Delay all restorations for 14 days.
Caries, cracks, or fractures.
Wide = periodontal pocket; Narrow = vertical crack, draining sinus.
Lack of symptoms, lack of evidence of ongoing pathosis, radiographic signs of bone repair, no new radiolucency or signs of resorption, function maintained, patient comfortable with tooth.
1) Lesions that mimic PA radiolucency but are not of endodontic origin, such as cysts or tumors. 2) Persistent radiolucency on a recently root-filled tooth (<5 years ago) indicating intra-radicular or extra-radicular infection, foreign body reaction, true cyst, or PA scar. 3) New radiolucency on a tooth that had root canal filling >5 years ago, indicating conditions like acute or chronic apical abscess.
Fill the space; Create an environment unfavorable for bacterial survival; Slow the further progression of infection; Indicate overall technical standard of endo treatment; Treat the current problem; Prevent future infection.
Internal bleaching is used for non-vital teeth only.
Re-treatment is ideal as it has a more predictable course and a higher rate of favorable outcomes.
Composite resin has low toxicity, good sealing ability, a chemical bond to dentine, is radiopaque, easy to mix/place, has a short setting time, and requires moisture control.
Through internal bleaching after root canal filling (RCF).
Unfavorable outcomes can occur due to poor treatment planning, case selection, diagnosis, poor technique, treatment errors, mechanical errors, resistance bacteria, poor seal, fractures, and patient factors such as poor oral hygiene or diet.
Be biocompatible/non-irritating; Easily introduced into RCF; Seal laterally & apically; Not shrink; Be bacteriostatic; Be sterile/able to be disinfected; Radiopaque; Not stain tooth structure; Be removable for re-treatment.
Local (delivered directly to site of required action) and systemic (absorption into bloodstream).
1) Simple to use, 2) Able to be aligned with beam, 3) Reproducible image, 4) Accurate image, 5) Stable positioning with no hands.
A wide perio probing defect indicates a periodontal pocket.
1) Assess pulp/RCS + PA status 2) Remove RCF to below CEJ 3) Base over CEJ with Cavit (allow 1 week set) 4) Rubber dam 5) Acid etch 6) Apply thick paste H2O2/Na Perborate paste 7) Temporary filling (Cavit) 8) Review 1 week + repeat if needed 9) Restore access cavity 10) Review (6m, 2-3y).
The 50:50 mixture allows for a slower release of Ledermix components, lasts longer than paste alone, and maintains canal sterility for a longer duration.
Extrinsic staining can be caused by substances like cigarettes, marijuana, coffee, and tea.
Labial infiltration, palatal infiltration, anterior middle superior alveolar block.
1) Accessory canals, 2) Lateral canals, 3) Developmental grooves, 4) Cracks.
Perception, expectation, pre-op and post-op pain relationship, distress, and lack of sleep.
Triangular or trapezoidal.
Changing behaviors (like smoking and coffee consumption), prophylaxis, abrasion/enamel microbrasion, external whitening, labial veneers, and crowns.
Allodynia – pain to normally non-painful stimulus; Hyperalgesia – increased pain response to normally painful stimuli.
'Seal': mostly impossible, prevents entry & exit of canal space; 'Apical seal': prevents AP, keeps tissue fluids out of canal; 'Coronal seal': prevents infection, keeps bacteria out; 'Fill': obliterates canal space.
Examples include cracked cusps, fractures, root caries, grooved roots, resorption, traumatic occlusion, perio cysts, perforations, hypersensitivity, and developmental anomalies.
Keep area clean, don’t lift lip, avoid hot foods, and no smoking.
More time required, RCF not redone prior to surgery, possible vertical root fracture, patient refused surgery, previous surgery.
Removal of all potential causative factors, comprehensive interim restoration, combination of irrigants, medicament regimes suited to diagnosis, longer periods of intra-canal dressings, re-assessment of healing response prior to RCF, specific indications for surgery, re-treatment prior to surgery when possible.
Periapical curettage, apicoectomy, retrograde RCF, perforation repair, rot resection, hemi-section, exploratory surgery, drainage.
2 or 2T, can use 9 or 9T (but not preferred due to restricted access).
The canal is clean & disinfected, no symptoms associated with the tooth, canal can be dried, mobility, percussion & palpation are normal, and any draining sinus has healed with swelling resolved and evidence of healing.
Similar flora between infected root canals and deep periodontal pockets, with cross-infecting organisms that are highly motile and survive in a highly reduced environment.
1) Diagnosis, 2) Dental treatment, 3) Drugs.
IRM + SuperEBA is soluble, difficult to handle, requires a large cavity, and releases eugenol which creates fibrous adjacent tissue.
It involves a redox reaction where the agent must diffuse through dentin, free radicals attack organic molecules converting them to simpler molecules, resulting in less light reflected and a whiter appearance.
It occurs more than 5 years after treatment and indicates new disease rather than failure of endodontic treatment.
Even light source, block peripheral light, correctly mounted, magnify image, troll viewer to block light.
It is characterized by bleeding on probing (BOP), possible suppuration, possible ankylosis, and is usually asymptomatic.
Radiographs, suture removal in 4-5 days, and review at 3-4 months, 12 months, and 3 years.
Secondary acute apical periodontitis or abscess, while very tender indicates primary acute conditions.
Not recommended due to scarring, difficult moisture control, and uncomfortable healing.
Antimicrobial, dissolution of tissue & debris (organic & inorganic), flushing action, lubrication, help clean areas inaccessible to files.
Plastic – doesn’t need to be removed for radiographs; Sits under dam – allows suction underneath; Holds dam away from face – comfort.
It applies to teeth that have both an infected root canal system causing some form of apical periodontitis and some form of marginal periodontal disease.
Fluorosis (white, yellow, brown, grey, black) and ageing (yellow).
Pain control during treatment, hemostasis during treatment, control of post-op pain.
When at least one criterion for favourable outcome has not been achieved, requiring more time to assess.
Spreaders are used for lateral compaction, with D11T for F-F points and D11 for F points in the coronal area. Pluggers are used for vertical compaction, being wider at the tip to finish root canal filling.
Without communication, manage by performing endodontic treatment first, followed by periodontal treatment.
Bevel apex, locate canal, use angled U/S tips, dry, cement, and GP.
Two or more visits are recommended for infected canals to increase predictability of periapical healing, destroy more bacteria, change the environment within the canal, reduce post-operative pain, and reduce external inflammatory resorption.
When there are systemic symptoms like fever, malaise, progressive swelling, trismus, lymphadenopathy, suppressed immune system, cellulitis, rapid onset infection, preventing complications of infection, bacterial endocarditis, cavernous sinus thrombosis, orbital cellulitis, Ludwig's angina, brain abscess, or osteomyelitis.
Neuropathic pain is a type of pain with an aetiology that is not well understood, commonly occurring in teeth following treatment for acute irreversible pulpitis. It can result in phantom pulp pain after endodontic treatment due to severing nerve fibers, invoking periapical inflammation.
Using an Eggler post remover, which grasps the side of the post (labial & lingual), or a Masserann kit, usually used in conjunction with ultrasonic vibration, or ultrasonic tips that remove cement and rock the post out of position.
Ledermix contains 1% Triamcinolone (steroid) and 3% Demeclocycline (antibiotic) in a water-soluble paste with triethanolamine NF, calcium chloride, zinc oxide, sodium sulphite, polyethylene glycol, and distilled water.
Diagnosis must be based on history, symptoms, visual appearance of tissues, caries, restorations, radiographic findings, and clinical tests.
6 months for initial indication, 1-3 years for more accurate assessment, and 5 years for the time required for accurate assessment.
1) Identify PA radiolucency. 2) Perform re-treatment. 3) Re-assess/review in 6-12 months. Depending on healing, continue to review every 3-5 years or take further action if there is no change or an increase in size.
Alternate at 2-hour intervals: 2 x Nurofen (ibuprofen) starting immediately post-op for 2-3 days; 2 x Panadene Forte starting 2 hours later and stopping the next day.
With communication, manage using long-term medicament, periodontal treatment, and root canal filling.
Localized to one tooth, extensive caries/restoration, pulp sensibility tests, percussion, palpation, crestal bone loss.
The sequence of irrigation is EDTAC, NaOCl, EDTAC. This sequence results in the cleanest canal walls, maintains dentin permeability, removes both organic and inorganic tissue, provides more efficient antibacterial action, and leaves the tubules open for better access by medicaments.
Quick, cheap, predictable, can be re-done, conservative, restores natural color & translucency, and has no effect on periodontal tissues.
1st injection given prior to commencing treatment targeting the complete mandibular division of the Trigeminal nerve.
Use targeted narrow spectrum antibiotics based on type of organism present, high initial dose, consider IM or IV if severe, commence ASAP, monitor progress daily, and continue until systemic symptoms subside plus 1-2 days after.
Delay restoration of access cavity and other restoratives for a minimum of 14 days, and fill the cavity with Cavit.
Ledermix can wash out of the canal, may discolour teeth if used incorrectly, and does not increase pH.
Caries, bacteria within teeth, restoration breakdown, cracks, pulp pathosis, periapical conditions, and periodontal diseases.
Control haemorrhage and pain.
GIC has low toxicity, good sealing ability, a chemical bond to dentine, is radiopaque, easy to mix/place, and has a short setting time.
Direct – blocks discharge from peripheral nerves (min – hrs); Indirect – prolonged block of peripheral input to reduce central sensitisation (hrs – days).
It occurs soon after treatment (up to 5 years) and may indicate true failure of endodontic treatment due to bacteria left behind.
Lateral condensation is a technique used for root canal filling that involves placing a master GP point with cement, condensing it, placing accessory points, and then performing vertical compaction with a plugger.
Mild pain, NSAIDs not contraindicated; dosage is 400mg x 4-hourly.
The most accurate positioning device, simple, can be aligned with beam, reproducible image, and has a bite block for hands-free positioning.
Periapical inflammation, requiring PA radiographs for confirmation.
Use No. 15 for periosteal flaps.
A periodontal problem.
Good access and vision, good moisture control, heals without scars, and easy to reposition.
Calcium hydroxide is used for apexification, treating pulpless and infected root canals, and root-filled infected root canals due to its antibacterial activity and ability to stimulate hard tissue repair.
No supplementary injections needed, less muscles involved, less painful, less blood at site, safer.
Calcium hydroxide has toxicity (initial and long-term), can increase replacement resorption and ankylosis, and may promote inflammatory resorption.
Intrinsic staining can be caused by factors such as fluorosis, genetic conditions like amelogenesis imperfecta, and systemic issues like jaundice.
Should not leave tooth open to get drainage.
Doesn't achieve desired results of favourable outcome, bacteria persisting in canals, new bacteria entering, ongoing periapical disease.
Nutrients (pulp tissue, debris, food/saliva); Space to occupy; Low O2 tension (anaerobic); Co-colonizing organisms.
1) How much pain is present/most-likely post-op? 2) Can the patient use NSAIDs?
Modified Parallel, Parallel, and Bisecting angle.
A narrow perio probing defect indicates a vertical crack or draining sinus.
Will not resolve pulpitis, usually unnecessary, not pain relieving, will not reach bacteria in cracks/caries, do not cure infection – only assist body’s defence mechanisms.
Caustic solutions, changes to tooth structure, not always permanent, potential for external invasive resorption, and possible discolouration after bleaching.
H2O2 may leave a precipitate on enamel or dentine, etches to open tubules, is absorbed by enamel & dentine, and reduces bond strength of GIC, dentin, composite, and enamel & dentin when immersed in water.
The body's natural response includes derangement of the nerve plexus around the apical third of the root, leading to disorganized axon sprouting and branching. This inflammatory and neural response can continue for over a year after treatment, differing from natural amputation where healing occurs gradually.
NaOCl (1%) dissolves organic tissue, has antimicrobial action, and is preferred for its good antibacterial properties and lower toxicity. EDTAC (17%) with cetrimide dissolves inorganic tissue, acts as a chelating agent, and can change and remove the smear layer.
Factors associated with EIR include 30% H2O2 plus heat and dentine thickness. Not associated with EIR are walking bleach technique, internal etching, H2O2, and Na Perborate.
External bleaching can be used for both vital and non-vital teeth.
Factors include clinical history, clinical examination, and radiographs.
Cuff technique – punch overlapping holes to create slit, better access, won’t mask features on x-ray; Single tooth isolation – clamp tooth you are working on, restrictive for handpiece, restricted vision.
Given if pain felt upon reaching pulp; injection directly into pulp via small pulp exposure.
Cases where tests are inconsistent with signs/symptoms, including primary endo lesions, primary perio lesions, primary endo with secondary perio involvement, and true combined lesions.
Remove pus and clean the area with a curette.
The smear layer is a layer of moistened debris compacted against canal walls during instrumentation. It is mainly inorganic and reduces dentine permeability, preventing access to bacteria in tubules and reducing treatment effectiveness. It also reduces adhesion of sealers to canal walls and can be removed by EDTAC.
The use of Superoxol (35% H2O2) solution as an oxidizing agent combined with Sodium Perborate, which have a synergistic effect.
1) Reduce extrusion of foreign bodies into the periapical region. 2) Remove intraradicular bacteria.
Vertical tube shift (increase vertical angulation of 15° for modified parallel technique, foreshortens image, gives more apical detail; decrease vertical angulation elongates image, no value) and horizontal tube shift (mesial or distal shift separates images superimposed over each other).
1) Bacteria (caries, cracks, broken down restorations, fractures, trauma, perio disease, mainly anaerobes as lower O2 deeper into RCS); 2) PA inflammation (directly related to bacterial invasion of canal).
1) Review – has the pain gone, if no then re-assess; 2) Re-assess – re-assess original diagnosis & establish new one; 3) Re-consider – reconsider management.
It breaks down to H2O2 (10%) and has an alkaline pH of 10, which increases the effectiveness of H2O2.
Amoxicillin, administered as 2g one hour pre-op.
Pulp sensibility tests indicate that the pulp is capable of producing a response; necrotic, pulpless, and infected teeth will not respond.
Canal transplantation occurs when the apical foramen gets enlarged and can be transported apically.
If there is still no healing, PA surgery should be considered.
Given if pain felt upon reaching dentin; intraosseous injection requiring pressure to force anaesthetic into bone; site: gingival sulcus + PDL; types include Stabident and X-tip.
Gutta Percha is a hand-rolled rubber-based filling material consisting of 19-22% GP and 60-75% ZnO. It is radiopaque and comes in standardized ISO sizes as well as non-standardized sizes like F(D11) and FF(D11T).
Heat tests, percussion, palpation, and periodontal probing.
1) Remove the causes, 2) Remove pulp/debris from canal, 3) Provide drainage if required.
Gutta Percha has low toxicity, good sealing ability, is radiopaque, provides colour contrast, has antibacterial action, and is easy to mix/place.
Inflammation activates nociceptors & associated central pain mechanisms; inflammatory mediators reduce threshold of nociceptor activation.
Increased access; Infection control; Increased visibility; Increased efficiency; Patient safety.
Mild pain, Ibuprofen contraindicated; dosage is 500-1000mg.
They are characterized by a rapid increase in probing depth, suppuration, increased mobility, and pain.
1) Treat the current problem (diagnosis & remove cause, remove pulp or infected debris, clean & disinfect canal, medicate, interim restoration); 2) Prevent re-infection (RCF + coronal restoration, OH).
1) Identify & remove the cause; 2) Aseptic procedures; 3) Mechanical instrumentation; 4) Anti-bacterial irrigants; 5) Intracanal medicaments; 6) Interim + temporary restos; 7) RCF; 8) Coronal restos.
Clindamycin, with a loading dose of 300mg then 150mg every 8 hours for 5-7 days.
Difficult to condense, shrinkage, corrosion, marginal breakdown, and no antibacterial action.
Vertical 15° increase; mesial shift.
Vertical 15° increase; horizontal shift only if problem suspected.
EPT involves placing an electric current through the tooth to test for a tingling sensation.
Available cements include resin-based cement (recommended), ZnO-Eugenol cement, Ca(OH)2 based cement, glass ionomer based cement, and medicated cements.
Periodontal probing and mobility tests.
Remove the apex and create an apical bevel.
MTA has low tissue toxicity, good sealing ability, is radiopaque, provides colour contrast to tooth, requires moisture control, but is difficult to handle and place, has a long setting time, and is expensive.
1) Pre-empt difficult situation; 2) Pre-medication with Ibuprofen; 3) Test tooth; 4) Give Gow-Gates block; 5) Re-test; 6) Place rubber dam; 7) Re-test; 8) If pain when reaching dentine, give PDL injection; 9) If pain when reaching pulp, give intrapulpal injection; 10) If still experiencing pain, don’t continue treatment.
Inadequate technique, inadequate asepsis, inadequate temporization, broken down restoration, caries, cracks, or trauma.
It is weakly acidic and produces perhydroxyl and O2 free radicals which are highly unstable and reactive.
In alkaline pH, there is a greater bleaching effect due to more perhydroxyl free radicals being produced.
Penicillin V, with a loading dose of 1000mg then 500mg every 6 hours for 5-7 days.
To test for pain, check for cracks, and assess apical or lateral periodontitis.
Well defined borders indicate it has been present for a long time, poorly defined borders suggest it is rapidly spreading.
Remove tissue and debris that may decompose into destructive by-products, support bacterial growth, avoid periapical irritation, and create space for intracanal medication.
Leding occurs when the file is rotated too much, digging into the side of the canal and creating a ledge.
1) Antibacterial - eliminate residual bacteria, need inter-appointment microbial dressings. 2) Reduce PA inflammation - can reduce inflammatory and neural responses. 3) Reduce or prevent pain - Ledermix for control of post-op pain. 4) Stimulate periapical repair - direct and indirect effects. 5) Prevent or inhibit inflammatory resorption - kill bacteria to prevent infection and resorption.
Apical periodontitis, secondary acute apical periodontitis, endo re-treatment, chronic apical periodontitis, foreign body reaction, infection, secondary acute apical abscess, extra-radicular infection, periapical cyst, true cyst, periapical scar, and other pathosis.
Appointment 1: Examination, diagnosis & identify the cause, remove ALL restorations, locate canals & remove existing RCF, place initial dressing (Ledermix or 50:50 mix), interim restoration. Appointment 2: Access through interim, establish working length, prepare, clean & disinfect canals, place 2nd dressing (Ca(OH)2 or 50:50 mix), temporary filling in access cavity (CW, Cavit, IRM). Appointment 3: Either change dressing or root canal filling.
Very few indications, FBR, true cyst, perforation repair, if non-surgical treatment not feasible, very long/wide post, patient factors such as medical/dental conditions, time, costs, recent crown.
Using an Eggler post remover reshaped into a cube with flat crown margins, a Masserann kit with hollow burs to cut away cement, or ultrasonic tips that alternate application to the sides of the post to dislodge it.
Hedstrom file (circle shape, cuts on outward stroke), K-file (square shape, cuts in and out), Reamer file (inverted triangle, cuts on inward stroke).
1) Patient comfort, 2) Moisture control, 3) Improved treatment outcomes.
Psychological factors, non-surgical has higher success, no ideal retrograde filling material, surgery entombs bacteria rather than killing, doesn’t remove pathway of bacterial entry.
Using heated instruments, Gates Glidden to soften GP, solvents like eucalyptus oil and chloroform, or Hedstrom files for circumferential filing.
1) The tooth 2) The status of the pulp or the root canal 3) The status of periapical tissues 4) Identify the cause.
CO2 is applied to unaffected teeth first, then to the affected tooth to test the response of the pulp. Pulpless teeth won't feel anything, irreversible pulpitis will have long-lasting pain, and reversible pulpitis will have pain that goes away quickly.
Vertical 15° increase; horizontal shift only if problem suspected.
Swelling & bruising, infection, pain & discomfort, paresthesia, tissue discolouration, scarring, gingival recession, loss of interdental papillae, aesthetic alteration.
The best test is CO2 combined with Electric Pulp Testing (EPT).
1) Negotiate canal (size 10-15), 2) Coronal flare, 3) Establish working length, 4) Canal preparation (25mm Hedstrom files, 0.02mm taper), 5) Finish with GG bur.
Metronidazole, used only in severe infections with a loading dose of 800mg then 400mg every 12 hours for 5-7 days.
Vertical 15° increase; distal shift.
Reversible pulpitis is sensitive to extreme temperature with short pain, while irreversible pulpitis is sensitive to mild temperature with long duration pain.
Easiest to remove stains are grey, light yellow, black, and dark yellow. Stains due to trauma and fresh stains are easier to remove, while stains due to restorative materials are harder to remove.
Erythromycin, which can cause nausea, vomiting, and diarrhea.
1) Turn 1/8 clockwise to engage dentin, 2) Push/pull action, 3) Circumferential filing to create conical preparation with no wings.
Antibacterials and anti-inflammatories that stimulate hard tissue repair, such as Ledermix (CS-Ab) and Calasept (Ca(OH)2).
Apical periodontitis, secondary acute apical periodontitis, endo re-treatment, chronic apical periodontitis, foreign body reaction, infection, secondary acute apical abscess, extra-radicular infection, periapical cyst, true cyst, periapical scar, and other pathosis.
Vertical 15° increase; mesial shift.
Apical foramen (opening of apex), radiographic apex (end of tooth root on radiographs, 1-2.5mm from apical constriction), physiological foramen (where the pulp begins apically).
Keep the apical foramen in the same location and as small as possible, create a conical shape that narrows apically, create a shape easy to fill, and fill the prepared canal with a biocompatible filling to completely seal apically and coronally.
Gates Glidden burs are side cutting burs used to flare the coronal portion of the canal, used without pressure and only cut on withdrawal.
