1

ENDODONTICS FINAL REVIEWER

ENDODONTICS
Branch of dentistry concerned with the :
o Morphology shape of the pulp cavity
o Physiology reversible or irreversible state
o 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 diagnosis
2. Treatment of oral pains of pulpal and/or periapical origin
(orthograde/conventional RCT)
3. Vital pulp therapy
a. Pulp capping
b. 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 teeth
7. Surgical removal of tooth structure
a. Root-end rsection
b. Bicuspidization cut molar to form 2 bicuspids
c. Hemisection - 1 root only for RCT
d. Apicoectomy (retrograde/conventional endodontics)
8. Bleaching of discolored dentin
9. Retreatment of teeth
10. 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 present
3. Removal of pulp from root/s of tooth
4. 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 asepsis
a. Paper points = 5 secs in glass beads
b. Gutta percha = 1 min in chlorox
c. Rubber dam = alcohol
d. Instruments = sterilize (autoclave)
e. Files = autoclave or glass beads
2. Correct diagnosis and treatment planning
3. Atraumatic holding of tissues
4. Cleaning of the canal debridement and removal of biofilm
sticking on the canal walls
5. Shaping of the canal
6. Complete obturation
7. Restoration
8. Recall
RATIONALE
1. Saving the natural teeth to health
2. Restore efficient mastication
3. Control pain and swelling
4. Speech and phonation
5. Preserved occlusion
6. 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 SYSTEM
2. SIGNIFICANCE OF STUDYING THE ROOT CANAL SYSTEM
3. 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 morphology
3. To understand the effect of root canal system complexities to
endodontic treatment
4. To be familiar with other variations in the canal systems
5. 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 canal
2. TREATMENT to guide us in all treatment procedures
3. PROGNOSIS to predict the outcome of the treatment

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ROOT CANAL SYSTEM
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 FLOOR
LOCATION C3rd of crown C3rd of root
COLOR Yellowish Darker
DENTINAL 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. Histologic
3. Radiograph
4. Clearing technique
5. Acrylic cast
6. Silicone injection
FACTORS AFFECTING ROOT CANAL MORPHOLOGY
1. Age
2. Caries
3. Developmental anomalies
a. Dilacerations severe bend or distortion 45 - 90
b. Taurodontism bull or prism teeth
c. Dens en dente
d. Microdontia
e. Macrodontia
4. Irritatnts pulp stones, internal resorption
5. Attrition
6. Abrasion
7. Erosion
a. Internal resorption (thermoplastic gutta percha)
b. External resorption
8. Trauma
9. Clinical procedures
ROOT CANAL CONFIGURATION
TYPE CONFIGURATION
I 1-1
II 2-1
III 1-2-1
IV 2-2
V 1-2
VI 2-1-2
VII 1-2-1-2
VIII 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 chamber
3. To allow for complete irrigation
4. 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 molar
o 3 roots = 4 canals (MB, DB, MP and P)
Mandibular incisors
o 2 canals
Mandibular second molar
o 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 canals
o incomplete cleaning because apical end can be
inaccessible
faulty canal access = infection
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o perforations = man-made canals
o ledges step being created
o strip side of danger zone
o zipping of the apical end
o opening of the apical end
o 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 chamber
4. Rubber dam isolation
5. 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 chamber
7. Refine the access preparation using non-end cutting tapering
fissure bur
8. Explore the orifice using the endo explorer
9. 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 preparation
2. Correct outline form
3. Properly unroofed pulp chamber, lingual shelf/shoulder removed
4. Gouging and ledging absent
5. Refined access cavity preparation
6. Canal orifice should be visible
7. Conserve the tooth structure
8. Straight line access
DIAGNOSIS
Objectives:
1. To be able to systematically collect, record and analyze
data in order to formulate a correct diagnosis
2. To know how to and when to perform the different
endodontic tests
I. Definition and importance of diagnosis
II. Science of diagnosis (data development)
a. Patients history
b. Clinical examination
i. Extraoral examination
ii. Intraoral examination
c. Radiographic examination
d. Diagnostic tests
i. Thermal pulp testing
1. 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 tester
iii. Percussion test
iv. Palpation test use index finger
v. Periodontal probing depths
vi. Mobility testing use 2 mouth mirrors
vii. Cavity test teeth with caries only
viii. Transillumination used to see if there is a
suspected fracture on the tooth
ix. Gutta percha tracing
x. Hot/cold water bath
1. Most reliable
2. 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 PATIENTS PERSONAL INFORMATION
THERMAL PULP TESTING
1. COLD TEST
a. Cold water bath most accurate
b. Ice tube least accurate
2. Response to thermal test
a. No response no-vital pulp
b. False negative excessive calcification, immature apex
c. Reversible pulpitis
d. Moderate to strong response
ELECTRIC PULP TESTING
FALSE POSITIVE RESPONSE
o Patient anxiety
o Wet tooth (to gingiva)
o Metallic restorations (to adjacent tooth)
o Liquefactive necrosis (to attachment apparatus)
FALSE NEGATIVE RESPONSE
o Premedication (drugs or alcohol)
immature teeth
o Trauma
SPECIAL TEST
Wedging and staining
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DIAGNOSIS
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 limits
2. PULPITIS
a. REVERSIBLE
b. IRREVERSIBLE
i. SYMPTOMATIC
ii. ASYMPTOMATIC
3. NECROSIS
HEALTHY PULP
TEST RESULT
THERMAL/EPT Mild to moderate transient response
PERCUSSION -
PALPATION -
RADIOGRAPH clearly delineated root canal
negative resorption
intact 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 recover
A. SYPMPTOMATIC
Episodes of pain due to sudden temperature change
Localized referred pain which lingers
Pain is:
i. Moderate to severe
ii. Spontaneous, intermittent or continuous
iii. Sharp or dull
Pain may be:
i. Relieved by application of heat/cold
ii. Affected by postural change
iii. Radiating or referred
iv. Difficult to localize
Radiograph:
i. Deep caries with apparent pulpal exposure
ii. Has normal surrounding structures
iii. Lamina dura is intact
Treatment:
i. RCT best solution to preserve the strong
tooth
ii. Extraction f patient doesnt want to
undergo RCT
B. 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 polyp
ii. 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, its
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

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Percussion is either positive or negative
Thickening of the periodontal ligaments and
may manifest as tender to percussion and
chewing
1. PARTIAL NECROSIS
May produce symptoms associated with irreversible
pulpitis
2. TOTAL NECROSIS
Asymptomatic before it affects the periodontal
ligaments
3. Treatment:
RCT or extraction

CLINICAL CLASSIFICATION OF PERIAPICAL DISORDERS

1. APICAL PERIODONTITIS
a. ACUTE
i. Percussion (+)
ii. Radiograph shows slightly widened
periodontal ligament
iii. Need for endodontic treatment
iv. 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. CHRONIC
i. Asymptomatic; breakage of lamina dura
ii. Tooth feels different
iii. Thermal is negative
iv. EPT is negative
v. Percussion and palpation are positive
2. PERIRADICULAR ABSCESS
ABSCESS except acute periradicular abscess,
radiolucency of the apex is seen in the radiograph
a. ACUTE
i. Moderate to severe pain
ii. Rapid onset of slight to severe swelling
iii. Patient may be febrile infection has
spread out with cellulitis
iv. Tooth is non-vital
v. 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. CHRONIC
i. There is drainage of the pus so it is not
painful
ii. 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 consideration
3. 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 abutment
b. for limited correction of malposed teeth
c. 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 RCT
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5. OPEN APEX
Yes, but some procedures should be
performed
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 findings
2. Difficult diagnosis
3. Difficulty in obtaining films of diagnostic value
4. Malpositioned tooth, rotated, tipped too far distally
5. Clinicians level of expertise
6. Availability of necessary materials and equipments

PATIENT CONSIDERATIONS

1. MEDICAL CONSIDERATIONS
2. LOCAL ANESTHETIC CONSIDERATIONS
a. Allergy, vasoconstrictor contraindications, history of
difficulty in obtaining profound anesthesia
3. PERSONAL FACTORS
a. Size of mouth, limited ability to open mouth, gagger,
motivation to preserve dentition, physical impairment,
limitation to be reclined, oral hygiene
4. SPECIAL NEEDS
a. Psychological and mental health
b. Economic status
5. TIMING OF APPOINTMENT
6. LENGTH OF APPOINTMENT

TREATMENT PLANNING

1. PHASE OF TREATMENT
a. PRE-TREATMENT PHASE
b. TREATMENT PROPER
c. POST-TREATMENT PHASE/FINAL RESTORATION
2. SINGLE VISIT RCT
3. MULTI-VISIT RCT

OBJECTIVES OF TREATMENT:
To restore teeths 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/personalized
2. It is flexible
3. 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)
Clinicians skill
Severity of patients symptoms

MULTIPLE VISIT RCT

Complex cases
o Anatomy of the tooth
o 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
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SUMMARY AND CONCLUSION

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

PRE-ENDODONTIC PROCEDURE

1. PREPARATION OF OPERATORY
2. PATIENT PREPARATORY
a. SCALING AND POLISHING
b. PAIN CONTROL
i. ANESTHESIA
ii. PHARMACOLOGY
3. TOOTH PREPARATION
a. CARIES CONTROL
b. RADIOGRAPH
c. BUILD UP/TEMPORIZATION
d. CROWN LENGTHENING
e. 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 endodontics
8. Review the appropriate use and dosage of analgesics and
antibiotics
9. Describe the indications for systemic antimicrobial therapy in RCT
10. 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 B
2. Proper protective attire
3. Disposable latex gloves
4. Wash hands before and after wearing gloves
5. Wear mask and protective eyewear
6. Contaminated disposable sharp objects must be placed into
separate, leak proof, puncture resistant containters with
biohazard label
7. Use of mouth rinse before treatment
8. All instruments must be cleaned and sterilized

METHODS OF STERILIZATION

1. AUTOCLAVE
Most common means of sterilization
15-40mins at 121C at 15psi
Rust and corrosion can occur
Advantages:
i. Excellent penetration of packages
ii. Sterilization is verifiable
Disadvantages:
i. Can destroy heat sensitive materials
1. 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
320C for 30mins for 2 hours
Advantages
i. Complete corrosion protection for dry
instruments
ii. Equipment is of low initial cost
iii. Sterilization is verifiable
Disadvantages
i. 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
patients
4. GLUTARALDEHYDE SOLUTIONS
14 28 days shelf
2 4 or 3.4% concentration
6 10 hours sterilization
Advantages
i. For heat sensitive instruments
ii. Non corrosive and non-toxic
Disadvantages
i. Require long immersion time
ii. Some odor which may be objectionable
iii. Sterilization is non-verifiable
iv. Irritating to mucous membrane

METHODS OF DISINFECTION (ZONROX)

Cup of NaOCl + gallon of water
10 30mins
Corrosive to metals and irritating to skin
Biocidal against:
a. Bacterial vegetative forms
b. Virus
c. Spore forms




8

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
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 presentation
2. 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
infiltration
2. 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 pain
Acute and chronic periapical diseases; pulp necrosis no need to
anesthetize

Irreversible
pulpitis
(symptomatic or
asymptomatic)
Necrosis Periradicular
pathosis
Maxillary
infiltration
PDL
IP

+
+
+

Ok
X
X

X
X
X
Mandibular
IANB
PDL
IP

+
+
+

Ok
No
No

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

INFILTRATION (MAXILLARY)

CENTRAL INCISOR
o Labial
o One root
LATERAL INCISOR
o Labial or lingual
CANINE
o Labial because of the apical eminence of the cervical
portion of the crown which is more labially inclined
1
ST
PREMOLAR
o Buccal and lingual
2
ND
PREMOLAR
o Buccal because there is only one root
1
ST
MOLAR
o Palatal and buccal
MANDIBULAR

INCISORS TO PREMOLARS
o Infiltration and mental block
MOLARS
o 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. CARIES
2. 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
9


PREOPERATIVE RADIOGRAPH

1. To determine root anatomy
a. Ex. Mandibular 1
st
premolar with 4 canals
2. To look for the fast break
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 chamber
4. To determine the axis of the crown as relates to root axis
5. To decide the relative difficulty of the case

HOW MANY TIMES SHOULD YOU TAKE A RADIOGRAPH? 3 TIMES

1. Straight on
2. Mesial shift
3. Distal shift

BUCCAL OBJECT RULE/ CONE SHIFT TECHNIQUE/ SLOB/ CLARKS RULE (20
M/D)

1. Location of additional canals/roots
2. Distinguished between objects that have been superimposed
3. Locate foreign bodies
4. 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 shifted
a. Shift Mesially lingual canal goes mesial
b. Shift Distally lingual canal goes distal

3. BUILD UP/ TEMPORIZATION
4. CROWN LENGTHENING
5. 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 protection
iii. Surgically clean operating field isolated
from saliva, hemorrhage and other tissue
fluid
iv. Retraction and protection of the soft tissue
v. 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 Radiograph
8. Describe alternative techniques in canal preparations
Greater taper files

TERMINOLOGIES IN BIOMECHANICAL PREPARATION

REFERENCE POINT
o Important to determine the working length
o Incisors incisal edge
o Molars depends on where the files would go
o 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 terminates
o Located 0.5 1mm at the apical 3
rd
of the root
WORKING LENGTH
o 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. PATENCY
3. SCOUTING
4. RADICULAR PREPARATION
5. WORKING LENGTH DETERMINATION
SELECTION OF IAF
6. APICAL PREPARATION/SERIAL FILING
7. STEP-BACK (FOR LATERAL COMPACTION)
8. CIRCUMFERENTIAL FILING

SPREADER REACH TEST to check for flaring
10


STEPS IN BIOMECHANICAL PREPARATION

1. Measure the pre-operative radiograph
2. Get a file, insert then subtract 2mm (patency file) (-2 mm of tooth
length image)
3. Divide the root length into 3 parts
4. Crown down preparation
Cervical and middle preparation
Use bigger to smaller files
5. Crown down computation
CL + C3rd
CL + M3rd
NOTE: size 35 is contant. It meanst that you have
aldeady reached the end of the middle 3
rd
and you
have already enlarged the canal (cervical and middle
3
rd
)
DENTIN MUD
i. Happens when you do not irrigate every
after filing
ii. 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 FILE
10. SERIAL FILING
Done to enlarge the canal 3x larger than the working
length
11. STEP BACK
RECAPITULATION
i. Using of previous file to remove ledges
ii. MAF is done every after filing to remove the
ledges making it smooth
12. 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 instrument
4. BALANCED FORCE
About 90 degrees clockwise and then about 270
degrees counterclockwise

WORKING LENGTH DETERMINATION

METHODS OF ESTABLISHING WORKING LENGTH
1. Tactile sensation
2. Paper point evaluation use it during or after canal
preparation
3. Electronic apex locator
4. 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 foramen
2. creation of an even, progressive taper from the apical stop to the
pulp chamber following the natural curvature of the canasl
3. provision for an apical stop at the end of the canal
4. adeqyate cleaning of the canal at optimum working length

11

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
2. precurve files if SS. If curved, use directional stoppers
3. select proper instruments depending on their use and properties
4. always keep debris suspended in irrigant: irrigate copiously
5. use instruments in proper sequence without skipping sizes
6. establish a straight line access
7. have a vision of the shape of the canal and work towards shaping
it with the 5 mechanical objectives in mind
8. never force down instruments. Stop at resistance.
9. Always recapitulate to ensure canal patency
10. Verify working length at all times
11. 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 copiously
2. Use needle guage 25 27

OBJECTIVES IN IRRIGATION:

1. Gross debridement
2. Removal of microbes
3. Lubrication
4. Dissolution of pulp tissue remnants
5. Removal of smear layer

ERRORS IN CANAL PREPARATION

1. Blockage
2. Canal transportation
3. Perforations
4. Zipped no canal stop
5. 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 canal
2. Seals canal laterally and apically
3. Dont shrink after being inserted
4. Free of moisture
5. Bactericidal
6. Radiopaque
7. Doesnt stain tooth structure because gutta percha was not cut
properly. Should be 1mm beyond cervical line
8. Non-irritable to the tooth structure/periapical tissue
9. Sterile
10. Easily removed

TYPES OF FILLING MATERIAL

1. SOLID
a. GUTTA PERCHA
i. From dried juice of TABAN TREE
ii. 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 files
2. 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 canal
3. Low toxicity nearly inert
overtime
vi. Disadvantages:
1. Lack of adhesion to dentin
2. Slight elasticity which causes a
rebound and pulling away from
the canals
b. SILVER POINTS
i. Composition:
1. Pure silver
ii. Shape:
1. Same as 0.2 gutta percha
iii. Advantages:
1. Ease of placement
12

2. Length control rigid and flexible
iv. Disadvantages:
1. Corrosion
2. Toxicity
3. Non adaptability
4. Difficult to remove
5. Post space removal
6. Long term failure
7. Apical and coronal seal infection
with that of gutta percha
c. RESILON
i. A synthetic root canal filling material based
on polymers of polyesters
ii. Brand: epiphany
iii. Soluble in water
2. PASTES (SEMISOLIDS)
a. ZINC OXIDE EUGENOL
i. Advantage:
1. Long history of successful usage
ii. Disadvantage
1. Discoloration if not properly
placed
b. N2 (DERIVATION OF SARGENTIS FORMULATION)
c. RC 2B
i. Opaque's metallic oxide
ii. Chlorides
iii. Steroids
3. PLASTICS
a. EPOXY
b. 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 SHRINKAGE
3. SLOW SETTING TIME
Provide adequate working time for placement
4. ADHESIVE
5. RADIOPACITY
Readily visible on the radiograph
6. DOESNT STAIN
7. SOLUBILITY IN SOLVENTS
8. INSOLUBLE IN ORAL & TISSUE FLUIDS
To retain compactness inside the tooth structure
9. BACTERISTATIC
10. CREATION OF SEAL

TYPES OF SEALER:

1. ZOE
2. CALCIUM HYDROXIDE
Shows short term seal ability to tissue toxicity
3. PLASTICS
Ah-26; AH26+
4. GLASS IONOMERS
Dentin bonding properties
Minimal antimicrobial activity
5. RESIN
Provides adhesion

MIXING OF SEALER

1. DROP TEST
2. 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 points
2. Files
3. Lentulo spirals
4. Injection with special syringe
5. 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 insertion
2. Fills up the canal irregularities

METHODS OF OBTURATION

1. LATERAL CONDENSATION TECHNIQUE
a. ADVANTAGES:
i. Simple armamentarium
ii. Length control
iii. Ease of retreatment
iv. Adaptation to the canal walls
v. Positive dimensional stability
vi. Ability to prepare post space
b. DISADVANTAGES
i. Inability to obturate > cured canal, open
apex, internal resorption
2. VERTICAL CONDENSATION TECHNIQUE
3. TECHNIQUE THAT INVOLVES CHEMICAL AND PHYSICAL
ALTERATION OF GUTTA PERCHA
VARIOUS OBTURATION TECHNIQUES AND DEVICES


1. SPREADER/PLUGGER SELECTION
Pointed apex; blunt apex
SPREADER
i. Condenses gutta percha laterally
ii. Finger spreader
iii. Advantages:
1. Better tactile
13

2. Enhance instrument contact
3. Improved apical seal
4. Reduced dentin stress
5. Obturation
6. 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
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. Visual
ii. Radiographic
Remember: what is removed from the root canal
system is more important than what is inserted

APPROPRIATE TIME FOR OBTURATION:

1. Asymptomatic
2. Properly prepared
3. Canal reasonably dry
4. No sinus tract
5. No foul odor
6. Negative in culture
7. Intact TF
8. 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 orifices
3. FLARE
Should reflect canal shape
Tapering from coronal to apical

RESTORATION OF ENDODONTICALLY TREATED TOOTH

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

RESTORATIVE CONSIDERATIONS

1. STRUCTURAL CONSIDERATIONS
a. Endodontically treated teeth are weakened because:
i. Decreased amount of tooth structure
1. Caries
2. Previous restorations
3. Fracture
4. Access opening
5. Canal preparation
ii. Decreased moisture content of the tooth
2. PROTECTIVE CONSIDERATIONS
a. Need for both exterior (post) and interior support to
ensure crown
3. INTERNAL CONSIDERATIONS
4. AESTHETIC ACCEPTABILITY
a. Natural translucency and color
b. Good anatomy
c. Characterization are restored

BASIC RESTORATIVE PRINCIPLES

1. RETAIN SOUND TOOTH STRUCTURE
2. CUSPAL PROTECTION
a. Onlay
i. Full cusp made of restorative material
b. Inlay
i. Not all cusp made of restorative material
ii. Some tooth structure still present/visible
3. FERRULE EFFECT
4. PRESERVATION OF BIOLOGIC WIDTH
5. 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 restorations
4. PROTECTION OF TOOTH STRUCTURE
Restoration is designed to transmit functional loads
equally

EXTERNAL RESTORATIONS

BONDED COMPOSITE
14

BLEACHING
o First choice of treatment
o Destaining of yellow and brownish color is made
successful
CUSPAL PROTECTION

INTERNAL RESTORATIONS

CORES
o Replaces missing crown structure and therefore aid in
retention
POST
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
post
2. BONDABLE POST
Good for anterior teeth
3. POST SPACE PREPARATION
Use for heated instruments
Post system drill

TEMPORIZATION

OBJECTIVES:
o To keep tooth-to-tooth relationship from being altered
o 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 patient
2. location and function of tooth
3. cervical circumference
4. amount of remaining tooth structure
5. socio-economic status of patient
6. motivation and ability of dentist to do the procedure

ENDODONTIC PROGNOSIS

OBJECTIVES:
o To evaluate result or outcome of RCt
o 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 Gender
o Jaw
o Tooth group
o Quality of root canal
o Long term survival of root canal treated teeth

FACTORS AFFECTING ENDODONTIC PROGNOSIS

1. Presence of periradicular lesion
2. 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, overfilling
3. ERRORS IN CASE SELECTION
Coexisting periodontal lesion, resorption
4. 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 evaluation
2. Radiographic evaluation
3. 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
15

Non-pathologic formation of fibrous connective tissue in apical
part which appears radiolucent

CATEGORIES OF SUCCESS OR FAILURE

1. COMPLETE HEALING
a. No clinical symptoms
b. Continuous lamina dura
c. Uniform thickness of periodontal space
2. INCOMPLETE HEALING
a. No clinical symptoms
b. Reduction in size of apical lesion
3. NO HEALING
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 selection
2. use greater care in treatment
3. proper restoration with no coronal discoloration and
microleakage

MANAGEMENT OF FAILURE:

1. not to resort to extraction immediately
a. retreatment should be done first
b. 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 SELECTION
o Questions we ask ourselves:
Should endodontic or periodontal
treatment be done or both?
What will serve the patients best interest:
doing endo-perio treatment, or simply
extraction?



PREDISPOSING CONDITIONS
o 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 history
2. Vitality test
3. Thermal test
4. 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 ones 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
16


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:

Perforations
Vertical fracture
Non odontogenic

TREATMENT

ENDO
o RCT calcium hydroxide, gutta percha
o Endo surgery
o MTA perforations
PERIO
o Medications
Antibiotics
Antiseptics
Anti-inflammatory
o Scaling and root planning
o GTR (guided tissue regeneration)
o Root resection
o Hemisection; radisection (cutting of 1 root of maxillary
molar)







-Rosette Go 101910
Notes of Fernandez, Celine