ENDODONTICS

2nd SEMESTER | S.Y. 2022-2023

PROFESSOR: Dr. Maria Liza Orense

MODULE 1
ENDODONTICS - Treatment of diseases and injuries of
A specialized field in dental science that deals with: the pulp; and associated periradicular
• The study of a healthy pulp tissue conditions.”
• The diagnosis
• Prevention Diagnostic Tests:
• Treatment of diseases of the pulp and • Dental pulp test
periapex to render the tooth biologically • Periapical tissue test
acceptable:
- Function is restored
- Tooth is comfortable SCOPE OF ENDODONTICS
- The canatomy of tooth is properly • Differential diagnosis and treatment of
restored oral pain of pulpal or periapical origin.
- There should be no diagnosable • Vital pulp treatment
pathosis • None surgical treatment of root canal
systems with or without periradicular
The root canal and periapex are closely pathosis of pulpal origin and its obturation.
interrelated because of their proximity. From the • Selective surgical removal of pathological
pulp tissue, the blood vessels would enter the apical tissues resulting from pulp pathosis.
foramen and pass through the periapex. Any • Repair procedures related to such surgical
problem with the periapex can affect the blood removal of pathologic tissue.
supply of the pulp. In the same manner, any infection - Intentional replantation and
or disease from the pulp tissue will always deposit it replantation of avulsed tooth.
to the periapex via the portal of exits and entries. - Surgical removal of tooth structure
Thus, Endodontics is closely interrelated with (root-end resection (apicoectomy) and
Periodontics. root-end filling).
Endodontics is referred to when the periapical - Hemisection; bicuspidization and root
lesion is pulp in origin, meaning it is the pulp tissue resection
that cause the periapical lesion. When the pulp is - Endodontic implants
treated and the cause of periapical lesion is - Bleaching of discolored dentin and
eliminated, without touching the periapex, healing enamel
will set in because the periapical lesion is simply a • Retreatment or revision of teeth previously
reaction of the stimulation from the pulp tissue. treated endodontically.
• Treatment procedures related to coronal
According to American Association of restorations by means of post and/or cores
Endodontics: involving the root canal space.
• “It is concerned with the morphology,
physiology and pathology of the human Others:
dental pulp and periradicular tissues. • Diagnosis of extraoral referred pains
• Its study and practice encompass the basic • Management of traumatic injuries to the
clinical sciences including: teeth
- Biology of the normal pulp • Biopsy of pathological tissues
- Etiology • Growing recognition of pathological
- Diagnosis conditions between maxillary posterior teeth
- Prevention and maxillary sinus
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
Other Term for Root Canal Treatment:
• Pulpectomy
• Complete tooth devitalization
• Complete pulp extirpation

SIGNIFICANCE OF ENDODONTICS IN
OTHER FIELD OF DENTISTRY 3 Important Anatomies:
Why Endodontics? 1. Apical Foramen
• To SAVE a pulpally involved tooth - Not part of the root canal.
- Located at the surface of the
• To PRESERVE the affected tooth and its
cementum (which is part of the
supporting structures periodontium).
• To RESTORE an affected tooth and its - Whenever you do your
periapex back to a biologic functioning instrumentation, you do not let your
condition files or instruments go up to the apical
foramen, because you will traumatize
1. PROSTHODONTICS the periodontal ligament or periapical
tissue.
• Helps create a more retentive RPD design.
2. Dentinocementum or Cementodentin
• Accidental pulp exposure during crown Junction (DCJ or CDJ)
preparations. - of the root canal
• Prevents or lessens edentulous area - Junction between cementum and
• Retains pulpally involved abutment dentin
- Tells you that it is the end of the root
2. RESTORATIVE DENTISTRY canal, because it is where the dentin
ends.
• Accidental pulp exposure during cavity
- Where the dentin ends, the root canal
preparations. ends.
• Misdirected pin placement with 3. Apical Constriction
perforation. - Part of the root canal
• Inflammation due to unprotected pulp from - Narrowest portion of the canal
harmful restorative materials. - Narrowing at the end of the pulp cavity
• Death of the pulp as a result from at least 1 mm away from the DCJ or
generation of heat during cavity location exactly at the DCJ.
preparations. - It is clinically detectable; when your
instrument suddenly feels constriction
at the apical third area (only do it when
3. ORTHODONTICS the pulp is vital).
• Restores and saves a pulpally involved
anchor. *Pulp cavity – hollow space within the dentin.
• Maintains ideal dental arch and jaw form. *Any part associated to the root canal within the
dentin is part of the root canal.
4. PERIODONTICS * Irrigation up to the DCJ
*How will you estimate the end of the DCJ? By
• Are in close proximity to one another. approximating the average thickness of the
• Success of treatment is dependent on the cementum – 0.5-1.0 mm.
status of both the pulp and periapex.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense

c. Marsupialization
- Done when you have a cystic lesion.
- Instead of bursting out and draining the
cystic lesion, you curette the entire
lesion.
d. Replantation
- Transferring a third molar to the
edentulous molar area.
- One problem with replantation, there are
only two things that can happen: bone
deposition or bone resorption.
o Intentional replantation –
intentionally transplanted molar.
Make sure that there is no
dehydration of the PDL of the third
molar.
o Avulsed tooth replantation – what
is important is viability of the
periodontal ligament because it
can reattach. Condition of the PDL
• When there is stimulation to bone or tooth, it’s
either it deposits or it resorbs. is very essential, you keep it moist.
e. Hemisection
- More commonly used.
5. SURGERY
- Instead of removing the root portion only,
• A procedure that is done if failure after you remove including the crown.
observation of the RCT or the arrest of the - Split the tooth in half and extract the
lesion in the periapical does not show any problematic half.
resolution. f. Bicuspidization
- Usually, there is problem with the
Plays significant role in the following: cervical area.
a. Apicoectomy - Splice into two separate roots.
- Also known as Apical root amputation - More biologic, you will just split the tooth
or Root resection and create a crown.
- Open flap, expose the root end/tip, cut at g. Endo implantation
least the apical third (maximum) of the - Usually done for anterior teeth, when it
root, but the minimum the better. has fracture on the middle third.
- Remove the portion of the root canal h. Transplantation
where mostly there is biofilm that cannot
be arrested.
b. Apical curettage Basic Principles of Root Canal Therapy
- Simply excavate the bone, disinfect, and • Chain of asepsis
then seal the area.
- What causes endodontic failure is the
microleakage of microorganisms and
*Orthograde procedure irritants.
Mineral Trioxide Aggregate (MTA) is considered
• Correct diagnosis and treatment planning
as one of the best discoveries of the 20th century
• Atraumatic handling of tissue
because it can attach to the moist surface with good
• Cleaning of canal system (biofilms)
quotation.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
- Usually, biofilms form when there is (accessory canals). Many are embedded
necrosis. where some loopings arise from and
- For a biofilm to form it has it has to terminate in the pulpal wall.”
have free elements: - Pulp cavity is referred to as a root canal
o Solid surface (Dentin) system.
o Moisture (Necrotic pulp)
o Bacteria
• Shaping of the canal
- Remove irregularities but maintain its
original shape.
• Complete obturation
- Obliteration of the root canal with an
effective filling material: gutta percha
• Restoration
• Recall
- Basic pulp cavity is composed of pulp
chamber and radicular pulp.

THE PULP In a well filled main canal, it would show good

periapical reaction despite the unfilled
ramification.
Scouting – portion in the root canal treatment where
- This means that all canals whether fine
you search and confirm the anatomy of the root
or big will always be supplied with a
canal as you see it from the radiograph.
nourishment with the periapex. With this
very tiny pulp tissue, that remains
From the radiograph, what will be seen is the
infected inside the root canal and is not
prominent cavities of the root canal which is
disinfected, or was not able to protect
radiolucent.
itself, it will cause ramification. So, it is
Accessory Canals important to seal all possible orifices that
may cause microleakage and exit into
Deltas – island of dentin that is surrounded by two the periapex.
fusing pulp chambers. - If there is an external connection, when
the accessory canal has been infected, it
Majority of the accessory canals are found either at is usually the main canal that has most
the cervical third and/or apical third. Seldom seen microorganisms. There will be toxins that
in middle third. can enter but to a level that vital pulp
tissue that is inside can arrest its entry.
The Pulp The pulp tissue will be irritated and will
form secondary dentin to seal the
The dental pulp is made up of vascular orifices.
connective tissue confined within the rigid dentin - Wince there is irritation in the process of
walls located at the center of the tooth. RCT, the pulp will continuously produce
secondary dentin or calcified ridge, so
the pulp tissue will seal the orifices and
Many canals show complexities and seal itself inside.
ramifications. According to Thomas: - If there is an external communication, the
• “Many canals at the apical region do not pulp will seal secondary dentin, and then
communicate directly with the pulp the cementum around the opening of the
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
orifice will be irritated and will be STRUCTURES OF THE PULP
stimulated to form more cementum and
Pulp tissue have several peculiarities:
seal the portion.
• It is considered as an organ.
- You don’t have to worry about failing to
seal the accessory canals up to the • It is highly sensitive or very reactive to
orifice because the accessory canals will temperature changes despite the fact that it
seal itself through the cementum so that is covered by a dentine (which is a very good
there will be no portal of entry and exit insulator) and cementum.
and no microleakage from that portion. • It adapts to the size and form of the
But not unless there is necrosis, because continuously narrowing pulp cavity.
there will be no defense.
- There is what you called partial It is made up of:
necrosis in multirooted teeth. There is • Extracellular fluid
faster progression of necrosis in one - Blood and interstitial fluid – similar to
root, and the other roots, the process of plasma
necrosis, although it’s continuous and is - 63% (largest volume)
deteriorating, is slower. In the apical - Through the blood, it provides the
area, there might still be a vital pulp nourishment (source of life) of the dentin
tissue that is infected and is undergoing that makes it elastic.
the process of necrosis. If you test it with • Ground substances
pulp vitality test, the patient will feel a little - Gel-like structureless mass that
bit of sensitivity. surround and supports the structures of
- Through a radiograph, if there is necrosis the pulp, transport medium between
on one main canal, you expect periapical cells and vessels
reaction. There may be a wide apical - The arrangement of cells in the pulp are
radiolucency, and there will be a simple loosely arranged.
thickening of the space on the other - With the pulp tissue, time element is very
roots. significant, if there is entry of the
- When there is blood supply, the pulp is microorganisms, you should address it
vital. immediately, you should stop the entry
so that no greater amounts of
• “All fine canals contain living tissues that microorganisms will enter. Whatever
remains after extirpation and forms may have entered or penetrated, the self-
cementum that may completely obliterate defense of the pulp tissue will take care
the lateral canals.” -Kronfeld (1939) of it, because through the ground
substances and the loosely arranged
cells, the microorganisms may go
deeper.
- In vital pulp treatment, we have time
frames. If there is an accidental pulp
exposure of a vital healthy pulp, you
should immediately close it. But if the
exposure is more than 24 hours, and
within 72 hours, it means the depth and
amount of the microorganisms is much
more that pulp capping cannot control.
There will also be inflammation in the
pulp chamber area. What we can do is to
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
amputate the pulp tissue where there is Odontoblasts
no inflammation yet, immediately put a ▪ Most distinctive cells of the pulp
biocompatible pulpotomy agent, and ▪ First line of defense
then seal. But if it is after 72 hours, for ▪ If there is irritation, they are the one
sure the microorganisms have deeply that protects by forming secondary
penetrated into the root canal and the dentin
progress of inflammation is continuous
and it is deteriorating. Fibroblasts
▪ Most common cell type of the pulp
• Protoglycans
▪ Helps maintain integrity, helps
- Present as a characteristic gel used as
maintain structure within the pulp,
protection against compression of
and if there is need to form cells of
connective tissue.
fibroblast capacity, then they will
- There is continuous deposition of
form.
secondary dentin throughout life.
- Constantly, the pulp tissue decreases in
Immunocompetent Cells
size and volume, but it remains healthy.
▪ Defense cells which maintain normal
- If the pulp does not adapt with the
sea around.
narrowing of the pulp cavity, we will think
▪ They are simply hovering around in
that the secondary dentin will compress
the cell rich zone, they are trying to
the pulp tissue, which the pulp will react
guard the area to make sure that
as an irritation. But that is not what’s
everything is in balance.
happening, the reason for this is the
protoglycans. It protects the connective
Cells of Immune System
tissue from being compressed. So
▪ Macrophages, Lymphocytes, and
instead of compressing, what happens is
Dendritic Cells
the tissues are irritated to adapt to the
▪ These are recruited from the blood
environment.
stream
• Fibronectin ▪ They only appear when there is
- Acts as a mediator for cell-to-cell and irritation
cell-to-matrix adhesion thus have a
major effect on the proliferation, Undifferentiated Mesenchymal (Reserve)
differentiation, and organization of Cells
cells. ▪ First cells to divide into fibroblasts
- Also, it is very essential in the process of and odontoblasts cells
forming calcified bridge on direct pulp ▪ They are the one’s responsible to
exposure when your odontoblasts die, as replace dead odontoblast cells, the
they are not replaced. odontoblast-like cells.
- It is through the mediator, the fibronectin,
will inform the stem cells, the
undifferentiated mesenchymal cells.
- Through the fibronectin, the structures of
the cells are maintained.
• Cellular structures (odontoblasts,
fibroblasts, immunocompetent cells)
- Maintains homeostasis
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
ZONES OF THE PULP

✓ The odontoblasts are well arranged along the

pulpal wall. They are the frontliners. 1. Odontoblastic Zone
✓ Once there is irritation of the odontoblasts that - Where odontoblasts are located
results to death of the odontoblasts, the TGF- responsible for dentin formation.
β1 (Transforming Growth Factor-beta 1), - Where secondary dentin formation
which is specific for the pulp, they are the one’s happens.
that are immediately informed of the death of
the odontoblasts. They will travel from the 2. Cell Free Zone or Zone of Weil or
area of the odontoblastic layer, from the cell free Subodontoblastic Nucleus Poor Zone
zone, they will travel into the cell rich zone, and - Area for mobilization or replacement of
inform the undifferentiated mesenchymal cells odontoblasts
(stem cells) that there are areas of dead
odontoblasts and needed to be replaced. 3. Cell Rich Zone or Bipolar Zone
- Source of cells that differentiate into
secondary or replacement odontoblasts
upon injury to primary odontoblast.
- If the odontoblast become injured, the
undifferentiated cells will still form
odontoblasts, because it’s still there to
replace the injured ones. But if the
✓ The TGF- β1 will transport the odontoblast-like odontoblast dies, there’s no odontoblast to
cells into the area and arrange them again and report, the it’s the odontoblast-like cells will
later on will form calcified dentin and cover the be formed by the undifferentiated cells.
area.
✓ This is only possible if the irritation has been 4. Pulp Core / Pulp Proper
arrested by using a biocompatible filling - Contains cells, blood vessels, nerves,
material. If you don’t use biocompatible filling and lymphatics.
material, irritation will constantly penetrate and
it might kill other odontoblasts. So there will be
wider area, where there will be no secondary
DEGENERATIVE CHANGES OF THE PULP
dentin formation to cover the exposure.
Calcification will not happen, if there is strong • Pulp recession
irritant existing in the exposed areas. • Pulp stone/denticles
✓ With the presence of a good biocompatible - If the stimulation is so intense, there’s a
filling material, you seal the area, then the high irritation, and it causes pulp stones.
odontoblast-like cells will be arranged, and then • Fibrosis of the pulp
calcifies, to form the calcified bridge to seal off - Very slow irritation of the pulp, and it is
the entry into the pulp. naghihingalo na.
• Atrophy of the pulp
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
PULP MICROVASCULATURE Capillary Network
• Key vessels in the pulp.
Pulpal Microvasculature Units
• Transport nutrients and oxygen to the cells.
• Arterioles
• Maintains hemeostasis within the pulp by
• Terminal capillary network
removing waste products and CO2 from
• Venules
the cells.
• Site of exchange between the blood and
Vasculature Segments
interstitial fluid.
• Muscular arterioles
• Post capillary venules are also site of
• Terminal arterioles
exchange between blood and interstitial
• Pericapillary arterioles
fluid.
• Capillary
• Drains into the small venular network that
• Post capillary venules in turn connects with fewer and successively
• Collecting or Muscular venules larger venules.

Arterial Supply Venules

• Posterior superior alveolar arteries • Single venule enters the foramina
• Infraorbital branch of the internal alongside the arterioles and exits with
maxillary arteries multiple venules.
• Inferior alveolar branch of the internal • Connects with the vessels that drain to the
maxillary arteries PDL and alveolar bone.

Arterioles Antero Venous Anastomosis (AVA)

• Pass through the root pulp to supply coronal • Relatively small vessel that arises to
pulp connect the arterioles directly to venules.
• Travels straight at the center of the pulp to • More frequently found in the radicular area
the coronal area then branches pattern of the pulp.
develop

• As it approaches dentin area, arterioles • Function not completely known but

losses its coating and forms a dense speculated that they play a role in the
terminal capillary network near the dentin regulation of blood flow around the area
around the odontoblastic area at the of injury or inflammation by forming AVA
subodontoblastic region. shunts that redirected blood flow to avoid
thrombosis.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
“U” Turn Loops DEFENSE
• Forms simultaneously with AVA shunts a. Morphologic reaction through formation of
and believed to have the same function as secondary and reparative dentin
AVA shunts when pulp is injured. b. Inflammatory reaction (pulpitis)
• Filled with streaming blood.

SENSORY
Characteristics of Pulp Vasculature
• Antero-venous anastomosis
• Venous-venous anastomosis
• U-turn loop arterioles (apical area)
• True isolated microcirculatory network

PULP INNERVATIONS
• Maxillary and mandibular branches of the
Trigeminal Nerve INDUCTIVE
• Superior Cervical Ganglion • Source of odontoblasts.

PULP FUNCTIONS
FORMATIVE
a. Synthesizing and secreting organic
matrix
b. Transporting inorganic components to
newly formed matrix
c. Creating an environment that permits
mineralization of matrix

NUTRITIVE
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
CLINICAL PULP Theories of Dentin Hypersensitivity:
1. Direct innervation
Normal Pulp 2. Hydrodynamic theory (Brannstorm and
• Symptoms free unless stimulated Astrom)
• Responsive to vitality testing 3. Transduction theory (Ten Cate)
• Presents strong response but not painful
Common Symptoms:
The dental pulp is the most unique organ with • Sharp shooting pain that would last for 3
several peculiarities. days to 1 week.
• Dull and lingering
Character of a Normal Pulp • Dull and throbbing
1. The size of the pulp is dependent on the size • Paresthesia
and shape of the pulp cavity. • Flare-up (Phoenix abscess)
2. There is continuous decrease in the volume • Moderate to severe pain with or without
of the pulp. swelling will occur if:
3. The pulp does not swell but with abnormally o Asymptomatic at the start of
high pressure in the area of inflammation. treatment and experienced pain after
4. Presents localized necrosis and anoxia due to treatment.
the interruption of the blood flow resulting o With pretreatment pain.
from the collapse of pulpal veins during
inflammation. Pain
5. It is an organ of terminal circulation due to the • “An unpleasant sensory and emotional
limited portals of exit and entry. experience associated with actual or
6. Has limited collateral circulation because of potential tissue damage, or described in
limited portals. terms of such damage.”
• The pulp has 2 types of sensory nerve
fibers (Nociceptive mechano receptors):
DISEASES OF THE PULP a. Nerve bundles contain A-β and A-δ
• Pulp disease is identified based on the fibers (myelinated)
b. C-fibers (unmyelinated)
signs and symptoms of the disease
process.
• Provides general description that implies A-β fibers
the fullest extent of pulpal disease. ✓ Found within the pulp
✓ Not associated with detection of pain
Pulpal Pain or Pulpalgia ✓ Also responsive to noxious stimuli but
functionally indistinct from A-δ fibers.
- Pulp’s response to insults.
✓ Sensation: Light touch
- Hyperactive pulpalgia or Dentinal
sensitivity
• Normal reaction to stimuli that is non- C fibers
pathologic. ✓ Transmit slow pain described as dull,
- Starts from peripheral sensory neurons of aching, throbbing or burning pain
the trigeminal nerve innervating the dental associated with pulpitis.
pulp and other oral tissues. ✓ Generally, the nerve terminal found in the
- Substance P (neurotransmitter) from the pulp proper often adjacent to blood
central terminal of the trigeminal nerve is vessels.
involved in the initiation of pain.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
✓ Activated by inflammatory mediators Cause:
(bradykinin, prostaglandin, and • Agents (resto mats) capable of injuring the
histamine). pulp.
• Trauma
A-δ fibers • Thermal shock
✓ Are small myelinated fibers. • Irritation of exposed dentin at the neck of
✓ Comprises 90% of A fibers. a tooth.
✓ Transmits fast pain perceived as sharp and • Circulatory disturbances
piercing associated with dentin
hypersensitivity. Prevention:
✓ Terminates a short distance within the • Periodic care to prevent development of
dentinal tubules at the predentin and caries.
odontoblast region of the pulp. • Early insertion of filling if a cavity has
developed.
Referred Pain • Use of cavity varnish or cement base
• When pain did not cross the midline. before insertion of a filling.
• Wide range of pain felt not only at the deep
but also at the superficial and
subcutaneous tissue.

1. REVERSIBLE PULPITIS
- An inflammatory condition of the pulp giving
moderate to severe response to noxious
stimuli.
- The pulp is capable of returning to the If you are basing your diagnosis on clinical
uninflamed state following removal of the symptoms, it is still considered a bit subjective
irritant. because we should take into consideration other
factors: the present condition of the patient, if the
Symptoms: patient is too sensitive at the moment, or if the
• Basically, asymptomatic in the absence of patient is taking medications or is under medications
stimuli. at the moment during exposure, during testing, or
• Once stimulated, it is characterized by a the race of the individual. There is subjectivity
sharp pain of short duration lasting but a involved. Thus, all diagnosis that are based on
moment or as much as a minute. symptoms only are subjective. You can only arrive
• Normal periapical diagnosis. at the definitive diagnosis once you see the condition
• Has increased response to cold that is of the tissue with your own eyes, or analyze it
non-lingering. histopathologically.
• Generally, brought on by cold water or food,
or cold air, sweet or sour foodstuffs. In the case above (right side), if there is an
accidental pulp exposure, there’s no hemorrhagic
• Does not occur spontaneously and does
bleeding. Although there is an inflammatory fluid
not continue after the cause is removed.
secretion, it simply indicates that the healthy pulp
• Often associated with recent resto, perio
tissue is trying to protect itself, which does not flood
therapy, or minor dental trauma.
but make the canal moist.

A healthy pulp tissue would appear pinkish. But in

the case above (right side), you can see a darkened
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
and inflamed pulp tissue already. But this is after do closure of the exposed dentin or if
several hours of exposure, which means that the there is a pulp involvement, then we do
pulp is trying to have congestion already, but it is still a vital pulp treatment. But with
in reversible condition. This case usually happens in irreversible pulpitis, there’s no other
less than 24 hours of exposure. You can still do recourse but to remove the pulp tissue,
direct pulp capping and place a permanent and do root canal treatment. But if the
restoration. patient is not agreeable with the RCT,
then the only option there is extraction.
Unlike the other picture (left side), the exposure is • Spontaneous pain throughout the day or
dry, as you can see the white mask there that is a evening.
necrotic pulp tissue. There’s no redness, no signs of • Severe pain when taking hot or cold
inflammation, but rather dry exposure which you can drinks.
consider that it is a necrotic tooth. • Pain when biting causing patient to avoid
biting on the tooth.
2. IRREVERSIBLE PULPITIS o If there is pain when biting, it means that
- An inflamed pulp is no longer capable of there’s a great chance that it will have a
healing and returning to normalcy. positive reaction to percussion, which is
- Generally characterized as lingering an indication that there is a probability of
painful thermal responses particularly to an acute apical periodontitis. This
cold. implies that there is already a periapical
- Intensified by stimulus but can be involvement.
spontaneous.
Types:
*Cold stimuli have more conclusive symptoms that it a. Symptomatic Irreversible Pulpitis
will react to. ▪ An acute inflammation of the dental pulp
characterized by intermittent paroxysms
*The longer the duration of pain felt during tests, the of pain which may become continuous.
more we are convinced that it is an irreversible ▪ If left to run its course, acute pulpitis will
pulpitis. ultimately terminate in death of the pulp.

*When you stimulate, it can be a provoked pain or it Etiology:

can also be spontaneous pain, without any • Bacterial involvement of the pulp through
provocation that pain may intensify. caries.
• Clinical factors (chemical, thermal,
General Symptoms (both symptomatic & mechanical)
asymptomatic):
• There is long lasting pain (several minutes Symptoms:
to hour). • Paroxysms of pain
o Compared with the control tooth, which • Excited by:
the normal duration, in tooth with IP, it - Sudden temperature change
should be 10 seconds longer than the - Cold, acid, or sweet foodstuff
normal. - Pressure from food impaction
• Pain that throbs or intense causing
sleepless nights.
o If there is teeth sensitivity, you should
have doubts whether to hive vital pulp
treatment or root canal treatment
because with reversible pulpitis, we only
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
b. Asymptomatic Irreversible Pulpitis mature teeth, in adult individuals like 32
Etiology: years old.
• May result from slow progressive irritation *Actually, hyperplastic pulpitis is a defense
of the pulp. mechanism of the pulp tissue, that’s why
hyperplastic tissue forms.
Symptoms:
• Basically, symptomless unless 3. NECROSIS
stimulated. - Death of the pulp
• Mild to moderate painful response that - Devitalized pulp
lingers after removal of the stimuli. - Non-responsive pulp

Etiology:
• Untreated irreversible pulpitis
• Sudden impact / traumatic injury
• Long term interruption of blood supply of
the pulp.

Types:
Differential Diagnosis: a. Partial Necrosis
• The pain of irreversible pulpitis is more ▪ Similar with irreversible pulpitis.
severe and lasts longer while the pain of
reversible pulpitis is transitory, lasting a b. Total Necrosis
matter of seconds. ▪ Asymptomatic before it affects the
periodontal ligament.
Subtype: ▪ Crown discoloration in anteriors.
i. Canal Calcification
*It is created through a constant, slow or
long-standing stimulation or irritation of the
pulp.

ii. Internal Resorption

*Opposite of calcification. Instead of dentin
deposition, what is happening is the dentin
is being resorbed.
*This is also caused by slow, long-standing,
progressive irritation of the pulp tissue.
*It simply means that calcification and
internal resorption, the pulp is trying to
protect itself, that’s why it is inflamed. But
the reaction is to the dentin is either
calcification or internal resorption.

iii. Hyperplastic Pulpitis

*Another is term is Pulp Polyp.
*This was usually associated with immature
pulp with underdeveloped root apex. But
now, there are already cases of
hyperplastic pulpitis in adult teeth, in
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
THE PERIRADICULAR SAP
Character:
▪ Inflammation of the apical periodontium.
▪ Mild discomfort to painful response to
biting and or percussion.
▪ There is thickening of the periodontal
space (lateral or furcal).
▪ May or may not be associated to apical
radiolucent.

Acute Apical Abscess (AAA)

Normal Periapical Tissue (WNL) Character:
▪ Severe tenderness of the tooth to
Character
pressure.
Clinically
▪ Widened PDL space
• Asymptomatic to tapping or palpation.

Radiographically
• Lamina dura is intact
• PDL space is normal and consistent in
width along the entire root similar to the
adjacent tooth.
Acute Alveolar Abscess
Disease of Periapical
Apical Periodontitis Cellulitis
- An inflammatory disorder of periradicular Character:
tissue caused by irritant from endodontic ▪ Symptomatic edematous inflammatory
origin mostly by persistent microbes living process.
in the root canal system of affected tooth. ▪ Invasive microorganism spread diffusely
through the connective tissue and facial
Types: planes.
a. Symptomatic (Acute) Apical Periodontitis ▪ There is various degrees of swelling and
(SAP) discomfort.
• Result from initial or start of infection or ▪ Rapid in onset requiring close observation.
trauma.
o Phoenix Abscess Phoenix Abscess
o Acute Apical Periodontitis Character:
o Cellulitis ▪ An acute exacerbation of a chronic
periapical lesion.
b. Asymptomatic (Chronic) Apical Periodontitis ▪ Extreme pain/ discomfort and/or swelling
✓ Long standing periapical inflammatory on the area of a previously asymptomatic
lesion. alveolar abscess.
o Granuloma
o Cyst Asymp AP
o Chronic Alveolar Abscess Character:
o Condensing Osteitis ▪ Inflammation and destruction of apical
o Apical Scar periodontium of pulpal in origin.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
▪ No clinical symptom. ▪ Believed to be associated with low-grade
▪ May be accompanied by root and bone inflammatory stimulus.
resorption. ▪ A localized bony reaction commonly found
▪ Radiographically evident (apical in cases of long standing pulpal pathosis.
radiolucent area).
Apical Scar
Character:
▪ A dense CT in the bone that has been
surgically treated.
▪ A form of repair associated with lesions
involving destruction of both facial and
lingual osseous cortical plates.
▪ Dark radiolucency found at or near the
apex.
Cystic Apical Periodontitis
▪ An inflammatory jaw cyst (closed
pathologic cavity, lined by epithelium that
contains liquid or semisolid material) of the 4 PHASES OF RCT
periodontium of a tooth with infected and 1. Pre-treatment phase
necrotic pulp. 2. Treatment phase
3. Obturation phase
Chronic Alveolar Abscess 4. Post-treatment phase or Maintenance Phase
Character:
▪ Inflammatory reaction of the pulp
infection and necrosis. Entire Endodontic Procedure in General
▪ Gradual onset of inflammatory reaction or 1. Pre-treatment
discomfort. 2. Treatment
▪ With little or without discomfort. 3. Post-treatment
▪ Intermittent discharge of pus with or a. Recall
without an associated sinus tract. b. Crown restoration
▪ Large periapical radiolucency may be
present.
▪ Apical root resorption with widened apical
foramen.

357

Condensing Osteitis
Character:
▪ A diffused radiopaque lesion at the apex
of the tooth or extraction site.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
BIOMECHANICAL PREPARATIONS grow and form until they meet at a certain
- It is the simultaneous physical and point, you call this meeting the
mechanical cleaning and shaping of the root developmental fusion line, on the occlusal
canal together with chemical dissolution of portion. They will always meet at the center,
any chemicals that would potentially irritating and this is the time that the crown is fully
not to the pulp tissue but to the periapex, formed. So, by looking at the crown you can
because biomechanical preparation is done identify the mesiobuccal lobe, distobuccal
in root canal treatment. lobe, and palatal lobe through their fusion
- It is done in root canal treatment, this is line. These lobes meet at the center, and
where we remove the pulp tissue, we clean the center of their union or fusion, is
mechanically the root canal system, and we called the central pit.
flush out with very good disinfectant and
antibacterial agent in order to establish a
good disinfected status of the root canal
system.
- Initial step of biomechanical preparation
is access preparation, that is how you will
be able to get into the pulp tissue. There is
need to remove one wall of the pulp
chamber.
- In anteriors, lingual wall will be removed,
limited to pulp horns above the cingulum,
and walls of mesial and distal. - In the development of the tooth, as the lobes
develop, and they fused together creating
Applied Anatomy and Endodontic Entries one crow, the pulp c of this crown also fuses,
the pulp chamber of the pulp of the three
- “Internal anatomy of the pulp tissue
lobes now fuses together creating one
compliments the external anatomy.”
chamber. That’s why on molars, they have a
- Anterior teeth are monorooted. They
common pulp chamber.
developed from one single tooth germ, from
- When the time the root is formed, and the
this tooth germ develops the dentin and the
molars receive more functional forces, so the
crown, creating one lobe of a crown. Once
occlusal lobe of molars are much more
the crown is fully formed with a fully formed
heavy, so there is a need for more
pulp chamber, then the root starts to form, so
anchorage. This is the reason why they have
the dentin migrates downward to create the
more roots. To make it anchor better, they
root portion creating one single root canal
need to spread out along the alveolar bone,
because it developed from one single lobe.
they need retention, strength, more bone
- For each lobe, there will always be one
support, and more resistance to gravity
pulp cavity, which is located at the center
during function.
of the tooth.
- So what happens is, once the crown is
- For posterior teeth, it is made up of three
formed, the pulp in the pulp chamber fuses
lobes particularly for example the maxillary
together, the pulp tissue starts to separate at
molars. They have three lobes and some
the cervical third, and they create their own
accessory lobes.
roots, that’s why there are thee separate
- Basically, for max posterior teeth, you have
roots because there are three separate
three lobes of tooth germs, three tooth germs
lobes.
that developed into the crown. Two on the
- With the separation therefore, it creates a
buccal and one on the palatal side.
floor, and because there are three lobes that
Simultaneously all these lobes of the crown
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
fused together, a roof is created. They will Guidelines (Access Preparation)
always have a fusion between the roof and
Pulp Anatomy in Relation to Access
the wall, which is what you call the pulp
horns. This is the angle of the union or point Preparation:
of contact of the roof and the wall. 1. Develop a mental image of the pulp cavity in
- In ateriors you only have one lobe. The labial three dimensions with the aid of the
wall, lingual wall, and mesial wall fuse radiograph and knowledge of canal
together, creating an apex, that is your pulp anatomy.
horn. It is the union of walls.
- From the floor of the pulp chamber, that is
where your root starts, because it is where
the separation started. The anatomy where
the root starts is the canal orifice.
- The start of the pulp chamber is the roof.
- So, for initial penetration, penetrate at the - The shape of the root canal varies.
center of the occlusal area of the tooth and - The root canal system is very complex.
then extend, remove the ledge, remove - It is really essential to not destroy the
completely the roof, up to the pulp horn. integrity and morphology of the pulp
That’s the limitation because in the pulp chamber, because if you destroy it, you will
horn, that is where the wall starts. We don’t be misdirected.
want to undermined the dentin because it will
weaken the crown, and you will loose the 2. Know the possible morphology of the root
position of the orifice. canal system.
- Through the files, you will be provided with
a tactile sensation of the possible
morphology of the root canal.

- Each root has their own accessory canals.

You may have AC that has connection to the
periapex, that will drain out all by-products,
infection to the periapex. Classification is based on the number of the
canal orifice, lumen within the root and the
apical foramen:
a. Type I (1) – there is 1 orifice, canal and
apical foramen.
b. Type II (2-1) – there are 2 orifices, 1 canal
and apical foramen.
c. Type III (1-2-1) – there is 1 orifice and the
canal splits (creating an island of dentin/delta
which separates the two canals) into 2 and
merges again to form 1 apical foramen.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
d. Type IV (2-2) – there are 2 orifices, and 2 5. Radiograph measurement of the depth of the
separate apical foramina (lateral apical pulp chamber roof from the occlusal table.
foramina).
e. Type V (1-2) – there is 1 orifice, and 2 apical 6. Assessment of complicating factors.
foramina. - Pulp stones
f. Type VI (2-1-2) – there are 2 orifices, fused - Calcifications inside canal
together in the middle third, 1 canal, and - Extensive calcification where the roof of the
separates again creating 2 apical foramina. pulp chamber is below the middle third
g. Types VII (1-2-1-2) – there is 1 orifice,
separates (2) , fused again (1) , then *What remains constant and unchanged in the
separates creating 2 apical foramina. development of the tooth and in the
h. Type VIII (3) – 3 separate canals. progression of the secondary dentin formation
is the cervical third.
This classification pertains to one root only of a *It is the drop in the initial access prep that will
single tooth, so it might happen in other roots also. give you the information that you have
For instance, in MB root of molar tooth, you may find penetrated the pulp chamber.
3 root canals. *In access preparation, our main intention
really is to expose the floor of the pulp
chamber. But do not touch the floor and walls,
just the roof.

7. Develop a mental image of the possible

positions of the canal orifices.
- Key factor, know the position of the roots.

- It is common in mandibular molars to have

3. Determine the point of penetration. 4 canals, not 3.
- Entry usually done at the center of the
occlusal table (it is the center of the fusion
of the lobes) except for maxillary molars
(because fused ang central pit of max
molars, which is the center of the fusion
line, because there is distolingual lobe). In
access prep, it is viewed as having
triangular arrangement of the cusps
excluding the distolingual cusp despite 8. Develop a mental image of possible shapes
rhomboidal outline of the occlusal table. and size of the canal orifices.
- Common fusion is mesiobuccal,
4. Assess the occlusal and external root form. distobuccal and distolingual, naiiwan
- Mentally envision the angulation of the bur ang mesiolingual.
in 3-dimension in relation to the angulation
of the jaw and the external root surface at
the CEJ.
- For anterior teeth, widest portion of the
chamber is behind the cingulum. That’s
why we use a 45 degrees angulation/
- For molars, since there is a roof, it should
be perpendicular to the occlusal plane.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
9. C-shaped canals 3. Law of CEJ
- Classified as complex canal. • The distance from the external surface of
the clinical crown to the wall of the pulp
chamber is the SAME throughout the
circumference of the tooth at the level of
the CEJ.

“The pulp chamber floor has a specific and

consistent anatomy at the cervical third.”
- Krasner & Rankow
4. First Law of Symmetry
• Except maxillary molars (because of their
growth, 3 separates roots that are flared),
Cervical Level the orifices of the canals are equidistant
from the line drawn in a mesio-distal
Krasner and Rankow’s 9 Laws of Anatomy
direction throughout the pulp chamber
the Anatomy of the Floor of the Pulp floor.
Chamber: • The orifice is dictated by the position
and shape of the root.
1. Law of Centrality
• The floor of the pulp chamber is always
located at the center of the tooth at the
level of the CEJ.

5. Second Law of Symmetry

• Except maxillary molars, orifices lie on a
line perpendicular to a line drawn in a
mesiodistal direction across the center
2. Law of Concentricity of the chamber.
• The walls of the pulp chamber are always
centric to the external surface of the
tooth at the level of the CEJ.
• Compliments the law of centrality.
• Always look at the cervical area not the
occlusal.

6. Law of Color Change

• The color of the pulp chamber is always
darker than the walls.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
VITAL PULP THERAPY
or ROOT CANAL THERAPY?

• Secondary dentin forms over the primary

dentin at the pulp chamber. This means
that the dentin above the PC has more
pearly white or clearer color than the dentin
on the pc. There is change in the color.

7. First Law of Orifice Location

• The orifices of the root canals are always Where do we draw the line?
at the junction of the wall and the floor.
• You should never destroy the wall, do not Characteristics of the Pulp
undermine because you will be lost from • Inherent capability to heal
the orifice. • Capacity to form reparative tissue
• Never change the position of the wall and • Forms calciotraumatic line
the floor.
Notes:
Calciotraumatic line
- Gap between the primary and secondary
dentin.
- Prevents toxins from going into the traumatic
pulp.
8. Second Law of Orifice Location Rate of dehydration is faster in crown portion.
• The orifices of the root canals are always Dehydration is delayed in the root portion.
located at the angles of the floor-walls of
the chamber. Lines of Defense of the Pulp
• E.g. mesiobuccal orifice

9. Third Law of Orifice Location

• The orifice of the root canals are located
at the terminus of the root development *Tubular dentin – primary dentin
fusion lines.
• Fusion lines on the floor is called the dentin Apexogenesis
map or developmental fusion lines. • A physiologic process of root
development in the presence of an
environment necessary for continued
apical and lateral growth of the rooth.
• It is not a procedure but rather is a normal
physiologic process of root development.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
• Therefore, preservation of the radicular Vital Pulp Therapy
dental pulp in the presence of a coronal • The treatment of a non-inflamed pulp
carious or traumatic exposure is tissue either with direct or indirect pulp
essential. –James L. Guttman environment.
Notes: • Ability of pulp to promote apical closure.
Apexogenesis
- Process of apical closure using pulp Pulp Capping
tissue. • Aims to stimulate irritation dentin
- Responsible for HERS (Hertwig’s Epithelial formation to block ingress of bacteria and
Root Sheath) – only present when the pulp is toxins, irritants to the pulp.
vital.
- Dentin migrates apically/medially to form the 2 Types:
apex. - Direct
Apexification - Indirect
- For immature tooth
- Stimulates apex to form calcified bridge at Indication:
the apical portion. - Ideal condition = Good prognosis
- Pulp exposure is iatrogenic in nature
Ideal Environment - Normal pulp
1. Healthy radicular pulp tissue - Unaffected dentin
2. Maintained viability of Hertwig’s epithelial - No signs and symptoms indicating pathosis
root sheath
3. Viable dentin within the root Agents Used:
- Calcium Hydroxide
Assessment o Highly irritating
➢ History of the Signs and Symptoms - MTA (Mineral Trioxide Aggregate)
• Clinical Signs and Symptoms o One of the best discoveries of 20th
o Reactions to pulp tests century.
▪ Normal o Highly biocompatible
▪ Irreversible - ZOE (Zinc Oxide Eugenol)
▪ Reversible
• Visual conditions Pulp Horn Exposure (Iatrogenic):
o Amount of hemorrhage upon exposure 1. Isolation with rubberdam
o Size of exposure 2. Removal of caries
o Maturity of the tooth 3. Disinfection
o Color of exposed pulp 4. Direct application of pulp cap on exposure
➢ History of restoration procedure/amount of 5. Restore the crown with bonded resin
residual dentin 6. Observe
➢ Degree of dentinal caries
➢ Presence or absence of periodontal disease
➢ Degree of exposure Pulpotomy
• Iatrogenic • A therapy for vital pulp exposure.
• Caries • Amputates the coronal pulp.
• Trauma • Indicated for immature dentition.
➢ Duration of exposure • Emergency treatment in case pulpectomy
• Less than 24 hours – pulp capping cannot be immediately employed.
• Less than 72 hours – pulpotomy
• Longer – RCT
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
Indications: Root Canal Therapy
- Carious or traumatic exposure of the pulp • Cleaning, shaping, and obturation of the
of an immature tooth. root canal system of the tooth.
- Mature tooth with no signs and symptoms
of pulp pathosis. Indication:
➢ Clinical Condition
Marginal Condition: • With Signs and Symptoms of Pathosis
- Minimal hemorrhage • Necrotic pulp
- Small to moderate carious exposure and
• Periapical involvement
traumatic injury of immature dentition.
- Extensive carious tooth with underdeveloped
➢ Visual condition
root apex.
• Pale yellowish exposure without
hemorrhage or exudate
Agents Used:
• Excessive hemorrhage upon exposure
- Formocresol
- Ferrous sulfate • Necrosis with underdeveloped root apex
- Calcium hydroxide
- MTA
- ZOE
- NaOCl (Sodium Hypochloride)
o Hemostatic (controls bleeding)
o Kills immediately bacteria upon
contact.

Types:
a. Partial Pulpotomy
- Removal of inflamed coronal pulp up to
the level of healthy coronal pulp.
Summary
VPT RCT
1. Rubberdam isolation
Favorable response to Pale yellow exposure
2. Removal of caries
stimuli
3. Disinfect
No symptom, no Profuse hemorrhage
4. Remove greater amount of coronal pulp but exposure
not all. Iatrogenic exposure in Long standing
5. Control hemorrhage with pressure less than 24 hrs-72 hrs exposure
6. Apply pulp cap Vital pulp with under
7. Restore the tooth with bonded resin developed apex
8. Observe
Summary
b. Cervical Pulpotomy PC Pulpotomy
- Removal of the entire coronal pulp. Iatrogenic exposure Exposure within 24-72
1. Rubberdam isolation hrs
2. Removal of caries Small to moderate
3. Disinfect exposure on immature
4. Remove coronal pulp tooth
As an emergency
treatment if pulpectomy
cannot be given
immediately
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
Conclusion ARMAMENTARIUM
• Early and careful intervention will yield Dental Dam Isolation
higher percentage of outcome.
Dental Dam Isolation
• Developed by Dr. Stanford C. Barnum in
1864.
• Use: To isolate the tooth structure during
dental procedure.
• Considered as the optimal method for
endodontic isolation.
• Routine placement is a “standard of care”.
• The system is composed of 3 components:
1. Dental Dam Sheet
2. Clamp
3. Frame
• Without encroachment on the patient’s nose
or eyes or show of lips.

Advantages:
✓ Establishes aseptic field of operation.
✓ Prevents saliva from contaminating the
root canal system and instruments during
treatment.
✓ Protects and retracts soft tissue.
✓ Reduces cross-contamination.
✓ Facilitates treatment by minimizing
rinsing and patient interruptions or
conversation.
✓ Protects the patient from assimilation of
easily dropped endo instruments, irrigants or
medicaments.

Dental Dam Sheet

• Available at different forms, thickness and
color.
• Autoclavable

Dental Dam Clamps

• Function:
o To retain the dental dam and frame in
place on the tooth to be isolated.
• Autoclavable metal or plastic.
• Types:
o Winged
o Wingless
• Positioned at the buccal/labial and
palatal/lingual aspect of the tooth below
the height of contour.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
• Varies in sizes and shapes to conform Clamp Forceps/Carrier
with the varied tooth form, orientation, • Function:
degree of debilitation and technique. o Adapts the clamp at the cervical third
of the tooth to be isolated with the beaks
of the clamp.

Other Dental Dam System

Dental Dam Frame

• Function:
o Retracts the sheet during procedure.
o Provide visualization of the field of
operation.
o Allow access to the tooth during
treatment.
• Autoclavable metal or plastic.
• Varies in Forms and Shapes:
o Young’s frame – most common
o Nygaard Ostby
o Plastic Hinged Frame

Dental Dam Holes

• Can be placed on the sheet using dam
punch or scissors. Techniques
• The size of the hole must be appropriate Routine Techniques
to the tooth to be isolated. ➢ Single Motion Technique
• The wings of the clamp are inserted and - The dam, clamp and frame are adapted to
adapted into the hole. the tooth together in single motion.
• Location of the hole will dictate the ➢ Two-motion Technique
centeredness of the dental dam isolation - The clamp is first adapted on the tooth and
assembly. the dam is stretched over the clamp to hug
the cervical area of the tooth or vice versa.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
Techniques for Special Situation Notes:
➢ Multiple Isolation Contraindication of endo
- Isolates multiple adjacent teeth. - When the tolth cannot be isolated, due to
saliva seepage
Indication:
• Mobile tooth cannot which cannot hold a Can do multiple tooth isolation
clamp or tooth with calcified pulp chamber OPTIDAM SYSTEM — isolate up to 3rd molar.
and canals. Dictates the centerness of dental dam isolation –
location of punch hole
Techniques: Dictates the uprightness of dental dam isolation –
• 2 clamps used with the position of clamp during single motion
posterior tooth clamped Latex dental dam material
with bow at the distal Spool sheets - you’re the to choose the size
and the more anterior length
tooth clamped in reverse. Soft resin clamp – soft on the gingiva
• The most posterior Winged type is the most commonly used –
tooth is clamped single motion
normally and the dam is Buccal/lingual – apron of the clamp
tucked with a strip of Base towards the chin
dam, floss or wedgets OPTIDAM system – frequently used in resto due
cord at the interproximal to its efficiency
at the other end to hold Split dam isolation must be associated by
the anterior portion of the cotton roll isolation.
dam in place. Prongs and apical extension used for tooth
without undercuts for special technique (expect
➢ Split Dam Method bleeding).
- Used for isolation of insufficient tooth
crown structure or teeth difficult to
isolate.

Techniques:
• Two holes are punched creating one
opening.
• Clamp is adapted in the most posterior tooth
and the dam is stretched mesially to include
the anterior tooth and secured with strip of
dam, floss, or Wedjets cord.
• Cotton roll isolation is used to supplement.

➢ Use of Clamps with Prongs at Apical

Extension, Pin-retained crown build-up or
Periorontal crown lengthening
- This is indicated for terminal tooth with
insufficient crown structure.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
ARMAMENTARIUM Cleaning and Shaping Instruments
Access Preparation
Files
Material Used: Function:
✓ Burs (round bur, rose bur, excavabur, • Shaves/rasps canal walls
untrasonic or sonic instruments.
• Enlarges canal lumen
✓ Handpiece w/ contra-angle
✓ Basic explorer
Classification According to J. Gutmann:
➢ Hand-Applied Filing Instrument (HAFI)
Bur
• Stainless Steel K-type Files
➢ Function:
• Hedstrom-type Files
• To drill through dentin to deroof the pulp
chamber to “drop” through the roof of the
Motion: K-Type File
pulp chamber as initial access and move
✓ Passive filing, Passive-
the drill in an outward sweeping motion to
pull filing
completely remove the roof without touching
the floor of the chamber.
Motion: H-File
✓ Push-pull / Filing motion
Basic Explorer
➢ Function:
Motion: NiTi K-Type File
• To check the access opening if roof of the
✓ Passive filing
pulp chamber is still intact.
➢ Hand-Applied Rotary Instrument (HARI)
Exploring Instruments: Explorer/Path finder
• K-Type Tapered
➢ Function:
• Progressive Tapered Hand Instruments
• Explores the floor of the pulp chamber.
(Contemporary Files)
• Confirms position of canal orifice.
• Assess direction of canal at the cervical Motion: K-Type Reamer
area. ✓ ¼ to ½ clockwise turn and pull
Exploring Instruments: K-type File #10 Motion: Progressive Tapered Files
➢ Function: ✓ Continuous ¼ clockwise turn.
• Checks the glide path of the root canal. ✓ When binding is felt, counter clockwise turn
• Provides tactile information of the to release the file.
morphology of the root canal.
• Helps provide information of position of ➢ Power Assisted Rotary Instrument (PARI)
difficult areas of the root canal like sharp • GATES Glidden drill / Peeso drill
curvatures or obstructions. • Contemporary power-driven files system
like ProTapers, Hero, K3, etc.
Notes:
Main function is to de-roof (between pulp horn Motion:
and above cingulum) ✓ Continuous rotation driven by motor and
Endo explorer - steward probe; probe the manually moved in and out by the clinician.
orifices. ✓ Reciprocating (30° clockwise - 60°
K type #10 file - explore the morphology of the counterclockwise) motion.
root canal (wide or narrow) tells whether there’s
obstruction; simply confirming what you see on
the radiograph.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
Notes: Elastic deformation Plastic deformation
NITI - nickel titanium; flexible; cannot cut - Disadvantage with - When you bend
through if there’s obstruction; can only be used filing particularly the file and insert
in a glide type canal with PARI. to the canal, as
K type reamer - aggressive - When you use you remove it, it
Peeso - non cutting; flexible; cervical third power assisted remains bended.
instrumentation,
as the files rotate,
the files has the
Instruments Differ According to: tendency to
• Metal straightens up.
• Taper - With PARI, the role
o Increase in diameter of the files from the of the operator is to
tip as it goes up to the head of the files. use a push-pull
o It is tapered simply because the root motion for the file
canal is in conical shape, in a tapered as it rotates, to
shape. avoid gouging of
• Tip design the canal.
o Cutting tip – negotiates canals
(calcified canals) that are smaller than
the size of the files. The tip directs you
to the root canal.
o Non-cutting tip – have the tendency to
bend.
• Cross sectional geometry
o Tells you how strong or how effective or
how much shaving or carving that Taper
certain file can do. Definition:
• Length of cutting blades - Increase in diameter per unit length.
o There are blades that have 16 flutes,
there are those that are just half of the
16, others only have the tip that can cut.
• Sizing

Metals
Nickel titanium Stainless steel
Excellent flexibility Less flexible
- Introduced to root - In order to follow
canal files by Ben the anatomy of the
Johnson. canal, you have to For stainless steel files (refer to the image
- We need flexibility pre-curve the file. above, the slim one), we have a standard ISO
because the root 0.02 taper (the one we’re going to use in the
canal is really laboratory).
tortuous. You can - Per files, from the tip (D0), to the end flute
have an S (D16), it has 16 flutes.
curvature in your - For every increase in flute, you have 0.32
root canal.
mm diameter increase.
Conforms to canal Straightens and
curvature transports canal
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
For greater tapered files (refer to the image Different Tip Designs:
above), which is the contemporary files, ▪ Non-cutting tip
there’s a same number of flutes, but there is ▪ Bullet nose (60 degrees) tip
0.96 mm diameter increase per flute. ▪ Smooth transition angle where tip meets
- Wider diameter in D16. flat radial lands
For nickel titanium, because it is so flexible, an
O2 taper will not be efficient in a narrow canal
because it has the tendency to bend, you will
not be able to push it.
ISO taper for Nickel Titanium – 0.04 taper
ISO taper for Stainless Steel – 0.02 taper

(Left pic K-type file), you can see sharp edges

on a cutting tip, and once it goes in to the canal,
you turn it and it will shape making the canal
bigger.
(Left pic ProFile 0.04 taper), this kind of non-
cutting tip, where the tip meets the radial lands,
0.02 taper – for SS files is usually type of tip for Nickel Titanium file,
0.04 taper – for NiTi files either hand file or PARI NiTi. It has grooves
0.06 taper – orifice shapers; flutes up to the where shavings would settle.
middle only (D9); used for enhancing the
coronal 1/3 or orifice; has a bigger taper
Cross-sectional Geometry
Taper of Instruments:
- There are only two cross sections, files with
• Stainless steel files – 0.02 taper (hand files) three radial lands, or a triangular shape.
o All files have the same taper from file - Both have directional cutting edges.
15 to file 80.
• OS (orifice shaper) – variable tapers Three radial lands
ranging from 0.05 to 0.08 (depending on how • Each contains bidirectional cutting edges.
big the orifice is).
• Keep instrument centered in the canal.
• Series 29 rotary Profiles – 0.06 taper
• Cutting edges scrape dentin.
o System; power assisted
• NiTi hand files – 0.04 taper (standard) from
Gouging – creates indentation on the canal
file 15 to file 80.
walls.
Filing – shaves or scrapes the dentin.
0.02 and 0.04 tapers are usually hand files.

Tip Design
Function of File Tip
• Designed to follow a pilot hole
• Guides instrument through canal during
preparation.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
0.04 Protaper (left pic) with radial lands – when K-type files – continuously twisted ang flutes.
you turn it clockwise or counterclockwise it will 25 mm – usually used for the average length
shave. of the incisors.
Triangular Three tip/corners (left pic) – cross Files length varies.
section of reamer. Molars – files are shorter; 20-22 mm.
Canines – longer; 30-32 mm.
Radial Lands Separated by Three U-shaped All hand files (HAFI) follow a standard in their
Flutes sizing.
• Provide space for accumulation of debris. The number listed on the file represents the
• Moves debris out of canal. diameter of the teeth of the file.
- So that it will not be packed at the apical Standard tray: 5, 10, 15, 20, 25, 30, 35, 40
and prevent apical blockage by your Tray for bigger files: 45, 50, 55, 60
dentin shaving debris. After 60, the diameter of the tip increases by
10 mm.
So, from 60, next file size is 70, 80.
If you have bigger size files, the next one will be
90, 100, 110.
110 is the biggest and last file.
Contemporary files using rotary instruments
(PARI) DO NOT follow the 15-20 because they
have greater taper and they are using NiTi.
ISO number refers to stainless steel and
Pic on left, simply shaves the canal so it is not nickel titanium hand files only.
self-threading and it’s a gentle plaining action. We need to have sequence of instruments
Pic on right, there’s an aggressive cutting action because files are very fragile. When it gets stuck
with triangular shaped files. on the wall of the canals, it will break. To avoid
breakage, you should gradually increase the
diameter.
Aside from no.15, there are also smaller files:
Length of Cutting Blades
0.06 (6 mm), 0.08 (8 mm), and 0.10 (10 mm).
- Traditionally 16 mm (D0-D16) Average diameter of root canal is 15 mm.
- Orifice shapers – 10 mm (with D19) In order to identify whether 15 goes in, you need
to use a smaller file.
End of the root canal is DCJ.
With progressive tapers (PARI), they have
different file tip diameter. They call the
sequence Shapers (S1) and (S2); and
Finishing files (F1), (F2), (F3), (F4).
All files are color coded.
For hand files both NiTi and SS, they follow
white, yellow, red, blue, green, black. This is
Sizing of Instruments repeated on the next tray starting 45.
ISO sizes For smaller files, 0.06 (pink), 0.08 (gray), 0.10
▪ Number refers to tip diameter in tenths of (violet)
mm. In PARI, violet, white, yellow, red, blue,
▪ The tip diameter increases by 0.05 mm green, black.
from sizes 10 to 16 then by 0.10 mm.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
ARMAMENTARIUM
Disinfection and Temporization

Cleaning and Shaping Instruments

Disinfection and Temporization

Function:
✓ Arrest or control the infective capacity of
bacteria in the root canal system before,
during and after biomechanical preparation
of the root canal.
✓ Assist in the mechanical preparation of
the canal by flushing out debris.
✓ Prevent microleakage.

Disinfectant and Temporization Used:

1. NaOCl (Sodium hypochlorite)
- Irrigation solution / irrigant
- Main solution
- First and last irrigation material that will
be used.
2. EDTA (Ethylenediaminetetraacetic acid)
- Chelating agent
3. Ca (OH)2 (Calcium hydroxide)
- A powder mixed with distilled water.
- Forms cement which does not set and
is used as temporary obturation.
In biomechanical preparation, this is the 4. Hypodermic syringe
simultaneous cleaning, and shaping of the root - Used to introduce Sodium
canal. hypochlorite.
Shaping is done by mechanically removing the 5. ZOE Paste
by-product materials inside the canal and - Seals the pulp chamber and access
flushed out by solution. preparation for interim appointment.
Irrigation armamentarium: Sodium - A temporary obturation material
hypochlorite, absorbent paper points (to dry the which you can flush out with an
canal), and hypodermic syringe (3 cc or 5 cc). irrigant.
Chelates – dentin softener in the form of 6. 2% chlorhexidine (CHX) Digluconate for
Ethylenediaminetetraacetic acid (EDTA) 30 sec. to 1 min.
liquid form, or in a paste form of Glyde - A very good disinfectant used for
(lubricant), so filing will be easy. cases of necrotic pulp.
- Additional disinfectant to address
biofilms.

One disadvantage is you cannot mix Sodium

hypochlorite and chlorhexidine.
If you mix them inside the canal, it will produce
a dark-brown precipitate and the solution will
turn dark-brown.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
If the precipitate goes out of the periapex, it
is highly toxic and difficult to remove. It will
cause post-op pain to the patient.
CHX is irrigated into the canal before closing
the canal either temporarily or permanently.
During instrumentation, you use NaOCl.
Before injecting the CHX, you need to flush
out first the NaOCl.
Since the NaOCl is the first and last solution,
leave CHX for 30 seconds to 1 min., then flush You have sodium hypochlorite as irrigant
it out with distilled water. Then flush again the which you will introduce to the canal using the
canal with NaOCl for 5 mins. hypodermic syringe.
Remove the NaOCl by drying the canal with the Absorbent paper points to observe the
absorbent paper points. irrigation solution inside before sealing.
Don’t leave NaOCl if you’re going to seal the Seal the entire root canal using the Ca(OH)2
orifice and dismiss the patient. powder and distilled water to form a cement.
You introduce it inside the canal using lentulo
7. Ultrasonics fillers.
- This is the best, but in ultrasonics, you Temporary ZOE paste, to seal the canal.
have a file that goes inside the canal and
then vibrates through acoustic Currently used Disinfectants:
streaming sometimes, it can shave the ➢ Calcium hydroxide
canals. - Mix with water to make it slurry and
- A very effective disinfectant but is introduce into the canal.
expensive, and sometimes changes the ➢ Iodine
shape of the canal. - Used in a form of iodine potassium
8. ZOE paste iodide (IKI 2%) – very effective but not
9. Photoactivated disinfection commercially available because iodine
(photodynamic therapy) discolors the dentin.
- Similar with extraoral bleaching. ➢ Ledermix paste
10. Ozone (Healozone) - Composed of 3.21%
- Liquid demethylchlortetracycline (antibiotic
11. High frequency current (Endox) paste) and 1% water triamcinolone
- Electrocutes the bacteria. acetonide (has an excellent
- Heats NaOCl in the canal. antimicrobial property) in water-soluble
12. Endo Vac System cream (currently not recommended for
- System that is very expensive but is very use USA).
expensive. ➢ Chlorhexidine (CHX)
- There is a tip that will be inserted into the - 2% solution of Chlorhexidine
canal, and will flush the NaOCl, and next Digluconate; Chlorhexidine (CHX) 5%
to it is the vacuum that will suction out all embedded in points for application in the
the solution. root canal. Have excellent
antimicrobial property.
➢ MTAD
- Mixture of Tetracycline and Acid and
Detergent (an acid root canal cleanser
that is a futuristic projection for irrigation
and disinfection and disinfection). This
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
material conists of doxycycline, citric
acid, and Tween 80.
- Highly irritating because it has acid,
antibiotic, and detergent.

Obturation
Gutta Percha, Sealer
- The only obturation materials, and should be
a biocompatible filling material.
Lentulo fillers – delivers cement into the canal.
Function: Hand plugger / finger plugger
✓ Seal the canal with an innert filling material Finger spreader / hand spreader
(gutta percha) and cement (sealer – which Gutta percha – inert filling material that
can be a catalyst or base). obliterates/seals the entire canal.
Sealer (cement) – lutes the gutta percha to the
Lentulo Filler wall and to each other.
Function: Gutta percha and sealer are the combination
✓ Deliver cement into the canal. of obturation materials.
Once the canal is sealed, you will now seal the
Also, an instrument used for temporary pulp chamber and the access prep with
obturation with calcium hydroxide and distilled composite restoration.
water.

Spreader/Endo Plugger
Function:
✓ Compacts and condenses gutta percha
laterally and apically to create a solid
obturation (seal).

Spreader – pointed tip.

Endo plugger – flat tip.

Alcohol Lamp and Fuji 7 GI

Function:
✓ Alcohol lamp is used as a heating device
to cut excess gutta percha from the orifice
and compact it 1-2 mm below the orifice.
✓ GI seals the orifice as intraorifice drug.

Fuji 7 is highly recommended because it is

pink in color, similar to the color of the gutta
percha. If you will need to relocate the orifices,
it is easy to find.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
ACCESSORIES AND CONTEMPORARY
TECHNOLOGIES AND MATERIALS

Operating Microscope
• Provide improved visualization compared
to an unaided eye.
• Levels of magnification is from 15x to 30x.
• Has better lighting of the operating field
compared with the dental operating light or
head lamp.
Maillefer Endo Organizer – produced by • Photography and videography may be
Maillefer; Swiss-made. attached to document the treatment.
Pinborg Tray – very first organizer.

Loupes
• With a fixed magnification configuration of
2.5x to 6.0x.
• Focuses at close range magnification.
Endo Block – a measuring device, measures • Used for routine procedures like resto
the length of the files. dent, endo, and perio surgery.
Clean Stand – cleans the files after using it; you
stick it in with alcohol inside the stand, then you Comparison
remove it then place it in the shot glass. Loupe Microscope
Endo Organizer – where you can arrange your 2.5x to 6.0 Higher magnification
files; autoclavable. magnification
Apex Locator – very efficient in determining the configuration
end of the root canal or how deep the files have Fixed magnification Magnification level may
penetrated. be changed without
refocusing
Magnification Ability to move with Patient should remain
the patient in fixed position to
• Magnification in routine dental procedure
maintain operation
has become a necessity today because it
field.
provided the operator the ability to focus at Entire work area and There is a line of sight.
close range specially for older clinicians for operating field is
better delivery of quality care. visible.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense

Accu-cam – for external diagnosis of the oral

cavity.

Lighting
• Additional lighting aside from those provided
by the dental operating light is essential for
better illumination of the field of
operation.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
FINALS Less aggressive instrumentation: Shaving

MOTIONS OF INSTRUMENTATION PASSIVE-PULL FILING

• Back and forth oscillation of a file (30-60
Motions of Instruments – dependent on what degrees) right and left as the instrument is
type of file you’re using. pushed forward into the canal then retract.
Types of files: K-files, H (Hedstrom)-files, &
Reamers. Add’l:
Shaving motions of files have two actions: (1) Filing motion that will be used in the remaining
Back-and-Forth (oscillation clockwise- apical third of the canal.
counterclockwise), (2) Push-pull motion Crown-down preparation up to the coronal 2/3’s
(Motion: Passive Filing). If the file # used is
WATCH-WINDING binding on the walls and is not cutting, it means
• Rotation motion of ¼ turn using scouting that it is negotiating a narrow canal. Do not
instruments (#8 or 10) k-type files to reach intend to push it further because you will make
WL (working length. a narrow canal a size of a T, creating a ledge.
• Used before coronal flaring When you get into the apical portion, this is the
• Less aggressive phase where you will intentionally make your file
• Used to explore the canal reach the narrow end of the canal.
When you get into the apical third (4 mm),
Add’l: during the step-back technique, it is required for
Watch-winding is a motion that does not cut, but you to make your file the same size/diameter of
rather will provide a tactile sense of the canal the tip at the end of the root canal. You will make
whether it is narrow or wide, or if negotiating a the canal 3 sizes bigger. This means that you
curved canal. have to make your original size file (Initial Apical
Usually, we pre-curve the tip of the file so that it File (IAF)) reach the working length through
will touch the wall, in order to feel the wall of the recapitulation (you go back to smaller size file).
canal. The files are in sequence, so you use first the
With the rotation motion, you will be able to feel file size that fits into the canal and shape (using
the circumference of the canal as you go down push-pull motion) it to its working length so that
into the root canal. it will easily accommodate the next file size. If
You don’t have to force your file because your the file doesn’t go down, you always
main intention is merely to scout or explore. recapitulate until the file reaches the end of the
root canal.
Since we are intentionally making the file reach
PASSIVE FILING the narrow canal, then we need to have a gentle
• Back and forth oscillation of a file (30-60 but effective carting out of the debris. So, what
degrees) right and left as the instrument is you will do is passive filing. When you feel
pushed forward into the canal. binding, you will make a pull motion. This way
• Less aggressive. you are enlarging the narrow apical third.
Remember: Files cut and shave, so they can cut
Add’l: through dentin. When you force the files to turn,
Passive filing is the one we use in the laboratory definitely they will cut, but will create a wider
for the crown down preparation, which is on the cutting than the original canal, which is called
shaving already, enlarging the canal. ledge. So, make sure that the file does not bind
The motion in PF is shaving. into the canal more than 3 mm or at 3 mm,
Aggressive instrumentation: Carve walls and because once file binds into the canal, it will fit
make it irregular; the file used is Reamer. into the canal at the same taper, it is called taper
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
lock. If you have a taper lock by 3 mm, when When you finish the shaping, you file out the
you turn the file, you will break it. circumference of the root canal, push-pull on all
With passive pull, atleast a 1 mm taper lock walls of the root canal.
because you forced the file into a narrow canal.
So, make sure that when you feel tightening REAM or TURN AND PULL
approximately it will be a 1 mm taper lock, you • Indicates a clockwise or right-hand ¼ to ½
pull it out. turn of a reamer instrument to engage the
Never make the file go deeper when you feel the blades into dentin and then withdrawn.
lock, because you’re going to break your • The motion is penetration, rotation,
instrument. retraction.
Make sure to irrigate constantly, so that the
shavings will be suspended into the solution and Add’l:
it will not cause mud at the apical portion and Aggressive motion
block your apical third.
If you have an apical block, you will have
difficulty negotiating the entire root canal.

FILE MOTION
• Indicates a push-pull action
with the instrument.

Add’l:
Used when finished reaching the
entire working length.
While you are trying to enlarge the
canal you use passive filing for the coronal
2/3’s, and the passive-pull filing for the apical
third.

FILING
• The file has a rake angle that primarily has a
cutting action on withdrawal as the walls are
rasped by the rake of the flutes.
• It will also cut in push motion.

Add’l:
Do not let your files touch the walls when you
push it because the shavings that you cut will be
pushed apically and will cause apical blockage.

CIRCUMFERENTIAL FILING
• The filing motion against the dentin wall
around the circumference of the canal
lumen.

Add’l:
Usually the push-pull motion is used in
circumferential filing.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
COMMON ERRORS IN ACCESS tissue which is vascular. So, it may have
PREPARATION discoloration due to blood stains that may
have entered the dentinal tubules. It is much
1. INTACT ROOF OF PULP CHAMBER darker than the floor and the roof.
2. When you insert the angulated end of the
explorer in one of the openings, then you let
it touch the roof and pull up, you still have
a ledge, there is a resistance. Unlike when
you are in the orifice, the tip of the explorer
will only enter but you will not be able to
move it around because the orifices are
Add’l: small. This means that when you insert the
The most common error of students in access explorer in the orifice and you can move it
preparation is failure to deroof the pulp around the area, and when you lift it there is
chamber particularly in molars. a catch, then that is still the roof of your pulp
When you say failure to deroof, it means that the chamber.
roof of the pulp chamber is intact. 3. Location. If it is on the middle third of the
Since the roof of the pulp chamber is our main crown, then it is still the roof of the pulp
objective in access preparation, we will remove chamber because the floor of the pulp
it. It means that our concentration should only chamber is below the cervical line.
be limited to the middle third of the crown, The floor of the pulp chamber is much darker
within the crown. than the primary dentin.
The roof of the pulp chamber, which is the start What is the main reason for the failure or
of the pulp chamber, located at the middle third, error in retaining the roof of the pulp
is the pulp horns. chamber? Failure to drop at the center and
There are students who pre-empt or pre-shape incomplete deroofing of the pulp chamber,
the canal, or pre-shave the outline of the pulp failure to assess anatomy, and pre-shaping
chamber without dropping at the center yet. the outline the shape of access preparation.
Without dropping at the center and you start
preparing the canal, then definitely the pulp 2. INTACT DENTIN SHELF
horns will be open and will appear like an orifice
because it’s the same location as your orifice,
but the openings are at a different location, it is
at the middle of the crown.
If your openings are at the middle of the crown,
then it’s not your orifice, because the orifice is
found at the floor of the of the pulp chamber,
located below the cervical line. It is not within Add’l:
the crown. It is closer to the furcation area of the You have to remove the cervical bulge
root. because most of accessory canals in molars are
How will you identify if the roof is still intact? hidden in the cervical bulge of the anatomy of
1. Color, law of color change. If the color of the tooth.
the floor is the same color as the walls, all of Once the bulge is removed, underneath you will
it are primary dentin, then that is still the see the accessory canals.
roof. However, as stated in the law of color What gave you an idea or revealed that there is
change, the pulp chamber walls and floor accessory canal is the fusion line, that will lead
are darker from the primary dentin. Why? you to the end of the orifice, which will lead you
Because of secondary dentin attachment,
and also because it is attached to the pulp
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
to the 9th law of the orifice location, ‘at the NOT DEPEND ON THE DROP, depend on
end of the fusion line is the orifice’. the law of color change. It is essential that
What will happen if you fail to locate all when you do the drop, it should be in
canals? You call that missed canal. So, if it is pecking motion. Once you see an opening
missed canal, even if it’s just one, it remains on the floor area, instead of using your bur,
infected. Even if the rest of the root canals were immediately use the explorer and feel the
cleaned properly, but if you leave one missed ledge. So, the management of a very narrow
canal, the tooth will always be symptomatic, chamber floor or very slim distance between
because this canal be the source of infection of roof and floor is slow drilling, and you base
periapex. the identification of the chamber in color
change.
3. PERFORATION AT THE FURCATION If there is perforation, there will be a
continuous bleeding inside the canal.

4. CROWN PERFORATION

Add’l:
Perforation of the furcation area, particularly
occurs in molars. Add’l:
This happens due to inadequate training or In this kind of perforation, the cause is failure to
failure to be attentive during instructions. assess the radiograph and failure to drill the
This is caused by failure to limit the deroofing center of the crown, because they fail to
up to the walls of the canal. So, you gouged the assess the anatomy of the tooth.
wall creating a ledge. It becomes a perforation Remember that when we do access preparation
when you create an opening on the surface of for instance on a multirooted teeth, on premolar,
the tooth. But in the process before perforation the angulation of your drill should be
occurs there becomes a ledge. perpendicular to the occlusal table.
What would be the probable cause why you The drop should always be at the center of the
missed the roof and penetrated the crown, because the canals are always at the
chamber? center.
1. Failure to assess the OD radiographs.
We need to assess the level of the roof with
the floor of the pulp chamber. Since the
calcification always starts at the roof of the
pulp chamber and it goes down, there will be
a point in time where the roof will be too
close to the floor, so during access
preparation you will not feel the drop. One
indication that you have penetrated the pulp
chamber is through the drop. So, in the
radiograph if it is impossible to see the drop
because the floor is too close to the roof, DO
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
If the tooth is calcified, you have to search for COMMON ERRORS IN CANAL SHAPING
the opening of the canal.
Orientation and anatomy are very important in 1. UNDER INSTRUMENTATION
locating the center of the crown. • An error in canal shaping where the working
In a calcified tooth, divide the crown of the length of the root canal was NOT
tooth into three, and at the center, with 45 negotiated leaving an undebrided apical
degrees angle of the bur at the center of the portion.
crown, drill slowly but do not depend on the
drop, instead when you feel that the round bur
is at the center, redirect the bur towards the
middle of the root and drill a little until you feel
the opening.
In this kind of situation, you need series of
radiographs.
The key here is the orientation of the Causes:
direction of the drilling, orientation of the • Error in working length registration.
root, and evaluation of radiographs before • Failure to negotiate curved canals.
you start. • Canal blockage.

Add’l:
We want to determine the end of the root canal
so we will avoid under instrumentation.
Short working length by 2 mm or 1.5 mm is
still considered under instrumentation.
The depth of instrumentation that we want is
up to the end of the root canal, which is at the
DCJ.
How will you approximate the DCJ since you
cannot see it with your naked eyes? By
approximating 0.5 mm from the tip.
Canal blockage will prevent the file from going
down.

Effects:
• Undebrided and infected canal.
• Ledge formation along canal wall.
• Persisted periapical lesion and
symptoms.

Add’l:
Undebrided canal means you fail to disinfect
the area, and ofc that area becomes infected
that may cause periapical pathosis.
If you have curved canals, usually the ledge is
formed at the outer wall of the curvature.
Ledge formation occurs when you insert
straight file in a curved canal. If you are not
sure of the end of the root canal, do not enlarge
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
it to next bigger size. Maintain a scouting file most straight portion. You need to pre-curve it
size, file #10. in order to enter the canal.
If there is undebrided area and ledge However, as you continuously rotate the NiTi file
formation then there is persistent periapical as it goes in, just like rotary files, it will straighten
lesion and symptoms as if no treatment has and will cause gauging which will form a ledge.
been done. Do not let PARI to stay long inside the canal you
need to move it in and out to avoid ledge
To Correct: formation or transportation.
• Re-establish the working length.
• Establish the apical matrix at the apical Management:
constriction area. • Early recognition is advantageous.
• Clean and shape the remainder of the • Use techniques indicated for penetration
canal. of blockage if caused by dentin plug.
• Obturate or seal the canal • If ledge cannot be bypassed, immediately
establish a new working length coronal to
the ledge.
2. LEDGE FORMATION • Obturate the canal using softened gutta
• A ledge is an artificially created percha with thin mix of sealer.
irregularity on the surface of the root canal • Schedule periodic recalls after obturation.
wall that prevents the placement of • Evidence of failure may need surgical
instrument to the apex of a patent canal. – intervention.
James Gutman
Add’l:
Add’l: Early recognition, lesser extent of ledge which
This means that the canal is patent, all files go you can file out without too much enlargement
in, but because of incorrect order of of the canal.
instrumentation, failure to feel the binding, and If you cannot bypass the ledge, then you have
you proceeded with using bigger file even if you to do a surgical intervention, because
feel constriction, the it will create a ledge. definitely, it’s bound to fail. You need to do a
surgical intervention by sealing the apical
Causes: foramen. So whatever intervention was inside
• Insertion of uncurved file HAFI short of the the ledge to the apical foramen, you seal it, so it
working length with excessive amount of will be confined inside the root canal. So, your
apical pressure. intention now here is to protect the periapex.
• Repeated placement of the PARI with Soften the gutta percha because it is flowable,
pressure in canals with abrupt curvature so the gutta percha will flow into the canal.
apically. You may need to do apicoentomy or an
• Allowing PARI to rotate in a position orthograde (patching up the opening of the
longer than necessary in canals with walls).
curvature.

Add’l: 3. APICAL PERFORATION

With PARI, we are using NiTi, which has an • Is a torn and enlarged apical foramen due
elastic deformation. If you bend it, and release to the insertion of shaping instruments
it, it will go back to straight. That is what makes beyond the apical foramen.
it a good instrument in following curved canals.
Unlike SS files, which will only enter up to the
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2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
inside the root canal will drip out into the
periapex.

Causes:
• Over estimation of working length.
• Failure to constantly verify working
length on instrument.
Add’l: • Loose instrument rubber stop.
If your file is exactly at the tip of the root apex, it
means that you are at the apical foramen. Add’l:
If you are at the apical foramen, then you are Instrument stop should be tight so that when
traumatizing the apical foramen and you are you push into the canal it will not move.
enlarging the diameter of the apical foramen. Failure to constantly verify working length
One of the recommendations of Grossman on instrument is addressed by the endo block.
(one of the fathers of endodontics), in which
Schilder also based his recommendation, is the
five rules in shaping, in which, as much as
possible you must keep the apical foramen
as minimum as possible because it will
prevent fluids and microorganisms to enter
easily into the root canal. If you remove the
apical constriction and you open up the apical
foramen, it’s like an open gate everything will go
inside into the root canal. In the same manner,
everything the you put inside the RC like your
irrigants will easily go outside the periapex and
cause irritation. Add’l:
Apical perforation is different from lateral What we want with our working length is up to
perforation. Lateral perforation is the the DCJ, which is 0.5 to 1 mm from the tip of
overzealous filing out of dentin in the inner the apex.
curvature of the file, and you call this
stripping, in which you create a strip. Another Effects:
kind of lateral perforation is when you fail to • Loss of apical constriction.
identify the ledge, in a curved canal, and you • Enlarged apical foramen.
continue shaping until it perforates the • Mechanical and chemical irritation of the
lateral side of the canal. periapex.
• Periapical pathosis
• Seepage/weeping canal
• No control in overfilling due to absence of
apical matrix

In apical perforation, you can see the file

outside the foramina and you have an
enlarged apical foramen, and whatever that is
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2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
Add’l: Add’l:
Do not enlarge the apical foramen, only up to If it’s already a serous type it means that there
the apical constriction or end of the root canal, are inflammatory fluids, and the abscess was
the DCJ. drained out already from the canal. But still,
If you perforate your file up to the end, the tip there is still irritation going on from the
of the root canal, you lose the gate valve, your periapex so continuously white fluid goes in.
apical constriction. This is because your irrigation and
In enlarged apical foramen, if you have a instrumentation is still irritating the periapex and
curved canal, it will be in tear-drop shape with causing secretion of inflammatory fluids by the
an angle, and it is now called the apical zip or cells and this inflammatory fluids now goes in.
external transportation. “Pag serous na ang lumalabas it means wala
Once you have an enlarged AF, it will nang abscess, na-drain out na ang abscess”
traumatize the bone and create periapical
involvement, you lose your apical matrix, and Sources of Inflammatory Fluids:
everything goes in. 1. Chronic Periapical Infection
There will be seepage of the canal. So, as the 2. Mechanical Trauma of the Periapex
inflammatory fluid goes in, the canal 3. Chemical Trauma of the Periapex
continuously becomes wet, and you refer to it
as your weeping canal. Pattern of Seepage:
When there is weeping canal it could either be 1. Chronic Apical Infection
serous or blood or abscess, and it means you - Suppuration
have an enlarged apical foramen or lateral - Bleeding
perforation. - Clear or Serous Fluid
The most problematic effect of apical 2. Mechanical and Chemical Trauma
perforation is the ‘no control in overfilling - Bleeding
due to absence of apical matrix’. We do not - Clear or serous fluid
like this because the gutta percha, which is a
filling material is inert, it cannot dissolve by Add’l:
tissue fluids. If it were cement sealers, pwede When the condition of the periapex is chronic
pa, because sealers are soluble to periapical apical infection, upon access preparation the
tissue, but not gutta percha. ‘first’ thing that will come out is suppuration
abscess, ‘followed by’ bleeding. Once all the
Weeping Canal suppuration and bleeding has been removed
- A persistent wet root canal system caused or arrested, then there will still be weeping
by continuous seepage or ingress of canal but it will be clear or serous fluid. So, if
inflammatory tissue fluids from the it is clear or serous fluid then immediately you
periapex. have to seal the canal.
If the condition is mechanical and chemical
Types of Seepage: trauma with no periapical pathosis, the
1. Purulent ‘initial’ seepage into the canal is blood. If
2. Hemorrhagic there’s bleeding, it means there’s no apical
3. Serous resorption, what is being traumatized here is
the periodontal ligament, and the bleeding is
coming from the PDL. Once the trauma to the
PDL is arrested, there will still be clear or
serous fluid formation because the apex is
open. There will always be irritation to the
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2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
periapex and inflammatory secretion that will go Add’l:
inside the canal. What is the cause of strip perforation?
Failure to use anti-curvature filing motion.

Causes:
• Overzealous canal filing.
• Failure to pre-curve instruments when
filing curve canals.
• Failure to use anti-curvature filing motion
in curved canals.
Apical Matrix
- Is an artificially produced ledge at the Add’l:
apical constriction area that serves as the How will you identify the position of your
terminus of a shaped canal. lateral strip? When you place your absorbent
paper points, the side of the APP where there
is blood, that is the location of the strip.

5. Transportation
a. External Transportation
a) Zip/ Rip/ Teardrop Transportation
b) Direct Perforation
b. Internal Transportation

Add’l: Add’l:
Why is there failure to create a stop on you All direct perforation is external perforation,
filling material? Because you lost your apical for instance, you created your own canal
matrix, there is no apical matrix. during access preparation.
Where do we want to stablish our apical Internal transportation is ledge formation.
matrix? At the DCJ, the end of the root canal.
When we shape the canal, we will make it 3 External Transportation
sizes bigger with an artificial ledge at the a) Zip/ Rip/ Teardrop Transportation
DCJ. So, when you fill the canal up, there will - It is an external transportation of the
be no microleakage. You should follow the apical when the foramen is torn and
curvature of the canal. altered from its original size and shape into
Creation of your apical matrix is the intention a bigger diameter delta-shaped or “tear-
of the apical preparation. drop” shape.

4. Strip Perforation
• Is a type of lateral perforation that is
caused by overreduction of dentin tissue
at the inner curvature of the root canal.

Causes: (Apical Zip)

• Reaming action in curved canal using SS
file.
• Failure to pre-curve SS file.
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2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
• NiTi files maintained a position longer Internal Transportation
than necessary. - Another canal path that branch-off from
the main canal is created but is confined
within the canal system.
- A canal wall is gouged or ledged.

Causes: (IT)
• Clogged foramen with dentin mud or
denticles.
Effect: (Apical Zip) • Misdirected file
• “Teardrop” shaped apical foramen
Add’l:
• Seepage/weeping canal
IT is just like Zip transportation except that you
• Difficulty in obtaining apical seal
have correct working length.
Cause is basically incorrect filing motion.
Add’l:
In Zip, when you insert your file outside the
periapex in a curved canal and you turn it in a
6. Blockage
reaming motion, ¼ turn, the apical foramen gets
a. Soft Tissues/ Collagenous Blockage
stripped and became bigger, and you will notice
- The pulp tissue is packed into the apical
that there will be a pivot area, an elbow, and
region by insertion of instrument is too
that is your tear-drop shaped or Zip
large for the canal.
transportation.
Causes: (ST/CB)
b) Direct Perforation
• Failure to use lubricant during initial filing.
- It is an apical perforation that creates
• Incorrect instrument motion
another canal path that branches out
from the main canal and perforates the
Add’l:
root surface creating another exit or
Why do we need lubricant? It’s because
opening.
lubricant will coat the pulp tissue before you
- It can also be an external teardrop tear.
start. Usually this is done with narrow canals.
Unlike when you use sodium hypochlorite
Causes: (DP)
first, which irritates the pulp and creates
• Deflected instrument that continues its
wound, if the pulp tissue is packed after
misdirected path until it perforates the
irrigation apically and it dried up, there is
surface.
coaptation of the injured part of the tissue, and
• Presence of ledge
you will not be able to remove it because the
• Presence of blockage pulp tissue already got stuck together.
The most difficult to remove is collagenous
Add’l:
blockage because the pulp tissue is packed
What causes deflection of the instrument? If
and if it remained there and you fail to notice and
there is blockage or there is ledge inside the remove it immediately, it will dry up and you will
canal. never be able to negotiate it.
It’s easier to negotiate dentin shavings than
dentin mud that is packed apically because it is
hard when dry but when you irrigate it, it will
soften and you will be able to penetrate it.
ENDODONTICS
2nd SEMESTER | S.Y. 2022-2023
PROFESSOR: Dr. Maria Liza Orense
Effects: (ST/CB) • Excessive force applied on instrument that
• Unnegotiated apical third. binds on the canal walls.
• Obturation falls short of working length. • Reuse of stressed instrument.
• May lead to ledge formation or
internal/external transportation. Effects:
• The fragment blocks the root canal
b. Hard Tissue Blockage system.
• Prevents routine cleaning and shaping.
Add’l: • Compromises obturation.
Hard tissue blockage is the dentin shavings • Most likely will cause treatment failure if the
blockage. tip of the fragment is at the apical
constriction as those that lies more
Causes: (HTB) coronally.
• Inadequate recapitulation.
• Inadequate irrigation/ failure to flush out
dentin chips or shavings.
• Incorrect filing motions specially at the
apical third region.

Effects: (HTB)
• Unnegotiated apical third
• Obturation falls short of working length
• May lead to ledge formation or
internal/external transportation.

7. Separation of Instrument

Add’l:
What causes separation of instruments?
Taper lock of the files longer than 3 mm from
the tip, forcing the instrument when it binds.

Causes:
• Excessive stress applied on the instrument.