422 RDS

Clinical Endodontic Procedures

Academic Year 2011-2012G [1432-1433H]

Course Director:

DR. EBTISSAM AL-MADI

COURSE DESCRIPTION AND OBJECTIVE

Course Description:

This course is given to the 4^th year level students who have successfully completed course 322 RDS in theory and practical part. It continues with the endodontic instruction learned in 322 and elaborates on the theoretical part, while giving students clinical experience and exposure to actual patient treatment. The emphasis of the course is the integration between the clinical and biological principles. The students will be trained to treat endodontically involved teeth – anterior and posterior. In addition, they will be trained to manage endodontic emergencies, traumatic injuries, and follow up endo lesions.

The Course Components:

The course is composed of lecture and clinical components, in which the students must learn to recognize, diagnose and treat pulpally and periapically involved teeth. Students will also learn to relate endodontics to various dental disciplines.

Concepts & Skills:

At the completion of 422 RDS, students should be able to:

1. Diagnose endodontic pain by organizing clinical findings, symptoms and pain history in a systematic manner.

2. Utilize endodontic tests to determine pulp vitality.

3. Establish a differential diagnosis of odontogenic and non-odontogenic pain.

4. Establish a differential diagnosis between endodontic and periodontal disease.

5. Recognize major pulpal and periapical pathology and their sign and symptoms.

6. Record status of the pulpal and periapical tissue through clinical and radiographic examinations both in clinical forms, files, and endodontic summaries.

7. Plan and deliver routine non-surgical endodontic treatment to patients with pulpal and periapical disease.

8. Select cases for treatment based on knowledge, experience and ability.

9. Recognize need for and refer cases beyond level of the course.

10. Determine the prognosis of the treated tooth.

11. Recognize the need for endodontic surgery in appropriate cases.

12. Identify the need for adjunctive procedures subsequent to endodontic therapy.

13. Plan and refer case for appropriate restoration.

14. Recall treated patients, and be aware of the value of post-operative follow-up (recall), and continuing prognosis.

15. Diagnose, evaluate and perform retreatment on suitable cases.

16. Be exposed to trauma cases, emergency cases, endo-perio cases, bleaching and preventive therapy cases.

17. Exposure to new endodontic technologies; such as apex locators, rotary instrumentation, innovations in irrigation, and contemporary obturation techniques.

COURSE REQUIREMENTS:

It is expected that each student will:

Attend all the lectures, quizzes, exams and clinical sessions. Absences will be looked upon with disfavor and it will be reported to the administration when it reaches 25% or above.

The following minimum requirements MUST be completed:
1. Two single rooted teeth
2. A premolar with two canals
3. Three (3) molars (upper and lower). THIRD MOLAR TEETH SHOULD NOT BE TREATED
4. A retreatment case (regardless # of canals- this will be considered as both a retreatment case and one of the above requirements).
5. Two (2) recall case, with a minimum of 3 months passed from treatment, and they MUST BE RESTORED

Preventive endodontic therapy and management of deep carious lesions (CARIES CONTROL), and other procedures approved by the instructor are considered as part of the course.

COURSE GRADING:

– Attendance

– Assignments= 5%

– Quizzes= 5%

– Midterm = 10%

– Final = 20%

– Requirements = 45%

– Daily knowledge evaluation, attitude and prompt attendance= 5%

– Oral exam= 10%

– Total= 100%

A point system will be applied to the requirements; the points will be accumulated for each case to include the following factors:

· Difficulty of case (patient factor)

· Number of canals

· Curvature of the canals

· Accessibility of the tooth

· Retreatment case (removal of GP)

· Caries control

· Vital pulp therapy

· Extra procedure (build-up, gingivectomy, etc.)

· Initial access and pulp extirpation

· Completed case (all endodontically involved teeth in pt)

· Partial procedures (incomplete pt’s)

· Final Restoration of case

· recall

• Cases that are of poor quality, and considered for retreatment will not be credited as requirements.

• Student must pass theoretical and practical parts.

Required Textbook

• Principles & Practice of Endodontics

– Walton & Torabinejad 4^th ed (2009)

• Additional reading is encourage

– Pathways of the pulp 9^th ed. , Cohen & Hargreaves

– Endodontics 5^th ed. , Ingle

Instructors:

To be announced

CLINICAL PROTOCOL

• Prompt attendance to the clinic is mandatory. You are responsible for signing the attendance sheet which will be with the head nurse of the clinic (sheet will be available at the first 15 minutes of the session).

• Clean & tidy attire & clinic is important as this is your presentation of yourself and your profession to the patient.

• Infection control measures must be utilized, with barriers in place, overgloves and adequate handling of equipment. The protection of the patient and your team as well as yourself is your responsibility, failure to comply with infection control procedures will result in a significant loss of points and/or suspension from the clinic.

• The patient must be booked by the booking area, and patient placed by the booking area to another student because you did not book the patient means the patient is not yours.

• After diagnosis of the case, and before proceeding with treatment, the form must be completed with instructor's signature for diagnosis.

• Start check must be signed BEFORE any procedure, this indicates your instructor has seen the case- failure of start-check will result in (0) for that clinic daily evaluation.

• Working without a rubber dam is prohibited, if you can’t put it on- do not proceed. Failure to comply will lead to suspension.

• Sign each procedure as soon as you perform it, indicating that your instructor has approved it, otherwise don’t expect your instructor to fill it in later.

• Every procedure & file must be signed before 4:30pm, to allow time for clean up and return of instruments, as stated by the director of clinics.

• If your patient did not show up within 30 minutes, you should get an emergency case. If there are no emergency patients, you have to assist one of your classmates. You are not allowed to leave the clinical hall before 4:30 P.M.

• Extra cases are encouraged as the point system means the more you work, the more you will gain points (and more importantly experience).

• Be sure to fill in all fields of your endodontic form, including your name and comp. number. Keep radiographs in endodontic envelopes, and keep them in a clear plastic envelope to prevent radiographs from getting lost. Keep all envelopes after grading in your logbook.

• Complete set of radiographs (pre-operative, initial file, master file, master cone, intermediate and final) must be presented. Radiographs of finished case must be mounted dated and placed in the envelope, make sure to mount the radiographs, with the correct orientation (dot facing you), in a plastic frame as you take them starting with the initial (diagnostic) radiograph and date each radiograph as you add them to the frame. You must mount your radiograph as you get it from the processor and before you show it to your instructor. The final radiograph must be after placement of temporary restoration and rubber dam removal. A second copy of radiographs of the finished case must be mounted, dated and placed in the patient's file.

• You must be ready for the step you are going to perform that day, you should be prepared for a quiz on how to perform that step, failure to demonstrate an acceptable level of understanding the biological and mechanical principles for the intended clinical procedure might result in dismissal of your patient, You should also be ready for oral questions each session. Knowledge will be evaluated by your instructor each session and will be graded.

• Present cases to the course director as soon as you finish the case, to allow evaluation of your progress. Cases must be accompanied by a Summary of Case (see template), this summary should include your examination, diagnosis, and treatment rendered, as well as complications and prognosis of the case. Logbooks must also be presented in a timely manner when requested.

PROCEDURAL SEQUENCE:

v Have your instrument set-up ready.

Ø Rubber dam set-up

Ø High-speed handpiece

Ø Low-speed handpiece

Ø Endodontic bur block

Ø Endodontic files

Ø Sodium hypochlorite and saline

Ø Glass slab

Ø Sealer cement (AH26)

Ø Appropriate single and double radiographic films

Ø Cotton pellets

Ø Absorbent paper points

Ø Cavit

v Carefully review the patient’s record and his/her medical history, indicate any medical conditions, allergies, and/or medications.

v Carefully document the patient’s pain history, with emphasis on duration, frequency, character, and triggering/relieving factors.

v Complete the clinical diagnosis:

v Extra-oral Examination.

v Fill in the ENDODONTIC CLINICAL form (all data must be completed).

v Obtain a current pre-operative radiograph "today" of the involved area including any questionable adjacent or opposing teeth. Mount the radiograph in a (6-8 slot) plastic frame, with correct orientation, and with the name of the patient, patient number, and date written on the frame. Make sure to correctly mount and date each subsequent radiograph before you show it to your instructor.

v Obtain the following diagnostic tests on each and every case even if the tooth involved and diagnosis are obvious:

Ø Ice test (involved tooth/teeth and at least two controls, one ipsilateral and one contrallateral).

Ø Percussion test (involved tooth and adjacent teeth)

Ø Palpation (involved quadrant)

Ø Periodontal pockets (walking probing around the involved tooth/teeth and 6 points probing for the teeth mesial and distal to the involved tooth)

v Administration of local anesthesia.

v Tooth isolation.

v Pulp extirpation. Remove pulp chamber contents with an excavator or barbed broach if indicated.

v Determine initial file.

v Working length radiograph should be taken, remember you must use at least a size 15 file. Apex locators are encouraged to be used with your instructor permission, however this does not negate WL radiograph, only decrease repititions.

v Record the working length.

v Instrumentation of all canals 3-5 files larger than the initial file (depending on the root anatomy).

v Irrigation of the canals between filing.

v Take a radiograph with master apical file (MAF).

v Flare the canals using the step-back technique, check flare with the spreader.

v Check the master cone, it has to go to the same length as the MAF, with tug-back, and the same size.

v Complete obturation with gutta-percha and AH26 using cold lateral condensation.

v Temporization e.g. Cavit, IRM, temporary crown cemented, etc.

v Occlusal adjustment if needed.

v You should take final post-operative radiograph after temporization and rubber dam removal.

v Advise patient about post-op complications (e.g. possibility of post-op. Discomfort).

v Advise the patient on the importance of getting a final restoration.

v Refer patient for final restoration. Appropriate final restoration is a crown for posterior teeth (premolars and molars) and a crown or tooth colored restoration for anterior teeth depending on the condition of the remaining tooth structure.

RECORD AND PATIENT TREATMENT

In order to maintain a professional clinical practice and to comply with the school’s clinical regulations, we need to develop a uniform format for writing up patient's record of treatment (patient’s file). The following items must be included, maintaining the sequence:

1. History of involved tooth (e.g. patient had discomfort on mastication two days following last appointment, etc.). Record of any communication with the patient's physician, etc.

2. Diagnostic examination: write down all clinical findings. (Ice test, percussion, palpation, probing)

3. Record of any previous treatment done to the involved tooth before starting your treatment (e.g. tooth had amalgam filling 5 years ago).

4. Indicate if pre-op radiograph were taken before you start.

5. Amount and type of anesthesia including topical, if no anesthesia was administered, state no anesthesia. For an example under local anesthesia, 2% xylocaine with 1:100,000 adrenaline 3.6 ml, inferior alveolar nerve block …...

6. Isolated with rubber dam.

7. Caries removal.

8. Indicate if the pulp was pathologically exposed during caries removal.

9. Pulp disposition, e.g. bleeding vital, necrotic, etc.

10. Working length radiograph findings including type, length and size of file(s) and reference points.

11. Record any untoward and unusual happening e.g. patient experienced discomfort when entering the pulp chamber, broken file or perforation (indicate the canal and location), etc.

12. Record instrumentation. Write down a table with the canal, reference point, length etc.

Canal	Reference point	Initial length (I.L.)	Working length	Master apical file
B	Buccal cusp	19 mm (#15K)	21 mm	#35 (21 mm)
P	Palatal cusp	20 mm (#20H)	19 mm	#40 (19 mm)

13. Master cone radiograph taken. Describe it, e.g. 0.5 mm short.

14. Obturation including the name of the sealer cement (e.g. AH26) and the technique e.g. cold lateral condensation.

15. Temporization e.g. Cavit, IRM, temporary crown cemented, etc.

16. Occlusal adjustment if it is done.

17. Post-obturation radiograph should be taken after temporization and rubber dam removal.

CLINICAL ENDODONTIC

Saturday 1:00 - 2:00 P.M.

Room #202 [MUC]

LECTURE OUTLINE

	DATE	TITLE	PAGE NO.	FACULTY
1	10 Sept 2011	Introduction	Course syllabus	Dr. Ebtissam Al-Madi
2	17 Sept 2011	Clinical Diagnostic procedures	Ch. 5	Dr. Ebtissam Al-Madi
3	24 Sept 2011	National Day Vacation
4	1 Oct 2011	Preparation for clinical Endodontic therapy (Assignment 1 Due)	Ch. 8,11,14	Dr. Ebtissam Al-Madi
5	8 Oct 2011	Clinical endodontics	Ch. 14, 15,17	Dr. Ebtissam Al-Madi
6	15 Oct 2011	Endodontic retreatment (Quiz #1)	Ch. 19	Dr. Ebtissam Al-Madi
7	22 Oct 2011	Restoration of endodontically treated teeth	Ch. 16	Dr. Ebtissam Al-Madi
8	29 Oct 2011	Midterm Exam Collect Log books		Dr. Ebtissam Al-Madi
	31 Oct- 11 Nov	Hajj Vacation
9	12 Nov 2011	Endo-perio relationship	Ch. 6	Dr Sumaya BaSoudan
10	19 Nov 2011	Endodontic emergency treatment (Assignment 2 Due)	Ch. 9	Dr. Ebtissam Al-Madi
11	26 Nov 2011	Discoloration & Bleaching	Ch. 22	Dr Reem Al-Sulaimani
12	3 Dec 2011	Traumatic injuries (Quiz #2)	Ch. 10	Dr Reem Al-Sulaimani
13	10 Dec 2011	Endodontic Surgery	Ch.20	Dr Dina Sudani
14	17 Dec 2011	Prognosis of root canal therapy	Ch. 21	Dr Sumaya BaSoudan
15	24 Dec 2011	New trends in Endodontics	Additional material	Dr Dina Sudani
16	31 Dec 2011 Prep Exam Week	Review		Dr Ebtissam Al-Madi
17	Week of 7 Jan till 18 Jan	Final Exam

Lecture outline and learning objectives:

1) Introduction

a) Review of objectives and requirements of course

b) Introduction to all the endodontic forms used in the clinic.

c) Documentation of procedures and treatment

d) Clinical Protocol

2) Clinical Diagnostic Procedure

a) The use of endodontic form

b) Pulpal responses to testing methods

c) Documentation of pulpal responses and related data

d) Diagnostic perplexities (sinus tract, numbness, persistent discomfort, cracked tooth syndrome, idiopathic tooth resorption, and failure cases)

e) Systematic approach to endodontic diagnosis

f) Diagnosis and treatment planning

3) Preparation for Clinical Endodontic Therapy

a) Local anaesthesia

i) Pain threshold and factors affecting it.

ii) Patient management techniques

iii) Supplementary injection techniques

b) Isolation

i) Importance, difficulties & management

c) Endodontic radiography

i) Buccal object rules “Clark”

4) Clinical Endodontics

a) Access preparation and length determination

b) Cleaning and shaping

c) Obturation

5) Endodontic Re-treatment

a) Recognize indication for re-treatment of endodontic failure

b) Determine whether surgical or non-surgical re-treatment is indicated

c) Describe the technique for re-treatment

6) Restoration of endodontically treated teeth

a) Need for adequate coronal restoration

b) Structural considerations in dentine

c) Requirements of proper restoration

d) Restoration timing and design

e) Temporary restorations

7) Endodontic Emergency Treatment

a) Type of endodontic emergencies

b) Initial therapy for hot tooth

i) Emergency therapy for intra-treatment pain

c) Flare-up

i) Definition

ii) Management

d) The use of systemic antibiotic

e) Post-emergency evaluation

8) Traumatic Dental Injuries I & II

a) Classification – World Health Organization

b) Enamel fractures

c) Crown fracture with pulp involvement

d) Root fracture

e) Crown-root fracture

f) Tooth luxation, extrusion and intrusion

g) Tooth avulsion

h) Fracture of alveolar process, mandible and maxilla

i) Apexification

j) Splinting technique

9) Endodontic-Periodontal Relationship

a) Classification

b) Effect of periodontal tissue on pulp

c) Effect of pulp on periodontal tissue

d) Treatment & alternate treatments

e) Prognosis

10)Prognosis of Root Canal Therapy

a) Describe the importance of recall

b) Describe modalities used to determine success and failure

c) Factor determine success and failure

d) Identify causes other than endodontic that may lead to failure

11) Endodontic Surgery

a) Indications and contraindications for endodontic surgery

b) Techniques of endodontic surgery:

i) Surgical drainage

ii) Flap design

iii) Apicectomy

iv) Retropreparation

v) Ultrasonic retropreparation

vi) Retrofilling

c) Corrective Surgery

d) Perforation repair

e) Periodontal repair

f) Root amputation

g) Tooth hemisection and bisection

h) Surgical correction of the radicular lingual groove

i) Replacement surgery (replant surgery – intentional replantation)

ii) Implant surgery (endodontic implants)

12)Discoloration and Bleaching

a) Causes of tooth discoloration

b) Contraindications to bleaching

c) Methods of bleaching discolored teeth

i) Intracoronal bleaching

ii) Extracoronal bleaching

d) Success and failure of intracoronal and extracoronal bleaching

e) Veneering discolored teeth

13)New Trends in Endodontics

a) Mechanical preparation

b) Ultrasonic irrigation

c) Radiographic methods

d) Thermoplasticized obturation (materials and mechanism)

Procedure	Points awarded
Caries control (one tooth)	5
Caries control (2 or more teeth)	10
Vital pulp therapy	10
Pulp extirpation	5
Buildup for access reasons	5
Gingivectomy	5
Final restoration	5
Retreatment (removal of GP)	10 per canal
Within 2 visits (completed endo)	5
Incomplete case (Exam)	5
Incomplete case (Exam + Working length)	10
Incomplete case (Exam + working length & preparation of canal up to MAF)	15 per canal
Incomplete case (E + WL + MAF +MAC)	20 per canal
Completed Case (Patient with 3 or more endo completed by student)	10
Difficult patient management	5
Difficult in accessibility of canal	5
Difficulty in curvature of canal	5
Recall case (after 3 months)	10
Special Booking	-10

Points Awarded

Summary of 422 RDS Case

Case #:

Tooth Type:

Summary of case:

Includes briefly: Chief complaint, dental history, medical history, extra oral exam, intraoral exam including soft and hard tissues. A professional presentation of the tooth in question; history, pain character, clinical exams performed, diagnosis, treatment planned, complications and prognosis. A description of any non-clinical aspects (those that can/should not be included in treatment summary) can be presented afterwards. Students are encouraged to reflect upon the case and lessons learned.

Example:

Case #: 2

Tooth type: Single rooted (upper left first premolar #24)

Summary of case:

Non Surgical RCT #24

Subjective Examination:
Chief Complaint: “I want to keep all my teeth.”

Referral form from Emergency clinic in dental college.

Medical History: 62 y/o female. Hx hypertension and osteoarthritis. No allergies reported. The patient is currently taking Metoprolol 100mg/day for hypertension, 800mg ibuprofen prn arthritis pain, and a daily OTC multi-vitamin supplement.

Dental History: The patient presented with multiple extractions and restorations attributed mostly to extensive coronal destruction due to caries; most molars were extracted many years ago while the patient. The patient is not currently receiving any routine dental maintenance. Her comprehensive treatment plan includes a maxillary RPD. About 1 month prior to the patient’s initial visit with the 422 RDS clinic, a general dentist initiated endodontic treatment on #24. The dentist then referred the case to 422 RDS.

Objective Examination:
Clinical Evaluation
EOE/IOE WNL. No swelling, lymphadenopathy or sinus tract noted. The patient has a composite resin filling on the DBL of tooth #24, with a temporary filling in the access opening. Remnants of previous occlusal amalgam still present.

Tooth	Perc	Palp	Prob	Mob	Cold
#24	WNL	WNL	3-4mm	WNL	NR
#15	WNL	WNL	3-4mm	Class I	WNL
#14	WNL	WNL	3-4mm	WNL	WNL

Radiographic Evaluation:
#24 has a large distal restoration extending to cervical and possibly into pulp chamber, previous access into pulp evident.

Diagnosis: #24: Previously initiated treatment, chronic periapical periodontitis.

Treatment Plan:
Recommended completion of NonSurgical RCT #24. Preoperative endodontic prognosis is guarded until the case will be accessed. The patient was informed of the proposed treatment including its major risks/complications, and alternative treatment options (no treatment, extraction). The restorative aspects of the case were addressed as well with recommendation for full coronal coverage and a guarded prognosis if #24 is to be engaged by an RPD. The patient accepted the recommended treatment.

Treatment:
History and diagnosis, patient consent to treatment plan. Local anesthesia ; 2% lidocaine ; 1 carpule (--mg) local infiltration buccal and palatal #24. RD and access. Cotton pellets in chamber, palatal canal located, white paste in canal. Coronal calcification removed, one canal orifices located, obtained patency canals, WLs w/ EAL, confirmed radiographically.

Working length: 19.5mm

WLs w/ EAL confirmed w/ paper points: 19.5mm

Cleaning and shaping procedures were completed using pre-curved stainless steel hand files. Copious irrigation was performed throughout the procedure using 2.25% NaOCl and RC Prep. After a final irrigation with NaOCl, and drying thoroughly with paper points, MAC check films was exposed. Canals were obturated with gutta percha and AH26 sealer, by lateral compaction technique. Cotton pellet and IRM were placed as a temporary filling and post operative instructions were given to the patient. The endodontic treatment was concluded in 2 visits. The patient was referred to 4th year fixed course for the placement of a final restoration. Advised patient to call or come to ER if problem developed. Will follow with 3 month recall.

Complications: None

Final Prognosis: Good

Radiographs included in form: 1.Initial, 2. WL, 3. MAF, 4. MAC, 5. Intermediate, 6. Final

By Ebtissam Al-Madi

Academic Year 2011-2012

ساره مبارك محمد القحطانى

RDS 422

RECORD AND PATIENT TREATMENT

Points Awarded