB, DB, MP and P)

Mandibular incisorso 2 canals

Mandibular second molaro 2 roots = 3 canals (Distal, MLi and MBu)o C-shaped canal

Fusion of MB and Distal canals 2 canals

WAYS OF GAINING ACCESS

ANTERIOR – LINGUAL POSTERIOR OCCLUSAL Enamel = size2 round bur Dentin = size 1 or 2 round bur Roof = size of bur depends on the size of roof and pulp chamber

o has reddish color if it is vital but it is whitish color if it is non-vital because there is no more or there is little space

if access is small:o you cannot locate all of the canalso incomplete cleaning because apical end can be

inaccessible faulty canal access = infection

o perforations = man-made canalso ledges – step being created

2

o strip side of danger zoneo zipping of the apical endo opening of the apical endo formation of an elbow

STEPS IN ACCESS

1. Study pre-operative radiograph To know how big the chamber is To know which bur to use in gaining access

2. Remove all caries, weak restorations and do crown build-up after locating the canal

Caries – to remove microbes Weak restorations – debris, leaks Crown buildup – for adaptation of rubber dam

3. Draw outline form on the lingual or occlusal surface of teeth Size and shape of the access cavity depends on the size

and shape of the pulp chamber4. Rubber dam isolation5. Use #4 round bur for initial access through the enamel then

dentin on narrow canals 45° angulation of the bur

6. When the bur “drops in”, unroof the pulp chamber7. Refine the access preparation using non-end cutting tapering

fissure bur8. Explore the orifice using the endo explorer9. Use nerve broach to remove vital pulp on large canals and small

sized files on narrow canals

EVALUATION O F ACCESS CAVITY PREPARATION

1. Correct location of access preparation2. Correct outline form3. Properly unroofed pulp chamber, lingual shelf/shoulder removed4. Gouging and ledging absent5. Refined access cavity preparation6. Canal orifice should be visible7. Conserve the tooth structure8. Straight line access

DIAGNOSIS

Objectives:1. To be able to systematically collect, record and analyze

data in order to formulate a correct diagnosis2. To know how to and when to perform the different

endodontic testsI. Definition and importance of diagnosis

II. Science of diagnosis (data development)a. Patient’s historyb. Clinical examination

i. Extraoral examinationii. Intraoral examination

c. Radiographic examinationd. Diagnostic tests

i. Thermal pulp testing1. Heat test – use gutta percha

stick then put it n the surface of the tooth after putting Vaseline

2. Cold test – how long before the patient feels it? How long does the patient feel after?

ii. Electric pulp testeriii. Percussion testiv. Palpation test – use index fingerv. Periodontal probing depths

vi. Mobility testing – use 2 mouth mirrorsvii. Cavity test – teeth with caries only

viii. Transillumination – used to see if there is a suspected fracture on the tooth

ix. Gutta percha tracingx. Hot/cold water bath

1. Most reliable2. Use rubber dam for isolation

All non-vital teeth = for RCT

All vital teeth = depends if it is reversible or irreversible pulpitis

DEVELOPING DATA – PATIENT HISTORY

CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS

1. PRIMARY SOURCE OF PAIN Pulp Periodontal ligament

2. REFERRED PAIN Adjacent tooth Opposing tooth Non-odontogenic in nature Organic cause: emotional/systemic

MEDICAL HISTORY – vital signs DENTAL HISTORY OTHER PERTINENT PATIENT’S PERSONAL INFORMATION

THERMAL PULP TESTING

1. COLD TESTa. Cold water bath – most accurateb. Ice tube – least accurate

2. Response to thermal testa. No response – no-vital pulpb. False negative – excessive calcification, immature apexc. Reversible pulpitisd. Moderate to strong response

ELECTRIC PULP TESTING

FALSE POSITIVE RESPONSEo Patient anxietyo Wet tooth (to gingiva)o Metallic restorations (to adjacent tooth)o Liquefactive necrosis (to attachment apparatus)

FALSE NEGATIVE RESPONSEo Premedication (drugs or alcohol)

immature teetho Trauma

SPECIAL TEST

Wedging and staining

DIAGNOSIS

3

The dentist/clinician must be able to analyze and synthesize the gathered results to arrive at a correct choice of treatment and therefore a good case prognosis

HOW WILL YOU KNOW IF THE TOOTH NEEDS RCT WHEN YOU USED THE COLD TEST?

If the patient still feels pain even if the stimuli has been removed for a long time

FOR PERCUSSION TEST

It has a different feeling compared to the other teeth that has been percussed

PERCUSSION, MOBILITY AND PALPATION

Cannot determine whether there is pulpitis or a necrotic pulp because the disease is confined within the internal of the tooth, particularly the pulp. These are tests for the surrounding tissue of the tooth such as bone support and the periodontal ligament

CLINICAL CLASSIFICATION OF PULPAL DISEASES

1. NORMAL PULP – within the normal limits2. PULPITIS

a. REVERSIBLEb. IRREVERSIBLE

i. SYMPTOMATICii. ASYMPTOMATIC

3. NECROSIS

HEALTHY PULPTEST RESULT

THERMAL/EPT Mild to moderate transient responsePERCUSSION -PALPATION -

RADIOGRAPH clearly delineated root canalnegative resorptionintact lamina dura

REVERSIBLE PULPITIS

Inflammation of the pulp that is manifested by initial congestion of blood vessels

If the cause is eliminated, inflammation will be resolved and the pulp will return to normal

Treatment: restoration

IRREVERSIBLE PULPITIS

All irreversible pulpitis needs ANESTHESIA The tooth cannot go back to its normal state because the pulp

cannot recoverA. SYPMPTOMATIC

Episodes of pain due to sudden temperature change Localized referred pain which lingers Pain is:

i. Moderate to severeii. Spontaneous, intermittent or continuous

iii. Sharp or dull Pain may be:

i. Relieved by application of heat/cold

ii. Affected by postural changeiii. Radiating or referrediv. Difficult to localize

Radiograph:i. Deep caries with apparent pulpal exposure

ii. Has normal surrounding structuresiii. Lamina dura is intact

Treatment:i. RCT – best solution to preserve the strong

toothii. Extraction – f patient doesn’t want to

undergo RCTB. ASYMPTOMATIC

1. CHRONIC HYPERPLASTIC PULPITIS Aka PULP POLYP Reddish cauliflower-like growth Low-grade chronic irritation of the pulp and

generous vascularity May cause mild, transient pain during

mastication Treatment:

i. Excision of the pulp polypii. RCT or extraction

CLINICAL DIAGNOSIS (PULP POLYP vs GINGIVAL HYPERPLASIA DIFFERENTIAL DIAGNOSIS

i. Raise and trace the stalk of the tissue back to its origin, if it is inside the pulp cavity, it is pulp polyp, if not, it’s gingival hyperplasia

2. INTERNAL RESORPTION “PINK SPOT” Painless expansion of the pulp chamber that

results in destruction of dentin Low-grade inflammation; negative to pulp test Identified during routine radiograph: shows an

irregular shape of the pulp Treatment:

i. Prompt RCT to prevent root destruction

3. INTERNAL CALCIFOCATION/CANAL CALCIFICATION (PULP STONE)

Appear as excessive deposition of dentin throughout the canal system

Coronal discoloration suggests chamber calcification

Identified during routine radiograph exam Treatment:

i. RCT – however, it is difficult to do because it is difficult to see the floor

1. Drill with round bur then remove with explorer

Positive to thermal test

PULP NECROSIS (DEAD PULP)

1. Visual exam: With or without toth discoloration Thermal test is negative Ept is negative

Percussion is either positive or negative

4

Thickening of the periodontal ligaments and may manifest as tender to percussion and chewing

1. PARTIAL NECROSIS May produce symptoms associated with irreversible

pulpitis2. TOTAL NECROSIS

Asymptomatic before it affects the periodontal ligaments

3. Treatment: RCT or extraction

CLINICAL CLASSIFICATION OF PERIAPICAL DISORDERS

1. APICAL PERIODONTITISa. ACUTE

i. Percussion (+)ii. Radiograph shows slightly widened

periodontal ligamentiii. Need for endodontic treatmentiv. Note: the only one that is /may be vital or

non vital. The others are non vital because it can be caused by trauma

b. CHRONICi. Asymptomatic; breakage of lamina dura

ii. Tooth feels “different”iii. Thermal is negativeiv. EPT is negativev. Percussion and palpation are positive

2. PERIRADICULAR ABSCESS ABSCESS – except acute periradicular abscess,

radiolucency of the apex is seen in the radiographa. ACUTE

i. Moderate to severe painii. Rapid onset of slight to severe swelling

iii. Patient may be febrile infection has spread out with cellulitis

iv. Tooth is non-vitalv. Percussion and palpation are positive

vi. Mobility – possibility of slight increase in mobility

vii. Radiograph shws a widened periodontal space (no radiolucency)

viii. Rapid onset of disease because the cortical plate is not yet affected

b. CHRONICi. There is drainage of the pus so it is not

painfulii. Radiograph shows a periapical radiolucency

3. PHOENIX ABSCESS (ACUTE EXACERBATION OF CHRONIC LESION) has to undergo chronic stage first radiograph shows a periapical radiolucency visual exam: no sinus tract

In chronic abscesses, there is no need to give antibiotics because there is drainage

CASE SELECTION AND TREATMENT PLANNING

OBJECTIVES

1. to be able to identify important factors to consider in case selection

2. to determine which teeth are salvageable for RCT and which are not

3. to be able to develop an individualized endodontic treatment plan for each patient

WHY DO WE DO CASE SELECTION?

1. To determine if endodontic treatment should and could be performed

2. To determine the need for consultation and specialist referral

FACTORS TO CONSIDER IN CASE SELECTION

1. Tooth consideration 2. patient consideration3. clinician consideration

INDICATIONS FOR RCT

1. teeth with irreversible pulp disease with or without periradicular disease

2. teeth with normal or reversible inflamed pulps but:a. will be used as overdenture abutmentb. for limited correction of malposed teethc. need to do pulp cavity to retain the restoration

3. extensive restoration on a tooth with questionable pulp status

TOOTH CONSIDERATION PROPER CASE SELECTION SHOULD ENDODONTIC TREATMENT BE PERFORMED?

1. An endodontic problem exists but certain conditions contraindicate RCT

CAN ENDODONTIC TREATMENT BE PERFORMED?1. An endodontic problem exists but does the clinician

have the skill and armamentarium to get it done Examples:

1. PERIODONTAL SUPPORT Yes, even with bone loss, the tooth is still

not mobile Strategic location of the tooth Get clearance from periodontist

2. RESTORABILITY Yes, but a specialist is needed to perform If perforation happened

Hemisection Crown lengthening

3. DILACERATION With the advent of witi files (nickel

titanium) root canal curvatures can now be negotiated. Refer to a specialist, since it is a difficult case. But if conventional therapy it is possible or impractical

4. CARIOUS LESION BELOW THE GINGIVA Yes, it can be restored but first same

procedure should be done prior to RCT5. OPEN APEX

Yes, but some procedures should be performed

5

Use of MTA (Mineral Trioxide Aggregate) to close the apex

REVASCULARIZATION New treatment to close the apex Continuous formation of dentin

and growth of the tooth even without the pulp

6. INTERNAL RESORPTION Immediate RCT (thermoplasticized gutta

percha)7. “S” SHAPED CANAL

Has 3 angles Refer to a specialist

8. CALCIFICATION Refer to a specialist

9. CENTRAL INCISOR (DIFFERENT) Traumatic injury (formation)

10. LENTILOSPIRAL (BROKEN) See a specialist Location of the canal is difficult

11. LARGE PULPAL CHAMBER Orifice is too far Location of the canal is difficult

12. VERTICALLY FRACTURED No RCT because it cannot be sealed

CLINICAL CONSIDERATIONS (CAN IT BE DONE?)

1. Objective clinical findings2. Difficult diagnosis3. Difficulty in obtaining films of diagnostic value4. Malpositioned tooth, rotated, tipped too far distally5. Clinician’s level of expertise6. Availability of necessary materials and equipments

PATIENT CONSIDERATIONS

1. MEDICAL CONSIDERATIONS2. LOCAL ANESTHETIC CONSIDERATIONS

a. Allergy, vasoconstrictor contraindications, history of difficulty in obtaining profound anesthesia

3. PERSONAL FACTORSa. Size of mouth, limited ability to open mouth, gagger,

motivation to preserve dentition, physical impairment, limitation to be reclined, oral hygiene

4. SPECIAL NEEDSa. Psychological and mental healthb. Economic status

5. TIMING OF APPOINTMENT6. LENGTH OF APPOINTMENT

TREATMENT PLANNING

1. PHASE OF TREATMENTa. PRE-TREATMENT PHASEb. TREATMENT PROPERc. POST-TREATMENT PHASE/FINAL RESTORATION

2. SINGLE VISIT RCT3. MULTI-VISIT RCT

OBJECTIVES OF TREATMENT: To restore teeth’s function and esthetics

OBJECTIVES OF TREAMENT PLANNING: To achieve treatment goals efficiently discuss before, during and

after

CHARACTERISTICS OF A GOOD TREATMENT PLAN:

1. It is individualized/personalized2. It is flexible3. Patient has a final choice (tell the pros and cons)

PRE-TREATMENT PHASE

To prepare Scaling and polishing Extraction Caries control – to know the restorability of the tooth and asepsis

TREATMENT PROPER (ORDER WIL DEPEND ON CHIEF COMPLAINT)

Endodontic treatment Operative procedures Prosthetic rehabilitation Periodontal therapy (periodontist) Complex surgical procedures Orthodontic treatment

MAINTENANCE PHASE (POST-TREATMENT PHASE)

To monitor healing To detect new disease Take recall radiograph Perform clinical examinations Reinforce oral hygiene Do scaling and polishing

SINGLE VISIT RCT

6 months/ 1 year / 2 years Vital cases (irreversible pulpitis) Clinician’s skill Severity of patient’s symptoms

MULTIPLE VISIT RCT

Complex caseso Anatomy of the tootho Calcified cases

Retreatment cases Non-vital cases with apical periodontitis

o The use of intracanal antimicrobial agents will add significantly to the effectiveness of the treatment

Appointments should be approximately one week apart to maximize antimicrobial effects

Allow 5 – 7 days between instrumentation and obturation for the periradicular tissues to recover

SUMMARY AND CONCLUSION

Proper case selection will affect treatment outcome To do or not to do retreatment

6

PRE-ENDODONTIC PROCEDURE

1. PREPARATION OF OPERATORY2. PATIENT PREPARATORY

a. SCALING AND POLISHINGb. PAIN CONTROL

i. ANESTHESIAii. PHARMACOLOGY

3. TOOTH PREPARATIONa. CARIES CONTROLb. RADIOGRAPHc. BUILD UP/TEMPORIZATIONd. CROWN LENGTHENINGe. ISOLATION

SPECIFIC OBJECTIVES

1. To describe proper infection control and occupational safety procedures

2. To explain the importance of treatment planning and case presentation during patient discussion

3. Recognize the need for adjunct procedures (ex. Scaling and polishing, etc)

4. Describe the routine approaches to endodontic anesthesia, when and how to anesthetize

5. Describe when to employ alternative methods of obtaining pulpal anesthesia

6. Review the techniques for periodontal ligament, intra-pulpal, infiltration, block, intraosseal and mental block anesthesia

7. Explain the pre-medication and pain control in endodontics8. Review the appropriate use and dosage of analgesics and

antibiotics9. Describe the indications for systemic antimicrobial therapy in RCT10. Relate the reasons for caries removal and temporization to RCT

PREPARATION OF OPERATORY

IMPORTANCE: To minimize the risk of cross-contamination GOAL: Reduce the number of microorganisms in immediate

dental environment to the lowest level possible ADA CONSIDERATION/RECOMMENDATION: “each patient must

be considered potentially infectious”

INFECTION CONTROL GUIDELINES:

1. All dentists and staff must be vaccinated against Hepatitis B2. Proper protective attire3. Disposable latex gloves4. Wash hands before and after wearing gloves5. Wear mask and protective eyewear6. Contaminated disposable sharp objects must be placed into

separate, leak proof, puncture resistant containters with biohazard label

7. Use of mouth rinse before treatment8. All instruments must be cleaned and sterilized

METHODS OF STERILIZATION

1. AUTOCLAVE Most common means of sterilization 15-40mins at 121⁰C at 15psi Rust and corrosion can occur

Advantages:i. Excellent penetration of packages

ii. Sterilization is verifiable Disadvantages:

i. Can destroy heat sensitive materials1. Files, endoblock, clean stand,

sterile gauze (1min), sodium hypochlorite 5.25% (chlorox) – gutta percha, bead sterilization/dry heat – paper points for 5 secs

2. PROLONGED DRY HEAT Kills microorganism through an oxidation process 320⁰C for 30mins for 2 hours Advantages

i. Complete corrosion protection for dry instruments

ii. Equipment is of low initial costiii. Sterilization is verifiable

Disadvantagesi. Slow turnover time

ii. If sterilizer temperature is too high, instruments may be damaged

3. INTENSE DRY HEAT (GLASS BEADS) Not predictable Sterilize contaminated hand files Not verifiable Not for sterilization of hand files bet use of different

patients4. GLUTARALDEHYDE SOLUTIONS

14 – 28 days shelf 2 – 4 or 3.4% concentration 6 – 10 hours sterilization Advantages

i. For heat sensitive instrumentsii. Non corrosive and non-toxic

Disadvantagesi. Require long immersion time

ii. Some odor which may be objectionableiii. Sterilization is non-verifiableiv. Irritating to mucous membrane

METHODS OF DISINFECTION (ZONROX)

¼ Cup of NaOCl + gallon of water 10 – 30mins Corrosive to metals and irritating to skin Biocidal against:

a. Bacterial vegetative formsb. Virusc. Spore forms

PATIENT PREPARATION

IMPORTANCE: To have a well-informed patient who is willing to accept root canal treatment and whatever it entails

GOAL:1. Educate the patient of the risk as well as the benefits if

RCT

7

2. Inform the patient what is expected of him before, during and after the treatment

3. Convince the patient to accept, value and appreciate RCT

Scaling and polishing Pain control Medical history

1. Case presentation2. Informed consent

Premedication if necessary Antibiotic needed American Heart Association (AHA, 2010) prophylactic regimen

for dental procedures

LOCAL ANESTHESIA

Important part of endodontic treatment of vital teeth Deep anesthesia Lidocaine and adrenaline containing anesthetics are the first

choice

DIFFERENT TECHNIQUES

1. INFILTRATION ANESTHESIA (SUPRAPERIOSTEAL INJECTION) The first choice for all teeth in the upper jaw Molars palatal injection may sometimes be needed

in addition to buccal injection Lower jaw, incisors, canines and premolars local

infiltration2. BLOCK ANESTHESIA (MANDIBULAR BLOCK)

Mandibular molars and sometimes other mandibular teeth (some cases of acute pulpitis)

3. LIGAMENT ANESTHESIA (PERIODONTAL LIGAMENT INJECTION) Ligament anesthesia may be used to help the first 2

methods in difficult situations However, there may be some concerns about possible

damage to the root surface Rapid onset: 10 – 20mins duration

4. INTRAPULPAL ANESTHESIA Done directly into the exposed pulp if other forms

have not been effective Good back pressure and adrenaline in the anesthetic

are required Lasting for only 15 – 20mins Should not be used with prior PDL injection 3-5secs of pain

5. INTRAOSSEAL ANESTHESIA Anesthetic is applied directly into the cancellous bone

6. MENTAL BLOCK Lower anterior canine to central incisors

Duration of anesthesia consideration

All irreversible pulpitis (symptomatic) anesthetized painAcute and chronic periapical diseases; pulp necrosis no need to anesthetize

Irreversible pulpitis (symptomatic or asymptomatic)

Necrosis Periradicular pathosis

MaxillaryinfiltrationPDLIP

+++

OkXX

XXX

MandibularIANBPDLIP

+++

OkNoNo

XXX

Ok – partial necrosis - patient feels pain - take a radiograph

INFILTRATION (MAXILLARY)

CENTRAL INCISORo Labialo One root

LATERAL INCISORo Labial or lingual

CANINEo Labial because of the apical eminence of the cervical

portion of the crown which is more labially inclined 1ST PREMOLAR

o Buccal and lingual 2ND PREMOLAR

o Buccal because there is only one root 1ST MOLAR

o Palatal and buccalMANDIBULAR

INCISORS TO PREMOLARSo Infiltration and mental block

MOLARSo Mandibular block

HOW WILL YOU KNOW THE LOCATION OF THE APEX?

With the help of knowing the average tooth length of each tooth

TOOTH PREPARATION

1. CARIES2. RADIOGRAPH

a. Importance:i. To be able to master radiographic

techniques to achieve films of maximum diagnostic quality

ii. Are essential to all phases of endodontic therapy because RCT relies on accurate radiography, it is necessary to master radiographic techniques to achieve films of maximum diagnostic quality

PREOPERATIVE RADIOGRAPH

1. To determine root anatomya. Ex. Mandibular 1st premolar with 4 canals

2. To look for the fast break

8

a. FAST BREAK – a term used in endodontics that relates to the splitting off of a single canal into 2 separate canals

3. To locate the chamber4. To determine the axis of the crown as relates to root axis5. To decide the relative difficulty of the case

HOW MANY TIMES SHOULD YOU TAKE A RADIOGRAPH? 3 TIMES

1. Straight on 2. Mesial shift3. Distal shift

BUCCAL OBJECT RULE/ CONE SHIFT TECHNIQUE/ SLOB/ CLARK’S RULE (20⁰ M/D)

1. Location of additional canals/roots2. Distinguished between objects that have been superimposed3. Locate foreign bodies4. Locate anatomic landmarks in relation to root apex (especially the

mandibular premolar)5. The buccal object moves in the opposite direction where the cone

is shifteda. Shift Mesially lingual canal goes mesialb. Shift Distally lingual canal goes distal

3. BUILD UP/ TEMPORIZATION4. CROWN LENGTHENING5. ISOLATION (RUBBER DAM ISOLATION)

a. PRINCIPLES/RATIONALE OF ISOLATION:i. Patient protection from aspiration or

swallowing of instruments of instruments, tooth debris, medicaments and irrigating solutions

ii. Clinicians protectioniii. Surgically clean operating field isolated

from saliva, hemorrhage and other tissue fluid

iv. Retraction and protection of the soft tissuev. Improved visibility

vi. Increased efficiency

ROOT CANAL PREPARATION

OBJECTIVES:1. Describe the objectives for both cleaning (use of

irrigant) and shaping (use of files); explain how to determine when these have been achieved

2. Diagram the shapes of the flared (step back) the standardized (serial shaping) and crown down preparation

3. Describe the various techniques in canal preparation (step by step)

4. Distinguish between apical stop, apical seat and open apex and how they affect canal preparation and obturation

5. Describe the techniques of pulp removal Narrow canals use small files Big canals barbed broach

6. Characterize the fiddiculties of preparation of anatomic aberrations that make complete debridement difficult

7. Enumerate possible procedural errors which can happen and how to avoid and manage them

Failures in biochemical preparation: Overshaping – strip perforation Breakage of the files

o Measure files prior and after insertion

o Radiograph8. Describe alternative techniques in canal preparations

Greater taper files

TERMINOLOGIES IN BIOMECHANICAL PREPARATION

REFERENCE POINTo Important to determine the working lengtho Incisors – incisal edgeo Molars – depends on where the files would goo Note: always have a straight line access to have a

correct reference point RUBBER STOPPERS

o Should be perpendicular to the loing axis of the tooth and should not be slanted

o Important to determine the working length RADIOGRAPHIC TOOTH IMAGE

o Distance from the reference point up to the apex APICAL CONSTRICTION

o Where the working length terminateso Located 0.5 – 1mm at the apical 3rd of the root

WORKING LENGTHo Distance from reference point up to the apical end of

the canal constriction ACTUAL LENGTH

o Actual length of initial apical file (IAF) inserted inside the canal for working length determination

WL = AWL (+/-) Discrepancy between the file and the tip of the apex

CANAL PREPARATION TECHNIQUE

1. CORONAL PREPARATION Orifice opening and enlargement Establish tentative working length

2. PATENCY3. SCOUTING4. RADICULAR PREPARATION5. WORKING LENGTH DETERMINATION

SELECTION OF IAF6. APICAL PREPARATION/SERIAL FILING7. STEP-BACK (FOR LATERAL COMPACTION)8. CIRCUMFERENTIAL FILING

SPREADER REACH TEST – to check for flaring

STEPS IN BIOMECHANICAL PREPARATION

1. Measure the pre-operative radiograph2. Get a file, insert then subtract 2mm (patency file) (-2 mm of tooth

length image)3. Divide the root length into 3 parts4. Crown down preparation

Cervical and middle preparation

9

Use bigger to smaller files5. Crown down computation

CL + C3rd CL + M3rd NOTE: size 35 is contant. It meanst that you have

aldeady reached the end of the middle 3rd and you have already enlarged the canal (cervical and middle 3rd)

DENTIN MUDi. Happens when you do not irrigate every

after filingii. The accumulation of dentin chips that will

clog the canal Remember to insert the patency file every after

insertion of files and irrigation, to make sure you still have the correct patent

6. WORKING LENGTH IAF APICAL BINDING

i. Resistance felt at the apical when file is inserted

7. TAKE A RADIOGRAPH To know if the file is at the correct working length

8. COMPUTE FOR WORKING LENGTH WL = AWL (+/-) discrepancy – 0.5 safety factor

9. INITIAL APICAL FILE10. SERIAL FILING

Done to enlarge the canal 3x larger than the working length

11. STEP BACK RECAPITULATION

i. Using of previous file to remove ledgesii. MAF is done every after filing to remove the

ledges making it smooth12. CIRCUMFERENTIAL FILING

CANAL PREPARATION

Systemic procedure of removing pulp tissue, debris and microorganisms with the use of files, irrigants, and chemicals while shaping to facilitate filing of the root canal system

BIOLOGICAL OBJECTIVES:

1. CANAL CLEANING Removal of all contents of the root canal system Infected materials, organic substances, etc.

2. CANAL SHAPING creates a continuously tapering cone preserving the canal in multiple planes facilitates cleaning by removing restrictive dentin,

allows greater volume of irrigant to work deeper and into all aspects of the root canal system, thus eliminating the pulp from any infections, microorganisms, etc.

MOTIONS OF INSTRUMENTATION:

1. TURN AND PULL Quarter turn (clockwise) rotation and then pull

2. FILING Push and pull motion

3. WATCH WINDING About 30 -60 degrees clockwise and counterclockwise

movement of instrument4. BALANCED FORCE

About 90 degrees clockwise and then about 270 degrees counterclockwise

WORKING LENGTH DETERMINATION

METHODS OF ESTABLISHING WORKING LENGTH1. Tactile sensation2. Paper point evaluation use it during or after canal

preparation3. Electronic apex locator4. Use of radiograph

SERIAL FILING

Sequential use of files from IAF to MAP at working length with recapitulation

Motion of instrumentation: watch winding and pull Change file if there is no more apical binding felt Use the previous file used if the next file cannot fit to avoid future

errors like ledges

MASTER APICAL FILE (MAF)

Largest file that has already reached the apex Minimum size: 25 for narrow canals

CIRCUMFERENTIAL FILING use of MAF to smoothen all the canal walls

SPREADER REACH TEST

insert the MAF together with the spreader inside the canal (length of spreader should be at least 1-2 mm short of the working length)

done to verify if the canal has been properly flared size 30 – larger canals size 25 – smaller canals

FEATURES OF AN IDEAL PREPARATION

1. minimal enlargement f the apical foramen2. creation of an even, progressive taper from the apical stop to the

pulp chamber following the natural curvature of the canasl3. provision for an apical stop at the end of the canal4. adeqyate cleaning of the canal at optimum working length

IMPORTANCE OF APICAL STOP:

so that the gutta percha will not go out from the apex

you are sure that you have already cleaned and shaped the canal if you have already felt the glass feeling

GUIDELINES IN INSTRUMENTATION

1. check instrument prior to use for any sign of instruments strain or metal fatigue

10

2. precurve files if SS. If curved, use directional stoppers3. select proper instruments depending on their use and properties4. always keep debris suspended in irrigant: irrigate copiously5. use instruments in proper sequence without skipping sizes6. establish a straight line access7. have a vision of the shape of the canal and work towards shaping

it with the 5 mechanical objectives in mind8. never force down instruments. Stop at resistance.9. Always recapitulate to ensure canal patency10. Verify working length at all times11. Be patient. Try to do it once but well

INTRACANAL MEDICATION:

Use of calcium hydroxide requires direct contact For cases which cannot be finished in 1 appointment Coronal seal has to be maintained between appointments with

the use of durable cements

INTRACANAL IRRIGANTS:

SODIUM HYPOCHLORITE 5.2% best irrigant. It can also dissolve CHLORHEXIDINE GLUTAMATE 2% WITHOUT ALCOHOL HYDROGEN PEROXIDE 3% (not used alone) NORMAL SALINE STERILE WATER MTA (MINERAL TRIOXIDE AGGREGATE) EDTA

GUIDELINES IN IRRIGATION:

1. Irrigate copiously2. Use needle guage 25 – 27

OBJECTIVES IN IRRIGATION:

1. Gross debridement2. Removal of microbes3. Lubrication4. Dissolution of pulp tissue remnants5. Removal of smear layer

ERRORS IN CANAL PREPARATION

1. Blockage2. Canal transportation3. Perforations4. Zipped – no canal stop5. Broken bur

OBTURATION

3D filling of the entire root canal system as close to the CEJ as possible

PURPOSE OF OBTURATION

1. Eliminate all avenues of leakage from the oral cavity/perpendicular tissue into the root canal system

2. To seal within the system any irrtants that cannot be fully removed during biomechanical…

REQUIREMENTS OF AN IDEAL FILLING MATERIAL

1. Easily introduced in canal2. Seals canal laterally and apically3. Don’t shrink after being inserted4. Free of moisture5. Bactericidal6. Radiopaque7. Doesn’t stain tooth structure because gutta percha was not cut

properly. Should be 1mm beyond cervical line8. Non-irritable to the tooth structure/periapical tissue9. Sterile10. Easily removed

TYPES OF FILLING MATERIAL

1. SOLIDa. GUTTA PERCHA

i. From dried juice of TABAN TREEii. Since 1865

iii. Composition:1. Gutta percha 19 – 22%2. Heavy metal salts 1 – 17%3. Zinc oxide 59 – 79%4. Wax/resin 1 – 4%

iv. Shapes:1. Standardized 0.2 taper; same

size as files2. Conventional (fine or medium)3. Greater taper – smaller tips with

wider body (0.4 or 0.6)v. Advantages:

1. Plasticity – adapt to walls after compaction

2. Easy to remove from canal3. Low toxicity – nearly inert

overtimevi. Disadvantages:

1. Lack of adhesion to dentin2. Slight elasticity which causes a

rebound and pulling away from the canals

b. SILVER POINTSi. Composition:

1. Pure silverii. Shape:

1. Same as 0.2 gutta perchaiii. Advantages:

1. Ease of placement2. Length control rigid and flexible

iv. Disadvantages:1. Corrosion2. Toxicity3. Non adaptability4. Difficult to remove5. Post space removal6. Long term failure7. Apical and coronal seal infection

with that of gutta perchac. RESILON

i. A synthetic root canal filling material based on polymers of polyesters

11

ii. Brand: epiphanyiii. Soluble in water

2. PASTES (SEMISOLIDS)a. ZINC OXIDE EUGENOL

i. Advantage:1. Long history of successful usage

ii. Disadvantage1. Discoloration if not properly

placedb. N2 (DERIVATION OF SARGENTIS FORMULATION)c. RC 2B

i. Opaquers metallic oxideii. Chlorides

iii. Steroids3. PLASTICS

a. EPOXYb. AH26

SEALERS

Fluid tight seal Gets into lateral canals

DESIRABLE PROPERTY OF SEALSRS:

1. TISSUE TOLERANCE Should not cause tissue damage Low degree of solubility

2. NO SHRINKAGE3. SLOW SETTING TIME

Provide adequate working time for placement4. ADHESIVE5. RADIOPACITY

Readily visible on the radiograph6. DOESN’T STAIN7. SOLUBILITY IN SOLVENTS8. INSOLUBLE IN ORAL & TISSUE FLUIDS

To retain compactness inside the tooth structure9. BACTERISTATIC10. CREATION OF SEAL

TYPES OF SEALER:

1. ZOE2. CALCIUM HYDROXIDE

Shows short term sealability to tissue toxicity3. PLASTICS

Ah-26; AH26+4. GLASS IONOMERS

Dentin bonding properties Minimal antimicrobial activity

5. RESIN Provides adhesion

MIXING OF SEALER

1. DROP TEST2. STRING OUT TEST

o Thick consistency, creamy and homogenous mayonnaise-like

o The thicker the mix, the better the proterties of the mixture

o Should string 2-3 inches

PLACEMENT OF SEALER

1. Paper points2. Files3. Lentulo spirals4. Injection with special syringe5. Master cone

TECHNIQUE IN PLACING SEALER

Placed counter clockwise Flooding is not desirable Must not be placed in all canals at once

FUNCTIONS OF SEALERS

1. Lubricant of master cone during insertion2. Fills up the canal irregularities

METHODS OF OBTURATION

1. LATERAL CONDENSATION TECHNIQUEa. ADVANTAGES:

i. Simple armamentariumii. Length control

iii. Ease of retreatmentiv. Adaptation to the canal wallsv. Positive dimensional stability

vi. Ability to prepare post spaceb. DISADVANTAGES

i. Inability to obturate > cured canal, open apex, internal resorption

2. VERTICAL CONDENSATION TECHNIQUE3. TECHNIQUE THAT INVOLVES CHEMICAL AND PHYSICAL

ALTERATION OF GUTTA PERCHAVARIOUS OBTURATION TECHNIQUES AND DEVICES

1. SPREADER/PLUGGER SELECTION Pointed apex; blunt apex SPREADER

i. Condenses gutta percha laterallyii. Finger spreader

iii. Advantages:1. Better tactile2. Enhance instrument contact3. Improved apical seal4. Reduced dentin stress5. Obturation6. Can be inserted deeper

2. MASTER CONE SELECTION Same size or larger than MAF

3. FITTING OF MASTER CONE Tug back/slight resistance

i. Importance: to reach working length only 0.5 – 0.1 mm from tip of apex Take radiograph to verify length

12

4. STEPS IN OBTURATION Sealer is mixed and then applied to canal walls Sealer is inserted slowly to allow air and excess cement

to escape Before spreader is inserted and removed, accessory

cone is picked up with locking pliers at measured length, ready to be inserted

i. Accessory cone – size depends on the size of spreader, 1-2 mm size smaller (thickness)

Measured spreader is inserted between master cone and canal wall

Same angle with insertion and removal of the accessory cone

Repeated until spreader can no longer be pressed beyond apical third

Evaluate obturation with x-ray Excess gutta percha is cut 1mm from cervical line

(molar-orifice) Clean with cotton and alcohol Percolation – movement of fluid Test applied for master cone:

i. Visualii. Radiographic

Remember: what is removed from the root canal system is more important than what is inserted

APPROPRIATE TIME FOR OBTURATION:

1. Asymptomatic2. Properly prepared3. Canal reasonably dry4. No sinus tract5. No foul odor6. Negative in culture7. Intact TF8. Negative in percussion and palpation

EVALUATION OF OBTURATION

1. DENSITY Degree of whiteness Uniform density form coronal to apex

2. LENGTH Gutta percha should end at apical terminus (0.5 of the

apex) and must be cut below the orifices3. FLARE

Should reflect canal shape Tapering from coronal to apical

RESTORATION OF ENDODONTICALLY TREATED TOOTH

OBJECTIVES:1. Replace missing tooth structures2. Retain the final restoration 3. Protect the remaining tooth structure

RESTORATIVE CONSIDERATIONS

1. STRUCTURAL CONSIDERATIONSa. Endodontically treated teeth are weakened because:

i. Decreased amount of tooth structure1. Caries2. Previous restorations3. Fracture4. Access opening5. Canal preparation

ii. Decreased moisture content of the tooth2. PROTECTIVE CONSIDERATIONS

a. Need for both exterior (post) and interior support to ensure crown

3. INTERNAL CONSIDERATIONS4. AESTHETIC ACCEPTABILITY

a. Natural translucency and colorb. Good anatomyc. Characterization are restored

BASIC RESTORATIVE PRINCIPLES

1. RETAIN SOUND TOOTH STRUCTURE2. CUSPAL PROTECTION

a. Onlayi. Full cusp made of restorative material

b. Inlayi. Not all cusp made of restorative material

ii. Some tooth structure still present/visible3. FERRULE EFFECT4. PRESERVATION OF BIOLOGIC WIDTH5. EXTRA CORONAL RETENTION AND RESISTANCE

PRINCIPLES AND CONCEPTS OF A RESTORATIVE DESIGN

1. CONSERVATION OF TOOT STRUCTURE Cuspal protection is important

2. REINFORCEMENT Post weakens the tooth because of the thin walled

canal and sudden step

3. RETENTION Elective RCT is often necessary to provide support and

retention for complex restorations4. PROTECTION OF TOOTH STRUCTURE

Restoration is designed to transmit functional loads equally

EXTERNAL RESTORATIONS

BONDED COMPOSITE BLEACHING

o First choice of treatmento Destaining of yellow and brownish color is made

successful CUSPAL PROTECTION

INTERNAL RESTORATIONS

CORESo Replaces missing crown structure and therefore aid in

retention POST

13

o Only placed when there is no enough tooth structure for the core

o Not advisable

INTERNAL RESTORATIVE SUPPORT

1. DOWEL POST Used with very minimal coronal structure Used only to retain and support the core Must at least leave 4-5mm gutta percha when using a

post2. BONDABLE POST

Good for anterior teeth3. POST SPACE PREPARATION

Use for heated instruments Post system drill

TEMPORIZATION

OBJECTIVES:o To keep tooth-to-tooth relationship from being alteredo To prevent gingival tissue from creeping over the

margins Remember: good endo treatment = apical and coronal seal

FACTORS IN CHOOSING RESTORATION:

1. oral hygiene potential of patient2. location and function of tooth3. cervical circumference4. amount of remaining tooth structure5. socio-economic status of patient6. motivation and ability of dentist to do the procedure

ENDODONTIC PROGNOSIS

OBJECTIVES:o To evaluate result or outcome of RCto To determine success or failure of treatment

PROGNOSIS

Production of possible outcome or success and failure Success rate = healing capacity vs survival rate = longevity of

function and maintenance of the tooth

SUCCESS RATE

Capability of the clinician to do biomechanical preparation Factors without any effect on the success rate:

o Gendero Jawo Tooth groupo Quality of root canalo Long term survival of root canal treated teeth

FACTORS AFFECTING ENDODONTIC PROGNOSIS

1. Presence of periradicular lesion2. Apical extent of root canal preparation and filling

CAUSES OF ENDODONTIC FAILURE

1. APICAL PERCOLATION Due to poor obturation Slow ingress of microorganisms into spaces

2. OPERATIVE ERRORS Perforations, presence of obstruction resulting to

inadequate cleaning, overfilling3. ERRORS IN CASE SELECTION

Coexisting periodontal lesion, resorption4. CASE SELECTION AND DIAGNOSIS

Should RCT be done? Clinician should be able to identify

5. ANATOMY OF ROOT CANAL SYSTEM Number of canals Location of canals Location of apical foramen

6. QUALITY OF INSTRUMENTATION Procedural errors Obturation errors

7. QUALITY OF OBTURATION AND RESTORATION Coronal seal Exposed to oral environment

METHODS OF EVALUATING TREATMENT OUTCOME

1. History and clinical evaluation2. Radiographic evaluation3. Histologic evaluation

HISTORY AND CLINICAL EVALUATION

Absence of subjective symptoms/pain Functional restoration without occlusal trauma Normal response to percussion, palpation and mobility (no

periodontal lesion) Absence of sinus tract No signs of fracture, recurrent caries or crown discoloration

RADIOGRAPHIC EVALUATION OF REPAIR

Restoration of continuous and even lamina dura Normal periradicular bone and periodontal attachment Decrease size of radiolucency with bone regeneration New cementum may be formed Irregular area of resorption

Exception: APICAL SCARRING Non-pathologic formation of fibrous connective tissue in apical

part which appears radiolucent

CATEGORIES OF SUCCESS OR FAILURE

1. COMPLETE HEALINGa. No clinical symptomsb. Continuous lamina durac. Uniform thickness of periodontal space

2. INCOMPLETE HEALINGa. No clinical symptomsb. Reduction in size of apical lesion

3. NO HEALING

14

a. Clinical symptoms of an endodontically induced apical periodontitis

b. Size of apical lesion with no reduction in size or it gets even bigger

WAYS TO ENHANCE SUCCESS

1. use great care in case selection2. use greater care in treatment3. proper restoration with no coronal discoloration and

microleakage

MANAGEMENT OF FAILURE:

1. not to resort to extraction immediatelya. retreatment should be done firstb. endodontic surgery for removal of pathologic tissues

and exploratory procedures

CONCLUSION: prognosis should be assessed before a treatment is initiated to

determine whether to proceed or not

ENDODONTIC – PERIODONTAL INTERRELATIONSHIPS (LESIONS)

OBJECTIVES:o Identification of endodontic and periodontal lesions

and understand their interrelationship to determine treatment and assess the prognosis

DIAGNOSIS AND CASE SELECTIONo Questions we ask ourselves:

Should endodontic or periodontal treatment be done or both?

What will serve the patient’s best interest: doing endo-perio treatment, or simply extraction?

PREDISPOSING CONDITIONSo Pulpal disease and its extension into the periodontium

causes localized periodontitis with the potential for further extension into the oral cavity

o Periodontal disease and its extension has Vascular system Dentinal tubules Lingual grooves Root/tooth fractures Hypoplasia/cemental agenesis Root anomalies Bifurcation ridges Firbrinous communication Enameloma, dens invaginatus Furcation class I, II, III

BACTERIAL PATHWAY

Gingival sulcus, it may cause gingivitis, periodontitis, pulpal infection, root caries

DIAGNOSIS BASED ON THE FF:

1. Medical/dental history2. Vitality test3. Thermal test4. Mobility test

Directly proportional to the amount of alveolar bone support

5. Pocket probing Normal is 3mm; if probe suddenly goes down from one

side to another, it means that it needs endo. If gradual, it means perio, if both (sudden and gradual) it means both

6. Radiography Should not be used as the only basis of one’s diagnosis

although it is truly useful

CLASSIFICATION

CLASS I – primary end CLASS II – primary perio CLASS III – combined “J – type of lesion” suspects vertical

fracture

DIFFERENTIAL DIAGNOSIS

ENDO PERIO

Non vital Vital

Apical periodontium Marginal periodontium

Single tooth involvement Multiple teeth involvement

Narrow pockets Broad-based pockets

Minimal calcular deposits Calcular deposits

Angular bone loss Horizontal bone loss

Pulpal infection Periodontal infection

Deep extensive caries Not related

ENDO PERIO

Acute inflammation Chronic inflammation

Single narrow pockets Multiple wide coronally

Acid (due to caries) Alkaline

Primary – secondary trauma Contributing factors

Few microbiota Complex microbiota

RADIOGRAPHIC

ENDO PERIO

Localized pattern Generalized pattern

Wider apically Wider coronally

Radiolucent periapex Not often related

No vertical bone loss With vertical bone loss

LESIONS OTHER THAN ENDO AND PERIO IN ORIGIN:

15

Perforations Vertical fracture Non odontogenic

TREATMENT

ENDOo RCT – calcium hydroxide, gutta perchao Endo surgeryo MTA – perforations

PERIOo Medications

Antibiotics Antiseptics Anti-inflammatory

o Scaling and root planningo GTR (guided tissue regeneration)o Root resectiono Hemisection; radisection (cutting of 1 root of maxillary

molar)

-Rosette Go 101910 Notes of Fernandez, Celine

16