Saturday, August 19, 2017

Endodontics First Lecture

Dental Trauma
- Dental trauma is divided into fracture, luxation, and avulsion.
- Young children’s upper anterior teeth are prone to trauma since they have increased overjet; if
the overjet is greater than 3 mm then the risk for trauma increases almost 5 times.

- Types of injuries: fractures are the most common type (with or without pulpal exposure), then
luxation, avulsion, intrusion.

- There is a form to fill out and then examination should be done.

- Clinical examination. The number of the tooth being examined should be recorded, and the
teeth around it are also examined. First palpation is checked; it's either zero or negative, +, ++,
+++ for severe pain. Same for percussion done both horizontally and vertically (0/-,+,++,+++)
in order to differentiate if there’s inflammation in the pulp or PDL. The color is also recorded;
discoloration in the crown could be brownish or yellowish. The apex situation is also recorded,
an x-ray is taken to examine the diameter of open apices for follow-up purposes to see if apex
closure occurs; the x-ray is taken using the parallel technique through film holders. Mobility is
not always examined since if a tooth is luxated it's already mobile. If the patient already has a
splint installed then the dentist should find out which type of splint is it; for example if a
patient went to the ER they are more likely to use a rigid splint where they tie the teeth
together with wires; this is advantageous since if the tooth was intruded then these wires
prevent farther intrusion of the tooth into the socket, but the disadvantage is that it causes
periodontal inflammation and it will cause bone loss and recession and so this type of splinting
should be removed immediately and a flexible splint should be put in instead preferably a fiber
since children’s teeth aren't aligned perfectly and so the splint must be flexible enough to
cover all surfaces easily, this is very difficult when using a wire and composite; the period the
splint has been put in should be recorded, and if the dentist is the one that put it in it should be
recorded when the dentist is planning on removing the splint (2-4 weeks). Probing depth
should not be done after trauma since the tooth is already luxated and this would lead to
inserting microorganisms.

- Vitality tests: the tooth will be irresponsive to the cold test even if it has a closed apex; since
there is temporary damage for 3 months, and for the open apex there will be no response since
the A-Delta fibers which are responsible for the cold response aren't matured or in their full

1
 Saturday, August 19, 2017
number yet (4 years after eruption) for this reason children may have an abscess and not feel
it. The electrical pulp test will also be irresponsive. The drill test is done for a patient with a
closed apex and even after 3 months there is not response and the dentist isn’t sure if he should
proceed with RCT or follow-up. If the tooth is extruded for more than 3 mm (empty space
between the tip of the root and the tooth socket) or intruded for 7 mm (severe) then do surgical
extrusion and do RCT after one week but in some cases we wait for 3 months if there’s not
separation or symptoms but the dentist is still suspicious a drill test can be done if the tooth is
irresponsive then go for RCT.

- Intrusion for a tooth with an open apex has good prognosis since it will undergo spontaneous
re-erruption. For avulsion cases the period of time the tooth has been avulsed should be known
since PDL’s die after one hour — prevents resorption (minute 12)

- There should be 4 x-rays using the paralleling technique using a holder and the tooth should be
centered; and one occlusal, mesial and distal and for every injury in the upper take an x-ray for
the lower opposing teeth. X-rays allow the dentist to examine the length of the root (greater
than half or less than half in comparison to the crown), the diameter of the apex (apical
opening) should also be examined, if there's a root fracture; find the distance between the
gingival margin and the fracture, and then splint and examine the area of fracture if bone
formation will occur or if it’s going to become inflamed and granulation tissue is to be formed.
Any abnormality or resorption will only be visible on x-rays. If there’s fracture in the bone 15
min

- If there was resorption it should be recorded whether it’s internal or external or inflammatory
resportion or if it’s ankylosed.

- If there was a lesion, its size should be measured in mm’s so that follow up could be done after
calcium hydroxide placement. If it were an endo-lesion it will decrease in size, however if it
were a cyst it will not be affected; it will either stay the same or increase in size, this allows
the dentist to know whether to refer the patient for surgery or will endo treatment be sufficient.

- Fracture shows on x-rays. It could be apical, mid-root, or cervical fractures. The more apical
the fracture the better the prognosis; fractures in the apical third have a good prognosis while
fractures in the middle third have worsening prognosis and fractures in the cervical third have
the worst prognosis since there will be contamination and inflammation in the pulp and
necrosis.

- Bone fractures usually don't show on intra-oral x-rays so extra-oral x-rays should be taken like
OPG.

2
 Saturday, August 19, 2017
- Tracing a fistula is using a large size of a gutta percha and placing it through the fistula to find
out which tooth is the causative effect The size of gutta should be above 20 but a size 40 is
more preferable. If it lead to the central incisor and the central is prepared and disinfected and
filled with calcium hydroxide for 2 weeks to one month. Essentially the fistula needs one to
two months to heal. After one month the patient comes back for a follow up if the fistula
hasn’t closed, repeat the procedure of preparing and disinfecting and filling with calcium
hydroxide which could be mixed with chlorhexidine for better disinfection. The calcium
hydroxide should be applied under pressure so that it leaves through the fistula itself (the
patient is not affected by this and doesn't feel it). At the next month’s review the patient returns
and the fistula still hasn’t closed; this means that there are epithelial cells that have leaked into
the fistula through the saliva and are preventing it’s closure. Hence, the fistula should be filled
with a large H file that has been disinfected with chlorhexidine and file the sinus tract for
regeneration of the tissues. In most cases healing occurs but in extreme cases the filing method
could be used.

- There are split opinions nowadays; some suggest that if there was a sinus tract the dentist
should disinfect and do the obturation in the same appointment; others advice to wait for the
healing after filling the root with chlorhexidine. The second option is preferable even though
there is no contraindication to doing the obturation in the same setting.

- Electrical pulp tester is used, there are slow, medium, and rapid currents. Examine the tooth in
question and nearby teeth. So if the patient sense the electrical current at 14 watts at the
canine, however the other canine reaches 25 watts before the patient can sense it; this means
that there is inflammation and that the pulp is abnormal. If it goes beyond 40 this means that
there’s necrosis. Each manufacturer has values of their own for example some suggest it has to
be over 70 for the pulp to be necrotic. Also, the age of the patient makes a huge difference, a
young patient with wild canals and a large pulp chamber will sense the electrical current at a
lower value than an older patients with narrow canals and a lot of dentine formation; where the
normal value could be 30. Each patient has a specific set of values for normal, inflamed, and
necrotic.

- The electrical pulp test is contraindicated in ortho patents, patients with metallic bridges, if the
patient has an amalgam filling (since the amalgam would transmit the electrical current to
other teeth), and in pediatric patients who have open apices. In conclusion any patient with
metallic restorations would give a false reading.

- The cold test is performed by using dry ice on a cotton and placing it on a dry tooth surface in
an area that is the closest area to the pulp. It may be indicated to spray directly on the crown if

3
 Saturday, August 19, 2017
the patient has thick dentine formation or if the patient has crowns on. Since trauma interrupts
the pulp response the patient will not respond to the cold test for 3 months which is normal. If
the patient had an open apex then 4 years after the eruption the patient can finally respond to
the cold test (which explains why some young patients with distracted 6’s don't feel any
response).

- Treatment plan selection: when to go with endodontic treatment, extraction, or orthodontic

treatment. If a patient in the age range 7-10 years with distructed 6’s; the enamel is gone, the
dentine is soft, and the pulp might even be necrotic. The 6’s could be treated with RCT if the
apex is formed, or pulptomy if it has an open apex, or extraction if the orthodontic
consultation indicates it. An emergency treatment could be done initially if the apex isn’t
completely closed such as a pulpotomy or if there is an abscess it needs to be drained. An
orthodontic consultation is done since if the 6 is extracted at about 10 years old the 7 could
erupt in its place without orthodontic treatment. So if a patient has the four 6’s distructed and
endodontic treatment is to be done with stainless steal crowns, and once the patient grows the
crowns will have to be replaced, consult an orthodontist; if the patient has the need to extract
any teeth to fix the alignment then the 6’s are extracted.

- A patient who is 6-7 years old with a distructed lower 6 and the patient keeps on getting an
abscess from the tooth that only has one third of the root formed. The dentist kept on filing the
tooth every time; hence introducing bacteria into the tooth and causing recurrent abscess
formation. The treatment in such a case for this tooth with a necrotic pulp and a very short root
is to do revascularization; since the revascularization potential for the tooth is very high.
Apexification is not an option since the root that is present is very short and it would take a
great amount of time to reach a good root length with apexification and the crown:root ratio
would be incompatible.

‣ The treatment begins with taking out all the caries and disinfecting the tooth using
sodium hypochlorite careful that the sodium chloride does not leak into the
surrounding periapical tissues. Then apply 3 mix:

➡metronidazole,
➡ciprofloxacin
➡minocycline (re-vascularization)
‣ These three tablets are powdered and mixed with normal saline or local
anesthesia without adrenaline; powder these tablets in the plastic bag of elevator

4
 Saturday, August 19, 2017
which is sterile and then mix them with the liquid so that it’s a creamy mixture and
fill it up in a syringe and with a wide needle use it to inject the 3mix into the canals.
The injection should be made slowly and preferably without having anesthetized the
patient so that if it goes into the periapical tissues the patient would feel pressure and
alert the dentist; since there is the mandibular canal and sensitive structure that could
get harmed. After having injected the 3mix use a cotton with some alcohol to clean
the orifice that is on the floor of the pulp chamber; and then place a cotton with
some 3mix on the floor of the chamber and the coronal seal should be either GI or
IRM; since micro-leakage of the IRM starts within two months if the thickness is
4mm or more, and the GI micro-leakage starts within 4 months while the regular
temporary filling material has micro-leakage within days to a week. Sandwich
technique could be used where the floor of the chamber is blocked with TF and then
covered with GI; but remove the TF using a scaler and not a bur to avoid causing a
perforation.

‣ Any material placed on the floor of the pulp chamber should be removed using a
scaler and not a bur to avoid making a perforation.

‣ The material is kept in the tooth for 21 days to a month’s time; 21 days if there is no
fistula and a month if there is a fistula/ sinus tract. After 21 days the patient should
be asymptomatic the percussion and palpation should be negative and there
shouldn’t be any pain. If there was a sinus tract it should be closed.

‣ After this period of time the patient returns; anesthetize the patient with LA without
adrenaline so that it doesn’t cause vasoconstriction; place the rubber dam and wash
out the creamy mixture with some sodium slowly and gently so that it doesn’t go
periapically. Then get a large sterilized H file (70- 80 -90) wipe the file with some
chlorhexidine or alcohol. Measure the length of the root on the x-ray and then over-
file by 2mm but pay close attention in the areas of the lower 6 and 7 because of the
ID canal and also in the area of the mental nerve.

‣ Once the file is over-extended into the periapical tissue bleeding occurs; in
inflammation the blood comes out dark but once it becomes a fresh red place a
cotton immersed in sodium (like in a pulpotomy) and press it to the cervical area or
to the orifice to stop the bleeding. Then place MTA at the orifice in the amalgam gun
then using a cotton with some normal saline press it gently towards the pulp to
prevent the occurrence of further bleeding and seal with Fugi GI.

5
 Saturday, August 19, 2017
‣ Follow up every 3-6 months to a year and take x-rays to evaluate the success of the
revascularization.

‣ This is indicated in the following cases:

➡ If the crown: root ratio is less than 1:1;
➡ Young Patient;
➡ Open Apex;
‣ Since the stem cells are not in the apical papilla but rather in the bone; and they
came along with the blood. What the resultant root is made out of isn’t exactly
known if it’s bone or dentine; there won’t be a canal only dentine. There might be
discoloration in the future due to the presence of dentinal tubules in the crown.

✤ Fractures:
- Any patient with a tooth that has been traumatized shouldn’t be put under the pressure of
biting and mouthwash should be used.

- Fractures could be uncomplicated or complicated. Crown root fractures may be uncomplicated

or complicated. Root fractures may be in the cervical, middle, or in the apical area. And the
alveolar bone fracture.

- In all fractures a flexible splint is used; however, in alveolar bone fractures a semi-rigid splint
is used. Titanium or fiber splints may be used.

- When there’s a fracture that’s far from the pulp and there are no symptoms (even though it’s
rare that there is a fracture or trauma without some damage in the PDL); it could be fixed in
the same appointment.

- If there is pain upon touching the tooth; don’t start any treatment. If there is a pink color at the
site of the fracture then disinfect the area using sodium or chlorhexidine and then cover the
cavity with Dycal and GI or IRM could be applied very gently without any pressure or matrix
and wedge or anything that could move the tooth. Give the patient an appointment for after 2
weeks until the PDL’s have healed and composite can finally be used to restore the tooth.

- Never use a ready made temporary filling with any vital tooth; since the TF absorbs the
dentinal fluid since it needs fluids to set hence drying the tubules; the patient will feel pain on
percussion or sensitivity if a TF is used since the dentinal tubules will be damaged.

6
 Saturday, August 19, 2017
- If the patient has a fractured tooth but no pain on percussion or anything but the patient has
hypersensitivity the treatment could be started immediately.

- There could be crown fracture without exposure of the pulp; the patient might have the
fractured part of the tooth in hand. Place the piece in water and keep it moisturized. Even if the
patient has hypersensitivity keep the tooth immersed in water for two weeks until the patient
returns and then itch and dentine and put it back in place. The edges of the tooth could be
smoothened with a finishing bur beforehand.

- However, a patient might come without the fractured piece and with a swollen lip; the dentist
must take an x-ray of the lip to make sure that the fractured piece isn’t in fact in the lip. If the
piece of the tooth isn’t available build the tooth with composite.

- In complicated root fractures there’s an exposure of the pulp:

➡ The size of the exposure is assessed, great or minimal;
➡ Time elapsed since the exposure; a lot of trauma patients are referred from hospitals; the
patient might reach the dentist after 2 weeks of having endured the trauma.

➡ This important in cases where the tooth has an open apex (if the tooth has a closed apex
and a sufficient amount of dentine then regular RCT could be done).

๏ If the pulp was exposed less than 24 hours ago and the exposure was minimal;
the treatment of choice is direct pulp capping.

๏ If the pulp was exposed for longer than 24 hours; and the exposure was
minimal; the treatment of choice is Cvek’s pulpotomy; (where 1-3 mm of the
pulp is removed).

๏ If the pulp was exposed for more than a week; then a full pulpotomy is done
where the whole coronal pulp is removed is the treatment of choice.

๏ The time intervals are important since the spread of inflammation of the pulp. In a
study done on teeth with open apices or a wide closed apex (young patient) the
pulp was exposed for a week and the spread of the inflammation was 1 mm; this
is why the treatment of choice if the pulp was exposed for less than a week is a
Cvek’s pulpotomy since the spread of inflammation was only 1mm.

7
 Saturday, August 19, 2017
- Pulpotomy procedure:
‣ Using a large carbide bur with a low-speed with water coolant; or work using a
highspeed in a brushing motion with water coolant.

‣ Remove the coronal pulp and press a cotton pellet with sodium for 5 minutes for a
maximum of 15 mins; if the bleeding stops fill the pulp chamber with MTA and use
vetra-bond if a final restoration is to be done with composite, or an IRM if the patient
will return for a second visit. If the patient wants to do a composite restoration don’t
use IRM.

‣ If the bleeding doesn’t stop after 15 minutes go for a deep pulpotomy or partial
pulpectomy.

๏ The success rate for a pulpotomy is higher than direct pulp capping. The success rate
for direct pulp capping is 80% while for the success rate for the pulpotomy is 97-99%.
Since when doing a pulpotomy the material is placed in the pulp chamber and is not
easily dislodged and then vetra-bond is placed with composite; however the direct
pulp capping the material is placed on the tooth surface and not within it so it’s easily
dislodged. The calcium in the pulpotomy also causes partial necrosis.

๏ In the follow-up it’s important to make sure that the root is forming and dentine is
deposited on the canal walls.

- Crown-Root fracture:
‣ Crown-root fractures could be with or without pulp exposures.
‣ In an emergency case where there isn’t pulpal exposure however the fracture is below
the gingiva and the isolation is impossible; the fracture should be temporary bonded.
An emergency extirpation or pulpotomy might be done if there’s pain.

‣ The dentist then must make the treatment plan:

๏ Crown lengthening procedure (palatally and not buccally since crown
lengthening is not done in the esthetic zone);

๏ Post, core and crown;

๏ Extraction if the fracture is extensive.

8
 Saturday, August 19, 2017
๏ In young patients the tooth should be preserved until the patient is old enough
to get implants; in case the patient is old the dentist should extract the tooth
and place an implant instead of doing crown lengthening and losing bone.

- Root fractures:
‣ Patients with root fractures will have to be older than 15 years; between 15-20 years
old patient.

‣ In literature; it’s stated that patients started at the age of 10 could experience root
fractures; however; it’s impossible for root fracture at such an early age since the bone
is still soft so the result would be avulsion, extrusion, or intrusion. Once the bone is
harder and there’s force applied to the tooth the root might fracture.

‣ Pulpal necrosis in the coronal part occurs in 20-24% and it occurs mostly when the
fracture is in the cervical third of the root; since there is inflammation and necrosis of
the coronal pulp.

‣ The necrosis 53:40

‣ The worst prognosis is in the cervical > middle> apical thirds; since the contamination
is higher cervically.

‣ If the patient is old, and the canal is calcified; the cervical part could be removed
through RCT, or extrusion if it’s below the gingiva, and if there are periodontal
problems crown lengthening could be done. Or extract and do an implant.

‣ If the fracture is in the middle or apical thirds; the first radiograph to be taken is to
make sure if the fracture line is separated or not; if the tooth is slightly extruded for
less than 3 mm; put it back in place and splint it for 4 weeks and don’t do RCT only
follow up the case for 3 months.

‣ If there is a fracture and the tooth is extruded for more than 3 mm; then there is a
separation in the pulpal tissue; this tooth will need RCT. Treat this tooth as if it’s an
open apex; only to the fracture line.

‣ If the patient has been in an accident and only saw the dentist after 7-10 days, and the
area between the fracture lines is 3-4 mm; leave it where it is and splint it. If there is
no inflammation bone will fill; or granulation tissue could form. It’s essentially
impossible for the apical part to get necrotic; since it’s connected to the pulpal tissue,
it only gets necrotic if the dentist interferes and harms it with a file; so only work until

9
 Saturday, August 19, 2017
the fracture line and consider the apex. The files must be sterile, meticulous irrigation
should be done, and treat it as if it’s an open apex and fill it with MTA.

‣ minute 57 1.1
-

10