Professional Documents
Culture Documents
TWELFTH EDITION, 2011; CO-EDITORS: Thomas A. Levy DDS, MS, Yaara Berdan, DDS
USC ENDODONTICS
FIGHT ON!
1
TABLE OF CONTENTS
Preface
Expected Outcomes
Course Information
Lecture Schedule
Laboratory Schedule
Articles for Literature Review
Section 1
Selection and Mounting of Teeth, Processing Radiographs
Section 2
Rubber Dam
Section 3
Endodontic Armamentarium
Section 4
Endodontic Access Preparation
Common Objectives for Access Preparations
Anatomy and Access of Maxillary Anterior Teeth
Errors in Access Preparation of Maxillary Anterior Teeth
Anatomy and Access of Mandibular Anterior Teeth
Errors in Access Preparation of Mandibular Anterior Teeth
Anatomy and Access of Maxillary Premolars
Errors in Access of Maxillary Premolars
Anatomy and Access Preparation in Mandibular Premolars
Errors in Access of Mandibular Premolars
Anatomy and Access of Maxillary Molars
Errors in Access of Maxillary Molars
Anatomy and Access of Mandibular Molars
Errors in Access of Mandibular Molars
Variations in Molar anatomy
Section 5
Shaping and Cleaning the Root Canal System
Working Length
Electronic Apex Locator
Shaping the Root Canal System
Hand Files
Balanced Force
Rotary files
USC Technique
Fine Tuning
Irrigation
Section 6
Intracanal Medication
Section 7
Obturation
Section 8
Temporary Restorations
Section 9
Procedural Accidents
Section 10
Clinical Applications
AAE Assessment Form
Presession Form
SOAP Notes
Diagnostic Terminology
Required Radiographs
Laboratory Progress Sheet
Brown Form for Clinic
Section 11
Practical Procedures and Grading
Section 12
10 Steps to Endodontic Heaven
Section 13
Endodontic Clinic Requirements
2
p. 3
p. 3
p. 4
p. 5
p. 6
p. 7
p. 8
p. 15
p. 17
p. 25
p. 25
p. 29
p. 32
p. 33
p. 35
p. 36
p. 39
p. 39
p. 42
p. 42
p. 47
p. 48
p. 52
p. 53
p. 54
p. 55
p. 57
p. 59
p. 60
p. 62
p. 63
p. 65
p. 69
p. 70
p. 72
p. 73
p. 80
p. 82
p. 89
p. 89
p. 91
p. 92
p. 95
p. 97
p. 99
p. 100
p. 102
p. 104
p. 105
PREFACE
This manual serves as a step-by step teaching guide for the introductory laboratory course in root canal therapy
for sophomore dental students. The information included in this manual together with the lecture material
presented will serve as a foundation for endodontic treatment in the clinic. It is not intended to be a complete
representation of endodontics, but as a basic reference for techniques and concepts that are basic to endodontics.
The recommended textbook and current literature will provide important additional information. The field of
endodontics continues to evolve with new materials, products and techniques, as we continually strive to
provide our patients with the best endodontic care available. The concepts presented here are the foundation on
which to build your endodontic knowledge.
Endodontics: 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.
Expected Outcomes:
Recognize pulpal and periradicular disease and be able to make a correct pulpal and
periradicular diagnosis
Know tooth/pulp anatomy
Evaluate a case for treatment or referral
Expose and interpret radiographs used in endodontics
Know the composition of materials used in endodontics
Safely make an endodontic access preparation
Accurately determine working length for canal preparation
Correctly clean and shape root canals using hand files and rotary files
Correctly prepare and place root canal sealer
Completely obturate root canals by lateral condensation of gutta-percha
Accurately evaluate rendered treatment
Thoroughly complete endodontic records
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Course Information
The sophomore endodontics course has a lecture component and a lab component.
Lecture is on Thursday from 8am-9am in the Century Club Lecture Hall.
Laboratory portion is Friday from 8am-12pm or 1pm5 pm in the SIM lab.
The first half hour of lab will be spent reviewing the assigned literature and taking the occasional quiz.
Attendance at the laboratory sessions is mandatory.
There will be one grade for the course. The lecture will comprise half of the grade and the lab will comprise half
of the grade.
The lecture grade is based on one midterm (40%), one final (50%), and 5 quizzes (10%)
The final has two parts- a written multiple choice portion and an OSCE portion (Objective Structured
Clinical Exam)
The lab grade is based on 2 midterms (25% each), and one final (50%).
Each step of the root canal treatment is to be checked off on your lab sheet prior to moving on to the next step
REFERENCES
Cohen, S, Hargreaves: Pathways of the Pulp, Tenth Edition. 2010
Endodontic Manual 12th edition (available electronically via the intranet)
PowerPoint presentations of the lectures (available on the intranet)
Lecture Schedule
Date
09/01/11
09/08/11
Topic
Lecturer
Introduction to Endodontics
Lab Orientation
Anterior Access
Dr. Levy
Hand Instrumentation
Dr. Schechter
09/15/11
Dr. Berdan
Principles of Root Canal
Preparation
Working Length Determination
09/22/11
Rotary Instrumentation
Dr. Thomson
09/29/11
TBD
10/06/11
Dr. Levy
10/13/11
Endodontic Infections
Dr. Berdan
Midterm
Pulp Bio, Caries, and VPT
Dr. Levy
11/03/11
Irrigation
Intracanal Medication
Dr. Levy
11/10/11
11/17/11
Diagnosis
Trauma
Dr. Berdan
Dr. Berdan
11/24/11
12/01/11
Happy Thanksgiving
Safety Lecture
Dr. Levy
12/9/11
Final
Reading
Pathways: Ch 9 Framework for RCT
p. 283-289
Pathways: Ch 7;1.Objectives and
Guidelines for Access Cavity Prep,
2. Mechanical Phases of Access
Cavity Preparation (thru ant access
prep), 3. Morphology and Access
Preparation of Ant Teeth
p. 150-162, 177-183, 200-203
Pathways: Ch 9; 1. Cleaning and
Shaping: Technical Issues p. 289294. 2. Canal Preparation
Techniques (through Balanced
Force) p. 319-324
Pathways: Ch 9;1. Cleaning and
Shaping: Clinical Issues, 2. Canal
Preparation Techniques (through
Balanced Force Technique)
p. 316-324
Pathways: Ch 7 Anatomy of the
Apical Root.
Pathways: Ch 8 Devices for
Measuring Root Canal Length
p. 145-150, 242-243
Pathways: Ch 8 Rotary Instruments
for Canal Preparation
Pathways: Ch 9 Nickel titanium
Rotary Instruments
Read only the Profile System
p. 294-297, 324-326
Pathways: Ch 10
Pathways: Ch 22; Clinical
Procedures Post Placement
p. 794
Pathways: Ch 7 Posterior Access
Cavity Preparations
p. 162-165, 184-199, 204-219
Pathways Ch 15
MUST BE IN
ATTENDANCE
Manual p. 89-105
Laboratory Schedule
DATE
ASSIGNMENT
READING
09/02/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
09/09/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
09/16/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
09/23/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
09/30/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
10/07/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
10/14/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
10/21/11
Midterm 9-12 lab. 1-2 written
10/28/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
11/04/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
11/11/11
8-9 or 1-2 lit review
9-12 or 2-5 lab
11/18/11
Exam 8-12 or 1-5
11/25/11
12/2/11
8-9 or 1-2 intro to clinic
9-12 or 2-5 lab
12/9/11
Rotary demonstration
Obturate first anterior tooth
Access second anterior tooth
Rotary Instrumentation
Complete anterior teeth
Find and mount one lower and one
upper (2 canal) bicuspid
Coronal and radicular access of
plastic bicuspid
Access lower bicuspid and
instrument with hand files
Complete lower bicuspid
Access upper bicuspid and
instrument with rotary files
Complete bicuspids
Jafarzadeh
Carvalho
Manual p. 59-62, 65-71
Allison
Ibarrola
Manual p. 63-69, 73-79
Brannnstrom
Holland
Manual p. 36-42
Torabinejad
Henry
No article
Swift
Barrieshi-Nusair
Manual p. 13
Final
Spencer
Sjogren
Manual p. 42-53
Sigurdsson
No article
dimple
Fold a piece of foil as shown and cover half of the film. Place the tooth on the uncovered side and orient it
for a buccal lingual (frontal) view. (Wax may be used to keep the tooth in the desired position) Expose the x-ray.
Place the foil on the half of the x-ray that was just exposed and place the tooth on the uncovered side. Orient the
tooth for a mesial distal (proximal) view. Expose the film again. Process the film and observe both views.
Processing Radiographs
The liquids in the portable dark rooms are arranged as follows:
Developer
1
5-10 sec
Water
2
3sec
Fixer
3
30 sec
Water
4
3 sec
1. Be sure the cover on the developing box is properly in place obstructing leakage of light.
2. Holding the film packet with the dimple in the upper right hand corner (away from you), peel back the
tab and partially unfold the black paper liner.
3. Attach the film clip at this upper right corner this will prevent clamping the film near the image of the
apex of the root. (Remember, the film was oriented with the dimple toward the occlusal, or incisal of the
tooth).
4. Gently agitate the film in the developer (first cup) for 5-10 seconds. Remove from the developer once a
distinct image appears on the film.
6. Remove film from the developer and rinse in the water in the cup for 3-5 seconds.
7. Gently agitate the film in the fixer (third cup) for at least 30 seconds. The image will appear to darken.
8. Remove film from the fixer and rinse in the water in the fourth cup.
9. After removing the film from the developing box, rinse it again under running tap water. Photographic
fixer will leave a brown stain if it drips onto clothing.
10. Evaluate the radiograph. If all the information you need is there and it is of good quality, continue
fixing the radiograph in a separate cup at your work area. The image is not permanently fixed until the
film has been fixed for 3-4 minutes. Over fixing the x-ray will erase the image. The fixer then needs to be
removed by running the x-ray under water and rubbing the surface gently with your fingertips. The
radiograph now needs to be set out to dry.
11. Proper radiograph criteria are:
a.
No fixer stains
b.
No scratches
c.
Tooth centered mesial-distal
d.
Radiographic apex at least 4mm from the edge of the film
e.
Proper exposure/contrast
The main problem students have with radiographs in the preclinical course is under fixation and
inadequate rinsing of the fixer from the films.
Following approval by an instructor, the teeth can now me mounted either in an acrylic block, or in the typodont,
depending on the lab exercise. The anterior teeth will NOT be mounted and will be treated by holding in the hand.
This will allow an appreciation for the relationship between the termination of the root canal and the anatomical
apex.
2.
Make shallow score marks at 2 cm intervals along the length of the wax strip.
3.
Fold the wax strip with the score marks toward the outside to form a box. The score marks will be
the fold lines. The 4 mm excess at one end of the original strip will extend out from the side of the box.
4.
Fold over the flap of excess wax and weld the box together with a heated wax spatula.
10
5.
7.
Cut a 2.5 cm square of boxing wax and weld onto one open end of the box to seal that end.
Roll up a 4-5 mm ball of wax and place at the end of each root.
This ball of wax simulates a periapical lesion and helps visualize the
apical portion of the tooth during root canal treatment on the tooth.
The balls of wax CANNOT touch the floor of the wax form. Acrylic
must be present at the bottom of the block, no wax can be exposed.
7.
Place 20 cc of acrylic polymer in a plastic cup. Add just enough stone (approximately one gram or 1/4th
teaspoon) to very thinly cover the surface of the polymer.
8.
Add monomer and mix until runny and pour acrylic into the box.
9.
With the box held on the laboratory vibrator, seat the tooth into the acrylic to the level of the cervical line.
Keep any caries or restorations at least 2mm above the acrylic and do not let the apical wax touch the
bottom of the box. Align the buccal, lingual, mesial, and distal surfaces of the tooth parallel with the sides of the
box, move the tooth out of the box slightly, if necessary to keep the apical wax from touching the bottom of the
box. Remove the box from the vibrator and place it on a table remote from the vibrator.
11
10.
Ensure that the acrylic is about 2mm below the CEJ of the tooth.
11.
Hold the tooth in place until the acrylic is at a consistency that will prevent the tooth sinking into the mix.
12.
Allow the acrylic to set and cool, then strip away the wax with a lab knife.
DO NOT TRIM THE ACRYLIC BLOCKS ON THE MODEL TRIMMER.
The acrylic will damage the trimmer disc.
12
13
Place rod (or high vacuum suction tip) to hold the mandible in
place.
14
15
Determine proper clamp size, place floss for safety and place securely on the tooth.
Place the rubber dam sheet over the clamp and position the frame. When working with the typodont, place the
clamp on the adjacent tooth. This will prevent dislodgement of the tooth.
16
17
Gates-Glidden Drills
Latch-type Gates-Glidden drills are used to open the coronal 1/2 to 2/3 of the canal. Gates-Glidden drills
are intended to cut upon withdrawal from the canal. The cutting flutes are on the back of the instrument
head rather than the tip. Size 2=0.70mm; Size 3=0.90mm; Size 4=1.1mm
We do not use size 1 Gates Glidden drills (0.5mm) since they tend to break at the bud, not at the shank.
18
In the schools endo block, file sizes 8-20 are stainless steel, file sizes 25-60 are nickel titanium, and file
sizes 70-100 are stainless steel.
Silicone Stoppers
Used to set working length on files, spreaders, and pluggers.
19
Endo-Ring
The endo ring is a convenient way to hold
endodontic files and gates glidden during a
procedure. The blue ring is autoclavable and the
foam insert is disposable. HOWEVER, IN
PRECLINIC LAB, THE FOAM INSERT CAN
BE REUSED FROM TOOTH TO TOOTH.
Gutta-percha
Moldable material used to obturate prepared canals. Gutta-percha comes in various sizes and shapes.
There are standardized and conventional gutta percha cones. The standardized gutta percha cones
correspond to the master apical file. The standardized gutta percha cones come in sizes 15-90+ and have a
0.02 taper. (0.02 increase in width for each mm increase in height). The conventional gutta percha cones
are named for the size at the tip and the size of the body. In the cold lateral obturation technique (which is
currently being taught at the USCSD) they are used as accessory cones.
The tolerance for gutta percha points is less stringent than for files and is 0.05mm. For that reason size #40
gutta percha can be anywhere from #35 to #45. (#40 +/- 0.05). If a gutta percha point does not go length or
is too long, then try another gutta percha point prior to re-shaping the apical portion of the canal. The FF
and MF gutta percha points are used as accessory points in lateral condensation.
We will use standardized .02 taper cones in sizes 25-80 for the main cone and accessory cones FF and MF.
(FF- a fine tip and a fine body, MF a medium tip and a fine body) for use with the D11T spreader and
size 20 and 25 standardized gutta percha cones for use with the #25 and #30 finger spreaders, respectively.
20
Iris scissors
Either straight or curved are, on rare occasions, used for cutting the tips of gutta-percha cones when fitting
a master cone.
21
Paper points
Paper points come in many sizes and are used to dry fluids from canals. Remember to aspirate the canal
with your irrigation syringe first prior to using the paper points.
22
Glick #1
The paddle end of the Glick is used to carry and place temporary filling material while the plugger end is
used to compact the temporary filling material. Both ends may be heated and used to sear off and remove
excess gutta-percha and to soften gutta-percha as needed.
Plugger
Gutta-percha is seared off at the canal orifice at the end of completion of lateral condensation. The plugger
is a flat-ended instrument used to condense the cervical portion of this warm gutta-percha. (The plugger
end of the Glick instrument can also be used for this purpose. It is also used for the entire compaction of the
heat-softened gutta-percha with the vertical compaction technique. DO NOT USE AS A HEAT
CARRIER!
23
Film clip
It is mandatory that you use film clips. YOU MUST BUY AT LEAST 4. They are used to hold
radiographic films during processing, viewing, and air-drying. A hemostat or other pliers should not be
used to hold the film. If you lose your clips, buy more.
Cavit
This temporary material is used to the fill access opening. It is a thick putty-like paste requiring no mixing
and sets upon contact with water (saliva). It has better sealing ability but less strength than IRM.
IRM
This material is used to fill an access opening. Powder and liquid must be mixed to make a thick putty-like
paste. IRM also comes in capsules for ease of mixing.
24
horizontal and coronal direction. The concept is intended to prevent ledging of the canal or perforation of
the root surface during the access preparation.)
9.
After complete removal of the pulp chamber roof, the preparation is refined. Special burs with a
blunt tip, such as Endo Z burTM or Endo Access bur TM have been designed for this purpose and allow
preparation without removing dentin from the pulpal floor. (However, care needs to be taken to prevent too
much removal of dentin from the chamber walls.) Canal orifices are located with an endodontic explorer.
All tissue, debris, pulp stones, and other loose mineralizations are removed. The pulp chamber is
disinfected by rinsing with sodium hypochlorite solution.
10. Once the access is completed in a clinical case, it should be possible to view the orifice of every
canal with minimal movement of the mirror. This is known as straight-line access.
11.
Although the above steps should have completed the access cavity, in certain cases it may need to be
refined during the subsequent procedures to assure straight line access. It is often necessary to refine the
access as the canals are instrumented to assure straight line access. However, do not remove structure from
the walls or floor of the pulp chamber unless specifically instructed to do so by an instructor. Unnecessary
dentin removal results in weakening of the tooth.
12. To maintain a sterile work environment and to prevent an air embolism, water and the air water
syringe should not be used once the pulp chamber has been entered. The tooth should be irrigated with
sodium hypochlorite and the surgical suction can be placed inside the chamber to dry the tooth. The
27
irrigation syringe can also be used to aspirate the irrigant from the canals thereby quickly and efficiently
drying the canal and using fewer paper points.
In order to accomplish these objectives, adequate enlargement of the access must be made.
The most common error in making endodontic access is making it too small. The most critical error
is making the endodontic access in the wrong place. Excessive removal of tooth structure by
overextension of the access will needlessly weaken the tooth and make it more susceptible to fracture.
However, saving tooth structure at the expense of a proper access could result in failure of the treatment
and complete loss of the tooth. .
The illustrations following each tooth type depicts the size, shape, and location of the pulp space within
each tooth. Each illustration gives the following information:
In addition, the percentage of the more common morphologic variations of the roots and canals are given. With
28
many of the tooth groups, the percentages do no total 100%. The remaining percentage represents the less
common variations not illustrated.
Access into the maxillary central is triangular in shape, reflecting the triangular form of the pulp chamber.
It is made by first cutting the triangular outline into tooth structure to a depth of 2mm. A #4 F.G. round bur
or a fissure bur such as the 557 are usually used for access. Hold the bur perpendicular to the lingual
surface of the tooth. Entrance is always gained through the lingual surface of all anterior teeth. (Unless the
tooth is rotated and the lingual surface is not accessible.) This is purely for aesthetic reasons. Initial
penetration into the pulp chamber is made with the bur just above the cingulum as shown in the picture. A
common error is to begin the cavity too far gingivally. Make an outline extending from the cingulum to 2/3
29
Make initial penetration into the pulp chamber. Do not penetrate more than 4 mm from the lingual surface
there is a risk of perforating the buccal surface. Get help if you have not found the pulp chamber at this
point. After penetration is made, the chamber is unroofed with withdrawal strokes, cutting with the top of the
round bur. It is very important to include the pulp horns in the access cavity so that all tissue and discolored
dentin are removed to prevent discoloration of the tooth. Removal of the pulp horns is evaluated with an
explorer.
30
Checking for the removal of the pulp horns with the endo explorer.
The lingual overhang of dentin partially obstructing the orifice of the canal (the lingual triangle) is removed with
an Endo Z bur or a Gates-Glidden drills creating straight-line access into the canal.
Access is accomplished similarly to the maxillary central incisor. The outline is usually oval (as opposed to
triangular in the central) due to the smaller pulp chamber.
Maxillary Canines
The coronal pulp is ovoid in cross-section and the access preparation reflects this shape. The access
31
cavity is prepared as described for the maxillary and lateral incisor. The point of entry is at the cingulum
with the tip of the bur aiming for the center point at the CEJ level. The occlusal outline form is ovoid as
the single pulp horn does not tend to fan out to the mesial and distal; however it is broad labiolingually.
As with the central and lateral, the lingual triangle must be removed. The incisal extension is about 2/3 of
the distance to the cusp tip.
The maxillary canine is the longest tooth in the dental arch with an average length of 26.5mm. The root
may have mild to moderate apical curvature and the foramen is usually close to the anatomic apex.
Accessory canals occur less frequently than in maxillary incisors. The root apex may have a disto-labial
curvature.
2.
Gouging of buccal wall due to failure to recognize the lingual inclination of
maxillary anterior teeth.
3.
the
2
4.
Ledge formation caused by using a too large instrument through an inadequately shaped access and
inadequate coronal canal preparation
4
32
5.
33
Mandibular Canine
The mandibular canine has an average length of 25.6mm. It is a fairly straightforward tooth with
minimal complications, similar to the maxillary canine. The mandibular canine, though, may on occasion
have two canals or two roots evidenced on the radiograph by an apparent termination of the visible canal
somewhere at mid-root level. Where two canals are present, it is usually easier to gain access into one than
the other. Nonetheless, both must be located and treated. Frequently the foramen exits to the buccal or
mesial (35%-50%).
The access preparation is oval as in the maxillary canine.
34
SUMMARY: The most common error made in accessing anterior teeth is perforation of the facial
crown or root surface. If the canal is not easily encountered within the confines of the crown of the tooth,
an instructor must be consulted. Remember to estimate the location of the pulp chamber and if you do
not find it there take a radiograph and ask for help
In order to minimize perforations you must evaluate the radiographs and estimate where the pulp chamber
will be found and determine if you are comfortable with this search.
If so, then go to this predetermined location. If you do not find the pulp chamber at this point, take at least
2 radiographs (at different angles) to help guide you along with faculty consultation. Always have an
objective when you cut on a tooth. When in doubt, ASK FOR HELP!!
35
6) no straight line access and no instrument control due to access in wrong location. Access is never
through the proximal. In rotated teeth access may need to be placed in buccal or through incisal but that still
allows for straight line access.
6
36
The access preparation is oval in shape with the largest dimension in the buccal-lingual direction. Buccal
and lingual extensions are 2/3 the distance up the cusp tips. Mesial-distal extension need be no greater than
the width of the #4 round bur.
37
3.
In the center of the outline, make initial penetration into the pulp chamber - it should be encountered
within 4-6 mm from the occlusal surface. In order to avoid furcal perforation in a multi-rooted premolar,
do not exceed 8 mm in penetration. Take radiographs if pulp chamber is not found. Evaluate location of
access and pulp chamber and adjust appropriately.
4. Locate the opening into the chamber with the endodontic explorer.
5. With light horizontal and outward (occlusal) motions, unroof the rest
of the chamber extending buccally and lingually.
6. Smooth the walls with the Endo-Z bur and create the occlusal
reference point(s).
7. Locate the canal orifice(s) with the DG16 endodontic explorer
Access cavity of maxillary premolars
For a tooth that almost always has a single root, the mandibular first premolar has a great variety
in canal anatomy. The anatomy can be as simple as a single orifice and single foramen or as
complex as a single cervical orifice dividing in the mid-root into three canals terminating in three orifices.
Single-canal first premolars may have an apical arborization that divides into multiple apical foramina. The
single canal form occurs 70% of the time and two canals combining to exit in one foramen 4% totaling 74% of
first premolars with a single foramen.
The most common deviation from the single canal form is a single orifice dividing mid-root into two canals
with two foramina. This condition must be anticipated since it accounts for 25% of mandibular first premolars.
The radiographic appearance of a canal disappearing mid-root is indicative of a bifurcation of the canal.
Delicate probing into the canal with a small file can also reveal much of the internal anatomy and can confirm
the presence or absence of a canal bifurcation.
Average length of the first premolar is 21.6 mm. The foramen very often deviates from the apex (85%-90%).
1/3 of deviations are toward the distal.
Access in the mandibular first premolar, like all other premolars, is oval to encompass the oval shape of the pulp
39
and to aid the search for divisions in the canal, extension to the buccal and lingual is 2/3 the distance to the cusp
tips.
continued until the contra-angle handpiece rests against the occlusal surface. This depth of 9 mm is the usual
position of the canal orifice that lies at the cervical level. In removing the bur, the occlusal opening is widened
buccolingually to twice the width of the bur to allow room for exploration.
2. Working from inside the pulp chamber to outside, a regular-length round bur is used to
extend the cavity buccolingually by removing the roof of the pulp chamber. The Endo ZX
bur is used to smooth out the access and achieve straight line access.
2
3. Extend the cavity outline bucco-lingually. Keep the mesio-distal dimension smaller
than the bucco-lingual dimension.
43
oval shape.
Locate the opening into the chamber with the DG16 endodontic explorer.
5.
6.
Smooth the walls of the preparation with the Endo-Z bur and create the occlusal reference point(s).
46
7.
2. Overextended preparation undermining enamel walls. The crown is badly gouged owing to failure to
observe pulp recession radiographically and searching for pulp in incorrect area.
3. Perforation into the furcation by failing to compare length of bur to depth of pulp chamber
floor.
3
4. Ledge formation due to failure to achieve straight line access.
47
Average tooth length is 19.8 mm. Access is triangular in shape. The mandibular second molar is the
most frequent tooth to suffer a mesial-distal fracture.
4-6mm
8-10 m m
2.
Using a #557 F.G. bur, reduce the occlusion 1mm then make an outline of
the access preparation 2 mm into tooth structure. The outline is triangular for both
mandibular and maxillary molars.
2
Mandibular molars:
a)
The base of the triangle is on the mesial side of the occlusal surface of the tooth paralleling the
mesial marginal ridge. It extends 2/3 of the way up the cusp tips.
b)
c) The apex angle may need to be expanded into a straight side forming a trapezium if the distal canal is
broad bucco-lingually or there are two distal canals.
3.
Holding the handpiece at a slight angle so the bur parallels the mesial surface of the
crown; make initial penetration into the pulp chamber, staying within the above limits.
4.
Locate the opening into the chamber with the DG16 endodontic explorer.
4
5.
6.
Smooth the walls of the preparation with the Endo-Z bur and create
the occlusal reference point(s).
7.
52
53
The term chemo-mechanical preparation accurately describes two important goals that must be achieved
to obtain an ideally prepared root canal space. The mechanical removal of all organic debris, microbes, and
microbial irritants from the root canal system , and the desired final shape of the canal space are
accomplished to a great extent through the use of endodontic files. However, there are areas in the root
canal system which are inaccessible to files. Complex canal ramifications, fins, apical deltas, and
54
communications between canal systems are not able to be cleaned by files. In fact, depending on the
original shape of the root canal only 40-60% of the surface is mechanically prepared. In order to remove
bacteria and pulpal remnants from these inaccessible areas the remaining sections and the walls of the main
root canals need to be chemically cleaned by a disinfecting solution that also dissolves necrotic and residual
vital tissue. Clinically, this goal is achieved by copious irrigation with sodium-hypochlorite solution
(NaOCl). A chemo-mechanically disinfected and shaped root canal space represents an important step
towards a successful treatment outcome.
Working Length
Working length determines the depth of the canal to which cleaning and shaping will be accomplished.
Working length is the distance from an occlusal reference point, such as an incisal edge, a marginal ridge,
or a cusp tip to the apical endpoint of the radicular preparation and obturation of the canal. Occlusal
reduction on a posterior tooth makes the reference point more reproducible and easier to use. It is extremely
important to have an accurate working length so that the whole length of the canal is treated but the
periapical tissue is not encroached upon. Instrumentation and filling materials should terminate at the apical
constriction (minor foramen), the narrowest point within the canal. This is where the pulp tissue and ends
and the periapical tissue begins. This point is often 0.5 to 1.0mm from the radiographic apex or 0.5mm
from the major foramen. The apical stop preparation allows for the condensation of gutta-percha and for the
keeping the files within the root canal. This will maintain the integrity of periapical tissue and will
minimize postoperative pain and discomfort.
55
Anatomical Apex
(Major Foramen)
Apical Constriction
(minor foramen)
Cementum
Dentin
56
.
3) Never use the unit when the battery power indicator is flashing on and off. The unit will not function
properly when the battery power is low.
4) The numerals 1,2,3 do NOT represent length in millimeters
5) The apical line indicates that the tip of the file is in the apical constriction. (That is the dark line in the
diagram above.) The apical constriction is considered the narrowest part of the canal and represents a junction
between the pulp and surrounding periapical tissue. Microscope studies have determined it is 0.5 to 1 mm from
the apex.
6) Turn the unit on first and then place the contrary electrode in the corner of the patients mouth preferably on
the opposite side of the tooth being treated.
7) Always clip the file holder to the upper part of the file shaft, near the handle. Do not clip to cutting part. Also
when the canal is longer than 23mm it may be easier to use the 31mm file for measurement with the EAL. This
allows more room for the stopper and file holder on the file.
57
8) Insert the file into the canal until the meter reads 0.5. Then advance the file apically until the word APEX
begins to flash. This signifies that the file is at the major foramen. When the apex is reached, turn the file slowly
counter clockwise until the meter reads 0.5 again. Since some canals have multiple constrictions, it is essential
that the file be taken to the apex and then returned to the apical constriction (0.5 reading). Position the rubber
stopper on the tooth surface at a reference point to determine the root canals working length.
9) When you are done with the measurements remove the lip clip from the patient and place the apex locator in
a safe place. You may forget about the lip clip and when seating the patient up the apex locator may fall to the
floor. A dropped apex locator will not function properly and need to be replaced. These are your apex locators.
TAKE GOOD CARE OF THEM.
58
Shape first
Shape second
Shape last
This file did not go to length initially due to coronal obstructions. Once the canal has been flared with gates
glidden burs, the file fits easily to length. Also note the file initially being bent away from the cusp near the
orifice. This indicates the lack of straight line access in the coronal portion of the canal.
2) improved tactile sensation. It is easier to sense the apical portion of the canal once the middle and
coronal obstructions have been removed. Canal curvatures can be better assessed since they are not
confused with obstructions in the coronal and middle portion of the canal.
3) better apical gauging (studies have shown that the assessment of apical size is more accurate after
preflaring the canal). After coronal preflaring the first file to bind at the apex was 2 times larger than
59
before the preflare. That is because the smaller file was binding coronally prior to removal of coronal
obstructions.
4) less instrument separation (studies have shown less instrument separation when the canal has been
preflared
5) increased efficiency of irrigation. The irrigant is better able to penetrate the full length of the canal. As
the debris is being flushed out from the coronal to the apical area there is also less extrusion of debris
periapically. This results in less tissue irritation and less chance of a flare up.
The size designation of files is derived from the diameter at the tip of the instrument. D0 is the diameter of the
instruments in hundredths of a millimeter.
Dimensions of standardized K-type files and gutta percha cones
SIZE
006
008
010
015
020
025
030
035
040
045
050
055
060
070
080
090
100
110
120
130
140
D0
0.06
0.08
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
0.55
0.60
0.70
0.80
0.90
1.00
1.10
1.20
1.30
1.40
D16
0.38
0.40
0.42
0.47
0.52
0.57
0.62
0.67
0.72
0.77
0.82
0.87
0.92
1.02
1.12
1.22
1.32
1.42
1.52
1.62
1.72
COLOR
Pink
Grey
Purple
White
Yellow
Red
Blue
Green
Black
White
Yellow
Red
Blue
Green
Black
White
Yellow
Red
Blue
Green
Black
60
D0 is the diameter at
the tip of the file.
This is a size 25 file
so D0 is 0.25 mm
the file is not tightly bound in the canal. With circumferential filing tooth structure is removed uniformly from
the canal walls.
Watch-Winding - is a back-and-forth movement of the file while it is gently being advanced apically. The
amplitude of the motion in a straight canal is 30-60 degrees right and left from the center point, with a curved
canal the rotation may be only a few degrees in each direction. It is much like the file handle is being rolled back
and forth between the thumb and forefinger while a slight apical pressure is applied.
Anti-curvature filing - instruments the walls of the canal away from DANGER AREAS such as the furcation
or root concavities to minimize the chance of a stripping perforation.
DANGER AREAS:
Lower Molar
Upper Molar
engagement
cutting
removal
Always inspect your files and other instruments for cleanliness and defects, e.g. unwinding, before
you place them in a canal and after you withdraw them. All your instruments work better when
cleaned of debris. The file you do not inspect is the one that will break!
AS FILE SIZE INCREASES, ITS STIFFNESS INCREASES MAKING A LARGE FILE LESS
ABLE TO INSTRUMENT AROUND A CURVE.
ROTARY INSTRUMENTATION
All rotary instrumentation begins with handfiles. The operator should have a radiographic knowledge of
canal morphology and an established working length. A size 20 stainless steel handfile should create a
glide path to working length before any rotary instruments are used in the apical 1/3. When instrumenting
with nickel-titanium rotary files use a light touch, do not force the instrument. Each nickel-titanium
instrumentation system has its own usage guidelines. For the Profile rotary instruments which are used at
the USC the force applied should be no more than that required to snap a mechanical lead pencil point.
Ignoring this basic rule will increase the risk of instrument fracture. Go down the canal in small
increments using the same pressure that advanced the file into the canal 1mm in 1 second. This has been
described as a light pecking force. The smaller the diameter of the rotary file, the less pressure the file
can withstand before deforming or separating. The greater the curvature of the canal, the less pressure the
rotary file can withstand before separation. BE GENTLE. If the rotary file gets stuck and does not
advance go to a smaller size or hand files. Ledging and then perforation occurs when files are used
for an extended period at the same position in the canal.
Rotary commandments:
1.
The Rotary electric motor is set at 275 - 300 RPM-torque control is set at midrange
2.
Keep the canal wet-NaOCl and EDTA
3.
Frequently clean and inspect the rotary files-use the files on 3 cases or less
4.
Always work with straight line access
63
5.
6.
7.
8.
9.
10.
A glide path to WL must be created with a size 20 stainless steel hand file prior to use of rotary
instruments
Never force rotary files - avoid the BEEP!
Look to see the area on the rotary file that is picking up dentin, this tells you where the file is
working in the canal
No more than 1 second at any length
Respect the nickel-titanium rotary and it will be good to you
Files should always enter and exit the canal while rotating. NEVER stop a rotary instrument
inside the canal.
Notch
64
Size 1 Gates is 0.5 mm (size 50). We do not use this size since it has a high tendency of breaking at the bud.
When larger size gates glidden burs break it is high on the shank and easily removed. In small canals use the tip
of the #4 gates to only flare the orifice with the chamber. Only insert it into the canal to the depth of the #4
65
gates. In large canals, upper incisors, lower cuspids, one canal bicuspids, the #4 gates can be inserted deeper,
but never forced. The gates are always brushed away from the furcation (danger zone) and toward the wall of
the canal you are shaping (i.e. mesial buccal canal brush the gates towards the mesiobuccal, palatal canal, brush
the gates towards the palatal). It is important to be as conservative as possible with the use of any instruments in
the root canal system. Unnecessary removal of tooth structure during access or of dentin during instrumentation
will not improve the treatment for the tooth. On the contrary, injudicious removal of tooth structure weakens the
tooth making it more susceptible to fractures and treatment failure. The careful use of gates glidden drills in the
coronal 3 5 mm of the root should not result in any mishaps. Since most teeth are 19-25 long and most clinical
crowns are 10mm long, most roots are 9-15 mm in length. Roots therefore can be divided into thirds that are 3-5
mm long.
Size of gates-glidden drills used at USC
Size 2 is 0.7 mm (Size 70)
Size 3 is 0.9 mm (Size 90)
Size 4 is 1.1 mm (Size 110)
6) Determining working length. Now that the coronal portion of the canal is preflared, the apical portion of the
canal is ready to be negotiated and working length determined. Use a size 15 stainless steel file with a
File (MAF). For example, if the FIRST FILE TO BIND is #20, MAF will be at least #35 with an optimal size
of 45. If the FIRST FILE TO BIND is #40 (possible in young maxillary anterior teeth), the optimal MAF is at
least #70. Minimal MAF is #30 for very narrow or curved roots and # 40 for straight roots, most MAFs fall
into the range of #30-#80. As the file size increases, the stiffness of the file also increases. The stiffer the file,
the more of a tendency it has to straighten out in the canal and less of a tendency it has to follow the natural
curve of the canal. Therefore, the MAF is also dictated by the curvature of the canal. Using a large file in a
small curved canal would cause ledging, apical transportation, or perforation.
) Preparing the apical stop. We want to create an apical stop at the apical constriction (minor
foramen)
Hand instrumentation with nickel titanium hand files. Use the balanced force technique in a crown down or
step back fashion until the desired file size reaches working length. This is the master apical file. Take a
radiograph of the MAF at WL.
Rotary instrumentation with Profiles. ALL rotary instrumentation begins with hand files. It is imperative to
create a glide path prior to the use of rotary files in any canal. This is accomplished by assuring that a #20
stainless steel file can go to working length. After a glide path is created begin using the rotary instruments in a
crown down fashion. Start with a size 40 Profile. Insert it into the canal as it is rotating. (Never start or stop a
rotary file in the canal. This significantly increases the risk of instrument breakage). Use the Profiles with a
light pecking motion. The force applied should be no more than that required to snap a sharp lead pencil.
Ignoring this simple yet basic rule will unnecessarily increase the risk of instrument fracture. When an
instrument is no longer advancing apically, it should be replaced with a smaller instrument. Ledging and
perforation occur when an instrument is used for an extended period at the same length. For example, start with
the size 40 Profile. When it can no longer advance, use the size 35 Profile. This instrument will advance further
apically. When the size 35 Profile can no longer advance apically, use the size 30 Profile. Continue this
sequence until your selected MAF reaches working length. This sequence may have to be repeated several
times. But each time the instruments are used they are able to more closely approach working length.
Crown down instrumentation denotes an instrumentation technique in which the root canal is instrumented from
the coronal portion to the apical portion. The advantages to this sequence is
1. less potential for bacteria and other irritants to be forced into the periapical tissue
2. less force is placed on the files resulting in less torsional fatigue
With both hand or rotary instrumentation it is important to recapitulate to the WL after the use of each
instrument. During root canal shaping, dentinal shavings are generated and these can become packed at the
apical end of the root canal. The resulting dentinal blockage prevents subsequent instruments from reaching the
established working length (WL). Forceful filing in an attempt to regain WL can lead to ledging, canal
transportation, and perforations. Recapitulation is the sequential re-use of previously used smaller files to full
WL. This achieves apical patency and eliminates blockages. Apical patency means keeping the foramen area
67
free of debris and preventing apical blockages by passing small files only (usually no larger than a size 10 file)
1 mm past working length. This step does not alter the size, shape, or position of the apical foramen, but stirs up
and facilitates subsequent irrigation of debris. Remember to pre-curve these small files with a pathfinder
bend.
Step back and creating apical flare. After the root canal has been enlarged throughout its entire length to the size
of the MAF, the subsequent files are each made 1 mm shorter than the previous file. Set a file one size larger
than the MAF to WL less 1.0 mm. Decrease the length of each successively larger file by 1.0 mm until a file at
least 4sizes larger than MAF is reached. In most roots this will allow the creation of a flare in the apical portion
of the canal and allow the blending of the apical and middle portions of the root canal preparation.
A good stop should be present after the step back or flaring stage. A hand file the same size as the MAF should
be used to gently test the apical stop. It should virtually drop and stop at the WL in a properly flared canal
with a proper apical stop preparation.
68
IRRIGATION
Endodontic irrigation is an extremely important aspect of endodontic therapy as shaping and cleaning of all
pulp spaces is impossible to achieve with only instrumentation. Most root canal systems are complicated
and nothing like the schematic that is used to explain the basics. Compare this commonly used schematic to
a more accurate root canal system. Files alone cannot clean out the anastomoses between the mesial canals
but irrigants can dissolve that tissue and flush it out. Irrigants should be used at all times during canal
instrumentation. The pulp chamber should always be full of irrigant except for when visualizing anatomy,
using the electronic apex locator, and when obturating the canals. Files are never used in a dry canal.
The ideal irrigant should 1) kill bacteria, 2) dissolve vital and necrotic tissue, 3) lubricate the canal, 4)
remove the smear layer, and 5) not irritate healthy tissue.
SODIUM HYPOCHLORITE:
Sodium Hypochlorite 5.25%, is a mainstay of modern endodontics; it is an excellent disinfectant,
tissue solvent and lubricant. As a tissue solvent it works best full strength, 5.25% (and heated), its efficacy,
as a disinfectant seems to be as good diluted as full strength. Care must be taken with the use of sodium
hypochlorite regardless of the strength used; its unpleasant taste can disturb patients and forceful injection
into or through the tooth can be catastrophic (See Sodium Hypochlorite Accident). When using sodium
hypochlorite a well fitting (sealed) rubber dam should be in place and the solution should be gently placed
70
EDTA, 16-20%, is a useful irrigant and its chelating properties facilitate instrumentation especially in
narrow canals. It is not particularly useful as an aid in searching for canals. It removes the smear layer
produced on the walls of canals during instrumentation by acting on the inorganic component of the dentin.
It has little if any antibacterial activity. However it has been shown that removal of the smear layer
improves the antibacterial effect of NaOCl since it improves access of the solution into the dentinal tubules.
Chlorhexidine, is a long lasting antibiotic solution. It is sometimes used as a final rinse after EDTA. It
has no tissue dissolving capability. It is used as a 2% solution for irrigation and as an intracanal
medicament.
Note: mixing NaOCl with Chlorhexidine causes a brown/orange precipitate. These solutions should not be
used together for irrigation.
71
A cotton pellet should always be placed in the access cavity to make reaccess more predictable. Always
indicate that a cotton pellet was placed and how many were placed. Upon re-entry the original operator or a
new operator will know what to expect. In a large anterior canal, it is possible to inadvertently force a cotton
pellet down the canal if one is not expecting to remove it.
To remove the calcium hydroxide at the next visit, irrigation and recapitulation with the MAF and several stepback sizes should be adequate. If CaOH is not completely removed from canals, it could interfere with the
properties of the sealer and affect the seal desired by obturation. As with any other material untoward events
may occur if CaOH is not used carefully, i.e., make sure not to extrude it beyond the canal and into the
periapical tissue.
Section 7 - OBTURATION
Outcomes
1.
2.
3.
4.
5.
6.
shaping the spreader (or pluggers for vertical condensation) should be fit into the canal(s) to the desired
length.
2) the tooth should be asymptomatic
3) the root should be able to be dried. Any fluid present should be easily removed with paper points.
Continued leakage of fluid, serous, purulent, or bloody, indicates that the canal is not ready for obturation.
Gutta Percha
Gutta percha is the material of choice as a solid core filling material for canal obturation. Although it does not
meet all the criteria for an ideal filling material, it satisfies most of them. Gutta-percha is the trans isomer of
polyisoprene and exists in tow crystalline forms (alpha and beta). In the unheated beta phase the material is a
solid mass that is compactable. When heated the material changes to the alpha phase and becomes pliable and
tacky and can be made to flow when pressure is applied. A disadvantage to the alpha phase is the material
shrinks on setting. Gutta-percha consists of approximately 20% gutta-percha, 65% zinc oxide, 10%
radiopacifiers, and 5% plasticizers.
Gutta percha cones are available in conventional and standardized sizes. The conventional nomenclature refers to
the dimensions of the tip and body. A fine-medium cone has a fine tip with a medium body. Standardized cones
are designed to match the taper of stainless steel and nickel titanium instruments. Tolerance in less stringent for
gutta percha then for files. (0.02mm for files, 0.05mm for gutta-percha). This means that in a box of size 40
gutta-percha the cones can be anywhere from a size 35 to a size 45. (40 +/- 0.05).
Gutta-percha can be placed using lateral compaction, warm vertical compaction, or a carrier system.
Lateral compaction is a common method for obturation. The technique can be used in most clinical situations and
provides length control during compaction.
The lateral condensation technique involves fitting a master gutta-percha cone and condensing with accessory
cones and sealer to fill the root canal. A spreader with a pointy tip is used to condense the gutta-percha, creating
space for placement of accessory gutta-percha cones. The gutta-percha is added sequentially until the canal is
completely filled.
Sealers are used with all the different obturation techniques. Sealers fill voids and irregularities in the root canal,
lateral and accessory canals, and spaces between gutta-percha points used in lateral condensation. Sealers also
serve as lubricants during the obturation process. The properties of an ideal sealer are listed below. Currently no
sealer satisfies all the criteria.
Exhibits tackiness when mixed to provide good adhesion between it and the canal wall when
setting
No staining of tooth structure
Establishes a hermetic seal
Radiopacity so that it can be seen on the radiograph
Very fine powder so it can be mixed easily with the liquid
No shrinkage
Bacteriostatic, or at least does not encourage bacterial growth
Exhibits a slow set
Insoluble in tissue fluids
Tissue tolerant; that is nonirritating to periradicular tissue
Soluble in a common solvent if it necessary to remove the root canal filling
Sealers should be biocompatible and well tolerated by the periapical tissues. All sealers exhibit toxicity
when freshly mixed; however, their toxicity is greatly reduced on setting. Sealers are resorbable when
exposed to tissues and tissue fluids. The most popular sealers are zinc oxide-eugenol formulations, calcium
hydroxide sealers, glass ionomers, and resins.
AH26
- epoxy resin sealer, positive handling characteristics
- good flow, seals well to dentin walls, sufficient working time
- initial toxicity due to a small release of formaldehyde
- After 24 hours, toxicity is extremely low. Weinberg et al 1974.
- Volume stability is good, low solubility
75
Resilon
- resin composite sealer
- composed of BisGMA, methacrylates, CaOH, barium, silica
- designed for use with resilon
- self etch primer required
- biocompatibility established
8. Coat the master cone with sealer and place into the canal coating the walls with the sealer as you
progress to working length. Sealer is necessary to seal the space between the dentinal walls of the canal and
the core obturating material (gutta percha). However the sealer is resorbable when exposed to tissue fluids
and initially irritating to the periapical tissue. For these reasons a minimal amount of sealer should be used.
9. Set the silicone stop at 1 mm short of working length on the spreader. Insert the spreader into the canal
alongside the gutta-percha and work it to length with a light apical pressure. Ideally the spreader will go to
within 1mm of the working length and should get to at least within 3mm of working length. Remember, if
the spreader does not reach the required length, adequate condensation does not occur. (Allison et al,
J of Endod, 15(10) p. 298)
10. After the spreader has reached length, leave it in place briefly so the gutta-percha will distort and leave
a track for an accessory cone. Always monitor the position of the spreader and see that the accessory
point goes to the same level as the spreader it is replacing.
14. Slowly withdraw the spreader from the canal while rotating it in back and forth to prevent it from
sticking to the gutta-percha and pulling out the master cone.
15. Immediately upon removal of the spreader insert an accessory cone to length in the pathway left by
the spreader. A thin coat of sealer is placed on the accessory cones. This lubricates the cone to facilitate
full penetration. The sealer also fills the voids and minor discrepancies of fit between the gutta percha
cones and the root canal walls. Be sure the accessory cone inserts to the same length as the spreader.
The accessory cones should be premeasured so that they can be immediately placed to the correct length
into the space created by the spreader. If there is a delay the space created by the spreader will close and the
accessory will be placed short.
16. Initial condensation radiograph. After enough accessory cones have been placed in the canal to fill the
apical third and the spreader only goes to within 4 mm of working length, take a radiograph. This
INITIAL CONDENSATION radiograph allows the evaluation of the gutta-percha fill in the apical portion
of the canal, and if not acceptable, the gutta-percha can be grasped by the extended ends of the cones and
removed from the poorly filled canal. The canal can then be properly re-filled.
17. Add additional accessory points until the spreader will not penetrate more than 2-3mm past the CEJ
level.
18. Heat the plugger end of the Glick instrument and sear off the gutta percha at the level of the orifice.
Condense the gutta-percha apically with a cooled Glick plugger.
20. Place a cotton pellet and an appropriate temporary restoration.
21. The final radiograph is taken with the rubber dam OFF. This is done to check obturation and the quality
of the seal of the access cavity.
See Examples of lateral condensation on p.79
77
Outcomes
1.
2.
OBTURATION OF MOLARS
Follow the same procedures as obturation of a single canal. The following are the differences in the
procedure.
1. The cone fit radiograph should be taken with all the cones in place. A straight on and an angled view
should be taken.
2. Adjust the master cones as needed.
3. Place the master cones on a paper with a label for each canal i.e. MB, DB, B, L, etc.
4. Obturate as many canals as possible keeping in mind that the accessory points will start to fill the access
cavity as you proceed. Start with the canals with the easier access. (Usually start with the distal canal(s) of
a mandibular molar and the palatal canal of the maxillary molar. Always obturate canals that merge at the
same time.
5. In a curved canal, insert the spreader between the gutta-percha and the convex side of the curve to avoid
gouging the tip of the spreader into the gutta percha, which may prevent the spreader from advancing to full
length (e.g. in the mesial root of a mandibular molar, which has a curve toward the distal, the spreader is
78
inserted along the mesial side of the gutta-percha so the tip of the spreader contacts dentin as it passes
around the curve.)
6. Place a temporary restoration. The final radiograph is taken with the rubber dam off.
Fit of spreader
Cone Fit
Spreader with
Accessory cones
79
Laterally compacted
gutta-percha
Sealing of the access preparation between appointments and after final obturation is absolutely
necessary to prevent microorganisms from contaminating the root canal system. A number of recent
studies have demonstrated contamination of an obturated root canal as a result of an open access cavity or an access
with a deficient restoration. This leakage into the root canal system, therefore, has the potential
to be an etiologic factor for failure of a completed root canal treatment.
Temporary cements must be capable of providing a temporary seal to prevent bacteria and fluid products from
the oral cavity from contaminating the pulp space. The cement must be able to withstand masticatory forces
and retain a seal. The thickness of the temporary filling material in the access cavity should be at least 3 5 mm
in order to provide an adequate seal. The temporary restoration is placed prior to removal of the rubber
dam.
Many different materials have been used or recommended as endodontic temporary restorations. Two of the
more common materials are Cavit and IRM.
CAVIT - a ready mixed cement of zinc oxide , calcium sulfate, glycol,polyvinyl acetate, polyvinyl
chloride, triethanolamine
- sets on contact with water (calcium sulfate)
- excellent marginal adaptation
- 4-5mm of thickness necessary or a cover of harder cement for an adequate seal
- absorb fluid into the entire body of restoration
- supplies a significantly better seal than Term over 3 weeks-Beach CW, 1996.
- provides a better seal than IRM Anderson RW et al 1988
- only used if tooth is to be restored within 2 weeks
TERM-filled composite resin, light activated
-easily removed
-better seal than IRM
used if tooth will be restored after 2 weeks
IRM
Note- when compared as passive temporary filling, IRM and Cavit provide a similar quality of seal. When these
cements are exposed to repetitive occlusal cyclic loading, IRM has been found to provide a superior seal. IRM
should be considered for temporary cement when occlusal forces are present. Liberman R. 2001. The author
80
contends that all microleakage studies should be done using radioactive tracers and with mastication forces present.
One of the most important factors in determining success of root canal treatment is the quality of the final coronal
restoration. The temporary restorations leak and a permanent restoration should be placed within at least 4 weeks
of completion of the root canal treatment. The final restoration is considered a part of the root canal therapy.
Patients should not consider them two different procedures. They should follow each other in a timely fashion or the
risk of failure is significantly increased.
IRM
CAVIT
COTTON
PELLET
GUTTA PERCHA
81
List dental and restorative characteristics that may result in perforation during access preparation.
Describe various ways to avoid perforation during access preparation.
Discuss the prognosis of a tooth with a perforation made during access preparation.
Explain how blockage can lead to ledge and perforation formation.
Discuss the prevention of blockage, ledging, and perforation.
Describe the treatment and prognosis of blockage, ledging, and perforation.
Explain the cause, prevention, and treatment of file breakage.
Tell how a sodium hypochlorite accident can be avoided.
Discuss the causes and treatment of underfill and overfill.
Describe how vertical root fracture can be avoided.
PROCEDURAL ACCIDENTS
I. Perforation during access preparation
Accidents can occur in endodontic treatment as early as making access - the principle problem being lateral
perforation of the crown or root, or perforation into the furcation. This problem can best be avoided by
thoughtful case selection and referral. In reality, any case, even an easy case, has potential for
perforation if access is not done carefully and cautiously.
Causes:
Tipped or crowded tooth with abnormal orientation of its long axis.
Beware the tipped posterior tooth that has a restoration recreating a normal occlusal table but with the long
axis of the crown not parallel to the long axis of the roots.
This situation is most often encountered when a mandibular bridge has been placed on a mesially tipped
distal abutment tooth.
l ong axis of roots
82
l ong axis of
c rown
Prevention of perforation
Case Selection! - let someone else struggle with it.
Remember, the average distance from occlusal surface to roof of chamber is 4-6 mm and to floor of
chamber is 8-10 mm.
Study the radiographs and measure the distance to roof and floor of the chamber on the particular tooth you
are treating.
Measure bur length and stay within the dimensions measured above.
In clinic, never extend a bur past the alveolar crest in search of the chamber or canals. Get an
instructor for help.
Canals are located with an endo explorer not with a bur
High and slow speed burs are used only to carve out the internal anatomy of a tooth to allow the operator to
locate the canals with the explorer
Burs are not probes - they are not used to locate canals
Begin access with the rubber dam off.
This allows visibility of the whole exposed part of the tooth and orientation on the long axis of the roots as
the crown emerges from the alveolus - the long axis of the crown may not be parallel to the long axis of the
roots. The ultimate goal is to gain straight-line access to the canals within the roots. Visibility of the
cervical outline of the tooth helps keep orientation on the true long axis of the roots.
Or, clamp a more distal tooth, eliminating the rubber dam clamp as an obstacle to seeing all of the tooth
structure.
Recreate the normal shape and volume of the chamber within the crown.
Progress slowly
Periodically take bitewing radiographs (perpendicular to the buccal crown surface i.e. bite-wing) to observe
orientation.
Prognosis
Lateral perforation coronal to the attachment level can be included within the preparation of the restoration.
Lateral perforation at or just apical to the attachment level, and furcal perforation do not have a good
prognosis.
Periodontal defect will usually form Better prognosis if treated promptly
If a perforation occurs, inform the patient and make proper, prompt referral for treatment (may necessitate
hemisection or extraction)
Prevention
This can be avoided by frequent irrigation and use of a patency file.
Treatment
Irrigate the canal, carefully work a small file (#10-20) to working length, then follow with subsequent files
to remove debris and regain the MAF at WL. Keep the canal flooded with irrigant.
Use RC Prep or other chelating agent as irrigant and proceed as described above.
Ledge formation
Ledge formation is a frequent sequel to canal blockage in a curved canal. The apical canal becomes
blocked with debris because of inadequate use of irrigation and patency file. Subsequent files, then, are
prevented from following the path of the canal and are diverted off-axis forming a ledge. If large files are
forced, this misadventure continues, and creation of a new canal and perforation of the root can occur.
Ledge formation is most likely to happen in narrow, curved, and long roots.
Ledge formation can also occur by overfiling with a given file. All files have elastic memory - if confined
in a curved space, they want to straighten out. If a file is used repeatedly at a certain length in a curved
canal, it will try to straighten out, and the tip of the file will begin to cut preferentially on the outside of the
curve, thus creating a ledge.
Excessive use of chelating agents (RC Prep, EDTA) can result in ledge formation or perforation in curved
canals. Chelating agents are not selective in the type of dentin they affect - all dentin is softened by
chelating agents.
If a ledge is created, it might be possible to bypass and eliminate the ledge by precurving stainless steel
files and re-entering the original canal path. If this is not possible, the canal is filled to the point of the
ledge, and the case observed for development of pathology. A tooth that had a vital pulp at the start of
treatment, and a tooth with a necrotic pulp that had already been well debrided before the ledge was formed
have the best prognosis if the ledge cannot be passed.
Blockage or aggressive use of files (especially in an exaggerated filing motion) in the apical 1/3 of a canal
with an apical curve can result in a tearing perforation of the foramen often referred to as an apical strip
or apical zip. The outcome of this mishap is a foramen that has been changed from essentially round to a
long slot extending from the original position of the foramen coronally along the outer surface of the curve.
Cause
Blockage
Forcing files to length
Over-use of a given file at a given length
Misuse of chelating agent
Prevention
Repeated recapitulation through the series of files from small to large creating a tapered shape that is
carried to the apex rather than forcing files to their assumed final lengths helps prevent ledge formation.
Do not use a particular file for a long time at a specific length. Keep moving through the sequence of files
repeatedly. Each file should be used for only 20-30 seconds before proceeding to the next-size file.
Do not use chelating agents (RC Prep, REDTA) with a file larger than #25.
Perform apical preparation with just watch-winding and minimal filing motion.
Perforation
There are other situations in which perforation can occur during instrumentation besides that described
above. In two cases, the perforation penetrates to the furcation.
Perforation can occur while using the Gates-Glidden drills during coronal flaring. Gates-Glidden drills are
not intended to be used as flexible instruments and pass around a curve. They are meant to be used only in
the straight, coronal portion of the canal. The diameter of the canal preparation should never be larger than
84
1/3 the diameter of the root. The largest Gates-Glidden drill we routinely use is a #4, which is 1-1.1 mm in
diameter. This must be kept in mind when performing the coronal flare. If a root is observed on a
radiograph to be unusually narrow, the depth of each Gates-Glidden drill must be adjusted accordingly.
The second situation when perforation may occur on the furcal side of the root is during preparation of the
middle 1/3 of a severely curved canal. Over-aggressive filing motion in a sharply curved canal will
preferentially remove material from the inside of the curve in the mid-root area similar to the preferential
removal on the outside of the curve in the apical 1/3 due to the tendency of a file to straighten out. This is
referred to as a strip perforation and is very difficult to adequately obturate due to its linear nature.
Poor determination of working length and lack of length control with overextended instrumentation will
result in an apical perforation. Irritation to periapical tissue and difficulty in controlling gutta percha during
obturation due to the lack of an apical stop create problems similar to those associated with a perforation in
any other part of the root. Whereas an apical zip occurs in a root with an apical curve, an apical perforation
can occur with a curved or a straight canal.
Prevention
Study the dimensions, curvature, and emergence of roots from the crown on radiograph and foresee
possible problems due to curvature.
Remember, canals curve buccal-lingually as often as mesial-distally this curvature is not visible
radiographically.
Establish proper working length, use repeatable, stable reference points and control the depth of penetration
of instruments.
If significant resistance is felt with any instrument, do not force it. Adjust depth of instruments
accordingly.
Treatment
Furcal perforations of any cause have a poor prognosis but prompt referral for treatment before periodontal
breakdown occurs may improve the prognosis.
Strip perforations are hard to obturate because there is no resistance form for the gutta-percha.
If on the furcal side, mid-root, the prognosis may not be good because surgical access for repair is very
difficult.
Apical zips may have a less than good prognosis following orthograde treatment but are more easily
accessed surgically than mid-root strips.
An apical perforation is treated by shortening working length, creating an apical stop with a newly
determined, larger MAF and obturating to the new length.
Even these cases may have some long-term chronic inflammation.
The sooner a perforation is treated, the better.
The prognosis for a perforation changes, according to location - best prognosis for a perforation in the
apical 1/3, and worst prognosis for a perforation in the coronal 1/3.
Gates-Glidden drills are never extended into a curve. They are to be used only in the coronal portion of the
canal prior to any curvatures.
File breakage
Though file breakage can happen due to manufacturing flaws, it usually is due to overuse or misuse of files.
Failures to notice signs of excessive wear (kinking, tightening or unwinding of flutes or other deformationsometimes these show up as a shiny spot in the flute area) and continued use of an overused file will likely
result in its breakage. Inspect each file for cleanliness and defects before you place it in a canal and
after you remove it. When in doubt, throw it out. Regular disposal of files will greatly reduce the
incidence of file breakage. At USC, we discard files #10-25 (stainless steel) after each case if these files
85
were involved in the instrumentation performed on that day. Files sized #30-50 (nickel-titanium) are
discarded after 5 cases. Those files numbered 55-80 are discarded when they show wear or seem to cut
inefficiently.
The most common cause of file breakage is using it too aggressively. The confusing thing about file
breakage is having it occur when the file is being used relatively gently or even during recapitulation after
larger files have already been used. This happens all too often, and the breakage is wrongly attributed to a
manufacturing flaw. In reality, the file had already been overstressed, probably showing some signs of
deformation, and the reinsertion into the canal was done in a manner that was sufficient to separate a
segment of the file. The one fortunate aspect of breakage with this nonaggressive use is that the file
segment is not tightly bound in the canal and might be removed or, more likely, bypassed and full treatment
of the canal completed.
Lubricant (i.e., irrigation solution) makes the files cut more efficiently without gouging and binding, and
should always be used during instrumentation.
Prevention
Always instrument a wet canal.
Never instrument a dry canal.
Apply apical pressure on a given file no greater than the pressure you can apply with your fingertip directly
to the point of the file without causing pain.
Do not force files to predetermined lengths.
Recapitulate multiple times, if necessary, to progress a file to its expected, eventual length.
If a file becomes bound in a canal, gently manipulate it in a watch-winding motion of small amplitude and
with light withdrawal pressure.
Inspect each file for cleanliness and defects before you place it in a canal and after you remove it. If
in doubt, throw it out.
Treatment
Inform the patient. Having an instrument break during treatment is not malpractice but failure to inform the
patient is. Use the phrase separated instrument
Attempt to bypass the fragment using RC-Prep and small (#8, 10, 15) files, then complete instrumentation.
The file segment becomes embedded within the gutta percha when obturated.
If the fragment cannot be bypassed, complete instrumentation to the fragment, fill to this length, inform the
patient and follow for an extended time.
Or, explain the presence of the separated instrument and refer.
acute, ballooning swelling and excruciating pain. The swelling will probably increase over the next couple
days accompanied by extensive ecchymosis. The pain will steadily decrease after the initial episode
although swelling may be increasing. This misadventure is completely avoidable with proper care and
handling of sodium hypochlorite.
Prevention
Never wedge the irrigating syringe needle into the canal. There must be space for fluid to back-flow out of
the canal. Keep the irrigating needle in motion, going in and out of the canal.
Never express the irrigant rapidly out of the syringe. It is not being injected into the canal - it is being
deposited slowly into the pulp chamber. The files carry the sodium hypochlorite into the canal.
Treatment
Re-anesthetize
Oral steroid
Antibiotic
Ice pack
Reassure the patient and have daily monitoring of symptoms.
Advise the patient of likely severe increase in swelling and severe ecchymosis.
Unlike other procedural mishaps that have higher potential to occur due to anatomic or
restorative conditions, a sodium hypochlorite accident is totally avoidable.
III. Accidents during obturation
Under-extended fill
One of the most frequent mishaps during endodontic therapy is to underextend the fill of a canal, i.e., fill it
short of working length. The sequence of events is as follows: proper length has been determined and
verified radiographically, instrumentation has been completed, the canal obturated, but when a radiograph
is made, the fill is clearly short of working length. There are two reasons for a short fill. First, and
unfortunately much too common, is a short fill due to accumulation of dentin filings in the apical portion of
the canal preventing full seating of the master cone. The canal has not been kept irrigated and debris has
not been removed from the apical part of the canal by recapitulation.
The second situation of a short fill occurs after proper fitting of the master cone at correct working length.
It is noted after obturation that length has been lost. In this case, cement has been placed into the canal, the
master cone seated to working length, and the spreader inserted alongside the master cone. The tip of the
spreader, though, either has become imbedded into the master cone, or dried sealer on the spreader (the
spreader was not properly cleaned after prior use) has adhered to the sealer and master cone pulling it back
when the spreader is removed from the canal. This pullback usually occurs when placing the first or
second accessory cone. After 2-3 accessory cones have been placed and laterally condensed, the master
cone is usually locked in place and will not pull back.
Prevention
At the end of instrumentation, irrigate and recapitulate through the files, inserting each file to its length,
rotating clockwise 1/2 turn and removing debris. Inspect the spreader before use and clean sealer off of the
spreader after use. Insert the spreader along the side of the master cone toward the outside of the curve so
the tip of the spreader runs along the dentin wall. Insert the spreader using a watch-winding motion;
continuing the watch winding while the spreader is left in place for 30 seconds and during withdrawal.
87
Treatment
Irrigate; starting with #10-15 file, pick through debris regaining working length; recapitulate through the
whole series of files in a debris-removal manner. Always take a radiograph before searing off excess gutta
percha to evaluate proper fill - if short (or long), grasp and remove gutta percha, and refill.
OVER-EXTENDED FILL
Over-extended filling (filling longer than working length) is attributable to one cause - lack of length
control. Part of the design of root canal preparation is to provide resistance form to prevent extrusion of
filling material into periapical tissues. Lack of an apical stop and proper taper to the preparation will allow
gutta percha to be pushed through the foramen into periapical tissues.
Prevention
Establish correct length determination.
Check stopper position on files throughout instrumentation to be sure they have not moved.
Expect effective working length to shorten slightly on a curved canal as the canal is widened and the curve
straightened out
If there is question about length at completion of cleaning and shaping, check with paper points for the
consistent drying length - the length at which paper points come back dry and at which, if the paper point
were inserted further, it would come out with the tip wetted with blood or tissue fluid (tan or straw
colored). This is accomplished by first drying the bulk of irrigant out of the canal with large paper points.
Then, the largest sized paper point that will fit to length is grasped with the cotton pliers at WL, placed into
the canal to the reference point, withdrawn, and the tip of the paper point examined.
Treatment
If the canal has not yet been filled, determine a shorter working length, and establish an apical stop with a
new, larger master apical file.
Fit a master cone 1/2 mm short of the new working length (when condensed, it will slide apically to
working length)
If the canal has already been obturated, grasp the extensions of gutta percha and pull the mass out of the
canal and then follow the above steps.
ROOT FRACTURE
Although it is not an everyday occurrence, a vertical root fracture can be created during obturation by the
wedging action of the spreader. This is more likely to occur with a hand spreader than with a finger
spreader because of the greater taper of the hand spreader and the ability to generate more force. This is the
most common cause of vertical root fracture.
Prevention
Properly shape the canal with adequate taper. Do not make the master apical file larger than necessary.
Slowly advance the spreader apically. If significant resistance is felt, do not force the spreader.
Treatment of Root Fracture
Extraction
88
89
90
Endodontic Case #:
Appt Date:
Student Name:
Student #:
Patient Name:
Age:
Chart #:
Medical History:
Medications:
Assessment (Diagnosis)-
Plan-
Yes
No
Rotaries Approved
Yes
No
RPC
FPC
Faculty Signature
Date
91
S: SUBJECTIVE DATA:
The CHIEF COMPLAINT is generally the first information obtained. The chief complaint is the symptoms(s) or
problem(s) expressed by the patient in his or her own words relating to the condition that prompted the patient
to seek treatment. The chief complaint should be recorded in non-technical language: for example, I have a
tooth that really bothers me when I drink cold water. Subjective symptoms must be differentiated from
objective findings. Subjective data includes 1) the chief complaint
2) history of the problem (i.e., how long the chief complaint has been present)
3) the character of the pain (i.e., sharp, throbbing, lingering)
4) what initiates or relieves the symptoms
5) significant dental history (i.e., new restoration placed in #30 one month ago)
6) or any other information the patient may convey concerning the problem
A thorough subjective description by the patient most probably will enable the dentist to gain some insight
as to the nature of the problem as well as to its management. For example, for a patient with a chief complaint
of lingering pain to cold, the dentist will suspect an irreversible pulpitis. The subjective symptoms need to be
duplicated and confirmed by objective findings.
O. OBJECTIVE DATA
Objective findings are the result of observations as well as pulp tests conducted by the dentist. They will
usually, but not always, correspond with information obtained from the patient in the subjective history.
The objective examination includes:
a) Visual Exam includes hard and soft tissues. For example: large carious lesions, fracture lines in teeth,
crown discoloration, sinus tracts, redness or swelling of tissues.
b) Radiographs Usually includes two periapical films (one angled and one straight on), and a bitewing
x-ray.
c) Percussion/biting may determine the presence of periapical pathosis. The incisal or occlusal surface
of the tooth is tapped perpendicular to the occlusal surface and parallel to the long axis with the end of a mirror
handle. Adjust your tests according to the patients symptoms. If a patient complains of severe pain to biting,
do not percuss heavily on the offending tooth. With severe pain, light finger pressure may be all that is needed
to reproduce the patients pain. The bite test allows the patient to place as much pressure as they feel
comfortable putting on the tooth. Have the patient bite on the saliva ejector or a bite stick for this test.
d) Palpation finger pressure is applied to the buccal and lingual mucosal areas to root apices attempting
to locate spots tender or painful to the patient. Like percussion, palpation determines how far the
92
inflammatory process has extended periapically. The degree of periradicular inflammation can be better assessed
if the apical area is palpated. Extraoral palpation of lymph nodes and tissues is also assessed. Palpation is an
underappreciated diagnostic tool. Early swelling can also be detected this way. By interpreting these results, the
patients post-op course can be better predicted.
e) Electric Pulp Test (EPT) The electric pulp test is used only to determine whether the pulp is vital or nonvital. An electric current is applied to several teeth to stimulate the fast conducting myelinated sensory fibers of
the dental pulp. The EPT cannot be performed on teeth with full-coverage restorations. Always test the adjacent
and contralateral normal teeth first. This is so the patient knows what to expect from the test and a baseline is
established. The tooth is isolated with cotton rolls and dried after the procedure is explained to the patient. Place
a small amount of electrolyte (such as toothpaste) on the electrode tip to assure good contact. The tip of the
electrode is then placed on the facial enamel near the incisal edge (in anterior teeth) and the cusp tips (in
posterior teeth) being certain not to contact any restoration (be sure to distinguish composite restoration) or the
gingiva. To complete the circuit and to start the (EPT), the patient is to contact the metal handle with two or more
fingers. The patient is to remove his/her fingers from the handle when a tingling, itching, or other sensation is felt
in the tooth. A number from 0 to 80 will be displayed and locked in on the pulp tester for several seconds.
Stimuli can pass through metal-to-metal contacts. Metal-to-metal contacts as with an MO amalgam adjacent to a
DO amalgam should be separated with a Mylar strip. Different numbers DO NOT indicate different stages of
pulp degeneration. Therefore, this test is not a measure of the degree of health of a pulp. The EPT is used ONLY
TO DETERMINE WHETHER THE PULP IS VITAL OR NON-VITAL.
f) Thermal Tests
Cold Test At the USCSD we use EndoIce R for the cold test. EndoIce R is a refrigerant spray of
tetrafluoroethane which is a clear, colorless liquefied gas, with a spearmint odor. It has a low liquid temperature
of -26O C and is therefore an effective cold test for restored and nonrestored teeth. A loosely woven cotton pellet
is held in cotton pliers. A short burst of EndoIce is sprayed onto the cotton pellet and then the cotton pellet is
gently placed buccally on the incisal edge or near the pulp horn of the tooth. Always test the adjacent and
contralateral normal teeth first. Then test the tooth in question for comparison. The procedure is explained to
the patient, ensuring they understand they are to respond to cold sensation, not just to pain (the pulp has only
pain fibers, however, the patients interpretation of these signals varies. Some patients will interpret all cold as
pain, while others will interpret normal cold sensation as non-painful. Since a response to cold (painful or not)
indicates vital tissue, we want to ensure that the patient signals when they feel a sensation to cold. The patient is
instructed to raise his or her hand when the onset of cold is felt. The cotton pellet is immediately removed from
the tooth. The patient is instructed to put his/her hand down when the cold sensation is gone. The number of
seconds is noted as to when the onset of cold was felt initially and when the cold sensation ended. The patient
should also indicate if there is exaggerated or lingering discomfort relative to the other teeth. An exaggerated
and/or lingering response to cold indicates pulpitis. No response to the cold (no pain, no sensation whatsoever)
indicates pulpal necrosis. *Note a cotton pellet is more effective than a cotton swab since the cotton pellet can
cover more of the tooth surface and better simulate the feeling of cold water around the tooth. Also the swab
cannot hold as much of the spray and may therefore give a false negative response.
Older techniques such as refrigerated ice sticks are less effective. Dripping water may result in a false positive
response from the gingival and the ice stick is also less effective for the same reason as the cotton swab.
Heat Test the heat test is only used when the patients only complaint is sensitivity to heat. It is much more
difficult to carry out then a cold test and the only information it gives that a cold test does not is which tooth is
sensitive to heat and we want to duplicate the patients symptoms with our objective tests. As with the cold test,
always test adjacent and contralateral normal teeth first. Then test the tooth in question. There are two methods
for the heat test. 1) Gutta percha is heated over a flame until it becomes soft and is then placed on the buccal
surface or the incisal edge of the tooth. The tooth should be lightly coated with Vaseline to prevent the gutta
perch from sticking to it. The response to the heat is evaluated similarly to the response to cold. (It is only a
93
different stimulus that is being evaluated). 2) The teeth are isolated with rubber dam one at a time. Hot water (not
scalding, not tepid) in a large syringe is flowed over the tooth while being evacuated. The patient should raise
his/her hand when they feel pain (whereas cold usually has an immediate sharp response, there may be a delay
before heat is recognized. Heat is more often interpreted as pain by the patient but will not linger once it is
removed from normal teeth). When the patient signals, irrigation is immediately stopped. As with cold, if the
response was exaggerated and lingering, this indicates pulpitis.
For poorly localized pain the objective data should be gathered from the whole quadrant in which the offending
tooth is located and also from a contralateral tooth to the one in question. The opposing arch should also be
evaluated since there can be referred pain from the upper to lower arch or vice versa.
Mobility
A. ASSESSMENT: This is where you analyze the results of the subjective and objective evaluations and come
up with a diagnosis. You need to note a pulpal and an apical diagnosis.
Pulpal diagnosis:
Periapical diagnosis:
P: PLAN:
This describes your plans for the diagnosis that was made. (i.e. if the assessment was tooth #19 necrotic pulp
with an acute periradicular periodontitis the plan may be #19 caries removal. #19 evaluate for restorability. If
restorable, #19 RCT.
It is important to note that the diagnosis reached is based on the subjective and objective data. The dentist cannot
microscopically examine the pulp and surrounding periradicular areas to arrive at an accurate histopathologic
diagnosis. Furthermore, the diseases of the pulp and periradicular area correlate poorly with the actual
histopathology that may be present. However, this does not mean that it is not possible to differentiate normal
pulps from diseased pulps. The reliability of the diagnostic process is improved when it is possible to reproduce
the chief complaint. In fact the inability to reproduce a symptom should be a red flag indicating that any
treatment rendered may not effectively address the physiological basis of the chief complaint.
94
The following is the terminology pulpal and periapical terminology used at USC.
Pulpal
Normal pulp - A clinical diagnostic category in which the pulp is symptom-free and normally responsive to
pulp testing.
Reversible pulpitis - A clinical diagnosis based on subjective and objective findings indicating that the
inflammation should resolve and the pulp return to normal.
Symptomatic irreversible pulpitis - A clinical diagnosis based on subjective and objective findings indicating
that the vital inflamed pulp is incapable of healing. Additional descriptors: lingering thermal pain, spontaneous
pain, referred pain. (On national boards irreversible pulpitis is used.)
Asymptomatic irreversible pulpitis - A clinical diagnosis based on subjective and objective findings
indicating that the vital inflamed pulp is incapable of healing. Additional descriptors: no clinical symptoms but
inflammation produced by caries, caries excavation, trauma. (On national boards irreversible pulpitis is used.)
Pulp necrosis - A clinical diagnostic category indicating death of the dental pulp. The pulp is usually
nonresponsive to pulp testing.
Previously treated - 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.
Previously initiated therapy - A clinical diagnostic category indicating that the tooth has been previously
treated by partial endodontic therapy (i.e., pulpotomy,pulpectomy).
Apical
Normal apical tissues - Teeth with normal periradicular tissues that are not sensitive to percussion or palpation
testing. The lamina dura surrounding the root is intact, and the periodontal ligament space is uniform.
Symptomatic apical periodontitis - Inflammation, usually of the apical periodontium, producing clinical
symptoms including a painful response to biting and/or percussion or palpation. It might or might not be
associated with an apical radiolucent area. (On national boards acute apical periodontitis is used.)
Asymptomatic apical periodontitis - Inflammation and destruction of apical periodontium that is of pulpal
origin, appears as an apical radiolucent area, and does not produce clinical symptoms. (On national boards
chronic irreversible pulpitis is used.)
Acute apical abscess - An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset,
spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues.
Chronic apical abscess - An inflammatory reaction to pulpal infection and necrosis characterized by gradual
onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract.
Condensing osteitis - Diffuse radiopaque lesion representing a localized bony reaction to a low-grade
inflammatory stimulus, usually seen at apex of tooth.
95
In the following table the pulpal and periradicular diagnosis are listed along with clinical information.
Chief
Complaint
Normal Pulp
Reversible
Pulpitis
Asymptomatic
Irreversible
Pulpitis
Symptomatic
Irreversible
Pulpitis
Necrotic
Pulp
Periradicul
ar
Diagnosis
History
None
Hot &/or
Cold
Sensitivity
None
Lingering
Hot &/or
Cold
Sensitivity
Normal
Thermal
sensitivity
(cold is
most
common)
No pain
Spontaneo
us Pain
Variable
Variable
Chief
Complaint
Radiographic
Findings
History
Electro
nic
Pulp
Test
Respons
ive
Normal
Respons
ive
Normal
periradicular
radiolucency
or widened
PDL
Respons
ive
Normal,
Periradicular
Radiolucency,
or
Widened PDL
Normal,
Periradicular
Radiolucency,
or
Widened PDL
Radiographic
Findings
Respons
ive
No
Respons
e
Symptomatic
apical
periodontitis
Acute
Apical
Abscess
Asymptomatic
Apical
Periodontitis
Chronic
Apical Abscess
Focal
Sclerosing
Osteomyelitis
(Condensing
Osteitis)
Normal
Discomfort
When
Biting or
Chewing
Restoratio
n?
Pain usually
with
Slight to
Large
Swelling
Coronal
Microleak
age?
Widened PDL
Asympto
matic
Periradicular
Radiolucency
Asympto
matic
Periradicular
Radiolucency
Extensive
Restorativ
e History /
Opacity
Increased
Radiodensity /
Opacity
None
Bad Taste
or
Gum
Bump
Asymptoma
tic or
Variable
Pulpal
Symptoms
Recent
Normal,
Widened PDL
or
Periradicular
Radiolucency
Mild,
fleeting
Percuss
ion
Palpati
on
Mobi
lity
Treatment
normal
normal
none
none
Exaggerated,
Nonlingering
Removal of
stimulus
Root canal
treatment
(RCT)
Exaggerated,
Lingering
No Response
Variabl
e
Varia
ble
Root canal
treatment
(RCT)
Percuss
ion
Palpati
on
Mobi
lity
Treatment
WNL
none
Variabl
e
Thermal
Testing
Respons
e
Response,
Nonlingering
Not
sensitiv
e
Not
sensitiv
e
Respons
e / No
Respons
e
Variable
Modera
tely
Sensitiv
e
Sensitiv
e or Not
sensitiv
e
+/-
No
Respons
e
No
Response
Exquisi
tely
Sensitiv
e
Sensitiv
e
+/-
No
Respons
e
No
Respons
e
No
Response
Not
sensitiv
e
Not
sensitiv
e
Not
sensitiv
e
Not
sensitiv
e
Respons
e / No
Respons
e
Variable
Sensitiv
e or Not
sensitiv
e
Sensitiv
e or Not
sensitiv
e
Normal,
or
Periradicular
Radiolucency
96
No
Response
DDx
Caries,
Cracks,
Restorative
Procedures
, or
Trauma
Root canal
treatment
(RCT)
EPT
Normal
None
Thermal
Testing
RCT. If
occlusal
trauma,
occlusal
adjustment
will relieve
the pain
Open for
drainage, I
&D
through
bone and
mucosa and
RCT
WNL
RCT
WNL
RCT
WNL
DDx
Occlusal
Trauma?
Necrotic or
Pulpless
Necrotic or
Pulpless
Necrotic or
Pulpless
with
Sinus
Tract
Condition
due to
pulpal
inflammati
on
Required Radiographs
All lab radiographs have two views
1. Suitability radiograph: unmounted tooth. Check suitability for lab exercise. Pulp chamber
should be readily seen. Canal should be relatively straight from orifice to foramen. Apices
should be closed. In clinic, this is your pre-operative radiograph.
2. Working length (WL) radiograph: WL file (use at least a #15 file) is usually between 0.5 and
1mm from the radiographic apex. If it is not at the correct length, adjust the working length and
take a new radiograph. (If the discrepancy is less than 0.5mm another radiograph is not
necessary to confirm the corrected length). In the typodont mounted teeth and in clinic, use the
apex locator prior to taking the working length x-ray.
3. Master Apical File radiograph (MAF): Shows largest file taken to WL. This radiograph is
taken after you have completed the preparation of the apical constriction and prior to the step
back preparation.
4. Master gutta percha cone radiograph: Evaluate fit and length. Should appear to fill up the
apical 2-3mm of canal. Should have space around cone and canal walls in the middle and
coronal section signifying adequate flare. At WL (with slight tugback) is preferable.
5. Initial condensation radiograph: Evaluate fit and length after sealer is placed and enough
accessory gutta percha cones are placed to fill the apical third of the canal. Length control and
density of fill are evaluated.
6. Final radiograph: Evaluate gutta percha condensation from CEJ to apical stop. Temporary
fill should be in place from where the gutta percha stops to the cavo-surface margin. THE
FINAL RADIOGRAPH IS WITHOUT THE RUBBER DAM AND WITH A RESTORATION
(USUALLY A TEMPORARY RESTORATION) IN PLACE.
97
a.
b.
98
The endodontic preclinical laboratory-grading sheet must be filled out and signed by an instructor. Each step
must be checked prior to progressing to the next step.
Anterior Tooth
Upper
bicuspid
Lower
Bicuspid
Upper
Molar
Lower
Molar
RL =
RPC =
FPC =
RL =
RPC =
FPC =
RL =
RPC =
FPC =
RL =
RPC =
FPC =
N/A
N/A
Tooth selection
Radiographs
Length Evaluation
Rubber Dam
RL=
RPC =
N/A
Access
Coronal Flare
Straight Line Access
Working Length
MAF size
Step Back
Last file size
Cone Fit
Initial Condensation
Completed Root
Canal Filling
99
Student Name
Student Number
Patient Name
Axium #
Endo Case #
Group #
Patient
information
Rubber Dam
Access
Coronal Flare
Working Length
Spreader Fit
Circle One: hand/finger
Cone Fit
Initial
condensation
Final X-Ray
No rubber, with
restoration
100
3rd appointment
Date
4th appointment
Date
Canal
Reference Point
Working Length
First File
to Bind
Single
MB
MB2
ML
DB
DL
D
P
B
L
101
MAF
Master Cone
Grading Scale:
3 Above clinical standard clinical excellence competent
2 At clinical standard clinical acceptability beginner
1 Below clinical standard unacceptable novice
All ones will need to be redone before proceeding to the next exercise.
102
103
104
...
1. PROPER PREPARATION:
Take appropriate high quality preoperative radiographs (BW and 2 PAs)
Treatment Plan & Restorability Check.
Examine, pulp test, record.
SOAP notes. Each visit is unique and the SOAP notes need to reflect that.
Measure and record RL, RPC, FPC.
2. PROPER ACCESS:
Isolation,
Rubber dam
Buildup
Occlusal reduction
Straight line access
3. CORONAL FLARE
Create guide path for Gates-Glidden burs
Using Gates-Glidden burs to create coronal flare
4. DETERMINE WORKING LENGTH
Use electronic apex locator
Confirm WL with radiograph
5. APCIAL STOP PREPARATION
Determine and record first file to bind at WL (MAF should be 3-5 times larger)
Rotary or hand instrumentation to get to MAF
Continual irrigation and occasional patency file
6. MAF RADIOGRAPH
Correct as necessary
7. SHAPING CANAL
Step back in 1 mm increments extending 4- 5 mm from WL
8. MASTER CONE
Apical stop verification
Tugback
Flare check
Radiograph
5. Obturation
Sealer/Master Cone
Initial Condensation
Radiograph/evaluate
GP removal to CEJ/orifice
Complete Obturation
Radiograph/evaluate
Temporary
Remove Rubber Dam
Final Radiograph (with rubber dam off!!)
103
Endodontic Requirements
1. Assist an endodontics resident with a root canal treatment in the endodontics clinic
This is a requirement PRIOR to treating any patients in the endodontics section on the second floor
2. Successful treatment of six teeth requiring root canal therapy (at least one tooth must be a molar, the
remaining teeth can be bicuspids or anterior teeth)
The following are required for each tooth treated in the endodontics clinic:
PRESESSION FORM - Prior to starting any root canal treatment a presession must be completed
and SWIPED by an endo resident or endo faculty.
AAE CASE DIFFICULTY FORM- this form is part of the presession and must also be
completed with the presession.
BROWN FORMS These forms are to be checked off at each step of the procedure.
POSTSESSION FORM This form is filled out and reviewed with the clinical instructor as soon
as the treatment is completed. The root canal treatment will not be swiped complete until the postsession review is done.
The completed cases are turned in to Jackie in the endodontics office on the first floor. Each case that you turn
in will consist of
1. AAE Case Difficulty Form
2. Brown Form
3. Postsession Form
4. Copy of final radiograph
ALTERNATIVE CREDIT
Successful passage of the 3 bench exams may count as one of the anterior/bicuspid teeth of the 6 tooth
requirement.
Assisting an endodontics resident on a root canal treatment case from start to finish may count as one of the
anterior/bicuspid teeth of the 6 tooth requirement. THIS IS IN ADDITION TO THE INITIAL ASSIST IN
THE POSTGRADUATE ENDODONTICS CLINIC. To receive credit for the assist, a brown form needs to be
filled out by the resident you assisted and the triplicate form needs to be signed by Dr. Levy.
105
106