1 - Introduction PDF

Endodontics
Lec. 1 ‫ عالء مهدي الحداد‬.‫د‬

Endodontics: (from the Greek origin endo "inside" and odont "tooth")
It is a branch of dentistry concerned with the study and treatment of the dental pulp and
periradicular tissues. It includes studying the morphology, histology, physiology and
pathology, as well as diagnosis and treatment of diseases and injuries of theses tissues.
Endodontic treatment also called root canal treatment or root canal therapy (RCT).
Indications of RCT
We can divide teeth that need RCT into:
 Teeth with vital pulp:
1. Irreversible pulpitis.
2. fractured teeth with pulp exposure.
3. Need for intrapulpal anchorage to increase retention (intentional RCT).
 Teeth with nonvital pulp:
1. Pulp necrosis without apical pathosis.
2. Pulp necrosis with apical pathosis (may need apical surgery).
Clinical presentation of teeth that need RCT. The tooth that needs RCT could be
symptomatic or asymptomatic. It may be carious, with large restoration, with attrition or
could be sound. The teeth that need RCT may have the following signs and symptoms:
1. Pain.
2. Exposed pulp: fractured tooth (mostly anterior teeth).
exposure during preparation.
3. Discolored teeth (history of trauma or ortho).
4. Periapical swelling.
5. Sinus with pus discharge.
6. Asymptomatic nonvital tooth, discovered by: a) Vitality test.
b) Radiographic examination.
Objectives of RCT
1. Remove the diseased pulp tissue.
2. Clean the canals and treat infection inside the canals and periradicular area (if
present).
3. Fill the canals with a suitable material.
When these steps are done correctly the tooth will become asymptomatic, functional
and free of any diagnosable pathology.
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Endodontics
Causes of pulpal disease. The causes of pulpal and periradicular inflammation are
usually microbial, mechanical or chemical irritations.
I) Microbial irritation: although fungi and most recently archaea and viruses have
been found in association with endodontic infections, bacteria are the major
microorganisms implicated in endodontic infection. Bacteria and their toxins can reach the
pulp either via direct pulp exposure or exposed dentinal tubules. Microorganisms can
reach the pulp via the apical foramen in the following cases:
1. From deep periodontal pocket in advanced periodontitis.
2. Extension of periapical infection from adjacent tooth.
3. From blood stream (anachoresis).
II) Mechanical irritation: trauma, operative procedure, excessive orthodontic force or
subgingival scaling.
III) Chemical irritation: some restorative material if not used properly.
Classification of pulpal disease. Irritation from any of the above sources can cause
some degree of inflammation. Depending on the severity of the insult, the response of
the pulp may vary from a transient (reversible) inflammation to an irreversible one,
which will proceed to pulp necrosis. Many studies have shown that there is no great
correlation between clinical signs and symptoms and the histopathology of the pulp.
Because removal of the questionable pulpal tissue for histologic examination is not
practical, clinical classifications have been developed in order to formulate treatment
plan options.
A) Reversible pulpitis (pulpal hyperaemia): it is a transient condition of vasodilation
characterized by the following symptoms:
 The pain is triggered by external stimuli (mostly cold).
 The pain subsides immediately after removal of stimulus (less than 15 sec.)
 Teeth are not tender to percussion.
 Pain is difficult to localize (why?).
 Normal radiographic findings.
Treated by removing the irritant and an immediate restorative treatment.
B) Irreversible pulpitis
 Pain is more severe and triggered by external stimuli (especially cold stimuli) and
could be spontaneous, and interferes with sleep.
 Pain remains even after removal of the thermal stimulus (more than 15 sec.).
 Tooth not tender to percussion.
 No changes in the radiographic appearance.
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Endodontics
Treatment by RCT or extraction. If not treated the condition may convert into a clinically
chronic phase, which is characterized by:
 Mild to moderate pain that may be tolerated by the patient.
 Some episodes of exacerbation characterized by spontaneous, continuous
throbbing pain that prevents sleep.
 Tenderness to percussion and radiographic changes are not seen until
inflammation reaches the periapical region.
If remains untreated, the pulp will eventually become necrotic.
Hyperplastic pulpitis: it is a form of chronic pulpal inflammation

also known as pulp polyp. Pulpal exposure in primary and
immature permanent teeth with rich blood supply can lead to this
proliferative response.
C) Pulp Necrosis: Suppuration and pulp necrosis will lead to degradation of tissue
elements.
 After the pulp becomes completely necrotic, the tooth will typically become
asymptomatic until the time when the disease process extends into the periradicular
tissues.
 With pulp necrosis, the tooth will usually not respond to electric pulp tests or to cold
stimulation.
 Sometimes pain elicited by heat and relieved by cold, this response could possibly be
related to remnants of fluid or gases in the pulp canal space expanding and
extending into the periapical tissues.
 Pulpal necrosis may be partial or complete and it may not involve all of the canals in
a multirooted tooth. For this reason, the tooth may present with confusing
symptoms.
D) Periapical periodontitis: After the pulp becomes necrotic, bacterial growth can occur
within the canal. When the bacteria (or its byproducts) extends into the periodontal
ligament space:
 The tooth may become symptomatic to percussion or exhibit spontaneous pain.
 Radiographic changes may occur, ranging from a thickening of the periodontal
ligament space to the appearance of a periapical radiolucent lesion.
 The tooth may become hypersensitive to heat, even to the warmth of the oral
cavity, and is often relieved by applications of cold.
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Endodontics
Asymptomatic Irreversible Pulpitis
On occasion, deep caries will not produce any symptoms, even though clinically or
radiographically the caries may extend well into the pulp. If left untreated, the pulp may
become necrotic.
Asymptomatic Apical Periodontitis
A tooth with asymptomatic apical periodontitis generally presents with no clinical
symptoms. This tooth does not respond to pulp vitality tests, and the radiograph or
image will exhibit an apical radiolucency. This tooth is generally not sensitive to biting
pressure but may “feel different” to the patient on percussion.

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Endodontics

Lec. 1 ‫ عالء مهدي الحداد‬.‫د‬

Hyperplastic pulpitis: it is a form of chronic pulpal inflammation

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