Everand Logo

Welcome to Everand!

  • Discover millions of ebooks, audiobooks, and so much more with a free trial

    Only $11.99/month after trial. Cancel anytime.

    NBDE Part II Lecture Notes
    NBDE Part II Lecture Notes
    NBDE Part II Lecture Notes
    Ebook1,068 pages11 hours

    NBDE Part II Lecture Notes

    By Kaplan Medical

    4.5/5

    ()

    Read preview

    About this ebook

    Kaplan Medical's NBDE Part II Lecture Notes provide comprehensive board prep for third-year and fourth-year dental students. Updated for the current NBDE Part II exam, Kaplan's full-color lecture notes feature board-style practice and in-depth review of all major exam disciplines – a comprehensive approach that will deepen your understanding while focusing your efforts where they'll count the most.

    Comprehensive Review
    • In-depth coverage of every major discipline on the exam, including endodontics, operative dentistry, oral diagnosis, pedodontics, periodontics, pharmacology, prosthodontics, and more
    • Full-color diagrams and charts for better comprehension and retention
    • Board-style practice questions and explanations in each chapter
    • Ten sample case studies to help develop your critical thinking skills
    • Organized in bulleted, outline format for efficient reading and review
    • Learning objectives and key concepts help you focus your study on the essential content
    Expert Guidance
    • Test-taking strategies and an overview of the exam from Kaplan's experts
    • We invented test prep—Kaplan (www.kaptest.com) has been helping students for almost 80 years. Our proven strategies have helped legions of students achieve their dreams.
    LanguageEnglish
    PublisherKaplan Test Prep
    Release dateJun 6, 2017
    ISBN9781506212821
    NBDE Part II Lecture Notes

    Read more from Kaplan Medical

    Related to NBDE Part II Lecture Notes

    Titles in the series (51)

    View More
    View More

    Related ebooks

    Study Aids & Test Prep For You

    View More
    View More

    Related podcast episodes

    Related articles

    • Article

      Nashville S Top Dentists 2019

      Sep 1, 2019

      This list is excerpted from the 2019 topDentists™ list, a database that includes listings for more than 170 dentists and specialists in the Nashville and Middle Tennessee areas. The Nashville-area list is based on thousands of detailed evaluations of

      35 min read

    • Article

      A Clear View

      Feb 1, 2020

      A Clear View
      2 min read

    • Article

      Opinion: Make The Step 1 Test For Medical Students Pass/fail

      Mar 8, 2019

      Step 1 "cutoff scores" are being used to help medical residency programs choose candidates. That's a misuse of the test, which is a poor predictor of future clinical performance and…

      5 min read

    • Article

      America’s Best EYE DOCTORS 2O21

      Jul 23, 2021

      America’s Best EYE DOCTORS 2O21
      3 min read

    • Article

      How To Make The right Choice

      May 14, 2022

      How To Make The right Choice
      11 min read

    • Article

      Opinion: Making Step 1 Pass/fail Is ‘Root Rot’ That Will Undermine The Medical Profession

      Jun 28, 2019

      Well-intended efforts to reduce pressure on medical students and increase physician diversity by eliminating grades and standardized test scores are likely to have the opposite effect.

      3 min read

    • Article

      America’s Best Eye Doctors 2022

      Jul 22, 2022

      America’s Best Eye Doctors 2022
      3 min read

    • Article

      Opinion: Ideas For Easing Medical Students’ Match Day ‘Frenzy’

      Mar 15, 2019

      The Match, the brilliant algorithm that pairs medical students with residency programs on #MatchDay, is being jeopardized by the growing number of programs students apply to.

      5 min read

    • Article

      3 Main Reasons Why the Government Denies Social Security Disability Benefits

      Jul 16, 2022

      Social Security Disability Insurance (SSDI) is one of the least understood insurance policies available to U.S. workers. Many workers don’t realize they have the income protection SSDI provides or that they contributed to the coverage with every payc

      3 min read

    • Article

      Opinion: Testing Medical Students Is Big Business. I See It As Extortion

      Mar 20, 2020

      As medical students plod along in the physician-trainee pipeline, it's easy for us to feel helpless in the face of community-sanctioned extortion by the National Board of Medical Examiners.

      3 min read

    • Article

      Opinion: Teach Medical Students To Use Diagnostic Tools With Their Patients

      Sep 19, 2018

      Medical students deserve to get consistent training in skills that define high quality, evidence-based, modern medical practice.

      3 min read

    • Article

      Opinion: Digital Health Startups May Not Want To Do Randomized Trials, But They Need To

      Oct 15, 2018

      Digital health is a fast-moving field that's impeded by the slow timelines of clinical research organizations and top medical journals. They need to pick up the pace.

      4 min read

    • Article

      Opinion: Medicaid’s Unnecessary Barriers Delay Care For Children With Complex Needs

      May 1, 2018

      Reforming the process for enrolling physicians in Medicaid programs will make it easier for children to get the care they need.

      4 min read

    • Article

      Opinion: Diagnostic Innovations Are Slowed By Bureaucratic Roadblocks

      Jan 18, 2019

      It's a long and winding road to bringing diagnostic innovations to the U.S. market. We need to clear the roadblocks.

      5 min read

    • Article

      Retirees, Create a Plan to Pay for Dental Care

      Jan 23, 2018

      When she needed dental work recently, Terry O'Brien, age 76, didn't worry too much about the cost, at least initially. After all, she was paying $36 a month for an individual dental insurance plan, with up to $1,000 in coverage. But her problems far

      5 min read

    • Article

      Disrupting the Healthcare System

      Jan 1, 2020

      What are the biggest wicked problems in healthcare right now? There are several, and from my perspective they are driven by two factors. The first is that there are so many stakeholders involved, which often means that there is no one ‘right’ solutio

      7 min read

    • Article

      Motorhoming after 70

      Sep 16, 2021

      ...previously a civil engineer, then Technical Officer at the Camping and Caravanning Club, Barry now enjoys the motorhoming lifestyle to the fullest Reaching 70 years of age doesn’t mean you suddenly change your approach to living. However, if you’r

      6 min read

    • Article

      Opinion: Medicare’s New Primary Care Payment Rule Is Good News For Patients

      Nov 22, 2019

      Cracks are appearing in the doctor-patient relationship — the result of decades in which Medicare and other payers have devalued primary care.

      2 min read

    • Article

      Opinion: FDA Is Smashing The Status Quo For Regulatory Science

      Oct 14, 2019

      The FDA can enable innovation by being a partner in advancing new approaches to drug development and regulatory science. Its recent reorganization signals a revolutionary shift in regulatory velocity.

      5 min read

    Related categories

    Reviews for NBDE Part II Lecture Notes

    4.5/5

    7 ratings1 review

    What did you think?

    Tap to rate

    Review must be at least 10 words

    • 5/5
      ****Thank **you ***too*** much*** for great ***useful ***book(Caroline kHALAF)

      1 person found this helpful

    Book preview

    NBDE Part II Lecture Notes - Kaplan Medical

    Section I

    Clinical Dentistry

    1

    Endodontics

    Learning Objectives

    Define and recall appropriate strategies for the clinical diagnosis, case selection, treatment planning, and management of patients requiring endodontic therapy

    Explain basic endodontic treatment procedures

    Identify and explain appropriate treatment modalities for procedural complications of endodontic therapy and traumatic tooth injury

    Describe appropriate adjunctive therapy and post-treatment evaluation for endodontic patients

    Endodontics involves knowledge of tooth morphology, instrumentation, materials, anesthesia, trauma, complications, and pain control. Look for questions in both standard and case-study formats.

    Diagnosis, Treatment Planning, and Patient Management

    The dental pulp is a loose connective tissue organ composed of collagen, ground substance, cells, blood vessels, and nerves. The cells of the pulp include fibroblasts, odontoblasts, undifferentiated mesenchymal cells that may become phagocytic or fibrocytic, and large monocytic cells that can be phagocytic. The vascular supply of the pulp is an end type of circulation. The arteries and capillaries of the pulp are so small as to allow passage of cells only 1 at a time. There is no organized lymphatic system in the pulp, although there are spaces for lymphatic drainage. Nerves enter through the apical foramen and sometimes send branches into the dentin. There are sympathetic nerves that regulate expansion and contraction of blood vessels. Sensory nerves in the pulp cannot distinguish cold, heat, touch, etc. All sensation to these nerves is interpreted as pain.

    When the dental pulp is traumatized, whether from a physical, chemical, or bacterial cause, the pulp responds the same way as any other area of the body—by inflammation. Unfortunately, the pulp is surrounded by hard walls of dentin, and there is no room for pulp expansion. The expansion causes strangulation of the vascular supply. When the vascular supply is gone, the pulp has no mechanism for repair. Pulpal death occurs because of a lack of blood supply; it leads to cellular breakdown. Noxious agents are thus released, and they seep through the apical foramen and irritate or destroy the apical periodontal ligament and surrounding bone.

    When a tooth is necrotic, it is the goal of endodontics to remove the pulp tissue, necrotic debris, bacteria (if present), and all substances that may serve to irritate the periapical tissue. After this is accomplished, the attainment of an apical seal with a filling agent will prevent reinfection of the tooth from the periapical area and will also prevent periapical exudate from draining into an unfilled portion and forming a new area of infection.

    Key Concept

    The pulp is an expandable tissue that is enclosed within a nonexpandable space.

    It should seem obvious at this point that if there were no inflammation, there would be less pulpal death. Indeed, Board questions may test your knowledge of the inflammatory process. The classic signs of inflammation are pain, redness, swelling, and disturbance of function. With pulpal disease, only the first and last of these may be detected clinically. The sequence of events in inflammation may be described as follows:

    Initial vasoconstriction followed by vasodilation

    Increased capillary permeability causes a fluid exudate

    Decreased rate of blood flow

    A move to the periphery (margination) of red and white blood cells, which usually travel in the center of the vessel 

    The emigration of WBCs through the vessel wall (diapedesis)

    Medical History

    Medical history is important in endodontics because endodontic therapy may be modified by a systemic illness. However, no systemic illness completely contraindicates endodontic therapy. Normal AHA premedication rules apply. With diabetes, one should expect a reduced healing rate.

    It is important to distinguish oral facial pain caused by an endodontic (odontogenic) etiology from pain caused by a systemic or nonodontogenic origin. Many orofacial disease manifestations can mimic tooth pain. Nonodontogenic pain may have the following characteristics:

    Episodic

    Associated with trigger points

    Travels across the facial midline

    Appears with mental stress

    Seasonal or cyclic

    Associated paresthesia

    Odontogenic tooth pain generally does not exhibit these symptoms.

    Dental History

    Taking a good dental history is imperative in making an accurate endodontic diagnosis. Factors that should be addressed include:

    Chief complaint (in patient’s own words)

    Location, quality, and duration of pain

    Intensity and duration of symptoms

    Affecting factors—pain stimuli or relief

    History of pain (how long and changes in quality)

    Intraoral and Extraoral Examination

    The first clinical aid in diagnosis is visual inspection. An extraoral assessment should occur first. The practitioner should look for facial asymmetry/swelling, visible facial lesions (i.e., sinus tracts), and other abnormalities. The presence of a visible sinus tract may aid in diagnosis; therefore, all such tracts should be traced with with a gutta-percha point and radiographed to help isolate the offending tooth.

    Intraoral examination should include a thorough examination of the area of chief complaint for the patient and the surrounding tissues and teeth. The presence of caries, swelling, intraoral sinus tracts, periodontal disease, occlusal discrepancies, tooth color changes, etc., may all be indicators of endodontic disease and should be investigated. Intraoral sinus tracts should also be traced with gutta-percha and radiographed to help isolate the offending tooth.

    The correct diagnosis cannot be obtained without a thorough history and examination. The dentist should be able to gain information about the duration and extent of pain, how long the pain lasts after the stimulus is removed, etc. With this information, simple clinical tests will aid in arriving at a diagnosis. Diagnosis without a history is very difficult and often results in erroneous conclusions.

    Key Concept

    The only clinical contraindications to an attempt at endodontic therapy are when the tooth lacks enough periodontal support, cannot be restored to function, or the comprehensive treatment plan excludes the tooth for other reasons.

    In making treatment planning decisions, the clinician must also consider local and systemic case-specific issues, economics, the patient’s desires and needs, aesthetics, potential adverse outcomes, ethical factors, history of bisphosphonate use, and/or radiation therapy. Although the treatment planning process is complex, it is clear that appropriate treatment must be based on the patient’s best interest.

    Definitions for Pulpal and Periapical Diagnoses

    The American Association of Endodontists (AAE) has developed a standard glossary of definitions that are important to know for the exam and in practice.

    Key Concept

    Every tooth considered for endodontic therapy should have both a pulpal and periapical diagnosis.

    Normal apical tissues and pulp: state in which the pulp is symptom-free and normally responsive to pulp testing; the periradicular tissues are not sensitive to percussion or palpation testing, the lamina dura surrounding the root is intact, and the PDL space is uniform

    Reversible pulpitis (pulp): clinical diagnosis based on subjective and objective findings indicating the inflammation present should resolve and the pulp should return to normal

    Symptomatic irreversible pulpitis(pulp): clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing; additional descriptors: lingering thermal pain, spontaneous pain, referred pain

    Asymptomatic irreversible pulpitis (pulp): clinical diagnosis based on subjective and objective findings indicating the vital inflamed pulp is incapable of healing; additional descriptors include no clinical symptoms, but inflammation produced by caries, caries excavation, or trauma

    Symptomatic apical periodontitis (periapical): inflammation of the apical periodontium producing clinical symptoms including a painful response to biting and/or percussion or palpation; may or may not be associated with periapical radiolucency (PRL)

    Asymptomatic apical periodontitis (periapical): inflammation and destruction of apical periodontium that is of pulpal origin; appears as a PRL and does not produce clinical symptoms

    Acute apical abscess (periapical): inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and swelling of associated tissues

    Chronic apical abscess (periapical): inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and may include the intermittent discharge of pus through an associated sinus tract

    Pulpal necrosis (pulp): a clinical diagnostic category indicating death of the dental pulp; pulp is usually nonresponsive to pulp testing

    Condensing osteitis (periapical): diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus; usually seen at apex of the tooth

    Diagnostic Tests

    The following are examples of clinical tests.

    Percussing a tooth, or tapping on the tooth with a dental instrument, can be valuable. The tapping is transferred to the periodontal ligament (PDL); if the PDL is irritated, the tapping will elicit sensitivity. Teeth with the following periapical conditions may elicit a positive response to percussion:

    Symptomatic apical periodontitis

    Acute apical abscess

    Condensing osteitis

    Palpation, or placing light pressure on the soft tissues with a gloved finger, will help to diagnose swelling that may not yet be clinically evident—such as in the case of acute apical abscesses and symptomatic apical periodontitis.

    Mobility, or trying to wiggle the tooth to see how much it moves, is a valuable diagnostic tool. Teeth that are highly mobile because of severe periodontal disease are contraindicated for endodontic therapy. Mobility may also be caused by an abscess that when treated may resolve the mobility. Proper diagnosis is crucial to distinguish between appropriate treatment modalities.

    X-rays (radiographs) are an extremely valuable aid. For endodontic diagnosis, they aid in diagnosis of PDL damage, deep caries, calcified pulp, resorbed pulp, and the nature and extent of bone destruction. This bone destruction may take several forms, and only a microscopic exam will truly differentiate them.

    The buccal object rule (same lingual, opposite buccal, or SLOB) is important to remember. The principle is that an object closest to the buccal surface appears to move in the direction opposite the cone head when compared to a subsequent radiograph. Objects closest to the lingual appear to move in the same direction as the cone head. This allows the practitioner to isolate canals, foreign bodies, anatomical landmarks, periapical lesions, etc., within the 2-dimensional radiograph.

    Key Concept

    Never diagnose endodontic problems primarily by X-ray. History and visual examination are most crucial.

    The electric pulp tester (EPT, or vitalometer) is one of the most debated diagnostic methods. The clinician dries off the tooth to be tested. Normally the tooth in question, the tooth adjacent to it, and the contralateral tooth are tested. (Note that teeth with crowns cannot be tested, and teeth with large restorations often react unreliably.) On an enamel surface, one places some paste and the tip of the tester, which can deliver various currents. The teeth will respond or not respond to the various currents. This indicates whether there is pulp vitality. To some extent, the degree of response can be correlated to a specific pulpal state of health. The diagnosis is not always precise, but in general, it is described in the following table.

    In a thermal test, the sensory fibers of the pulp transmit pain whether the pulp has been cooled or heated. The ice test is simply placing ice or cold spray on a cotton roll on the tooth enamel; the heat test is placing a hot instrument on the enamel. Ethyl chloride is often used as a cold source. Ideal thermal testing involves isolation of individual teeth before testing. Cold testing is used more frequently in practice than heat.

    Key Concept

    Positive response to cold is more likely in vital pulps that are less damaged, whereas positive response to heat indicates greater level of pulpal damage.

    A bite test may be conducted in cases of suspected tooth fracture. The tooth is subjected to differential occlusal forces on individual cusps using a rubber, plastic, or wood object in an attempt to replicate the reported discomfort and isolate the pain.

    A cavity test is used when there is still some question about the vitality of the tooth. Without anesthesia, a bur is drilled to, or just beyond, the dentinoenamel junction. In vital teeth, this will usually elicit a painful response. Necroticead pulps will elicit no reaction. This is rarely performed, as it is quite painful for the patient.

    In selective anesthesia, when it is difficult to diagnose which tooth is causing pain through prior testing techniques, the dentist may try and anesthetize single teeth with local anesthetic to identify the culprit. This technique should be used as an adjunct, as it is very difficult to localize anesthesia to a single tooth.

    When finding a diagnosis to be difficult, it is important to consider the phenomenon of referred pain as a possibility. Tooth pain can be referred from 1 tooth or teeth to:

    Adjacent teeth

    Down the neck

    Around the ear

    Into the temple

    Zygomatic, parietal, and occipital areas

    Ipsilateral quadrant or opposing jaw

    Periodontal considerations can include  perio/endo lesions. Communication can occur between the pulp and periodontium by means of the dentinal tubules, lateral or accessory canals, furcation canals, and apical foramen. Endodontic disease can cause periodontal disease, but the opposite is generally not true unless the periodontal disease is so severe that it extends to the root apex.

    Periodontal treatment can affect pulpal health if bacterial penetration from treatment (such as scaling and root planing) occurs. Bacterial penetration into or exposure of the dentinal tubules can cause thermal sensitivity and pulpitis.

    Perio/endo combination lesions are diagnosed by clinical presentation and often appear as long, narrow periodontal pockets that follow the PDL space. Lesions that are primarily endodontic in nature can be treated with nonsurgical endodontic therapy. Primary periodontal lesions with subsequent endodontic involvement are treated with endodontic therapy first, followed by periodontal treatment.

    When periodontal and endodontic lesions coalesce, they may be clinically indistinguishable and require endo and perio treatment. An unfavorable prognosis may be made if the periodontal disease is advanced, there are generalized periodontal probing defects throughout the patient’s mouth, and/or the tooth exhibits pulp necrosis with generalized bone loss (horizontal, vertical, or both).

    After Pulpal and Periapical Diagnosis

    Nonsurgical endodontic therapy is appropriate for restorable, periodontally stable teeth diagnosed with the following conditions:

    Irreversible pulpitis (symptomatic or asymptomatic)

    Pulpal necrosis

    Periapical periodontitis (acute or chronic)

    Periapical abscess (acute or chronic)

    It is always important to consider the overall comprehensive treatment plan and the patient’s wishes when determining whether or not endodontic therapy should be performed.

    Oftentimes, endodontic procedures are performed in the acute phase of the comprehensive treatment plan because the patient is experiencing pain and/or swelling. During the definitive phase, however, asymptomatic disease as well as the following situations may suggest endodontic therapy is indicated even in the absence of symptoms or active disease:

    Teeth with very deep or large restorations or that have a direct or indirect pulp cap that requires a crown as a definitive restoration or will serve as an abutment tooth for a fixed or partial denture

    A severely broken-down tooth that requires a post and core to restore missing tooth structure and retain the final restoration

    Teeth that will be devitalized in the process of overdenture construction or are in hyperocclusion and will likely have a pulp exposure during the process of evening out the occlusal plane

    Retreatment of previously endodontic teeth in which there are signs of failure (usually detected radiographically)

    After establishing the need for endodontic therapy, the dentist must establish the overall value of retaining the tooth. Not all severely broken-down teeth can be restored, and the dentist must be sure an acceptable restoration can be placed to give the best possible chance for long-term survival of the tooth and appropriate oral function.

    Restorative success depends greatly on the degree of remaining tooth structure, especially near the level of the alveolar bone crest. Even if a crown-lengthening procedure can be performed to increase clinical crown length, the tooth may have a guarded or questionable long-term prognosis due to diminished bone support, etc. An acceptable ferrule of 1–1.5 mm must be attainable, along with a crown-to-root ratio of at least 1:1.

    Patient Management

    Endodontic pain can be severe but varies greatly from case to case. The sensibility of the pulp is to A-delta and C-afferent nerve fibers. A-delta fiber pain is usually perceived as quick and sharp momentary pain, which goes away quickly upon removal of the painful stimulus. A-delta fibers are located in the cell layer and dentin, which are referred to as the pulpo-dentinal complex.

    Long, lingering pain sensations are caused by the C-fibers (dull and throbbing sensations). C-fiber pain is associated with inflammation and tissue damage. The more C-fiber pain that is exhibited, the more ominous the prognosis of the tooth.

    Patient symptoms can range from asymptomatic, to chewing and temperature sensitivity, to intense pain, and everything in between. Good pain control during endodontic therapy can be difficult at times. Every effort must be made to control patient pain before, during, and after treatment. Quality of pain is also very helpful in the diagnosis process.

    Informed Consent

    Patient input into the decision to undergo endodontic therapy is important, as it is with any other aspect of treatment planning, with 1 caveat. Dentists must remember that pain is a very strong motivator. If a patient presents to the dental office with extreme pain, they may not be thinking clearly about the long-term ramifications of undergoing endodontic treatment or not. The patient may opt for a dental extraction as a quick fix instead of permanent pain relief, or they may jump quickly into a root canal without consideration of the entire comprehensive treatment plan.

    Dentists must take extra time to obtain a thorough informed consent from such patients, perhaps performing an intermediary emergency intervention (such as pulpectomy and temporary restoration or just local anesthesia alone) for pain relief prior to obtaining consent for definitive treatment.

    Definitive endodontic therapy may also be contraindicated in patients who do not have a comprehensive treatment plan or current comprehensive exam. In such cases, performance of an intermediary procedure to get the patient out of pain is always appropriate until a comprehensive exam and treatment plan can be devised. (See the next section, Basic Endodontic Treatment Procedures.)

    Endodontic Referrals

    When the difficulty of the endodontic procedure that is indicated exceeds the skill level of the general dentist, referral to an endodontist is appropriate. The AAE has a free guide available on its website for assessing the difficulty of endodontic cases (www.aae.org). In general, difficulty levels of endodontic cases can be categorized as the following:

    Minimal: Preoperative condition indicates routine complexity (uncomplicated). Achieving a predictable treatment outcome should be attainable by a competent practitioner with limited experience.

    Moderate: Preoperative condition is complicated, exhibiting 1 or more patient or treatment factors listed in the Moderate Difficulty category. Achieving a predictable treatment outcome will be challenging for a competent, experienced practitioner.

    High: Preoperative condition is exceptionally complicated, exhibiting several factors listed in the Moderate Difficulty category or at least 1 in the High Difficulty category. Achieving a predictable treatment outcome will be challenging for even the most experienced practitioner with an extensive history of favorable outcomes.

    Endodontics and Bisphosphonate Use

    Bisphosphonates are commonly used to treat certain resorptive bone diseases, such as osteoporosis, Paget’s disease, and hypercalcemia, which are associated with certain malignancies including multiple myeloma and bone metastasis from the breast or prostate. Bisphosphonates inhibit bone resorption by inhibiting osteoclast activity.

    There is growing recognition that bisphosphonates may be associated with a rare adverse event called osteonecrosis of the jaws (ONJ). Signs and symptoms of ONJ may include some or all of the following:

    An irregular mucosal ulceration with exposed bone in the mandible or maxilla

    Pain or swelling in the affected jaw

    Infection, possibly with purulence

    Altered sensation (e.g., numbness or heavy sensation)

    The site of occurrence of the osteonecrosis is the jaws, and presentation occurs more frequently in the mandible than in the maxilla. The reasons for the presentation of osteonecrosis in the jaws versus other parts of the skeleton are unknown at this time.

    Consensus guidelines promote careful and complete oral care for all patients receiving bisphosphonates as the cornerstone of osteonecrosis prevention and treatment. The following are recommended when considering the endodontic implications of treating patients taking bisphosphonates:

    Know the risk factors of bisphosphonate-associated ONJ.

    Recognize that patients taking IV bisphosphonates are at higher risk for developing bisphosphonate-associated ONJ. 

    Because treatment of ONJ is not predictable at this time, preventive procedures for high-risk patients are important to reduce the risk of developing ONJ.

    Recognize that patients taking oral bisphosphonates are at low risk for developing bisphosphonate-associated ONJ.

    Preventive care might include caries control, conservative periodontal and restorative treatments, and, if necessary, appropriate endodontic treatment.

    Similar to the management of the patient with osteoradionecrosis, management of high-risk patients might include nonsurgical endodontic treatment of teeth that otherwise would be extracted. Teeth with extensive carious lesions might be treated by nonsurgical endodontic therapy, possibly followed by crown resection and restoration similar to preparing an overdenture abutment. Surgical procedures such as tooth extractions, endodontic surgical procedures, or placement of dental implants should be avoided in these patients if possible.

    Basic Endodontic Treatment Procedures

    Materials

    The following are the chemicals, solutions, or substances used in endodontic therapy and their functions.

    Sodium hypochlorite (NaOCl) is a good tissue solvent that has antimicrobial effect, used as an irrigant during canal cleaning and shaping. It is used at 5.25%, but is caustic to soft tissue. This is another reason for rubber dam usage.

    Hydrogen peroxide (3%) is used for canal irrigation, often in conjunction with NaOCl. It is used because of its antimicrobial and effervescent effect (it can bubble out debris).

    Hydrogen peroxide (30%) and sodium perborate are used as ingredients of walking bleach: nonvital tooth bleaching. This material is for endodontically treated teeth only and is sealed in the tooth for a period of a few days. Sodium perborate may also be combined with saline for this purpose.

    Key Concept

    Paraformaldehyde-containing pastes or obturating materials have been shown to be unsafe. Use of these products is now considered below the standard of care in endodontics.

    EDTA (ethylenediaminetetraacetic acid) is an odorless white crystalline solid that has various salts that are soluble in water. It is a good chelating agent. A chelating agent has the ability to combine with a metallic ion and thereby inactivate it. It is used to remove calcium and demineralize and soften dentin, and it also removes the smear layer.  Additionally, it has an antimicrobial effect.

    Chlorhexidine is used as an intracanal cleansing antibacterial agent. Care should be taken not to combine NaOCl and chlorhexidine within the same tooth, as an undesirable precipitate may form and interfere with canal sealing.  

    Root canal sealer (cement) is a radiopaque material used in combination with core materials (like gutta-percha) to fill voids and seal root canals during obturation; examples are bioceramics, resins, calcium hydroxide, zinc oxide-eugenol, glass ionomer, and others. 

    Metallic salts in sealer are substances that make the sealer radiopaque.

    Calcium hydroxide (CaOH) is commonly used between appointments. It is placed within the canal(s) as an antibacterial agent. It increases the pH within the canal and is also a component of some root canal sealers.

    Gutta-percha is the purified coagulated exudate from the Palaquium gutta tree, commonly called the mazer wood tree, found in and around Burma. Dental gutta-percha points are reported to contain approximately 19–22% gutta-percha, 1–4% plasticizing waxes and resins, 59–75% zinc oxide, 1–17% metal sulfates for radiopacity, and trace amounts of organic dyes for coloration. In the United States, gutta-percha is primarily made from the Mimusops globsa tree of South America. It is shaped into various size cones and used in conjunction with sealers for root canal obturation.  

    Mineral trioxide aggregate (MTA) is a cement-like material used as a root-end filling material, for perforation repair, for pulp capping procedures, or as a root-end barrier in teeth with open apices.

    Iodine potassium iodide is an intracanal medicament/irrigant composed of iodine, potassium iodide, and distilled water. It exhibits antimicrobial action with little toxicity or tissue irritation.

    Essential oils (eugenol and eucalyptol) are derived from plants used for the treatment of pain. In endodontics, they have been used as intracanal medicaments.  They are also found as components of some sealers and sedative restorations.    

    Lubricants such as glycerine are used during root canal instrumentation to decrease friction and enhance negotiation of the canal, especially with rotary instrumentation. Lubricants decrease the risk of file separation. 

    Zinc oxide is a fine and odorless powder used in combination with eugenol in various sealers and temporary cements, and it is also found in gutta-percha.  

    Instruments

    The following are common instruments used in the performance of endodontic procedures.

    Burs are used to perform the access-opening step of endodontic treatment along with some canal debridement. There are many sizes, shapes, and lengths of burs that can be used to perform this step. Dentists should select the right size and shape based on tooth anatomy and personal preference. Gates Glidden burs may be used to pre-enlarge canals prior to filing.

    Barbed broaches are thin and flexible metal hand instruments with sharp projections curving backward and obliquely. Broaches are primarily used to remove pulp tissue or other easily engaged materials from root canals. 

    Reamers are twist drills that should not be rotated more than one-half turn at a time. The reamer is turned after it just engages dentin. Reamers, used sequentially, will form a circular, continuously tapered funnel.

    Use of a rubber dam is imperative in the performance of endodontic procedures, both to protect the patient from caustic irrigants such as sodium hypochlorite and the accidental aspiration or swallowing of endodontic files and broaches. Rubber dams also keep the operating field as free from bacterial contamination as possible.  

    Endodontic files come in several types. There are hand instrument files and rotary files (designed for use in an endodontic handpiece). All files are tapered and pointed metal instruments with cutting edges used to enlarge and shape the root canal space by rotation or filing action. The common file types are as follows:

    D-type: made from a rhomboid blank that has alternating large and small flutes along its length  

    H-type (Hedstrom): a file with spiral edges arranged as a threaded screw; cutting occurs on pulling stroke only

    K-type: a file that is tightly spiraled; edges cut when pushed, pulled, or rotated

    NiTi (nickel-titanium): a hand or rotary file manufactured with super elastic nickel titanium alloy that is available in many designs

    Key Concept

    Know the common file colors:

    A spreader is a smooth and pointed metal instrument that is slightly tapered and designed to condense the root canal filling material into the prepared canal.

    Orifice shapers are a variety of hand or rotary instruments that widen the orifice of root canals to facilitate instrumentation (cleansing and shaping).

    A plugger is a smooth, flat-ended, and slightly tapered metal instrument designed to compact materials vertically within a prepared root canal.

    Nonsurgical Endodontics

    The goals of nonsurgical endodontics include alleviating pain and infection, cleaning and shaping the root canal, promoting healing and repair of apical tissues, and minimizing the possibility of future adverse events for a particular tooth.

    Asepsis and Isolation

    To make the area as aseptic as possible, a rubber dam is applied. All burs or instruments entering the root canal must be rendered sterile. In addition to prior autoclave sterilization, some instruments may be single use and disposable post-treatment.

    Key Concept

    Rubber dam isolation is generally required, except in highly unusual circumstances, and is considered the standard of care. The rubber dam will protect the field of operation from contamination from blood or saliva, protect the patient from tissue damage from chemicals, and prevent accidental aspiration or swallowing of instruments by the patient.

    Access Preparation

    The access preparation is the first step in the performance of nonsurgical endodontic procedures. It is the process of obtaining entrance to the tooth’s root canal system for the purpose of cleaning and shaping the canals for obturation.

    The objectives of access preparation include:

    Straight-line access to the canals to prevent ledging, stripping, or perforation

    Preservation of tooth structure (only removing what is necessary to maintain tooth strength)

    Unroofing of the pulp chamber to expose canal orifices 

    Access preparation is achieved using a high-speed handpiece and burs. Dentists must be cognitive of normal tooth anatomy when performing an access preparation in order to conserve tooth structure, minimize the risk of tooth perforation, and find all appropriate canal orifices.

    All access cavities are made through the lingual on anterior teeth and through the occlusal on posterior teeth. To achieve the principles of endodontic entry without unnecessary tooth destruction, one must know where the canal orifices and apices are. A short synopsis of root canal shapes is as follows:

    Maxillary central incisor: access is triangular on the lingual; canal is large, generally conical, and confluent with pulp chamber

    Maxillary lateral incisor: access is triangular on the lingual; canal is smaller than in central and conical; root tip often palatal or distal

    Maxillary cuspid: Canal is larger than in maxillary incisors; wider buccolingually than mesiodistally (conelike shape); rarely has divided canal near apex

    Maxillary first premolar: generally 2 canals; palatal canal larger; canals sometimes merge; access cavity oval; wider buccolingual than mesiodistal

    Maxillary second premolar: same shape as first premolar; 1 canal 60% of time; 2 canals common, usually single root

    Maxillary molars: access cavity; triangular in shape; usually without violation of the oblique ridge; usually 3 or 4 canals; the palatal canal is straightest, widest, most tapering canal; a fourth canal, if present, is usually between the MB and palatal canals, located in the MB root

    D-B: small tapering canal

    M-B: smallest canal; often splits into 2 canals; often calcified and difficult to instrument

    Mandibular central and lateral incisors: narrow single canals that may divide into labial and lingual canals to form either 1 common or 2 separate apices

    Mandibular cuspids: compared with maxillary cuspids, these more often have 2 canals

    Mandibular first and second premolars: simple access cavity; oval in outline; cone-shaped canals (70–80% have 1 canal)

    Mandibular molars: wide variation in shape, number of foramina, and number of canals (usually 3 only); usually there are 2 mesial canals with the distal canal being a bisector of the 2 mesial canals; if the distal canal is more buccal, there will usually be a fourth canal (DL)

    Working Length Determination

    Once all canal orifices are located, one must establish a working length for each canal. The working length is the distance from a coronal reference point (such as a cusp tip or marginal ridge) to the point at which canal preparation and obturation should end. Working length is determined by the following process:

    Selecting a stable reference point that is easily accessible and visualized

    Estimating the working length with a #10 or #15 K-file and taking a working length radiograph using a paralleling technique

    Alternatively, using an apex locatorto estimate the working length prior to inserting the #10 or #15 working length K-file and taking the radiograph

    If necessary, correcting the working length by compensating for the discrepancy (pushing file in or pulling it farther out) and taking another radiograph to confirm placement; repeating as necessary

    The working length should be 1 mm short of the radiographic apex

    Key Concept

    An apex locator is an electronic instrument used to assist in determining the root canal working length or presence and location of a perforation. It operates on the principles of resistance, frequency, or impedance.

    Establishment of the Master Apical File

    The creation of an apical stop is important to keep instruments, materials, and chemicals confined to the canal space as well as provide a surface for which gutta-percha can be condensed.

    The master apical file is the largest file used to the full working length of the canal when it is completely prepared.

    Instrumentation: Cleansing and Shaping of Canals

    After the access cavity is prepared, the canal is cleansed and shaped with hand or rotary instruments. The goal of instrumentation is to remove all the pulp tissue, to remove any infected dentin that may house bacteria and serve to reinfect the canal, and to prepare the canal into the shape of a continuously tapered funnel that will aid in the complete obturation (filling) of the root canal system.

    The canal is cleansed via 2 methods, which are usually employed together:

    Biomechanical: The use of rotary or hand instruments to expose, clean, enlarge, and shape the pulpal and canal spaces. Files, reamers, and broaches are the primary instruments used to accomplish this task (see previous Instruments section for detailed information on each of these tools).

    Chemomechanical: The use of chemicals for irrigation of the root canal system. The chemicals help to demineralize dentin, dissolve pulp tissue, and neutralize bacterial byproducts and toxins (see previous Materials section for detailed information on common chemicals used in nonsurgical endodontics).

    Cleansing and Shaping Techniques

    There are 3 main techniques for cleansing and shaping root canals during the instrumentation step of nonsurgical endodontics:

    Crown-down is a technique of canal preparation involving early flaring with rotary instruments, followed by incremental removal of canal debris and dentin from the orifice to the apical foramen using files in a larger-to-smaller sequence. Cleaning and shaping of the coronal portion of the canal occurs before the apical portion. 

    Step-back is a method of canal preparation using smaller, more flexible files in the apical third, followed by files sequentially larger than the master apical file at incremental lengths of 0.5–1 mm short of the working length. In this technique, the apical portion of the canal is prepared before the coronal portion.

    Hybrid: Some providers will combine elements of both techniques listed above to achieve the best outcome.  

    Obturation

    After the canal has been cleared of debris and affected dentin and has been shaped to allow for the filling, the next procedure is obturation or filling of the canal. There are different materials used for obturation and different techniques by which to use them. By far, the most used obturation material taught in dental schools today and, therefore, the most tested on the NBDE, is gutta-percha.

    Gutta-percha is pliable and easily bent or flexible at room temperature, and becomes plastic at 60°C (140°F). It is made opaque through the use of opacifiers, such as barium salts. It is slightly soluble in eucalyptol and is freely soluble in chloroform, ether, and xylol. There are several methods of obturation with gutta-percha.

    In lateral compaction, a gutta-percha cone is placed into the canal. If it goes past the apex, it is cut back. If it binds slightly more than 1 mm short of the apex, this is the master apical cone.

    Key Concept

    The master apical cone (point) is the largest gutta-percha point that can be placed either to the full working length or to within 0.5 mm or less of the working length of the completely prepared canal prior to obturation by either lateral or vertical compaction. 

    The walls of the canal are then coated with cement sealer, and the cone is condensed against a lateral wall with a plugger instrument. As the instrument is removed, another cone is placed in the place the spreader occupied. This continues until the canal is packed.

    In warm vertical compaction, a gutta-percha cone (GPC), master apical, is fitted as above and is removed while sealer is placed on the walls. Then the cone is pushed in and a hot instrument cuts the GPC off at the orifice. A hot instrument is placed halfway down the canal, which removes the coronal gutta-percha and melts the apical gutta-percha and makes it plastic. Then a condenser pushes the plastic gutta-percha apically. This is repeated with vertical pressure, forcing gutta-percha into accessory canals and any other irregularities in the root canal.

    The chloropercha technique is similar to the warm gutta-percha technique, except that instead of using heat to make the gutta-percha plastic, chloroform is used.

    In the plasticized technique, several new systems exist that use warm, melted, or chemically treated materials (usually gutta-percha) for compaction into the canals.   

    In carrier-based obturation, sealer is placed in the canal followed by a core carrier coated with gutta-percha or other materials; the device is heated prior to placement.

    Continuous wave compaction is a variation of warm vertical compaction in which a master point is placed in a sealer-lined canal and compacted by a pre-fitted, tip-heated electrical plugger. The canal is then back-filled with thermoplastic material.

    The use of silver points was a popular means of obturating root canals in the past. The AAE now recommends against the continued use of silver points, as they have been shown to be clinically problematic. Specifically:

    Post and core buildups become impossible with intact silver points, necessitating re-treatment and replacement of the points with another material.

    Apical surgery becomes more complicated due to the difficulties encountered when attempting a root-end preparation in canals that are filled with metal.

    Corrosion products, which cause argyrosis and periradicular inflammation, have the potential to induce inflammatory root resorption.

    The AAE does not recommend, however, the prophylactic removal of existing silver point obturations if they are asymptomatic or do not pose one of the challenges previously covered. This is in order to conserve tooth structure and prevent possible tooth trauma from the removal process.

    Surgical Endodontics

    Simply stated, surgical endodontics is performed when conventional endodontics cannot be performed. Often, it is best to re-treat the canal with traditional endodontic therapy 1 time before resorting to surgical endodontics. Specifically, surgical endodontics is likely to be considered when:

    There is extensive destruction of the periapical tissue, bone, or periodontal ligament involving 1/3 or more of the root apex

    There is an apical cyst

    The canal is obstructed by a pulp stone, broken instruments, etc.

    A perforation has occurred in the apical 1/3 of a canal

    The root apex is very wide and makes obturation difficult

    There is an inaccessible canal

    There is persistent apical periodontitis in a well-filled canal

    There is large internal and external resorption of a root

    There is a fracture of the root apex

    The root canal is calcified

    A post and core have been placed in the tooth, and an area of rarefaction persists

    Contraindications to surgical endodontics include:

    A tooth that would be left with inadequate root support

    A tooth that is severely mobile because of periodontitis

    A tooth that has a periodontal abscess present

    Access that is too difficult

    A patient with an active debilitating disease or a history of bisphosphonate use

    Root amputation, or apicoectomy, is a procedure where the buccal tissue is flapped back, the buccal bone around the apex is removed, the root apex is removed, and the area is curetted out. A retrograde filling is usually then placed. When this procedure is done without removing the root apex, it is known as periapical curettage.

    Key Concept

    Signs of a successful root resection or root end amalgam should include regrowth of periapical bone and shrinkage of lucent periapical pathology area.

    Retrograde amalgam or MTA filling is used when a root resection will not innately have a good apical seal of the canal. For example, if the root canal appears calcified, it would be impossible to obturate most of the canal and get a seal. If just the root apex were cut off, the incompletely filled canal might act as a source of reinfection. To prevent this, after the root tip is resected, the foramen is found, enlarged, and filled with amalgam or MTA to create a seal.

    The objective of incision and drainage (I & D) and trephination is to remove toxins, purulence, and exudates from the soft tissues with trephination extending into the hard tissues (alveolar bone). Both I & D and trephination relieve pain by relieving pressure in the area and giving the infection a path from which to drain, expediting healing.

    A hemisection may be performed on a multirooted tooth to treat vertical fractures, severe bony periodontal defects, root resorption, or perforation defects. The tooth is cut vertically in half through the crown and into the furcation, and the defective half of the tooth is extracted. Root canal therapy is performed on the remaining portion of the tooth.  

    Root amputation differs from hemisection, as the crown of a multirooted tooth is left intact and only the defective root is cut. Root canal therapy is then performed on the remaining tooth structure.

    In cases of intentional reimplantation, the tooth is extracted, and the root canal is treated outside the mouth and then intentionally reimplanted into the alveolar socket. The prognosis of teeth treated by this means is very poor; limit to only those teeth for which conventional or simple surgical endodontic therapy is impossible.

    Complications

    Complications may occur during the process of endodontic therapy, similar to any dental procedure.

    Canal Ledging

    Canals may be ledged during the process of access preparation and filing. Ledging is an artificial irregularity iatrogenically created on the surface of the root canal wall that impedes instrumentation to the apex of a normally patent and accessible canal. Ledging may occur at the canal orifice or farther apically, and does not allow the operator access to the true working length of the canal, thus compromising an adequate seal if the ledge goes undetected and the canal is filled.

    The chance of ledging may be minimized by the performance of a good access preparation that gives straight-line access to the canals. Curved and long canals are more susceptible to ledging. Good canal lubrication and the use of flexible files can also decrease the likelihood of ledging.

    When ledging occurs, the canal must be relocated and renegotiated. The working length must be confirmed so the canal can be properly filled and sealed. If the ledge cannot be completely removed, the canal should be instrumented to the new working length of the ledge and the patient informed of the occurrence. The prognosis of a ledged canal depends upon the location of the ledge and the amount of debris that remains in the canal at the apex after obturation. Surgical intervention may be required if the tooth becomes symptomatic after treatment.

    Perforation

    A perforation is present when there is a communication between the pulp chamber or root canal system and the external tooth surface. Perforations may occur in the crown, furcation area, or the root canal itself. They are iatrogenic in origin. Perforations can occur at any stage of tooth preparation. Common signs of perforation include:

    Sudden and uncontrollable hemorrhage during tooth preparation

    Sudden pain during tooth preparation

    Radiographic evidence

    Aberrant apex locator readings

    Deviant file course from previous passes

    Unusually severe post-operative pain

    The prognosis of a perforated tooth depends upon the location, timing and size of the perforation, as well as the methods and timing of treatment employed. In general, the prognosis of a perforated tooth is better if it:

    Is located at or above the alveolar bone level

    Is smaller than 1 mm

    Occurs later in treatment (after complete or partial canal debridement)

    Is easily accessible and treated quickly

    Is well isolated during the perforation repair

    Is well sealed after repair

    Treatment of a perforation may be difficult, and referral to an endodontist is often warranted to ensure the best prognosis. Treatment modalities are defect-specific:

    Nonsurgical repair with MTA (material is very biocompatible and promotes deposition of cementum-like material)

    Orthodontic extrusion and defect repair with restorative material

    Flap surgery and/or crown lengthening and defect repair with restorative material

    Root amputation or hemisection

    Intentional reimplantation procedures

    Instrument Separation

    A separated instrument is one that breaks within the confines of the root canal. Instruments may break if they are overused and brittle from the sterilization process or excessive force is applied to them. Manufacturer defects that cause instrument separation are very rare.

    In order to prevent instrument separation, dentists should do the following:

    Use the right instruments for the right application

    Use adequate lubrication and irrigation during the filing process to avoid binding within the canal

    Examine instruments prior to use for signs of file or instrument fatigue (fluting distortions, unwound files, or excessive bending)

    Replace files often

    Not proceed with larger files until the smaller ones do not bind

    The treatment of canals that contain separated files may include the following:

    Removing the instrument if it is easily accessible and loose in the canal

    Navigating around the instrument in a similar technique to treating a ledge and filling the canal, leaving the instrument in place

    Preparing and instrumenting the canal to a new working length above the separated instrument; an adequate seal must be attainable

    The prognosis of a tooth with a separated instrument is better if:

    The debris that remains in the root canal apical to the separated instrument is minimal

    The separation of the instrument occurs in the later stages of treatment (the canal is completely or nearly completely cleansed and shaped)

    The separated instrument is larger in size (i.e., a #35 file vs. a #10 file)

    After the occurrence of a separated instrument, patients must be informed of the incident and the treatment recommended or performed. Most of the time, if well managed, instrument separation cases have a good prognosis. If residual postoperative symptoms occur, referral to an endodontist may be necessary for surgical intervention.

    Vertical Root Fracture

    Vertical root fractures that happen during endodontic therapy have a poor prognosis. They occur down the long axis of the tooth and cannot be adequately sealed. Causes of vertical root fractures include:

    Excessive filing or condensation forces

    The wedge effect during the cementation of a post

    Overpreparation of the root canal resulting in very thin remaining cementum thickness

    Diagnosis of vertical fractures can be difficult, as symptoms may be vague and the fracture not visible on a radiograph. Oftentimes, vertical fractures are accompanied by:

    Severe perio pocketing in an otherwise periodontally sound dentition

    Sinus tract development

    Pain with chewing

    Lateral root radiolucencies

    Surgical intervention (flap surgery and alveolar bone removal) is sometimes needed to confirm the diagnosis of vertical root fracture.

    Treatment includes extraction of the affected tooth (single root) or root amputation if possible (multirooted teeth only).

    Traumatic InjurY

    Traumatic injury of teeth frequently requires endodontic intervention.

    Tooth and Alveolar Fractures

    Orofacial trauma may result in fractures to the teeth and the alveolar bone. Endodontic procedures may need to be employed in either case. The specific types of fractures that may occur are described below along with appropriate interventions and prognosis.

    Crown and Crown/Root Fracture

    Fractures of teeth may involve just enamel; enamel and dentin; or enamel, dentin, and cementum. When cementum is involved, so is a portion of the root.

    Uncomplicated crown or crown/root fracture is a fracture involving enamel, dentin, and cementum and does not include a pulp exposure. Complicated fracture does involve the pulp. Fractures should be thoroughly assessed and diagnosed using the methods described in the Diagnosis, Treatment Planning, and Patient Management section of this chapter.

    Uncomplicated fracture may be treated with the restorative material of choice and followed postoperatively for the development of symptoms suggesting pulpitis or pulpal necrosis. Generally, the prognosis is very good unless it

    Enjoying the preview?
    Page 1 of 1