ENDODONTICS

LEGEND

Major Topic

Abbreviation

Diagnostic MethodslTests
Individual Teeth
Instruments/MaterialslTechniques
Miscellaneous
Pulp
Replantation (Intentional and
Avulsed Teeth)
Resorption
Terms/Conditions

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DENTAL DECKS

Diag Meth
Ind Tth
InstlMatlTech
Misc.
Pulp
Replant
Resorp
Terms/Cond

Inst/MatlTech

ENDODONTICS

Which of the following is the procedure of choice when a broken endodontic instrument protrudes past the apex of a tooth?
Extract the tooth
The broken instrument is surgically removed, and then the entire canal is filled with
gutta-percha
Fill the tooth with gutta-percha and observe
None of the above

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DENTAL DECKS

 The broken instrument is surgically removed, and then the entire canal is filled
with gutta-percha
As a general rule, when a broken instrument protrudes past the apex , surgery should
be performed to remove the constant irritation.
When an instrument breaks off anywhere in the canal and a periapica l radiolucency
is present and minimal canal enlargement has been performed before the accident ,
surgery is indicated since the periapical tissues have had little opportunity for
healing to be stimulated. You would prepare and obturate to the point of blockage and
then perform apicoectomy and retrofilling.
However, when an instrument is broken off in the apical third and is lodged tightly with
no periapical radiolucency evident , the canal can be filled in the remaining root canal
space. The patient should be informed of this and placed on a 3-6 month recall.
The prognosis of a tooth with a broken instrument is best if the tooth had a vital pulp
and no periapical lesion.

Ind Tth

ENDODONTICS
Which tooth below will almost always have two canals?

Maxillary first premolar

Maxillary second premolar
Mandibular first premolar
Mandibular second premolar

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DENTAL DECKS

 Maxillary first premolar

Approximately 60% have two roots, one buccal and the other palatal , each with a single
canal. The two roots may be completely separate or merely twin projections rising from the middle third of the root to the apex (this is more common). The two roots are usually equal in length
from apex to cusp. However, the palatal root and canal may be wider.
In approximately 40% of maxillary first premolars, only one root is present, usually with
two separate canals. A cross section at the cervical line shows a canal shaped like a figure eight
(ellipse). The access opening is a thin oval. Be careful not to perforate on the mesial (the con cavity on the mesial makes pe rforation vel)' common ).
Maxillary second premolars : The most common configuration in this tooth is a single root,
occurring approximately 85% of the time. Approximately 15% of the time, two separate roots are
present, each with a single canal. The access opening is exactly the same as that for maxillary first bicuspids (thin oval).
Notes :
When only one canal is present (first or second premolars), it is usually found in the center
of the access preparation. If only one canal is found, but it is not in the center of the tooth, it
is probable that another cana l is presen t.
Overfill ing either tooth may force materials directly into the maxillary sinus.

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ENDODONTICS
Which tooth listed below may have a pulp chamber that is somewhat triangular as
opposed to oval?

Maxillary central incisor

Mandibular central incisor
Maxillary lateral incisor
Mandibular lateral incisor

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DENTAL DECKS

 Maxillary central incisor

The base of the triangle will be the facial. The apex will be the lingual. If it is not triangular, then it will be oval.

The cervical cross sections below of the

anterior teeth show the relationship of the
crown outline to the pulp chamber and the root canal

Max

Mand.

00(@
@ @ 0
Central

Lateral

Canine

Central

Lateral

Canine

Ind Tth

ENDODONTICS
Which of the following will have a pulp chamber that will be triangular?

Permanent
Permanent
Permanent
Permanent

mandibu lar second premolars

mandibular molars
maxillary molars
maxillary lateral incisors

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DENTAL DECKS

 Permanent maxillary molars

- Base is formed by buccal canals and apex by palatal canal.
- The line connecting the mesial with palatal canal is the longest.
- Remember: The fourth canal, if present , is usually found lingual to the orifice
of the mesiobuccal canal (It is located in the mesiobuccal root).
Mandibular molars
Trapezoidal outline, formed by the two canals in the mesial root and the oval canal
in the distal root.
Remember: The distal root has a second canal approximately 30% of the time.

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ENDODONTICS
Which of the following canals in a maxillary first molar is usually the most difficult
to locate?

Palatal
Distobuccal
Mesiobuccal
All of the canals are relatively easy to find

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DENTAL DECKS

 Mesiobuccal
Canal orifices of a maxillary fi rst molar are arranged in the shape of a triangle. The orifice to
the mesiobuccal canal is usually the most difficult to locate, since it is under the
mesiobuccal cusp and must be entered from a distolingual position. This canal is the smallest canal and often splits into two canals. It maybe calcified and difficult to instrument. The
palatal canal is the straightest, widest and most tapering canal. The most common curvature of
the palatal root is to the facial. The distobuccal canal is also small and tapering. The orifice to
this canal has no direct relation to its cusp. The distobuccal orifice is usually located by means
of its relation to the mesiobuccal orifice, with the distobuccal found approximately 2 to 3 mm to
the distal and slightly to the palatal aspect of the mesiobuccal orifice.
Note: In approximately 59% of maxillary first molar teeth, a fourth canal is present with its orifice being just lingual to orifice to the mesiobuccal canal. The canal is located in the
mesiobuccal root and may join the mesiobuccal canal or exit through a separate foramen. If a
lesion is present on the mesiobuccal root prior to root canal therapy and doesn't heal in the usual
amount of time (6-12 months) following treatment, it is most likely due to a missed canal (mesiolingual).
Remember : The U-shaped radiopacity commonly seen overlying the apex of the palatal root
of the maxillary first molar is most likely the zygomatic process of the maxilla.

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ENDODONTICS
The root canal for a mandibular canine is:
Wide mesiodistally but thin labiolingually
Thin mesiodistally but wide labiolingually
The same width mesiodistally and labiolingually

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DENTAL DECKS

 Thin mesiodistally but wide labiolingually

The root canal for a mandibular canine is thin mesiodistally but wide labiolingually.
Mandibul ar canines usually have only one root but in rare cases may have two separate roots. The access opening is a large oval with the greatest width placed
incisogingivally.
This tooth usually has a slightly labial axial inclination of the crown, therefore the
access opening needs to be directed towards the lingual surface.

Ind Tth

ENDODONTICS
Which mandibular premolar presents with more variations in root canal anatomy?
First premolar
Second premolar

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DENTAL DECKS

 First premolar
The mandibular first premolar may cause problems during treatment because of the
relatively frequent ( 15%) existence of a bifurcated canal dividing in the middle or apical
third into a buccal and a lingual branch. The shape of the access opening is oval. When
divided canals are present, the entry must be widened buccolingually.
The second premolar has fewer variations than the first premolar, usually having one
root and one well-centered canal. The access opening is oval. Consideration must be
given to the mental foramen which lies in close proximity to the apex. Avoid overinstrumentation and overfill. When viewing an x-ray of this area, the mental foramen is
sometimes misdiagnosed as a premolar abscess. Therefore, before performing root
canal therapy, make sure all diagnostic tests confirm your finding.
Note: If a straight-on preoperative radiograph of a mandibular first premolar shows the
pulp canal disappearing in mid-root, this is an important indication that two canals
are present.

Misc.

ENDODONTICS

Which of the following is the most commonly used bleaching agent for endodontically treated teeth?

Ether
Superoxol
Chloroform
Sodium hypochlor ite

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DENTAL DECKS

 Superoxol
Superoxol is a 30% aqueous solution by weight of hydrogen peroxide in distilled water.
It is a potent oxidizing agent whose bleaching effect results from direct oxidation of
stain-producing substances.
Chairside technique: Application of heat to Superoxol-saturated cotton pellets in the
tooth chamber. Repeat until tooth is lighter.
Note: The heat liberates the oxygen in the bleaching agent.
Important:
The most probable postoperative complication of bleaching a tooth that has not
been adequately obturated is an acute apical periodontitis.
Tooth bleaching causes a color change in both enamel and dentin.
Walking bleach technique: Place a thick paste consisting of sodium perborate and
2-3 drops of Superoxol in the tooth chamber with a temporary restoration. Several
repetitions of this procedure can work quite well.

Ind Tth

ENDODONTICS
Which tooth below is most likely to have a curved root?

Maxillary central incisor

Maxillary lateral incisor
Maxillary canine
Mandibular central incisor

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DENTAL DECKS

 Maxillary lateral incisor

The maxillary lateral incisor always has one root with one canal. The root is more slender than
the maxillary central incisor, and frequently (55%) has a distal and/or lingual curvature or dilaceration. The access opening is oval.
Maxilla ry cent ral inc isor: The maxillary central incisor always has one root and one canal.
The root is bulky with a slight distal axial inclination, but rarely has a dilaceration. The access
opening is ova l-triangular.
Maxilla ry canine: The maxillary canine always has one root and one canal. This tooth is the
longest in the arch. The access opening is oval.
Note: The maxillary central, lateral and canine roots and, hence, canals all have a distal axial
inclination . This means in penetrating along the long axis of the tooth, the bur must be slightly
angled toward the distal surface. Failure to do this may lead to perforation of the mesial portion of the root.
Mandibular central incisor : The mandibular incisors (laterals and centra ls) have only one root
which is narrow mesiodistally but relatively wide labiolingually and may have a distal and/or
lingual curvature. Two canals may be present. When there are two canals, the labial canal is
the stra ighter one. The access opening for a mandibular central or lateral is a long oval , with
the greatest width placed inciosogingivally and the incisal extent very close to the incisal edge.

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ENDODONTICS
Which of the following teeth most often refer pain to the tempo ral region?

Mandibular molars
Maxillary incisors
Maxillary second premolars
Maxillary molars

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DENTAL DECKS

 Maxillary second premolars

If carefu l diagnosis does not reveal the affected tooth, other teeth and related
anatomic structures become suspect. Pulpitus in one tooth may cause pain in other
areas. The pain is referred.
Site of Pain Referral

Tooth PUlp Causing Pain

Forehead region
Nasolabial area
Temporal region
Ear
Mental region of mandible

Maxillary incisors
Maxillary canines, premolars
Maxillary second premolars
Mandibular molars
Mandibular incisors, canines, and premolars

Important: The nerve endings of cranial nerves VII, IX, and X are widely distributed
within the subnucleus caudalis of the trigeminal (V) nerve. A profuse intermingling of
these nerve fibers creates the potential for the referral of dental pain to many
sites.

Ind Tth

ENDODONTICS
Which tooth listed below requires endodontic treatment most frequently?

Maxillary second molar

Mandibular first molar
Mandibular second bicuspid
Maxillary first bicuspid

Copyr ight 2001 - DENTAL DECKS

 Mandibular first molar

The most common morphology for the access opening in mandibular first molars is a trapezoid formed by the two canals in the mesial root and the oval canal in the distal root. Both the
mesial and distal canals lie in the mesial two-thirds of the crown. The mesiolingual canal lies
beneath the mesiolingual cusp. The mesiobuccal canal Is the most difficult to locate but is
usually found on a straight line to the buccal from the mesiolingual orifice and is tucked deeply
beneath the mesiobuccal cusp. The distal canal is the largest and easiest to find. Therefore,
it should be located first, lying slightly distal to the buccal groove, closer to the buccal than the
lingual wall.
Note: If the distal canal is more buccal (not in center of tooth), there will usually be a fourth canal
(towards the lingual). This occurs in approximately 30% of mandibular first molars.
The lingual wall of mandibular molars is most easily perforated when preparing the access
opening (compared to maxillary molars). Perforations into furcation areas have the poorest
prognosis. When instrumenting the mesial canals of mandibular molars, be careful not to
strip-perforate the distal surface of the root (this can happ en if you are too aggress ive).
Remember: The mesiobuccal roots of maxillary molars and the mesial and distal roots of
mandibular molars often have two root canals. Make sure you look for them.

Diag Meth

ENDODONTICS

Which of the following are con tra indications to the use of the electric pulp tester?

Inability to dry the tooth

Teeth that have crowns or are heavily restored
Tooth traumatized recently
Anesthetized teeth
Patient in severe pain
All of the above

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DENTAL DECKS

All of the above

Note: The EPT (also called vitalometer) is the most popular and most debated diagnostic method.
The clinician dries off the tooth to be tested. Normally the tooth in question, the tooth
adjacent to it and the contralateral tooth are tested . On a dry enamel surface, one
places some toothpaste (conductive medium) on the tip of the tester, which is then
applied to sound tooth structure. The operator then delivers various electrical currents
to the tooth and the patient will respond to these. This indicates to some people
whether there is pulp vitality or not. To others, the degree of response can be correlated to a different pupal state of health. Not all clinicians agree about this, but everyone
seems to be in agreement that the EPT is not always reliable.
Note: The EPT should be applied first to at least one tooth other than the tooth in question. This will determine a normal response for the patient.

Diag Meth

ENDODONTICS

According to the buccal object rule, when the x-ray tube is repositioned either at a
more mesialor at a more distal angulation and a film is exposed, the root or canal farther from the film (the buccal) will:

Move in the opposite direction that the cone is directed

Move in the direction that the cone is directed
Not move at all

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DENTAL DECKS

 Move in the direction that the cone is directed

Therefore, when the cone is aimed to the distal (angled from the medial direction)
the buccal root or canal moves to the distal and appears distal to the lingual or
palatal root (or canal).
Note: In order to apply this rule, you must have a reference object.
When treating multicanaled bicuspids and molars, it is often difficult to ascertain on
the radiograph which canal is more toward the buccal. When a straight on exposure is
taken of a bicanaled tooth, the canals become superimposed on the film and visualization of each canal is impossible. If the x-ray cone is moved to give an angled exposure, the roots will be separate on the film.
By applying the buccal object rule you will be able to determine which canal is the
buccal and which is the lingual.

Diag Meth

ENDODONTICS

What diagnostic tests are indicated for teeth that have recently been traumatized?

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DENTAL DECKS

The dental examination should include:

Soft tissue exam - observe the lips, face, tongue , etc.
Hard tissue exam - visually look and then palpate the injured tooth and alveolus to
reveal the extent of tooth mobility as well as alveolar fractures and area of inflammation.
Check for occlusal disharmonies to help detect tooth displacements and jaw fractures.
Radiographic examination - x-rays reveal tooth displacement and root fractures
as well as other important facts (previous root canal, periapical radiolucencies, etc.).
Other diagnostic tests - pulp vitality testing is contraindicated because the
traumatized pulp undergoes a temporary paresthesia and would give a false reading. The percussion test is not usually performed , since it is painful.
Observe the adjacent and opposing teeth for injury.
Teeth that have been traumatized may be fine for a long time , however, many will
develop radiolucencies. Do not indiscriminately do root canals without first checking pulp vitality and perform root canal therapy only in those teeth that do not respond
to pulp testing. Example: Trauma to maxillary anterior teeth. A few years later x-rays
reveal radiolucencies around the region of the apices of the incisors . Check the pulp
vitality of all anterior teeth before performing root canals . Note: Trauma (causing deep
intrusion) to a permanent tooth will most likely result in necrosis of the pulp and conventional root canal therapy will be necessary.

Diag Meth

ENDODONTICS

Wearing gloves when using the electric pulp tester to test the vitality of a tooth may
lead to a:
False-positive response
False-negative response

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DENTAL DECKS

 False-negative response
False-negative responses can also be caused by the following:
Saliva on tooth
Secondary dentin obliterating the pulp chamber or multiple canals presenting various stages of pulpal pathosis
Recently traumatized teeth - these teeth may exhibit interrupted neural transmis sion which may be temporary
Patients who have recently taken analgesics for pain
Immature teeth
Not using conductive toothpaste
Batteries are dead in tester

Diag Math

ENDODONTICS
If an electric pulp tester is used to test a hyperemic tooth, the usual respons e will be
which of the following?

The
The
The
The

tooth will
tooth will
tooth will
tooth will

respond to less curre nt than normal

respond immediately to any current
respond to higher cu rrent than normal
not respond to any curren t

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DENTAL DECKS

 The tooth will respond to less current than normal

To some people, the electric pulp tester (EPT) only suggests whether the tooth is vital or non vit al. To others, the degree of response can be correlated to a different pulpal state of health.
Importa nt: The electric pulp tester alone is not sufficient to allow a diagnosis of the pulp and
must be combined with other tests.
Other test s that need to be done for a diagnosis:
o
Percussion - this test is a valuable diagnostic tool. It is performed by tapping the surface of
the tooth with an instrument (mirror handle). Once the infection has extended through the apical oramen into th P.D pace and apica tissue Rai ts localized wi the percussio ts t.
o
Palpation - isolation of an inflamed or swollen area. It is performed by manipulating the tissue or applying pressure on an area with the fingers or hand.
Radiograph - the most important diagnosis aid. X-rays can reveal deviations from the normal that cannot be detected by any other method.
o
Hot and cold tests - how tooth responds is a clue to the status of the pulp.
Response to EPT:
Hy remi oot - tooth will respond to less current than normal
o
A
ul i ' - tooth will respond to even less current than hyperemia
C
I "s - tooth will respond to higher current than normal
o
P.
ros ' - tooth will not respond to any current

Diag Math

ENDODONTICS

Which of the following are useful diagnostic aids that can be used to determine if a
tooth has a vertical crown-root fractur e?

Fiberoptic light for transillumination

Wedging the tooth in question and then taking an x-ray
Persistent periodontal defects in an otherwise healthy tooth
Having a patient bite forcefu lly on a bite stick
All of the above

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DENTAL DECKS

 All of the above

Impo rtant: Radiographs (without first wedging the tooth) rarely will show vertical fractures.
Notes :
1. A tooth with a vertical fracture through root structure has a poor prognosis.
2. Studies have indicated that most vertical root fractures are caused by too much
condensation force during obturation with gutta-percha.
Therapy for horizontal fractures of the root always involves considerable difficulty.
Root canal treatment is not indicated if the fracture sites remain in close proximity and
if the pulp retains its vitality. However, if clinical symptoms develop or the segments
appear to be separating according to the x-ray, some treatment is necessary.

Terms/Cond

ENDODONTICS
The chronic apical abscess (CAA) is gen erally:

Very painful
Asymptomatic

Mildly painful

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DENTAL DECKS

 Asymptomatic
The chron ic apical abscess (also called suppurative apical pe riodon titis) is sometimes so painless that
it may go undetected for years until revealed by an x-ray. It is a long-standing, low-grade infection of the
periapical bone with the root canal being the source of the infection. This condition may follow an acute
alveolar abscess or unsatisfactory root canal therapy. RadlograRh will ell a diffuse radiplucency and
hickening. The tooth may e lightly loose on tender t percussion. The chronic abscess may be
differentiated from cysts and granulomas by the fact that both cysts and granulomas have well-defined
radiolucencies associated with them. The treatment is conventional root canal treatment.

eo

Remember : 3
braakdo

00

to 500 0
bona calcium must be altered befor ra diographic idence of periapical
(this alteration takes place at the j unction between the cortical and cancellous bone).

The acute apical abscess (MA) is a localized collection of pus in the alveolar bone at the root apex following death of the pulp with extension of the infection into the periapical tissue. The first symptom may
be a slight tenderness of the tooth. This later develops into a severe throbbing pain to percussion with
swelling of the overlying mucosa. The tooth becomes more painful, elongated and loose. At times the
pain may decrease or disappear completely. The patient may appear weakened, irritable and present with
a fever. The diagnosis is based on the history, exam, and radiographs. The tooth will not respond to
the EPT or cold test but may respond to heat. Treatment of an acute alveolar abscess includes
establishing drainage and debriding the canal system of necrotic tissue which will relieve the
acute symptoms. This is followed at a later date by conventional root canal therapy.
Note: if the abscess ruptures through the periosteum into the salt tissue, the patient's symptoms will subside.

Terms/Cond

ENDODONTICS

In which of the following conditions are the pulps of the involved teeth likely to be non-

vital?

Apical scar
Cementoma
Radicular cyst
Traumatic bone cyst
Chronic dental abscess
. Globulomaxillary cyst
Chronic periapical granuloma

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DENTAL DECKS

 Apical scar
Radicular cyst

Chronic dental abscess

Chronic periapical granuloma

An apical scar is represented by a periapical granuloma. cyst. or abscess that heals with scar tissue.
Well-circumscribed radiolucency resembling a granuloma. Tooth is non -vita l.
A radicular cyst usually occurs in a preexisting granuloma. Seldom is painful. Radiolucency at apex
of non-vital tooth.
A chr onic dental abscess is often a result of a periapical granuloma. Radiolucent area at apex of
non-vit al too th . Fistula is often found leading from an abscess cavity. Once drainage is established,
the tooth stops being painful. A chronic periapical abscess is often the cause of a sinus tract in
the gingival tissues of children.
A chron ic periap ical granuloma is the most common sequelae of pulpitis. It is asymptomatic and
associated with a non-vital too th .
A cementoma occurs most frequently in the anterior region of the mandible. Starts as radiolucent lesion and then calcifies. The cementoma does not affect pulp vitality. Also called periapical
cemental dysplasia.
A traum atic bone cys t is not a true cyst since there is no epithelial lining. Found mostly in young
people, asymptomatic. Radiolucency which appears to scallop around the roots of teeth. Teeth are
usually vital.
A globulomaxillary cyst is found at the junction of the globulus and maxillary processes of the maxilla, between the lateral incisor and the cuspid roots. It is a developmental (fissural) cyst which arises
from cells in a fissural line of bone. Teeth are vital.

Terms/Cond

ENDODONTICS
The most widely used material for apexif ication procedures is:

Gutta-percha
Calcium hydroxide
Zinc oxide
Eugenol

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DENTAL DECKS

 Calcium hydroxide
Apex if ication is a technique whose goal is to induce further root development in a pulpless
tooth by stimulating the formation of a hard substance at the apex, so as to allow obturation of
the root canal space.
The technique consists of isolation of the field with a rubber dam , making an access cavity and
removing all pulpal tissue by the use of reamers and files. A premixed syringe of a calcium
hydroxide-methylcellulose paste (for example, a Pulpdent syringe) is injected into the canal
until it is filled to the cervical level. The paste must reach the apical portion of the caOSll1Q...tirn:
ulate the tissues to form a calcific barrier. A double seal of cement is made to close off the access
cavity. The patient is recalled after three months to see if apexification has taken place. If not, a
fresh supply of paste is placed. If apexification has occurred , convent ional root canal therapy is
instituted.
The action of calcium hydroxide in promoting formation of a hard substance at the apex is
best explained by the fact that calcium hydroxide creates an alkaline environment that promotes
~rd tissue deposition
Note: If a permanent tooth fractures and has a fully formed root and the pulp is exposed (large
exposure), the treatment of choice is complete root canal therapy. Apexification is not needed because the root is fully formed. If the exposure is small and the length of time is short (1/2
hour to 1 hour) , then a direct pulp cap with CaOH followed by a restoratioD is the treatment of
choice.
--

Terms/Cond

ENDODONTICS
The most common cause of acute osteomyelitis of the jaws is:

Unknown
Iatrogenic
Dental infection
Radiation

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DENTAL DECKS

 Denta l infect ion

It is not a particularly common disease. It is a serious sequela of periapical infection that often
results in a diffuse spread of infection throughout the medullary spaces, with subsequent necrosis of a variable amount of bone.
Acute or subacute osteo myelitis may involve either the maxilla or the mandible. In th e maxill a, the disease usually remains fairly we ll- localized to the area of initial infection. In the
mandible, bone involvement tends to be mo re diffuse and w idespread.
Clin icall y, the person afflicted with acute osteomyelitis is usually in rather severe pain and manifests an elevation of temperature with regional lymphadenopat hy. The teeth in the area of
involvement are loose and sore so that eating is difficult, if not impossible.
Radiographi cally, acu te osteomyelitis progresses rapidly and demonstrates little radiographic
evidence of its presence until the disease has developed for at least one to two weeks. At that
time, diffuse lytic changes in the bone begin to appear. A "moth-eaten" radiolucent appearance
is evident.
The general principles of treatment demand that drainage be established and maintained and
that the infection be treated with antibiotics to prevent further spread and complications.

Terms/Cond

ENDODONTICS
Which material listed below has historically been the retrofilling material of choice?

Compos ite
Zinc-free amalgam
Gutta-percha
Methyl methacrylate

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DENTAL DECKS

Zinc-free amalgam

"The best argument for the use of zinc-free amalgam is the lack of expansion found when contaminated with moisture.
A retrofilling (also called a reverse filling or retrograde amalgam filling) is placed to seal the apical
portion of the root canal. This procedure is used wh en an ap icoe ctom y alone will not y ield a good
result. Whenever there is any chance whatsoever that an apical seal may be faulty, a reverse filling
material must be pl aced. For example, if the root canal appears calcified, it would be impossible to
obturate most of the canal and get a seal. If just the root apex were cut off (apicoectomy), the incompletely filled canal might act as a source of reinfection. To prevent this after the root tip is resected, the
foramen is found, enlarged, and filled with a zinc-free amalgam to create a seal.

An apicoectomy (root resection, root amputation) is a procedure where the buccal tissue is flapped
back, the buccal bone about the apex is removed, th e root apex is remo ved , and the area is curetted out. Indication s for apicoe ctomy: 1) A rever se fil ling needs to be placed. 2) It Is necessary to
gain access to an area of pathosis. 3) The poorly filled apical portion of the root is to be removed to
the level of canal obliteration. Note: A retrograde amalgam filling should always be done after an apicoectomy. Teeth that have posts in them and need to be retreated are the most common reason for
an apicoecto my and a retrograde filling.
Remember: Periapical curettage is the same procedure as an apicoectomy (as far as flap and
removal of buccal bone), but witho ut removing the root apex. Removal and examination of the diseased tissue and determination of the extent of the lesion are the objectives of apical curettage.

Terms/Cond

ENDODONTICS
Which condition listed below is characterized by pain that is spontaneous and has
periods of cessation (intermittent in nature)?
Reversible pulpitis
Irreversible pulpitis

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DENTAL DECKS

 Irreversible pulpitis
The severity of the clinical symptoms will vary as the inflammatory response increases. Pain will
vary from a mild and readily tolerated discomfort to a severe, throbbing and excruciating pain.
The pain is spontaneous and is intermittent In nature. The pain lingers after the removal of
the irritant. The pain is usually not readily localized by the patient but is diffuse in character.
Lying down or bending over intensifies the pain of irreversible pulpitis because the overall
increase in cephalic blood pressure is relayed to the confined pulp tissue. The tooth may be tender to percussion, heat may intensify the pain response while cold may relieve it (in advanced
stages). Usually they both will cause seve re and lasting pain. The radiographs will usually disclose ~riap lcal pathologY.. Treatment is root canal therapy.
Reversible pul pitis (hyperemia): The pain associated with hyperemia does not occur spontaneously. It requires an external irritant to evoke a painful response (i.e., cold, sweets). The
pains are sha rp and of brief duration, ceas ing whe n the irri tant Is removed. Radiographs
appear normal (may show deep caries or cavity preparation). The tooth is usually percussion
negative. In thermal tests, the pulp responds more readily to cold stimuli than to hot (the
response leaves shortly after removal of stimulus). Treatment usually is a sedative filling
or new restoration with a base .
Note: Pulpal Inflammation (hyperemia) is most commonly caused by bacteria.

Terms/Cond

ENDODONTICS
Which condition below is an apical lesion that develops as an acute exacerbation of a
chronic apical abscess (also called a suppurative apical periodontitis)?

Cyst
Phoenix abscess
Granuloma
None of the above

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 Phoen ix abscess
It is also known as a recr udescent abscess. It develops as the granulomatous zone becomes
contaminated or infected by elements from the root canal. Diagnosis is based on the acute symptoms (pain to percussion) plus radiographic examination, which reveals a large periapical radiolucency.
A granuloma is defined as a growth of granulomatous tissue continuous with the periodontal ligament resulting from pulpal death with diffusion of toxic products into the periapical area. In most
cases a granuloma is symptomless. Radiographically, one sees a well-defined area of rarefaction with some irregularities, while clinically the tooth is not sensitive. A massive Invasion
of pulpal contaminan ts will result In the formation of an acute abscess (Phoenix abscess) .
A cyst is an inflammatory response of the periapex, which develops from preexisting granulomatous tissue (granuloma ). It is characterized by a central, fluid-filled, epithelium-lined
cavity , surrounded by granulomatous tissue and peripheral fibrous encapsulation. It is often
associated with a chronically infected tooth. The tooth may be mobile. On radiographs, one will
see a well -defined area of rarefaction (radiolucency), which is limited by a continuous
radiopaque, sclerotic border of bone. It is usually asymptomatic .
Remember: A granuloma or a cyst can only be differentially diagnosed by histological
examination .

Terms/Cond

ENDODONTICS
The earliest and most common symptom of an acute pulpltls is:

A dull throbbing sensation

Pain upon chewing
Thermal sensitivity
Discomfort, particularly on palpation

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DENTAL DECKS

 Thermal sensitivity
As caries enters the dentin it begins with a lateral spread at the DEJ. This is due to
the increased organic content and the involvement of many dentinal tubules. The
Tomes fibers react, causing fatty degeneration, then later decalcification (sclerosis). As
caries progresses, destruction of dentin is followed by bacterial invasion of the tubules
and complete destruction of dentin. Once odontoblasts are involved, pulpal
changes occur. Initially there is vascular dilation and local edema. The earliest common symptom of this edema (acute pulpitis) is thermal sensitivity (usually increased
and persistent pain on application of cold).
Remember: The only reliable clinical evidence that secondary dentin has formed is
decreased tooth sensitivity (usually seen a few weeks after placement of a filling).
When dentinal tubules become completely calcified, the dentin is insensitive.

Terms/Cond

ENDODONTICS
Which condition listed below is the result of a pulpal infection that extends through
the apical foramen to the periapical tissues?
Periodontal abscess
Gingival abscess
Periapical abscess

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DENTAL DECKS

 Periapical abscess
Of all the dental abscesses, the periapical is the most common type. It is a localized collection of pus in the alveolar bone at the root apex following death of the pulp with extension of the
infection into the periapical tissue. The first symptom may be a slight tenderness of the tooth.
This later develops into severe throbbing pain (acute abscess) with swelling of the overlying
mucosa. The tooth w ill not res pond to the EPT or cold test but may respond to heat.
Emergency treatment includes establishing drainage (ideally through the canal) and prescribing
antibiotics and analgesics. This will relieve the acute symptoms followed by conventional
endodontic therapy at a later date. For dodo tic iote ti s tha 0 not respon 1 Renici in,
c1iodamycin i of en recomm nded. It produce igb bone e)/els an 's ettacH e gains
aerobic bacteria bu must be used with caution because of th pote ti I f ~ s udo e branous coli-

tis.
The periodontal abscess is an acute abscess that develops through the periodontal pocket.
Alveolar bone loss, Rocket formation and lJ,eriodontal pathologic conditions are suggestive of the
periodontal abscess: The tooth will usually be palpation and percussion positive. It will respond
the electric pulp tester (unlike the periapical abscess ). Bacteria associated with this abscess
include gram-negative rods such as Capnocytophaga species. Vibrio-corroding organisms and
Fusobacterium species.

1<\0

The gingival abscess is a relative rarity that occurs when the bacteria invade through some
break in the gingival surface. Such abrasions may be the result of mastication, oral hygiene procedures or dental treatment.

Misc.

ENDODONTICS
All of the following cells would be found in a hyperemic pulp after an exposure during
caries removal, except

Plasma cells
Lymphocytes
Goblet cells
Mast cells
Neutrophils (PMN's)

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DENTAL DECKS

 Goblet cells

Plasma cells, lymphocytes, mast cells and neutrophils (PMN 's) are all chronic
inflammatory cells.
The increased blood volume associated with hyperemia ("reversible pulpitis") also
increases the intrapulpal pressure in the involved area, which may be limited to a pulp
horn or include the entire coronal chamber. Histologically, the tissue is likely to show
signs of acute inflammation near the site of exposure and a band of chronic inflammatory cells (plasma cells, Iympocytes , PMN 's and mast cells) between the acute inflammation and the underlying normal pulp.
Remember: Most clinicians agree that carious exposure of a permanent tooth generally requires root canal treatment. Bacterial invasion of the pulp has already taken
place. An exception would be a carious exposure in a tooth with an immature apex.
Performing a partial pulpotomy and pulp capping may have a higher chance of success.

Misc.

ENDODONTICS
In most cases where there is endodontic-periodontic therapy indicated on a tooth,
which is performed first?
Endodontic therapy
Periodontic therapy

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DENTAL DECKS

 Endodontic therapy
Combined endodontic-periodontal therapy is widely used because the anatomic
and clinical connections between the pulp and periodontal structures are close and
numerous. In most cases of this nature, endodontic procedures are performed first
and,when necessary, are followed by periodontal measures.
In these cases , the value of precise pocket probing and correct appraisal of the vitality of the pulp is crucial. In some doubtful cases, the better part of wisdom is to wait
until after the completion of the root canal therapy to see whether spontaneous resolution (pocket closure and osseous fill-in) will occur before surgical periodontal procedures are begun.
Periodontal therapy should be initiated first only in the case of a primary periodontal lesion with subsequent secondary endodontic involvement.
Remember: A perioendo abscess is a combined lesion. The lesion usually demonstrates radiographic involvement of the periodontium and apex of the involved tooth.
There is significant probing depths, percussion sensitivity, and pulpal sensitivity.
Note: A common clinical finding of a periodontal problem Is pain to lateral percussion on a tooth with a wide sulcular pocket.

Misc.

ENDODONTICS
Which of the following are the two basic reasons for the use of a post when restoring
an endodontically treated tooth?

To strengthen the root

To retain the restoration
To protect the remaining tooth structure
To help in the fabrication of a crown

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DENTAL DECKS

 To retain the restoration

To protect the remaining tooth structure
Important : Posts do not strengthen the root
Options available when restoring endodontically treated posterior teeth:
Resto ration of occlusal opening only - in rare instances the access opening and caries
destruction do not encroach on the cusps and marginal ridges. These teeth may be restored with
an occlusal amalgam; however, a cuspal coverage restoration would provide protection from
fracture.
Onlay resto ration - in most cases it is imperative that root canal treated teeth be protected
from fracture by a cusp-coverage type of restoration. The minimum (most conservative) preparation should be for an onlay covering the cusps and marginal ridges.
Crown - a full-coverage crown is preferred when the remaining coronal tooth structure does not
afford sufficient tooth structure for an onlay.
Crown with post and core - to reinforce the treated tooth and provide suitable coronal tooth structure for an optimum crown preparation, the use of a post and core is often indicated. Be very careful when placing posts. Perforations and vertical root fractures can occur.
Notes:
1. If you are performing a pulp chamber-retained amalgam. you need to place amalgam 3mm into
each canal for retention.
2. Endodontically treated posterior teeth are more prone to fracture than untreated posterior teeth
due mainly to the destruction of the coronal tooth structure (they have reduced structural integrity).

Misc.

ENDODONTICS
Which of the following are contraindications to endodontic therapy?

A non-restorable tooth
A tooth with insuffi ci ent periodontal support
A tooth with a vertical root fracture
All of the above

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DENTAL DECKS

 All of the above

Other contraindications include:
A non-strategic tooth (a tooth not in occlusion)
A tooth with massive internal or external resorption
A tooth that has a canal unsuitable for instrumentation or for surgery (i.e., broken instruments, dentinal sclerosis, sharp dilacera tions, etc.)
A medical condition such as hemoph ilia is not a contraind ication to conventional
endodontic therapy. However, it is strong ly recommended that a dentist obtain clearance from the patient's physic ian prior to treatment.
Any teeth not contraind icated are excel lent candidates for successful endodontic
therapy.

Note: Example of a special case : A previously traumati zed tooth may show complete
obliteration of the pulp chamber and canal. The periodontal ligament may appear normal. The patient will be asymptomatic and the tooth will not respond to pulp vitality testing. The treatment of choice is to observe as long as the tooth remains asymptomatic and no periapical changes are evident.

ENDODONTICS

Misc.

An apicoectomy is a resection:

Of
Of
Of
Of

the
the
the
the

most coronal portion of the root

coronal portion of the pulp horn
most apical portion of the root
entire pulp horn

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DENTAL DECKS

 Of the most apical portion of the root

" ' An apicoectomy is best accomp lished by obliquely resecting the most apical
portion of the involved root.
If a tooth has had previous endodontic therapy and becomes reinfected , it is usually best to try and retreat it conventionally (remove filling material, debride the canals
and refill). However , if the tooth has been restored with a post, core and crown then
apical curettage, apicoectomy and a retrofill should be performed.
Indications for apicoectomy:
o
A reverse filling needs to be placed.
o
It is necessary to gain access to an area of pathosis.
o
The poorly filled apical portion of the root is to be removed to the level of canal obliteration.

Misc.

ENDODONTICS
When symptoms and clinical tests show the presence of pulpal pathosis in a posterior
tooth and the radiograph shows no decay or restoration in any proximity to the pulp, this
is virtually path ognomon ic of :

Condensing osteitis
A vertical fracture of the tooth
Periodontal abscess
Secondary occlusal trauma

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DENTAL DECKS

 A vertical fracture of the tooth

Radiographic examination seldom reveals the fracture because the crack is usually parallel to
the x-ray film. One of the most puzzling and frustrating dental conditions involving the possible
need for endodontic treatment is the cracked tooth syndrome. Symptoms from this condition usually are characterized by a sharp but brief pain occurring unexpectedly only when
the patient is chewing . Having a patient bite forcefully on a bite stick and noticing the cusps that
occlude when the pain occurs will aid in the location of the offending tooth.
Vertical fractures through root structure, however, have an almost hopeless prognosis . If the
fractured segment can be removed and gingivoplasty and alveoloplasty performed, treatment
can be successful. However, unrealistic or overambitious case selection leads to a high degree
of failure.
When an anterior tooth fractures, it generally occurs in a more horizontal plane and may show
up on the x-ray. The cause is usually accidental trauma such as a blow to the jaw or teeth. If the
fracture line is not too far down the root of the tooth, it may be able to be saved with a root canal
and a crown.
Inlays have been shown to be a cause of fractures. If a patient complains of pain on mastication since the placement of an inlay, suspect a fractured cusp (using a bite stick will help determine which cusp may be fractured).

Misc.

ENDODONTICS
Which of the following flap designs is preferred when performing endodontic surgery
in the maxillary anterior region?

Vertical (single or double) flap

Scalloped (Leubke-Ochsenbein) flap
Curved (semilunar flap)
Palatal flap

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DENTAL DECKS

 Scalloped (Luebke.-Ochsenbein) flap

This flap is a modified double vertical flap. It has the advantage of being able to be
sutured into the dense attached gingiva, thus causing less scarring.
Verti cal fl aps
Single - allows for visualization of the complete length of the root, the option of performing periodontal surgery, incisions to be made over sound bone, and retaining an
excellent blood supply.
Double - allows for greater visualization and access to the surgical site than does
the single vertical flap. However, there is increased hemorrhage and flap shrinkage.
The curved (semilunar) flap was at one time the most commonly used flap, however,
it is not used much today due to excessive shrinkage and the formation of an
obv ious, uns ightly collagen scar.
The palatal flap is used around the gingival margins of maxillary bicuspids and molars
to expose the palatal roots.

Replant

ENDODONTICS
Which of the following appears to be the ideal storage media for a tooth that has been
traumatically avulsed and will be out of its socke t for more than an hour?

Soda
Sodium hypochlorite
Milk
Hydroge n peroxide

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DENTAL DECKS

 Milk
Five fact ors that are critical to the management of traumatic avulsion injuries to teeth:
1. Time : The time interval from injury to replacement of the tooth is a rnalor factor in the maintenance of ligament viability and subsequent root resorption. Teeth replanted within 30 minutes have been reported to exhibit very little resorption, whereas most of the teeth replanted
after 2 hours show a lot of external root resorption (which is the main cause of failure of
replanted teeth).
2. Storage media : If the tooth cannot be immediately replanted, proper storage of the tooth
can favorably influence periodontal ligament viability. The preferred storage media
seems to be saliva, physiologic saline or milk. The root that is allowed to dry will show the
maximum amount of resorption. If the footH will e 0 t 0 tfi e soc et for mor t an an our,
milk appear to be th Ideal storage mellia.
3. Tooth socket: Should not be damaged by curettage or forceful replantation
4. Splint stabilization: A splint that allows the physiologic movement is placed for a maximum
of 2 weeks. This time period allows for the initial reattachment of the periodontal ligament
fibers.
5. Root surface: Should not be scraped, dried or manipulated with caustic chemicals.
Note: The above information changes when a tooth has been out of the mouth for more
than 2 hours (mainly the treatment of the tooth socket and root surfaces as well as the time for
splint stabilization).

Replant

ENDODONTICS
Which of the following factors are important to the success of intentional replantat ion?

A short extraoral time period (to maintain the viability of the periodontal ligament)
A healthy periodontium
A skillful extraction technique
All of the above

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DENTAL DECKS

 All of the above

Intentional replantation implies that a tooth requiring endodontic therapy is purposely removed from its socket, some type of canal or apical preparation and/or filling is performed and the tooth is returned to its original socket.
Indications for intentional replantation (also called replant surgery):
When routine endodontic therapy of a tooth is impractical or impossible
When an obstruction of a canal is present, such as a broken instrument or a calcification, and periapical surgery is impractical (a lower molar with the mandibular
canal in close proximity).
When perforating internal or external resorption is present , yet surgery is
impractical
When a previous treatment has failed but nonsurgical treatment or surgery is
impractical.
Note: Intentional replantation should be considered when it is the only alternative
to extraction.

Replant

ENDODONTICS
Primary avulsed teeth:

Should be cleaned very well and replanted if within five hours of the injury
Are usually not replanted
Should be replanted immediately
Should have a pulpotomy performed on them prior to replantation

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DENTAL DECKS

 Are usually not replanted

"Most clinicians advise against replantation of primary avulsed teeth unless ideal conditions exist to prevent trauma to the permanent succedaneous tooth.
Proper management of an avulsed permanent tooth that has been rep lanted w ith in two hours of the
acci dent:
Ten days to two weeks after replantation, the root canal is prepared (cleaned and shaped) and a calcium hydr oxi de pas te is placed into the canals
This paste is rep laced every three months for one year
If after one year , it appears that resorption has reversed or stopped, a permanent gutta-percha filling can
be placed
Important: If a tooth Is out of the mouth for more than two hours :
Anky losis and external root resorption will probably result within two years. Ankylosis resulting from
replacement would give a better prognosis than external resorption, which would lead to failure.
Root canal therapy is performed in its entirety pr ior to replantati on.
The tooth is soaked In a 2.4% fluoride so lution acidulated at pH 5.5 for 20 minutes or more. (The fluoride will slow the resorptive p rocess .)
Gentl y curette blood clot out of the alveolar socket and irrigate with saline.
Rinse tooth with saline, replant into socket and splint for 4-6 weeks.
Note: Resorption is the most frequent sequela to replantation. Three different types of resorption have been identified: surface, inflammatory and replacement (ankylotic resorption). Replacement resorption refers to resorption
of the root surface and its substitution by bone, resulting In ankylosis.

Resorp

ENDODONTICS
Which of the following is generally believed to be the cause of internal resorption of
a tooth?

Orthodontic treatment
Tooth fracture
The presence of a chronic pulpitis
Periodontal disease

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DENTAL DECKS

 The presence of a chronic pulpitis

>This condition is frequently precipitated by traumatic injury to the tooth. Undifferentiated
reserve connective tissue cells of the pulp are activated to form dentinoclasts, which resorb the
tooth structure in contact with the pulp.
Internal (inflammatory) resorption is usually asymptomatic and is discovered on routine radiographic evaluation. The anatomic configuration of the root canal is altered and increases in size
with internal resorption. It will appear as an irregular radiolucency anywhere along the canal
space. The tooth involved may respond to pulp vitality tests.

When internal resorption is detected, a pulpectomy should be performed. Once the pulp tissue
responsible is removed, all resorption ceases. To "wait and see" may result in sufficient destruction of the tooth to create a perforation of the root.

Typical radiographic appearance of internal resorption

Resorp

ENDODONTICS
Which type of external root resorption listed below may occur from combined injury
to the POL and cementum complicated by bacteria from an infected root canal space?
Surface resorption
Inflammatory resorption
Replacement resorption

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DENTAL DECKS

 Inflammatory resorption
80 I-shaped areas f resorption involving cementum and dentin characterize external inflammatory root resorption. This type of resorption is rapidly progressive and ill
continue i treatment is not institute . Sif.1ee bot
eereti
I
d th pr~sen e of
bacteria are necessary components
ato resorption t
R 0 S ca be
nal tr atme . The tooth is opened and the canal is
arrested by immediate roo
cleaned and shaped. .A calcium hydroxide paste is placed in the canal. This is
replaced every three months for one year. If after one year, it appears that the resorption has stopped, a permanent root canal filling (gutta-percha) can be placed. A calcium hydroxide-based root canal sealer Is strongly recommended.

Surface resorption is caused by acute injury to the periodontal ligament and root surface. If injury is not repeated, healing takes place with new cementum and PDL.
Replacement resorption refers to resorption of the root surface and its substitution by
bone, resulting in ankylosis. Remember: This is often seen in unsuccessful replant
cases.

Pulp

ENDODONTICS
Anatomically, the dental pulp is divided into two portions, the coronal and radicular
pulp. Which portion is located in the pulp chamber and pulp horns?
Coronal pulp
Radicular pulp

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DENTAL DECKS

 Coronal pulp
Portions of pulp
1. Coronal pulp - located in the pulp chamber and pulp horns (crown portion of tooth).
2. Radicular pulp - located in the pulp canals (root portion of tooth)..
Accessory canals extend from the pulp canals through the root dentin to the PDL. An abrupt
change in the radi olu cent appearance of a canal in the middle third of the root is most likely
due to a bifurcation of the cana l.
The central zone or pu lp proper contains large nerves and blood vessels. This area is lined
peripherally by a specialized odontogenic area which has three layers (from innermost to outermost):
1. Cell-rich zone which contains fibroblasts.
2. Cell-free zone or zone of Weil which is rich in both capillaries and nerve networks. The
nerve plexus of Rashkow is located in this zone.
3. Odontoblastic layer which contains odontoblasts and lies next to the predentin and mature
dentin.
Cells found in th e denta l pulp include fibroblasts (the principal cell), odontoblasts, histiocytes
(macrophages), and lymphocytes.
Note: In a diseased pulp, the following cells are present: PMN's , plasma cells, basophils,
eosinophils, lymphocytes and mast cells (contain histamin e and heparin).

Pulp

ENDODONTICS
Which of the following is the main function of the dental pulp?

Nutritive
Sensory
Protective
Formative

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DENTAL DECKS

 Formative

' --The primary function of the dental pulp is to form dentin (by the odontoblasts)
Other functions include:
Nutritive - the pulp keeps the organic components of the surrounding mineralized
tissue supplied with moisture and nutrients .
Sensory - extremes in temperature , pressure , or trauma to the dentin or pulp are
perceived as pain.
Protective - the formation of reparative or secondary dentin (by the odontoblasts).
Note: The primary response of the pulp to tissue destruction is inflammation.
Composition of the pulp:
Loose connective tissue (collagen and reticulin fibers)
Fibroblasts (principal cell), odontob lasts, reserve cells and undifferentiated mesenchymal cells (histiocytes and macrophages)
Blood vessels (arteries and veins),nerves , and a lymphatic system
Ground substance

Pulp

ENDODONTICS
Which two of the following decrease with age in the dental pulp?

Number of collagen fibers

Number of reticulin fibers
The size of the pulp
Calcifications within the pulp

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DENTAL DECKS

 Number of reticulin fibers

The size of the pulp
As the pulp ages there is a decrease in reticulin fibers (the pulp becomes less cellular and more fibrous). The size of the pulp also decreases because of the continued deposition of dentin.
~\ 612o LJ S Put-(='

As the pulp ages there is an increase in the number of collagen fibers and calcifications within the pulp (called denticles or pulp stones).
The pulp contains both myelinated and unmyelinated nerve fibers. They are afferent and sympathetic. The myelinated fibers are sensory and the unmyelinated fibers
are motor (they playa role in the regulation of the lumen size of the blood vessels).
Note: Proprioceptors (which respond to stimuli regarding movement) are not found
in the pulp.
The only type of nerve ending found in the pulp is the free nerve ending, which is a
specific receptor for pain. Regardless of the source of stimulation (heat, cold, pressure), the only response will be pain.
Note: Pulp stones are associated with chronic pulpal disease (from advanced carious
lesions or large restorations).

Inst/Mat/Tech

ENDODONTICS
Which of the following methods for using endodontic instruments involves no rotation
of the instrument whatsoever and relies on hard tissue removal on the outstroke
only?

Filing
Reaming
Circumferential filing
All of the above

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DENTAL DECKS

 Filing
Filing is a push-pull action with emphasis on the withdrawal stroke. Its efficiency is
greater with files than with reamers for removing dentin because of the greater number of flutes in contact with the canal walls during the rasping motion of removing the
instrument. The appearance of the canal is irregular and for this reason a canal prepared with this action must be filled with gutta-percha in a condensation procedure.
Reaming is defined as repeated clockwise rotation of the instrument, particularly
during insertion. The appearance of the canal is approximately round (this method is
recommended if using a silver cone to fill canal). Reamers are usually most efficient for
this function.
Circumferential filing is a push-pull action with emphasis on scraping the canal
walls to create a smooth, tapered preparation. It is a method of filing whereby the
instrument is moved first towards the buccal side of the canal, then reinserted and
moved slightly mesially. This is done all the way around the tooth until all the dentin
walls have been planed. This technique enhances preparation when a flaring
method is used.

Inst/MatlTech

ENDODONTICS
A reaming action produces a canal that is relatively:

Square in shape
Irregular in shape
Round in shape
Triangular in shape

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DENTAL DECKS

 Round In shape
Studies have shown that the action of using the instrument, rather than the instrument
used, determines the general shape of the canal preparation. Therefore, a reaming
action produces a canal that is relatively round in shape while a filing action produces a canal that is irregular in shape.
Important: A canal should be instrumented and shaped so that it has a continuously
tapering funnel shape. The widest diameter would be at the canal opening and the
narrowest at the d nti oeem
I j cti n (0.5 to .0 mm from the radiograpbi(;
apex). ij:hi i here II ee h sho Id b fil d to and filled to (ideally).

Inst/MatlTech

ENDODONTICS
When fitting the master cone in a properly prepared canal, the cone must :

Be 2 mm from the apex

Be within 1 mm of the working length and have a slight resistance to dislodgement
Fit to the exact apex
Be at least 1 mm past the apex

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DENTAL DECKS

 Be within 1 mm of the working length and have a slight resistance to dislodgement

This slight resistance to dislodgement is referred to as "tugback". The cone should also have
a definite apical seat (it should not be able to be pushed further apically).
If the preparation is properly flared , fitting the master cone is not a time-consuming procedure. A gutta-percha cone the same size as the file used last during preparation (MAF) is selected and placed as far as possible into the canal, but not beyond the working length. Once satisfactory tugback and apical positioning appear to be obtained, a radiograph is taken to verify cone
positioning. If an accurate determination and careful enlargement have been performed, the xray will show that the master cone reaches the most apical position of the preparation or
extends to a point just short of that (1 mm). When the cone is slightly short, the pressure of
condensation plus the lubricating action of the sealer will be sufficient to produce complete seating of the cone.
If the cone is more than 1 mm from the radiographic apex, discard the cone and fit a smaller one
or instrument more in the apical third.
Remember: The main reason for recapitulation (using your MAF after each increase in file size)
during instrumentation of the canal is to clean the apical segment of the canal of any dentin
filings that were not removed by irrigation.

Inst/MatlTech

ENDODONTICS
The primary function of root canal sealers is:

To act as a lubricant . facilitating placemen t of the gutta-percha

To form a bond between the filling material and the dentin walls
To fill in the discrepancies between the filling material and the dentin walls
To exert antibacterial activity

Copy righ t 2001 - DENTAL DECKS

 To fill in discrepancies between the filling material and the dentin walls

Other purposes or functions of a root canal sealer include :

To act as a lubricant , facilitating placement of the gutta-percha
To form a bond between the filling material and the dentin walls
To exert antibacterial activity (some exert more than others). This activity is the
highest in the period of time immediately after its placement
Most root canal sealers are some type of zinc oxide-eugenol cement and are capable of producing a seal while being well-tolerated by periapical tissues.
All sealers display some degree of radiopacity (caused by metallic salts in the sealer) ;
therefore their presence can be demonstrated on a radiograph. This is an important
property, since it may disclose the presence of accessory canals. resorptive areas, root
fractures. and the shape of the apical foramen and other structures of interest.
Note: After filling a tooth with gutta-percha, if you see a horizontal line of material
(gutta-percha or sealer) extending both mesially and distally from the canal to the
periodontal ligament space, this is indicative of a root fracture.

Inst/Mat/Tech

ENDODONTICS
Which of the following intracanal instruments is designed for the removal of pulp tissue, cotton pellet absorbent points and other soft materials, but not for canal enlargement?

Files
Reamers
Broaches
None of the above

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DENTAL DECKS

 Broaches
The barbs are notched out of the instrument shaft and represent a weakened point. If the
broach is not used with the utmost of care or if it is forced apically, the barbs will be bent
and will engage the walls, making removal difficult.
K-type instruments:
File s are the most useful instruments in endodontics for the removal of hard tissue in canal
enlargement. They are manufactured by twisting a blank, which is a square rod, producing a
series of cutting flutes. The action used for placing this type of file into a canal should resemble a clockwise-counterclockwise motion with pressure directed apically (can be a filing or
reaming action). Note: These files are the strongest of all files and cut the least aggressively. A modification to this type of file is the K-f1ex file.
Reamers are manufactured in a manner similar to files, only they have fewer flutes. They are
used in canal preparations to shave dentin with a reaming action only. They remove intracanal debris with clockwise reaming action. They are also used to place materials into the apical portion of the canal by using a countercl ockwise rotation.

H-type instruments:
Hedstrom files are manufactured by using a sharp, rotating cutter to gauge triangular segments out of a round blank shaft. This produces a very sharp edge and therefore an effective
cutting instrument. If used carefully, with a filing action only, it will successfully plane the
dentin walls much faster than K-type files or reamers. A modification of this file is the Sfile.
Note: All of the above are made of stainless steel.

InstiMatITech

ENDODONTICS
Which two of the following situations offer better success for pulp capping?

Accidental exposure of the pulp

Pulp of a middle-aged person
Carious exposure of the pulp
Pulp of a young child

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DENTAL DECKS

 Accidental exposure of the pulp

Pulp of a young child
Pulp capping is the placing of a sedative and antiseptic dressing on an exposed healt!}}' pulp
in order to allow it to recover and maintain normal function and vitality. The dressing most commonly used is CaOH2 (Oyca~ . Pulp capping is overused in dentistry today. In reality it has only
very few indications for its use. Young pulps are more vascularized and, therefore, more
amenable to repair. Pulp cappings are more successful if the exposure was accidental
(trauma or with a dental bur) as opposed to carious. In addition, the exposure should only be
pinpoint to expect success. Repair is accomplished by the formation of a dentin bridge at the
site of exposure. Even a small carious exposure should have root canal therapy for the best
long-term prognosis.
A tooth may stay asymptomatic for several weeks after pulpcapping has been performed.
However, this may be only temporary. Unfortunately, if pulp capping fails and the tooth
becomes symptomatic, it may be difficult, if not impossible, to treat with routine endodontics
because of the severe calcifications in the root canal. Perforations may occur during attempts to
follow the obliterated canal to gain patency to the apex. Perforations into furcations of multi-rooted teeth have the poorest prognosis.
Traumatic blows to teeth are also a cause for calcification of the pulp space sometimes to a
point where locating the canal is very difficult. With primary teeth, trauma may cause calcifications in the pulp chamber, which in turn cause a yellowish discoloration of the tooth.

Inst/Mat/Tech

ENDODONTICS
Which of the following are chelating agents?

EDTA
RC-Prep

EDTAC
All of the above

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DENTAL DECKS

 All of the above

"'Important: These agents all contain ethylene diam ine tetra-acetic acid as the active ingredient.
Chelat ing agents are used to aid and simplify preparation for very sclerotic canals after the apex
has already been reached with a fine instrument. These agents act on calcified tissues only
and have little effect on periapical tissue. Their action is to substitute sodium ions, which combine with the dentin to give soluble salts for the calcium ions that are bound in less soluble combination. The edges of the canal are thus softer, and canal enlargement is facilitated.
EDTA will remain active in the canal for 5 days if not inactivated. For this reason, at the completion of the appointment, the canal must be irrigated with a sodium hypochlorite (NaOe L)containing solution.
EDTAC is EDTA with the addition of Cetavlon, a quaternary ammonium compound. It has
greater antimicrobial action than EDTA. However, it has greater inflammatory potential to tissue
as well. The inactivator for EDTAC Is NaOCL.

@C.~R~mbines the functions of EDTA

Ius urea
Ion. The foam solution has a natural efferve
NaDeL to aid in the removal of debrig:

~nga

rovide both chelation and

irn ation with

Inst/MatlTech

ENDODONTICS

No endodontic cases lend themselves to successful treatment without some degree

of:

Irrigation
Debridement
Obturation
Medication

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DENTAL DECKS

 Debridement
Debridement is defined as the removal of foreign material and contaminated or devitalized tissue from or adjacent to a traumatic infected lesion until surrounded healthy tissue is exposed.
Chemomechanical debridement of the root canal system is the most crucial aspect of root
canal treatment.
Complete debridement of the cana l is the most effective means to reduce root canal microorganisms. It can be carried out in various ways as the case demands , and may include instrumentation of the canal, placement of medicaments and irrigants andlor surgery.
Remember:
The most common cause of root canal failure is incompletely and inadequately disinfected root canal systems.
The second most common cauOse of failures of root canals is leakage from a poorly filled
canal. This is common even after apical curettage. Example: Root canal treatment performed
on a tooth with apical curettage of a lesion that was found to be a cyst. Three years later the
lesion is even bigger than it was before. The most likely cause of this failure is leakage from
a poorly filled canal .
When a canal is properly prepared, any of the accepted methods of filling will almost certainly produce a successful result (as long as canal is completely filled).

InstlMatlTech

ENDODONTICS

Gutta-percha is freely soluble in which two solvents listed below?

Alcohol
Chloroform
Xylol
Eugenol

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DENTAL DECKS

 Chloroform (most effective)

Xylol
It is slightly soluble in eucalyptol. Gutta-percha is pliable at room temperature and
becomes plastic at 60 C (140 F).
The simplest method of removing gutta-percha from a root canal is by softening the
gutta-percha with a solvent , such as chloroform, xylol, or euca lyptol. Once the orifice of
the canal has been uncovered , the access cavity is filled with solvent. After 1 to 2 minutes, the solvent in the pulp chamber will dissolve the gutta-percha to the extent that a
small file will easily negotiate the canal. Be careful not to use any solvent at or near
the apical foramen. Passage of these chemicals past the end of the root may result in
severe postoperative discomfort.
Notes:
1. Gutta-percha points may be disinfected by placing them in 5.25% NaOCl (sodium hypochlorite) solution for one minute .
2. Endodontic files should be immersed in a bead sterilizer at 220 C (428 F) for
15 seconds for sterilization.

Inst/MatlTech

ENDODONTICS
Which of the following are indi cations for performing a pulpotomy?

Treatment of pulp exposures in deciduous teeth

Treatment of pulp exposures in permanent teeth with undeveloped root apices
An alternative to extraction when endodontic therapy is unavailabl e
Temporary emergency treatment for an acute pulpitis
All of the above

Copyright 2001 -

DENTAL DECKS

 All of the above

A pulpotomy is the removal of a portion of the pulp. Usually the injured or infected
coronal pulp is removed in an attempt to preserve the health of the radicular pulp. Note:
If there is a radiolucency, draining sinus tract present, internal resorption, or pain
in percussion, a pulpectomy is the treatment of choice.
Unfortunately, pUlpotomy procedures performed in permanent teeth often result in
having their entire root canal systems calcified. This is a result of degenerative
changes. The canals of these teeth may be inoperable when the presence of periapical pathosis makes root canal therapy necessary. For this reason, a pulpotomy is
regarded as a temporary treatment.
Important: The success of a pulpotomy for a primary tooth is dependent upon vital
pulp tissue in the root.

Inst/MatlTech

ENDODONTICS

Which of the following irrigants is the most widely used in endodontics?

Sodium hypochlorite
Urea peroxide
Hydrogen peroxide
Saline

Copyright 2001 -

DENTAL DECKS

 Sodium hypochlorite (NaGe L)

It is the most widely used irrigant and has effectively aided canal preparation for many years.
A .25% soltitian p vides e cellen germicidal
Iven action, ut is dilute enough to cause
only mild irritation when contacting periapical tissue. NaOCl is a good tissue solvent as well as
having some antimicrobial effect. It also acts as a lubricant for root canal instrumentation. Note:
It is toxic to vital tissue; always use rubber dam.
Hydrogen peroxide 30 soJution)a is also widely used in endodontics with two modes of action.
The bubbling of the solution when in contact with tissue and certain chemicals physically foams
debris from the canal (effervescent effect). In addition, the libecatio f oxyge(l will destroy strictIy anaerobic icroorganis . The solve t action of hydrogen peroxide is much les b that of
NaeC . However, many clinicians use the solutions alternately during treatment.
[
r ide is available in an anhydrous glycerol base, as y,.
to prevent decomposition and is a useful irrigant. It is better tolerated by periapical tissue than NaOCl, yet has
greater solvent action and is more germicidal than hydrogen peroxide. Therefore, it is an excellent irrigant for treating canals with normal periapical tissue and wide apices. The best use for
Gly-Oxide is in nan w an L r c
c
, utilizing the Iippery ff
of the lv.ce I.
Note: Irrigants perform the important biologic function of destroying bacteria during endodontic
therapy. Their action is unquestionably more significant than that supplied by the use of
intracanal medicaments. Irrigants should be used copiously throughout the instrumentation
phase of root canal procedures.

Inst/MatlTech

ENDODONTICS
Which of the following are cons idered to be the two object ives of the access opening?

To provide patient comfort

To provide direct access to the apical portion of the canal
To facilitate visualizati on (location ) of the canal
To remove all old restorative materials from the tooth

Copyright 2001 -

DENTAL DECKS

 To provide direct access to the apical portion of the canal. Important: This is
the primary function of access openings.

To facilitate visualization (location) of the canal.

Access to the root canal is the initial step in canal preparation. It is necessary to
establish straight-line access to the apical foramen to ensure free movement of the
instrument during debridement and preparation of the canal. All the treatment that follows hinges on the correctness of the access preparation. All access cavities are
made through the lingual on anterior teeth and through the occlusal on posterior
teeth (see note below).
Remember:..Mandibular incisors and maxillary first premolars are the easiest teeth
to perforate during preparation of the access opening due to the limited access mesiodistally. Therefore care must be taken when initiating treatment on these teeth.
~o~e: A facial appraaQ.!.1 is recommended for. an access opening on maxillary p.nmary
mmsors,

Inst/MatlTech

ENDODONTICS

Which of the following criteria must be met before a canal is considered ready to fill
with gutta-percha?
The canal must be prepared in a manner that ensures optimum debridement and
access to the apical area so that the filling material can be condensed to obliterate
the entire preparation
The tooth must be asymptomatic
At the time of fill, the canal must be dry
If a bacteriologic culture test is being used, a negative culture must be obtained
All of the above

Copyright 2001 -

DENTAL DECKS

 All of the above

The most important consideration before filling a root canal is proper cleaning (debridement)
and shaping (instrumenting) of the canal. Once the canal is obturated, any organisms that have
entered the periapical tissues from the canal are eliminated by the natural defenses of the body.
Objectives of root canal obt uratio n:
To develop a fluid-tight seal at the apical foramen
Complete filling of the root canal space
To create a favorable biologic environment for the process of tissue healing
In endodontic treatment the importance of canal obliteration (filling) is second only to canal
debrid ement. A proximately 40% of failures ar belie ed to be caused b incom lete a Iiteratio 0 h to ca al. If the canal is not filled, tissue fluid and microorganisms from the periapical tissues are able to enter the voids, with failure as the ultimate result. However, if an accessory canal is not tot ally fill ed during obturation, the appropriate treatment is to observe
the tooth and ~va l u ate every three months .
Note: Atter endodontic therapy is completed on a tooth with a periapical radiolucency, it usually
takes
2
a
a con e ize ut radioltJcency ' evident on an xray.
ir
a
i
9
e n
'on
0
bo , deposition of
apical cementum and re-establishment of the PDL.