ENDODONTICS FINAL REVIEWER ENDODONTICS Branch of dentistry concerned with the :

1.

To be able to retain a tooth inside the oral cavity which may otherwise require extraction (ex. For extraction: no bone support anymore; horizontal fracture or root fracture) Relief of pain, if present Removal of pulp from root/s of tooth Disinfection of root and surrounding bone by cleaning and shaping of the root canal walls (use of irrigate sodium hypochlorite) Complete filling of root canal (obturation) Placement of final restoration (if not restorable, extract) Main contraindication: non-restorable tooth

2. o o o Morphology shape of the pulp cavity 3. Physiology reversible or irreversible state Pathology of the human dental pulp and periradicular tissues 5. 6. 4.

Its study and practice encompass the basic and clinical sciences including the biology of the normal pulp and the etiology, diagnosis, prevention and the treatment of diseases and injuries of the pulp and associated periradicular conditions

7.

REVERSIBLE PULPITIS diagnosis of class 1 to 5 restoration IRREVERSIBLE PULPITIS do root canal therapy SCOPE OF ENDODONTICS 1. 2. Differential diagnosis Treatment of oral pains of pulpal and/or periapical origin (orthograde/conventional RCT) Vital pulp therapy a. b. 4. Pulp capping Pulpotomy

HISTORY (1977 to PRESENT) Improved visibility is now available with the advent of the endodontic microscope The single visit endodontic therapy globally accepted by all school taught Newer and better

3.

BASIC PRINCIPLES 1. Chain of asepsis a. b. c. Paper points = 5 secs in glass beads Gutta percha = 1 min in chlorox Rubber dam = alcohol Instruments = sterilize (autoclave) Files = autoclave or glass beads

Non-surgical treatment of root canal systems with or without periradicular pathosis of pulpal origin Selective surgical removal of pathological tissues resulting from pulpal pathosis (e.g. cyst) Intentional replantation and replantation of avulsed teeth 2. Surgical removal of tooth structure 3. a. b. Root-end rsection 4. Bicuspidization cut molar to form 2 bicuspids 5. c. d. Hemisection - 1 root only for RCT 6. Apicoectomy (retrograde/conventional endodontics) 7. 8.

5.

d. e.

6.

Correct diagnosis and treatment planning Atraumatic holding of tissues Cleaning of the canal debridement and removal of biofilm sticking on the canal walls Shaping of the canal Complete obturation Restoration Recall

7.

8. 9.

Bleaching of discolored dentin Retreatment of teeth

RATIONALE 1. 2. 3. Saving the natural teeth to health Restore efficient mastication Control pain and swelling

10. Treatment procedures related to coronal restorations OBJECTIVES

4. 5. 6.

Speech and phonation Preserved occlusion Esthetics

The shape of the pulp chamber and the outline of the canals are a reflection of the outline of the surface of the crown and root

DIFFERENCE BETWEEN ROOF AND FLOOR ROOF C3rd of crown Yellowish Absent Rough; no definite shape FLOOR C3rd of root Darker Present Smooth; convex

BASIC CONCEPT OF ROOT CANAL THERAPY If bacteria and byproduct of pulpal inflammation has been reduced to a non-critical level of infection, it will effect a cure allowing resolution and repair of damaged depends on the virulence LOCATION COLOR DENTINAL MAP TEXTURE

APPLIED ANATOMY OF THE ROOT CANAL SYSTEM 1. 2. ROOT CANAL SYSTEM SIGNIFICANCE OF STUDYING THE ROOT CANAL SYSTEM FACTORS AFFECTING ROOT CANAL MORPHOLOGY

DENTINAL MAP line that connects the orifice of the canal METHODS OF STUDYING THE ANATOMY OF THE ROOT CANAL 1. 2. 3. 4. 5. 6. Ground section (cross or lingual) Histologic Radiograph Clearing technique Acrylic cast Silicone injection

3.

SPECIFIC OBJECTIVES 1. To review the individual root canal morphology of human teeth and relate it to endodontic treatment To know the factors that alter root canal morphology To understand the effect of root canal system complexities to endodontic treatment To be familiar with other variations in the canal systems To recognize the relationship of internal anatomy to endodontic procedures

2. 3.

FACTORS AFFECTING ROOT CANAL MORPHOLOGY 1. 2. 3. Age Caries Developmental anomalies a. Dilacerations severe bend or distortion 45 - 90 Taurodontism bull or prism teeth Dens en dente Microdontia Macrodontia

4.

5.

Maxillary molar 3 roots (MB, DB and palatal) 4 canals (MB, DB, MP and palatal)

b. c. d. e. 4. 5. 6. 7.

ROOT CANAL MORPHOLOGY AND ITS SIGNIFICANCE 1. DIAGNOSIS to know indication and case selection for root canal TREATMENT to guide us in all treatment procedures PROGNOSIS to predict the outcome of the treatment

2.

Irritatnts pulp stones, internal resorption Attrition Abrasion Erosion a. Internal resorption (thermoplastic gutta percha) External resorption

3.

ROOT CANAL SYSTEM Pulp is located and found at the center of the tooth Unique for every tooth and is highly variable 8. 9.

b. Trauma

SCHEMATIC SECTION (CROSS SECTION) OF THE TEETH

Clinical procedures

ROOT CANAL CONFIGURATION TYPE I II III IV V VI VII VIII CONFIGURATION 1-1 2-1 1-2-1 2-2 1-2 2-1-2 1-2-1-2 3-3

Maxillary first molar o 3 roots = 4 canals (MB, DB, MP and P)

Mandibular incisors o 2 canals

Mandibular second molar o 2 roots = 3 canals (Distal, MLi and MBu) C-shaped canal Fusion of MB and Distal canals 2 canals

o Maxillary Second Premolar The only tooth that showed all 8 possible configurations

ACCESS CAVITY PREPRARATION Cavity prepared on crown of teeth fro endodontic instruments and materials to gain direct path towards the apex for biomechanical preparation and obturation

WAYS OF GAINING ACCESS ANTERIOR LINGUAL POSTERIOR OCCLUSAL Enamel = size2 round bur Dentin = size 1 or 2 round bur Roof = size of bur depends on the size of roof and pulp chamber o has reddish color if it is vital but it is whitish color if it is non-vital because there is no more or there is little space

OBJECTIVES 1. To create a smooth, straight line path to the canal system up to the apex To remove caries and debris from the chamber To allow for complete irrigation To establish maximum visibility to gain access up to the end of the canal (apical foramen)

2. 3. 4.

if access is small: o o you cannot locate all of the canals incomplete cleaning because apical end can be inaccessible o o faulty canal access = infection

IDEAL ACCESS RESULTS IN 1. Straight entry into the canal orifices, with the line angles forming a funnel drops smoothly into the canal or canals Quality endodontic result

2.

Variation of rooth canal anatomy is more of a rule rather than an exception. ANATOMY OF THE TEETH

perforations = man-made canals ledges step being created strip side of danger zone zipping of the apical end opening of the apical end formation of an elbow

o Center (x-ray) o Create imaginary line to know how many orifice are there Maxillary second premolar o o 1 root = 1 canal (canal is at the center) Variations: 2 roots = 2 canals 3 roots = 3 canals o o

STEPS IN ACCESS 1. Study pre-operative radiograph To know how big the chamber is To know which bur to use in gaining access

2.

Remove all caries, weak restorations and do crown build-up after locating the canal Caries to remove microbes

II.

Science of diagnosis (data development) a. b. Patients history Clinical examination i. ii. c. d. Extraoral examination Intraoral examination

Weak restorations debris, leaks Crown buildup for adaptation of rubber dam

3.

Draw outline form on the lingual or occlusal surface of teeth Size and shape of the access cavity depends on the size and shape of the pulp chamber

Radiographic examination Diagnostic tests i. Thermal pulp testing 1. Heat test use gutta percha stick then put it n the surface of the tooth after putting Vaseline Cold test how long before the patient feels it? How long does the patient feel after?

4. 5.

Rubber dam isolation Use #4 round bur for initial access through the enamel then dentin on narrow canals 45 angulation of the bur

2.

6.

When the bur drops in, unroof the pulp chamber Refine the access preparation using non-end cutting tapering fissure bur Explore the orifice using the endo explorer Use nerve broach to remove vital pulp on large canals and small sized files on narrow canals ii. iii. iv. v. vi.

7.

Electric pulp tester Percussion test Palpation test use index finger Periodontal probing depths Mobility testing use 2 mouth mirrors Cavity test teeth with caries only Transillumination used to see if there is a suspected fracture on the tooth Gutta percha tracing Hot/cold water bath 1. 2. Most reliable Use rubber dam for isolation

8. 9.

EVALUATION O F ACCESS CAVITY PREPARATION 1. 2. 3. Correct location of access preparation Correct outline form Properly unroofed pulp chamber, lingual shelf/shoulder removed Gouging and ledging absent Refined access cavity preparation Canal orifice should be visible Conserve the tooth structure Straight line access

vii.

viii.

4. 5. 6. 7. 8.

ix. x.

DIAGNOSIS Objectives: 1. To be able to systematically collect, record and analyze data in order to formulate a correct diagnosis To know how to and when to perform the different endodontic tests

All non-vital teeth = for RCT All vital teeth = depends if it is reversible or irreversible pulpitis DEVELOPING DATA PATIENT HISTORY CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS 1. PRIMARY SOURCE OF PAIN

2.

I.

Definition and importance of diagnosis

 2.

Pulp Periodontal ligament

The dentist/clinician must be able to analyze and synthesize the gathered results to arrive at a correct choice of treatment and therefore a good case prognosis

REFERRED PAIN Adjacent tooth Opposing tooth Non-odontogenic in nature FOR PERCUSSION TEST Organic cause: emotional/systemic It has a different feeling compared to the other teeth that has been percussed HOW WILL YOU KNOW IF THE TOOTH NEEDS RCT WHEN YOU USED THE COLD TEST? If the patient still feels pain even if the stimuli has been removed for a long time

MEDICAL HISTORY vital signs DENTAL HISTORY OTHER PERTINENT PATIENTS PERSONAL INFORMATION

PERCUSSION, MOBILITY AND PALPATION Cannot determine whether there is pulpitis or a necrotic pulp because the disease is confined within the internal of the tooth, particularly the pulp. These are tests for the surrounding tissue of the tooth such as bone support and the periodontal ligament

THERMAL PULP TESTING 1. COLD TEST a. b. 2. Cold water bath most accurate Ice tube least accurate

CLINICAL CLASSIFICATION OF PULPAL DISEASES 1. 2. NORMAL PULP within the normal limits PULPITIS a. b. REVERSIBLE IRREVERSIBLE i. ii. 3. NECROSIS HEALTHY PULP TEST THERMAL/EPT PERCUSSION PALPATION RADIOGRAPH RESULT Mild to moderate transient response clearly delineated root canal negative resorption intact lamina dura SYMPTOMATIC ASYMPTOMATIC

Response to thermal test a. b. No response no-vital pulp False negative excessive calcification, immature apex Reversible pulpitis Moderate to strong response

c. d.

ELECTRIC PULP TESTING FALSE POSITIVE RESPONSE o o o o Patient anxiety Wet tooth (to gingiva) Metallic restorations (to adjacent tooth) Liquefactive necrosis (to attachment apparatus)

REVERSIBLE PULPITIS Inflammation of the pulp that is manifested by initial congestion of blood vessels If the cause is eliminated, inflammation will be resolved and the pulp will return to normal Treatment: restoration

FALSE NEGATIVE RESPONSE o Premedication (drugs or alcohol) immature teeth Trauma

o SPECIAL TEST

IRREVERSIBLE PULPITIS All irreversible pulpitis needs ANESTHESIA

Wedging and staining

DIAGNOSIS

The tooth cannot go back to its normal state because the pulp cannot recover SYPMPTOMATIC Episodes of pain due to sudden temperature change Localized referred pain which lingers Pain is: i. ii. Moderate to severe Spontaneous, intermittent or continuous Sharp or dull 2.

CLINICAL DIAGNOSIS (PULP POLYP vs GINGIVAL HYPERPLASIA DIFFERENTIAL DIAGNOSIS i. Raise and trace the stalk of the tissue back to its origin, if it is inside the pulp cavity, it is pulp polyp, if not, its gingival hyperplasia

A.

INTERNAL RESORPTION PINK SPOT Painless expansion of the pulp chamber that results in destruction of dentin Low-grade inflammation; negative to pulp test Identified during routine radiograph: shows an irregular shape of the pulp Treatment: i. Prompt RCT to prevent root destruction

iii.

Pain may be: i. ii. iii. iv. Relieved by application of heat/cold Affected by postural change Radiating or referred Difficult to localize 3.

INTERNAL CALCIFOCATION/CANAL CALCIFICATION (PULP STONE) Appear as excessive deposition of dentin throughout the canal system Coronal discoloration suggests chamber calcification Identified during routine radiograph exam Treatment: i. RCT however, it is difficult to do because it is difficult to see the floor 1. Drill with round bur then remove with explorer

Radiograph: i. Deep caries with apparent pulpal exposure Has normal surrounding structures Lamina dura is intact

ii. iii.

Treatment: i. RCT best solution to preserve the strong tooth Extraction f patient doesnt want to undergo RCT

ii.

B.

ASYMPTOMATIC 1. CHRONIC HYPERPLASTIC PULPITIS Aka PULP POLYP Reddish cauliflower-like growth Low-grade chronic irritation of the pulp and generous vascularity May cause mild, transient pain during mastication Treatment: i. ii. Excision of the pulp polyp RCT or extraction 1. Visual exam: PULP NECROSIS (DEAD PULP)

Positive to thermal test

With or without toth discoloration Thermal test is negative Ept is negative

Percussion is either positive or negative Thickening of the periodontal ligaments and may manifest as tender to percussion and chewing

ii.

Rapid onset of slight to severe swelling Patient may be febrile infection has spread out with cellulitis Tooth is non-vital Percussion and palpation are positive Mobility possibility of slight increase in mobility Radiograph shws a widened periodontal space (no radiolucency) Rapid onset of disease because the cortical plate is not yet affected

iii.

1.

PARTIAL NECROSIS May produce symptoms associated with irreversible pulpitis

iv. v.

2.

TOTAL NECROSIS Asymptomatic before it affects the periodontal ligaments

vi.

vii.

3.

Treatment: RCT or extraction b. viii.

CHRONIC i. There is drainage of the pus so it is not painful Radiograph shows a periapical radiolucency

CLINICAL CLASSIFICATION OF PERIAPICAL DISORDERS

1.

APICAL PERIODONTITIS a. ACUTE i. ii. Percussion (+) Radiograph shows slightly widened periodontal ligament Need for endodontic treatment iv. Note: the only one that is /may be vital or non vital. The others are non vital because it can be caused by trauma 3.

ii.

PHOENIX ABSCESS (ACUTE EXACERBATION OF CHRONIC LESION) has to undergo chronic stage first radiograph shows a periapical radiolucency visual exam: no sinus tract

iii.

In chronic abscesses, there is no need to give antibiotics because there is drainage

b.

CHRONIC i. Asymptomatic; breakage of lamina dura Tooth feels different Thermal is negative EPT is negative Percussion and palpation are positive OBJECTIVES CASE SELECTION AND TREATMENT PLANNING

ii. iii. iv. v.

2.

PERIRADICULAR ABSCESS ABSCESS except acute periradicular abscess, radiolucency of the apex is seen in the radiograph ACUTE i. Moderate to severe pain

1.

to be able to identify important factors to consider in case selection to determine which teeth are salvageable for RCT and which are not

a.

2.

3.

to be able to develop an individualized endodontic treatment plan for each patient

Examples: 1. PERIODONTAL SUPPORT Yes, even with bone loss, the tooth is still not mobile Strategic location of the tooth Get clearance from periodontist

WHY DO WE DO CASE SELECTION?

1. To determine if endodontic treatment should and could be performed To determine the need for consultation and specialist referral 2.

2.

RESTORABILITY Yes, but a specialist is needed to perform If perforation happened Hemisection Crown lengthening

FACTORS TO CONSIDER IN CASE SELECTION

1. 2. 3.

Tooth consideration patient consideration clinician consideration 3.

DILACERATION

INDICATIONS FOR RCT

With the advent of witi files (nickel titanium) root canal curvatures can now be negotiated. Refer to a specialist, since it is a difficult case. But if conventional therapy it is possible or impractical

4. 1. teeth with irreversible pulp disease with or without periradicular disease teeth with normal or reversible inflamed pulps but: a. b. c. will be used as overdenture abutment for limited correction of malposed teeth need to do pulp cavity to retain the restoration 5.

CARIOUS LESION BELOW THE GINGIVA Yes, it can be restored but first same procedure should be done prior to RCT

2.

OPEN APEX Yes, but some procedures should be performed Use of MTA (Mineral Trioxide Aggregate) to close the apex REVASCULARIZATION New treatment to close the apex Continuous formation of dentin and growth of the tooth even without the pulp

3.

extensive restoration on a tooth with questionable pulp status

TOOTH CONSIDERATION PROPER CASE SELECTION SHOULD ENDODONTIC TREATMENT BE PERFORMED? 1. An endodontic problem exists but certain conditions contraindicate RCT 6.

INTERNAL RESORPTION Immediate RCT (thermoplasticized gutta percha)

CAN ENDODONTIC TREATMENT BE PERFORMED? 1. An endodontic problem exists but does the clinician have the skill and armamentarium to get it done

7.

S SHAPED CANAL Has 3 angles Refer to a specialist

8.

CALCIFICATION Refer to a specialist 5. 6.

a. b.

Psychological and mental health Economic status

9.

CENTRAL INCISOR (DIFFERENT) Traumatic injury (formation)

TIMING OF APPOINTMENT LENGTH OF APPOINTMENT

10. LENTILOSPIRAL (BROKEN) See a specialist Location of the canal is difficult 1. PHASE OF TREATMENT a. b. c. PRE-TREATMENT PHASE TREATMENT PROPER POST-TREATMENT PHASE/FINAL RESTORATION TREATMENT PLANNING

11. LARGE PULPAL CHAMBER Orifice is too far Location of the canal is difficult

12. VERTICALLY FRACTURED No RCT because it cannot be sealed 2. 3. CLINICAL CONSIDERATIONS (CAN IT BE DONE?)

SINGLE VISIT RCT MULTI-VISIT RCT

OBJECTIVES OF TREATMENT: 1. 2. 3. 4. 5. 6. Objective clinical findings Difficult diagnosis Difficulty in obtaining films of diagnostic value Malpositioned tooth, rotated, tipped too far distally Clinicians level of expertise Availability of necessary materials and equipments CHARACTERISTICS OF A GOOD TREATMENT PLAN: OBJECTIVES OF TREAMENT PLANNING: To achieve treatment goals efficiently discuss before, during and after To restore teeths function and esthetics

PATIENT CONSIDERATIONS

1. 2.

It is individualized/personalized It is flexible Patient has a final choice (tell the pros and cons)

1. 2.

MEDICAL CONSIDERATIONS LOCAL ANESTHETIC CONSIDERATIONS a. Allergy, vasoconstrictor contraindications, history of difficulty in obtaining profound anesthesia

3.

PRE-TREATMENT PHASE

3.

PERSONAL FACTORS a. Size of mouth, limited ability to open mouth, gagger, motivation to preserve dentition, physical impairment, limitation to be reclined, oral hygiene

To prepare Scaling and polishing Extraction Caries control to know the restorability of the tooth and asepsis

4.

SPECIAL NEEDS

 TREATMENT PROPER (ORDER WIL DEPEND ON CHIEF COMPLAINT)

Non-vital cases with apical periodontitis o The use of intracanal antimicrobial agents will add significantly to the effectiveness of the treatment

Endodontic treatment Operative procedures Prosthetic rehabilitation Periodontal therapy (periodontist) Complex surgical procedures

Appointments should be approximately one week apart to maximize antimicrobial effects Allow 5 7 days between instrumentation and obturation for the periradicular tissues to recover

SUMMARY AND CONCLUSION

Orthodontic treatment

Proper case selection will affect treatment outcome To do or not to do retreatment

MAINTENANCE PHASE (POST-TREATMENT PHASE) PRE-ENDODONTIC PROCEDURE

To monitor healing 1. To detect new disease Take recall radiograph Perform clinical examinations Reinforce oral hygiene Do scaling and polishing 3. 2. PREPARATION OF OPERATORY PATIENT PREPARATORY a. b. SCALING AND POLISHING PAIN CONTROL i. ii. ANESTHESIA PHARMACOLOGY

TOOTH PREPARATION a. b. CARIES CONTROL RADIOGRAPH BUILD UP/TEMPORIZATION CROWN LENGTHENING ISOLATION

SINGLE VISIT RCT

6 months/ 1 year / 2 years Vital cases (irreversible pulpitis) Clinicians skill Severity of patients symptoms

c. d. e.

SPECIFIC OBJECTIVES MULTIPLE VISIT RCT 1. Complex cases o o Anatomy of the tooth Calcified cases 3. To describe proper infection control and occupational safety procedures To explain the importance of treatment planning and case presentation during patient discussion Recognize the need for adjunct procedures (ex. Scaling and polishing, etc)

2.

Retreatment cases

10

4.

Describe the routine approaches to endodontic anesthesia, when and how to anesthetize 1. AUTOCLAVE Most common means of sterilization 15-40mins at 121C at 15psi Rust and corrosion can occur Advantages: i. ii. Excellent penetration of packages Sterilization is verifiable Describe when to employ alternative methods of obtaining pulpal anesthesia Review the techniques for periodontal ligament, intra-pulpal, infiltration, block, intraosseal and mental block anesthesia Explain the pre-medication and pain control in endodontics Review the appropriate use and dosage of analgesics and antibiotics Describe the indications for systemic antimicrobial therapy in RCT

5.

6.

7.

8.

9.

Disadvantages: i. Can destroy heat sensitive materials 1. Files, endoblock, clean stand, sterile gauze (1min), sodium hypochlorite 5.25% (chlorox) gutta percha, bead sterilization/dry heat paper points for 5 secs

10. Relate the reasons for caries removal and temporization to RCT

PREPARATION OF OPERATORY

IMPORTANCE: To minimize the risk of crosscontamination GOAL: Reduce the number of microorganisms in immediate dental environment to the lowest level possible ADA CONSIDERATION/RECOMMENDATION: each patient must be considered potentially infectious

2.

PROLONGED DRY HEAT Kills microorganism through an oxidation process 320C for 30mins for 2 hours Advantages i. Complete corrosion protection for dry instruments Equipment is of low initial cost Sterilization is verifiable

INFECTION CONTROL GUIDELINES: ii. 1. All dentists and staff must be vaccinated against Hepatitis B Proper protective attire Disposable latex gloves Wash hands before and after wearing gloves Wear mask and protective eyewear Contaminated disposable sharp objects must be placed into separate, leak proof, puncture resistant containters with biohazard label Use of mouth rinse before treatment All instruments must be cleaned and sterilized 3. iii.

Disadvantages i. ii. Slow turnover time If sterilizer temperature is too high, instruments may be damaged

2. 3. 4. 5. 6.

INTENSE DRY HEAT (GLASS BEADS) Not predictable Sterilize contaminated hand files Not verifiable Not for sterilization of hand files bet use of different patients

7. 8.

METHODS OF STERILIZATION

4.

GLUTARALDEHYDE SOLUTIONS

11

14 28 days shelf 2 4 or 3.4% concentration 6 10 hours sterilization Advantages i. ii. For heat sensitive instruments Non corrosive and non-toxic

2.

Inform the patient what is expected of him before, during and after the treatment Convince the patient to accept, value and appreciate RCT

3.

Scaling and polishing Pain control Medical history 1. 2. Case presentation Informed consent

Disadvantages i. ii. Require long immersion time Some odor which may be objectionable Sterilization is non-verifiable Irritating to mucous membrane iii. iv.

Premedication if necessary Antibiotic needed American Heart Association (AHA, 2010) prophylactic regimen for dental procedures

LOCAL ANESTHESIA METHODS OF DISINFECTION (ZONROX) Cup of NaOCl + gallon of water 10 30mins Corrosive to metals and irritating to skin Biocidal against: DIFFERENT TECHNIQUES a. b. c. Bacterial vegetative forms Virus 1. Spore forms INFILTRATION ANESTHESIA (SUPRAPERIOSTEAL INJECTION) The first choice for all teeth in the upper jaw Molars palatal injection may sometimes be needed in addition to buccal injection Lower jaw, incisors, canines and premolars local infiltration PATIENT PREPARATION 2. BLOCK ANESTHESIA (MANDIBULAR BLOCK) IMPORTANCE: To have a well-informed patient who is willing to accept root canal treatment and whatever it entails GOAL: 1. Educate the patient of the risk as well as the benefits if RCT Mandibular molars and sometimes other mandibular teeth (some cases of acute pulpitis) Important part of endodontic treatment of vital teeth Deep anesthesia Lidocaine and adrenaline containing anesthetics are the first choice

3.

LIGAMENT ANESTHESIA (PERIODONTAL LIGAMENT INJECTION) Ligament anesthesia may be used to help the first 2 methods in difficult situations However, there may be some concerns about possible damage to the root surface

12

 4.

Rapid onset: 10 20mins duration INFILTRATION (MAXILLARY)

INTRAPULPAL ANESTHESIA Done directly into the exposed pulp if other forms have not been effective Good back pressure and adrenaline in the anesthetic are required Lasting for only 15 20mins Should not be used with prior PDL injection 3-5secs of pain

CENTRAL INCISOR o o Labial One root

5.

LATERAL INCISOR o Labial or lingual

INTRAOSSEAL ANESTHESIA Anesthetic is applied directly into the cancellous bone

CANINE o Labial because of the apical eminence of the cervical portion of the crown which is more labially inclined

6.

MENTAL BLOCK Lower anterior canine to central incisors

1ST PREMOLAR o Buccal and lingual

Duration of anesthesia consideration

2ND PREMOLAR o Buccal because there is only one root

All irreversible pulpitis (symptomatic) anesthetized pain

1ST MOLAR o Palatal and buccal

Acute and chronic periapical diseases; pulp necrosis no need to anesthetize

MANDIBULAR

Irreversible pulpitis (symptomat ic or asymptoma tic) Maxillary infiltration PDL IP Mandibular IANB PDL IP + + + + + +

Necrosis

Periradicula r pathosis

INCISORS TO PREMOLARS o Infiltration and mental block

MOLARS o Mandibular block

Ok X X

X X X With the help of knowing the average tooth length of each tooth HOW WILL YOU KNOW THE LOCATION OF THE APEX?

Ok No No

X X X 1. 2. CARIES RADIOGRAPH TOOTH PREPARATION

Ok partial necrosis - patient feels pain - take a radiograph

13

a.

Importance: i. To be able to master radiographic techniques to achieve films of maximum diagnostic quality Are essential to all phases of endodontic therapy because RCT relies on accurate radiography, it is necessary to master radiographic techniques to achieve films of maximum diagnostic quality

5.

The buccal object moves in the opposite direction where the cone is shifted a. b. Shift Mesially lingual canal goes mesial Shift Distally lingual canal goes distal

ii.

3. 4. 5.

BUILD UP/ TEMPORIZATION CROWN LENGTHENING ISOLATION (RUBBER DAM ISOLATION) a. PRINCIPLES/RATIONALE OF ISOLATION: i. Patient protection from aspiration or swallowing of instruments of instruments, tooth debris, medicaments and irrigating solutions Clinicians protection Surgically clean operating field isolated from saliva, hemorrhage and other tissue fluid Retraction and protection of the soft tissue Improved visibility Increased efficiency

PREOPERATIVE RADIOGRAPH

1.

To determine root anatomy a. Ex. Mandibular 1st premolar with 4 canals ii. iii.

2.

To look for the fast break a. FAST BREAK a term used in endodontics that relates to the splitting off of a single canal into 2 separate canals

3. 4.

To locate the chamber To determine the axis of the crown as relates to root axis To decide the relative difficulty of the case

iv.

v. vi.

5.

HOW MANY TIMES SHOULD YOU TAKE A RADIOGRAPH? 3 TIMES

ROOT CANAL PREPARATION

1. 2. 3. Straight on Mesial shift Distal shift

OBJECTIVES: 1. Describe the objectives for both cleaning (use of irrigant) and shaping (use of files); explain how to determine when these have been achieved Diagram the shapes of the flared (step back) the standardized (serial shaping) and crown down preparation Describe the various techniques in canal preparation (step by step) Distinguish between apical stop, apical seat and open apex and how they affect canal preparation and obturation Describe the techniques of pulp removal Narrow canals use small files Big canals barbed broach

2. BUCCAL OBJECT RULE/ CONE SHIFT TECHNIQUE/ SLOB/ CLARKS RULE (20 M/D) 3. 1. 2. Location of additional canals/roots Distinguished between objects that have been superimposed Locate foreign bodies Locate anatomic landmarks in relation to root apex (especially the mandibular premolar) 5.

4.

3. 4.

14

6.

Characterize the fiddiculties of preparation of anatomic aberrations that make complete debridement difficult Enumerate possible procedural errors which can happen and how to avoid and manage them Failures in biochemical preparation: Overshaping strip perforation Breakage of the files o Measure files prior and after insertion Radiograph

Distance from reference point up to the apical end of the canal constriction

ACTUAL LENGTH o Actual length of initial apical file (IAF) inserted inside the canal for working length determination

7.

WL = AWL (+/-) Discrepancy between the file and the tip of the apex

CANAL PREPARATION TECHNIQUE

o 8.

1.

CORONAL PREPARATION Orifice opening and enlargement Establish tentative working length

Describe alternative techniques in canal preparations Greater taper files

2. 3.

PATENCY SCOUTING RADICULAR PREPARATION WORKING LENGTH DETERMINATION SELECTION OF IAF

TERMINOLOGIES IN BIOMECHANICAL PREPARATION

4. 5.

REFERENCE POINT o o o Important to determine the working length Incisors incisal edge Molars depends on where the files would go Note: always have a straight line access to have a correct reference point

6. 7. 8.

APICAL PREPARATION/SERIAL FILING STEP-BACK (FOR LATERAL COMPACTION) CIRCUMFERENTIAL FILING

SPREADER REACH TEST to check for flaring

RUBBER STOPPERS o Should be perpendicular to the loing axis of the tooth and should not be slanted Important to determine the working length 1. 2. Measure the pre-operative radiograph Get a file, insert then subtract 2mm (patency file) (-2 mm of tooth length image) Divide the root length into 3 parts Crown down preparation Located 0.5 1mm at the apical 3rd of the root 5. Cervical and middle preparation Use bigger to smaller files STEPS IN BIOMECHANICAL PREPARATION

RADIOGRAPHIC TOOTH IMAGE o Distance from the reference point up to the apex

3. APICAL CONSTRICTION 4. o o Where the working length terminates

WORKING LENGTH

Crown down computation

15

CL + C3rd CL + M3rd NOTE: size 35 is contant. It meanst that you have aldeady reached the end of the middle 3rd and you have already enlarged the canal (cervical and middle 3rd) DENTIN MUD i. Happens when you do not irrigate every after filing The accumulation of dentin chips that will clog the canal

Systemic procedure of removing pulp tissue, debris and microorganisms with the use of files, irrigants, and chemicals while shaping to facilitate filing of the root canal system

BIOLOGICAL OBJECTIVES:

ii.

1.

CANAL CLEANING Removal of all contents of the root canal system Infected materials, organic substances, etc.

Remember to insert the patency file every after insertion of files and irrigation, to make sure you still have the correct patent 2.

6.

WORKING LENGTH IAF APICAL BINDING i. Resistance felt at the apical when file is inserted

CANAL SHAPING creates a continuously tapering cone preserving the canal in multiple planes facilitates cleaning by removing restrictive dentin, allows greater volume of irrigant to work deeper and into all aspects of the root canal system, thus eliminating the pulp from any infections, microorganisms, etc.

7.

TAKE A RADIOGRAPH To know if the file is at the correct working length

8.

COMPUTE FOR WORKING LENGTH WL = AWL (+/-) discrepancy 0.5 safety factor

MOTIONS OF INSTRUMENTATION:

9.

INITIAL APICAL FILE

1.

TURN AND PULL Quarter turn (clockwise) rotation and then pull

10. SERIAL FILING Done to enlarge the canal 3x larger than the working length 2.

FILING Push and pull motion

11. STEP BACK RECAPITULATION i. Using of previous file to remove ledges MAF is done every after filing to remove the ledges making it smooth 4. 3.

WATCH WINDING About 30 -60 degrees clockwise and counterclockwise movement of instrument

ii.

BALANCED FORCE About 90 degrees clockwise and then about 270 degrees counterclockwise

12. CIRCUMFERENTIAL FILING WORKING LENGTH DETERMINATION CANAL PREPARATION

16

METHODS OF ESTABLISHING WORKING LENGTH 1. 2. Tactile sensation Paper point evaluation use it during or after canal preparation Electronic apex locator Use of radiograph

2.

creation of an even, progressive taper from the apical stop to the pulp chamber following the natural curvature of the canasl provision for an apical stop at the end of the canal adeqyate cleaning of the canal at optimum working length

3. 4.

3. 4.

IMPORTANCE OF APICAL STOP: SERIAL FILING Sequential use of files from IAF to MAP at working length with recapitulation Motion of instrumentation: watch winding and pull Change file if there is no more apical binding felt Use the previous file used if the next file cannot fit to avoid future errors like ledges you are sure that you have already cleaned and shaped the canal if you have already felt the glass feeling so that the gutta percha will not go out from the apex

GUIDELINES IN INSTRUMENTATION

MASTER APICAL FILE (MAF)

1.

check instrument prior to use for any sign of instruments strain or metal fatigue precurve files if SS. If curved, use directional stoppers select proper instruments depending on their use and properties always keep debris suspended in irrigant: irrigate copiously use instruments in proper sequence without skipping sizes establish a straight line access have a vision of the shape of the canal and work towards shaping it with the 5 mechanical objectives in mind never force down instruments. Stop at resistance. Always recapitulate to ensure canal patency

Largest file that has already reached the apex Minimum size: 25 for narrow canals

2.

3.

CIRCUMFERENTIAL FILING use of MAF to smoothen all the canal walls

4.

5. SPREADER REACH TEST

6. 7.

insert the MAF together with the spreader inside the canal (length of spreader should be at least 1-2 mm short of the working length) done to verify if the canal has been properly flared size 30 larger canals size 25 smaller canals

8. 9.

10. Verify working length at all times 11. Be patient. Try to do it once but well

FEATURES OF AN IDEAL PREPARATION

INTRACANAL MEDICATION:

1.

minimal enlargement f the apical foramen

Use of calcium hydroxide requires direct contact

17

For cases which cannot be finished in 1 appointment Coronal seal has to be maintained between appointments with the use of durable cements

5.

Broken bur

OBTURATION

INTRACANAL IRRIGANTS:

3D filling of the entire root canal system as close to the CEJ as possible

SODIUM HYPOCHLORITE 5.2% best irrigant. It can also dissolve CHLORHEXIDINE GLUTAMATE 2% WITHOUT ALCOHOL HYDROGEN PEROXIDE 3% (not used alone) NORMAL SALINE STERILE WATER MTA (MINERAL TRIOXIDE AGGREGATE) EDTA

PURPOSE OF OBTURATION

1.

Eliminate all avenues of leakage from the oral cavity/perpendicular tissue into the root canal system To seal within the system any irrtants that cannot be fully removed during biomechanical

2.

REQUIREMENTS OF AN IDEAL FILLING MATERIAL

GUIDELINES IN IRRIGATION:

1. 2.

Easily introduced in canal Seals canal laterally and apically Dont shrink after being inserted Free of moisture Bactericidal Radiopaque Doesnt stain tooth structure because gutta percha was not cut properly. Should be 1mm beyond cervical line Non-irritable to the tooth structure/periapical tissue Sterile

1. 2.

Irrigate copiously Use needle guage 25 27

3. 4. 5.

OBJECTIVES IN IRRIGATION:

6. 7.

1. 2. 3. 4. 5.

Gross debridement Removal of microbes Lubrication Dissolution of pulp tissue remnants Removal of smear layer 8. 9.

10. Easily removed

TYPES OF FILLING MATERIAL ERRORS IN CANAL PREPARATION 1. 1. 2. 3. 4. Blockage Canal transportation Perforations Zipped no canal stop SOLID a. GUTTA PERCHA i. ii. From dried juice of TABAN TREE Since 1865

18

iii.

Composition: 1. 2. 3. 4. Gutta percha 19 22% Heavy metal salts 1 17% Zinc oxide 59 79% Wax/resin 1 4% c. RESILON i. Standardized 0.2 taper; same size as files ii. 2. Conventional (fine or medium) Greater taper smaller tips with wider body (0.4 or 0.6) 2. iii.

5. 6. 7.

Post space removal Long term failure Apical and coronal seal infection with that of gutta percha

iv.

Shapes: 1.

A synthetic root canal filling material based on polymers of polyesters Brand: epiphany Soluble in water

3.

PASTES (SEMISOLIDS) a. ZINC OXIDE EUGENOL i. Advantage: 1. Long history of successful usage

v.

Advantages: 1. Plasticity adapt to walls after compaction Easy to remove from canal Low toxicity nearly inert overtime b.

2. 3.

ii.

Disadvantage 1. Discoloration if not properly placed

vi.

Disadvantages: 1. 2. Lack of adhesion to dentin

N2 (DERIVATION OF SARGENTIS FORMULATION) RC 2B i. ii. iii. Opaquers metallic oxide Chlorides Steroids

c. Slight elasticity which causes a rebound and pulling away from the canals

b.

SILVER POINTS i. Composition: 1. ii. Shape: 1. iii. Same as 0.2 gutta percha SEALERS Pure silver 3. PLASTICS a. b.

EPOXY AH26

Advantages: 1. 2. Ease of placement Length control rigid and flexible

Fluid tight seal Gets into lateral canals

iv.

Disadvantages: 1. 2. 3. 4. Corrosion Toxicity Non adaptability Difficult to remove

DESIRABLE PROPERTY OF SEALSRS:

1.

TISSUE TOLERANCE

19

 2. 3.

Should not cause tissue damage Low degree of solubility

Thick consistency, creamy and homogenous mayonnaise-like

o NO SHRINKAGE SLOW SETTING TIME Provide adequate working time for placement o

The thicker the mix, the better the proterties of the mixture Should string 2-3 inches

PLACEMENT OF SEALER 4. 5. ADHESIVE RADIOPACITY 1. 6. 7. 8. Readily visible on the radiograph 2. 3. 4. 5. Paper points Files Lentulo spirals Injection with special syringe Master cone

DOESNT STAIN SOLUBILITY IN SOLVENTS INSOLUBLE IN ORAL & TISSUE FLUIDS To retain compactness inside the tooth structure

9.

BACTERISTATIC

TECHNIQUE IN PLACING SEALER

10. CREATION OF SEAL TYPES OF SEALER: 1. 2. ZOE CALCIUM HYDROXIDE Shows short term sealability to tissue toxicity 1. 3. PLASTICS 2. 4. Ah-26; AH26+ Fills up the canal irregularities Lubricant of master cone during insertion FUNCTIONS OF SEALERS Placed counter clockwise Flooding is not desirable Must not be placed in all canals at once

GLASS IONOMERS Dentin bonding properties Minimal antimicrobial activity

METHODS OF OBTURATION

1.

LATERAL CONDENSATION TECHNIQUE a. ADVANTAGES: i. ii. Simple armamentarium Length control Ease of retreatment Adaptation to the canal walls Positive dimensional stability

5.

RESIN Provides adhesion

MIXING OF SEALER

iii. iv.

1. 2.

DROP TEST STRING OUT TEST

v.

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vi. b.

Ability to prepare post space

DISADVANTAGES i. Inability to obturate > cured canal, open apex, internal resorption

Before spreader is inserted and removed, accessory cone is picked up with locking pliers at measured length, ready to be inserted i. Accessory cone size depends on the size of spreader, 1-2 mm size smaller (thickness)

2. 3.

VERTICAL CONDENSATION TECHNIQUE TECHNIQUE THAT INVOLVES CHEMICAL AND PHYSICAL ALTERATION OF GUTTA PERCHA

Measured spreader is inserted between master cone and canal wall Same angle with insertion and removal of the accessory cone Repeated until spreader can no longer be pressed beyond apical third Evaluate obturation with x-ray Excess gutta percha is cut 1mm from cervical line (molar-orifice) Clean with cotton and alcohol Percolation movement of fluid Test applied for master cone: i. ii. Visual Radiographic

VARIOUS OBTURATION TECHNIQUES AND DEVICES

1. SPREADER/PLUGGER SELECTION Pointed apex; blunt apex SPREADER i. ii. iii. Condenses gutta percha laterally Finger spreader Advantages: 1. 2. Better tactile Enhance instrument contact Improved apical seal Reduced dentin stress Obturation Can be inserted deeper

3. 4. 5. 6. 2.

Remember: what is removed from the root canal system is more important than what is inserted

APPROPRIATE TIME FOR OBTURATION:

MASTER CONE SELECTION Same size or larger than MAF 1. 2. Asymptomatic Properly prepared Canal reasonably dry No sinus tract No foul odor Negative in culture Intact TF Negative in percussion and palpation

3.

FITTING OF MASTER CONE 3. Tug back/slight resistance 4. i. Importance: to reach working length only 5. 6. 7. 8.

4.

0.5 0.1 mm from tip of apex Take radiograph to verify length

STEPS IN OBTURATION Sealer is mixed and then applied to canal walls Sealer is inserted slowly to allow air and excess cement to escape

21

EVALUATION OF OBTURATION

a.

Need for both exterior (post) and interior support to ensure crown

3. 1. DENSITY 4. 2. LENGTH Gutta percha should end at apical terminus (0.5 of the apex) and must be cut below the orifices Degree of whiteness

INTERNAL CONSIDERATIONS AESTHETIC ACCEPTABILITY a. Natural translucency and color Good anatomy Characterization are restored

Uniform density form coronal to apex

b. c.

BASIC RESTORATIVE PRINCIPLES

3.

FLARE Should reflect canal shape Tapering from coronal to apical 1. 2. RETAIN SOUND TOOTH STRUCTURE CUSPAL PROTECTION a. Onlay i. Full cusp made of restorative material

RESTORATION OF ENDODONTICALLY TREATED TOOTH

OBJECTIVES: 1. 2. 3. Replace missing tooth structures Retain the final restoration Protect the remaining tooth structure 3.

b.

Inlay i. Not all cusp made of restorative material Some tooth structure still present/visible

ii.

FERRULE EFFECT PRESERVATION OF BIOLOGIC WIDTH EXTRA CORONAL RETENTION AND RESISTANCE

RESTORATIVE CONSIDERATIONS

4. 5.

1.

STRUCTURAL CONSIDERATIONS a. Endodontically treated teeth are weakened because: i. Decreased amount of tooth structure 1. 2. 3. 4. 5. ii. Caries Previous restorations Fracture Access opening Canal preparation 3. RETENTION Elective RCT is often necessary to provide support and retention for complex restorations 2. PRINCIPLES AND CONCEPTS OF A RESTORATIVE DESIGN

1.

CONSERVATION OF TOOT STRUCTURE Cuspal protection is important

REINFORCEMENT Post weakens the tooth because of the thin walled canal and sudden step

Decreased moisture content of the tooth

2.

PROTECTIVE CONSIDERATIONS

22

4.

PROTECTION OF TOOTH STRUCTURE Restoration is designed to transmit functional loads equally TEMPORIZATION

EXTERNAL RESTORATIONS

OBJECTIVES: o To keep tooth-to-tooth relationship from being altered To prevent gingival tissue from creeping over the margins

BONDED COMPOSITE BLEACHING o o First choice of treatment Destaining of yellow and brownish color is made successful

Remember: good endo treatment = apical and coronal seal

FACTORS IN CHOOSING RESTORATION:

CUSPAL PROTECTION 1. oral hygiene potential of patient location and function of tooth cervical circumference amount of remaining tooth structure socio-economic status of patient motivation and ability of dentist to do the procedure

INTERNAL RESTORATIONS

2. 3.

CORES o Replaces missing crown structure and therefore aid in retention

4. 5. 6. Only placed when there is no enough tooth structure for the core Not advisable

POST o

ENDODONTIC PROGNOSIS

OBJECTIVES: o o To evaluate result or outcome of RCt To determine success or failure of treatment

INTERNAL RESTORATIVE SUPPORT

1.

DOWEL POST Used with very minimal coronal structure Used only to retain and support the core Must at least leave 4-5mm gutta percha when using a post

PROGNOSIS

Production of possible outcome or success and failure Success rate = healing capacity vs survival rate = longevity of function and maintenance of the tooth

2.

BONDABLE POST Good for anterior teeth

3.

POST SPACE PREPARATION Use for heated instruments Post system drill

SUCCESS RATE

Capability of the clinician to do biomechanical preparation

23

Factors without any effect on the success rate: o o o o o Gender Jaw Tooth group Quality of root canal Long term survival of root canal treated teeth 1. 2. 3.

Coronal seal Exposed to oral environment

METHODS OF EVALUATING TREATMENT OUTCOME

History and clinical evaluation Radiographic evaluation Histologic evaluation

FACTORS AFFECTING ENDODONTIC PROGNOSIS HISTORY AND CLINICAL EVALUATION 1. 2. Presence of periradicular lesion Apical extent of root canal preparation and filling CAUSES OF ENDODONTIC FAILURE 1. APICAL PERCOLATION 2. Due to poor obturation Slow ingress of microorganisms into spaces Normal response to percussion, palpation and mobility (no periodontal lesion) Absence of sinus tract No signs of fracture, recurrent caries or crown discoloration

Absence of subjective symptoms/pain Functional restoration without occlusal trauma

OPERATIVE ERRORS Perforations, presence of obstruction resulting to inadequate cleaning, overfilling

RADIOGRAPHIC EVALUATION OF REPAIR

3.

ERRORS IN CASE SELECTION Coexisting periodontal lesion, resorption Restoration of continuous and even lamina dura Normal periradicular bone and periodontal attachment Decrease size of radiolucency with bone regeneration New cementum may be formed Irregular area of resorption

4.

CASE SELECTION AND DIAGNOSIS Should RCT be done? Clinician should be able to identify

5.

ANATOMY OF ROOT CANAL SYSTEM Number of canals Location of canals Location of apical foramen

Exception: APICAL SCARRING Non-pathologic formation of fibrous connective tissue in apical part which appears radiolucent

6.

QUALITY OF INSTRUMENTATION Procedural errors Obturation errors

CATEGORIES OF SUCCESS OR FAILURE

7.

QUALITY OF OBTURATION AND RESTORATION

24

o 1. COMPLETE HEALING a. b. c. 2. No clinical symptoms Continuous lamina dura Uniform thickness of periodontal space

Identification of endodontic and periodontal lesions and understand their interrelationship to determine treatment and assess the prognosis

DIAGNOSIS AND CASE SELECTION o Questions we ask ourselves: Should endodontic or periodontal treatment be done or both? What will serve the patients best interest: doing endo-perio treatment, or simply extraction?

INCOMPLETE HEALING a. b. No clinical symptoms Reduction in size of apical lesion

3.

NO HEALING a. Clinical symptoms of an endodontically induced apical periodontitis Size of apical lesion with no reduction in size or it gets even bigger

b.

PREDISPOSING CONDITIONS o Pulpal disease and its extension into the periodontium causes localized periodontitis with the potential for further extension into the oral cavity Periodontal disease and its extension has Vascular system Dentinal tubules Lingual grooves Root/tooth fractures Hypoplasia/cemental agenesis Root anomalies Bifurcation ridges Firbrinous communication Enameloma, dens invaginatus Furcation class I, II, III

WAYS TO ENHANCE SUCCESS

1. 2. 3.

use great care in case selection use greater care in treatment proper restoration with no coronal discoloration and microleakage

MANAGEMENT OF FAILURE:

1.

not to resort to extraction immediately a. b. retreatment should be done first endodontic surgery for removal of pathologic tissues and exploratory procedures

CONCLUSION: prognosis should be assessed before a treatment is initiated to determine whether to proceed or not BACTERIAL PATHWAY

ENDODONTIC PERIODONTAL INTERRELATIONSHIPS (LESIONS)

Gingival sulcus, it may cause gingivitis, periodontitis, pulpal infection, root caries

DIAGNOSIS BASED ON THE FF: OBJECTIVES:

25

1. 2. 3. 4.

Medical/dental history Vitality test Thermal test Mobility test Directly proportional to the amount of alveolar bone support

Primary secondary trauma Few microbiota

Contributing factors Complex microbiota

RADIOGRAPHIC

ENDO Localized pattern Wider apically Radiolucent periapex No vertical bone loss

PERIO Generalized pattern Wider coronally Not often related With vertical bone loss

5.

Pocket probing Normal is 3mm; if probe suddenly goes down from one side to another, it means that it needs endo. If gradual, it means perio, if both (sudden and gradual) it means both

LESIONS OTHER THAN ENDO AND PERIO IN ORIGIN:

6.

Radiography Should not be used as the only basis of ones diagnosis although it is truly useful Perforations Vertical fracture Non odontogenic

CLASSIFICATION

CLASS I primary end CLASS II primary perio CLASS III combined J type of lesion suspects vertical fracture

TREATMENT

ENDO o o RCT calcium hydroxide, gutta percha Endo surgery MTA perforations

DIFFERENTIAL DIAGNOSIS ENDO Non vital Apical periodontium Single tooth involvement Narrow pockets Minimal calcular deposits Angular bone loss Pulpal infection Deep extensive caries PERIO Vital Marginal periodontium Multiple teeth involvement Broad-based pockets Calcular deposits Horizontal bone loss Periodontal infection Not related

o PERIO o

Medications Antibiotics Antiseptics Anti-inflammatory

o o o o

Scaling and root planning GTR (guided tissue regeneration) Root resection Hemisection; radisection (cutting of 1 root of maxillary molar)

ENDO Acute inflammation Single narrow pockets Acid (due to caries)

PERIO Chronic inflammation Multiple wide coronally Alkaline

26

-Rosette Go 101910 Notes of Fernandez, Celine

27