Endodontics Copyright 2009 2006 by Saunders an imprint

Chapter 54 Lesson 54. 1 Copyright © 2009, 2006 by Saunders, an imprint of

Learning Objectives Pronounce, define, and spell the Key Terms. Describe the diagnostic testing performed for endodontic diagnosis. List the conclusions of the subjective and objective tests in the endodontic diagnosis. Assist in an electric pulp-vitality test. Describe diagnostic conclusions for endodontic therapy. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Introduction Endodontics is the specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the periradicular tissues surrounding the root of the tooth. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Causes of Pulpal Nerve Damage Physical irritation Ø Extensive decay moving into the pulp Trauma Ø Blow to a tooth or the jaw Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Signs and Symptoms of Pulpal Nerve Damage Pain on occlusion Pain during mastication Sensitivity to hot or cold beverages Facial swelling Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endodontic Diagnosis Subjective examination Chief complaint Ø Character and duration of pain Ø Painful stimuli Ø Sensitivity to biting and pressure Ø (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endodontic Diagnosis (Cont’d) Objective examination Extent of decay Ø Periodontal conditions Ø Extensive restoration Ø Tooth mobility Ø Swelling or discoloration Ø Pulp exposure Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 54 -1 Radiograph showing extensive decay into the pulp. (From Johnson W: Color atlas of endodontics, St. Louis, 2002, Saunders. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 54 -2 Radiograph of a necrotic tooth resulting from trauma. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Testing Percussion tests These tests are used to determine whether the inflammatory process has extended into the periapical tissues. Ø The dentist taps on the incisal or occlusal surface with the end of the mouth-mirror handle held parallel to the long axis of the tooth. Ø (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 54 -3 Percussion test. (From Johnson W: Color atlas of endodontics, St Louis,

Diagnostic Testing (Cont’d) Palpation Tests These tests are used to determine whether the inflammatory process has extended into the periapical tissues. Ø The dentist applies firm pressure to the mucosa above the apex of the root. Ø (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 54 -4 Palpation test. (From Johnson W: Color atlas of endodontics, St Louis,

Diagnostic Testing (Cont’d) Thermal sensitivity Ø Cold test Ø Necrotic pulp will not respond to cold or heat. Ice, dry ice, or ethyl chloride is used to determine the response of a tooth to cold. Heat test Ø A piece of gutta-percha or an instrument handle is heated and applied to the facial surface of the tooth. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 54 -5 Ice used for testing thermal sensitivity. (From Johnson W: Color atlas of endodontics, St Louis, 2002, Saunders. ) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Testing (Cont’d) Electric pulp testing Ø A small electrical stimulus is delivered to the pulp. Factors that may influence readings: The patient has extensive restorations. Ø The patient has teeth with more than one canal. Ø Failing pulp produces a variety of responses. Ø Control teeth don’t respond as anticipated. Ø There is moisture on the tooth during testing. Ø The batteries in the tester are weak. Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Procedure 54 -1 Placement of a pulp tester. Copyright © 2009, 2006 by Saunders,

Radiographs in Endodontics Initial radiograph Ø Working-length film Ø Final-size files in all canals Root canal completion film Ø To determine the length of the canal Final-instrumentation film Ø Diagnosis Taken after the tooth has been temporized Recall films Ø Taken at evaluations Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Requirements of Endodontic Films Must show 4 to 5 mm beyond the apex of the tooth and the surrounding bone or pathologic condition Must present an accurate image of the tooth without elongation or foreshortening Must exhibit good contrast so that all pertinent structures are readily identifiable Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 54 -6 Good-quality radiograph in endodontics. Copyright © 2009, 2006 by Saunders, an

Diagnostic Conclusions Normal pulp Ø No subjective symptoms or objective signs are noted. The tooth responds normally to sensory stimuli, and a healthy layer of dentin surrounds the pulp. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Conclusions (Cont’d) Pulpitis Ø Reversible pulpitis Ø The pulp tissues have become inflamed. The pulp is irritated, and the patient is experiencing pain in response to thermal stimuli. Irreversible pulpitis Ø The tooth displays symptoms of lingering pain. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Conclusions (Cont’d) Periradicular abscess Ø This inflammatory reaction to pulpal infection may be of chronic or acute onset with pain, tenderness of the tooth in response to pressure, pus formation, and swelling of the tissues. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Conclusions (Cont’d) Periodontal abscess Ø This inflammatory reaction is frequently caused by bacteria trapped in the periodontal sulcus. A patient will experience rapid onset of pain, tenderness of the tooth in response to pressure, pus formation, and swelling. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Conclusions (Cont’d) Periradicular cyst Ø This type of cyst develops at or near the root of a necrotic tooth. They develop as an inflammatory response to pulpal infection and necrosis of the pulp. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Conclusions (Cont’d) Pulp fibrosis Ø A decrease in living cells within the pulp causes fibrous tissue to take over the pulpal canal. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Diagnostic Conclusions (Cont’d) Necrotic tooth Ø The tooth may also be referred to as nonvital. The term is used to describe a tooth that does not respond to sensory stimulus. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 54 Lesson 54. 2 Copyright © 2009, 2006 by Saunders, an imprint of

Learning Objectives List the types of endodontic procedures. Discuss the medicaments and dental materials used in endodontics. Provide an overview of root canal therapy. Assist in root canal therapy. Describe surgical endodontics and how it affects treatment. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endodontic Procedures Pulp capping Ø Calcium hydroxide is placed over an exposed or nearly exposed pulp to encourage the formation of dentin at the site of injury. Indirect pulp capping is indicated when a thin partition of dentin is still intact. Direct pulp capping is indicated when the pulp has been slightly exposed. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endodontic Procedures (Cont’d) Pulpotomy This procedure involves removal of the coronal portion of an exposed vital pulp. Ø It is used to preserve the vitality of the remaining portion of the pulp within the root of the tooth. Ø The procedure is commonly indicated for vital primary teeth, teeth with deep carious lesions, and emergency situations. Ø (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endodontic Procedures (Cont’d) Pulpectomy Ø Also referred to as root canal therapy, this procedure involves the complete removal of the dental pulp. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Instruments and Accessories for Endodontic Procedures Hand instruments Instruments for pulp preparation Hand- and finger-operated files Ø Instruments attached to a low-speed handpiece Ø Rotary files Ø Ancillary instruments Rubber stops Ø Paper points Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Table 54 -1 Colors and Sizes of Endodontic Files Copyright © 2009, 2006 by

Medicaments and Dental Materials in Endodontics Irrigation solution Sodium hypochlorite Ø Hydrogen peroxide Ø Parachlorophenol, or PCP Ø Root canal–filling materials Ø Gutta-percha points Root canal sealers Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Overview of Root Canal Therapy Anesthesia and pain control Isolation and disinfection of the site Access preparation Débridement and shaping of the canal Obturation Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Surgical Endodontics Indications for surgical intervention Ø Endodontic failure • Persistent infection, severely curved roots, perforation of the canal, fractured roots, extensive root resorption, pulp stones, or accessory canals that cannot be treated Exploratory surgery • To determine why healing did not occur Ø Biopsy Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Apicoectomy and Apical Curettage To surgically remove the apical portion of the root with the use of a high-speed handpiece and bur To evaluate: Inadequate sealing of the canal Ø Accessory canals Ø Fractures of the root Ø Pathologic tissue around the root apex Ø Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Retrograde Restoration This procedure is undertaken when an apical seal is not adequate. Ø A small class I preparation is made at the apex and sealed with filling materials such as guttapercha, amalgam, or composite. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Root Amputation and Hemisection Root amputation Ø This surgery is performed to remove one or more roots of a multirooted tooth without removing the crown. Hemisection Ø The root and the crown are sectioned lengthwise and removed. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.