RFE304_Advanced Endodontics

"CONVENIENCE"

"CONVENIENCE" • Removal of future disease sources • Occlusal plane alignment • Simplified prosthesis design - Patient welfare, oral health, & function must trump dentist convenience

'Strict' vs. 'Functional' Success

'Strict' vs. 'Functional' Success •Strict ............no detectable disease •Functional .....tooth functions without clinical symptoms

Pulp Chamber Not Unroofed

Pulp Chamber Not Unroofed - Why it matters • Leave bacterua under roof • Can't find canals - How it happens • Mistakenly think that pulp horns are canal orifices - Avoiding: • Check for undercuts with EXDG 16-17 explorer • Check with Bitewing radiograph • Look for dentinal map, darker pulpal floor • Transition from floor to canal is rounded - Management: • Remove with Round bur upstroke, or Endo Z laterally

QUALITY OF LIFE & SATISFACTION

QUALITY of LIFE & SATISFACTION Degree of enjoyment of important life possibilities. Oral Health Impact Profile (OHIP): • Functional Limitation • Pain • Psychologic Discomfort • Physical Disability • Psychologic Disability • Social Disability • OHIP used • Quality of life improved after RCT • High improvement: Physical Pain & Psychological Disability • Moderate Improvement: Social Disability & Physical Disability • Endodontists increased: job performance & temp. sensitivity • More improvement with PAI > 3 • More improvement with > 2 missing teeth • More improvement with high school education • Satisfaction ratings were high • Cost (& time, pain, poor esthetics) caused dissatisfaction Patients Want • Not a root canal, We Provide COMFORT • Not a tooth retained, We Save SMILES • Not to lose their $s, We provide QUALITY & VALUE • Not detached professionalism But genuine CARING & EMPATHY APPEARANCE Loss of a visible tooth is a life event as important as a family wedding or a funeral SUMMARY - TALKING POINTS • Pulpal disease affects QOL with moderate severity • Primarily through Physical Pain & Psychological Discomfort • RCT results in broad improvement in QOL • RCT improves: Physical Pain, Psychological Discomfort, Psychological Disability, & Social Disability • Some provider preferences, endodontists, were found • Satisfaction is extremely high (again & recommend) • Cost was the primary reason for dissatisfaction

REASON FOR RCT

REASON FOR RCT • PULPAL DEATH • IRREVERSIBLE PULPITIS • PULP EXPOSURE • PROPHYLACTIC • SENSITIVITY PULP CAPPING • DIRECT (clean, no caries, open apex) • INDIRECT • DYCAL (past) • ADHESIVE (current) • OUTCOMES POOR HOW MUCH REMAINING DENTIN THICKNESS IS NEEDED ? • 0.5 mm (Stanley V Cox) • SUBCLINICAL EXPOSURE • CONTAMINATION • PRIOR INSULT ~ 10 % OF PULPS DIE AFTER RESTORATION • CHRONIC • ACUTE •UNDER - DIAGNOSED REASONS FOR PATHOLOGY • PRIOR INSULT • TOOTH REDUCTION • OVERHEATING • MICROBIAL CONTAMINATION • HEMOSTATICAGENTS • OVERDRYING • PROVISIONALIZATION • CEMENT AND CEMENTATION

RESTORATION FOLOWING RCT

RESTORATION FOLLOWING ENDO • Separate distinct procedure, or integral ? • Coronal Leakage is a major cause of failure • Restoration quality as important as endo ! • Timely restoration often not provide

ROOT CANAL SEALER

ROOT CANAL SEALER • Eugenol • Inhibits resinous polymerization • DBAs and composites affected • Wait until the sealer has set • Mechanically clean the dentin • Non eugenol: AH 26, Sealapex BC

Radiographic Presentation of Vertical Defects

Radiographic Presentation of Vertical Defects - "Periapical (Radiographic) Lesion" - Size/Shape/Location ➡ Notice the difference radiologically between a primary endo lesion (no fracture, tear drop) and a VRF (J shaped lesion) - the taper is a result of the progression of the fracture, it starts coronally and progresses apically ➡ VRF can be visualized running apically - Lesion associated with vertical defect (crack/fracture) DOES NOT respond well

Re-Tx Indications

Re-Tx Indications • PERIAPICAL PATHOLOGY • HIGH RISK OF FAILURE ➡ Intracanal Bacteria ""But Doc, it Doesn't Hurt" Words I use: "retreatment will reduce the risk of future problems" "this is the right time, before your new crown is made" "like a house, secure the foundation first" "the problem will not go away on its own" "earlier treatment has a better prognosis" "do you always win in Vegas?" Contraindications • POOR PROGNOSIS • POOR FEASIBILITY • INADEQUATE TOOTH STRUCTURE "Can I really do any better than the first time, and substantially improve the patient's prognosis?"

Rubber Dam

Rubber Dam - Why do you need to use one: • To keep bacteria from getting in the tooth • It makes treatment easier • Avoid aspiration and swallowing of objects

STUDY MOTIVATION

STUDY MOTIVATION • Data for Evidence - Based Treatment ? • Adequate size • Adequate duration • Clear outcome criteria • Manufacturer driven ? Eckert et al, J Prosthet Dent 1997 "on the basis of data supplied bythe manufacturers, only one implant system demonstrated scientifically valid long-term success"

SYSTEMATIC & NARRATIVE REVIEW

SYSTEMATIC & NARRATIVE REVIEW CARIES - Dental Caries the 1° Cause of Endo - 79% US children experience at least one tooth decay by the age of 17 - $85 billion $ dental spending in 2007 - 65% of dental spending is related to dental caries - 19 million RCTS pa in the USA! SR PREVALENCE RCT in Elders - High Incidence of RCT in Elders - Peterson 2.1 % RCT initial 3.7 % RCT previously Txed patients 3.5 % RCT w lesions 2.9 %AP - Owall 0.7 % RC ➡RCT saves a very high proportion of elders teeth! ➡ Presence of PARL in RCT Teeth decreases with age (reduced inflammatory response) so RCT actually works better in elderly!! But they aren't getting enough RCTs - RCT Rises with Age - PARL Rises slightly with age SR INCIDENCE RCT in Elders SR FREQUENCY RCT by DECADE of AGE - Incidence of RCT drops from 40s onwards, But the prevalence of untreated AP remains SR QUALITY RCT in Elders - Poor Quality: 69 (7.1)% - Very Very Disappointing ! Both Treatment Quality & Treatment Access issues ACCUMULATION OF RCT , AP, EXTs & DISEASE - Prevalence of caries is highest in young and older populations -> in older populations root caries is most problematic -> most likely due to decreased salivary flow

Lecture 3 - Chugal - Endodontic Prognosis

Scope of Presentation • Etiology of endodontic disease • Prognosis - Prediction of outcome - How do we assess prognosis? • Outcome - assessment of the results of treatment - How do we assess the outcome • The etiology of failure of endodontic treatment • The factors which promote favorable prognosis, i.e. long term success of endodontic treatment

Separated File Removal

Separated File Removal • VISUALIZE, microscope small ss files, round file but oval canal • BYPASS: • REMOVE • NiTi or SS FRAGMENT ? (harder to remove Niti) • NiTi locks itself in - Shape Memory • ULTRASONIC VIBRATION • TINY PLIERS • SPECIAL TOOLS, tubes

Separated Instruments

Separated Instruments - Why it matters • In the way, can't clean or obturate the entire canal (file itself doesn't matter since we're filling the canal with foreign material anyways) - How files break: • Cyclic fatigue (spin something around corner = break) • Excessive torsional stress (tip of file binds tooth and keeps spinning = break) - Avoiding: • Case selection • Straight line access • Don't engage hand files more than 1/4 turn • Don't re-use files • Glide path, good initial apical preparation, before rotary files • Don't force files - Management: • Don't try - place calcium hydroxide, temporize and refer • An endodontist may remove or bypass the fragment • May have an excellent prognosis (can leave in tooth sometimes)

Vertical Defects are Lesions of EndoPerio Continuum

Vertical Defects are Lesions of EndoPerio Continuum - Vertical defects (tooth crack and vertical root fracture [VRF]) are examples of Endo-Perio lesions. - Tooth crack starts from coronal to apical direction and VRF mainly involves root dentin. - Vertical defects lead to destruction of alveolar crest bone and narrow bony defect. - Tooth crack is often not complete apically. Boneloss extends to the level of crack. - If tooth crack occurs in vital tooth, patient will complain of pain resembling irreversible pulpitis.

Systematic Review - Shabahang S 2009

Systematic Review - Shabahang S 2009 - Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review - "it appears that endodontic surgery offers more favorable initial success, but nonsurgical retreatment offers a more favorable long-term outcome - With microsurgery, not all bacteria is removed from root canal system, only apical portion

Transportation

Transportation - Why it matters • May lead to: lead formation, zip formation, elbow formation, damage to apical foramen, loss of apical constriction, apical perforation, difficult cleaning all of apical canal, difficulty obturating below elbow - How it happens • Happens in curved canals • Files want to straighten out and preferentially cut the outer way of a curve and deviate from actual canal path ➡ Note very sharp apical curves on distal root #31 ➡ Note sharp apical curve on mesial root #31 ➡ Note "S" or "bayonet" curve on mesial root #31 - Avoiding: • Pre-bend stainless-steel files • Avoid over-shaping curved canals • 1/4 turn and pull technique, minimize push-pull filing • Use thin, flexible, centering rotary files (ex: V-taper), don't keep in canal long ➡ Avoid apical transportation, but midroot transportation occurred - Management: • Carefully finish case, consider MTA obturation for large apices

Typical Exam Questions

Typical Exam Questions - Tricking you into ignoring inadequate endo or pathology & doing post / bleaching / restoration without addressing endo problem - Tricking you into doing surgery to save a crown / bridge instead of doing more appropriate retreatment 1) Endodontic retreatment is similar to routine intial endodontic treatment except: a)Extensive restorations, posts, and obturating materials may have to be removed b) Iatrogenic sequellae from initial treatment may been countered c) The success rate is usually slightly lower than for initial treatment d) a and b e) All of the above 2) Contraindications to retreatment include: a) Short roots, fused roots, open apices b) Poor feasibility c) Proximity to the inferior alveolar canal or to the mental foramen d) a and b e) None of the above 3) The prognosis of retreatment is best when: a) There is no peripical lesion b) A canal was missed in the initial treatment c) A permanent restoration was not placed d) Silver points were used in the initial treatment e) Perforations are on the coronal part of the root

Routes of Endo-Perio Continuum:

Routes of Endo-Perio Continuum:

ENDO PROGNOSTIC CRITERIA

*0.2 mm bone loss is acceptable after the first year and 0.1 mm there after ENDO PROGNOSTIC CRITERIA • Radiographic & clinical • Measuring the healing process • Differing & inconsistent definitions • 3-5 category outcome scales • Healing spectrum • Strindberg Criteria • Orstavik's periapical index (PAI) • Success % Versus Survival %)

Lecture 6 - White - Restoration vs Extraction/Implants

- Both driven by patient rehabilitation - ENDODONTICS ADDRESSES DISEASE WHEREAS: IMPLANT THERAPY MUST START FROM HEALTH - Implants should never be placed in unhealthy bone

Radiographic Presentation of Vertical Defects Example

- Exploratory surgery done to investigate the lesion and what is going on -> lesion was directly buccal to the root surface, explain why a PARL could not be seen - A VRF can be seen on the buccal of the root surface (bottom right image) - Unsuccessful treatment of VRF

Treatment Sequence Diagram

- Intentional replantation = intentional extraction and RCT therapy benchtop then replanting the tooth back into its original socket within 5 mins ➡ Major complications of intentional replantation = ankylosis and external root resorption - Autotransplantation= use of another tooth that needs to be extracted (i.e. 3rd molars), RCT is performed on that tooth and implanted on the site of a hopeless tooth - Root amputation ➡ Periodontist like amputating the DB of upper molars = smallest root and most difficult furcation to access ➡ Endodontists like amputating the MB of upper molars = most likely to have multiple canals

Modern Endodontic Microsurgery - Techniques

- Modern endo surgery allows us to open the osseous window so that we are precisely perpendicular to the apical 1/3rd of the root -> before the instruments were huge!! Osteotomy had to be massive so that we could utilize these instruments, now the instruments are microscopic allowing us to make smaller osteotomies - When handling gutta percha in clinic, always wipe down the GP master cone and accessory cones with sodium hypochlorite followed by alcohol wipe! - ~3mm of apical 1/3rd should be resected

Difficulties in Treatment Considerations

- Radiographic Difficulties • Structural anomolies (tori) causing angulation problems and need to increase exposure time • Calcifications of either the canals or pulp chamber • Full coverage and/or tooth rotation that obscures the position of the pulp chamber and canal position • Unable to position the film or X-ray tubeproperly with the rubber dam in place • Failing to use the collimator for initial and final films - Arch Position & Isolation • Tooth below gingiva • Fabricate customclamp • Visibilityproblems • Saliva contamination - Canal and Root Morphology • If canal appears to be off center on radiograph, give away that there is another canal - RadiographicAppearance • Canal appearancechanged • Off-angle view needed • Canal walls are rough • Apex is larger than coronal • MTA used as finalfill in resorbed area of the root - Resorption • Clean out the entire resorptive defect using large round bur • MTA is well tolerated by the tissues • Bone repair occurs even with external perforative defects

Root Resection

-*KNOW 3 mm of apical 1/3rd should be resected because any less will result in decreased chances of disrupting any chronic infection in apical ramifications and lateral canals

How Many Problems?

1. AAP and Prior RCT - Short, underflared, cotton, leaky restoration 2. Cotton & Cavit left, Furcal perforation, Missed canal 3. Sneaky Anatomy 4. Missed Apical Bifurcation

Tricky Cases

1. Short by 3mm, trust your apex locator 2. Pulpotomy Calcification Necrosis - AAP (& CO) - Attempt to find 2nd mesial canal with ultrasonic, stopped searching before perforating (if you can't do better, then stop) 3. Short Ledged CPP - Small precursved SS files, always helpful in troubleshooting 4. Short Ledged AAP

AAE and AAE Foundation 2005

AAE and AAE Foundation 2005 • Healed • Nonhealed • Healing ➡Functional • Healed-Functional* - Asymptomatic teeth with no or minimal radiographic periradicular pathosis * Functional - A treated tooth or root that is serving its intended purpose in the dentition • Healing - Teeth with periradicular pathosis, which are asymptomatic and functional, or - teeth with or without radiographic periradicular pathosis which are symptomatic but whose intended function is not altered.

ANXIETY & FEAR

ANXIETY & FEAR FELT & EXPRESSED • Felt by RCT Patients • Expressed in different ways Crying Anger Physiologic responses: hyperventilation, fainting, cortisol Body language: clenching, gripping chair, silence, talking • Read all the patients' expressions • Treatment Avoidance • Tooth Loss • 44% reported less fear after RCT, 50% same & 6% more • Prior experience decreases anxiety - Female patients are more likely to cry and male patients are more likely to express their anxiety via anger - *KNOW - 44% are less likely to be fearful after RCT - Older patients are less fearful than younger patients REASONS & CONSEQUENCES • Vulnerability • Danger • Lack of control • Unpredictability • Expectation of pain • Profoundly influence patient's behaviors • Profoundly influence patients' felt experiences • More pain experienced & remembered • Cycle of fear and avoidance • Cycle of overestimation pain and avoidance LOCAL ANESTHESIA • Physiologic stress peaks early with local anesthesia • Least to most anxiety producing: - EPT - Rubber Dam - Appointment Length - Multiple Radiographs - Rubber Dam Placement - X-ray Film Placement - Access Opening - Percussing a Sore Tooth - Sensing Files / Initial Instrumentation - Local Anesthesia Injection Systematic Review - Anxiety • NSRCT Anxiety is generally moderate • Anxiety decreased following treatment, 30% • Anxiety is influenced by patient & treatment factors • State Anxiety - Specific event anticipated • Trait Anxiety - General, personality, environmental, genetic SUMMARY - TALKING POINTS • We must accurately Inform & Educate patients about pain • Information decreases fear of pain • Patients would almost all choose to have a RCT again • Prior experience decreases anxiety • Negative hearsay increases anxiety • Prior negative experiences do not increase anxiety! • Consider behavioral management, nitrous, conscious sedation • Train your referrals to communicate carefully

Alternatives to Re-Tx

Alternatives to Re-Tx • No treatment, monitor • Surgery • Extraction • Extraction and implant

Anterior Access Perforation

Anterior Access Perforation - Why it matters • Difficult/ sometimes impossible to seal • Weakens tooth - How it happens • Access angulation, pointing the bur to the buccal • Drilling too far upon access - Avoiding: • Case selection - choose non-calcified teeth • Angulation of access is not perpendicular to tooth surface • Almost impossible to perf out the lingual • Its okay to violate the incisal edge if necessary - Management: • Place calcium hydroxide • Repair with MTA if below the attachment, RMGI if above • Refer

Anterior Access Perforation & Repair

Anterior Access Perforation & Repair - Needed to access through the incisal edge

Anterior Cervical Snap Off

Anterior Cervical Snap Off - Why it matters • Often poor prognosis or non-restorable - How it happens • Over preparing canals, large posts, & crown preps weaken anterior teeth - Avoiding: • Avoid gouging and over-preparing canals in the cervical third • If a post is needed, conservative, etc • Avoid crowns on anterior teeth whenever possible - Management: • Restore if adequate ferrule • Consider orthodontic extrusion or crown lengthening • vs extract & replacement

Apexogenesis vs Apexification

Apexogenesis vs Apexification APEXOGENESIS - Promotion of root growth to length and maturation of the apex - Pulp is VITAL APEXIFICATION Induction of root end formation (apical calcific barrier) Pulp is NECROTIC

Case Selection System

Case Selection System A. Patient Considerations • Medical history • Anesthesia • Patient disposition • Ability to open mouth • Gag reflex • Emergency condition B. Diagnostic and Treatment Considerations • Chief complaint • Medical & dental history • Physical exam and dental tests • Radiographic interpretation • Data evaluation • Diagnosis, treatment or referral C. Additional Considerations and Conditions • Restorability - should be first decision made - Class III mobility - Probes beyond apex - Visible vertical fracture - Decay extends belowbone - Tooth has migrated mesial - Patient in acutepain - Patient refuses endo therapy - Tooth was removed • Trauma history • Endodontic treatment history - Pain constant to percussion - Thermafil carrier used -overfilled - Able to remove the overfill - Established an apical stop - Re cleaned & refilled the canal • Periodontal-Endodontic conditions - 9mm probing defect - Tooth tested non-vital - Two accessory canals seen - Alloy used as a coronal seal - Good bone infill on recall

Apical Perforation

Apical Perforation - Why it matters • It means you didn't clean the actual canal and now you have a new hole to seal • Weakens root - The Prognosis is generally better for perforations that are: • Smaller • In vital teeth without intracranal bacteria or apical pathology • Further from the gingival pocket that will not communicate to the oral environment • Immediately cleaned and carefully disinfected • Effectively and permanently sealed - How it happens • Not following the natural apical curve • Drilling through the root tip, forcing files • Focusing on "length: • The myth of apical calcification - Every root is naturally patent, even radical apical turns have smooth transitions that can be followed unless you ledge, etc - Avoiding: • Case selection, understand anatomy • Passive negotiation and shaping, crown-down • Pre-bend file tips (ex: endo bender plier) • Avoid EDTA until glide path made •Avoid stiff files and pushing - Management: • Locate and treat actual canal • Obturate with gutta percha or MTA if large (apical surgery is a fall-back if healing does not occur) - Look for location of radiolucency to determine path of drainage to see where canal is

Lecture 9 - Lim - Modern Endodontic Microsurgery

Apicoectomy is indicated when conventional RCT fails - What are the common reasons conventional root canals fail? • Clinical indications • Retreatment vs Apicoectomy - What is "modern" endodontic micro-surgery? • Microscope • Materials (MTA, Bio-Ceramic) • Instruments • CBCT - What is the long-term success rate forapicoectomy?

BUILD UP MATERIALS

BUILD UP MATERIALS • Strength • Stability • Good sealing • User friendly • Fast √AMALGAM (Tytin fast set is the fastest!) √ COMPOSITE, LIGHT CURE √ COMPOSITE, AUTO CURE X GLASS - IONOMER X RESIN - MODIFIED GLASS - IONOMER X SILVER - REINFORCED G - IONOMER Amalgam • corono - radicular • build up, • MOST MOLARS - No pins/post -> retention/resistance from pulp chamber walls Sequence • Remove ~ 2 mm of GP •Matrix / copper band • + DBA • Amalgam BUILD-UP REQUIREMENTS • depth of pulp chamber • axial thickness of dentin • 2 - 3 parallel / undercut pulpal walls - If unavailable, then use a cemented parallel passive serrated post and amalgam - Keep the post inside the buildup

CEMENTS FOR POSTS

CEMENTS FOR POSTS • Know your material • Clean the canal • Venting for seating • Clean / sandblast the post • Retention versus retrievability • Fluoride release ZINC PHOSPHATE + Forgiving + Moisture tolerant + Retrievable (only big advantage) - Brittle - Poor seal - No adhesion • Slow incremental mix GLASS - IONOMER + Strong + Fluoride release + Seals well - Brittle, somewhat retrievable • Moisture control is important • Correct proportions • Protect excess • Wait 10 mins for initial set RESIN - MODIFIED GLASS - IONOMER + User friendly + Moisture tolerant + Good properties + Good seal + Fluoride release - Shorter track record ? New materials more Stable • Spectrum of materials RMGI SPECTRUM • Vitremer, 3M • Rely X, 3M • GCem, GC • Advance, Caulk • Principle, Caulk • Protec, Ivoclar • Infinity, Den-Mat • Resinomer, Bisc RESIN - COMPOSITE + Very strong & tough (R&R) + Can be used with a DBA + Good seal with a DBA - Poor retrievability - Limited working time - be quick • Don't overfill the canal • Follow instructions exactly • Use solvent based (A+ B) DBA

COCHRANE REVIEWS

COCHRANE REVIEWS OF IMPLANT INTERVENTIONS • Implants v. Preprosthetic Surgery • Implant Types • Surgical Techniques • Bone Augmentation Techniques • Time to Loading • Zygomatic Implants • Hyperbaric Oxygen Therapy for Radiotherapy • Maintaining Health Around Implants • Perimplantitis Treatment

COMPLICATIONS

COMPLICATIONS ENDODONTIC PROCEDURES - Treated as being failures, or Biological outcome measured IMPLANT PROCEDURES - Often treated as being distinct from a failure ENDO TREATED TOOTH COMPLICATIONS • Endodontic procedural errors • Endodontic failure • Post perforation • Coronal leakage • Root fracture • Caries (most common) • Perio disease (most common) IMPLANT COMPLICATIONS • Surgical procedural complications • Implant position problems • Osseointegration failure • Screw loosening, fracture • Attachment wear, fracture • Prosthetic Complications • Implant fracture • Peri - implantitis COMPLICATIONS Goodacre et al, J Prosthet Dent 2003 - there appears to be a greater number of clinical complications associated with implant prostheses - post and core prostheses had a substantially lower rate of complications than either fixed partial dentures or implant prostheses

CONCLUSIONS

CONCLUSIONS • RCT IMPROVES QUALITY of LIFE • ANXIETY & FEAR HAVE PROFOUND EFFECTS • RCT REDUCES PAIN PREVALENCE & SEVERITY • ANESTHESIA is VERY IMPORTANT • We PROVIDE COMFORT • We SAVE SMILES & TEETH • RCT has FAVORABLE ECONOMICS • We MUST LISTEN CAREFULLY • We MUST UNDERSTAND OURSELVES • We MUST COMMUNICATEVERY WELL • We ENDODONTISTS BEHAVE DIFFERENTLY

CORONAL MICROLEAKAGE

CORONAL MICROLEAKAGE • A key cause of endo failure • Quality of the temporary is critical • Restoration as important as RCT ? • How fast does it happen ? • Retreat after 90 days exposure ? • Type of temporary • Time in the mouth • Depth of the temporary • Masticatory forces Place the final build up at the time of obturation • Restore ASAP • Use a better temporary material • RMGI > Ketac > IRM > Cavit CONCLUSIONS • PLAN WAY AHEAD • CONSERVE TOOTH STRUCTURE • POSTS WEAKEN TEETH • Passive Parallel Serrated Vented • SEAL THE ACCESS CAVITY WELL • RESTORE ASAP

Can't get back to length

Can't get back to length - Why it matters • Can't clean out entire canal (packing debris down there) - How it happens • Packed dentin mud • Ledged • Broken file, amalgam, other debris - Avoiding: • Between each file change: Irrigate, use a patency file, & irrigate again • Don't skip files in sequence • Make sure each file is loose and floating before moving to next file • Best to avoid, sometimes impossible to manage - Management: • Irrigation and recapitulation • Use pre-curved files to scout around ledges • Refer for retreatment and possible apical surgery if healing does not occur

Can't get to length during canal negotiation

Can't get to length during canal negotiation - Why it matters • Bacteria left in tooth - How it happens • Frictional file binding (sticky stop) ➼ canal is tight, so enlarge canal coronally to allow file to go further • Hit outer wall of curve (hard stop) ➼ check with x-ray and bend a file to find the way around corner ➡ Does NOT occur because canal is calcified apically, quit having this mindset - Avoiding: • Start with a small K-file: 6, 8, or 10 • Pre-curve stainless steel file tips • Realize that pushing harder is never the solution - Management: • Coronal flaring, crown-down technique ➡ Measue where you are at, then shape from a 6 k-file to a 20 k-file 2mm short of where you are, then a 6 k-file will go further. Repeat as many times as needed to get length. This opens the canal to minimize frictional resistance and creates room to keep the bend at the tip of the file • Refer

Case Assessment Criteria When to Consider Referral

Case Assessment Criteria When to Consider Referral • Beyond your capabilities - Determined after a complete diagnosis & treatment plan is formulated • Your treatment will not meet Standard of Care criteria • You choose to treat other facets of dentistry Standard of Care - The quality of endodontic care which you provide a patient should be similar to hat provided by an endodontist

Case Selection

Case Selection - Choose teeth with: • Open pulp chambers • Canal is visible on radiograph to apex • Mature apices • Minimal curves • Round roots = Nice round canals • Without prosthetic Crown

Classification of Endodontic Outcome - Strindberg 1956 - Assessment at 4-year followup Failures

Classification of Endodontic Outcome - Strindberg 1956 - Assessment at 4-year followup Failures Clinical •Symptoms present Radiographic •Little or no reduction in periradicular rarefaction •Decrease in periradicular rarefaction, but no resolution •Appearance of new rarefaction or an increase in the size of initial rarefaction •Broken or poorly defined lamina dura

Classification of Endodontic Outcome - Strindberg 1956 - Assessment at 4-year followup Success

Classification of Endodontic Outcome - Strindberg 1956 - Assessment at 4-year followup Success Clinical • No symptoms Radiographic • Contours and width or PDL are normal • PDL contours are widened mainly around excess root filling (When excess filling, a widened periodontal membrane around the excess is acceptable) • Lamina dura intact

Classification of Endodontic Outcome - Strindberg 1956 - Assessment at 4-year followup Uncertain

Classification of Endodontic Outcome - Strindberg 1956 - Assessment at 4-year followup Uncertain Radiographic •Ambiguous or technically unsatisfactory ra□diograph which could not be interpreted with certainty •Periradicular rarefaction less than 1 mm and broken lamina dura •Tooth was extracted prior to recall due to reasons not related to endodontic outcome

Combined Endo-Perio Lesions

Combined Endo-Perio Lesions Presents both characteristics of Endo & Perio lesions 1. Loss of vitality 2. Generalized bone loss 3. Mobility 4. Failing restoration 5. Gingival inflammation 6. Caries Treatment: 1. RCT first then Perio follow-up. 2. Pulpal infection will continue to feed infection to periodontium. Prognosis: 4. Bony defect from Endo lesion will regenerate. 5. Periodontal defect is irreversible - In a situation like this which would treatment would you do first, endo or perio? - Endo RCT must be done first!! - Periodontal defect from a primary perio lesion is irreversible!

Communication through lateral canals

Communication through lateral canals - Lateral canals are very frequently found: • Posterio > Anterior • Apical 1/3 > Coronal 1/3 • Also located in furcation of molars (30%) - Lateral canals can transmit bacterial irritants from pulp to perio or vice versa. - This is most predominantly common for 1' endo lesions. - Lateral canals are very FREQUENT route for 1' endo lesions to cause periodontal breakdown. - Lateral lesions respond very well with conventional endodontic therapies, i.e., root canals. - How about 1' Perio disease causing pulpal infection through lateral canals? "Severe periodontitis cause root canal infection?" - This is very unlikely: Non-existent 1. Location of lateral canals 2. Pulpal resistance to infection Note: A study conducted in extracted teeth that had both endo and perio lesions showed that only 2% of lateral canals were present within the periodontal lesion... in other words, it is very rare for endo lesions to be secondary to perio lesions

Comparison of Outcomes of Ca(OH)2 Apexification vs MTA Apical Barrier

Comparison of Outcomes of Ca(OH)2 Apexification vs MTA Apical Barrier • Clinical success of both procedures is the same • Advantages of apexification using MTA Apical Barrier are: - Reduced treatment time - More predictable apical barrier formation (MTA results in denser dentinal bridge formation)

Concept of the Open Apex

Concept of the Open Apex Open Apex - Found in the developing roots of immature teeth - Normal in the absence of pulp or periradicular disease - If the pulp undergoes necrosis before the root growth is complete: • dentin formation ceases, and • root growth is arrested

Coronal Leakage

Coronal Leakage - Why it matters • Lets bacteria back in: causes failures (Dr. B never uses temporary material, he uses composite between visits to avoid leakage) - How it happens • Leaking temporaries • Cotton pellets left behind • Leaking permanent restorations • Voids under restorations, posts - Avoiding: • Don't use temporary materials for extended tiem periods • Use better temporary materials (GI, RMGI) • Restore immediately • Place the core foundation before removing the rubber dam - Management: • Usually requires RCT retreatment & re-restoration

Current Trends

Current Trends • Pulpal tissue engineering • Stem cell research • Regenerative endodontics • No more Apexification? Shifting Apexification to Apexogenesis

DIAGNOSTIC CONTRAST

DIAGNOSTIC CONTRAST - RADIOGRAPHY - RESTORATIVE PLANNING - MEDICAL IMPLICATIONS - FACTORS AFFECTING PROGNOSIS RCT TREATMENT PLANNING • REASON FOR RCT • PRE-OP DIAGNOSIS • PROGNOSIS • LONG TERM ROLE • SEQUENCING • RESTORATION • CONTINGENCIES RESTORATION - PRESERVE TOOTH STRUCTURE • Substantial Dentin Height: >75% circumference, > 1 mm thick, > 1 mm high • Minimal Dentin Height: <75% circumference 1 mm high, >25% circumference < 1 mm high, No 1-2 mm ferrule - AVOID POSTS - CORONAL COVERAGE? - PROVISIONAL RESTORATION - CORONAL MICROLEAKAGE IMPLANT TREATMENT PLANNING • RESTORATIVE PLAN • FIRST STAGE SURGERY • PROVISIONALIZATION • SECOND STAGE SURGERY • SEQUENCING • RESTORATION • CONTINGENCIES PATIENT FACTORS • DIABETES • SMOKING • ORAL HEALTH

DO ENDODONTICALLY TREATED TEETH NEED CROWNS ?

DO ENDODONTICALLY TREATED TEETH NEED CROWNS ? - ANTERIOR TEETH WILL BE MORE SUCCESSFUL WITHOUT CROWNS - Unless there is no other way to replace missing tooth structure - Coronal coverage increased success in postrior teeth, but not in anteriors - Teeth with posts failed more by fracture and dislodgement than teeth without posts - Tapered custom posts had the most failure - Cast and prefab parallel passive serrated vented posts did best

Definition of Terms

Definition of Terms Open Apex - Developmental anomalies - Dens-in-dente

ENDO STUDY DESIGNS

ENDO STUDY DESIGNS Torabinejad et al J Endodod 2005 • 306 studies from 1966 to 2004 • 6 RCTs • 12 low quality RCTs • 14 cohort studies • 5 case control studies • 8 cross - sectional studies • 4 low quality cohort studies • 73 case - series analyses • 42 descriptive epidemiological studies • 114 case reports 18 expert opinions • 4 literature reviews • 1 meta - analysis

New Systematic Review - Torabinejad 2015

New Systematic Review - Torabinejad 2015 - Tooth retention through endodontic microsurgery: a systematic review - Modern microsurgery has greater success but still short period of survival

Case Example - Diagnosis

Diagnosis - History: A 76 year old white male presents with discomfort and swelling on the palate adjacent to the palatal roots of teeth #14 and #15. He has a history of heart disease, amyloidosis,lymphoma and memory loss. He is currently taking flurosimide, digoxin, plavix, lipitor, aricept, and wellbutrin. He states that he has been treated for sinus problems in the past. He reports that he has a little discomfort to biting and chewing. Hot and cold drinks do not evoke a painful response. - Diffuse apical bone loss around the root of #14 & 15 -> looks like chronic apical periodontitis but possibly AAA due to swelling Clinical Testing: Clinical testing of teeth #12, 14,15 • EPT: #14, 15 (no response) #12 normal • Dry Ice: #14, 15 (no response) #12 normal • Heat: #14, 15 (no response) #12 normal • Percussion: #12, 13, 14, 15, (normal) • Bite: #12, 13, 14, 15, (normal) • Transillumination: all (normal) • Probing: all normal (2-3mm) • Radiograph: #14, 15 apical radiolucency • Occlusion: #14 (+) lingual cusp tip • Swelling: #14, 15 palpable palatal swelling Diagnosis: • Pulpal -- Pulpal necrosis #14 &#15 • Periradicular --AAA #14 &#15 Treatment Endodontic therapy #14 &#15 Findings • Upon accessing, tooth #14 was totally vital • I decided not to begin#15 • I should have been suspicious when the patient said "I have pain to bite and chewing" which I could not reproduce • The patient was referred to his oral surgeon and oncologist • The final diagnosis was recurrence of the non-Hodgkin's lymphoma with swelling and destruction of palatal bone • Patient did not return for 8 months while being treated by his oncologist for the reoccurrence of the lymphoma • RCT was then completes

Differential Dx for Endo-Perio Lesions

Differential Dx for Endo-Perio Lesions Symptoms Endo lesion 1. Localized 2. Often associated with severe pain (more with endo lesion) 3. May have temperature sensitivity Perio lesion 4. Generalized and diffuse discomfort 5. Little or no pain Clinical appearance Endo lesion 1. Coronal defects - caries & failing large restoration (for primary endo lesion, there MUST be a clinical or coronal defect) Perio lesion 2. No coronal defect 3. Inflamed gingiva, plaque, calculus Radiographic Appearance Endo lesion 1. Coronal Defect: Caries, failing restoration, fracture 2. Bony lesion extends from apical to cervix (retrograde perio). 3.Bony defect is localized Perio lesion 4. Generalized bone loss 5. Multiple teeth involved 6. No coronal defect 7. Bony lesion extends from cervical to apex Vitality Endo lesion 1. May or may not be vital, but 2. For Endo-Perio cases, it is mostly non-vital. Perio lesion 3. Vital.. very vital. So, if you access on Primary Perio lesion, what will you see? Palpation & Percussion Endo lesion 1. Depends on periradicular status. Perio lesion 2. Generally non-responsive Periodontal Probing Endo lesion 1. None. 2. If sulcular drainage, narrow probing down to apex. 3. If VC or VRF, narrow probing down to the level of crack. (With endo lesions you can sometimes have a fistula, resulting in a narrow probing defect all the way down to the apex which may be difficult to ascertain from a VR) Perio lesion 4. Generally increased. Broad attachment loss. 5. Multiple teeth involved. 6. Usually does not extend to apex

Direct Pulp Capping (DPC)

Direct Pulp Capping (DPC) A. Pre-op radiograph B. Photo after caries removal C. MTA placement D. Post-op radiograph with temporary restoration E. Post-op radiograph with permanent restoration F. Radiograph 6-year post-op

ECONOMICS

ECONOMICS "The natural state has intrinsic value; the alternative to the natural must be better or less expensive or both." - Cost Benefit - Resources - Time • Diagnosis Endodontics, Build up, Crown ~ 2 months • Diagnosis Surgery, Provisionalization, Healing, Restoration ~ 1 year Kim & Solomon JOE 2011 CE USA - Cost-effectiveness analysis showed that endodontic surgery was the most cost-effective among all treatment modalities for a failed RCT first molar. A single implant-supported restoration, despite its high survival rate, was shown to be the least cost-effective option based on current fees. Pennington et al IEJ 2009 Lifetime C & CE UK - Modeling available clinical and cost data indicates that, root canal treatment is highly cost-effective as a first line intervention. Re-treatment is also cost-effective, but surgical re-treatment is not. Implants may have a role if re-treatment fails. Balevi & Shepperd BMCOH 07 CU & CB Canada - Patients ranked RPDs, RCT, FDPs, implants, in order of both cost utility and cost benefit, but RPD was the least preferred choice. Loss of a maxillary incisor was not tolerated; patients were willing to pay more out of pocket to save an anterior tooth.

ECONOMICSS

ECONOMICS - The natural state has intrinsic value. The alternative to the natural must be either better or less expensive. Jack Brown in Torabinejad et al 2007 - Patients believe in: the importance of keeping teeth, & that teeth are part of overall health Gatten et al J Endod 201 SUMMARY - TALKING POINTS • The natural state has intrinsic value • RCT Initial Costs are lower than replacement • RCT Lifetime Costs lower than implant • RCT is highly Cost Effective • RCT has good Cost Utility • It is not just about the $: the patient & the prognosis

ENDO DIAGNOSIS

ENDO DIAGNOSIS • Full Endo Evaluation • Caries Removal • Endo Evaluation • Scope • Flap CROWN LENGTHENING • Isolation for endo • Isolation for restoration • Margin placement • > Crown : Root ratio ORTHO EXTRUSION • Slow • Esthetics improved • > Crown : Root ratio ROOT RESECTION AND AMPUTATION (rare) • Loss of tooth structure • Fracture • Caries 1. Always remove the caries first -> sometimes Endo and Perio would be successful but after caries removal there isn't enough tooth structure for restorative success 2. Identify Cracked Teeth

ENDO OUTCOMES

ENDO STUDY OUTCOME Friedman 1998 • Teeth without apical periodontitis did better • Retreatment without AP better than initial treatment • Retreatment with AP worse than initial treatment • Surgery alone: weighted average 59 % success • Surgery & retreatment: weighted average 80 % success • Surgery with retrograde filling better than without Strindberg 1956 • Teeth without apical periodontitis: 93 % success • Teeth with apical periodontitis: 88 % success • Retreat with apical periodontitis: 84 % success Chugal et al 2001 • Teeth without apical periodontitis: 88 % success • Teeth with apical disease: 63 % success • Retreatment: 79 % success Kojima et al 2004 Meta Analysis • Teeth with vital pulps: 83 % success • Teeth with non-vital pulps: 79 % success ENDO RETREATMENT or SURGERY Strindberg 1956 • Retreat with apical periodontitis: 84 % success Chugal et al 2001 • Retreatment: 79 % success Peterson & Gutmann 2001 • Surgery: 64 % success • Resurgery: 36 % success Friedman 1998 • Surgery after Retreatment 80 % success • Surgery:59 % success ENDO STUDY OUTCOMES Peterson & Gutmann 2001; Systematic Review • Endo surgery: 93 % success weighted average • Endo re-surgery: 36 % success weighted average SURGERY CONCLUSIONS • Always retreat before surgery • Extract instead of re-surgery

ESTHETICS

ESTHETIC OUTCOMES • Very important to patients • Little data ! • Emergence profile • Gingival architecture • Depth of implant placement • Tooth form & Appearance • Technical challenges • Disease and Misalignment

EXPERTISE, EXPERIENCE, QUALITY

EXPERTISE, EXPERIENCE, QUALITY • Endo: mostly generalists • Implants: mostly specialists • Literature reflects the histories • Endo: weak evidence for E E & T Q • Implants: weak evidence supporting GDs Lararski et al J Endodod 2001 - A retrospective study of over 44,000 endodontic cases showed that specialist practice provided similar rates of clinical success, even when treating more complex cases

Effects of periodontal infection on pulp

Effects of periodontal infection on pulp - Only applies with deep periodontal disease, radiographically: When perio defect reaches apex. - Clinical effects of periodontal disease on pulp is quesitonable. - Question: If the lesion is purely periodontal origin, is RCT indicated on #19? - There is biological effects of periodontal disease on pulp. - There is no clinical evidence that periodontal disease cause pulpal inflammation. - "Do teeth with severe periodontitis require root canal therapy?" - In most cases endo infection secondary to primary periodontitis is NOT common or expected - It is very questionable that primary perio infection can cause secondary endo infection..... - Therefore teethwith severe periodontitis DO NOT require RCT!!

Effects of pulpal infection on periodontium

Effects of pulpal infection on periodontium - Pulpal inflammation progresses to pulp necrosis. - Necrotic pulp allows egress of bacteria and toxins along the root canals. - Periodontal tissue destruction from apical foramen migrate from apex to CEJ: "retrograde periodontitis."

Endo-Perio Continuum

Endo-Perio Continuum - An important way that perio and endo lesions can communicate is through root crack or a vertical root fracture -> Root crack and VRF are two different pathologies that we must recognize as separate entities

Endodontic Examination and Diagnosis

Endodontic Examination and Diagnosis Subjective Examination • Chief Complaint • Medical History • Dental History (History of present illness) Objective Examination • Objective Examination (EOE, IOE, Pulp and PA Tests) • Radiographic Examination and Interpretation • Special Tests (Bite Test) • Cracked Tooth and Vertical Root Fracture Tests • Difficult Diagnoses (Referred pain) Assessment • Diagnosis Plan • Treatment Plan - Case Selection Objective Examination Diagnostic Tests: • Pulpal status tests: CO2 Ice, EPT • Color changes: Gray vs. Yellow • Mobility: Persistent or lack of mobility • Percussion: (+/-); High-pitched metallic sound • Palpation: (+/-) • Periodontal probing: Long and narrow pockets • Transillumination: Fractures • Radiographic: Evidence of dentoalveolar changes

Endodontic Treatment Outcome

Endodontic Treatment Outcome • Repair • Regeneration Endodontic Prognosis and Outcome Assessment • Prognosis refers to the prediction of outcome at some time in the future, i.e. forecast of the course of the disease or its resolution. • Outcome assessment refers to the evaluation of treatment results some time after endodontic treatment completion. Endodontic Prognosis • Prediction of the outcome at some time in the future (prognostication) • Assessment of outcome of endodontic treatment, both, conventional (orthograde) and surgical (retrograde) • These are essential ingredients of due informed consent, endodontic treatment planning and overall treatment planning of the dental patient Endodontic Prognosis • How do we predict outcome? • How do we assess treatment outcome?

Endodontic Treatment Proper

Endodontic Treatment Proper • Endodontic access • Working length determination • Root canal disinfection • Intracanal medication • Temporary restoration • Placement of the root filling • Permanent restoration • Observation and follow up

Factors Associated with the Outcome of Endodontic Treatment Endodontic treatment associated factors

Factors Associated with the Outcome of Endodontic Treatment Endodontic treatment associated factors - Quality of Instrumentation • Level in relation to radiographic apex • Size of apical preparation (apical enlargement) - Quality of Obturation • Level in relation to radiographic apex and the working length • Obturation (condensation) voids - Apical void • Excess of root filling material - Gutta Percha or sealer - Procedural Errors • Fractured instruments • Ledging • Periapical irritants • Transportation • Perforations - Remaining infection* - Teeth that have vital pulp will still have an apical constriction, we should instrument and obturate up to this constriction→ this is lost with pulp necrosis

Factors Associated with the Outcome of Endodontic Treatment Biologic Factors

Factors Associated with the Outcome of Endodontic Treatment • Biologic factors - Pulp and Periapical Diagnosis • Presence and size of periapical lesion* - Tooth Considerations • Tooth and root canal anatomy, calcifications • Resorption, caries, periodontal disease • Restorability - Age and Gender - Systemic Health - Remaining infection*

Factors Associated with the Outcome of Endodontic Treatment

Factors Associated with the Outcome of Endodontic Treatment • Biologic factors • Endodontic treatment associated factors • Restorative factors • Patient associated factors

Factors Associated with the Outcome of Endodontic Treatment - Patient associated Factors

Factors Associated with the Outcome of Endodontic Treatment Patient associated Factors - Motivation and compliance with care - Age - related conditions ? - Systemic diseases • Diabetes - Other factors • Smoking • Xerostomia - Diabetics have an 80% increase in non-healing Apical Periodontitis ▪ No difference in healing with HIV+ Pts → not a contraindication to endo treatment unlike diabetes

Factors Associated with the Outcome of Endodontic Treatment - Restorative Factors

Factors Associated with the Outcome of Endodontic Treatment Restorative factors - Tooth was restored • Was permanent restoration was placed? • Was final restoration was placed? - Quality of restoration Timing of restoration • When was permanent restoration placed? • How soon after endodontic treatment was it placed? - Coronal leakage • Associated with interim (temporary) restoration Coronal Leakage Studies - Swanson & Madison, 1987 - Madison, Swanson & Chiles, 1987 - Torabinejad, Ung & Kettering, 1990 - Chong BS, 1995 Effect of Coronal Restoration on the Outcome of Endodontic Treatment - Influence of delayed coronal permanent restoration on endodontic prognosis Safavi, Dowden & Langeland, 1987 - Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration Ray & Trope, 1995

For Elders:

For Elders: • Prevalence of Teeth with RCT is high, • Prevalence of Teeth with RCT Increases with Age • RCT Teeth are Preferentially Retained by Elders • Prevalence of PARL increases with Age • Prevalence of PARL is higher than for others • Prevalence of PARL in RCT Teeth Decreases with Age • Prevalence of PARL in RCT Teeth is Lower than for Others • Prevalence of PARL in Untreated Teeth Increases with Age • Prevalence of PARL in Untreated Teeth is Higher than for Others • More unmet need in Elders • Longitudinal Outcomes are equal to others • Accumulation of RCTs & AP through Life • Untreated Disease - It won't get Better & Prognosis Decreases

GP Removal

GP Removal • HEATED PLUGGERS • Flex-R- FILES • HEDSTROM FILES - don't unscrew • SOLVENTS, chloroform - careful! (used to soften GP, 1 drop is sufficient, but chloroform is volatile, explosive, and a general anesthetic) • ROTARY INSTRUMENTS, GPX • VERIFY w. additional X-ray & scope

General Dentist Responsibilities & Endodontist Responsibilities

General Dentist Responsibilities • Explain a possible referral before it is needed • Written instructions on what to expect following tx • Appropriate radiographs • Call the specialist when needed • Call and arrange the patients appointment • Explain why endodontics is needed and the restorative goals following completion of endodontic therapy Endodontists Responsibilities • Identify the correct tooth - retest the teeth • Clarify diagnostic or periodontal problems • Contact the general dentist before treatment if a different tooth is diagnosed as needing treatment • Send thank you notification and a final treatment report with final radiographs & photos • Discuss tooth treatment, prognosis, unusual findings and restorative recommendations • Provide proper patient feedback

Geriatric Considerations

Geriatric Considerations • Possible changes in cellular, extracellular and supportive elements in the pulp • More pulpal calcification • Increased cervical caries • Healing similar to younger patients if healthy • Access and canal location more difficult

Goals of Endodontic Treatment

Goals of Endodontic Treatment • To eliminate intracanal microorganisms and a contaminated substrate to a sub-threshold level necessary to induce periradicular disease by mechanical instrumentation and antiseptic irrigation • To create a bacteria-tight seal of the root canal system coronally and apically in order to prevent re- infection of the root canal system and communication between the apical portion of the canal and the periradicular tissues.

Gouging

Gouging - Why it matters: • Significantly weakens teeth, sets them up for future fracture - How it happens: • Careless accessing • Not understanding where to look for canals • Using too big bur - Avoiding: • Pre-plan your access • Use #2 SL round bur for non-molars, #4 SL round bur for molars • Once into canal use a non end cutting bur (Endo Z, LA Axxess) - Management: • Careful restoration

HOW DO POSTS FAIL?

HOW DO POSTS FAIL? •Mechanical Cyclic Fatigue • Cement microfracture • Leakage • Loosening • Caries • Dislodgement • Root fracture • Perforation The marginal cement fails first PREFAB POST MATERIALS (flexible posts preferred) • Stainless steel • Titanium alloys • Zirconia Ceramic (ceramic more likely to break than metal and difficult to remove if breaks) • Alumina Ceramic (ceramic more likely to break than metal and difficult to remove if breaks) • Carbon Fiber • Glass Fiber CERAMIC • Very very stiff • Brittle •White color •Limited design options • Can't drill it out • Ultrasonic dislodgemant of smooth tapered designs • eg Brassler ER Cerapost CARBON FIBER • Reasonably stiff • Strong • Black color • Limited design options • Splinters on drilling • eg Bisco, Den-Mat FIBER GLASS • Flexible • White, translucent • More design options • Splinters on drilling • eg Pentron, Dentatus, Bisco, Den-Mat FibreKor Post • Pentron • Translucent • Glass fibers (weaker if cut into) • White color • Parallel sided • Serrated / vented DT Light-Post • Bisco • Translucent •Quartz fibers •Pale yellow color • DT: "Double Taper" (good compromise) • Smooth

HOW MUCH TOOTH STRUCTURE IS NEEDED?

HOW MUCH TOOTH STRUCTURE IS NEEDED? - Fokkinga et al, J Dent 2007 • 1.0-1.5mm Ferrule MAXIMIZE DENTIN PRESERVATION - The shape and design of the prep is not all that important... what is more important is the amount of remaining tooth structure IS A POST NEEDED? - Posts DO NOT make the tooth stronger.. They actually weaken the tooth! REINFORCEMENT IS A MYTH - The only rationale for post placement is if there is no other way to get RESISTANCE or RETENTION form for the final coronal restoration POSTS DO NOT REINFORCE TEETH Guzy & Nicholls J Prosthet Dent 1979 - The diameter of the tooth bulk in the same direction as the applied force is most important or fracture resistance Cailleteau et al, J Endod, 1983 - Stress patterns within a root change upon post insertion. Stress tends to be concentrated at the apical termination of the post Eshelman & Sayegh, J Prosthet Dent, 1983 - Posts tend to move the site of fracture apically

HOW SHOULD THE POST SPACE BE MADE ?

HOW SHOULD THE POST SPACE BE MADE ? • 1st Heated instrument (Not a D11T spreader) • 2nd Gates Glidden • 3rd Post drill / Peeso under rubber dam & provisionalized HOW LONG SHOULD THE POST SPACE BE? - Compromise on post length, not on apical seal - Apical seal (apical 1/3rd) with the gutta percha must be preserved! - Preserving ~6 mm of gutta percha in the apical 1/3rd will actually leave any accessory and/or lateral canals sealed -> apical 1/3rd is the most likely place for these accessory canals Post Guidelines • > Clinical Crown • 6 mm apical GP remaining • Compromise on length • Parallel post design • Resin post cement • < 1/4 (NOT 1/3) root width MAKE POST SPACE @ OBTURATION • Familiarity with the anatomy • Isolation maintained • Easy to adjust / repair • Temporary seal is critical MAKE POST SPACE UNDER DAM - NO BUGS, NO PATHOLOGY - Even though the post perforated into the furcation area, infection did not occur because of excellent isolation when the RCT, post, build-up, and crown were don

Hard Paste Removable

Hard Paste Removable - Very difficult w curved canals - Was sometimes used in Eastern Europe & Japan - Sometime zinc phosphate or black-copper based - Sometimes contain toxins - e.g. "Russian Red"

Retreatment Characteristics

IDENTIFY the PROBLEM(S) • DIAGNOSIS • LOCATION OF PROBLEM • REASON(S) FOR FAILURE ? • CAN IT BE TREATED ? • IS THE TOOTH CRACKED ? • IT IS ALL ABOUT THE BACTERIA - "Changing the tire is not enough" INCOMPLETE BACTERIAL ELIMINATION • POOR ISOLATION & DISINFECTION • ANATOMICAL FACTORS • INSTRUMENTATION TECHNIQUE • IATROGENIC FACTORS • OBTURATION TECHNIQUE • RESTORATIVE FACTORS • CORONAL MICROLEAKAGE (BIG REASON) • MISSED CANALS (BIG REASON) PROCEDURAL CONSIDERATIONS • MORE ACCESS, cut old crown off • MORE ANATOMY TO CLEAN, findit • MORE CANAL ENLARGEMENT • MORE TIME, operator & disinfecting • MORE MAGNIFICATION, microscope • MORE ILLUMINATION, microscope • MORE CLEANING & SHAPING, FLARING • MORE DISINFECTION Hypochlorite • LONGER TERM ICM, CaOH2 (2 weeks in btw appts recommended) TECHNICAL CONSIDERATIONS • ACCESS THROUGH RESTORATION • CROWN REMOVAL, disassembly • POST REMOVAL, disassembly • ANATOMICAL FACTORS • SEALING MATERIALS • LEDGES, TRANSPORTATION, APICALPERFS • PERFORATION • SEPARATED INSTRUMENTS • REMOVING or BYPASSING • GAINING LENGTH

IMPLANT SUCCESS CRITERIA

IMPLANT OUTCOME CRITERIA Albrektsson et al, IJOMI 1986 • Absence of mobility • Absence of radiolucency • Low rates of vertical bone loss • Absence of signs & symptoms • Minimum 10 year success rate of 80 % Branemark, J Dent Educ 1988: Steady State • Life Table Methods • Implant or Prosthesis ? • Success or Survival ? • Restorative Problems, complications ? IMPLANT CRITERIA NOW New systematic review: Torabinejad et al, J Endod 2015 1. Misch - Survival 2. Albrektsson - Success 3. Albrektsson & Isidor - Success 4. Buser - Success (most used criteria, based on # of implants) • SI success rates and survival rates did not differ for each of the 3 time periods studied, but SIs are known to need additional interventions. • Success criteria are not discriminatory if they do not differentiate from survival. • A steady-state appears to be reached between 2 & 6 years. • A slight increase in single implant survival since 2006, a 6+ years survival rate of 98%.

IMPLANT SITE FACTORS

IMPLANT SITE FACTORS • ANATOMY • QUANTITY • QUALITY • MANDIBLE / MAXILLA • ANTERIOR / POSTERIOR BONE CLASSIFICATION • QUANTITY cortical & cancellous (even 1mm diff can make a difference) • LOCATION • QUALITY (more difficult to quantify/predict) IMPLANT FACTORS • GEOMETRIC FORM • DESIGN • LENGTH • WIDTH • SURFACE TEXTURE • SURFACE TREATMENT • MATERIAL SURGICAL FACTORS • SITE PREPARATION • GRAFTS • MEMBRANES • ANTIBIOTICS • ONE / TWO STAGE • IMMEDIATE PLACEMENT • SINUS LIFT • NERVE REPOSITIONING (no longer done) • HEALING TIME • GRAFTING • OPERATOR EXPERIENCE RESTORATIVE FACTORS • TIME TO LOADING • CANTILEVERING • ABUTMENT TYPE • PROSHESIS TYPE • IMPLANT - TOOTH LINK • SCREW (easier) OR CEMENT ?

IMPLANT STUDY DESIGNS

IMPLANT STUDY DESIGNS Eckert et al Int J Oral Maxillofac Impl 2005 • Case series studies mostly • No direct comparison of systems • Manufacturer driven ! • Large institutions, specialists mostly

IMPLANT OUTCOMES

IMPLANT STUDY OUTCOMES Eckert et al Int J Oral Maxillofac Impl 2005 • Pooled data studies on 6 majors in US • 7,398 implants • 5 year survival: 96 % Creugers et al J Dent 2000 • Systematic review of single tooth implants • 4 year survival: 97 % • 4 year uncomplicated maintenance: 83 % Lararski et al J Endodod 2001 • Retrospective Endodontic Study • Over 44,000 cases • 3.5 year functional: 94 %

Implant vs RCT

Implant vs RCT - Study comparing implants and RCT head to head - No statistical difference between the two - A lot more treatment/maintenance to maintain implant than RCT CONCLUSION 1 LITERATURE SHORTCOMINGS - Comparative Data Largely Absent - Little Prospective Data - Differing Success Definition CONCLUSION 2 CLINICAL OUTCOMES In patients with periodontally sound teeth that have pulpal / periradicular pathosis, RCT results in superior long-term survival compared to extraction without replacement and to replacement with a FPD, and results in equal survival to replacement with an implant. CONCLUSION 3 LIMITED PSYCHOSOCIAL DATA Suggests that in patients with periodontally sound teeth that have pulpal / periradicular pathosis, RCT results in superior psychosocial outcomes compared to extraction without replacement, and results in equal outcomes to replacement with a FPD or with an implant CONCLUSION 4 PROSPECTIVE CLINICAL TRIALS with large sample sizes, long durations, clearly defined criteria for survival, patient life-quality and economic outcomes are needed

Indications & Contraindications

Indications & Contraindications • Vital Pulp Therapy -Apexogenesis • Pulp Capping • Pulpotomy • Root-End Closure - Apexification • Regenerative Procedures

Indications for Micro-Surgery

Indications for Micro-Surgery 1) Large"cystic" lesions (usually maxillary anterior): often times large cystic lesion do not heal despite retreatment

Ledging

Ledging - Why it matters • Prevents you from cleaning & shaping the apical canal • Leaves bacteria in tooth - How it happens • Forcing your way down canals • Not precurving the tip of the file • Using stiff files • Skipping files in sequence • Using EDTA before you have created a glide path - Avoiding: • Never put force on a file to move apically • Understand that canals are rarely calcified apically • You are hitting the outer wall of a curve and need to bend the tip of a file to scout it • It's usually not tissue clumped up that you need to pick through - Management: • Open the canal to 2mm from the ledge • Pre-bend small K-files, 6, 8, or 10 and scout around the ledge • Once past, then push-pull the file 100 times, keeping its tip below the ledge • Repeat with 8, 10, and 15 K-files until have smooth path • Refer

SINUS AUGMENTATION

MAXILLARY SINUS FLOOR AUGMENTATION • Short term implant survival rates 62 to 100 % • Approximately 90% often quoted

MEDICAL FACTORS

MEDICAL FACTORS • Very few conditions impact endo healing; • Possibly, severe diabetes • Some Conditions Demand Avoidance of Surgery: ● Bleeding Disorders ● Head & Neck Radiation ● Bisphosphonate Therapy • Medication changes are very rarely needed • Avoid using EPT with Pacemaker Patients American Society of Anesthesiologists (ASA) Classification System • Class 1: No systemic illness. Patient healthy • Class 2: Patient with mild degree of systemic illness, but without functional restrictions, eg well-controlled hypertension • Class 3: Patient with severe degree of systemic illness which limits activities, but does not immobilize the patient • Class 4: Patient with severe systemic illness that immobilizes and is sometimes life threatening • Class 5: Patient will not survive more than 24 hours whether or not surgical intervention takes place

Kakehashi - Etiology of Endodontic Infection

Maximizing Endodontic Prognosis - Rests on elimination of microorganisms (bacteria) from infected root canals

Meaning of Endodontic Outcome Studies

Meaning of Endodontic Outcome Studies - TREATMENT SEQUENCE for DISEASE of PULPAL ORIGIN is to: 1. TREAT with RCT 2. RETREAT with RCT if not healing 3. SURGERY after RE-Tx if still not healing 4. EXTRACT - Implant ? ➡ RETREAT BEFORE SURGERY ➡ EXTRACT INSTEAD OF RE-SURGER

Modern Endodontic Microsurgery - Microscopes

Microscopes • Isthmus • C-shape canal • Fractures • Accessory canals / Missed canals • Canal fin • Non-intact root end fill Methylene Blue: - The periodontal ligament can be easily identified by staining the resected root surface with Methylene Blue Microsurgery • Flap Elevation • Osteotomy • Root Resection • Curettage • Root-End Examination • Root-End Preparation • Root-End Fill

Misdiagnosis

Misdiagnosis - Were all of these RCTs really needed? Diagnostic tips: - If there is pain, you need to localize and reproduce their pain (if can't reproduce, then do NOT start endo) - You need to find an etiology for pulp infection (a virgin tooth has no etiology for how bacteria got in) - It is statistically unlikely that multiple teeth develop symptoms at the same time (unless full mouth restorations/caries down to the pulp is the only time) - Don't overlook the medical history

Misdiagnosis Example A

Misdiagnosis Example A - Wrong tooth? - Usually only one tooth has an endodontic problem at a time - If you cannot reproduce the symptoms or identify the tooth - wait - Things generally become clearer over time ➼ Pt had pain on UL, Dentist completed RCT #14 -> Pain persisted -> RCT #13 -> Pain persisted -> RCT #15 -> Pain persisted -> RCT #12 -> Pain persisted -> Sinus surgery -> Pt has seen orofacial pain specialist for decade ➼ CBCT showed missed MB2 & apical lesion ➼ Apical surgery of MB2 of #14 caused complete resolution of symptoms

Misdiagnosis Example B

Misdiagnosis Example B - Wrong Tx Decision • 3 different diagnosis • 3 Different treatments

Misdiagnosis Example C

Misdiagnosis Example C - Non endo • Normal anatomy • Mental foramen

Misdiagnosis Example D

Misdiagnosis Example D - Non endo • Pain not localized • Suspect tooth largely intact • Hx bisphosphonates ➼ RCT performed ➼ Probing defect persists ➼ Parulis persists ➡ Tooth extracted ➡ BRONJ recognized ➡ Resection ➡ Quality of life diminished - If they discovered this sooner, resection may have been much smaller, should have been obvious from beginning based on patient's medical history - NOT every tooth with draining fistula or with pain needs an RCT Systemic - Metastatic carcinoma: breast, lung, kidney, thyroid, prostate, stomach, skin. - Osteoporosis, osteopetrosis, scleroderma, Langerhan's cell-histiocytosis, hyperparathyroidism, Paget's disease, multiple myeloma, etc... Local: - Primary carcinoma, Staphne's bone defect, mandibular canal, mental foramen, osteonecrosis (bisphosphonate or radio-induced), periodontal disease, ameloblastoma, OKC, cemental dysplasia, osteomyelitis, incisive canal cyst, traumatic bone cyst, apical scar, lateral periodontal cyst, dentigerous cyst, maxillary sinus, etc

Misdiagnosis Example E

Misdiagnosis Example E - VRF - A fracture should be visually confirmed, provne, not just assumed - "Vertical root fracture" is the most common casually misdiagnosed excuse to extract a tooth • J shaped radiolucency and isolated deep proving is NOT sufficient for diagnosis of VRF, NEED to be able to visualize VRF • Need to differentiate VRF which starts at apex and tends to crack in B-L direction vs Split tooth where crack starts on occlusal surface and then cracks travel down the outside of the root (never in furcation!) ➼ No VRF found ➼ Searched for on accessing ➼ RCT completed ➼ Healing occurred

Missed Anatomy

Missed Anatomy - Why it matters • Bacteria left in tooth • Pulpal tissue left in tooth - How it happens • Couldn't find canal(s) (no excuse when using CBCT) - Avoiding: • Case selection: calcified, multiple PDL outlines, Fast Breaks (UCLA John Wood basketball play: 1 canal splitting into multiple, will appear suddenly and just disappear) • Understand normal anatomy & its variations • Magnification • CBCT • Often missed: Mx molar MB2, Mn molar DB, Mn incisor L - Management: • Locate and treat missed anatomy

Missed Anatomy #14 Example

Missed Anatomy #14 Example - Missed the mind-set of thoroughness and precision - MB1 is not centered in the root (if canal not centered in tooth, likely there are multiple canals - There are multiple MB root PDL outlines - So, where is the MB2? - The CBCT shows MB2, MB3, and MB4 to the palatal of MB1

Missed Anatomy #20 Example

Missed Anatomy #20 Example - Two separate radiolucencies = must be a portal of exit feeding each radiolucency so that is a clue that there are multiple canals

Modern Endodontic Microsurgery

Modern Endodontic Microsurgery • Apicoectomy • Root Amputation • Incision and Drainage • Exploratory Surgery (not common anymore due to CBCT) • Intentional Replantation • Extraction/Grafting Outcomes of nonsurgical retreatment and endodontic surgery: a systematic review Shabahang S, Handysides R, Corr R, TorabinejadM • Found that endodontic surgery is not successful! (50-80%) Outcome of Endodontic Surgery: A Meta-analysis of the Literature—Part 1: Comparison of TraditionalRootend Surgery and Endodontic Microsurgery Frank C. Setzer, DMD, PhD, MS • Found that TRS (Traditional Root-end Surgery) is only 60% while modern EMS (Endodontic Microsurgery) is 94% Discussion: • Root End Preparation-Bur vs Ultrasonic • Osteotomy-Large vs Small • Instruments-Large vs Microinstruments • Root-End Filling-Amalgam vs Biocompatible • Magnification

NON-RESPONSIVE to COLD, HEAT, EPT:

NON-RESPONSIVE to COLD, HEAT, EPT: • EITHER NECROTIC, or ALIVE and the patient just didn't feel it. • CHECK: Was it previously responsive? • CHECK: Prior Charting • CHECK: X-rays • CHECK: 2° Dentin, Calcification • CHECK: ALL OTHER FINDINGS. DANGEROUS MYTHS: "The Stressed Pulp" "Preventive Endodontics: "Corrective Endodontics" - RCT is only indicated by objective diagnosis of pulpal or periradicular pathology - Even if existing RCT seems to be of poor quality, unless patient has symptoms DO NOT retreat

NON-VITAL BLEACHING STEPS

NON-VITAL BLEACHING STEPS • Barrier to protect PDL & prevent resorption • Glass-ionomer base over the RCT • Sodium perborate with water / local • Mix into a thick slurry, pack • Temporize • Do not use superoxyl (resorption) • Do not use heat ( resorption) • Change weekly • Effective on blood breakdown products • Ineffective on tetracycline, metal oxides

OVERDENTURE ABUTMENTS

OVERDENTURE ABUTMENTS • GOLD DOMES • AMALGAM PLUGS + Vertical support + Improved crown : root ratio + Lateral stability + Retention with attachments + Proprioception + Easier transition AMALGAM PLUGS • Solid tooth structure needed • Quick & easy • Inexpensive • Prep tooth to dome shape CAST GOLD DOMES - Less tooth structure needed - Second appointment - Expensive Cast to dome shape - Attachments can be added

Lecture 5 - Chugal - Incompletely Formed Roots Management of Open Apex

Objectives • Differentiate between the open and closed apices • Open apex in health and disease • Diagnosis and selection of appropriate treatment • Indications for vital pulp therapy (Apexogenesis), root-end closure (Apexification), Regendo and root canal therapy • Describe how to perform vital pulp therapy by pulpotomy • Describe how to perform root-end closure in necrotic teeth • Regenerative endodontics

Outcome Assessment

Outcome Assessment • Strindberg's Criteria 1956 (HUMAN STUDY) - He established the criteria, outcome rates, related outcome rates to preoperative diagnosis, and defined duration/frequency of follow-up - Clinical and radiographic • Success • Failure • Uncertain • AAE Foundation Criteria 2005 - Clinical, radiographic and functionality • Healed • Healing • Non-healing • Investigators/Clinicians Criteria - Defined by the investigator • Survival vs. success • Quality of life issues • Patient satisfaction • Masticatory function

PA lesion linked to Vertical Root Fracture (VRF):

PA lesion linked to Vertical Root Fracture (VRF): - Lesion associated with vertical defect (crack/fracture) DOES NOT respond well - Occurs with Bucco-Lingual orientation along the root. Note: Most of the time the VRF is fully progress from the coronal to the apex and in the Buccolingual orientation

PAIN

PAIN - Pain is a feeling triggered in the nervous system. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen or chest or you may feel pain all over, such as when your muscles ache from the flu. - Pain can be helpful in diagnosing a problem. Without pain, you might seriously hurt yourself without knowing it, or you might not realize you have a medical problem that needs treatment. Once you take care of the problem, pain usually goes away. However, sometimes pain goes on for weeks, months or even years. This is called chronic pain. Sometimes chronic pain is due to an ongoing cause, such as cancer or arthritis. Sometimes the cause is unknown. - Fortunately, there are many ways to treat pain. - Treatment varies depending on the cause of pain. - An unpleasant sensory and emotional experience associated with actual or potential tissue damage,or described in terms of such damage. - The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. - Many people report pain in the absence of tissue damage or any likely pathophysiological cause; usually this happens for psychological reasons. There is usually no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause. - Pain and pleasure are two important motivational forces that shape our behavior and help us to make informed decisions. I use an experimental approach in animals to analyze the circuits in the brain that mediate pain and reward. My interest in addiction is a natural outgrowth of my research on analgesic drugs, many of which are addicting. The studies of pain and reward are not as disparate as they might first appear. In fact, the relief of pain and the production of pleasure are closely related at both the subjective and neural circuit level. Both have strong influences upon, and are influenced by, learning. - Our expectations, mood & perspective on pain powerfully influence how much something actually hurts & the decisions we make every day. Most people think of pain as resulting from physical injury or disease, but psychological factors play a huge role in pain perception. In the case of my patient, my reassurance that the treatment would not significantly worsen his pain - because he could stop me if it did - produced an analgesic effect. In addition, reducing the man's fear enabled him to look forward to pain relief instead, and that positive expectation also eased his pain.

PATIENT BASED MEASURES

PATIENT BASED MEASURES ENDODONTICS • Some supportive data • Overwhelming relief of pain ! IMPLANTS • Some supportive data, Strassberger et al2004 • Overdentures, Feine and Others

IF A POST IS NEEDED WHAT KIND ?

POST TYPES • CAST TAPERED • CAST PARALLEL • PREFABRICATED CAST TAPERED + Strong + Non-corrosive - Wedging effect - Poor retention - Dentin removal (too wide and fat) - Extra appointment - Expensive CAST MOSTLY PARALLEL (preferred cast post) + Strong + Non-corrosive + Good retention + No wedging effect + Conservative - Extra appointment - Extra lab fee PREFABRICATED + Good retention + No wedging effect + Conservative + Fast + Inexpensive - Weaker - Less well adapted - No shoulder DESIGN REQUIREMENTS • Parallel sided • Passive • Vented • Serrated • Shoulder Standlee et al, J Prosthet Dent 1978 • Serrated parallel posts were more retentive than smooth tapered • Long posts were more retentive than short posts • Wider posts Were not more retentive

WHY PSYCHOSOCIAL FACTORS MATTER

PSYCHOSOCIAL FACTORS - We have prognostic instruments such as the Strindberg Criteria, Orstavik's Periapical Index & the Molven, Halse & Grung Classification. These have been used to measure outcomes, maybe inappropriately. But, they tell us nothing about how the patient perceives, feels, or values RCT. Patients chose, undergo, pay for, & live with RCT. They inform friends & community. - Clinicians' perspectives are limited. - Patients can tell us how RCT affects their physical, psychosocial & social function, i.e. their quality of life - Psychometry includes validity, reliability & responsiveness.

PSYCHOSOCIAL IMPACTS on ELDERS

PSYCHOSOCIAL IMPACTS on ELDERS - Jimena (1998) reported that elders' attitudes towards NSRCT were generally very positive. Patients appreciated NSRCT for the following reasons: pain and swelling relief, better diet and appreciation of food, better chewing and digestion, esthetics and self-esteem, the dignity of retaining their natural teeth, speech, avoiding further tooth loss and prostheses, and to support existing prostheses. However, some negative comments addressed: long appointments, mouth opening & mouth dryness. Jimena concluded that management of the elderly requires considerable patience, sensitivity, flexibility, understanding, skill and refined judgment on the part of the dentist. CONCLUSIONS ● Caries & Sequellae! ● Very High Prevalence of RCTs in Elders ● Elders accumulate RCTs ● Elders also accumulate disease, AP ● Significant disease, AP, is untreated ● Elders also accumulate extractions ● Extractions generally not due to RCT ● RCT Quality Generally Poor in Elders ● Patients do Appreciate RCT ● Social Factors are Important ● Elders heal at least as well as other adults

Pain

Pain - RCT isn't supposed to hurt - RCT need not hurt - Tips for local anesthesia • Accessory innervation (IAN with long buccal) • Lidocaine, Mepivacaine (carbocaine), Articaine • Wait until fully numb (can do cold test to confirm) • Intrapulpal when needed on vital teeth (can use brand new bur and water spray to avoid intrapulpal pain) • Intraosseous can be a useful adjunct • Be sensitive to every patient, especially to the anxious or fearful

Pain Prevalence & Severity before, during, and after RCT

Pain Prevalence & Severity before, during, and after RCT - Pain of endodontic origin is widely feared by the public. Root canal procedures are commonly believed to be the most painful dental treatment, but only 17% of subjects experiencing root canal treatment described it as their most painful dental experience. - Indeed, the provision of over 15 million elective root canal treatments annually in the United States suggests that the public values root canal treatment. - Pain prevalence generally drops in a WEEK PAIN DURING TREATMENT - Prevalence: up to 100 % of the time - Severity: low - We must monitor patient comfort - We must provide supplemental anesthesia SUPPLEMENTAL ANESTHESIA - Supplemental anesthesia was necessary 60% of the time. - Supplemental anesthesia was generally successful in reducing pain and & achieving anesthesia. - Pain was commonly experienced during needle insertion, needle placement, & solution deposition, suggesting the need for care in communication & injection technique - The Worst Part was the Shot FLARE UP & EMERGENCY - Flare up incidence ~ 2 + % - Timing: several days post op - microbial - Associated with • Multiple appointments +/- ? • Retreatment • Pre Tx pain • PARLs • Use of pain meds • Ethnicity • Incomplete endoTx • Necrotic teeth - bacteria - Endo emergencies are resource intensive SUMMARY - TALKING POINTS • A physiologic, emotional & psychologic construct • Closely related to pleasure • Mediated by reward • If the patient says "Pain" - believe them • "The worst part was the shot" • Intraoperative pain common - supplemental anesthesia • Listen to the patient very carefully

Pick an Ideal First Case

Pick an Ideal First Case if you want to do retreatment: • Anterior tooth • Simple anatomy • Single canal • Existing GP fill • Use calcium hydroxide ICM - YOU ARE ALLOWED TO DO SIMPLE RETREATMENTS WITH THE APPROVAL OF THE COVERING FACULTY, typically a straight upper anterior with a short RCT fil

Post Characteristics

Post Characteristics FLEXIBILITY? - Glass Fiber is too flexible - Alumina is too stiff - Post is actually placed in the least ideal place in the tooth! -> in the pulp canal system where the tooth is actually the weakest -> The "hollow" center of the tooth is called the neutral axis SHORT BEAM SHEAR STRENGTH ? - Glass Fiber is rather weak - SS & Type 5 Ti may be unnecessarily strong IMPACT TOUGHNESS? - Ceramics are too brittle - Type 5 Ti may be unnecessarily tough Fiber Posts - Profound loss of strength - More restoration failure - Fewer fractured roots FIBER POST REMOVAL - Strong - Brittle - Some flexibility - Tough - Probably resin - bonded - Splinters on drilling - Bisco Kit

Post Perforation

Post Perforation - Why it matters • Difficult to seal, weakens tooth - How it happens: • Drill out of the root while performing post space - Avoiding: • Place fewer posts - hardly ever needed in molars • Place at time of obturation, under rubber dam • Understand root anatomy: curves & concavities • Accurate measurements, root appropriate diameters • Place in bigger roots - P of Mx molars, D of Mn molars • Use tapered fiber posts where appropriate - Management: • Don't try - place calcium hydroxide, temporize and refer

Post Removal

Post Removal • POST TYPE: harder to remove is ➡ Active Versus Passive ➡ Serrated Versus Smooth ➡ Tapered Versus Parallel • CEMENT TYPE: Zinc Phosphate - Glass-Ionomer - Resin • ULTRASONIC VIBRATION - cracks the cement • POST EXTRACTORS • If all else fails, drill the post out carefully Ultrasonics • Ultrasonics • Sonics • "Spartan" • "Mini-Endo" • Tips hardened, nitrided, or diamond coated • Very small cutting tips • Good vision • Use dry mostly in endo • Finding canals (low intensity) • Post removal (high intensity) • Retrofill preparations

Posterior Access Perforation

Posterior Access Perforation - Why it matters • Difficult/ sometimes impossible to seal • Weakens tooth - How it happens • Drilling too far upon access - Avoiding: • Case selection - choose teeth with large pulp chambers • Measure distance to pulp chamber roof and to floor on Bitewing • Make interoperative Bitewing - Management: • Place calcium hydroxide and temporize • Repair with MTA if below the attachment, RMGI if above • Refer

Pre-treatment Assessment of Prognosis

Pre-treatment Assessment of Prognosis • Favorable • Questionable • Unfavorable Decision Making Process • Risk factors (save or extract): • Endodontic criteria • Periodontal condition • Remaining tooth structure • Restorability • Perceived strategic value • Ability of dentist • Cost, desires of patient

Retreatment and Endo Surgery

Retreatment - Eliminates bacteria - Better outcome than Sx - Preserves root length - New restoration needed - Surgery as a fall-back Endo Surgery - Apicectomy - Amputates infected part of root - Retrofill attempts to confine bacteria (attempts to "cap the sewer" - Sx: lesser long-term outcome (short term is great) - Shorter root - Restoration may be preserved? - Limited fall-back options

Retreatment or Apical Surgery? - Grung, Molven & Halse, 1990

Retreatment or Apical Surgery? - Grung, Molven & Halse, 1990 • Success of endodontic surgery is closely related to the standard of the treatment of the root canal • Orthograde treatment should be preferred whenever possible, and success rate of more than 90% can be expected when incomplete healing/scar tissue cases are included Results of Endodontic Retreatment: A Randomized Clinical Study Comparing Surgical and Nonsurgical Procedures - Kvist & Reit, 1999 • No systematic difference in outcome of surgical and non- surgical treatment. • At the 12-month recall, a higher healing rate was observed for surgically retreated cases (p<0.05) At the final 48-month recall, no such difference was found. • Slower healing dynamics of re- treatment group. • Late failures in surgical group.

Root Canal Therapy

Root Canal Therapy • Purpose: To prevent or heal apical periodontitis by removing and excluding bacteria, their toxins and metabolites, inflamed or necrotic tissues and debris from the root canal system, without destroying the tooth immediately or setting it up for long term failure Mind-set of thoroughness and precision • Biologic process, not a series of mechanical or procedural goals • How fast you can do it doesn't matter - take the time needed Why do root canals fail? • Bacteria left in the tooth • Bacteria got back in the tooth • Tooth fracture (due to restorative failure/bacteria got back in) Common Complications • Misdiagnosis • Pain • Gouging • Treating through pulp horns • Anterior access perforation, Posterior access perforation • Missed anatomy • Can't get to length • Losing length • Ledging, transportation, apical perforation • Separated instruments • Strip perforation • Post perforation • Hypochlorite accident • Coronal leakage • Vertical root fracture in posterior teeth • Cervical snap-off fracture in anterior teeth

Root-End Closure (Apexification) with MTA

Root-End Closure (Apexification) with MTA Description of Technique • Local anesthesia • Dental dam isolation & surface disinfection • Conventional access is made with a high- speed burr to allow debridement of the canal(s) • Calcium hydroxide paste is placed for one week to disinfect the root canal system • Mixture of MTA and sterile water is prepared, and carried into the canal with an amalgam carrier • MTA mix is condensed to the apical extent using pluggers or paper points to create a 3-4 mm apical barrier • MTA placement is verified radiographically. If unsatisfactory, rinse and repeat the procedure • Moist cotton pellet is placed in the canal to ensure proper setting of MTA Note: Minimal of 1 week of MTA then you can obturate, MUCH quicker than Ca(OH)2 alone - Can also be done in adult teeth

Root-End Closure Technique with Ca(OH)2

Root-End Closure Technique with Ca(OH)2 Three general phases: • Access • Instrumentation • Placement of Ca(OH)2 , MTA or BC Putty APEXIFICATION : • Induction of apical calcific barrier in immature teeth with incomplete root formation • The pulp is necrotic (non-vital) • Accomplished by thorough chemomechanical debridment of root canal and placement of Ca(OH)2 • Description of technique Treatment Evaluation • First recall, in 4-6 weeks; - Radiographic evaluation - Indications for tooth re-entry • Recall in 3-6 months thereafter • Hard tissue barrier is probed and/or observed under the microscope - If apex is still open, replace Ca(OH)2; ○ Recall in 3-6 months thereafter ○ Re-enter the tooth for clinical testing of calcific barrier formation - If calcific barrier has formed, proceed with obturation • After 1 year, evaluate bony resolution radiographically Prognosis • Generally, good success rate • Very immature teeth (thin dentin walls) are at high risk of root fracture • The incidence of root fracture depends on the stage of root development • Apical barrier formation occurs more rapidly when the apical opening (diameter) is less wide Assessment of Outcome • Successful Treatment • Failed Treatment Outcome Evaluation Criteria for Success • Absence of signs or symptoms of pulpal or periapical disease • Presence of calcific barrier across the apex as demonstrated by - Radiographs - Tactile probing with a file upon tooth re-entry Determinants of Failed Treatment • Primary cause: bacterial contamination • Source is generally loss of coronal seal or inadequate debridement

Root-End Closure: Indications

Root-End Closure: Indications • Restorable immature tooth with pulp necrosis Definition of Terms: APEXIFICATION • Root-End Closure - Also called Apexification - Defined as the process of creating an environment within the root canal and periapical tissues after pulpal death that allows a calcific barrier to form across the open apex Root-End Closure: Contraindications • All vertical and most horizontal root fractures • Replacement resorption (ankylosois) • Very short roots • Marginal periodontal breakdown • Vital pulps Treatment Techniques • Vital Pulp Therapy • Root-End Closure w/ Ca(OH)2 • Root-End Closure w/ MTA • Root-End Closure w/ BC Putty • Coronal Restoration Apexification • Induction of a calcific barrier across an open apex, or • Creation of an artificial barrier across an open apex

Root-End Filling Material

Root-End Filling Material - Micro-ultrasonic tips allow us to remove even more than 3mm of affected gutta percha • Amalgam • Super-EBA • MTA • Bio-Ceramic Long-Term Evaluation of Surgically Placed Amalgam Fillings - 57% successfull - 43% failures Amalgam (no longer used) Pros - Material of choice for decades - Easy to manipulate - Easily available - Acceptable seal initially - Radioopaque Cons - Systemic distribution of mercury* - Corrosion and percolation with time Slow setting time - Leakage - Tattoo formation - Microfracture ? MTA - MTA is the arguably one of the best material available on the market as retrofilling material on the basis of histologicalanimal experimental results. However, clinical manipulation of the material is problematic. Pros - Least toxic material - Available - Excellent histological result - Reasonable radioopacity - Long setting time - Hydrophilic material Cons - Difficult to manipulate - Long setting time - Cost BioCeramic: can be used in direct pulp capping - Sealer - Paste - Putty

Shallow Pulpotomy vs Deep Pulpotomy OUtcome

Shallow Pulpotomy: Outcome Evaluation Criteria for Success • Tooth is asymptomatic and functions properly • No radiographic evidence of apical periodontitis • No indication of root resorption • The tooth responds to pulp testing (shallow pulpotomy) Treatment Evaluation • Clinical testing for - Pulp responsiveness • Radiographic evaluation for - Continued root development and - Continued dentin formation, if the tooth was immature at the time of treatment Deep Pulpotomy: Outcome Evaluation Criteria for Success • Tooth is asymptomatic and functions properly • No radiographic evidence of apical periodontitis • No indication of root resorption • The tooth does not respond to pulp testing (unlike shallow pulpotomy) Possible Outcomes • Treatment success - continued apical growth of the root with a normal or nearly normal apex • Treatment failure - cessation of root growth and apical disease. This requires procedures for root-end closure: Apexification or Regenerative Endodontic Procedures (REPs) - Unresponsive pulp testing following deep pulpotomy DOES NOT indicate failure of the procedure!

Shallow Pulpotomy: Technique

Shallow Pulpotomy: Technique • Local anesthesia • Dental dam isolation • Exposed dentin is washed with normal saline or NaOCl, currently at UCLA 4% is used • Exposed pulp tissue is removed with a spoon excavator from the pulp wound site • Extruding granulation tissue that forms within 24 hours and may proliferate and protrude with time, is also removed • Pulpotomy is accomplished with a water cooled #4 round metal or diamond burr in a high speed handpiece • The tissue is removed to a depth of 2 mm below the exposure (shallow or partial pulpotomy) • The wound is gently washed with normal saline, and hemostasis is attained • Hemostasis is attained by placement of a cotton pellet moistened with 4.0%NaOCl (UCLA protocol) with a contact time of 1-10 minutes • If hemostasis is not attained after 10 min, proceed with complete pulpotomy • The wound is washed again to remove the clot (important!), and dressed with a liner • The wound should be washed to remove excess NaOCl, and dentin gently dried before placement of appropriate material. • Material should cover the entire pulp wound and proximal dentin • A minimum thickness should be 1.5-2.0 mm with Direct Pulp Cap (DPC) and thicker for partial and complete pulpotomy • Materials used: - Ca(OH)2 paste, - Hard-setting calcium hydroxide - MTA - BC Putty - Other calcium silicate compounds (CSC) • The reminder of the cavity is carefully sealed with a hard-setting cement, such as IRM, or glass ionomer • When the cement has set, the tooth may be restored with acid-etched composite • This will prevent microleakage at the site and restore the tooth to its proper form

Silver Point Removal

Silver Point Removal - Antiquated Obturation Method - Round point in an oval canal - Silver points are very parallel, hard and brittle

Sodium Hypochlorite Accident

Sodium Hypochlorite Accident - Why it matters • Causes intense pain, swelling, bruising, and tissue necrosis • Many months to recovery • Possible damage to nerves or maxillary sinuses - How it happens • Extrusion of NaOCL out of the tooth - Avoiding: • Side vented needle • Avoid locking needle tip into canal • Keep tip moving • Gentle, slow, minimal pressure • Apical negative pressure irrigation devices (ex: EndoVac) - Management: • Ice pack, NSAIDs, referral to OMS, possible antibiotics

Soft Paste Removable

Soft Paste Removable - Sometimes used in South America - Pastes are often ZOE based, but can contain toxins, steroids (anti-inflammatory, can relieve pain but not treat infection), etc. - Some yellow-brown pastes contain iodine disinfectant

Strip Perforation

Strip Perforation - Why it matters • Difficult to seal (hole on side of root), weakens tooth - How it happens: • Over shaping a canal; drilling out the side of the root - Avoiding: • Know where Danger Zones are ➡ Furcal side of mandibular molar mesial root ➡ Furcal side of maxillary molar MB roots • Shaping must be appropriate to the root-form • Use Anti-curvature filing technique • Following the 3 rules for using Gates Glidden Drills • Don't use large Gates Glidden drills in narrow canals - Management: • Don't try - place calcium hydroxide, temporize and refer

TECHNICAL FACTORS

TECHNICAL FACTORS - Don't change prognosis - Do change the difficulty - Need for referral ? CALCIFICATION TIPS • Careful measurement ref point to roof of pulp chamber • Careful measurement ref point to floor of pulp chamber • Rectangular chamber becomes a flat disc • Don't drill too deep or you will remove the dentinal map •Root calcification is concentric so an open canal lumen remains • Calcification is more pronounced coronally • Canals remain open apically • Precurved small SS files • Pulp stones increase but rarely block the chamber completely • Pulp stones are usually free-floating • Ultrasonics are helpful in shaking pulp stones out • Ultrasonics are helpful searching for canals • Magnification & illumination are very helpful ACCESS TIPS • Careful depth measurements • Probing below the gingiva for root orientation / for root concavities (to see inclination of tooth) • Draw on the tooth crown • Indirect vision from the side • Lost: stop and make a BW • Deep: stop and make a BW

& WHAT ABOUT THE DENTIST

THE DENTIST - Knowledge, beliefs, attitudes, and decisionmaking are cognitions, embedded in the mental process by which we know the world. - Our behaviors are shaped by these cognitions; whereas, dissonance results from their conflict DISSONANCE - Dissonance is inconsistency or conflict among one's beliefs or between one's beliefs and one's behaviors. • Rubber Dam • Antibiotic Use (only benefit for acute abscess) • Restoration • Recall ENDODONTISTS BEHAVE DIFFERENTLY - Substantial behavioral differences were discerned between GDPs & Endodontists: • Tooth conservation • Case assessment • Treatment planning • RCT provision • RCT technique • Technology • Retreatment • Regenerative endodontics • Antibiotic use SUMMARY - TALKING POINTS • Knowledge • Belief • Attitude • Decision Making • Behavior • Dissonance • Endodontists are different • We all carry some baggage • Evidence-Based Practice is not so simple & easy

THE ENDODONTICALLY TREATED TOOTH HAS BEEN WEAKENED

THE ENDODONTICALLY TREATED TOOTH HAS BEEN WEAKENED • Loss of tooth structure • Decay • Prior restoration • Mechanical instrumentation • Fracture susceptible LOSS OF TOOTH STRUCTURE, NOT CHANGE IN DENTIN QUALITY IS THE TOOTH RESTORABLE? - HOW WILL IT CONTRIBUTE TO THE PATIENT'S REHABILITATION ? • FPD abutment • Single tooth restoration • RPD abutment • Overdenture abutment • Contingencies ? CONSERVATION OF TOOTH STRUCTURE • QUANTITY OF DENTIN • HEIGHT OF STUMP (FERULE) • LONG TERM PROGNOSIS

TOOTH SURVIVAL

TOOTH SURVIVAL - Little in life is certain, but patients may reasonably expect a high probability of long term retention of their treated teeth. - Most have >90-95% survival rates SUMMARY - TALKING POINTS • Excellent long-term survival rates • RCT supported by rigorous systematic review • RCT studies are distinguished by very large sample sizes • High prevalence of teeth with RCT • High prevalence of teeth with PARL (treated & not) • RCT teeth are preferentially retained by elders • Existing RCT "Success" definitions are problematic - avoid • Billions of teeth retained by root canal treatment

TREATMENT OUTCOMES

TREATMENT OUTCOMES STUDY MOTIVATION ENDO STUDY DESIGNS IMPLANT STUDY DESIGNS ENDO SUCCESS CRITERIA IMPLANT SUCCESS CRITERIA ENDO OUTCOMES RESTORATION FOLLOWING RCT IMPLANT OUTCOMES COCHRANE REVIEWS SINUS AUGMENTATION COMPLICATIONS EXPERTISE, EXPERIENCE, QUALITY PATIENT BASED MEASURES ESTHETICS LIFE CURVES

The Dependence of the Result of Pulp Therapy on Certain Factors - Strindberg 1956 - Assessment of Outcome

The Dependence of the Result of Pulp Therapy on Certain Factors - Strindberg 1956 - Assessment of Outcome • Study design: Prospective cohort study • Single operator • Sample: N=344 patients; 529 teeth; 779 roots • Recall rate: N=254 patients, = 75% retention • Observation period: 6 years • Follow up exam frequency: Every 6 months for the first two years, yearly thereafter • Established and defined the criteria for the evaluation of endodontic outcome • Arrived at the outcome rates for orthograde endodontic treatment • Related the outcome rates to the preoperative periapical diagnosis • Defined duration and frequency of the follow up - Follow up for minimum 4 years post operatively Every 6 months for the first two years, yearly thereafter

Old Exam Questions

The prevalence of root canal treatment in the elderly is: a) ~23% of elderly people b) ~23 of all teeth - Throughout adult life: a) The prevalence of RCT rises b) The prevalence of tooth loss rises c) The prevalence of periradicular disease rises d) The prevalence of untreated periradicular pathology rises e) All of the above - The prevalence of RCT in the elderly: a) RCT has a lower prognosis in older people b) Older people do not like rubber dams c) Older people don't mind losing teeth d) Most extractions are due to endo failure e) All of the above are false

Thermafill Removal

Thermafill Removal • Carrier-Based-Obturation • Quick obturation method • GP on a stick • Plastic (or metal) carrier (metal easier to remove than plastic because plastic metals and breaks) • Plastic: ductile, but groove • Often used without adequate shaping, the GP gets wiped off, and the carrier gets wedged in - Look for thin skinny fill -> GP was "squeezed" off of carrier as it was inserted into the narrow canal space

Tooth crack can be successfully treated Endodontically

Tooth crack can be successfully treated Endodontically - Apical Periodontitis from 1° pulpal infection responds well to conventional non-surgical therapy. Ex: Crack on distal of #18 and #19 - PARL completely healed in #18 and #19 - In many cases, cracked tooth can be treated successfully where VRF CANNOT!!

Vertical Root Fracture

Vertical Root Fracture - Why it matters • Sudden catastrophic tooth failure with through & through cracks • Vital teeth, partial cracks - chronic, often vague, discomfort • Non-vital teeth, partial cracks - let bacteria in and out causing failure • Big cracks generally can't be disinfected or sealed - usually treatable - How it happens • Teeth become structurally weakened and break - Avoiding: • Always conserve tooth structure • Conservative access preps • Avoid gouging • Use root form appropriate RCT preparation shapes • Coronal coverage for posterior RCT teeth • Avoid posts whenever possible, almost all molars • If unavoidable, then passive parallel serrated venter narrow posts • Very conservative, minimal post preparations - Management: • Extraction

Vertical Root Fracture (VRF): is DIFFERENT from TOOTH CRACK

Vertical Root Fracture (VRF): is DIFFERENT from TOOTH CRACK - Tooth crack occurs primarily in the MD orientation unlike the VRF which occurs in BL direction!!! - Ex: in Md 2nd molars, if a crack/ fracture is seen in the distal, this is a tooth crack, NOT VRF!! - Cracked tooth with probing depths lower than 6mm have a 96% survival rate after 2 years -> with greater than 6 mm, less than 74% survival rate after 2 years

Vital Pulp Therapy: Contraindications

Vital Pulp Therapy: Contraindications • Avulsed, replanted or severely luxated tooth (blood supply gone) • Severe crown-root fracture that requires intraradicular retention for restoration • Tooth with unfavorable horizontal root fracture (i.e., close to the gingival margin) • Necrotic pulp

Vital Pulp Therapy: Indications

Vital Pulp Therapy: Indications • Immature tooth with incomplete root formation and with damage to the coronal pulp (radicular pulp is presumed to be healthy) • The crown must be fairly intact and restorable Definition of Terms: APEXOGENESIS •Vital Pulp Therapy - Also called Apexogenesis - Defined as treatment of vital pulp in an immature tooth to permit continued dentin formation and apical closure - The goal is maintenance of vitality to allow continued development of the entire root, not just the apex Treatment Techniques: Vital Pulp Therapy • Vital Pulp Therapy • Root-End Closure • Root-End Closure with MTA • Coronal Restoration • Pulp capping • Shallow pulpotomy (pulp horn removable) • Deep pulpotomy with Ca(OH)2 • Deep pulpotomy with MTA (preferred) • Deep pulpotomy with BC (bioceramic) Putty (preferred)

Vital Pulp Therapy: Prognosis

Vital Pulp Therapy: Prognosis Favorable • For pulp capping or shallow pulpotomy (Cvek technique) when done correctly. A completely formed root is then produced that can support an appropriate restoration • Conventional pulpotomy is slightly less successful, because of tissue damage when the coronal pulp is severed Vital Pulp Therapy (Apexogenesis): Assessment of Outcome • Successful Treatment • Failed Treatment Vital Pulp Therapy: Outcome Evaluation Recall Schedule • 3-6 month intervals - Monitor pulp vitality (by pulp testing), and - Monitor apical maturation and root growth (radiographically) • Shallow pulpotomy allows pulp testing; conventional deep pulpotomy does not Possible Outcomes • Treatment success - continued apical growth of the root with a normal or nearly normal apex • Treatment failure - cessation of growth and apical disease. This requires procedures for root-end closure: Apexification or Regenerative Endodontic Procedures (REPs) Vital Pulp Therapy: Complications • Microbial contamination through a leaking provisional (temporary) or permanent restoration may cause pulpal necrosis & periapical pathosis • If contamination occurs before complete root formation, root-end closure is necessary • If contamination occurs after root formation, root canal treatment is required

WHAT ARE THE CONSEQUENCES OF FAILURE?

WHAT ARE THE CONSEQUENCES OF FAILURE? • FALLBACK POSITIONS ? • PATIENT PREFERENCE ? BIG PICTURE • Quality of adjacent abutments • Inter - arch space • Occlusal plane • Opposing dentition • Caries risk • Periodontal risk CAMBRA = CAries Management By Risk Assessment PERIODONTAL RISK ASSESSMENT Good • Probing Pocket Depth: ≤3 mm • Bleeding on Probing: - ve • Probing Attachment Loss ≤25% • Furcation Involvement: ≤I Questionable • Probing Pocket Depth: ≥6 mm • Bleeding on Probing: + ve • ProbingAttachment Loss: ~ 50% loss • Furcation Involvement: II or III • Root Proximity Hopeless - Insufficient aresidual aattachment THE BOTTOM LINE SAVE OR EXTRACT? - LACK OF TOOTH STRUCTURE - Need >1.5 mm Ferrule - "Even when crown extension therapy is required, RCT and crown is substantially less expensive than a single tooth implant, is placed more rapidly and entails fewer office visits. The Key factor for dictating treatment should be prognosis for the remaining root"

What is failed RCT?

What is failed RCT? Failure is... - the presence of symptoms (pain, swelling or sinustract) - an increase of radiolucency (time factors should be considered) Why do root canals fail? - Bacteria (esp. E. faecalis) Causes of endodontic failure • Inadequate cleaning and shaping - missed canals, endodontic complications (perforations, ledges, instrument fractures) • Non-endodontic causes (caries, periodontitis, tooth fracture, restorative failure) Indications For Retreatment - IN CASE OF FAILURE WE HAVE TO EVALUATE THE POSSIBILITY OF A RETREATMENT KEEPING IN MIND THAT PERIRADICULAR SURGERY HAS TO BE THE LAST CHOICE TO SAVE THE TOOTH - These are cases where retreatment is indicated, NOT microsurgery, b/c the RCT did not go to length the first time and root morphology is simple Retreatment vs. Apicoectomy??? • can the fill of the root canal be improved upon? • is it likely that a canal was missed? • is the restoration leaking? • is disassembly a reasonably safe task? • will retreatment work? • Is surgery possible? - Endodontic surgery is not a substitute for poor endodontics BUT.......in certain clinical situations it is the only alternativeto extraction.

TOOTH SENSITIVITY

~ 20 % TOOTH SENSITIVITY AFTER RESTORATION (reversible pulpitis) • DECREASES STEADILY - REASSURE • MOST GONE WITHIN 3 MONTHS • ALMOST ALL GONE BY 6 MONTHS SENSITIVITY PREVENTION • MODERATE TOOTH REDUCTION • WATER SPRAY • ANTIMICROBIALS: Consepsis • DESENSITIZERS: Gluma, Hurriseal (at UCLA) • BONDINGAGENTS • RMGI CEMENTS: Duet, Protec, Rely ROOT DESENSITIZATION • Any DBA - dentin bonding agent(eg GLUMA /Hurriseal) -> DBAs Decrease Dentin Permeability • Or a desensitizer • Use as directed • Cure well CROWN PREP DESENSITIZATION • Thin solvent based A& B type DBA • eg Tenure or All Bond • Only use conditioner and A& B parts • Or use a desensitizer (eg GLUMA /Hurriseal) • Use a resinous cement • At time of prepping, or • At final cementation