Endodontic Treatment

Anatomy and Pathology

Inside the tooth lies the dental pulp, a loose connective tissue. In single-rooted teeth, it transitions smoothly from the coronal to the radicular part, whereas in multi-rooted teeth, this border is clearly localized at the level of the canal orifices. Around the root, between the cementum and the alveolar bone, is the periodontal ligament.

The primary reasons for endodontic intervention are inflammatory processes:

• Pulpitis — inflammation of the dental pulp, most commonly associated with deep caries. It can present acutely or progress to a chronic form.
• Apical periodontitis — inflammation of the tissues surrounding the root apex. It develops when root canals become infected due to untreated pulpitis or gross medical errors.

Methods of Pulpitis Treatment

Treatment tactics depend on the clinical presentation and the form of inflammation.

1. Biological (conservative) method. Used in cases of accidental pulp exposure or inflammation of a small coronal area. The goal is to keep the pulp vital. It involves the placement of special therapeutic liners (direct or indirect pulp capping). Treatment requires multiple visits, cavity preparation, and strict asepsis. The use of alcohol or hydrogen peroxide is strictly prohibited. The method is considered insufficiently reliable and is rarely used.
2. Surgical methods. These include all other approaches, the essence of which reduces to partial or complete extirpation (removal) of the pulp.

Opening and Unroofing of the Dental Pulp Chamber

Access to the root canal system is created in two stages:

• Opening. This is the creation of a primary point communication between the carious cavity and the pulp chamber. It is performed using a round bur directed toward the most prominent pulp horn.
• Roof removal (unroofing). This is the complete excision of the chamber roof to provide unobstructed access to the orifices. Fissure burs are used (preferably with a non-cutting tip, e.g., Endo-Z, to avoid perforating the chamber floor).

Signs of proper unroofing:

• The roof is removed entirely, with no overhanging dentin edges.
• The walls of the carious cavity and the pulp chamber form a single smooth contour.
• Endodontic instruments enter the canal straight, without shaft bending.

General Rules for Access Cavity Preparation

Access is prepared using a turbine handpiece with a diamond or carbide bur. Initially, the bur moves perpendicular to the surface, and upon breaking through ("dropping" into the chamber), it is aligned parallel to the long axis of the tooth.

Features by tooth groups:

• Incisors: trephination strictly from the palatal/lingual side (in the center of the crown). Access from the incisal edge is unacceptable (leads to fracture of the walls). On intact maxillary lateral incisors, entry is made in the blind pit (fovea caeca).
• Maxillary premolars: unroofing is performed in a buccopalatal direction. The chamber floor lies subgingivally. Common errors include creating two holes instead of complete unroofing and extension in the mesiodistal direction (risk of proximal wall perforation).
• Mandibular premolars: in the first premolars, the crown is lingually inclined relative to the root — this must be taken into account to avoid perforation.
• Molars: opening begins in the mesial fissure, directing the bur toward the mesiobuccal cusp. If secondary dentin is present, orientation can be based on the widest canal (usually the palatal or distal one).

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Features of preparation of maxillary second and third molars
• Crown morphology variants of maxillary second molars
• Technique for working with non-cutting tip endodontic burs
• Indications and application technique for therapeutic liners
• Topography of root canal orifices in various tooth groups

Other topics in "Chapter 7. Endodontics"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.