Filling the Canal: Lateral Condensation: Simple, Highly effective, GOLD standard -
Limitations:
GP is not homogeneous, Sealer pools, not concentrated at apical 1/3, causes vertical rt fractures
Thermoplasticized GP: Pressurized/Alpha Pressurized/Alpha (hot) phase = GP FLOWS, FLOWS , -
Limitations:
Thermal shrinkage
Continuous Wave:
Vibrates? GP into all canals
Thermafill:
Matching files and obturators, heats up and shove it in,
A spiraled GP cone = ledge or blockage
Retreatment: Success Rate of Endo Tx:
85% (nobody knows)
Management:
RCT>Surgical Endo>Extraction
-
Retreatment can improve the prognosis of surgery (if retreat fails, it’s still helpful)
-
Untreated (missed) canals are more responsive to retreatment
-
Surgery is indicated for any severe curves/ledges or calcifications
-
Reduced Success with Separated instruments, ledges, perforations
Removing Restoration:
Better access, radiographs, visual
Access through Restoration:
Maintains function, less costly, esthetics
Contraindication of Post Removal:
LONG, WELL FITTING posts, thin dentin
Devices for Post Removal: -
Ultrasonics:
-
Hemostats:
-
Stiegletz Pliers:
-
Ruddle Post Puller:
-
Masserann Kit:
Gaining Access to Apex: -
Pull Out GP:
straight or overextended canals
-
Dissolve GP:
curved canals
-
GP Removal:
Coronal portion with Gates Glidden
-
o
Chloroform dissolves the rest, cheap and fast, carcinogenic though
o
Eucalyptol is less irritating, but least effective
Silver Cone Removal: o
-
prep around, pull hard, ultrasonics, trephine burs
If it can’t be removed, bypass it with hand file or ultraonics, ultraonics, double hedstrom technique
Cement Removal (apical plug): penetrate with file or dissolve/vibrate/drill
Mishaps: Indications for 3D Accuitomo: -
Perio: Bone contour in deep pockets and furcations
-
Endo:
-
Ortho: RT configuration, PDL and anatomy
MTA: -
75% Portland Cement, Tri (and Di)calcium silicate, Bismuth Oxide, Tricalcium aluminate Use: o
Perforations: -
RTC configuration, measurements, variations and additional canals
Perfs, apexification, surgical root repair, internal resorption, pulp cap, pulpotomy Any time you “fix” the pulp Size, duration, location
Matrix: accessible perforations below bone >1 mm, large perforations in middle/apical 1/3 of straight canals
NaOCl Accidents:
Women, maxillary, posterior, abscesses most common.
Terms: Anasthesia:
no sensation
Parathesia:
altered sensation w/no stimulus*
Dysethesia:
painful sensation w/no stimulus
Hypoesthesia: decreased sensation to pain* Hyperesthesia: increased sensation to pain (allodyna) Neurological Defects: -
Pressure:
pin prick
-
Touch:
brush
-
Touch:
Von Freys Hairs
Injections: “Electric shock” does NOT = nerve damage If recovery is >2 weeks, prognosis is poor Most common neurologic pain: -
Overfill (Hyperesthesia)
-
Phantom (Dysethesia)
Overfills:
-
IAN:
EARLY Tx may REVERSE effects of Endo-IAN accidents!
-
Mx Sinus:
Aspergillosis (zinc = growth factor, purely opportunistic), surgery is CURATI VE
-
Document everything
Ultrasonic Burns: o
-
Double temperature if no coolant used on stainless steel post 145
-
Titanium with coolant = 55
-
Metal core delivers heat to APEX (vital bone)
-
Monitor post temp each minute, ice post if needed, use irrigation, try pulling with pullers o
o
Rest intervals needed if post removal excee ds 10 min
Mishaps Notes: Md. Incisors having two roots:
50%
Chance of visualizing the IAN in an FMX:
60%
Pantograph:
80%
(20% of the time, IAN is not in a canal )
Voxel = 3D Pixel (on exam) Sealer Puffs are OK, but NEVER in the SINUS or IANC Zinc Oxide Eugenol or Formaldehyde paste creates a crushing and chemical injury, large re sponses Dysathesia: ongoing burning pain. Case 1: Decompression of the sealer at the apex, saline irrigation for 1 hr. -
Case 2: Do Nothing… Permanent parasthesia
Literature says: REMOVE WITHIN 2 DAYS! Symmetry is KEY. Always look for symmetric and centered canals. Perforations: -
Repair matrix concept
-
Use COLLAGEN hemostasis, then CollaCote, pack/fill perforation, and then pack MTA against it.
-
Collagen matrix = bioabsorbable, osteoinductive/conductive
-
Use a matrix anywhere you have an accessible perforation
MTA: -
Can create and apical closure, instead of using calcium hydroxide
NaOCl: -
Best Irrigant, pH 11, cheap, removes smear layer, dilute to 1.5%, canal needs to accept a 25 file before full irrigation.
-
INJURY ONLY HAPPENS ONE WAY; o
NEVER BIND NEEDLE INTO ROOT CANAL
-
NaOH “Accident” : immediate profuse bleeding
-
Women, posterior, maxillary, necrosis = high chance of injury
Anesthesia: no pain Paresthesia: altered *Dysestheasia: pain with NO stimulus. IAN is within 1mm from apex of 2
nd
premolars/molars: 40%
Almost no correlation between “Electric Shock” fee ling and parenthesis -
You will win in court
-
If a problem occurs, then an intraneural hematoma is likely. Simple bad luck.
4% Sln: -
Use often for infiltrations, but NOT for blocks or weirdoes
Reflex Sympathetic Dystrophy: -
Get and injury to arm/leg, and pain never goes away
-
A CNS problem
-
Injury during dentistry causing pain forever...
Management of Gutta Percha in IANC: -
IMMEDIATLEY remove it!
-
2 days to remove
-
3 days = damage completely occurred. (on ex am)
-
Need an amazing OS to de-roof the IA and microsurgery of the IAN
-
Aspergillosis: fungus that grows on ZINC (zinc oxide sealer*), purely opportunistic
Overfills: -
Tx IMMEDIATLEY
-
Neurotoxic material
-
Allodynia with triggers is a sign
-
Document Anything
-
Refer to an amazing specialist
Ultrasonics: -
Post Removal: remove circumferential restorative materials, medium-full intensity
-
Sustained heat at 50 = Necrosis
-
10 is the RED LINE, relative to BONE (not dentin/tooth)
-
Post delivers heat to the apical dentin
-
USE ENDO ICE to cool post during removal with ultrasonics.
-
Don’t remove long posts fast, burn out is common lawsuit
o
o
Trauma: Incidence: -
30% of ages 2-5 yrs
-
1 in 3 males, 1 in 4 females
Prevention:
Mouthguards, ortho
Hx: -
Blow to ant. Fractures ant. crown
-
Blow to chin fractures any tooth
-
Padded blows = root fracture or displacement
-
Sharp blows = coronal fracture
-
Hx is important for tetanus and LITIGATION
Neurologic Exam:
Communicate? Rotate head? Parasthesia? Dizzy?
External:
condylar fractures (have pt. open)
Soft Tissue:
lacerations
HT:
take pano, mobility
Pulp Tests:
cold and EPT, retest at 30-90-180 days, beware of false negatives
Laser Doppler Flometry:
Measures blood flow
Radiographs:
multi-angle, soft tissue (low Kvp),
Accuitomo:
sweet
Pt Instructions: Soft diet 2wk, brush teeth soft brush after each meal, CHX bid, recall Tx: -
Acute = immediate, Subacute = 48 hrs, Delayed = mutual convalescence
-
Fractures: o
Infraction:
bonding agent or nothing
o
Enamel only:
smooth, restore if esthetic
o
Uncomplicated (enamel and dentin only):
o
Complicated:
base and seal tubules w/composite (good prognosis)
pulp cap if AT ALL possible, MTA>GI>(etch)Composite
Apexification: Fill canal wit MTA, coronal with Composite
No pulp caps on calcified or displaced mature teeth
Pulpotomy:
Pulpal Regeneration:
large exposure + immature
Irrigate w/NaOCl, Tri-antibiotic paste, blood clot
-
Concussion:
adjust occlusion
-
Subluxations:
+splint if mobile, monitor
-
Luxation:
+Reposition, splint 2 weeks, RCT 2 weeks after
-
External/Internal Root Resorption: Fill with Ca(OH) 2
-
Intrusion:
Slight = Spontaneous eruption, Severe = RTC (poor prognosis)
-
Avulsions:
TIME is KEY, 90% success if <30 min
o
Keep tooth, wet and cold
o
Remove debris with saline, but that’s it
o
If dry, soak in saline 5 min
o
Irrigate socket, don’t curette
o
Take radiograph on re-implant
o
Doxycycline antibiotic (if over 12), tetanus booster
o
2 wks post implantation:
o
Autotransplantation
RCT with Ca(OH)2, poor prognosis
Tauma Notes: Goal of Trauma: Preserve the vitality of the pulp -
Strength of the root is low in younger teeth
Mouthguards don’t protect against concussion Blows: -
Chin… can fracture any tooth
-
Padded blows give root fractures
-
Impact blows give coronal fractures
Transillumination is best way to see fractures RADAR:
You are a mandated reporter
-
Recognize
-
Ask
-
Document
-
Asses
-
Review
Exam: Start globally Neurologic:
Drowsy, dizzy, nausea, eye movement, cognitive ability
Hard Tissue:
Number, malposition, tooth sloth
Pulp Tests:
Use as a baseline only, but retest again later
Radiographs:
Multiple Angle + Soft Tissue
DWP:
Soft Diet for two weeks, soft toothbrush after each meal, chlorohexidine rinse
Infraction:
A fracture
Enamel and Dentin = Uncomplicated Pulp = Complicated Transient apical breakdown: can turn into apical Don’t do too much work that day, just get some composite in it. *Keep pulps alive if you can. Irrigate exposure w ith clorohexidine, place MTA, GI, then Fill. -
If there’s too much bleeding, or calcific changes, then it needs a root canal
Apexogenesis: keeps root alive, builds dentin Apexification:
basically endo
Racemic epinephrine pellets: no coagulation Pulp Response of Trauma: -
Obliteration/calcification
-
Necrosis
Regeneration: Triple antibiotic paste, MTA Dentaltraumaguide.org
Internal Resorption: -
Just do a normal root canal
Intrusion: blood supply is destroyed, Ankylosis is likely and prognosis is poor.
Root Fracture and Resorption: Horizontal Fracture:
Impact trauma, actually OBLIQUE, resorption/ankylosis are common (cementum coating is lost)
-
Reposition, splint 2-4 weeks
-
(25% need RCT) apex is vital so stop RCT at fracture site
-
Root Extrusion: allows restoration
-
Dentin is foreign to osteoclasts
Vertical Fracture:
Various etiologies
Resorption: -
angled radiographs>
external lesions “move”
-
Internal resorption needs vital pulp
-
CBVT
Non Mineralized Pre-cementum doesn’t adhere to osteoclasts, breaching this layer (with inflammation) causes external resorption. Emergencies: Diagnosis Requires: -
CC, Med Hx, Pain Hx
-
Odontogenic Pain:
-
Peri-redicular (endo) Pain:
-
Hypersensitivity:
Patients can localize painful tooth 75% of the time Patient can localize 90% of the time
Dx: o
-
-
Fast onset, short duration
Reversible Pulpitis: o
new restorations, tertiary dentin laid down 8 um/d, so wait acute, stabbing pain, COLD DOES NOT LINGER, no radiolucency
Treat by replacing filling (with GI)
Irreversible Pulpitis:
sharp pain, difficult to localize, COLD LASTS >30s
o
20% of RCT is needed due to reactions to restorations
o
If you don’t have any time to treat> EUGENOL (sedative) pellet (only pellet!) and temp filling
o
Pulpotomy w/ZOE works for 96% of cases
o
Pulpectomy is an option (crown down prep/irrigation), prep to #25 file, ONLY use Ca(OH) 2 in canals
Necrosis: o
dull pain, cold = relief , darkened tooth
Use Ca(OH) 2 in canal for 1-2 weeks before obturating
-
Abscess:
usually don’t need antibiotics unless ICP
-
Retreat Case:
Antibiotics and ASAP appointment
-
Root fracture:
rule this out because it’s a hopeless prognosis
o
CBVT is very helpful
Endo Surgery: MOST ENDOS SHOULD GET RETREATMENT -
Surgery is an ALTERNATIVE
Indications: -
Pain relief, drainage, anatomic complication
Contraindications: -
Medically compromised, unidentified cause of tx failure
Surgery:
-
Incision:
drainage, block anesthesia is preferred
-
Apical Surgery: o
Failed Endo with immobile post, separated instrument, deep filling, failed conventional endo
o
Flap, access, curettage, root-end resection, prep, restore, post op instructions, post op visit
Flap:
Semilunar, Submarginal (leaves MGM and papilla alone), Full (sulcular)
Curettage:
biopsy always indicated
o
-
10 bevel, more depth is better, 3mm fill into canal, isthmus prep
Microhandpeice is too large, use ultrasonics
IRM, GI, MTA are best fillers
Radiograph before suturing, hold flap for 5 mins, 4-0 silk
POI both oral/written
* Always use microscope. -
-
Corrective Surgery: o
Procedural accidents, resorptive perforations
o
More difficult than apical surgery
o
Root amputation, hemisection, bicuspidization,
Indicated for vertical root fractures or untreatable canals
Contraindications:
Bicuspidization is for furcations
Intentional Replantation:
strong abutment teeth available
LAST RESORT PRIOR TO EXTRACTION
o
Forceps only (no elevator)
o
<15 mins extraoral time
o
HBSS (Hank’s)
On Exam: Know the composition of Gutta Percha (in reading) -
Alpha Phase = Sticky Soft Phase
-
Beta Phase =
Hard Phase, non-adhesive
Horizontal Condensation Resistance Form:
Apical Stop
Vertical Condensation Resistance Form:
Taper
Wrinkled GP: -
Block or Ledge
Always get patency (with a 15 or 20 file since the apex is .27)
Ledge: -
Make sure you’re patent by using a J-hook then filing (50 times) against the ledge
Heating GP: Heat, Pack, keep packing after stop heating. The cone won’t come out if you have a good fit. -
Vertical Condensation gives the best Apical Seal, Horizontal Condensation gives the best Coronal Seal
-
Must stay 5mm from apex, because GP WILL heat seal at the apex. If you go closer than 5mm, the GP WILL spill out of the apex.
-
5 Second Fill (compensate for shrinkage)
Filling multiple canals:
-
Always block one canal (with a file) while filling the other canal
Pro-Root MTA: -
Apical seal with cementum GROWTH
Mix it thick, then pack Apical Dx is different than Pulpal Dx. Abscesses ALWAYS = NECROSIS and NON-VITAL tooth. Osteitis indicates pulpitis. Success: 50-90% Know the Management flowcchard (2
nd
lec)
Prognosis of Retreatment: Always POOR J shaped lesion = CRACK (root fracture) RotoPro Bur: gets posts out Trephen Bur: cuts around object to allow retrieval Ultrasonics: can be dangerous at the apex, causing perforations Quantek: good bur to remove GP Chlorophorm is a Beta Carcinogen Eucalyptol is slower but not carcinogenic Separated Instrument: -
Immediately take an x-ray o
Apex- won’t get it out
o
Mid-root/coronal, possible
o
If you can see it, ultrasonics
Endo Perio Connection: The endo exam is challenging because 1/2 the q's are multiple answer. 25/60 Q's are multiple answer. Apical Foramen, Lateral canals and even (young) dentinal tubules are portals of exit for bacteria.
Origin and Progression: • Endo is quick, perio is slow • Perio has less potency and low concentration of irritants (ON EXAM) Pulp to Periodontium: • Granulomatous tissue at the apex due to breakdown at apex (ON EXAM: resorption, bone breakdown, granulomatous tissue, PDL breakdown, select the 5 things that occur at the apex) Periodontium to Pulp: • Apex is minimally effected until plaque covers the entire r oot
• slow progression • Cementum is an effective barrier, but 30 yrs of root planing can make ceentum suceptible Primary Perio dis has ATTACHMENT LOSS Aging Pulp:
less cells and more mineralization and collagen (mineralization and fibrosis)
Periodontal Disease:
angular bone loss
Endodontic Disease:
apical loss
Subjective Symptoms determine the Tx. • EPT, Thermal, Test Cavity • Probing • NOT USEFUL: percussion/palpation Periodontal Defects are wider, Endo defects are more like sinus tracts. Both diseases must be primary on a tr ue combined lesion: • Do RTC first, then perio Tx.
