3

Access to the Root Canal

System: Preparation for
Treatment

ENDODONTIC RADIOGRAPHY

It is imperative that a good and current radiograph be available before

root canal treatment is started. All too often, patients are referred for
endodontic treatment along with a dated film or one of poor quali-
ty. The first order of procedures should be to take a new radiograph
or, better yet, take additional films from a different horizontal angle.
By this action multiple roots or canals may be revealed (Figure 3-1),
or what appears to be a periapical lesion may be determined to be the

Figure 3-1 Maxillary premolars. A, Horizontal, right-angle projection produces

the illusion that the maxillary molar has only one canal. Courtesy of R.E.
Walton. (Continued on the next page).
 Access to the Root Canal System 59

Figure 3-1 Continued. Maxillary premolars. B, Varying the horizontal projec-

tion by 20° mesially separates the two canals. The lingual canal is toward the
mesial. Courtesy of R.E. Walton.

mental or incisive foramen (Figure 3-2). Always check by pulp test-

ing. Do not base your judgment on a single film. Remember, what
one sees is a two-dimensional view of a three-dimensional object.
Radiography, both traditional and digital, is discussed in Chapter 1.

Figure 3-2 Mental foramen is super-

imposed exactly at the apex of the
vital premolar, and may be easily mis-
taken for a periradicular lesion.
60 PDQ ENDODONTICS

PULP TESTING

Pulp testing of the suspected tooth and adjacent teeth should follow
radiography. Comparative tests on the opposite side and the oppo-
site arch are often in order. Again, these procedures are covered in
Chapter 1.

ANESTHESIA

Endodontic treatment should be painless. The old saw, “That’s worse

than having a root canal,” should long have disappeared from our
lexicon. However, some endodontic procedures can be painful unless
special precautions are taken. On the other hand, some cases, such
as total pulp necrosis, can be treated without anesthesia. In fact,
during canal instrumentation, as a file approaches the apical fora-
men, the patient often responds not in pain, but in sensation. This
is a warning that the working length has been reached. If anesthe-
sia were to be used, that length might have been exceeded. If the
placement of a rubber dam clamp is likely to be painful, minimal
local injections are in order. Block anesthesia is usually satisfactory
for most cases. Do not overlook the advantages of seldom-used block
injection sites—for example, the mental foramen area, which blocks
all mandibular teeth from second premolar to the midline and not
the tongue; or the infraorbital injection, which blocks two premo-
lars and the ipsilateral maxillary anterior teeth. This latter injection
is made by inserting the needle into the buccal fold above the max-
illary first premolar and aiming for the infraorbital foramen, found
by palpation. A small deposit is made there and is forced into the
foramen by finger pressure. In the event that inflamed pulp tissue is
not entirely anesthetized by blocks, there are additional injection
techniques that can be used.

SUPPLEMENTAL INJECTION TECHNIQUES

Probably the most widely employed supplemental injection is the

periodontal ligament (PDL) injection. It is used principally in the
mandible when block anesthesia is not complete. The needle is placed
alongside the root of the tooth. The bevel of the needle, not the sharp
tip, faces the root! The needle is then advanced down the PDL space,
 Access to the Root Canal System 61

and 0.02 mL of solution is slowly deposited (Figure 3-3). Each root

must be separately anesthetized. Onset is immediate; duration,
although limited, should be long enough to enter the pulp and com-
plete the pulpectomy. PDL injections should not be used on prima-
ry teeth or teeth with periodontal infection.
Intraosseous anesthesia is indicated in those cases of a “hot tooth”
that seems refractory to being anesthetized. The anesthetic is inject-
ed directly into the bone surrounding the root. To do this a small
perforation must be made through the heavy cortical bone with a
tiny dental bur. The needle is inserted through this hole, and 0.45 to
0.6 mL of anesthetic solution is deposited in the highly vascular can-
cellous bone. The recent introduction of the X-tip Intraosseous
Anesthesia Delivery System (Maillefer/Dentsply, Tulsa, OK) has great-
ly improved the efficacy of this form of anesthesia (Figure 3-4). The
X-tip comes in two parts: a tiny drill used in a slow-speed handpiece
to perforate the cortical plate, and a very short 27 g needle that inserts
into the guide sleeve left behind. After the anesthetic is injected, the
guide sleeve is withdrawn with a hemostat.

Figure 3-3 Insertion of the needle for periodontal ligament injection. Incorrect
insertion of the sharp needle tip toward the root (left). Correct insertion of the
bevel facing the root (right).
62 PDQ ENDODONTICS

Figure 3-4 Intraosseous anesthesia delivery system X-tip (Dentsply/Maillefer).

A, The X-tip system comes in two parts: the drill and the guide sleeve and spe-
cial injection needle. To use the system, first anesthetize the area to be fully
anesthetized with a few drops of anesthetic in the mucobuccal fold. Select a
site 2 to 4 mm apical to the bony crest and between the roots. B, Place the X-
tip drill and guide sleeve in a slow-speed (15,000–20,000) handpiece, and drill
at maximum speed at 90° to the bone. In 2 to 4 seconds the drill will perforate
the cortical bone to the cancellous bone. (Continued on the next page).
 Access to the Root Canal System 63

Figure 3-4 Continued. C, Hold the guide sleeve in place and withdraw the
drill. D, Insert the special short needle into the tiny hole in the guide sleeve and
slowly inject a few drops of anesthetic. In the event additional anesthesia may
be needed, the guide sleeve may be left in place until the end of the appoint-
ment.
64 PDQ ENDODONTICS

A word of caution, however: owing to rapid absorption, one must

be careful not to inject too much anesthesia. A reaction to the anes-
thetic and/or the vasopressor may ensue. For this reason a nonepi-
nephrine anesthetic should be used. Anesthesia usually applies to one
or two teeth. This injection has proved of great value when extirpat-
ing pulps with irreversible pulpitis refractory to block anesthesia.
Because it can be momentarily painful, intrapulpal anesthesia is
the anesthesia of last resort. While injecting ahead, the needle is insert-
ed into the pulp chamber and down a canal until it meets resistance.
The anesthetic must be injected under pressure. A tiny amount of
solution is deposited into the pulp tissue (Figure 3-5). Although it
is painful at first, the discomfort should subside immediately and
one may proceed with impunity.
When all else fails, concurrent administration of inhalation seda-
tion (N2O–O2) or intravenous midazolam (versed) provides con-
scious sedation and negates any pain response.

A B

Figure 3-5 Intrapulpal pressure anesthesia with lidocaine. A, Coronal injection

through a pinhole opening in the dentin. B, Pulp canal injection for each indi-
vidual canal. The needle is inserted tightly, and one drop of solution is deposit-
ed. Courtesy of C. Lambert and G. Lambert.
 Access to the Root Canal System 65

RUBBER DAM APPLICATION

It is mandatory that a rubber dam be used during endodontic treatment

to isolate the involved tooth and prevent further contamination of the root
canal. Besides providing a dry, clean, and disinfected field, the dam pro-
tects the patient from swallowing or aspirating endodontic instruments or
debris (Figure 3-6). Usually, only the single tooth needs be incorporated
in the dam. The dam can be placed in less than a minute. The best dam
sizes for endodontics are the 12.7 × 12.7 cm (5” × 5”) or 15.2 × 15.2
(6” × 6”)cm sheets; however, occasionally a small, circular dam (Zirc
Co., Buffalo, NY) or the small, oblong HandyDam (Dentsply/Tulsa)
may be used for dressing changes or emergencies (Figure 3-7).

Figure 3-6 A, Abdominal radiograph

of a swallowed endodontic instru-
ment now caught in the duodenum. It
must be removed surgically. Courtesy
of J. Goultschin and B. Heling. B,
Swallowed endodontic file that ended
up in the appendix and led to acute
appendicitis and appendectomy. The
use of a rubber dam would have pre-
vented this tragedy. Courtesy of L.C.
Thomsen and colleagues.

B
66 PDQ ENDODONTICS

Figure 3-7 A, Instant, circular rubber dam with attached frame

(Dentsply/Maillefer). B, Insta-Dam (Zirc Co.) used to isolate a single tooth for
endodontic therapy.

“Rubber” dams come in latex and nonlatex materials—silicone

rubber, (Coltene/Whaledent/Hygienic Corp.)—for patients and den-
tists who are allergic to latex. Most popular are the nonmetal, radi-
olucent rubber dam frames that do not block important areas from
x-rays. These include the shield-shaped Nygaard-Ostby frame (Figure
3-8A) (Coltene/Whaledent/Hygienic Corp., Mahwah, NJ), the Starlite
VisuFrame (Interdent, Inc., Culver City, CA), and the Articulated
 Access to the Root Canal System 67

Frame (Dentsply/Tulsa), which may be folded back to better place

x-ray films (Figure 3-8B). A new, soft metal frame that may be formed
into shapes to fit the face has recently been introduced (Derma Frame,
Ultradent Products, Inc. South Jordan, UT) (Figure 3-8C). These

B C

Figure 3-8 A, Nygaard-Ostby Rubber Dam Frame (Coltene/Whaledent/Hygienic

Corp.), developed in nylon by Nygaard-Ostby, is radiolucent and does not
impede x-rays. The frame is curved to fit the patient’s face and may be posi-
tioned so that the patient breathes behind the dam and not into the operating
field. B, Articulated rubber dam frame (Dentsply/Maillefer). In the closed posi-
tion the frame is curved to fit the face. In the open position it may be folded
back, allowing the passage of a radiographic film holder. C, Derma Frame
(Ultradent Products, Inc.) is a soft, metal frame that may be formed to fit the
patient’s face. The frame retains its configuration but then may be reshaped.
68 PDQ ENDODONTICS

frames also hold the dam away from the face so that the patient may
breathe more freely. The dam is best mounted high enough on the
face to cover the nostrils; that way the patient is breathing behind
the dam and not exhaling bacteria down into the operating field (see
Figure 3-8A).
Most dentists can get by with five to seven rubber dam clamps.
Unusual cases, however, such as those involving rotated, malaligned,
fractured, or partially erupted teeth, will require additional clamps.
The rubber dam clamp selection shown in Table 3-1 is a complete
list to cover any exigency. Clamps with “wings” are helpful in hold-
ing the dam down buccally and lingually.
Dam placement is started by punching a single hole in the dam in
the proper location for the tooth in question. The punched hole, well
off center, can be positioned for any tooth by rotating the dam for an
upper or lower tooth or to the right or left. It can also be placed on
the frame ahead of time according to this location. The clamp can be
inserted into the punched hole with the bow to the distal before the
dam is positioned on the tooth. The wings are again useful in this
instance. Much of this preparation can be done by the dental assistant.
Incidentally, a good precaution is to mark the selected tooth with a felt
marking pen to be sure the correct tooth is clamped (Figure 3-9).

Table 3-1
RUBBER DAM CLAMP SELECTION

Tooth Rubber Dam Clamp

Maxillary teeth
Central incisor Ivory 00, 2, 212, or 9A; Hu-Friedy 27; Ash C
Lateral incisor Ivory 00, 212, or 9A; Ash C
Canine Ivory 2, 2A, 212, or 9A
Premolars Ivory 2 or 2A; Hu-Friedy 27
Molars Ivory 3, 4, 8A, 12A, 13A, 14, or 14A; Ash A
Mandibular teeth
Incisors Ivory 0, 00, 212, or 9A; Ash C
Canine Ivory 2, 2A, 212, or 9A
Premolars Ivory 2 or 2A; Hu-Friedy 27
Molars Ivory 8A, 12A, 13A, 14, 14A, or 26, or fatigued
Ivory 2A; Hu-Friedy 18, Ash A
 Access to the Root Canal System 69

Figure 3-9 A, Rubber dam in place, exposing the involved tooth, previously
marked with a marking pen. B, Clamp placement in gingival undercuts. Dental
floss caries the dam past the interproximal contacts and is removed by pulling the
floss to the buccal rather than back through the contacts. Courtesy of J.M. Coil.

The clamp is then spread with the rubber dam forceps and placed
over the marked tooth. Mesially and distally the dam is pulled
through the contact points with dental floss. A blunted instrument
is used to tuck the dam into the gingival crevice all around the tooth.
In the posterior mouth, adding clamps over the outside of the dam,
two or three teeth distant mesially and distally, provides more work-
ing room (Figure 3-10A). The mesial clamp should be reversed with
the bow to the mesial. The saliva ejector should be placed under
the dam not in a hole cut in the dam. In the event a leak develops it
may be stopped by applying Oraseal (Ultradent Products Inc.) (Figure
70 PDQ ENDODONTICS

3-10B and C). When the dam is removed it is important it be inspect-

ed to be sure no interproximal dam septum was left.
Again, it is imperative that the rubber dam be used in all endodon-
tic cases.

Figure 3-10 A, Four-tooth and two-clamp dam isolation in a patient with

phenytoin hyperplasia. B, Possible leakage toward the buccal and lingual
aspects is controlled by Oraseal (Ultradent Products, Inc.). Courtesy of J.M.
Coil. C, Oraseal injectable sealant.