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222 Cards in this Set

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Cleaning Shaping and Obturation
Cleaning Shaping and Obturation
Cleaning Shaping and Obturation
Why do we clean, shape and obturate?
Bacteria break down the pulp and disease develops and persisits
Irreversible Inflammation is followed by _____.

Infarction is followed by ____.
Irreversible Inflammation>>>Ischemia>>>Infarction>>>Necrosis>>>Periradicular spread of disease throug POE's
Teeth with LEO's heal ____% after extraction since all the infective contents of the root canal system are removed.
100%
What does LEO mean
Lesions of endodontic origin
Removal of existing or potential irritants from the root canal system.

Ideally complete elimination

Realistically: Significant reduction b/c of complex _____ and ____ would weaken the tooth.
Def of Cleaning and Debridment

Realistically it is reduced b/c of complex CANAL anatomy and OVERENLARGMENT will weaken the tooth
How does one achieve cleaning and debridement?
(2 ways)
Instruments: Mechanically scraping the walls

Chemical Irrigants:flusing out debris and bacteriocidal action
What is shaping?
When one shapes the canal in a conical form form apical to coronal. The apical portion will be as small as possible and in its normal position.

In order to do this correctly you want to remove an a uniform layer of dentin all around the canal
Shaping facilitates ___ and ____.
Cleaning and Obturating
How does shaping the canal in a conical fashion help in cleaning. (3 things)
Shaping the canal helps cleaning by

Eliminating pulpal tissue and endotoxins

Removing restrictive dentin

Allowing effective volume of irrigation to work deeper and circulate
How does shaping the canal in a conical fashion help in obturation.
Removes canal contents

Removes restrictive dentin

Creates a smooth, tapered, and logical cavity preparation to the apex, which is good for obturation
What are the requirments for shaping?

_____ canal

Taper?

How does one know when shaping is done?
Enlarge the canal

Taper of .06 for warm vertical compaction

Shaping is done when you can fit a NON standardized MED or FINE gutta percha cone to the working length
There are two objectives to cleaning and shaping. What are they?
Biological
Mechanical
List the biological objectives of cleaning and shaping
Remove ALL pupal tissue

Remove ALL bacteria

Remove ALL endotoxins
List the Mechanical Objectives
Produce sufficient canal shapes
-Achieves hydraulics required for 3D obturation
-Gets a solid canal seal
Define Obturation
To stop up or close and opening
What are Shilder's Five Mechanical Objectives of cleaning and shaping?

1) To develop an continuous tapering ____.

2) To have the narrowest cross sectional diameter at the ___.

3) Maintain the orginal flow of the ____.

4) Do not transport the ___.

5)To keep the apical opening as ___as practical.
Continuous Tapering Cone

Narrowest cross sectional diameter at the apex

Maintain the original flow of the canal

Do not transport the foramen

Keep the apical foramen as small as practical.

In Summary:
Tapered Cone
Smallest @ Apex
Contour of Canal
Dont Perforate the foramen
Apical opening small
Name that instrument:

Cylindrical Shape w/ Barbs and Hooks

Removes paper points and cotton pellets

Used to take out large amounts of vital pulp tissue
Broach
Name that instrument:

Made from twisting triangular shafts

Used for shaping the CORONAL and MIDDLE 1/3 of canal

Used in a CLOCKWISE motion followed by a withdrawl stroke.
Reamer
Name that instrument:

Made from twisting square/trianglar shafts
-Up to size 30

Used to shape the APICAL and MIDDLE 1/3 of the canal

Used in s short stroke up and down motion (watch winding)

Recently hybrids of these instruments have been made. Produced by machining metal blanks with different cross sections tips and designs
Files
Iso Files are also known as ____ files. What is unique about these files.

All have ___mm of cutting flute.

All have a ____ mm taper

Sizes range from 10-60. As it increases in size the tip diameter increases by ____mm

In sizes from 60-140 the tip diameter increase ___ each file size.
Iso files have tips that are 1/100 of a mm. This corresponds to the file size.

All have a 16mm cutting flute

All have a 0.02 taper

Increases in size= Increase in .05mm for 10-60 sizes

Increases in size= Increase in .1mm for 60-140 sizes
State the advantage of the series 29 files.
Seriew 29 files
-sizes 1-9
-increas 29% each file size
-smaller files with increases in tip size= advantage
Name the Instrument:

Milled from round steel wire w/ spirls milled into it

Sharper edges

Circumferential filing

Used to retrieve gutta percha and separated instruments.
Hedstrom (H-type) files
Name instrument:

Milled from round Ni-Ti blank

All have .2 tip

Taper varies from 6-12%mm
GT (greater taper) files
Name instrument:

Engine Driven
Latch Attachment
Flame shaped
Sizes 1-50, 2-70,3-90 and 4-110 ect

Used for opening orifices, getting straight line access, and shaping the CORONAL 1/3 of the canals

IMPORTANT: Brush against the walls AWAY from the furcation area.
Gates Gliddens
Name Instrument:
Engine DRIVEN
Latch attachment
Parallel Sided*

Used for opening orifices, gaining straight line access, and shaping the CORONAL 1/3 of canal

Brush against wall AWAY from furcation.
Pesso Reamer
Name instrument:

56% nickel
44% titanium

Have a MEMORY
Engine driven
Latch attachment
Various tapers (2-12%)
Various file designs (tips, angles, land etc)

*Can be used to shape the CORONAL,MIDDLE,and in some cases the APICAL 1/3 of canal
Ni-Titanium
Ni Titanium is not a Panacea. What does this mean
It is NOT a cure all, remedy for all problems or to be used in EVERY situation

although it is a great instrument
How do you use the Ni-Ti instrument

RPM?
Done in a ____ technique.
Gentle "____" motion
Flutes are ____ between each insertion
Must NEVER be taken beyond ___.


You can use these instruments with varing:

Tip size/Keep Taper constant
Taper/Keep Tip size constant

or vary both simultaneously
RPM= 150-600 rpm
Crown Down Technique
Gentle Pecking Motion
Flutes are cleaned between insertion
Must NEVER be taken beyond the APEX
Irrigants MUST provide:

Washing (Lavage) and dislodge debris

Tissue ____.

Antibacterial effects

Lubricate

Have Low/High surface tension?

Remove ___ layer

___ toxicity
Irrigants must

wash and dislodge debris

provide tissue disolution

antibacterial effects

lubricate

have a LOW surface tension

remove smear layer

have a low toxicity
Name 4 irrigants
Saline
NaOCl (5.25% or 1/2 strength @ 37C)

H2O2 (peroxide)

Chlorhexidine

Chelators (EDTA or citric acid)
-removes metal ions from blood
What did the Abou-Raas study prove in 1987.
Irrigants can reach the apex if a 27-30 gauge needle is within 3-4 mm of the apex that has been opened to a size 30 file
Name a Dentin softening agent
17% EDTA or 10% citric acid
Removes metal ions
Name a lubricant uses in the canal for less friction for the passage of files
EDTA + Glycerin (RC prep, Endo-Gel, ect)
Name a common medicament used in the canal?
-Use when?
-It is an ____.
-Has a high ___
CaOH
Use when RCT is NOT indicated
It is an antibacterial
High pH
Define Working Length
distance from the coronal reference point to a point where canal preparation and obturation should be terminated
Define Patency
Openness of the apical foramen
apex should remain unblocked using a small file throughout the procedure
Define Recapitulation
Reinstrumentation of the canal withe the same series of instruments
Define Crown Down Technique
Instrumentation from the coronal to the apex. Larger instruments used first
Define Step Back Technique
Instrumentation of canal starting from apex towards the crown. Smaller instruments taken to working length and larger instruments are worked to shorter distances away from apex
Define Canal Transportation
Removal of canal wall structure on the OUTSIDE half of the apical curve
Apical Zipping?
Over instrumentation which creates a tear drop shape @ apex instead of round apex. Increases area for leakage and creates difficulty in obturation
Canal ledges?
Instrumentation in the same depth without reinstrumenting area and establishing patency.
Apical Perforation?
Created when a ledge is repeatly instrumented. go through apex
Stip perforations occur when a clinician doesnt brush ___ from the furca.
Brush AWAY from the furca
What is determined from a radiograph in the canal preparation.
Determine the # of roots and canals

Orifice location

Curvatures

Root Angulation
Technique used for the proper access cavity is

____ generated

_____ access

Reduction of ____ interferences to prevent instrument separation.
Access Cavity

Anatomically Determined
Straight Line Access
Reduce CORONAL interferences
What is Body Shape and Pre-Flaring?

What is the advantage to doing this body shaping//preflaring?
Body Shape and Pre flaring confirms CORONAL patency and probes for curves, obstructions and extra canals

Advantages:
Volume Irrigants early
Prevent extrusion of necrotic debris beyond the apex
Better tactile sensation to detect apical constricture
Working Length

Note the Average Morphology
Radiographic Terminus
Electronic _____
Tactile
Paper Points


T or F: Loss of WL is NOT expected after cleaning and shaping
Electoronic apex locators

F: Loss of WL IS expected after cleaning and shapign
In 1976 Caldwell showed that a ___ mm WL loss in the MB roots of Max Molar
.35 WL loss in MAX molars
In 2002 Davis and Baumgartner demonstrated a WL loss is greater using what instruments.
Stainless Steel instruments lose WL more than Ni-T
How do you determine your MASTER APICAL FILE length?

Apical opening must be @ least a size ___ file for adequate irrigation and obturation.
-If less you MUST enlarge to a size 25
It is the largest binding file at the correct working length

@ least a size 25 file
In 2002 75% of the 1st instruments that bound the canal walls were only contacting one wall. 25% did not contact any walls. T or F
TRUE
After WL and MAF has been determined the ___ provides resistance form
Deep Shape
What Hand instruments are used to shape the apical portion of the canal

-Technique
-Why are these good
Smaller Tapered Files
-Use step back technique
-Good: Flexible and can be precurved, good for difficult anatomy
How can you be successful at apical shaping.

Instrumentation?
Irrigation?
Patency?
Anatomy?
Recapitualate-Reinstrument

Irrigate well

Matain Patency

Note anatomical constrictures
How do you blend the coronal and middle 1/3 of your canal preparation.
Brush canal walls with:

Ni-Ti rotary

Gates Glidden

Precurve files and reamers
How do you remove the smear layer.
Use NaOCl rinse and EDTA rinse (1min)
What are the 4 objectives of obturation?
Completely seasl the entire length of the root canal system

3D fill

Get as close to the CEJ as possible

Use a core material and minimal amounts of biocompatible sealer
What material is used to obturate most commonly.

What is this material composed of:
75% ____, 22%____ , and 3% _____ .


Name the 2 phases and there corresponding temperatures.

When does shrinkage occur
Core Material= Gutta Percha

75% Zinc Oxide
22% Gutta Percha
3% Wax w/ coloring agents and salts

2 crystalline phases
-Beta phase @ 37C
-Alpha phase @ 42-44 C

Shrinkage occurs when going from alpha to beta phase
What does sealer do in the obturation step. (2)
Aid in the seal between the GP and the canal walls

Lubricates
Do you condense in obturation.
NO condense means to make MORE dense!

In obturation you compact- putting firmly together
What are the two methods of compaction of GP?

Which one is used at BU
Warm Vertical
-use @ BU
Cold Lateral
Obturation steps

1) GP conefit

2)Radiographic confirmation

3) Cut back GP cone

4) Get 3 pluggers: Smallest must reach within ___ -____mm of the apex PASSIVELY

5) Dry canal w/ paper points

6) Mix Sealer

7) Coat GP with Sealer

8) Radiographic confirmation; Cone fit with sealer

9) Segmental Down Pack within ___to ___ mm of apex

10) Back fill to the level of the ___ using Obtura Gun or small GP cone
4) 4-5 mm passively

9) 4-5 mm

10)CEJ
Hutter's Lect
Hutter's Lect
Hutter's Lect
By volume DENTIN is:

____% Inorganic (Hydroxyappetite)

____% Organic (Collagen)

_____% Fluid
45% Inorganic

33% Organic

22% Fluid
Name the 6 types of Dentin
Developmental Dentin (orthodentin): Has dentin tubules

Mantle Dentin: first dentin formed. Stays dentin

Pre Dentin: Matrix turns into dentin, always stays dentin

Circumpulpal Dentin: surrounds dentin tubules

Secondary Dentin

Tertiary Dentin (Reparative Denitin): dentin layed down throughout the life of the tooth
Dentin Tubules make up ___ to ____ of the volume of dentin

Mean # of tubules @ DEJ //Pulpal Surface

The total tubular suface area @ DEJ//Pulpal Surface
20-30% of the volume is dentin tubules

Mean # of tubules per square mm:
10-25,000 @ DEJ
30-52,000@ Pulpal Surface

Tubular Surface Area
@DEJ=1%
@Pupal Surface=4%
Name the parts and functions of the dentin tubules
Peritubular Dentin: Highly calcified and mineralized

Intertubular Dentin: between tubules

Periodontoblastic Space: surrounds odontoplastic process which extends from odontoblast

Lamina Limitins

Dentinal Fluid
What are the 4 functions of the pulp?
Makes Dentin by havitn odontoblast

Provides Nutrition to the tooth

Provides Neuarl imput to the tooth

Provides Defense to the tooth
You are a Doctor
You are a Doctor
You need to know this stuff
Pulp Morphology

Predentin which will turn into dentin is ____ matrix and ___-____u is width


Odontoblastic layer
-How many layers thick
-Contains ___ and ____.
-What type of junctions.
Pre dentin: Uncalcified Matrix;20-25u in width

Odontoblastic Layer
-One cell layer thick
-Has capillaries and nerve endings
-Desmosomal Juctions
Pulp Morphology

Cell poor region
____U in width
Contains ___ and _____fibers.


Cell Rich Zone:
____ and _____ cells
Cell Poor:
-40 u thick
-Capillaries and Unmylenated Nerve Fibers

Cell Rich:
Fibroblast and Undifferentiated Mesenchymal Cells
Pulp Morphology:

Pulp Proper
Core of the ____ which is made up of ___ and ___.

Contains ___ and ____

Contains Cells (___, ___, ___, and ___.)
Pulp Proper

Core of the CT
-made up of collagen and ground substance

-Contains nerves adn blood vessels

-Contains fibroblast,macrophages, lymphocytes and plasma cells
Cell Free zone is always present unless tooth is doing what?
Actively producing dentin
The undifferentiated mesenchymal cells of the cell rich region become what types of cells
odontoblast to make 2ndary and tertiary dentin
Cells of the Pulp

Lymphocytes and Plasma Cells are in the _____ region of the CORONAL PULP

They are known as Immunologically Competent Cells
Subodontoblastic Region of the coronal pulp
Cells of the Pulp:(Odontoblast)
-Fully Differentiated Cells
-When they make dentin they use: Type ___ collagen, ___, and ____.

What does the activity and location of the odontoblast mean.
Dentinogeneis
-Type I collagen
-Ground Substance
-Hydroxyappetite crystals

Coronally Located: Columnar in appearance// More active

Apically located: Cuboidal appearance// less active

Shape depends on function
Cells of the PULP: (Fibroblast)

What is important about these cells

What do they do?

Unique about this cells appearance
IMPORTANT: Fibroblast are the most numerous cells of the PULP

Function: Produce and degrade collagen and ground substance= alter matrix

Unique appearance= Relatively an undifferentiated cell
Cells of the PULP:
(Fibrocytes)
-Mature ___.
-# increases with ___.
-Functions to ____
Fibrocytes
-Mature fibroblast
-Increase in # due to pulpal maturity
-Functions to maintain collagen
Cells of the PULP:
(Undifferentiated Mesenchymal Cells)

-Found in the ___ zone
-Source of ____.
-Stem cells (pluripotent cells)
Undifferentiated Mesenchymal Cells
-Found in cell rich zone
-Source of Odontoblast
Other cells of the PULP Name them:

-Fixed Macrophage, aids in the mononuclear phagocytic system

-In odontoblastic layer

-Source of Histamine, may or may not be in NON inflammed pulp
-Histocyte= macrophage

-Odontoblastic layer= Class II APC's

-Mast Cells= histamine, and noninflammed pulp
Ground Substance of Pulp

____ system

_____ + water

Matrix of CT and collagen

Influences spread of ___.
Ground Substance

Sol-Gel Colloidal System

Proteoglycans + Water

Influences the spread of inflammation
Fibers of the PULP. Name them and there location.

# of fibers increase with what?
Type I: Dentin and Pulp

Type II: Pulp

Type IV: BM of BV

# of fibers increases with AGE!
One fiber of particular importance is ___ which is in the walls of arterioles.
ELASTIN
All stimuli will be interperted as ___ to the pulp
PAIN
Afferent Nerve Fibers are also called___.

Pain is described as what?

Threshold is low/high?

Neural pathway is where?

How long does it take for these fiber to develop in the oral cavity

Stimulated by ___ and ___.
AKA: Myelinated A Delta Fibers

Pain is sharp and pricking

Low threshold of stimulation

Neural pathway is athe the central area of the pulp

Not completed in development until 5 years of age

Stimulated by EPT and COLD
Describe the Neural Pathway of the Mylenated A delta fibers

what important happens in the
-plexus of raschkow
-odontoblastic layer
-dentin
1) Enter through foramen

2)Goes through plexus of raschkow
-Loses Mylein Sheath
3) Cell free zone

4) Odontoblastic layer
-New plexus forms

5)Predentin

6)Dentin
-Loss of Shwann Cell Coating here
Unmeylenated C fibers give what types of sensation of pain?

Threshold?

Where is the Neural pathway located?

Do the Unmylenated C Afferent fiber branch in dentin.

Which has more C or A
Burning, Aching, Throbbing PAIN

HIGH threshold!!!!

Neural pathway located with A delta fibers bundles througout BODY of pulp

No branching in dentin

C is more numerous than A delta fibers
AFFERENT Unmylenated C Fibers are known as true ____ nerve fibers.

They resist ____ and are stimulated by ____ liquids
C fibers
-True Nociceptive Fibers
-Resist Necrosis
-Stimulated by HOT liquids
EFFERENT Unmylenated C fibers (going from brain)

Have ____ganglionic sympathetic nerve fibers that VASOcontrict

Involved in dentin formation

Are cholinergic parasympathetic fibers in the pulp?
Postganglionic SYMPathetic nerve fibers that vasocontrict

NO, cholinergiv parasympathetic fibers in the pulp thus NO VASODialation
Pulpal Sensitivity
Pulpal Sensitivity
Pulpal Sensitivity
How many theories exsists for pulpal sensitivity (4).
Direct Stimulation
Transduction
Hydrodynamic
Modulation
What is Modulation?
Tissue destruction stimulates pain

Depending on the pain type depends on the nerve fibers stimulated


If pain continues then that is the basis for rct
What is Brannstroms Hydrodynamic Theory?
Rapid movment of dentin tubules stimulate the A delta nerve fibers in the odontoblastic layer of the pulp

Mechano-stimulation
In Brannstrom's Theory

Dentinal tubules function as ____ tubes
-Heat ____the tubes and fluid move inward to stimulate the free nerve endings of the A delta fibers

Cold ____ the dentinal tubules and fluid move outward to stimulate the A delta fibers

Are C fibers activated?

Is Pulp tissue irreversible damagedat this point.
-What does this explain?
In Brannstrom's Theory

Dentinal Tubules function as capillary tubes

Heat expands tubules=fluid moves inward=stim A delta fiber nerve endings

Cold=contracts tubules= fluid moves outward and A delta fibers are stimulated

C fiber are NOT activated thus Pain does not linger

Pulp tissue is NOT irreversibly damaged- this explains the hypersensitivity of dentin
Deep Pulpal Pain

This is Pulpal Inflammation. When a patient is at this state the ____ theory is beleived to hold true. Tissue destruction has stimulated pain.

____ substances are released

____ fibers are stimulated

Pain lingers and is spontaenous.
Modulation Theory
-Alogenic Substances released
-C fibers stimulated

Lingering spontaneous pain
What are proprioceptive nerve fibers.

Are they in the pulp?
Proprioceptive Nerve fibers are what help to localize pain.

They are in teh PDL...NOT the pulp
Vascular Supply of Pulp consists of what 4 components

What is NOT present
Arterioles
Capillaries
Venules
Arteriovenous Anastomoses

NO ARTERIES// VEINS
What is the diameter of an arteriole

Vasoconstriction is controlled by ____ ganglionic ______ nerve fibers

Is there vasodialatory control?
Arteriole Diameter
10-100u

Vasoconstriction via POSTganglionic sympatheic fibers

There is NO Vasodialation in the pulp
Capillaries in the pulp are termed ____. They are in the _____zone in an area called the ______plexus
Capillaries are Fenestrated
Cell Free Zoned
Subodontoblastic Plexus
Venules have a max diameter of ____u.

What happens when subjected to too much pressur.
Max 200 U

Collapse when subjected to increase pulpal intersitial pressure
The ____-____ connection is a low compliant system. Since there is no room for expansion b/c of surrounding dentin ____ pressure is maintained.
Arteriole-Artery connection
maintains hydrostatic pressure
Arteriovenous Anastomoses

Venules are ____U in diameter

This is a direct connencetion between arterioles and venules

2 Functions:
-Regulates _____
-Shuts ____ drung inflammation in pulp
10u thick

-Regulates Blood Flow
-Shunt Blood during inflammation process
Are lympatics in the pulp?
Dont Know-Controversal if so they would be in the pulpal tissues
Pulpal Pathophysiology
Pulpal Pathophysiology
Pulpal Pathoplysiology
What makes the pulp susceptible to irreversible injury:

____ compliance system.

Poor _____.

Pulpal ____.

Abundant ____.
Low compliant system
(surrounded by dentin)

Poor collateral circulation

Pulpal degeneration

Abundant Oral Bacteria
Since there is a direct connection betwwen the dentin and the pulp, if caries gets into the dentin what happens to the pulp.
It reacts to the
caries products (bacterial products)
Endotoxins
Immune Complexes
What is the initial defense of dentin to protect the pulp from injury.
Sclerotic Dentin
(Hardening of the dentin)
via laying down increased amounts of peritubular dentin

This is highly mineralized/initial defense against low grade carious lesions
What is a dead tract
response to and acute carious lesion
-loss of odontoblastic processes
-which is an OPEN pathway for infection to the pulp
What is reparative dentin (aka tertiary dentin)

What is a calciotraumatic line?
reparative dentin tries to replace the odontoblast.

It is less tubular and more permeable than primary dentin

Calciotraumatic line= line that is seen from where the odontoblastic layer was originally
So now the pulp is infected with bacteria.

What is the 1st response of the pulp?

-Chronic/Acute?
-Cells?
-Collagen?
-BV
1st response in a CHRONIC one
-lymphocytes, macrophages and plasma cell try to ward off infection

-collagen is deposited

-proliferation of blood vessels
Is pulp in a reversible state during the chronic phase of pulpal inflammation.
It can be at a reversible state...YES
Bacteria gets deeper into the pulp and then a ____ response is illicited.

Vascular changes like ____ occur

Cells?

Fluid?

Pressure?

Fibers stimulated?
Acute Response
-Vasodialation/Increase permeability of BV
-PMN's
-Increase in intrapulpal fluid (edema)
Increase in intrapulpal pressure
Stimulation of C fibers
What is happening to the pulpal tissue during the inflammatory process
Tissue is being destructed

MICRO Abcess are forming
-the pulps way of trying to wall off infection

Venules eventually collapse due to pressure

Ischemia (restricted blood supply) followed by necrosis (death of cells/tissue)

Complete necrosis of pulp

C-fibers may still be viable

This is
Now we talked about many stages during the pulpal inflammatory process. Lets give them names. (3 ways to classify pulpal inflammation)
Reversible Pulpitis

Irreversible Pulpitis

Complete Necrosis
Reversible Pulpitis
-Localized/Generalized?
-Localized/Generalized increase in intrapulpal pressure?
-Threshold for ____fibers is LOWERED!!! This is known as _____.

There is an exaggerated response to ____ stimuli but it does not linger

Is there perm pulpal damage?

How do you tx:
Reversible Pulpitis

-Localized
-Localized intrapulpal pressures
-Threshold for A delta fibers is LOWERED. Called Hyperalgesia (barely touch-feel pain)
-Exaggerated response to thermal stimuli

NO perm pulp damage

Tx: Take care of etiology. Take care of caries
Irreversible Pulpits
____spread of inflammation

Threshold for ___ and ___ fibers is LOWERED!!!

Pain lingers after ____ stimulus.

Pain is described as ____, ___ and ____.

Is there pulp damage?

How do you tx
Circumferential spread of inflammation

Threshold for A and C delta fibers is LOWERED!!!

Pain lingers with THERMAL stimulus

Spontaneous, Dull, Aching Pain

Pulp is irreversibly damaged

Tx:Pulpectomy -remove pulp
Complete Pulpal Necrosis

Symptoms?
Response to vitality tests?
Necrosis of fibers?


How do you tx
Complete Necrosis of Pulp
May/May not be symptomatic
NO response to vitality tests
All A delta fibers are GONE...DEAD!!!

C delta fibers may still be viable

Tx: RCT
Periradicular Pathophysiology
Periradicular
Pathophysiology
Periradicular Pathophysiology
Periradicular tissues have a ____ communication with the pulpal tissue. Thus if the pulp gets infected to a certain degree the periradicular tissues will also be affected.

Note: Inflammation _____ infection.

In the periradicular tissues there is a _____ cirulation

___bone allows for drainage of edematous fluids

_____ fibers are present.
Direct Communication

Inflammation PROCEEDS INFECTION

Cancellous Bone allows for the drainage of the edematous fluids from the pulp

Proprioceptive fibers are present
There are 7 classifications of periradicular disease. Name them
Acute Periradicular Periodontitis

Acute Periradicular Abcess

Chronic Periradicular Periodontitis

Chronic Suppurative Periradicular Periodontitis

Phoneix Abcess

Chronic Periradicular Periodontitis w/ Symptoms

Focal Sclerosing Osteomylelitis (condensing osteitis)
Acute Periradicular Periodontitis

This is an acute response in the ____. Due to ____ or ____.

Pt will complain about
____ teeth or when doing a ____ test.

At this point you know that the _____ fibers have been stimulated so the pt can localize pain

Radiographically you should see as widened ____ and a brean in the ____.
Acute Response in the PDL
-due to pulpal disease (pathoses) or occlusal trauma

Pt complains about occluding teeth and during percussion test (sensitive)

Proprioceptive fibers activated

Radiographically= Widened PDL//break in the lamina dura
Acute Periradicular Abcesss

This let you know that there is an ____ in the periradicular tisses.
-The host is trying to ward off the infection so it forms an abcess. This occurs in the ____phase of the infection.

It will have a _____ exudate

What types of swelling or systemic symptoms will you note?

Radiographically I will see
Infection in Periradicular tissue
-Acute phase
-Purulent Exudate

Systemic Symptoms: Cellulitis, Fascial Space Involvement

Radiographically: Widened PDL and break in lamina dura
Chronic Periradicular Periodontitis

____grade, long standing lesion.

This is the body's way of trying to wall off infection from the root canal system.

Clinically the pt will be _____.

On a radiograph you will see a _____associated with the periradicular area of the tooth b/c of a _____ or _____.
Chronic Periradicular Periodontitis

Low grade, long standing lesion

Asymptomatic pt

Radiographically: Radiolucency associatd with the root of the tooth b/c of a periradicular granuloma or cyst
Chronic Periradicular Periodontitis cont

What is the granulomatous tissue composed of?

What is the periradicular cyst?
Macrophages
Lympocytes
Plasma Cells
Fibrous Tissue Capsule with Increased vascularity

Periradicular Cyst
-3D epithelial lined cavity with fluid
-lumen may or may not communicated with apical foramen
-Stim of epi rests of malassez with/in granuloma
Chronic Suppurative Periradicular Periodontitis

This occurs when a chronic periradicular lesion has established ____ in the ___ or ____.

____is present
Established Drainage in cortical plate or peridontal tissues

Sinus tract present
Phoenix Abcess

This is an exacerbation of the _____ lesion.

_____ are more virulent

_____ is decreased

Clinically: Acute Periradicular Abcess

Radiographically it is ____.
Chronic Periradicular Periodontitis
-Virulent Bacteria
-Decreased Host response

Radiograhically it will lok like Chronic periradicular peridontitis
Chronic Periradicular Periodontitis w/ Symptoms

Occurs when chronic lesion becomes ____. There will be an increase in _____.

Clinically the pt will have symptoms

Radiographically there will be what?
CPPS

Chronic lesion becomes acute
-increase in PMN's

Radiographically= RL in periradicular area
Focal Sclerosing Osteomyelitis

this is ____ grade pulpal inflammation

host resistance is ____.

Histology:
Mild inflammatory response leads to an _____ in bone deposition

clincially pt is symptomatic or asymptomatic?

radiographically there will be an increase in ____ and ____ on the radiograph.
Focal Sclerosing Osteomyelitis
(local hardening of inflammation in the bone)

Low GRADE pulpal inflammation

Host resistance is HIGH

Histology: Mild inflammation--> INCREASE in bone deposition

Clinically pt is Asymptomatic

Radiographically---> increased bone density and trabeculations
Classify Pulpal Pathoses
Reversible
Irreversible
Complete Necrosis
Classify the Periradicular Pathoses
Acute PR Peridontits
Acute PR Abcesss
Chronic PR Periodontits
Chronic Supparative PR Periodontitis
Phoneix Abcess
Chronic PR Periodontits w/ Symptoms
Focal Sclerosing Osteomyelitis (AKA condensing osteitis)
What info do you need in order to make the right dx
Dental History
Clinical Exam
Radiographic Exam
There are 2 dx we are concerned with,...what are they.
Pulp Dx
PR Dx
Pathophysiology of _____.

Hyperemia (sensitive to light touch)

Transient vasodialation

Increased Hydrostatic pressure in the pulp

reversible if the etiology of inflammatory process is removed.
Reversible Pulpitis
Dental History of ____.

NO prior history of pain
Sharp, Hyper-response to thermal change (cold/hot)
-Pain DOES NOT linger after stimulus removal

Pain is NOT spontaneous
-it has to be provoked

May be a restoration just placed on tooth
Reversible Pulpitis
Clinical Examine of RP

Recently placed restoration will have____.

Carious Lesion may be present

Restoration is defective

Cervical ____ /abrasion
Clincal Exam of RP

Wear Facets
Cervical Erosion/Abrasion
RP Radiographically

PDL?
Lamina Dura?
Lesion?
Restoration?
PDL// Lamina Dura= WNL

May see carious lesion or deep restoration w/ without base
How do you test for RP
EPT (electronic pulp test)
- +

Thermal Test
-Hypersensitive to pain but when stimulus remove pain stops

Percussion Test
-Negative

Palpation
-Negative
What is the emergency tx for RP
Adjust occlusion
Remove restoration
-place temp w/ zoe
Irreversible Pulpitis (IP)
Known as ____ spread of infection

Acute/Chronic response of pulp?

Exudate?

Pressure?
-Compliance System?

Is it reversible
IP
Known as circumferential spread of infection
-Acute Response
-exudate has NO escape
-increased pressure due to low compliance system
- NOT reversible
Dental History of IP
Pt is going to say they are having spontaneous pain (comes and goes)

remembers having pain episodes before but not to this degree

Pain response is exaggerated to cold, hot, sweet BUT pain lingers after stimulus is removed
Clincial Exam of IP pt. (see 3 things)
lg restoration CLOSE to pulp

defective restoration

carious lesion by pulp
Radiographic Exam of IP pt.
Deep restoration w/ or without base

carious lesion

PDL WNL or larger
may see break in lamina dura
How do you test for IP
EPT: Positive
Thermal:Hyper response= lingers
Percussion= Neg/Positive depends if Periradicular tissue is inflammed

Palpation +/- depending on if periradicular tissue is inflammed
Emergency TX of IP:

Pulpotomy= Use ____ or if immature tooth you would do an _____ b/c of open apex

Pulpectomy?

Pain Killers given?
Non surgical RCT

Pulpotomy: Use FORMOCRESOL
-immature tooth= apexogenesis

Pulpectomy
-Anesthesia
-CaOH (medication)
-Seal access cavity

Pain Killers= NSAIDs
What if IP is asymptomatic...What does this mean?

Name the 2 situations that can occur due to this?
Asymptomatic means that exudate escaped

Hyperplastic Pulpitis
(Pulp Polyp) or

Internal Resorption
Necrotic Pulp

-due to ____, ____, or ____.

-can be the result if etiology is not removed in RP
-it is the result of circumferential spread of inflammation
Due to caries, trauma, pdd
What is the dental history of necrotic pulp
History of trauma, caries, pdd

had pain

presently asymptomatic

no pain when provoked or stimulated
Necrotic Pulp clinically
Carious lesion close to pulp
Lg restoration close to pulp

Tooth Discoloration
PDD
NP Radiographic Exam
-carious lesion approximates or exposes pulp

-deep restorations within proximity of pulp

PDL space?
Lamina Dura
PDL WNL or widened slightly
May see break in lamina dura
How do you test for NP?
EPT: NEG

Thermal: NEG

Percussion: NEG/ + if pr tissue is inflammed

Palpation: NEG/ + if pr tissue is inflammed
Tooth with a hx of previous rct.
-Pulpotomy
-Pulpectomy
-Non surgical RCT
-Surgical RCT
Pulpless or Previous Root Canal Tx
Periradicular Dx
Periradicular Dx
Periradicular Dx
Primary Acute Periradicular Periodontitis
-Inflammation in pulp has extended through apical foramen into PR area
T or F: T
Dental History of Primary Acute Periradicular Periodonitis
Feels like tooth is HIGHER than adjacent teeth

-Increased pain when chewing
-may/may not have increased pain with temp change
-may/may not have spontaneous and/or continuous pain
-past hx of pain
Clincially someone with Acute Periradicular Peridontitis will have
Caries near pulp

Lg restoration near pulp

Tooth discoloration

PDD

Fractured tooth
Radiographically

PDL?
LAMINA DURA?
Caries
Restoration
PDL WNL or slightly widened

YOU WILL SEE A BREAK IN THE LAMINA DURA
Dx APP:
EPT: +/no response

Thermal: +/no response

Percussion: POSITIVE

Palpation: POSITIVE
Emergency TX:
NO Pulpotomy
Pulpectomy
-anesthesia
-cleanse root canal system
-CaOH in canal

Seal Access Cavity
-Occlusal Adjustment

Pain Killer- NSAID
Secondary Acute PR Peridontitis occurs when the pt has had a ____ in the past 1-2 days

Pt might say?

Pain?
RCT in past 1-2 days
Pain is spontaneous/cont
-pain in chewing, percussion, palpation

Feels like tooth is higher than the others

Feels like pressure is building up in my jaws
(swelling)
Emergency Tx for secondary acute PR peridontitis
occlusal adjustment
is there another canal
place a corticosteroid paste
seal access cavity

put a hole in the buccal or cortical plates (trephination)
Acute PR Abcess can occur b/c of 1 of three things

It is known as a TRUE infection
Advances Acute PR periodontitis

Decreased host resistance

Increase virulence of bacteria
Dental Hx of Acute PR Abcess
History of Pain

Pain may/may not be present currently

Swelling is present

Fever, lymphodenopathy, sweating, chills, GI disturbance.

Pt feel and look sick
Acute PR Abcess Clinically Examination
Extraoral/Intraoral swelling

Tooth mobilty

Carious lesion

Lg Restoration

Discolored teeth
-Hx of Trauma
Radiographic Exam of Acute PR abcess

PDL
Lamina Dura
PDL=WNL or slightly bigger

Lamina Dura= BREAK
Acute PR Abcess Dx Test
EPT: -
Thermal:-
Percussion: +
Palpation: +
When managing odontogenic infections you must consider what 3 things
pt's health
anatomical factors
-where is the infection in relation to B/L plates
-what is the closest muscle attachment
microbial factors
What is your intial tx of odontogenic infections dependent on
Dependent on initial dx taken from your history taking, clinical exam and lab data

It is also based on the origin of the infection
Goals of Tx of Bone infections when in the surgical phase (incise/drain and decompress)
Decrease the # of bacteria
Decrease pressure
---> thus alleviates pain, trismus and improves circulation in the area

Prevent the spread of infection any further

Alter Oxidation/Reduction potential in tissue

Acclerates healing
What is used to decontaminate the site in the surgical phase

Anesthesia given= regional blocks and infiltrations
*avoid needle track infections
Betadine Scrub
The incision
- In ____ tissue
-Most DEPENDENT area
-___-____ in length
-Rule of "___"
In healthy tissue
-1/2-3/4 in
-Rule of index finger
Blunt dissection is done with ____.
Hemostate curved
-open to separate tissue
-extend into adjacent spaces
Insert Drain made of _____ tubing (H/T shapes)
Suture to healthy tissue
Allow to stay in for ___ days
Sterile Penrose Tubing
Stays in for 2-7 days
Can you do endo while drain is in place
YES
Remove drain ___hrs after cleaning and shaping root canal system or

After infection resolves
24 hrs
Antibiotic Therapy
Antibiotic Therapy
Antibiotic Therapy
Indications for Anti-B therapy (4).
Host Resistance not doing well or is being tested

Systemic is involved

Fascial space involvement

Inadequate surgical drainage
Guidelines for Anti-B
Want Anti B in anerobic spectrum

lg dose= short period

collect specimen BEFORE initiating Anti-B therapy

Utilize gram stain to select anti- b if you can
If no gram stain or culture sensitive test done which anti- b should you use
Penicillin
Penicillin is the 1st drug of choice b/c it kills ____ and _____.

Dosage?
-Loading dose
-After that?
Gram +/- aerobic cocci Anerobic bacteria (most)

Dosage:
1-2 gram loading dose
500 mg every 6 hrs for 5-7 days
What is the 2nd drug of choice
use if allergic to penicillin/ no improvement in pt condition within 48 hrs

What does it kill?(2)

Dose?
-Loading and then after that?

If on this for too long a pt can get what?
Clindamycin (cleocin)
Kills
-Gram + Aerobic Streptococci
-Gram -Anerobic Rods

Dose:
-Loading: 600 mg
-150-300 mg every 6 hrs for 5-7 days

Psuedomembranous Colitis
What is Pseudomembranous Colitis
Overgrowth of clostridium difficil (gram + spore forming anerobic rod)

-growth is inhibited by lactobacillus, porphymonas and peptostreptococci

Pt at risk: elderly, immunocompromised
Pseudomembranous Colitis is most often associated with
_____>_____>_____.


C difficil produces what 2 toxins
Cephalosporin>Ampicillin>Clindamycin

2 toxins=Toxin A (enterotoxin) and Toxin B (cytotoxin)
Give the 3 forms of Pseudomembranous colits
1) Anti B associated
-diarrhea w/out colitis
-no overgrowth of c difficil
-diarrhea develops in 3-10% of adults when taking anti-b

2) Anti- B associated without pseudomembrane
-overgrowth of c difficil
-has colits
-no toxins

3)Anti-B associated with prod of pseudomembrane
Metrodiazole (AKA: Flagyl)
Absorbed Where?
Excreted Where?
Mode of Action?
-How?
Adverse effects?
What does it kill?
-which ones are more resistant

What is the dosage
Absorbed in the mouth
Excreted in the kidney

Bacteiocidal
-via disrupting DNA

Adverse affects:Antabuse effect

Kills
-ALL ANEROBIC Rods (-)
-Anerobic (+) cocci
-Faculative aerobes more resistant

dosage 500 mg every 6 hrs for 5-7 days
Anti B effect oral contraceptives
T
What is the NSAID of choice

Dosage?
-pre-op
-after that?
Ibuprofen (motrin)

600 mg tablets
-1 tab pre-op 1 hr
-1 tab every 6 hrs
Applied Heat
-Warm mouth rinse
-Extraoral heat compressors (moist)

Why use it:

How often
Aid in body defenses
-vasodialation
-increases circulation into infected area
-removal or tissue products
-increased inflammatory cells into infected area

NOT USED to regulate localized infection

How often:20-30 min
Fluids
-which one
-how much
8-10 glasses of gatorade per day
Chronic PR Peridontitis is perapical inflammation / infection resulting in ____

Lesion is of Endodontic Origin

Histologic Dx of Granuloma or cyst
bone resorption
Dental Hx of Chronic PR Peridontitis
-Symptomatic?
-History of pain?
-Restoration, caries, or trauma=YES

Clinically
-Restoration, caries, trauma

Radiographic exam
-?

Dx Test?
No symptoms
History of Pain

Radiographically= PR radiolucency
Chronic Supparative Periodontitis must have an ____.
Intraoral sinus tract
Phoenix abcess is a _____ that becomes acute periradicular abscess
Chronic PR Periodontitis that becomes and acute pr abscess
Emergency tx for Phoenix Abscess
Managed the same as acute pr abscess
Chronic PR Periodontitis w/ symptoms

Symptoms are?

Emergency tx
Spontaneous Pain
Pain on chewing and brushing

emergency tx: rct
-pulpectomy
-caOH
-seal
-NSAID's
Chronic Focal Sclerosisng Osteomyelitis
AKA?

Low grade pulpal inflammation w/ ___ host resistance

clinically pt is symptomatic or asymptomatic
AKA: Condensing Osteitis
-increased host response
-pt asymptomatic
1982 Abou-Rass stated that the ability of the pult ot recover depends on what 6 things
Type of injury
Duration of injury
thickness of remaining dentin
age of tooth
host factors
past trauma
What should you consider when selecting a pt for endo
can this tooth be endo tx
are the canals negotiable
can the tooth be isolated
non surgical/surgical
How do you know if a tooth should be endodontically tx
Is the tooth restorable
Periodontal status
Strategic value of tooth
Health of pt
Motivation of pt
What is SOAP
Subjective Findings

Objective Findings

Assessment (Dx)

Plan of tx
-endo
-perio
-pros
Which are mylenated and which are not:

A//C

What are the other fiber in the tooth.
A delta fiber=mylenated

C delta fibers=unmylenated

Proprioceptive fiber (in the PDL)
When trying to get the Hx of pain from the pt ask:

-When was the problem first noticed?

-Describe Pain?

-Duration of pain?

-Aggressive Factors to consider?

-Any swelling?

Give the translation for these questions
Translation:
How long has it been going on

Is it local, diffuse, unsure// is it sharp/dull, throbbing

when it starts how long does it last (constent/intermitant)
Sharp Pain is from ___ delta fibers

Delayed (crescendo), throbbing (deep tissue), or a pulsating/pounding pain is from _____ delta fiber stimulatin
A delta fibers=Sharp

C delta= delayed, throbbing, pounding, pulsating
T or F: Pain is referred across the midline
FALSE
When you ask question like:

Is it hurting now?
Did it hurt yesterday?
Have you ever noticed the pain before
Once it starts how long does it last
Does it come and go or is it constant?

You are asking these questions to find out the ____ of pain
Duration
What the heck are aggresive factors..?

You would ask questions like?
Is it provoked by stimulus
What causes the pain (hot, cold, sweet, biting)

Does it continue after stim is removed

Does posture increase pain
During the clinical exam you are looking for what extraorally//intraorally?
Extraoral
-swellings of the fascial spaces
-Lymphodenopathy
-Fever

Intraoral
-soft// hard tissue
-swelling
-sinus tract
-discoloration
-caries
-trauma
-fractures
Radiographic Exam
-good angulation
-Use ___ Bw's for posterior teeth

*Take your own films. Do not rely on someone elses
Vertical BW's for posterior teeth
What is the reason we do dx test?
You must reproduce the symptoms in office
EPT
-Isolate teeth with ___
-Put topical gel when using electrolyte
-DONT place tip below ____.
-Must test adjacent teeth
cotton roll isolation
DO NOT place below cervical 1/3
Cold Test
-Use ____.
-Spray on q-tip
-place on ___ surface of tooth
Endo ice
-Place on B surface of tooth
What can I gather from teh pulp test
If pt feels cold: Pulp is vital/ if not= necrotic

if painful to pt: tooth is localized

can determine extent of disease: does pain linger---->reversible pulpitis /or ache after removal of stimulus---> Irreversible pulpitis
Heat Test
-Use flat instrument
-Heat ___
-Vaseline teeth
-Place in ____ of tooth
Heat Gutta percha with touch n- heat

place in coronal 2/3
Heat test is only used to confirm a dx of ______ from dental history
dx of pulpitis from dental history
How do you do a Thermo-Test?
Use hot/cold water
Percussion
Gentle tapping not banging of tooth
True percussion sensitivity is extremely well localized and very ____. So____ first.

Tip: leave suspected tooth last

___ is also acutely tender to percussion BUT a PERIO abscess the tooth ALWAYS Test ___ usually with generalized condition elsewhere.
Painful- so palpate first

Acute Periodontal Abcess

Perio test vital
How do you decide if Perio/Endo?
EPT
Thermo
Probing
Tracing the lesion from sinus tract using GP
Cracked Tooth Syndrome
-Typical Symptoms?
-Is pain constant?
-Is it hard to localize?

Multiple attempt to dx b/c non reproducible response to the test: Which one
Hot/Cold Sensitive

Hurts on biting

Pain is intermittant

Hard to localize=YES

EPT, Thermo, Percussion
Dx the cracked tooth
chief complaint

What do you do?
Sensitivity to both hot and cold

Sharp pain on release of biting pressure

Identify tooth w/ cotton roll test

Remove restoration and chase crack using methylene blue and magnification
Tx of Cracked Tooth
Enamel Abrafaction- No Tx

Incomplete Fracture of enamel/dentin: remove restoration, stain, crown restoration

3)Incomplete:Fracture of enamel and dentin into pulp-RCT with crown

4)Split (cleaved) toot-fracture of enamel and dentin into pulp chamber- ext.