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Endodontics: It is a branch of clinical dentistry concerned with the study of anatomy, morphology, histology and pathology of the dental pulp and periradicular tissues including diagnosis and treatment of diseases and injuries of theses tissues.-Endodontic is a Greek word (“Endo= Inside” and “odont=Tooth”).

Endodontic treatment also called root canal treatment root canal therapy (RCT) complete pulpectomy.

Objectives of Root Canal Treatment:A. Maintain vitality of the pulp.B. Preserve and restore the teeth with damaged and necrotic pulp.C. Preserve and restore the teeth which have failed to the previous

endodontic therapy (retreatment).

Scope of endodonticsEndodontics includes the following procedures:1. Diagnosis and differential diagnosis of oral pain2. Vital pulp therapy

Direct &indirect pulp capping. vital pulpotomy (apexogenesis) as in cases of trauma to open

immature tooth apex in pediatric patient (fig 1)3. Non vital pulpotomy; it is the conventional removal of coronal portion of the pulp. 4. Root canal treatment for the infected tooth with or without periapical lesion.5. Surgical endodontic such as apicectomy, hemisection, endodontic implant).6. Bleaching of discolored non vital teeth.7. Coronal restoration of endodontically treated tooth.

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A B C(fig 1) apexogenesis, at the time of trauma the apex was not completely formed flare up after 2 years as shown in (C) completely closed.

Basic Phases of Therapy1. The diagnostic phase, in which the disease to be treated is

determined and the treatment plan developed.2. The preparatory phase, when the contents of the pulp are removed

and the canal prepared for the filling material.3. Filling or obliteration of the canal to gain a hermetic seal with an

inert material as close as possible to the cemento-dentinal junction.

Indication of endodontic treatment:Unless there is a real cause to contraindicate R.C.T, All teeth with pulpal or periapical pathology are indicated for endodontic treatment which can be divided into:

1. Teeth with vital pulp.

a) Acute pulpitis.b) traumatized tooth with pulp exposure.

2. Teeth with non vital pulp.

a) Necrotic tooth with apical pathosis.b) Necrotic tooth without apical pathosis.

3. In some cases elective endodontic treatment is the treatment of choice,such as:

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1. post space: vital tooth with un sufficient tooth structure & intrapulpal extension of the final restoration (post) is needed to increase the retention.

2. Overdenture: decoronated teeth retained in the arch to preserve alveolar bone must be root-treated.

3. Teeth with doubtful pulps: R.C.T. must be considered to the teeth with questionable state of the pulp such as direct pulp capping or non vital tooth particularly if it is to be a bridge abutment.

Contraindication of endodontic treatment1. Non restorable tooth: the tooth that cannot be restored by final crown

restoration because no sound tooth structure onto which the finishing line can be placed .

2. Insufficient periodontal support: checking the mobility of the tooth must be done at the diagnostic phase .

3. Non-strategic tooth: extraction should be considered rather than endodontic treatment for unopposed and non-functional teeth.

4. Root fractures: both vertical &horizontal fracture of the root are contraindicated unless the horizontal fracture at the level of the apical third (apicectomy can be the solution).

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5. Massive internal or external root resorption: both types of resorption may eventually lead to pathological fracture of the tooth.

6. Bizarre anatomy: severely curved roots, dilacerated teeth.

7. Poor oral hygiene.8. Inadequate access: difficulty to reach the

infected tooth due to restricted mouth opening. A simple guide to measure mouth opening is possible to place two fingers between the mandibular and maxillary incisor teeth.

Note: maxim opening of the mouth is about= 50mm, less than 35mm consider as restricted.

Taking history &Clinical examination

Chief Complaint

The clinician must pay close attention to the actual expressed complaint from the patient own word. (pain, swelling, sinus or fistula, tenderness on chewing or just discoloration).

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Medical HistorySpecial dental management is needed for medically compromised patient 1. Short visit emergency treatment for critical cases such as pulpotomy

or pulp extirpation for the patient with un stable angina, myocardial infarction, prosthetic heart valve with prophylactic AB regimen at 1 hour before starting the dental work to decrease the chance of bacteremia & infective endocarditis: amoxicillin :1g as a single dose. clindamycin: 600mg as a single dose. (if the pt.allergic to pencillen)

2. Patient takes medication such as anticoagulant therapy, thyroid medication, and corticosteroid.

• Consultation with physician.• Plain anesthesia is advisable.

5. Medical conditions can have clinical presentations that mimic oral pathologic lesions For example; tuberculosis involvement of the cervical and submandibular lymph nodes can lead to a misdiagnosis of lymph nodeEnlargement secondary to an odontogenic infection.

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Extra-oral examination:The patient’s face and neck are examined and any swelling, tender areas, lymphadenopathy, or extra-oral sinuses noted.

Intra-oral examination:An assessment of the patient’s general dental state is made:

1) General periodontal condition.

2) Presence of soft or hard swellings. 3) Discolored tooh .4) Tooth wear and facets.5) Intraoral sinus tracts: occasionally a chronic endodontic infection

will drain through an intraoral communication to the gingival surface known as a sinus tract. This pathway, which is some time lined by epithelium, extends directly from the source of infection to a surface opening, on the attached gingival surface.

Diagnostic tests:1. Palpation:

The tissues overlying the apices of any suspect teeth are palpated to

locate tender areas. The site and size of any soft or hard swellings are noted and examined for fluctuation and crepitus.

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2. Percussion:

Gentle tapping by dental mirror both laterally and apically on a tooth is sufficient to elicit any tenderness. It is not necessary to strike the tooth with a mirror handle aggressively, as this invites a false positive reaction from the patient.

3. Mobility:The back ends of two mirror handles shouldbe used, one on the buccal aspect and one on the lingual aspect of the tooth

4. Radiography:In all endodontic cases, a good intra-oral

parallel radiograph of the root and periapical region is mandatory. Radiography is the most reliable of all the diagnostic tests and provides the most valuable information.

5. Pulp testing:

The electric pulp tester is an instrument which uses gradations of electric current to excite a response from the nervous tissue within the pulp. Pulp testers should only be

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used to assess vital or non vital pulps, they do not to judge the degree of pulpal disease or to quantify disease.

6. Thermal pulp testing:

This involves applying either heat or cold to a tooth, but neither test is particularly reliable and may produce either false positive or false negative results.

A. Heat:

There are several different methods of applying heat to a tooth. The tip of a gutta-percha stick may be heated in a flame and applied t a tooth.

B. Cold:

An ethyl chloride spray on a pledged of cotton wool or an ice stick may be applied to the suspect tooth. Ice stick is made by filling the plastic covers from a hypodermal needle with water and placing in a refrigerator.

7. Selective anesthetic:

The diagnosis of the tooth with diffused pain may be challenging because of referred pain to the adjacent or opposing teeth, the patient may not even be able to specify whether the symptoms are emanating from the maxillary or mandibular arch. In these instances, the clinician should first selectively anesthetize the maxillary arch using a periodontal ligament (intraligamentary) injection. The injection is administered to the most posterior tooth in the quadrant

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of the arch that may be suspected in an anterior direction, one tooth at a time, until the pain is eliminated. If the pain is not eliminated after an appropriate period of time, then the clinician should similarly repeat this technique on the mandibular teeth below. It should be understood that periodontal ligament injections may anesthetize an adjacent tooth and thus are more useful for identifying the arch rather than the specific tooth.

8 .Cavity test (drilling test) :When other tests have given an indeterminate result, a test cavity

may be cut in a tooth which is believed to be pulpless. In the author’s opinion, this test can be unreliable as the patient may give a positive response although the pulp is necrotic. This is because nerve tissue can continue to conduct impulses for some time in the absence of a blood supply.

9. Wooden stick:

If a patient complains of pain on chewing and there is no evidence of periapical inflammation, an incomplete fracture of the tooth may be suspected. Biting on a wood stick or rubber stick in these cases can elicit pain, usually on release of biting pressure.

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