Abnormal

occlusal
contacts

Recently inserted
restoration with high
points

Wedging of a
foreign object

Vital tooth Traumatic blow

No
radiographic
changes
Sequelae of
pulpal diseases

Overinstrumentation

Nonvital tooth
Asymptomatic/Pink Perforation
Tooth

Forcing of irrigants/Medicaments/Obturation materials

Symptoms
External surface Diagnosis-
resorption Symptomatic apical Pain on percussion
periodontitis Slight widening of the apical
periodontal ligament space Cause- Bacterial invasion
Types External root resorption of dead pulp tissue
External inflammatory Symptomatic Treatment- Determining the cause and
root resorption periradicular relieving the symptoms
diseases Rapid onset

External replacement Spontaneous pain

resorption or ankylosis Acute alveolar abscess
Causes Tenderness of the
tooth to pressure
Trauma

Pus formation Swelling

Excessive force Treatment-Treat
the cause

Granuloma, cyst,
Disease of Periradicular tissues Phoenix abscess
Exacerbation of a
chronic lesion
central jaw tumors Rise in
temperature,Chills
Treatment-Establish
Symptoms,Treatment-Same as drainage
Acute alveolar abscess
Negative response
Replantation of teeth to Vitality tests
Periradicular
Systemic diseases.
radiolucent changes
Bleaching
Post-treatment apical periodontitis in an
Endodontically treated tooth
Classification Mild irritation of
the periradicular tissue
Impaction of teeth Persistent apical
periodontitis Asymptomatic Asymptomatic Discovered by routine
periradicular diseases apical periodontitis radiographic examination

Apical biofilms Negative response

Etiology to vitality tests

Treatment-Root
Actinomycosis infection canal therapy
Foreign body reaction
to gutta-percha Chronic Long- standing, low-grade infection of
alveolar the periradicular alveolar bone
abscess
Intraoral/Extraoral
Cholesterol crystals
Sinus Tract
Periapical scar tissue No/Slight pain

Cellulose granuloma Diseases of the periradicular tissues of

nonendodontic origin Negative response
Treatment-Elimination of to vitality tests
Major diagnostic infection from the root canal
feature-Vital pulp
Central giant cell
granuloma
Discoloration of the crown
Periapical cemental
dysplasia or cementoma

Closed cavity / sac internally lined with Nutritional

Cementoblastoma Fissural cysts epithelium, filled with deficient theory
Radicular cyst fluid or semisolid material.

Odontogenic cysts Hypotheses

proposed for growth
Abscess theory

Periapical pocket
Two categories cyst/Bay Cyst

Negative response
Confirmed only after to vitality tests
Periapical true cyst
histopathology

Treatment of choice - Nonsurgical

root canal therapy alone, followed by
periodic observation.

Discovered on
radiographs
Diffuse radi-
opaque lesion

Long-standing pulpal pathosis.

Condensing osteitis

Due to stimulated
osteoblastic
activity

Discovered on
radiographs

Treatment- Endodontic Therapy

 Pain- Sharp and
short in duration

Relieved on
removal of stimuli
Mechanical
Negative- Pain on
percussion
Thermal Reversible pulpitis
Physical
No
periradicular
Electrical changes
Causes Chemical Treatment Pain- Spontaneous /Continuous
Removal of causative agent /Lingering / Nocturnal

Bacterial Inflammatory diseases Negative- Pain on

percussion

Irreversible pulpitis No
Symptomatic periradicular
changes

Treatment- Pulpectomy

Asymptomatic No Pain
No
periradicular
changes
Classification Chronic
Diseases of the Dental Pulp hyperplastic
Treatment- Pulpectomy

pulpitis
Symptomless, except
during mastication

Treatment- Pulpectomy

Pulp degeneration Internal resorption Root- [Link]- pink spot

Treatment- Pulp Extirpation

Symptomatic tooth
Calcific
Clinical management- Endodontic therapy

Asymptomatic tooth
Atrophic - Esthetic management

Fibrous

Coagulation

Types

Liquefaction
Pulp necrosis

No Pain

Discoloration

Negative response
to Vitality tests

Treatment-Pulpectomy
 Dentinal Tubules - 1 to 4
micrometer in diameter
Nutrient trapping
CARIOUS CAVITY
Size of bacteria lesser
Establishment of conducive than 1 micrometer
metabolic environment in a biofilm

CHARACTERISTICS OF BIOFILM Bacterial penetration in healthy

Organised internal
vital tooth proceeds slowly
compartmentalization

Less than 2mm penetration

Bacterial cell exchange of TRAUMA
after 2 weeks of exposure
genetic materials

Necrotic, dead tracts are

Heterogeneous arranged cells PATHWAYS OF quickly penetrated
MICROBIAL
Microcolonies
PENETRATION
Bacteria enters through
periodontal membrane, lateral
Glycocalyx matrix canals, apical foramen
GINGIVAL SULCUS AND PDL
ENDODONTIC MICROBIOLOGY
85% matrix and 15% cells BIOFILM Exposure due to dental prophylaxix, dental
(PART 1) luxation, periodontal pockets

Tower/ Mushroom ULTRASTRUCTURE OF BIOFILM

Attraction of bacteria present in the blood or
ANACHORESIS lymph to the dental pulp following trauma
Water Channels or operative procedures

Microbial biofilm on the Salivary contamination through broken

Intra Canal Biofilm FAULTY RESTORATION AND
root canal dentin coronal seal can reach periapical region-
CORONAL LEAKAGE
results in periapical infection

Biofilm on the root

Extraradicular Biofilm
surface (cementum) STAGE 1- Adsorption of organic and
inorganic molecules to the solid surface.
TYPES OF BIOFILM Forms conditioning layer
In the periapical region. Has ability to
overcome host defense mechanism. Periapical Biofilm
Induce periapical infection STAGE 2 - Adhesion of microbial
cells to the conditioning layer

Bacteria adhere to the artificial

Biomaterial Centered Infections
biomaterial-obturating material STAGE 3 - Development of biofilm
DEVELOPMENT OF BIOFILM and biofilm expansion occurs. Gives
rise to final stucture
 Microbial colonization in
NORMAL FLORA
symbiotic relationship

Multiplication of microorganisms
MICROBIAL COLONIZATION
without tissue invasion or damage
These microorganisms initially invade and colonize necrotic pulp tissue

The organism is called pathogen- Bacteria,

Dominated by anaerobic bacteria. Some facultative or microaerophillic Ability of an organism
PATHOGENECITY fungi, viruses, protozoa, parasites. They evade
species can be found to cause disease
host defense mechanisms
INTRARADICULAR INFECTIONS AND
INTRARADICULAR PATHOGENS
Black pigmented gram negative anaerobes, Prevotella spp.,
Porphyromonas spp, Tannerella forsythia, Dialister spp, Fusobacterium, Using host nutrients
Spirochetes, Pseudoramibacter, Actinomyces, Streptococcus spp,
Camphylobacter spp, Neisseria, Fungi - Candida albicans, Viruses -
Causing direct damage in
Herpes
immediate vicinity
Degree of pathogenecity or disease
VIRULENCE 4 ways to damage host cells
Microorganisms resistant to antimicrobial treatment. Can producing ability of a microorganism By producing toxins. It is transported by
survive in the root canal after cleaning and shaping lymph/blood - damages sites far

Also called recurrent infection By inducing hypersensitivity

SECONDARY OR PERSISTENT reactions
Responsible for persistent exudation, interappoitment INTRARADICULAR INFECTIONS
exacerbation, failure of endodontic treatment AND PATHOGENS
Exotoxin

Enterococcus faecalis, Actinomyces spp,

Endotoxin
Streptococci, Lactobacilli, Fusobacterium nucleatum, MECHANISM OF
Prevotella spp, Camphylobacter rectus PATHOGENECITY
Peptidoglycan

These are bacteria persisting after intracanal disinfection

and after root canal treatment Lipoteichoic Acid

Actinomyces spp, Propionibacter propionicum, Fimbriae

EXTRARADICULAR
Treponema spp, Porphyromonas endodontalis, VIRULENCE FACTORS
INFECTIONS AND
Porphyromonas gingivalis, Treponema forsythia,
PATHOGENS Capsules
Prevotella spp, Fusobacterium nucleatum
ENDODONTIC INFECTIONS AND ENDODONTIC MICROBIOLOGY
ENDODONTIC PATHOGENS (PART 2) Extracellular vesicles
Acute alveolar abscess is due to extraradicular
pathogens
Short chain fatty acids

Gram positive cocci,

facultative anaerobe Polyamines

Live and persist in poor Superoxide Anions

nutrient environment

Causes tissue
Survives in the presence of
disintegration.
several medications

ENZYMES
Forms biofilm
Coagulase, streptokinase, hyaluronidase,
chondrointin, sulphatase, beta
Invades and metabolize fluids within glucuronidase, DNase, acid phosphatase
dentinal tubules and adhere to collagen
ENTEROCOCCUS FAECALIS
Growth occurs only when high
Converts into viable but OBLIGATE AEROBES
concentrations of oxygen is available
non cultivable state

Both aerobic and anaerobic

Acquires antibiotic resistance FACULTATIVE ANAEROBES growth. Grows better in the
presence of oxygen
Survives in extreme environments with
low pH, high salinity, high temp Grows only in the absence of
CLASSIFICATION OF OBLIGATE ANAEROBES oxygen. Lacks enzymes to neutralize
Endures prolonged MICROORGANISMS harmful effects of oxygen
periods of starvation
Growth occurs in anaerobic
AEROTOLERANT ANAEROBES condition. Can tolerate oxygen by
Utilizes tissue fluids
partial neutralization of oxygen

Only aerobic growth. Growth

MICROAEROPHILES occurs only with low
concentration of oxygen.
 Cracked tooth or
fractured cusp

Tooth sloth or Bite test

Frac finder

Pain on releasing bite

Special tests
Intraligamentary injections- Selectively
When patient can not identify
one tooth at a time starting anaesthetise one Selective anaesthesia
which arch pain is in
from most distal tooth arch

To identify crack
Staining
Methylene blue dye

Does not need

processing

Xeroradiography
Charged photoconductor dissipates
the charge by exposure to X rays to
form a latent image
Digital
Facial asymmetry-
facial swelling
Minimal exposure

RVG Extra oral Palpable lymph nodes

Numerous possibilities
to process image
Presence of extra oral sinus tract or
fistula opening - scar seen

Tuned Aperture Diagnostic aids

Computed Tomography Soft tissue examination -
lesions, ulcers , etc
Series of radiographs taken
from different angles to form a Examined with low grade air syringe
TACT
multiplanar image or 2X2 inch gauze pad

Canal visualisation, detection

Diffuse/localised
of caries, diagnosis of
external root resorption Intraoral oral
Radiographs
Firm/fluctuant
Intraoral swelling
Like CT but machine
uses spiral path Periapical ,
Spiral Computed
space infections
Tomography
Faster
Tracing with
Advanced digital Intraoral sinus tract
#25 or #30GP
3D hard and soft tissue imaging
without ionising radiation
Colour : discolouration,
MRI opaque, lifeless
Magnetic
resonance
imaging Contour: fracture, wear
Hard tissue
facets,restorations

3D imaging
Consistency: caries, internal
or external resorption
Cone shaped beam of
ionising radiation
CBCT
Clinical evaluation Colour :Deviation
Image from healthy pink
Resolution 0.4mm 3 Cs - Colour,
captured as Visual and tactile
to 0.076mm Contour Consistency
voxels Contour: swelling,
Gingiva
inflammation

Measures rate of Consistency: soft,

blood flow Soft tissue fluctuant,spongy tissue
Diagnosis
632nm laser is used
Williams probe

Works on Laser Doppler

flowmetry Periodontium UNC 15
Doppler
principle
WHO Probe
Light enters tooth - gets absorbed my
moving RBCs - leads to shift in
frequency of scattered light Mobility test - moving the tooth laterally
Mobility and
depressibility Depressibility - moving tooth
Measures oxygen
vertically in its socket
saturation level of pulp

Recent To check if tissue is enlarged

Red light 660nm
sufficiently for incision and drainage
2 LEDs
Pulse oximetry
Infrared light 940nm
Presence, intensity
location of pain
Oxygenated and deoxygenated Palpating
Hb absorb different amounts of
Presence and location
red and infrared light
of adenopathy

Can detect temperature changes Presence of

as small as 0.1 degree C bone crepitus

Measures blood Quick moderate blow Indicates symptomatic

Hughes probe camera Percussion
flow in pulp with instrument apical periodontitis

Tooth is cooled- then re warmed.

Vital teeth re warm within 5 sec ; nonvital in 15sec Pain

Pulp vitality tests Chief complaint Patients own words

Dentinal Stimulation of A
Same threshold as Exposed dentin
Normal response hypersensitivity delta divers
control tooth

Patient history TB, diabetes,

No response- nonvital Negative response Oral manifestations
Nerve stimulation by and records anaemia, etc
subjecting tooth to increased EPT Medical history
Responds to threshold less than degree of electric current
Early response Require modification in Hypertension, diabetes,
control tooth - diseased state
dental treatment thyroid disease, neurological diseases

Responds at significantly higher

Delayed response Chronological events that lead Kind of pain, location, duration, persistent or
electric current - diseased state Dental history
up to the chief complaint lingering,spontaneous,nocturnal

Immediate excruciating
Irreversible pulpitis
pain that lingers

Electrical heat carrier, hot GP, Hot

Positive response Similar to burnished, hot compound, dry Heat test
Healthy
contra lateral tooth rubber polishing wheel
Conventional

Non vital No response

Positive response similar to Thermal tests

Healthy
contralateral tooth

Short sharp pain that

Reversible pulpitis
disappears rapidly Endoice , CO2 snow,ice
Cold test
pencil, ethyl chloride
Excruciating pain
Irreversible pulpitis
that lingers

Non vital No response

Test cavity made on

Sensitivity or pain felt Test cavity
unanaesthetized tooth
 Radiographs

Computed Tomography
CLINICAL METHODS

Visualization Endogram
using Ruddle's Solution - NaOCl, EDTA, Hypaque

Sectioning -Horizontal/ Longitudinal

METHODS OF
Pulp Cavity DETERMINING PULP
Ground Sections
ANATOMY
Pulp Horn
Radiographs
IN VITRO METHODS
Pulp Chamber
Clearing Technique

Major Diameter/Apical foramen Computed Tomography

Minor Diameter/ SEM Analysis

Apical Constriction

Variation in size and shape Apical Root Anatomy TYPE I - 1 CANAL

PARTS OF ROOT CANAL
Curvature more common TYPE II - 2 - 1 CANAL
WEINES
Presence of accessory and lateral TYPE III - 2 CANALS
canals, calcification, resorption

TYPE IV - 1-2 CANALS

TYPE I - 1 CANAL

Isthmus
TYPE II - 2-1 CANAL

TYPE III- 1-2-1 CANAL

VERTUCCI TYPE IV- 2 CANALS

Radix Entomolaris
ROOT CANAL ANATOMY TYPE V - 1-2 CANALS
Radix Paramolaris
TYPE VI- 2-1-2 CANALS
MB2
TYPE VII- 1-2-1-2 CANALS
Middle mesial canal
TYPE VIII- 3 CANALS

3-1 CANAL

CANAL CONFIGURATION
3-2 CANALS

2-3 CANALS
VARIATIONS

Melton's Classification
C shaped canal

GULABIWALA

2-1-2-1 CANALS

4-2 CANALS
Fan's Radiographic Classification

4 CANALS

5-4 CANALS

SERT AND BAYRILI

 One High (8kHz) One Low (400kHz)

Multi Frequency

Dual Frequency

Types
Voltage Gradient Grossman Ingle Weine's
Apical Periodontal Paper Points BEST
Modification
Sensitivity
1st Resistance based
BREGMAN
Apex Locators Non Radiograhic Methods Tactile Radiographic Methods
2nd Impedence based Generations
BRAMANTE
3rd Frequency based
kuttler
Resistance & Working Length
4th Capacitance based Digital radiography
Determination Endometrics X-ray Grid
5th Combination
Torabinajad
Over Extension RVG PSP
Endometric Probe
Short of Actual WL Consequences
Anatomical Xeroradiography
Consideration
Loss of WL
Coronal
Anatomical Apex
Reference
Point

Radiographic Apex Major Diameter

Minor Constrictor

CDJ
 Continuously tapering preparation
with narrower apical diameter

The walls should taper eventually

towards apex and should be
confluent with the access cavity

Mechanical To give the prepared root

canal the "quality of flow"

To maintain the
apical foramen as small as pratical
Watch winding
Objectives To maintain the position of the apical
Filing foramen without transporting it

Reaming Confinement of the instruments

Hand Operated within the root canals
Balanced Force
Ensuring that the necrotic debris are not
Circumferential filing Instrument Motions used forced beyond the foramen
Biological
Anti-Curvature filing
Removal of all tissues from
the root canal space
Rotation
Creation of sufficient
Reciprocation Machine assisted space for optimal obturation
Cleaning and shaping
Self adjusting file

Flushing the debris

Techniques
Lubrication
Irrigants
Tissue Dissolving

Antibacterial Apico-Coronal Corono-Apical Hybrid

To check if the apical foramen is blocked Patency Filing

Going back to the previous file Recapitulation

Step- back Step- Down technique Combination

Modifications

Crowndown Balanced Force Double Flare

Pressureless
 Syringe irrigation with E.g., Green tea
needles and cannula (End-venting and Side-venting needles) Natural
and Triphala

Brushes (Endo
Manual Tissue dissolving
rush; NaviTip FX) Classification
Chemical Antibacterial
Manual dynamic agitation E.g., Hand
operated well fitting gutta-percha
Chelating

Rotary brushes
Non-toxic and
Irrigation Agitation biocompatible
Quantec-E Continuous irrigation during rotary instrumentation
techniques and devices
Antimicrobial
Ultrasonic file;
Intermittent
Smooth file
Passive Ultrasonic Mechanically flush out
Machine assisted Root canal irrigants debris from root canal
Nusstein's needle
Continuous
holding device Ideal requirements
Tissue dissolving
Endo Activator Sonic
Remove smear layer
Pressure alteration
EndoVac
devices Lubricant

Low surface tension

Parachloroanaline Orange Precipitate NaOCL + CHX
Interactions
White precipitate CHX + EDTA 3% NaOCl

Saline
Commonly Used 2% CHX

Final irrigant Saline EDTA & NaOCl Saline NaOCL Irrigation protocol
17% EDTA
CHX
 What?
Bacteriostatic Radiopaque

Why? Impervious to moisture Should not stain

Obturation
Should not shrink
When? Ideal req Biocompatible

Good seal
Quickly sterilized
With what?

Easily introduced Removed easily

Obturating materials

ZnO based

SS files Silver cone Classification Iodoform based

Ti wires Metals PAA based

Core
Sealer
CaOH based

Guttapercha Plastics Pastes Resin based

Resilon N2 Silicone based

MTA
 1959 - Ingle & Levine -
Standardized GP cones

1914 - Callahan -
Chemically softened

1887 - SS White Co - Comm prod

1867 - Bowman

20% GP - Matrix
History

2%, 4%, 6%, 8%.... Taper

66% ZnO - Filler

Guttapercha Composition
Standardized
11% Heavy metal SO4
- Radiopacifier
Sizes
Non standardized

3% Wax or resin - plasticizer

Phases

Property Beta Alpha Gamma

At room temp Stable & flexible Brittle ___

Commercial GP Room temp 42-44 C 56-64 C

Non sticky, solid Sticky, tacky Sticky, tacky

State

Plasticity Compactable Non compactable Non compactable

Technique Cold lateral Thermoplasticized

 No staining Easy to remove

Biocompatible
No shrinkage

Fluid tight seal

Radiopaque Slow set
Ideal Req
Lubricant
Fluid tight seal Insoluble
Functions
Antibacterial prop
Tackiness when mixed Bactericidal

Fill lateral & accessory canals

SEALERS

Classification

ZnO based Iodoform based

PAA based CaOH based Resin based Bioceramic based
Silicone based

Eugenol Non eugenol Iodoform paste Ketac Endo Sealapex Diaket Roekoseal MTA Fillapex

Grossman's cement
Nogenol Vitapex CRCS AH Plus Guttaflow Endosequence BC

Rickert's formula
Kloropercha N-O
Apexit Epiphany
Tubliseal

Apexit plus
Wach's cement