Clinical Management of

Endodontic Cases

Dr. Abhishek Parolia

International Medical University
1

Learning Objectives

To be able to analyze the criteria for patient selection for root canal procedure
To be able to apply the objectives of access cavity preparation
To be able to understand the clinical importance of anatomy of root apex
To be able to understand the need of debridement of root canal
To be able to select a suitable irrigant and use them in various clinical scenario
outcome for the best
To be able to understand the role of biofilm
To be able to explain the need of intracanal medicament
To be able to correlate the importance of coronal seal with the endodontic success
To be able to understand the mechanism of tissue regeneration

To follow the Hippocratic Oath which

says First, do not harm the vital
healthy surrounding tissues

Healthy tooth

Let me
read
first..

Oh NO..

Shocked

This is my
first time,
GOD please
save me

Root canal treatment usually fails when treatment

falls short of acceptable standards
PROCEDURAL
ERRORS

MICROBES

FOREIGN
BODY
REACTION

In most cases, procedural errors do not jeopardize the

outcome of endodontic treatment unless a concomitant
infection is present.

Microbes-responsible for success and failure in Endodontics

Elimination= Success
Persistence= Failure

ROOT CANAL THERAPY

What is it ?

The complete removal of all vital, necrotic tissue

and micro-organisms from the complex root
canal system

3
2

OBTURATION AND
POST ENDODONTIC
RESTORATION

SHAPING AND CLEANING

DISINFECTION

CORONAL CAVITY
PREPARATION

The technical
quality of the
coronal
restoration

The technical
quality of the
endodontic
treatment

Poor coronal restorations even in

combination with good endodontic
fillings

Negative impact on
outcome
Ray HA, Trope M (1995). Periapical status of endodontically treated teeth in relation
to the technical quality of the root filling and the coronal restoration. Int Endod J
28:12-18.

?
What percentage of success
after root canal treatment ?
Reason for failures of endodontically
treated teeth (Vire 1991)
59.4%
Restorative

8.6%
Endodontic

32%
Periodontal

Both the quality of the endodontic treatment

and the coronal restoration affect the health
of the periradicular
tissues in a synergistic way

Kirkevang LL, rstavik D, Hrsted-Bindslev P, Wenzel A (2000).

Periapical status and quality of root fillings and coronal restorations
in a Danish population. Int Endod J 33:509-515.

Knowledge

Basic knowledge of the tooth and root canal

morphology of all the teeth and anatomical
variations in the number and locations of root
canals is crucial in endodontic treatment
outcome.

Accurate Diagnosis;
the first stage of successful therapy

ACCURATE DIAGNOSIS
Is a result of the synthesis of
Scientific knowledge-recognize
outside/inside the scope of the dentist
Clinical experience- very important
Interest- attitude

Curiosity to suspect the unusual

Intuition

Patience- to know the details

ULTRASOUND

PULSE OXIMETRY

CBCT
DENTA SCAN

Treatment

Diagnosis
Consult Referral

Data Evaluation
Radiographic Interpretation

Diagnostic
tests

Medical
history

Physical
inspection

Dental
history
Chief complaint

Patient
interaction

Factors to be considered before

initiating endodontic therapy
Infection control

FEAR OF LAW

Isolation (Rubber Dam)

Anesthesia and Pre-operative radiographs

Application of Radiography to Endodontics

Diagnosis of hard tissue alterations of the teeth and periradicular
structures
Determine the number, location, shape, size, and direction of
roots and root canals
Estimate and confirm the length of root canals before
instrumentation
Aid in locating a pulp that is markedly calcified and/or receded
Determine the relative position of vital structures in the facial
lingual dimension
During following periradicular surgery
Evaluate the outcome of endodontic treatment

INTERNAL ANATOMY OF TOOTH

Complex root canal system

Root apex

Major apical diameter

Apical foramen
(Morning glory appearance)
Cementodentinal junction

Cementum
Dentin

Minor apical diameter/

Apical constriction/
Histological foramen

CORONAL CAVITY PREPARATION

Factors to be considered
Assessment of tooth restorability
Presence of caries/ old restorative material

Removal of the Remaining Carious Dentin and Defective

Restorations
1. To mechanically eliminate as many bacteria as possible
2. To eliminate the discoloured tooth structure that may
ultimately lead to staining of the crown
3. To reduce the risk of bacterial contamination and
blocking of the root canal space

 Position of teeth in jaws

Number, position and curvature of entire root canal

Radiographic measurement of the depth of the pulp

chamber from the occlusal table
Use of magnifying loupes/ microscope

50% of all molars (maxillary and mandibular) have a

fourth canal, more than 30% of all premolars have a
third canal, and close to 25% of all anterior teeth
have two canals.
S. Kim, S. Baek / Dent Clin N Am 2004 ;48 :1118

Exploration of
hidden canals at
high magnification

MICRO-OPENER

Diagnosis
Detection of microfractures
Locating hidden canals
Management of calcified canals
Perforation repair

 Achieve straight-line access to the apical foramen

locate all root canal orifices
Conserve sound tooth structure

Optimal access results in straight entry into the

canal orifice, with the line angles forming a funnel

that drops smoothly into the canal(s).

The cementoenamel junction (CEJ) is the most important

anatomic landmark for determining the location of pulp
chambers and root canal orifices.
Krasner P, Rankow HJ. Anatomy of the pulp chamber floor. J Endod
2004;30(1):5.

Ceiling of the pulp chamber

At the level of the cementoenamel junction in 97 percent
to 98 percent of the maxillary and mandibular molars
Deutsch AS, Musikant BL. Morphological measurements of anatomic
landmarks in human maxillary and mandibular molar pulp
chambers. J Endod 2004;30:38890.

oLaw of orifice location 1

The orifices of the root canals are always located at
the junction of the walls and the floor

oLaw of orifice location 2

oThe orifices of the root canals are located at the
angles in the floor wall junction

Law of orifice location 3

The orifices of the root canals are located at the
terminus of the root development fusion lines

ARMAMENTARIUM

LONG SHANK
ROUND BUR

DG 16 PROBE/
ENDODONTIC
EXPLORER

ENDO
ACCESS

LONG SHANK
SPOON
EXCAVATOR

SAFE ENDED
DIAMOND
ABRASIVE

GATES GLIDDEN

C Inci

Lat In

Canine

1st PM

2nd PM

1st Mo

2nd Mo

3rd Mo

C Inci

Canine

2nd PM

1st Mo

1st PM

2nd Mo

Access cavity

The occlusal projection of the access cavity must be larger

than the base, to allow better visualization of the floor.

OCCLUSAL LOAD

OCCLUSAL LOAD

REMEMBER!!!
Pulp extirpation should be done completely.
Tissues from the pulp horns should be carefully removed
Always check the patency of canal
Periapical instrumentation should be avoided-Post-op pain
Dont use an air syringe - possibility of an air embolism
Use Sodium hypochlorite (NaOCl)
Disinfection
Removal of hemorrhagic or purulent fluids
Flushing action of debris and dentin chips

Patency is important
Significant debris to
remain harbored in the
canals apical third
(predisposing the case to
failure)
Blockage can be a major
factor in causing
iatrogenic events (most
commonly, ledging and
separated instruments)

Determine Correct working length

Shaping and Cleaning

OBJECTIVES

MECHANICAL

BIOLOGICAL

 Shaping facilitates cleaning by removing restrictive

dentin which allows for a more effective reservoir of

irrigant.
Shaping is the development of a logical cavity
preparation that is specific for the anatomy of any
given root.
Shaped canals hold a larger volume of irrigant that can
potentially circulate, penetrate, and clean into all
aspects of the root canal system.

PROFILE

RaCe

Crown down technique is preferred

Greater tactile awareness of the apical constriction
Reduce coronal binding of instruments
Less risk of inoculation of endodontic pathogens into
the periradicular tissues
Enhance penetration of irrigant into the root canal
system
Less likelihood for a change in the working length
measurement during preparation
More effective performance of electronic apex locators

Shortening of
the working
length

Mechanical instrumentation of root

canals can reduce bacterial
population
Effective elimination of bacteria
cannot be achieved without the use of
antimicrobial root canal irrigation
and medication

DISINFECTION
Elimination of the
smear layer

Debridement of
pulp remnants and
irritants

Disruption and
removal of the
biofilm

Biofilm
A biofilm is a structured community of bacteria
enclosed in a protective, sticky polysaccharide matrix
that can adhere to a root canal surface.
Further, planktonic, free floating organisms within
biofilm fragments disrupt, drift, and reattach to any
surface within the root canal system, including within
dentinal tubules

Deposition of
a conditioning
film,
detachment of
biofilm
microorganism
s into
surroundings

Endodontic Infection
and
Biofilm

co-adhesion of
other
organisms

adhesion
planktonic
microbes

colonization of
planktonic
microorganism
s in a
polymeric
matrix

BIOFILM

R.C.S.-Microenvironment; dense biofilm adhere to dentin

There is convincing evidence that

microorganisms organized in this manner are far
less susceptible to antimicrobial agents than
their planktonic counterparts, which have
traditionally been used to test the antimicrobial
efficacy of substances in vitro.

Wilson M. Susceptibility of oral bacterial biofilms to antimicrobial

agents. J Med Microbiol 1996;44:7987.
Matthias Zehnder. Root Canal Irrigants. J Endod 2006;32:]389398

IRRIGATION

Irrigation

NaOCl-2.5%,1%,0.5%
CHX gluconate-0.2%,2%
Ozonated water
Bio Pure MTAD
EDTA-17%
Ultrasonics
Photo-activated disinfection
ECA
LASER

Significant factors that influence cleaning

VOLUME

STRENGTH

SEQUENCE

TIME

FREQUENCY

The potential to debride and disinfect is further

influenced by alternating between specific types
of intracanal solutions, or using them in
combination.
Final Rinse Solutions
Advocated to enhance root canal cleaning
MTAD (Dentsply Tulsa Dental Specialties)
Smear Clear (SybronEndo Specialties)
Chlorhexidine (CHX)

Vital pulp tissue can defend against microorganisms and is

thus largely noninfected until it gradually becomes necrotic
Langeland K. Tissue response to dental caries. Endod Dent Traumatol
1987;3:149 71.

Treatment of vital cases should focus

on asepsis, i.e. the prevention of
infection entering a primarily sterile
environment (apical portion of the root
canal)

In contrast, the pulp space of nonvital teeth with

radiographic signs of periapical rarefaction always harbors
cultivable microorganisms
Zehnder M. Root Canal Irrigants. J Endod 2006;32:389398

Antisepsis
key issue in nonvital cases

NaOCl
Tissue solvent-Best property
Effective on biofilm and against micro-organism
present in dentinal tubules
Removes organic components of smear layer
Tissue irritant-confine to root canal system .
2.5-3% Best concentration
Combine with chelating agent for better action
Heat it, combine with ultrasonics better action

ULTRASONICS
25 gauge irrigating needle connected to ultrasonic
unit+ 6% NaOCl solution for 1 min.- Very clean
canals
GutartsR. Et al. In vivo debridement efficacy of ultrasonic irrigation
following hand rotary instrumentation in human mandibular
molars J.Endod 2005;31;166

Device for
heating syringes
filled with
irrigation
solution (e.g.,
NaOCl) before
use

23.10.2012

63

CHX
Antibacterial, Substantive properties
Various forms- Acetate/Hydrochloride/Digluconate
(Prferred)
Effective against E faecalis, A israelli,
P intermedia, F nucleatum
Ability to inhibit adherence of certain pathogens
Lacks tissue dissolving property
Does not remove smear layer
2% concentration Best as a final irrigant

Zamany A, Safavi K, Spngberg LS. The effect of chlorhexidine as an endodontic

disinfectant. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:57881.

EDTA
It removes inorganic component of the smear layer
It detaches biofilm adhering to the root canal
It reacts with calcium ions of dentin
and forms soluble calcium chelates.
It decalcifies dentin upto the depth
of 20-30 micrometer in 5 minutes

A continuous irrigation of 5 ml of 17% EDTA for 1 minute

Erosive EDTA-Use it carefully

Use 7% Maleic acid instead of 17% EDTA

N. Vasudev Ballal,, K. Sreenesh,, M. Kundabala,, K.S. Bhat,
Shashirashmi Acharya. Comparison of the Efficacy of Maleic Acid
and EDTA in Smear Layer Removal From Instrumented Human Root
Canal: A Scanning Electron Microscopy Study . J Endod. 2009

Sodium Hypochlorite
Improves working
time of the irrigant
Improves cutting
efficacy of hand
instruments
Reduces torsional load
on rotary nickeltitanium instruments

17 % EDTA

After the smear

removing
procedure a final
rinse with an
antiseptic
solution appears
beneficial

..

If calcium hydroxide is used for the

interim, the final rinse should be done
with sodium hypochlorite, as these
two chemicals are perfectly
complementary to each other
If the canal walls are perceived to be
clean of debris and the plan is to
obturate the root canal then
chlorhexidine appears to be the most
promising agent to be used as a final
irrigant.

Antibiotics
The local application of antibiotics -more effective
mode for delivering drugs than systemic routes of
administration.
BioPure (MTAD) is effective in removing the smear
layer.
Tetraclean, is a mixture of an antibiotic
(doxycycline), an acid and a detergent (like MTAD),
with a very low surface tension and high degree of
efficacy against bacterial biofilms.

MTAD
A) Tetracycline:

i) Broad spectrum antibiotic

Bacteriostatic in nature.

ii) Low pH
iii) Calcium chelator
Surface demineralization similar to citric acid
iv) Substantive property
v) Promotes healing
vi) Removes smear layer
B) Citric Acid also removes smear layer, Bactericidal
C) Detergent Tween 80, decreases surface tension.

Electrochemically activated (ECA)

solutions
Produced from tap water and low concentration
salt solutions
ECA solution found to be similar to NaOCl in debris
removal but was more effective than NaOCl in
smear layer removal.
Solovyeva AM, Dummer PM. Cleaning effectiveness of root canal
irrigation with electrochemically activated anolyte and catholyte
solutions: a pilot study. Int Endod J 2000;33:494-504.

Lasers assisted canal preparation

Nd:YAG,erbium:YAG laser, Diode laser
induces lethal photosensitization on canal
microbiota
Adjuant to chemomechanical preparation
High cost of lasers
No access into severely curved canals
Not cleaned where optic fiber has not been touched

Light activated disinfection

or photodynamic therapy(PAD)
In combination with chemomechanical preparation ,the
advanced non-invasive LAD significantly inactivated
bacteria in biofilms

Z.Lim et.al. Light activated disinfection: an alternative

endodontic disinfection strategy. Aust Dent J 2009;54;108114.

Recent techniques
Ozonated water
Ozone (Healzone)
High frequency current (Endox)
Efficacy on endodontic microbiota in biofilms, there is
good evidence that none of these aproaches can
match a simple sodium hypochlorite irrigation

Intracanal Medication
Ca(OH)2- Universal for chronic infections
Triple antibiotic paste (ciprofloxacin, metronidazole,and

minocycline)-Acute as well as chronic infections

Ledermix for acute infections and to prevent resorptions

Ledermix and Ca(OH)2-chronic infection & to prevent

resorption
IKI- resistant infections
Eugenol- as obtundent
CMCP-tissue fixative

Calcium Hydroxide
The lethal effects of calcium hydroxide are due to several
mechanisms

Chemical action
Damage to the microbial cytoplasmic membrane by the
direct action of hydroxyl ions
Suppression of enzyme activity and disruption of
cellular metabolism
Inhibition of DNA replication by splitting DNA

Calcium hydroxide
The biological properties
Biocompatibility (due to its low solubility in
water and limited diffusion)

The ability to encourage periapical hard tissue

healing around teeth with infected canals
Inhibition of root resorption and stimulation of
periapical healing after trauma.

Calcium Hydroxide
The ability of E. faecalis to colonize within
dentinal tubules and thus evade the hydroxyl ions
Promotes the adhesion of bacteria to collagen (the
main organic component of dentine) which
increases the extent of tubule invasion and thereby
resistance to further disinfection.

Ledermix
A glucocorticosteroid-antibiotic compound, has
anti-inflammatory,
anti-bacterial
and
antiresorptive properties, all of which help to
reduce the periapical inflammatory reaction
including clastic-cell mediated resorption.
Prompts more favorable healing in replanted
teeth.
Z. Mohammadi, & P. V. Abbott. On the local applications of
antibiotics and antibiotic-based agents in endodontics and
dental traumatology International Endodontic Journal, 42, 555
567, 2009

Tri- mix
A triple antibiotic paste consisting of
metronidazole, ciprofloxacin and minocycline, has
been reported to be very effective in the
disinfection of the root canal system.
Windley et.al.,2005,Disinfection of immature teeth with a triple
antibiotic paste. J. Endod,31,439-43

Irrigating solutions

23.10.2012

83

OBTURATION
Root canal obturation

should be done
completely seal (fluid

tight) the root canal

space three

dimensionally till the

apical constriction.

 To achieve success -follow sound biologic principles.

Gentle manipulations carried out locally would give
better and faster results Avoid systemic drugs such as
antibiotics and analgesics.

It is fallacy to think that use of newer endodontic

equipment and instrument would give higher success
rate, these should be taken only as adjuncts.
The real factor being the sound knowledge and skill of
handling the biologic tissues.

FUTURE
Tissue engineering
Enamel crystals
Implanting -Pulp dentin complex
Revascularization

Morphogen

TOOTH

Stem cell

Scaffold
ENAMEL

TissueEngineered
Tissues
PULPDENTIN

PERIODONTAL
LIGAMENT

Amelogenin

Fluorapatite Nanorods

Stem Cells
BMPs

Scaffold
Pulp-Dentin
Complex

3-D Tissue Culture

Regeneration of
Dentin

Transplantation

R E VA S C U L A R I Z AT I O N

PULPAL
NECROSIS

APICAL
TERPHINATION

CLOT
FORMATION

ANGIOGENESIS

Success of revascularization depends on canal disinfection during

the process with triple antibiotic paste

THANK YOU