Endo PDF

"I
s of
Topic Cards Topic Cards

access preparations 1-6 pulp 56-58
diagnostic methods/ 7-22 pulp cross-sections 59-66
terminology
individual teeth 23-30 replantation 67-69
instruments/material/ 31-44 resorption 70-72

techniques
miscellaneous 45-55
access preparations
What is the shape of the access preparation for the maxillary central incisor,
lateral incisor, and canine?
What is the respective length and number of canals for each tooth?
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ENDODONTICS
Maxillary Central Incisoi Maxillary Lateral Incisor Maxillary Canine
Access Opening Access Opening Access Opening
Maxillary Central Maxillary Lateral Maxillary Canines

Incisors Incisors
Average 26 - 27 mm
Average 22-23 mm Average 22-23 mm Length (longest)
Length Length
Shape of Oval
Shape of Oval-triangular Shape of Oval A.O.
A.O. A.O.
Canal One 100%
Canal One 100% Canal One 99.9%
Reprinted from Ingle, JI. and Bakland LK. Endodontics, Fourth Edition a 1994, with permission from Williams & Wilkins.
access preparations
What is the shape of the access preparation for the mandibular central incisor,
lateral incisor, and canine?
What is the respective length and number of canals for each tooth?
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Mandibular Central Mandibular Lateral Mandibular Canine
Incisor Incisor Access Opening
Access Opening Access Opening
Mandibular Central Mandibular Lateral Mandibular Canines

Incisors Incisors
Average 26 mm
Average 21-22 min Average 21-22 m/11 Length
Length Length
Shape of Oval
Shape of Oval Shape of Oval A.O.
A.O.
Canal One canal 94%
Canal One canal Canal One canal Two canals
One foramen 70% One foramen 56% Two foramens 6%
Two canals Two canals
One foramen 24% One foramen 14%
Two canals Two canals Reprinted from Ingle, 11, and Bakland LK.
Two foramens 6% Two foramens 30% Endodontics, Fourth Edition 5 1994, with
permission from Williams & Wilkins.
access preparations
What is the shape of the access preparation for a maxillary first and
second premolar?
What is the respective length, number of roots, and number of canals for
each tooth?
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Maxillary First Premolar
Access Opening Maxillary Second Premolar
Access Opening
Maxillary First Premolars
Average 20-22 mm Maxillary Second Premolars
Length
Average 21-22 mm
Shape of Oval Length
A.O. buccal-lingual
Shape of Oval
Roots One 22% A.O. buccal-lingual
Two 78%
Canal One canal
Canal One canal
One foramen 75%
One foramen 9%
One foramen 13% Two foramens 24%
Two canals Three canals 1%
Two foramens 72%
Three canals Reprinted from Ingle, JI, and Bakland LK. Endodontics, Fourth Edition
Three foramens 6°A a 1994, with pennission from Williams & Wilkins.
access preparations
What is the shape of the access preparation for a mandibular first and
second premolar?
What is the respective length, number of roots, and number of canals for
each tooth?
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Mandibular First Premolar Mandibular Second Premolar
Mandibular First Premolars Mandibular Second Premolars

Average 21 -2 3 mm Average 22 mm
Length Length
Shape of Oval Shape of Oval

A.O. A.O.
Canal One canal Canal One canal


Two foramens 20% Two foramens 12%
Reprinted from Ingle. JI. and Hakland LK. Endodontics, Fourth Edition 5 1994, with permission fron Williams & Wilkins.
access preparations
What is the shape of the access preparation for a maxillary first and
second molar?
What are the respective root lengths, number of roots, and number of canals
for each tooth?
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Maxillary First Molar Maxillary Second Molar
Maxillary First Molars Maxillary Second Molars
Average MB — 19.9 mm Average MB — 20.2 mm
Length DB — 19.4 mm Length DB — 19.4 mm
Palatal — 20.6 mm Palatal — 20.8 mm
Shape of Triangular Shape of Triangular
A.O. Base at buccal cusps A.O. Base at buccal cusps

Canal Three canals 42% Number Three 54%

Four canals 56%
of Roots Fused 46%
Five canals 2%
Canals in One canal Canals in One canal
the MB One foramen 42% the MB One foramen 63%
Root Two canals Root Two canals
Two foramens 18% Two foramens 24%
Reprinted from Ingle. B. and Bakland LK. Endodontics, Fourth Edition 5 1994, wi It permission from Williams & Wilkins.
access preparations
What is the shape of the access preparation for a mandibular first and
second molar?
What are the respective root lengths, number of roots, and number of canals
for each tooth?
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ENDODONTICS
Mandibular First Molar Mandibular Second Molar
Mandibular First Molars Mandibular Second Molars

Average Mesial — 20.9 mm
Average Mesial 20.9 mm
Length Distal — 20.9 mm
Length Distal 20.8 mm
Shape of A.O. Trapezoidal
Shape of A.O. Trapezoidal
Roots Two 98%
Three 2% Canals
Canals Two canals 6% Mesial Distal
Three canals 65% One canal
Four canals 29%
One foramen 13% 92%
Canals Two canals
Mesial Distal One foramen 49% 5%
Two canals One canal 72% Two canals
One foramen 41% Two canals 28% Two foramens 38% 3%
Two foramens 59% One foramen 62%
Two canals Reprinted from Ingle, JI, and Bakland LK. Endodontics, Fourth
Two foramens 38% Edition z 1994, with permission from Williams & Wilkins.
diagnostic methods/terminology
Which of the following is a clinical diagnosis based on subjective and objec-
tive findings indicating that the vital inflamed pulp is incapable of healing
and has the following additional descriptors: lingering thermal pain, sponta-
neous pain, and referred pain?
• reversible pulpitis
• asymptomatic irreversible pulpitis
• symptomatic irreversible pulpits
• none of the above
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ENDODONTICS
• symptomatic irreversible pulpitis
Very Important: The AAE Glossary of Endodontic Terms is used in reference to endodontic pathoses.
In May 2012, the endodontics diagnostic terminology adopted by the American Association of En-
dodontists as described in the December 2009 Journal of Endodontics [Volume 35, Number 12, p. 1634],
will be incorporated in the NBDE Part II.
AAE Consensus Conference

Recommended Diagnostic Terminology
Pulpal:
Normal Pulp A clinical diagnostic category in which the pulp is symptom-free and normally
responsive to pulp testing.
Reversible Pulpitis A clinical diagnosis based upon subjective and objective findings
indicating that the inflammation should resolve and the pulp return to normal.
Symptomatic A clinical diagnosis based on subjective and objective findings indicating that
Irreversible the inflamed pulp is incapable of healing. Additional descriptors: Lingering
Pulpitis thermal pain, spontaneous pain, referred pain.
Asymptomatic A clinical diagnosis based on subjective and objective findings indicating that
Irreversible the vital inflamed pulp is incapable of healing. Additional descriptors: No
Pulpitis clinical symptoms but inflammation produced by caries, caries excavation,
trauma, etc.
Pulp necrosis A clinical diagnostic category indicating death of the dental pulp. The pulp is
usually nonresponsive to pulp testing.
Previously A clinical diagnostic category indicating that the tooth has been endodontically
Treated treated and the canals are obturated with various filling materials other than
intracanal medicaments.
Previously A clinical diagnostic category indicating that the tooth has been previously
Initiated Therapy treated by partial endodontic therapy (e.g., pulpotomy, pulpectomy).
Which of the following is an inflammatory reaction to pulpal infection and
necrosis characterized by rapid onset, spontaneous pain, tenderness of the
tooth to pressure, pus formation and swelling of associated tissues?
• symptomatic apical periodontitis
• acute apical abscess
• chronic apical abscess
• asymptomatic apical periodontitis
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• acute apical abscess
Very Important: The AAE Glossary of Endodontic Terms is used in reference to endodontic pathoses.
In May 2012, the endodontics diagnostic terminology adopted by the American Association of En-
dodontists as described in the December 2009 Journal of Endodontics [Volume 35, Number 12, p. 1634],
will be incorporated in the NBDE Part II.

Apical:
Normal Apical Teeth with normal periradicular tissues that are not sensitive to percussion or
Tissues palpation testing. The lamina dura surrounding the root is intact and the
periodontal ligament space is uniform.
Symptomatic Inflammation, usually of the apical periodontium, producing clinical symptoms
Apical including a painful response to biting and/or percussion or palpation. It may or
Periodontitis may not be associated with an apical radiolucent area.
Asymptomatic Inflammation and destruction of apical periodontium that is of pulpal origin,
Apical appears as an apical radiolucent area, and does not produce clinical symptoms.
Pcriodontitis
Acute Apical An inflammatory reaction to pulpal infection and necrosis characterized by
Abscess rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus
formation and swelling of associated tissues.
Chronic Apical An inflammatory reaction to pulpal infection and necrosis characterized by
Abscess gradual onset, little or no discomfort, and the intermittent discharge of pus
throu gh an associated sinus tract.
Condensing Diffuse radiopaque lesion representing a localized bony reaction to a low-grade
Osteitis inflammatory stimulus, usually seen at apex of tooth.
Which of the following are related to vital teeth and usually do not warrant
endodontic therapy?
Select all that apply.
• apical scar
• cementoma
• traumatic bone cyst
• globulomaxillary cyst
• radicular cyst
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ENDODONTICS
• cementoma
• traumatic bone cyst
• globulomaxillary cyst
- An apical scar is represented by a periapical granuloma, cyst, or abscess that heals with scar
tissue. Well-circumscribed radiolucency resembling a granuloma. Tooth is nonvital.
- A radicular cyst usually occurs in a preexisting granuloma. Seldom is painful. Radiolucency
at apex of nonvital tooth.
- A cementoma occurs most frequently in the anterior region of the mandible. It starts as a
radiolucent lesion and then calcifies. The cementoma does not affect pulp vitality. Also called
periapical cemental dysplasia.
- A traumatic bone cyst is not a true cyst since there is no epithelial lining. Found mostly in
young people; asymptomatic. Radiolucency that appears to scallop around the roots of teeth.
Teeth are usually vital.
- A globulomaxillary cyst (developmental cyst) is found at the junction of the globular and
maxillary processes of the maxilla, between the lateral incisor and the canine roots. Teeth are
vital.
- A lateral periodontal cyst occurs on a lateral periodontal location and it is of developmen-

tal origin arising from cystic degeneration of clear cells of the dental lamina. Tooth is vital.
- An ameloblastoma is a benign, locally aggressive tumor arising from the odontogenic ec-
toderm. Lesions occur as multilocular radiolucencies and frequently cause extensive root re-
sorption. The mandible is affected four times more frequently than the maxilla.
- A cementoblastoma is an odontogenic tumor characterized by the proliferation of functional

cementoblasts that form a large mass of cementum or cementum-like tissue on the tooth root.
The most superior of all other retrofilling material -- mineral trioxide aggregate
(MTA) has all of the following advantages, EXCEPT two. Which TWO are not
properties of MTA?
• radiopaque
• easy to manipulate
• hydrophilic
• biocompatible
• not toxic
• short setting time
• induction of hard tissue formation

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• easy to manipulate
• short setting time
The main ions found in MTA are calcium and phosphorus. MTA has a high pH so it induces
hard tissue formation. MTA has superior sealing ability and is not adversely affected by blood
contaminants. It also causes only low levels of inflammation because it forms fibrous con-
nective tissue and cementum when in contact with the periodontium. Note: MTA is difficult
to manipulate and has a long setting time. Despite these disadvantages, it's the material of
choice today.
A retrofilling (also called a reverse filling or retrograde amalgam filling) is placed to seal the
apical portion of the root canal. This procedure is used when an apicoectomy alone will not
yield a good result. Whenever there is any chance whatsoever that an apical seal may be
faulty, a reverse filling material must be placed. For example, if the root canal appears cal-
cified, it would be impossible to obturate most of the canal and get a seal. If just the root apex
were cut off (apicoectomy), the incompletely filled canal might act as a source of reinfection.
To prevent this after the root tip is resected, the foramen is found, enlarged, and filled with a
zinc-free amalgam to create a seal.
An apicoectomy (root-end resection) is a procedure where the buccal tissue is flapped back,
the buccal bone about the apex is removed, the root apex is removed, and the area is curet-
ted out. Indications for apicoectomy: 1) A reverse filling needs to be placed 2) It is neces-
sary to gain access to an area of pathosis 3) The poorly filled apical portion of the root is to
be removed to the level of canal obliteration. Teeth that have posts in them and need to be re-
treated are the most common reason for an apicoectomy and a retrograde filling.
Remember: Periapical curettage is the same procedure as an apicoectomy (as far as flap and
removal of buccal bone) but without removing the root apex. Removal and examination of the
diseased tissue and determination of the extent of the lesion are the objectives of apical curet-
tage.
The earliest and most common symptom associated with an inflamed pulp is:
• a dull throbbing pain on mastication
• sensitivity to hot and/or cold stimuli
• a persistent feeling of discomfort
• mild bleeding
• pain on percussion
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• sensitivity to hot and/or cold stimuli
*** Thermal sensitivity is the earliest and most common symptom of an inflamed pulp.
As caries enters the dentin, it begins with a lateral spread at the DEJ. This is due to the increased organic content and
the involvement of many dentinal tubules. The Tomes fibers react, causing fatty degeneration then, later, decalcifi-
cation (sclerosis). As caries progresses, destruction of dentin is followed by the bacterial invasion of the tubules and
complete destruction of dentin. Once odontoblasts are involved, pulpal changes occur. Initially there is vascular di-
lation and local edema. The earliest common symptom of this edema is thermal sensitivity (usually increased and
persistent pain on application of con!).
Remember: The only reliable clinical evidence that secondary dentin has formed is decreased tooth sensitivity
(usually seen a Jew weeks after placement of a .filling). When dentinal tubules become completely calcified, the dentin
is insensitive.
1.Thermal tests are especially valuable when the patient describes the pain as diffuse. The cold test can
Notes be done with cold water baths, sticks of ice, ethyl chloride, dichlorodifluoromethane (DDM; Endo Ice)
or carbon dioxide ice sticks.
2. The heat test can be done with warm sticks of gutta-percha, using a rubber wheel mounted on a man-
drel revolving at a polishing speed to generate heat, or a hot water bath.
3. The best method to elicit the most accurate thermal response is to individually isolate the suspected
teeth with a rubber dam and then bathe each tooth in hot or cold water. This is done because all other
methods may stimulate the tooth at only one section of one surface.
Responses to thermal tests:
• Nonresponsive: indicates pulp necrosis
• Mild-to-moderate response: slight pain that subsides within I to 2 seconds; indicates nor-
mal pulp
• Strong, momentary painful response: subsides within I to 2 seconds; indicates reversible
pulpitis
• Moderate-to-strong painful response: lingers for several seconds or longer; indicates
symptomatic irreversible pulpitis
4. Thermal tests may be false-negative in immature, recently traumatized teeth or because of pre-
medication with an analgesic.
5. Although the percussion test does not indicate the health of the pulp, the sensitivity of the proprio-
ceptive fibers does reveal inflammation of the apical PDL.
6. A positive response to percussion indicates not only the presence of inflammation of the PDL, but
also the extent of the inflammatory process.
A phoenix abscess is also known as a:
• recrudescent abscess
• granuloma
• cyst
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• recrudescent abscess
A phoenix abscess develops as the granulomatous zone becomes contaminated or in-

fected by elements from the root canal. Diagnosis is based on the acute symptoms (pain
to percussion) plus radiographic examination, which reveals a large periapical radiolu-
cency. Note: A phoenix abscess is always preceded by asymptomatic apical periodonti-
tis. Signs and symptoms are identical to those of an acute apical abscess, but a radiograph
will show a periapical radiolucency that indicates the presence of a chronic disease. Note:
The term "phoenix Abscess" is becoming obsolete. The term replacing it seems to be "an
acute exacerbation of asymptomatic apical periodontitis" (yes, the definition is now the
term).
A granuloma is defined as a growth of granulomatous tissue continuous with the peri-
odontal ligament resulting from pulpal death with diffusion of toxic products into the pe-
riapical area. In most cases, a granuloma is symptomless. Radiographically, one sees a
well-defined area of rarefaction with some irregularities, while clinically the tooth is not
sensitive. A massive invasion of pulpal contaminants will result in the formation of an
acute abscess (phoenix abscess).
A cyst is an inflammatory response of the periapex, that develops from preexisting gran-
ulomatous tissue (granuloma). It is characterized by a central, fluid-filled, epithelium-
lined cavity surrounded by granulomatous tissue and peripheral fibrous encapsulation. It
is often associated with a chronically infected tooth. The tooth may be mobile. On radi-
ographs, one will see a well-defined area of rarefaction (radiolucency) that is limited by
a continuous radiopaque, sclerotic border of bone. It is usually asymptomatic.
Important: A granuloma or a cyst can only be differentially diagnosed by histological

examination.
Which of the following defines the difference between a chronic apical
abscess and a periapical cyst/granuloma?
• chronic apical abscess is asymptomatic
• chronic apical abscess is symptomatic
• only histological examination can differentiate
• the border of the radiolucent lesion
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• only histological examination can differentiate
The chronic apical abscess is sometimes so painless that it may go undetected for years until revealed
by an x-ray. It is an inflammatory reaction to pulpal infection and necrosis characterized by gradual
onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract. The
chronic abscess may be differentiated from cysts and granulomas by the fact that both cysts and gran-
ulomas have well-defined radiolucencies associated with them. The treatment is conventional root
canal treatment.
Remember: 30% to 50% of bone calcium must be altered before radiographic evidence of periapical
breakdown occurs (this alteration takes place at the junction between the cortical and cancellous bone).
The acute apical abscess is an inflammatory reaction to pulpal infection and necrosis characterized by
rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of asso-
ciated tissues. The patient may appear weakened, irritable, and present with a fever. The diagnosis is
based on the history, exam, and radiographs. The best treatment of an acute apical abscess includes es-
tablishing drainage and debriding the canal system of necrotic tissue which will relieve the acute
symptoms. This is followed at a later date by conventional root canal therapy.Note: If the abscess rup-
tures through the periosteum into the soft tissue, the patient's symptoms will subside.
Incision and drainage of soft tissues is indicated:

• If a pathway is needed in soft tissues with localized fluctuant swelling that can provide necessary
drainage. Note: It should be emphasized that, whenever possible, the acute apical abscess should be
incised and drained through the root canal system.
• When pain is caused by the accumulation of exudate in tissues.
• When it is necessary to obtain a culture of the exudate
Apical trephination is accomplished by aggressively placing a No. 15 to 25 K-file beyond the confines
of the apex. Surgical trephination is a perforation of the alveolar cortical bone to release accumulated
tissue exudates. A small (5-mm) horizontal incision is made with a No. 15 scapel blade at the level slightly
apical to the root apex. A No. 6 or 8 round bur is used on a straight handpiece to penetrate the cortical
plate above the root apex. If there is diffuse swelling (cellulitis), antibiotics are usually indicated.
A patient is diagnosed with symptomatic apical periodontitis and refuses treat-
ment due to fear of needles. Your statement to the patient should include the
fact that:
• eventually, the acute nature of the lesion will progress into a chronic and nonpainful
lesion
• this lesion can progress into the bone causing osteomyelitis, a more severe condition
• the apical lesion has been there for years and the tooth needs treatment immediately
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• this lesion can progress into the bone causing osteomyelitis,
a more severe condition
Osteomyelitis is not a particularly common disease. It is a serious sequela of periapi-

cal infection that often results in a diffuse spread of infection throughout the medullary
spaces, with subsequent necrosis of a variable amount of bone.
Acute or subacute osteomyelitis may involve either the maxilla or the mandible. In the
maxilla, the disease usually remains fairly well-localized to the area of initial infection.
In the mandible, bone involvement tends to be more diffuse and widespread.
Clinically, the person afflicted with acute osteomyelitis is usually in rather severe pain
and manifests an elevation of temperature with regional lymphadenopathy. The teeth in
the area of involvement are loose and sore so that eating is difficult, if not impossible.
Note: Another clinical symptom of acute osteomyelitis is leukocytosis, an elevated num-
ber of white cells in the blood.
Radiographically, acute osteomyelitis progresses rapidly and demonstrates little radi-

ographic evidence of its presence until the disease has developed for at least I to 2 weeks.
At that time, diffuse lytic changes in the bone begin to appear. Note: A "moth-eaten" ra-
diolucent appearance is evident.
The general principles of treatment demand that drainage be established and main-
tained and that the infection be treated with antibiotics to prevent further spread and com-
plications.
An acute apical abscess will not respond to pulp vitality tests.
An acute apical abscess is only observed in association with a necrotic pulp.
• both satements are true
• both statements are false
• the first statement is true, the second is false
• the first statement is false, the second is true
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ENDODONTICS
• both statements are true
Of all the dental abscesses, the apical is the most common type. It is an inflammatory reaction to pulpal infec-
tion and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus forma-
tion and swelling of associated tissues. Note: The first symptom may be a slight tenderness of the tooth to pressure.
This later develops into a severe throbbing pain (acute abscess) with swelling of the overlying mucosa. Reduc-
ing the irritant, reduction of pressure, or the removal of the inflamed pulp is the immediate goal. Of these, pres-
sure release is the most effective in relieving the patient's pain. Emergency treatment includes establishing
drainage (ideally through the canal) and prescribing antibiotics (only if indicated by systemic signs and elevated
temperature) and analgesics. This will relieve the acute symptoms followed by conventional endodontic therapy
at a later date. Note: Complete cleaning and shaping of the root canals is the preferred treatment. However, if
for some reason this is not possible, a pulpotomy is usually effective in the absence of percussion sensitivity.
Important: When diffuse swelling exists, the swelling has dissected into fascial spaces. The most important ob-
jective is the removal of the irritant via canal debridement or extraction of the offending tooth. Swelling may be
incised and drained followed by drain insertion and systemic antibiotics.
Note: For endodontic infections that do not respond to penicillin VK, clindamycin is often recommended. It pro-
duces high blood levels and is effective against anaerobic bacteria but must be used with caution because of the
potential for pseudomembranous colitis.
1. A history of preoperative pain and swelling is the best predictor of interappointment emergencies.

Notes 2. No relationship exists between flare-ups and treatment procedures (i.e., single or multiple visits).
3. The periodontal abscess is an acute abscess that develops through the periodontal pocket. Alve-
olar bone loss, pocket formation and periodontal pathologic conditions are suggestive of the peri-
odontal abscess. The tooth will usually be palpation- and percussion-positive. It will respond to the
electric pulp tester (unlike the apical abscess). Bacteria associated with this abscess include gram-
negative rods such as Capnocytophaga species, Vibrio-corroding organisms, and Fusobacterium
species.
4. The gingival abscess is a relative rarity that occurs when the bacteria invade through some break
in the gingival surface. Such abrasions may be the result of mastication, oral hygiene procedures, or
dental treatment.
Condensing Osteitis is a diffuse radiopaque lesion representing a localized
bony reaction to a low-grade inflammatory stimulus, usually seen at apex of
tooth.
Reversible pulpitis is a clinical diagnosis based upon subjective and object-

ive findings indicating that the inflammation should resolve and the pulp
return to normal.
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Pulpal:
Normal Pulp A clinical diagnostic category in which the pulp is symptom-free and normally
Reversible Pulpitis A clinical diagnosis based upon subjective and objective findings
indicating that the inflammation should resolve and the pulp return to normal.
Sympto made A clinical diagnosis based on subjective and objective findings indicating that
Irreversible the inflamed pulp is incapable of healing. Additional descriptors: Lingering
Pulpitis thermal pain, spontaneous pain, referred pain.
Asymptomatic A clinical diagnosis based on subjective and objective findings indicating that
Irreversible the vital inflamed pulp is incapable of healing. Additional descriptors: No
Pulpitis clinical symptoms but inflammation produced by caries, caries excavation,
trauma, etc.
Pulp necrosis A clinical diagnostic category indicating death of the dental pulp. The pulp is
usually nonresponsive to pulp testing.
Previously A clinical diagnostic category indicating that the tooth has been endodontically
Treated treated and the canals are obturated with various filling materials other than
intracanal medicaments.
Previously A clinical diagnostic category indicating that the tooth has been previously
Initiated Therapy treated by partial onclodontte therapy to ,Q-. pulpolonly. pulpeclomy).

Apical:
Normal Apical Teeth with normal periradicular tissues that are not sensitive to percussion or
Tissues palpation testing. The lamina dura surrounding the root is intact and the
periodontal ligament space is uniform.
Symptomatic Inflammation, usually of the apical periodontium, producing clinical symptoms
Apical including a painful response to biting and/or percussion or palpation. It may or
Periodontitis may not be associated with an apical radioluccnt area.
Asymptomatic Inflammation and destruction of apical periodontium that is of pulpal origin,
Apical appears as an apical radiolucent area, and does not produce clinical symptoms.
Perindontitis
Acute Apical An inflammatory reaction to pulpal infection and necrosis characterized by
Abscess rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus
formation and swelling of associated tissues.
Chronic Apical An inflammatory reaction to pulpal infection and necrosis characterized by
Abscess gradual onset, little or no discomfort, and the intermittent discharge of pus
through an associated sinus tract.
Condensing Diffuse radiopaque lesion representing a localized bony reaction to a low-grade
Osleitis inflammatory stimulus, usually seen at apex of tooth
A 7-year-old boy arrives at the office with a complaint that tooth #8
is draining pus into his mouth. The tooth had been traumatized earlier.
The vitality tests reveal no response. What is the treatment of choice?
• extraction
• apexogenesis / pulpotomy
• pulpectomy
• periodontal surgery to remove sinus tract
• it is only necessary to give the child analgesics and antibiotics for pain and infection
• apexification
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ENDODONTICS
• pulpectomy
• apexification
The goal of apexification is to induce further root development in a pulpless tooth by stimulat-
ing the formation of a hard substance at the apex, so as to allow obturation of the root canal space.
Apexification may be required after pulpectomy if the apex of the tooth is open. Remember: Apex
closes 2-3 years after eruption.
The technique consists of isolation of the field with a rubber dam, making an access cavity, and re-
moving all pulpal tissue by the use of reamers and files. A premixed syringe of a calcium hy-
droxide-methylcellulose paste (for example, a Pulpdent syringe) is injected into the canal until it
is filled to the cervical level. The paste must reach the apical portion of the canal to stimulate the
tissues to form a calcific barrier. A double seal of cement is made to close off the access cavity. The
patient is recalled after 3 months to see if apexification has taken place. If not, a fresh supply of paste
is placed. If apexification has occurred, conventional root canal therapy is instituted.
The action of calcium hydroxide (CaOH) in promoting formation of a hard substance at the apex
is best explained by the fact that calcium hydroxide creates an alkaline environment that promotes
hard tissue deposition. Note: Its high pH (pH 12.5) also causes an antibacterial effect and it inac-
tivates lipopolysaccharide.
Note: If a permanent tooth fractures and has a fully formed root and the pulp is exposed (large ex-
posure), the treatment of choice is complete root canal therapy. Apexification is not needed be-
cause the root is fully formed. If the exposure is small and the length of time is short (1/2 hour to
1 hour), then a direct pulp cap with CaOH followed by a restoration is the treatment of choice.
Remember: Apexogenesis is the process of maintaining pulp vitality during pulp treatment to
allow continued development of the entire root. Unlike apexification, this procedure relates to teeth
with retained viable pulp tissue in which this pulp tissue is protected, treated, or encouraged to per-
mit the process of normal root maturation.
All of the following statements regarding adjuncts to endodontic treatment
are true EXCEPT one. Which one is the EXCEPTION?
•transplanted teeth with partial root development have a better prognosis than do
those with developed roots
• orthodontic extrusion is commonly indicated prior to implant placement
• intentional replantation is a viable alternative to endodontic surgery
• a major disadvantage of endodontic implants is the lack of an apical seal
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ENDODONTICS
• intentional replantation is a viable alternative to endodontic surgery
*** Intentional replantation is not a substitute for endodontic surgery whenever en-
dodontic surgery can be performed.
Transplantation is the transfer of a tooth from one alveolar socket to another either in the
same person or in another person.
Orthodontic extrusion is defined as force-controlled vertical tooth movement occlusally

in the socket. Indications include untreatable subgingival pathoses cervical caries),
cervical fracture, periodontal defects, resorptive lesions and perforations in the cervical
area.
Crown lengthening is a procedure used to apically position the gingival margin and/or
to reduce the cervical bone. It is employed during the treatment of subgingival caries,
perforations, and resorption.
Root submersion involves resection of tooth roots 3 mm below the alveolar crest. The
coronal portion of the tooth is removed and the roots are covered with a mucoperiosteal
flap. Indications include rampant caries, adverse periodontal conditions, and repeated
prosthetic failures. The submerged roots will prevent alveolar resorption and maintain
better proprioception. This is especially useful in medically compromised or handicapped
patients requiring better denture control. Sometimes, this is also done to avoid formation
of an esthetic defect that may result after extraction.
Which of the following is the most characteristic radiographic evidence of a
vertical root fracture?
• a persistent periodontal defect
• a radiolucent halo surrounding the root of the fracture
• a radiopaque lesion at the sight of the fracture
• a visible fracture when transillumination is used
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• a radiolucent halo surrounding the root of the fracture
Transillumination is often used to see the defect, but of course, this cannot be diagnostic
on tooth structure that is under bone. Also, persistent periodontal defects are often caused
by vertical root fractures; however, this is not radiographic (read the question carefully).
Important: Radiographs (without first wedging the tooth) rarely will show vertical frac-
tures.
Vertical fractures will often be recognized radiographically by their effect on the peri-
odontal ligament that is seen as a diffuse radiolucency or "halo" surrounding the fractured
root. This can be differentiated from other periapical radiolucencies because it surrounds
the tooth uniformly rather than being located at the portal of exit of the apical foramen or
lateral canal.
1.A tooth with a vertical fracture through root structure has a poor progno-
Notes sis.
2. Studies have indicated that most vertical root fractures are due to iatrogenic
causes including: excessive force during obturation, inappropriate post length
or width, and excessive shaping of canals.
Therapy for horizontal fractures of the root always involves considerable difficulty.
Root canal treatment is not indicated if the fracture sites remain in close proximity and
if the pulp retains its vitality. However, if clinical symptoms develop or the segments ap-
pear to be separating according to the x-ray, some treatment is necessary.
Remember: Root fracture can only be visualized on a radiograph if the x-ray beam passes
through the fracture line. As the fracture line could extend diagonally, an additional radi-
ograph is taken with a 45' (steep) vertical angulation in addition to the conventional 90°.
A patient complains of a slight tooth ache that has been "on and off"for a week.
The tooth in question #18. Which of the following teeth would be optimum to
use as a baseline?
• #19 -virgin
• #15 - primary cavitation on occlusal
• #3 - full gold crown
• #30 - occlusal amalgam
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ENDODONTICS
• #19-virgin
EPT checks the sensibility of a tooth by stimulating nerve endings with a low current and high
potential difference in voltage. Although manufacturers of this device give normal reference val-
ues of current, the best way to check "normal/baseline" values is to use it on adjacent (nonpatho-
logical) teeth. This is then compared with the values obtained on the tooth being questioned. The
EPT uses electrical excitation to stimulate the A-delta sensory fibers in the pulp. A positive re-
sponse does not provide any information about the health or integrity of the pulp; it simply indi-
cates that there are vital sensory fibers present. Important: The EPT fails to provide any
information about the vascular supply to the pulp, which is the true determinant of pulp vitality.
Note: EPT is not considered reliable in the following conditions.

1. A pus-filled canal— false positive
2. A nervous patient — false positive
3. Recent dental trauma false negative
4. Insulating restoration—false negative
5. Secondary dentin deposits — false negative
6. Moisture contamination — false positive
7. Immature tooth (open apex) — false negative
8. Patient who has taken analgesics—false negative
9. Improper application/weak batteries in EPT false negative
Important: If a patient's medical history reveals that a cardiac pacemaker has been implanted,
the use of an electric pulp tester is contraindicated.
Remember:
• Normal pulp: A clinical diagnostic category in which the pulp is symptom-free and normally
• Pulp necrosis: A clinical diagnostic category indicating death of the dental pulp. The pulp is
usually non responsive to pulp testing.
The main concept of the cone shift technique is that as the vertical or
horizontal angulations of the x-ray tube head changes, the object buccal
or closest to the tube head moves to the side of the radiograph
when compared to the lingual object.
• same
• opposite
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ENDODONTICS
• opposite
In other words, we can say that the cone image-shift technique separates and identifies the facial
and lingual structures. Note: The cone shift technique is also known as the buccal object rule,
SLOB rule (Same Lingual, Opposite Buccal), Clark's rule- or Walton's Projection.
As the cone position moves from parallel either toward horizontal or vertical, the object on the film
shifts away from the direction of the cone (i.e., in the direction of the central beam).
Note: In order to apply this rule, you must have a reference object.
Important: A disadvantage of the cone shift technique is that it results in blurring of the object,
which is directly proportional to cone angle. The clearest radiograph is achieved by the paralleling
technique so when the central beam changes direction relative to the object and the film, the ob-
ject becomes blurry.
When treating multicanaled bicuspids and molars, it is often difficult to ascertain on the
radiograph which canal is more toward the buccal. When a straight-on exposure is taken of a bi-
canaled tooth, the canals become superimposed on the film, and visualization of each canal is im-
possible. If the x-ray cone is moved to give an angled exposure, the roots will be separate on the
film.
By applying the cone shift technique, you will be able to determine which canal is the buccal and
which is the lingual.
Explanation of SLOB (Same Lingual, Opposite Buccal) rule; the object toward the lingual
side (closer to the film) will appear to shift on the film to the same direction as the reposi-
tioned x-ray cone. For example, if the x-ray cone is mesially angulated, the lingual/palatal ob-
ject (root) will shift toward the same (mesial) side in the resultant radiograph film, and thus
will be easily visualized.
Note: Using this technique you can determine:
1. Working length of superimposed canals.
2. Curvatures of root/canals.
3. Facial-Lingual orientation of instruments, or other anatomical objects.
Your practice is involved with a local minor hockey team, the Millwrights.
A player gets hit with a stick, and his central incisors are intruded. Which of the
following is the least useful examination procedure?
• soft tissue exam
• hard tissue exam
• radiograph
• vitality test
• percussion test
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ENDODONTICS
• vitality test
*** This test is contraindicated. The percussion test is usually not performed because
of its pain. However, the vitality test will give you a truly false reading, because of tem-
porary paresthesia in the area.
For teeth that have been recently traumatized, the dental examination should include:
• Soft tissue exam: observe the lips, face, tongue, etc.
• Hard tissue exam: visually look and then palpate the injured tooth and alveolus to
reveal the extent of tooth mobility as well as alveolar fractures and area of inflamma-
tion. Check for occlusal disharmonies to help detect tooth displacements and jaw frac-
tures.
• Radiographic examination: x-rays reveal tooth displacement and root fractures as
well as other important facts (previous root canal, periapical radiolucencies, etc.).
• Observe the adjacent and opposing teeth for injury.
Teeth that have been traumatized may be fine for a long time, however, many will de-
velop radiolucencies. Do not indiscriminately perform root canals without first check-
ing pulp vitality, and perform root canal therapy only in those teeth that do not respond
to pulp testing. Example: Trauma to maxillary anterior teeth. A few years, later x-rays re-
veal radiolucencies around the region of the apices of the incisors. Check the pulp vital-
ity of all anterior teeth before performing root canals.
Note: Trauma (causing deep intrusion) to a permanent tooth will most likely result in
necrosis of the pulp, and conventional root canal therapy will be necessary.
Pulpal necrosis: is a clinical diagnostic category indicating death of the dental pulp. The
pulp is usually nonresponsive to pulp testing.
individual teeth
require endodontic treatment more often than any other tooth,
while have the highest endodontic failure rate.
• mandibular first molars, maxillary first molars
• mandibular first molars, maxillary second molars
• maxillary second molars, mandibular first molars
• maxillary first molars, mandibular first molars
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ENDODONTICS
• mandibular first molars, maxillary first molars
Mandibular molars are characterized by a trapezoidal outline of the pulp chamber. This
outline is formed by two canals in the mesial root and one oval canal in the distal root. In
approximately 28% (offirst molars) of the cases, the distal root may have a second canal
(fourth canal overall). The pulp chamber is located in the mesial two-thirds of the crown.
Important: You must look for the fourth canal if the first-found canal in the distal root
lies more toward the buccal instead of being located in the center.
1. The lingual wall of mandibular teeth is most easily perforated when prepar-
Notes ing an access opening due to the lingual inclination of these teeth.
2. The mandibular first molar requires endodontic treatment more frequently
than any other tooth in the oral cavity.
Maxillary molars have a triangle outline of the chamber:

• The base of it is formed by the buccal canals, the apex by the palatal canal
• The line connecting the mesial with the palatal canal is the longest
• If a fourth canal is present, it is usually located lingual to the orifice of the mesiobuc-
cal canal and in the mesiobuccal root. It is much more common than previously
thought.
1. The mesiobuccal root of the maxillary molars is the most complex root in
Notes the entire dentition because 90% have either second canals or accessory canals
leading off of the mesiobuccal canal.
2. The maxillary first molar is the posterior tooth with the highest endodon-
tic failure rate. The lingual or palatal root is the longest, has the largest diam-
eter. and offers the easiest access. The clinician should always assume there are
two canals in the mesiobuccal root until it is proven there is only one.
individual teeth
Which of the following are correct associations?
• maxillary incisors most often refer pain to the forehead region
• maxillary second premolars most often refer pain to the temporal region
• maxillary molars most often refer pain to the ear
• manbibular molars most often refer pain to posterior region of the neck
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ENDODONTICS
• maxillary incisors most often refer pain to the forehead region
• maxillary second premolars most often refer pain to the temporal region
• manbibular molars most often refer pain to posterior region of the neck
If careful diagnosis does not reveal the affected tooth, other teeth and related anatomic structures be-
come suspect. Pulpitis in one tooth may cause pain in other areas -- the pain is referred.
Site of Pain Referral Pulp of Tooth Causing Pain

Forehead region Maxillary incisors
Nasolabial area Maxillary canines, premolars
Temporal region Maxillary second premolars
Ear, angle ofjaw, or posterior Mandibular molars

regions of neck
Mental region of mandible Mandibular incisors, canines. and premolars
Zygomatic, parietal, and occipital Maxillary molars

regions of head
Opposing quadrant or to other Maxillary and mandibular molars
teeth in the same quadrant
Important: The nerve endings of cranial nerves VII, IX, and X are widely distributed
within the subnucleus caudalis of the trigeminal (V) nerve. A profuse intermingling of these nerve fibers
creates the potential for the referral of dental pain to many sites.
Orofacial pain can be the clinical manifestation of a variety of diseases involving the head and neck re-
gion. The cause of the pain must be differentiated between odontogenic and nonodontogenic. Charac-
teristics of nonodontogenic involvement:
• Episodic pain with pain-free remissions
• Trigger points
• Pain travels and crosses the midline of the face
• Pain that surfaces with increasing stress
• Pain that is seasonal or cyclic
• Pain accompanied by paresthesia
individual teeth
Which of the following teeth is most likely to have two canals, in fact, it has
two canals most of the time?
• tooth #4
• tooth #12
• tooth #20
• tooth #28
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ENDODONTICS
• tooth #12 - maxillary first premolars almost always have two canals
Maxillary first premolars: Approximately 78% have two roots, one buccal and the other
palatal, each with a single canal. The two roots may be completely separate or merely twin
projections rising from the middle third of the root to the apex (this is more common). The two
roots are usually equal in length from apex to cusp. However, the lingual root and canal may
be wider.
In approximately 22% of maxillary first premolars, only one root is present, and there may
either be one or two canals with one foramen. A cross section at the cervical line shows a canal
shaped like a figure eight (ellipse). The access opening is a thin oval. Be careful not to per-
forate on the mesial (the concavity on the mesial makes perforation very common).
The apical foramen of the maxillary first premolar is usually close to the anatomic apex, and
the apical portion of the roots often tapers rapidly, ending in extremely narrow and curved
root tips. The buccal root can fenestrate through the bone, leading to problems such as inac-
curate apex location, chronic postoperative sensitivity to palpation over the apex, and increased
risk of an irrigation accident. This tooth is also prone to mesiodistal root fractures and frac-
tures at the base of the cusps, especially the buccal cusp.
Maxillary second premolars: The most common configuration in this tooth is a single root,
occurring approximately 75% of the time. Approximately 25% of the time, two separate roots
are present, each with a single canal. The access opening is exactly the same as that for max-
illary first premolars (thin oval).
Remember: Maxillary second premolars have a higher incidence of accessory canals (60%),
than do maxillary first premolars.
I. When only one canal is present (first or second premolar), it is usually found in
Notes the center of the access preparation. If only one canal is found, but it is not in the
center of the tooth, it is probable that another canal is present.
2. Overfilling either tooth may force materials directly into the maxillary sinus.
individual teeth
One year after performing endodontic treatment on tooth #3, you take a new
periapical radiograph and notice that there is still a lesion present.
What is the most likely problem?
• you failed to locate a second mesiobuccal canal
• you failed to locate a second distobuccal canal
• you failed to locate a second palatal canal
• nothing, it takes more than 12 months for the bone to heal
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ENDODONTICS
• you failed to locate a second mesiobuccal canal
*** Not only is the mesiobuccal canal the hardest canal to find on tooth #3 and #14, but
it also often splits into two.
Canal orifices of a maxillary first molar are arranged in the shape of a triangle. The ori-
fice to the mesiobuccal canal is usually the most difficult to locate, since it is under the
mesiobuccal cusp and must be entered from a distolingual position. This canal is the
small canal and often splits into two canals. It may be calcified and difficult to instru-
ment. The palatal canal is the straightest, widest, and most tapering canal. The most com-
mon curvature of the palatal root is to the facial. The distobuccal canal is also small and
tapering. The orifice to this canal has no direct relation to its cusp. The distobuccal ori-
fice is usually located by means of its relation to the mesiobuccal orifice, with the disto-
buccal found approximately 2 to 3 mm to the distal and slightly to the palatal aspect of
the mesiobuccal orifice.
Note: In approximately 58% of maxillary first molar teeth, a fourth canal is present with
its orifice being just lingual to the orifice of the mesiobuccal canal. The canal is located
in the mesiobuccal root and may join the mesiobuccal canal or exit through a separate
foramen. If a lesion is present on the mesiobuccal root prior to root canal therapy and
doesn't heal in the usual amount of time (6-12 months) following treatment, it is most
likely due to a missed canal (mesiolingual).
Fracture of the maxillary first molar is usually through the central groove or at the base
of the buccal cusp. These fractures can extend into the furcation, creating an untreatable
periodontal defect.
Remember: The U-shaped radiopacity commonly seen overlying the apex of the palatal
root of the maxillary first molar is most likely the zygomatic process of the maxilla.
individual teeth
Which of the following teeth have pulp chambers that can be characterized as
oval or ovoid?
• maxillary central incisor
• mandibular central incisor
• maxillary lateral incisor
• mandibular lateral incisor
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ENDODONTICS
• mandibular lateral incisor
The cervical cross sections below of the maxillary permanent teeth

show the relationship of the crown outline to the
pulp chamber and the root cam&

Central Incisor Lateral Incisor Canine
First Premolar Second Premolar

First Molar Second Molar
Reprinted from Ash. Major M. Wheeler's Denial Anatomy, Physiology and Occlusion, Seventh Edition. 5 1993, with permission from W. B. Saunders Company.
individual teeth
Approximately what percentage of mandibular first premolars may have two
canals with two apical foramina?
• 5%
• 20%
• 45%
• 65%
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ENDODONTICS
• 20%
*** Almost one-fourth of all mandibular first premolars may have two canals with two foram-
ina.
The treatment of mandibular first premolars can really be tricky! At least 27% may have
two canals with either one or two foramen. This is quite different from the mandibular second
premolar 86% are found to have one canal with one foramen.
The second premolar has fewer variations than the first premolar, usually having one root and
one well-centered canal. The access opening is oval. Consideration must be given to the men-
tal foramen which lies in close proximity to the apex. Avoid overinstrumentation and over-
fill. When viewing an x-ray of this area, the mental foramen is sometimes misdiagnosed as a
premolar abscess. Therefore, before performing root canal therapy, make sure all diagnostic
tests confirm your finding.
Note: If a straight-on preoperative radiograph of a mandibular first premolar shows the pulp
canal disappearing (or going from dark to light) in midroot, this is an important indication
that two canals are present
Other diagnostic tests:
• Selective anesthesia test: can be used when other tests have not determined which tooth
is the source of pain.
• Test cavity: only done in cases where a strong suspicion of pulp necrosis is present and
confirmed with other tests and radiographic findings, but a definitive test is required.
Remember: A radiolucency will not begin to manifest until demineralization of bone extends
through the cortical plate of the bone —Key point: You should not rely exclusively on x-rays
in an attempt to arrive at a diagnosis.
Important: Because an x-ray is only a two-dimensional image, two films of the tooth or teeth
in question should be taken at the same vertical angulation but with a 10- to 15-degree change
in horizontal angulation.
individual teeth
A mandibular canine typically requires an oval access preparation.
The access should be directed slightly toward the lingual surface due to slight
labial axial inclination of the crown.
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ENDODONTICS
Mandibular canines usually have only one root but, in rare cases, may have two sepa-
rate roots. The access opening is a large oval with the greatest width placed incisogingi-
vally.
This tooth usually has a slightly labial axial inclination of the crown, therefore the ac-
cess opening needs to be directed toward the lingual surface.
The canal of the mandibular canine is somewhat ovoid at the cervical area, but it be-
comes rounder at the apex.
Note: The root canal for a mandibular canine is thin mesiodistally but wide labiolin-
gually.
individual teeth
Which of the following teeth is most likely to have a curved root?
• maxillary central incisor
• maxillary canine
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ENDODONTICS
The maxillary lateral incisor always has (99.9%) one root with one canal. The root is more slender than
in the maxillary central incisor and frequently (55%) has a distal and/or lingual curvature or dilaceration.
The access opening is oval.
Maxillary central incisor: The maxillary central incisor always has one root and one canal. The root
is bulky, with a slight distal axial inclination but rarely has a dilaceration. The access opening is oval-
triangular.
Maxillary canine: The maxillary canine always has one root and one canal. This tooth is the longest
in the arch. The access opening is oval.
Note: The maxillary central, lateral, and canine roots and hence, canals, all have a distal axial inclina-
tion. This means that, in penetrating along the long axis of the tooth, the bur must be slightly angled to-
ward the distal surface. Failure to do this may lead to perforation of the mesial portion of the root.
Remember: The mandibular incisors (laterals and centrals) have only one root, which is narrow
mesiodistally but relatively wide labiolingually and may have a distal and/or lingual curvature. Two
canals may be present. When there are two canals, the labial canal is the straighter one. The access
opening for a mandibular central or lateral is a long oval, with the greatest width placed incisogingivally
and the incisal extent very close to the incisal edge.
Perforation: Although many errors can potentially occur during access preparations, the most deleteri-
ous is perforation of the pulp chamber space into the oral cavity or periodontal tissues. If the perforation
occurs above the osseous crest in the gingival sulcus or above the free gingival margin, consider the
following measures: (1) Control hemorrhage with a dry cotton pellet or some hemostatic agent, do not
use formocreosol (2) Seal with a temporary cement, such as Cavit or ZOE, (3) Proceed with RCT (4) Plan
to restore perforated area separately or make such restoration part of the final tooth preparation. If the
perforation is at or below the osseous crest or into the furcation region, the following steps can be con-
sidered; however, the prognosis for these cases is very poor. (1) Seal the perforation immediately. (2) If
the perforation is close to a canal orifice, place a file, gutta-percha cone, or silver cone into the canal to
prevent the placement of material in the canal during the repair (3) Control the hemorrhage, if it can not
be controlled due to size, then use a pulp capping agent, such as Dycal, if it is controllable, use Cavit or
ZOE to seal perforation. (4) Try to avoid pushing any sealing materials into the periradicular tissues.
inst/mat/tech
While doing a vital pulpotomy on a young, immature permanent tooth, the
hemorrhage after pulp amputation could not be controlled with cotton pellets,
even after several minutes. What is the next step in completing this treatment?
• control the hemorrhage with hemostatic agents
• apply formocresol with cotton pellets at the amputation site
• irrigate the canal with sodium hypochlorite then apply calcium hydroxide
• perform the amputation at a more apical level
• stop the procedure and close the tooth with an interim restoration
• all of the above
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ENDODONTICS
• perform the amputation at a more apical level
*** Uncontrolled bleeding is a sign of inflamed pulp tissue. The radicular pulp must he
uninflamed for the success of this procedure. It is not uncommon to find uninflamed pulp
at a more apical level, especially in cariously exposed teeth. If bleeding does not stop
even after more apical amputation, hemostatic agents are used as a compromise
treatment. These are closely monitored and, if vitality is lost, apexification (pulpectomy)
procedures should be instituted.
Pulpotomy is the surgical removal of the coronal portion of a vital pulp to preserve the
vitality of the remaining radicular pulp. The common indications include:
• Cariously exposed deciduous teeth — with healthy radicular pulps
• Traumatic or carious exposure of permanent teeth with undeveloped roots
• An alternative to extraction when endodontic treatment is not available
• Emergency treatment in permanent teeth with acute pulpitis
Unfortunately, pulpotomy procedures performed in fully developed permanent teeth

are not found to be successful. For this reason, it is regarded as a temporary procedure in
these teeth.
i n st/m at/tech
Which of the following situations offer better success for pulp capping?
• accidental exposure of the pulp
• pulp of a middle-aged person
• carious exposure of the pulp
• pulp of a young child
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ENDODONTICS
• accidental exposure of the pulp
• pulp of a young child
Pulp capping is the placing of a sedative and antiseptic dressing on an exposed healthy pulp to
allow it to recover and maintain normal function and vitality. The dressing most commonly used
is CaOH2 (Dycal). Pulp capping is overused in dentistry today. In reality, it has only very few in-
dications for its use. Young pulps are more vascularized and, therefore, more amenable to repair.
Pulp cappings are more successful if the exposure was accidental (trauma or with a dental bur)
as opposed to carious. In addition, the exposure should only be pinpoint to expect success. Repair
is accomplished by the formation of a dentin bridge at the site of exposure. Even a small carious
exposure should have root canal therapy for the best long-term prognosis.
Note: Direct pulp capping is indicated if there is a small mechanical exposure (or small traumatic
exposure), an asymptomatic vital pulp, and no coronal or periapical pathology. A hard tissue bar-
rier (reparative dentin bridge) may be visualized as early as 6 weeks postoperative.
A tooth may stay asymptomatic for several weeks after pulp capping has been performed. However,
this may be only temporary. Unfortunately, if pulp capping fails and the tooth becomes sympto-
matic, it may be difficult, if not impossible, to treat with routine endodontics because of the severe
calcifications in the root canal. Perforations may occur during attempts to follow the obliterated
canal to gain patency to the apex. Note: Perforations into furcations of multirooted teeth have the
poorest prognosis.
Indirect pulp capping involves removing infected dentin almost up to the point of pulpal expo-
sure. Calcium hydroxide is placed and then a resin-modified glass ionomer cement is placed over
that. Formation of secondary dentin should occur, and then a final restoration is placed after re-
moval of the intermediate restoration and residual caries. The goal of indirect pulp capping is to
have the tooth participate in its own recovery. Indications for indirect pulp capping include deep
carious lesions that encroach but are not actually in the pulp, no history of chronic pain, no radi-
ographic pathology, vital pulp, and normal tooth mobility and color.
inst/mat/tech
In which of the following scenarios would you consider using solvent-softened
custom cones?
• lack of an apical stop
• an abnormally large apical portion of the canal
• an irregular apical portion of the canal
• after an apexification procedure
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ENDODONTICS
• lack of an apical stop
• an abnormally large apical portion of the canal
• an irregular apical portion of the canal
• after an apexification procedure
If the preparation is properly flared, fitting the master cone is not a time-consuming pro-
cedure. A gutta-percha cone the same size as the file used last during preparation (MAF)
is selected and placed as far as possible into the canal, but not beyond the working length.
Once satisfactory tugback and apical positioning appear to be obtained, a radiograph is
taken to verify cone positioning. If an accurate determination and careful enlargement
have been performed, the x-ray will show that the master cone reaches the most apical
position of the preparation or extends to a point just short of that (1 mm). When the
cone is slightly short, the pressure of condensation plus the lubricating action of the sealer
will be sufficient to produce complete seating of the cone.
1. If the cone is more than 1 mm from the radiographic apex, discard the cone
Notes and fit a smaller one or instrument more in the apical third.
2. Remember: The main reason for recapitulation (usingyour MAF after each
increase in file size) during instrumentation of the canal is to clean the apical
segment of the canal of any dentin filings that were not removed by irrigation.
3. Common solvents used to soften gutta-percha are chloroform, methylchlo-
roformate, halothane, rectified white turpentine, and eucalyptol.
4. Studies show that solvent softening does not ultimately result in a better api-
cal seal.
5. Slight resistance to dislodgement is referred to as "tugback."
6. The cone should also have a definite apical seal -- it should not be able to be
pushed further apically.
inst/mat/tech
During the master cone fitting procedure in the endodontic treatment of a
patient's tooth, the patient says he has a "sharp shooting pain in the same
tooth that ached earlier."What should be your response and why?
• continue with obturation, the anesthetic is simply wearing off
• continue with obturation, this is a normal complaint during this part of the procedure
• consider looking for an accessory canal and refiling, there is likely pulpal tissue that
has not been properly debrided
• irrigate further, the sodium hypochlorite should take care of this problem
• temporize the tooth and obturate at a later date
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ENDODONTICS
• consider looking for an accessory canal and refiling, there is
likely pulpal tissue that has not been properly debrided
*** This indicates inadequate debridement, as a pulpless tooth should not respond to any
stimuli.
The most important consideration before filling a root canal is proper cleaning (debride-
ment) and shaping (instrumenting) of the canal. Once the canal is obturated, any organisms
that have entered the periapical tissues from the canal are eliminated by the natural defenses
of the body.
Objectives of root canal obturation:

• To develop a fluid-tight seal at the apical foramen
• Complete filling of the root canal space
• To create a favorable biologic environment for the process of tissue healing
In endodontic treatment, the importance of canal obturation (filling) is second only to canal
debridement (which is the key to success). Approximately 40% of failures are believed to be
caused by incomplete obturation of the root canal. If the canal is not filled, tissue fluid and mi-
croorganisms from the periapical tissues are able to enter the voids, with failure as the ultimate
result. However, if an accessory canal is not totally filled during obturation, the appropri-
ate treatment is to observe the tooth and evaluate every 3 months.
Remember: The presence of a periapical lesion before root canal treatment will reduce the
success rate of the treatment by 10%-20%.
Note: After endodontic therapy is completed on a tooth with a periapical radiolucency, it usu-
ally takes 6-12 months before marked reduction in the size of the radiolucency is evident on
an x-ray. Desired periapical tissue changes include regeneration of alveolar bone, deposition
of apical cementum, and reestablishment of the PDL.
inst/mat/tech
Which of the following are suggested as irrigants during root canal therapy?
• orea peroxide (Gly-Oxide)
• hydrogen peroxide
• sodium hypochlorite
• calcium hydroxide
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• urea peroxide (Gly-Oxide)
• hydrogen Peroxide
• sodium Hypochlorite
*** Calcium hydroxide is not an irrigant.
Sodium hypochlorite (NaOC1) is the most widely used irrigant and has effectively aided
canal preparation for many years. A 5.25% solution provides excellent germicidal solvent
action, but is dilute enough to cause only mild irritation when contacting periapical tissue.
NaOCl is a good tissue solvent as well as having some antimicrobial effect. It also acts as a
lubricant for root canal instrumentation. Note: It is toxic to vital tissue; always use rubber
dam. Note: To date there is no agreement on any single concentration-value of NaOCI as
being the most effective while being the safest.
Hydrogen peroxide (3% solution) is also widely used in endodontics with two modes of ac-
tion. The bubbling of the solution, when in contact with tissue and certain chemicals, physi-
cally foams debris from the canal (effervescent effect). In addition, the liberation of oxygen will
destroy strictly anaerobic microorganisms. The solvent action of hydrogen peroxide is much
less than that of NaOC1. However, many clinicians use the solutions alternately during
treatment.
Urea peroxide is available in an anhydrous glycerol base, as Gly-Oxide, to prevent
decomposition and is a useful irrigant. It is better tolerated by periapical tissue than NaOC1,
yet has greater solvent action and is more germicidal than hydrogen peroxide. Therefore, it is
an excellent irrigant for treating canals with normal periapical tissue and wide apices. The
best use for Gly-Oxide is in narrow and/or curved canals, utilizing the slippery effect of the
glycerol.
Note: Irrigants perform the important biologic function of destroying bacteria during en-
dodontic therapy. Their action is unquestionably more significant than that supplied by the use
of intracanal medicaments. Irrigants should be used copiously throughout the instrumentation
phase of root canal procedures.
inst/mat/tech
You are retreating a previously root canal treated tooth. Which of the follow-
ing might you possibly use?
• rotary files
• chloroform
• glass bead sterilizer
• ultrasonic
• heated instruments
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ENDODONTICS
• rotary files
• chloroform
• ultrasonic
• heated instruments
Techniques to remove gutta-percha include:
• Rotary removal
• Ultrasonic removal
• Heat removal
• Heat and instrument removal
• File and chemical removal
Chloroform is the reagent of choice to dissolve gutta-percha. It is very effective but
should be used with caution. Its vapor is potentially hazardous, so it is dripped directly in
the canal avoiding excessive flooding.
Other chemicals that can dissolve gutta-percha to a varying degree include xylol,
halothane, benzene, carbon disulfide, essential oils, methyl chloroform, and white recti-
fied turpentine.
If a gutta-percha cone has passed beyond the apex then a file must be used beyond the
apex to avoid breakage of the cone. A broken cone in the periapical area may result in an
orthograde retreatment failure.
I. Gutta-percha points may be disinfected by placing them in a 5.25% NaOCl
Notes solution for 1 minute.
2. A glass bead sterilizer can sterilize endodontic files in 15 seconds at 220°
C (428° F).
inst/mat/tech
Which of the following statements regarding ethylene diamine tetra-acetic acid
(EDTA) are true?
• it is a chelating agent with the capability to remove the mineralized portion of the
smear layer
• it can decalcify up to a 50 mm thin layer of the root canal wall
• it is also an excellent irrigation solution
• normally used in a concentration of 17%
• RC-Prep and EDTAC are other preparations of EDTA
• it can be used in place of NaOCI
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• it is a chelating agent with the capability to remove the mineralized portion
of the smear layer
• it can decalcify up to a 50 mm thin layer of the root canal wall
• normally used in a concentration of 17%
• RC-Prep and EDTAC are other preparations of EDTA
***EDTA is not suitable as an irrigant and cannot be used in place of Na0C1. The decalcify-
ing process induced by EDTA is self-limiting and stops as soon as the chelator is used up.
Chelating agents are used to aid and simplify preparation for very sclerotic canals after the
apex has already been reached with a fine instrument. These agents act on calcified tissues
only and have little effect on periapical tissue. Their action is to substitute sodium ions, which
combine with the dentin to give soluble salts for the calcium ions that are bound in less solu-
ble combination. The edges of the canal are thus softer, and canal enlargement is facilitated.
EDTA will remain active in the canal for 5 days if not inactivated. For this reason, at the com-
pletion of the appointment, the canal must be irrigated with a solution containing (NaOC1).
Note: Rinsing for 1 minute with EDTA eliminates the smear layer, opens dentinal tubules,
and provides a cleaner surface for gutta-percha and sealer to adapt.
EDTAC is EDTA with the addition of Cetavlon, a quaternary ammonium compound. It has
greater antimicrobial action than EDTA. However, it has greater inflammatory potential to tis-
sue as well. The inactivator for EDTAC is NaOCI.
RC-Prep combines the functions of EDTA plus urea peroxide to provide both chelation and
irrigation. The foamy solution has a natural effervescence that is increased by irrigation with
Na0C1 to aid in the removal of debris.
inst/mat/tech
The most acceptable method to achieve adequate root canal debridement is:
• to obtain clean shavings of the canal
• to attain a clean irrigating solution
• to achieve glassy smooth walls of the canal
• all of the above criteria are reliable
• none of the above criteria is acceptable
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• to achieve glassy smooth walls of the canal
*** Clean shavings are difficult to see on a file. The attainment of a clean irrigating so-
lution is considered an inaccurate way to determine the end point of debridement.
Debridement is defined as the removal of foreign material and contaminated or devital-
ized tissue from or adjacent to a traumatic infected lesion until surrounding healthy tis-
sue is exposed. Chemomechanical debridement of the root canal system is the most
crucial aspect of root canal treatment.
Complete debridement of the canal is the most effective means to reduce root canal
microorganisms. It can be carried out in various ways as the case demands, and it may in-
clude instrumentation of the canal, placement of medicaments and irrigants and/or surgery.
Remember:
• The most common cause of root canal failure is incompletely and inadequately disin-
fected root canal systems.
• The second most common cause of failures of root canals is leakage from a poorly
filled canal. This is common even after apical curettage. Example: Root canal treat-
ment was performed on a tooth with apical curettage of a lesion that was found to be a cyst.
Three years later, the lesion is even bigger than it was before. The most likely cause of
this failure is leakage from a poorly filled canal.
• A ledge is an artificially created irregularity on the surface of the root canal wall that pre-
vents the placement of instruments at the apex of an otherwise patent canal. Ledging is
caused by insertion of uncurved instruments short of the working length with excessive
amounts of apical pressure. The canal wall is gouged or a false canal is created, which re-
sults in ledge formation. The effective use of circumferential filing, with either hand or
rotary systems, will ensure smoothness and occlusal flaring of the canal walls and prevent
the development of steps or irregularities.
inst/mat/tech
While cleaning and shaping the canal, an instrument seperates in the canal.
As you attempt to retrieve it, the broken instrument passes partially through
the apex, thus partly protruding into the periapical lesion.
How do you manage this case?
• use a smaller H file to bypass it and try retrieving it
• use Gates Glidden drills to widen the canal and then try retrieving it
• raise a flap and remove the instrument surgically followed by filling the canal with
gutta-percha
• extract the tooth as irreparable damage has occurred to the apex
• just inform the patient, fill the canal with gutta-percha, and monitor
39
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• raise a flap and remove the instrument surgically followed by
filling the canal with gutta-percha
Generally, when a broken instrument protrudes past the apex, surgery should be
performed. This constant irritant must be removed.
Note: It is relatively easier to retrieve an instrument if it is wedged coronal to the

curvature or at the curvature of the canal, but, very difficult if it has passed the curvature.
When an instrument breaks off anywhere in the canal and a periapical radiolucency is
present and minimal canal enlargement has been performed before the accident, surgery
is indicated since the periapical tissues have had little opportunity for healing to be
stimulated. You would prepare and obturate to the point of blockage and then perform
an apicoectomy and retrofilling.
However, when an instrument is broken off in the apical third and is lodged tightly with
no periapical radiolucency evident, the remaining root canal space can be filled. The
patient should be informed of this and placed on a 3-6 month recall.
Important: Prognosis of a tooth with a broken instrument is best if the tooth had a vital
pulp and no periapical lesion.
inst/mat/tech
Which of the following are acceptable methods to clean and shape a canal
using nickel titanium instruments?
• push and pull stroke
• reaming motion
• engine-driven rotary motion
• All of the above
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• all of the above
*** The engine-driven instruments, however, use only the reaming motion. Nickel tita-
nium instruments can be both hand-operated and engine-driven.
Generally, hand instrumentation is done by either filing (push and pull) or reaming (re-
peated rotations).
Filing is a push-pull action with emphasis on the withdrawal stroke. Its efficiency is great-
est with files than with reamers for removing dentin because of the greater number of
flutes in contact with the canal walls during the rasping motion of removing the instru-
ment. Filing action produces an irregularly shaped canal and, therefore, must be filled
with gutta-percha in a condensation procedure.
Reaming is defined as the repeated clockwise rotation of the instrument, particularly

during insertion. Reaming produces a canal that is round. Reaming is recommended if
using a silver cone to fill canals.
Circumferential filing is a push-pull action with emphasis on scraping the canal walls
to create a smooth, tapered preparation. After the file is placed in the canal, it is with-
drawn in a directional manner to sequentially plane the mesial, distal, buccal, and lingual
walls. This technique enhances preparation when a flaring method is used and when
canals are large or irregularly shaped.
inst/mat/tech
The major advantage of zinc oxide-eugenol based sealer types is:
• non-staining property
• fast setting time
• adhesion
• insolubility
• long history of successful usage
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• long history of successful usage
Remember: The primary function of a root canal sealer is to till in the discrepancies
between the core-filling material and the dentin wall. In fact, it is said that it is more im-
portant than the core-filling material.
Other purposes or functions of a root canal sealer include:

• To act as a lubricant, facilitating placement of the gutta-percha
• To form a bond between the filling material and the dentin walls
• To exert antibacterial activity (some exert more than others). This activity is the
highest in the time immediately after its placement.
Most root canal sealers are some type of zinc oxide-eugenol cement and are capable of
producing a seal while being well-tolerated by periapical tissues.
All sealers display some degree of radiopacity (caused by metallic salts in the sealer);
thus they are visible on a radiograph. This helps disclose the presence of accessory canals,
resorptive areas, root fractures, and the shape of the apical foramen and other structures
of interest.
Note: After filling a tooth with gutta-percha, if you see a horizontal line of material
(gutta-percha or sealer) extending both mesially and distally from the canal to the pe-
riodontal ligament space, this is indicative of a root fracture.
ZOE disadvantages: staining, slow setting time, non-adhesion, solubility.

inst/mat/tech
Which tooth is IMPROPERLY matched with the reason for difficulty of its
access preparation?
• maxillary first premolar - mesial concavity
• maxillary molar - proximity of canals to distobuccal line angle
• mandibular molar - mesio lingual tilt of tooth
• mandibular incisor - narrow mesial distal dimension
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• maxillary molar - proximity of canals to distobuccal line angle
Major objectives of the access preparation:
1. Straight-line access
2. Conservation of tooth structure
3. Unroofing of the chamber and to remove pulp horns
Access to the root canal is the initial step in canal preparation. It is necessary to estab-
lish straight-line access to the apical foramen to ensure free movement of the instrument
during dcbridement and preparation of the canal. All the treatment that follows hinges on
the correctness of the access preparation. All access cavities are made through the lingual
on anterior teeth and through the occlusal on posterior teeth.
Note: A facial approach is recommended for an access opening on maxillary primary

incisors.
Remember: Mandibular incisors and maxillary first premolars require the most care
to avoid perforation during preparation of the access opening. This is due to the narrow
mesiodistal dimension of the mandibular incisors and the mesial concavity of the max-
illary first premolars.
Important: During access preparation on mandibular molars, the following two re-
gions tend to be "overcut," which results in the undesirable overpreparation of the tooth:
• The mesial aspect under the marginal ridge
• The lingual surface under the lingual cusps
*** Mandibular molars tip mesially and lingually. If a bur is directed straight inferior,
it may cause unnecessary loss of tooth structure from the these areas.
inst/mat/tech
The action of using a file often dictates the shape of the canal.
A reaming action produces a canal that is relatively round in shape.
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Studies have shown that the action of using the instrument, rather than the instrument used, de-
termines the general shape of the canal preparation. Therefore, a reaming action produces a canal
that is relatively round in shape while a tiling action produces a canal that is irregular in shape.
Important: A canal should be instrumented and shaped so that it has a continuously tapering fun-
nel shape. The widest diameter would be at the canal opening and the narrowest at the dentinoce-
mental junction (5 to 1.0 mm from the radiographic apex). This is where all teeth should be filed
to and filled to (ideally).
The common methods for sterilization used in endodontics are:
• 2% glutaraldehyde:
- Cold or heat-labile instruments such as rubber dam frames, etc.
- Generally, 24 hours are required to achieve cold sterilization.
- Least desirable method.
• Autoclave:
- Instruments should be wrapped and autoclaved for 20-30 minutes at 250° F (121° C) and 15
psi.
- This will kill all bacteria, spores, and viruses.
• Dry heat sterilization:
- Is superior for sterilizing sharp-edged instruments (hand instruments, files, reamers, broaches,
burs, etc.) to best preserve their cutting edges.
- Temperature is 320° F (160° C) for a minimum of 1 hour.
- Dry heat is effective as a sterilizing agent because the resistance of proteins to heat denatu-
ration decreases as they dry.
• Hot salt (or heads):
- Bead sterilizers are receptacles that heat contents to approximately 450° F (232° C).
- Intracanal instruments (files, reamers, broaches, etc.) should be sterilized by immersion in the
salt for 5 seconds.
inst/mat/tech
Which of the following statements are true regarding files?
• broaches can be used for canal enlargement
• k-type files can be machined or twisted
• significant apical pressure is needed when using a broach
• stainless steel files are less flexible than NiTi files
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• k-type files can be machined or twisted
• stainless steel files are less flexible than NiTi files
***Broaches are not used for canal enlargement because of their design. Barbs are notched in the shaft of a
broach, and this represents a weakened point. Therefore, these need to be used with care and minimal apical
pressure.
K-type instruments:
• Files are the most useful instruments in endodontics for the removal of hard tissue in canal enlargements.
They are manufactured by twisting a blank, which is a square rod, producing a series of cutting flutes. The
action used for placing this type of file into a canal should resemble a clockwise-counterclockwise motion
with pressure directed apically (can be a filing or reaming action). Note: These files are the strongest of
all files and cut the least aggressively. A modification to this type of file is the K - flex file.
• Reamers are manufactured in a manner similar to files, but they have fewer flutes. They are used in canal
preparation to shave dentin and enlarge canals with a reaming action only. They remove intracanal debris
with clockwise reaming action. They are also used to place materials into the apical portion of the canal by
using a counterclockwise rotation.
H - type instruments:
• Hedstrom files are manufactured by using a sharp, rotating cutter to gauge triangular segments out of a
round blank shaft. This produces a very sharp edge and, therefore, an effective cutting instrument. If used
carefully with filing action only, it will successfully plane the dentin walls much faster than K-type files
or reamers. A modification of this file is the S - file.
Note: All of the above are made of stainless steel.
File dimensions: The position at which the cutting blades begin on an instrument is called D i , and the flutes
extend up the shaft for 16 mm to stop at D 2. The remaining portion of the shaft extending to the handle has no
flutes, and its length is the difference between 16 mm, and the total length from the tip to the handle. The
length of cutting edges (the distance between D 1 and D2) remains 16 mm, regardless of the length or style of
the instrument. The numbering system for instrument identification is based on the diameter at D I , stated in
hundredths of millimeters. Therefore, the name of each instrument gives considerable information about its di-
mensions. A size-10 file (with .02 taper) is indicated to be 0.10 mm in width at D I and .10 mm plus 0.30 mm
(or 0.40 mm) at a point 16 mm farther up the shaft (D2), etc.
misc.
Which cells do not characterize the cellular response at the onset of chronic
pulpal inflammation?
• plasma cells
• macrophages
• lymphocytes
• polymorphonuclear (PMN) leukocytes
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• polymorphonuclear (PMN) leukocytes
The onset of pulpal inflammation is an insidious process and is characterized by a chronic cel-
lular response (plasma cells, macrophages, and lymphocytes). There is no direct exposure of
the pulp to dental caries, and the response, therefore, is not acute. After pulp exposure, the
acute inflammatory cells (mainly PMN cells) are chemotactically attracted to the area. Histo-
logically, the tissue is likely to show signs of acute inflammation near the site of the exposure
and a band of chronic inflammatory cells between the acute inflammation and the underlying
normal pulp.
The response of vital pulp to microbial invasion is very resistant. Based on the observation
that, even after 2 weeks of traumatic pulp exposure, only 2 mm of coronal pulp may "give in"
to microorganisms. Nonvital pulp, in contrast, is a "fertile ground" for the growth of mi-
croorganisms.
Remember: Carious exposures in permanent teeth generally require root canal treatment. Im-
mature (open apex) permanent teeth with carious exposures can be treated by pulp capping
or pulpotomy procedures.
Important: Pulp capping is not recommended in primary teeth with carious exposures due
to its high failure rate and because pulpotomy, having similar time requirements, has shown
to be very successful. Pulp capping can be done, however, in mechanical exposures.
1.Calcium hydroxide has a high pH of 12.5, which cauterizes tissue and causes su-
Notes perficial necrosis.
2. This necrotic zone encourages the pulp to induce hard tissue repair with sec-
ondary odontoblasts laying down reparative dentin.
misc.
A patient presents with all the characteristics of pulpal pathosis. Your assistant
hands you an x-ray that shows no evidence of any restoration or caries.
At first you don't believe that the x-ray is from the right patient, but it is.
This scenario is pathognomonic of:
• condensing osteitis
• a vertical fracture of the tooth
• periodontal abscess
• secondary occlusal trauma
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• a vertical fracture of the tooth
Radiographic examination seldom reveals the fracture because the crack is usually parallel
to the x-ray film. One of the most puzzling and frustrating dental conditions involving the
possible need for endodontic treatment is the cracked tooth syndrome. Symptoms from this
condition usually are characterized by a sharp but brief pain occurring unexpectedly only
when the patient is chewing. Having a patient bite forcefully on a bite stick and noticing the
cusps that occlude when the pain occurs will aid in the location of the offending tooth.
In most cases, there is an isolated probing defect at the site of fracture. An important diagnostic
sign is a radiolucency from the apical region to the midline of the root (J-shaped or teardrop-
shaped). Vertical fractures through root structure, however, have an almost hopeless progno-
sis. If the fractured segment can be removed and gingivoplasty and alveoloplasty performed,
treatment can be successful. However, unrealistic or overambitious case selection leads to a
high degree of failure.
When an anterior tooth fractures, it generally occurs in a more horizontal plane and may
show up on the x-ray. The cause is usually accidental trauma such as a blow to the jaw or
teeth. If the fracture line is not too far down the root of the tooth, it may be able to be saved
with a root canal and a crown.
Important: Inlays have been shown to be a cause of fractures. If a patient complains of pain
on mastication after the placement of an inlay, suspect a fractured cusp (using a bite stick will
help determine which cusp may be fractured).
Remember: Condensing Osteitis is a diffuse radiopaque lesion representing a localized bony

reaction to a low-grade inflammatory stimulus, usually seen at apex of tooth. This process is
asymptomatic and benign and does not require root canal therapy.
misc.
There are multiple techniques for internal bleaching.
Hydrogen peroxide is a key ingredient in all of them.
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*** Hydrogen peroxide is the most effective bleaching agent; it is used in concentrations
of 30-50%. It is best delivered in an alkaline medium.
Superoxol is a 30% aqueous solution by weight of hydrogen peroxide in distilled water.
It is potent oxidizing agent whose bleaching effect results from direct oxidation of stain-
producing substances.
Chairside technique: Application of heat to Superoxol-saturated cotton pellets in the
tooth chamber. Repeat until tooth is lighter. Note: The heat liberates the oxygen in the
bleaching agent.
Important:
• Cervical root resorption relating to bleaching is a potential side effect; usually it
does not manifest for at least 6 months. This is a reason why recall appointments are
important.
• The most probable postoperative complication of bleaching a tooth that has not
been adequately obturated is an acute apical periodontitis.
• Tooth bleaching causes a color change in both enamel and dentin.
Walking bleach technique: uses a mixture of sodium perborate and water and may be
utilized if the chairside results are inadequate or if you prefer to avoid the possibility of a
higher chance of cervical root resorption. Place a thick paste in the tooth chamber with a
temporary restoration for four to seven days. Several repetitions of this procedure can
work quite well. The sodium perborate, when fresh, is 95% perborate giving off 9.9% of
available oxygen. This material is more easily controlled and safer than Superoxol; there-
fore, it is the material of choice.
misc.
Tooth # 9 requires root-end surgery. Which flap design is generally NOT indi-
cated?
• a submarginal curved flap (semilunar)
• a submarginal scalloped flap (Ochsenbein-Luebke)
• a full mucoperiosteal flap (triangular, rectangular, trapezoidal, horizontal)
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• a submarginal curved flap (semilunar)
This half-moon shaped flap is raised with a curved horizontal incision in the mucosa or attached gin-
gival with the concavity toward the apex. Although it's simple and does not impinge on the surrounding
tissue, the disadvantages outweigh its advantages. These include:
• Limited access and visibility
• Tearing of corners of the incisions when an attempt is made to improve accessibility by stretching
the flap
• If somehow a lesion is found to be bigger than anticipated, the incisions come to lie over the bony
defect
• Its extent is also limited by attachments (e.g., frenum, muscles, etc.)
*** Therefore, this technique is not used for anterior root end surgery.
Surgical flaps on the basis of horizontal incision can be classified into two major types:
1. Full mucoperiosteal flaps:
• Triangular (one vertical releasing incision) • Trapezoidal (broad-based rectangular)
• Rectangular (two vertical releasing incisions • Horizontal (no vertical releasing incisions)
2. Limited mucoperiosteal flaps:

• Submarginal curved (semilunar)
• Submarginal scalloped (Ochsenbein-Luebke)
The submarginal scalloped (Ochsenbein-Luebke) flap requires at least 3-5 mm of attached gingiva and
a healthy periodontium. It is raised by a scalloped incision in the attached gingiva with one or two ver-
tical incisions. There is less risk of incising over bony defects and no postsurgical recession of gingiva.
Its disadvantages include hemorrhage from the cut margins and scarring. Access and visibility are bet-
ter (and more acceptable) than semilunar flap but not as good as full mucoperiosteal flap.
Full mucoperiosteal flaps allow maximal access and visibility. They are raised from the gingival sul-
cus (elevating gingival crest and interdental gingiva). This wide outline of the flap precludes any inci-
sions over bony defects and allows various periodontal procedures including curettage, root planing,
and bone reshaping. A large flap may be difficult to reposition, suture, and make alterations. Postsurgi-
cal gingival recession is also a possibility.
misc.
In which of the following cases could a dentist choose not to perform root
canal therapy even when it is advised?
RCT is contraindicated
• on a nonrestorable tooth
• on a periodontally insufficient tooth
• on a tooth with a vertical root fracture
• on an asymptomatic tooth with a calcified chamber
• on a tooth that has massive external resorption
49
ENDODONTICS
• on an asymptomatic tooth with a calcified chamber
*** In all the other scenarios, root canal therapy is contraindicated.
Other contraindications include:
• A nonstrategic tooth — a tooth not in occlusion
• A tooth with massive internal or external resorption
• A tooth that has a canal unsuitable for instrumentation or for surgery (i.e., broken instruments,
dentinal sclerosis, sharp dilacerations, etc.)
A medical condition such as hemophilia is not a contraindication to conventional endodontic ther-
apy. However, it is strongly recommended that a dentist obtain clearance from the patient's physi-
cian prior to treatment. The only systemic contraindications to endodontic therapy are
uncontrolled diabetes or a very recent myocardial infarction (within the past 6 months).
Note: Example of a special case: A previously traumatized tooth may show complete
obliteration of the pulp chamber and canal. The periodontal ligament may appear normal. The pa-
tient will be asymptomatic and the tooth will not respond to pulp vitality testing. The treatment of
choice is to observe as long as the tooth remains asymptomatic and no periapical changes are ev-
ident.
Fracture injuries:
• Infraction: an incomplete crack of enamel without the loss of tooth structure
• Enamel fracture (Ellis Class I): involves enamel only; no pulpal involvement
• Enamel and dentin fracture (Ellis Class H): involves enamel and dentin; no pulpal involve-
ment
• Enamel and dentin fracture with pulpal involvement (Ellis Class III): pulpal treatment de-
pends on stage of development of tooth (immature vs mature) and time after traumatic injury
(after 24 hours, the chances of direct bacterial contamination increase)
• Root fractures: prognosis depends on location; coronal root fractures have a poor prognosis,
midroot fractures have guarded prognosis, and apical root fractures have the best prognosis.
Important: Prognosis improves as fracture approaches apex; horizontal is better than vertical;
nondisplaced is better than a displaced fracture; and oblique is better than transverse.
misc.
A periodontal probing defect that may not be managed by endodontic treat-
ment alone is:
• a conical shaped probing
• a narrow sinus tract type probing
• a blow-out type probing
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ENDODONTICS
• a conical shaped probing —this is typical primarily of a periodontal problem
***In "blow-out type" and "sinus tract type" probings, another clue for diagnosis is a nonvi-
tal (necrosed) pulp — these two lesions can completely heal after root canal treatment.
Acute or blow-out lesions: a tooth with this type of lesion will show normal sulcus depth all
around the tooth until the area of the swelling is probed. At this point, the probe drops suddenly,
to a level near the apex. The probing depths in all other areas are within normal limits.
Periodontal lesions characteristically show bone loss, which begins at the crestal bone level
and progresses apically. Hence, the probing defect would be conical in shape. This type of le-
sion may not be amenable to root canal treatment alone, even if it is associated with a pulp-
less tooth. However, endodontic treatment must be completed prior to tackling the periodontal
problem.
A narrow sinus tract type lesion: the probing reveals normal depths all around the tooth ex-
cept at one very narrow area. Here, the probe can pass down the root surface to some distance
and sometimes even to the apex. The tooth is pulpless (nonvital). Once the root canal treatment
is completed, the lesion heals within I week. Note: All sinus tracts should be traced with a
gutta-percha point by radiograph.
Remember: A perio-endo abscess is a combined lesion. The lesion usually demonstrates ra-
diographic involvement of the periodontium and the apex of the involved tooth.
Important: To distinguish a periodontal lesion from an endodontic lesion, pulp vitality tests
along with periodontal probing are essential.
Note: A common clinical finding of a periodontal problem is pain to lateral percussion on a

tooth with a wide sulcular pocket.
misc.
Regarding the restoration of endodontically treated teeth, all of the following

are generally believed to be true EXCEPT one. Which one is the EXCEPTION?
• a major disadvantage of posts/dowels is that they do not reinforce the tooth

structure, in fact, they weaken it
• all post designs are predisposed to leakage
• at least 4 mm of gutta-percha must remain to preserve the apical seal
• threaded screw posts are preferred over parallel-sided and tapered posts
• pins add to stresses and microfractures in dentin and should not be used
• cusps adjacent to lost marginal ridges should be restored with an onlay
51
ENDODONTICS
• threaded screw posts are preferred over parallel-sided and tapered posts
***These may actually increase the chance of fracture. The parallel-sided posts are preferred.
Options available when restoring endodontically treated posterior teeth:
• Restoration of occlusal opening only: in rare instances, the access opening and caries destruction
do not encroach on the cusps and marginal ridges. These teeth may be restored with an occlusal amal-
gam; however, a cuspal coverage restoration would provide protection from fracture.
• Onlay restoration: in most cases, it is imperative that root-canal-treated teeth be protected
from fracture by a cusp-coverage type of restoration. The minimum (most conservative) preparation
should be for an onlay covering the cusps and marginal ridges.
• Crown: a full-coverage crown is preferred when the remaining coronal tooth structure does not af-
ford sufficient tooth structure for an onlay.
• Crown with post and core: to reinforce the treated tooth and provide suitable coronal tooth struc-
ture for an optimum crown preparation, the use of a post and core is often indicated. Be very careful
when placing posts. Perforations and vertical root fractures can occur. Important: The primary
purpose of the post is to retain a core in a tooth when there is an extensive loss of coronal tooth struc-
ture. Posts do not reinforce the tooth, but further weaken it. At least 4 to 5 mm of remaining gutta-per-
cha is recommended.
1. If you are performing a pulp chamber-retained amalgam, you need to place amalgam 3
Notes mm into each canal for retention.
2. Endodontically treated posterior teeth are more prone to fracture than untreated posterior
teeth due mainly to the destruction of the coronal tooth structure they have reduced struc-
tural integrity.
3. More endodontically treated teeth are lost because of restorative factors than failure of the
root canal treatment itself.
4. Permanent restorations are best placed ASAP after obturation to seal the internal aspect
of the tooth from contamination.
5. Endodontically treated teeth do not become brittle. The moisture content of endodonti-
cally treated teeth is not reduced even after 10 years. Key point: Teeth are weakened by the
loss of tooth structure.
misc.
Retreating a tooth with a post is the most common reason for an apicoectomy
and retrograde filling.
Whenever a reverse filling procedure is to be used, apicoectomy is mandatory

to provide a table into which the preparation and filling will be placed.
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ENDODONTICS
An apicoectomy is the preparation of a flat surface by the excision of the apical portion of the root and any subse-
quent removal of attached soft tissues.
If a tooth has had previous endodontic therapy and becomes reinfected, it is usually best to try and retreat it con-
ventionally — remove fillin g material, debride the canals, and refill. However, if the tooth has been restored with a
post, core, and crown, then apical curettage, apicoectomy, and a retrofill should be performed. Note: Retreating a tooth
with a post is the most common reason for an apicoectomy and retrograde filling.
Indications for apicoectomy (root-end resection):
• A reverse filling needs to be placed
• It is necessary to gain access to an area of pathosis
• The poorly filled apical portion of the root is to be removed to the level of canal obliteration
• Non-negotiable canal, blockage, or severe root curvature in which nonsurgical treatment is impossible
• Complications arising from procedural accidents (e.g., separation of instruments, !edging, and/or perforations)
which cannot be handled without surgical exposure of the site
• Failed treatment due to irretrievable posts or root fillings
• Horizontal apical fractures in which apical end of the pulp becomes necrotic
• Biopsy — to diagnose non-odontogcnic causes of symptoms (e.g., patient with a history of previous malig-
nancy, lip paresthesia, or anesthesia)
Contraindications for apicoectomy (root-end resection):
• Anatomic factors that limit access • Medical or systemic complications • Tooth is nonrestorable or has a poor
crown/root ratio
Procedure:
• Radiographs are taken to determine the length of the root and its proximity to adjacent structures
• Administer anesthesia
• On the labial surface of the tooth, with the help of a periosteal elevator, locate the root apex, so that an incision
can be made
• Flap designs used: submarginal scalloped (Ochsenbein-Luebke) and full mucoperiosteal flaps (the best)
• Reflect the flap
• Root apex is exposed, then apex is cut off with a fissure bur about one-third of its length
• Curette the surrounding pathologic tissues and round off the end of the cut root
• For retrograde filling, a bevel of 0-10 degrees is given
• Retrograde filling to 3 mm is done
• Irrigate the wound and suture the flap in position
misc.
Endodontic procedures involve taking multiple radiographs. How should you
protect yourself or your staff while taking radiographs if there is no barrier
available to stand behind?
• stand at least 4 feet away anywhere around the patient
• stand at least 5 feet away exactly opposite the x-ray beam source
• stand at least 6 feet away and in the area that lies between 90 to 135 degrees to
x-ray beam
• stand at least 7 feet away and in the area that lies between 60 to 90 degrees to
x-ray beam
• never take an x-ray without a barrier
53
ENDODONTICS
• stand at least 6 feet away and in the area that lies between
90 to 135 degrees to x-ray beam
Notes related to radiation safety and diagnostic radiographs:

1.A fast (sensitive) film, for example F-speed film, is preferred over both E- and D-speed
films. Faster films can significantly cut down on the amount of radiation required for a qual-
ity image.
2. Dental units should operate at 70 kV or higher. The higher the kV, the lower the patient's
skin doses. Note: The optimal setting for maximal contrast between radiopaque and radi-
olucent structures is 70 kV.
3. Collimation (i.e., restriction of the x-ray beam size so that it does not exceed 2.5 inches
at the patient's skin, reduces exposure).
4. Patient should be protected with a lead apron and a thyroid collar for each exposure.
5. If there is no barrier for the clinician to stand behind while exposing films, he/she
should stand in an area of minimal scatter radiation (i.e., 6 feet away and in the area that
lies between 90° to 135° to x-ray beam).
6. Dental personnel who may get exposed to occupational x-radiation must wear film
badges to record exposure and must never exceed the maximum permissible dose (MPD)
of 0.05 Sv/year
7. An operator should never remain in the room holding an x-ray packet in place for a pa-
tient. If film must be held in place by someone (i.e., fbr a child), drape the patient and have
him/her hold the film.
8. The most accurate radiographs for endodontics are made using the paralleling tech-
nique. Remember: When using the paralleling technique, you must center the x-ray film
packet behind and parallel with the long axis of the tooth being x-rayed. The tube head must
be positioned so that the central x-ray beam is projected perpendicular to the tooth and
the film packet.
misc.
Most bacteria in endodontic infections are strict anaerobes.
The diversity of polymicrobial endodontic infections has been well estab-

lished isolating anywhere from 3 to 12 species of microbes in the majority
of endodontic infections.
54
ENDODONTICS
• both staements are true
Predominant bacterial species isolated from infected root canals include:

• Porphyromonas species
• Bacteroides melaninogenicus
• Eubacterium species
• Peptostreptococcus species
• Fusobacterium species
• Prevotella species
*** Note: Strict anaerobes predominate
Virulence factors which play a role in periradicular pathosis include:

• Lipopolysaccharide (LPS): found on the surface of gram-negative bacteria
• Enzymes: neutralize antibodies and complement components
• Extracellular vesicles: involved in bacterial adhesion, proteolytic activities, hemag-
glutination and hemolysis
• Fatty acids: affect chemotaxis and phagocytosis
A vital pulp resists bacterial invasion. Even if the pulp is exposed to microorganisms for
2 weeks, the penetration of bacteria may extend no more than 2 mm into the pulp. In con-
trast, a nonvital pulp is a fertile ground for the growth of microorganisms and leads to
necrosis.
Remember: Streptococcus species may be more important in the initiation of, rather
than the progress of a carious lesion leading to a pulp exposure. Strict anaerobes are
found to play a significant role in periapical pathosis.
misc.
During a routine radiographic evaluation, you notice bone loss extending from
the cementoenamel junction to the apex of tooth #21. Further evaluation
reveals that probing depths are above normal limits all around the tooth.
However, at one point, the probe drops precipitously to an even greater depth.
Vitality test is negative. This patient may require:
• extensive periodontal treatment followed by vitality reassessment
• endodontic treatment only
• endodontic treatment followed by periodontic treatment
• root-end surgery
• periodontic treatment followed by endodontic treatment
55
ENDODONTICS
• endodontic treatment followed by periodontic treatment
***In a combined perio-endo lesion, endodontic treatment generally takes precedence

over periodontal management.
Combined endodontic-periodontal therapy is widely used because the anatomic and

clinical connections between the pulp and periodontal structures are close and numerous.
In most cases of this nature, endodontic procedures are preformed first and, when nec-
essary, are followed by periodontal measures.
In these cases, precise pocket probing and correct appraisal of the vitality of the pulp
are crucial. In some doubtful cases, the better part of wisdom is to wait until after the
completion of the root canal therapy to see whether spontaneous resolution (pocket clo-
sure and osseous will occur before surgical periodontal procedures are initiated.
Periodontal therapy should be initiated first only in the case of a primary periodontal le-
sion with subsequent secondary endodontic involvement.
Remember: A common clinical finding of a periodontal problem is pain to lateral per-

cussion on a tooth with a wide sulcular pocket.
Note: The combination lesion (perio-endo) is dominated by gram-negative anaerobic

bacteria
pulp
Which of the following are NOT found in the pulp?
• reticulin fibers
• collagen fibers
• unmyelinated nerve fibers
• myelinated nerve fibers
• proprioceptor nerve fibers
56
ENDODONTICS
• proprioceptor nerve fibers
*** Proprioceptors (which respond to stimuli regarding movement) are not found in the pulp.
The pulp contains both myelinated and unmyelinated nerve fibers. They are afferent and sympathetic.
The myelinated fibers are sensory, and the unmyelinated fibers are motor —they play a role in the
regulation of the lumen size of the blood vessels.
Important: The only type of nerve ending found in the pulp is the free nerve ending, which is a spe-
cific receptor for pain. Regardless of the source of stimulation (heat, cold, pressure), the only response
will be pain.
Afferent Nerve Fibers found in the Dental Pulp:
• Large myelinated A delta fibers: enter at the apical foramen, follow the path of the blood vessels,
and then branch to form the plexus of Raschkow beneath the cell rich zone. Within the plexus, the
fibers lose their myelin sheath and proceed to the cell-free zone where they form a subodontoblastic
plexus. The free nerve endings then pass into the odontoblastic layer and the predentin. A-delta fiber
pain is immediately perceived as a quick, sharp, momentary pain that dissipates quickly on removal
of the stimulus. Note: The intimate association of A delta fibers with the odontoblastic cell layer and
dentin is referred to as the pulpodentinal complex.
• Small unmyelinated C fibers: enter at the apical foramen within the A delta fiber bundles; distrib-
uted throughout the pulp. They are associated with burning, aching, throbbing types of pain. Charac-
terized by having a high threshold of stimulation. These fibers are true nociceptive
fibers pain-conducting fibers that respond to stimuli capable of injuring tissue. They remain ex-
citable even in necrotic tissue. Note: These fibers are stimulated by hot liquids or foods.
Important: When C fiber pain dominates, it signifies irreversible local tissue damage.
1.As the pulp ages, there is a decrease in reticulin fibers (the pulp becomes less cellular and
Notes more fibrous).
2. The size of the pulp also decreases because of the continued deposition of dentin.
3. As the pulp ages, there is an increase in the number of collagen fibers and calcifications
within the pulp (called denticles or pulp stones).
4. Pulp stones are associated with chronic pulpal disease — from advanced carious lesions
or large restorations.
pulp
The absence of which layer of dentin predisposes it to internal resorption by
cells present in the pulp?
• mantle dentin
• circumpulpal dentin
• predentin
• secondary dentin
• tertiary dentin
57
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ENDODONTICS
• predentin
Immediately adjacent to the odontoblast layer in the pulp, 10-47 !_im of the dentin matrix
remain unmineralized. If this unmineralized layer of dentin is lost (e.g., due to trauma or
infectious process), it predisposes the dentin to internal resorption by odontoclasts.
Types of Dentin:
• Mantle dentin: is first-formed dentin that is laid before odontoblast layer gets
organized. Hence, the pattern of deposition and size of collagen fibers are different
from circumpulpal dentin.
• Circumpulpal dentin: represents most of the dentin that is formed.
• Secondary dentin: forms after eruption of a tooth and throughout life, resulting in a
gradual but asymmetric reduction in pulp size.
• Tertiary dentin or reparative dentin: is an irregular and disorganized layer of dentin
laid down in response to any injurious/irritant stimuli.
Remember: Dentin formation is the primary function of pulp.

• Induction: forms dentin that, in turn, induces enamel formation
• Nutrition: dentinal tubules are linked to the pulp that maintains its hydration and
formation of peritubular dentin
1. Once bacteria enter the pulp with sufficient quantity or virulence, complete
Notes pulpal necrosis is imminent and irreversible.
2. Bacteria from dental caries are the main cause of more serious pulpal injury,
and the main cause of pulpitis.
pulp
The in the apical portion of the pulp helps to form the pulp
into a semisolid mass, facilitating a
• collagen, pulpectomy
• network of capillaries and nerves, pulpectomy
• collagen, pulpotomy
• network of capillaries and nerves, pulpotomy
58
ENDODONTICS
• collagen, pulpectomy
Mainly, Type I and Type III collagen is present in the pulp in a ratio of 55% : 45%. Type
V is found in small amounts. In dentin, Type I collagen predominates. Odontoblasts syn-
thesize Type I, while fibroblasts in the pulp synthesize both Type I and III.
The central zone or pulp proper contains large nerves and blood vessels. This area is
lined peripherally by a specialized odontogenic area that has three layers (from innermost
to outermost):
1. Cell rich zone: innermost pulp layer that contains fibroblasts.
2. Cell-free zone or zone of Weil: is rich in both capillaries and nerve networks. The
nerve plexus of Raschkow is located here.
3. Odontoblastic layer: outermost pulp layer; contains odontoblasts and lies next to
the predentin and mature dentin.
Cells found in the dental pulp include fibroblasts (the principal cell), odontoblasts, his-
tiocytes (macrophages), and lymphocytes.
Note: In a diseased pulp, the following cells are present: PMN's, plasma cells, basophils,
eosinophils, lymphocytes, and mast cells (contain histamine and heparin).
Important: The pulp lacks collateral circulation, which severely limits its ability to
cope with bacteria, necrotic tissue, and inflammation.
pulp cross-sections
The cervical cross section of the pulp cavity below represents which tooth?
• the permanent maxillary right first molar
• the permanent maxillary right second molar
• the permanent maxillary right third molar
• the permanent maxillary right first premolar
59
ENDODONTICS
Mesiodistal Buccolingual Mesiodistal Buccolingual

cross-section cross-section cross-section cross-section
Cervical Midroot Cervical Midroot

Pulp cavity of the permanent maxillary Pulp cavity of the permanent maxillary
right first molar right second molar
pulp cross-sections
• The permanent maxillary right first premolar
• The permanent maxillary right second premolar
• The permanent maxillary right first molar
• The permanent maxillary right third molar
60
ENDODONTICS
Cervical Cervical
cross-section cross-section
Mesiodistal Buccolingual
Mesiodistal Buccolingual cross-section cross-section
Pulp cavity of the permanent Pulp cavity of the permanent

maxillary right first premolar maxillary right second premolar
pulp cross-sections
• the permanent maxillary right canine
• the permanent maxillary right lateral incisor
• the permanent maxillary right second premolar
61
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ENDODONTICS
AIM
Cervical Cervical
Mesiodistal Labiolingual Mesiodistal Labiolingual


maxillary right canine mandibular right canine
pulp cross-sections
• the permanent mandibular right third molar
• the permanent mandibular right second molar
• the permanent mandibular right second premolar
• the permanent mandibular right first molar
62
ENDODONTICS
• the permanent mandibular right first molar
Mesiodistal Buccolingual
cross-section cross-section Mesiodistal Buccolingual


mandibular right first molar mandibular right second molar
pulp cross-sections
• the permanent mandibular right canine
• the permanent mandibular right lateral incisor
• the permanent mandibular right first premolar
63
ENDODONTICS
Cervical Cervical

Pulp cavity of the permanent mandibular Pulp cavity of the permanent

right first premolar mandibular right second premolar
(three-cusp type)
pulp cross-sections
• the permanent maxillary right central incisor
• the permanent maxillary right second premolar
64
ENDODONTICS
Cervical Cervical


maxillary right central incisor mandibular right central incisor
pulp cross-sections
• the permanent maxillary right first molar
65
ENDODONTICS



maxillary right third molar mandibular right third molar
pulp cross-sections
66
ENDODONTICS
Cervical Cervical

The pulp cavity of the permanent The pulp cavity of the permanent
maxillary right lateral incisor mandibular right lateral incisor
replant
A patient walks into your office holding a cup with a tooth in it.
What liquid would you LEAST hope the patient kept the tooth in?
• milk
• water
• saliva
• saline
67
ENDODONTICS
• water
Important: The first priority of treatment of avulsion injuries is to protect the viability of the periodontal ligament.
Five factors that are critical to the management of traumatic avulsion injuries to teeth:
1.Time: the time interval from injury to replacement of the tooth is a major factor in the maintenance of liga-
ment viability and subsequent root resorption. Teeth replanted within 30 minutes have been reported to exhibit very
little resorption, whereas most of the teeth replanted after 2 hours show a lot of external root resorption (which is
the main cause offailure of replanted teeth).
2. Storage media: if the tooth cannot be immediately replanted, the proper storage of the tooth can favorably
influence the viability of PDL cells. Milk is considered best for this purpose because of its near neutral p1-1 (6.5-
6.8) and osmolality, conducive for the survival of cells. Other storage media are physiologic saline and saliva.
3. Tooth socket: should not be damaged by curettage or forceful replantation. Replant slowly with slight
digital pressure.
4. Splint stabilization: a splint that allows the physiologic movement is placed for a maximum of 2 weeks (7 to
10 days is ideal). This time period allows for the initial reattachment of the periodontal ligament fibers.
5. Root surface: should not be scraped, dried, or manipulated with caustic chemicals.
Important:
• 10 days to 2 weeks after replantation, the root canal is prepared (cleaned and shaped) and a calcium hydroxide
paste is placed into the canals
• This paste is replaced every 3 months for one year
• lf, after 1 year, it appears that resorption has reversed or stopped, a permanent gutta-percha obturation can be
done
• Antibiotic therapy is recommended when avulsed teeth are replanted in less than 1 hour
Note: The above information changes when a tooth has been out of the mouth for more than 1 hour--
mainly the treatment of the tooth socket and root surfaces. Changes are as follows:
• Ankylosis and external root resorption will probably result within 2 years. Ankylosis resulting from replace-
ment would give a better prognosis than external resorption, which will lead to failure.
• Root canal therapy is performed in its entirety (holding the tooth in fluoride soaked gauze) prior to replantation.
• The tooth is soaked in a 2.4% fluoride solution acidulated at pH 5.5 for 5-20 minutes. The fluoride will slow
the resorptive process.
• Suction the alveolar socket carefully to remove the clot and irrigate with saline
• Replant slowly with slight digital pressure
• Stabilize with splint for 4 weeks
replant
Which of the following situations may be indications for intentional
replantation?
• when routine endodontic therapy is impractical
• when a canal is obstructed
• when perforating internal or external resorption is present
• when previous treatment has failed
68
ENDODONTICS
• when routine endodontic therapy is impractical
• when a canal is obstructed
• when perforating internal or external resorption is present
• when previous treatment has failed
Intentional replantation implies that a tooth requiring endodontic therapy is purposely removed from
its socket, some type of canal or apical preparation and/or filling is performed, and the tooth is returned
to its original socket.
Indications for intentional replantation (also called replant surgery):
• When routine endodontic therapy of a tooth is impractical or impossible
• When an obstruction of a canal is present, such as a broken instrument or a calcification, and pe-
riapical surgery is impractical (e.g., a lower molar with the mandibular canal in close proximity)
• When perforating internal or external resorption is present, yet surgery is impractical
• When a previous treatment has failed but nonsurgical treatment or surgery is impractical
Note: Intentional replantation should be considered only when there's no other alternative treatment
to maintain a "strategic" tooth. Long-term follow-up is required to monitor for complications, including
periodontal defects and ankylosis with replacement resorption.
Other surgical endodontic procedures:
• Bicuspidization: is a process in which a tooth is divided into mesial and distal halves without re-
moval of any tooth structure/root. Endodontic treatment is done and two separate crowns are fixed
on both halves. It is performed on mandibular molars with furcation involvement. Better stability of
the tooth is achieved when their roots are divergent.
• Hemisection: is the division of a mandibular molar buccolingually into two single-rooted teeth;
the defective root is extracted. Hemisection requires root canal therapy on all retained root segments.
Note: When possible, it is preferable to complete the root canal treatment and place a permanent
restoration into the canal orifices prior to the hemisection.
• Root amputation: refers to the removal of a root from any molar without sectioning through the
crown. Root amputation requires root canal therapy on all retained root segments.
• Surgical removal of the apical segment of a fractured root: performed on a tooth when a root
fracture occurs in the apical portion and pulpal necrosis results. Note: The coronal tooth segment
must be restorable and functional or else this procedure is worthless.
replant
The main benefit of primary incisor replantation is:
• maintenance of a normal anterior dentition
• to relieve parental guilt
• to maintain child's self-esteem
• to maintain child's social acceptance
69
ENDODONTICS
• maintenance of a normal anterior dentition
*** The question of whether to replant primary teeth has been a focus of debate and contro-
versy in the dental literature. However, most dental textbooks uniformly recommend that pri-
mary teeth not be replanted. Replantation of a primary tooth is not recommended because of
the potential danger to the permanent successor from sequlae of trauma (e.g., infection, anky-
losis, or damage due to manipulation during procedure itself).
Proper management of an avulsed permanent tooth that has been replanted within 1 hour
of the accident:
• 10 days to 2 weeks after replantation, the root canal is prepared (cleaned and shaped) and
a calcium hydroxide paste is placed into the canals
• This paste is replaced every 3 months for 1 year
• If after 1 year, it appears that resorption has reversed or stopped, obturation with gutta-
percha filling can be done
Important: If a tooth is out of the mouth for more than 1 hour:
• Ankylosis and external root resorption will probably result within 2 years. Ankylosis
resulting from replacement would give a better prognosis than external resorption, which
will lead to failure.
• Root canal therapy is performed in its entirety prior to replantation.
• The tooth is soaked in a 2.4% fluoride solution acidulated at pH 5.5 for 5 to 20 min-
utes. The fluoride will slow the resorptive process.
• Suction the alveolar socket carefully to remove the clot and irrigate with saline.
• Rinse tooth with saline, replant into socket, and splint for a maximum of 2 weeks.
Note: Resorption is the most frequent sequela to replantation. Three different types of re-
sorption have been identified: surface, inflammatory, and replacement (ankylotic resorption).
Replacement resorption refers to resorption of the root surface and its substitution by bone,
resulting in ankylosis.
resorption
Internal resorption of a tooth is generally believed to be caused by
inflammation due to an infected corona! pulp.
This condition is frequently precipitated by traumatic injury to the tooth.
70
ENDODONTICS
Internal (inflammatory) resorption is usually asymptomatic and is discovered on routine

radiographic evaluation. The anatomic configuration of the root canal is altered and in-
creases in size with internal resorption. It will appear as an irregular radiolucency any-
where along the canal space. The tooth involved may respond to pulp vitality tests. When
internal resorption is detected, a pulpectomy should be performed. Once the pulp tissue
responsible is removed, all resorption ceases. To "wait and see" may result in sufficient
destruction of the tooth to create a perforation of the root.
Internal resorption of maxillary

right lateral incisor.
Note: Although, internal resorption can occur only when some of the pulp tissue is still
vital, a negative sensitivity test does not rule out this etiology. Also remember that some-
times on a radiograph, an external resorptive lesion can superimpose the canal space to
mimic internal resorption. In such cases, another radiograph should be exposed at an
angle to the tooth. The radiolucent lesion inside the canal space will not shift.
resorption
"The external resorption in which an infected pulp may further complicate
the resorptive process," is termed as:
• surface resorption
• inflammatory resorption
• replacement resorption
71
copyright V 2013-2014 - Dental Decks
ENDODONTICS
• inflammatory resorption
Bowl-shaped areas of resorption involving cementum and dentin characterize external inflammatory root
resorption. This type of resorption is rapidly progressive and will continue if treatment is not instituted. Since
both a necrotic pulp and the presence of bacteria are necessary components of inflammatory resorption, the
process can be arrested by immediate root canal treatment. The tooth is opened, and the canal is cleaned and
shaped. A calcium hydroxide paste is placed in the canal. This is replaced every 3 months for 1 year. If, after
I year, it appears that the resorption has stopped, a permanent root canal filling (gutta-percha) can be placed.
A calcium hydroxide-based root canal sealer is strongly recommended.
Surface resorption is caused by acute injury to the PDL and root surface. It is very common, self-limiting, and
reversible. If injury is not repeated, healing takes place with new cementum and PDL. Root surface resorption
is limited to cementum, may heal itself, and is not radiographically visible.
Replacement resorption refers to resorption of the root surface and its substitution by bone, resulting in anky-
losis. Replacement absorption accompanies dentoalveolar ankylosis due to extensive trauma to the tooths at-
tachment apparatus (PDL damage). The tooth is often in infraocclusion due to progressive submergence with
growth. There is a metallic sound on percussion. Remember: This is often seen in unsuccessful replant cases.
Remember the etiology of external and internal resorption:

• External resorption: periradicular inflammation, dental trauma (resulting in damage to attachment ap-
paratus), excessive orthodontic forces, impacted teeth, internal bleaching of nonvital teeth.
• Internal resorption: dental trauma (resulting in loss of vitality and subsequent infection), dental caries, pulp
capping with calcium hydroxide, cracked tooth.
Note: Invasive cervical resorption is a clinical term used to describe a relatively uncommon, insidious, and
often aggressive form of external tooth resorption. Characterized by its cervical location and invasive nature,
this resorptive process leads to progressive and usually destructive loss of tooth structure.
Resorption of coronal dentin and enamel often creates a clinically obvious pinkish color in the tooth crown
as highly vascular resorptive tissue becomes visible through thin residual enamel.
Important:The majority of misdiagnoses of resorptive defects are made between internal root resorptions,
cervical caries, and cervical resorption.
resorption
Which of the following is NOT a key feature of replacement resorption?
• lack of mobility
• lack of PDL on x-ray
• pink appearance
• infraocclusion
72
ENDODONTICS
• pink appearance
*** Traditionally pink tooth has been considered pathognomonic of internal resorption
and is sometimes a feature of cervical root resorption. It is characterized by a pinkish ap-
pearance of the tooth due to the growth of granulation tissue undermining the corona]
dentin.
Replacement resorption, which accompanies dentoalveolar ankylosis resulting from ex-

tensive trauma to the attachment apparatus of the tooth, is characterized by progressive
replacement of the root by the bone. Note: Histologically, it shows direct contact be-
tween dentin and bone with no intervening PDL or cemental layer.
Remember: Replacement resorption's pathognomonic signs are:

I. Lack of mobility
2. Metallic sound to percussion
3. Infraocclusion of the involved tooth in the developing dentition
Important: Tooth mobility is directly proportional to the integrity of the attachment

apparatus or to the extent of inflammation of the PDL. Other causes of tooth mobility in-
clude:
• Horizontal root fracture
• Recent trauma
• Bruxism
• Overzealous orthodontic treatment

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instruments/material/ 31-44 resorption 70-72

copyright 0 2013-2014 - Dental Decks

Maxillary Central Maxillary Lateral Maxillary Canines

Mandibular Central Mandibular Lateral Mandibular Canines

Mandibular First Premolars Mandibular Second Premolars

Shape of Oval Shape of Oval

Mandibular First Molars Mandibular Second Molars

• asymptomatic irreversible pulpitis

• symptomatic irreversible pulpits

• none of the above

AAE Consensus Conference

• symptomatic apical periodontitis

• acute apical abscess

• chronic apical abscess

• asymptomatic apical periodontitis

AAE Consensus Conference

• traumatic bone cyst

- A lateral periodontal cyst occurs on a lateral periodontal location and it is of developmen-

- A cementoblastoma is an odontogenic tumor characterized by the proliferation of functional

• short setting time

• induction of hard tissue formation

• a dull throbbing pain on mastication

• sensitivity to hot and/or cold stimuli

• a persistent feeling of discomfort

• none of the above

A phoenix abscess develops as the granulomatous zone becomes contaminated or in-

Important: A granuloma or a cyst can only be differentially diagnosed by histological

• chronic apical abscess is asymptomatic

• chronic apical abscess is symptomatic

• only histological examination can differentiate

• the border of the radiolucent lesion

Incision and drainage of soft tissues is indicated:

• none of the above

Osteomyelitis is not a particularly common disease. It is a serious sequela of periapi-

Radiographically, acute osteomyelitis progresses rapidly and demonstrates little radi-

An acute apical abscess is only observed in association with a necrotic pulp.

• both satements are true

• both statements are false

• the first statement is true, the second is false

• the first statement is false, the second is true

Reversible pulpitis is a clinical diagnosis based upon subjective and object-

• both statements are true

• both statements are false

• the first statement is true, the second is false

• the first statement is false, the second is true

AAE Consensus Conference

• periodontal surgery to remove sinus tract

• orthodontic extrusion is commonly indicated prior to implant placement

• intentional replantation is a viable alternative to endodontic surgery

• a major disadvantage of endodontic implants is the lack of an apical seal

Orthodontic extrusion is defined as force-controlled vertical tooth movement occlusally

• a persistent periodontal defect

• a radiolucent halo surrounding the root of the fracture

• a radiopaque lesion at the sight of the fracture

• a visible fracture when transillumination is used

• #15 - primary cavitation on occlusal

• #3 - full gold crown

• #30 - occlusal amalgam

Note: EPT is not considered reliable in the following conditions.

• soft tissue exam

• hard tissue exam