National Diploma in Dental Nursing

Endodontics
 Endodontics

∗ Learning Outcomes.

• 1. Pulp therapy of permanent teeth

• Root canal treatment (RCT)
• Apicectomy & retrograde RCT
• Direct and indirect pulp capping

• 2. Pulp therapy in deciduous teeth

• Pulpectomy
• Pulpotomy
 Endodontics

∗ Endodontics is the branch of dentistry that deals with

treating the pulp.

∗ The purpose of endodontic treatment is to save teeth

from extraction even though their nerves are dead or
dying.

∗ An Endodontist a specialist who deals with pup therapy.

 Reasons for pulp disease

1. Exposure of pulp to oral bacteria due to:

a) deep caries
b) crown fracture
c) accidental exposure during cavity preparation

2. Trauma – e.g. blow to the tooth resulting in cutting off of

blood supply

3. Irritation from an unlined filling

4. Overheating of tooth – by using a turbine hand-piece

without water
 Progression of pulp disease

Irritation of the pulp causes the inflammation of the

pulp or pulpitis.
Stage 1: Reversible pulpitis = inflammation will subside
after the irritant factor is removed, e.g. after shallow
caries is removed.
Stage 2: Irreversible pulpitis = the damage to the pulp
is permanent
Stage 3: Pulp necrosis = pulp death
Stage 4: Periapical abcess = the infection in the canals
spreads to the alveolar bone surrounding the apex of
the tooth
 Mechanism of pulpitis

1. The irritation to the pulp tissue results in increased

blood flow to the pulp leading to swelling
2. Swelling is restricted as pulp is surrounded by hard
dentine
3. Pressure builds up within the pulp cavity
4. The pressure compresses nerves causing pain
5. Pressure compresses blood vessels so blood flow to
pulp is cut off resulting in necrosis ( the slow death of
the nerve)
 Diagnosis of pulp health

Dentists need to determine whether a tooth is vital

(alive) and the extent of the disease before deciding
on the appropriate treatment.

Dentists use several diagnostic tests to reach a

conclusion.

A diagnostic test which checks pulp vitality is called a

vitality test = hot, cold, electricity, percussion.
 Diagnostic tests

TEST RESPONSE CONCLUSION

COLD TEST Quick sharp pain Reversible pulpitis
(Ethyl chloride, ice
stick)
Longer lasting pain Irrevirsible pulpitis

No response Non vital pulp

HEAT No response Non vital pulp

(Warmed up gutta
percha)
 Diagnostic tests (cont.)

TEST RESPONSE CONCLUSION

ELECTRICITY using an Faster response Pulpitis
ELECTRIC PULP
TESTER (EPT) Slower response Partly vital pulp
An electrical stimulus
is applied to the tooth No response Non vital pulp
and the time it takes for  
the patient to feel a  
tingling sensation is
recorded.

This time is compared

to the time the patient
feels the same
sensation in a healthy
tooth.
 Diagnostic tests (cont.)

TEST RESPONSE CONCLUSION

PERCUSSION Tender to Periapical

percussion (TTP) pathology

PALPATION Tenderness over Infection

root apex of tooth
 Diagnostic tests (cont.)

TEST RESPONSE CONCLUSION

RADIOGRAPHS Dark area around root Non vital pulp
(periapical or apex
OPG X-rays)

TOOTH Black/grey Non vital pulp

DISCOLOURATIO discolouration
N

CAVITY PREP. Patient feels no pain on Non vital pulp

WITHOUT L.A. drilling even though
the tooth has not been
numbed up.
 Diagnostic tests (cont.)

TEST RESPONSE CONCLUSION

DISCHARGING A small nodule oozing pus Non vital tooth

SINUS seen on gum or outside of
face. Caused by infection
around roots of teeth.
Infection forms a tract
(channel) in the bone in
order to drain itself.
If a GP point is inserted into
the tract it will follow the
path of the infection and
reach the origin of the
infection. This will be seen
on a periapical x-ray .
 1. Pulp therapy in adult teeth

∗ A tooth has the best chance of survival in the mouth if it is

vital. This means that it has to have a healthy pulp (nerve
and blood supply).

∗ The dentist’s aim is to keep the pulp alive.

∗ A direct and indirect pulp cap procedures are done when
there is very deep decay but the pulp is still alive.

∗ Once the pulp is dead or dying the only solution would be a

root canal treatment (RCT) or extraction.

∗ If the infection in the tooth is left untreated for a long time it

can spread to the surrounding bone and an apicectomy can
be used to remove it in an effort to save the tooth.
 Indirect pulp capping

∗ This procedure is done when there is very deep decay and the
dentist feels that if he removes it all the pulp tissue will
become exposed.

∗ For this reason the layer of decay closest to the pulp is left
behind and covered with calcium hydroxide and a sedative
filling material like IRM is placed over it for 6-8 weeks.

∗ The calcium hydroxide stimulates the production of a

“dentine bridge”. This is a layer of reparative dentine
between the pulp and the decay.

∗ After 6-8 weeks the cavity is reopened and the remaining

decay is removed without exposing the pulp. The tooth is
restored with a base and a permanent filling.
Indirect pulp capping
 Direct pulp capping

∗ This procedure is done when the pulp is accidentally exposed

when removing very deep decay.

∗ A “pin point exposure” results when the area of the exposed

pulp is less than 0.5 mm

∗ If the pulp is healthy and the exposed area very small there is a
chance that the pulp tissue will recover and a root canal
treatment will not be needed.

∗ This procedure is more successful in primary teeth as they tend

to heal better than permanent teeth.
 Steps of direct pulp capping

∗ Immediately after the exposure the tooth should be isolated with

rubber dam and the bleeding stopped with cotton pellets.

∗ Setting calcium hydroxide or MTA can be used to cover the

exposure which will stimulate the formation of a “dentine bridge”

∗ Calcium hydroxide should be covered by a base material like GIC

and then the permanent restoration.

∗ The tooth should be monitored regularly for signs of pulp death.

 Root canal treatment

A dead or dying nerve in an adult tooth is treated with a

root canal treatment (RCT). The purpose of RCT is to
remove the pulp tissue and infection from the canals and fill
the canals so that bacteria can not infect them again.

Reasons for RCT

1. pulpitis
2. periapical pathology (abcess)
3. crown fractures
4. accidental pulp exposure in adult teeth
5. preventive measure before crown preparation
6. retained roots to be used for overdentures
 Procedure for RCT

∗ 1. Periapical x-ray to determine number, shape & location

of roots

∗ 2. Local anaesthesia
∗ 3. Rubber dam placement
∗ 4. Access cavity preparation using turbine & diamond burs
to open the pulp chamber and reach the canals
∗ 5. Caries removal using slow hand-piece & steel burs
∗ 6. Extirpation – nerve tissue is removed using barbed
broach
Barbed Broach
 Procedure for RCT

∗ 7. Widening of canal openings using Gates Glidden drills

Gates Glidden drills to be
attached to slow hand piece

∗ 8.Working length determination – a hand file or a GP point

is placed in the canal and a periapical x-ray is taken or an
apex locator is used. Periapical
Apex radiograph
taken with
locator
file in canal
 Procedure for RCT

9. Cleaning and shaping the canal - knowing the length of the

canal the dentist can set this length on the first file which goes
all the way to the tip of the root.

Using a ruler the length is measured and marked by a rubber

stopper which comes with the file.

The files get progressively thicker. With each thicker file the
length is reduced by 1mm.
This will give the canal a conical shape.

The files are colour coded according to thickness & taper.

 Files Sizes and
Colours

Size 6 pink Size 35 green

Size 8 grey Size 40 black
Size 10 purple Size 45 white
Size 15 white Size 55 red
Size 20 yellow Size 60 blue
Size 25 red Size 70 green
Size 30 blue Size 80 black
Procedure for RCT

Root canal files remove infected dentine from the sides of the
canal.

Files are moved up and down the canals.

10. Canals are irrigated between filing to remove any debris.

Solutions are in a disposable endodontic syringe with a thin
needle

Irrigation solutions can be:

- sodium hypochlorite, e.g. Milton solution
- chlorhexidine 2%
- EDTA
 Procedure for RCT

11. Once the canal is shaped and cleaned it is rinsed one final
time and dried using paper points.
If canals are completely dry – no blood or exudate on paper
points then the canals can be filled in the same appointment.

If there is still infection in the canals – exudate on paper points

then medication such as calcium hydroxide is put in the canals
and the tooth is sealed with cotton wool and a temporary
filling.

Patient returns in 2-3 weeks and canals are checked again. If

infection is still present medication is repeated. If not canals
are filled.
 Procedure for RCT

12. A sealant paste is placed in the dry canal using a rotary

paste filler

13. Canal obturation - Canals are filled using gutta percha (GP).
This is a form of natural rubber and comes as individual GP
points, on a GP carrier or as flowable GP.

1. individual GP points
GP points are placed 1 by 1 till the canal is tightly packed and
no more points can fit. A finger spreader makes space for
more GP points by compressing the ones already in the canal.
This technique is called lateral condensation.

The ends of he GP points are cut off with a warm instrument.

 Rotary/spiral paste filler

Colour coded GP Points

Finger spreader
 Procedure for RCT

2. A GP carrier is a much thicker GP point which fills the canal

in one go.

The GP carrier is warmed up in a special machine before being

inserted in the canal.

Its top has to be cut off with a bur

Sealants used for both techniques are:

- ZnO and eugenol cement, e.g. Tubli-seal
- Calcium Hydroxide e.g. Sealapex

3. Flowable GP is warmed up and squirted into the canals

 Procedure for RCT

14. Access cavity is filled with a temporary or permanent

filling.

15. A periapical x-ray is taken to check that canals have been

filled to the full working length.
 • Indications
APICECTOMY – Root canal filling
• Definition unsuccessful
– Operation for the
– Escape of irritant
removal of an pulp through the
infected apex apex
– Amputation of the
– Root filling
apex of the tooth impossible
• Broken instrument
• Abscess on a post
crown tooth
43
previous unsuccessful
endodontic therapy • Granulation tissue removed
using curette

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Reasons for apicectomy:

1. RCT has failed and there is an abscess

2. sealant has gone through the apex causing an abscess
3. Normal RCT can not be done because there is a broken
instrument in the canal or the roots are too curved
4. tooth has a post crown (PCs are difficult to remove and taking
them out might fracture the root).

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 Apicectomy procedure

∗ 1. periapical X-ray taken

∗ 2. Local anaesthesia
∗ 3. Flap raised –scalpel used to make incision (cut in
gum), periosteal elevator to separate the gum from the
underlying bone, a retractor is used to hold the gingival
flap so that the bone over the root apex remains visible.
∗ 4. Bone over the root apex is removed using a straight
hand piece and a SHP steel round bur.
∗ 5. Apex is cut off using a diamond or carbide bur.
∗ 6. apex is removed and the infection is removed with a
surgical curette or Mitchell's trimmer
∗ 7. Area is rinsed with saline
 Apicectomy procedure (cont.)

∗ 8. If the root filling is intact the gingival flap is pulled back

over the bone and sutured into place using needle
holders, needle and sutures and scissors.

∗ 9. if the root canal needs more filling material a

retrograde root filling is placed. (Retrograde means
backward)
∗ Sealant cement such as GIC, ZnO or Mineral Trioxide
Aggregate (MTA) is placed in the canal. Area is rinsed and
flap sutured using needle holders, suture thread and
needle and scissors
 2. Pulp therapy in deciduous teeth

∗ It is very important to save deciduous teeth from being

extracted too early.

∗ If a deciduous tooth is removed before it is supposed to be

exfoliated naturally, the permanent teeth will not erupt in
the correct position.

∗ A pulpectomy is done when all the pulp tissue is removed

and a pulpotomy when the only the pulp from the pulp
chamber is removed.
 • Definition: the removal of
PULPOTOMY the infected part of the pulp
in the pulp chamber
(usually) entire coronal
pulp, leaving intact the vital
radicular pulp within the
canals.

• Procedure mainly done on

deciduous teeth as healing is
facilitated by the rich blood
supply to the tooth due to an
open apex

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 2. RCT in deciduous & recently erupted
permanent teeth (Pulpotomy)

The apex formation of a tooth is completed in about 3 years after

the tooth has erupted.

In that time the apical foramen is quite wide.

This means that when the pulp becomes inflamed its chance of
recovery is much higher than in an adult tooth as the wider foramen
means that blood supply to the pulp will not be cut off.

Pulpotomy means that in these teeth only the pulp tissue in the pulp
chamber is removed. The pulp in the root canal is left untouched.
 Pulpotomy procedure

1. Local anaesthetic
2. Access cavity prepared
3. Pulp tissue in pulp chamber removed with a bur.
4. Rinsed and dried with cotton pellet
5. A pellet with ferric sulphate is placed for 15 seconds to help
with hemostasis
5. Calcium hydroxide to promote secondary dentine formation
is placed followed by a zinc oxide and eugenol cement.

This method is better for such teeth because if the

conventional RCT is used it will be difficult to fill the canals to
the end without sealant escaping into the surrounding
periapical tissues.