Introduction and Scope of Endodontics

Endo is a Greek word for “Inside” and Odont is Greek word for “Tooth”.
Endodontic treatment treats inside of the tooth.
Definition: Endodontics is the art and science of prevention, diagnosis and treatment
of the pathosis of the dental pulp and peri-radicular tissue.

Objectives of endodontics:

Endodontic treatment is performed to render the affected tooth

1) Biologically acceptable:
The primary objective of endodontic therapy is to create a biologically
acceptable environment within the root canal system which allows the healing
and continued maintenance of the health of the peri-radicular tissue. This
objective can be achieved by eliminating the bacteria (source of infection) from
within the root canal system and sealing the root canal and tooth to prevent re-
infection.
2) Symptomfree.
3) Functioning without any diagnosable pathosis.

Phases of endodontic therapy:

Three basic steps of endodontic treatment are:

1. Diagnostic phase
2. Access cavity preparation
3. Bio-mechanical preparation (preparatory) phase
4. Obturation phase
5. Final coronal restoration
 1. Diagnostic phase.

a) The cause of the disease is identified

b) The treatment plan is developed

2. Preparatory phase: The contents of the pulp chamber and root canals are
removed and the root canal space itself is shaped to receive a three-dimensional
filling.
3. The obturation phase: In which the root canal system is filled with an inert
material to ensure a fluid tight seal.

SCOPE OF ENDODONTICS
The extent of the subject has altered considerably in the last 50 years. Formerly,
endodontic treatment confined itself to root canal filling techniques by conventional
methods, even endodontic surgery, which is an extension of these methods, was
considered to be in the field of oral surgery. Modern endodontics has a much wider
field and includes the following:

INDICATIONS FOR ROOT CANAL TREATMENT

a. Endodontic therapy can be successfully done in the majority of teeth suffering from
pulpal or periradicular pathosis.

b. However there are some teeth, indicated without pulp or periapical pathosis.

1. Teeth that need post and core to rebuild the missing coronal portion of the tooth.

2. Traumatic pulp exposure due to dental work or accidental fracture.

3. Internal resorption.

4. Overerupted and mesially drifted teeth where crown reduction may cause pulp

exposure.
 5. Teeth retained in the mouth to support overdenture.

6. Esthetic requirement: which means that all teeth should be in the same harmony.

CONTRAINDICATIONS FOR ROOT CANAL TREATMENT

Modern Endodontics can solve many problems of what was considered as

contraindications of Endodontic treatment. However, there are some conditions to be
considered when planning for endodontic treatment

1. Teeth with insufficient periodontal support and tooth will not be functioning

well. Unless good periodontal support is present to ensure retention of the tooth,
endodontic treatment is specially planned.
2. Teeth with vertical root fracture. Extraction may be the only solution for single

rooted teeth.
3. Teeth with extensive internal or external resorption or large perforations which

cannot be treated surgically.

4. Non restorable tooth which cannot function properly after treatment. (Such as
teeth with extensive root caries, furcation caries, poor crown/root ratio and with
fractured root are contraindicated for endodontic treatment).
5. Teeth with root canals not suitable for instrumentation (Such as teeth with sharp
curves, dilacerations, calcifications, dentinal sclerosis are treatment difficulties)
making passage of the endodontic instruments to the apex impossible. Though
use of recent instruments and techniques may help sometimes like NiTi files,
anticurvature filing may help sometimes. Several teeth with previous treatment
show canal blockage by broken instruments, fillings, posts, ledges, and
untreatable perforations and canal transportations. So, careful evaluation is
needed before starting treatment in such teeth).
 6. Patients with systemic disease contraindicating surgical endodontics.

7. Teeth with poor prognosis, uncooperative patients or patients where dental

treatment procedures cannot be undertaken.

8. Non-strategic teeth: There are two major factors which render a strategic tooth
to be in a hopeless status; restorability and periodontal support. The tooth that
cannot be restored or that has inadequate, unmanageable periodontal support is
hopeless. Evaluation of the oral cavity can decide whether tooth is strategic or
not, for example, if a person has multiple missing teeth, root canal of third molar
may be needed. But in case of well maintained oral hygiene with full dentition,
an exposed third molar can be considered for extraction.

HISTOLOGY OF DENTAL PULP

The dental pulp is soft tissue of mesenchymal origin located in the centre of the tooth.
It consists of specialized cells, odontoblasts arranged peripherally in direct contact with
dentin matrix. This close relationship between odontoblasts and dentin is known as
“pulp-dentine complex”. The pulp is connective tissue system composed of cells,
ground substances, fibres, interstitial fluid, odontoblasts, fibroblasts and other cellular
components. Pulp is actually a microcirculatory system consists of arterioles and
venules.

Figure 1. histology of the pulp

 Macroscopic anatomy of the pulp space
Pulp lies in the center of tooth and shapes itself to miniature form of tooth. This space
is called pulp cavity which is divided into a pulp chamber and root canal/s starting
from the orifice to the apical foramen.

A thorough knowledge of tooth morphology, careful interpretation of radiograph, and

adequate access and exploration of tooth are important for the success of treatment.

Therefore, to master the anatomic concept of the pulp space morphology, the operator
must develop a mental, three- dimensional image of the inside of the teeth.

PULP SPACE:

It is the entire internal space which contains the pulp it consists of the following
entities:

1) Coronal pulp:
A- Pulp chamber: it is the part of pulp cavity lying in the crown of the tooth. It
consists of:

i. The ROOF of the pulp chamber: the dentin covering the pulp chamber
occlusally or incisally.
ii. The FLOOR of the pulp chamber: the dentin bordering pulp chamber in
the furcation area.
iii. The walls of the pulp chamber: located axially (mesially, distally,
buccally, lingually)

B- Pulp horns: accentuation of the pulp chamber directly under a cusp or a

developmental lobe.
2) Radicular pulp:

A- Root canals: most of root canals have curvature this varies for gradual
curvatures to sharp curvatures.

i. Anatomical apex: is the tip or end of the root, determined morphologically. It

is the point where the neurovascular bundle enters the rooot apex.
ii. Radiographic apex: it is the tip or end of the root determined
radiographically.
iii. Apical constriction: It ends at cemento-dentinal junction, and considered the
narrowest part of the root canal.

The distance between anatomic apex and radiographic apex ranges from (0.5
1mm).

iv. Apical foramen: the exit of the neurovascular bundle which supply the tooth.
It is possible to have many apical foramina in one root.
 Anatomic apex VS Radioographic apex

Apical foramen Vs Apical constriction

 Anatomic apex: is the tip or end of the root, determined morphologically. It is the
point where the neurovascular bundle enters the root apex.
 Radiographic apex: it is the tip or end of the root determined radiographically.

Root morphoology and radiographic distortion may cause the location of the
radiographic apex too vary from the anatomic apex.

 Apical foramen (major diameter/Minor constriction): it is the main opening of the

root canal, through which blood vessels nerves and lymphatic that supply the pulp
enter the canal.

It may be located away from the anatomic or radiographic apex.

It may not always be located at the centre of the apex. It may exit mesial, distal buccal
or lingual.

 Apical constriction (minor foramen/diameter/major constriction): it is the apical

portion of the root canal having the narrowest diameter. It is usually 0.5-1mm short of
apical foramen.
From the apical constriction, the canal widens as it approaches the apical foramen.
 B- Lateral canals: canals that are located approximately at right angles to the
main canal extending from the main canal to the outer surface of the root.

*Lateral canal: Is a canal that is located approximately at right angle to the main root
canal. Lateral canals are clinically significant; like the apical foramen, they represent
pathways along which bacteria and/or their byproducts from the necrotic root canal
might reach the periodontal ligament and cause disease and occasionally allow disease
in periodontium to extend to the pulp.

Lateral canals are not usually visible in preoperative radiographs. Clinically, lateral
canals cannot be instrumented. In this way, their content can only be neutralized by
means of effective irrigation with a suitable antimicrobial solution or with an additional
use of intracanal medication.

lateral canal is defined as an accessory canal located at the coronal or middle third of
the root

*Accessory canal: Is one that branches off from the main root canal, usually located
in the apical region of the root.
Accessory and lateral canals connect the pulp to the periodontal tissue, but many
of these canals are sealed by cementum and/or dentin, however many remain
viable which make them a source of spread of infection even after successful
debridement of the main canal. These canals can be exposed by removal of
cementum during scaling and root planning, which establishes a communication
between the oral cavity and the pulp, which can lead to necrosis.
 Furcation canals: Canals connecting the pulp chamber to the periodontal ligament in
the furcation region of a multirooted tooth. In some cases, furcation canals have been
associated with primary endodontic lesions in the interradicular region of multirooted
teeth. Recently, micro-CT studies have also demonstrated the presence of furcation
canals in two-rooted mandibular canines and three-rooted mandibular premolars.

3) Root canal orifice: Opening in the floor of the pulp chamber leading to the root

canal.
 Types of roots:

Type I: These types have mature root canals (having apical constriction).

Type II: These types have mature root canals but not straight, it could be:

a- Slightlycurved.
b- Severely curved.

c- Dilacerated.

d- Bayonet.

Type III: These types having immature root canals, it could be:

a. Tubular
b. Blunderbuss

They could be either straight or curved roots.

 Root canal systems: (Weine classification)

The shape of root canals is divided into four types:

Class I:

Single root canal, single orifice, and single apical foramen. It refers to 1-1

Class II:

Two root canals, two orifices, and single apical foramen. (Two canals leave the pulp
chamber then join each other at the apical third to open in a single apical foramen.) It
refers to 2-1

Class III:

Two orifices, two root canals, and two apical foramina. It refers to 2-2.

Class IV:

A single canal leaving the pulp chamber, and bifurcating at the apical
third into two canals and open in two apical foramina. It refers to 1-2.

FUNCTIONS OF PULP
Pulp performs four basic functions:
1. Formation of dentine
2. Nutrition of dentine
3. Innervation of tooth
4. Defense of tooth
 Only for reading/ for self knowledge and better understanding.

Why does patient Need Root Canal Therapy?

Because tooth will not heal by itself, the infection may spread around the tissues
causing destruction of bone and supporting tissue. This may cause tooth to fall out.
Root canal treatment is done to thoroughly clean and shape the root canal system and
fill it with gutta-percha to prevent recontamination of the tooth. Then a permanent final
restoration is placed.

Figure 2. Tooth with infected pulp and abscess formation

In summary, the principles of modern endodontic treatment are:

Clean: remove microorganisms and pulpal debris from the root canal system.
Shape: produce a gradual smooth taper in the root canal with the widest part coronally
and the narrowest part 1mm short of the apex.
Fill: obturate the canal system with an inert, insoluble filling material.
That is, the main aim of the endodontic therapy involves:
i. Maintaining vitality of the pulp.
ii. Preserving and restoring the tooth with damaged and necrotic pulp.
iii. Preserving and restoring the teeth which have failed to the previous endodontic
therapy, to allow the tooth to remain functional in the dental arch.