What are some factors that contribute to providing wrong tooth/treatment?
- Continue symptoms after dx
- Teeth look alike
- Failure to test vitality
- Non-odontogenic lesion
- Referred pain
- Case difficulty
What are some non-odontogenic causes of pain?
- Musculoskeletal - Myofasical pain, TD
- Neutropathic - Trigeminal Neuralgia, Phantom tooth pain
- Neurovascular - Migraine, Cluster HA
- Inflammatory - Sinusitis
- Systemic Disorders - Cardiac, Herpes Virus, Tumors
- Psychogenic - Munchausens
What are some things you can do to prevent doing RCT on the wrong toth?
- Time Out
- Don't use RD INITIALLY
- Complete vitality testing
- Refer when necessary
What is canal transportation?
- When the central axis is dislocated from original position
- "Hour-glass appearance"
What is a zip perforation?
- A transportation that leads to perforation apically
What is a ledge?
- Iatrogenically created
- Impedes Instrumentation
- An artificial irregularity created on the surface of the root canal wall that impedes the placement of instruments to the apex of an otherwise patent canal
What are some adverse consequences of ledging?
- Incomplete canal debridement
- Incomplete Obturation
What factors contribute to canal transportation?
- Lack of expertise
- Insufficient access cavity
- Poor control of length
- Lack of coronal flare
- Use of end cutting files
- Excesive axial filing
- Oversized MAF
How do you avoid canal transporation?
- Achieve excellent access
- Control Length
- Have good coronal flare which reduces coronal curvature, improves straight line access, reshapes "C" into "J"
- Avoid end-cutting files
- Use safety-tipped files: Flex-R, Sure Flex, NiTi rotary
- Think small
- Minimize axial filing motions - especially apically
- Used balanced force technique
How do you treat a ledge?
- Attempt to bypass - Short radius bend in file
- If not, obturate, may require root end surgery
Iatrogenic or pathologic communication between pulp space and oral cavity or attahment apparatus
How do you recognize a perforation?
- Pain short of apex
- Excessive bleeding
- Visually inspect
- Apex locator reads out
- Bleeding on paper point
- Confirm radiographically
What 3 factors influence perforation treatment?
What is the most determinant of success when treateting a perforation?
The distance between the perforation and gingival sulcus
Coronal to attachment = good
Apical to attachment = good
AT LEVEL OF ATTACHMENT = BAD!
Is a small or large perforation easier to seal?
Small eaiser to seal
Large harder to seal
How does time influence perforation?
Seal immediately for best prognosis
What are the 5 Perforation Types?
3. Chamber Floor
4. Midroot and Strip
What factors contribute to coronal and crestal perforations?
Disoriented during access
Calcified canals, etc...
What tooth factors work against you in avoiding a perforation?
- Tipped tooth
- Calcified toot
- Crown-root deviations
What can a dentist do to help avoid a perforation?
- Access without RD
- Isolate multiple teeth
- Make check radiograph
- Observe dentin roadmap
- Observe exit angle of file handle
- Study chamber position and dimensions
- Aim for largest pulp space, careful with highspeed round burs!
- Make proper access
How do you treat a perforation?
- Locate and protect canals
- Control bleeding
- External matrix
- Composite, RMGI, Compomer (Geristore)
How do you avoid a chmber floor perforation?
- Be aware of the dark chamber floor
- DO NOT BE TOO AGRESSIVE WITH HIGH SPEED ROUND BURS!
What clues will the canal give you if it's calcified?
- Sticky with endo explorer
- "Dust spots"
- White calcified dentin
- Dentin road map
- NaOCl chapagne bubbles
How do you treat a perforation?
1. Use NaOCl cautiously
2. Control hemorrhage
3. Internal matrix (prevents material extrusion: ie: Collagen materials, Calcium sulfate, Calcium hydroxide, FDBA)
4. MTA or RMGI
5. Once repaired, complete RCT
What factors contribute to a Midroot/Strip perforation?
- Overzeals coronal flaring
- Forcing instrument
- Calcified canal
- Previously obturated
How does one avoid a perforation at the mid root or strip?
- Use caution near danger zone
- Appropriate size and type of files
- Anticurvature filing
- Avoid aggressive files
- Understand radicular anatomy
How do you treat a strip perforation?
1. Gutta-percha apically then MTA
2. Fill entire canal with MTA
3. Avoid sealer extrusion through perforation
How do you treat a midroot perforation?
1. Attempt to treat original canal
2. Clean and shape perforation and obturate with GP/Sealer
3. Use root ZX/paper point to determine WL
What factor contributes to an apical perforation?
Failure to control apical transporation in a curve
How do you prevent an apical perforation?
- Excellent coronal access
- Length control
- Balanced force (hand files)
- NiTi rotary files
- Appropriate sized files
How do you treat an apical perforation?
1. Clean, shape, obturate perforation channel
2. Root ZX and paper points
3. Attempt to locate/treat original canal
What are some treatment options if you have a chamber floor perforation?
- Root Amputation
What are some treatment options if you have a Midroot/strip perforation?
- Root amputation
What are some treatment options if you have an apical perforation?
- Root-end surgery
- Intentional replantation
What 2 factors contribute to seperated instruments?
1. Torsional fatigue
2. Cylic fatigue
What is the definition of Torsional Fatigue?
Instrument tip locks or drags in canal while shaft continues to rotate, thereby exerting enough force to fracture the tip
What are some warning signs of seperating instruments?
- Too much apical force
- Clicking sounds
How do you prevent sperated instruments?
- Monitor file use
- Examine files
- LIGHT APICAL PRESSURE
- Adequate irrigation/lubrication
- Clean your files
- Rotaries at correct RPM
- Know your anatomy
What is cylic fatigue?
When cyclic load leads to metal fatigue - like bending/breaking a metal coat hanger - no warning signs
How do you prevent instruments from seperating?
- Caution around abrupt curves
- Discard rotary files after 3 uses
- New files
- Discard small SS files liberally
- May be a case for hand instumentation
What considerations should you have when using a Lentulo Spiral?
- Should be Pre-fit
- FORWARD DIRECTION ALWAYS
- Consider other delivery methods for CaOH sealer (NaviTip, Master cone)
How would you prevent amalgam scraps in root canal zone?
- Refine acess prior to instrumentation of canals
- Block orifices if access needs to be refined later
What are your 3 options when considerting treatment for a sperated instrument?
What are 3 methods one can use to remove a broken file?
When should you bypass seperated instruments?
- Small files with short radius bends
- Incorporate instrument into root fill
When you leave an instument, how do you treat?
- Complete RCT to sperated file
- Prognosis dependent upon: 1. Level of seperated file, 2. Size of seperated file, 3. Initial Diagnosis
- Reserch has found NO DIFFERENCE IN SUCCESS RATE
What patient considerations should you have when an instrument seperates?
- It is not malpractice to break an instrument
- Inform pt of seprated file
- Failture to inform is beneath standard of care
- Document a sperated file occurred
- "A file sperated in the root canal of your tooth" vs. "I seperated a file in your root canal"
- Prognosis usually not adversely affected
What factors contribute to obturation overfilles?
- Inadequate WL
- Inadequate apical stop
- Inappropriate use of thermoplasticized GP
- Adversely affects success of case
How does one prevent overfilles?
- Determine WL
- Obseve paper points when drying canal
- Good apical stop
- Consider MTA barrier for open apex/resorption
What factors contribute to obturation underfills?
- Inadequate instrumentation
- Inadequate access/taper
- Canal blockage/dentin plugs
- Lack of effort
How do you prevent underfills?
- Adequate irrigation
- Avoid ledges
- Make sure GP goes to length
How do you avoid Dentin Plugs?
- Start with small files and gain patency early
- Rotaries require glid path with #15 file first
- Adequate irrigation to flush debris out
- Avoid filing technique
- Recapitulate WL with small files to break up dentin mud
- Fill canal with NaOCl
- Use #10 C file to "pick" at blockage to break up dentin mud
What are some sequaele of a Sodium Hypochlorite Accident?
- Immediate severe pain - self limiting
- Profuse bleeding from tooth
- Rapid swelling
How do you treat a NAOCL Accident?
- Recognize, reassure pt
- Ice packs 4-6 hrs - Warm moist compresses on day 2
- Pain medication
- Careful follow-up
- If severe - Steroid, Hospitalization, Surgical Intervention
How would you prevent a NAOCL Accident?
- Passive needle placement
- Side-vented needle
- MEasure length of needle
- Substitute 2% CHX for Resorptive cases/perforations
Is CaOH neurotoxic? What teeth should you exercise care around when using CaOH?
- CaOH IS neurotoxic
- Exercise care - man premolars and 2nd molars (due to nerve proximity)
How can you prevent a CaOH accident?
- Quality Radiographs
- Recognize the intimacy of root apices to vital anatomy (IAN nerve)
- Correct WL - verify with Root ZX, radiogaphs and if need, paper points
- DO NOT bind CaOH needle in canal
- Place needle 2 mm short of WL before depositing CaOH
- Dispense slowly and look for back flow while withdrawing needle
How do you manage a CaOH accident?
- Inform Patient
- Immediately refer to OMFS for same-day management of CaOH extrusion into the IAN canal. Best to escort pt to OMFS
- Extract tooth and lavage sock with sterile saline
- If extrusion extends anterior or posterior in canal, may need to surgically expose canal and flush remainig CaOH out.
- Pain mangement
- Paresthesia follow-ups
What is Air Emphysema?
- Compressed air into tissue
- Rapid swelling
How do you treat Air Emphysema?
- Airway management if necessary
How do you prevent Air Emphysema?