ENDODONTIC TREATMEANT REVIEW General shape of the by jizhen1947


									                          ENDODONTIC TREATMEANT REVIEW

I want to remind you with some term that we already went through this semester because
you will ask about it in the clinic.

Some time if we do good work in the clinic, no one will ask you and you will finish three hours
and go home, but if you do any mistake you will answer a lot of questions, if you don’t know
what is the master apical file for example, they will say it is the fault of who ever taught you
the course.

So, Please I want you to remember these terms until you graduate and you have a cupules of
years to graduate , it’s important in the clinic and in your exam, and from the makeup exam ,
I found very unexpected errors . I thought because maybe it was tricky questions !!! when I
ask what is the most common irrigent ? Why nobody answer calcium hydroxide?

So there is some principle that I want you to remember , forget about the pulp histology ,
innervations, lymph node or whatever.

General shape of the access cavity
General shape of the access cavity, it is trapezoid or rectangular in the lower molar, but
definitely you should know it is not circle or ovoid,, and whatever it required to following
caries, access cavity might not have any shape at all. If you follow caries and locate the canals
. You don’t have to reshape the access cavity and make it rectangular.

But remember generally the access cavity make sure that you completely unroof the pulp
chamber to show me in the exam today in the molar make sure that when you look at right
angle on the tooth you will visualize all three canals on the mandibular molar , I don’t want
you to bend your head to be able to see the distal canal for example . that is the meaning of
the compete deroofing

initial apical file
 also in the book might be mix with the master apical file. The definition of the initial apical
file is the first file that bind slightly at the corrected working length after straight line access {{
after straight line access should be there in the definition }} because it is different when you
make gate for initial apical file without straight line access the file might bind higher in the
canal in the middle third if it is curve while the apical file is still large.

Master apical file
 is the largest file that binds slightly at corrected working length after straight line access and
most of the me it is to larger sizes from ini al apical le, I know that I said sizes larger
than the ini al but it can be out of to sizes.

 in the exam a lot of you answer the definition of the recapitulation as the step back
technique , it is wrong ,,, recapitulation is returning to a small size before proceeding to a
large size during the root canal prepara on, so if you are working on          going back to
before proceeding to     with recapitula on and it’s not irrigation ,, recapitulation is different
form irrigation ,, recapitulation is determine to a smaller size instrument and it help to
maintaining vatancy (not sure) canal.

apical size of your preparation
what the size that we going to finish our root canal prepara on remember at least        le ,
apical le of ,if it is curve You can go to and if palatal or distal canal it is at least

It also important to achieve enough cleaning the root canal because enlarge surface will
occupy a mass that will be seen in the radiograph.

Even if anyone read in the book we don’t achieve good result from instrumentation irrigation
unless we enlarge it into     , but it’s not correct with the instrument that we have , if you
enlarge it with a curve canal you might perforate the apex.

       Root canal sealer
how many type?!!      type

 -   Calcium hydroxide base
 -   Zinc oxide base
 -   Glass inomar base
 -   Resin base sealer

{ base } should be there , if you put zinc oxide only it’s wrong , because zinc oxide can
be use as a secondary impression Material so you can’t say zinc oxide ,, the correct
answer is zinc oxide base. And make sure that which sealer do we use , in the lab we
use resin base sealer Ah and in the clinic you might see zinc oxide base root canal

Smear layer

 What does the smear layer mean ?
It is the material form of the surface of the root canal from mechanical
instrumentation and it compose of both organic and inorganic content and bacteria.
How can we remove the smear layer?
If I ask about Inorganic component remember Chelating agent { EDTA} or acetic acid ,
EDTA it’s that we use in the clinic

If I ask about organic component , remember sodium hypochlorite NaOCL
When I asked what’s is the most type of the irrigant some answer was chlorohixidine
!! it’s not one of the most common irrigant , it is just recent irrigint , it is not effective
when we have a vital case because it doesn’t resorb organic debris, it useful only
when we have teeth with open apex ,, and you are worried about pushing NaOCL
beyond the apex and cause necrosis of the tissue .

Tip size of endodontic file

what is the p size of the le    ?? just divided by     . ,, in the exam, one of the
answer of the p size of the le size is . !! that’s wrong ..

Taper of the hand instrumentation
     of the size of the le or mul ply by . , all the type instrument { H le ,       le ,
hedstrom le } any hand instrument is      tapered , but in the rotary le it is di erent
, maybe it is     ,    ,    , .   , di erent cases , just remember taper of the hand
instrument you don’t have to memorize the rotary file.

Method of working length determination

 when we ask about method how can we determine working length ,, it is not the
procedure of determining the working length { it’s different } . estimation , put a file ,
take a radiograph . it is not the methods , it is only one method .
Soo,, the methods are
 - Radiography
 - Electronic apex locator
 - Tactile sensation
 - estimate average length
 - Paper point tip

The most reliable and the most commonly use is radiography, and the second one is
electric apex locater. Also recommended that you confirm with radiography either
with a working length size or with master con . if you want apex locater it is fine just
take a radiograph with files just before you obturate take the master con radiograph
just to make sure that your apex locator is accurate .

When we men on irriga on it is NaOCL it is not calcium hydroxide ca(OH) and it is
not chlorohixidine .. about the advantage of the irrigent non toxic non irritant is one
point. Don’t say non toxic then not irritant. It almost the same, you have to mention
the most important at the top >> antibacterial or bactericidal, non toxic non irritant is
one ,, tissue solvent , inexpensive ,,low surface tension for flow.

open apex
it need a special consideration you can’t just do a regular stepback and you can’t do
obturation with lateral condensation .

This is an example of open apex,, it is not terribly open but we can see it is a large size
, if you measure it , it can be up to      or      hand le. You might to put an apical
stop with the file but if you put your getta percha with master con it is will be fine ,
but don’t apply apical pressure for lateral condensation because getta percha will be
pushed beyond the apex

If you have a patient and he come with a painful tooth , you take a radiograph history
of a severe continuous pain one week ago , now the patient is asymptomatic you take
a radiograph and you see it, a definite apical radioleusency, so what’s the cause of it ?

So you have to have to component , if an exam questions is what is your diagnosis and
the choices are

A- Pulp necrosis .
B- Chronic apical periodontitis

If you answer A it is wrong , if you answer B it is wrong ,, you have to combine both
the pulp necrosis and chronic apical periodontitis

What if there is sinus tract labialy >> suppurative apical periodontiis ,, pulp necrosis
with suppurative ,, you have to add the word suppurative on chronic apical
periodontitis with a sinus tract ,, always a draining sinus.

Look at this tooth, it treated with apixcefication (not sure) try to establish an apical
barrier but with Conventional mean. What pushed beyond the apex is not getta
percha it is actually a calcium hydroxide , who medicated this tooth he pushed the
lentulo spiral and pushed calcium hydroxide too much beyond the apex and the past
they used to do it conventionally thinking of that periapical lesion contain bacteria , it
is not true , and when the pushed non-setting calcium hydroxide beyond the apex it is
an antibacterial or bactericidal because its high PH so it is will help in aseptic the
periapical lesion . it is not significant and I don’t want you to do it.

Some also push sealer beyond the apex because sealers asep c in the rst                hours
and they use it as antibacterial , it is not practical , you should limit the irrigation and
medication and obturation inside the root canal , however calcium hydroxide will
cause local irritation for a while but it should be after that biocompatible will resolve

So this is after obteruration and already show some resorption cause by the non
setting calcium hydroxide .

Now , if you have a patient and you take a radiograph – last lecture we talked about
fixing the difficulty Of the case - this tooth is long and curved and the anatomy of the
    apex is not clear , it is may be divided if you think this tooth is difficult just explain to
    the patient that this tooth need special consideration and referral , it is more than
    mm ( may be       mm ) and look at the curvature , it is double curve , it is very easy to
    fracture a file (even if the file was brand new) in the canal , it need to a careful
    technique , suggested difficulty don’t throw away form scarf , retentive not preferred
    but nothing on the surface {not sure of this sentence }

    This is another example of a case will need to referral. It is a lower premolar , the
    radiopaque is orthodontic span cemented on the tooth ,, if you see there is abscess
    Performer access cavity but the dentist does not find the canal because it is calcified
    or whatever reason , trauma or chronic caries ,, the canal was located and obturated
    and referral back as crown, You will not fail cases if it happened to you do your job, if
    you are a root canal specialist do the root canal treatment , and referred the other job
    to a general practitioner or prostodontist , who ever referred to doing the extra work.

This a radiograph also with a patient has a crown on the anterior teeth canine and
premolar ! the patient complaining of pain , when you take a periapical radiograph you
can see a periapical lesion because the obturation is very short while the root canal space
is evident , in this case I think the dentist doesn’t take radiograph because if he take
radiograph he will see the root is not longer and he may be decide         le , and do capule
of irrigation and placing getta percha inside the canal , so bacteri is left in this empty
space and infection is sustain , this also called a post inside the root canal . Next year in
prostodontics you will learn about posts. this consider very short in relation to the root at
least it have to be extended until this level. So what is your option ??

-   Retreatment of the root canal
-   Retreatment of the posts
-   And removal of the crown

This is a complex job, and you shouldn’t attempt doing this procedure , you should
referral to prostodontist who will remove the crown and then he can send it back to you
after removal of the crown and then you can treat the tooth, it is simple case to retreat
because the canal space is evident so we don’t expect to leave the canal like this.

Procedural error
The main concern of perforation or ledge or short filling or over filling or over
instrumentation is bacterial control , if you do error you won’t able to control the bacteria
and the failure will happen.

So , look at this example , this is a ledge canal , so instrumentation will shorten the apex
,instrumentation very short does not mean pushing debris beyond the apex , how could
short instrumentation push the debris beyond the apex if it short , if you instrument short
from the apex you will lose your working length and you will create an artificial stop so
This will cause infection because of incomplete preparing of the root canal you might
never be able to really reach the canal if it truly ledge ,and the apical third require cut this
part of the root if you want to keep the infection in the free apex.

However, it might be a second canal in this tooth and the second canal is not properly the
cause of infection , so first we try to do Conventional retreatment , retreat the extra canal
even if you can’t increase the length , just irrigate it in case of bacteria , treat the second
canal and wait, if healing occur then is no need to further surgical treatment.

Here is multiple error , short filling , ledge of the canal , perforation with a file because of
incorrect access and over preparation of the root , so this tooth need to extraction after
all these errors, this root is very weak , getta percha is exposed to the oral cavity, bacteria
and saliva will be in large amount, the access is completely exposed, tooth is weak from
this part. Again amalgam in the periodontiumvery untolerated so this tooth need to
surgical extraction.

Remember that , gates glidden are for

 - establish straight line access

 - enlarge the canal.

But remember over preparation of gates glidden will lead to perforation of the tooth. So ,
avoid over use of gates glidden , this is very will obturated molar. However, the root is
weaken and actually perforated and that’s why we can see the radioluencey in the
furcation area, and in the cross section this is anatomical canal with overuse of gate
glidden , so it is open.

Please remember both pulpal and periapical tissue ,, collect information on symptoms
and always pulp test and take radiograph , combine all these finding to achieve your
diagnosis. And remember the antibiotics do not treat pain. If you have a swelling and you
go to a dentist he can’t examine your tooth Because you have a swelling ,antibiotic is not
the correct treatment . never place antibiotic unless the tooth has an open apex , then
you can get antibiotic , but remember antibiotic is not a cure treatment of a painful tooth
because antibiotic never relief pain , you need a analgesic to relief the pain , in case of
infection you have to establish drainage before antibiotic.

This is example of diagnosis ,, this patient come to your clinic with severe history of
spontaneous pain and the tooth is asymptomatic now And you take a radiograph and this
is what you find

What is your radiographic finding ?

What is your apical diagnosis ?

What is your pulpal diagnosis ?

You can see a large carious lesion at the stage of the pulp, this is the pulp canal stage and
caries is extended to the pulp, it is mean the pulp is infected .

When you look periapically , the periapical area is necrotic , we can’t have vital pulp with
periapical area , so never say irreversible pulpitis with chronic apical periodontitis they
don’t’ match at all.

So your pulpal diagnosis is necrotic pulp with chronic apical periodontitis ,, you will get
deep pulp necrosis , you will get these type of questions and you won’t be supply with the
radiograph ,

The final patient complains of severe spontaneous pain on examination percussion and
negative pulp testing radiographically with normal periodontium.
    So you can say pulp necrosis, maybe it is acute apical peredontitis if there is acute
    pressure on percussion.

    This is a radiograph , we can see a short obturation , it is only one canal and there is a
    space lateral to it indicating the second canal but look at the periapical area , it is
    extended to the canine and central incisor , maybe the filling is fine with the tooth but
    the problem is with the second tooth.

    How would know ? we do pulp testing ,, these teeth is crowned , you can’t do electronic
    pulp testing on crown teeth because porcelain does not transmit electric current ,, so we
    have to use cold testing ( dry ice test ). If the patient doesn’t feel also on the crown then
    we test it at the neck of tooth near the gingiva , if the patient feel it so the teeth is vital
    and you have to do retreatment of this tooth

                                                     ☺ THAT’S IT ☺
Forgive me for any mistake cz Dr, Nisreen was talking too fast……

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