Endodontics Flashcards
(17 cards)
Obturation of 11 ( tooth is already prepped to 22cm with reciproc 25) and vitre bond lining.
Also asked to assess another RCT of a 11
What to tell patient to expect after RCT and how to monitor?
- Obturate as normal
- RCT assessment
~ not to length
~ Voids
~ not funnel shape - Things to tell pt to expect
~ Pain - could take a week to settle
~ Swelling
~ Need cuspal coverage as soon as symptoms are away - Monitoring
~ Clinically by absence of symptoms and not TTP , no sinus
~ Yearly by radiographs (normal PDL for 4 years ) - used ESE guidelines
Irreversible pulpitis pain history
- introduce yourself
- ask about presenting complain and reason for attendance
- SOCRATES
- ask pt if it kept them awake at night
- give provisional diagnosis - irreversible pulpitis
~ This is where the nerve of the tooth “pulp” is alive but inflamed and incapable of healing which makes irreversible as it needs a root canal treatment that would involve the nreve to be taken out - take good noted (4 marks)
Symptomatic Irreversible pulpitis symtpoms , causes and treatment?
Diagnosis
Pulpal - symptomatic irreversible pulpitis
Symptoms
~ sharp pain upon thermal stimulus
~ Lingering pain lasting more than 30 seconds after stimuli removed
~ Referred pain
~ Bending over or lying down makes pain worse
~ OTC medications do not work well
Causes
~ Deep caries
~ Extensive restorations
~ Fracture exposing pulp
Treatment
~ RCT
Asymptomatic irreversible pulpitis symptoms, causes and treatment?
- Symptoms
~ no clinical symptoms and responds well to thermal testing
~ Causes
- Trauma
- Deep caries
- Pulpal exposure
~ Treatment
- RCT as vital pulp is incapable of healing
Endo restoration options (6mins)
Molar tooth. Explain to pt.
” you’ve just got a root filling and following a root canal treatment there are different options for the final filling “
” The RCT has been successful as there are no symptoms/signs of pain or swelling/pus and from the x-ray the area of the infection is getting smaller , as well as the root filling being to the correct length and with no voids”
” Following an RCT tooth is usually weakened and we would like to provide it with something to make it stronger , molars are used for chewing so lots of forces are applied to them which makes them at risk of fracture , we also want to seal the tooth to prevent bacteria from entering and causing infection again”
” Based on evidence , the best thing is cuspal coverage of the tooth which is covering all the tips of the tooth , this covering is made by the lab (Onlay or Crown) , this depends on the amount of tissue left. “
So the options for the restoration are as follows :
- Gold standard - cuspal coverage onlay
- Gold, composite , porcelain
- Reduced risk of tooth fracture
- Less microbial leakage (better seal)
- Two stage process ( prep, impression, fit)
- Less destructive than a crown - Full coverage - MCC, GDC, all ceramic , all zirconia
- more destructive , used when there is not much tooth tissue left
- Two stage process
- All metal have better longevity and required less prep but not as aesthetic
- MCC is porcelain fused to metal - reduced longevity to all metal / more prep / better aesthetics - Direct restorations - Comp or AM
- If only occlusal cavity present
- Not as favourable based on evidence as more leakage and more likely to fracture
** Core build up if **
- Gold standard - Composite
- Tooth has been hollowed and need a filling to retain the crown , we call this a core
- Nayyar core not favourable - can only be used for multi-rooted teeth
- Metal cast post if necessary - not favourable
“ Depending on tooth tissue left we might need a post ( a metal screw which is made in the lab to retain and hold the core) , it is not favourable as causes stress to tooth and preping for it can cause perforations , if possible it is better to just have a core”
- Ask if pt have any questions , and ask which option do they prefer?
Failed RCT - causes and options (6 mins)
Pt have a failed RCT , Explain why it may have failed.
What options are available?
- Say to the pt that RCT did not work which is one of the risks of the procedure
- What indicates its not worked
~ Clinically TTP
~ Pain on biting
~ X-ray shows residual area of infection - This means that you have Symptomatic periapical periodontitis
- The failure could be due to technical or biological causes
~ Biological - not disinfected enough
~ Technical - over filled
- under filled
- broken instrument
- blockage
- Perforation
- less optimal coronal seal
- final restoration get bacterial ingress causing reinfection
- missed canals
- poor preparation
- Extrusion of debris
- RCF incorrect shape
- endo file fracture
- Lack of patency
- accessory canals missed - the RC system is complex where bleach cant reach
~ Treatment options
1. Leave and monitor
- may get infected and might flare up ( if asymptomatic)
- Retreatment
- no surgery needed
- same as before but won’t guaratee it will be any better
- chances of success are decreased from 90 to 70-80%
- If post/core is present , this will involve removing it which may cause perforations, vertical root fracture of failure to remove , little tooth tissue so might be unrestorable - Periradicular surgery (surgical removal of the end of the root where most accessory canals and bacteria are present)
- if retreatment is not possible
- more difficult to tolerate
- invasive
- time consuming
- expensive
- Risk of nerve damage
- scarring may occur
- reduced support
- need referral and specialist assessment
- needs good RCF
- not an option for molars as hard to do - XLA
- tooth loss
- need replacement
- loss of function and aesthetic problems
- Ask pt if they have any questions and which option do they prefer?
Broken file (6 minutes)
Endo file separation during RCT
you temporise the tooth and explain what happened
Discuss options
~ Introduce yourself
~ State separated instrument and explain
“ we use metal files to clean and shape canals , and one of the risks of this procedure is that those files can break or seperate in tight or curved areas , which has unfortunately happened.”
~ Explain attempt has been made to retrieve file but not successful
~ Explain what has been done to temporise the tooth
~ Explain that unable to remove file but can work within current expertise
~ Explain possible consequences
1. Based on some evidence , teeth that have a PA lesion and has been root treated which is compromised with procedural errors have reduced healing
- Depending on which stage it has fractured but there might be incomplete disinfection and bacteria can remain leading to reinfection and poorer prognosis
~ Possible treatment ( take x-ray to locate file)
- Do nothing - dress and monitor , still need RCT high risk of symptoms to return
- Attempt removal with tweezer if the file is visible
- use another smaller file to remove it with the help of EDTA to soften dentine
- remove broken file with an untrasonic instrument - vibration
^ if not possible to remove it , accept and obturate to file
^ If removed continue RCT as normal
- Retrograde RCT - apicectomy, peri-radicular surgery
- XLA as last resort
- Ask if they have any symptoms
- Check understanding and conform an option
In other words
1- do nothing
2 - re-attempt retrieval at a future appt
3. Refer to secondary care , higher chance of removing file or providing alternative treatment such as apecectomy ( access root through gums and remove the end of the root and seal it )
Depends on what stage it has fractured , if it has been cleaned well and fractured at the end , it might not affect outcome of treatment
RCT risks and benefits
~ introduce yourself
~ Explain what RCT is
- multiple appointments
- Under LA , dental dam
- Rx required before/during/after
- Drilling involved
- filed / irrigation/ drying canals
- temp dressing
- Obturation - GP root filling coated in sealer
- Lining placed, tooth restored , review required
~ Prognosis
- Be specific for case - good/poor/limited
- Orthografe RCT - not guaranteed but usually successful
- up to 90% over 10 years for irreversible pulpitis and 80% for irreversible pulpitis
~ Alternatives
- no treatment - risk of flare up
- Extraction
- Retrograde RCT
~ Risks
- instrument separation
- Failure to negotiate canals to working length
- hypochlorite accident
- material extrusion
- post-op pain
- post op swelling
- need for pain control
- perforation and root fracture
- failure to resolve symptoms
- Bruising
- Tooth might be unrestorable
- might not be able to find canals
~ Benefits
- Removal of infection +/- symptoms
- Retain tooth
- prevent bone loss
- does not require reolacement for missing teeth
- better aesthetics
- better function and perception through PDL
Protaper retreatment Files
In which order are they used and speed of handpiece used
what solvents can be used for GP removal
Choose 3 common irrigants you would use
~ Order of instruments to remove GP
- D1,D2,D3 for coronal middle and apical GP removal
~ Solvents for GP removal
- NaOCl
- Eucalyptus oil
~ Irrigants
- NaICl 3%
- EDTA (17%)
- CHX (0.2%)
~ Order of prep instruments
SX , S1 , S2 , F1 , F2 , F3
Speed
- D files - 450 RPM
- Universal protaper - 250
- Gates glidden - 800
- Protaper gold - 300
Direct pulp cap (12 mins)
Assume dam is placed
Tooth with cavity close to the pulp
Please place a direct pulp cap on an exposed 36 following a pulpal exposure on the mesial axial wall
~ Explain to pt
- pulp exposed and required a pulp cap
- material is placed directly over a small exposure of the tooth’s nerve to help it heal and avoid needing a root canal.
- prevents possible death of tooth pulp
~ Indications for a pulp cap
- Asymptomatoc / vital / no history of pulpitis / not hyperaemic
~ Pulp exposure is small and surrounding dentiine is hard - otherwise extirpate
~ Process
- Dam should be placed before the exposure to prevent infection from saliva
- Arrest bleeding with saline (irrigate)
- Irrigate with CHX once bleeding is arrested
- Cavity dried with a cotton wool pledges
- Exposed pulp covered with hard setting calcium hydroxide (dycal)
- RMGI lining placed (vitrebond) and restoration completed as placced
~ Monitor vitality - if symptomatic then required RCT
~ Process if carious pulp exposure
- Extirpation - coronal pulp removal with escavator , saline irrigation and dried
- Explain than RCT or XLA will be required
- Place Ledermix/Odontopaste and dress
Procedure of indirect pulp cap?
- cleanse cavity (saline/CHX)
- Cover stained dentine with setting CaOH
- Place vitrebond on top
- Dress with GI as a provisional
- Monitor for 3 months and if vital/asymptomatic , remove provisional
- Remove stained dentine
- Place final restoration
Tooth must be asymptomatic , Vital and have no history of previous pulpi
Access cavity (12 mins)
26 RCT. Number of roots, canals and %
~ Shape of cavity ; Quadilateral
~ Number of roots 3
~ Number of canals 4 (93%) and 3 (7%)
~ Remember to use endo Z if available
~ Procedure
- dental dam placement
- cut access using high speed diamond bur (estimate depth of penetration to reach largest pulp horn) - for pre-op radiograph
- make opening in pulp chamber ( do not touch floor)
- check depth again
- Remove the remainder of pulp chamber roof using endo Z bur
- remove contents of pulp using a discoid excavator
- Remove any overhanging edges and smooth using endo Z bur
You are a dental student working in the endodontic clinic. Your patient today has been referred to the clinic by his GDP for re-RCT of his lower left first molar. [6]
The referral letter writes that the GDP is unable to carry out re-RCT in their practice so they have handed it to a dental student. Within the referral letter there is an attached post-op periapical radiograph. The referral mentions that this tooth was filled 2 months ago, which is now asymptomatic. The patient has a clear medical history.
The patient knows that he has been referred for re-RCT of tooth 36, but is unsure why there may be a need to re-treat this tooth. You do not need to take any more radiographs. The tooth was restored with a MCC which is intact.
Using the radiograph provided, discuss with the patient why it may be advisable to re-RCT this tooth, along with the different management options for their case.
After discussion with the patient, the examiner has a question to ask you.
~ Introduce yourself
~ Reason for referral mentioned for re-rct
~ Radiographic error on Rx
- RCT issues - underprepped canals , underfilled canals , periapical radiolucency present
- show pt how far a canal filling should be ( 1mm short of rx apex)
- currently asymptomatic but high chance of failure in near future and might cause pain/swelling/infection
~ Management options
- Do nothing and monitor - may fail
- Re-RCT 36 - attempt though MCC
- XLA of 36
~ Re-rct risks
- Damage to crown
- may need to remove crown
- pain
- fracture of tooth
- tooth might be unrestorable
- damage to tooth
- blocked canal
- instrument fracture and separation
- infection
- hypochlorite incident
~ Mention risks of XLA
You are a dental student in the GDH planning treatment for your patient. The patient complains about pain on biting on their upper left canine. There is no sign of infection or swelling associated with this. [EQ]
After carrying out special investigations, the tooth is negative to sensibility testing and there is an obvious periapical radiolucency present at the apex. The definitive diagnosis is a necrotic tooth.
Communicate this information to the patient and explain how this can be managed with an RCT. You should include information about the procedure and risks associated.
~ Introduction
~Explain situation
- upper left canine has an infected root canal and infection is present in one
- high risk of symptoms worsening in left untreated and a formation of an abscess
~ Risks of re-RCT
- Post op discomfort
- Fracture of tooth beyond repair
- damage to tooth/root
- Blocked root canal
- instrument fracture in canal
- Failed treatment = persisting infection
- Leakage of bleach into mouth or tissues causing bruising/swelling / nerve damage (rare)
From the previous question
the pt asks : Could you please give me some more information on the bleach accident? What will you do if this happens to me?
- if symptoms are very severe , immediate referral to hospital
- If mild pain , LA in area for immediate pain relief
- Copious amount of saline applied
- Arrest bleeding if present
- Medication put insude tooth and sealed ( steroid containing)
- Cold and warm compress at intervals for the nexr 24h to reduce swelling
- Pain killers should be taken
- reviewed the following day
From previous question ,
pt asks : That puts me more at ease. What specifically do you do during the procedure to prevent this from happening?
- Use a side venting needle
- controlled pressure when using needle
- Needle never taken tot he end of the root canal
- Needle not locked in the canal
