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46 Cards in this Set

  • Front
  • Back
Subjective information
Objective findings
Plan of treatment
Reversible pulpitis
Non lingering to thermal tests and non spontaneous

- Happens after restoration for a week and goes away
Symptomatic Irreversible pulpitis
Lingering pain after stimulus like thermal test and spontaneous. Usually severe
Asymptomatic irreversible pulpitis
No clinical symptoms and inflammation of the pulp caused by caries, caries excavation, trauma, that causes pulp exposure in the chair
Pulpal diagnosis
Reversible pulpitis
Symptomatic Irreversible pulpitis
Asymptomatic Irreversible pulpitis

Necrotic pulp - No response to thermal or electrical stimuli
Previous root canal therapy - Canals are obturated and normally have no response
Previously initiated therapy - Partial endodontic therapy like pulpotomy or pulpectomy. Usually have no response
Periapical diagnosis
Normal apical tissues
Symptomatic apical periodontitis
Asymptomatic apical periodontitis
Acute apical abscess
Chronic apical abscess

Condensing Osteitis
Focal osteopetrosis/Periapical osteosclerosis
Symptomatic apical periodontits
Pain to biting and percussion.

Have symptoms but may or may not have swelling or Periapical radiolucency
Asymptomatic apical periodontits
Cannot elicit pain or altered sensation

However, must have apical radiolucency.
Acute apical abscess
Localized swelling, pain, and pus formation.

- Tender to pressure and may have fever and lymphadenopathy.
- Possible radiolucency
Chronic apical abscess
Minimal or no pain since pus drains from sinus tract
Functions of pulp
- Formation of dentin
- Sensation
- First line of defense to injuries and infection of dentin
Components of pulp
Fibers and glycoproteins
Ground substances
Blood vessels, nerves, and lymphatics
Movements of tubules
Heat makes fluid and odontoblastic process move inward

Tactile, evaporation and osmotic makes it go outward
Pulpal axonal reflex due to dentin stimulation
Release Substance P and CGRP which may release inflammatory agents and increase pulp pressure
- Without bacterial infection, vascular changes could be resolved
Routes of root canal infection
Trauma induced fractures
Restorative procedures
Periodontal scaling and root planning
Pathogenecity vs Virulence
Pathogenecity is the ability of microbe to cause disease

Virulence denotes degree of pathogenicity
Collagen in dental pulp
Concentration varies between species but is 32% in humans

- Higher content in the middle and apical region
- Total collagen decreases with age
- High levels of type III collagen
A-delta fibers
- Lower threashold, so involved in fast and sharp pain
- Stimulated by hydrodynamic stimuli
- Sensitive to ischemia
C fibers
Higher threashold and involved in slow, dull pain
- Stimulated by direct pulp damage
- Sensitive to anesthetics
Dentinal tubules
Largest diameter at near the pulp - 2.5 nanometer
Smallest at the periphery - 0.9nanometer

Smallest tubule still compatible with diameter of most oral bacterial species which ranges from 0.2 to 0.7 nanometer
Delay of bacteria invasion
Outward movement of dentinal fluid and tubular content

Dentinal sclerosis beneath a carious lesion

Tertiary dentin
Primary vs Secondary infection
Primary infection - Caused by microorganisms that initially invade and colonize necrotic pulp tissue

Secondary infection - Caused by microorganisms not present in the primary infection but introduced at some time after professional intervention

Most part clinically indistinguishable, but if symptoms arise after professional intervention in a previously uninfected tooth, its typically a secondary infection
Most common bacteria found in failing root canals
Enterococcus Faecalis

Other include:
Fusobacterium Nucleatum
Prevotella species
Actinomyces species
Sources of nutrients for bacteria
- Necrotic pulp tissue
- Proteins and glycoproteins from tissue fluids and exudate that seep into root canal system via foramens
- Components of saliva that may coronally penetrate into the root canal
- Products of metabolism from other bacteria
Key points
Instruments shape, Irrigants clean

Endodontic therapy is not complete until the tooth is restored to function
Diagnostic measures to locate canals
- Multiple pretreatment radiographs
- Examination of pulp chamber floor with a sharp endo explorer
- Staining chamber floor with methylene blue dye
- Performing the sodium hypochlorite "champagne bubble" test
Anterior access
Burr should be directed perpendicular to the lingual surface
- Initial external outline form should be cut with a #2 or 4 round bur or a tapered fissure bur to penetrate through enamel and into dentin
- Access should be 1/2 to 3/4 the size of the projected final size of access cavity

- Penetrate pulp floor with same round or tapered bur, and frequently, a drop in effect is felt
- Change the bur from perpendicular to parallel to the long axis
Removal of lingual shoulder and coronal flaring
Usually a lingual shelf of dentin that extends from the cingulum to a point 2mm apical to the orifice

- Use a safety tipped bur or a Gates-Glidden bur inclined to the lingual to slope the shoulder
Final position of the incisal wall
Determined by complete removal of pulp horns and straight line access
Maxillary central
Root canal at CEJ is triangular in younger teeth and oval in older teeth
- External access outline form is a rounded triangle with its base at the incisal
Maxillary lateral
Pulp chamber outline form is similar to central and is smaller and has two or no pulp horns
- External access may be a rounded triangle or oval depending on the prominence of the mesial and distal pulp horns
Maxillary canine
Similar to incisors but they are wider Buccolingually than Mesiodistally
- No pulp horns
- External outline is oval or slot shaped
Mandibular central and lateral
Must eliminate lingual shoulder to allow direct-line access because it may conceal a second canal directly beneath it in 41.4% of cases. So access cavity should extend into the cingulum

- Outline may be triangluar or oval depending on prominence of mesial and distal pulp horns
Mandibular Canine
Similar to maxillary canine but occasionally has 2 roots and 2 canals located labial lingually
- Must eliminate lingual shoulder to access lingual wall of canal or second canal
- Access cavity is oval or slot shaped
Maxillary 1st premolar
May have three canals in MB, DB, and Palatal
- Buccal root may fenestrate
- Access shape is oval or slot shaped, but if there is three canals, outline form becomes triangular
Maxillary second premolar
Similar to maxillary first molar and may have two or three canals
Mandibular 1st premolar
Very difficult tooth to treat and has a high flare-up rate
- Sometimes has 3 roots and 3 canals, and lingual orientation directs files into the buccal root
- Oval shaped, with access centered between the cusp tips
Mandibular second premolar
Lingual pulp horn is usually larger
- More often oval shaped but can be triangular shaped if 3 cusps are present
- Access cavity form varies in atleast 2 ways in its external anatomy

- Because crown has a smaller lingual inclination, less extension up the buccal incline is required
- Because lingual half of tooth is more fully developed, lingual extension is typically halfway up the lingual cusp incline
Pre-op films for tooth #3 and for Anteriors
#3: One buccal PA, one distal angled PA

Anteriors: Buccal PA, Mesial PA
Five types of longitudinal tooth fractures
Craze lines
Fractured cusp
Cracked tooth
Split tooth
Vertical root fracture
Cracked tooth syndrome
Acute pain on mastication of grainy tough foods, and sharp brief pain with cold
Craze lines
Most adult teeth have craze lines usually crossing marginal ridges and extending along buccal and lingual surfaces

- Long vertical craze lines commonly appear on anteriors. Since they only affect enamel, its only esthetic.

Use transillumination. Entire tooth will light up with a craze line
Fractured cusp
Defined as a complete or incomplete fracture initiated from crown of tooth and extending subgingivally
- Usually involves two aspects of a cusp by crossing marginal ridge and extending down a buccal or lingual groove

- Treat with cuspal reinforced restoration like full crown or onlay
Cracked tooth
Incomplete fracture initiated from the crown and extending subgingivally usually directed mesiodistally
- May be described as incomplete or greenstick fractures

- If detected, use wedging to test for movement of segments to differentiate with fractured cusp or split tooth. No mobility with wedging indicates cracked tooth

Pulpal and periapical diagnosis, not just crack detection determines the final treatment plan
Split tooth
Complete fracture initiated from the crown and extending subgingivally usually directed mesiodistally through both marginal ridges

- Split teeth can never be saved in tact. If fracture is severe, tooth must be extracted. If fracture shears to a middle to cervical third of tooth, larger segment may be saved
Vertical root fracture
True vertical root fracture is defined as a complete or incomplete fracture initiated from the root at any level usually directed buccolingually
- Almost always associated with endo treatment, and presents with minimal signs and symptoms till periapical pathosis occurs.
- Only predictable treatment is removal of fractured root or extraction