ENDODONTICS (LECTURE) 4.
Complete Obturation
Branch of dentistry concerned with the morphology,
physiology and pathology of the human dental pulp &
periradicular tissues. Morphology is the anatomy & forms.
Physiology deals with function. Pathology deals with
diseases of the human dental pulp & periradicular tissues.
Endodontics doesn’t only concern the inner structures but
also the periradicular (peri; around, radicular; root) tissues.
Its study and practice encompass the basic and clinical
sciences including the biology of the normal pulp & the
etiology, diagnosis, prevention & treatment of diseases &
injuries of the pulp & associated periradicular conditions.
Etiology means cause. Again, pulp & periradicular
conditions. Laging partner yan sa endo. When you study
endo, your study is just confined to the root canal or inner
structures of the tooth, NO. Kasama yan lagi is the
periradicular tissues & the periradicular conditions.
Endodontics - pulp & periradicular tissues.
( 3 ) MAIN RATIONALE FOR ENDODONTIC TREATMENT
1. Retain Tooth, Retain Function
Why do we do RCT? What’s its importance /
significance? Because we don’t want the tooth to be
extracted. We want to retain the tooth as much as
possible. Ngayon, pag na-retain yung tooth, it
should function. The retain on function is more on
posterior.
2. Preserve Occlusion
No normal occlusion affects mastication, digestion,
and overall health of the patient.
3. Preserve Esthetics - Particularly for Anteriors
( 6 ) PRINCIPLES IN RCT
1. Aseptic Technique
Sterilization, RDI, proper rubber dam isolation.
Asepsis yan. So, all instruments used for rct should
be sterile, autoclaved properly. Another way of
observing aseptic technique is application of your
rubber dam or rubber dam isolation. It should
always be in place & it has to be done properly or
else maddefeat yung purpose.
2. Gentle Handling of Tissues (Periradicular Tissues)
All instrumentation must be within the root canal
only. All instruments whenever we insert those files,
those obturating materials inside the canal, should
be confined to the canal & not go over the
periradicular tissues & you should not induce
damage or injury to your periodontal ligament. Kasi
once na lumabas na yung instrument mo, then
you’ll damage the periradicular tissue. That could
be irritated, could cause inflammation & infection.
3. Adequate Disinfection
Use of irrigants & medicaments to prevent any
reinfection. We want to reduce the microorganisms
present inside the canals. How? By placing irrigants
& medicaments to prevent any re-infection. Kaya ka
gagawa ng endo sa ngipin na yan kasi may infection
going on & we want to treat the infection. We don’t
want to add more infection into the root canal.
Goal is to seal off the apical end of the canal.
Kailangan ma-seal yung opening na yon para hindi
na magkaroon ng reinfection ang iyong canal.
5. Proper Restoration
To seal the coronal part by the restoration.I always
tell my students, obturation is not the final phase in
rct. It is the restoration. Without putting a good
restoration on an endodontically treated tooth, then
it’s bound to fail.
6. Recall
To monitor healing. It could be after a month, after
6 months, after 2 years. That’s the basic recall.
Why is there a need to recall? To monitor healing.
Especially for those cases that started with
periapical infection. You want to monitor if there are
signs of healing or maybe you weren’t able to
disinfect it correctly that's why there is tooth pain.
Note: You can only say that you’ve done a
successful endodontic treatment when you do a
recall after 2 years & everything was okay. After 2
years, if there’s no infection, the patient is satisfied,,
tooth is functioning, that’s the only time for you to
say that you did a successful endodontic treatment,
doon mo palang siya pwedeng i-claim na
successful.
( 10 ) PROCEDURES INVOLVED IN ROOT CANAL TREATMENT
1. Diagnosis & TR. First we begin with proper history
taking & examination of the involved tooth to be
able to arrive at a correct diagnosis & subsequently
be able to provide the appropriate treatment plan.
Note: Always remember, you cannot give a proper
treatment without proper diagnosis. Ganon ka-
significant ang proper diagnosis.
2. Anesthesia. To provide local anesthetic if necessary.
For each diagnosis available, there is a specific
administration of local anesthesia depending on the
vitality of the tooth being treated. Hindi naman lahat
ng cases ni endo is vital. Pag vital lang, that’s the
only time you need to put anesthesia pero kung may
mga cases na necrotic, anesthesia may not be
required anymore. But make sure when the patient
is in pain, make sure that your anesthesia is
effective enough kasi kung in pain si patient,
he/she wouldn’t cooperate.
3. Rubber Dam Isolation. Essential to endodontic
treatment. This is done to achieve a clean & dry
environment during treatment & also to prevent
ingestion or aspiration of the medications /
medications & instruments. Irrigants like Sodium
Hypochlorite “Zonrox” could be prevented.
There have been cases na nalunok yung file and nakita sa
radiograph. Endodontic files and instruments are sharp and
fine. Ingatan niyo nakakasugat yan. Kahit yung clamp, pag di
kayo nag-iingat sa paglalagay pag di mo pa nalalagay yung
rubber dam, possible na tumalsik, baka malunok ng
pasyente niyo, kaya kayo maglalagay ng dental floss sa
clamp para pag nahulog sa oral cavity or malunok ng patient
niyo (wag naman sana), you can easily pull it out. Some
irrigants in endo can be irritating. For example, sodium
hypochlorite ( Zonrox ). It doesn’t have a pleasing smell mas
lalo na taste. Imagine working with that sa bibig ng pasyente.
You have to be careful na wag tumulo sa oral cavity or
malunok ng pasyente. Kaya tayo may rubber dam isolation.
4. Access Preparation. We gain access through the
pulp chamber by means of drilling through the
crown
5. Removal of Vital Pulp. Some use files, broaches.
6. Canal Cleaning, Irrigated & Shaping. The canals are
then cleaned, irrigated and shaped. We shape the
canal into a form that can be easily obturated &
filled up. The main purpose of Canal Shaping is for
us to perform a good obturation.
7. Medications. We just don’t use files & these
instruments, we also use some medications. The
antiseptic medicines can be placed into the canal
& it should have an antibacterial property because
an endodontically treated tooth is a tooth with an
infection inside. Kaya I mentioned that most of the
cases in endodontics are accompanied with
infection that’s why we have to use a disinfectant to
reduce the amount of microorganisms that are
present & those medications are placed in your
canal hopefully eliminating the infection after the
treatment.
8. Temporary Filling. Then, we put a temporary filling
also which is placed in the access opening to
protect the root canals from infection in between
appointments especially if you’re not doing a one
sitting endo.
One-sitting Endo / Single Visit Endo - no need for temporary
filling kasi pagbukas mo, obturate then close edi final na
yung restoration mo. Multiple Visit Endo - temporary filling is
a must).
9. Obturation
Then, when completely clean & free from infection,
then the root canal is filled & obturated with gutta
percha points & sealants.
10. Crown Restoration
It should have an adequate seal with a protective
filling material to cover the crown & satisfy the
functional & aesthetic demands of the patient
especially if it is an anterior tooth. Anterior tooth
sometimes, even before you start your endo,
discolored na yan pag necrotic yan.
( 10 ) SCOPE OF ENDODONTICS
1. Diagnosis (Pulpal / Apical Origin). Diagnosis,
differential diagnosis and treatment of oral pain.
Symptoms either: Pulpal / Periapical Origin
2. Vital Pulp Therapy (Pulp Capping, Pulpotomy,
Pulpectomy, Apexogenesis, Apexification)
3. Non-surgical Treatment (Obturation). You will only
fill the canal & you don’t have to make a flap. Wala
masyadong complicated procedure na involved.
4. Surgical Treatment (Root End Resection,
Hemisection, Bicuspidization). All of these
procedures are scope of study of endodontics.
5. Root Repair (for Root Perforation). This is related to
pathologic or iatrogenic damage.
6. Replantation (for Avulsed Tooth). If you replant the
avulsed tooth, high chances are it will become
necrotic later on. Only a very slim chance of a
reimplanted avulsed tooth remains vital. It is very
time sensitive. The shorter the time, the better the
prognosis. It may reattach but since the blood
supply is cut, pulp could lead to necrosis. No other
treatment but only root canal.
7. Endo-Perio Interrelationship. Check if bone support
is still fine. Mobility & all.
8. Bleaching. Usually intracoronal bleaching is done
because most of the endodontically treated tooth’s
problem is discoloration. So, bleaching is an option.
9. Re-treatment. Mga previously treated the root canal
system. Ito yung mga ginawa previously tapos
nagkaroon ng problema, nagkaroon ng re-infection.
So, kahit na root canal na yan basta nagkaroon ng
re-infection.
10. Restoration. Involves root canal space & access
opening.
( 1 ) MAIN CONTRAINDICATION
A non-restorable tooth. An endodontically treated
tooth that is not properly restored is bound to fail. You have
to restore the function.
What to Assess:
● Pulpal involvement?
● Periapical involvement?
● Condition of the crown?
● Possible crown restorations after endodontics?
( 1 ) PRIMARY OBJECTIVE / GOAL
To create an environment within the root canal
system which allows the healing and continued maintenance
of the health of the periradicular tissue. Healing will only take
place once you get to address the source of infection. (e.g.,
necrotic pulp causing infection).
( 2 ) SPECIFIC OBJECTIVES
1. To bring the tooth back to a healthy state. It can be
even if there’s no pulp anymore. Pero needless to
say, meron pa rin dapat yang bone support, gingiva,
and the needs to be able to function

2. To relieve pain. Because endodontically involved
teeth are usually accompanied by pain like for
example root canal treatment.
( 1 ) ULTIMATE OBJECTIVE / GOAL
Restoration of the treated tooth to its proper form &
function (in the masticatory apparatus, in a healthy state).
Root canal treatment will not be successful if the restoration
is poorly made because the only thing that would increase
the longevity of the tooth is a sealed restoration. No matter
how good the root canal treatment was, if not sealed
properly, it is bound to fail. Appreciate & understand the
value of what you’re doing for you to do it properly.
May link sa Canvas about sa history ng endo, check it out. I
will not elaborate on that anymore.
DIAGNOSIS
When you diagnose, it’s not enough to just know the
pulpal diseases. You should match it with the result of the
diagnostic test. Diagnosis is similar to matching types. You
shouldn’t just just run some tests without knowing the type
of pulpal disease. You need to know the different diseases
& you should make a diagnostic test & you should have data
with the result. Then, that result will be matched in the
characteristics of the different diseases that you know.
That’s how you diagnose.
(5) PULPAL DIAGNOSIS
1. Reversible Pulpitis
A normal pulp is symptom free & it will give a normal
response to testing. Like for example a Thermal
Test, a normal pulp would react because it’s normal
but without the stimulus, it wouldn’t be possible.
Hyperemia is the old term of Reversible Pulpitis. It
also means sensitivity to cold. Now, the response is
provoked or stimulated by the cold.
Kapag Reversible Pulpitis, sumasakit siya kapag
may cold stimulus. There’s discomfort or sensitivity
to sharp pain but pain doesn’t linger kasi nga
stimulus dependent siya. So, kapag nandon ang
cold stimulus atsaka lang siya masakit.
Common Chief Complaint:
“Doc, kumain ako ng ice cream eh. Grabe sobra ngilo ng
ngipin ko.” Then ask mo how long sumakit; “mabilis lang,
nung tumigil ako kumain ng ice cream, nawala naman na
siya”. So ibig sabihin, na-trigger lang siya ng stimulus. Nung
wala ng stimulus, wala na yung pain.
Reversible pulpitis indicates that it can return to normal.
There’s a chance for the pulp to heal.
If the pulp can heal, can we do an RCT to a Reversible
Pulpitis?
No. RCT is not indicated in REVERSIBLE PULPITIS cases. All
you need to do is remove the cause of RP which is caries
(frequent cause of RP).
All you have to do is clean the open cavity - clean it & put in
a restoration.
Placing a permanent restoration provides a seal that would
prevent microorganisms entering the dentinal tubules
therefore it will create a stable environment for the pulp.
There are cases na kapag medyo malaki ang caries,
naglalagay muna ng temporary filling. If a temporary filling is
placed, then you observe the case. It is more prone to failure
& leakage which will allow bacteria to enter kaya hindi din
dapat masyadong matagal ang filling and you should also
inform the patient na “Pag na natanggal ang filling, you have
to come back to me asap”. Kasi pag nagkaroon ng leakage
yun, papasukan ng bacteria and magkaroon ng chance to
progress to irreversible pulpitis.
2. Irreversible Pulpitis
A. Symptomatic ( Symptomatic Irreversible Pulpitis)
aka “Acute Irreversible Pulpitis” but we don’t use
the term ‘acute’ for this anymore.
Pain is spontaneous
Does not need a stimulus but can be triggered by
stimulus. For example, uminom ng malamig and
after uminom, andun pa rin yung pain, lingering for
hours.
Pain is lingering & spontaneous, pulsating & throbbing & is
usually affected by postural change because this is due to
the increase of blood pressure in the head which increases
intrapulpal pressure in the pulp. Inflamed na nga yung pulp
eh tas dadagdagan mo pa ng pressure, sasakit talaga yon.
Usual Complaints of a Patient: “di makatulog sa gabi”.
Often they wouldn’t say it na “Doc tuwing humihiga po ako,
sumasakit” Di nila maoobserve yun. Ang maoobserve nila, di
sila makatulog sa gabi. Mapapansin nila yun kapag nakahiga
na sila bago matulog. It’s not because of the time. Nighttime
has nothing to do with it but it’s the postural change, the
bending position.
In SIP, pain may be referred
Referred Pain - actual source of infection is different from
where the patient perceives the pain
Anterior teeth seldom suffer from referred pain, madalas
posterior yan. Pain is a prominent feature of SIP kasi nga
symptomatic.
Pag nasa advanced stage na and SIP, sometimes the cold
stimulus can relieve the pain because it causes constriction
of blood vessels which decreases the intrapulpal pressure,
chances are there would be less pain. You can advise them
to put cold compress to the affected area to relieve the pain.
B. Asymptomatic ( Asymptomatic Irreversible Pulpitis)
No clinical symptoms, no pain, Kung meron mang
pain, mild to moderate lang yan, short-lasting,
occasional. Could have a history of spontaneous
pain but don’t have anymore at present. Pwede
ganun ang HPI ng patient.
 Clinical Variations:
● Internal root resorption (indicates that pulp is
irreversible, inflamed - and the only way that the
resorption can be stopped is via RCT) Di naman kasi
to symptomatic, walang nararamdaman ang
pasyente.
● Pulp Polyp / Pulp Hyperplasia / Chronic Hyperplastic
Pulpitis - common in young patients, young
adolescents. low intensity and pain niya. Long term
irritation of pulp, has red pulpal mass in the cavity,
common in 1st permanent molar.
3. Necrosis. Asymptomatic. May have a history of pain
na nawala na in the present. May be discolored if
long-standing (brownish or grayish in color).
Indicated for RCT.
4. Previously Treated (exclusive for endo only). Tooth
that has undergone treatment but has failed. RCT,
obturated, re-treated. As such RCT should be done
again, if possible. Is it re-treatable? If yes, you need
to have the diagnosis that it is. This would be cases
na inobturate, tapos nagkaroon ng re-infection.
5. Previously Initiated Therapy (exclusive for endo,
additional diagnosis). Partial treatment was done
due to an emergency. Pulpotomy and pulpectomy
are initial treatments. This would be cases na in-
open tas treatment was not final.
Sa lahat ng pulpal diseases, Reversible Pulpitis ang hindi
indicated for RCT. The rest indicated for RCT or extraction.
Normal Diagnosis
- You can diagnose as normal.
- Normal pulp
- Normal periapex
- There is little pressure when you do
percussion but there is no pain, tenderness
If the sinus tract is seen on 22, do not assume that it is the
or discomfort
source of infection because it can be the adjacent tooth (23).
- Radiographically, the PDL space and lamina
dura is intact, uniform and continuous
- Lamina dura - thin radioopaque line that
surrounds the root of the tooth right next to
PDL space.
( 5 ) PERIAPICAL DISEASES
1. Symptomatic Apical Periodontitis
Radiograph either meron or wala with pain. Need for
RCT/only tx? You will only do RCT if the partner of
pulpal diagnosis is necrosis. THE TREATMENT
DEPENDS ON THE PULPAL DIAGNOSIS. POSSIBLE
CAUSE COULD BE PREMATURE CONTACT (1-2 DAYS
MAWAWALA YUNG PAIN).
● Presence of inflamed periodontal tissue
● Pain on biting, use your finger to test so
that the test wouldn’t be too much for the
patient compared to butt end of the mouth
mirror.
● When percussed, oops masakit. Positive to
percussion.
● If the patient doesn’t respond, you may
switch to a mouth mirror & then you do a
palpation test it will help you determine if
there is swelling or bony expansion.
● Radiographic findings could be normal or
not.
● Diagnosis could be reversible or
irreversible etc.
● You can do RCT IF THE PULPAL DIAGNOSIS
IS IRREVERSIBLE PULPITIS AND
NECROSIS.
● BUT IF THE PULP IS NORMAL and there is
pain upon biting, check if there is
premature contact due to overfill
restoration. Upon removal of this
premature contact, in 1-2 days mawawala
ang pain
2. Asymptomatic Apical Periodontitis
● Associated with necrotic pulp. Percussion
& palpation is negative. Radiograph will
always have radiolucencies pero walang
pain
3. Chronic Apical Abscess
● Associated with necrotic pulp. There’s little
or no discomfort since there is a long-
standing lesion.
● There are radiolucencies.
● There's a pathognomonic sign - sinus tract
opening (pus usually comes out. Bavarian
cream).
● They put gutta percha to show where the
pain on the tooth is, usually there’s no pain
but you can put topical anesthesia
● There is no pain because there is no
pressure build-up because the pus is able
to exit through the sinus tract.
4. Acute Apical Abscess
● Associated with necrotic pulp. Rapid onset
of severe pain and swelling & long-standing
● Talagang maghahanap ng dentista nag
patient kasi namamaga, super sakit,
sometimes with fever pa. Sobrang masakit
ito.
● Minsan may lymphadenopathy, inflamed
ang lymph nodes (ito ang indications niya)
● Radiograph sometimes has no
radiolucencies, loss of continuity of lamina
dura “disrupted”
● There can be periapical radiolucency or
none
5. Condensing Osteitis
● Localized bony reaction to a low grade
stimulus. Asymptomatic.
● Radiographic appearance is radiopaque
seen at the apex of the tooth but usually is
asymptomatic.
 ● Instead of radiolucency, radiopacity.
● Common in molars & usually involves the
mesial roots
QUESTION: IS RADIOGRAPH SIGNIFICANT TEST IN PULPAL
DIAGNOSIS? CAN YOU SEE THE PULP ON THE RADIOGRAPH?
ANSWER: NO. WHEN YOU ARE DIAGNOSING THE PULP, WE
CAN’T SEE THE PULP IN THE RADIOGRAPH, YOU’LL ONLY SEE
THE PULP SPACE, TISSUE. WHAT IS IMPORTANT IS THE
SYMPTOM.
ALWAYS LISTEN TO YOUR PATIENT. THEN DO A
CONFIRMATORY TEST BECAUSE A PULP IS DEPENDENT ON
THE STIMULUS. SA PULPAL DISEASE, MAKINIG KA LANG SA
PATIENT, MAY INITIAL DIAGNOSIS KA NA PERO HINDI
KASAMA DOON ANG RADIOGRAPH.
QUESTION: PERCUSSION, IS IT SIGNIFICANT IN DIAGNOSING
PULPAL DISEASE?
ANSWER: NO. PERCUSSION IS A PERIAPICAL TEST, NOT FOR
PULPAL CONDITION.
CASE SELECTION & TREATMENT PLANNING
Why Do Case Selection?
Because not all painful teeth are for endo. Success of endo
tx depends on how you choose your case.
1. To determine if root canal treatment (RCT) should
be performed.
Example:
- Symptomatic Irreversible Pulpitis + 6. Traumatically Displaced or Avulsed Teeth
Asymptomatic Apical Periodontitis
2. To determine if RCT can be performed.
Factors:
- Itsura ng canal
- Curvature ng root manageable ba
- Patient mo ba highly motivated
- Do you have enough instruments
- Do you have the skill
- Etc. mamaya madiscuss
( 6 ) INDICATIONS FOR RCT
● Teeth with irreversible pulp disease or with necrotic
pulp with or without periapical disease.
● Teeth with pulps that would be compromised during
dental procedures (we call this intentional / elective
root canal treatment)
1. Overdenture Abutments
2. Limited Correction of Alignment
For example, your central incisors are
labioverted but the patient cannot afford
ortho treatment.
Now studying all the possible course of
action, you and the patient have agreed
that you will be crowning the two central
incisors with the correct alignment given
that the labioversion is minimal.
Kaso kapag naglabial reduction ka, pwede
mo ma-expose ang pulp. So, if that is the
case, you can do RCT and there would be
no limit as to how much tooth preparation
you can do labially because you already did
RCT.
3. Restorative Needs. The patient presents a
tooth with an extensive cavity, you assume
there’s no pulp exposure.
After removing all the undermined tooth
enamel, the tooth may not be able to retain
the restoration.
Anlala na pala to do point na need mo
maglagay ng reinforcement, na need mo na
maglagay ng post so mag-r-Rct ka talaga.
4. Complexion + Questionable Pulp Status.
But medyo leaning to pulpal inflammation,
it’s safe to do RCT rather than putting a
crown & later on patients would complain
of pain edi sisirain mo rin, what a waste of
money, time and effort.
5. Root Resection, Hemisection,
Bicuspidization. You can do RCT to those
with good support, just remove the poor
periodontal support then retain the other
half by performing RCT on this half.
E.g., boxers, you could reimplant right away
but it is time bound. It could reattach but
no assurance that pulp could regain its
vitality.
(4) CONSIDERATIONS WHEN THE CASE IS INDICATED
1. The tooth should be restorable
2. Does it have adequate periodontal support - take
into consideration the periodontal support of the
tooth.
3. Presence of a pathologic condition - there’s internal
root resorption. RCT not indicated.
4. Whether or not the tooth has strategic value.
(diagnosis is previously treated).
With pictures:
1. The tooth should be restorable
● If not restorable, you can opt for extraction then
implant.
 2. Does it have adequate periodontal support - take 2. Objective Clinical Findings
into consideration the periodontal support of the a. Difficulty in obtaining films of diagnostic
tooth. value
b. Malpositioned teeth
c. Pulp space
d. Root morphology - dilaceration
e. Apical morphology

Others:
a. Problem with isolation
b. Existing restorations (example: mga
3. Presence of a pathologic condition - there’s internal pasyenteng ayaw ipagalaw yung fixed
root resorption. RCT not indicated. bridge)
c. Fracture resorption
In this case, the walls have already resorbed and is d. Trauma
not an ordinary case of open apex. e. Previous RCT
f. Procedural errors
Internal root resorption is usually progressive so this
will resorb overtime. So, RCT will not be applicable 3. Clinician’s Level of Expertise
anymore as this is through and through already.
4. Availability of Necessary Equipment & Instruments
If yung resorption hindi pa connected sa outside of - If 27mm yung haba ng canal mo tas 25mm lang
the root, pwede pa i-RCT pero kung ganto ka- mga files mo, di pwede yun.
aggressive, di na to kaya ng RCT.
TREATMENT PLANNING
Treatment Objective: To restore health, function & esthetics

Treatment Planning Objective: To achieve treatment goals

efficiently

TREATMENT PLAN
4. Whether or not the tooth has strategic value.
(diagnosis is previously treated).
● Personalized
○ No two patients are the same in terms of
dentition so for each patient, there is an
individual treatment plan
● Flexible
○ The patient has the final say on the choice
of treatment
○ We cannot force a patient to undergo
treatment that he/she doesn’t want.

( 3 ) TREATMENT PHASES
A. PRE-TREATMENT PHASE
● Prepare the field to facilitate performance
of treatment proper
● OHI, S/P, caries control
○ Never start a treatment without
● When a tooth will be used as an abutment
giving proper education on proper
● Previously treated - pulpal diagnosis.
oral hygiene kasi kahit i-RCT mo
● The previous treatment has not been done properly,
yan tas di nya ittoothbrush, edi
yung canal preparation and obturation not done
wala rin yung treatment mo
properly so nagkaroon ng infection sa periapex.
○ Make sure that the patient knows
● Retreatment is needed in this case as it is a
how to maintain proper oral
valuable tooth.
hygiene
CAN IT BE DONE BY YOU?
1. Patient Considerations
B. TREATMENT PHASE
a. Medical conditions
● Chief complaint - address chief complaint
b. Local Anesthesia considerations - allergy
before anything else especially pain,
c. Personal factors - e.g., limited mouth
relieve pain first on treatment plan
opening, motivation to preserve dentition
● Other possible procedures you might need
(who would rather have the tooth extracted,
● Extraction, RCT
pero still try to educate them), physical
● Restoration
impairment
● Prosthetic rehabilitation
 ● Orthodontic treatment - We use this for loading temporary filling,
● Periodontal therapy compressing cavities into preparation.

C. MAINTENANCE PHASE
● To monitor healing
● To detect new disease
● Recall radiographs

SINGLE VISIT VS. MULTIPLE VISIT RCT ISOLATION

(5) Factors To Consider
1. Diagnosis
● Vital cases with normal apical tissues -
pwedeng single visit
● Cases with pulp necrosis & apical
periodontitis - multiple visits because mas
maraming bacteria and need a lot of time
to reduce and to improve the patient’s
periapical condition
2. Severity of the Patient’s Symptoms
- Kapag in pain ang pasyente, may lagnat,
probably multiple visit yan
3. Anatomy of the Pulp Cavity - if may dilaceration,
tignan mo kung kaya mo
4. Clinician’s Skill
5. Retreatment Cases - are problematic that’s why
multiple visits to
( 4 ) Reasons for using rubber dam:
1. Protects the patient from aspiration. ( aspiration of
instruments, clamps, files, solutions)
2. Prevents infection from fluids (saliva, blood) once
you have opened an access preparation which
prevents increase in microbial load.
3. It allows retraction of the soft tissues tissues and
tongue.
4. Enhances access so bacteria will not be introduced
into the canals. As I mentioned before, the oral
cavity has a lot of bacteria, there are a lot of teeth
with cavities. That's why part of the pre-treatment
phase is restoration of the carious tooth.
That's why we restore to minimize the amount of bacteria.
One way to help prevent bacteria from entering into the tooth
being treated RCT, is through rubber dam isolation.

** Kapag challenging, probably multiple visit yan

( 6 ) MATERIALS OF RUBBER DAM ISOLATION (pls insert pics)
( 5 ) BASIC HAND INSTRUMENTS
1. Rubber dam sheet - it is used to retract & cover soft
50% skill in dentists, 50% materials. If you’re not using
tissues that are supposed to be protected &
proper instruments, it’ll affect your performance.
retracted. It comes in different colors, thickness,
Understand the principles, theories and techniques.
and scent.
1. Mouth mirror
2. Rubber dam frame - could either be Young, nygaard-
Osby, metal. It is used to stretch the rubber dam
sheet in place.

2. Endodontic explorer (DG16)

- Explore floor of pulp chamber
- Path finder for orifices
- Also checks chamber roof & cervical ledges
3. Rubber dam clamps - it also comes from different
designs and sizes. It functions to hold the rubber
dam sheets in place around the tooth.

HOW DO YOU KNOW WHICH PROPER CLAMP TO USE?

3. Cotton pliers (locking)
You check on the cervical diameter of the tooth you’re going
- Para hindi continuous yung finger pressure
to isolate & check the pinaka-mouth nung clamp mo & it
- Without a lock, when you pick up a paper
should fit on the cervical area of the tooth. You don’t
point, continuous yung pressure mo and it
measure the crown, kasi hindi mo naman sa pinakang crow
would stress your finger right away
i-adapt eh.
4. Endodontics spoon excavator
4. Rubber dam forceps - it carries the clamp into the
- The neck of ordinary is shorter
tooth.
- Unlike ESE, a longer shaft can reach the
5. Rubber dam stamps / template - it serves as a guide
chamber in molar and premolar
on the correct area on where you are supposed to
5. Woodson plastic filling instrument
punch the hole.
- Common mistake of clinicians: not plastic.
6. Rubber dam punch - it creates the exact size of the
- Actually made of metal
hole into the rubber dam sheet.
( 2 ) ORGANIZATION SYSTEM (pls insert pics)
1. Endodontic sterilizing box / endodontic organizer -
this is the simplest organizer you can buy just make
sure that it should be autoclavable. Ito yung
tambayan ng files.
2. Clean stand - After you use the file, you clean it here.
Maraming debris na galing sa canal. Tatanggalin mo
yung debris by putting it here on your clean stand
which has a gauze or sponge with antiseptic. Wala
dapat tumatambay na files sa clean stand. Should
be autoclavable. Be particular with asepsis. Make
sure you replace the gauze every appointment
( 2 ) MEASURING DEVICE (pls insert pics)
Every instrument that you put inside the canal should be
properly measured because if you will not measure it & just
insert it inside the canal, there’s a tendency that you would
perforate the apical area of the tooth which could cause
further infection. You have to carefully measure the
instrument that you will put inside the canal, it has to have
its measurement before you put it inside.
1. Endodontic measuring block - each hole is
measured already to its length. The holes in the
middle represent point 5. In endodontics, we only
measure the exact what is only between .5. We
don’t measure .3, .4, etc.
2. Rubber stops / stoppers - it designates working
length. E.g, a 25 file, you put the stopper in the
middle of the file & then insert it into the hole then
push it down. Now, pag nag stop, yun na yon - you
have the exact measurement of the tooth. When you
put it inside the tooth, make sure it is touching or
resting on the reference point (cusp tip of molar or
incisal edge).
( 2 ) ACCESS PREPARATION (pls insert pics)
1. High speed and low speed handpieces
2. Endodontic access burs
a. Round bur #2, #4. Round burs is for the
initial access. Especially if i’m working on
mandibular incisors, I use #1 round bur.
b. Fissure burs. To finish & smoothen the
walls of your preparation.
c. Special endodontic burs (Diamendo,
Howard Martin, Endo 2 Bur). We usually
use this for access prep of posteriors & if
you notice, most of them especially its tip is
non-end cutting (not damage it severely
only scratches but at least you wouldn’t
burn out the floor), but the purpose is to -
in molar, it has a floor right? If you use end-
cutting, it’ll damage the floor. Mortal sin
yan kasi next to damaging is perforation na.
( 3 ) CANAL IRRIGATION (pls insert pics)
HOW MANY IRRIGATING SYRINGE DO YOU NEED?
2 or 3. 1 for loading of solution & 1 for aspiration.
1. Irrigating syringe - if you will buy the plain one, you
will have to label it. 1 for irrigating & 1 for aspirating
because you should not interchange them.
2. Irrigating needle - you have to make use of the side
vented needle; yung butas wala sa dulo, nasa side
yung butas kasi kapag nasa side, it would flow
evenly in the walls not on the end. Pag ang butas
nasa tip, lalabas ang solution mo sa apex which we
don’t want to happen kasi pwedeng ma-irritate,
lumabas yung irrigant sa apex at ma-irritate ang
periapical tissue. Your irrigant should backflow. Pag
masikip si needle, you have to retract a little bit,
 make it lose para may space for the solution to flow BIOMECHANICAL PREPARATION / CANAL ENLARGEMENT
back and that is what we want to happen. Gusto
lang natin iwash ang canal at ayaw natin lumabas
ang solution sa apex.
3. Irrigating solution (5.25% NaOCl) - some would use
EDTA. We use it as a lubricant and for narrow
canals. If the case is non-vital we combine EDTA &
sodium hypochlorite “zonrox” - EDTA it helps remove
smear layer of dentin. Zonrox is plainly just to
disinfect the root canal.

STANDARD FILES SIZES

Other patients would think that you’re trying to poison them,
you should be willing to explain to them what that is for. “We
use this po as an antibacterial agent, I will try my very best #6-#10 Increase of 2 units (6, 8, 10)
na hindi niyo malasahan or malunok. Ayan po ay plainly just
#10-#60 Increase of 5 units (10,15, 20)
to disinfect your root canal.”
#60-#140 Increase of 10 units (60, 70, 80)
( 3 ) CANAL EXPLORATION (pls insert pics)
After mo mag-access ng canal you would have to explore.
Color-coded
Ang RCT is like you’re going to a place you’re not familiar
Color coding of files
with, you cannot see. Ganun ka-exciting ang RCT. If-feel mo
#6 - pink
lang siya. You will try to explore a certain area.
#8 - gray
#10 - purple
Sa exploration, ffeel mo lang loob ng canal mo.
#15 - white
Dito mo malalaman if umaabot ba ko sa length ng canal ko,
#20 - yellow
may nagbblock ba sa canal ko, masikip ba canal ko, curved
#25 - red
canal ba to?
#30 - blue
1. Endodontic explorer (DG16)
#35 - green
2. Canal probe
#40 - black
● #12 (orange). It is used to locate small
canals not visible to the naked eye. A non-
cutting and has adequate size to be
Files
inserted in narrow and unprepared canals.
Standard length
Ginagamit sa super liit na canals.
● Posterior teeth - 21 & 25 mm. we use shorter files
in posterior teeth kasi kung sobrang haba nyan,
mahihirapan ka na maipapasok yan.
● Anterior teeth - 28 & 31 mm.

( 2 ) Types of file material

3. K files
- #6 (pink), #8 (gray), #10 (violet) -
commonly used as the first instrument that
should enter into your canal. Used if you
need to enlarge the canal
- After probing the canal, use #10 to enlarge
the narrow canal since it is more rigid.
a. Stainless steel - less expensive. More rigid. Limited
use only. You cannot use it on curved canals
because it is rigid and hard, not bending. You may
pre-bend it, but you cannot use it again, it should be
disposed of after use. Ito madalas na napuputol.
b. NiTi (Nickel Titanium) - mas mahal, more flexible.
You can use it on curved canals, it can curve by
itself. You can use it more times than the stainless
steel files.

ROTARY INSTRUMENTS / ENGINE DRIVEN: ProFile, Quantec,

Hero, PropTaper - is usually used in the clinic.

( 5 ) OBTURATION (pls insert pics)

 1. Lentulo spiral - we use this to load the sealer or to
mask, rubber gloves,
spread, coat the walls of the canal with the sealer. eye wear, plastic
barriers.

SOME STERILIZING EQUIPMENTS: (INSERT PIC)

2. Spreader - used to do lateral compaction during Autoclave or pressure steam - sterilize the majority of
obturation. There is a hand spreader where we use instruments.
our hands; it is usually used for lateral compaction
of anterior teeth. Finger spreader is used for lateral
compaction on the posterior tooth.

Glass bead sterilizer - chairside means of sterilization.

Should be beside your working area.

3. Plugger - used for vertical compaction during

obturation.
Glutaraldehyde solution - commonly used if there is no
means of sterilization.

4. Gutta percha points - seal the major foramen of your

canal during obturation. Same color coding with
paper points
Full strength 5.25% NaOCl - sterilize only the gutta percha
points.

5. Paper points - it can be used during biomechanical

preparations too. It is used to dry the canals to
absorb the excess irrigant inside the canal and used
to dry the canal completely. It also comes with the ACCESS PREPARATION
same sizes as our files. Same color coding Access Cavity - the initial stage.
● It is the opening in the dental crown that permits
localization, cleaning, shaping, disinfection, and
obturation of the root canal system.
● A properly prepared access cavity creates a smooth,
( 3 ) STERILIZATION FOR ENDO. PROCEDURE straight-line path to the canal system & ultimately to
the apex or position of the first curvature.
Techniques Description
A proper access preparation can give you a non-problematic
1. Sterilization Use of physical or experience. Smooth access from the opening, the orifice up
chemical procedure to to the apex or up to the first curvature.
destroy all microbial
life including bacterial ( 6 ) OBJECTIVES OF ACP
endospores inside the
1. Remove all caries when present
root canal and area of
operation. - to lessen or minimize presence of bacteria,
- for us to realize the sound tooth structure
2. Disinfection Elimination of virtually remaining,
all pathogenic - for us to prevent any microleakage in
vegetative between appointments kasi pag hindi mo
microorganisms but tinanggal yung caries, dito mag leak yung
does not eliminate
fluid.
endospores.

3. Barrier Technique Use of headcap, face

 - Do not remove sound tooth structure as
well as overextend preparation as it can
weaken the tooth
2. Conserve sound tooth structure - when we access
prep, we have to be able to prepare the ideal
7. Law of Orifice Location 1
preparation only. We don't remove sound tooth
8. Law of Orifice Location 2
structure that is not supposed to be removed
9. Law of Orifice Location 3
because it will weaken the tooth.
3. Unroof the pulp chamber completely - you have to
remove the entire roof to expose the entire floor.
4. Remove all coronal pulp tissue (vital or necrotic) - if
it's removal of vital pulp, “Pulp extirpation” & here
we use a barbed broach. We just do “debridement”
which is similar to irrigation - this is a procedure
where we flush out all the non-vital or necrotic 1.) REMOVAL OF ALL DEFECTIVE RESTORATION AND
debris through irrigation. CARIES BEFORE ENTRY INTO THE PULP CHAMBER
5. Locate all canal orifice - because canal orifice is the To prevent further leakage.
opening to the root canal. If you can’t see the
opening, di mo mapapasok yan. All canal orifices
should be visible.
6. Achieve straight - or - direct-line access to the apical
foramen or to the initial curvature of the canal. This
is the main goal for access preparation.
2.) REMOVAL OF UNSUPPORTED TOOTH STRUCTURE
( 9 ) KRASNER AND RANKOW LAWS OF PULP CHAMBER To preserve sound tooth structure. Stable tooth
ANATOMY (pls insert pics) structure is your reference point.
With access preparation, you could use this as your guide. I
will not elaborate on this anymore, just check and read it on
canvas so you would be guided on your access preparation.
1. Law of Centrality

2. Law of Concentricity

PROCEDURE (pls insert pics)

ANTERIOR POSTERIOR
3. Law of CEJ
1. External Outline Form 1. External Outline Form
Removal of caries & Determine the access start
restorations as necessary to location:
establish sound tooth
margins. The pulp chamber of posterior
teeth is positioned in the
4. Law of Symmetry 1 The initial external outline center of the tooth at the level
opening is on the lingual of the CEJ. You have to locate
surface. Whether it is the pulp chamber.
maxillary or mandibular, you
start at the lingual surface. Maxillary premolar - point of
entry is on the central groove
5. Law of Symmetry 2 Penetrate the enamel & between the cusp tips.
6. Law of Color Change - the floor is darker than the slightly (1 mm) into dentin
walls. using #2 or #4 round bur (or Mandibular premolar - adjust
a tapered fissure bur) on a starting location to
high speed handpiece. If your compensate for the lingual tilt
lower incisor is too small, you of the crown.
will need #1 round bur. You
may use low speed for a Molars - correct starting
beginner at baka ma- location is on the central
overwhelm ka sa high speed. groove halfway between the
mesial and distal boundaries.
Always start on the central
groove.
#2 or #4 round bur
(premolars) and #4 or #6
round bur (molars) on a high
speed handpiece may be
used to penetrate the enamel
& slightly (1 mm) into dentin.
Bur is directed perpendicular
to the occlusal table.
_________________
3. Removal of the Chamber
Roof (Deroofing)
The 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.
Pag nag drop ka sa chamber,
outward stroke na lahat. Hindi
na palalim kasi kung ganon,
papunta ka sa ilalim ng orifice
mo which is pwede kang mag
gauge sa pinakang orifice.
access.
_________________
3. Removal of the Chamber
Roof (Deroofing)
The remaining roof is
removed by catching the end
of a round bur under the lip of
the pulp horn and cutting on
the bur’s occlusal withdrawal
stroke.
Funnel the corners of the
access cavity directly into the
orifices using a safety tip
diamond or carbide bur.

_________________
2. Penetration of the Pulp
Chamber Roof
For anterior: with no. 2 or no.
4 round bur: penetrate into
the tooth to the roof until a
drop into the chamber is felt
in an angle that is
perpendicular to parallel to
the long axis of the root.
Drop is reaching the
chamber.
_________________
2. Penetration of the Pulp
Chamber Roof
After initial penetration, the
angle of penetration changes
from perpendicular to the
occlusal table to an angle
appropriate for penetration
through the roof of the pulp
chamber.
– Premolars: angle is parallel
to the long axis of the root/s
both in the mesiodistal &
buccolingual directions.
This enables the internal pulp
anatomy to dictate the
external outline from the
access opening Tanggalin mo
lahat ng roof. The goal. Kaya
movement of round bur is
sweeping out.
How many times should you
drop in an anterior or
posterior? 1 drop only
because we only have 1
chamber. We do not create
the orifice because the orifice
is already there & will come
out by itself.

– Molars: angle is towards the You can use a non-end cutting

largest canal because the
pulp chamber space is
usually largest just occlusal to
the orifice of this canal;
maxillary - toward palatal
orifice; mandibular - toward
distal orifice.
Penetrate into the tooth to the
roof until a drop into the
chamber is felt.
An endodontic explorer is
used to probe the depth of the
bur to avoid damaging the
floor.
_________________
_________________
4. Removal of the Lingual 4. Identification of all canal
Shoulder & Coronal Flaring of orifices
the Orifice Orifices are located at the
Remove the shelf of dentin corners of the final
that extends from the preparation (junction of the
cingulum to a point floor and the wall).
approximately 2mm apical to
the orifice. The access cavity should have
all orifices positioned entirely
Safety-tip diamond or carbide on the pulp floor not into the
bur - tip is placed 2mm apical axial wall. Pag naghahanap
to the canal orifice and ka ng orifice, it should be
inclined to the lingual during entirely on the floor.
rotation to slope the lingual
shoulder.
In anterior, you have to bevel
the margin in the incisal but
don’t flatten the incisal
because nothing now will hold
your temporary filling & will
cause dislodgement of
temporary filling.
Frequent dislodgment of
temporary filling - kaya hindi
ito finflatten ang incisal
margin
_________________
5. Straight Line Access
Determination
Using a small intracanal file
that can reach the apical
foramen or the first portion of
canal curvature with no
deflections.
Anterior tooth with big canal:
#10.
If small or laterals: #6 or #8 Removes bulges safely with
depending on the initial size burs
of the canal.
_________________
6. Visual Inspection of the
Access Cavity
Inspect for grooves that might
indicate an additional canal.
Evaluate orifice and coronal
portion of the canal for a
bifurcation. Remember, not
all anterior teeth are mono
rooted. The anatomy is highly
variable.
7. Refinement & 7. Visual Inspection of the
Smoothening of Restorative
Margins
Final step is to refine &
smooth cavosurface margins.
“Mouse hole” effect is the
extension of an orifice into the
axial wall which indicates that
your access prep is still
underextended. Meaning, you
have to bawas sa wall para
maging ideal orifice mo,
entirely on the floor.
ACCESS OUTLINE FOR INDIVIDUAL TEETH
_________________
5. Removal of Cervical Dentin
Bulges & Orifice & Coronal
Flaring
Cervical bulges are shelves of
dentin that frequently
overhang orifices restricting
access into root canal and
accentuating existing canal
curvatures. You will check if
there's a need to lessen to
achieve the straight access.
or ultrasonic
instruments placed at orifice
level and with light pressure
cut laterally toward the dentin
bulge to remove overhanging
ledges. You are going to clear
the orifices to check if
something is blocking.
_________________
6. Straight Line Access
Determination
Files must have unimpeded
access to the apical foramen
or the first point of canal
curvature to perform properly.
Maglalagay ka na ng #10 na
file. Check mo dapat straight
at hindi nag bend kasi ibig
sabihin may nakaharang
diyan na tooth structure.
Pulp Chamber Floor
Ensure all canal orifices are
visible & no roof overhangs
are present.
Smoothen walls using fissure
burs.
_____________________
8. Refinement &
Smoothening of Restorative
Margins
Restorative margins should
be refined & smoothened to
minimize potential for coronal
leakage.
Maxillary Central & Lateral Maxillary Premolars
Incisors (triangular) (extended ovoid
buccolingually) extended
ovoid na buccolingual, ha.
BAKA MAGPREP KAYO NG
MESIODISTAL, ANG CANAL
NIYAN AY BUCCAL AT
PALATAL.Oki? It should be
extended ovoid
buccolingually.
Maxillary Canines (ovoid to Maxillary Molars (triangular)
triangular kasi depende sa Always remember that you
shape ng roof ng pulp seldom would find a maxillary
chamber) always remember molar with only 3 canals.
what dictates the external More frequent yung 4 canals.
outline of your access
preparation. It is always
dictated by the shape of the
roof of the pulp chamber kasi
pag natanggal mo ng buo
yung roof, that is the correct
access outline. Your access
outline is always dictated by
the shape of the roof of your
pulp chamber.
Mandibular Central & Mandibular Premolars
Lateral Incisors (usually mono rooted kaya round
(always triangular. lang, minsan ovoid kapag malaki
Misan ovoid din) yung canal niya)
depende. How will you
know if it is triangular
or ovoid? Check it with
your explorer.
 Mandibular Canines Mandibular Molars (rhomboidal:4 /
(usually ovoid or triangular: 3) will depend on how
pwede rin triangular many orifices you will have
kung bata pa ang
pasyente at meron
pang pulp horns)
.YUNG
GITNA, IT’S WRONG
OVEREXTENDED NA SIYA.
The Law of Symmetry applies on mandibular molars. Ang
galing kasi ni Lord eh, isipin mo - even the internal anatomy
of our tooth talagang na-design niya yun na may ganong
configuration na kahit ang loob ng anatomy ng ngipin, should
be symmetrical o pantay. It is very true on the mandibular
molar. Pag ang orifice mo nasa gitna kagaya nito, ibig sabihin
isa lang yan. Pag ang orifice mo nasa side, dalawa yan kasi
dapat meron siya laging partner sa kabilang side. Okay?
Parang mukha lang natin yan. Ilang nose ba ang meron ka,
Rochelle? 1 po. Oh diba kaya isa lang yan kasi nasa gitna
yan.
How many eyes do you have Alfred? 2 po. Oh diba dalawa
yan isa sa kanan isa sa kaliwa.
How many heads do we have? Only one. Kaya nasa gitna.
How many hands do we have? Dalawa. Kaya both sides.
So, ganun rin sa internal anatomy ng ngipin. Pag nakita mo
ng ang orifice mo ay nasa gitna, wag ka na maghanap ng iba
pa. Mag-isa lang yan kasi it’s at the center. But if you have it
at the side, nasa lateral yan, asahan mo meron pa sa kabila
yan kasi it is always symmetrical. That’s applicable only to
mandibular molars.
I would suggest, if you have extra natural tooth/specimen,
mag practice kayo, Kahit hand held na muna kung meron
kayong mga ngipin diyan na sira or ginagamit niyo na dati. If
you want to seek comments from me before Thursday, you
can do so. Kunan niyo ng picture then send it to my inbox, i’ll
try to make some comments if it needs to improve.
SCOUTING, EXPLORATION & IRRIGATION ( insert pics)
The following are procedures and guidelines in scouting &
exploration:
1. Probe the canal orifice with an endodontic explorer
(pathfinder/Stewart probe) to determine the
direction of the canal at the cervical third.
2. Establish the Trial Working Length (TWL).
a. Using the endo tooth model specimen
(JChenny), measure the tooth length (TL)
from the reference point (incisal; anterior
or cusp tip/occlusal; posterior) to the apex
or end of the root. Whatever the
measurement, subtract 2 mm as a safety
factor to get the TWL.
NOTE: TLI means Tooth Length Image applies to radiographs.
Wala naman tayong x-ray. So, TL lang.
Example ang measurement ng central mo is 25 edi minus 2
= 23 mm TWL mo.
Sa molar naman, ito palatal ha, make sure natatandaan mo
anong cusp tip ang ginamit mo for reference point kasi sa
molar, maraming cusp tip ang laman isa lang yan and every
cusp tip, iba ang height.
Halimbawa sa palatal, ito ang ginamit mong reference point
- tandaan mo, na ito ang ginamit mong cusp tip kasi dapat
consistent ka para hindi ka mamali sa measurement mo.
Okay?
b. Record the measurement on your printed
portfolio.
I think the portfolio I have posted is on canvas. You may print
or download it for you to fill it up. Your final grade will be
based on the completion of your portfolio. As we go with the
procedure, you will be able to fill that portfolio with the
information that is needed depending on the exercise that
we’re about to be doing.
There’s one portfolio for central, one for premolar and one
for molar.
3. Mark on the scouting instruments of the TWL.
a. Mark the TWL on SS K-type files #8 and
#10 with rubber or silicone instrument
stop.
b. Select which from the two files can glide
freely through the canal. The file that glided
through will be referred to as the scouting
instrument.
 4. Confirm the canal morphology as the scouting
instrument was inserted apically.
a. Feel the patency of the root canal using the
scouting instrument. I-fill mo ngayon.
Pumapasok ba? Nag-glide ba ng canal
yung instrument mo.
b. Taking note of any abrupt changes in the
canal anatomy. At this point, you have to
identify what is blocking the canal.
c. Interpret the tactile information and take
note of the probable direction or location of
resistance and curvatures. Baka kailangan
mo lang i-redirect or di mo na-irrigate
properly kaya na-block ang canal mo ng
debris, need mo i-irrigate more. There is
some information that you have to observe
to do this procedure.
PROCEDURE AND GUIDELINES IN IRRIGATION
1. Prepare two (2) disposable hypodermic syringes.
Color code or label each of the syringes for easy
identification. One will be used to introduce the
irrigation solution & the other to aspirate excess
solution when the oral cavity is ready for sealing.
2. Prepare the irrigation solution.
a. In a clear & clean container, dilute 1 part of
5.25% Sodium hypochlorite (NAOCl) with 5
parts distilled water (1:5 ratio). If full
concentration is preferred, simply transfer
the commercially prepared 5.25% solution
in another container to conceal the brand.
Ito yung sinasabi ko na hindi dapat nakikita
ng patient mo yung Zonrox.
b. Fill up one syringe with the solution. Lift the
syringe with the needle in an upward
direction and tap the barrel to remove the
bubbles toward the surface of the solution.
Tap mo para kung may air, bubble, space.
Dapat walang empty space doon sa top at
walang bubbles kaya pinipitik yun.
c. Push the plunger & express out the trapped
air. Minsan may lumalabas na konting
solution, that’s fine.
That’s how you prepare your irrigating solution. It should be
freshly mixed every appointment kasi nag contaminate rin
yan pag matagal nang naka prepare, it precipitates under.
Prepare just enough for today. If there's an irrigating solution
left, dispose of it.
3. Irrigation of the canal.
a. Position the needle into the widest portion
of the canal allowing an adequate space for
the backflow of the solution. For narrow
canals, simply flood the pulp chamber with
NAOCl.
b. Place a cotton ball next to the access
preparation to catch the backflow of the
solution.
c. Very slowly and without pressure, push the
syringe plunger to introduce at least 1 cc of
the solution into the canal. For narrow
canals, simply flood the chamber with the
solution.
d. Place a drop of lubricant.
e. File the canal once it’s ready.
f. Leave the solution inside the canal while
filling. Constantly irrigate before changing
the file size.
g. At the end of the instrumentation, and as a
final rinse before sealing the canal either
temporarily or permanently, repeat the
procedure, except for the application of the
lubricant (step d), until all dentin shavings
or debris are flushed out of the canal.
4. Aspirate the excess solution when the canal is ready
for drying & sealing.
a. With the second syringe, express out the air
from the barrel by pushing the plunger to
the fullest before insertion into the orifice.
b. Position the tip of the needle inside the root
canal.
c. Pull the plunger to aspirate the access
irrigation solution & air.
d. Repeat the procedure when necessary.
5. Dry the canal with sterile absorbent paper points.
 EXTRACTION
• More invasive than RCT.
• If a patient has a medical condition, ask yourself
kaya mo ba i-manage? If yes, go with RCT
• Always seek for doctor’s clearance if patient is
medically compromised for him or her to undergo
any dental procedure

a.Sterilize the absorbent paper points in an PHYSICAL EXAMINATION

autoclave. Paper points must have the
same size as the MAF.
b. Mark the WL on the paper points.
c. Pass the paper point over the flame of an
alcohol lamp 3x or immerse in glass beads
sterilizer for a few seconds.
d. Insert the sterilized absorbent paper into
the canal & swab the walls to the full WL
marker to absorb the fluids from the canal.
e. Repeat the procedure until the canal is
“bone dry”
6. Seal the canal either temporarily with Calcium
hydroxide (only when canal shaping was completely
done) or with final root canal obturation materials.
ENDODONTIC (LABORATORY)
DIAGNOSIS
These diagnostic procedures will help you arrive at a
diagnosis with confirmatory tests to your tentative diagnosis
and arrive at a definitive diagnosis.
You need to record and analyze the results.
INTERVIEW
1. Chief Complaint
• “Doc, masakit po ipin ko.”
2. History of Present Illness
• Ask questions
• History of present condition
• Try to dig in the background of pain
• Does the px experience pain? When?
How long? Seconds? Minutes? Hours?
Days?
Intensity of pain? (rate the patient to rate
the pain, 10 being the most).
What provokes it, hold cold?
Is there something that relieves the pain?
Other symptoms?
3. Medical & Dental History
• Systemic conditions
• Ask, “Naospital na po ba kayo?”
“May iniinom na po ba kayo?”
“Why are you taking
“Do you know why you’re taking it?”
• Your knowledge in pharmacology is
necessary.
1. General appearance
• Gait
• Physical deformity
• Special needs
• Limp
• Swollen parts of body
• Skin color (Unusual, black and blue)
2. Extraoral examination
• Check for swellings, lesions around the
mouth.
3. Intraoral examination
• Don’t go agad to the suspected tooth.
• Check the oral health muna of the patient.
Dami ba calcular deposits, caries?
• Oral Health Status is an important factor in
Endodontics dahil kahit gano kaganda
yang pagka-RCT mo, kung di marunong
mag-alaga yung patient ng oral hygiene,
balewala rin.
Clinical condition of suspected tooth:
• WNL “within normal limit”,
• pulp exposure,
• discoloration,
• prior access “e.g., in attempt in-root
canal”,
• caries, restoration).
• Soft tissue exam: sinus tract, swelling
You can use this data later on when you try to diagnose.
DIAGNOSTIC TESTS
• These tests are done to be able to diagnose
what the problem is.
• This will help you arrive at a right diagnosis.
• Before doing anything to the patient,
explain it.
• Perform more than one test on one tooth.
• There should be a controlled tooth for your
comparison.
• Know what the normal response of the
patient is by using the response of the
control tooth
Controlled vs. Suspected Tooth
it?” • There is no single test that will tell you
everything you need to know, you need to
do several tests.
• Know when the normal response is of a
normal tooth.
• Don't use controlled teeth with
restorations. Use the one within normal.
 • You can use adjacent tooth or contralateral
tooth as long as they are normal
Vitality Test - determine blood supply if normal, intact.
Pulp Test
• We depend on stimulus
1. Thermal
“common, reliable.”
1.1 Cold Test
Tetrafluoroethane (Endo Ice)
ALTERNATIVE: sterile anesthesia empty carpule with water
then refrigerate
Procedure:
1. Give instructions to the patient.
• “May ilalagay po ako na malamig sa ngipin niyo”. -
IMPORTANT.
• “Pag may ngilo or sakit, taas kamay. Pag wala,
baba.”
• Pag taas kamay, start counting, pagbaba ng kamay
stop counting.
2. Isolate the area of the CT with cotton rolls & saliva ejector.
Dry the tooth with a small cotton ball/gauze. (Do not use
compressed air to dry! Bc may mga ngipin na nangingilo pag
nahahanginan)
3. Spray the refrigerant on an approximately-sized cotton
pellet.
4. Apply the cotton pellet on the labial/buccal surface,
approximating the middle or cervical third of the tooth. Not
on the incisal edge. If you’re applying on the cervical third,
make sure you do not come in contact with the gingiva.
You’re supposed to put it on an area that has the thinnest
enamel, manipis sa cervical kaso ayun nga malapit sa
gingiva. Kaya mas safe sa middle third. Kung sa middle third
ka, dapat both control and suspected tooth sa middle third
lang.
5. When the patient raises his/her hand, withdraws the cold
stimulus then starts counting in seconds, until the patient
puts down his/her hand. (Count 1001, 1002, 1003….)
6. Record the duration of time from stimulus removal until
the time the patient puts down his or her hand. Also not the
intensity of the response of the patient.
a. Mild sensation = record as (+)
b. Moderate pain = record (++)
c. Severe pain = record as (+++)
If you’re going to give out a rating:
1-4 = mild
5-6 = moderate
10 = severe pain
It’s better to do control tooth first as to avoid bias on pain.
7. Do steps 1-6 on the Suspected Tooth
8. Do steps 1-6 on another Control Tooth (CT - CT may mean
contralateral tooth)
1.2 Heat Test
Has gutta percha wall
Procedure:
1. Give instructions to the patient
• “Pag may ngilo or sakit, taas kamay. Pag wala,
baba.”
• Pag taas kamay, start counting, pagbaba ng kamay
stop counting.
2. Isolate the area of the CT with cotton rolls and saliva
ejector. Dry the tooth with cotton/gauze.
3. Apply petroleum jelly to the labial/buccal surface of the
CT.
Why? Because gutta percha is rubber medyo sticky pag
uminit, pwede siya dumikit sa ngipin
4. Heat the gutta percha ball in an open flame until warm,
soft and start to glisten or kintab.
5. Apply the GP ball to the labial/buccal surface,
approximating the middle or cervical third of the tooth.
6. When the patient raises his/her hand,withdraws the hot
stimulus then starts counting in seconds until the patient
puts down his or her hand
7. When the patient raises his/her hand, withdraws the cold
stimulus then starts counting in seconds, until the patient
puts down his/her hand. (Count 1001, 1002, 1003….)
8. Record the duration of time from stimulus removal until
the time the patient puts down his or her hand. Also not the
intensity of the response of the patient.
a. Mild sensation = record as (+)
b. Moderate pain = record (++)
c. Severe pain = record as (+++)
9. Do steps 1-6 on the Suspected Tooth
10. Do steps 1-6 on another Control Tooth (CT - CT may mean
contralateral tooth)
2.) Test Cavity
“Real test for vitality”
Pwedeng wag na gawin if satisfied ka sa cold & heat test.
Procedure:
You drill until dentin * you will know the pulp is vital if there
is sensitivity felt by the patient.
• Not routinely done, because it is irreversible,
invasive & destructive.
• Sometimes if the previous tests mentioned are all
inconclusive, there is no choice but to do a test
cavity. Pag mahirap i-interpret yung cold or heat test
mo or inconclusive ang results, you can do this test
cavity.
3.) Electric Pulp Test
Isolation of the teeth is very critical
• Saliva is a conductor of electricity
• Isolate, then dry with a piece of gauze
• Always warn px about procedure
o “Gagamitin ko lang po itong gadge na ito sa
inyong ngipin. Medyo may mararamdaman
po kayong pain tingling sensation. Pakitaas
po ang kamay kapag may nararamdaman
po kayong kakaiba”
• EPT has a fast mode & slow mode. Should
always be slow mode
• Put a blob of toothpaste on the tip of the
EPT
• Complete the circuit by letting the patient
touch the metal part of the EPT with the
pointer and middle finger, then turn the
EPT on
o There are also EPT’s with “lip-clip”
that may be attached to the lower
lip (no need to touch metal part)
• Different response levels DO NOT indicate
different stages of pulp degeneration
• It’s just a rough indicator of presence or
absence of vital nerve tissue
• YES or NO only (vital or not)
Procedure when using EPT:
1. Make sure the patient does not have a pacemaker, or
fixed orthodontic appliance. Remove RPD’s with metal
framework - not allowed
2. Give instructions to the patient
3. Isolate the area of the CT with cotton rolls and saliva
ejector. Dry the tooth with cotton/gauze.
4. Put the setting of the EPT to slow mode
METHOD A METHOD B
5. Hang the lip clip on the 5. Apply toothpaste
side of the patient’s mouth (conductor) on tip of tester
to complete the circuit 6. Apply the electrode lip to
6. Apply toothpaste dry tooth enamel on the
(conductor) on tip of tester labial/buccal surface,
7. Apply the electrode lip to approximating the middle or
dry tooth enamel on the cervical third of the tooth
labial/buccal surface, 7. Have the patient touch
approximating the middle or the EPT with the pointer and
cervical third of the tooth middle finger tot complete
the circuit
8. Press the button and observe while the reading on the EPT
increases (one unit increase per second)
***NOTE: For Method A, inform the patient that when
he/she feels something, the EPT will stio the tingling
sensation
Pag hindi gumagalaw, ibig sabihin tooth is non responsive
Note: Among the 3, the thermal test is the easiest.
Periapical Test
1. Percussion
• When you give instruction, tell patient they will feel
something removing contact of the fingers from the
EPT wall
• For the condition of the periapex/periapical area.
• Even if +++ pain, pulp isn’t the related cause here.
• Ask them if they feel tenderness or pain?
• If it's different from what the control teeth
felt? Don’t be suggestive. Just extract on
the narrative of the patient
• Controlled > suspected > contralateral
tooth
• You can change the sequence to prevent
bias
 • IS THE TOOTH VITAL WHEN YOU PERCUSS
IT?
• WHAT IS THE GOAL WHEN WE PERCUSS
THE TEETH?
• Goal of percussion: To test the condition of
the periapical.
• If positive, something is wrong with the
periapex but not with the pulp.
• Anterior teeth: percuss from the incisal & labial
surfaces
• Posterior: percuss from the occlusal, buccal &
lingual surfaces
• Do not tell the patient if you're percussing the
suspected tooth, to prevent bias.
Note the intensity of the response of the patient:
a. Mild sensation = record as (+)
b. Moderate pain = record as (++)
c. Severe pain = record as (+++)
2. Palpation
Procedure
• Apply the pressure, approximating the apex of the
tooth
• Aside from telling you if the inflammation has
extended the periapical area, you will also be able
to feel if there is a very soft or hard swelling.
• Make sure that your gloves don’t have excess
rubber at end of fingertips
• Palpate the mucosa, vestibule and the lingual
3. Radiographic
One of the most common basic necessity tests.
Not necessary in pulp.
You can see in this case that this has disrupted lamina dura,
less bone support, and the extent of caries.
#1 indication of a non-restorable tooth.is loss of bone
support and extensive caries
NOTE: Radiograph is insignificant to pulpal test. Only for
periapical area.
Tells you about the anatomy of the tooth, continuity of lamina
dura & periapical radiolucencies.
• Gum boil: if there’s sinus tract, ALWAYS TRACE
• Gum boil / parulis / open sinus tract
• Gum boil manifests in chronic apical periodontitis
• Using a #20 or #25 GP - because soft and flexible
Use thin Gutta Percha. Do not use expired Gutta
Percha, they are brittle when bended.
• Insert GP gently in the opening (the pus follows the
path of least resistance) there is no pain but you can
use topical anesthesia
• Stop if you can’t insert the GP anymore
• Then take a radiograph to know the source of
infection
• Be careful of some errors like using the wider end
of the GP or using a different size
• Can also tell if there is a possible endo-perio lesion
affecting the tooth
• Can tell you if the tooth can undergo RCT
(sometimes the tooth is not restorable anymore)
• If it is indicated, prescribed doing a CBCT. Especially
if it will help you understand the complex anatomy
of the tooth you will work on.
4. Periodontal Probing
• Useful in knowing if there is an endo-perio lesion
involved
• 6 Sites to probe: mesial, mid-labial, distal,
mesiolingual, mid-lingual, distolingual
• Normal pocket depth : 2-3 mm
5. Mobility Test
• Determine the periodontal support
• Usee butt ends of 2 instruments (don’t use your
finger).
• Grade 1 , Grade 2 , Grade 3
• 3 is severe mobility
SUPPLEMENTARY TESTS
1. Transillumination
Done if you suspect a presence of fracture
Could give you an idea whether the tooth is vital or not.
Additional test if there is history of trauma or fracture
You can use light curing system or a strong light
Fractures can be seen in radiographs but it does not offer
definitive diagnosis for fracture. Better do transillumination
to confirm.
Limited only fractures to the crown. If suspected root
fracture, do staining test
May fracture to. If wala tong fracture, dapat nailawan or
tumagos yung light hanggang lingual. Kaso hindi, so may
fracture to.
 • Light will not traverse the fracture line
• Part beyond the fracture will be dark
• If there is no fracture, the entire tooth will be bright
Transillumination can also determine is the pulp is still vital
or not. Reddish or pinkish color indicates blood supply hence
vital. Black or brown color indicates no blood supply hence
not vital anymore.
2. Staining
Test for a suspected crown fracture using methylene dye.
Could show you the exact fracture line. Additional test if
there is history of trauma or fracture. Dye seeps through the
crack so when washed, the fracture can be seen.
3. Bite Test.
Additional test if there is history of trauma or fracture. This
can determine if the fracture has reached the pulp
manifesting through sharp pain when releasing from a bite.
• Tooth slooth is used (place the concave part of it on
the cusp, then ask the patient to bite).
4. Selective Anesthesia Test
• Anesthesia by elimination, when pain cannot be
identified.
• Used when you cannot localize the location of the
pain.
• It is easier to anesthetize the maxillary area.
• For example, you anesthetize an area, then the pain
suddenly disappears, then probably the pain comes
from that area.
Record your data for every test and match it with pulpal and
periapical diagnosis.
Radiographic: destruction of lamina dura, periapical
radiolucency
Among the periapical diseases, alin doon may periapical
radiolucency
You cannot give proper treatment without proper diagnosis.
Canvas (Lecture)
MODULE 1: INTRODUCTION
Endodontics is the branch of Dentistry concerned
with the human dental pulp and periradicular tissues. This
module will introduce you to the field of Endodontics, its
scope, its general objectives and its interrelationship with
the other disciplines of Dentistry. As you will be doing
independent learning, this module will involve tasks and
activities that require you to immediately apply what you
learned in your reading assignments. Your involvement in
your learning is expected to facilitate retention of the
concepts for your future use as clinicians.
ENDODONTICS
● is 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 biology of the normal
pulp and the etiology, diagnosis, prevention and
treatment of diseases and injuries of the pulp and
associated periradicular conditions.
The scope of endodontics includes, but is not limited to, the:
● differential diagnosis and treatment of oral pains of
pulpal and/or periapical origin;
● vital pulp therapy such as pulp capping and
pulpotomy;
● nonsurgical treatment of root canal systems with or
without periradicular pathosis of pulpal origin, and
the obturation of these root canal systems;
● selective surgical removal of pathological tissues
resulting from pulpal pathosis;
● intentional replantation and replantation of avulsed
teeth;
● surgical removal of tooth structure such as in:
○ root-end resection
○ hemisection
○ root resection
● endodontic implants;
● bleaching of discolored dentin and enamel (teeth);
● retreatment of teeth previously treated
endodontically;
● treatment procedures related to coronal
restorations by means of post and/or cores
involving the root canal space
General Objectives of Endodontics
The following are the primary objectives of Endodontic
Treatment:
● Prevent pulpal/periradicular pathosis
● Intercept pulpal/periradicular pathosis
● Preserve the natural dentition when affected by
pathosis

That is, the dentist should be able to relieve pain (if present),
bring the tooth back to a healthy state in order to retain the
tooth and prevent re-infection. Retaining the tooth in the oral
cavity not only preserves aesthetics but also preserves
occlusion which results in proper function and mastication.
The primary cause of pulpal and periradicular pathosis are
the microorganisms. Through cleaning of the root canal
system, endodontic treatment reduces the volume of
microorganisms in a pathosis to a level compatible with
healing. It is important that the root canal system is filled
(obturated) to prevent re-infectionS
Significance of Endodontic in other field of Dentistry
This module presents an overview of the interrelationship of
Endodontics with other fields of Dentistry. For a more
detailed discussion, please refer to pp. 82-86 of Cohen's
Pathways of the Pulp
1. Endodontics and Periodontics
● The interrelationships between pulpal and
periodontal disease primarily occur by way of the
intimate anatomic and vascular connections
between the pulp and the periodontium.
● Extensive periodontal lesions may complicate
endodontic prognosis.
● Lesions with endodontic and periodontal
components may necessitate consultation with an
endodontist or periodontist in order to gather more
information about the tooth’s prognosis.
2. Endodontics, Restorative Dentistry and Prosthodontics
● The quality of the coronal restoration is as important
as the quality of the root canal treatment.
● Therefore, to increase the success of the treatment,
it is strongly suggested that the clinician discuss the
restorative plan of the tooth with both the patient
and the referring dentists (if referred patient) before
initiation of treatment.
● Some teeth may be endodontically treatable but
non-restorable, or they may represent a potential
restorative complication because of a large
prosthesis.
● Whenever possible, restorations should be removed
before endodontic treatment.
Full coverage restorations are usually suggested after
endodontic treatment. A systematic review on tooth survival
following non-surgical root canal treatment, four factors
were found to be of significance in tooth survival:
● A crown restoration after root canal treatment
● Tooth having both mesial and distal proximal
contacts
● Tooth not functioning as an abutment for removable
or fixed prosthesis
● Tooth type or specifically non-molar teeth
Problems with restoration must be recognized before
endodontic treatment is initiated. For complex cases, a
restorative treatment plan should be in place before
initiating endodontic treatment
3. Endodontics and Surgery
● Surgical evaluation is particularly valuable in the
diagnosis of lesions that may be nonodontogenic.
● When retreatment is being considered, the clinician
must determine whether nonsurgical, surgical, or
combined treatment is appropriate
● Endodontic surgery is most often performed in an
attempt to improve the apical seal and correct
failure of nonsurgical therapy. Bacteria are the
essential cause of failure.
● Endodontic surgery may also be performed as a
primary procedure when there are complications
such as calcific metamorphosis.
MODULE 2: M2 Objectives and Basic Principles of Root
Canal Treatment (Introduction)
As with all other disciplines of Dentistry, there are principles
governing Endodontic Treatments. This module will briefly
discuss those principles and provide an overview of
concepts that will be discussed in detail in the succeeding
modules. As you will be doing independent learning, this
module will involve tasks and activities that require you to
immediately apply what you learned in your reading
assignments. Your involvement in your learning is expected
to facilitate retention of the concepts for your future use as
clinicians.
( 7 ) STEPS
1. ASEPSIS
The primary etiologic agents of pulpal and periapical pathosis
are microorganisms and their byproducts Biofilms are
involved in all stages of root canal infection and can be found
on root canals walls, in dentinal tubules, and on extra-
radicular surfaces (AAE, 2018).
Successful endodontic treatment depends on effective
measures to eliminate and prevent infection of root canals.
Initially treatment should start with isolation and disinfection
of the operating field (Malmberg, Bjökner, Bergenholtz,
2016).
● This simply means using a rubber dam during the
duration of endodontic treatment. No endodontic
treatment must be done without placing a rubber
dam. Additionally, all of the armamentaria must be
sterilized or disinfected to prevent microbial
infection.
2. DIAGNOSIS
Diagnosis is the art and science of detecting and
distinguishing deviations from health and the cause and
nature thereof. The process of determining the existence of
an oral pathosis is the culmination of the art and science of
making an accurate diagnosis.
The process of making a diagnosis can be divided into five
stages:
1. The patient tells the clinician the reasons for seeking
advice.
2. The clinician questions the patient about the
symptoms and history that led to the visit.
3. The clinician performs objective clinical tests.
4. The clinician correlates the objective findings with
the subjective details and creates a tentative list of
differential diagnoses.
5. The clinician formulates a definitive diagnosis.
● No appropriate treatment recommendation can be
made until the clinician has arrived on a definitive
diagnosis. (Hargreaves, et. al, 2011).
3. BIOMECHANICAL PREPARATION
The clinical management of infected root canals undergoing
nonsurgical root canal treatment involves instrumentation
and disinfection. Instrumentation disrupts biofilms which
colonize infected soft and hard tissues, and provides access
for irrigation and exposure to antimicrobial solutions for
disinfection of the root canal system.
Instrumentation also shapes the root canal system. The
purpose of shaping is to facilitate debridement and
disinfection and to provide space for the placement of
obturation materials. The main technical objectives of
shaping are to maintain the apical foramen in its original
position, allowing it to remain as small as possible, and to
develop a continuously tapering funneled preparation from
the canal orifice to the apex allowing the tapered shape to
provide apical resistance during obturation.
● Only a well-prepared canal system can provide ideal
conditions for appropriate obturation. A well shaped
and well-debrided canal system will potentially
create the conditions for healing periapical tissues
(AAE, 2018).
4. DISINFECTION
Disinfection is achieved by the use of both antimicrobial
agents and the mechanical flushing action of irrigation, with
the goal being the disruption, displacement and removal of
pulpal remnants, microorganisms, metabolic byproducts,
debris and the smear layer created during instrumentation.
When treatment is provided over multiple appointments,
interappointment intracanal medicaments provide
additional opportunities for disinfection (AAE, 2018)
5. OBTURATION
In general, canals should only be filled when the patient is
asymptomatic, there are no signs or symptoms of pathosis,
and the canal can be dried. A good primary fit with apical
tug-back of a master cone is one adjusted to fit both the
apical size and the taper of the preparation. This is critical
to promote a good obturation.
● Prepared and filled canals should demonstrate a
homogenous radiopaque appearance, free of
voids and filled to working length (AAE, 2018).
6. CROWN RESTORATION AFTER ROOT CANAL
TREATMENT
As per the discussion in the previous module, the quality of
the coronal restoration is as important as the quality of the
root canal treatment.
● Root canal treatment should not be considered
finished until the tooth in question is restored in a
timely and adequate fashion. It is clear from the
literature that any delay between endodontic
treatment and tooth restoration should be as brief
as possible, since numerous studies report that
there is notably reduced survival after endodontic
treatment for teeth restored with temporary
restorations, compared to those receiving a
permanent restoration. Providing a fluid-tight seal,
preventing bacterial leakage, and protecting the
remaining tooth structure will provide long-term
stability following the root canal treatment. (AAE,
2018)

7. RECALL
It is necessary to recall ALL completed cases in order to
detect the small percentage of failures and re-treat them
(Riley, 1974). This is the only way to monitor if you were
successful in controlling the pulpal/periapical pathosis
M3 LEC
MODULE 3: DIAGNOSIS, CASE SELECTION, AND TREATMENT
PLANNING
Introduction
● Historically, there have been a variety of diagnostic
classification systems advocated for determining
endodontic disease.
● Unfortunately, the majority of them have been
based upon histopathological findings rather than
clinical findings, often leading to confusion,
misleading terminology, and incorrect diagnoses.
● A key purpose of establishing a proper pulpal and
periapical diagnosis is to determine what clinical
treatment is needed.
● For example, if an incorrect assessment is made,
then improper management may result.
● This could include performing endodontic treatment
when it is not needed or providing no treatment or
some other therapy when root canal treatment is
truly indicated.
● Another important purpose of establishing a
universal classification system is to allow for
communication between educators, clinicians,
students and researchers.
● A simple and practical system which uses terms
related to clinical findings is essential and will help
clinicians understand the progressive nature of
pulpal and periapical disease, directing them to the
most appropriate treatment approach for each
condition.
PULPAL DIAGNOSIS
● Normal Pulp
● Reversible Pulpitis
● Symptomatic Irreversible Pulpitis
● Asymptomatic Irreversible Pulpitis
● Pulp Necrosis
● Previously Treated
● Previously Initiated Therapy
1. NORMAL PULP
● Normal Pulp is a clinical diagnostic category in
which the pulp is symptom-free and normally
responsive to pulp testing.
● Although the pulp may not be histologically normal,
a “clinically” normal pulp results in a mild or
transient response to thermal cold testing, lasting
no more than one to two seconds after the stimulus
is removed.
● One cannot arrive at a probable diagnosis without
comparing the tooth in question with adjacent and
contralateral teeth.
● It is best to test the adjacent teeth and contralateral
teeth first so that the patient is familiar with the
experience of a normal response to cold.
2. REVERSIBLE PULPITIS
● Reversible Pulpitis is based upon subjective and
objective findings indicating that the inflammation
should resolve and the pulp return to normal
following appropriate management of the etiology.
● Discomfort is experienced when a stimulus such as
cold or sweet is applied and goes away within a
couple of seconds following the removal of the
stimulus.
Typical etiologies may include:
● exposed dentin (dentinal sensitivity)
● Caries
● deep restorations
● There are no significant radiographic changes in the
periapical region of the suspect tooth and the pain
experienced is not spontaneous.
● Following the management of the etiology (e.g.
caries removal plus restoration; covering the
exposed dentin), the tooth requires further
evaluation to determine whether the “reversible
pulpitis” has returned to a normal status.
● Although dentinal sensitivity per se is not an
inflammatory process, all of the symptoms of this
entity mimic those of a reversible pulpitis.
3. SYMPTOMATIC IRREVERSIBLE PULPITIS
● Symptomatic Irreversible Pulpitis is based on
subjective and objective findings that the vital
inflamed pulp is incapable of healing and that root
canal treatment is indicated.
Characteristics may include:
● sharp pain upon thermal stimulus
● lingering pain (often 30 seconds or longer after
stimulus removal)
● spontaneity (unprovoked pain)
● referred pain.
● Sometimes the pain may be accentuated by
postural changes such as lying down or bending
over
● over-the-counter analgesics are typically ineffective.
Common etiologies may include:
● deep caries
● extensive restorations, or
● fractures exposing the pulpal tissues.
Teeth with symptomatic irreversible pulpitis may be difficult
to diagnose because the inflammation has not yet reached
the periapical tissues, thus resulting in no pain or discomfort
to percussion. In such cases, dental history and thermal
testing are the primary tools for assessing pulpal status.
4. ASYMPTOMATIC IRREVERSIBLE PULPITIS
● Asymptomatic Irreversible Pulpitis is a clinical
diagnosis based on subjective and objective
findings indicating that the vital inflamed pulp is
incapable of healing and that root canal treatment
is indicated.
● These cases have no clinical symptoms and usually
respond normally to thermal testing but may have
had trauma or deep caries that would likely result in
exposure following removal.
5. PULP NECROSIS
● Pulp Necrosis is a clinical diagnostic category
indicating death of the dental pulp, necessitating
root canal treatment.
● The pulp is non-responsive to pulp testing and is
asymptomatic.
● Pulp necrosis by itself does not cause apical
periodontitis (pain to percussion or radiographic
evidence of osseous breakdown) unless the canal is
infected.
● Some teeth may be unresponsive to pulp testing
because of calcification, recent history of trauma, or
simply the tooth is just not responding.
● As stated previously, this is why all testing must be
of a comparative nature (e.g. patient may not
respond to thermal testing on any teeth).
6. PREVIOUSLY TREATED
● Previously Treated is a clinical diagnostic category
indicating that the tooth has been endodontically
treated and the canals are obturated with various
filling materials other than intracanal medicaments.
● The tooth typically does not respond to thermal or
electric pulp testing.
7. PREVIOUSLY INITIATED THERAPY
● Previously Initiated Therapy is a clinical diagnostic
category indicating that the tooth has been
previously treated by partial endodontic therapy
such as pulpotomy or pulpectomy.
● Depending on the level of therapy, the tooth may or
may not respond to pulp testing modalities.
APICAL DIAGNOSIS
● Normal Apical Tissues
● Symptomatic Apical Periodontitis
● Asymptomatic Apical Periodontitis
● Chronic Apical Abscess
● Condensing Osteitis
1. NORMAL APICAL TISSUES
● Normal Apical Tissues are not sensitive to
percussion or palpation testing and
radiographically, the lamina dura surrounding the
root is intact and the periodontal ligament space is
uniform.
● As with pulp testing, comparative testing for
percussion and palpation should always begin with
normal teeth as a baseline for the patient.
2. SYMPTOMATIC APICAL PERIODONTITIS
● Symptomatic Apical Periodontitis represents
inflammation, usually of the apical periodontium,
producing clinical symptoms involving a painful
response to biting and/or percussion or palpation.
● This may or may not be accompanied by
radiographic changes (i.e. depending upon the
stage of the disease, there may be normal width of
the periodontal ligament or there may be a
periapical radiolucency).
● Severe pain to percussion and/or palpation is
highly indicative of a degenerating pulp and root
canal treatment is needed.
3. ASYMPTOMATIC APICAL PERIODONTITIS
● Asymptomatic Apical Periodontitis is inflammation
and destruction of the apical periodontium that is
of pulpal origin.
● It appears as an apical radiolucency and does not
present clinical symptoms (no pain on percussion
or palpation).
4. CHRONIC APICAL ABSCESS
● Chronic Apical Abscess is an inflammatory reaction
to pulpal infection and necrosis characterized by
gradual onset, little or no discomfort and an
intermittent discharge of pus through an
associated sinus tract.
● Radiographically, there are typically signs of
osseous destruction such as a radiolucency.
● To identify the source of a draining sinus tract
when present, a gutta percha cone is carefully
placed through the stoma or opening until it stops
and a radiograph is taken.
5. ACUTE APICAL ABSCESS
● Acute Apical Abscess is an inflammatory reaction
to pulpal infection and necrosis characterized by:
○ rapid onset
○ spontaneous pain
○ extreme tenderness of the tooth to
pressure
○ pus formation and
○ swelling of associated tissues.
 ● There may be no radiographic signs of destruction
and the patient often experiences:
○ Malaise
○ fever
○ lymphadenopathy
6. CONDENSING OSTEITIS
● Condensing Osteitis is a diffuse radiopaque lesion
representing a localized bony reaction to a low-
grade inflammatory stimulus usually seen at the
apex of the tooth.
M3 LESSON 3 Treatment Planning and Case Selection
Contemporary Endodontic Treatment Recent
technological advances in endodontic treatment have
resulted in the retention of teeth that were previously
deemed untreatable. However, technology, instruments and
materials are not a replacement for clinical skill and
experience, but rather adjuncts that a practitioner can
employ to reach a desired goal. With that in mind, it is
imperative that a careful sequence of case selection and
treatment planning is carried out based on clinical factors
and the dentist’s own knowledge of his or her abilities and
limitations. A recent ADA survey estimates that some 15.8
million endodontic procedures were performed in the United
States alone in 1999. This number has climbed from an
estimated six million root canal procedures 30 years prior.
With demand as high as it is for the treatment of pulpal
disease, general practitioners should at a minimum be
comfortable with diagnosis of pulpal and periradicular
pathosis, and endodontic treatment planning.
Treatment Planning
The first step in treating the patient is planning the
case in full. This initially involves a comprehensive medical
review to predict any conditions that may require
modification of the usual treatment regimens. The
identification of medical conditions that may complicate
endodontic treatment will help the dentist avoid potential
medical emergencies during treatment. In addition,
consideration of complicating patient factors such as
anxiety, limited opening or gag reflex will allow the dentist to
avoid situations that may compromise treatment outcomes.
Following the medical evaluation, a subjective examination
and a radiographic survey should be completed. The
practitioner should then be able to perform and interpret
diagnostic tests to arrive at a diagnosis and high-quality
treatment plan that addresses the patient’s needs and
desires. Collection of this data makes it possible to avoid
misdiagnosing and therefore mistreating a patient—actions
that could lead to a loss of the patient’s confidence in the
practitioner, the prescribed treatment and ultimately the
dental profession. Proper treatment planning not only helps
the practitioner avoid procedural shortcomings (e.g., missed
canals, excessive removal of dentin, perforations, ledges,
separated instruments or over/underfill of the canal space),
but also allows the dentist to choose cases based upon his
or her experience, skill set and comfort level. Every clinician
must constantly evaluate his or her diagnostic and technical
skills. The practitioner then has a legal and ethical obligation
to determine, based on the case at hand, whether he or she
possesses the skills necessary to predictably manage the
patient’s endodontic needs, and assure the delivery of timely
and effective care. Practitioners electing to perform
endodontic treatment are held to the same standard of care
as endodontists. Cases that exceed the comfort level or skill
set of the dentist should be referred to a specialist with the
requisite skills and experience to manage the patient.
Case Selection Using AAE’s Case Difficulty Assessment
Forms and
M3 LESSON 3 CONTINUATION
The American Association of Endodontists has
developed a practical tool that makes case selection more
efficient, more consistent and easier to document. The
Endodontic Case Difficulty Assessment Form is intended to
assist practitioners with endodontic treatment planning, but
can also be used to help with referral decisions and record
keeping. The assessment form identifies three categories of
considerations which may affect treatment complexity:
patient considerations, diagnostic and treatment
considerations, and additional considerations. Within each
category, levels of difficulty are assigned based upon
potential risk factors. The levels of difficulty are sets of
conditions that may not be controllable by the dentist. Each
of the risk factors can influence the practitioner’s ability to
provide care at a consistently predictable level. This may
impact the appropriate provision of care and quality
assurance. For each level of difficulty, guidelines are given
to aid the dentist in determining whether the complexity of
the case is appropriate for his or her experience or comfort
level.
* Dentists should be familiar with the information in the
form, and be able to assess each case to determine its level
of difficulty 1
Please click and study carefully the following:
Patient Difficulty AssessmAssessmentForm.pdf (Links to an
external site.) (Links to an external site.)
Extra Readings:
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ssl.com/specialty/wp-
content/uploads/sites/2/2017/06/2014treatmentoptions
guidefinalweb.pdf
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ssl.com/specialty/wp-
content/uploads/sites/2/2019/02/19_TraumaGuidelines.
pdf
M3 LESSON 3 CONTINUATION-2
If Referral is Necessary
If the level of difficulty exceeds the practitioner’s experience
and comfort, referral to an endodontist is appropriate. There
are several components to an effective referral that make
the process a positive experience for the patient, referring to
the dentist and endodontist.
1. Develop a referral relationship with an endodontist
prior to the need for referral. Endodontists and
general dentists are part of the same team and
reinforce each other’s value. Establishing a
relationship with an endodontist will allow the
endodontist to serve as a consultant and a
resource, and will encourage communication, which
will better serve the patient. 2. When it becomes
apparent that a referral is necessary, make the
referral in a timely manner. An efficient referral
minimizes the possibility of potential complications
such as pain or swelling associated with untreated
endodontic pathosis. 3. Explain the reason for
referral to the patient. If possible, the referral should
be made with the patient in the office, so that any
literature, maps and preoperative instructions may
be provided at that time.
2. Discuss your diagnosis with the endodontist, and
tell him/her exactly what you have explained to the
patient. If applicable, discuss the treatment plan
and the desired outcome with the endodontist. It is
appropriate to include information regarding the
planned restoration—if a post and core is necessary,
describe how much post space is desired so that it
can be prepared at the time of treatment. If verbal
communication is not convenient, information can
be provided by written referral.
3. If possible, schedule the restorative appointment
within one month of the endodontic treatment. For
example, if a buildup and crown are planned
following endodontic therapy, this should be
scheduled with the referring dentist in advance to
avoid lengthy delays between completion of the
endodontic treatment and placement of the final
restoration. Significant delays in the placement of
the final restoration can lead to coronal
microleakage and nonhealing. 6. Following
endodontic treatment, a report including pre- and
post-treatment radiographs should be returned to
the patient’s general dental office. The prognosis
and additional treatment needs should also be
clearly stated. For example, if a canal is previously
blocked and the endodontist believes that a root
end resection may be necessary, this should be
communicated in the report.
Conclusion
In today’s society, patients are better educated and
have higher expectations regarding the dental care they
receive. Dental professionals have the technology,
methodology and scientific rationale to repair damage to the
dentition that was viewed as irreversible only years ago.
These advances allow patients to keep their natural
dentition, with a few exceptions, for a lifetime. Teeth that
have had surgical and nonsurgical endodontic treatment
that has not allowed healing can often be disassembled and
“re-engineered” to allow healing, preservation and function
of the tooth. Any of the treatment options offered to the
patient must have the patient’s best interests and health as
a primary goal. The treatment must be delivered in a
predictable manner by the treating practitioner to optimize
the healing potential. Nonsurgical root canal therapy results
in one of the highest retention rates of any dental procedure
when completed under optimal conditions. As clinicians, we
can ensure the highest quality treatment with our ability to
plan a treatment plan for the patient in such a way that we
honestly assess the difficulty of the case and our personal
skill levels, and then determine whether to treat or refer. In
the final analysis, when the treatment proceeds without
complication and healing occurs, the patient and the dentist
benefit
M4 Armamentarium and Pre-treatment (INTRODUCTION)
Before initiation of a nonsurgical root canal
treatment, a number of treatment, clinician, and patient
needs must be addressed. These include proper infection
control and occupational safety procedures for the entire
health care team and treatment environment; appropriate
communication with the patient, including case presentation
and informed consent; pre-medication, if necessary,
followed by effective administration of local anesthesia; a
quality radiographic survey; and thorough isolation of the
treatment site.
M4 Objectives
● Identify the different instruments used in
Endodontics
● Categorize the instruments as to its function.
● Explain the importance of Disinfection and
Sterilization in Endodontics
● Recognize the significance of Preparatory Phase in
Endodontic Treatment.
● Understand the benefits of good asepsis through
good oral hygiene and properly isolated, disinfected
field of operation during treatment.
M4 LESSON 1 Classification of Armamentarium According to
Procedure
1. Basic Instruments for Endodontic Treatment
● Mouth mirror
● Endodontic explorer
● Endodontic excavator
● Endodontic locking pliers
● Woodson plastic filling instruments
2. Rubber Dam Isolation - a procedure where to be treated ● Lentulo filler / lentulo spiral
is isolated from saliva and other structures in the oral cavity. ● Finger plugger
● Rubber dam sheet ● Finger spreader
● Rubber dam clamp
● Rubber dam template M4 LESSON 2 Sterilization of Instruments
● Rubber dam clamp forcep
● Rubber dam puncher Sterilization – is the process of making something /
● Rubber dam frame instruments free from bacteria or other living
● Rubber dam napkin microorganisms.
● Disposable saliva ejector tip
3. Access Preparation - a procedure done to gain an opening Methods of Sterilization
to the internal structure of the tooth.
● High handpiece with burs 1. Steam Sterilization / Steam Under Pressure
- Round bur no. 2 or no. 4 2. Dry Heat Sterilization
- Safe tip tapered fissure bur ● Static-air type
● Gates glidden drill ● Forced-air type
● Basic instruments for endodontics 3. Cold Sterilization/ Chemical Sterilization
● Irrigating syringe
● Irrigating solution Steam Sterilization / Steam Under Pressure
● Aspirating syringe
(Autoclave) a strong heated container used for chemical
● Sterile cotton pellet
reactions and other processes using high pressures and
4. Exploration, Cleaning & Shaping of Root Canal - procedure
temperatures, e.g. steam sterilization.
done to clean and shape the root canal in preparation for
obturation.
Dry Heat Sterilization
A. Work Length Registration
● Smooth broach / path finder
he high heat and extended time are major factors in
● Rubber stopper
achieving sterilization.
● Endodontic ruler
● Periapical x-ray film Dry heat may be used to sterilize patient-care items that
B. Pulp Extirpation might be damaged by moist heat (e.g., burs and certain
● Smooth broach orthodontic instruments). Although dry heat has the
● Barbed nerve broach advantages of low operating cost and being noncorrosive, it
● Irrigating syringe is a prolonged process and the high temperatures required
● Sodium hypochlorite solution are not suitable for the sterilization of many instruments and
● Aspirating syringe devices.
C. Cleaning and Shaping
● Endodontic files
● Irrigating syringe
● Sodium hypochlorite solution There are two types of dry-heat sterilizers used in dentistry:
● Aspirating syringe static-air and forced-air types.
● Paper points / absorbent points
D. Disinfection & Temporization - a procedure done 1. The static-air type is commonly called an oven-type
after root canal cleaning and shaping to ensure the sterilizer. Heating coils in the bottom or sides of the
reduction of bacteria inside the root canal. unit cause hot air to rise inside the chamber through
● Intracanal medicaments natural convection.
- Calcium hydroxide intertreatment 2. The forced-air type is also known as a rapid heat-
dressing / eugenol / camphorated transfer sterilizer. Heated air is circulated
monochlorophenol throughout the chamber at a high velocity, which
- Temporary filling material / permits more rapid transfer of energy from the air
hydrophilic cement to the instruments, thereby reducing the time
E. Obturation - is the placement of root canal filling needed for sterilization.
material inside the canal to ensure sealing of all
portals of entry of bacteria. Cold Sterilization/ Chemical Sterilization
● Gutta percha points
● Root canal sealer
 Chemical sterilization is a method used for the
decontamination of thermosensitive instruments, which
cannot withstand cycles of autoclaving. For the rest,
autoclave sterilization should be considered the elected
procedure
Pitfalls in achieving sterilization
● Interrupting the sterilization cycle, or inadequate
time, temperature, or pressure
● Inadequate pre-cleaning of instruments
● Overloading of sterilizer
● Inadequate drying cycle (autoclaves)
● Faulty gaskets or seals
● Improper packaging
● Bulky packaging
● Inadequate spacing of instruments
● Improper operation of unit
M4 LESSON 3 Pre-treatment Phase
1. Preparation of operatory (Infection Control)
2. Patient Preparation (Treatment Planning)
● Case presentation
● Informed consent
3. Pain Management
4. Preparation of tooth for access
5. Oral Prophylaxis and Rehabilitation
● Caries control and Crown build up
● Tooth Isolation
PREPARATION OF OPERATORY (INFECTION CONTROL)
All dental personnel are at risk of exposure to a host
of infectious organisms that may cause a number of
infections, including influenza, upper respiratory tract
disease, tuberculosis, herpes, hepatitis B, and AIDS, it is
essential that effective infection control procedures be used
to minimize the risk of cross-contamination in the work
environment.
These infection control programs must not only protect
patients and the dental team from contracting infections
during dental procedures but also must reduce the numbers
of microorganisms in the immediate dental environment to
the lowest level possible.
PATIENT PREPARATION (TREATMENT PLANNING)
Aside from emergency situations that require
immediate attention, endodontic treatment usually occurs
early in the total treatment plan for the patient, so that any
asymptomatic but irreversible pulpal and periradicular
problems are managed before they become symptomatic
and more difficult to handle.
The most important rationale for the high priority of
endodontics, however, is to ensure that a sound, healthy
foundation exists before further treatment is undertaken. A
stable root canal system within sound periradicular and
periodontal tissues is paramount for the placement of
definitive restorations.
Regardless of the specifics of the case, it is the
responsibility of the clinician to explain effectively the nature
of the treatment as well as inform the patient of any risks,
the prognosis, and other pertinent facts.
As a result of bad publicity and hear say, root canal
treatment is reputed to be a horrifying experience.
Consequently, some patients may be reluctant, anxious, or
even fearful of undergoing root canal treatment. Thus it is
imperative that the dentist educate the patient before
treatment (i.e., informing before performing) to allay
concerns and minimize misconceptions about it.
Case Presentation
Good dentist-patient relations are built on effective
communication. There is sufficient evidence to suggest that
dentists who establish warm, caring relationships with their
patients through effective case presentation are perceived
more favorably and have a more positive impact on the
patient's anxiety, knowledge, and compliance than those
who maintain impersonal, noncommunicative relationships.
Most patients also experience an increase in
anxiety while in the dental chair; a simple but informative
case presentation that leaves no question unanswered not
only reduces patient anxiety but also solidifies the patient's
trust in the dentist.
The American Association of Endodontists (AAE) and
the ADA publish brochures such as "Your Teeth Can Be
Saved by Endodontic (Root Canal) Treatment"1 to help
patients understand root canal treatment. Valuable
educational aids of this nature should be available to the
patient, either before or immediately after the case
presentation. This supportive information addresses the
most frequently asked questions concerning endodontic
treatment. These questions are now reviewed.
Accompanying each question is an example of an
explanation that patients should be able to understand. In
addition, the dentist will find it useful to have a set of
illustrations or drawings at hand to help explain the
procedure.
Informed Consent
A great deal of controversy surrounds the legal
aspects of informed consent. The current thinking of the
courts holds that, in order for consent to be valid, it must be
freely given; that all terms must be presented in language
that the patient understands; and that the consent must be
"informed." for consent to be informed, the following
conditions must be included in the presentation to the
patient: the procedure and prognosis must be described
(this includes prognosis in the absence of treatment);
alternatives to the recommended treatment must be
presented along with their respective prognoses;
foreseeable and material risks must be described; and
patients must have the opportunity to have questions
answered. It is probably in the best interests of the dentist-
patient relationship to have the patient sign a valid informed
consent form. With today's continuous rise in dental practice
litigation, a good rule to follow is to realize that "no amount
of documentation is too much and no amount of detail is too
little”.
A critical portion of the endodontic case
presentation and informed consent is educating the patient
about the requirement for radiographs as part of the
treatment. The dentist must communicate to the patient that
the benefits of radiographs in endodontics far outweigh the
risks of receiving the small doses of ionizing radiation, as
long as techniques and necessary precautions are properly
executed. Although levels of radiation in endodontic
radiography range from only 1/100 to 1/1000 of the levels
needed to sustain injury, it is still best to keep ionizing
radiation to a minimum, for the protection of both the patient
and dental delivery team. A simple analogy can be used to
help the patient conceptualize the minimal risk levels with
dental radiographs. A patient would have to receive 25
complete full-mouth series (450 exposures) within a very
short time frame to significantly increase the risk of skin
cancer. Nevertheless, the principles of ALARA (as low as
reasonably achievable), which are essentially ways to reduce
radiation exposure, should be followed as closely as possible
to minimize the amount of radiation that both patient and
treatment team receive. ALARA also implies the possibility
that no matter how small the radiation dose, there still may
be some deleterious effects.
PAIN MANAGEMENT
It is paramount to obtain a high level of pain control
when performing root canal treatment, and in no other
specialty is this task as challenging or as demanding. The
clinician must strive for "painless" local anesthetic injection
technique with relatively rapid onset of analgesia.
The problem of managing pain and anxiety in the
practice of dentistry is a significant one. Studies have
demonstrated that the major reason that over 50% of adult
Americans do not seek routine dental care is fear of pain.
Interviews with patients indicate that although they may
not be in pain when they visit their dentist, the overwhelming
majority truly believe that at some time during a dental
appointment they will experience pain. The person most
frequently cited as being responsible for this discomfort is
the dentist.
Pain and anxiety are entirely different problems, yet
at the same time they are closely related. Pain produced by
dental treatment can usually be minimized or entirely
prevented through thoughtful patient management and the
judicious use of the techniques of pain control, especially
local anesthesia. Anxiety, too, can usually be managed
effectively; however, before anxiety can be managed, it must
be recognized. Discovery of the cause of a patient's anxiety
is the major factor in managing the problem. Once aware of
a patient's fears, the dentist has many techniques available
with which to care for the patient.
In most areas of dental treatment, the problem of
anxiety control is greater than the management of pain. Pain
control is usually readily obtained with a local anesthetic.
Once effective pain control is established, anxiety control
usually is more readily achievable. In endodontics more than
in any other specialty of dentistry, pain control often proves
to be more of a difficult problem than the management of
anxiety. Because of this difficulty in achieving effective pain
control, the patient undergoing endodontic treatment often
anticipates the experience with a great deal of
apprehension.
Although achieving adequate pain control for
endodontic care is not usually difficult, there appear to be all
too many instances when a satisfactory result eludes the
doctor. The most likely explanation for the greater
percentage of anesthetic failures in endodontics than in
other areas of dental care lies in the tissue changes that
commonly develop in and around pulpally involved teeth
Although this procedure is somewhat effective,
injection of anesthetic solutions into infected areas is
undesirable because of the possibility of the spread of
infection to a previously uncontaminated area. Deposition of
the anesthetic into an area at a distance from the involved
tooth is more likely to provide adequate pain control,
because of the normal tissue conditions that exist there.
Regional nerve block anesthesia is therefore a major factor
in pain control for pulpally involved teeth.
There are also occasions, fortunately rare, when
even regional block anesthesia at a distance from the
infected tooth fails to produce adequate pain control.
Omitting for a moment the most likely cause of this situation,
faulty injection technique, has proposed that inadequate
pain control may be due to the fact that morphologic
changes (e.g., neurodegenerative changes in the axon or the
presence of inflammatory mediators) are developing.
Yet another unfortunate situation in endodontic
pain control relates to the inflamed tooth that when
anesthetized becomes asymptomatic but, on attempts to
gain access to the pulp chamber and canals, becomes
exquisitely sensitive to manipulation. Although no entirely
satisfactory explanation exists for this circumstance, it may
be explainable on the basis of an increase in the rate of
stimulation to the nerve endings that occurs with use of the
high or low-speed handpiece. The degree of neural blockade
may be adequate for a lower level of stimulation prior to
preparation yet prove inadequate to block completely the
rapid flood of impulses arising with use of the handpiece.
This is equivalent to the so-called anesthetic window noted
in obstetric anesthesia following epidural nerve block during
delivery: The degree of pain control is quite adequate except
during the most intense uterine contractions. The same
intense increase in the rate of neural stimulation is thought
to be responsible for this phenomenon in endodontics.
The tissue changes and their possible actions on
the effectiveness of local anesthetics influence the choice of
local anesthetic technique used in attempting to prevent
discomfort during treatment. A variety of techniques are
available in the maxilla and mandible.
PREPARATION OF TOOTH FOR ACCESS
Oral Prophylaxis and Rehabilitation
Elimination of sources of infection is essential in
Endodontics.
Prior to Endodontic treatment removal of plaque and
calcular deposits is required. Carious teeth must be restored
and severely carious teeth must be removed.
Caries control and Crown build up
The tooth to be treated endodontically must be cleaned and
freed of carious lesion as part of the preparatory phase.
Tooth Isolation
The use of the rubber dam is mandatory in root
canal treatment.
The best way to prevent seepage through the rubber
dam is meticulous placement of the entire system. Proper
selection and placement of the clamp, sharply punched,
correctly positioned holes, use of a dam of adequate
thickness, and inversion of the dam around the tooth all
help reduce leakage through the dam and into the root canal
system. Nevertheless, there are clinical situations in which
small tears, holes, or continuous minor leaks may occur.
These often can be patched or blocked with Cavit, Orabase,
rubber base adhesive, "liquid" rubber dam, or periodontal
packing. If leakage continues, the dam should be replaced
with a new one.
LOSS OF TOOTH STRUCTURE
If insufficient tooth structure prevents the
placement of a clamp, the clinician must first determine
whether the tooth is periodontally sound and restorable.
Meticulous and thorough treatment planning often can
prevent embarrassing situations for both doctor and patient.
One example is the not uncommon case in which the
endodontic treatment is completed before restorability is
determined and it is then discovered that the tooth cannot
be restored.
Once a tooth is deemed restorable but the margin
of sound tooth structure is subgingival, a number of methods
should be considered. Less invasive methods, such as using
a clamp with prongs inclined apically or using an Ivory no. 21
clamp, should be attempted first. If neither of these
techniques effectively isolates the tooth, the dentist may
consider the clamping of the attached gingiva and alveolar
process. In this situation, it is imperative that profound soft
tissue anesthesia be induced before the clamp is placed.
Although the procedure may cause some minor
postoperative discomfort, the periodontal tissues recover
quickiy with minimal postoperative care.
RESTORATIVE PROCEDURES
If none of the techniques mentioned above is
desirable, a variety of restorative methods may be
considered to build up the tooth so that a retainer can be
placed properly. A preformed copper band, a temporary
crown, or an orthodontic band may be cemented over the
remaining natural crown. This band or crown not only
enables the clamp to be retained successfully; it also serves
as a seal for the retention of intracanal medicaments and
the temporary filling between appointments.
MODULE 5 ACCESS PREPARATION
Access preparation focuses on the tooth crown. It
is the first step in root canal treatment. It exposes the inner
core of the tooth through the pulp cavity. The pulp cavity is
made up of 2 parts, the pulp chamber located at the crown
area of the tooth and the root canal found within the root
portion. By removing the roof of the pulp chamber, the pulp
cavity is opened allowing entry for endodontic instruments
to reach the entire root canal system. This step will help
facilitate an effective cleaning and shaping of the pulp
cavity to eliminate infection throughout its length.
 ● Mesial Third: is the mesial side of the crown from
the incisal/occlusal to the cervical
● Distal third: is the distal side of the crown from the
incisal/occlusal to the cervical

And the root into:

● Cervical third: at the cervical line area
● Middle third
M5 Lesson 1: Morphology of the Pulp Cavity ● Apical third or 3-4 mm from the tip of the root
In the study of Anatomy, it has been emphasized
that the external shape and form of structures compliments
its internal shape and form. Since Endodontics is involved
with structures within the tooth, the external anatomy can
provide clues or guides as to the morphology of the inside
of the tooth particularly the pulp cavity. Tooth’s external
anatomy will provide a three-dimension mental image of
the approximate location of the center of the chamber and
its bounderies. This is essential in establishing the location
of the initial penetration of the roof of the pulp chamber as
you drill through the solid tooth crown during actual access
preparation.

In an outward sweeping motion of the bur, the pulp

chamber is completely "deroofed" up to the limitation of the
walls, and only then will the true size, shape and form of
the pulp chamber will be established. Therefore, it is the
anatomy of the pulp chamber that will dictate the final
outline form of the access preparation.

The pulp chamber, on the other hand, is a cavity

located within the center of the tooth crown starting from the
middle third extending to the cervical third. It is bounded by
the roof of the pulp chamber, floor of the pulp chamber and
the 4 lateral walls (Labial, Lingual, Mesial and Distal walls).
On the floor of the pulp chamber located at the cervical third
Youtube vid:
of the tooth, slightly below the cervical line, is where the
https://www.youtube.com/watch?time_continue=5&v=itpO
canal orifices are found. These are the openings of the root
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canals. According to the 9 Laws of the Cervical third, this
M5 Lesson 1.1: Pulp Chamber
area has the most consistent anatomy unaffected by
physiologic changes. Exposure of these orifices is the
The tooth is divided into the crown and the root demarcated
objective of access preparation. To expose them correctly
by a cervical line. The crown is further divided into 3 parts:
will help facilitate success in succeeding steps of root canal
● Incisal/Occlusal third: which is the functioning
treatment.
surface of the tooth during mastication
● Middle third: beneath the occlusal third and
between the mesial and distal third
● Cervical third: is the base of the crown located at the
border between the crown and the root at the area
of the cervical line.

Since the pulp chamber is enclosed within the solid
external tooth structures, correct preparation is dependent
on the external anatomy of the occlusal third particularly the
occlusal table, where important land marks guide the extent
and possible location of the pulp chamber without unduly
removing crown tissue during preparation thus preserving
and maintaining the strength and integrity of the tooth crown
structures.
For further discussion on the 9 Law of the Anatomy of the
Pulp Chamber, click the link below:
https://www.juniordentist.com/krasner-and-rankow-
guidelines-or-laws-of-pulp-chamber-anatomy-to-help-in-
access-opening.html
7. Law of Orifice location 1: The orifices of the root
canals are always located at the junction of the
dentin walls and the floor of the pulp chamber
8. Law of Orifice location 2: The orifices of the root
canals are located at the angles of the junction of
dentin wall to the pulpal floor
9. Law of Orifice location 3: The orifices of the root
canals are located at the terminus of the root
developmental fusion lines.
M5 Lesson 2: Coronal Access
Access preparation is the initial entry into the root
canal system. This lesson will focus more on understanding
the significance and principles of each step of preparation
rather than the technical aspect to help arrive at a correct
coronal access preparation. Guidelines and pointers will be
emphasized in order to avoid errors. Appreciating the
importance of the preservation of the remaining tooth
tissue by starting with correct access preparation is a very
significant factor in the success of root canal treatment.

KRASNER AND RANKOW LAWS OF PULP CHAMBER

ANATOMY
1. Law of Centrality: The floor of the pulp is always
located in the center of the tooth at the level of CEJ
(cementoenamel junction). This law helps in
determining the depth to which you can go without
causing any perforation. You can use an IOPA X-ray
or just place the bur against against the tooth and
measure it against the Bur length to have an idea of
the depth to which you can extend in search of the
pulp orifice
2. Law of concentricity: The walls of pulp chamber are
always concentric (or around the pulp chamber
following its shape) to the external surface of the
tooth at the level of CEJ.
3. Law of CEJ: It should be used as a landmark to
locate the pulp chamber as it is repeatable and
consistent in its position in any tooth.
4. Law of Symmetry 1: Except for maxillary molars, the
orifices of the canals are equidistant from a line
drawn in a mesial distal direction through the pulp-
Guidelines:
chamber floor.
● Develop a mental image of the pulp cavity in three
5. Law of Symmetry 2: Except for maxillary molars, the
dimension with the aid of the radiograph and
orifices of the canals lie on a line perpendicular to a
knowledge of canal anatomy
line drawn in a mesial-distal direction across the
● Know the possible morphology of the root canal
center of the floor of the pulp chamber
system
6. Law of Color Change: The color of the pulp chamber
● Determine the point of penetration
floor is always darker in comparison to the vertical
● Assess the occlusal and external root form
surrounding dentin walls
● Radiograph measurement of the depth of the pulp
chamber roof from the occlusal table
 ● Assessment of complicating factors
● Develop a mental image of possible positions of
the canal orifices
● Be guided by the 9 Laws of Anatomy at the cervical
third of the tooth according to Krasner and
Ranskow

Youtube vid link:

https://www.youtube.com/watch?v=6G7a-
1cPE2s&feature=emb_title

M5 Lesson 2.1: Objectives, Rules and Principles

Coronal Access Opening:

Provides a convenient entrance to the root canal/s via the
canal orifice/s to facilitate cleaning and shaping.

Objectives of Entries:
2. Create a straight line access (SLA)
● To provide visualization (location) of all canal
● SLA to the apical portion of the canal
orifices.

With straight line access

● To provide direct insertion of instruments to the

apical third of the Root Canal System (RCS)

No straight line access

Rules of Access Preparation:

1. Remove the roof of the pulp chamber.
○ After the "drop" remove the remainder of
the roof in an outward sweeping motion.
○ Check the location of the ledge after initial
access using the basic explorer.
3. Avoid damage to the floor of the pulp chamber

4. Conserve tooth substance

5. Establish a resistance form A completely deroofed pulp chamber will expose its floor
showing the fusion lines of the dentin map
The Access Preparation is Completed when it is:
1. Chamber walls are smooth and continuous with 2. Intact dentin shelf
the radicular portion of the pulp canal
2. When it provides direct access to the apical third of
the root canal

The Outline form of the Access:

1. Reflects the shape of the internal anatomic
structure of the chamber
2. Limited to the walls of the chamber
3. Confined within the marginal ridges

M5 Lesson 2.2: Common Errors in Access Preparation

Common Errors in Access Preparation

3. Perforation at the furcation
1. Intact roof of pulp chamber

4. Crown Perforation

Presence of intact roof of the pulp chamber

 Canvas (Laboratory) Step 1: HISTORY
- Medical History Form
CLINICAL ENDODONTIC DIAGNOSIS - Completed by patient
- Signed and dated
Diagnosis and treatment planning are two of the most - Reviewed completely
important facets of endodontics. - Follow-up questions
Without accurate diagnosis and proper treatment planning, - Highlight significant conditions
all other aspects become of little importance.
A clinician can perform the most skillful treatment but if it is Example: a patient takes an arthritic drug which may or may
on the wrong tooth, then you may find yourself drowning in not mask the symptoms that they are complaining about or
those difficult waters. results of your testing on that day.
There have been a lot of changes in the last several years
due to the developments in science, technology, and CHIEF COMPLAINT
understanding. - Must be written in the patient's own words.
- Reason for visiting the dentist
PRIMARY DIAGNOSTIC OBJECTIVES - Problem that urged the patient to have a dental
● Reproduce chief complaint check up
● Determine the cause - It is not uncommon for patients to have multiple
● Eliminate the cause problems.
● Address patient symptoms - Identify problems that are endodontic in nature and
● Prevention of endodontic disease problems which may be related to something else.

If the first two can’t be done then the astute clinician does a. SUBJECTIVE INFORMATION
not proceed with treatment. It is where the process starts. ● History of pain
- When did it start? How has it
Ultimate Goal: help patient symptoms, and prevent & progressed?
eliminate endodontic disease. - Was the pain related to a specific
experience?
Despite a thorough assessment, the clinician may or may - Recent dental treatment, trauma,
not be able to determine the exact nature of the patient's or no specific incident
chief complaint. ● Location of pain
- Localized to one tooth
NOTE: DO NOT TREAT UNLESS YOU KNOW THE CAUSE OF - Poorly localized to one quadrant
THE CHIEF COMPLAINT. - Poorly localized to one side of the
face (may or may not be
● Hippocrates endodontic problem)
- “”First, Do No Harm”. - Poorly localized to both sides of
- From (what is) to their harm or injustice, I the midline (NOT an endodontic
will keep (them) problem)
● Severity of pain
Hippocratic Oath: DO NO HARM. - Scale of 1 to 10
It is acceptable and even ethically required that a clinician - 1 = NO pain
not guess at the diagnosis when you need to refer or ask - 10= WORST pain imaginable
your endodontist. - Subjective patient judgment
● Nature of pain
Standard Diagnostic Framework: SOAP format - Throbbing, burning, shooting,
● Subjective information dull,sharp
- What the patient tells you - Very subjective descriptors
- Chief complaint - Different types of pain in
● Objective findings endodontic:
- What is seen by clinicians Neuralgic, Muscle
- Results of tests ● Frequency of pain
● Assessment - Intermittent or continuous?
- Information are put together to come up - How often do episodes occur? And
with a formula of diagnosis for how long?
● Plan of treatment ● Spontaneity of pain
- Follows the diagnosis - SPONTANEOUS: no stimulus
related to it, wakes patient up at
We want to know if things match up to what the patient tells night.
us and what we see matched up and backed up by the - TRIGGERED: always needs a
results from the tests. stimulus, does the stimulus cause
the pain?
● Stimulus of pain
 ● Duration of pain
Severe spontaneous pain is an indication of irreversible
pulpitis.
Chewing can act as a stimulus (aggravating factor).
Triggered pain could be an indication of pulpitis or
something non endodontic. It could be a biting sensitivity
from malocclusion or bruxism or a periodontal problem. -
- we want to collect all this information and get it together
to make diagnosis
Approach the patient with 12 oclock position, it give you a
chance to palpate the neck nodes, submandibular nodes,
submental nodes, we know that of course if somebody has
pain to palpation of the muscles, and mastication we may
not dealing with an endodontic problem at all , and on the
other hand if they are have tender or enlarged nodes in the
neck or under the jaw, the of course we may be dealing with
spreading infection and something that is definitely
endodontic in nature.
Intra-oral examination (oral cancer screening)

Subjective Information

Stimulus of the pain

- Cold/heat
- Biting/chewing/ touching/ pressure
- Pushing on the gums

Duration of the pain

- How long does it persist after removing the Looking for asymmetries swelling areas of redness or
stimulus? inflammation, i like to compare the right and the left sides of
- 0 to 30 seconds >30 seconds. the mouth and at the same time while we’re examining these
- Persists minutes to hours after stimulation. soft tissues now is the time to check the palate and tongue
and do our oral cancer screening as well.
● Clinical examination
○ Extraoral As for soft tissue findings, one important sign to look for is a
○ Intraoral draining sinus tract, if a sinus tract is present must be traced
● Comparative testing with a gutta percha points and a radiograph taken you will
● Radiographic assessment be surprised how often the draining sinus tract does not
arise from the tooth that you think it should be arising from
in other words the draining sinus tract may not be right the
Get that and the tell us we’re gonna figure out the rest out in side of the tooth.
our testing specifically but we want to know what they think
and what they are feeling on a day to day basis in terms of
the pain when they’re having episodes how long does it last,
in particular with the cold we want to know when you had
drink a cold glass of water, does that pain last 30 seconds,
less than that just well the colds on there or is it something
that lingers that persist on when cold sensitivity persists
greater than 30 seconds or minutes or hours we know that
that’s indication of reversible pulpitis

CLINICAL EXAMINATION EXAM:

Extra-oral exam

- Soft tissue findings

- Redness, swelling draining sinus tract.
General conditions:
- Wearing facets - may be indicating the present of
strong occlusal forces and perhaps a pair of
functional habits such as bruxism and occlusal
trauma is frequently misdiagnosed endodontic
disease so this finding is very relevant
- Gingival recession
- Exposed dentin
Another thing to know is gingival recession, exposed dentin
can be quite sensitive to cold and it may be an indication of
reversible pulpitis and if it is reversible then it is something
where endodontics not needed and there may be a more
simple solution.
- Caries - a sign of bacterial invasion of the tooth and
if the caries and the bacteria are getting into the
pulpal tissue then we’re dealing with an irreversible
pulpitis which will eventually lead to necrosis.
- Extensive restoration or leakage.
- Tooth fractures.
Areas of recession may be also associated with tooth
fractures and tooth fractures is another that the bacteria get
into the pulp where there’s recession check carefully using
magnification and a perio probe to examine and see if there
may be a fracture present on roots especially below crown
fractures.
- transillumination of a fractured tooth.
I turn off the operating lights and sometimes turn off my
overhead lights and I'm shining the light through the dentin
of the crown and where there is a crack that light
transmission will be disrupted and you will be able to see
that crack.
So now that we look at the general oral conditions we want
to move on to our clinical testing of the suspected tooth and
its entire quadrant, we’re often going to find secondary
problems or that symptoms are related to more than one
thing, it could be endodontics and periodontics for example.
Comparative Testing
I like to consider the periodontal probe as the first
instrument of my endodontic testing. It's a critically
important step.
PERIODONTAL PROBING, MOBILITY
Here we have a case, the patient was sent for endodontic
treatment for a toothache. It’s a good idea to consider
measuring at least 6 points around the tooth and we also
want to look for things such as are we dealing with an
isolated pocket where we’ve got normal periodontal probing
and then all of a sudden, the probe drops into a 10 mm
depth. This could be an indication of a fracture perhaps this
tooth isn’t savable if we’re probing at those 6 points and we
find a broad area of bone loss, then that can be something
that is periodontal bone loss. We want to refer for that or be
looking at periodontal support to determine whether or not
prognosis for long-term outcome is good for this tooth.
PALPATION
Palpation is done in the quadrant and it’s done to detect
periapical inflammation that spreads to the surface of the
mucosa and it may indicate an underlying problem.
I think it’s useful also to note the precise area of the mucosa
that may be sensitive, for example, if your patients are
finding that they’re sensitive but it;s along the gingival
margin, we may be dealing again with a periodontal problem
not an an endodontic problem. This is quite different from
when they’re sensitive to palpation at the root ends. Note the
area and location of that sensitivity to palpation. To be aware
with upper molars particularly that there’s muscle insertion
in this area at the root apices and patients will often say that
this area is sensitive to palpation. Compare the right side
and left side in these areas to make sure there is a
difference.
PERCUSSION
Percussion testing is used to more specifically examine for
inflammation at the root ends. One should bear in mind,
however that this is in fact a periodontal test, periodontal
inflammation can be caused by endodontic infection
certainly if it’s spreading to the apical tissues from the pylp
space going to get sensitivity to percussion but also things
such as bruxism, malocclusion, pair of functional habits,
these can also stretch and traumatize those periodontal
fibers causings sensitivity to percussion.
THERMAL TESTS
Every tooth that’s considered for endodontic therapy should
have a cold test. Cold testing is an essential element of our
tests. There are several ways that we can do it so you can
use water. Water is ice so to do this, you take your cleaned
and disinfected empty anesthetic cartridges, you fill them
with water put them in a little plastic cup upright and freeze
them and then when you want to take them out for your cold
testing then you make a little ice pencils which you can hold
in a 2x2 gauze. When you’re using this method, it is
important to start with teeth distal and then move mesially
because as you are testing the ice will melt onto the adjacent
teeth and we don’t want to get any false positives.
COLD (H20, CO2, ENDO ICE)
I would like to use endo ice spray, it’s a tetra fluoro ethane
spray and it’;s very convenient and easy to use. It comes out
of a can, you spray it onto a cotton pellet or a cotton swab
and then you can test the teeth very specifically and
individually without having melting where cold is transferring
from one tooth to another. Be aware that as you’re using the
can, a temperature can vary so give it a really good shake
before you spray it onto your cotton pellet. CO2 snow which
is dry ice can be used as well but the temperature is very
extreme and also you need a lot of armamentarium, a big
canister in your office to be able to have that available.
THERMAL TESTS
● COLD (H2O, CO2, Endo Ice)
● HEAT (Warm Gutta-Percha)
A heat test, so if someone complains of hot sensitivity then
we should be doing a heat test and there are several ways to
do that. One of the ways that you can do this, is by using a
rubber cup and creating friction on the tooth to create heat.
I don’t find this works as well as safe for example as using
warm gutta-percha on a tooth and a heated instrument or
using a rubber dam test in hot water.
HEAT (Warm Gutta Percha)
The heat test when we’re using a heated instrument or warm
gutta-percha is used similar to the way we would do the cold
test where we hold that hot or cold stimulus on the tooth for
about a second or until the patient feels that stimulus and
then remove it right away.
So when we’re doing the heat test, with a hot gutta-percha
and heated instrument, what we want to remember is to put
a little vaseline on the tooth first to prevent gutta percha
from sticking.
CLINICAL EXAMINATION - SEPARATION MEDIUM
What we want to remember is to put a little vaseline on the
tooth first to prevent gutta percha from sticking.
When we are doing the rubber dam test, what we are doing
is placing rubber dam and flowing hot water onto one
specific tooth at a time.
So while rubber dam placement is not comfortable for
everyone you'd be surprised at how often you can get that
on comfortably to be able to do a nice accurate hot test .
CLINICAL EXAMINATION - HEAT TESTING
There is equipment available as well that will have the
ability to heat test. for example the
calamus tool has a specific heat desk tip and you can apply
that to teeth as well for heat testing.
So we've used our thermal tests for vitality testing the pulp.
Objective findings - comparative testing
Another vitality test is the electric pulp test and it's
unfortunately of limited value if you've got teeth that are
heavily restored which is often the case when we're testing
for endodontic problems. So it's not all that frequently used
but it does become very important with trauma cases and
in trauma cases we want to establish a baseline of what
our electric pulp tests say and then follow that through over
the weeks or months of follow-up assessments that we're
doing.
Bite tests are performed using a tooth sleuth or a similar
instrument a wooden stick or a cotton swab again and a
positive test result here may indicate periapical
inflammation but it may also indicate something like a
crack for example in the tooth.
So with the bite test as well to establish your baseline of
what is normal and where a patient may be specifically bite
sensitive it's a good
idea to test all the cusps of all the teeth in that quadrant
and again doing that in a random order.
So do be aware with all of these testing the percussion, the
bite testingm, and our temperature testing it's a good idea
not to go in order. We want to establish what's normal
around the tooth before moving to the tooth in question
and we don't want the patient to necessarily anticipate the
test result.
With the bite test also we have the advantage of being even
more specific than that because these tooth sleuths allow
us to place forces on specific cusps and we can document
exactly where that sensitivity may be coming from.
Selective anesthesia is not used often but can be used
where we have patients that are complaining of pain to the
entire side of the face where they can't tell if the pain is
coming from a top or a bottom tooth. In this case what you
can do is anesthetize the arch that you think the pain is in
and if the patient's pain goes away entirely then at least
you know that that is the area from where the pain is
coming.
Now if you're not only able to eliminate the pain then you
may be dealing with pain from the opposite arch of course
but also you may very well be dealing with a non
endodontic pain or a non dental pain which of course we
can't anesthetize away.
● Cold
○ Blowing air is inaccurate
○ Use endo ice, ice stick, or CO2 snow
● Heat
○ Use dab of petroleum jelly to keep gutta
percha from sticking to tooth
● Anesthetic test - anesthetizes adjacent teeth,
useful to elucidate upper vs lower pain, or non-
endodontic pain.
So to review some of the clinical tips just to note that
blowing air is very inaccurate for cold testing as can be the
ice stick if you're not careful about it and letting the melted
water drip. So use endo is something that you can use
specifically to touch the tooth in question and remove
immediately.
When doing the hot test do put some petroleum jelly on the
tooth to prevent the gutta-percha from sticking and be
aware that anesthetic tests are not able to anesthetize just
one tooth but they are very useful when you can't tell
whether pain is coming from an upper versus a lower arch.
So moving on to our radiographic assessments when
exposing radiographs it's a great idea to use some form of
film device and this way you can get reproducible
angulations. It's also good
because we're able to get a better view for endodontic
purposes when we compare to using a bisecting angle
technique for example. So here's an example of a
radiograph that was taken using a bisecting angle
technique which is on the left and a radiograph taken by
the endodontists on the right using a Rin device.
so the tube head is moved distally to take the image of the
tooth what that will do is it will move all the objects that are
closest to the tube head away so my analogy for this is if
you're driving down the highway the trees in the front move
quickly and they move by you fast they but the moon which
is far away it stays relatively still

So the suspected tooth is tooth number three and we note

that on the radiograph on the left the zygomatic arch covers
the palatal root end and the buccal roots are quite
foreshortened so not as clear as I'd like to see to determine
whether or not this is the tooth in question whether this has
a tooth that has difficult anatomy. when I take look at the
radiograph on the right which is the one that was taken by
an endodontist at the corrected angulation we can see that
there's extensive caries it's approaching the furcation.
so in this second view on the right what we see is the mesial
root which is filled is closer to the distal aspect of that mesial
root it's not centered in that root anymore so my suspicion is
that there may be canal anatomy unfilled which is centered
in that mesial root and that would be to that right side of that
image to the mesial side
so knowing that that has now moved away in my distal and
angulation I know that that must be the mesial-buccal root
end

There’s a severe distal periodontal defect there's quite a

curvature of those mesiobuccal roots and the palatal roof is
of course easier to see and can see that the amount of
calcification there the corrected angulation on the image on here in our post-operative view of that radiograph we can see
the right hand side has enhanced clarity and this may be a now both the mesial-lingual and the mesial-buccal roots are
tooth that i want to think twice about what I'm going to do in both filled
my treatment my endodontic treatment here.
we can use the same concept to move other objects away
so we can also see how two different types of images can from root end
show two different types of information and it's for this
reason that in my office I always take two views of every
tooth and we take a straight-on view and then a distal
angulated view now this also reminds us of something we
may have learnt in dental school which is the buccal object
rule

so here we've had an orthographic surgery and some pins

and retention devices which are covering the root apices in
our straight-on view

i want to move those elements which are on the front face

away from root ends so by moving the tube head down I can
get those elements to move up away from the root ends and
so here's an example of a previously treated tooth and we're there we can see the root apices
seeing a periapical lesion on the medial roots and we're
suspecting that there may or may not be a miss canal either
way we want to see more information about this tooth the
image on the right is a distal angulated view of that tooth
 ● Spontaneous pain
● Pain lingers after stimulus (lingers after cold
usually a very severe type of pain)
● Usually severe

Irreversible pulpitis (asymptomatic)

● The bacteria have infected the pulp tissue but
there are no symptoms and it’s quite common as
we’ll see when there are deep caries and
sometimes in trauma cases.
now where we have foreign objects that we can remove
which is more common these days as well nose piercings (So our pulp test would elucidate that there is an in-depth
and lip piercings do have patients remove them so that we indeed and irreversible pulpitis even though the patient
can just see what we need to see in the image without it may not complain of that.)
being obstructed
Pulp necrosis
reviewing some of our clinical tips: ● No response to thermal or electrical stimuli
● Perio probe- record your depths measurements at 6
points at least also take an assessment of the Previously root canal therapy
● Mobility- of the tooth whether it's slight moderate or ● Canals are obturated
extensive remember that grade three mobility
always refers to a tooth that can be compressed in Previously initiated therapy
an apical direction ● Start to do some sort of emergency treatment such
● Percussion and palpation testing and temperature as pulpotomy or pulp ectomy
testing start with the uninvolved teeth and be ● Parital endodontic treatment
random working towards the of all involve tooth get
the patient accustomed to normal perhaps test the Case Examples:
right side versus the left side
● Images- for your imaging remember you must Reversible pulpitis
always have a current image and you should show
both the tooth and all its surrounding tissues if
there's a lesion present you want to show the entire
lesion in your radiograph

so we've gathered all the information from our patient and

we've gathered all the information for ourselves so now it's
time to put everything together into our diagnosis

● Pulpal diagnosis
● Periradicular diagnosis
● Non-endodontic pathology

the diagnosis actually separated up into two areas and then

non endodontic pathology meaning there's something else
going on but the endodontic diagnosis we want to look at the
Findings:
pulpal diagnosis and the perioradicular diagnosis
Percussion -
so there are six classifications for Pulpal diagnosis and
Bite -
these are the first three:
Cold ++
(non-lingering)
● Reversible pulpitis
- Non-lingerinng (thermal tests)
Radiograph <-really??
- Not spontaneous
(No sensitivity to percussion, no sensitivity to bite because
They have to do with vital pulp, pulp that is still alive but may
there is no periapical inflammation at this point. We’ve got
or may not be bacterial II infected so in a reversible pulpitis
a pulp tissue that’s inflamed and it could have some cold
we have sensitivity usually to thermal but it's not lingering
sensitivity. Maybe if it’s more severe sensitivity or starting
and it's not spontaneous this is an inflammation of the pulp.
to linger, we may start to think well is it moving to revert
irreversible pulpitis but if it’s just sensitive for a short time
Irreversible pulpitis (symptomatic)
without percussion or bite sensitivity we’re probably dealing
● A bacterial infection usually of the pulp and it’s
with a reversible pulpitis and no endodontic treatment
causing pain for the patient
would be needed in theses cases.)
● Symptomatic
Irreversible Pulpitis (symptomatic)
Findings:
Percussion + or -
Bite + or -
Cold +++
(linger > 30 sec)
Heat +++ or -
Radiograph usually unremarkable
(We start to get percussion sensitivity perhaps and bite
sensitivity perhaps. Our cold sensitivity would be more
severe and then we start to get that lingering quality.
Patients may also have or not have heat sensitivity
associated. When looking at a radiograph of a tooth that
has irreversible pulpitis, we may or may not see some small
signs in the x-ray. In this radiograph, there may be a sign of
some condensing osteitis, a little widen PDL space so be
aware of those changes as well.
Irreversible Pulpitis (Asymptomatic)
Findings:
Percussion -
Bite -
Cold + or -
(may linger)
Heat + or -
Radiograph caries approaching pulp
(The patient is not complaining of any symptoms but here
we’re seeing quite a large carious lesion. It’s very close to
the pulp space and our testing may either find that there’s
a lingering response same with the thermal testing of hot or
cold and again we want to look for those radiographic signs
perhaps we will also see small signs of condensing osteitis
or widened PDL space in a case like this.
Pulp Necrosis
Findings:
Percussion - to +++
Bite - to +++
Cold -
(non-lingering)
Heat -
Radiograph evidence of apical periodontitis frequently
(Once the infection progresses to pulp necrosis, now we’re
gonna start seeing more signs of periapical inflammation.
We’re going to see bite sensitivity, and percussion and
sometimes that can be fairly minimal but sometimes quite
severe. Since there’s no live tissue, we’re going to have a
negative response to both hot and cold testing. In the
radiograph, we see the sign of that periapical inflammation
and periapical bone changes associated with infected as
that darkness forms around the ends of the root)
Previously Treated
Findings:
Percussion - to +++
Bite - to +++
Cold -
Heat -
Radiograph appearance variable (root filling evident)
(There is no percussion or bite sensitivity, it may be minor,
severe. Again we’re gonna have no response to thermal
test because there is no living tissue in this tooth but
radiographically we start to see signs of disease, signs of
endodontic infection. We’ve got periapical radiolucency.
With previously treated teeth, we also want to look for other
types of elements like caries, where are the post, are there
signs of fracture, are there untreated canals. Going back to
what I said before about the radiographs here’s a really
great time to have more than one view of a tooth.
Periapical diagnosis
Normal apical tissues
● Asymptomatic, intact lamina dura
Symptomatic apical periodontitis
● Pain to biting and percussion
● May or may not have associated PA radiolucency
Asymptomatic apical periodontitis
● Cannot elicit pain or altered sensation (By tapping
or palpation)
● Apical radiolucent area
Acute apical abscess
● Localized swelling, pain, pus formation
● Tender to pressure
● fever ? Lymphadenopathy?
● PA radiolucency?
Chronic apical abscess
● Minimal or no pain
● Pus drains from a sinus tract
● getting that same pressure build up like we do with
the acute apical abscess here we've got pass and
it may be draining from a sinus tract and now we're
looking for draining sinus tracts
● ● She is holding a cup of ice water
Facial cellulitis
● Extraoral spread of infection
● Dangerous- treat aggressively
● want to treat this aggressively we're going to see
swelling of the face there may be redness
tenderness.
There are other things that can mimic endodontic
symptoms and we want to be very aware not to create any
misset diagnosis, so here are some of those entities. We
can have
● periodontal abscesses or other periodontal
problems even food impaction can mimic and
endodontic symptoms
● vertical root fractures
● Acute/chronic sinusitis- sinusitis so pressure in the
sinuses causing pressure on the ends of the roots
and upper molars will sometimes cause a dental
pain we can have
● Muscular pain, TMD/MPD (inc. occlusal trauma) -
TMJ pain or muscular pain and this can include
occlusal trauma or pair of functional habits
● Neuropathic pain- pain that's not actually occurring
in the dental structures themselves but in the
nerves and in the in the blood vessels around up
around the dental tissues and then we can have
● Atypical facial pains - so pain that's associated with
nothing dental a little
All of those conditions listed on the previous slide can
mimic endodontic disease and you have to rule those out
prior to instituting root canal therapy. If you're not sure refer
or ask many misadventures have occurred and thousands
of unnecessary treatments performed because of
misdiagnosis of non dental pain
Plan of treatment
● Endodontic therapy
○ Emergency treatment
○ Elective treatment
● Extraction
● Referral
The treatment planning part of this presentation we've got
our subjective findings. We've got our objective findings.
We've made our assessment in our diagnosis so we're
looking at endodontic therapy. If we've assessed that we've
got a tooth that needs it then we can go ahead and do that
endodontic therapy. If the tooth is restorable and the
periodontal condition is sound the tooths not restorable or
we don't have a good periodontal prognosis and we may
want to consider extraction and in cases where either you
think the tooth is a child is presents a challenging case or
you have any doubts about the diagnosis that you've made
then this may be a good time to refer.
Case #1
● 28 y.o female
● Caucasian
● Office worker
● She is obviously in pain
● She doesn’t look as if she’s slept well
Medical history
● Generally good health
● Mitral valve prolapse with regurgitation
● Allergic to penicillin
Subjective information
● Pain started on its own three days ago- worsening
● Pain is a spontaneous, constant throbbing
● Pain worsens when ingesting hot substances,
lingers
● Pain is relieved by cold
● Pain is slightly worsened by biting pain
● Pain feels like 9 out of 10 - wakes patient up at
night
Document everything!
Our radiographic analysis we've see a pulp exposure
carious lesion under an existing restoration and possibly
some condensing osteitis and some PDL thickening.
Case #1 - Pulpal diagnosis? rid of the source of the infection and getting rid of the
● Spontaneous pain - severe symptoms by getting rid of the bacterial
● Lingering pain after heat
● Relieved by cold For case number two..
● Heat sensitivity reproduced with tests
Case #2
Symptomatic irreversible pulpitis
34 y.o. Male
● Asymptomatic “bump” on gums
● Recent crown replacement
● Perioprobing WNL
○ Percussion - +
○ Palpation - -
○ Bite - -
○ Cold - -
● Dx: Pulp necrosis
● Chronic apical abscess
● Tx: NSRCT

We know that that the pain was severe, we know that there
was lingering pain after heat that was relieved by cold and
our heat sensitivity and testing reproduced what the patient
had as their complaint

So based on all of this we know we have a symptomatic

irreversible pulpitis. Bacteria is invading that pulp and
killing that nerve and we need to get rid of it

Case #1 - Periradicular Diagnosis?

● Mild bite sensitivity
● Mild percussion sensitivity - reproduced with tests We Trace that sinus tract and our radiographic image
shows that that sinus tract just draining from the mesial-
Symptomatic apical periodontitis buccal root of that tooth so based on our negative cold
response we know that the tooth has no vital nerve tissue
We’ve got bite sensitivity we've got mild percussion to feel anything we're dealing with pulp necrosis draining
sensitivity and it's again reproduced with the test. the sinus tract meaning it's got a chronic apical abscess
patient knows that when you tap on that two thoughts the
one so we have a symptomatic apical periodontitis So our treatment in this case is non-surgical root canal
therapy and in this case within days or weeks the draining
Case #1 - Plan of treatment sinus tract will heal
Non surgical root canal therapy
Case #3
64 y.o. Male
● Asymptomatic “bump” on the gums
● Perio probing 10+ mm - broad pocket
○ Percussion - +
○ Palpation - +
○ Bite - -
○ Cold - +
● Dx: Normal pulp
● Chronic periodontal abscess
● Tx: Likely extraction

And our treatment plan for this tooth is non-surgical root

canal therapy and elimination of the carries on top getting
 she said there was a sore lump on her gums and her
dentist tried to do a root canal treatment but it hasn't
helped the clinical exam showed a tender swelling on the
gum being there for two months despite the previously
attempted non-surgical root canal treatment she describes
that she's got a paresthesia meaning she's got altered
sensation of the chin but no other pain

Dynamic Diagnosis
● Develop diagnostic findings
● Derive a “provisional diagnosis”
● Continue observation
● Continue collection of significant data
● Derive a final diagnosis
○ After treatment
○ After outcome

Cold positive response indicates that there is indeed vital

and healthy nerve tissue in that tooth so our diagnosis in
this case is a normal pulp and a periodontal abscess

In this case endodontic treatment is not indicated but the

question becomes is the tooth savable from periodontal
perspective

Case #4
48 y.o. Female
● Caucasian
● Malpractice litigation attorney
● Medical history (non-contributory)
● “There’s a sore lump on my gums”
● “My dentist tried root canal… it hasn’t helped”

Case#4 - Subjective history

● Tender swelling on gums
● Present two months
● Dentist attempted NSRCT #21 - unsuccessful
● Referred So I'd like to introduce with this case the idea of dynamic
● Paresthesia - mild diagnosis it's a concept that's very important to note in that
● No other pain diagnosis is an ongoing state it doesn't just stop when the
dentist picks up the handpiece it's got to be continually
verified and modified throughout the procedure since
sometimes findings and observation during treatment can
cause the Stute practitioner to change their diagnosis and
that's the concept of dynamic diagnosis it's fluid and it's
changeable you want to follow the procedure until it's
completed and healing has occurred and this way we're
taking our provisional initial diagnosis to its endpoint

So going back to the case, the dent the patient has this
gingival swelling and the paresthesia so here it's a nice idea
to outline with a skin pencil the area she describes as
having altered sensation and you want to record that so as
that area diminishes over time which are hopefully will
Now is that important and you know the dentist may be you've got a record of that
thinking while I should refer this patient and I need to take
better records but the truth of the matter is that every
patient should be treated exactly the same and those
records should be the same for every patient document
everything it's always really important and it will help you for
your treatment and patient management moving forward
always

So for this patient her medical history was non-contributory

 Periradicular Diagnosis
● Tender to palpate alveolus
● Negative periradicular tests
● Drainage from gingival sulcus
● Apical periodontal ligament thickening

the tooth is tender to palpate, it's negative period radicular

tests, there's drainage from the gingival sulcus and the
apical periodontal ligament thickening indicates that we
have a chronic apical abscess

And you want to record that so as that area diminishes over
time which are hopefully will you've got a record of that
so though it's rare also just bear in mind that paresthesia in
this area can result from endodontic infection and swelling
that presses on the mental nerve, but that's not all that
common
Instrumentation:
● Crown-down and rotary
● Two appointment
○ High level disinfection
Obturation:
● Hybrid lateral/ warm vertical compaction
so based on the pulpal and the periradicular diagnosis, the
endodontic treatment was completed by the endodontist. It
was done in two appointments with a high level of
disinfection. the coronal seal was maintained throughout
and a good temporary well fitting well sealed temporary
was put on the tooth afterward. no fractures were seen
using the general operating microscope and no other
canals were detected

so looking at our standardized form here we've got our

dental findings and our test results and we see that
everything is consistent with a persistent endodontic
disease

radiographically the significant findings include:

● we've got a leaking temporary restoration so so despite our treatment the lesion never healed and this is
recontamination of that canal space bacteria is where the idea of dynamic diagnosis concept comes in.
getting in there reevaluation and performing another diagnostic sense
● we've got thickened cervical level periodontal sampling with reformation of a treatment plan is indicated
ligament space and that's consistent with a clue here
cell trauma or root fracture or loosen the loosening
of the tooth
● we've got a periodontal ligament thickening around
the end of the root that's consistent with the
endodontic infection

Pulpal Diagnosis:
● No pain
● No response to pulp tests
● Dentist started NSRCT

PREVIOUSLY INITIATED THERAPY

so creating our Popple diagnosis she has no pain, no

response to pulp tests and the dentist started the non-
surgical root canal therapy so we have previously initiated
therapy
Options:
● Do nothing
● Non-surgical retreatment
● Extraction
● Surgical endodontic therapy
so what are the patient's options they were discussed and
they are: do nothing non-surgical retreatment, extraction, or
surgical endodontic therapy, and the patient here chose
surgical endodontic therapy.
flap was reflected and an unexpectedly large lesion was
filled with necrotic bony sequester was found. It was
curated and the route and resection and filling of the first
premolar was done. just note here also that the cuspid root
is hanging within this lesion resulting in its pulp losing
vitality. so that material that granulation tissue and bode
sequester that was sent to a qualified oral pathology
service
Change the diagnosis:
● Lesion was too large
● Bony sequestra found and removed
○ Does not occur with LEO
● Biopsy performed
● Pre-existing paresthesia
here's our new information for our changing diagnosis. the
lesion was very very large, there's bony sequester found
and they were removed and that doesn't usually occur with
lesions of endodontic origin. we've got our biopsy we're
waiting for that information and now that idea of that pre-
existing paresthesia we're starting to think of how that may
not have just been swelling pressing on a mental nerve in
the area
Final diagnosis: central giant cell granuloma
so the final diagnosis was a central giant cell granuloma, a
non endodontic pathology that in this case truly mimicked
an endodontic infection
Re-evaluation:
so following through on the dynamic diagnosis right to its
endpoint, here, twenty six months later we've got complete
healing following that surgical debridement and the non-
surgical root canal therapy was done on the on the cuspid
tooth it was the one that was devitalized during the surgery
you may also note here that the patient unfortunately
hasn't got their final restoration replaced and it's 26
months later. so this tooth is definitely subject to coronal
leakage and ultimately the potential for post endodontic
infection in these teeth is really great. we may not be at the
end of the story here
so as you can see diagnosis can be an area that can be
really complex but there are ways that we can simplify it.
take great notes and do things systematically and
consistently the same.
do your testing and clinical examinations covering all bases
from the general to the specific. gather that information
and put it together in a way that makes sense for an
accurate diagnosis. if you're not sure call your local
endodontists, ask questions. but where you know the
diagnosis the treatment plan follows and from a great
treatment plan comes. great treatment and great treatment
makes a happy patient
MODULE 2 – TOOTH ISOLATION (Introduction)
INTRODUCTION
In Dentistry, to work under dry conditions, free of
saliva is essential. That need has been recognized for
centuries, and the idea of using a sheet of rubber to isolate
the tooth.
The introduction of this notion was attributed to
a young American dentist from New York, Dr. Sanford
Christie Barnum, who in 1864 demonstrated for the first
time the advantages of isolating the tooth with a rubber
sheet. At that time, keeping the rubber in place around the
tooth was a problem, but things soon improved a few years
later, in 1882 S.S.White introduced a rubber dam punch
similar to that being used now. In the same year, Dr. Delous
Palmer introduced a set of metal clamps which could be
used for different teeth.
The Quality Assurance Guidelines of the American
Association of Endodontists says that “Cleaning, shaping,
disinfection and obturation of all canals are accomplished
using an aseptic technique with dental dam isolation
whenever possible”
According to Dr. Arnaldo Castelluci, “When it is
not possible, the clinician has two options: one is to make it
possible and the other is to extract the tooth.”
M2 OBJECTIVES
and cements
reduces mercury exposure when using amalgam materials
in the mouth;
reduces aerosol splatters in the oral cavity from dental
procedures;
protects dentists, hygienists, and patients from possible
exposure to HIV, hepatitis, and other infectious diseases or
blood-borne pathogens during procedures

Identify functions of each of the armamentarium for rubber The disadvantages of using a rubber dam:
dam isolation
Use the different armamentarium for rubber dam tooth additional application time, which can be difficult and time-
isolation consuming
Understand the disadvantages and advantages of rubber additional cost of materials: stamp, dental clamps, rubber
dam isolation dam, frame
Describe the different methods of rubber dam isolation rubber dam could break in the patient’s mouth, thus floss is
Perform rubber dam isolation on a mounted jaw placed around the clamp as a precaution for retrieval
could cause damage to the oral mucosa during placement
M2 LESSON 1. Armamentarium for rubber dam tooth and removal of the dam
isolation patient may have discomfort or difficulty breathing due to
blockage of the airway
● Basic Instruments for Endodontics if the rubber dam is latex, it could cause a latex allergy or
● Mouth Mirror episode to occur
● Endodontic Locking Plier may decrease communication between patient and operator
● Endodontic Excavator may increase patient anxiety
● Woodson plastic filling instrument many patients refuse the rubber dam
● Rubber Dam Sheet For more information on rubber dam isolation, click the link
● Rubber Dam Template below:
● Rubber Dam Clamps
● Rubber Dam Clamp Forcep https://www.rdhmag.com/patient-
● Rubber dam Punch care/article/16408220/dammed-if-you-do-dammed-if-you-
● Rubber Dam Frame dont
● Floss
M2 LESSON 3.Different methods of rubber dam isolation
Additional Requirement for Virtual Rubber Dam Isolation: Method 1- Clamp and Rubber Dam Sheet Together

1. Table top

2. Metal jaw or any type of jaw (with complete upper and

lower natural or typodont tooth specimen) that will fit in your
chosen table top.

To view the details of each material and instrument and to

know their function, please click the link below and view the
Method 2- Clamp first followed by Rubber Dam Sheet
powerpoint presentation.

https://cden.tu.edu.iq/images/New/2016/Lectures/Dr.Ah
med/5/Tooth-isolation.pdf

M2 LESSON 2.Advantages and disadvantages of rubber dam

isolation

The advantages of using a rubber dam: Method 3-Rubber dam Sheet followed by Clamp

enhances visibility of the treatment site since the dam

retracts the cheeks and lips
reduces the risk of the patient swallowing instruments or
debris
reduces the risk of contamination of oral microorganisms in
the blood and/or saliva
provides a clean and dry operating field that is free of saliva,
blood, and debris from the procedure, as well as achieves
maximum bond strength when using restorative materials
M2 LESSON 3 CONTINUATION

Rubber Dam Isolation Procedure:

Step 1. Remove calcular deposits on tooth surfaces.

Step 6. Choose what Method of Isolation you like to use.

Method 1- Clamp and Rubber Dam Sheet together.

1. Attach the wings of the clamp to rubber dam sheet

Step 2. Select the appropriate clamp and check its fit on the over the area of the punched hole.
tooth to be isolated.

2. With the clamp forcep , place the clamp with rubber

dam sheet beyond the greatest contour of the
crown.

Step 3. Designate the area to punch hole on the rubber dam

sheet using rubber dam stamp or template.

3. Release the clamp from the forcep and adapt the

rubber dam sheet around the cervix of the tooth.

Step 4. Punch a hole on the rubber dam sheet, appropriate

for the size and location of the tooth.

4. With a hand instrument release the rubber dam

sheet from the wing of the clamp to allow the sheet
to constrict around the cervix of the tooth.

Step 5. Lubricate the inner surface of the rubber dam sheet

with Vaseline to allow it to slide better over the contours of
the tooth and contact areas closely and tightly around the
cervix.
 5. After placement of clamp and rubber dam sheet, a
dental floss may be used to draw the sheet through 1. Slide the rubber dam sheet over the contours of the
the proximal contact area. tooth.

Method 2 - Clamp first followed by Rubber Dam Sheet 2. With the forcep , place the clamp beyond the
greatest contour of the crown.
1. Place the clamp on the tooth crown using the clamp
forcep.

3. Release the clamp from the forcep and adapt the

rubber dam sheet around the cervix of the tooth.
2. Slide and stretch the rubber dam sheet over the
bow of the clamp.

4. After placement of clamp and rubber dam sheet, a

dental floss may be used to draw the sheet through
the proximal contact area.
3. Slide and stretch the rubber dam sheet over the
under jaw and prong of the clamp.

Step 5. Place the frame over the rubber dam sheet, and
stretch out the sheet on the frame to provide soft tissue
retraction.

4. After placement of clamp and rubber dam sheet, a

dental floss may be used to draw the sheet through
the proximal contact area.

Step 6. Swab with disinfectant the isolated tooth and the

adjacent structures .

Method 3 - Rubber dam Sheet followed by Clamp


(12) Cross check for missing pictures and details and M1
MODULE 4 SCOUTING, EXPLORATION, PULP EXTIRPATION
AND IRRIGATION
Canal scouting is the first phase of canal instrumentation,
during which procedural difficulties or errors might more
frequently occur.
As a first step, the negotiation is most often essential.
Negotiation might be thought of as the process of
exploration and discovery to determine the individual canal
anatomy noted previously using small K-files(6-10s).
Therefore, canal scouting and exploration is necessary prior
to canal cleaning and shaping. Another equally important
procedure is pulp extirpation, it is the complete removal of
vital dental pulp, which is also called pulpectomy.
Irrigation on the other hand facilitates the physical removal
of materials from the canal and introduction of chemicals for
antimicrobial activity, deodorizing and hemorrhage control.
M4 Lesson 1:Armamentarium for Scouting, Exploration, Pulp
Extirpation and Irrigation:
1. SS K-type files #6,#8 and #10
2. Rubber stop
3. Specimens: Maxillary Central Incisor, Maxillary First
Premolar and Maxillary First Molar
4. 5.25% Sodium Hypochlorite
5. Lubricant (EDTA)
6. 2-3 pieces of 3 cc or 5 cc hypodermic syringes
7. 2-3 pieces side vented or side port needles
8. Absorbent paper points size #15 to #40
9. Lamp with denatured alcohol and match or lighter
10. Distilled water for dilution
M4 Lesson 2: Procedure and Guidelines in Scouting,
Exploration, Pulp Extirpation and Irrigation
A normal pulp tissue as in the case of intentional root canal
treatment or a diseased pulp tissue with an irreversible
pulpitis case is removed during canal cleaning and shaping
with the use of endodontic files and irrigating solutions.
However, in cases where canal cleaning and shaping is not
possible on the same treatment appointment pulp
extirpation is recommended.
Click the link below to view a case of pulp extirpation using
photoacoustic irrigant streaming.
The following are Procedures and Guidelines in Scouting and
Exploration:
1. Probe the canal orifice with endodontic explorer
(pathfinder/Stewart probe) to determine the direction of the
canal at the cervical third.
2. Establish the Trial Working Length (TWL).
a. Using the endo tooth model specimen
(JChenny), measure the tooth length (TL)
from the reference point (incisal or
occlusal) to the apex or end of the root.
Whatever the measurement, subtract 2mm
as a safety factor to get the TWL.
b. Record the measurement on your
printed portfolio.
3. Mark on the scouting instruments the TWL.
a. Mark the TWL on SS K-type files #8
and #10 with rubber or silicone instrument
stop.
b. Select which from the two files can
glide freely through the canal. The file that
glided through will be referred to as the
scouting instrument.
4. Confirm the canal morphology as the scouting
instrument was inserted apically.
a. Feel the patency of the root canal
using the scouting instrument.
b. Take note of any abrupt changes
in the canal anatomy.
c. Interpret the tactile information and
take note of the probable direction or
location of resistance and curvatures.
Procedure and Guidelines in Irrigation:
1. Prepare two (2) disposable hypodermic syringes.
a. Color code or label each of the
syringes for easy identification. One will be
used to introduce the irrigation solution
and the other to aspirate excess solution
when the canal is ready for sealing.
2. Prepare the irrigation solution.
a. In a clear and clean container, dilute
1 part of 5.25% Sodium hypochlorite
(NAOCl) with 5 parts distilled water (1:5
ratio). If full concentration is preferred,
simply transfer the commercially prepared
5.25% solution in another container to
conceal the brand.
b. Fill up one syringe with the
solution. Lift the syringe with the needle in
an upward direction and tap the barrel to
remove the bubbles toward the surface of
the solution.
c. Push the plunger and express out the
trapped air.
3. Irrigation of the canal.
a. Position the needle into the widest
portion of the canal allowing an adequate
space for the backflow of the solution. For
narrow canals, simply flood the pulp
chamber with NaOCl.
 b. Place a cotton ball next to the
access preparation to catch the backflow
of the solution.
c. Very slowly and without pressure,
push the syringe plunger to introduce, at
least,
4. 1 cc of the solution into the canal. For narrow
canals, simply flood the chamber with the solution.
d. Place a drop of lubricant.
e. File the canal once it’s ready.
f. Leave the solution inside the canal
while filing. Constantly irrigate before
changing the file size.
g. At the end of instrumentation and as
a final rinse before sealing the canal either
temporarily or permanently, repeat the
procedure, except for the application of
lubricant (step d), until all dentin shavings
or debris are flushed out of the canal.
5. Aspirate the excess solution when the canal is ready
for drying and sealing.
a. With the second syringe, express out
the air from the barrel by pushing the
plunger to the fullest before insertion into
the orifice.
b. Position the tip of the needle
inside the root canal.
c. Pull the plunger to aspirate the excess
irrigation solution and air.
d. Repeat the procedure when
necessary.
6. Dry the canal with sterile absorbent paper points.
a. Sterilize the absorbent paper points
in an autoclave. Paper points must have
the same size as the MAF.
b. Mark the WL on the paper points.
c. Pass the paper point over the flame
of an alcohol lamp 3x or immerse in glass
beads sterilizer for a few seconds.
d. Insert the sterilized absorbent
paper point into the canal and swab the
walls to the full WL marker to absorb the
fluids from the canal.
e. Repeat the procedure until the
canal is "bone dry".
7. Seal the canal either temporarily with Calcium
hydroxide or with final root canal obturation materials.
M4 Lesson 3: Procedure in Handling Chemical Adjuncts
Irrigation performed with mechanical cleaning and shaping
of root canals constitutes one of the most important stages
of root canal treatment. The antibacterial effects of current
irrigation solutions have been reported to be enhanced by
increasing the concentration, temperature and amount of
solution and by agitation.
Sodium hypochlorite is currently the most commonly used
irrigating solution due to its pronounced antimicrobial
effects and the capacity for organic tissue dissolution.
Decreasing the concentration of the solution reduces its
toxicity, antibacterial effect and ability to dissolve tissues.
Increasing its volume or warming it increases its
effectiveness as a root canal irrigant.
However, due to its (NaOCl) limited effects on inorganic
component of the smear layer, ethylene diamine tetraacetic
acid (EDTA) is used which acts on the inorganic part of the
smear layer. NaOCl is an adjunct solution for removal of the
remaining organic components. Irrigation with 17% EDTA for
1 minute followed by a final rinse with NaOCl is the most
commonly recommended method to remove the smear
layer. EDTA has little or no antibacterial effect.
Chlorhexidine has broad-spectrum antibacterial action,
sustained action and low toxicity. Because of this properties
it has also been recommended as a potential root canal
irrigant. The major advantages of chlorhexidine over NaOCl
are its lower cytotoxicity and lack of foul smell and bad taste.
However, like NaOCl, it is unable to kill all bacteria and
cannot remove the smear layer.
An alternative solution to EDTA for removing the smear layer
is the use of MTAD, a mixture of a tetracycline isomer, an
acid (citric acid) and a detergent. MTAD was developed as a
final rinse to disinfect the root canal system and remove the
smear layer. The effectiveness of MTAD to completely
remove the smear layer is enhanced when a low
concentration of NaOCl (1.3%) is used as an intracanal
irrigant before placing 1 ml of MTAD in a canal for 5 minutes
and rinsing it with additional 4 ml of MTAD as the final rinse.
it appears to be superior to chlorhexidine in antimicrobial
activity. In addition, it has sustained antibacterial activity, is
biocompatible and enhances bond strength.
M4 Lesson 4: Errors in Scouting, Exploration, Pulp
Extirpation and Irrigation as Well as its Management
Sodium hypochlorite is generally not utilized in its most
active form in a clinical setting. For proper antimicrobial
activity, it must be prepared freshly just before its use.
Exposure of the solution to oxygen, room temperature and
light can inactivate it significantly. Extrusion of NaOCl into
periapical tissues can cause severe injury to the patient. To
minimize NaOCl accidents, the irrigating needle should be
placed short of the WL, fit loosely in the canal and the
solution must be injected using a gentle flow rate. Constantly
moving the needle up and down during irrigation prevents
wedging of the needle in the canal and provides better
irrigation. The use of irrigation tips with side venting reduces
the possibility of forcing solutions into the periapical tissues.
Treatment of NaOCl accidents is palliative and consists of
observation of the patient as well as prescribing antibiotics
and analgesics.
(Video from Canvas-https://youtu.be/PX3tezaj1ns)
ENDODONTIC DISINFECTION
- Debridement
- Smear Layer
- Biofilm
There's been a variety of methods that our profession has
utilized to better appreciate root canal system anatomy but
what we all agree upon is that well shaped canals have the
potential to be clean canals regardless of the method
utilized in the night disinfection is comprised of removing
all the pulp the byproduct of our instrumentation the smear
layer and finally communities of bacteria biofilms.
Many clinicians relate to a block canal is the inability to
pass a ten file to the full working length but in reality
especially with the advent of nickel titanium instruments
and with particular emphasis on the cross section of the file
many blocked canals are in turned blocked laterally rotary
nickel titanium instruments especially the radial landed
variety tend to burnish more debris into the lateral canals
eccentricities off the rounder canals and dentinal tubules
than cutting instruments these blocked anatomical spaces
need to be cleansed so we can encourage and promote our
irritants to move laterally into the deep anatomy
There has been tremendous interest in the endodontic
marketplace on how to improve clinical disinfection there's
a variety of methods that are either to market or are
emerging rapidly for clinical practice let's quickly take a
look at some of the more popular methods:
DISINFECTION METHODS
- EndoVac
- RinsEndo
- Ultrasonic fluid delivery
- Photo activating Disinfection
- Plastic endo File
- Irrisafe file vibringe
- Endobrushes
- EndoActivator
The endo vac is nothing more than placing a suction device
in a well shaped canal to the full working length this
method is quite interesting sucking out debris or livering it
through vacuassin procedures is useful and helps us have
less flare-ups and potentially allows us to pack better
The Rinsendo is a german device that is made by the Durr
company and in this method they use pulsating positive
irrigation and suction to better enhance disinfecting
Yet another method that has proven to be quite interesting
as based on the evidence presented in the Journal of
endodontics is ultrasonic fluid delivery in this method a
cannula is attached to a ultrasonic handpiece the power
setting is going to move the tip between 25 and 40
thousand Hertz and dispense the reagent of your choice
into a well
Shaped canal as per usual with ultrasonic activation one
has to be concerned about internal ledges transportations
and broken instruments
Photo activating disinfection is a very interesting method
that it was born primarily in Western Europe in this method
of disinfection a low diode laser is used the preferable
wavelength is 980 nanometers of light in this method a
solution such as tellurium chloride can be flushed liberally
into a well shaped canal and presumably the solution will
move out and enter The cell wall of a microorganism this is
called tagging the bacteria when the diode laser is placed
in the canal and activated the light seeks out the tagged
bacteria it implodes the microorganism rendering it non
virulent plastic end o file is
nothing more than a plastic instrument that's impregnated
with a diamond coating as this instrument turns clockwise
in a canal the diamond grit tends to sand and continue to
prepare and already optimally shaped canal this
instrument is actually producing its own smear layer
although some evidence has been produced to show its
efficacy the
Erie safe file is a non cutting instrument that attaches to an
ultrasonic handpiece and I've already given the cautionary
remarks about
vibrating metallic instruments below the orifice
the vibrance is one of the newer devices that has recently
come to market and it's basically like a handheld
anesthetic syringe except in this case the operator is
dispensing reagent as the cannula again being metal is
vibrated we've seen some movement towards endo
brushes not as quickly as I would have anticipated but we
now see some brushes on the market the problem with the
current market version brushes
is the d0 diameters are quite large on the order of about 50
or 60 which means
they don't often get all the way to length on smaller
diameter canals stay tuned though we don't know the final
verdict on brushes because technology always drives new
innovations the one that you're probably familiar that I've
been involved with and our group and team built is the
endoactivator in this method of activation
we use a polymer which is highly flexible and strong and it
goes into a fluid-filled chamber is
introduced into a canal and through activation we use sonic
energy to kindly activate the tip the polymer tips are not
subject to a diminishing return on their vibration they can
write on thewalls of prepared dentin and still activate a
solution to length and around multiplanar curvatures there
is plenty of emerging evidence on the endoactivator and I'll
show you just
three images that were produced at Paris
by a postgraduate residence named korone and you can
see in that low magnification 500x a bifida T both
branches have been cleaned one presumably with the
instrument and with reagents and the other one the
lateral canal is where the instruments never went in a
higher magnification you can begin to see the potential
for the reagent to move as much as three to four hundred
microns back through the dentinal tubules to enhance
deep lateral cleaning and finally a 2000 X you can
see open Patent dentinal tubules in the apical one third
of this specimen and this was
around the curvature if we're ever going
to bond obturation materials against
Dentin we must divide remove the smear layer and finally
all the bacteria when present my final remark would be
when you look at this rather lengthy list of devices one
must assess the cost to get into the technology to the
ease of use and finally is there evidence or science
behind it to show that it actually
disinfects a root canal system