Endodontics 1: Prelims
Endodontics 1: Prelims
Endodontics 1: Prelims
Endodontics includes, but is not limited to: Basic Concept of Root Canal Therapy
1. Differential diagnosis
2. Treatment of oral pains of pulpal and / or → If bacteria and by-products of pulpal inflammation
periapical origin (orthograde / conventional have been reduced to a non-critical level of infection,
RCT) it will effect a cure, allowing resolution and repair of
3. Vital pulp therapy damaged peri radicular tissue.
a. pulp capping
b. pulpotomy ➔ The extent of damage depends on the virulence
4. Nonsurgical treatment of root canal systems with or and number of microorganisms and the reactance of
without periradicular pathosis of pulpal origin the best.
5. Selective surgical removal of pathological tissues
resulting from pulpal pathosis Conclusion
6. Intentional replantation and replantation of avulsed
teeth To appreciate Endodontics, all of the scope, history,
7. Surgical removal of tooth structure: rationale, and principles must be fully understood.
a. root-end resection
b. bicuspidization Dentin-Pulp Complex; Biology of the Pulp and
c. hemisection Periradicular Tissue
d. apicoectomy (retrograde/non-conventional endo)
8. Bleaching of discolored dentin and enamel Dental Pulp
9. Retreatment of teeth
10. Treatment procedures related to coronal • Loose connective tissue in the center of the tooth
Restorations • Primary function: Form and support dentin that
surrounds it, forms the bulk of the tooth.
Objectives
• Contains odontoblasts
1. To be able to retain a tooth inside the oral • Remains vital throughout life
cavity which may otherwise require extraction • Responds to external stimuli
2. Relief of pain, if present • Dentin and pulp contain nociceptive nerve
3. Removal of pulp from root(s) of tooth fibers.
4. Disinfection of root and surrounding bone by • Autonomic (sympathetic) nerve fibers only
5. Complete filling of root canals (obturation) occur in the pulp
6. Placement of final restoration (if not
• More dentin is laid down and new odontoblasts
restorable, extract
7. Main contraindication: non-restorable tooth differentiated when needed for repair
• Pulp equipped with all necessary peripheral
Basic Principles components of the immune system.
• Injury and foreign antigens=inflammation, pain
1. Chain of asepsis • Good health of the pulp vital to restorative and
2. Correct diagnosis and treatment planning prosthodontics dental procedures
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• Size and shape of pulp depend on: ➢ Branch and narrow toward the OL and form
➢ Type of tooth plexuses beneath
➢ Degree of tooth development related to • Dentin formation continues throughout life in an
px’s age incremental pattern
➢ Any restorative procedures carried out. ➢ Lines in the matrix changes in the direction of the
tubules
Development of the Dental Pulp- Early Development • Rate of deposition slows in adulthood, but never
completely stops.
• Starts as band of epithelial cells on the surface of Stem cells under odontoblast- still have potential to
the embryonic jaws= dental lamina differentiate
• Down growths from the band form the teeth Predentin- adjacent to ameloblast, unmineralized
• Initially looks like a bud (bud stage)—bud Rate of dentin deposition slows down but does not
becomes invaginated (cap stage) –deepening of completely stop.
invagination (bell stage)
• Enamel organ = bell-shaped downgrowth Root Formation
• Tissue within the invagination=dental pulp (dental
papilla) • Cervical loop = point where cells of IDE + ODE
➢ Bell stage: Inner layer of cells of enamel organ meet
differentiate into ameloblasts—outer layer of cells • Delineates the end of the anatomic crown
differentiates into odontoblasts. • Site where root formation begins
• Tissue layer begins to differentiate around the • Hertwig’s epithelial root sheath (HERS): apical
enamel organ and DP = dental follicle – proliferation of the fused epithelia, where
periodontal attachment root formation is initiated.
• Tooth germ= DP + DF • Provides signal for odontoblast differentiation
• Acts as template for the root
Dental lamina- down growths- forming the teeth= • Pattern of cell proliferation here determines
enamel organ root configuration
Inner layer- ameloblast
Outer- odontoblast ED- epithelial diaphragm
HERS- apical proliferation of cells
Dental follicle- pdl
Tooth germ= dental papilla & Dental follicle • After fist dentin in root has formed, basement
membrane beneath (HERS), breaks up and
innermost cells secrete hyaline material
Starting to become odontoblast (@periphery)
overly newly formed dentin= hyaline layer of
Very little enamel
Hopewell-Smith
• Histo and morphodifferentiation of tooth germ
• Fragmentation of HERS then occurs – allows
genetically determined and executed by growth
cell of DF to migrate and contact newly
factors, transcription factors, signaling molecules.
formed dentin --- differentiate into
• Differentiation of odontoblasts from
cementoblasts --- initiate acellular cementum
undifferentiated ectomesenchymal cells initiated and
formation
controlled by ectodermal cells of IDE of EO --- basal
• Epithelial cell rests of Malassez: remnants of
lamina of IDE disappears, odontoblasts begin to lay
root sheath found in the periodontium close
down dentin --- IDE cells start to deposit enamel.
to the root (after completion of root
• Deposition of unmineralized dentin matrix begins at
development)
the cusp tip, continues in a cervical (apical) direction
at an average of 4.5 μm/day
• Crown shape predetermined by proliferative pattern Epithelial cell rest- during inflammation= it can
of IDE cells give rise to radicular cysts under certain conditions
• 1st layer of dentin formed= mantle dentin
Formation of Lateral Canals and Apical Foramen
• Matrix formation, mineralization continues
throughout dentin deposition
• Lateral canals/ accessory canals: channels of
• Predentin: between 10-50 μm of dentin matrix
communication between the pulp and PDL
immediately adjacent to odontoblast layer
• Forms when a localized portion of the root
• Nerves and BVs migrate into pulp from future
• Single/multiple, small/large
root apex in a coronal direction as crown formation
occurs
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• May occur anywhere along the root, but • Numerous undifferentiated mesenchymal
most common in apical third ; cells (tissue -specific stem cells) possess ability
➢ Molars: may join pulp chamber PDL in root to form new cementoblasts, osteblasts, or
furcation fibroblasts.
Principal perio fibers- suspend tooth in socket
Lateral canals- entryways of bacteria or disease Cellular cementum- lesser role in support
could extend. • Blood supply derived from surrounding bone,
gingiva, and branches of the pulpal vessels
• During root formation: AF usually located at • Supports high level of cellular activity in the
end of anatomic root area
When tooth development has completed: AF • Neural supply has small, unmyelinated
is smaller, found a short distance coronal to sensory and autonomic nerves and larger
the anatomic root end myelinated sensory nerves.
• Distance increases as more apical cementum
is formed Anatomic Regions
• One or multiple foramina at apex • Tooth has crown and root joined at the cervix
Multiple foramina occur more often in (cervical region)
• multirooted teeth • Pulp space divided into coronal and radicular
regions
Apical foramen- located a little above the root ➢ Shape and size of tooth surface reflect
shape and size of the pulp space
If there are multiple foramina:largest is referred to as ➢ Coronal pulp – pulp horns, pulp chamber
AF, smaller ones are accessory canals= apical delta. Pulp space become asymmetrically smaller
Diameter = usually 0.3-0.6 mm after completion of root growth due to slower
dentin production.
➢ Largest diameters found on D canal of Md molars, • Molars apico-occlusal dimension is reduced
palatal root of Mx molars. more than MD dimension
• Excessive reduction in pulp space can lead to
Formation of the Periodontium problems in locating, cleaning and shaping the
RCS
Develop from ectomesenchyme derived tissue (dental • Anatomy of root canal differs between and
follicle) within tooth types
Root sheath breaks down after mineralization has • Variation in size and location of the AF
occurred. influences degree to which blood flow to pulp
➢ Allows cells from the follicle to proliferate and may be compromised after trauma
• Young partially developed teeth have better
differentiate into cementoblasts.
Bundles of collagen are embedded in forming prognosis for pulp survival
cementum and will become principal fibers of the 1mm cavity prep for pedo ptx(large pulp horns)
PDL. Orifice- opening of canal
Apical constriction- we do not see it clinically, not even
clear in radiographs, point where pulp terminate and
Formation of Lateral Canals and Apical Foramen
pdl begins
• Disparity between radiographic apex and AF
• Lateral canals/ accessory canals: channels of
seen when there is post-eruptive deposition
communication between the pulp and PDL
of cementum in the area of the AF
• Forms when a localized portion of the root
• Created a funnel-shaped opening of the
sheath is fragmented before dentin formation
foramen larger than intraradicular portion of
Collagen bundles formed= sharpeys fiber
the foramen
• Cells in outermost area of follicle differentiate
• Apical constriction narrowest portion of the
into osteoblasts = from bundle bone that will
canal
anchor periodontal fibers.
• Coincides with the cementodentinal junction
• Periodontal fibers produce more collagen that
(CDJ)
binds anchored fragments together= principal
• Estimated to be 0.5-0.75mm coronal to apical
periodontal fibers
opening
• Loose fibrous CT that has nerves and BVs
• Point where the pulp terminates and the PDL
remains between the principal fibers
begins
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• Cleaning, shaping and abturation of RC should o Dentin formed in event of an injury,
terminate short of the AF particularly when original dentin thickens has
• Must also be confined to the canal to avoid been reduced (caries, attrition, trauma, resto
injury to the periapical tissues procedures)
• Determination of the root length and o Also formed at sites where its continuity is
establish lost (ex. Site of pulp exposure)
o Induction, differentiation and migration of
0.5mm from apex- stop file (debris will block) -
Constant length dapat-TERMINATE cleaning short of
apical foramen 0.5mm)
Pulp Function
➢ Induction
➢ Formation
➢ Nutrition
➢ Defense
➢ Sensation
INDUCTION
• Participates in the initiation and development
of dentin- enamel formation
new odontoblasts to exposure site
• Enamel epithelium induces differentiation of o Can process and identify foreign substances
odontoblasts and dentin induce formation of and elicit an immune response to their
enamel. presence
FORMATION
• Odontoblast participate in dentin formation
SENSATION
by:
➢ Unmyelinated fibers= slow, dull pain ➢
• Synthesizing and secreting inorganic matrix
Myelinated nerves= fast and sharp pain:
• Initially transporting inorganic components to
transmitted by Ab fibers.
newly formed matrix
• Creating an environment that allows
mineralization of the matrix Morphologic Zone of the Pulp
• Primary dentinogenesis: occurs during early
development, rapid process ➢ Odontoblast layer
• Secondary dentinogenesis: happens after ➢ Cell-Poor Zone
tooth maturation and when root elongation is ➢ Cell-rich zone
complete: slower rate, les symmetric pattern ➢ Pulp Proper (Pulp core)
• Tertiary dentin: forms in response to injury
➢ Less organized to 1st and 2nd dentin • Pulp and dentin function as a unit
➢ Mostly localized to site of injury • Odontoblasts are in periphery of pulp tissue,
extending into inner part of dentin • Impacts on
• Reactionary dentin: tubular tubules dentin affects pulpal disturbances affects quantity and
continuous with those of the original dentin quality of dentin produced
• Formed by original odontoblasts
• Reparative dentin: atubular →Formed by new Odontoblast Layer (OL) (coronal pulp)
odontoblasts differentiated from stem cells • Outermost stratum of cells
after original odontoblast after being killed. • Cell bodies odontoblasts: capillaries, nerve
fibers, dendritic cells
DB-dentin bridge- after carious exposure of pulp • Coronal pulp has more cells per unit than
radicular area than the radicular pulp
NUTRITIVE • Coronal pulp columnar
Midportion of radicular pulp: cuboidal
➢Supplies nutrients essential for dentin
Near apical foramen: squamous
formation, for maintaining integrity of the
• Tight junctions determine permeability of OL
pulp
when dentin is covered by enamel or
DEFENSIVE
cementum
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• Disrupted during cavity prep in increased • Continues at varying levels of activity for a
dentin permeability lifetime (some die by apoptosis)
Cell-Poor Zone • Disease processes (mainly caries) can kill
• Immediately subjacent to OL odontoblasts
• Narrow zone 40 um in width • Are end cells = DO NOT UNDERGO FURTHER
• Cell-free layer of well CELL DIVISION.
• Blood capillaries: unmyelinated nerve fibers, -- protein secreting cell
cytoplasmic process of fibroblasts
• Presence/absence on functional status of pulp ODONTOBLAST PROCESS
o Dentinal tubule forms around each of major
Cell-Rich Zone odontoblastic process
• Contains high proportion of fibroblasts o Occupies most of the space within the tubule
• More prominent in coronal pulp o Coordinates formation of peritubular dentin
Also has immune cells (macrophages, o Microtubules and microfilaments (principal
dendrific cells) undifferentiated mesenchymal components), collagen fibrils, ground
stem cells substance
Pulp Proper o Membrane junctions join cell bodies; gap
• Central mass of the pulp junctions, tight junctions, desmosomes
• Loose connective tissue o Gap junctions: Allow communication between
cells in the layer
• Fibroblast is the most prominent cells
o Desmosomal junctions; mechanically link cells
into a coherent layer
Cells of the pulp
o Tight junctions; control permeability of the
o Odontoblast
layer
o Odontoblast process
o Other parts of the cell membrane are
o Fibroblast
specialized to be membrane receptors
o Macrophage
Synthesizes maily type I collagen
o Dendritic cell
o Secretes dentin sialoprotein and
o Lymphocyte
phosphophoryn
o Mast cell
o Secretes acid phosphatase and alkaline
phosphatase
Odontoblast
o Resting/inactive
• Most characterized and specialized cell of the
number of organelles, may become shorter
D- P complex
• Form dentin and dentinal tubules
STEM CELLS (Preodontoblasts)
• Matrix that has fibrils, non-collagenous
• proteins, proteoglycans ➢ Undifferentiated mesenchymal cells
• Highly ordered RER, Prominent golgi complex, ➢ Newly differentiated od ontoblasts develop after
secretory granules, numerous mitochondria injury, results in death of existing odontoblasts
• Rich in RNA, nuclei contain one or more ➢ Densest in pulp core
prominent nucleus ➢ Migrate to the site of injury and differentiate
• Form a single periphery ➢ Key signaling molecules; bone morphogenic
• Synthesize the matrix, control mineralization protein (BMP), family and transforming growth factor
of dentin B
• Produce collagen that becomes fibrous, 3
noncollagenous proteins in which collagen FIBROBLAST
fibers are embedded ➢ Most common cell type in pulp, seen in greatest
• Coronal part of the pulp space: 45,000- numbers in coronal pulp
65,000/mm2 ➢ Tissue-specific cells capable of creating cells
• Relatively large involved in differentiation
• Columnar in shape
➢ Synthesize Type I and III collagen, as well as
• Cervical & midportion of root: lower in
proteoglycans and GAGs
number, appear flattened
➢ Responsible for collagen turnover
• Larger cells have well-developed synthetic
apparatus, capacity to synthesize more ➢ Abundant in cell-rich zone
matrix. ➢ As cells mature, they become stellate in form, Golgi
complex enlarges, RER proliferates, secretory vesicles
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appear, fibroblasts take on appearance of protein- o Form irregularly arranged bundles, except in
secreting cells periphery (lie approx, parallel to predentin
➢ Increase in number of BVs, nerves, collagen fibers: surface)
decrease in number of fibroblasts in the pulp o Non collagenous fiber present: 10-15 nm wide
➢ Many fibroblasts are undifferentiated. beaded fibrils of fibrillin.
o Elastic fibers absent from pulp
MACROPHAGE
➢ Monocytes that have left the bloodstream, entered CALCIFICATIONS
the tissues, and differentiated into subpopulations. Free stones, attached stones, embedded stones
➢ Act as scavengers-remove extravasated RBCs, dead o Free: surrounded by pulp tissue
cells, foreign bodies from tissue. o Attached: continuous with dentin
o Embedded: surrounded entirely by tertiary
➢ Take an active art in signaling pathways in the pulp
dentin
➢ When activated by appropriate inflammatory o Can occur in both young and old patients, and
stimuli, can produce factors (IL-1, TNF, GF, cytokines) in one or more teeth, in normal and
chronically inflamed pulps
DENDRITIC CELL o Do not produce painful symptoms, regardless
• Accessory cells of size
• Most prominent immune cells in pulp
o May also occur in the form of diffuse or linear
• Antigen-presenting cells
deposits associated with neurovascular
• Present most densely in OL and around BVs
bundles in pulp core
• Recognize wide range of foreign antigens and
o Seen in aged, chronically inflamed,
initiate immune response (together with traumatized pulps
odontoblasts) o Mayor may not be seen on the radiograph
Antigen presenting- more in odontoblast layer May block access to canals or root apex
during RCT
LYMPHOCYTE
• T8 (suppressor) lymphocytes are the NONCOLLAGENOUS MATRIX
predominant subset • Collagenous fibers embedded in clear gel
• Blymphocytesarerarelyfountinnormalpulp made up of GAGs and other adhesion
indicates pulp well equipped with cells required for molecules
initiation of immune responses • GAGs link to protein and other saccharides =
MAST CELL proteoglycans
o Seldom found in normal pulp tissue, but have • Around 6 types of adhesion molecules
been routinely fount in chronically inflamed detected in pulp matrix
pulps • Fibronectin- responsible for cell adhesion to
o Role in the inflammatory reactions matrix.
o Granules contain heparin (anticoagulant),
histamine (inflammatory mediator), other BLOOD VESSELS - Afferent Blood Vessels (Arterioles)
chemical factors • Branches of the interior alveolar artery,
MAST CELL superior posterior alveolar artery. Infraorbital
o Seldom found in normal pulp tissue, but have artery
been routinely fount in chronically inflamed • Once inside the radicular pulp, arterioles
pulps travel toward the crown, narrow then branch
o Role in the inflammatory reactions extensively and lose their muscle sheath, then
o Granules contain heparin (anticoagulant), form a capillary bed.
histamine (inflammatory mediator), other
chemical factors Precapillary sphincters: formed by muscle fibers
o Type I and III collagen found in pulp in ratio of before the bed: control blood flow and pressure
55:45 • Most extensive capillary branching occurs in
o Odontoblasts are only produce type I collagen subodontoblastic layer where vessels form a
o For incorporation into dentin matrix dense plexus
o Fibroblasts produce type I and III collagen • Exchange of nutrients and waste products
o Present as fibrils 50 nm wide and several occur in the capillaries
micrometers long • Extensive shunting system (arteriovenous and
venovenous anastomoses) - become active
after pulp injury and during repair.
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afferent- artery ➢ All cardinal signs of inflammation are vascular in
venules- efferent-exit origin (except pain)
▪ Increased blood flow = heat, redness
EFFERENT BLOOD VESSELS ▪ Increased formation of interstitial tissue
o Venules comprise the efferent (exit) side of fluid = swelling = increase in tissue fluid P
pulpal circulation
o Slightly larger than corresponding arterioles ALL CARDINAL SIGNs (EXCEPT PAIN)- VASCULAR IN
o Formed from the junction of venous ORIGIN
capillaries, enlarge as more branches unite ➢Elevations in tissue fluid P remain localized to
with them injured area
o Run with arterioles and exit at AF ➢Intraluminal (inside) P of local capillaries increase to
o Drains posteriorly into Mx vein through balance any rise in interstitial fluid P
pterygoid plexus
➢Gradients by which nutrients and wastes leave and
o Drains anteriorly into facial vein
enter the capillaries change to allow greater exchange
(during response to injury)
LYMPHATICS
• Lymphatic vessels work more, removing
o Arise as small, thin-walled vessels in periphery
excess tissue fluid and debris
o Pass through to exit as one or two larger
• Anastomoses allow blood to be shunted
vessels through the AF
around area of injury
o Walls composed of an endothelium rich in
➢If injury persists and increases in size = tissue
organelles and granules
necrosis
• Can remain localized as a pulpal abscess, but
➢ Porosities in the walls and in basement membrane more often spreads throughout the pulp
➢ Permits passage of interstitial tissue fluid and • Necrosis extends as toxins from carious lesion
lymphocytes (when necessary) diffuse through tissue
• A cyst in removal of inflammatory exudates, Neurogenic inflammation – mechanism in w/c
transudates and cellular debris excitation of sensory elements results in increased
• After exiting the pulp, this join similar vessels blood flow & increased capillary permeability.
from the PDL → drain into regional lymph Antibiotic-just an adjunct- must remove infection,
glands (submental, submandibular, cervical) clean inside of canal
→ empty into subclavian and internal jugular INNERVATION
veins
➢ 2ND & 3RD divisions of CN V provide principal
VASCULAR PHYSIOLOGY sensory innervation to pulp of Mx and Md teeth ➢
➢ Young dental pulp is highly vascular Md PMs also receive sensory branches from
Capillary blood flow in coronal area almost twice that mylohyoid nerve of V3 (motor nerve)
of radicular area ▪ Branches reach teeth via small foramina
on Li aspect of Md
➢ Blood supply largely regulated by precapillary
• Md molars occasionally receive sensory
sphincters and their sympathetic innervation
➢ Volume of vascular bed greater than volume of innervation from 2nd & 3rd cervical spinal
blood normally passing through = allows for increases nerves (C2 & C3)
• Pulp also receives sympathetic (motor)
in blood flow in response to injury
innervation from T1, C8 and T2 via superior
➢Concentration gradients, osmosis, hydraulic
cervical ganglion
pressure: factors determining what passes in & out
▪ Enter pulp space together w/ main BVs & are
between blood & tissue.
distributed w/ them.
➢Hydraulic Pin pulpal capillaries=35mmHg ▪ Maintain vasomotor tone in precapillary sphincters
(anteriolar end), 19 mm Hg (venular end). PULPAL AND DENTINAL NERVES
➢Interstitial Fluid P outside vessels would normally ➢ Contain both unmyelinated & myelinated axons
be 6 mm Hg (but varies).
➢ Myelinated axons – almost all narrow, slow-
conducting A6 axons (1-6 μm in diameter) associated
➢ Initial immune response is nonspecific but rapid w/ nociception
(minutes or hours) ▪ Small percentage are fast-conducting A
➢ 2nd response: specific, includes production of ▪ Terminating fibers from subodontoblastic plexus of
specific antibodies Raschkow
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Myelinated- faster, sharper pain along sites at root where BVs enter, and exit
Unmyelinated- slower, dull pulp at AF & lateral and accessory canals
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• Specially arranged collagen fiber bundles • Correct diagnosis → proper treatment &
support success of case → better prognosis
the tooth in the socket & absorb forces of →systematically collect facts and details
occlusion • Determine what problem a patient is having,
• ➢PDL space is small (0.21 mm young teeth, and why the patient is having that problem
0.15 mm in older teeth) • No appropriate treatment recommendation
▪ Uniformly od width is one criteria used can be made until all of the whys are
to determine its health answered
➢ Cementoblasts, osteoblasts line the space • Planned, methodical, systematic approach
Interwoven between principal perio fibers is loose CT
containing fibroblasts, stem cells, macrophages, 5 Stages Of Diagnosis:
osteoclasts, BVs, nerves, lymphatics; also ERM ✓ Patient tells clinician why the patient is seeking
➢ Arterioles supplying PDL arise from superior & advice
inferior alveolar branches of the Mx artery ✓ Clinician questions patient about symptoms and
• Pass through small openings in alveolar bone, history that led to the visit
& extends upward and downward throughout ✓ Clinician performs objective clinical tests
the space ✓ Clinician correlates objective findings with
• More prevalent in posterior teeth subjective details, & creates a tentative differential
➢ Unmyelinated sensory nerve fibers diagnosis
terminate as ✓ Clinician formulates a definitive diagnosis.
nociceptive free endings
➢ Large fibers – mechanoreceptors that Steps:
terminate in special endings throughout the o Chief complaint
ligament o History (medical and dental)
▪ Greater concentration in apical third of perio o Oral examination
space o Data analysis (leading to differential diagnosis
▪ Highly sensitive (record P associated w/ o Treatment plan
tooth movement)
Lamina dura- no break, uniform- indicates no peri Chief Complaint (offered by the patient)
radicular inflammation • First information obtained, volunteered by
the patient
ALVEOLAR BONE • Direct and unbiased
➢ Alveolar process – bone of jaws supporting • Clinician must pay close attention to:
teeth ✓ Actual expressed complaint
➢ Alveolar bone proper – bundle bone, ✓ Determine chronology of events leading
cribriform plate up to this complaint
o Bone lining the socket & into w/c ✓ Question any other pertinent issues
principal perio fiber are anchored to • Should be properly documented using
o Denser than surrounding cancellous patient’s own words
bone
o Distinct opaque appearance in Medical History
radiographs = lamina dura • Baseline BP and PR recorded at each visit;
o Principally lamellar take other vital signs
o Constantly remodels • Evaluate:
• Medical conditions & current and current
DIAGNOSIS, PULPAL & PERIAPICAL DISEASE medications that may alter manner in w/c
dental care is provided
Diagnosis • Medical conditions that may have oral
• Art & science of determining the disease manifestations or mimic dental pathosis
process by:
✓ Systematic collection and recording of facts Take note also of:
✓ Careful analysis and integration of these o Drug allergies to dental products
facts o Artificial joint prosthesis
• Science of recognizing disease by means of o Organ transplants
signs, symptoms, and tests o Taking medications that may negatively interact w/
common local anesthetics, analgesics, antibiotics
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Conditions (AAOS):
Ptx w/ major medical problems- need to note down -Those who have joint replacements within the past
vital signs every visit year, particularly those who are immunocompromised
immunosuppressed Those with hemophilia or insulin
Medical Conditions That Warrant Modification of – dependent diabetes
Dental Care or Treatment -Those who have had previous joint prosthesis
Cardiovascular: High – and moderate – risk categories infections
of endocarditis, pathologic heart murmurs, -Instrument beyond the apex
hypertension, unstable angina pectoris, recent -Periapical surgery
myocardial infarction, cardiac arrhythmias, poorly -Procedures that may produce bleeding (aggressive
managed congestive heart failure rubber dam placement, incision and drainage)
Pulmonary: Chronic obstructive pulmonary disease,
asthma, tuberculosis →endo procedures which is risk for cardiac ptx or
Gastrointestinal and renal: End – stage renal disease: prosthesis ptx
hemodialysis; viral hepatitis (types B, C, D, and E);
alcoholic liver disease; peptic ulcer disease; Regimen
inflammatory bowel disease; pseudomembranous o Adults: Amoxicillin 2 g 30-60 minutes prior to
colitis procedure
Hematologic: Sexually transmitted diseases, HIV and o Children: 50 mg/kg
AIDS, diabetes mellitus, adrenal insufficiency, o Allergic to amox: Clindamycin 600 mg 30-60
hyperthyroidism and hypothyroidism, pregnancy, minutes prior to procedure
bleeding disorders, cancer and leukemia,
osteoarthritis and rheumatoid arthritis, systemic lupus → To prevent infective endocarditis
erythematosus
Neurologic: Cerebrovascular accident, seizure Dental History
disorders, anxiety, depression and bipolar disorders, • Guide to w/c diagnostic test must be
presence or history of drug or alcohol abuse, performed
Alzheimer’s disease, schizophrenia, eating disorders, • Must include past and present symptoms,
neuralgias, multiple sclerosis, Parkinson’s disease. procedures or trauma that elicit CC
• Medication side effect: stomatitis, xerostomia, • Past dental procedures, frequency of dental
petechiae, ecchymoses, lichenoid mucosal lesions, visits, oral hygiene status, adverse reaction to
bleeding of oral soft tissues local anesthetics.
• Medical conditions have clinical presentations that
mimic pathological lesions: Dental History Interview
• Lymph node enlargement due to odontogenic 5 Basic directions of questioning:
infection – lymphomas, TB involving cervical ✓ Localization
and subMd lymph nodes ✓ Commencement
• Odontogenic pain, loss of trabecular bone ✓ Intensity
pattern in radiographs in lesions of endo
✓ Provocation
origin – sickle cell anemia
✓ Duration
• Tooth mobility – multiple myeloma
• Increased sensitivity of teeth,
Pain: most common symptom that leads to
osteoradionecrosis – radiation therapy to
consultation or treatment
head and neck
o Location – localized, diffuse, radiating, referred
• Dental pain – trigeminal neuralgia, multiple
o Quality – sharp, piercing, dull
sclerosis
o Onset – spontaneous, provoked
• Tooth pain in Mx posterior quadrant – acute
o Provoking/alleviating factor – cold, heat,
Mx sinusitis
biting, sweets
•
o Intensity – mild, moderate, severe
ANTIBIOTIC PROPHYLAXIS
o Duration – constant, momentary, intermittent
Conditions (AHA):
-Artificial heart valve
Questions to Ask – PAIN
-Previous history of infective endocarditis Incomplete
▪ When did the pain begin?
or repaired congenital heart tissue repair
▪ Where is the pain located?
-Heart transplants
▪ Isthepainalwaysinthesameplace?
▪ What is the character of the pain (short, sharp,
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long-lasting, dull, throbbing, continuous, • Mucobuccal fold – infection associated w/
occasionally)? apex of root of any Mx tooth exiting the
▪ Does the pain prevent sleeping or working? alveolar bone on the facial aspects & is
▪ Is the pain worse in the morning? inferior to the muscle attachment present in
▪ Is the pain worse when you lie down? the area; same as in Md, but if root apices are
▪ Did or does anything initiate the pain (trauma, superior to the level of muscle attachment
biting)? *Anterior- associated w/ lingual root of 1st
▪ Once initiated, how long does the pain last? premolar *Posterior: palate
▪ Is the pain continuous, spontaneous, or -mucobuccal fold fr central incisor
intermittent?
▪ Does anything make the pain worse (hot, cold, Sublingual space - infections from root apex spreads
biting)? Does anything make the pain feel better (cold, to the lingual & exits the alveolar bone superior to the
analgesics)? mylohyoid muscle attachment
Questions to Ask – SWELLING
▪ When did the swelling begin? Submandibular space – exits to the lingual of Md
▪ How quickly has the swelling increased in size? molars & is inferior to mylohyoid muscle attachment
▪ Where is the swelling located?
▪ What is the nature of the swelling Parapharyngeal space (swelling of tonsillar and
(soft,hard,tender)? pharyngeal areas) extensions of severe infections of
▪ Is there drainage from the swelling? Mx & Md molars.
▪ Is the swelling associated with a loose or tender
tooth?
Intraoral Exam
o ST. check the lips, oral mucosa, cheeks, tongue,
periodontium, palate, muscles
o Dentitice: check for discolorations, fractures,
abrasions, erosions, caries, failing restorations
INTRAORAL SWELLINGS
• IO swellings should be visualized & palpated –
localized/diffuse, firm/fluctuant
• Attached gingiva, alveolar mucosa,
mucobuccal fold, palate, sublingual tissues
* Palpate to check texture and density
• Anterior part of palate – infection at apex of
Mx lateral incisor or P root of Mx 1st PM
• Posterior part of palate – associated w/ P
root of Mx molar
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INTRAORAL RADIOGRAPHY
*2-dimensional image of 3-dimentional structure
*High quality processing needed for maximum
diagnostic value
*Understanding of anatomy is needed in
differentiating anatomical & pathological images
*Various views from multiple angles to capture more
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Percussion Recording Furcation Defects
→Indicator of inflammation in PDL.
✓ Secondary to physical trauma, occlusal Class I furcation defect: The furcation can be probed
prematurities, periodontal disease, extension of but not to a significant depth.
pulpal disease into PDL space Class II furcation defect: The furcation can be entered
✓ Test contralateral tooth first (control), then into but cannot be probed completely through to the
adjacent teeth opposite side.
✓ Gloved finger tapping initially, applying light Class III furcation defect: The furcation can be probed
pressure com pletely through to the opposite side.
✓ Repeat test using blunt end of
Periodontal Exam
Probing
• Percussion testing: Simultaneously test for
tenderness to percussion and listen for the ✓ Record pocket depths on the mesial, middle, and
percussion note. If the tooth is tender, this will distal aspects in both buccal and lingual sides (mm)
minimize how many times you will need to tap ✓ Document amount of furcation bone loss Watch
the tooth Probing vid:
• Explain the procedure to the patient. Ask the
patient to raise their hand or tell you if the ➢ 3 keys of probing
tooth is tender ✓ Adaptation
• Gently tap the tooth being tested in an axial ✓ Walking stroke
direction. Ensure you are tapping the tooth ✓ Access
with a metal instrument. The metal handle of
a mirror is ideal for this PULP TESTS
• Listen to the sound that the tooth made when - Thermal
percussed. Document whether the tooth - Electric
tested sounded different to the other teeth or - Laser Doppler Flowmetry - assesses blood
the same flow in microvascular systems
➢ Ask the patient if the tooth felt sore when you - Pulse Oximetry - measures oxygen
tapped it. Document any tenderness felt concentration in blood and the pulse rate.
THERMAL
Mobility - Baseline/normal response: sensation is felt, but
→Indication of compromised periodontal disappears immediately on removal of stimulus
attachment apparatus. ✓ Abnormal responses: lack of response,
✓ Result of acute/chronic physical trauma, occlusal lingering/intensification of a painful sensation after
trauma, parafunctional habits,periodontal disease, the stimulus is removed; immediate, excruciating
root fractures, rapid orthodontic movement, painful sensation as soon as stimulus is placed
extension of pulpal disease into PDL space
✓ Apply simple finger pressure - visually subjective Heat Test: Hot water, heated GP, dry rubber
polishing wheel (seldom used)
✓ Use back ends of two mirror handle Cold Test: Primary pulp testing method for many
✓ Evaluate on how mobile affected tooth is relative clinicians.
to adjacent & contralateral teeth Used in conjunction with EPT to verify findings of
each test
➢ Dry ice/carbon dioxide snow
Recording Tooth Mobility
➢ Refrigerant spray
+1 mobility: The first distinguishable sign of No response- nonvital pulp
movement greater than normal False negative response- excessive calcification,
+2 mobility: Horizontal tooth movement no greater immature apex, recent trauma, premedication
than 1 mm
+3 mobility: Horizontal tooth movement greater than * NO VITALITY TEST ON TRAUMATIC INJURIES
+ mobility test
1 mm, with or without the visualization of rotation or
vertical Cold Test & Heat Test - how many seconds nag batyag;
(+ mild, ++moderate or +++severe)
=ISOLATE TOOTH FIRST
*Visually Subjective Cold – ice stick
*Use ends of mouth mirror
PLACE ON MIDDLE 3RD OF FACIAL SURFACE OF CROWN-
ANTERIOR TEETH
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ENDODONTICS 1
Heat - heated instrument, gutta percha o Does not cause px diseases
HEAT TEST- BRADE CONE- HEAT- PLACE ON SURFACE OF o Transient sensation that disappear in seconds
TOOTH
• R: varying degrees of pulpal calcification
Percussion - mild, moderate, severe
Palpation o No evidence of resorption, caries, mechanical pulp
exposure
• No endo tx indicated
Heat Test: Hot water, heated GP, dry rubber
Tx= treatment
polishing
Heat- place Vaseline on tooth to prevent gutta percha fr
adhering to tooth REVERSIBLE PULPITIS
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ENDODONTICS 1
CONDENSING OSTEITIS Lesson 2: Armamentarium
o Variation of AAP Hand Instruments:
o Increase in trabecular bone in response to
persistent irritation
o Irritant diffusing from root canal into periradicular • Front-surface mouth mirror, regular/diagnostic
tissues explorer (D-5 explorer), D-16 endodontic explorer,
o Lesion usually found around apices of cotton pliers, spoon excavator, set of pluggers,
mandibular posterior teeth; but can occur in plastic instrument, hemostat, periodontal probe,
association with the apex of any tooth
ruler
o Asymptomatic/associated with pain (depending on
causes – pulpitis or necrosis) (we need to have at least 2 mouth mirror and has
o May or may not respond to electrical or thermal front surface)
stimuli (the mouth mirror is a front surface if you place any
o May or may not be sensitive to palpation or finger on the mirror, if there’s no space on your finger
percussion and reflection on the mirror then it’s a front surface)
o R: diffuse, concentric arrangement of radiopacity
around the root
o Tx: RCT D-5 Explorer or regular explorer has 2 hook
ends with diff. designs
ACUTE APICAL ABSCESS
o Acutely painful to biting pressure, percussion, D-16 endodontic explorer
palpation has straight ended that is
o Will not respond to any pulp vitality tests
angled at different directions
o Exhibit varying degrees of mobility
o R: widened PDL space, apical radiolucency
from the long axis
o IO swelling present, facial tissues adjacent to
tooth will almost always present with some § Endodontic explorer: 2 straight, sharp end that
degree of swelling are angled in two different directions from the
o Febrile long axis
o Cervical & subMd lymph nodes exhibit tenderness
§ Endodontic spoon excavator: much longer offset
to palpation
o Tx: removal of underlying cause; release of
from the long axis than regular spoons
pressure (drainage where possible); RCT ➔ Removes carious material, excise pulp
tissue
CHRONIC APICAL ABSCESS
o Not generally present with clinical symptoms
o Will not respond to vitality tests
o R: apical radiolucency
o Generally, not sensitive to biting pressure, but
“feels different” on percussion
• Intermittent drainage through an
associated sinus tract
(Difference between endodontic spoon and regular
spoon is that the shank of endo spoon excavator is
longer)
• Film
• Film positioners
• Film holders
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• Floss is then used to carry dam through the (the design of the handle is more squarish and the
contacts indentation is more pronounced)
• Use plastic instrument to invert edge of the dam
around the tooth B. K-TYPE INSTRUMENTS
Instruments For Cleaning And Shaping The Root • K-file and K-reamer are oldest instruments used
Canal Space for cutting and machining dentin
• File has more flutes per length unit than a reamer
• Provide a biologic environment (infection control) • Useful for penetrating and enlarging root canals
conducive to healing • Works primarily by compression-and-release
• Develop a canal shape receptive to obturation destruction of dentin
(we do it manually)
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ENDODONTICS 1
• Canal transportation is unlikely to occur as long • Flute: groove in the working surface used to
as the file is engaged 360° collect soft tissue and dentin chips removed from
o ➔ File begins to cut on one side if the wall of the canal
overused transportation ➔ Effectiveness depends on depth, width,
o ➔ Most instrumentation errors occur configuration, surface finish
when file tip is loose in the canal • Leading (cutting) edge/blade: surface with the
• Beginner's rule: greatest diameter that follows the groove as it
o ➔ If the canal is smaller than the file, rotates
more efficient if a cuffing lip is used ➔ Forms and deflects chips from the canal walls
o ➔ If the canal is larger than the tip, use a ➔ Severs/snags soft tissue
less-effective cuffing tip ➔ Effectiveness depends on angle of incidence and
sharpness
• Introduction of nitinol (Ni-Ti), alloy of nickel and • Rake angle: angle formed by the leading edge and
titanium, has proved a significant advancement in radius of the file
endodontic instruments ➔ Obtuse angle = positive or cutting
(recommended, super elastic metal. It has memory) ➔ Acute angle = negative or scraping
➢ Superelastic metal-has the ability to return to its • Cutting angle/effective rake angle: determined by
original shape after being deformed measuring the angle formed by the cutting edge
➢ Currently are the only readily available affordable and the radius when the file is sectioned
materials with the flexibility and toughness for routine perpendicular to the cutting edge
use as effective rotary endo files in curved canals ➔ better indication of file's cutting ability
➢ New alloys may be 5x flexible than currently used
alloys • Better to use electric handpiece when using rotary
files since it allows. precise speed and torque
*GROUP II: LOW-SPEED ROTARY INSTRUMENTS control
• A. ProFile B. ProTaper
(do not use in curve portions to avoid
errors, only use this on straight
portions of the canal prep to avoid
perforating the tooth)
• Burs with extended shanks = good
visibility during deep preparation
of the pulp chamber
• Gates-Glidden burs, Peeso
instruments - available in 32-
mm(for anterior) and 28-mm
lengths (posterior teeth) *GROUP IV: ENGINE-DRIVEN THREE-
• Should be limited to the straight portion of the DIMENSIONALLY ADJUSTING FILES
canal prep
• Risk of perforation if attempts are made to
instrument beyond the point of curvature or if
they are used to cut laterally
➔ pronounced on furcation sides of mesial roots of
molars
• Peeso reamer used mostly for post space prep
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ENDODONTICS 1
➔ Operated clockwise, inserted not rotating to • Wide-spectrum antimicrobial agent, active against
WL, then retracted 1-2 mm gram (+) and (-) bacteria as well as yeasts
➔ Started and rotated at a slow speed • Bacteriostatic or bactericidal (depending on
• Files, paper points, concentration)
syringes also can be • Low level of tissue toxicity
used to apply sealer • Same antibacterial efficacy as NaOCI
• May delay coronal recontamination of the RCS
• Locks tissue-dissolving property (unlike NOOCT)
• May induce allergic reactions (rash, contact
Materials for Disinfecting the Pulp Space dermatitis, urticarial)
• Chemomechanical preparation-irrigating solutions
• Mechanical and biologic objectives
3. MTAD, TETRACLEAN
➢ Mechanical: flushing out debris, lubricating the
canal, dissolving organic and inorganic tissue (MTAD= mixture of tetracycline, citric acid, and
detergent)
➢Biologic: antimicrobial effect
• New irrigants
Ideal characteristics of an endodontic irrigant • Mixture of antibiotics, citric acid, detergent
• MTAD-1st irrigating solution capable of removing
• Be an effective germicide and fungicide the smear layer and disinfecting the RCS
• Be non-irritating to the periapical tissues ➔ Biopure MTAD (Dentsply)
• Remain stable in solution ➔ Final rinse after completion of conventional
• Have a prolonged antimicrobial effect chemomech prep
• Be active in the presence of blood, serum, and • TetraClean (Ogna Laboratori Farmaceutici)-similar
protein derivatives of tissue to MTAD, but differ in concentration of antibiotics
• Have low surface tension tissues and kind of detergent
• Not interfere with repair of periapical
• Not stain tooth structure 4. ETHYLENEDIAMINE TETRA-ACETIC ACID (EDTA)
• Be capable of inactivation in a culture medium
• Not Induce a cell-mediated immune response (not used alone, used in conjunction with sodium
• Be able to completely remove the smear layer, hypochlorite )
and be able to disinfect the underlying dentin and (it is good if you experience blockage in your canal, it
tubules will dislodge the debris)
• Be non-antigenic, non-toxic, and noncardiogenic • Can chelate and remove the mineralized portion
to tissue cells surrounding the tooth of the smear layer
• Have no adverse effects on the sealing ability of • Cannot remove smear layer alone, proteolytic
filling materials component is added to remove organic
• Have convenient application components (NaOCI)
• Be relatively inexpensive • 17% concentration
• Direct contact with RC wall for less than 1 minute
1. SODIUM HYPOCHLORITE (NGOCI)
• Alternating regimen: wash out remnants of EDTA
with copious amounts of
(a household bleach that we can dilute)
• Most commonly used irrigating solution
5. NAOCI HYDROGEN PEROXIDE
• Excellent antibacterial agent
• Capable of dissolving necrotic tissue, vital pulp
tissue, and organic components of dentin and • 3-5% concentration
biofilms • Active against bacteria, viruses, yeasts
• Hypersensitivity, contact dermatitis in rare cases • No longer recommended as a routine irrigant
(iodine potassium iodide)
(1:9 solution, 1-part sodiuhypo/bleach and 9-parts
6. IODINE POTASSIUM IODIDE
distilled water)
• 2% iodine in 4% potassium iodide
• Excellent antibacterial properties, low cytotoxicity
2. CHLORHEXIDINE (CHX)
• May act as a severe allergen, also stains dentin
(less irritating but it doesn’t dissolved tissue)
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ENDODONTICS 1
7. INTRACANAL MEDICATION • Disinfection: submerge cones in 5% NaOCI for 1
minute
• Acts to inhibit proliferation of bacterial and
• Rinse in ethyl alcohol after NoOCI submersion and
eliminate surviving bacteria
before obturation
• Minimizes ingress through a leaking restoration
• EX: Phenols, formaldehyde, halogens (chlorinated
solutions), chlorhexidine, calcium hydroxide, Composition Of Gutta-Percha For Endodontic Use
Ledermix, triple-antibiotics paste, bioactive glass
• Gutta-percha (19-22%)
8. CALCIUM HYDROXIDE • Zinc oxide (59-79%)
• Heavy metal salts (1-17%)
• Kills bacteria in RC space; slow-acting
• Wax or resin (1-4%)
• May be mixed with sterile water or saline
• Best applied with Lentulo spiral
• Requires some form of compaction pressure-
• Removal is frequently incomplete = shortens
compresses GP cones to get a more 3D complete
setting time of ZOE-based sealers
fill of RCS. (we need to have a sealer)
• May interfere with
• Oxidizes with exposure to air and light, eventually
the seal of the root
becoming brittle
filling =
• Store in a cool, dry place for better shelf life
compromised quality
• Cannot be used alone since it lacks adherent
• Not totally effective
properties necessary to seal the RC space, thus a
against several endo
sealer (cement) is needed for final seal ●
pathogens (E. faecalis, C. albicans)
• 02, .04, .06 tapers to match rotary instruments
• Biocompatible, low tissue toxicity
9. LEDERMIX (LEDERLE PHARMACEUTICALS) ➔ Equal biocompatibility with Resilon
• Corticosteroid-antibiotic
paste 1. RESILON (PENTRON CLINICAL TECHNOLOGIES)
• May be an initial dressing
• RC medicament or as
direct/indirect pulp capping • Thermoplastic, synthetic, polymer-based
agent • Designed to be used with Epiphany (resin sealer
with bonding capacity to dentin)
Materials for Disinfecting the Pulp Space • Can be used with any current obturation
technique
• EndoActivator • Bioactive glass, radiopaque fillers (bismuth
• Passive ultrasonic activation oxychloride, barium sulfate)
• EndoVoc • Can be softened with heat or dissolved with
• Safety-Irrigator solvents (chloroform)
• Self-Adjusting File (SAF) • Compatible with current restorative techniques in
• HealOzone which cores & posts are placed with resin bonding
agents
• Superoxidized water
• Photoactivation disinfection
• Intralight ultraviolet disinfection
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ENDODONTICS 1
calcification, number of roots and canals,
• Does not normally exit at the anatomic apex, approximate canal length
but is offset 0.5-3.0 mm from the apex • Anterior teeth: lingual surface; posterior teeth:
• Root canal prep and obturation end short of occlusal surface
the anatomic root apex • Remove all defective restorations
• Difficult to locate AC and AF clinically: • All carious dentin must be removed prevent
- radiographic apex may be a more reliable irrigating solutions from leaking past the RD into
the mouth, prevents carious dentin and its
reference point diagnosis)
bacteria from entering RCS
• Terminate at or within 3 mm from
radiographic apex (depending pulpal
➔ If chamber wall is perforated during removal of
diagnosis) carious dentin, repair immediately with a temporary
• Vital pulp = 2-3 mm short filling material
• Nonvital pulp or within 2 mm
• Retreatment = 1-2 mm short ➔ Crown lengthening procedure if there is not
• enough tooth structure to support a RD clamp
ACCESS CAVITY PREPARATION
• Remove all unsupported tooth structure: avoid
unnecessary removal of sound tooth structure
• Walls of the RC must guide the passage of
instruments down the canal
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ENDODONTICS 1
• Law of the CEJ: the distance from the external BURS
surface of the clinical crown to the wall of the PC
is the same throughout the circumference of the • Round carbide (#2, #4, #6)
tooth at the level of the CEJ • Remove caries
• Create initial external outline shape
➔ the CEJ is the most consistent, repeatable • Penetrate through and remove the roof of the PC
landmark for locating the position of the PC
FISSURE CARBIDE AND DIAMOND
• First law of symmetry: canal orifices are
equidistant from a line drawn in a MD direction • with safety tips (noncutting ends) = axial wall
through the center of the PC floor (except for Mx extension
molars) • Can be allowed to extend to pulp floor, and entire
• Second law of symmetry: canal orifices lie on a axial wall can be moved and oriented all in one
line perpendicular to a line drawn in a MD plane from enamel surface to pulp floor =
direction across the center of the PC floor (except produces axial walls free of gouges
for Mx molars) • Used to level off cusp tips and incisal edge
• Law of color change: the PC floor is always darker • Round diamond burs (#2, #4) to access teeth with
in color than the walls porcelain or ceramometal restorations
• Orifice location:
➔ Less traumatic to porcelain than carbide, can
1st law: The orifices of the root canals are always penetrate without cracking or fracturing it
located at the junction of the walls and the floor;
➔ Switch to carbide to penetrate metal or dentin
2nd law: the orifices of the root canals are always
located at the angles in the floor-wall junction; Receded PC and calcified orifices: extended-shank
round burs
3rd law: and the orifices of the root canals are always
located at the terminus of the roots’ developmental • Mueller bur (Brasseler USA), LN bur (Dentsply).
fusion lines. • Munce Discovery bur (CJM En ineerin )
• Moves the head o the handpiece away rom the
tooth, improving visibility
• Alternative: ultrasonic units
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ENDODONTICS 1
- detect any remaining PC roof, particularly in the • Remove the lingual shoulder = aids
area of a pulp horn straight-line access and allows for
more intimate contact o files with
ULTRASONIC UNIT AND TIPS canal walls
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ENDODONTICS 1
POSTERIOR ACCESS CAVITY PREPARATIONS • Assess each canal for SLA
• Inspect PC floor
• Mx PMs: central roove between cusp tips
• Refine and smooth the restorative mar ins
• Md 1st PMs: hallway up the lingual incline of the 8
➔ Final permanent resto of choice: crown or onlay
cusp on a line connecting the cusp tips
• Md 2 PMs 1/3 the way up the L Incline o the B ERRORS IN ACCESS CAVITY PREPARATIONS
cusp on a line connecting the 8 cusp tip and the Li
groove between the UI cusps Molars: establish M
and D boundary limitations
• Mx and Md M boundary: line connecting the M
cusp fiips
• Mx D boundary: oblique ridge
• Md D boundary: line connecting the B and Li
Note: Gouge-Gouging Note: under extended
grooves
• Central groove hallway between the M and D
boundaries
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