ENDODONTICS 1
PRELIMS 3. Atraumatic handling of tissues
I. Introductions
• The branch of dentistry concerned with the;
morphology, physiology and pathology of the
human dental pulp and periradicular tissues
• its study and practice encompass the basic and
clinical sciences including the biologr of the
normal pulp and the etiology; diagnosis,
prevention and treatment of diseases and injuries
of the pulp and associated perradicular conditions
SCOPE
Endodontics includes, but is not limited to:
1. Differential diagnosis
2. Treatment of oral pains of pulpal and / or
periapical origin (orthograde / conventional
RCT)
3. Vital pulp therapy
a. pulp capping
b. pulpotomy
4. Nonsurgical treatment of root canal systems with or
without periradicular pathosis of pulpal origin
5. Selective surgical removal of pathological tissues
resulting from pulpal pathosis
6. Intentional replantation and replantation of avulsed
teeth
7. Surgical removal of tooth structure:
a. root-end resection
b. bicuspidization
c. hemisection
d. apicoectomy (retrograde/non-conventional endo)
8. Bleaching of discolored dentin and enamel
9. Retreatment of teeth
10. Treatment procedures related to coronal
Restorations
Objectives
1. To be able to retain a tooth inside the oral
cavity which may otherwise require extraction
2. Relief of pain, if present
3. Removal of pulp from root(s) of tooth
4. Disinfection of root and surrounding bone by
5. Complete filling of root canals (obturation)
6. Placement of final restoration (if not
restorable, extract
7. Main contraindication: non-restorable tooth
Basic Principles
1. Chain of asepsis
2. Correct diagnosis and treatment planning
1 ESTECOMEN | DDM 4A
4. Cleaning of the canal debridement and removal of
biofilm sticking on the canal walls
5. Shaping of the Canal Complete Obturation 6.
Restoration
7. Recall
Rationale
1. Saving the natural teeth to health
2. Restore efficient mastication
3. Control pain and swelling
4. Speech and phonation
5. Preserve occlusion
6. Aesthetics
Basic Concept of Root Canal Therapy
→ If bacteria and by-products of pulpal inflammation
have been reduced to a non-critical level of infection,
it will effect a cure, allowing resolution and repair of
damaged peri radicular tissue.
➔ The extent of damage depends on the virulence
and number of microorganisms and the reactance of
the best.
Conclusion
To appreciate Endodontics, all of the scope, history,
rationale, and principles must be fully understood.
Dentin-Pulp Complex; Biology of the Pulp and
Periradicular Tissue
Dental Pulp
• Loose connective tissue in the center of the tooth
• Primary function: Form and support dentin that
surrounds it, forms the bulk of the tooth.
• Contains odontoblasts
• Remains vital throughout life
• Responds to external stimuli
• Dentin and pulp contain nociceptive nerve
fibers.
• Autonomic (sympathetic) nerve fibers only
occur in the pulp
• More dentin is laid down and new odontoblasts
differentiated when needed for repair
• Pulp equipped with all necessary peripheral
components of the immune system.
• Injury and foreign antigens=inflammation, pain
• Good health of the pulp vital to restorative and
prosthodontics dental procedures
 ENDODONTICS 1
• Size and shape of pulp depend on:
➢ Type of tooth
➢ Degree of tooth development related to
px’s age
➢ Any restorative procedures carried out.
Development of the Dental Pulp- Early Development
• Starts as band of epithelial cells on the surface of
the embryonic jaws= dental lamina
• Down growths from the band form the teeth
• Initially looks like a bud (bud stage)—bud
becomes invaginated (cap stage) –deepening of
invagination (bell stage)
• Enamel organ = bell-shaped downgrowth
• Tissue within the invagination=dental pulp (dental
papilla)
➢ Bell stage: Inner layer of cells of enamel organ
differentiate into ameloblasts—outer layer of cells
differentiates into odontoblasts.
• Tissue layer begins to differentiate around the
enamel organ and DP = dental follicle –
periodontal attachment
• Tooth germ= DP + DF
Dental lamina- down growths- forming the teeth=
enamel organ
Inner layer- ameloblast
Outer- odontoblast
Dental follicle- pdl
Tooth germ= dental papilla & Dental follicle
Starting to become odontoblast (@periphery)
Very little enamel
• Histo and morphodifferentiation of tooth germ
genetically determined and executed by growth
factors, transcription factors, signaling molecules.
• Differentiation of odontoblasts from
undifferentiated ectomesenchymal cells initiated and
controlled by ectodermal cells of IDE of EO --- basal
lamina of IDE disappears, odontoblasts begin to lay
down dentin --- IDE cells start to deposit enamel.
• Deposition of unmineralized dentin matrix begins at
the cusp tip, continues in a cervical (apical) direction
at an average of 4.5 μm/day
• Crown shape predetermined by proliferative pattern
of IDE cells
• 1st layer of dentin formed= mantle dentin
• Matrix formation, mineralization continues
throughout dentin deposition
• Predentin: between 10-50 μm of dentin matrix
immediately adjacent to odontoblast layer
• Nerves and BVs migrate into pulp from future
root apex in a coronal direction as crown formation
occurs
2 ESTECOMEN | DDM 4A
➢ Branch and narrow toward the OL and form
plexuses beneath
• Dentin formation continues throughout life in an
incremental pattern
➢ Lines in the matrix changes in the direction of the
tubules
• Rate of deposition slows in adulthood, but never
completely stops.
Stem cells under odontoblast- still have potential to
differentiate
Predentin- adjacent to ameloblast, unmineralized
Rate of dentin deposition slows down but does not
completely stop.
Root Formation
• Cervical loop = point where cells of IDE + ODE
meet
• Delineates the end of the anatomic crown
• Site where root formation begins
• Hertwig’s epithelial root sheath (HERS): apical
proliferation of the fused epithelia, where
root formation is initiated.
• Provides signal for odontoblast differentiation
• Acts as template for the root
• Pattern of cell proliferation here determines
root configuration
ED- epithelial diaphragm
HERS- apical proliferation of cells
• After fist dentin in root has formed, basement
membrane beneath (HERS), breaks up and
innermost cells secrete hyaline material
overly newly formed dentin= hyaline layer of
Hopewell-Smith
• Fragmentation of HERS then occurs – allows
cell of DF to migrate and contact newly
formed dentin --- differentiate into
cementoblasts --- initiate acellular cementum
formation
• Epithelial cell rests of Malassez: remnants of
root sheath found in the periodontium close
to the root (after completion of root
development)
Epithelial cell rest- during inflammation= it can
give rise to radicular cysts under certain conditions
Formation of Lateral Canals and Apical Foramen
• Lateral canals/ accessory canals: channels of
communication between the pulp and PDL
• Forms when a localized portion of the root
• Single/multiple, small/large
 ENDODONTICS 1
• May occur anywhere along the root, but
most common in apical third ;
➢ Molars: may join pulp chamber PDL in root
furcation
Lateral canals- entryways of bacteria or disease
could extend.
• During root formation: AF usually located at
end of anatomic root
When tooth development has completed: AF
is smaller, found a short distance coronal to
the anatomic root end
• Distance increases as more apical cementum
is formed
• One or multiple foramina at apex
Multiple foramina occur more often in
• multirooted teeth
Apical foramen- located a little above the root
If there are multiple foramina:largest is referred to as
AF, smaller ones are accessory canals= apical delta.
Diameter = usually 0.3-0.6 mm
➢ Largest diameters found on D canal of Md molars,
palatal root of Mx molars.
Formation of the Periodontium
Develop from ectomesenchyme derived tissue (dental
follicle)
Root sheath breaks down after mineralization has
occurred.
➢ Allows cells from the follicle to proliferate and
differentiate into cementoblasts.
Bundles of collagen are embedded in forming
cementum and will become principal fibers of the
PDL.
Formation of Lateral Canals and Apical Foramen
• Lateral canals/ accessory canals: channels of
communication between the pulp and PDL
• Forms when a localized portion of the root
sheath is fragmented before dentin formation
Collagen bundles formed= sharpeys fiber
• Cells in outermost area of follicle differentiate
into osteoblasts = from bundle bone that will
anchor periodontal fibers.
• Periodontal fibers produce more collagen that
binds anchored fragments together= principal
periodontal fibers
• Loose fibrous CT that has nerves and BVs
remains between the principal fibers
3 ESTECOMEN | DDM 4A
• Numerous undifferentiated mesenchymal
cells (tissue -specific stem cells) possess ability
to form new cementoblasts, osteblasts, or
fibroblasts.
Principal perio fibers- suspend tooth in socket
Cellular cementum- lesser role in support
• Blood supply derived from surrounding bone,
gingiva, and branches of the pulpal vessels
• Supports high level of cellular activity in the
area
• Neural supply has small, unmyelinated
sensory and autonomic nerves and larger
myelinated sensory nerves.
Anatomic Regions
• Tooth has crown and root joined at the cervix
(cervical region)
• Pulp space divided into coronal and radicular
regions
➢ Shape and size of tooth surface reflect
shape and size of the pulp space
➢ Coronal pulp – pulp horns, pulp chamber
Pulp space become asymmetrically smaller
after completion of root growth due to slower
dentin production.
• Molars apico-occlusal dimension is reduced
more than MD dimension
• Excessive reduction in pulp space can lead to
problems in locating, cleaning and shaping the
RCS
• Anatomy of root canal differs between and
within tooth types
• Variation in size and location of the AF
influences degree to which blood flow to pulp
may be compromised after trauma
• Young partially developed teeth have better
prognosis for pulp survival
1mm cavity prep for pedo ptx(large pulp horns)
Orifice- opening of canal
Apical constriction- we do not see it clinically, not even
clear in radiographs, point where pulp terminate and
pdl begins
• Disparity between radiographic apex and AF
seen when there is post-eruptive deposition
of cementum in the area of the AF
• Created a funnel-shaped opening of the
foramen larger than intraradicular portion of
the foramen
• Apical constriction narrowest portion of the
canal
• Coincides with the cementodentinal junction
(CDJ)
• Estimated to be 0.5-0.75mm coronal to apical
opening
• Point where the pulp terminates and the PDL
begins
 ENDODONTICS 1
• Cleaning, shaping and abturation of RC should o Dentin formed in event of an injury,
terminate short of the AF particularly when original dentin thickens has
• Must also be confined to the canal to avoid been reduced (caries, attrition, trauma, resto
injury to the periapical tissues procedures)
• Determination of the root length and o Also formed at sites where its continuity is
establish lost (ex. Site of pulp exposure)
o Induction, differentiation and migration of
0.5mm from apex- stop file (debris will block) -
Constant length dapat-TERMINATE cleaning short of
apical foramen 0.5mm)
Pulp Function
➢ Induction
➢ Formation
➢ Nutrition
➢ Defense
➢ Sensation

INDUCTION
• Participates in the initiation and development
of dentin- enamel formation
• Enamel epithelium induces differentiation of
odontoblasts and dentin induce formation of
enamel.
FORMATION
• Odontoblast participate in dentin formation
by:
• Synthesizing and secreting inorganic matrix
• Initially transporting inorganic components to
newly formed matrix
• Creating an environment that allows
mineralization of the matrix
• Primary dentinogenesis: occurs during early
development, rapid process
• Secondary dentinogenesis: happens after
tooth maturation and when root elongation is
complete: slower rate, les symmetric pattern
• Tertiary dentin: forms in response to injury
➢ Less organized to 1st and 2nd dentin
➢ Mostly localized to site of injury
• Reactionary dentin: tubular tubules
continuous with those of the original dentin
• Formed by original odontoblasts
• Reparative dentin: atubular →Formed by new
odontoblasts differentiated from stem cells
after original odontoblast after being killed.
DB-dentin bridge- after carious exposure of pulp
NUTRITIVE
➢Supplies nutrients essential for dentin
formation, for maintaining integrity of the
pulp
DEFENSIVE
new odontoblasts to exposure site
o Can process and identify foreign substances
and elicit an immune response to their
presence
SENSATION
➢ Unmyelinated fibers= slow, dull pain ➢
Myelinated nerves= fast and sharp pain:
transmitted by Ab fibers.
Morphologic Zone of the Pulp
➢ Odontoblast layer
➢ Cell-Poor Zone
➢ Cell-rich zone
➢ Pulp Proper (Pulp core)
• Pulp and dentin function as a unit
• Odontoblasts are in periphery of pulp tissue,
extending into inner part of dentin • Impacts on
dentin affects pulpal disturbances affects quantity and
quality of dentin produced
Odontoblast Layer (OL) (coronal pulp)
• Outermost stratum of cells
• Cell bodies odontoblasts: capillaries, nerve
fibers, dendritic cells
• Coronal pulp has more cells per unit than
radicular area than the radicular pulp
• Coronal pulp columnar
Midportion of radicular pulp: cuboidal
Near apical foramen: squamous
• Tight junctions determine permeability of OL
when dentin is covered by enamel or
cementum

4 ESTECOMEN | DDM 4A
 ENDODONTICS 1
• Disrupted during cavity prep in increased • Continues at varying levels of activity for a
dentin permeability lifetime (some die by apoptosis)
Cell-Poor Zone • Disease processes (mainly caries) can kill
• Immediately subjacent to OL odontoblasts
• Narrow zone 40 um in width • Are end cells = DO NOT UNDERGO FURTHER
• Cell-free layer of well CELL DIVISION.
• Blood capillaries: unmyelinated nerve fibers, -- protein secreting cell
cytoplasmic process of fibroblasts
• Presence/absence on functional status of pulp ODONTOBLAST PROCESS
o Dentinal tubule forms around each of major
Cell-Rich Zone odontoblastic process
• Contains high proportion of fibroblasts o Occupies most of the space within the tubule
• More prominent in coronal pulp o Coordinates formation of peritubular dentin
Also has immune cells (macrophages, o Microtubules and microfilaments (principal
dendrific cells) undifferentiated mesenchymal components), collagen fibrils, ground
stem cells substance
Pulp Proper o Membrane junctions join cell bodies; gap
• Central mass of the pulp junctions, tight junctions, desmosomes
• Loose connective tissue o Gap junctions: Allow communication between
cells in the layer
• Fibroblast is the most prominent cells
o Desmosomal junctions; mechanically link cells
into a coherent layer
Cells of the pulp
o Tight junctions; control permeability of the
o Odontoblast
layer
o Odontoblast process
o Other parts of the cell membrane are
o Fibroblast
specialized to be membrane receptors
o Macrophage
Synthesizes maily type I collagen
o Dendritic cell
o Secretes dentin sialoprotein and
o Lymphocyte
phosphophoryn
o Mast cell
o Secretes acid phosphatase and alkaline
phosphatase
Odontoblast
o Resting/inactive
• Most characterized and specialized cell of the
number of organelles, may become shorter
D- P complex
• Form dentin and dentinal tubules
STEM CELLS (Preodontoblasts)
• Matrix that has fibrils, non-collagenous
• proteins, proteoglycans ➢ Undifferentiated mesenchymal cells
• Highly ordered RER, Prominent golgi complex, ➢ Newly differentiated od ontoblasts develop after
secretory granules, numerous mitochondria injury, results in death of existing odontoblasts
• Rich in RNA, nuclei contain one or more ➢ Densest in pulp core
prominent nucleus ➢ Migrate to the site of injury and differentiate
• Form a single periphery ➢ Key signaling molecules; bone morphogenic
• Synthesize the matrix, control mineralization protein (BMP), family and transforming growth factor
of dentin B
• Produce collagen that becomes fibrous, 3
noncollagenous proteins in which collagen FIBROBLAST
fibers are embedded ➢ Most common cell type in pulp, seen in greatest
• Coronal part of the pulp space: 45,000- numbers in coronal pulp
65,000/mm2 ➢ Tissue-specific cells capable of creating cells
• Relatively large involved in differentiation
• Columnar in shape
➢ Synthesize Type I and III collagen, as well as
• Cervical & midportion of root: lower in
proteoglycans and GAGs
number, appear flattened
➢ Responsible for collagen turnover
• Larger cells have well-developed synthetic
apparatus, capacity to synthesize more ➢ Abundant in cell-rich zone
matrix. ➢ As cells mature, they become stellate in form, Golgi
complex enlarges, RER proliferates, secretory vesicles

5 ESTECOMEN | DDM 4A
 ENDODONTICS 1
appear, fibroblasts take on appearance of protein-
secreting cells
➢ Increase in number of BVs, nerves, collagen fibers:
decrease in number of fibroblasts in the pulp
➢ Many fibroblasts are undifferentiated.
MACROPHAGE
➢ Monocytes that have left the bloodstream, entered
the tissues, and differentiated into subpopulations.
➢ Act as scavengers-remove extravasated RBCs, dead
cells, foreign bodies from tissue.
➢ Take an active art in signaling pathways in the pulp
➢ When activated by appropriate inflammatory
stimuli, can produce factors (IL-1, TNF, GF, cytokines)
DENDRITIC CELL
• Accessory cells
• Most prominent immune cells in pulp
• Antigen-presenting cells
• Present most densely in OL and around BVs
• Recognize wide range of foreign antigens and
initiate immune response (together with
odontoblasts)
Antigen presenting- more in odontoblast layer
LYMPHOCYTE
• T8 (suppressor) lymphocytes are the
predominant subset
• Blymphocytesarerarelyfountinnormalpulp
indicates pulp well equipped with cells required for
initiation of immune responses
MAST CELL
o Seldom found in normal pulp tissue, but have
been routinely fount in chronically inflamed
pulps
o Role in the inflammatory reactions
o Granules contain heparin (anticoagulant),
histamine (inflammatory mediator), other
chemical factors
MAST CELL
o Seldom found in normal pulp tissue, but have
been routinely fount in chronically inflamed
pulps
o Role in the inflammatory reactions
o Granules contain heparin (anticoagulant),
histamine (inflammatory mediator), other
chemical factors
o Type I and III collagen found in pulp in ratio of
55:45
o Odontoblasts are only produce type I collagen
o For incorporation into dentin matrix
o Fibroblasts produce type I and III collagen
o Present as fibrils 50 nm wide and several
micrometers long
6 ESTECOMEN | DDM 4A
o Form irregularly arranged bundles, except in
periphery (lie approx, parallel to predentin
surface)
o Non collagenous fiber present: 10-15 nm wide
beaded fibrils of fibrillin.
o Elastic fibers absent from pulp
CALCIFICATIONS
Free stones, attached stones, embedded stones
o Free: surrounded by pulp tissue
o Attached: continuous with dentin
o Embedded: surrounded entirely by tertiary
dentin
o Can occur in both young and old patients, and
in one or more teeth, in normal and
chronically inflamed pulps
o Do not produce painful symptoms, regardless
of size
o May also occur in the form of diffuse or linear
deposits associated with neurovascular
bundles in pulp core
o Seen in aged, chronically inflamed,
traumatized pulps
o Mayor may not be seen on the radiograph
May block access to canals or root apex
during RCT
NONCOLLAGENOUS MATRIX
• Collagenous fibers embedded in clear gel
made up of GAGs and other adhesion
molecules
• GAGs link to protein and other saccharides =
proteoglycans
• Around 6 types of adhesion molecules
detected in pulp matrix
• Fibronectin- responsible for cell adhesion to
matrix.
BLOOD VESSELS - Afferent Blood Vessels (Arterioles)
• Branches of the interior alveolar artery,
superior posterior alveolar artery. Infraorbital
artery
• Once inside the radicular pulp, arterioles
travel toward the crown, narrow then branch
extensively and lose their muscle sheath, then
form a capillary bed.
Precapillary sphincters: formed by muscle fibers
before the bed: control blood flow and pressure
• Most extensive capillary branching occurs in
subodontoblastic layer where vessels form a
dense plexus
• Exchange of nutrients and waste products
occur in the capillaries
• Extensive shunting system (arteriovenous and
venovenous anastomoses) - become active
after pulp injury and during repair.
 ENDODONTICS 1
afferent- artery
venules- efferent-exit
EFFERENT BLOOD VESSELS
o Venules comprise the efferent (exit) side of
pulpal circulation
o Slightly larger than corresponding arterioles
o Formed from the junction of venous
capillaries, enlarge as more branches unite
with them
o Run with arterioles and exit at AF
o Drains posteriorly into Mx vein through
pterygoid plexus
o Drains anteriorly into facial vein
LYMPHATICS
o Arise as small, thin-walled vessels in periphery
o Pass through to exit as one or two larger
vessels through the AF
o Walls composed of an endothelium rich in
organelles and granules
➢ Porosities in the walls and in basement membrane
➢ Permits passage of interstitial tissue fluid and
lymphocytes (when necessary)
• A cyst in removal of inflammatory exudates,
transudates and cellular debris
• After exiting the pulp, this join similar vessels
from the PDL → drain into regional lymph
glands (submental, submandibular, cervical)
→ empty into subclavian and internal jugular
veins
VASCULAR PHYSIOLOGY
➢ Young dental pulp is highly vascular
Capillary blood flow in coronal area almost twice that
of radicular area
➢ Blood supply largely regulated by precapillary
sphincters and their sympathetic innervation
➢ Volume of vascular bed greater than volume of
blood normally passing through = allows for increases
in blood flow in response to injury
➢Concentration gradients, osmosis, hydraulic
pressure: factors determining what passes in & out
between blood & tissue.
➢Hydraulic Pin pulpal capillaries=35mmHg
(anteriolar end), 19 mm Hg (venular end).
➢Interstitial Fluid P outside vessels would normally
be 6 mm Hg (but varies).
➢ Initial immune response is nonspecific but rapid
(minutes or hours)
➢ 2nd response: specific, includes production of
specific antibodies
7 ESTECOMEN | DDM 4A
➢ All cardinal signs of inflammation are vascular in
origin (except pain)
▪ Increased blood flow = heat, redness
▪ Increased formation of interstitial tissue
fluid = swelling = increase in tissue fluid P
ALL CARDINAL SIGNs (EXCEPT PAIN)- VASCULAR IN
ORIGIN
➢Elevations in tissue fluid P remain localized to
injured area
➢Intraluminal (inside) P of local capillaries increase to
balance any rise in interstitial fluid P
➢Gradients by which nutrients and wastes leave and
enter the capillaries change to allow greater exchange
(during response to injury)
• Lymphatic vessels work more, removing
excess tissue fluid and debris
• Anastomoses allow blood to be shunted
around area of injury
➢If injury persists and increases in size = tissue
necrosis
• Can remain localized as a pulpal abscess, but
more often spreads throughout the pulp
• Necrosis extends as toxins from carious lesion
diffuse through tissue
Neurogenic inflammation – mechanism in w/c
excitation of sensory elements results in increased
blood flow & increased capillary permeability.
Antibiotic-just an adjunct- must remove infection,
clean inside of canal
INNERVATION
➢ 2ND & 3RD divisions of CN V provide principal
sensory innervation to pulp of Mx and Md teeth ➢
Md PMs also receive sensory branches from
mylohyoid nerve of V3 (motor nerve)
▪ Branches reach teeth via small foramina
on Li aspect of Md
• Md molars occasionally receive sensory
innervation from 2nd & 3rd cervical spinal
nerves (C2 & C3)
• Pulp also receives sympathetic (motor)
innervation from T1, C8 and T2 via superior
cervical ganglion
▪ Enter pulp space together w/ main BVs & are
distributed w/ them.
▪ Maintain vasomotor tone in precapillary sphincters
PULPAL AND DENTINAL NERVES
➢ Contain both unmyelinated & myelinated axons
➢ Myelinated axons – almost all narrow, slow-
conducting A6 axons (1-6 μm in diameter) associated
w/ nociception
▪ Small percentage are fast-conducting A
▪ Terminating fibers from subodontoblastic plexus of
Raschkow
 ENDODONTICS 1
Myelinated- faster, sharper pain
Unmyelinated- slower, dull
DEVELOPMEMTAL ASPECTS
➢ Type & number of nerves depend on the state of
tooth maturity
➢ Myelinated & unmyelinated nerves - enter the
pulp at about at about the same time, but not form
plexus of Raschkow until after tooth eruption =
variations in responses of partially developed teeth to
pulp vitality tests
➢ Number of nerves diminishes w/ age
Theories of Dentin Hypersesitivity
➢ 2 explanations for peripheral dentin sensitivity:
• Stimuli that are effective in eliciting pain from
dentin cause fluid flow through
dentinal tubules/” hydrodynamic
hypothesis”
• Some substances diffuse through dentin
and act directly on pulpal nerves
Fluid movement- causes sensation
Age Change in Pulp and Dentin
➢ Secondary dentin is laid down throughout life =
pulp chamber and root canals become smaller,
eventually becoming invisible on the radiograph
➢ More peritubular dentin is laid down as age
increases = decreased dentin permeability
➢ Pulp tissue becomes less cellular and less vascular,
has fewer nerve fibers
➢ Between 20-70 y/o, cell density by approx.. 50%
Repair & Regeneration
➢ Pulp can respond positively to external irritants
➢ Inflammation is part of response that leads to new
dentin formation
➢ Tertiary response dentin and Tertiary reparative
dentin
▪ Type of dentin laid down determined by
intensity of stimulus
PERIRADICULAR TISSUES
➢ Periodontium originates from the DF;
formation initiated when root development
begins
➢ Dentogingival junction = GE + RDE
(enamel) ▪ Protects underlying periodontium
from potential irritants
➢ Pulp & periodontium form a continuum
8 ESTECOMEN | DDM 4A
along sites at root where BVs enter, and exit
pulp at AF & lateral and accessory canals
CEMENTUM
• Bonelike tissue covering the root
• Provide attachment for principal periodontal
fibers
• Types:
o Primary acellular intrinsic fiber
o Primary acellular extrinsic fiber
o Secondary acellular intrinsic fiber
o Secondary cellular mixed fiber
o Acellular afibrillar
• Primary acellular intrinsic fiber – 1st
cementum formed
o Present before principal perio fibers
are fully formed
o Extends from cervical margin to
cervical third of tooth in some
teeth/around entire root in other
teeth (incisors, cuspids)
o More mineralized on the surface
o Contains collagen produced initially
by cementoblasts and later by
fibroblasts
• Primary acellular extrinsic fiber cementum –
continues to be formed about the primary
perio fibers after incorporation into PAIF
cementum
• Secondary cellular intrinsic fiber cementum –
bonelike appearance
o Minor role in fiber attachment
o Occurs mostly in apical part of PM
and molar roots
➢ Secondary cellular mixed fiber cementum –
adaptive type w/c incorporates perio fibers as they
continue to develop
▪ Recognized by cementocytes, laminated
appearance, cementoid on surface
➢ Acellular fibrillar cementum – sometimes seen
overlapping enamel; no role in fiber attachment
CEMENTOENAMEL JUNCTION (CEJ)
➢ Varies in arrangement
▪ Cementum overlaps enamel
▪ Enamel overlaps cementum
➢ Gap between cementum & enamel = exposed
dentin may be sensitive
PERIODONTAL LIGAMENT
• SPECIALIZED CT
 ENDODONTICS 1
• Specially arranged collagen fiber bundles
support
the tooth in the socket & absorb forces of
occlusion
• ➢PDL space is small (0.21 mm young teeth,
0.15 mm in older teeth)
▪ Uniformly od width is one criteria used
to determine its health
➢ Cementoblasts, osteoblasts line the space
Interwoven between principal perio fibers is loose CT
containing fibroblasts, stem cells, macrophages,
osteoclasts, BVs, nerves, lymphatics; also ERM
➢ Arterioles supplying PDL arise from superior &
inferior alveolar branches of the Mx artery
• Pass through small openings in alveolar bone,
& extends upward and downward throughout
the space
• More prevalent in posterior teeth
➢ Unmyelinated sensory nerve fibers
terminate as
nociceptive free endings
➢ Large fibers – mechanoreceptors that
terminate in special endings throughout the
ligament
▪ Greater concentration in apical third of perio
space
▪ Highly sensitive (record P associated w/
tooth movement)
Lamina dura- no break, uniform- indicates no peri
radicular inflammation
ALVEOLAR BONE
➢ Alveolar process – bone of jaws supporting
teeth
➢ Alveolar bone proper – bundle bone,
cribriform plate
o Bone lining the socket & into w/c
principal perio fiber are anchored to
o Denser than surrounding cancellous
bone
o Distinct opaque appearance in
radiographs = lamina dura
o Principally lamellar
o Constantly remodels
DIAGNOSIS, PULPAL & PERIAPICAL DISEASE
Diagnosis
• Art & science of determining the disease
process by:
✓ Systematic collection and recording of facts
✓ Careful analysis and integration of these
facts
• Science of recognizing disease by means of
signs, symptoms, and tests
9 ESTECOMEN | DDM 4A
• Correct diagnosis → proper treatment &
success of case → better prognosis
→systematically collect facts and details
• Determine what problem a patient is having,
and why the patient is having that problem
• No appropriate treatment recommendation
can be made until all of the whys are
answered
• Planned, methodical, systematic approach
5 Stages Of Diagnosis:
✓ Patient tells clinician why the patient is seeking
advice
✓ Clinician questions patient about symptoms and
history that led to the visit
✓ Clinician performs objective clinical tests
✓ Clinician correlates objective findings with
subjective details, & creates a tentative differential
diagnosis
✓ Clinician formulates a definitive diagnosis.
Steps:
o Chief complaint
o History (medical and dental)
o Oral examination
o Data analysis (leading to differential diagnosis
o Treatment plan
Chief Complaint (offered by the patient)
• First information obtained, volunteered by
the patient
• Direct and unbiased
• Clinician must pay close attention to:
✓ Actual expressed complaint
✓ Determine chronology of events leading
up to this complaint
✓ Question any other pertinent issues
• Should be properly documented using
patient’s own words
Medical History
• Baseline BP and PR recorded at each visit;
take other vital signs
• Evaluate:
• Medical conditions & current and current
medications that may alter manner in w/c
dental care is provided
• Medical conditions that may have oral
manifestations or mimic dental pathosis
Take note also of:
o Drug allergies to dental products
o Artificial joint prosthesis
o Organ transplants
o Taking medications that may negatively interact w/
common local anesthetics, analgesics, antibiotics
 ENDODONTICS 1
Conditions (AAOS):
Ptx w/ major medical problems- need to note down -Those who have joint replacements within the past
vital signs every visit year, particularly those who are immunocompromised
immunosuppressed Those with hemophilia or insulin
Medical Conditions That Warrant Modification of – dependent diabetes
Dental Care or Treatment -Those who have had previous joint prosthesis
Cardiovascular: High – and moderate – risk categories infections
of endocarditis, pathologic heart murmurs, -Instrument beyond the apex
hypertension, unstable angina pectoris, recent -Periapical surgery
myocardial infarction, cardiac arrhythmias, poorly -Procedures that may produce bleeding (aggressive
managed congestive heart failure rubber dam placement, incision and drainage)
Pulmonary: Chronic obstructive pulmonary disease,
asthma, tuberculosis →endo procedures which is risk for cardiac ptx or
Gastrointestinal and renal: End – stage renal disease: prosthesis ptx
hemodialysis; viral hepatitis (types B, C, D, and E);
alcoholic liver disease; peptic ulcer disease; Regimen
inflammatory bowel disease; pseudomembranous o Adults: Amoxicillin 2 g 30-60 minutes prior to
colitis procedure
Hematologic: Sexually transmitted diseases, HIV and o Children: 50 mg/kg
AIDS, diabetes mellitus, adrenal insufficiency, o Allergic to amox: Clindamycin 600 mg 30-60
hyperthyroidism and hypothyroidism, pregnancy, minutes prior to procedure
bleeding disorders, cancer and leukemia,
osteoarthritis and rheumatoid arthritis, systemic lupus → To prevent infective endocarditis
erythematosus
Neurologic: Cerebrovascular accident, seizure Dental History
disorders, anxiety, depression and bipolar disorders, • Guide to w/c diagnostic test must be
presence or history of drug or alcohol abuse, performed
Alzheimer’s disease, schizophrenia, eating disorders, • Must include past and present symptoms,
neuralgias, multiple sclerosis, Parkinson’s disease. procedures or trauma that elicit CC
• Medication side effect: stomatitis, xerostomia, • Past dental procedures, frequency of dental
petechiae, ecchymoses, lichenoid mucosal lesions, visits, oral hygiene status, adverse reaction to
bleeding of oral soft tissues local anesthetics.
• Medical conditions have clinical presentations that
mimic pathological lesions: Dental History Interview
• Lymph node enlargement due to odontogenic 5 Basic directions of questioning:
infection – lymphomas, TB involving cervical ✓ Localization
and subMd lymph nodes ✓ Commencement
• Odontogenic pain, loss of trabecular bone ✓ Intensity
pattern in radiographs in lesions of endo
✓ Provocation
origin – sickle cell anemia
✓ Duration
• Tooth mobility – multiple myeloma
• Increased sensitivity of teeth,
Pain: most common symptom that leads to
osteoradionecrosis – radiation therapy to
consultation or treatment
head and neck
o Location – localized, diffuse, radiating, referred
• Dental pain – trigeminal neuralgia, multiple
o Quality – sharp, piercing, dull
sclerosis
o Onset – spontaneous, provoked
• Tooth pain in Mx posterior quadrant – acute
o Provoking/alleviating factor – cold, heat,
Mx sinusitis
biting, sweets
•
o Intensity – mild, moderate, severe
ANTIBIOTIC PROPHYLAXIS
o Duration – constant, momentary, intermittent
Conditions (AHA):
-Artificial heart valve
Questions to Ask – PAIN
-Previous history of infective endocarditis Incomplete
▪ When did the pain begin?
or repaired congenital heart tissue repair
▪ Where is the pain located?
-Heart transplants
▪ Isthepainalwaysinthesameplace?
▪ What is the character of the pain (short, sharp,

10 ESTECOMEN | DDM 4A
 ENDODONTICS 1
long-lasting, dull, throbbing, continuous,
occasionally)?
▪ Does the pain prevent sleeping or working?
▪ Is the pain worse in the morning?
▪ Is the pain worse when you lie down?
▪ Did or does anything initiate the pain (trauma,
biting)?
▪ Once initiated, how long does the pain last?
▪ Is the pain continuous, spontaneous, or
intermittent?
▪ Does anything make the pain worse (hot, cold,
biting)? Does anything make the pain feel better (cold,
analgesics)?
Questions to Ask – SWELLING
▪ When did the swelling begin?
▪ How quickly has the swelling increased in size?
▪ Where is the swelling located?
▪ What is the nature of the swelling
(soft,hard,tender)?
▪ Is there drainage from the swelling?
▪ Is the swelling associated with a loose or tender
tooth?
• Mucobuccal fold – infection associated w/
apex of root of any Mx tooth exiting the
alveolar bone on the facial aspects & is
inferior to the muscle attachment present in
the area; same as in Md, but if root apices are
superior to the level of muscle attachment
*Anterior- associated w/ lingual root of 1st
premolar *Posterior: palate
-mucobuccal fold fr central incisor
Sublingual space - infections from root apex spreads
to the lingual & exits the alveolar bone superior to the
mylohyoid muscle attachment
Submandibular space – exits to the lingual of Md
molars & is inferior to mylohyoid muscle attachment
Parapharyngeal space (swelling of tonsillar and
pharyngeal areas) extensions of severe infections of
Mx & Md molars.

Examination and Testing – EXTRAORAL EXAMINATION

• Observe patient as soon as they enter the
operatory
• Signs of physical limitations, facial asymmetry
• Do visual and palpation exams

EXAMINATION & TESTING- INTRAORAL

EXAMINATION

Evaluate soft tissues

o Dry mucosa and gingiva w/ air syringe or gauze
o Retract tongue & cheek to get a better view of soft
tissues – check abnormalities in color & texture
| January 31, 2022 o Take note of any raised lesions or
ulcerations –
biopsy or referral if needed

Intraoral Exam
o ST. check the lips, oral mucosa, cheeks, tongue,
periodontium, palate, muscles
o Dentitice: check for discolorations, fractures,
abrasions, erosions, caries, failing restorations

INTRAORAL SWELLINGS
• IO swellings should be visualized & palpated –
localized/diffuse, firm/fluctuant
• Attached gingiva, alveolar mucosa,
mucobuccal fold, palate, sublingual tissues
* Palpate to check texture and density
• Anterior part of palate – infection at apex of
Mx lateral incisor or P root of Mx 1st PM
• Posterior part of palate – associated w/ P
root of Mx molar

11 ESTECOMEN | DDM 4A
 ENDODONTICS 1
INTRAORAL RADIOGRAPHY
*2-dimensional image of 3-dimentional structure
*High quality processing needed for maximum
diagnostic value
*Understanding of anatomy is needed in
differentiating anatomical & pathological images
*Various views from multiple angles to capture more

What to look for:

o Continuity of lamina dura
o Width of periodontal space
o Any evidence of demineralization in the
bony architecture
o Condition of the root canal system:
resorptions, calcifications
o Anatomic landmarks
o Presence of extra roots/canals o Immature
INTRAORAL SINUS TRACT root apices
*Drainage of chronic endodontic infection through an o Tooth/root fractures
intraoral communication to the gingival surface
*Extends directly from the source of infection to a DIAGNOSTIC TEST
surface opening (stoma) on the attached gingival o Thermal Test
surface o Electric pulp test Percussion
*Provides a pathway for release of infectious exudate o Palpation
& subsequent relief of pain o Periodontal probing depths
*Aids in finding out the source of an infection o Mobilty
*Stoma may be directly adjacent or at a distant site o Special tests
from the infection o Do more than one endodontic diagnostic test
*Perform sinus tract tracing o Do tests on at least three or more teeth
Stomata may open in alveolar mucosa, attached -Involved tooth
gingiva, or through furcation or gingival crevice -Adjacent tooth
o May exit through facial/lingual tissues on -Contralateral tooth
proximity to root apices to cortical bone
*Presents as a narrow defect in 1 or 2 isolated areas PALPATION, PERCUSION, MOBILITY, PERIODONTAL
along the root surface if opening is in gingival crevices EXAMINANTION
o DD: perpendicular endo lesion, vertical root Palpation
fracture, developmental groove →Note any soft tissue swelling or bony expansion in
o Differentiated from a primary lesion (pocket alveolar hard tissues.
w/ broad coronal opening and more ✓ Question patient about any areas that feel
generalized alveolar bone loss around root). unusually sensitive
• To examine for sinuses, clearly visualize the
gutta percha (#25/#30) tracing, no need for area with good lighting. Retract the mucosa
anesthesia -topical anes can be applied gently as shown to facilitate this.
-sinus tract in a parulis • Record any sinuses or deviations from normal
anatomy in the notes
OBEJECTIVE EXAMINATION • To assess for alveolar tenderness, gently
• Extraoral exam – general appearance, skin palpate the alveolus with your finger.
tone, facial asymmetry, swelling, Compare this to a similar, healthy region in
discoloration, redness, EO scars or sinus the mouth
tracts, lymphadenopathy • Ask the patient if it feels sore when you
palpate the region. Document this
RADIOGRAPHIC EXAMINATION & INTERPRETATION • Also document any obvious swellings, or other
• Intraoral radiographs deviations from normal anatomy.
• Digital radiography
Cone-beam volumetric tomography

12 ESTECOMEN | DDM 4A
 ENDODONTICS 1
Percussion
→Indicator of inflammation in PDL.
✓ Secondary to physical trauma, occlusal
prematurities, periodontal disease, extension of
pulpal disease into PDL space
✓ Test contralateral tooth first (control), then
adjacent teeth
✓ Gloved finger tapping initially, applying light
pressure
✓ Repeat test using blunt end of
• Percussion testing: Simultaneously test for
tenderness to percussion and listen for the
percussion note. If the tooth is tender, this will
minimize how many times you will need to tap
the tooth
• Explain the procedure to the patient. Ask the
patient to raise their hand or tell you if the
tooth is tender
• Gently tap the tooth being tested in an axial
direction. Ensure you are tapping the tooth
with a metal instrument. The metal handle of
a mirror is ideal for this
• Listen to the sound that the tooth made when
percussed. Document whether the tooth
tested sounded different to the other teeth or
the same
➢ Ask the patient if the tooth felt sore when you
tapped it. Document any tenderness felt
Mobility
→Indication of compromised periodontal
attachment apparatus.
✓ Result of acute/chronic physical trauma, occlusal
trauma, parafunctional habits,periodontal disease,
root fractures, rapid orthodontic movement,
extension of pulpal disease into PDL space
✓ Apply simple finger pressure - visually subjective
✓ Use back ends of two mirror handle
✓ Evaluate on how mobile affected tooth is relative
to adjacent & contralateral teeth
Recording Tooth Mobility
+1 mobility: The first distinguishable sign of
movement greater than normal
+2 mobility: Horizontal tooth movement no greater
than 1 mm
+3 mobility: Horizontal tooth movement greater than
1 mm, with or without the visualization of rotation or
vertical
*Visually Subjective
*Use ends of mouth mirror
Recording Furcation Defects
Class I furcation defect: The furcation can be probed
but not to a significant depth.
Class II furcation defect: The furcation can be entered
into but cannot be probed completely through to the
opposite side.
Class III furcation defect: The furcation can be probed
com pletely through to the opposite side.
Periodontal Exam
Probing
✓ Record pocket depths on the mesial, middle, and
distal aspects in both buccal and lingual sides (mm)
✓ Document amount of furcation bone loss Watch
Probing vid:
➢ 3 keys of probing
✓ Adaptation
✓ Walking stroke
✓ Access
PULP TESTS
- Thermal
- Electric
- Laser Doppler Flowmetry - assesses blood
flow in microvascular systems
- Pulse Oximetry - measures oxygen
concentration in blood and the pulse rate.
THERMAL
- Baseline/normal response: sensation is felt, but
disappears immediately on removal of stimulus
✓ Abnormal responses: lack of response,
lingering/intensification of a painful sensation after
the stimulus is removed; immediate, excruciating
painful sensation as soon as stimulus is placed
Heat Test: Hot water, heated GP, dry rubber
polishing wheel (seldom used)
Cold Test: Primary pulp testing method for many
clinicians.
Used in conjunction with EPT to verify findings of
each test
➢ Dry ice/carbon dioxide snow
➢ Refrigerant spray
No response- nonvital pulp
False negative response- excessive calcification,
immature apex, recent trauma, premedication
* NO VITALITY TEST ON TRAUMATIC INJURIES
+ mobility test
Cold Test & Heat Test - how many seconds nag batyag;
(+ mild, ++moderate or +++severe)
=ISOLATE TOOTH FIRST
Cold – ice stick
PLACE ON MIDDLE 3RD OF FACIAL SURFACE OF CROWN-
ANTERIOR TEETH

13 ESTECOMEN | DDM 4A
 ENDODONTICS 1
Heat - heated instrument, gutta percha o Does not cause px diseases
HEAT TEST- BRADE CONE- HEAT- PLACE ON SURFACE OF o Transient sensation that disappear in seconds
TOOTH
• R: varying degrees of pulpal calcification
Percussion - mild, moderate, severe
Palpation o No evidence of resorption, caries, mechanical pulp
exposure
• No endo tx indicated
Heat Test: Hot water, heated GP, dry rubber
Tx= treatment
polishing
Heat- place Vaseline on tooth to prevent gutta percha fr
adhering to tooth REVERSIBLE PULPITIS

SPECIAL TESTS • Pulpal irritation wherein any stimulation is

• Bite Test uncomfortable to the px, but reversible quickly after
• Test Cavity irritation
• Staining and Transillumination • Caries, exposed dentin, recent dental tx, defective
resto
• Selective Anesthesia
• Conservative removal of irritant
• Dentin/dentinal hypersensitivity: sharp, quickly
BITE TEST
reversible pain felt by exposed dentin (without
• Indicated (along with percussion) when a px
evidence of pulp pathosis) when subjected to
presents with pain while biting
thermal, evaporative, tactile, mechanical, osmotic,
• Periradicular periodontitis: pain to both tests chemical stimuli
regardless where pressure is applied to • Clinical condition associated with subjective and
coronal part of tooth
objective findings indicating presence of mild
• Cracked tooth/fractured cusp: pain only inflammation in the pulp tissue
when test is applied in a certain direction to • Inflammation reverse, pulp returns to normal state
one cusp or section once cause is eliminated
• Tooth Slooth (Professional Results), • Mild/ short-acting stimuli: incipient caries, cervical
FracFinder (Hu-Friedy) erosion, occlusal attrition
Note whether pain is elicited during pressure →Most operative procedures, deep perio
phase or on quick release of the pressure curettage, enamel fractures
• Usually, Asymptomatic
TEST CAVITY • Application of Hot or Cold Stimuli or air may
• Used only when all other test methods are produce sharp, transient pain
found impossible or results of other tests are • Removal of Stimuli result in immediate relief
inconclusive • Heat: delayed initial response, but pain
• Small class 1 cavity prep made through increases in intensity as temperature rises
occlusal surface • Cold: response is immediate, intensity
• No anesthesia: px asked to respond if a decreases if maintained
painful sensation is felt during drilling
• Staining and Transillumination ➢ SYMPTOMATIC IRREVERSIBLE PULPITIS
Determines crack • Intermittent or spontaneous pain
• Selective Anesthesia • Heightened and prolonged episodes of pain
➢ Symptoms cannot be localized, pulp testing is to
inconclusive temperature changes (esp. cold stimuli),
➢ Mx arch anesthetized first- intraligamentary even
injection (from most posterior tooth at D sulcus, after stimulus removal
moving anteriorly) • Sharp / dull pain; localized/diffuse; referred
➢ More useful for identifying the affected arch • R: Minimal to no changes of periradicular
bone
o If advanced, PDL thickening • Deep restos, caries,
pulp exposure,
CLINICAL CLASSIFICATION OF PULPAL direct/indirect injury to pulp (prior or recent)
PERIAPICAL DISEASE ✓ Symptomatic or asymptomatic
✓ Indicated presence of severe inflammation
• Pulpal disease ✓ Does not resolve, even if cause is removed
• Normal pulp ✓ Pulp incapable of healing, and slowly or quickly
• Reversible pulp becomes necrotic
• Irreversible pulpitis – Symptomatic, Asymptomatic
• Pulp necrosis ASYMPTOMATIC IRREVERSIBLE PULPITIS
• Previously treated • No symptoms produced by deep caries, even if it
• Previously initiated therapy has reached the pulpclinically/radiographically
✓ Usually asymptomatic, but some pxs may
NORMAL PULP report mild symptoms’
• Do not exhibit any spontaneous symptoms ✓ Intermittent/continuous episodes of
• Mild response to pulp tests spontaneous pain
✓ Pain may be sharp/ dull, localized/diffuse; lasts
from a few minutes to a few hours
✓ RCT or extraction
14 ESTECOMEN | DDM 4A
 ENDODONTICS 1
HYPERPLASTIC PULPITIS Previously Initiated Therapy – partial endodontic
• Pulp polyp therapy has been performed
• Form of IP originates from overgrowth of a o Pulpotomy or pulpectomy performed as emergency
chronically inflamed young pulp onto the procedure for SIP/AIP
occlusal surface
• Found on carious crown of young pxs Apical (Periapical) Disease
• Usually, asymptomatic o Normal Apical Tissues
✓ Appears as a reddish, cauliflower-like o Symptomatic Apical Periodontitis
outgrowth CT into caries that has resulted in a large o Asymptomatic Apical Periodontitis
occlusal exposure o Acute Apical Abscess
✓ Responds within normal limits to percussion or o Chronic Apical Abscess
palpation
✓ Tx: pulpotomy, RCT, extraction NORMAL APICAL TISSUES
o Px is asymptomatic
HARD TISSUES CHANGES CAUSED BY PULPAL
o Tooth responds normally to percussion and
INFLAMMATION
palpation testing
o R: intact LD and PDL space
Pulp calcification- pulp stones, diffuse calcification
o Clinically and radiographically has normal
• Occurs as a response to trauma, caries, perio
periapical tissues
disease, other irritantS
o Not abnormally sensitive to percussion or
• Calcific metamorphosis: extensive formation
palpation
of hard tissue on dentin walls, often in
o Normal LD and PDL structures
response to irritation or death and
Indicators- percussion and palpation
replacement of odontoblasts
✓ Palpation, percussion: WNL SYMPTOMATIC APICAL PERIODONTITIS
✓ Not pathologic in nature o Acutely painful response to biting pressure or
✓ Does not require tx percussion
o May or may not respond to pulp vitality tests
Internal (intracanal) resorption o R: widened PDL space, may or may not have an
• Dentinal walls are resorbed from the center to the apical radiolucency with one or all roots
periphery o First extension of pulpal inflammation into
• Most cases are asymptomatic periradicular tissues
• Advanced IR= pink spots in crown • Pulpal and • Inflammatory mediators from an irreversibly
periapical test: WNL inflamed pulp
• R: RL, with enlarged of RC compartment• Tx: RCT • Egress of bacterial toxins from necrotic pulp
• Chemicals (irrigants, disinfecting agents)
PULP NECROSIS
• Restorations in hyperocclusion
• Nonvital pulp • Overinstrumentation of the root canal
• Pulpal blood supply is non-existent, pulpal • Extrusion of obturationg materials
nerve
o Moderate-severe spontaneous discomfort
are non-functional
o Pain on biting or percussion
• No response to cold and EPT, but may
o Tx: adjustment of occlusion, removal of irritants or
respond
a pathogenic pulp, removal of periapical exudate
to heat if applied for a long period of time
• Partial or complete *Occurred after cement the 3-unit bridge, leak into
periodontal tissues ang inflammation
• Bacterial growth can be
sustained and may extend ASYMPTOMATIC APICAL PERIODONTITIS
to PDL o Generally presents with no clinical symptoms
✓ Exudate is absorbed or drains through o Does not respond to pulp vitality tests
caries/pulp exposure in oral cavity= delayed o R: apical radiolucency
necrosis; radicular pulp may be vital for a long time o Generally not sensitive to
✓ Closure/ sealing of inflamed pulp = rapid & biting pressure, but may “feel
total pulpal necrosis & periradicular pathosis different” on percussion
✓ Usually asymptomatic, but may be associated o Results from pulp necrosis, usually a sequel to
with episodes of spontaneous pain & discomfort or SAP
pain (from periradicular tissues) on pressure o Percussion produces little to no pain
✓ Often sensitive to percussion because o Slight sensitivity to palpation
inflammation spreads to periradicular tissues
o R: interruption of LD to extensive destruction of
✓ Tx: RCT, Extraction
PA and interradicular tissues
o Tx: removal of irritants (necrotic pulp) and
Previously Treated
complete obturation of RCS
– tooth has already had nonsurgical RCT performed 1. Leaky margin, associated
and RCS filled with obturating material symptomatic periapical
o May or may not present signs or symptoms 2. B. post op, slab
o Will require additional nonsurgical/surgical technique for multi rooted teeth
endodontic procedures to retain the tooth

15 ESTECOMEN | DDM 4A
 ENDODONTICS 1
CONDENSING OSTEITIS Lesson 2: Armamentarium
o Variation of AAP Hand Instruments:
o Increase in trabecular bone in response to
persistent irritation
o Irritant diffusing from root canal into periradicular • Front-surface mouth mirror, regular/diagnostic
tissues explorer (D-5 explorer), D-16 endodontic explorer,
o Lesion usually found around apices of cotton pliers, spoon excavator, set of pluggers,
mandibular posterior teeth; but can occur in plastic instrument, hemostat, periodontal probe,
association with the apex of any tooth
ruler
o Asymptomatic/associated with pain (depending on
causes – pulpitis or necrosis) (we need to have at least 2 mouth mirror and has
o May or may not respond to electrical or thermal front surface)
stimuli (the mouth mirror is a front surface if you place any
o May or may not be sensitive to palpation or finger on the mirror, if there’s no space on your finger
percussion and reflection on the mirror then it’s a front surface)
o R: diffuse, concentric arrangement of radiopacity
around the root
o Tx: RCT D-5 Explorer or regular explorer has 2 hook
ends with diff. designs
ACUTE APICAL ABSCESS
o Acutely painful to biting pressure, percussion, D-16 endodontic explorer
palpation has straight ended that is
o Will not respond to any pulp vitality tests
angled at different directions
o Exhibit varying degrees of mobility
o R: widened PDL space, apical radiolucency
from the long axis
o IO swelling present, facial tissues adjacent to
tooth will almost always present with some § Endodontic explorer: 2 straight, sharp end that
degree of swelling are angled in two different directions from the
o Febrile long axis
o Cervical & subMd lymph nodes exhibit tenderness
§ Endodontic spoon excavator: much longer offset
to palpation
o Tx: removal of underlying cause; release of
from the long axis than regular spoons
pressure (drainage where possible); RCT ➔ Removes carious material, excise pulp
tissue
CHRONIC APICAL ABSCESS
o Not generally present with clinical symptoms
o Will not respond to vitality tests
o R: apical radiolucency
o Generally, not sensitive to biting pressure, but
“feels different” on percussion
• Intermittent drainage through an
associated sinus tract
(Difference between endodontic spoon and regular
spoon is that the shank of endo spoon excavator is
longer)

§ Cotton pliers: should be of the locking type

§ Periodontal probe: should be flexible
§ Other materials:
• Instrument trays
• Gauze
• Cotton rolls
• Cotton pellets
• Articulating paper
• Wooden/bite stick/tooth sloth
• Evacuation devices

Instruments for Taking Radiographs

• Film
• Film positioners
• Film holders

16 ESTECOMEN | DDM 4A
 ENDODONTICS 1

● Foldable plastic frame - has a hinge to facilitate film

or sensor placement without disengaging the entire
frame

Instruments and Materials for Rubber Dam

Application - Rubber Dam

● Mainstay of rubber dam system

● Autoclavable sheets of thin, flat latex with varying

thickness (thin, medium, heavy, extra heavy, special
heavy) and two sizes (5x5", 6x6")
(if px is allergic to latex nitrile is available)
(medium is typically recommended) ● Insti-Dam (Zirc), HandiDam (Aseptico)
o radiolucent plastic frame
● Medium thickness may be best- tears less easily,
retracts soft tissues better than thin type, easier to
place than heavy type

● Also available in different colors-darker ones may

provide better visual contrast (reduces eye strain)
(blue is recommended and always store it in the ref)
● For patients with latex allergies: non latex type
available from Coltene/Whaledent
➔ Powder-free, synthetic ● OptraDam (Ivoclar Vivadent) - disposable, single-
➔ 6x6", medium gauge isolation, flexible outer ring
➔ 3 years shelf life, but only 1/3 the tensile
strength of a latex dam

Rubber Dam Frame

(put it outside the mouth, it frames the mouth of the

● Metal frames - can also be used, but radiopacity
px)
blocks out the radiograph
• Retracts and stabilizes the dam
• Metal and plastic frames, but plastic is
Rubber Dam Clamps/Retainers
recommended - radiolucent, do not mask key
areas on working films, do have to be removed
before film placement
• Young, Nygaard-Ostby (N-O)

(make sure that the frames are sharp enough)

U SHAPE - YOUNG FRAME
ROUNDED- NYGAARD

(the bow always faces away or the distal of the tooth

we’re working on)

17 ESTECOMEN | DDM 4A
 ENDODONTICS 1
• Anchor the dam to the tooth requiring treatment,
or to the most posterior tooth in multiple tooth
isolation
• Aids in soft tissue retraction
• Stainless steel
• Bow, 2 jaws, prongs, holes, wings/wingless
• Prongs should engage at least 4 points on the
tooth
• Basic winged, butterfly-type for anterior teeth,
universal premolar, mandibular molar, and
maxillary molar clamps
• Wings - extensions of the jaws, provide additional
soft tissue retraction, facilitates placement of the
rubber dam frame and retainer as a single unit
• (underneath the wings we need to tuck the
rubber dam sheet so fluid can’t enter our working
area through the holes)
• 4: Dam first, then clamp and frame
•
• Some are designed for situations wherein clamp
placement may be hard (ex. Tiger clamps, Silker-
Glickman damp)
(silker is for multiple teeth isolation)
• gingiva
Rubber Dam Punch and Forceps
Punch
➔ has a series of holes on a rotating disk, selection
done according to the size of the tooth or teeth to be
isolated
Clamp Forceps
➔ holds and carries the retainer during placement
and removal
18
Methods of Rubber Dam Replacement
1: Position bow of clamp through the hole in the dam
and place rubber over the wings of the clamp
• Attach dam to the frame, secure clamp to the
tooth, then tease dam under the wings with a
plastic instrument
2: Place clamp on tooth and stretch the dam over the
tooth (clamp first)
3: Clamp and dam first, then frame
Split-dam technique: when there is insufficient crown
structure, prevents the possibility of the jaws of the
clamp chipping the margins of teeth restored with
porcelain crowns or laminates
(make multiple holes)
● Alternative for teeth with porcelain restorations-
ligation with dental floss, adjacent tooth can be
clamped
● 2 overlapping holes are punched in the dam
● Place cotton roll under the lip in the mucobuccal
fold over the tooth to be Treated Stretch the dam
over the tooth and over one adjacent tooth on each
side
● Edge of dam is eased through the contacts on the
distal sides of the 2 adjacent teeth
● Dental floss helps carry the same down around the
● Place clamp over the dam
Punching And Positioning Of Holes
• Divide dam into 4 equal quadrants, proper place
for hole is estimated according to which tooth is
undergoing treatment
• The more distal the tooth, the closer to the center
of the dam the hole is placed
• Hole must be punched cleanly, without tags or
tears
ORIENTATION OF THE DAM
• Dam must be attached to the frame with enough
tension to retract soft tissue and prevent
bunching, without tearing the dam or displacing
the clamp
• Dam should completely cover the patient's
mouth without encroaching their eyes or nose
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 ENDODONTICS 1
• Floss is then used to carry dam through the
contacts
• Use plastic instrument to invert edge of the dam
around the tooth
Instruments For Cleaning And Shaping The Root
Canal Space
• Provide a biologic environment (infection control)
conducive to healing
• Develop a canal shape receptive to obturation
GROUP I: MANUALLY OPERATED INSTRUMENTS
Files-instruments that enlarge canals with reciprocal
insertion and withdrawal motions
• First mass produced by Kerr Manufacturing Co,
hence the name K-file/K-reamer
• Number of sides and the number of spirals
determine whether the instrument is for filing or
reaming
• 3-sided with fewer spirals-for reaming
• 3-/4-sided with more spirals-for filling
A. Barbed Broaches And Rasps
● Does not cut or machine dentin
● Mostly used to engage and remove
soft tissue from the canal
● Can also remove cotton or paper
points that have accidentally become
lodged the canal
19
(the design of the handle is more squarish and the
indentation is more pronounced)
B. K-TYPE INSTRUMENTS
• K-file and K-reamer are oldest instruments used
for cutting and machining dentin
• File has more flutes per length unit than a reamer
• Useful for penetrating and enlarging root canals
• Works primarily by compression-and-release
destruction of dentin
(we do it manually)
• Reaming (constant file rotation) causes less
transportation than a filing motion (reciprocating
or watch-winding file rotation)
• Permanent deformation happens when the flutes
become more tightly wound or opened more
widely don't use instrument anymore when this
happens
• Fracture of instruments during clockwise motion -
when instruments become bound while force of
rotation continues
➔ Failure more in counterclockwise direction
➔ Operate carefully when applying pressure in a
counterclockwise direction
(do passive insertion)
C. H-TYPE INSTRUMENTS
(we don’t really use this that much because it cuts
more)
• Spiral edges arranged to allow cutting only during
a pulling stroke, ex. Hedström file
• Better for cutting-more positive rake angle, blade
with a cutting angle (rather than scraping)
• Do not bend this as it may lead to cracks and
fatigue failure
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 ENDODONTICS 1
• Canal transportation is unlikely to occur as long
as the file is engaged 360°
o ➔ File begins to cut on one side if
overused transportation
o ➔ Most instrumentation errors occur
when file tip is loose in the canal
• Beginner's rule:
o ➔ If the canal is smaller than the file,
more efficient if a cuffing lip is used
o ➔ If the canal is larger than the tip, use a
less-effective cuffing tip
• Introduction of nitinol (Ni-Ti), alloy of nickel and
titanium, has proved a significant advancement in
endodontic instruments
(recommended, super elastic metal. It has memory)
➢ Superelastic metal-has the ability to return to its
original shape after being deformed
➢ Currently are the only readily available affordable
materials with the flexibility and toughness for routine
use as effective rotary endo files in curved canals
➢ New alloys may be 5x flexible than currently used
alloys
*GROUP II: LOW-SPEED ROTARY INSTRUMENTS
(do not use in curve portions to avoid
errors, only use this on straight
portions of the canal prep to avoid
perforating the tooth)
• Burs with extended shanks = good
visibility during deep preparation
of the pulp chamber
• Gates-Glidden burs, Peeso
instruments - available in 32-
mm(for anterior) and 28-mm
lengths (posterior teeth)
• Should be limited to the straight portion of the
canal prep
• Risk of perforation if attempts are made to
instrument beyond the point of curvature or if
they are used to cut laterally
➔ pronounced on furcation sides of mesial roots of
molars
• Peeso reamer used mostly for post space prep
*GROUP III: ROTARY INSTRUMENTS FOR CANAL
PREPARATION
• Taper. amount the file diameter increases each
mm along its working surface from the tip toward
the file handle, sometimes expressed as
percentage (ex. 2% taper)
20
• Flute: groove in the working surface used to
collect soft tissue and dentin chips removed from
the wall of the canal
➔ Effectiveness depends on depth, width,
configuration, surface finish
• Leading (cutting) edge/blade: surface with the
greatest diameter that follows the groove as it
rotates
➔ Forms and deflects chips from the canal walls
➔ Severs/snags soft tissue
➔ Effectiveness depends on angle of incidence and
sharpness
• Rake angle: angle formed by the leading edge and
radius of the file
➔ Obtuse angle = positive or cutting
➔ Acute angle = negative or scraping
• Cutting angle/effective rake angle: determined by
measuring the angle formed by the cutting edge
and the radius when the file is sectioned
perpendicular to the cutting edge
➔ better indication of file's cutting ability
• Better to use electric handpiece when using rotary
files since it allows. precise speed and torque
control
• A. ProFile B. ProTaper
*GROUP IV: ENGINE-DRIVEN THREE-
DIMENSIONALLY ADJUSTING FILES
• Hollow device, designed as a cylinder of thin-
walled, delicate Ni-Ti lattice with a lightly abrasive
surface Initial glide path established with #20 K-
file to allow insertion of SAF
• 1 file used throughout procedure, which is initially
compressed into the root canal and gradually
enlarges while cleaning and shaping the canal
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 ENDODONTICS 1
• Unique: adapts to the shape of the canal
longitudinally and cross-sectionally
➔ Basic shape of canal is preserved
*GROUP V: ENGINE-DRIVEN RECIPROCATING
INSTRUMENTS
• Giromatic handpiece
• 3000 quarter-turn reciprocating movements per
minute
• Endo-Eze file system (Ultradent) - designed to
clean the middle third of the canal
➔ ss for apical third
*GROUP VI: SONIC AND ULTRASONIC
INSTRUMENTS
• Piezoelectric ultrasonic units
• U: operate at 25-30 kHz
o ➔ Cavi-Endo (Dentsply) ENAC (Osado)
o ➔ Use regular types of instruments (K-
files)
• S: operate at 2-3 kHz
➔ Endostor (Syntex Dental
Products),Megasonic 1400 (Megasonic Corp
➔ Use special instruments (Rispl-Sonic,
Shaper-Sonic files)
(cavi-endo would generate more heat than ENAC)
(ultrasonic you can use regular kfiles, while in sonic
we need specialized instruments)
Standards For Instruments
• Taper: .02
• Working diameter: taper and length of the tip
• Standard lengths: 21 mm, 25 mm, (28 mm), 31
mm
• Working part of the Instrument must be at least
16 mm
Devices For Measuring Root Canal Length
• Radiographs, presence of bleeding on paper
points, tactile sensation, knowledge of root
morphology
• Sunada: developed the original electronic apex
locator
21
• Apex locator: currently considered an accurate
tool for determining WL (working leg-the
measurement that we always need to follow
when we insert instruments in our canal)
➔ But better to combine with radiographs=
greater accuracy
• 3rd gen: Endex Plus/Apit (Osada), Neosono Ultima
EZ (Satelec)
• 4th gen: Apex Locator (SybronEndo), Bingo
1020/Ray-X4 (Forum Engineering Technologies)
• 4 parts: lip clip, fie clip, Instrument itself, cord
connecting the 3 other parts
• Display indicates advancement of file toward the
apex
• Generally safe, but should not be used on patients
with pacemakers without consultation from the
cardiologist
Instruments For Root Canal Obturation
• Lateral and vertical compaction techniques most
common
• Spreaders, pluggers
• Spreader-tapered, pointed instrument intended
to displace GP laterally for Insertion of additional
accessory GP cones
• Plugger-similar, but has blunt end (it will flatten
the gutta-percha)
• With handles or as finger-held instruments
(the spreader will push the gutta-percha at the side to
make room for other gutta-percha)
• Accessory cones must reach the depth of the
penetration of the spreader
➔ Thinner and/or with a smaller taper than the
spreader used
• Also available in Ni-Ti
• Heat carriers for vertical compaction obturation
techniques
➔ Electrical more common
➔ Introduction of battery-charged, handheld heat
carries
Lentulo spiral may be used to place sealer, cement,
and calcium hydroxide dressings
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 ENDODONTICS 1
➔ Operated clockwise, inserted not rotating to
WL, then retracted 1-2 mm
➔ Started and rotated at a slow speed
• Files, paper points,
syringes also can be
used to apply sealer
Materials for Disinfecting the Pulp Space
• Chemomechanical preparation-irrigating solutions
• Mechanical and biologic objectives
➢ Mechanical: flushing out debris, lubricating the
canal, dissolving organic and inorganic tissue
➢Biologic: antimicrobial effect
Ideal characteristics of an endodontic irrigant
• Be an effective germicide and fungicide
• Be non-irritating to the periapical tissues
• Remain stable in solution
• Have a prolonged antimicrobial effect
• Be active in the presence of blood, serum, and
protein derivatives of tissue
• Have low surface tension tissues
• Not interfere with repair of periapical
• Not stain tooth structure
• Be capable of inactivation in a culture medium
• Not Induce a cell-mediated immune response
• Be able to completely remove the smear layer,
and be able to disinfect the underlying dentin and
tubules
• Be non-antigenic, non-toxic, and noncardiogenic
to tissue cells surrounding the tooth
• Have no adverse effects on the sealing ability of
filling materials
• Have convenient application
• Be relatively inexpensive
1. SODIUM HYPOCHLORITE (NGOCI)
(a household bleach that we can dilute)
• Most commonly used irrigating solution
• Excellent antibacterial agent
• Capable of dissolving necrotic tissue, vital pulp
tissue, and organic components of dentin and
biofilms
• Hypersensitivity, contact dermatitis in rare cases
(iodine potassium iodide)
(1:9 solution, 1-part sodiuhypo/bleach and 9-parts
distilled water)
2. CHLORHEXIDINE (CHX)
(less irritating but it doesn’t dissolved tissue)
22
• Wide-spectrum antimicrobial agent, active against
gram (+) and (-) bacteria as well as yeasts
• Bacteriostatic or bactericidal (depending on
concentration)
• Low level of tissue toxicity
• Same antibacterial efficacy as NaOCI
• May delay coronal recontamination of the RCS
• Locks tissue-dissolving property (unlike NOOCT)
• May induce allergic reactions (rash, contact
dermatitis, urticarial)
3. MTAD, TETRACLEAN
(MTAD= mixture of tetracycline, citric acid, and
detergent)
• New irrigants
• Mixture of antibiotics, citric acid, detergent
• MTAD-1st irrigating solution capable of removing
the smear layer and disinfecting the RCS
➔ Biopure MTAD (Dentsply)
➔ Final rinse after completion of conventional
chemomech prep
• TetraClean (Ogna Laboratori Farmaceutici)-similar
to MTAD, but differ in concentration of antibiotics
and kind of detergent
4. ETHYLENEDIAMINE TETRA-ACETIC ACID (EDTA)
(not used alone, used in conjunction with sodium
hypochlorite )
(it is good if you experience blockage in your canal, it
will dislodge the debris)
• Can chelate and remove the mineralized portion
of the smear layer
• Cannot remove smear layer alone, proteolytic
component is added to remove organic
components (NaOCI)
• 17% concentration
• Direct contact with RC wall for less than 1 minute
• Alternating regimen: wash out remnants of EDTA
with copious amounts of
5. NAOCI HYDROGEN PEROXIDE
• 3-5% concentration
• Active against bacteria, viruses, yeasts
• No longer recommended as a routine irrigant
6. IODINE POTASSIUM IODIDE
• 2% iodine in 4% potassium iodide
• Excellent antibacterial properties, low cytotoxicity
• May act as a severe allergen, also stains dentin
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 ENDODONTICS 1
7. INTRACANAL MEDICATION • Disinfection: submerge cones in 5% NaOCI for 1
minute
• Acts to inhibit proliferation of bacterial and
• Rinse in ethyl alcohol after NoOCI submersion and
eliminate surviving bacteria
before obturation
• Minimizes ingress through a leaking restoration
• EX: Phenols, formaldehyde, halogens (chlorinated
solutions), chlorhexidine, calcium hydroxide, Composition Of Gutta-Percha For Endodontic Use
Ledermix, triple-antibiotics paste, bioactive glass
• Gutta-percha (19-22%)
8. CALCIUM HYDROXIDE • Zinc oxide (59-79%)
• Heavy metal salts (1-17%)
• Kills bacteria in RC space; slow-acting
• Wax or resin (1-4%)
• May be mixed with sterile water or saline
• Best applied with Lentulo spiral
• Requires some form of compaction pressure-
• Removal is frequently incomplete = shortens
compresses GP cones to get a more 3D complete
setting time of ZOE-based sealers
fill of RCS. (we need to have a sealer)
• May interfere with
• Oxidizes with exposure to air and light, eventually
the seal of the root
becoming brittle
filling =
• Store in a cool, dry place for better shelf life
compromised quality
• Cannot be used alone since it lacks adherent
• Not totally effective
properties necessary to seal the RC space, thus a
against several endo
sealer (cement) is needed for final seal ●
pathogens (E. faecalis, C. albicans)
• 02, .04, .06 tapers to match rotary instruments
• Biocompatible, low tissue toxicity
9. LEDERMIX (LEDERLE PHARMACEUTICALS) ➔ Equal biocompatibility with Resilon
• Corticosteroid-antibiotic
paste 1. RESILON (PENTRON CLINICAL TECHNOLOGIES)
• May be an initial dressing
• RC medicament or as
direct/indirect pulp capping • Thermoplastic, synthetic, polymer-based
agent • Designed to be used with Epiphany (resin sealer
with bonding capacity to dentin)
Materials for Disinfecting the Pulp Space • Can be used with any current obturation
technique
• EndoActivator • Bioactive glass, radiopaque fillers (bismuth
• Passive ultrasonic activation oxychloride, barium sulfate)
• EndoVoc • Can be softened with heat or dissolved with
• Safety-Irrigator solvents (chloroform)
• Self-Adjusting File (SAF) • Compatible with current restorative techniques in
• HealOzone which cores & posts are placed with resin bonding
agents
• Superoxidized water
• Photoactivation disinfection
• Intralight ultraviolet disinfection

Root Canal Filling Materials – Solid Matreials

• GUTTA PERCHA (THE CORE MATERIAL)

• (ZOE is the most prominent/dominant component
than gutta-percha)
• Most commonly used RC filling material (beta- or
processed form)
• Modern cones: 2. COATED GUTTA-PERCHA
➢ 20% GP • Uniform layer placed on GP by manufacturer
➢ 60-75% zinc oxide (major component)
➢ 5-10% resins, waxes, metal sulfates
23 ESTECOMEN | DDM 4A
 ENDODONTICS 1
• Resin bond is formed when the GP comes in ➢ Alpha-phase GP pre applied to a flexible solid
contact with the resin sealer = Inhibit leakage central carrier
between solid core and sealer ➢ Obturator is heated in a proprietary heater
• Need EndoRez sealer (Ultradent) (ThermaPrep Plus Oven)
• SimpliFil (Discus)
3. MEDICATED GUTTA-PERCHA
Injection Techniques
• Melding of antibacterial substance to GP cone or
other solid-core obturation materials may have • Obtura system currently most commonly used
use in preventing RCT failures due to coronal or • Dispenses heavy form of GP heated to a high
apical microleakage temp
• Not used on a regular basis • Shrinkage of GP comparable to normally heated
➔ More testing is needed to check their toxicity, GP
antibacterial and antifungal potential, and potential
for allergic reactions
1. ROTARY TECHNIQUES

4. SEALERS AND CEMENTS

• Sealer fills all the space the solid-core is unable to
fill
• Ideal sealer:
➢ Adheres strongly to dentin and core material
➢ Antimicrobial
➢ Must have some degree of radiopacity (silver, lead,
barium, bismuth)
5. ZINC OXIDE EUGENOL CEMENTS
• Zinc oxide - antimicrobial agent, low-level but
long-lasting antimicrobial effect
• Allergic reaction to eugenol
• Frictional heat can also be used to soften GP
• McSpadden Compactor device (Dentsply)
• Quickfil (J.S. Dental) - obturation comparable to
lateral compaction
• Inability to fill entire RCS due to sealer at apical
third
2. TEMPORARY RESTORATIONS
• Fermin, IRM (Dentsply), TERM (Dentsply), Cavit
(3M), Coltosol (Coltene), ZOE
• When placing Cavit or other soft temporary
cements, place at a thickness of 4-5 mm
ü If left for more than 1 week, cover soft cement
with harder one (IRM, GIC, resin)

6. CHLOROPERCHA 3. TEMPORARY CEMENTS

• White GP mixed with chloroform • Algenol, Alsip, Canseal, Caviton, Clearfil, Core
• No adhesive properties Restore.
• No longer used • Dynest AP, Dyract AP, Fermit, Fuji-IX GP, Fuji II LC
• GI, RMGI
• Ketac Fil, Ketac Fil Plus, Ketac Silver
7. CALCIUM HYDROXIDE
• Polycarboxylate, eugenol free
• Sealapex (Sybron Endo) • Scotch Bond, Temp Bond
• Antimicrobial effects • Ultratemp Firm
• Poor cohesive strength • Vidrion R
• Zinc phosphate
8. POLYMERS • Z100
• Will not prevent coronal leakage if left for long
• AH26, AH Plus (Dentsply)
time periods
EX:
• “restoration…should commence as soon as
• Epiphany (Pentron Clinical Technologies)
possible after RCT” (AAE)
• EndoREZ (ultradent)
• Bonded core build-up should be placed at
obturation appointment
9. DELIVERY SYSTEMS: CARRIER-BASED SYSTEMS
• Thermafil, Thermafil Plus, ProTaper, GT 4. LASERS
Obturators (Dentsply) (has special heating
• Neodymium-doped yttrium aluminum garnet
devices)
• Erbium-doped yttrium aluminum garnet
24 ESTECOMEN | DDM 4A
 ENDODONTICS 1
• Diode
• Erbium/chromium-doped yytrium scandium
gallium garnet
Lesson 3: Alterations in Internal Anatomy
(how to determine the anatomy of the pulp: reading
from textbooks, radiographic evidence and through
exploration)
• Age-dentin formation predominates in certain
area difficult in locating chamber and canals
• Irritants -increased dentin formation due to
dentin exposure (carious periodontal disease
abrasion, erosion attrition, cavity preps, root
planning. cusp, fractures. VPT)
• Irregularities/aberrations
➢ hills and valleys (bulges and concavities), intercanal
communications (isthmuses), cul-de-sacs, fins, etc.
ROOT CANAL ANATOMY
• 7 general configurations of the root shape in cross
section: round, oval, long oval bowling pin, kidney
bean, ribbon, hourglass
• Complex anatomy occurs often enough to be
considered normal
• Weine: categorized RCS in any root into 4 basic
types
• 8 pulp space configurations by Vertucci et al

• Calcifications-pulp stones (denticles) and diffuse

calcifications
• Internal resorption-uncommon; response to
irritation.

COMPONENTS OF THE ROOT CANAL SYSTEM

• Entire space in the dentin where the pulp is
housed
• Outline corresponds to the external contour of
the tooth/Shape of the pulp system reflects the
•
surface outline of the crown
• Pulp chamber and pulp/root canal(s)
• Pulp horns: accessory, lateral, furcation canals: I – (1)
canal orifices: apical deltas: apical foramina
II – (2-1)
III – (1-2-1)
PULP HORNS
• Represent what one does not want to encounter
IV – (2)
during restorative procedures, but does want to V – (1-2)
locate during access prep VI – (2 -1-2)
• Single pulp horn associated with each cusp VII – (1-2-1-2)
(posterior teeth) VIII – (3)
• Mesial and distal pulp horns in incisors
• Occlusal height of pulp horns corresponds to • Examination of the PC can give clues to location of
height of contour orifices and type of canal system

PULP CHAMBER ➔ if I canal is present, usually it is in the center of the

• Occupies the center of the crown and trunk of the
root
• Shape depends on shape of crown and trunk
• Configuration varies with tooth age and/or
irritation
• Roof is usually at level of CEJ
access prep
➔ Explore orifices thoroughly particularly if oval
shaped with apically precurved small Kifiles
❖ The closer the orifices are the greater the chance
they will join at some point in the body of the roof

ROOT CANALS ACCESSORY CANALS

• Begin as a funneled orifice and exiting as the
apical foramen (it will taper down) • Minute canals that extend in a horizontal, vertical,
• Varies with root shape and size, degree of or lateral direction from the pulp to the
curvature, age and condition of tooth periodontium
• Shape and number of canals reflect the facio
lingual depth and shape of the root at each level
25 ESTECOMEN | DDM 4A
 ENDODONTICS 1
• Found mostly in the apical third (74%), but can
also be found in the cervical third (15%) and
middle third (11%)
• Contain CT and vessels
• Serve as avenues for the passage of irritants
primarily from pulp to periodontium
• Furcation canals: in bi- or trifurcation of multi-
rooted teeth form as a result of the entrapment
of periodontal vessels during the fusion of the
epithelial diaphragm (pulp chamber floor)
• May range from 0 to more than 20 per specimen
May because of primary endodontic lesions place
adhesive restoration on chamber floor to prevent
furcal breakdown
Isthmus: narrow, ribbon-shaped communication
between 2 canals that contain pulp or pulpally derived
tissue
• Function as bacterial reservoirs
• Any root with 2 or more canals may have an
isthmus
26
ANATOMY OF THE APICAL ROOT
3 landmarks:
• Apical conviction (AC)
• Cementodentinal Junction (CD)
• Apical Foramen (AF)
• Kutter RC topering from canal orifice to AC (0.5-
1.5 mm coronal to the AF)
APICAL CONSTRICTION (AC)
• Part of the RC with the smallest diameter/minor
apical diameter
• Reference point used as apical termination for
cleaning, shaping and obturation
• Pulp BVs are narrow here
• Great post treatment discomfort felt when this
area is violated by instruments or filling materials
CEMENTODENTINAL JUNCTION (CDJ)
• Where pulp tissue ends and periodontal tissues
begin
• Not in the same area as AC
• Approximately 1 mm from AF
APICAL CONSTRICTION (AC)
• Part of the RC with the smallest
diameter/minor apical diameter
• Reference point used as apical termination
for cleaning, shaping and obturation
• Pulp BVs are narrow here
• Great post treatment discomfort felt when
this area is violated by instruments or filling
materials
CEMENTODENTINAL JUNCTION (CDJ)
• Where pulp tissue ends and periodontal
tissues begin
• Not in the same area as AC
• Approximately 1 mm from AF
APICAL FORAMEN (AF)
● Major apical diameter “ circumference or round
edge, like a funnel or crater, that differentiates the
termination of the cemental canal from the exterior
surface of the root”.
ESTECOMEN | DDM 4A
 ENDODONTICS 1
• Does not normally exit at the anatomic apex,
but is offset 0.5-3.0 mm from the apex
• Root canal prep and obturation end short of
the anatomic root apex
• Difficult to locate AC and AF clinically:
- radiographic apex may be a more reliable
reference point diagnosis)
• Terminate at or within 3 mm from
radiographic apex (depending pulpal
diagnosis)
• Vital pulp = 2-3 mm short
• Nonvital pulp or within 2 mm
• Retreatment = 1-2 mm short
• enough tooth structure to support a RD clamp
ACCESS CAVITY PREPARATION
OBJECTIVES FOR ACCESS CAVITY PREPARATION
• Remove all caries
• Conserve sound tooth structure
• Completely unroof the pulp chamber
• Remove all coronal pulp tissue (vital/necrotic)
• Locate all RC orifices
• Achieve straight- or direct-line access to the AF or
to the initial curvature of the canal
• Establish restorative margins to minimize
marginal leakage of the restored
• Properly prepared access cavity creates a smooth,
straight-line path to the canal system and
ultimately to the apex, or position of the first
curvature
• Straight-line access: gives best chance of canal
space debridement, reduces risk of file breakage
Allows complete irrigation, shaping and cleaning,
and quality obturation
GUIDELINES FOR ACCESS CAVITY PREPARATION
• Visualize position of pulp space
• Diagnostic radiographs help clinician estimate
position of the pulp chamber, degree of chamber
27
calcification, number of roots and canals,
approximate canal length
• Anterior teeth: lingual surface; posterior teeth:
occlusal surface
• Remove all defective restorations
• All carious dentin must be removed prevent
irrigating solutions from leaking past the RD into
the mouth, prevents carious dentin and its
bacteria from entering RCS
➔ If chamber wall is perforated during removal of
carious dentin, repair immediately with a temporary
filling material
➔ Crown lengthening procedure if there is not
• Remove all unsupported tooth structure: avoid
unnecessary removal of sound tooth structure
• Walls of the RC must guide the passage of
instruments down the canal
➔ Root perforation, misdirection of an instrument
from the main canal (ledge formation), instrument
separation, creation of an incorrect canal shape
(apical transportation)
• Locate canal orifices and determine their angle of
departure from the PC with a sharp endodontic
explorer
• Flare canals orifices and coronal portion of the
canals (use gates glidden burs)
• Explore canals with small precurved K-files (#6,
48, #10) (use canal probes)
• Keep instruments within confines of the canal
system until WL has been established
• Proper access cavity has tapering walls/divergent
walls
Krasner and Rankow:
• CEJ was the most important anatomic landmark
for determining location of pulp chambers and
root canal orifices
• Centrality: The floor of the pulp chamber is
always
• located in the center of the tooth at the level of
the CEJ.
• Concentricity: The walls of the pulp chamber
are always concentric to the external surface of
the tooth at the level of the CEJ; that is, the
external root surface anatomy reflects the
internal pulp chamber anatomy
ESTECOMEN | DDM 4A
 ENDODONTICS 1
• Law of the CEJ: the distance from the external
surface of the clinical crown to the wall of the PC
is the same throughout the circumference of the
tooth at the level of the CEJ
➔ the CEJ is the most consistent, repeatable
landmark for locating the position of the PC
• First law of symmetry: canal orifices are
equidistant from a line drawn in a MD direction
through the center of the PC floor (except for Mx
molars)
• Second law of symmetry: canal orifices lie on a
line perpendicular to a line drawn in a MD
direction across the center of the PC floor (except
for Mx molars)
• Law of color change: the PC floor is always darker
in color than the walls
• Orifice location:
1st law: The orifices of the root canals are always
located at the junction of the walls and the floor;
2nd law: the orifices of the root canals are always
located at the angles in the floor-wall junction;
3rd law: and the orifices of the root canals are always
located at the terminus of the roots’ developmental
fusion lines.
Mechanical Phases of Access Cavity Preparation
• Magnification and illumination
• Handpiece
• Burs
• Endodontic explorer (DG-16. DE-17)
• Endodontic spoon
• Explorer
• Ultrasonic unit and tips
28
BURS
• Round carbide (#2, #4, #6)
• Remove caries
• Create initial external outline shape
• Penetrate through and remove the roof of the PC
FISSURE CARBIDE AND DIAMOND
• with safety tips (noncutting ends) = axial wall
extension
• Can be allowed to extend to pulp floor, and entire
axial wall can be moved and oriented all in one
plane from enamel surface to pulp floor =
produces axial walls free of gouges
• Used to level off cusp tips and incisal edge
• Round diamond burs (#2, #4) to access teeth with
porcelain or ceramometal restorations
➔ Less traumatic to porcelain than carbide, can
penetrate without cracking or fracturing it
➔ Switch to carbide to penetrate metal or dentin
Receded PC and calcified orifices: extended-shank
round burs
• Mueller bur (Brasseler USA), LN bur (Dentsply).
• Munce Discovery bur (CJM En ineerin )
• Moves the head o the handpiece away rom the
tooth, improving visibility
• Alternative: ultrasonic units
To flare or enlarge orifices and blend them into the
axial walls: Gates-Glidden burs
➔ Start from small and progress to lar er sizes
➔ Be mindful in removing excessive dentin on the
furcation side of a RC = "strip" perforation
ENDODONTIC EXPLORER, ENDODONTIC SPOON,
#17 OPERATIVE EXPLORER
• DG-16 endodontic explorer: identify canal orifices
and determine canal angulation
➔ JW-17 ICK Dental Industries); thinner, stiffer tip
useful for identifying calcified canals
• Endodontic spoon: remove coronal pulp and
carious dentin
• #17 operative explorer:
ESTECOMEN | DDM 4A
 ENDODONTICS 1
- detect any remaining PC roof, particularly in the
area of a pulp horn
ULTRASONIC UNIT AND TIPS
• Specifically designed for endo procedures
• Tips can be used to trough and deepen
developmental grooves to remove tissue and
explore for canals
• Provide outstanding visibility
• Fine tips allow for sanding away dentin and
calcifications conservatively when exploring for
canal orifices
ANTERIOR ACCESS CAVITY PREPARATIONS
• Begin in the center of the lingual surface of the
anatomic crown
• Use a #2 or #4 round bur to penetrate through the
enamel and slightly into dentin (approx. 1 mm)
• Outline form is % -% the projected final size o
the access cavity
• Bur directed perpendicular to the lingual sur ace
• Change direction to parallel to the long axis o the
root
• Continue until the roof is penetrated="drop-in" e
• 45%
• Remaining roof is removed by catching the end of
a round bur under the lip of the dentin roof and
cutting on the bur's withdrawal stroke
➔ Vital case: amputate coronal pulp at the orifice
level with an endodontic spoon or round bur, then
irritate copiously with NaOCI
• Locate canal orifices with endo explorer
29
• Remove the lingual shoulder = aids
straight-line access and allows for
more intimate contact o files with
canal walls
➔ Lingual shoulder: lingual shelf of
dentin that extends from the cingulum to
a point approximately 2 mm apical to the orifice
➔ Removed with a tapered safety-tip diamond or
carbide bur or with GG burs
➔ GG: largest that can passively be placed 2 mm
apical to the orifice: lean against the shoulder during
the rotation and withdraw
• Flare orifice with GG burs (small to large), used in
a circumferential filing motion, flaring sequence
• Ledge: iatrogenically created RC wall irregularity
that may impede placement o an intracanal
instrument to the apex
• Transportation: occurs in the portion o the
canal apical to a curvature when canal wall
structure opposite the curve is removed, tending
to straighten the curvatures
• Zipping/elliptication of the AF: when an
overextended file transports the outer wall of the
AF
•
• Endo file can be used to approach the AF or first
point o canal curvature undeflected to check if
there is straight-line access
- No straight-line access: led in . transportation,
zipping
• Evaluate SLA by passively inserting the largest file
to the AF/point o first canal curvature, then take
a radiograph
ü Insert file gently and withdraw all the while
"feeling" for canal binding or deflection
ü Final position o the incisal wall determined by:
complete removal of the pulp homs. SLA
• Inspect and evaluate the access cavity
• Refine and smooth the CSM to avoid coronal
leakage on placement of a temporary or
permanent restoration
• Butt-joint CSM
ESTECOMEN | DDM 4A
 ENDODONTICS 1
POSTERIOR ACCESS CAVITY PREPARATIONS • Assess each canal for SLA
• Inspect PC floor
• Mx PMs: central roove between cusp tips
• Refine and smooth the restorative mar ins
• Md 1st PMs: hallway up the lingual incline of the 8
➔ Final permanent resto of choice: crown or onlay
cusp on a line connecting the cusp tips
• Md 2 PMs 1/3 the way up the L Incline o the B ERRORS IN ACCESS CAVITY PREPARATIONS
cusp on a line connecting the 8 cusp tip and the Li
groove between the UI cusps Molars: establish M
and D boundary limitations
• Mx and Md M boundary: line connecting the M
cusp fiips
• Mx D boundary: oblique ridge
• Md D boundary: line connecting the B and Li
Note: Gouge-Gouging Note: under extended
grooves
• Central groove hallway between the M and D
boundaries

• #2 round bur or PMs and #4 round bur or

molars
• Direct bur perpendicular to the occlusal table, and
initial outline shape is created at about %-3/4 its
Note: L: overextension R: underextension
projected final size
• PM: oval, widest in BL dimension
• Remove unsupported tooth structure
• Molar: oval initially: widest BL in Mx and MD in
Md • Do not put the rubber dam until all canals
➔ Final outline shape: triangular (3 canals), have been located
rhomboid (4 canal) • Locate, flare and explore all canal orifices
➔ Canal orifices dictate position of the comers • Diverge chamber walls occlusally
of the geometric shapes
Change angle of penetration
➔ PM: parallel to the long axis of the root(s) both in
MD and BL directions
➔ Molars: toward largest canal = palatal orifice (Mx),
distal orifice (Md)
• Guard against lateral and furcation perforations in
multirooted teeth
• Aggressive probing with endo explorer can help
locate PC Maxillary:
• Cervical dentin bulges and natural coronal canal
constriction: internal Impediments in posterior
teeth
➔ Cervical bulges: shelves of dentin that frequently
overhang orifices
➔ Remove with safety-tip diamond/carbide or GG Mandibular
burs place at orifice level and lean toward the bulge to
remove the shelf
• After removing the shelf, flare the orifice and
coronal portion of the canal
➔ Tapered and blended into the axial wall

30 ESTECOMEN | DDM 4A