3. Endo is a Greek word for "lnside" and Odont is Greek word for "Tooth" Endodontic
treatment treats inside of the tooth Endodontics is the branch of clinical dentistry associated
with the prevention, diagnosis and treatment of the pathosis of the dental pulp and peri-
radicular tissue. That is, the main aim of the endodontic therapy involves to:
1-Maintain vitalitY of the PulP'.
2-Preserve and restore the tooth with damaged and necrotic pulp.
3-Preserve and restore the teeth which have failed to the previous endodontic therapy' to
allow the tooth to remain functional in the dental arch'
4. Background and aims:
Toothache resulting from infection of the dental pulp is a cause of severe suffering. The infection
often occurs as a result of:
1- dental caries.
2-Pulpal infections can also occur in non-carious teeth by cracks or fractures, due to external
trauma or in heavily restored teeth.
The purpose of root canal treatment by root filling of teeth (endodontics) is to prevent and treat
pulpal infections and thereby symptoms such as toothache and swelling because of suppuration, and for
functional and asymptomatic tooth, without signs of residual root canal infection, including loss of bone
at the root apex.
5.
6. A. Set-up:
B. Charting: examination, diagnosis and treatment plan
1. Taking of medical history: Chief complaint, present illness, past medical
history, health form including medication, allergies and other relevant
information.
2. Examination; clinical and radiographical.
3. Diagnosis 4. Treatment plan, informed consent and cost of treatment.
C. Preparation of the tooth:
6. Preparative measures; pre-endodontic build-up, local anaesthesia,
access cavity preparation, rubber dam isolation.
D. Aseptic treatment:
7. Start locating and negotiating the rootcanal(s).
8. Decide working length with electronic apex locator.
9. Working length radiograph taken with a paralleling technique.
10. Radiographic verification or correction of working length.
11. Choose Reciproc-file.
12. Routine canal instrumentation.
13. Canal instrumentation deviant from normal routine.
14. Temporary canal dressing.
15. Master point radiograph.
16. Canal obturation E. Finalization procedures.
17. Coronal canal plug.
18. Coronal restoration, temporary or permanent.
19. Reflect upon and decicion of treatment prognosis.
F. Retreatment.
7. Examination and Diagnostic Procedures:
Endodontic diagnosis cannot be made from a single isolated piece of information. The clinician must
systematically gather all of the necessary information to make a “probable” diagnosis. When taking the
medical and dental history, the clinician should already be formulating in his or her mind a preliminary but
logical diagnosis, especially if there is a chief complaint. The clinical and radiographic examinations in
combination with a thorough periodontal evaluation and clinical testing (pulp and periapical tests) are then
used to confirm the preliminary diagnosis. Inspect extraorally for swellings or asymmetries; palpate the
lymph nodes.
A complete intraoral examination includes:
1-inspection.
2- palpation.
3- percussion and pulp sensibility tests.
Remember that pulp testing is a comparative test, so you need to test neighbouring as well as a
contralateral tooth to assess this patients normal response.
8. Electric pulp tester: Dry the teeth to be tested and maintain a dry working field. Place a dab of
toothpaste on the electrode tip, to enhance conductance. Place the probe incisally or on a cusp tip, well
away from any metal restorations or gum tissue. The current increases, indicated by the display, stop when
the patient can feel a sensation in the tooth and record the number on the display and what device and
scale that were used.
Cold testing is used alongside electric testing, but is well suited for teeth with large restorations that
block access with the electric probe. A cotton roll is held with a pair of pliers and one end is sprayed to
saturation with the test spray (Endo-Ice). Place the cotton roll end in firm contact with the buccal or lingual
surface of the tooth to be tested. Maintain a dry field; do not touch mucosa for prolonged periods. Record
reactions. The examination confirms which tooth that is to be treated, and is preceded by a preoperative or
starting radiograph, taken with a paralleling device. If a sinus tract is present, a separate radiograph is taken
with a gutta-percha point inserted in the tract.
9. In some cases, the clinical and radiographic examinations are inconclusive or give conflicting results and
as a result, definitive pulp and periapical diagnoses cannot be made.
It is also important to recognize that treatment should not be rendered without a diagnosis and in these
situations, the patient may have to wait and be reassessed at a later date or be referred to an endodontist.
The aim of pulp and root canal treatment is to prevent and treat pulpal infection. If the dentist
recommends treatment intended to preserve the pulp, the aim is that the tooth should be restored to a
healthy and functional state, and be free of symptoms such as shooting pain or toothache.
10.
11. Volumetric tomography (CBCT: cone beam computer tomography) to be aware that the different
radiographic methods vary in their potential to depict minor alterations in bone tissue, which can be of
diagnostic importance.
In assessing pulpal condition, radiographic examination is often an important supplement to clinical
examination. It is particularly important to detect changes in the bone tissue around the root apex indicative of
a severely inflamed or infected pulp.
Radiographic examination is also used to evaluate the result of root canal therapy. In recent years
conventional film radiography has been superseded by digital radiography. A new method called CBCT (cone
beam computed tomography) or volume tomography has been developed.
Both digital and film radiography have limited ability to demonstrate small experimental areas of bone
destruction but good ability to identify normal conditions.
The new method CBCT is more sensitive and discloses more small areas of bone loss in comparison with
conventional radiographic techniques. Meanwhile there is insufficient documentation with respect to the
diagnostic accuracy of this method.
12. Toothache and hypersensitivity:
1- cold or heat stimulation and tenderness to percussion do not provide reliable information on the
condition of the pulp.
2-There is also an insufficient basis to allow assessment of the reliability of different tests for determining
whether the pulp is vital or not.
3-There is also an insufficient basis to both electrical and thermal tests as well as methods used to
determine the existence of pulpal blood circulation.
Diagnoses:
The art and science of detecting deviations from health and the cause and nature thereof, and determine
teeth free of disease rather than diseased.
Differential diagnosis:
The process of identifying a condition by comparing the symptoms of all (or other) pathologic process
that may produce signs and symptoms.
13. 1-Medical and dental history:
-Medical and clarify medical history (Medical conditions, Medications).
2-Clinical examination:
-Review past dental experiences.
-Current concerns.
-subjective examination (Type of pain, Thermal sensitivity, Duration of pain).
-Objective examination (Intraoral tissues, Facial asymmetry, Swelling, Redness, Fistulas).
-Intraoral clinical examination (Tissues evaluated and palpated, Caries, Discoloration, Fractures).
-Clinical testing procedures:
.-Radiology (Radiolucent area on x-ray indicates bone involvement).
.-Palpation.
.-Precussion.
.-Mobility.
.-Cold test (Dry ice, ethylchloride, ice).
.-Heat test.
.-Pulp testing(Indicates if tooth vital or nonvital).
.-Transillumination test.
.-Selective anaesthesia.
.-Caries removal.
3-Refering dentist's notes.
Diagnoses:
14.
15. Diagnostic method:
Pulpal Diagnoses:
Normal Pulp is a clinical diagnostic category in which the pulp is symptom-free and normally responsive to
pulp testing. Although the pulp may not be histologically normal, a “clinically” normal pulp results in a mild or
transient response to thermal cold testing, lasting no more than one to two seconds after the stimulus is
removed. One cannot arrive at a probable diagnosis without comparing the tooth in question with adjacent
and contralateral teeth. It is best to test the adjacent teeth and contralateral teeth first so that the patient is
familiar with the experience of a normal response to cold.
16. Reversible Pulpitis is based upon subjective and objective findings indicating that the inflammation should
resolve and the pulp return to normal following appropriate management of the etiology.
Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away within a couple
of seconds following the removal of the stimulus. Typical etiologies may include exposed dentin (dentinal
sensitivity), caries or deep restorations. There are no significant radiographic changes in the periapical
region of the suspect tooth and the pain experienced is not spontaneous. Following the management of
the etiology (e.g. caries removal plus restoration; covering the exposed dentin), the tooth requires further
evaluation to determine whether the “reversible pulpitis” has returned to a normal status. Although
dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of a
reversible pulpitis.
17. Symptomatic Irreversible Pulpitis is based on subjective and objective findings that the vital inflamed pulp is
incapable of healing and that root canal treatment is indicated. Characteristics may include sharp pain upon
thermal stimulus, lingering pain (often 30 seconds or longer after stimulus removal), spontaneity
(unprovoked pain) and referred pain.
Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-
counter analgesics are typically ineffective. Common etiologies may include deep caries, extensive
restorations, or fractures exposing the pulpal tissues. Teeth with symptomatic irreversible pulpitis may be
difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no
pain or discomfort to percussion. In such cases, dental history and thermal testing are the primary tools for
assessing pulpal status.
18. Asymptomatic Irreversible Pulpitis is a clinical diagnosis based on subjective and objective findings indicating
that the vital inflamed pulp is incapable of healing and that root canal treatment is indicated. These cases have
no clinical symptoms and usually respond normally to thermal testing but may have had trauma or deep caries
that would likely result in exposure following removal.
19. Pulp Necrosis is a clinical diagnostic category indicating death of the dental pulp, necessitating root canal
treatment. The pulp is non-responsive to pulp testing and is asymptomatic. Pulp necrosis by itself does not
cause apical periodontitis (pain to percussion or radiographic evidence of osseous breakdown) unless the
canal is infected. Some teeth may be nonresponsive to pulp testing because of calcification, recent history
of trauma, or simply the tooth is just not responding. As stated previously, this is why all testing must be of
a comparative nature (e.g. patient may not respond to thermal testing on any teeth).
20. Previously Treated is 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. The tooth
typically does not respond to thermal or electric pulp testing.
Previously Initiated Therapy is a clinical diagnostic category indicating that the tooth has been previously
treated by partial endodontic therapy such as pulpotomy or pulpectomy. Depending on the level of therapy,
the tooth may or may not respond to pulp testing modalities.
21. Apical Diagnoses:
Normal Apical Tissues are not sensitive to percussion or palpation testing and radiographically, the
lamina dura surrounding the root is intact and the periodontal ligament space is uniform. As with
pulp testing, comparative testing for percussion and palpation should always begin with normal
teeth as a baseline for the patient.
22. Symptomatic Apical Periodontitis represents inflammation, usually of the apical periodontium,
producing clinical symptoms involving a painful response to biting and/or percussion or palpation.
This may or may not be accompanied by radiographic changes (i.e. depending upon the stage of the
disease, there may be normal width of the periodontal ligament or there may be a periapical
radiolucency). Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp
and root canal treatment is needed.
23. Asymptomatic Apical Periodontitis is inflammation and destruction of the apical periodontium that is
of pulpal origin. It appears as an apical radiolucency and does not present clinical symptoms (no pain
on percussion or palpation).
24. Chronic Apical Abscess is an inflammatory reaction to pulpal infection and necrosis characterized by gradual
onset, little or no discomfort and an intermittent discharge of pus through an associated sinus tract.
Radiographically, there are typically signs of osseous destruction such as a radiolucency. To identify the
source of a draining sinus tract when present, a guttapercha cone is carefully placed through the stoma or
opening until it stops and a radiograph is taken.
25. Acute Apical Abscess is an inflammatory reaction to pulpal infection and necrosis characterized by
rapid onset, spontaneous pain, extreme tenderness of the tooth to pressure, pus formation and
swelling of associated tissues. There may be no radiographic signs of destruction and the patient often
experiences malaise, fever and lymphadenopathy.
26. Condensing Osteitis is a diffuse radiopaque lesion representing a localized bony reaction to a low-
grade inflammatory stimulus usually seen at the apex of the tooth.
27. Diagnostic Case Examples:
Mandibular right first molar had been hypersensitive to cold and sweets over the past few months but the
symptoms have subsided. Now there is no response to thermal testing and there is tenderness to biting and
pain to percussion. Radiographically, there are diffuse radiopacities around the root apices. Diagnosis: Pulp
necrosis; symptomatic apical periodontitis with condensing osteitis. Non-surgical endodontic treatment is
indicated followed by a build-up and crown. Over time the condensing osteitis should regress partially or
totally
28. Maxillary left first molar was endodontically treated more than 10 years ago.The patient is complaining of
pain to biting over the past three months. There appear to be apical radiolucencies around all three roots.
The tooth was tender to both percussion and to the Tooth Slooth®. Diagnosis: previously treated;
symptomatic apical periodontitis. Treatment is nonsurgical endodontic retreatment followed by
permanent restoration of the access cavity.
29. Maxillary left lateral incisor exhibits an apical radiolucency. There is no history of pain and the tooth is
asymptomatic. There is no response to Endo-Ice® or to the EPT, whereas the adjacent teeth respond normally
to both tests. There is no tenderness to percussion or palpation. Diagnosis: pulp necrosis; asymptomatic
apical periodontitis. Treatment is nonsurgical endodontic treatment and placement of a permanent
restoration.
30. Factors influencing prognosis in endodontic patients:
The key to success for endodontic treatment is thorough debridement of the root canal system of necrotic or
infected pulp tissues, microorganisms, and complete sealing of the root canal space. This will prevent the
persistence of infection and reinfection of the root canal space. The failure of endodontic treatment can be
determined on the basis of clinical signs and symptoms and radiographic findings of root canal treated tooth.
Periapical disease is an inflammatory response around root canal termini in response to intra-radicular
bacterial infection. It can be prevented (in the case of pulp inflammation) or resolved (in the case of pulp
infection) by root canal treatment. The endodontic failure is a common problem in dentistry. The success of
endodontic and re-endodontic treatment depends on many factors. These includes periodontal disease, root
fractures, residual necrotic pulp tissue, presence of per-radicular infection, broken instruments, mechanical
perforations, root canal under fillings, root canal overbillings, missed canals or unfilled canals, also
endodontic failures are more related with the lack of knowledge on the part of the operator, complex
anatomy of the teeth involved and lack of referral of such patients to the specialists.
