En Do 2010
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Transcript of En Do 2010
Dr. T. LEVYDr. S. SUNDARESAN
Rule I : Bust your backside – universal law no matter what you doyou doRule II : Pay attention. Learn from everything and everyone all the time where ever you look there is something to seeRule III: Fall in love with your street, your tennis game, a pillow – fall in love with the back of your cereal box
Clinical Diagnosis, Case Selection, Treatment gPlanning, and Pt management 14Basic Endodontic Treatment Procedures 8Procedural Complications 3Traumatic Injuries 2 Adjunctive Endodontic Therapy 1Post‐ Treatment Evaluation 2
Approximately 60% of the questions are repeats from previous examsprevious exams
Diagnostic Methods / TestsgIndividual Teeth Instruments / Materials / Techniques/ / qMiscellaneousPulp u pReplantation – Intentional and avulsed teethResorptionResorptionTerms / Conditions
PULP BIOLOGYPULP BIOLOGYTOOTH ANATOMYPULP DIAGNOSISPULP DIAGNOSISROOT CANAL THERAPYENDODONTIC SUCCESS FAILUREENDODONTIC SUCCESS‐FAILURETRAUMA PERIRADICULAR SURGERIESPERIRADICULAR SURGERIESMISCELLANEOUS
In the normal dental pulp, which of the following histologicIn the normal dental pulp, which of the following histologic features is (are) the least likely to appear:
A) Cell-free zone of WeilB) Palisade odontoblastic layerB) Palisade odontoblastic layerC) Lymphocytes and plasma cellsD) Undiffentiated mesenchymal cells
Mantle – first formed dentin before odontoblast layer gets organizedorganizedPredentin – loss predisposes dentin to internal resorption, unmineralized organic matrix of dentin,betweend bl l d i li d d iodontoblast layer and mineralized dentin
Circumpulpal dentin, Secondary dentin – after tooth erupts and throughout life, major part of developmental denting , j p pTertiary or reparative dentin – Irregular, due to irritant / stimuli
Central zone pulp proper – cell rich zone – mostly f b blfibroblastCell free zone‐zone of weil – capillaries, nerve net works nerve plexus of Rashkowworks, nerve plexus of RashkowOdontoblastic layer – odontoblast, next to predentinand mature dentinand mature dentinCells in normal pulp – fibroblast, odontoblast, histiocytes, lymphocytes, stem cells
Which of the following cells are characteristic of Which of the following cells are characteristic of chronic inflammation of the dental pulp:
a) Neutrophilsb) Eosinophilsc) Lymphocytes d) Macrophages d) Macrophages e) Plasma cells
1) a,b,c & d 2) a,b, & d only 3) a,b, & e only 4) a, c & e 5) c, d & e only
Aging of the pulp is evidenced by an increase in fibrous elementsDecrease cell populationDecrease in number of blood vessels and nervesblood vessels and nervesSecondary and Irritation (Tertiary) dentin f ti d i formation – decrease in pulpal space
Efferent nerves found in the dental pulp are:‐‐ sympathetic post sympathetic post ganglionicganglionic fibresfibres… when stimulated will decrease blood flow because of constriction of blood vessels ( similar effect as constriction of blood vessels. ( similar effect as epinephrine)‐‐ parasympathetic parasympathetic fibersfibers…slight contribution to pulpalbl d flblood flow
Myelinated are sensoryMyelinated are sensoryUnmyelinated‐motor nerves control blood vessel sizeFree nerve ending is the only type found in the pulpFree nerve ending is the only type found in the pulp
A Fibers: Principally in region of pulp dentin j i i h i i i h d junction – pain characteristics is sharp and pricking – low stimulation threshold. C‐ Fibers: Unmyelinated – present throughout y p gpulp – pain characteristics are burning and aching – threshold stimulation is relatively high ‐associated with tissue injury – remain excitable associated with tissue injury remain excitable after blood flow is compromised – are able to function is presence of hypoxiaCold testing is better test for A fibers C fibers are Cold testing is better test for A fibers – C fibers are not activated
A‐ALPHA –myelinated, sharp localized pain,associated with id fl id t i th d ti l t b lrapid fluid movement in the dentinal tubule
C‐fiber – unmyelinated, dull throb, dentinal stimuli does not activate , thermal, mechanical, or chemical stimuli reaching d t f ldeeper part of pulpA‐BETA – myelinated, rapid velocity, respond to non‐noxious mechanical stimuli
A‐alpha are first to be stimulated with EPT.
C‐fibers after A‐alpha.
Y t th ith i t t h f A l h fib Young teeth with immature roots have few A‐alpha fibers‐reason for unreliable EPT on young teeth
PRIMARYSECONDARYSECONDARYTERTIARY
REACTIONARYREPARATIVEREPARATIVE
TUBULARPERITUBULARINTERTUBULARINTERTUBULARGLOBULARINTERGLOBULARSCLEROTIC
Studies indicated that patent blood vessels course in lateral or accessory canals connecting the accesso y ca a s co ec g ecoronal and/or radicular pulp with the PDL.They appear to be distributed at They appear to be distributed at any level of the root as well as on the floor of the pulp chamber chamber. Distribution of lateral canals
17% in the apical third8 8% i h iddl hi d 8.8% in the middle third 1.6% at the coronal portion
A non‐carious tooth with deep periodontal pockets that do not involve the apical third of the root has that do not involve the apical third of the root has developed an acute pulpitis. There is no history of trauma other than a mild prematurity in lateral
i Wh t i th t lik l l ti f excursion. What is the most likely explanation for the pulpitis?
1) Normal mastication plus toothbrushing has driven d h b lmicroorganisms deep into tissues with subsequent pulp
involvement at the apex. 2) During a general bacteremia, bacteria settled in this
d l d d d l i i aggravated pulp and produced an acute pulpitis. 3) Repeated thermal shock from air and fluids getting into the
deep pockets caused the pulpitis. 4)4) An accessory pulp canal in the gingival or the middle An accessory pulp canal in the gingival or the middle
third of the root was in contact with the pockets.third of the root was in contact with the pockets.
Th i l f The apical foramen most often exits the root:
) A h i a) At the anatomic apexb) Less than 0.5mm
from the anatomic apex
c) 0.5 – 1mm from anatomic apex
)d) More than l mm from anatomic apex
Initial Initial instrumentation in endodontic tx is done to:
a) Radiographic apexi l b) Dentino‐enamel
junctionc) Cemento dentinal c) Cemento‐dentinal
junctiond) Cemento‐pulpal ) p p
junction
CELLULAR – APICAL THIRD OF ROOTCELLULAR – APICAL THIRD OF ROOTACELLULAR – CORONAL 2/3 OF ROOT
Tooth Calcification Avg Length CommentsTooth Calcification Avg Length CommentsCentral 10 years 22.5mm Triangular Access
Lateral 11 years 22 0mm Apex toward L & DLateral 11 years 22.0mm Apex toward L & D
Cuspid 13-15 years 26.5mm Most consistent anatomy
1st Bi c spid 12 13 ears 20 6mm 2 canals 90%1st Bi-cuspid 12-13 years 20.6mm 2 canals – 90%
2nd Bi-cuspid 12-13 years 21.5mm 1 canal-53%; 2 canals 1 foramen-22%; c s o e %;2 canals 2 foramen-13%;
2 roots 2 canals-11%
1 t M l 20 8 MB 2 75 95%1st Molar 20.8mm MB 2:– 75-95%
2nd Molar 20.0mm MB 2:– 35%
Tooth Calcification Avg Length CommentsTooth Calcification Avg Length CommentsCentral 10 years 20.7mm 2 canals or dumbbell shaped
canal - 30 – 40% of the time2 separate foramen 5%Lateral 11 years 20 7mm 2 separate foramen-5%Lateral 11 years 20.7mm
Cuspid 25.6mm Frequently exits Buccal or Mesial - 35-50%
1st Bi-cuspid 12-13 years 21.6mm 2 canals – 25.5%3 canals – 0.5%
2nd Bi-cuspid 13-14 years 22 3mm 2 canals – 2.5%; 2 Bi cuspid 13 14 years 22.3mm ;3 canals – 0.05%;
1st Molar 21.0mm 4 canals – 33%
2nd Molar 19.8mm C – shape- 4 to 7.6%2 distal canals – 4%
Approximately what per cent of mandibular first l h b d l lmolars exhibit two distal canals?
1) 0 2) 0 1 2) 0.1 3) 0.34) 0.6 4) 0.6 5) 0.75
BUCCAL HOOK PALATAL ROOT BUCCAL HOOK PALATAL ROOT 4 CANALSMB1 (MB); MB2 (ML)MB1 (MB); MB2 (ML)74% 2nd canal
Half have a separate foramen Half have a separate foramen
The most common curvature of the palatal root of the maxillary first molar is to thefirst molar is to the
1) facial.2) mesial3) distal3) distal4) lingual
TRIANGLE – Apex is towards Palatal Canal4TH CANAL MB‐290% HAVE MB‐2 or FinPOSTERIOR TOOTH WITH HIGHEST ENDO FAILURE RATEFAILING RCT –SUSPECT MB‐2
EASIEST TOOTH TO PERFORATEMESIAL CONCAVITYCANAL NUMBER: 90% 2, 10% 1RADIOGRAPHRADIOGRAPHSLOB / Clark’s Rule/BUCCAL OBJECT RULECONE SHIFT
Th h h i f b li h i lThe teeth that are easiest to perforate by slight mesial or distal deviation from improper angulations of a bur are
mandibular incisors and maxillary first premolarsmandibular incisors and maxillary first premolars
POSSIBLE SEVERE DISTAL CURVATURE IN APICAL 1/3CURVE MAY HAVE A PALATAL ASPECT TO IT
Which of the following teeth are the least likel Which of the following teeth are the least likely to have more than 1 canal
1) Maxillary lateral incisors1) Maxillary lateral incisors2) Mandibular lateral incisors3) Mandibular first premolars3) Mandibular first premolars4) Maxillary second premolars5) Maxillary second molars5) y
MAXILLARY CUSPID
Access‐somewhat triangularg60% of max central incisors show accessory canalsApical foramen apart from apex 45%p p p 45One root, one canalDistal axial inclinationsta a a c at o
You are most likely to perforate in the maxillary You are most likely to perforate in the maxillary central incisor in which direction:
Faciallyy
One rootLong oval access2 canals buccal is straight2 canals – buccal is straight
PULP
PERIRADICULAR
ENDO- PERIOENDO PERIO
REFERRED PAIN
SINUS TRACTSSINUS TRACTS
CYST AND GRANULOMA
RESORPTION
NON-ODONTOGENIC
ANKYLOSIS
NORMALREVERSABLE PULPITISIRREVERSABLE PULPITISIRREVERSABLE PULPITISNECROTIC
Prolonged unstimulated night pain suggests which of the following Prolonged, unstimulated night pain suggests which of the following conditions of the pulp?
1) Pulp Necrosis2) Mild hyperemia3) Reversible pulpitis4) No specific condition
N t If IRREVERSIBLE PULPITIS i li t d th t i th Note: If IRREVERSIBLE PULPITIS is listed, that is the answer
Which of the following conditions indicates that a periodontal, rather than an endodontic problem, exists? p ,1.Acute pain to percussion with no swelling 2.Pain to lateral percussion with a wide sulcular pocket 3.A deep narrow sulcular pocket to the apex with exudate4 Pain to palpation of the buccal mucosa near the tooth apex4.Pain to palpation of the buccal mucosa near the tooth apex
ACUTE PERIRADICULAR PERIODONTITISACUTE PERIRADICULAR PERIODONTITISACUTE APICAL ABSCESSCHRONIC PERIRADICULAR PERIODONTITISCHRONIC PERIRADICULAR ABSCESS
SUPPURATIVE PERIRADICULAR PERIODONTITISSUBACUTE PERIRADICULAR PERIODONTITISFOCAL SCLEROSING OSTEOMYELITIS (CONDENSING OSTEITIS)FOCAL OSTEOPETROSIS / PERIAPICAL FOCAL OSTEOPETROSIS / PERIAPICAL OSTEOSCLEROSISNORMAL
How to differentiate between acute apical abscess and acute periodontal abscess:p
‐ Pulp vitality test
Percussion is a dental diagnostic procedure used in determining whether periodontitis exists!
The pathognomic symptom of chronic apical periodontitis is:1) Swelling 2) Intermittent pain3) Tenderness to palpation4) Tenderness of percussion4) Tenderness of percussion5) None of the above
Radiographs reveal a deep, distal carious lesion on the suspect tooth. The apical periodontal ligament p p p gappears normal most probable diagnosis for the condition of the pulp and the apical periodontal ligament isg
1) Vital pulp2) Necrotic pulp) I ibl i fl d l3) Irreversibly inflamed pulp4) Inflamed apical periodontal ligament5) Uninflamed apical periodontal ligament5) Uninflamed apical periodontal ligament
a) 1& 4b) 1 & 5c) 3 & 4d) 3 & 4d) 3 & 4e)e) 3 & 53 & 5
PRIMARY ENDOPRIMARY PERIOPRIMARY ENDO – SECONDARY PERIOPRIMARY PERIO – SECONDARY ENDOTRUE COMBINED LESIONPULP TEST – PERIO PROBE :‐ To help d ddetermine diagnosis
REFERRED PAIN
Forehead region‐Max incisorsForehead region‐Max incisorsNasolabial region‐Max cuspids/bicuspidsp pTemporal region‐Max 2ndbicuspidsEar‐Mandibular molarsMental region of mandible‐M dib lMandibularincisors,canines,premolars
SITE OF PAIN – WHERE IT IS FELTLOCATION
SOURCE OF PAIN – ORIGINREFERRED PAIN – THE SITE AND SOURCE ARE NOT THE SAME
Which of the following teeth most often refer pain c o t e o ow g teet ost o te e e pato the ear:
a) Max molarsb) Mandibular molarsb) Mandibular molarsc) Max Premolarsd) Max Anteriors) M dib l ie) Mandibular anteriors
Presence of sinus tract
• The cone should track back to the source of infection
• This willThis will demonstrate which root / tooth is theroot / tooth is the source of infection
1 Conventional RCT antibiotics not 1. Conventional RCT, antibiotics not needed.
2 Will heal in 2 4 weeks after 2. Will heal in 2‐4 weeks after conventional RCT
3 If present post + RCT do apical 3. If present, post + RCT do apical surgery with retrofill
(answer for the board)(answer for the board)
Vitality testVitality testNot of pulpal
i iorigin
Mythical lesion allegedly located between maxillary lateral incisor and cuspidVitality test
Periapical InflammationPeriapical Inflammation
•• An extension of pulpal An extension of pulpal inflammationinflammationP i i l ti illP i i l ti ill
Apex
•• Periapical tissues will Periapical tissues will become involved before become involved before total pulpal necrosistotal pulpal necrosis
•• Bacteria and Bacteria and inflammation by inflammation by products leak through AF products leak through AF
Gran lomaand start inflammationand start inflammation Granuloma
Central cavity lined by stratified squamous epitheliumCentral cavity lined by stratified squamous epithelium
Percentages:‐ 60% granulomas‐ 20% cysts‐ 12% apical scars12% apical scars‐ 8 % other
D/D Focal osteopetrosis, true
bl cementoblastoma, stage 3 osseous dysplasia dysplasia Confirm vitalityHistory of tooth or yrestorationRCT vs No RCT
lVitality testRadiolucent/opaque lesionlesionCalcifying fibromaPredominant location l ilower anteriorsEthnic link observed (Predominantly (Predominantly among African‐American)
A 34 year old black woman present for a routine 34 y poral exam. She is asymptomatic & there is no evidence of decay or tooth destruction, although li h i d l di i slight periodontal disease is present. Radiographically, there are periapical RL present on 2 mandibular central incisor EPT indicates all on 2 mandibular central incisor. EPT indicates all teeth are responsive in a similar fashion. Which of the following is tx of choice:g
‐ no treatment necessary at this time.
Kakehashi, Stanley, Fitzgerald1965 9 5Bacteria are the problem
RESISTANCE OF HOSTVIRULENCEPOPULATION/NUMBER
LYMPHOCYTESMACROPHAGESPLASMA CELLSPLASMA CELLS
SOME PROBLEMS SUCH AS ACTINOMYCOSES ARE EXTRARADICULAR ACTINOMYCOSES ARE EXTRARADICULAR AND MAY REQUIRE SURGERY TO RESOLVE THE INFECTION.TRUE CYSTSOSTEOMYELITISBIOPSY AND CULTURE
BACTERIABACTERIA
Pulpitisp
Pulpal inflammation is commonly caused by bacteria (b )(bugs)Reversible pulpitis‐early caries, scaling root planing, microleakage and restorations without base A microleakage and restorations without base. A symptom not a diseaseIrreversible pulpitis pain is spontaneous and Irreversible pulpitis pain is spontaneous and intermittent
BUGS FOUND IN INFECTED CANALS
Eubacterium speciesPeptostrptococusFusobacterium speciesProphyromonas speciesPrevotella species
VIRULENCE FACTORS IN PERIRADICULAR PATHOSISPATHOSIS
Lipopolysaccharide gram bugsLipopolysaccharide‐gram – bugsEnzymesExtracellular vesiclesExtracellular vesiclesFatty acidsVirus yeast cholesterol Virus, yeast, cholesterol
A BAC R AELIMINATE BACTERIAPROTECT AGAINST BACTERIA
Severity of the course of a periapical infection depends upon the :infection depends upon the :
1) Resistance of the host2) Virulence of the organism) g3) Number of organism present4) All of the above5) Only 1 and 2
What is the radiographic sign of successful What is the radiographic sign of successful pulpotomy in a permanent tooth?
1) Open apex) p p2)That the apex has formed3)Loss of periapical lucencyp p y4)No internal resorption
PHYSIOLOGIC OR PATHOLOGIC LOSS OF TOOTH STRUCTURE
A PHYSIOLOGIC PROCESS CAUSING SMALL SUPERFICIAL DEFECTS IN THE CEMENTUM AND DENTIN THAT UNDERGO REPAIR BY AND DENTIN THAT UNDERGO REPAIR BY DEPOSITION OF NEW CEMENTUMUSUALLY NOT DETECTABLE ON A USUALLY NOT DETECTABLE ON A RADIOGRAPH
ORTHODONTIC TOOTH MOVEMENTORTHODONTIC TOOTH MOVEMENTTOOTH ERUPTIONTUMORS
BACTERIAEXTERNALINTERNALPATHOLOGIC LOSS OF TOOTH STRUCTURE RESULTING IN A DEFECT IN STRUCTURE RESULTING IN A DEFECT IN THE ROOT AND ADJACENT BONE
ANKYLOSISTRAUMATRAUMAIDIOPATHICPATHOLOGIC LOSS OF TOOTH STRUCTURE WITH THE INGROWTH OF BONE INTO THE WITH THE INGROWTH OF BONE INTO THE DEFECTFUSION OF BONE TO CEMENTUM OR DENTIN
Which of the following characterizes replacement resorption: Ch i ia) Chronic pain
b) Apical pathosisc) Rapid progression) p p gd) Acute inflammatione) Ankylosis
Case showing replacement and inflammatory resorption
Inflammatory ResorptionInflammatory Resorption
Replacement Resorption
UNKNOWNTRAUMAORTHODONTICSINTERNAL BLEACHINGBACTERIA
SURFACESURFACEPRESSUREINFLAMMATORYINFLAMMATORYREPLACEMENTINFLAMMATORY PERIRADICULAR LESIONS INFLAMMATORY PERIRADICULAR LESIONS ALWAYS RESULT IN RESORPTION OF BOTH BONE AND TOOTH
SURFACESURFACEINFLAMMATORYNECROTIC TEETH ALWAYS HAVE INTERNAL NECROTIC TEETH ALWAYS HAVE INTERNAL INFLAMMATORY RESORPTIONPERFORATIONPERFORATION
Pink Tooth / Pink SpotPink Tooth / Pink SpotDue to internal resorption, sometimes cervical resorptionPink appearance due to growth of granulation tissue undermining the coronal dentin
PINK Tooth
Replacement resorptionTrauma to attachment apparatusAnkylosisMetallic sound
INTERNALREGULARROUNDOUTLINE OF CANAL IS DISTORTEDCENTERED, USE SLOB RULECENTERED, USE SLOB RULE
EXTERNALIRREGULAR, MOTH EATENOUTLINE OF CANAL IS NORMALOUTLINE OF CANAL IS NORMALOFF CENTER, USE SLOB RULE
INTERNAL RESORPTIONENDODONTIC TREATMENTENDODONTIC TREATMENTMAY BE DIFFICULTPERFORATIONPERFORATION
EXTERNAL INFLAMMATORYCALCIUM HYDROXIDECONTROL INFECTIONFILL CANALSFILL CANALS
EXTERNAL REPLACEMENTEXTERNAL REPLACEMENT‐ CALCIUM HYDROXIDE‐ CONTROL INFECTION‐ FILL CANALS
AVULSIONAVULSIONGUARDED TO HOPELESS
IDIOPATHICPROGNOSIS DEPENDS ON EXTENT AND LOCATION
Which of the following endodontic procedure has best prognosis?
1) RCT for internal resorption) RCT f E t l ti2) RCT for External resorption3) Overextension of Gutta Percha
Non-perforating internal resorption is best managed by 1.surgical curettage. 2 i i i d d i2.incision and drainage. 3.root canal treatment. 4.calcium hydroxide pulpotomy. y p p y5.periodic evaluation and recall.
Isolation
Accessccess
Irrigants
Files
Sealers
Gutta Percha
The use of rubber dam is considered an essential component of endodontic armamentarium
TRUETRUE
Exception to the use in a given situation is acceptable if p g pthe patient is informed and consents
FALSEFALSEFALSEFALSE
1. Provide unobstructed visibility into all canals.2. Allow files to be passed into each canal without bi di th ll f th ti ( t i ht binding on the walls of the access preparation (straight line access to avoid ledge).3 Allow obturation instruments to fully enter each 3. Allow obturation instruments to fully enter each canal without binding on the walls of the access preparation.4. Include removal of all caries and defective restorations. M k ibl th l f ll l ti5. Make possible the removal of all pulp tissue.
6. Removal of the roof of the pulp chamber.
OVAL – Cuspids, Mand central/lateral, Max lateral and Bicuspidslateral, and BicuspidsTRIANGULAR – Max central incisorTRAPEZOIDAL – Max and MandibularTRAPEZOIDAL – Max and Mandibularmolar with 4 canal orifice.
ACCESSACCESSDuring access of a mandibular molar 2 regions tend to b b h d b l l llbe overcut because the mandibular molar is usually tipped Mesially and LinguallyMesial aspect under the marginal ridgeMesial aspect under the marginal ridgeLingual surface under the lingual cuspMandibular incisor and max 1st premolar require care Mandibular incisor and max 1 premolar require care to avoid perforation due to the narrow M – D dimension
Which of the following can cause a ledge formation:ledge formation:
1) Infection2) Remaining debris within the canal2) Remaining debris within the canal3) No straight line access
A mandibular molar has 4 canals. How should the access opening be:
1) Round1) Round 2) Oval 3) Trapezoidal3) Trapezoidal4) Triangular
EDTASODIUM HYPOCHLORIDE
EDTA‐ 16‐20% solutionCh l i Chelating agentDecalcifies dentinRemoves smear layer
EDTAEDTAChelates, helps remove smear layerp yInactivate with NaoClNot an excellent irrigation solutionNot an excellent irrigation solutionDecalcifies 50 micronsC t ti %Concentration ‐17%
RC‐PREP
EDTA plus urea peroxidep p
Edtac – edta plus cetavion(soap)
5.25% NaOClDissolves organic materialgKills bacteriaSterilize GP (wipe with alcohol afterwards)Sterilize GP, (wipe with alcohol afterwards)
ll l l f lPrecurve all stainless steel files prior to placement in a curved canal
Precurving files is indicated1 f fil i #35 d1 for files sizes #35 and over. 2 in canals that are even slightly curved. 3 as a way to negotiate past canal obstructions3 as a way to negotiate past canal obstructions. 4 All of the above 5 Only (1) and (2) above y6 Only (2) and (3) above
Zinc oxide eugenol – Kerr SealerResin – AH26Paste fill
Which of the following represents the basic constituents of most root canal sealers:
Answer: Zinc oxide
ZOE SEALERS
History of successful usageRadiolucent
DISAVANTAGES:1. Stains2. Slow settingg3. Non‐adhesive4. Soluble4
SEALERS‐PURPOSESLUBRICANTBOND BETWEEN GP AND DENTINBOND BETWEEN GP AND DENTINANTIBACTERIALTISSUE TOLERABLETISSUE TOLERABLE
ApexificationPulpotomy Pulpotomy ApexogenesisApicoectomyPulp Capp p
NECROTIC IMMATURE TOOTHCONFIRM DIAGNOSISACCESS ‐ DEBRIDMENTSODIUM HYPOCHLORITE INSTRUMENTATIONSODIUM HYPOCHLORITE ‐ INSTRUMENTATIONPLACE CALCIUM HYDROXIDEPLUGGER, LENTULO SPIRAL, COMPACTOR, PLUGGER, LENTULO SPIRAL, COMPACTOR, MESSING GUN
What kind of procedure should be performed on aWhat kind of procedure should be performed on a tooth with necrotic pulp and unfinished root tip- apexification
A i l l h dA vital pulp therapy procedure performed to encourage continued
physiological development and formation of the root end.
This term is frequently used to describe vital pulp therapy performed to encourage the continuation of this g
process.
What is best sign for success of apexogenesisContinuous completion of apexContinuous completion of apex
Dr Mahmoud Torabinejad, Loma LindaModified Portland CementBismuth oxideVery good sealy gExpands slightly when sets with moistureLong setting timeg g
Pulp capPerforation repairpPulpotomyApexificationApexificationApical barrierR d filliRetrograde filling
RADIOPAQUEHYDROPHILLICBIOCOMPATIBLENOT TOXICINDUCTION OF HARD TISSUEMATERIAL OF CHOICE FOR RETRO FILLING (Apicoectomy)Repair of perforations ‐ Subosseous
BADSLOW SETTINGHARD TO USE
White MTASOC – Silicate Oxide CompoundSOC Silicate Oxide CompoundUSC – Universal Silicate Cement
Pulp capPartial/Cvek pulpotomy PulpotomyDeep pulpotomy
lPulpectomy
MAINTAIN NORMAL PULP VITALITYRETURN PULP TO NORMALAVOID ENDODONTIC TREATMENTAVOID EXTRACTIONAVOID EXTENSIVE TREATMENTPOSTPONE ENDODONTIC TREATMENT
P l i d tPulp capping and pupotomy can be more successful in newly erupted teeth than in adult teetherupted teeth than in adult teeth because :
1. a greater number of godontoblast are present
2. incomplete development f diof nerve endings
3. open apex allows for greater circulationgreater circulation
Calcium hydroxide is generally h i l f h i i i lthe material of choice in vital
pulp capping because :1) Encourages dentin bridge1) Encourages dentin bridge
formation2) Is less irritating to the pulp ) g p p3) Seals the cavity better4) Adheres well to dentin
C l iCalcium Hydroxide
To ensure better thermal and protective insulation
f th l d i Dentinalof the pulp during a capping procedure ,CaOH should b covered with
Dentinal Bridge
should b covered with stronger base
Pulp
CaOHMTABest prognosis with trauma, no bacterial involvement involvement Mechanical exposure, asymptomatic vital pulpCarious exposure poor prognosisCarious exposure‐poor prognosis
WHEN BOTH SURGERY AND RETREATMENT ARE DIFFICULT TREATMENT OPTIONS, THEN EXTRACTION AND REPLANTATION MAY BE THE TREATMENT OF CHOICE
TRANSPLANTED TEETH – BEST WITH OPEN APEXWITH OPEN APEX
Indications: Routine RCT is not possibleOb i i d i di l Obstruction is present and periradicular surgery not possiblePrevious RCT has failed‐nerve proximityPrevious RCT has failed nerve proximity
During procedure: Do not curettage socketRepair perforation or resorptive defectRetrograde filling in hand / complete RCT in hand , if possible
Poor condensation incomplete fillPoor condensation, incomplete fillInadequate disinfection
The most frequent cause of failure in endodontics isendodontics is
1. split roots. 2. root perforation. p3. Incomplete obturation.4. separated instruments. 5. filling beyond the apex.
To develop a fluid tight seal at the apical foramenComplete filling of the root canal spacep g pTo create a favorable biologic environment for the process of tissue healing
AVULSION:‐ Hanks balanced salt solution, Milk, Saline or Saliva. ( in decreasing preference order)‐ Replant ASAP, open apex, splint 7‐10 days, endotx 1wk, Ca(OH)2 , resorption, replacement, inflammatoryinflammatoryCONCUSSION: least damagingLUXATION: pulp necrosis likely, 60% immature LUXATION: pulp necrosis likely, 60% immature apex teeth become nonvitalIntrusive luxation, necrosis, ankylosisFRACTURES
Traumatize teeth
Deep intrusion most likely will result in RCTDo a soft tissue examRadiographs taken from multiple anglesVitality‐false negative‐check in 4‐6 weeksObserve adjacent teeth
An 8‐year‐old boy received a traumatic injury to a maxillary central incisor. One day later, the tooth failed to y y ,respond to electric and thermal vitality tests. This finding dictates
1. pulpectomy. p p y2. apexification. 3. calcium hydroxide pulpotomy. 4 delay for the purpose of re‐evaluation4. delay for the purpose of re‐evaluation.
The complete separation of a tooth from its alveolus isA A l iA. AvulsionB. AnkylosisC. SubluxationD E t i l tiD. Extrusive luxation
A maxillary central incisor of an adult patient is traumatized in an accident The tooth is slightly tender to traumatized in an accident. The tooth is slightly tender to percussion, is in good alignment, and responds normally to pulp vitality tests. Radiographic examination shows a horizontal fracture if the apical third of the root. The best horizontal fracture if the apical third of the root. The best treatment is which of the following?A.Root canal treatmentB. Splint and re‐evaluate the tooth for pulpal vitality . Sp t a d e eva uate t e toot fo pu pa v ta tyat a later time
C. ApexificationD. Apicoectomy to remove the fractured apical section of p y pthe root followed by root canal treatment
After obturation of a traumatized central incisor, a horizontal line of material in the mid root area extending both mesially and distally from the canal to the periodontal ligament space is noted This indicates the presence ofperiodontal ligament space is noted. This indicates the presence ofA. Accessory canalsB. A midroot fractureC. Internal resorptionD. External resorption
If periapical radiolucency is present at the apex of a tooth with a middle third If periapical radiolucency is present at the apex of a tooth with a middle third root fracture and the apical canal space is non‐negotiable ,the required treatment would be A. Extraction because of the poor prognosis
l h d d f h l lB. Calcium hydroxide treatment of the coronal segment onlyC. Apical surgery with a Super EBA reverse fillingD.Apical surgery with removal of the apical segment and root canal
treatment on the coronal segmenttreatment on the coronal segmentE. Extraction with removal of the apical segment and replantation of the
coronal segment
A patient experienced a blow to the mouth . Radiographs show a horizontal midroot fracture of a maxillary central incisor The tooth is NOT mobile and midroot fracture of a maxillary central incisor. The tooth is NOT mobile and NOT symptomatic, however , it does not respond to pulp testing. No radiographic lesion is present. The best treatment is toA. Institute root canal treatment to include both segments of the toothB Extract the coronal segment and surgically remove the apical segment B. Extract the coronal segment and surgically remove the apical segment .C. Surgically remove the apical segment and reverse fill the coronal segmentD. Perform root canal treatment and place an endodontic endosseous implant
pin to hold the two segments togetherg gE. Render no treatment at this time and periodically recheck clinically
and radiographicallyA 7‐ year old patient fractured the right central incisor three hours ago. A clinical examination reveals a 2‐mm exposure of “bleeding pulp " The clinical examination reveals a 2 mm exposure of bleeding pulp. The treatment of choice A. Pulpectomy and apexification B. Pulpectomy with calcium hydroxide
Di l i h l i h d idC. Direct pulp cap with calcium hydroxideD. One‐ appointment root canal treatment
Which of the following injuries to the teeth most often results in l l ipulpal necrosis
A. AvulsionB. Concussion
I i l iC. Intrusive luxationD. Extrusive luxationE. Mid root horizontal root fracture
Waiting to allow intruded permanent central incisors to reerupt in a 8‐year old child will likely lead toA. A healing response and reeruptionB. Calcific metamorphosisC. Internal resorptionD T th di l tiD. Tooth discolorationE. Ankylosis
Rigid splinting of an avulsed permanent incisor will g gmost likely lead toA.Normal healing response B C l ifi t h iB. Calcific metamorphosisC.Replacement resorptionD.Internal resorptionpE. Root fracture
One year ago, a 9-year-old boy fractured a central y g , y yincisor. A current radiograph of the tooth is adjacent. There are no symptoms. The tooth does not respond to pulp testing; however, control teeth do respond. What is the preferred treatment?
1 P lpotom ith Ca(OH)21. Pulpotomy with Ca(OH)2 2. Pulpotomy with formocresol3 Conventional root canal treatment3. Conventional root canal treatment 4. Debridement of the pulp space and apexification
ManagementImmature teeth
A h i h i lik l lA tooth with an open apex is likely to re‐erupt spontaneouslyMonitor the progress of re‐eruption No treatment is needed if tooth re‐erupts into normal position and there is no evidence of pulpal involvement
Mature teethIntruded mature teeth need to be repositioned immediatelyInitial extrusion will be made orthodontically or surgically depending on degree of intrusiondepending on degree of intrusion
PrognosisHigh risk of pulp necrosis; Endodontic therapy is often indicated; possibility of resorption shows the need to follow upp y p p
RecallsEvaluate 4‐6 weeks after trauma and after 6 months; after that yearly recall are indicated
Which of the following injuries to the teeth most often results in pulpalnecrosis?necrosis? 1.Avulsion 2.Concussion 3.Intrusive luxation3.Intrusive luxation4.Extrusive luxation5.Mid-root horizontal root fracture
Which of the following diagnoses represents an injury that causes the tooth to loosen but is not displaced? Concussion Concussion LuxationSubluxationExtrusion Intrusion
If a tooth is avulsed when do you do RCT? 7‐ 10 days after replantation
If a tooth is out of mouth for more than 2 hours, RCT is If a tooth is out of mouth for more than 2 hours, RCT is performed and then the tooth is implanted in socket.
‐ it is first soaked in 2.4% flouride solution acidulated at pH 5.5 ph > 20 min (to retard resorption), the socket is gently curetted ph > 20 min (to retard resorption), the socket is gently curetted and irrigated with saline , rinse tooth with saline and splint for 4‐6 weeks.
Which of the following is the most important factor Which of the following is the most important factor ggaffecting affecting pulpalpulpal response?response?
A)A) HeatHeatB)B) Depth to which dentinal tubules are cutDepth to which dentinal tubules are cutC)C) DesiccationDesiccationD)D) Invasion of bacteriaInvasion of bacteria
Root FracturesLimited to fractures involving roots only; cementum, dentin, and pulp
Tavitian/USC Endo
CORONAL THIRD CORONAL THIRD: ENDO AND ORTHO EXTRUSIONUS OMIDDLE THIRD: SPLINT AND OBSERVEAPICAL THIRD: ENDO TO THE FRACTURE LINE IF NECROTIC APEX IF NECROTIC, APEX USUALLY REMAINS VITAL
There is a root fracture in the apical third of the root of a mandibular tooth What will be the most likely result?mandibular tooth. What will be the most likely result?
1) Root resorption 2) Ankylosis) Vit lit ill b d3) Vitality will be preserved4) Teeth will show internal resorption
There is a root fracture in the middle third of the root in an 11 year old patient. The tooth is mobile and vital. What will you do?
1) Extract2) Pulpectomy3) Splint and observe3) Splint and observe4) Do nothing
l f h h l l d dFailure of tooth with recently placed post and core : Vertical root fracture
Majority of vertical root fractures of endo tx teeth result from: Condensation forces during gutta‐percha fillingpercha filling
Diagnose with perio probe, narrow periodontal Diagnose with perio probe, narrow periodontal pocket width
T i t tiTx is extraction
Radiographic –rarely shows vertical fractures, halo effect, take multiple angles
Radiolucency surrounds tooth uniformly rather than being located at portal of exitbeing located at portal of exit
RCT not indicated if fractured root sections are close together and if pulp remains vital
Semi‐flexible splinting may be necessarySemi flexible splinting may be necessary
APICAL 3RD & VITAL – fill and observe, APICAL 3 & VITAL fill and observe, temporize, no permanent restoration for 3‐6 monthsNON‐VITAL – refer to endodontistMIDROOT – refer to endodontistIn all cases inform patient
File separates File separates –Highest prognosis
l– Apical 1/3 separation – Vital case
Failing RCT where it is not possible (or practical) to retreatDisassemble?Post ? Is it practical???
A patient has a draining sinus tract apical to a maxillary A patient has a draining sinus tract apical to a maxillary lateral incisor. The tooth, which is restored with a post and crown, received a root canal filling and apicoectomy one year ago. Radiographically, the tooth measures 19 mm. in length. g g p y, 9 gAdjacent teeth respond normally to pulp testing. The patient is asymptomatic. Which of the following is the most acceptable treatment?
1. Retreat and refill the canal with gutta‐percha. 2. Retreat and refill the canal, then perform an apicoectomy. 3. Retreat by surgery using a retrofill amalgam. 3 y g y g f g
(MTA or EBA )1. No treatment is necessary unless the patient develops
symptomssymptoms.
REVERSE FILLREVERSE FILLCURETTAGE
ApicoectomyApicoectomy
R i f h i l i f h Resection of the apical portion of the root‐3mm‐area of accessory canalsIndications place a reverse filling gain access to area Indications‐place a reverse filling, gain access to area of pathosis, poorly filled apical portion removedReverse filling : MTA, Amalgam, EBAReverse filling : MTA, Amalgam, EBA
Periradicular surgeryg y
Indications: Non‐negotiable canal, procedural errors, horizontal apical fractureBiBiopsy
h f d h d3‐6 months for radiographic evidence Asymptomatic2‐4 weeks sinus tract gone
Prognosis of a tooth with a broken instrument located 3 mm. from the apex is probably best if the tooth has a
1) vital pulp with a periapical lesion. 2) it l l ith t i i l l i2) vital pulp without a periapical lesion. 3) necrotic pulp with a periapical lesion. 4) necrotic pulp without a periapical lesion4) necrotic pulp without a periapical lesion.
BONE BONE ‐ yesPDL ‐ yesyDENTIN – noCEMENTUM yesCEMENTUM – yesENAMEL ‐ no
Severity of the course of a periapical infection d d th depends upon the :
1) Resistance of the host2) Virulence of the organismg3) Number of organism present4) All of the above5) Only 1 and 25) Only 1 and 2
What is the radiographic sign of successful pulpotomy in a permanent tooth?pulpotomy in a permanent tooth?
1) Open apex2) That the apex has formed3) Loss of periapical lucency4) No internal resorption
Once the root canal is obturated what Once the root canal is obturated, what usually happens to the organism that had previously entered periapical tissues from the canal:
a) They persist and stimulate formulation of granuloma
b) They are eliminated by the natural b) They are eliminated by the natural defenses of the body
c) They re‐enter and re‐infect the sterile canal unless periapical surgery is canal unless periapical surgery is performed
d) They will have been eliminated by various medicaments that were used in the root medicaments that were used in the root canal
PULP NECROSISRESTORATIVE MATERIALSSYSTEMIC MEDICATIONSFLOURIDETETRACYCLINETETRACYCLINE
GENETICENVIRONMENTALENVIRONMENTAL
INTERNAL BLEACHINGWALKING BLEACHDO NOT USE STRONG 30 35% H2O2 DO NOT USE STRONG, 30‐35%, H2O2 (Superoxol or Perhydrol) – CERVICAL RESORPTIONSODIUM PERBORATENeed to put cement barrier between guttapercha and bleaching material percha and bleaching material
DUPLICATE DUPLICATE SYMPTOMSADJACENT AND ADJACENT AND CONTRALATERAL TEETHTEETHCOLDHEATCAVITY TEST PREP
SEE PATIENTSEE PATIENTDIAGNOSETREAT APPROPRIATELY
A patient of record calls late Saturday night because of severe throbbing pain aggravated by because of severe, throbbing pain aggravated by "heat, biting and touching" in a mandibular premolar. What procedure is recommended?
1. Instruct the patient to apply ice intermittently, 1. Instruct the patient to apply ice intermittently, take aspirin, and call Monday for an appointment.
2. See the patient at the office and initiate endodontic treatment.e dodo t c t eat e t.
3. See the patient at the office, remove the carious dentin and place a sedative zinc oxide‐eugenol cement.
4. Prescribe an analgesic and refer the patient to an endodontist.
5. Refer the patient to the hospital oral surgery 5. Refer the patient to the hospital oral surgery department for extraction.
A patient has a mandibular molar with pulp necrosis, pain to percussion, and with no periradicular lesions. The emergency treatment. for this tooth is which of the following? 1 Opening the tooth performing apical trephination tempori ing and checking1.Opening the tooth, performing apical trephination, temporizing, and checking the occlusion 2.Prescribing analgesics and antibiotics and rescheduling the patient 3 Performing pulpotomy temporizing and checking the occlusion3.Performing pulpotomy, temporizing, and checking the occlusion 4.Debriding the canals, temporizing, and checking the occlusion 5. Opening the tooth for drainage and leaving the tooth open
A 6-year-old patient has a dark brown discoloration of his maxillary central incisor. The discoloration started following trauma accompanied with a facial sinus tract. What is the treatment-of- choice? Extraction Pulpectomy Pulpotomy Di lDirect pulp treatment
Mesial of Max 1st Bicuspid pMESIAL ROOT OF MANDIBULAR 1ST MOLAR
DISTAL OF MESIAL ROOT
REMOVE CARIESPREVENT LEAKAGESECURE POSITION FOR CLAMPSECURE POSITION FOR CLAMP
Most commonly used bleaching agenty g g1. Ether 2. Superoxolp3. Chloroform4. Sodium hypochoride4. Sod u ypoc o de
EXPOSED DENTINRECESSION
TTx:SURGERYDESENSITISE
dPremedication‐ RHEUMATIC FEVERAHA Guidelines
P h l i l i h h Pt has large carious lesion, toothache, submandibular facial swelling, fever of 102F. Continuous exudate through gingival sulcus moth Continuous exudate through gingival sulcus, moth eaten radiolucent appearance.Most probable diagnosis: Acute osteomyelitisp g y
Endodontically treated posterior teeth are moreEndodontically treated posterior teeth are more susceptible to fracture than untreated posterior teeth. The best explanation for this is
1. moisture loss. 2. loss of root vitality. 3 l ti d f ti f d ti3. plastic deformation of dentin. 4. destruction of the coronal architecture. 5 increased susceptibility of the enamel to fracture5. increased susceptibility of the enamel to fracture.
ZOE i d t t ti ZOE is a good temporary restoration because :1) less irritant 1) less irritant 2) Increased strength3) Good seal3) Good seal4) Antibacterial
Which of the following is least useful in Which of the following is least useful in children
1) Percussion1) Percussion2) Palpation3) Electric pulp test3) Electric pulp test4) Thermal test
EPTChronis pulpitis‐at a higher currentAcute pulpitis‐lower readingp p gHyperemia lower than normal, higher than acuteNecrosis‐no responseExcites A‐delta fibers‐response does not tell about health or integrity of pulp
EPT – NOT RELIABLE
Pus filled canalNervous ptNervous ptRecent dental traumaI l i iInsulating restorationsImmature tooth
d h h f l fOn a radiograph, the facial root of a maxillary first premolar would appear distal to the lingual root if thedistal to the lingual root if the
1) vertical angle of the cone were increased. ) vertical angle of the cone were decreased 2) vertical angle of the cone were decreased. 3) x‐ray head were angled from a distal
position relative to the premolar position relative to the premolar. 4) x‐ray head were angled from a mesial
position relative to the premolarposition relative to the premolar.
A radiograph shows a lucency that does not appear to move with application of the Clarke’s Principle/ Rule Where is the Clarke s Principle/ Rule. Where is the lucency situated?
1) No way of telling2)Lingual 3)In the canal)B ll4)Buccally
Which Canal is not filled
Canal found by using SLOB rule of xray and filledy g y
Bisphosphonates are used in tx of osteoporosis, Paget’s disease and hypercalcemia associated with certain malignanciesand hypercalcemia associated with certain malignancies
Signs and symptoms:Mucosal ulceration with exposed bone in mandible and maxillaPain or swelling in the affected jawInfectionAltered sensationNumbness or a heavy sensation
Hence:Recognize the risk of osteo necrosis of the Jaw Preventative care includes caries control, conservative periodontic Preventative care includes caries control, conservative periodontic and restorative tx and endo txAvoid extractions
InstrumentsInstrumentsHAND FILESHAND FILESROTARY INSTRUMENTSREAMERSREAMERSBROACHESGATES GLIDDENSGATES GLIDDENS
HAND FILESHAND FILES
STAINLESSSTEEL TITANIUM
K – FILE H – FILE
REAMERS
K – FILE
K FILES K – FILES K‐Files used for apical and body preparation of and body preparation of canalPredominantly by filing action Can be used in action. Can be used in reaming action
K‐files have excellent cutting efficiencycutting efficiencyK‐files give better tactile feelV i tVarious tapersManufactured by twisting a blank SQUARE rod,
d i i f producing a series of cutting flutes
H FILES H – FILES Round tapered stainless steel iwire
Manufactured by using a sharp, rotating cutter to gauge triangular
f d bl k h fsegments out of a round blank shaft.
Cuts in one direction (retraction)Filing action only Filing action only
Fragile ( easily broken)
REAMERSREAMERSManufactured by twisting a blank TRIANGULAR rod a blank TRIANGULAR rod, producing a series of cutting flutes fewer than that of K files that of K – files Used in reaming action only – Clockwise Circular
imotionUsed in canal preparation to shave dentin and enlarge gcanals Used to remove intracanal debrisdebris
INSTRUMENTATION
Action of the instrument determines the general h f h lshape of the canal preparationReaming action produces a round in shapeFili i d l i l i hFiling action produces a canal irregular in shape
TITANIUMTITANIUM
Exceptional flexibility P i Protects against ledging , stripping and strip perforationstrip perforation
BROACHESBROACHESBarbs are notched out of the i t t h ftinstrument shaftIt represent a weakened point.It is used to engage pulpal tissue and take it out (according to Dr L ‐‐‐ yank it (according to Dr L yank it out) It is NOT USED for canal enlargementenlargementIt MUST NOT engage the walls as the barbs may bend / break
# # 8 8 –– GreyGrey ##45 45 –– WhiteWhite# # 8 8 GreyGrey##10 10 –– PurplePurple##15 15 –– WhiteWhite
4545##50 50 –– YellowYellow##55 55 –– RedRed##15 15 WhiteWhite
##20 20 –– YellowYellow##25 25 –– RedRed
##55 55 RedRed##60 60 –– BlueBlue##70 70 –– GreenGreen##25 25 RedRed
##30 30 –– BlueBlue##35 35 GreenGreen
##70 70 GreenGreen##80 80 –– BlackBlack##90 90 –– WhiteWhite##35 35 –– GreenGreen
##40 40 –– BlackBlack##90 90 WhiteWhite##100 100 ‐‐ YellowYellow
Acute or Blow out type ProbingAcute or Blow – out type ProbingNormal sulcus depth around the tooth EXCEPT area of h llthe swellingProbe drops suddenly to a level near apexCl f di i i i l h ( i ) l Clue for diagnosis is non – vital tooth ( necrotic) pulp. The lesion can completely heal after RCTACUTEACUTE
Narrow Sinus Tract type probingNarrow Sinus Tract type probingProbing reveals normal depth around tooth except hthat 1 narrow areaProbe could pass down root surface to or close to apexT h i i l L i h ld h l f RCTTooth is non – vital. Lesion should heal after RCTCHRONIC
Periodontal Lesion Probing Periodontal Lesion Probing Shows bone loss that begins at crestal bone level and
llprogresses apicallyProbing defect would be chronicThi f l i b bl RCT l This type of lesion may not be amenable to RCT alone even if associated with a pulpless tooth however endodontic treatment must be completed prior to endodontic treatment must be completed prior to tackling the problem
Perio endo abscessPerio – endo abscessPerio – endo abscess is a combined lesionLesion usually demonstrates radiographic involvement of the periodontium and the apex of the involved toothtoothPain to lateral percussion on a tooth with wide sulcularpocketpocket
CONTRAINDACATIONS OF RCT
Non‐restorableInsufficient periodontal supportVertical root fractureVertical root fractureNon‐strategic toothM i i t l t l tiMassive internal or external resorptionUnsuitable canal‐ dilaceration, broken filfileHemophilia is not a contraindicationp
Calcified canal
PDL is normalAsymptomaticVital or non vital If tooth remains asymptomatic and no periradicularchanges‐observe
RESTORATION OF ENDODONTICALLY TREATED TEETHTREATED TEETH
Parallel post preferredOnlay to protect tooth from fractureCrown when not enough tooth to do onlayPost can cause perforations or fractureEndodontically treated posterior teeth prone to fracture due to of coronal structure
AGING PULPS
Increase calcificationsIncrease collagen fibersDecrease size of the pulpDecrease size of the pulpDecrease cell population
VITAL TEETHVITAL TEETHCementoma
Traumatic bone cyst
Globularmaxillary cyst
NON‐VITAL TEETH
Apical scarRadicular cystChronic periradicularbabscess
Try and maintain pulp vitalityYoung pulps respond better than old pulps to traumaDisinfectS l Seal