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(1) Root Canal Treatment

(1) Root Canal Treatment

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Published by: Duong Le on Jun 07, 2014
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 Starting with a reminder of the anatomy of the tooth ..

- As you know , the part of the tooth that you can see in the oral cavity is
called crown . There is a much longer part that resides in the jaw bone
which is the root .

- You have teeth with a single root and multi-rooted teeth .

- You are already familiar with enamel and dentine .

If you imagined a very deep class I cavity , it will reach the core of the
tooth , where the pulp is present .

The part of the pulp that is found in the crown is called the pulp chamber
, the part that lies within the root is the root canal .

- Nerves and other structures are present in the pulp .

 In Root Canal Treatment ( RCT ) , you will be taking this soft tissue part out of
the core of the tooth , cleaning and shaping then placing a filling material
inside the root before you can place a filling in the crown .

So , we could have tooth decay , a bacteria that invaded enamel , dentine and
exposed the pulp .

- Infection is present in the pulp space , inflammatory mediators will reach
the bone and cause bone resorption .
When you get more familiar with radiographs - X-rays - , you will notice it
as a black shade in the bone .

- Normally , the bone is highly mineralized , so a radiograph of it will be
radio-opaque .
Infection here will appear either as a well or poorly defined blackish
lesion .

- So your job is to treat bacteria , to get rid of it and eliminate it and its
products from the Root Canal System , so that healing can occur in the
bone .


 The goals of RCT are :

1- Removing bacteria and infected pulp from the pulp chamber and root canals

After that you have to

2- Completely fill the root canal system to prevent the reinvasion of bacteria
and future troubles .

- The filling material appears white or radio-opaque on the radiograph .

 Now how do we do RCT ?

- 1
we have to establish the diagnosis .
A patient comes to you and says “ I have pain in my tooth “ .
How would you know if you just have to drill a class I cavity or to perform an

- After you establish the diagnosis , you should prepare the canal , clean and
shape it .

- Then finally you fill it .

So , the first step is opening the tooth .

- A very deep class I cavity that exposes the pulp . From this cavity you will
start RCT .

- You have to remove the decay or the caries completely from the crown
before entering the pulp . You reach the pulp chamber then you go into the
root canal .


- The nerves and blood vessels in the root canal join the inferior dental canal in
the mandible where the inferior dental nerve and the neurovascular bundle
are present .

- Some canals could still have pulp tissues . Here we use an instrument called
Endodontic File .

It’s a color coded instrument , every color refers to a size . So it’s not
randomly colored .
We use the file to clean and shape the canals .

- After that we fill the canals with a rubbery material called Gutta Percha .

- You are not supposed to use the same instrument between patients ,
otherwise you will transmit diseases .
Because the pulp is a soft tissue , even Mad Cow Disease , which is a very rare
disease , can be transmitted through root canal treatment . There is a nerve
tissue and Prion disease can contaminate root canals .

- So it’s very important to follow a very strict procedures for instruments
sterilization in your clinic .

 Stainless steel are conventional instruments for RCT .

- In the last 10 years , the NiTi system was introduced . NiTi refers to nickel
titanium . It has much more advantages than the stainless steel , but still we
are learning the conventional technique .
RCT is much easier with NiTi , but it’s expensive to teach at the university
levels .

 We can divide the instruments into :


1- Examination instruments , it include :

- A front surface mirror . As there are two type of mirrors , front and back
surface . They are completely different in terms of visibility and other stuff .

- A periodontal probe , an instrument to check the gum attachment around the
tooth .
- An explorer or an endodontic probe ( DG16 ) . Similar to a dental probe , but
has a straight end to get a straight line access to root canals .

- A spoon excavator .

- A ruler .

2- Cleaning and shaping instruments :

- Hand operated instruments which are used manually .

- Engine driven that are put in a high or slow speed handpiece .

- Ultrasonics .

- Nickel titanium .

- Irrigation needles .

 The difference between different types of hand instruments is their cross-
sectional shape .

- You have an instrument named Flex R .
In large sizes , it has a triangular cross-section . While in small sizes , it’s
square .

That’s because of you can still have some flexibility with stainless steel small
instruments .

- However , you are not supposed to memorize the cross-sectional shapes of
these instruments , as it’s nonsense !


Just know that cross-sectional shape is related to flexibility of the instrument

- You will be familiar with K-Files and Hedstorn files .

- A Hedstorn file is made of cones on top of each other . It’s more efficient in
cutting but it’s also prone to fracture .

 We have two methods for instruments fabrication ..

1- It’s either machined immediately .. It’s more fracture liable .

2- Or grinded and then twisted manually .

 Regarding standardization , we said that instruments are standardized in size

- Sizes are from 6 to 140 .

- They are all color coded .

- The diameter increases by 0.05 increments . So we have size 10 then 15 , 20 ,
25 and so on .. Until we reach 60 then we will have 70 , 80 … ‘till 140 .

- Moving to the length , we have 21 , 25 and 31 .

- A 31 is not needed except for an extremely long tooth like a canine .

- The advantage for the short instruments is that you have more operation
control on it . But when you use it on a long length , then it’s not very
efficient .


- Beside the color coding , you will see a numerical indication on the side of
the instrument .
1- A yellow instrument is 20
2- A green one will be 70
3- A Red one is 110

You are supposed to memorize the color coded instruments and their sizes ,
and you will know it and be familiar with it with practice .

4- White comes in 15 then it’s repeated in 45 and 90

- When we say size 10 , this refers to the size of the tip .

- When you proceed upward from the tip , there is what we call standard
taper of 0.02 mm/mm . Which means when we go up by 1 mm , there is an
increase in the diameter of 0.02 mm . And this is found in all stainless steel
files .

While in nickel titanium files , the taper is not constant and it’s different .

 There is something called auto torsional limit .

Suppose that you have a file , you place it in the tooth .. If you exceeded this
limit you will fracture the file in the canal , which will ruin your treatment .

So you have to know that there is a limit of force that you can exert on the
file , if it’s exceeded it will break .

- Nickel titanium instruments have and increased resistance to fracture . So
their torsional limit is much higher than stainless steel .

 We have an instrument called Barbed Broach .


- As we said , the pulp tissue is a soft tissue inside a hard compartment . If you
want to pull it out you need something like a fork to do so .

- It’s ideally single used . So once you use it for one patient , you throw it away
, as it’s very difficult to sterilize .

 Another instrument is called Lentulo Spiral .

- It’s used in a slow speed handpiece .

- It’s used for medication placement inside the root canal .

Most of the time we do RCT in multiple visits . Once you remove the pulp
tissue from inside the canal , you don’t leave the space empty . You have to
place an antibacterial medication which will help in disinfecting the root canal
. The material is called calcium hydroxide .

- So we use this Lentulo Spiral for calcium hydroxide and sealers placement in
the canals .

 A basic rule when you use this Lentulo Spiral you have to place it in the
tooth while it’s rotating and you take it out while it’s rotating too .

If you don’t place it while it’s rotating , you will end up with fracturing it .
This fractured segments appear as a whitish curves inside the canals on a
radiograph .

- Lentulo Spiral comes in 21 and 25 sizes , it’s also color coded .

 There are some sorts of burs called Gates-Glidden .

- Also used in a slow speed handpiece .

- It’s used for the enlargement of the coronal access of the canal .

- Its sizes varies from 40 to 140 , increasing by 20 .. 40 , 60 , 80 , .. and so on .


- Size 1 because it has 1 band , size 2 has 2 bands and so on ..

 When we use instruments inside the canal , we have to basic motions :

1- Filing : Combined in the root canal with a little bit of technique .. A
little bit forward and clockwise , a little bit anticlockwise .

2- Reaming : We use instruments called reamers . They are not
commonly used these days .

 After we take out any instrument from the tooth , we have to inspect it for
deformation .

- We said that there is a torsional limit , if you exceeded it the instrument will
deform or fracture .
Usually it has twists , so it will untwist or unwind ..

You have to get rid of such deformed instruments , you can’t use it again .

If you use it again it will fracture and leave some segments inside the tooth .

 When you come to filling the root canal , you will be using different
instruments .. Not the same files used for cleaning it .

For obturation , we have two types :

1- Spreaders : Used for lateral condensation of the Gutta-percha inside the root
canal .

1- Hand type : Has a handle , like a probe .

2- Finger type : Short , handled with your fingers .

- It come in stainless steel and NiTi .


- NiTi is very flexible , so it’s not good for condensing .. Although they are
much more expensive than the stainless steel , but they are of no significant
value !

2- Pluggers : They are used for vertical condensation .

- After we finish lateral condensation of the material , we cut the excess and
then we condense it vertically .

- Amalgam condenser can’t be used as it’s short and won’t reach the canal .

 A spreader has a pointed tip , it’s very sharp .
 A plugger is flat ended , to be able to vertically condense . They also come
in different sizes .

- The files have peaks while the spreaders are smooth .

- Spreaders are color coded just like endodontic files .
Yellow for 20 , red for 25 and blue for 30 .

 All of your work will be according to length measurements .. so a 0.1 mm is
very important .

- You measure the root length , let’s say it’s 20 mm .. Your preparation will be
of 20 mm . So you have to measure your instrument all the time and you
have to mark your measurements on it .

 Files don’t come clean and sterile from the manufacturer .

- Even if you got them from the company , you can’t use it directly inside the
patient’s mouth .
You have to sterilize it , because under microscope they still can have some
debris from manufacturing or transporting .
So it’s not actually 100 % clean .

 How we do sterilization ?


- It’s not enough to soak it in chemicals . You have to do an autoclave
sterilization .

- Remember that immersion with a disinfectant is undesirable .

- Autoclave sterilization is the most common method , done for short cycles ,
about 20 minutes .
That means that you can take instruments out of the sterilizer every 20

It kills bacteria’s spores and viruses .

- However , instruments become dull after sterilization , they are not as sharp
as you first bought them . So you have to consider replacement of instrument
every once in a while .

- Dry heat sterilization .. You need 60 minutes at least at 160 C ° to sterilize
instruments .
So it’s efficient but its disadvantage is that it’s a lengthy process .

- Molar teeth have more than one root as upper molars have 3 roots .
You take the instrument out of the canal , you immerse it with a sponge
soaked with alcohol before putting it back in the patient’s other canal .

You have to be wearing gloves all the time .


© Salah Mortaja

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