Filling the Canal: Lateral Condensation: - Limitations: Thermoplasticized GP: - Limitations: Continuous Wave: Thermafill: Simple, Highly effective,

GOLD standard GP is not homogeneous, Sealer pools, not concentrated at apical 1/3, causes vertical rt fractures Pressurized/Alpha (hot) phase = GP FLOWS, Thermal shrinkage Vibrates? GP into all canals Matching files and obturators, heats up and shove it in,

A spiraled GP cone = ledge or blockage

Retreatment: Success Rate of Endo Tx: 85% (nobody knows) Management: RCT>Surgical Endo>Extraction - Retreatment can improve the prognosis of surgery (if retreat fails, its still helpful) - Untreated (missed) canals are more responsive to retreatment - Surgery is indicated for any severe curves/ledges or calcifications - Reduced Success with Separated instruments, ledges, perforations Removing Restoration: Access through Restoration: Better access, radiographs, visual Maintains function, less costly, esthetics LONG, WELL FITTING posts, thin dentin

Contraindication of Post Removal: Devices for Post Removal: - Ultrasonics: - Hemostats: - Stiegletz Pliers: - Ruddle Post Puller: - Masserann Kit:

Gaining Access to Apex: - Pull Out GP: straight or overextended canals - Dissolve GP: curved canals - GP Removal: Coronal portion with Gates Glidden o Chloroform dissolves the rest, cheap and fast, carcinogenic though o Eucalyptol is less irritating, but least effective - Silver Cone Removal: prep around, pull hard, ultrasonics, trephine burs o If it cant be removed, bypass it with hand file or ultraonics, double hedstrom technique - Cement Removal (apical plug): penetrate with file or dissolve/vibrate/drill Mishaps: Indications for 3D Accuitomo: - Perio: Bone contour in deep pockets and furcations

MTA: -

Endo: RTC configuration, measurements, variations and additional canals Ortho: RT configuration, PDL and anatomy 75% Portland Cement, Tri (and Di)calcium silicate, Bismuth Oxide, Tricalcium aluminate Use: Perfs, apexification, surgical root repair, internal resorption, pulp cap, pulpotomy o Any time you fix the pulp

Perforations: Size, duration, location - Matrix: accessible perforations below bone >1 mm, large perforations in middle/apical 1/3 of straight canals NaOCl Accidents: Terms: Anasthesia: Parathesia: Dysethesia: Hypoesthesia: Hyperesthesia: Women, maxillary, posterior, abscesses most common.

no sensation altered sensation w/no stimulus* painful sensation w/no stimulus decreased sensation to pain* increased sensation to pain (allodyna)

Neurological Defects: - Pressure: - Touch: - Touch:

pin prick brush Von Freys Hairs

Injections: Electric shock does NOT = nerve damage If recovery is >2 weeks, prognosis is poor Most common neurologic pain: - Overfill (Hyperesthesia) - Phantom (Dysethesia) Overfills: - IAN: EARLY Tx may REVERSE effects of Endo-IAN accidents! - Mx Sinus: Aspergillosis (zinc = growth factor, purely opportunistic), surgery is CURATIVE - Document everything Ultrasonic Burns: - Double temperature if no coolant used on stainless steel post 145o - Titanium with coolant = 55o - Metal core delivers heat to APEX (vital bone) - Monitor post temp each minute, ice post if needed, use irrigation, try pulling with pullers o Rest intervals needed if post removal exceeds 10 min Mishaps Notes: Md. Incisors having two roots: Chance of visualizing the IAN in an FMX: Pantograph: (20% of the time, IAN is not in a canal) 50% 60% 80%

Voxel = 3D Pixel (on exam) Sealer Puffs are OK, but NEVER in the SINUS or IANC Zinc Oxide Eugenol or Formaldehyde paste creates a crushing and chemical injury, large responses Dysathesia: ongoing burning pain. Case 1: Decompression of the sealer at the apex, saline irrigation for 1 hr. - Case 2: Do Nothing Permanent parasthesia Literature says: REMOVE WITHIN 2 DAYS! Symmetry is KEY. Always look for symmetric and centered canals. Perforations: - Repair matrix concept - Use COLLAGEN hemostasis, then CollaCote, pack/fill perforation, and then pack MTA against it. - Collagen matrix = bioabsorbable, osteoinductive/conductive - Use a matrix anywhere you have an accessible perforation MTA: -

Can create and apical closure, instead of using calcium hydroxide

NaOCl: - Best Irrigant, pH 11, cheap, removes smear layer, dilute to 1.5%, canal needs to accept a 25 file before full irrigation. - INJURY ONLY HAPPENS ONE WAY; o NEVER BIND NEEDLE INTO ROOT CANAL - NaOH Accident : immediate profuse bleeding - Women, posterior, maxillary, necrosis = high chance of injury Anesthesia: no pain Paresthesia: altered *Dysestheasia: pain with NO stimulus. IAN is within 1mm from apex of 2nd premolars/molars: 40% Almost no correlation between Electric Shock feeling and parenthesis - You will win in court - If a problem occurs, then an intraneural hematoma is likely. Simple bad luck. 4% Sln: - Use often for infiltrations, but NOT for blocks or weirdoes Reflex Sympathetic Dystrophy: - Get and injury to arm/leg, and pain never goes away - A CNS problem - Injury during dentistry causing pain forever...

Management of Gutta Percha in IANC: - IMMEDIATLEY remove it! - 2 days to remove - 3 days = damage completely occurred. (on exam) - Need an amazing OS to de-roof the IA and microsurgery of the IAN - Aspergillosis: fungus that grows on ZINC (zinc oxide sealer*), purely opportunistic Overfills: - Tx IMMEDIATLEY - Neurotoxic material - Allodynia with triggers is a sign - Document Anything - Refer to an amazing specialist Ultrasonics: - Post Removal: remove circumferential restorative materials, medium-full intensity - Sustained heat at 50o = Necrosis - 10o is the RED LINE, relative to BONE (not dentin/tooth) - Post delivers heat to the apical dentin - USE ENDO ICE to cool post during removal with ultrasonics. - Dont remove long posts fast, burn out is common lawsuit

Trauma: Incidence: - 30% of ages 2-5 yrs - 1 in 3 males, 1 in 4 females Prevention: Mouthguards, ortho Hx: - Blow to ant. Fractures ant. crown - Blow to chin fractures any tooth - Padded blows = root fracture or displacement - Sharp blows = coronal fracture - Hx is important for tetanus and LITIGATION Neurologic Exam: Communicate? Rotate head? Parasthesia? Dizzy? External: condylar fractures (have pt. open) Soft Tissue: lacerations HT: take pano, mobility Pulp Tests: cold and EPT, retest at 30-90-180 days, beware of false negatives Laser Doppler Flometry: Measures blood flow Radiographs: multi-angle, soft tissue (low Kvp), Accuitomo: sweet

Pt Instructions: Soft diet 2wk, brush teeth soft brush after each meal, CHX bid, recall Tx: Acute = immediate, Subacute = 48 hrs, Delayed = mutual convalescence Fractures: o Infraction: bonding agent or nothing o Enamel only: smooth, restore if esthetic o Uncomplicated (enamel and dentin only): base and seal tubules w/composite (good prognosis) o Complicated: pulp cap if AT ALL possible, MTA>GI>(etch)Composite Apexification: Fill canal wit MTA, coronal with Composite No pulp caps on calcified or displaced mature teeth Pulpotomy: large exposure + immature Pulpal Regeneration: Irrigate w/NaOCl, Tri-antibiotic paste, blood clot Concussion: adjust occlusion Subluxations: +splint if mobile, monitor Luxation: +Reposition, splint 2 weeks, RCT 2 weeks after External/Internal Root Resorption: Fill with Ca(OH)2 Intrusion: Slight = Spontaneous eruption, Severe = RTC (poor prognosis) Avulsions: TIME is KEY, 90% success if <30 min o Keep tooth, wet and cold o Remove debris with saline, but thats it o If dry, soak in saline 5 min o Irrigate socket, dont curette o Take radiograph on re-implant o Doxycycline antibiotic (if over 12), tetanus booster o 2 wks post implantation: RCT with Ca(OH)2, poor prognosis o Autotransplantation

Tauma Notes: Goal of Trauma: Preserve the vitality of the pulp - Strength of the root is low in younger teeth Mouthguards dont protect against concussion Blows: - Chin can fracture any tooth - Padded blows give root fractures - Impact blows give coronal fractures Transillumination is best way to see fractures RADAR: You are a mandated reporter - Recognize - Ask - Document - Asses - Review

Exam: Start globally Neurologic: Drowsy, dizzy, nausea, eye movement, cognitive ability Hard Tissue: Number, malposition, tooth sloth Pulp Tests: Use as a baseline only, but retest again later Radiographs: Multiple Angle + Soft Tissue DWP: Soft Diet for two weeks, soft toothbrush after each meal, chlorohexidine rinse Infraction: A fracture Enamel and Dentin = Uncomplicated Pulp = Complicated Transient apical breakdown: can turn into apical Dont do too much work that day, just get some composite in it. *Keep pulps alive if you can. Irrigate exposure with clorohexidine, place MTA, GI, then Fill. If theres too much bleeding, or calcific changes, then it needs a root canal Apexogenesis: keeps root alive, builds dentin Apexification: basically endo Racemic epinephrine pellets: no coagulation Pulp Response of Trauma: - Obliteration/calcification - Necrosis

Regeneration: Triple antibiotic paste, MTA Dentaltraumaguide.org

Internal Resorption: - Just do a normal root canal Intrusion: blood supply is destroyed, Ankylosis is likely and prognosis is poor.

Root Fracture and Resorption: Horizontal Fracture: Impact trauma, actually OBLIQUE, resorption/ankylosis are common (cementum coating is lost) - Reposition, splint 2-4 weeks - (25% need RCT) apex is vital so stop RCT at fracture site - Root Extrusion: allows restoration

- Dentin is foreign to osteoclasts Vertical Fracture: Various etiologies Resorption: - angled radiographs> external lesions move - Internal resorption needs vital pulp - CBVT Non Mineralized Pre-cementum doesnt adhere to osteoclasts, breaching this layer (with inflammation) causes external resorption. Emergencies: Diagnosis Requires: - CC, Med Hx, Pain Hx - Odontogenic Pain: Patients can localize painful tooth 75% of the time - Peri-redicular (endo) Pain: Patient can localize 90% of the time Dx: Hypersensitivity: new restorations, tertiary dentin laid down 8 um/d, so wait o Fast onset, short duration Reversible Pulpitis: acute, stabbing pain, COLD DOES NOT LINGER, no radiolucency o Treat by replacing filling (with GI) Irreversible Pulpitis: sharp pain, difficult to localize, COLD LASTS >30s o 20% of RCT is needed due to reactions to restorations o If you dont have any time to treat> EUGENOL (sedative) pellet (only pellet!) and temp filling o Pulpotomy w/ZOE works for 96% of cases o Pulpectomy is an option (crown down prep/irrigation), prep to #25 file, ONLY use Ca(OH)2 in canals Necrosis: dull pain, cold = relief, darkened tooth o Use Ca(OH)2 in canal for 1-2 weeks before obturating Abscess: usually dont need antibiotics unless ICP Retreat Case: Antibiotics and ASAP appointment Root fracture: rule this out because its a hopeless prognosis o CBVT is very helpful

Endo Surgery: MOST ENDOS SHOULD GET RETREATMENT - Surgery is an ALTERNATIVE Indications: - Pain relief, drainage, anatomic complication Contraindications: - Medically compromised, unidentified cause of tx failure Surgery:

Incision: drainage, block anesthesia is preferred Apical Surgery: o Failed Endo with immobile post, separated instrument, deep filling, failed conventional endo o Flap, access, curettage, root-end resection, prep, restore, post op instructions, post op visit Flap: Semilunar, Submarginal (leaves MGM and papilla alone), Full (sulcular) Curettage: biopsy always indicated o 10 bevel, more depth is better, 3mm fill into canal, isthmus prep Microhandpeice is too large, use ultrasonics IRM, GI, MTA are best fillers Radiograph before suturing, hold flap for 5 mins, 4-0 silk POI both oral/written * Always use microscope. - Corrective Surgery: o Procedural accidents, resorptive perforations o More difficult than apical surgery o Root amputation, hemisection, bicuspidization, Indicated for vertical root fractures or untreatable canals Contraindications: strong abutment teeth available Bicuspidization is for furcations - Intentional Replantation: LAST RESORT PRIOR TO EXTRACTION o Forceps only (no elevator) o <15 mins extraoral time o HBSS (Hanks) On Exam: Know the composition of Gutta Percha (in reading) - Alpha Phase = Sticky Soft Phase - Beta Phase = Hard Phase, non-adhesive Horizontal Condensation Resistance Form: Vertical Condensation Resistance Form: Apical Stop Taper

Wrinkled GP: Block or Ledge - Always get patency (with a 15 or 20 file since the apex is .27) Ledge: - Make sure youre patent by using a J-hook then filing (50 times) against the ledge Heating GP: Heat, Pack, keep packing after stop heating. The cone wont come out if you have a good fit. - Vertical Condensation gives the best Apical Seal, Horizontal Condensation gives the best Coronal Seal - Must stay 5mm from apex, because GP WILL heat seal at the apex. If you go closer than 5mm, the GP WILL spill out of the apex. - 5 Second Fill (compensate for shrinkage) Filling multiple canals:

Always block one canal (with a file) while filling the other canal

Pro-Root MTA: - Apical seal with cementum GROWTH Mix it thick, then pack Apical Dx is different than Pulpal Dx. Abscesses ALWAYS = NECROSIS and NON-VITAL tooth. Osteitis indicates pulpitis. Success: 50-90% Know the Management flowcchard (2nd lec) Prognosis of Retreatment: Always POOR J shaped lesion = CRACK (root fracture) RotoPro Bur: gets posts out Trephen Bur: cuts around object to allow retrieval Ultrasonics: can be dangerous at the apex, causing perforations Quantek: good bur to remove GP Chlorophorm is a Beta Carcinogen Eucalyptol is slower but not carcinogenic Separated Instrument: - Immediately take an x-ray o Apex- wont get it out o Mid-root/coronal, possible o If you can see it, ultrasonics Endo Perio Connection: The endo exam is challenging because 1/2 the q's are multiple answer. 25/60 Q's are multiple answer. Apical Foramen, Lateral canals and even (young) dentinal tubules are portals of exit for bacteria. Origin and Progression: Endo is quick, perio is slow Perio has less potency and low concentration of irritants (ON EXAM) Pulp to Periodontium: Granulomatous tissue at the apex due to breakdown at apex (ON EXAM: resorption, bone breakdown, granulomatous tissue, PDL breakdown, select the 5 things that occur at the apex) Periodontium to Pulp: Apex is minimally effected until plaque covers the entire root

 slow progression Cementum is an effective barrier, but 30 yrs of root planing can make ceentum suceptible Primary Perio dis has ATTACHMENT LOSS Aging Pulp: less cells and more mineralization and collagen (mineralization and fibrosis) angular bone loss apical loss

Periodontal Disease: Endodontic Disease:

Subjective Symptoms determine the Tx. EPT, Thermal, Test Cavity Probing NOT USEFUL: percussion/palpation Periodontal Defects are wider, Endo defects are more like sinus tracts. Both diseases must be primary on a true combined lesion: Do RTC first, then perio Tx.