CHAPTER II

CONTENTS

I. Vital Pulp Therapy

I.1. Indications for vital pulp therapy
a. Teeth with incomplete apical development. This in excellent indication for
pulpotomy. Incomplete development of the apex can cause lack of apical
constriction needed to pack the root canal filling. Pulpotomy procedures will
usually keep the apical portion of the pulp vital and allow for relatively normal
root development and closure (apexogenesis).
b. Primary teeth. Calcium hydroxide and zinc-oxide eugenol as capping agents and
calcium hydroxide and formocresol as pulpotomy agents have been reported with
great success in primary dentition. Besides, endodontic therapy will be difficult to
accomplish in primary teeth since it has thin and curved canals, multiple lateral
canals, ramifications, and resorbing roots.
c. Teeth that would be difficult to treat endodontically. The examples are teeth with
sharp apical dilacerations, extremely long multirooted teeth, and third molars
with unusual root shape or number of roots.
d. Teeth with pulpal inflammation confined to a small segment of the coronal pulp.
If there’s only a small segment of the pulp is inflamed, probably adjacent to the
site of exposure, either pulp capping or pulpotomy could remove it.

I.2. Contraindications for vital pulp therapy

a. Teeth in which the canal space could be well utilized to hold a post and core. If
there’s a tiny pulp exposure, the tendency might be to do the vital pulp therapy
and then build up the crown with pin or screw posts in restoration. But, if the pulp
become necrotic later, it will be very difficult to locate the canal through the mass
of restorative materials. Restoration of the tooth probably would have been easier
if the pulp had been removed at the time of exposure with endodontic therapy and
later restoration with a post and core.
b. Splint, bridge, and precission partial denture abutments. If a tooth that is to be
used as a splint, fixed bridge, or precision partial denture abutment is exposed, it
probably should undergo routine endodontics initially.

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c. Teeth involved in complex periodontal therapy and resultant periodontal
prostheses. Pulpal inflammation is often accompanied with severe periodontal
lesions. If these teeth are flapped and the roots are scrapped and curetted during
periodontal treatment, prepared for splinting, temporized, and crowned in
restoration, it is obvious that any pulpal inflammation present will increase.

I.3. Kinds of vital pulp therapy

a. Pulp capping of posterior teeth

• Once the exposure occurs, the desired medicament is placed over the pulp
without pressure.
• A thin mix of zinc oxide eugenol is placed over the medicament.
• A thick mix of xinc oxide eugenol is zinc oxide accelerated with zinc acetate
crystals is prepared and used to close the entire preparation.
• The tooth may be restored if symptom free from 1 to 4 weeks later.
b. Formocresol pulpotomy for posterior teeth
• Once the exposure occurs, the roof of the pulp chamber is removed.
• A sharp, sterile, no. 4 round bur is used to remove the coronal pulp tissue so the
bleeding pulpal stumps only are seen at the floor of the chamber.
• Sterile cotton pellets are used to absorb hemorrhage.
• After hemostasis is achieved, a cotton pellet is lightly dampened with
formocresol and applied to the pulp stumps for 3 minutes.
• A thin mix of formocresol and zinc oxide is prepared and placed on the pulp

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• A thick mix of zinc oxide eugenol accelerated with zinc acetate crystals is placed
to provide occlusal seal.
• The tooth may be restored if symptom free from 1 to 4 weeks later.
c. Treatment of open apex with vital pulp
A pulpotomy procedure is indicated in the tooth with an open apex to allow
completion of apical closure, as long as the apical pulp remains vital. This is
referred to apexogenesis.
• Anesthetic administration and rubber dam application.
• The coronal pulp is amputated to approximately the cervical line with a sharp,
sterile, no. 4 bur.
• Sterile cotton pellets are used to absorb hemorrhage.
• A cotton pellet lightly dampened with formocresol is applied to the pulp stump
for 3 minutes.
• A thin mix of formocresol and zinc oxide is prepared and placed on to the pulp.
• A thick mix of zinc oxide eugenol accelerated with zinc acetate crystals is placed
to provide a seal to the canal and is followed by a suitable temporary restoration.
• The tooth is radiographed at 6-month interval. When apical closure has occurred,
routine endodontic treatment is undertaken. If the pulp becomes necrotic,
apexification procedure is required.
d. Treatment of open apex with nonvital pulp-apexification procedure
• Anesthesia is usually not needed. The rubber dam is applied.
• The working length is established and the canal is debrided.
• A large Hedstrom file may be used to rasp the walls of the canal with heavy
irrigation. The canal is dried with sterile paper points.
• A sterile, dry cotton pellet is placed in the chamber, and the access is closed with
zinc oxide eugenol.
• 1 to 2 weeks later, the rubber dam is again applied and the cotton removed.
• The canal is irrigated, the walls again rasped to remove debris, the canal dried.
• Place a thick paste composed of calcium hydroxide and CMCP in the debrided
canal. The paste must reach the apical portion of the canal to stimulate the tissue
to form a calcific barrier.

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• A cotton pellet is placed in the chamber, followed by zinc oxide eugenol, and a
suitable temporary seal.
• At 6 months, the patient is recalled for radiographic examination. There might be
some possibilities:

II. Endodontic Emergencies

II.1. Definition
Endodontic emergencies are usually associated with pain and/or swelling and
require immediate diagnosis and treatment. It is caused by pulp or periapical
disease or severe traumatic injuries.

II.2. Differentiation of emergency and urgency

Emergency is a condition requiring an unscheduled office visit with diagnosis
and treatment now. The visit can’t be rescheduled since the problem is so severe.
Urgency (less critical) is a condition in which the problem is less severe. A visit
may be rescheduled

Questions to determine severity include:

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a. Does the problem disturb you sleeping, eating, working, concentrating, or other
daily activities?

→ emergency disturbs patient’s activities

b. How long has this problem bother you?

→ emergency has rarely been severe for more than a few hours to 2 days

c. Have you taken any pain medication? It is effective?

→ analgesics don’t relieve the pain of a true emergency

II.3. System of diagnosis

a. Medical and dental histories
Medical and dental must be updated (old patient) or taken completely (new
patient). Dental history will include previous dental procedure and chronology of
symptoms.
b. Subjective examination
Purpose: gain information about the pain source and whether it comes from
pulp/periapical
→ questions related to history, location, severity, duration, character, and stimuli
caused or relieved pain → select appropriate objective tests
Pain caused by thermal stimuli, referred : possibly coming from pulp
Pain occurs on tooth contact, well localized : possibly coming from periapical
c. Objective examination
Purpose: repeat the stimuli which causes pain based on the patient report in
subjective examination
If similar subjective symptoms are not reproduced → may not an emergency →
patient may be over-reporting
Include: extraoral and intraoral examination, involving periapical and pulp
vitality test → observation of swelling, presence of defective restoration,
discolored crown, recurrent caries, or fracture
d. Periodontal examination

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 Probing helps distinguishing endodontic from periodontal disease. Example:
Periodontal abscess : the pulp is usually vital
Acute apical abscess : the pulp is usually necrotic
e. Radiographic examination
Periapical and bitewing radiograph can detect the presence of caries, pulpal
exposure, resorption, and periapical disease.
f. Diagnostic outcome
The clinical must identify the offending tooth and the tissue (pulpal or
periapical) that is the source of pain. He also must record a pulpal or periapical
diagnosis. Diagnosis is clear → treatment planning.

II.4. Treatment planning

Major cause of painful dental emergency: inflammation (increased tissue pressure
and release of inflammatory mediators). Treatment plan aims to reduce the
irritant or the tissue pressure or removal of the inflamed tissue → pain relief

II.5. Categories
a. Pretreatment emergency-situation in which the patient is seen initially with sever
pain and/or swelling.
b. Interappointment and postobturation emergency the problem occurs after an
endodontic appointment.
PRETREATMENT EMERGENCY
a. Patient management
The frightened patient in pain must have confidence that his problem is being
properly managed.
b. Profound anesthesia
Maxillary anesthesia : infiltration or block injections in the buccal and palatal
region
Mandibular anesthesia : inferior alveolar and lingual nerve block and long
buccal injection (helpful)
Although signs of profound anesthesia appear → access into pulp is painful →
supplemental injection (intraosseous, periodondtal ligament, intrapulpal injection)
c. Management of acute reversible pulpitis

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 Hyperemia can be localised by asking the patient to point the identify tooth and
making diagnosis based on the visual, tactile, thermal, and radiographic
examination of the isolated tooth.

• If a recent restoration has a bad contact point à recontouring.

• If persistent painful comes from cavity preparation à chemical cleansing of the

cavity or remove the restoration and replace it with a sedative cement (ex : ZOE).
The same method can be used if recurrent decay under an old restoration hasn’t
caused pulp exposure.

• The best treatment is prevention : use pulp protective under all restoration, avoid
marginal leakagem reduce occlusal trauma if present, properly contour
restoration, avoid injuring the pulp with excesssive heat while
preparing/polishing.

• Usually application ZOE as temporary sedative filling will make the pain
dissapear within several days, if it persists or worsens, the the pulp should be
extirpated.

d. Management of acute irreversible pulpitis

The preferably emergencies for both acute irreversible pulpitis (usually
abnormally responsive to cold or heat) is pulpectomy. If the patient describes
pain that last for hours, disturbing sleep or spontaneous or occurs when bending
over, most likely the patient require pulpectomy. The technique for pulpectomy is
as follows :
• Anesthetize the affected tooth

• Apply the rubber dam

• Prepare an access cavity into the pulp chamber

• Remove the pulp from the chamber with excavators or curettes

• Irrigate and debride the pulp chamber

• Locate the root canal orifices and explore the root canals

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• Extirpate the pulp by sequentially instrumenting with reamers or files to within 1
mm of the radiographic root apex

• Irrigate with sterile saline solution, anesthetic solution or sodium hypochlorite

solution

• Debride with a barbed broach, fitted loosely so it can be rotated in the root cana
without binding, usually at least no. 25 reamer to the root apex

• Dry the root canal with sterile absorbent points

• Insert a medicated cotton pledget moistoned with an obtundent such as ZOE into
the pulp chamber

• Place temporary filling such as cavit or ZOE cement over the medicated dressing
and seal the access cavity

• Relieve any occlusal trauma

• Prescribe an analgesic for only if pain recurs. Premedication or post treatment

medication with antibiotics is indicated only if the patient’s condition is
medically compromised or if systemic toxicity occurs subsequently

• Consult with the patient to alleviate any anxiety concerning the emergency
procedure or potential postoperative reaction and assure tha patient of your
availability

On some occasions, the dentist doesn’t have sufficient time to complete total
extirpation, therefore debridement, drying, and sealing of a medicated dressing in
the pulp chamber usually suffices. Although emergency pulpotomy isn’t as
effective as pulpectomy, it relieves the patient of pain for several days. The
patient should rescheduled as soon as possible for additional treatment.

e. Management of acute alveolar abscess

The pulp is necrotic therefore the treatment different with acute irreversible
pulpitis, local anasthesia is not needed routinely. In fact, local anesthesia is
frequently contraindicated in acutely inflamed tissue because the injection of an

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 infiltration anesthetic doesn’t anesthetize the tissue. Local anasthetics are
effective in tissue with a more alkaline pH and ineffective when injected into
acutely inflamed tissue. In addition, needle and infected and swollen area may
increase pain and may spread infection. Conduction anesthesia may be
administrated to reduce the pain of acute alveolar abscess, as long as the injection
route is distant from the inflamed area. A mandibular block or an infraorbital
injection can be used effectively when needed for the few isolated cases in which
some pulp vitality persist.
• Place the rubber dam over the infected tooth

• Complete the access opening painlessly by bracing the tooth with finger pressure

• Irrigate profusely, debride the pulp chamber, but avoid forcing any solution or
debris into the periapical tissue

• Using a no. 10 or no. 15 file as an explorer, locate the root canal orifices and
instrument each root canal within 1 mm of the root apex

• Continue to debride and to irrigate while enlarging each root canal, but keep all
instruments and irrigants within the root canal

• Frequently, a purulent exudate escapes into the chamber and indicates the root
canal is patent and draining. Relief follow quickly. If no evidence of drainage
appears, leave the tooth open. If no evidence of drainage appears, leave the tooth
open, its root canals patent and expect relief within a short time

• Advise the patient to use hot saline rinses for 3 min each hour

• Prescribe analgesics or antibiotics if indicated and necessary

f. Management of referred pain

Usually comes from pulpoperiapical pathosis but the pain also can originate from
many other sources (inflamed pulp to other parts of the body, usually on the same
side and in close proximity to the tooth or from other sources that simulates the
painful symptoms of pulpoperiapical disease.

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 Dental pain can have its origin in trigeminal neuralgia, atypical facial neuralgia,
migraine, cardiac pain or tempuromandibular arthrosis. Other causes are intensive
radiation, systemic diseases (malaria, typhoid, influenza, anemia, hypertension, or
neurasthenia), menstrual onset, neurologic diseases of the central nervous system,
and some malignant diseases ad tumors. Other example :

Origin Pain
Sinusitis, head cold, maxillary sinus and Maxillary posterior teeth
to the back and side of the head
Periodontal problems Pulpoperiapical pain
Basilar artery aneurysm produced Lower molar
pressure in the trigeminal nerve, otitis
media, ear or the back of the head
Herpes zoster of the maxillary division Maxillary Lateral incisor
of trigeminal
Vascular neck pain Mandibular posterior teeth
TMD Toothache
Myocardial infarction, angina pectoris Left side of the mouth
Therefore endodontic emergencies won’t relieve the pain
g. Analgesic and antibiotics
The use of analgesics and antibiotics is important in endodontic emergency
treatment. Because their role is essential and supportive to the previously
described emergency procedures, every clinican should be familiar with their
mode of action, dosage, toxicity, route of administration, indications,
contraindications, and interaction with other drugs.
Analgesics
Analgesics are pain relievers. Usually the narcotic analgesics are used to relieve
acute, severe pain, and the non narcotic (more common to use) or mild analgesics
are used to relieve slight to moderate pain. Clinician should considered the
strength of the drug, whether it is used alone or in compound form, the frequency
of use, and so on.
Mild analgesics reduce the syntehsis of prostaglandins à reduce / eliminate the
pain. The more frequently used non-narcotic analgesics are :
• Aspirin
Aspirin has antiinflammatory and antipyretic properties. It’s effective for mild to
moderate pain. It can cause an anaphylactoid reaction in and allergic person or

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 person with gastric ulcers. It’s contraindicated for patients receiving
anticoagulant therapy, undergoing antineoplastic chemotherapy, diabetics, goty
arthritis.
• Acetaminophen
It can relieve mild to moderate pain. It has lower incidence of side effects than
aspirin and is effective in smaller doses. It lacks the anti inflammatory effect of
aspirin. It is recommended for children and is available in liquid form.
• Naproxen
Like diflunizal, is a long lasting analgesic. It is prescribed 275 mg tablets to be
taken twice daily.
• Ibuprofen
Doses of 300-400 mg 4 times daily, is more effective for severe pain relief than
the daily therapeutic dose of aspirin, 3600 mg. Ibuprofen shouldn’t be used in
patients with a history of peptic ulcer or aspirin intolerence.

Narcotic drugs control pain better that other drugs. This drugs inhibition of
neurotransmission along central pain pathways by inhibiting the release of an
excitatory pain transmitter. Narcotic analgesics may depress the central nervous
system. They can interact adversely, sometimes fatally with alcoho,
antihistamines, barbiturate, local anesthetics, phenothiazines, tricyclic
antidepressants, and monoamine oxidase inhibitors by enhancing the depression
of the central nervous system. All opioid analgesics may be abused and should be
prescribed with discretion. Those narcotic drugs are :
• Morphine
Not administrated orally
• Meperidine
50-100 mg (demerol), 1 tab q4h p.r.n
• Codeine
30 mg, 1 tab q4h p.r.n
• Oxycodone
5 mg, with acetaminophen 325 mg (percocet-5), 1 tab q4h p.r.n
• Hydrocodone

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 5 mg, with acetaminophen 500 mg (vicodin), 1 tab q6h p.r.n
• Dihydrocodeine
16 mg, with aspirin 356.4 mg and caffeine, 30 mg (synalgos-DC), 1 tab q4h p.r.n
• Acetaminophen
300 mg, with codeine 30 mg (tylenol no. 3), 1 tab q4h p.r.n
• Aspirin
325 mg, with codeine, 30 mg (empirin no. 3), 1 tab q4h p.r.n
• Acetaminophen
650 mg, with propoxyphene napsylate, 100 mg (darvocet-N 100), 1 tab q4h p.r.n
Placebo is the other effect of drug administration. It can increase the analgesics
effect up to 40%.

Antibiotics
Antibiotics are life saving therapeutic agents of inestimable value. They are used
for an adjunctive treatment of acute periapical or periodontal infection.
Remember to consider patient allergy. The selection of a prescribed antibiotic
should be based on the result of susceptibility tests that indivate effectiveness
against the infecting microorganisms. The more lethal the antibiotic, the less
likely resistant microorganisms will develop to it. Practically this testing is rarely
done during endodontic emergencies because susceptibility tests require several
days to complete. Therefore it depends to the symptoms of the systemic toxicity.
The use of antibiotics should be limited to adjunctive treatment of acute
periapical and periodontal disease and only when truly needed.
The most effective antibiotic for use in endodontic emergencies is penicillin. Its
mode of action is by inhibition of cell wall syntesis during multiplication of
microorganisms à bactericidal.
The recommended standard regiment for dental procedures is penicillin V 2 g
orally 1 hour before the procedure, then 1 g 6 hours later. In case of allergy to
penicillin, erythromycin may be prescribed : 1 mg orally 1 hour before then 500
mg 6 hours later. Penicillin is contraindicated for those who allergy with it.
Erythromycin’s mode of action is inhibition of protein synthesis and it also have
the same bacterial spectrum as penicillin V.

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 Other antibiotics useful for treating endodontic emergencies are :
• Cephalexin (keflex) 250 – 500 mg every 6 hours
• Clindamycin phosphate (cleocin HCl, 150-300 mg every 6 hours
• Tetracycline hydrochloride (achromycin V) 250-300 mg every 6 hours, but it’s
the least effective of all antibiotic for endodontic emergencies

INTERAPPOINTMENT EMERGENCY
a. Causative factors
It can be related to the patient, to pulpal or periapical diagnosis, or to treatment
procedure.
b. Prevention
Procedures
Use of long anesthetic solution, complete cleaning and shaping of the root canal
system, analgesics.
Verbal instruction
Patiens should be told that there will be discomfort. It will subside in 1-2 days.
An increase in pain and swelling needs a call or a visit.
Therapeutic prophylaxis
Certain analgesics and anti-inflammatory agents will reduce post-treatment
symptoms.
c. Treatment
Previously vital pulp with complete debridement
It doesn’t need to open the teeth. Prescription of mild to moderate analgesic is
enough.
Previously vital pulp with incomplete debridement
The working length is rechecked → the canal is cleaned with sodium
hypochlorite → placement of dry cotton pellet → temporary filling →
prescription of mild to moderate analgesic
Previously necrotic pulp with no swelling
If there is active drainage from the tooth after opening → the canal is recleaned
and irrigated with sodium hypochlorite → the canal is dried → calcium
hydroxide is placed → access is sealed

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 If there is no drainage → the tooth is instrumented and irrigated → calcium
hydroxide is placed → access is sealed
Long acting anesthetic and strong analgesic is helpful. Antibiotic is not
indicated.
Previously necrotic pulp with swelling
Managed by incision and drainage.

POSTOBTURATION EMERGENCY
a. Causative factor
The etiology is unknown. But, levels of pain reported after obturation tend to
correlate to levels of pain before the appointment.
b. Treatment
- Retreatment → when prior treatment hasn’t been adequate
- Analgesic prescribtion → when patient reports severe pain, but no evidence of
acute apical abscess and root canal treatment is well done

III. Restoration After Endodontic Treatment

It’s better to give permanent restoration immediately after obturation. However,
in some cases we should delay the permanent restoration because of some
reasons:
a. The bad prognosis because of complicated root canal system, uncompleted
obturation, fractures of instrument, and perforation.
b. If the tooth is indicated as bridge supporter.
c. If we predict there is a possibility if failure and the only one solution is
extraction, we have to delay the PR.
During the delay of permanent restoration, we should put temporary restoration.
Material for permanent restoration can be direct or indirect. We can use direct
restoration if the remaining tooth structure is large enough.
Criteria of Temporary Restoration:
a. Enclose the crown tightly
b. Protect the tooth until PR is given
c. Easy to be placed and removed
d. Have good esthetic

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 Types of Temporary Restorative Material:
Zinc Oxide Eugenol
a. It’s not too strong, but have good hermetic
b. Long setting time à make deformation
Cavit
a. ZOE polyvinyl
b. Hydrophilicà set in wet condition
c. Easy to be used and has good hermetic
d. Low strength and low wear protection
e. Short time used
IRM
a. Intermediate Restorative Material
b. Higher protection of wear
TERM
a. Composite with special formula for endodontic treatment
b. Has polymerization shrinkage and water absorption
c. Same tightness with cavit buts stronger and have higher wear protection

IV. Local Anesthesia

Local anesthetics are divided into amide and ester classes. Amide and ester were
both used, but esters lost their favor after reports of increased sensitization.

IV.1. Lidocaine

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 Lidocaine is the most versatile and commonly used amide anesthetic. In 1943,
lidocaine was the first drug of the amino amide type to be introduced into clinical
practice, and its rapid onset and moderate duration of action ensure its
widespread use today. Lidocaine is available in solutions ranging from 0.5 to 4
percent; however, no studies have compared the efficacy of the different
solutions. Lidocaine at 2 percent concentration may be particularly useful when a
smaller injected volume is indicated.
IV.2. Mepivacaine and Prilocaine
Mepivicaine (Carbocaine®) and prilocaine (Citanest®) have much less
vasodilative qualities and hence can be used without the epinephrine
vasoconstrictor. The advantage to this is that these anesthetics can be used more
safely in patients who are taking medications which may interact negatively with
the vasoconstrictor. Carpules that do not contain vasoconstrictor do not
contain preservatives either. This is an important point, since it is most
frequently the preservatives, and not the anesthetics themselves which play a
roll in allergic reactions. Most anesthetic solutions are sold with added
vasoconstrictor. Only two, mepivicaine and prilocaine are sold with or without
vasoconstrictor.
IV.3. Bupivacaine and Etidocaine
Bupivacaine provides an intermediate onset and a longer duration of action. It is
especially useful when prolonged anesthesia is needed and epinephrine is
contraindicated (i.e., for joint injections and digital nerve blocks). Other
anesthetics in the amide group can be used in the office but are commonly
reserved for spinal and regional anesthesia. The most frequent use of Bupivicaine
is to prevent post-operative pain after surgical procedures. Some dentists will
inject a carpule of Bupivicaine after an extraction in order to delay the onset of
pain for up to nine hours. This delay effectively reduces the period of severe post
operative discomfort which generally tapers off during the first 12 hours post op.
IV.4. Articaine
Articaine is the newest addition to the local anesthetic arsenal and was approved
by the Food and Drug Administration in April 2000. Articaine has become the
local anesthetic of choice in most countries into which it has been introduced. I
have found that it produces profound anesthesia (in most patients) when used as

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 an infiltration (field block) for mandibular premolars and anterior teeth instead of
the traditional mandibular nerve block.. With clinical reports of profound
anesthesia, fast onset, and success in difficult-to-anesthetize patients, Septocaine
has become the most used dental anesthetic brand name in the US, although
lidocaine still remains the most used type of anesthetic.
Articaine and prolonged numbness and paresthesia
Unfortunately, one complication concerning the use of articaine has arisen.
There have been persistent reports of unexplained paresthesia. The most
common link with articaine and paresthesia was administration of mandibular
nerve block injections. For this reason a number of dentists have abandoned the
use of articaine for mandibular nerve blocks, but still use it for infilatration
anesthesia (field blocks) of mandibular anterior teeth and bicuspids.
IV.5. Initial management
a. Psychologic approach
• Control is achieved by obtaining and maintaining the upper hand.
• Communication is accomplished by listening and explaining what is to be done
and what the patient should expect
• Concern is shown by verbalizing awareness of the patient’s fear.
• Confidence is expressed in body language and in professionalism → give
patient’s confidence in the management, diagnostic, and treatment skills
b. Painless injection
Master injection technique that are almost painless → relaxes the patient and
raises the pain threshold
• Topical anesthetic-when a topical anesthetic gel is used, a small amount on a
cotton-tipped applicator is placed on the dried mucosa for 1-2 minutes before the
injection.
• Needle insertion-initially, the needle is inserted gently into the mucosal tissue.
• Small-gauge needles-as a recommendation, a 27-gauge needle is suitable for most
conventional dental injections
• Slow injection- it is effective to decrease pressure and patient discomfort during
injection. Slow deposition permits its gradual distribution into the tissues.
Solution deposition should take approximately 1 minute per cartridge.

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• Two stage-injection-initial very slow administration of a quarter cartridge of
anesthetic under mucosal surface then full depth cartridge at the target site.
c. When to anesthetize
Preferably, anesthesia should be given at each appointment. Although for the
necrotic pulps and periapical lesions (there may be vital tissue in the apical few
millimeters of the canal)
d. Additional pharmacologic therapy
Sedation (intravenous, oral, inhalation) may enhance local anesthesia.
IV.6. Mandibular anesthesia
The most commonly used agent is 2% lidocaine with 1:100,000 epinephrine. It is
safe and effective.
Contraindication: patients taking tricyclic antideppresant or nonselective
adregenergic blocking agent or patients with moderate to severe cardiovascular
disease
a. Related factors
• Lip numbness-numbness usually occurs in 5-7 minutes.
• Onset of pulpal anesthesia-pulpal anesthesia usually occurs in 10-15 minutes.
• Duration-anesthesia usually persists for approximately 2 ½ hours.
• Success-the incidence of successful mandibular pulpal anesthesia tends to be
more frequent in molar and premolar
b. Alternative techniques
• Increasing the volume-increasing the volume of anesthetic doesn’t increase the
success rate of pulpal anesthesia with the inferior alveolar nerve block.
• Alternative solution
(1) 2% mepivacaine with 1:20,000 levonordefrin
(2) 4% prilocaine with 1:200,000 epinephrine
(3) Solutions without vasoconstrictor (3% mepivacaine plain and 4% prilocaine
plain)
• Infiltration injection-labial or lingual infiltration injections used alone are not
effective for pulpal anesthesia
• Long-acting anesthetic-usage of bupivacaine and etidocaine → provide prolonged
analgesic period, indicated when post operative pain is anticipated

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• Pain and inflammation-patients with symptomatic pulpal or periapical pathosis
(or who are anxious) present additional anesthesia problems.
IV.7. Maxillary anesthesia
a. Anesthetic agent
2% lidocaine with 1:100,000 epinephrine
b. Related factors
Anesthesia is more successful in maxilla than in the mandible. The most common
injection for maxillary teeth is infiltration
• Lip numbness-usually occurs within few minutes.
• Success and failure-infiltration results in a high incidence of successful pulpal
anesthesia
• Onset of pulpal anesthesia-pulpal anesthesia usually occurs in 3-5 minutes
• Duration-duration of pulpal anesthesia will be:
In anterior teeth : decline after 30 minutes, most losing anesthesia by 60 minutes
In premolar & first molar : losing anesthesia by 45-60 minutes
c. Alternative techniques
• Volumes of solution-increasing the volume increases the duration of pulpal
anesthesia.
For anterior teeth and premolar : two cartridges directly or give one initially and
inject another 30 minutes later
For first molar : two cartridges directly
• Alternative solution
Prilocaine, mepivacaine, lidocaine (all with vasoconstrictor) act similarly.
Solutions without vasoconstrictor (3% mepivacaine plain and 4% prilocaine
plain) provide short duration of anesthesia,
• Other technique
The posterior superior alveolar (PSA) block anesthetizes the second and third
molars and usually the first molar. It is indicated when all molar teeth require
anesthesia.
The infraorbital block results in lip numbness. It usually anesthetizes the
premolars. Duration is less than 1 hour.

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 The second division block usually anesthetizes pulps of molars and some second
premolars
IV.8. Anesthesia difficulties
a. The anesthetic solution may not penetrate to the sensory nerves that innervate the
pulp, especially in the mandible.
b. Local tissue or nerve changes occur because of inflammation.
Lowered pH of inflamed tissue → reduces the amount of the base form of the
anesthetic available to penetrate the nerve membrane
Hyperalgesia theory: nerves arising in inflamed tissue alter resting potentials and
decreased excitability thresholds
c. Patients in pain often are afraid → lower their pain threshold.
IV.9. Supplemental anesthesia
Indications
It is used if the standard injection isn’t effective. It is done if the patient doesn’t
exhibit classic signs of soft tissue anesthesia.
Anesthetic agents
2% lidocaine with 1:100,000 epinephrine
a. Intraosseus anesthesia
Placement of local anesthetic directly into the cancellous bone adjacent to the
tooth. One part is a slow-speed handpiece-driven perforator, which drills a small
hole through the cortical plate. The anesthetic solution is delivered into
cancellous bone through a matching 27-gauge ultrashort injector needle
Technique The area of perforation and injection is on a horizontal line of the
buccal gingival margins of the adjacent teeth and a vertical line that passes
through the interdental papilla distal to the tooth to be injected. A point
approximately 2 mm below the intersection of these lines is selected as the
perforation site.
The soft tissue is first anesthetized by infiltration. The perforator is placed
through the gingiva perpendicular to the cortical plate. With the point gently
resting against bone, the handpiece is activated in a series of short
bursts, using light pressure, until there is a "breakthrough" into cancellous bone
(taking approximately 2 to 5 seconds).

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b. Periodontal ligament injection
A standard syringe or pressure syringe is equipped with a 30-gauge ultrashort
needle or a 27-or a 25-gauge short needle. The needle is inserted into the mesial
gingival sulcus at a 30-degree angle to the long axis of the tooth. The needle is
positioned with maximum penetration (wedged between root and crestal bone).
Heavy pressure is SLOWLY applied
on the syringe handle for 10-20 seconds (conventional syringe),
Back pressure is important. If there is no back-pressure (resistance) -that is, if the
anesthetic readily flows out of the sulcus, the needle is repositioned, and the
technique repeated until back-pressure is attained. The injection is then repeated
on the distal surface.

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c. Intrapulpal injection
Indication when intraosseous and periodontal ligament injections, even when
repeated, do not produce profound anesthesia. Pain persists when the pulp is
entered.
Advantage if the injection is given under back pressure, onset will immediate
and no special syringe or needles are required.
Disadvantage if the needle is inserted directly into a vital and very sensitive
pulp, the injection may be very painful. Duration of anesthesia, once attained, is
short (about 20 minutes).
Technique
An injection into each canal after the chamber is unroofed. A standard syringe is
usually equipped with a bent short needle. The needle is positioned in the access
opening and then moved down the canal, while slowly expressing the anesthetic,
Maximum pressure is then applied slowly on the syringe handle for about 10
seconds.

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IV.10. Anesthetic management of pulpal or periapical disease
a. Irreversible pulpitis
• General consideration
Conventional anesthesia, using primary techniques, is administered. Upon access
opening or when the pulp is entered, pain results because not all sensory nerves
have been blocked. A useful procedure is to pulp test the tooth with cold or an
electric pulp tester before the access is begun. If the patient responds, an IO or
PDL injection is given.
• Mandibular posterior teeth
A conventional inferior alveolar injection is administered, usually in conjunction
with a long buccal injection. Because of the high failure rate of anesthesia for
these teeth, an IO or PDL injection is routinely administered before access is
begun. If pain is felt, the IO or PDL injection may be repeated or an IP injection
is given if the pulp is exposed.
• Mandibular anterior teeth

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 An inferior alveolar injection is given. If pain is felt, an IO injection is
administered. If this is unsuccessful, an IP injection is added.
• Maxillary posterior teeth
The injection site may be a PSA block for molars. Infiltration of 0.5 ml of
anesthetic over the palatal apex enhances pulpal anesthesia. If pain is felt during
the access, an IO or PDL injection is administered.
• Maxillary anterior teeth
Anesthetic is administered initially as a labial infiltration and, occasionally, as a
palatal infiltration for the retainer.
b. Symptomatic pulp necrosis
For the mandible, an inferior alveolar nerve block and long buccal injection are
administered.
For maxillary teeth, if no swelling is present, anesthesia is given with a
conventional infiltration or block. If soft tissue swelling is present (cellulitis or
abscess), a regional block plus infiltration on either side of the swelling is
administered.
If conventional injections don’t provide adequate anesthesia. IO, PDL, or IP
injections are contraindicated. Although effective for vital pulps, these injections
are painful and ineffective with apical pathosis.
c. Asymptomatic pulp necrosis
Conventional injections are usually administered: inferior alveolar nerve block
and long buccal injection for mandibular teeth and infiltration (or PSA block) in
the maxilla.
Rarely, there may be some sensitivity during canal preparation that requires an IO
or PDL injection. IP injection is
not indicated because bacteria and debris may be forced periapically.

V. Root Canal Disinfection

Root canal disinfection is the destruction of pathogenic microorganisms by
capturing and removing pulp tissue, debris cleaning, widening of root canals with
biochemical means, and cleaning it with irrigation. Root canal disinfection is
along with root canal medication.
V.1. Root canal flora

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a. Microbial flora of root canal may consist of organisms that can live on dead pulp
tissue, which is a saprophyte that can grow in an environment with low oxygen
tension, and can survive in environments with limited food.
b. One of the endodontic problem is to eliminate gram positive organisms, because
these organisms are most abundant, consisting of streptococci and staphylococci.
There are also a small amount of enterococcus but they are resistance.
There are 4 factors that cause tooth susceptible to infection, and these factors can
also inhibit healing. These factors are:
a. Trauma
b. Devitalization Tissue→ If present in root canals or periapical tissue, it would
interfere disinfection or repair.
c. Death Spaces → For maximum effect, medikamen must come into contact with
microorganisms in the root canal.
d. Accumulated Exudate → So the exudate must be removed.

V.2. Intracanal medicament

Terms of root canal disinfection:
a. Must be germisida and fungicides.
b. Not irritate the periapical tissue.
c. Remain stable in solution,
d. Have the effect of antimicrobial.
e. Have low surface tension.
f. Not interfere periapical tissue repair.
g. Must be able to be non-activated in culture medium (medium biakan).
h. Should not induce an immune response

V.3. Essential oils

• The essential oil is a weak disinfectant.
• Eugenol → a chemical essence of clove oil and have a relationship with phenol.
A bit more irritating, and is antiseptic. Eugenol inhibits interdental nerve
impulses.

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V.4. Phenol collections
a. Phenol
• Melted Phenol (carbolic acid) consists of 9 parts phenol and 1 part water, and has
a distinctive smell of coal.
• It is a protoplasmic poison and causes soft tissue necrosis.
b. Para-chlorophenol
• This compound is a replacement product of phenol with chlorine replaces one of
atom hydrogen atom (C6H4HCl).
• This watery solution destroys various microorganisms that are usually found in
infected root canals and goes deeper into the dentin tubule compared with the
camphored chlorophenol.
c. Camphored Para-Chlorofenol
• Consists of two parts of para-chlorophenol and three parts of camphorgram.
• Camphor is useful as a tool and a diluent and reducing the irritating effect that
belongs to the pure para-chlorophenol, and also extending the antimicrobial
effect.
• Camphored steam chlorophenol passes through the apical foramen and has the
effect of medium irritation.
d. Formokresol
• This material is a combination of formalin and cresol with a ratio of 1 : 2 or 1 : 1.
• Formalin is a powerful disinfectant which joined with albumin to form a
substance that cannot be dissolved and cannot become rotten.
• Formokresol is a non-specific bactericidial medikamen and highly effective
against aerobic and anaerobic organisms found in the root canal, but it is high
degree irritating materials.
• It causes necrosis which lasted until 2-3 months.
e. Glutaraldehida
• Colorless oil that soluble in water and has a slightly acid reaction and also a
powerful disinfectant and fixative.
• Providing recommended in low doses (2%) as a drug intrasaluran.
f. Cresatin

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• Also known as metakresilasetat, this material is a clear liquid, stable, oily and not
very volatile.
• Has antiseptic properties and ease the pain.
• Cresatin antimicrobial effect is smaller than the formokresol or camphored para-
chlorophenol, but not so irritating.
g. Calcium Hidroxide
• The effect of antiseptic may be related to its high pH and influenced in the
melting of the necrotic pulp tissue.
• Calcium hydroxide caused a significant rise in dentinal pH when the compounds
are placed at circumpulpal root canals.
• Calcium hidroxide paste best is best used as a medikamen intracanal if there is a
delay too long between visits, because this material remains to be efficacious
(manjur) during root canals.
h. N2
• Contains formaldehyde as the main element, expressed both as intracanal
medikamen or as siler.
• Contains eugenol and fenilmerkury and sometimes additional materials such as
lead, corticosteroids, antibiotics, and perfumes.
• Antibacterial effect of N2 is only brief and disappear in about a week or ten days.

V.5. Halogen
a. Sodium Hypochlorites
• Steam sodium hypochlorite is bactericidal, watery para-chlorophenol and
chompered chlorophenol is bacteriostatic.
• Because the activity of sodium hypochlorite is great but brief, this this compound
is better applicated to root canal every two days, evenhough this material is
slightly irritating.
b. Yodida
• Highly reactive, combines with protein in loose binding so that the penetration is
not disrupted.
• It would probably destroy microorganisms by forming salt that harmful
microorganisms life.

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• The antibacterial effects is short while and this material is the least irritating
medikamen.
c. Quaternary Ammonium Compound
• "Quats" is a compound that lowers the surface tension of the solution, due to the
quartenary ammonium compounds are positively charger and the microorganisms
are negatively charged, there will be formed an activation surface with
coumpound attached to the microorganisms.

VI. Analgesics
In endodontic treatment, is usually required analgesic drugs as pain relievers.
Analgesics may be classified as follows:

6.1. Non-Opioid
a. Non-Steroid Anti-Inflammatory (NSAIDs) Nonsteroidal anti-inflammatory drugs
(NSAIDs)
Is a class of drugs that are pharmacologically active compounds that work has
inhibited the production of prostaglandins. The drug is used for pain in acute or
chronic inflammatory. These drugs have the characteristics to relieve pain, fever,
and inflammation.

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 NSAIDs are believed to have therapeutic effects through inhibition of
cyclooxygenase enzyme that is an enzyme that affects the synthesis of
prostaglandins from arachidonic acid and tromboxsan. So terjaid inhibition of
production of proinflammatory prostaglandins, especially prostaglandin E2
(PGE2). When this has been found in the enzyme cyclooxygenase 2
(COX2). Drugs that inhibit only the COX2 enzyme without inhibiting the enzyme
cyclooxygenase 1 (COX1) work more specifically, the common side effects of
drugs of this class of gastric irritation and ulceration can be prevented.
NSAID medicines are classified as follows:
Carboxylic acid
1) Acetic Acid
Phenylacetic acid derivative: Diclofenac, Fenklofenak
Asetat-inden/indol acid derivatives: Indomethacin, Sulindak, Tolmetin
2) Acid derivatives Salicylates: Aspirin, Benorilat, Diflunisal, Salsalat
3) Propionic acid derivatives: Acid tiaprofenat, Fenbuten, Fenoprofen, Flurbiprofen,
Ibuprofen, Ketoprofen, Naproksen
4) Acid derivatives Fenamat: Mefenamic acid, Maklofenamat
Acid enolate
1) Derivatives Pirazolon: Azapropazon, phenylbutazone, Oksifenbutazon
2) Oksikam derivatives: piroxicam, Tenoksikam
Here is an explanation of NSAID drugs are often used in dentistry:
Aspirin (acetyl salicylic acid)
Pharmacokinetics: absorption ◊ of oral administration, aspirin is absorbed
rapidly, partly from the stomach, a portion of the upper small intestine. The
highest concentration of approximately 2 hours after administration. Absorbsinya
speed depends on several factors, mainly the speed of tablet disintegration and
dissolution, the pH at the mucosal surface and gastric emptying time. Distribution
◊ once absorbed, aspirin would be spread throughout the body surface and the
fluid between cells. 50-90% of aspirin bound to plasma proteins, primarily
albumin. ◊ biotransformation biotransformation of aspirin occurs in many tissues,
especially in a system of liver microsomes and mitochondria. Excretion ◊
excreted through the kidneys (at most) in the form metabollit

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Pharmacodynamic: used to relieve mild to moderate pain, central (works on
hypothalamus) or peripheral (inhibit the formation of prostaglandins in the
inflammation and prevent the sensitization of pain receptors to mechanical or
chemical stimuli
Dosage: 325-650 mg orally every 3-4 hours (adults)
Side effects: gastrointestinal disorders such tools dyspepsia, nausea and
vomiting.Aspirin allergy can cause skin redness, edema of the larynx, asthma,
anaphylactic reactions. Effects on the CNS in the form of dizziness, blurred
vision, a lot of sweat, drowsiness, restlessness, vertigo, etc.
Derivatives Pyrazolon
Included in the pyrazolone: antipirin (fenazone), aminopropin (amidopirin),
fenilbutazone, and their derivatives.
Pharmacodynamic: analgesic, antipyretic and anti-inflammatory (stronger than
aspirin). Not interfere with acid-base balance
Pharmacokinetics: antipirin to measure the amount of water in the
body. Aminopirin experiencing metabolism by enzymes in liver
microsomes. Only 3% aminopirin original form excreted in urine
Side effects: agranulotosis, aplastic anemia and thrombocytopenia, the drug is to
form nitrosamines which are carcinogenic
:0,3-1 g dose 3 times a day
Fenoprofen
Pharmacodynamic: anti-inflammatory, analgesic, antipyretic
Pharmacokinetics: rapidly absorbed through oral administration, the highest
concentration in plasma is reached within 90 minutes, tightly bound in plasma
proteins, excreted through urine
Side effects: gastrointestinal disorders such as constipation, nausea, vomiting,
stomach bleeding.
Dose: 600 mg 4 times daily, after satisfactory, the dose adjusted
Ibuprofen
Efficacy and side effects similar to fenoprofen. Dose of 400 mg 4 times
daily.Contraindicated in pregnant and lactating mothers
Mefenamic acid
Pharmacodynamic: acute and chronic pain who are, are more tosik

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 Side effects: irritation of the stomach, intestinal colic and diarrhea.
Contraindications: patients with peptic gastric disorders, diarrhea, pregnant
women and asthma
Dose: 250 mg every 6 hours for no more than 7 days
Pengguanaan to be oriented on nonopioid oral, some such patients, small children
or patients who have intermaksilari fixation after maxillofacial surgery or trauma,
can not swallow tablets capsule atu. For these patients, liquid / liquid of
acetaminophen or ibuprofen can be considered.
For rare cases, such patients can not receive medication by mouth Parenteral
(ketorolac) or rectal (acetaminophen, aspirin).
b. Acethaminophen
Acetaminophen is an antipyretic analgesic drug which is used as a substitute
asprin out because of stomach problems or other contraindications.
Indications: Provides analgesic effects, the field of dentistry is widely used after
dental surgical procedures, are also commonly used after extraction of third molar
teeth. These drugs also provide anti-inflammatory effects, although not sepoten
aspirin. Acetaminophen shows positive effects to bear the pain until pemakaina
1000 mg.
Pharmacodynamic: similar to aspirin, relieve pain mild - moderate
Acetaminophen has analgesic and antipyretic effects are equivalent to
aspirin. Just as with other NSAID drugs, acetaminophen is also work by
inhibiting prostaglandin synthesis.That distinguishes only diinhibit spectrum of
different COX enzymes.Acetaminophene also been proven to work more actively
than spirin in the CNS, whereas the less active peripheral works. It's just anti-
inflamasinya work was minimal, this is due perokside produced by leukocytes in
inflamed tissue. Perokside highly reactive with acetaminophen, so the work
acetaminophenpun will be reduced.
Pharmacokinetics: Absorbed rapidly and completely through the gastrointestinal
tract. High concentrations in plasma reached within ½ hour. Experiencing
metabolism in the liver by enzin microsomes and secreted through the
kidneys.These drugs can be easily absorbed by the small intestine when given
orally. Well distributed in body tissues and fluids tubuh.sedangkan through
elimination occurs through the kidneys by glomerular filtration and secretion in

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 proximal tubule.
Side effects: Side effects caused by this drug caused by its relationship with
alcohol and drug overdose. When given an overdose of acetaminophen poisoning
will cause liver and kidney damage. In some patients, allergic reactions can also
occur, such as skin Eruption. Rare cases is neutropenia, thrombocytopenia, and
pancytopenia. The combination of these drugs with alcohol consumption can
cause liver disfunction because berfifat hepatotoksi. Side effects of these drugs is
lower than aspirin, does not cause allergies and irritation of the stomach.
Dose: 300 mg-1 g per time with max dose of 4 g per day for adults: 150-300 mg /
dose max times with 1.2 g / day for children aged 6-12 years
c. Corticosteroid
Function glucocorticosteroids suppress pain because of acute inflammation by
pressing vasodilatation, PMN migration and phagocytosis, and inhibit the
formation arakidonik acid that functions in the mechanism of pain.
Postoperative pain or flare-ups can be caused by inflammation and infection that
occurs in periapeks, as we have seen in response to irritants, inflammatory
mediators such as prostaglandins, leukotrienes, bradykinin, pAF, substance-P,
and others issued to surrounding tissue, which can cause vasodilation and
increased vascular permeability that can cause edema.
Mechanism of action:
Corticosteroids work by affecting the rate of protein synthesis. Hormone
molecule enters the network through the plasma membrane by passive diffusion
in the target tissue, and then react with a specific receptor protein in the cell
cytoplasm and form a complex network of receptor-steroid. These complex
changes conformation, and then move toward the nucleus and binds to
chromatin. These bond synthesis stimulates the transcription of RNA and specific
proteins. Induction of protein synthesis is an intermediary for the physiological
effects of steroids. .

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6.2. Opioid
Opioid analgesics are added to nonopioid to regulate rasasakit from medium to
severe or do not respond to nonopioid.
Limit dose used, based on physical samping.pertahanan effects and tolerance of
the body can occur virtually in all patients using opioid analgesics in the long
term.
Opioid analgesics, including both pure agonists (such as codeine and oxycodeine)
and agonist / antagonist (such as pentazocine and butorphanol)
Severe pain should be treated with a combination of nonopioid and opioid (such
as morphine or hydromorphone)
Adjuvants (substances added to a drug to add the power of component) agent
(anticonvulsant: an agent that inhibits seizures, or tricyclic antidepressan) can be
added also in accordance with the indication).
For patients who can not swallow tablets or capsules in a liquid formulation can
be useful opioids (codeine, hydrocodone, oxycodone).
Opioids and phenothiazines (chlorpromazine) is known to produce CNS
depression, including respiratory depression.
Aspirin and NSAIDs are used to reduce pain to pathological processes (pulpitis,
dentoalveolar, abscess)
Opioids for dentistry:

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a. Morphine and opium alkaloids
Pharmacodynamic: is highly selective and not accompanied by loss of function
snsorik. Usefulness based on 3 factors: elevated pain threshold, affect the
emotions, facilitate sleep (increased pain threshold)
Pharmacokinetics: morphine can not penetrate intact skin, but can penetrate the
oral mucosa. Effects of oral administration is lower than parenteral
administration.Morphine excretion through the kidneys, a fraction of faeces and
sweat
Side effects: addiction ◊ restlessness, rapid breathing, yawning, anorexia, etc.
b. Meperidine
Pharmacodynamic: same as morphine, faster and shorter tenure
Pharmacokinetics: good absorption after oral administration, maximum plasma
concentrations achieved within 1-2 hours. Metabolism in the liver
Side effects: dizziness, sweating, dry mouth, nausea and feeling weak
Dose: 50 mg (tablets) oral administration
c. Methadone
Pharmacodynamic: same as morphine
Pharmacokinetics: oral administration to work 20-30 minutes. Well absorbed in
the intestine. Quick out dri blood and accumulate in the lungs, liver, kidney,
spleen, and a small entrance into the brain
Dose: tablets 5, 7.5 and 10 mg (oral)
Side effects: dizziness, drowsiness, sweating and vomiting

VII. Antibiotics
VII.1. Contraindication
Healthy patients without systemic signs and symptoms of infection but with
symptomatic pulpitis, symptomatic apical periodontitis, draining sinus tract, or
localized swelling
VII.2. Prophylactic antibiotics for medically compromised patients
Patients who are at risk of metastatic infection after a bacteremia must receive a
regimen of antibiotics that either follows the recommendations of the American
Heart Association (AHA) or is determined in consultation with the patient's
physician.

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 The AHA recommends the use of antibiotics to protect against endocarditis for
canal instrumentation beyond the apex, for endodontic surgery and for anesthesia
delivered via the periodontal ligament.
Patients considered to be at risk include
immunocompromised/immunosuppressed patients, insulin-dependent (type I)
diabetic patients, patients who have had joint replacement in the past 2 years, and
those with previous joint infections, malnourishment, and hemophilia
VII.3. Antibiotics used in treatment
Antibiotic should be prescribed in conjunction with the appropriate endodontic
procedure when there is systemic involvement, a persistent infection, or a
spreading infection.
Signs and symptoms of systemic involvement and spread of infection include:
fever (>38' C), malaise, cellulitis, progressive abscess, and unexplained trismus,
alone or in combination → antibiotic
should be given as an addition to debridement and drainage or extraction when
indicated.
VII.4. Selection of an antibiotic regimen

a. Penicillin VK: first choice (it has remained effective against most of the
facultative and strict anaerobes commonly found in endodontic infections).
Penicillin is inexpensive, has low toxicity, but approximately 10% of the
population may be allergic to this medication. For penicillin prescription, an
adequate blood level must be obtained.

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 DOSAGE An initial oral loading dose of 1000 mg of penicillin VK is followed
by 500 mg every 6 hours for 7 days.
b. Amoxicillin has a broader spectrum than penicillin VK that includes bacteria not
usually found in endodontic infections.
DOSAGE An oral loading dose of 1000 mg is followed by 500 mg every 8 hours
for 7 days.
c. Metronidazole against anaerobes but doesn’t have activity against aerobes or
facultative anaerobes.
The addition of metronidazole to penicillin for combined therapy is indicated if
the patient's condition is not improving after 72 hours. The patient should
continue to take the prescribed penicillin to against aerobes or facultative
anaerobes.
DOSAGE 500 mg every 6 hours for 7 days
d. Clindamycin against many Gram-positive and Gram-negative microorganisms
including both facultative and strict anaerobes. It is a good (but expensive)
alternative to penicillin and is recommended for patients allergic to penicillin.
DOSAGE 300 mg loading dose followed by 150 to 300 mg every 6 hours for 7
days.
e. Clarithromycin and azithromycin prescribed for patients allergic to penicillin
with relatively mild indications for systemic antibiotic therapy.
DOSAGE Clarithromycin may be given with or without meals in a dose of 250
to 500 mg every 12 hours for 7 days
DOSAGE Asithromycin should be taken 1 hour before meals or 1 hour after
meals. A loading dose of 500 mg is followed by 250 mg daily for 5 to 7 days.

VIII. Considerations in Endodontic

The process of case selection and treatment planning begins after a clinician has
diagnosed an endodontic problem. The clinician must determine if the patient’s
oral health needs are best met by providing endodontic treatment and maintaining
the tooth or by advising extraction. Questions concerning tooth retention and
possible referral can be answered only after a complete patient evaluation. The
evaluation must include assessment of medical, psychosocial, and dental factors
as well as a consideration of the relative complexity of the endodontic procedure.

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 Although most medical conditions do not contraindicate endodontic treatment,
some can influence the course of treatment and require specific modifications.
The American Society of Anesthesiologists (ASA) Physical Status Classification
was devised in 1941 and revised to its present form in 1983. The ASA website
lists the following:
ASA I- Normal, healthy patient; no dental management alterations required.
ASA II- A patient with mild systemic disease that does not interfere with daily
activity or who has significant health risk factor (e.g., smoking, alcohol abuse,
gross obesity); may or may not need dental management alterations.
Examples: Stage I or II hypertension, type 2 diabetes, allergy, well-controlled
asthma.
ASA III- A patient with moderate to severe systemic disease that is not
incapacitating but may alter daily activity; may have significant drug concerns;
may require special patient care; would generally require dental management
alterations.
Examples: Type 1 diabetes, stage 3 hypertension, unstable angina pectoris,
recent myocardial infarction, poorly controlled congestive heart failure, AIDS,
chronic obstructive pulmonary disease, hemophilia.
ASA IV- A patient with severe systemic disease that is a constant threat to life;
definitely requires dental management alterations; best treated in special facility.
Example: Kidney failure, liver failure, advanced AIDS.
The ASA classification remains the most widely used assessment method for
preanesthetic patients despitebsome inherent limitations to its use as a
perioperative risk predictor. This is a generally accepted and useful guide for
preoperative assessment of relative risk. However, the prudent clinician should
also take into account other factors not considered in the classification scheme,
such as age, obesity, and skill of the health care provider.
COMMON MEDICAL FINDINGS THAT MAY INFLUENCE
ENDODONTIC TREATMENT PLANNING
VIII.1. Pregnancy
Although pregnancy is not a contraindication to endodontics, it does modify
treatment planning. An extensive body of literature exists concerning the use of
radiographs and drugs while treating pregnant patients. Protection of the fetus is

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 a concern when administration of ionizing radiation or drugs is considered. Of all
the safety aids associated with dental radiography, such as high-speed film,
digital imaging, filtration and collimation, the most important is the protective
lead apron with thyroid collar.
Drug administration during pregnancy is a controversial subject. A major concern
is that a drug may cross the placenta and be toxic or teratogenic to the fetus. In
addition, any drug that is a respiratory depressant can cause maternal hypoxia,
resulting in fetal hypoxia, injury, or death. Ideally, no drug should be
administered during pregnancy, especially during the first trimester. If a specific
situation makes adherence to this rule impossible, then that clinician should
review the appropriate literature and discuss the case with the physician and
patient.
Further considerations exist during the postpartum period if the mother breast
feeds her infant. Although most drugs are only minimally transmitted from the
maternal serum to the breast milk and the infant’s exposure is not significant, the
clinician should avoid using any drug known to be harmful to the infant. A
dentist should consult the responsible physician before using any medications for
the nursing mother. Alternative considerations include using minimal dosages of
drugs, having the mother bank her milk before treatment, having her feed the
child before treatment, or suggesting the use of a formula for the infant until the
drug regimen is completed.
Partial List of Drugs Usually Compatible with Breast Feeding
• Acetaminophen
• Many antibiotics
• Aspirin (should be used with caution)
• Codeine
• Ibuprofen
• Insulin
• Quinine
• Thyroid medications
In terms of treatment planning, elective dental care is best avoided during the first
trimester because of the potential vulnerability of the fetus. The second trimester

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 is the safest period in which to provide routine dental care. Significant surgical
procedures are best postponed until after delivery.

VIII.2. Cardiovascular Disease

Patients with some forms of cardiovascular disease are vulnerable to physical or
emotional stress that may be encountered during dental treatment, including
endodontics. Patients may be confused or ill informed concerning the specifics of
their particular cardiovascular problem. In these situations, consultation with the
patient’s physician is mandatory before the initiation of endodontic treatment.
Patients who have had a myocardial infarction (i.e., “heart attack”) within the
past 6 months should not have elective dental care. This is because patients have
increased susceptibility to repeat infarctions and other cardiovascular
complications and may be taking medications that could potentially interact with
the vasoconstrictor in the local anesthetic. In addition, vasoconstrictor should not
be administered to patients with unstable angina pectoris or to patients with
uncontrolled hypertension, refractory arrhythmias, recent myocardial infarctions
(less than 6 months), recent stroke (less than 6 months), recent coronary bypass
graft (less than 3 months), uncontrolled congestive heart failure, and uncontrolled
hyperthyroidism. Vasoconstrictors may interact with some antihypertensive
medications and should be prescribed only after consultation with the patient’s
physician. For example, vasoconstrictors should be used with caution in patients
taking digitalis glycosides (e.g., digoxin) because the combination of these drugs
could precipitate arrhythmias. Local anesthetic agents with minimal or no
vasoconstrictors are usually adequate for nonsurgical endodontic procedures.
A patient who has a heart murmur as a result of a pathologic condition may be
susceptible to an infection on or near the heart valves, which is caused by a
bacteremia. This infection is called infective or bacterial endocarditis and is
potentially fatal. Patients who have a history of murmur or mitral valve prolapse
with regurgitation, rheumatic fever, or a congenital heart defect must be given
antibiotic therapy prophylactically before endodontic therapy to minimize the
risk of bacterial endocarditis. Because the American Heart Association
periodically revises its recommended antibiotic prophylactic regimen for dental
procedures, it is essential for the clinician to stay current concerning this

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 important issue. A low compliance rate exists among at-risk patients regarding
their use of the suggested antibiotic coverage before dental procedures. Therefore
the clinician must question patients concerning their compliance with the
prescribed prophylactic antibiotic coverage before endodontic therapy. If the
patient has not taken the antibiotic, the procedure must be delayed.
Patients with artificial heart valves are considered highly susceptible to bacterial
endocarditis. Therefore consulting this patient’s physician regarding antibiotic
premedication is essential. Some physicians elect to administer parenteral
antibiotics in addition to or in place of the oral regimen. The coronary artery
bypass graft is a common form of cardiac surgery. Ideally, vasoconstrictors
should be minimized during the first 3 months after surgery to avoid the
possibility of precipitating arrhythmias. Ordinarily these patients do not require
antibiotic prophylaxis after the first few months of recovery unless there are other
complications. The clinician can play an important role in the detection of
hypertension. The clinician may be the first to detect an elevated blood pressure.
Further, patients receiving treatment for hypertension may not be controlled
adequately because of poor compliance or inappropriate drug therapy. Abnormal
blood pressure readings become the basis for physician referral. Few conditions
exist in which there is a possibility that dental treatment could seriously injure or
even result in the death of a patient. However, acute heart failure during a
stressful dental procedure in a patient with significant valvular disease and heart
failure or the development of infectious endocarditis represent two such life-
threatening disorders. Careful evaluation of patients’ medical histories including
the cardiac status of patients, the use of appropriate prophylactic antibiotics, and
stress reduction strategies will minimize the risk of serious cardiac sequelae.

VIII.3. Cancer
Some cancers may metastasize to the jaws and mimic endodontic pathosis,
whereas others can be primary lesions. A panoramic radiograph is useful in
providing an overall view of all dental structures. When a clinician begins an
endodontic procedure with a well-defined apical radiolucency, it might be
assumed to result from an extension of infectious agents from a nonvital pulp.
Careful examination of preoperative radiographs from different angulations is

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 important since lesions of endodontic origin would not be expected to be shifted
away from the radiographic apex in the different images. If a local anesthetic is
not administered and if the patient experiences pain during access or canal
instrumentation, it is advisable to reconsider the original diagnosis because the
radiolucency may be a lesion of nonodontogenic origin.
A definitive diagnosis of a periradicular osteitis can be made only after biopsy.
When a discrepancy exists between the initial diagnosis and clinical findings,
consultation with an endodontist is advisable.
Patients undergoing chemotherapy or radiation to the head and neck may have
impaired healing responses. Treatment should be initiated only after the patient’s
physician has been consulted. Resolving the question of endodontic treatment or
extraction for preradiation patients often requires a dialogue between the dentist
and physician.
The effect of the external beam of radiation therapy on normal bone is to decrease
the number of osteocytes, osteoblasts, and endothelial cells, thus decreasing
blood flow. Pulps may become necrotic from this impaired condition. Toxic
reactions during and after radiation and chemotherapy are directly proportional to
the amount of radiation or dosage of cytotoxic drug to which the tissues are
exposed. Delayed toxicities can occur several months to years after radiation
therapy.
The outcome of endodontic treatment should be evaluated within the framework
of the toxic results of radiation and drug therapy. The cancer patient’s white
blood cell (WBC) count and platelet status should also be reviewed before
endodontic treatment. In general, routine dental procedures can be performed if
the granulocyte count is greater than 2000/mm3 and the platelet count is greater
than 50,000/mm. If urgent care is needed and the platelet count is below
50,000/mm, consultation with the patient’s oncologist is required.

VIII.4. Human Immunodeficiency Virus and Acquired Immunodeficiency

Syndrome
It is important for clinicians treating acquired immunodeficiency syndrome
(AIDS) patients to understand their patient’s level of immunosuppression, drug
therapies, and potential for opportunistic infections. Although the effect of human

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 immunodeficiency virus (HIV) infection on long-term prognosis of endodontic
therapy is unknown, studies have shown that HIV patients do not have increased
risk for postoperative pain or inflammation after endodontic treatment. The
clinical team must also minimize the possibility of transmission of HIV from an
infected patient, and this is accomplished by adherence to universal precautions.
Although saliva has not been demonstrated to have transmitted the virus in a
dental situation, the potential for it to do so exists. Infected blood can transmit
HIV, and during some procedures it may become mixed with saliva. Latex gloves
and eye protection are essential for the clinician and staff. HIV can be transmitted
by needlestick or an instrument wound, but the frequency of such transmission is
low, especially with small-gauge needles.
A vital aspect of treatment planning for the patient with HIV/AIDS is
determining the current CD4 lymphocyte count and level of immunosuppression.
Generally patients having a CD4 count of more than 400 mm3 may receive all
indicated dental treatment. Patients with a CD4 count of less than 200 mm3 will
have increased susceptibility to opportunistic infections and may be effectively
medicated with prophylactic drugs. Medical consultation is advisable before
surgical procedures and before initiating complex treatment plans.

IX. Endodontic Evaluation

IX.1. When to evaluate
Suggested follow-up periods range from 6 months to 4 years. If at 6 months the
lesion is still present but smaller in size, there is an indication that it might heal
but additional recall is needed.
The larger the periapical lesion before the root canal treatment, the longer the
healing period.
IX.2. Methods of evaluation
a. Clinical examination
Failure : persistence of adverse significant signs (swelling or sinus tract) or
symptoms (spontaneous pain, dull persistent ache, or mastication sensitivity)
Success : absence of pain and swelling, disappearance of sinus tract, no evidence
of soft tissue destruction, including probing defects.

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b. Radiographic finding
SUCCESS - the elimination or nondevelopment of an area of rarefaction for a
minimum of 1 year after treatment (fig 19-1)

FAILURE - persistence or development of a radiolucent lesion that has remained

the same, has enlarged, or has developed since treatment (fig 19-2)

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 QUESTIONABLE – the radiolucent lesion has neither become larger nor
significantly decreased in size. A questionable status is considered to be
nonhealing if there is no resolution after more than 1 year (fig 19-3)

IX.3. Causes of endodontic failure

a. Preoperative causes

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 Misdiagnosis, errors in treatment planning, poor case selection (dentists
attempting treatment beyond their skill levels), or treatment of a tooth with a poor
prognosis.
b. Operative causes
Incomplete cleaning and shaping of the canal space, not enough dense obturation
that is confined to the root canal system and then by a bad quality coronal
restoration.
c. Postoperative factors
Restoration doesn’t occur soon after obturation, presence of space between
coronal filing and obturation in cervical area.

X. Healing Mechanism
Regeneration is a process by which altered periapical tissues are completely
replaced by native tissue to their original architecture and function. Repair is a
process by which altered tissues are not completely restored to their original
strictures. Healing of periapical lesion after root canal therapy is repair rather
than regeneration of the periapical tissues. Inflammation and healing are not two
separate entities and in fact constitute part of one process in response to tissue
injury. Inflammation dominates the early events after tissue injury, shifting
toward healing after the early responses have subsided.

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