Clinical Endo
Clinical Endo
Clinical Endo
Treatment of acute apical periodontits and acute apical abcess : first we should remove the source of infection if
there were spreading of infection (swelling or cellulities ) we should use systemic antibiotic ,then we treated by
incision for drainage and root canal treatment with good irrigation and cleaning or extraction to remove the source
of infection and clean the socket .
From where endodontics word came and what is endodontic?
It came from new Latin endodontia from endo- +Greek Odon teeth
Endodontic: is the branch of dentistry that deals with the diagnosis and treatment of disease and disorders of
tooth root and dental pulp and surrounding tissues.
The functions of pulp are:
1-formation of dentin, secondary dentin
2- nutrition and innervation because it has vessels and nerves
3-protevtive and defense that it responds to any injury or action and forms secondary dentin
4-sensory
If you did endo treatment for a tooth had apical lesion, and the patient came after 6 months with same size
of apical lesion what will you do?
6 month is very short time ,we should continue *follow up* by taking x ray after 6 month and one year and
two year till 4th year, if the prognosis is bad after 4 year we should do retreatment.
If the file was entering normally to the apex 19 mm, and after that it start stopping till it reach 16 MM,
what is the possible reasons?
Not good irrigation, and maybe broken file.
What is the possible ways to remove the broken files?
ultrasonic devices, make the canal wider and remove it by file, should say at least 3 techniques
If you had broken file in the canal what should you do and you cannot remove the file?
We should always think first about removal the file but because it is not possible, we go to the most important
was: 1 BY PASS*SHE WANTED TO LISTEN THIS technique* 2 fill the canal till the broken file.
If you perforated the furcation area which materials you should put in the perforated area?
MTA + CALCIUM HYDROXIDE
What do you know about the MTA?
preserve the tooth structures and prevent tooth resorption, it usually creating an apical plug in apexification,
repairing root perforation, and treating internal root resorption and can be used as both a root end filling and
pulp capping materials
WHAT IS THE MOST USED IRRIGATION SOLUTION?
sodium hypochlorite
What is the most imp features and the percentage and time of using sodium hypochlorite and EDTA?? And
irrigation sequence?
1-sodium hypochlorite 5.25% - for its anti-bacterial effect at least 5 min
2-EDTA 17% 1min - to remove organic structures
3-sodium hypochlorite 5.25%
4-sterile water - neutralize the effect of these irrigants
5-use 2% chloroxidine from 5 to 10 min - elimination of various bacteria
After you reach the MAF what you should do?
one bigger size file = enter the file 1mm less
What is the treatment of traumatic teeth?
It depends about the traumatic type, I explained it in the next pages.
What is temporary filling materials in RCT?
first CALCIUM HYDROXIDE then cotton roll then cement
Why we used cotton roll between the medication and temporary filling?
to not mix the medication with cement
What is the permanent filling materials after rct?
A: intracanal: gutta percha, then sealer * calcium hydroxide* in the pulp chamber, then composite
What are the pulp zone?
1. Odontoblast zone
2. Cell free zone
3. Cell rich zone
4. Pulp
How to know the fistula from which tooth?
we enter gutta percha to fistula and take x-ray and see where the gutta percha it means this is the tooth
What is the chemical proprieties of calcium hydroxide?
1- As intracanal dressing is antibacterial, because of its high ph, and it absorbs co2 that is necessary for
anaerobic bacteria, and it also has anti-inflammatory effect
2-as capping material it makes a layer of necrosis on the surface of the pulp which stimulate the formation of
secondary dentin.
Why we use calcium hydroxide?
Because of high ph*12.5* and its antimicrobial activity, resorn ph which is the source of anaerobic bacteria,
prevent tooth resorption, tissue dissolve ability.
How many days should calcium hydroxide be left in the canal?
7 days
How we remove calcium hydroxide from root canal?
By manual irrigation using sodium hypochlorite combined with hand instrumentation with final rinse of EDTA.
How many visits should root canal treatment finish? When we finish it in one visit?
Standard rct should be done in 2 visits, we can finish it when there is extensive crown fracture and need to do
post and core for esthetic goals, when there is a sealing and isolation problems.
What are the materials that use for irrigation?
Mentioned above. then we dry and fill
How to diagnose periodontitis?
Should have pain by percussion and palpation.
What you will do if pus come out of the cavity?
We should put calcium hydroxide and wait for 1 hour if it does not stop, we put calcium hydroxide again and
wait 2 days then continue the normal treatment.
Treatment of acute apical periodontitis and acute apical abscess.
First we should remove the source of infection if there were spreading of infection (swelling or cellulitis) we
should use systemic antibiotic, then we treat it by incision for drainage and root canal treatment with good
irrigation and cleaning or extraction to remove the source of infection and clean the socket.
What size abscess should be drained?
if it less than 5 mm it can resolve itself by using warm compress or antibiotic therapy, but if it is bigger than 5
mm then we should drain it.
When do we use antibiotics?
A: 1) Treatment of infection in periapical region
2) prophylaxis use penicillin as first choice, if there is allergic of penicillin using metronidazole.
2) Prophylaxis:
-(transient bacteremia) due to viridans group streptococci
1) manipulation of gingival tissue 2) manipulation of gingival region 3) all dental procedures involving oral
mucosa perforations
-(dental antibiotic prophylaxis) is the administration of antibiotics to a dental patient for prevention of harmful
consequences of bacteremia, that may be caused by invasion of the oral flora into an injured gingival or
periapical vessel during dental treatment
-it’s used to prevent the development of complications such as (infective endocarditis) or (post-surgical
infection) in dentistry
-antibiotic prophylaxis with dental procedures is reasonable only for patients with cardiac conditions
associated with the highest risk of adverse outcomes from endocarditis, including:
1) prosthetic cardiac value or prosthetic material used in value repair
2)previous endocarditis
3) congenital heart disease (CHD)
4) cardiac transplantation recipients with cardiac valvular disease
Which antibiotic? (These factors should be evaluated together)
1) detection of microorganisms 2) the severity of infection 3) general health status of the patient
-endodontic infections are (polymicrobial) and most of these isolated microorganisms are (obligate) or
(facultative anaerobic) bacteria
-(spectrum of the antimicrobial activity) is the range of bacterial types against which the antibiotic is effective
-selection the (narrowest spectrum antibiotics) sensitive to the causative microorganisms
-ideally, pre-treatment specimens should be taken to identify the causative microorganisms by (culture) and to
give the appropriate antibiotic according to the (susceptibility test) result
-takes several days to weeks –we know approximately the microorganisms found in endo infection
-empiric selection of (antibiotic)
-persistent infection → cultivation methods
-preferred antibiotics for endodontic infections:
1) penicillin V
2) amoxicillin
3) clarithromycin or azithromycin
4) metronidazole
5) clindamycin
Tooth Fractures
Enamel Fracture
• A complete fracture of the enamel. Loss of enamel. No visible sign of exposed dentin
• Not tender. If tenderness is observed, evaluate the
• Tooth for a possible luxation or root fracture injury.
• Normal mobility.
• Sensibility pulp test usually positive.
• Enamel loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposures. They are recommended in order
to rule out the possible presence of a root fracture or a luxation injury.
• Radiograph of lip or cheek to search for tooth fragments or foreign materials.
TREATMENT
• A fracture confined to enamel and dentin with loss of tooth structure, but not exposing the pulp.
• Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation or root
fracture injury.
• Normal mobility.
• Sensibility pulp test usually positive.
• Enamel-dentin loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposure to rule out tooth displacement or
possible presence of root fracture.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.
TREATMENT
• If a tooth fragment is available, it can be bonded to the tooth. Otherwise, perform a provisional treatment
by covering the exposed dentin with glass Ionomer or a more permanent restoration using a bonding
agent and composite resin or other accepted dental restorative materials.
• If the exposed dentin is within 0.5 mm of the pulp (pink, no bleeding), place calcium hydroxide base and
cover with a material such as a glass ionomer.
FOLLOW-UP
• A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.
• Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation or root
fracture injury.
• Normal mobility.
• Exposed pulp sensitive to stimuli.
• Enamel-dentin loss is visible.
• Radiographs recommended: periapical, occlusal and eccentric exposure to rule out tooth displacement or
possible presence of root fracture.
• Radiograph of lip or cheek lacerations to search for tooth fragments or foreign materials.
TREATMENT
• In young patients with immature, still developing teeth, it is advantageous to preserve pulp vitality by
pulp capping or partial pulpotomy. Also, this treatment is the choice in young patients with completely
formed teeth.
• Calcium hydroxide is a suitable material to be placed on the pulp wound in such procedures.
• In patients with mature apical development, root canal treatment is usually the treatment of choice,
although pulp capping or partial pulpotomy also may be selected.
• If tooth fragment is available, it can be bonded to the tooth.
• Future treatment for the fractured crown may be restoration with other accepted dental restorative
FOLLOW-UP
CROWN-ROOT FRACTURES
• Crown root fracture involves enamel, dentin and cementum with or without the involvement of pulp
• It is usually oblique in nature involving both crown and root.
• Crown fracture extending below gingival margin
• Percussion test: Tender.
• Coronal fragment mobile.
• Vitality test usually positive
• Apical extension of fracture usually not visible.
• Radiographs recommended: periapical and occlusal exposure.
TREATMENT
FOLLOW-UP
TREATMENT
FOLLOW-UP
PROGNOSIS
• Healing with calcified tissue in which fractured fragments are in close contact.
• Healing with interproximal connective tissue in which radiographically fragments appear separated by a
radiolucent line.
• Healing with interproximal bone and connective tissues.
• Interproximal inflammatory tissue without healing,
• radiographically it shows widening of fracture line
Classification (Andreasen, WHO, International Association of Dental Traumatology)
Luxation Injuries (Periodontal Tissue Injuries)
• Tooth concussion
• Subluxation
• Extrusive luxation (Extrusion)
• Lateral luxation
• Intrusive luxation (Intrusion)
• Avulsion
Concussion
• The tooth is tender to touch or tapping; it has not been displaced and does not have increased mobility.
• Tooth is not displaced.
• Mobility is not present
• Tooth is tender to percussion because of edema and hemorrhage in the periodontal ligament.
• No radiographic abnormalities.
TREATMENT
• No treatment is needed.
• Monitor pulpal condition for at least one year.
FOLLOW-UP
Subluxation
• The tooth is tender to touch or tapping and has increased mobility; it has not been displaced.
• Bleeding from gingival crevice may be noted.
• Sensibility testing may be negative initially indicating transient pulpal damage.
• Monitor pulpal response until a definitive pulpal diagnosis can be made.
• No radiographic abnormalities.
TREATMENT
• Normally no treatment is needed, however, a flexible splint to stabilize the tooth for patient comfort can
be used for up to 2 weeks.
FOLLOW-UP
TREATMENT
FOLLOW-UP
Lateral luxation
TREATMENT
• Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it
into its original location.
• Stabilize the tooth for 4 weeks using a flexible splint.
• Monitor the pulpal condition.
• If the pulp becomes necrotic, root canal treatment is indicated to prevent root resorption.
FOLLOW-UP
TREATMENT
• Allow eruption without intervention if the tooth is intruded less than 3 mm. If no movement after 2-4
weeks, reposition surgically or orthodontically before ankyloses can develop.
• If the tooth is intruded 3-7 mm, reposition surgically or orthodontically.
FOLLOW-UP
Closed Apex:
(IF TOOTH REPLANTED PRIOR TO THE PATIENT’S ARRIVAL AT THE DENTAL OFFICE OR CLINIC)
TREATMENT
PATIENT INSTRUCTIONS
TREATMENT
• Clean the root surface and apical foramen with a stream of saline and soak the tooth in saline
thereby removing contamination and dead cells from the root surface.
• Administer local anesthesia
• Irrigate the socket with saline.
• Examine the alveolar socket. If there is a fracture of the socket wall, reposition it with a suitable
instrument.
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth both, clinically and radiographically.
• Apply a flexible splint for up to 2 weeks, keep away from the gingiva.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at
appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be
considered before systemic administration of tetracycline in young patients (In many countries
tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl
Penicillin (Pen V) or amoxicillin, at appropriate dose for age and weight, is an alternative to tetracycline
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician
for a tetanus booster.
• Initiate root canal treatment 7-10 days after replantation and before splint removal.
PATIENT INSTRUCTIONS
FOLLOW-UP
• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament
for up to 1 month followed by root canal filling with an acceptable material.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.
CLOSED APEX: EXTRAORAL DRY TIME EXCEEDING 60 MIN OR OTHER REASONS SUGGESTING NON-VIABLE CELLS
TREATMENT
• Delayed replantation has a poor long-term prognosis. The periodontal ligament will be necrotic and
cannot be expected to heal. The goal in delayed replantation is, in addition to restoring the tooth for
esthetic, functional and psychological reasons, to maintain alveolar bone contour. However, the expected
eventual outcome is ankyloses and resorption of the root and the tooth will be lost eventually.
• Remove attached non-viable soft tissue carefully, with gauze.
• Root canal treatment can be performed prior to replantation, or it can be done 7-10 days later.
• Administer local anesthesia
• Irrigate the socket with saline.
• Examine the alveolar socket. If there is a fracture of the socket wall,
• Replant the tooth slowly with slight digital pressure. Do not use force.
• Suture gingival lacerations if present.
• Verify normal position of the replanted tooth clinically and radiographically.
• Stabilize the tooth for 4 weeks using a flexible splint. Reposition it with a suitable instrument.
• Administer systemic antibiotics. Tetracycline is the first choice (Doxycycline 2x per day for 7 days at
appropriate dose for patient age and weight). The risk of discoloration of permanent teeth must be
considered before systemic administration of tetracycline in young patients (In many countries
tetracycline is not recommended for patients under 12 years of age). In young patients Phenoxymethyl
Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight, is an alternative to
tetracycline.
• If the avulsed tooth has been in contact with soil, and if tetanus coverage is uncertain, refer to physician
for a tetanus booster.
• To slow down osseous replacement of the tooth, treatment of the root surface with fluoride prior to
replantation has been suggested (2 % sodium fluoride solution for 20 min.)
PATIENT INSTRUCTIONS
FOLLOW-UP
• Root canal treatment 7-10 days after replantation. Place calcium hydroxide as an intra-canal medicament
for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-
corticosteroid paste may be placed immediately or shortly following replantation and left for at least 2
weeks.
• Splint removal and clinical and radiographic control after 2 weeks.
• Clinical and radiographic control after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter
AVULSION:
Factors affecting the success of reimplantation:
1. Periodontal ligament
2. Extraoral time
3. Transportation
4. Splinting
5. Root Canal Treatment Timing
6. Calcium Hydroxide Therapy
7. Fluoride Application
PROGNOSIS:
Storage media for avulsed tooth (from the best to the worst)