Overview Of

Endodontics

What is Endo?

Study and treatment

of the dental pulp
General dentist can
perform RCT but
Endo:

Use
microscopes

Assigned difficult
& complicated
cases

Microsurgery

Why is Endo awesome?

Save teeth!!

Help relieve a patient of excrutiation pain

Become very specialized; Focus on one

specific area of dentistry

Deail focused

Cool technology

Microscopes

Electronic Apex Locator

3D Imaging

Top 5 Reasons for Endo Therapy

(In order of Prevalence)

Caries

Iatrogenic Treatment

Trauma and Resorption

Perio Endo Etiology

Orthodontic Tooth Movement

Trauma, Resorption, and Ortho: Necrosis

precedes infection

Questions for Patient

History of pain is very important!

Stimulated or Spontaneous pain?

Localized or Referred pain?

Pain when you bend or lie down?

Pain with hot or cold food and drinks?

Pain when eating certain foods?

Pain keeps you up at night or wakes you

up?
Take any medication for pain?

Interpretations

Spontaneous + sensitivity cold/ hot + lots of pain =

irreversible pulpitis
Pain bending over, + sinus pressure, inflammed sinuses =
sinusitis
Tooth mobility, thermal sensitivity, pain chewing, widened
PDL? Occlusal trauma: high restoration, abnormal biting
or habits

Pain upon waking in jaw and neck? Bruxism

Cant find cause of pain? Chronic Oral Facial Pain

Always check adjacent and contralateral teeth, especially

with referred pain!

Testing Methods

Palpation

Use finger tips to

apply light pressure
to mucobuccal fold
+ infection broken out
of bone

Percussion

Use handle of
instrument to tap
tooth

+ response =
inflammation of PDL

Patient Interview

Visual Inspection

Mobility

Perio probing

Sinus Tract testing

Anesthesia Test

Bite Test

Vitality Tests
Electric Pulp Test

Test neurons in pulp are

functioning

Cold Test

Put endo ice on cotton pellete.

Apply to tooth
Painful response?

Lingers 1-2 seconds

Sensitivitiy
Seceral secondsminute

Heat Tests

Apply heat to tooth.

+ advanced stage pulpal
inflammation

Irreversible
pulppitis
No response

Necrotic pulp

Periapical Radiolucency: larger =

greater # bacteria in root canal

Resorption
External

Internal

Review of Endodontic
Procedures

Karishma Sitapara
uni: kbs2137
Presentation Adapted from Mikes
Master Files and Anshuls Endo
Study Guide

Procedures

Pulpotomy

Pulpectomy/RCT

Pulp Cap (Direct & Indirect)

Apexogenesis

Apexif ication

Apicoectomy

Pulpotomy

What?

Make access opening, remove all pulp tissues in the pulp

chamber only, place cotton pellet and IRM

When?

In emergencies to relieve pain

In immature teeth in children (apexogenesis)

Why?

Opening the tooth vents the pressure build up and

relieves the pain

Pulpectomy/Root Canal Therapy

What?

When?

Make access opening, remove all pulpal tissue in

chamber and canals, clean and shape, medicament,
obturate (f ill) with gutta percha

Irreversible pulpitis, pulp exposure (carious), necrosis

Why?

Remove bacteria causing the inf lammation/pathology,

create hermetic seal

*90-95% success rate in vital teeth, 80% in non-vital

teeth

Direct Pulp Cap

What?

When?

The bleeding is stopped by irrigation w/ sterile, isotonic

saline, calcium hydroxide placed on exposed pulp, glass
ionomer cement, and permanent f illing placed. Check
radiographically and clinically for 4-5 years.

Non-carious or iatrogenic pin-point pulp exposure

Why?

To prevent bacteria from invading pulp

Indirect Pulp Cap

What?

Excavate deep carious lesion, but do not remove the

layer of carious dentin closest to the pulp. Place calcium
hydroxide, followed by GI, and then a temporary
restoration. *Temporary procedure

Wait few months for reparative dentin formation to act as

barrier between remaining carious lesion and pulp

Remove temporary restoration, excavate the remaining

carious dentin. If no pulp exposure, then f inal restoration
is placed.

When?

Deep carious lesion that will likely result in pulp exposure

Apexogenesis

What?

Exposed tissue is covered with calcium hydroxide in an

attempt to keep the pulp healthy while the root apex fully
forms

Procedure: Pulpotomy, pulp cap, or partial pulpectomy

When?

For an immature vital tooth with a pulpal exposure

Why?

To allow for continued root formation, while keeping the

pulp healthy/vital

Apexif ication

What?

Clean the root canal, place calcium hydroxide inside

canal, replace every few months (induces formation of
biological calcif ic barrier closure of apex with periapical
healing)

Or use MTA as apical barrier

Once closure has taken place, RCT can be performed.

When?

For an immature non-vital tooth with an open/not fully

formed apex

Why?

Procedure Overview

Procedures that can be used on vital teeth:

Pulpectomy

Pulpotomy

Pulp Capping

Apexogenesis

Procedures that can be used on non-vital teeth:

Pulpectomy

Apexif ication

Apicoectomy

What?

Drill through bone to apex, surgical resection of the end of

the root, f illed with MTA

Microsurgery > traditional approach

When?

After RCT re-treatment has failed

Why?

Eliminate infection (possible reinfection by bacteria in

accessory canals in apical third)

Access Opening &

Basics of Cleaning & Shaping
(Step Back/Crown Down Techniques)

Misun Chun
Class of 2017

Maxillary Access Opening

Mandibular Access Opening

Basics of Cleaning and Shaping

After the access opening is created, we need to remove

non-vital/necrotic pulp tissue from pulp chamber/canals.

Must reach to the apical constriction
1) Find the working length
2) Instrument the canal

1) Find the Working Length

Working length
Anatomic length - 1mm = Working length
Anatomic length: distance measured on a radiograph from root apex
to cusp tip
.5~1.5mm above the apex
The location of apical constriction
In pre-clinic, use a ruler and subtract 1
In clinic, apex locator/radiograph
Write it down so you dont forget!

2) Instrument the Canal

Clean the sick pulp tissue and shape it.
We want a long tapered canal to ensure no voids and gain

the convenience form for obturation.

2 techniques we learn at CDM:

Step-back
Crown-down
Step-up Rotary

Step Back Technique

Find the smallest file that binds at the working length (tug

back)
You take 3 files larger than this.
Ex) If the tug-back file is 20k, you work it up to 25, 30, 35k and

file them at the working length (lets say hypothetically 20mm)

Now that your canal is clean, its time to shape it.
You take the next file, 40k, and shape it to 19mm.
Keep going- 45k to 18mm, 50k to 17mm, etc.

Step Back Technique

Find the smallest file that binds at the working length (tug

back)
You take 3 files larger than this.
Ex) If the tug-back file is 20k, you work it up to 25, 30, 35k and

file them at the working length (lets say hypothetically 20mm)

Now that your canal is clean, its time to shape it.
You take the next file, 40k, and shape it to 19mm.
Keep going- 45k to 18mm, 50k to 17mm, etc.

Crown Down Technique

Start with a hand file and find the first K-file that gives you

a tug-back.
After hand-filing with 2 K-files at the working length, use

the largest rotary file and insert with gentle pressure for a
count of 3 until you feel the resistance.
If you reached the working length, you are done!
(If not use the next smallest rotary file until you reach the

working length.)

Instruments and Materials

Disclaimer:

The following information is not comprehensive but just an overview

of some of the instruments and materials you will hear about in your
introduction to preclinical Endo
All information is from Koteckis Master Files and Anshuls Endo
Study Guide: Read them! They are very helpful!

Endodontic Explorer
(aka: Stewart Probe)

Used for probing and exploring root canals

Used to find canals when you are in the pulp chamber

Endo Files

K files (what we use)

Made of either stainless steel or nickel titanium

Hand files used to shape and smooth the pulpal canals

All have a taper of .02 (.02 mm increase in diameter with every

1mm in length
Each file is labeled with a number (10, 15, 20) which represent
the diameter of the tip in hundredths of a mm (#15=.15 mm in
diameter at the tip of that instrument)
Color coded based on that number
Stoppers are used to mark a measurement on a file. Stoppers
should be measured to a reproducible landmark such as a
cusp/incisal tip.

K-Files

Hand files made of either stainless steel or nickel titanium

Nickel titanium is more flexible and better to use for curved canals

Stainless steel files are more rigid and need to pre-bend when
working on a curved canal to prevent perforation (making your own
new canal).
Reaming and Filing- two ways to clean and shape RC with K File:

Reaming= active in, passive out . - turn actively engaging in

dentinal wall on the instroke, then passively out

Filing= passive in, active out

Rotary Instruments

Nickel- titanium rotary instruments

Used with latch-type slow speed hand piece

Has a taper of 4 (in preclinic)

Advantages:

Less time needed

Fewer instruments required

Allows for better vision of the canal

Evenly tapered canals prepared that facilitate obturation (filling)

Disadvantages:

Expensive

Unexpected fractures

Navigating curved canals without first using hand instruments can cause

Gutta Percha

Material used to obturate (fill) root canals

Made mainly of Zinc Oxide

Coated with cement and inserted into the canal space to make up a
root canal filling
Gutta percha used in preclinic are non-standardized and come in
five sizes: fine-fine<medium-fine<fine<fine-medium<medium
As many cones as possible should be squeezed into the canal
space for a dense and air- tight fill

Lateral Condenser / Endodontic

Spreader

During obturation, the canal is filled with gutta percha and this
instrument is used to laterally condense the gutta percha

Glick #1

A double- ended instrument

Paddle shaped end: used to place temporary restorative materials
such as IRM and cavit
Plugger end: heated and then used to trim the end of the gutta
percha. Can also be used to condense the material.

Gates Glidden and Peeso Reamer

Burs used with slow speed latch- type hand piece

Both are used for creating taper and enlarging the coronal portion of
root canal
Can be used to remove gutta percha for post space preparation
The Peezo has cutting edges on its tip and side so it is more
dangerous and can cause perforations

Apex Locator

Used to determine position of apical foramen

It beeps when the file hits the apical constriction

IRM (zinc oxide eugenol)

Used as a temporary restoration in between RCT appointments

Soothing to the pulp because of the eugenol

Cavit

Another temporary restoration

Provides a good seal- expansion upon setting

Easier to use sets easy and fast

Removal of the smear layer after

mechanical instrumentation of the
Smear layer= organic and inorganic debris
canals

Organic debris= bacteria and pulp tissue

Inorganic debris= dentin slurry

Mechanical instrumentation of the canal does not get rid of the

bacteria in accessory canals and dentinal tubules. The smear layer
coats the walls and prevents chemical disinfectants from entering
the accessory canals and dentinal tubules

Chemicals that remove organic

component:

Sodium hypochlorite (Chlorox bleach): antibacterial and dissolves

necrotic and vital tissues
Calcium hydroxide: antibacterial (due to high pH) and dissolves
organic material
Chlorhexidine: broad-spectrum antimicrobial agent against gram
negative and gram positive bacteria

Calcium Hydroxide vs. Dycal

Calcium hydroxide= a powder mixed with a sterile solution to create

a paste placed into the root canal with a file
Dycal: a cement that has calcium hydroxide in it and used in deep
cavities for direct pulp capping

Chemicals that remove inorganic

component:

EDTA= a chelating agent (removes inorganic part of smear layer by

causing dimineralization. EDTA causes dimineralization by binding
to calcium)
Citric acid= also a chelating agent

RC Prep

A combination of EDTA (for chelation), urea peroxide (antibacterial

activity), and carbowax (for lubrication)
Used as a canal lubricant
Used to facilitate the mechanical action of the endodontic hand or
rotary files by removing debris

Post and Core

Lauren Chiang

All pictures were taken

from Dr. Zemnicks
slides!

Indications

When there is
insufficient coronal
structure for the
retention of a
restoration
Need to use a post
which holds in place
the core, which is
used to build up
tooth structure

Post preparation

After RCT, remove all but 5 mm of gutta percha

from the canal using a gates glidden, then use a
peezo reamer to ensure no undercuts are present
Width of the post should be as narrow as possible,
but fill the entire post prep space
If using multirooted teeth, choose the straightest root
Cut post to desired length before cementing it in to
the post space

Post placement has disadvantages

Requires an additional operative procedure

Placing a post does NOT strengthen the tooth

Post preparation weakens the tooth, and makes it more likely to fracture

The thinner the post space is, the better!

You need a minimum of 1 mm of surrounding axial width

Endodontic re-treatment may be complicated with the placement of a

post

Pre-fabricated post & core

Ready made dowels which you can immediately insert into the prepped
post space can be completed in one visit, vs. two for custom
Can be used in multirooted teeth, where you place two non-parallel to
each other to lock it in place

Custom fabricated or
cast post & core

Custom made for that specific tooth

Used in cases where insufficient tooth structure (2 or less axial walls) is
remaining after excavation and tooth prep
Accurately fills shape, and post & core is one structure

Add self-curing/dual curing cement directly into

the canal before inserting the post

Insert the post into the space,

and hold it down as it cures

Trim the post to the proper

height if you havent already

Core build-up

Add core material to remaining tooth structure

(e.g. FluoroCore)

Cure core material

Prepare tooth for a crown

Ferrule Effect

A ferrule is a ring of metal encircling the end of a wooden pole to

prevent it from splitting

E.g. if you hammered a nail into the end of the stick, the ferrule protects the
sides and prevents it from splitting

A tooth needs the same protection from the post, which acts as the nail in
this situation
The apical most portion of the crown acts as this ferrule (you need at
least 1.5 2 mm as a ferrule)

So the crown has to end at least 1.5 mm apical to where the core ends!

Ferrule vs. no ferrule

What if there isnt sufficient

crown length for a ferrule?

Ways to ensure sufficient ferrule:

Curettage

Crown lengthening procedure

Orthodontic extrusion