Strategies for Predictable Endo Treatment

ALARA
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Terms in this set (153)
ALARA
As low as reasonably achievable
ALADN
As low as diagnostically necessary
2 Dimesional Radiographic Basics

Ideally we use the _______ technique
Paralleling
2 Dimesional Radiographic Basics

Measurements in software utilize the known:
Sensor Dimensions

Pixel density / Resolution
2 Dimesional Radiographic Basics

Our wire tooth is approximately _____ in vertical dimension
5.2 units
Image: 2 Dimesional Radiographic Basics Our wire tooth is approximately _____ in vertical dimension
2 Dimesional Radiographic Basics

Calibrate the sensor using a ______
Known object
2 Dimesional Radiographic Basics

__________ along with ___________ create unpredictable dimensional changes
Unequal magnification

Foreshortening or elongation
2 Dimesional Radiographic Basics

__________ can at best estimate an objects dimensions
Intraoral radiographs
2 Dimesional Radiographic Basics

___________ provide the best anatomic relationships due to being most parallel and uniform distance
Bitewing radiographs
Shift shots
Image: Shift shots
FlipSilver moved farther right in opposite direction of x-ray Silver = closer to cameraWhich wire is further away?Distal shot Palatal root moved toward distal (SAME LINGUAL) M root = File furthest to right is probably the most buccalWhich one is the MB2?Flip backCBCT radiographic assessment ALARA/ALADNSmallest field required and highest resolution / smallest voxelYou are _________ for everything which may be found on the CBCT scanLiableAAE and AAOMR Joint Position Statement 1: ___________ should be considered the imaging modality of choiceIntraoral radiographsAAE and AAOMR Joint Position Statement 2: CBCT when ________ or ___________ associated with the toothContradictory Nonspecific clinical signs and symptomsAAE and AAOMR Joint Position Statement 3: CBCT potential for ________ and suspected ___________Extra canals Complex morphologyAAE and AAOMR Joint Position Statement 4: CBCT intra-appointment identification and localization of ______________Calcified canalsAAE and AAOMR Joint Position Statement 5: Intraoral radiographs for routine ____________Postoperative imagingAAE and AAOMR Joint Position Statement 6: CBCT if examination and intraoral radiography are inconclusive in the detection of _______________Vertical root fractureAAE and AAOMR Joint Position Statement 7: CBCT when evaluating non-healing of ____________Previous endodontic treatmentAAE and AAOMR Joint Position Statement 8: CBCT for assessment of _________________Retreatment complicationsAAE and AAOMR Joint Position Statement 9: CBCT for __________ treatment planningPresurgicalAAE and AAOMR Joint Position Statement 10: CBCT for surgical placement of ______ImplantsAAE and AAOMR Joint Position Statement 11: CBCT for what type of trauma?Dento-alveolar trauma, root fractures, luxation, and/or displacement of teethAAE and AAOMR Joint Position Statement 12: CBCT for ___________ and determination of appropriate treatment and prognosisResorptive defectsAAE and AAOMR Joint Position Statement 13: Intraoral radiographs for the evaluation of healing following ___________ in the absence of clinical signs and symptomsNonsurgical and surgical endodontic treatmentAAE and AAOMR Joint Position Statement 14: CBCT if CBCT was the __________ at the time of evaluation and treatmentImaging modality of choiceFlipIsolation SealIdentify open margins _______ during NS-RCT and the _______ after treatment is essentialOrientation and accurate anatomic relationshipsCarefully analyze BWx for _______________ Especially important with crowns and FDPs!Pulp calcification and pulp stonesCheck for ____________Cracks, splits, an fracturesLook for _____________FurcationsDon't forget __________PalatalMid-root RL moves and same direction as the shift -> ICR located on _________ side CBCT confirms location and reveals apical foreman is short of radiographic apex1. Dilaceration or bifid apex 2. Darkening of the roots 3. Deflection of the roots 4. Narrowing of the roots 5. Narrowing of the canalIdentification of difficult morphology of roots If near IAN:Confirms the source of sinus tract and somtimes much more Also helpful w/ vertical root fractures and furcation involvementGutta percha trachings...Intraoral radiographA single _____________ can reveal a lotMissed canalPrevious root-filling is off center --> clear indication of a __________ Confirmed with CBCTRetained objects Bone quality (Patient has multiple myeloma)Locate ____________ Identify abnormal ____________Widened PDL space Condensing osteitisIdentify abnormalitiesLocation, size, and level of developmentLook for apical foramen...Vertical root fracturesNot ALL J shaped RLs are _____________CBCTLesions are larger and better detected with __________Iatrogenic eventsIdentify previous ___________ and document them, don't be blamed for something you didn't do!Flip backRadiographic assessment1 PA (straight) 1 PA (shift) 1 BW (if posterior) 1 PA Tracing of sinus tract (if present) Occlusal (trauma) Soft tissue (trauma) Limited Field of View CBCT (when indicated)Rubber dam isolation - AAE Position Statement "Tooth isolation using the dental dam is the ___________; it is integral and essential for any _________ endodontic treatment."Standard of care NonsurgicalRubber dam isolation - AAE Position Statement "Only dental dam isolation minimizes the risk of ____________ by indigenous oral bacteria."Contamination of the root canal systemRubber dam isolation - BenefitsAiding in visualization by providing a clean operating field Preventing ingestion or aspiration of dental materials, irrigants and instrumentsRubber dam isolation - Benefits Preventing ingestion or aspiration of dental materials, irrigants and instrumentsNo informed consent, verbal or written exonerates the use of a rubber dam, under any circumstancesRubber dam isolation - MaterialsClamps Block-out materialsRubber dam isolation - Materials Clamps Wide variety available, depending on ___________Which tooth is being treatedRubber dam isolation - Materials Clamps Ensure that clamp has snug fit around the tooth, it should not __________Freely moveRubber dam isolation - Materials Clamps ________ - May be used in cases where multiple teeth in anterior need isolatingWedjetsRubber dam isolation - Materials Block out materialsEnsures a seal around entire tooth, avoiding possible leaksRubber dam isolation - Materials Block out materials ExamplesKool-Dam OraSealRubber dam isolation Ensure ___________ to best of your ability before placing rubber damProfound anesthesiaRubber dam isolation Isolation in most instances is limited to...Just the tooth receiving endodontic treatmentRubber dam isolation - ModificationsLarge interproximal caries, where excavation may be difficult Compromised tooth structure Severe crowding If tooth is unable to be isolated, clinican may have to re-evaluate restorabilityRubber dam isolation - Modifications Large interproximal caries, where excavation may be difficultClamp tooth behind and buildup tooth being treatedRubber dam isolation - Modifications Compromised tooth structurePlacing clamp on gingiva Wedjets (Take clinical photo and place in patient's chart)The first and arguably the most important phase of non-surgical root canal treatmentAccess openingAccess Opening - Objectives of access preparation1. Remove all caries 2. Conserve sound tooth structure 3. Complete unroofing of pulp chamber 4. Remove all coronal pulp tissue 5. Locate all root canal orifice 6. Achieve direct-line access to apical foramen or initial curvatureKey steps to considerVisualization of the internal anatomy Need to evaluate CEj and occlusal anatomyKey steps to consider Visualization of the internal anatomyUltimately dictates access shape Refers to the radiographic assessment of hte coronal, cervical, and root anatomyKey steps to consider Visualization of the internal anatomy Refers to the radiographic assessment of hte coronal, cervical, and root anatomy1. Estimate the position of the pulp chamber 2. The degree of chamber calicification 3. The number of roots and canals 4. The approximate canal lengthKey steps to consider Need to evaluate CEJ and Occlusal Anatomy Complete reliance on ________ is dangerousOcclusal/lingual anatomyKey steps to consider Need to evaluate CEJ and Occlusal Anatomy Complete reliance on occlusal/lingual anatomy is dangerousCrown could be destroyed Root may not be perpendicular to occlusal/lingual anatomyKey steps to consider Need to evaluate CEJ and occlusal anatomy What is the MOST important landmark for locating pulp chamber and orifices?CEJRelationship of pulp chamber to clinical crownLaw of centrality Law of concentricity Law of CEJRelationship of pulp chamber to clinical crown Law of centralityThe floor of the pulp chamber is always located in the center of the tooth at the level of the CEJRelationship of pulp chamber to clinical crown Law of concentricityThe walls of the pulp chamber are always concentric to the external surface of the tooth at the level of the CEJ The external root surface anatomy reflects the internal pulp chamber anatomyRelationship of pulp chamber to clinical crown Law of CEJThe most consistent, repeatable landmark for locating the position of the pulp chamber Confirms the level of the canal orificesRelationships on the pulp chamber floorLaw of symmetry (except MAX molars) Law of color Law of orifice locationRelationships on the pulp chamber floor Law of symmetry (except MAX molars)1. Orifices of the anals are equidistant from a line drawn in a mesial distal direction through the pulp-chamber floor 2. Orifices of the canals lie on a line perpendicular to a line drawn in a mesial-distal direction across the center of the floor of the pulp chamberRelationships on the pulp chamber floor Law of colorThe pulp chamber floor is always darker in color than the wallsRelationships on the pulp chamber floor Law of orifice locationOrifices of the canals are located: -At the junction of the walls and the floor -At the angles in the floor-wall junction -At the terminus of the root development fusion linesAccess cavity preparation - AnteriorsRemoval of caries and old restorations Feel a "drop" into the pulp chamber Safe-ended bur for deroofing Angled radiographs to assess progress Removal of the incisal pulp horn and lingual shoulderAccess cavity preparation - Anteriors Feel a "drop" into the pulp chamber#2 or #4 round burAccess cavity preparation - Anteriors Safe-ended bur for deroofingEndo-Z Allows internal anatomy to dictate external outline form of accessAccess cavity preparation - Anteriors Removal of the incisal pulp horn and lingual shoulderAllows for straight-line access Better contact of file with walls Reduces risk of transportationAccess cavity preparation - PosteriorsProcess is like anterior access Mandibular teeth have a lingual inclination Outline shape Access penetration should be direct toward the largest canal Identification of all canal orifices Removal of cervical bulge and coronal flaringAccess cavity preparation - Posteriors Process is like anterior accessRemove caries/old restoration, feel "drop" and deroof chamberAccess cavity preparation - Posteriors Mandibular teeth have a lingual inclination Mandibular 1st PMStarting location is halfway up the buccal cusp on a line connecting the cusp tipsAccess cavity preparation - Posteriors Mandibular teeth have a lingual inclination Mandibular 2nd PMRequire less of an adjustment because of less inclinationAccess cavity preparation - Posteriors Mandibular teeth have a lingual inclination Outline shape is...OvalAccess cavity preparation - Posteriors For MAX molarsMesial boundary = line connecting MB to L cusp tips Distal boundary = oblique ridgeAccess cavity preparation - Posteriors For MAND molarsMesial boundary = line connecting MB to ML cusp tips Distal boundary = line connecting B groove to lingual grooveAccess cavity preparation - Posteriors Outline shapeTriangular (3 canals) Rhomboid (4 canals)Access cavity preparation - Posteriors Access penetration should be directed toward the largest canalP for MAX molars D canal for MAND molarsAccess cavity preparation - Posteriors Identificaiton of all canal orificeLaws of symmetry, color and orifice location Found on pulpal floor and do NOT extend into axial wallDefining the working lengthThe length between a coronal reference point and the narrowest diameter of the canalWhere should be working length end? In younger patients (18-25 yo), the average distance from minor diameter to the apical foramen was ___________. In older patients (≥55 yo), the average distance from minor diameter to the apical foramen was _________0.52 mm 0.66 mmRadiographic working length Ending the working length ________ short of radiographic apex does not ensure that overinstrumentation beyond the apical foramen will be avoided in premolars and molars. This may be explained by apical foramen being located __________ in majority of the premolars and molars.0 - 2 mm LaterallyHow reliable is Root ZX? Inside the canal, EAP cannot detect __________ from the foramen. EAP can only detect the major diameter of the root canal terminus. The length of the canal should be measured once the apex mark reached0.5 mmHow reliable is Root ZX? Root ZX located the apical foramen in majority of the cases. 25 out of 26 vital teeth, Root ZX was able to locate the apical foamen within ____________±0.5 mmEAL instructions Make sure _________ is chargedBatteryEAL instructions Electrical connection - Lip clip good contact with _______ and file holder in good contact with ________Mucus membrane FileEAL instructions Always clip the file holder to the __________ of the file shaft, near the ________Upper part HandleEAL instructions File cannot touch ___________Metal restoration (amalgam, gold, crown)EAL instructions Lateral canals if ________ can give a false readingLargeEAL instructions ____________ - Very hard to get accurate readingOpen apexEAL instructions Turn on the unit before plugging in the...Attachments and probeEAL instructions __________ will automatically calibrateRoot ZXEAL instructions Contact metal part of file holder with ___________Contrary elecrodeEAL instructions Check that all canal length indicator bars on display are _________ and audible beep becomes _________Lit ContinuousEAL instructions Wet ______ and dry _________Canal Pulp chamberEAL instructions Advance the ________ until apex reading is obtainedFile (#10)EAL instructions You will hear Root ZX at full tone (_________)Patency lengthEAL instructions Subtract _______ fro mthe length in previous step to get your working length1 mmEAL troubleshootingCheck battery and connections Meter not moving? Meter overreacts once the file is inside the canalEAL troubleshooting Meter not moving?Canal might be calcified Canal might be obstructed Canal might be too dry Canal exists at sharp angle and file cannot negotiate bendEAL troubleshooting Meter overreacts once the file is inside the canalCanal has a large foramen Pulp chamber is too wet Perforation? Are you sure you are in canal? File touching metal restoration File is too smallProper use of wave one instrumentationInstrumentation 1. Establish __________ accessStraight-line coronal and radicularInstrumentation 2. In the presence of a viscous chelator, us a size ______ hand file to verify a glide path to length. Gently work this file until it is completely ________ at length.10 LooseInstrumentation 3. Expand this glide path to at least ______ using either a _________ file such as PathFile, ProGlider, or the dedicated WaveONe Gold Glider file0.15 mm Manual or dedicated mechanical fileInstrumentation 4. ALWAYS initiate the shaping procedure with the _________ in the presence of _________Primary file (25/.07 red) Sodium hypochloriteInstrumentation 5. Use gentle inward pressure and let the __________ passively progress through any region of the canal that has a confirmed glide path. After shaping 2-3 mm of any given canal, remove and clean the PRIMARY file, then irrigate, recapitulate with a size ______ and re-irrigatePrimary file 10 hand fileInstrumentation Utilize a _________ on the outstroke to eliminate ________ or to enhance shaping results in canals that exhibit irregular cross-sectionsBrushing motion Coronal interferencesInstrumentation 6. Continue with the primary file, in 2-3 passes, to pre-enlarge the _________ of the canal. Remove and clean the PRIMARY file, then irrigate, recapitulate with a size 10 hand file and re-irrigateCoronal 2/3rdsInstrumentation 7. Carry the primary file to the full working length in one or more passes. Upon reaching length, remove the file to avoid ___________. Inspect the apical flutes, if they are loaded with ___________, then the shape is finishedOver-enlarging the foramen Dentinal debrisInstrumentation 8. If the primary file is loose at length with no dentinal debris in the apical flutes then continue shaping with ___________ until the apical flutes are loadedMedium file (35/.06 green) and/or large file (45/.05 white)Instrumentation 9. If the primary doesn't progress then use the ________ in one or more passes to working length and then use the primary file to working length to optimize the shapeSmall file (20/.07 yellow)Instrumentation 10. When the shape is confirmed, proceed with ____________3-D disinfection protocolsCommon irrigantsSodium hypochlorite EDTACommon irrigants - Sodium hypochlorite ProsEffective irrigant Disrupts biofilm Antibacterial Dissolves organic tissue Removes organic components of the smear layerCommon irrigants - Sodium hypochlorite ConsCytotoxicity to tissue Foul smell and taste Stains clothingCommon irrigants - EDTAChelating agent - Removes inorganic smear layerIrrigant leakageLeakage from outside the tooth Extrusion from the tooth into periodontal tissuesIrrigant leakage - Leakage from outside the toothRubberdam leakage (improper seal) Syringe leakageIrrigant leakage - Extrusion from the tooth into periodontal tissuesRoot apex Root perforationsPrevention of outside leakageProper PPE Patient bib Patient glasses Examine the rubber dam Always pass/move syringe over the area of the rubber damPrevention of outside leakage Examine the rubber damEnsure seal Floss contacts Liquid dam Build up wallsPrevention of outside leakage Avoid:Eye area, exposed skin, clothingPrevention of extrusion within the toothIrrigation syringe safety Always examine pre-op readiographs for open apices/resoprtion Avoid over-instrumenting Ensure proper working length is maintained Make sure the syringe does not tightly bind to the canal walls Use controlled, constant, short, up and down movements Watch to make sure the irrigant is coming up from the orifice Proper suction Never blow air directly into canaliPrevention of extrusion within the tooth - Irrigation syringe safetyLuer lock syringe Label syringe Side-venting needle Size 30 gaugePrevention of extrusion within the tooth - Irrigation syringe safety Bending needleBend needle AWAY from hub Never bend at the hubPrevention of extrusion within the tooth - Irrigation syringe safety Use ________ while injectingCONTROLLED PRESSUREPrevention of extrusion within the tooth - Irrigation syringe safety Avoid using ___________Base/palm of thumbPrevention of extrusion within the tooth - Ensure proper working length is maintainedMEasure 2-3 mm SHORT of WL Irrigant travels approx. 1 mm past the syringePrevention of extrusion within the tooth - Make sure the syringe does not tightly bind to the canal walslNever wedge the needle Should FIT LOOSELY in the canalPrevention of extrusion within the tooth Use controlled constant, short, up and down movements Effective endodontic irrigation requires both adequate _________ of the irrigant and sufficient ________Penetration VolumePrevention of extrusion within the tooth NEVER BLOW AIR DIRECTLY INTO CANALIAlways dry canals with paperpoints Prevent air embolismHypochlorite accident What to look out forSevere and immediate pain Edema or bruising Can have spontaneous/profuse bleeding from canal space Periorbital pain (Mx posteriors) Irritation to throat Chlorine tasteHypochlorite accident What to look out for (Edema or bruising)Can extend to injured side of face, cheek, lipsHypochlorite accident - Possible serious outcomesParesthesia (transient or permanent) Sensory deprivation Motor dysfunction Mandibular teethHypochlorite accident - Possible serious outcomes Mandibular teethExtension into submandibular, submental, sublingual regions 🡲 Compromise airwayHypochlorite accident managmentCease further treatment immediately Irrigate canal and periradicular areas with saline Evaluate tissue, face, airway Pain control More severe cases require referral to ER and OMFS Monitor closely, frequent follow-ups Changes in swelling, paresthesia, orbital involvement, airway Inform patient, document in recordsHypochlorite accident managment - Pain controlLA, analgesics, NSAIDs, cold compress, Consider Abx