kenneth s. serota, dds, mmsc - endoexperience · diagnosis • nowhere near enough endodontics is...

Kenneth S. Serota, DDS, MMScKenneth S. Serota, DDS, MMSc

You are hereYou are here

Genesis, Exodus,Leviticus, Numbers, Deuteronomy

Genesis, Exodus,Leviticus, Numbers, Deuteronomy

Treatment Outcomes, Diagnosis, Anaesthesia, Access,Ultrasonics, Irrigation, Instrumentation, Obturation, MTA

Treatment Outcomes, Diagnosis, Treatment Outcomes, Diagnosis, AnaesthesiaAnaesthesia, Access,, Access,UltrasonicsUltrasonics, Irrigation, Instrumentation, , Irrigation, Instrumentation, ObturationObturation, MTA, MTA

Diagnosis - EPTDiagnosis - EPT

DiagnosisDiagnosis

Current radiographs – – serial radiographs

• central / mesial / distal• be temporal and systematic – guide the conversation

• chief complaint –P A I N• history, stimulus, severity, frequency, duration,

location, spontaneity• onset, duration

recreate the complaint• Article - Warning signs of Pulpal Insult.pdf

Current radiographs – – serial radiographs

• central / mesial / distal• be temporal and systematic – guide the conversation

• chief complaint –P A I N• history, stimulus, severity, frequency, duration,

location, spontaneity• onset, duration

recreate the complaint• Article - Warning signs of Pulpal Insult.pdf

DiagnosisDiagnosis

• nowhere near enough endodontics is done• major missing piece in diagnosis –

Restorative History• analyze and extrapolate• tooth function and location affects diagnosis

STRESSED PULP

• nowhere near enough endodontics is done• major missing piece in diagnosis –

Restorative History• analyze and extrapolate• tooth function and location affects diagnosis

STRESSED PULP

Treatment OutcomesTreatment Outcomes

Retrospective studies have shown that the success rate of teeth without apical periodontitis remaining free of disease after initial treatment or those with orthograde retreatment is 92 to 98 percent. The chance of teeth with apical periodontitis to completely heal after initial treatment or retreatment is 74 to 86 percent, and their functionality over time determined to be 91 to 97 percent.

The difference in outcome between initial treatment and orthograde retreatment

does not appear to be significant.

Retrospective studies have shown that the success rate of teeth without apical periodontitis remaining free of disease after initial treatment or those with orthograde retreatment is 92 to 98 percent. The chance of teeth with apical periodontitis to completely heal after initial treatment or retreatment is 74 to 86 percent, and their functionality over time determined to be 91 to 97 percent.

The difference in outcome between initial treatment and orthograde retreatment

does not appear to be significant.

Effects of 4 Ni-Ti preparation techniques on root canal geometry

[assessed by micro-computed tomography]

Effects of 4 NiEffects of 4 Ni--Ti preparation techniques Ti preparation techniques on root canal geometryon root canal geometry

[assessed by micro[assessed by micro--computed tomography]computed tomography]

Peters OA, Schonenberger K, Laib A. Int Endod J. 2001Peters OA, Schonenberger K, Laib A. Int Endod J. 2001Peters OA, Schonenberger K, Laib A. Int Endod J. 2001

Maxillary molars ....all instrumentation techniques left 35% or more of the canals' surface area unchanged. ….a strong impact of variations of canal anatomywas demonstrated..

Maxillary molars ....all ....all instrumentation techniques instrumentation techniques left 35% or more of the canals' left 35% or more of the canals' surface area surface area unchangedunchanged. . …….a strong impact of .a strong impact of variations of variations of canal anatomycanal anatomywas demonstrated..was demonstrated..

Pulpal and Periapical DiseasePulpal and Periapical Disease

physicalchemical

microbiological

• caries• trauma

• microleakageabfraction/fractures• dentinal exposure

physicalchemical

microbiological

• caries• trauma

• microleakageabfraction/fractures• dentinal exposure

Irritation of the pulpIrritation of the pulp

microbiologicalmicrobiological

Endodonticsis

Endodonticsis

The Prevention & Treatment

of

Apical Periodontitis

The Prevention & Treatment

of

Apical Periodontitis

Pulpal and Periapical DiseasePulpal and Periapical Disease

Oral microorganismsOral microorganisms

Debridement & DisinfectionDebridement & Disinfection

‘cleaning and shaping’the root canal system

‘cleaning and shaping’the root canal system

IS MUCH MORE THANIS MUCH MORE THAN

Canal Anatomy - ComplexCanal Anatomy - Complex

Root Canal TherapyRoot Canal Therapy

MechanicalInstrumentation

MechanicalInstrumentation IrrigationIrrigation

Intra-canal medicationIntra-canal medication

R.C. FillingR.C. Filling

Microbial Control PhaseMicrobial Control Phase

Control of Endodontic InfectionControl of Endodontic Infection

1. Mech. preparation1. Mech. preparation

Apical Apical ApertureAperture PreparationPreparation

Volu

me

of

Volu

me

of

Mic

robi

al C

onte

nts

Mic

robi

al C

onte

nts #25

#30

#35

#40

Card et al. JOE 2002Sjøgren U et al. IEJ 1997 Ørstavik D et al. IEJ 1991Bystrøm et al. EDT 1987Kerekes et al. JOE 1979

Card Card et al. JOE 2002et al. JOE 2002SjSjøøgren U et al. IEJ 1997 gren U et al. IEJ 1997 ØØrstavik rstavik D et al. IEJ 1991D et al. IEJ 1991BystrBystrøøm m et al. EDT 1987et al. EDT 1987Kerekes Kerekes et al. JOE 1979et al. JOE 1979

Effect of Ca(OH)2 on Microorganismsin Necrotic Pulp

Effect of Ca(OH)2 on Microorganismsin Necrotic Pulp

1- 4 weeks1- 4 weeks

200µ200µ

Endo is not little round holesEndo is not little round holes

Thermafil condenser removed from palatal canal

• floor is not clean nor sealed• debridement not achieved with

instruments nor irrigation protocol• neither straight line nor coronal

access adequate

Thermafil condenser removed from palatal canal

• floor is not clean nor sealed• debridement not achieved with

instruments nor irrigation protocol• neither straight line nor coronal

access adequate

Reasons for Shape/DesignReasons for Shape/Design

Convenience form• minimize overpreparation• gg’s - #1, #2, maybe #3• NiTi rotary systems

Resistance form• taper

Retention form• avoid apical displacement• Apical Control Zone

Convenience form• minimize overpreparation• gg’s - #1, #2, maybe #3• NiTi rotary systems

Resistance form• taper

Retention form• avoid apical displacement• Apical Control Zone

Goals and ObjectivesGoals and ObjectivesA substantial reduction in post treatment symptoms occurs when

using a crown down approach with rotary instruments as they are designed to remove debris coronally

A substantial reduction in post treatment symptoms occurs when using a crown down approach with rotary instruments

as they are designed to remove debris coronally

Goals and ObjectivesGoals and Objectives

“State of The Art”Gutta-Percha + Sealer?


• entomb existing bacteria• prevent coronal and apical

leakage• strengthen the root

• entomb existing bacteria• prevent coronal and apical


Bacteria and PrognosisBacteria and PrognosisSuccess by culturing resultsSuccess by culturing results

+ve culture+ve culture -ve culture-ve culture

Engstrom et al (1964)Engstrom et al (1964) 76%76% 89%89%

Zeldkow & Ingle (1963)Zeldkow & Ingle (1963) 83%83% 93%93%

Oliet & Sorin (1969)Oliet & Sorin (1969) 80%80% 91%91%

Sjögren et al. (1997)Sjögren et al. (1997) 68%68% 94%94%

Bystrom et al (1987)Bystrom et al (1987) 95%95%

Bacteria and PrognosisBacteria and PrognosisSuccess by culturing resultsSuccess by culturing results

+ve culture+ve culture -ve culture-ve culture

Engstrom et al (1964)Engstrom et al (1964) 76%76% 89%89%

Zeldkow & Ingle (1963)Zeldkow & Ingle (1963) 83%83% 93%93%

Oliet & Sorin (1969)Oliet & Sorin (1969) 80%80% 91%91%

Sjögren et al. (1997)Sjögren et al. (1997) 68%68% 94%94%

Bystrom et al (1987)Bystrom et al (1987) 95%95%

If bacteria were entombed,

there would be NO difference

in the healing of teeth with PA lesions

If bacteria were entombed,

there would be NO difference

in the healing of teeth with PA lesions



• entomb existing bacteria • prevent coronal and apical


• entomb existing bacteria • prevent coronal and apical


October / 05 JOEOctober / 05 JOESusceptibility of a Polycaprolactone-Based Root CanalFilling Material to Degradation. II. Gravimetric Evaluationof Enzymatic Hydrolysis…..Tay et al

Susceptibility of a Polycaprolactone-Based Root CanalFilling Material to Degradation. II. Gravimetric Evaluationof Enzymatic Hydrolysis…..Tay et al

Polycaprolactone is susceptible to enzymatic biodegradation via ester bond cleavage. This study examined the susceptibility of Resilon, a polycaprolactone-based root filling material to enzymatic hydrolysis. Resilon, gutta-percha, and polycaprolactone disks, prepared bycompression molding, were incubated in phosphatebuffered saline, lipase PS or cholesterol esterase at 37°C for 96 h. They were retrieved at different time intervals for gravimetric analysis and scanning electron microscopy. The materials exhibited slight weight gains when incubated in phosphate-buffered saline that can be attributed to water sorption. Gutta-percha showed similar weight gains in

the two enzymes. Conversely, Resilon and polycaprolactone exhibited extensive surface thinning and weight losses after incubation inlipase PS and cholesterol esterase. Glass filler particles in Resilonwere exposed following surface dissolution of the polymer matrix, creating rough surface topography. Biodegradation of Resilon by bacterial and salivary enzymes warrants further investigation oftheir activities using cultures of endodontically relevant microbes and human saliva extracts.

Polycaprolactone is susceptible to enzymatic biodegradation via ester bond cleavage. This study examined the susceptibility of Resilon, a polycaprolactone-based root filling material to enzymatic hydrolysis. Resilon, gutta-percha, and polycaprolactone disks, prepared bycompression molding, were incubated in phosphatebuffered saline, lipase PS or cholesterol esterase at 37°C for 96 h. They were retrieved at different time intervals for gravimetric analysis and scanning electron microscopy. The materials exhibited slight weight gains when incubated in phosphate-buffered saline that can be attributed to water sorption. Gutta-percha showed similar weight gains in

the two enzymes. Conversely, Resilon and polycaprolactone exhibited extensive surface thinning and weight losses after incubation inlipase PS and cholesterol esterase. Glass filler particles in Resilonwere exposed following surface dissolution of the polymer matrix, creating rough surface topography. Biodegradation of Resilon by bacterial and salivary enzymes warrants further investigation oftheir activities using cultures of endodontically relevant microbes and human saliva extracts.

Swanson et al. 1987 - Dye leakage to apex

Torabinejad et al. 1990 - Bacteria to apex

Khayat et al. 1993 - Bacteria to apex

Trope et al. 1994 – Endotoxins to apex

Swanson Swanson et al. 1987 et al. 1987 -- Dye Dye leakage leakage to to apexapex

Torabinejad Torabinejad et al. 1990 et al. 1990 -- Bacteria Bacteria to to apexapex

Khayat Khayat et al. 1993 et al. 1993 -- Bacteria Bacteria to to apexapex

Trope et al. 1994 Trope et al. 1994 –– Endotoxins Endotoxins to to apexapex

Coronal LeakageCoronal Leakage

Permaflo PurplePermaflo Purple

CLPCLPCLP

Tricks of the TradeTricks of the TradeLocate root canal orifices – stains, caries detection agentsLocate root canal orifices – stains, caries detection agents

Tricks of the TradeTricks of the Trade

Dentin of floor is darker than axial dentinAssess wet, never dry

Dentin of floor is darker than axial dentinAssess wet, never dry

Tricks of the TradeTricks of the Trade• > flare of mesial wall of molars by extension into

marginal ridge with > o of apical curvature• bevel cavo surface angle to improve optics

• > flare of mesial wall of molars by extension into marginal ridge with > o of apical curvature

• bevel cavo surface angle to improve optics

X-TipX-Tip

Uses• disassemble restorations • UNcover hidden or calcified canals!• remove canal obstructions• post/core removal• separated instrument removal• agitate/energize irrigants• apical surgical preparations

Uses• disassemble restorations • UNcover hidden or calcified canals!• remove canal obstructions• post/core removal• separated instrument removal• agitate/energize irrigants• apical surgical preparations

Trough the Line!Trough the Line!

Think ZThink Z

Even the world spins on an axisEven the world spins on an axis

Root Canal SYSTEMRoot Canal SYSTEM

Three Dimensions X, Y, ZThree Dimensions X, Y, Z

• access the apical terminus NOT the orifice• align cusp tip + pulp horn + orifice of the root canal space

+ the apical constriction

• access the apical terminus NOT the orifice• align cusp tip + pulp horn + orifice of the root canal space

+ the apical constriction

Straight Line AccessReproducible Glide Path

Straight Line AccessReproducible Glide Path

G.V. Black – he da man!G.V. Black – he da man!

Maxillary Anterior TeethMaxillary Anterior Teeth

• extension into incisal edge minimizes apical misadventure and maximizes debridement

• extension into incisal edge minimizes apical misadventure and maximizes debridement

Lingual TriangleLingual Triangle

Initial PenetrationInitial Penetration

Incisal TriangleIncisal Triangle

Maxillary Anterior TeethMaxillary Anterior Teeth

Mandibular Anterior TeethMandibular Anterior Teeth

Mandibular Incisor TeethMandibular Incisor Teeth

• must prepare access into incisal edge

• will miss lingual canal if straight line access not developed

• must prepare access into incisal edge

• will miss lingual canal if straight line access not developed

Maxillary Premolar TeethMaxillary Premolar Teeth

Mandibular Premolar TeethMandibular Premolar Teeth

Chromatic TopographyChromatic Topography

A road map exists, floor of the pulp chamber – dentin is darker than axial walls, fusion lines map the location of the orifices……..hypochlorite soak, etch, caries detection agents…..a road map exists beneath the layers

A road map exists, floor of the pulp chamber – dentin is darker than axial walls, fusion lines map the location of the orifices……..hypochlorite soak, etch, caries detection agents…..a road map exists beneath the layers

Maxillary Molar TeethMaxillary Molar Teeth

The spatial orientation of orifices is

The spatial orientation of orifices is

asymmetricalasymmetricalasymmetrical

Relocation of the canal orificesRelocation of the canal orifices

Mandibular Molar TeethMandibular Molar Teeth

Middle MesialMiddle Mesial

0 to 15%0 to 15%

ApexificationApexification

Clinical Procedures• apply MTA• confirm with x-ray• moist pellet• 4 hours setting time• seal canal with

gutta-percha

Clinical ProceduresClinical Procedures•• apply MTAapply MTA•• confirm with xconfirm with x--rayray•• moist pelletmoist pellet•• 4 hours setting time4 hours setting time•• seal canal with seal canal with

guttagutta--perchapercha

Pulp CapPulp Cap

PulpotomyPulpotomy

Indications• large pulp exposure• no symptoms

IndicationsIndications•• large pulp exposurelarge pulp exposure•• no symptomsno symptoms

PulpotomyPulpotomy

Clinical Procedures• MTA• moist pellet• temp filling• 1 week perm filling• check vitality every

3 to 6 months

Clinical ProceduresClinical Procedures•• MTAMTA•• moist pelletmoist pellet•• temp fillingtemp filling•• 1 week perm filling1 week perm filling•• check vitality every check vitality every

3 to 6 months3 to 6 months

Internal Resorption

Repair

Internal Resorption

Repair

Extra-radicularPerforation Repair

Extra-radicularPerforation Repair

Pre-OpDr. Lisa Germain

Pre-OpDr. Lisa Germain

5 month follow-up5 month follow-up

Iatrogenic PerforationMTA repair

4 – 6 hour setting timeNEVER USE RCPREP, PROLUBE

OR GLYDE WITH MTA

Iatrogenic PerforationIatrogenic PerforationMTA repairMTA repair

4 4 –– 6 hour setting time6 hour setting timeNEVER USE RCPREP, PROLUBENEVER USE RCPREP, PROLUBE

OR GLYDE WITH MTAOR GLYDE WITH MTA

FurcationPerforationFurcation

Perforation

FurcationPerforation Repair

FurcationPerforation Repair

Procedures

• MTA

• moist pellet

• temp filling

• complete RCT

• perm filling

ProceduresProcedures

•• MTAMTA

•• moist pelletmoist pellet

•• temp fillingtemp filling

•• complete RCTcomplete RCT

•• perm fillingperm filling

Furcal MisadventureFurcal Misadventure

Root End RepairRoot End Repair

• flap• osteotomy• root-end resection• root-end preparation• control bleeding• lack of moisture control

makes MTA unmanageable

•• flapflap•• osteotomyosteotomy•• rootroot--end resectionend resection•• rootroot--end preparationend preparation•• control bleedingcontrol bleeding•• lack of moisture control lack of moisture control

makes MTA unmanageablemakes MTA unmanageable

Root End RepairRoot End Repair

Place MTA with small carrier• condense• moist pellet• do not rinse!• suture

Place MTA with small carrierPlace MTA with small carrier•• condensecondense•• moist pelletmoist pellet•• do not rinse!do not rinse!•• suturesuture

kenneth s. serota, dds, mmsc - endoexperience · diagnosis • nowhere near enough endodontics is...

Documents