Endodontic Keys and Cases

ENDODONTIC KEYS AND CASES
A CLINICAL GUIDE TO MODERN ROOT CANAL THERAPY
Dr. Rico D. Short

Board Certified Endodontist
Assistant Clinical Professor
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Endodontic Keys And Cases
A Clinical Guide To Modern Root Canal Therapy
Endodontic Keys And Cases
A Clinical Guide To Modern Root Canal Therapy
Rico D. Short DMD, FICD
Board Certified Endodontist

Associate Clinical Professor, The Dental College of Georgia
Private Practice Endodontist
Apex Endodontics P.C / Atlanta Georgia
International Speaker & Lecturer
Independent Clinical Product Evaluator
This edition first published in 2022.
All cases were performed by Dr. Rico D. Short unless otherwise noted.
Some cases may be presented more than once in the topics due to multi-disciplined
explanations.
All rights reserved.

No part of this publication can be reproduced, published or transmitted in any form by law
unless approval by Dr. Rico D. Short.
©2022
CONTENTS
Forward
Preface
Acknowledgements
Table Of Contents
References & Review Articles
About Dr. Rico Short
FORWARD
It has always been my passion to author a book with simplicity and understanding of
endodontics. Endodontics is one of the most complex fields in dentistry. With over 25 years of
knowledge and thousands of cases performed, I wanted to put together a simple guide to help
navigate through various cases in the field of endodontic therapy. I hope you find this
information insightful, thought provoking, and useful in your clinical practice.
“A PROPERLY DIAGNOSED AND TREATED TOOTH WITH A PAIN-FREE ROOT CANAL IS A GIFT
FROM GOD.” ~ Dr. Rico D. Short
PREFACE
The foundation of endodontics goes back over 100 years. With every turn of the decade we
discover new materials and techniques to make what used to be a dreaded procedure a lot
more pleasurable; for the patient and the clinician. However, with so many materials and
techniques available which one should you use? This is a complex question that still is to be
answered. This clinical guide of endodontic keys and cases will assist the provider in proper
diagnosis and treatment of various endodontic issues that will arise in your clinical practice.
ACKNOWLEDGEMENTS
I would like to first acknowledge my Lord and Savior Jesus Christ for blessing me with the gift of
providing endodontic therapy in a pain free and high quality manor. God continues to ignite my
passion for this wonderful profession and share my knowledge with others around the world.
Secondly, I would like to thank my mom, Shirva Short-Brooks, for always supporting me.
Thirdly, I would like to thank Dr. Isaac S. Hadley for being my mentor since the 10 th grade in
high school. He introduced me to the field of dentistry and has encouraged me every step of
the way. Fourthly, Dr. Sam Dorn, my program director at Nova Southeastern University
Endodontic Department. He took a chance on me as a very young resident and said “Just Make
Me Proud Someday.” I hope I have done that Sam. Fifthly, my wife and 2 children: Angela, Ava,
and Jayla thanks for your support. I love you! And finally to all my referrals, dental colleagues,
friends, and those in the field of dentistry who have been supportive of “The SHORT Case Of
The Day” over the last 10 years…God Bless You!
TABLE OF CONTENTS
Topic 1. Access (Conservative, Traditional, Minimum Invasive)
Topic 2. Anatomy
Topic 3. Anesthesia & Pregnancy Update
Topic 4. Apex Locators
Topic 5. Apexification
Topic 6. Apexogenesis & Pulp Capping
Topic 7. Apical Surgery
Topic 8. Antibiotics
Topic 9. Bioceramic Technology
Topic 10. Calcium Hydroxide
Topic 11. Carrier Based Obturation
Topic 12. Cleaning And Shaping
Topic 13. Cone Beam Technology
Topic 14. Cracks and Fractures
Topic 15. Cysts vs Granuloma
Topic 16. Diagnosis
Topic 17. Endodontic Files
Topic 18. Endo/Perio Relationships
Topic 19. Endodontic Emergencies
Topic 20. Heat Carriers
Topic 21. Iatrogenic Mishaps And Perforation Management
Topic 22. Implants vs Root Canal Success
Topic 23. Internal Bleaching
Topic 24. Irrigation
Topic 25. Lateral Canals
Topic 26. Maxillary Sinusitis Of Endodontic Origin (MSEO)
Topic 27. Obturation Techniques
Topic 28. Pain Control In Endodontics
Topic 29. Regenerative Endodontics
Topic 30. Retreatment
Topic 31. Root Resorption
Topic 32. Sealers
Topic 33. Separated Instruments
Topic 34. Trauma
TOPIC 1 – ACCESS
The basic concepts of the endodontic triad has not changed in the last 75 years. It consists of
biomechanical preparation, microbial elimination and complete obturation of the canal space
(Cohen et al. Pathways of The Pulp 2006). This remains the basis of endodontic therapy.
The Law of Centrality can be used as a guide for the beginning of access. This was described by
Krasner et al. in the Journal of Endodontics in 2004. The pulp chamber is always in the center of
the tooth at the level of the CEJ. Therefore, the initial penetrating bur should be directed
towards the center of the CEJ.
There are various burs to access the pulp. The most common is a #557 tapered fissure bur.
There is also the 1958 bur used to go through metal crowns. In addition, there are special
zirconium burs to go through zirconia crowns such as the “Z-burs” by SS White. It is important
that these burs have plenty of water while accessing through the tooth or crown. This will help
prevent the periodontal ligament from heating up too much and can also prevent the crown
from being damaged.
The goal of every access is to remove the pulp chamber roof completely so you can visualize the
location of the canals. Once the access is completed look for a color change in the dentin. The
color of the pulp chamber is always darker than the surrounding walls. This will help minimize
iatrogenic perforations.
In the last 10 years, several endodontic access cavities have been proposed. The concept of
minimum invasive endodontics was introduced in the last five years. This involves the
minimal removal of tooth tissue for gaining entry to pulp chambers during root canal
treatment in hopes of reducing fractures in the future. However, several studies show the
smaller the access cavity, the more complicated it is to visualize and debride the pulp
chamber. In addition, it is more difficult to locate, shape, clean and fill the canals. This also
creates more time involved in performing adequate endodontic therapy which causes fatigue
for the clinician and patient. Furthermore, a small access cavity may increase the risk of
iatrogenic complications such as perforations, transportations, and zipping which can have an
impact on treatment outcome.
CASE 1
Conservative Access – Tooth #14
Conservative access is not a new concept. Now that heat treated Ni-Ti rotary files can be pre-
curved it’s easier to perform endodontic therapy through smaller access openings. In addition,
patients with limited openings can benefit from these heat treated files. Tooth #14 treatment
was performed using a conservative access.
The Technique:
*On this case I used a small round diamond with copious water to get through the porcelain.
*I used the Z round diamond by SS White on this case to get through the zirconium crown.
*I use a 1958 fissured bur to get through the metal under a PFM crown or any gold/metal
crown.
*I always use a sharp DG16 endo explorer to locate canals (there were 4 canals in this case).
*Irrigation was performed with full strength sodium hypochlorite.
*A glide path was established with small hand files up to size 10 while using RC Prep.
*A heat treated glide path file such as a size .02 taper can be uses as well.
*Then the working length was established with an apex locator.
*The EdgeEndo file X7/.04 taper was used to clean and shape the canals to length and warm
vertical condensation with ZOE sealer.
In the end I have a conservative access and a conservative shape.
The flexibility of the Edge Endo X7 / .04 taper rotary file
A pre-op radiograph of tooth #14. The diagnosis was symptomatic irreversible pulpitis.
Conservative access prepared with Z bur by SS White.
Completed endodontic therapy on tooth #14 using warm vertical condensation and ZOE based
sealer.
Case temporized with Cavit and sent back to restoring dentist for permanent restoration.
CASE 2
Patient was referred to my office from his general dentist with pain and swelling associated
with tooth #31. It had a previous root canal from India over 5 years ago and the crown kept
falling off. In addition, it had a very large periapical pathology and possible crack. He did not
want to have the tooth extracted and implant placed. I performed a retreatment in 2 visits
using calcium hydroxide for 2 weeks. There was no crack noted. Patient returned for a 5 year
recall. The tooth was still asymptomatic and very nice bone healing. Notice the shapes were
not “conservative” due to the fact this was a retreatment however nice healing still took place
and the tooth did not fracture.
Pre-Op radiograph showing pathology on a previously treated root canal on tooth #31. There
was no crown present on this tooth.
A retreatment was initiated on tooth #31. It was disassembled and calcium hydroxide was
placed for 2 weeks. Cavit was placed as a temporary restoration.
Patient returned asymptomatic and case was completed. Notice the shapes were not
“conservative” nor was the access. This is mainly due to the fact it was a retreatment.
Patient returned 5 years later with the tooth restored with a crown and very nice apical healing.
CASE 3
A 33 year old male patient had a previous root canal on tooth #30 about 10 years ago. He
started having biting sensitivity. The diagnosis was previous treatment with acute apical
periodontitis. The pre-op radiograph looked pretty good with the previous root canal. Patient
decided to retreat the tooth. A retreatment was performed in one visit. There was a missed
mid-mesial canal located with the assistance of the surgical microscope. According to Norsat et
al in JOE 2015, the incidence of mid-mesial canals (MM) is 32.1% in patients ≤20 years old,
23.8% in patients 21–40 years old, and 3.8% in patients >40 years. A 10 year recall was
performed and he's still asymptomatic with nice healing.
Look at the large shapes. These large or “deep shapes” were very popular in the early 2000’s.
Deep shape and large coronal flare was preached heavily. One of the main reasons was because
we were doing warm vertical condensation and/or continuous wave and needed to get the heat
within 5mm of the apex. Now we have heat treated Ni-Ti files. These files are more narrow and
more flexible than the original nickel titanium files. In addition, bioceramic sealers are more
common place. There is no heat required using this sealer so we don't have to open the apex
so large or increase the taper. Fortunately, no crack or root fracture and it's been 10 years since
retreatment (20 years in all).
Pre-Op radiograph of tooth #30. It had a previous root canal over 10 years ago. Notice the
large shapes.
Post-Op of retreatment on tooth #30 in one visit. This tooth had five canals all with a separated
portal of exit. There was a missed mid-mesial canal from previous treatment.
A 10 year recall showing the tooth is still stable and no pathology even with the large shapes
and on conservative access.
MINIMUM ACCESS CAVITY PREPARATIONS STUDIES
1. STUDY: “Current status on minimal access cavity preparations: a critical analysis and a
proposal for a universal nomenclature. “(E. Silva et al. IEJ 2020.)
CONCLUSIONS:
• Smaller access preparations can limit the view of the pulpal floor. When using a ninja
access prep the locations of the canals were impaired.
• The ninja and truss access preparations were associated with negative effects on
irrigation efficiency.
• There is limited supporting evidence that minimally invasive access preparations result
in greater fracture resistance than the traditional access prep.
• Conservative access preps did not appear to have a negative influence on the clinical
procedure
• Ultra-conservative (Ninja or Truss) did appear to negatively impact some treatment

objectives
2. A study in JOE shows the pulp chamber was significantly cleaner in a traditional access
compared with the orifice-directed access.
“Does the Orifice-directed Dentin Conservation Access Design Debride Pulp Chamber
and Mesial Root Systems of Mandibular Molars Similar To A Traditional Access Design”
(Neelakantan P. et al JOE 2017)
3. “Current strategies for conservative endodontic access cavity preparation techniques

– systematic review, meta-analysis, and decision-making protocol.”(Journal Of Clinical
Oral Investigations March 2021) By Frédéric Bukiet & Colleagues
Recently, a new nomenclature was proposed that considered 4 main geometric types of
AC designs: traditional access cavity (TradAC), conservative access cavity
(ConsAC), ultraconservative access cavity (UltraAC), and
truss access cavity (TrussAC).
Conclusion - Based on the current knowledge, Truss AC should not be recommended and
UltraAC applied in limited occasions.
4. A study in JOE (August 2021) shows there is a LACK of evidence that minimally
invasive access cavity designs will improve the fracture resistance of root canal–
treated teeth.
They also present potential risks during endodontic treatment.
Studies that defend minimally invasive access cavity designs as a resource to minimize
dental fractures must be reanalyzed under other methodological parameters that mimic
masticatory forces to provide external validity to this approach.
“Access Cavity Preparations: Classification and Literature Review of Traditional and
Minimally Invasive Endodontics Access Cavity Designs.” (Shabbir J et al JOE 2021.)
5. Access Size - Does It Matter?

A recent study from the JOE once again does not support a ninja, ultra conservative, or truss
access. A custom access cavity design is recommended for each tooth according to its static
and dynamic occlusal relations.
“The Effect of Access Cavity Designs and Sizes of Root Canal Preparation on the
Biomechanical Behavior of an Endodontically Treated Mandibular First Molar: A Finite
Element Analysis” (Saber S et al JOE 2019.)
MY SHORT KEYS REGARDING ACCESS :
*Just take the smallest amount of tooth structure needed to locate all the canals and instrument
properly.
**No need to over enlarge with .06 taper anymore (.04 is good) and keep apical preps below a
size 40 if it’s already tight at the apex.
***Also if a crown is placed access size may be a moot point.
TOPIC 2 - ANATOMY
Root canal anatomy can vary to something very simple like an anterior case with one canal to a
complex case like an upper molar with five canals or more. It is important to really study the
pre-op radiograph before treatment. In addition, a pre-operative CBCT scan can help
understand the root canal anatomy as well.
Maxillary Central Incisors –

• Average eruption age 7 to 8
• Apex closes around 10 years old
• Usually one canal
Maxillary Lateral Incisors –

• Canal usually has a disto-palatal turn in the apical 1/3 that can’t be seen on a 2D
radiograph. The apex locator will help locate this hidden anatomical area. It must be
adequately cleaned, shaped, and obturated. If not it will lead to endodontic failure. This
is one reason why maxillary lateral incisors are one of the most retreated teeth
endodontically.
Maxillary Canines –
• Apex closes around 13 – 15 years old
• Usually the longest root
Maxillary 1st Pre-Molars –

• Usually have 2 root canals
Maxillary 2nd Pre-Molars –

• Average eruption age 10 – 12
• Apex closes around 12- 14 years old
• May have 1, 2, or 3 root canals
Maxillary 1st Molars –

• Usually have at least 3 canals and often 4 canals (MB2)
Maxillary 2nd Molars –
• Average eruption age 11 – 13 years old
• Usually have at least 3 canals and occasionally an MB2
Mandibular Central and Lateral Incisors –

• Usually have one canal but can have two canals on occasion
Mandibular Canines –
• Usually have one canal
Mandibular 1st Pre-Molars –

• Varied canal anatomy – mostly once canal but can have more than one
Mandibular 2nd Pre-Molars –

• Varied canal anatomy – mostly one canal but can have more than one
Mandibular 1st Molars –

• Average eruption age 6 years old
• Most common root canal treated tooth
• Mostly have 3 canals – it can have 4 canals and sometime a mid-mesial canal
Mandibular 2nd Molars –

• Mostly have 3 canals
PROBLEM SOLOVING KEYS WHILE TRYING TO LOCATE CANALS
1. PROBLEM: Unable To Find Canals Due To Excessive Bleeding

SOLUTION: Enlarge the access, place hemostatic agents such as local anesthetic with
epinephrine, use headstrom files or Gates Gliddens to remove gross tissue.
2. PROBLEM: Calcified Canals or Pulp Stones

SOLUTION: Use ultrasonics to break up pulp stones or a high speed round bur to
carefully smooth the pulpal floor.
3. PROBLEM: Unable To See The Pulp Chamber

SOLUTION: The roof of the pulp chamber is usually not inadequately removed or you
are not deep enough in your access. Return to your previous bur and remeasure the
distance between the enamel and pulp floor on a bitewing radiograph. Go just a little bit
deeper.
4. PROBLEM: Unable To Locate The Canals Due To Not Enough Light

SOLUTION: This means your access is too small. Enlarge the access and use an accessory
light such as an LED headlight or microscope.
5. PROBLEM: Unable To Locate Canals Due To Restorative Materials

SOLUTION: Remove all restorative materials prior to starting endodontic treatment.
Some of these materials can be blocking access into the canals. Trying to remove the
material while performing endodontic treatment can lead to perforation.
CASE 1
Tooth #3 – A Five Canal Maxillary First Molar

Endodontic treatment was performed on this case in one visit. Once the access was made, gross
decay was removed with a large size 8 round bur on slow speed. This tooth had five canals
(MB, MB2, DB, P1, and P2). I could not tell any of this from the pre-op radiograph. I did not
discover this until I was able to access the case under the microscope. Notice the P1 and P2 join
in the apical 1/3.
Pre-Op of tooth #3 with large recurrent decay into the pulp and broken amalgam.
Post-Op of tooth #3 after endodontic therapy showing five canals. Notice the P2 canal (2) and
the P1 canal (3) join.
Post-Op inverted view of tooth #3 showing five canals. Notice the MB (5) and MB2 (4) had
separate portals of exits.
CASE 2
Tooth #15 – A 4 Canal Upper Molar

Patient came in with pain and swelling on tooth 15. The diagnosis was a necrotic pulp with
acute apical abscess. Endodontic treatment was initiated and calcium hydroxide was placed.
Patient was placed on a combination of NSAIDS (600mg IB + Acetaminophen 500mg) every 6
hours as needed for pain and Amoxicillin 500mg. Patient returned in 2 weeks asymptomatic
with no swelling. Endodontic treatment was completed. This tooth had an MB2 which is not as
common on the Mx 2nd molar than the Mx 1st molar. It also had a separate portal of exit and
was shorter than the MB.
Pre-Op radiograph on tooth #15 with a deep restoration and a temporary crown.
Calcium Hydroxide was place in tooth #15 after cleaning and shaping and temporized for 2
weeks.
Tooth #15 was obturated with warm vertical condensation and ZOE based sealer. There were
four canals all with separate portals of exits.
A SHORT KEY...If you are not sure of the canal anatomy take a CBCT of these cases. A good
understanding of root canal anatomy and use tools like a microscope, ultrasonics, champagne
bubble tests will help identify canals.
Champagne Bubble Test: When sodium hypochlorite is flooded into the access cavity, it
dissociates into Na+ and Cl- ions and release free oxygen. This bubbles up to the surface like a
champagne. Where the bubbles arise there is usually pulp tissue and/or a canal.
How Often Are MB2’s located In Maxillary 2nd Molars?

Stropko examined 611 maxillary 2nd molars over an 8 year period. He found an incidence of
an MB2 50% of the time in Maxillary 2nd molars. It occurred as a separate canal 45% of the
time and joined the MB1 54% of the time. (Stropko JJ. Canal Morphology Of Maxillary Molars:
Clinical Observations Of Canal Configurations. JOE 1999; 25:446-50)
CASE 3
Tooth #19 – Merging Canals

Patient came in pain on tooth #19. The diagnosis was a necrotic pulp with acute apical
periodontitis. Check out the mesial root. Notice the MB and ML merge. This is a danger zone for
file separation. Make sure you get to length with at least a 10 handfile before using rotary NiTi.
Heat treated NiTi files are best for these cases. I like to clean and shape the ML canal first.
Usually this is where files break most often. In addition, I obturate the ML canal first then the
MB. Endodontic treatment was performed in one visit.
Pre-Op radiograph of tooth #19. The arrow points the mesial root with the merging ML and MB
canals.
Post-Op completion of tooth #19 showing canals merge in the mesial root.
CASE 4
Patient came in pain on tooth #30. The diagnosis was previous treatment with acute apical
periodontitis. A LFOV 3D CBCT was taken with my Carestream 8100. The sagittal slice shows the
distal canal filled short and periapical pathology. The axial slice shows a missed canal (ML
canal). Endodontic retreatment was performed in one visit. I used chloroform and EdgeEndo
retreatment files to remove the bulk of the gutta percha. Then used handfiles to negotiate a
glide path around the curves. Canals were cleaned and shaped with EdgeEndo X7 heat treated
NiTi files and obturated with NeoSealer Flo bioceramic sealer. The canals were very narrow and
long.
A pre-op radiograph on tooth #30 with a previous root canal.
A LFOV 3D CBCT showing the distal canal filled short.
The axial slice of tooth #30 showing the missed mesiolingual (ML) canal.
A post-op of the one visit retreatment case on tooth #30.
CASE 5
Tooth #14 – A Five Canal Molar All With Separate Portals Of Exits
This started out to be a normal case. Upon access there was a lot of bleeding on the pulpal
floor. I used a slow round to smooth out the pulpal floor under the microscope. I was able to
see a total of 5 canals and treat them.
Pre-Op radiograph of tooth #14. It had a deep restoration that causes symptomatic irreversible
pulpitis.
A post-op radiograph showing completion of the case on tooth #14.
A post-op radiograph showing all five canals (MB-1, MB-2, DB-3, P2-4, P1-5). All with separate
portals of exits.
SHORT KEYS TO LOCATE THE POSSIBLILTY OF ADDITIONAL CANALS:
1. Take additional off-angle radiographs or take a limited field of view CBCT.
2. Ensure adequate “straight-line” access to improve visibility, remove other restorative

material, and make sure the canal is centered in the root.
3. Examine the pulpal floor for “lines” to areas where additional canals may be located.
This can be done by blowing air on the pulpal floor and follow where the “dust”
settles.
4. Remove a small amount of tooth structure or the dentinal shelf that often may
occlude a canal orifice. Many times the prep is not deep enough.
The frequency of a maxillary first molar with two palatal canals is very low, 1%. This case
contributes to our understanding of the complexity of the root canal morphology found in
maxillary first molars. Although such cases occur infrequently, dentists should be aware of them
when considering endodontic treatment of a maxillary first molar.
CASE 6
Tooth #18 – A Hypertaurodont

Patient came in pain on tooth #18. It had a history of a small crack which resulted in needing a
root canal. Examine the case carefully radiographically. It is a Taurodont...more specifically a
Hypertaurodont.
Taurodontism is a genetic condition found in the molar teeth whereby the body of the tooth
and pulp chamber is enlarged vertically at the expense of the roots. As a result, the floor of the
pulp and the furcation of the tooth is moved apically down the root. These can be very tricky to
treat. There was calcification like pulp stones present inside. The case was performed in 2 visits
using ultrasonics (Endo Ultra by Vista Dental Products), full strength sodium hypochlorite, and
calcium hydroxide intracanal medication for 2 weeks. Patient returned asymptomatic. Conefit is
very challenging on these cases. The gutta percha cones tend to bend on each other due to the
deep orifice. The case was obturated using bioceramic sealer and gutta percha. It had 3
separate portals of exits.
A pre-op radiograph on tooth #18. Notice the round root shape and the canal calcification.
Endodontic therapy was initiated on tooth #18 and calcium hydroxide was placed.
A conefit radiograph with gutta percha seated at the apex.
A post-op radiograph of tooth #18 after endodontic therapy. Notice it had 3 portals of exits.
CASE 7
Tooth #30 - Radix Molar or Radix Entomolaris

Patient came in with pain on tooth #18 due to a large carious lesion. Endodontic treatment was
recommended. The pre-op radiograph looked strange. See how uneven the mesial roots are?
What's going on with the distal root?
Upon access there were 4 canals with a separate disto-lingual root. The distal lingual canal was
very tight and calcified. I like heat treated NiTi files on these cases because file separation can
occur in the DL canal very easily with other file systems.
This case was called a Radix Molar or Radix Entomolaris (RE). The prevalence of RE in the
mandibular first molar is 40% in those with Mongolian traits, 3.4 - 4.2% in Europeans, 3% in
Africans and less than 5% in Indians and Eurasians. A tooth with a third root that is a
distolingual root is called a Radix Entomolaris described by Carabeli in 1915. If this root is
positioned buccally then it is called Radix Paramolaris described by Carlson in 1991.
A pre-op radiograph of tooth #19. It had a large carious lesion on the distal root into the pulp.
If you look closely there is the outline of another root.
A conefit radiograph showing all 4 canals.
A post-op radiograph of the completion of the Radix Molar.
Case 8
Tooth #30 - Mid-Mesial Canal

The presence of a third canal in the mesial root of mandibular molars has been reported to
have an incidence rate of 1 to 15% (Skidmore, Vertucci). These cases are very rare. This
additional canal may be independent with a separate foramen, or the additional canal may
have a separate foramen and join apically with either the mesiobuccal or mesiolingual canal as
in this case.
A pre-op radiograph of tooth #30.
A clinical photo after cleaning and shaping showing the three mesial canals.
A post-op radiograph showing the five canals located.
Keys To Locate The Mid-Mesial Canal
1. One key to help locate the mid-mesial canal is after access cavity preparation, trough
with a round bur, ultrasonics, or the EG2 by SS White between MB and ML canals.
2. Blow air inside the access and look where the dust settles. If it's there, the dust usually
settles smack dead in the middle.
3. Using the microscope or high power loupes with high magnification and illumination is a
plus to help locate it as well.
The incidence of mid-mesial canals is 32.1% in patients ≤ 20 years old, 23.8% in patients 21-40
years old, and 3.8% in patients > 40 years (Norsat). I find them often in the first mandibular
molars of young patients less than 20 years of age.
TOPIC 3 – ANESTHESIA & PREGNANCY UPDATE
Although the good doctor's name remains obscure in the history of medicine, every person who
has visited their dentist since the 1884 discovery of local anesthesia should thank Dr. Carl
Koller, who proposed numbing our gums and other exposed body tissues with cocaine. Indeed,
it was not until several decades later that safer, synthetic, less addictive and tissue-damaging
drugs, such as lidocaine, were developed.
Effective local anesthesia is the bedrock for modern day dentistry and especially endodontic
therapy. One of the main reasons why local anesthetics don’t work effectively is because of
TTX-R sodium channels (Goldstein et al. Psychosom Med 1982). Inflammation in the area can
cause these channels to block the local anesthesia from being effective leading to a “missed
block” or less numbness for the patient. Some studies show a one hour pre-op dose of 600mg
of NSAID’s can open these channels for more effective local anesthetic penetration.
Some other theories why patients have difficulty with local anesthesia are ph, red haired
people, central core theory (inner portion of the inferior alveolar nerve supplying anterior teeth
and the outer portion of the nerve bundle supplying the posterior teeth) and lowered pain
thresholds for individuals with high anxiety (Hargreaves et al. Endodontic Topics 2003).
HOW TO KEEP PATIENTS COMFORTABLE WHILE GIVING LOCAL ANESTHESIA
1. If giving a IANB shake the lip vigorously before injecting and during injection. This
distracts the patients and they feel the injection less.
2. If giving a palatal injection use pressure with the back of a mirror after placing the
anesthetic gel. You can also spray a Q-tip with Endo Ice shake for 5 seconds and hold it
on the tissue for 5 seconds while giving the injection.
3. If giving infiltration spray the Q-tip with Endo Ice shake for 5 seconds and hold it on the
tissue for 5 seconds prior to giving the anesthetic.
CASE 1
A Hot C- Shaped Molar

The patient came in with pain on tooth #18. The diagnosis was chronic irreversible pulpitis due
to buccal decay. This tooth was very difficult to anesthetize. I used 2 Carp 2% Xylocaine 1/100k
epi via an IANB then buccal infiltration with Septocaine 1/100k epi. The patient still would not
get completely anesthetized. I then used Carbocaine (no epi) with a PDL injection. It’s very
important to use a short needle and get pressure on all four corners of the molar.
Endodontic treatment was performed in one visit. This case had a C-shaped anatomy. This was
described in studies by Cooke and Cox in 1979. There is usually a lot of hemorrhage in these
cases once opened.
SHORT KEYS FOR C-SHAPED CANALS
1. Use local anesthesia with epinephrine via an intrapulpal injection. I like using Xylocaine
1/50k epi (green stripe). This will allow you to better visualize and locate the canals.
2. Gates Gliddens are good to remove the bulk of pulp tissue. I use the size 4, 3, and 2 via
crown down technique.
3. Full strength sodium hypochlorite activated with heat and ultrasonics will help clean
deep into the fins of the canal system.
Pre-Op Radiograph of tooth #18. It had a large buccal carious lesion.
A post-op radiograph. Endodontic treatment was performed in one visit. The intrapulpal
injection of the local anesthetic with epinephrine enabled better visualization of the canals.
CASE 2
Cracked Tooth Syndrome – Tooth #30

Patient came in with severe pain on tooth #30. He said it had been hurting for months but just
got unbearable especially to cold and biting. The diagnosis was acute irreversible pulpitis with
acute apical periodontitis. On the periapical film there was a small crack (black line). Endodontic
treatment was planned the same day. This patient would not get numb even after using an
Inferior Alveolar Nerve Block, Mental Block, and PDL. I could not even touch the tooth!
This was a very rare case for me. I can count on one hand in 20 years I couldn't get a patient
numb. I decided to reschedule the patient.
I placed him on a Medrol Dose Pack for 1 week to reduce the inflammation in the area and he
was placed on nitrous oxide to relax him. Some studies show nitrous oxide has an analgesic
affect to help promote deeper local anesthesia. The patient returned and was able to get him
numb with no problem. Upon access there was a small crack noted into the pulp (these usually
are the culprit for HOT TEETH). In addition, there were 5 canals (MB, ML, DB, MD, DL). It had 3
distal canals and 2 mesial canals. They were cleaned and shaped with heat treated NiTi files and
obturated with bioceramic sealer.
A pre-op radiograph of tooth #30 showing a deep restoration and a small crack indicated by the
arrow.
A clinical view showing the 5 canals after the case was cleaned and shaped. It had 2 mesial
canals (4 and 5) and 3 distal canals (1, 2, and 3).
A clinical post-op view showing the canals obturated with gutta percha.
A post-op radiograph of the completion of the endodontic therapy.
CASE 3
Large Swelling – Tooth #19

Patient came in with severe pain and swelling on the lower left side. The radiograph revealed a
large area of infection associated with tooth #19. Patient could barely open due to the swelling,
pain, and infection. The diagnosis was a necrotic pulp with acute apical abscess. I decided to
perform an intraoral incision and drainage procedure at the first appointment. I used an Akinosi
Block or closed mouth injection because the patient could not open using 1 carp 4% Prilocaine
and then 1 carp 2% Lidocaine 1/100k epi. In addition, I used Bupivacaine via IANB. A study by
Cook in the JOE published in 2018 found 4% prilocaine plain was significantly less painful upon
anesthetic solution deposition. However, pulpal anesthetic success was not significantly
different between the 2 combinations. I used the 2% Lidocaine for hemorrhage control and
Bupivacaine so the anesthesia would stay around longer.
Advantages of Akinosi Injection When Patients Are Swollen

1. Relatively less painful
2. Single injection blocks buccal and lingual nerves
3. Easy to perform
4. Very useful when patients can’t open due to trismus or swelling
5. The success rate is 97.14%
(Jendi et al. J Max Oral Surg. 2019)
Patient was placed on Clindamycin 300mg for seven days and NSAIDS as needed for pain.
He returned in one week for treatment. The swelling was reduced significantly. Endodontic
treatment was performed in one visit. I was able to properly clean/shape and dry the canals.
This case was performed using Profiles Series 29/ .04 taper Dentsply Sirona Endodontics in
crown down technique. I used 6% NaOCl, 17% EDTA, and 99% Alcohol as my irrigants. Canals
were obturated using warm vertical condensation and Kerr EWT sealer. That’s it! No MTAD,
Chlorhexidine, no other “magic potions” on this case. A 6 month recall shows remarkable
healing.
Pre-Op clinical photo of patient swollen on the lower left side.
Pre-op radiograph of large lesion on tooth #19.
A post-op radiograph of one visit endodontic therapy on tooth #19.
A 6 month recall showing nice healing on tooth #19.
CASE 4
One Visit vs Multiple Visit Endodontics
Due to the COVID-19 pandemic patients don’t want to be overexposed to the potential of
catching this virus due to multiple visits. Nor does the dentist. Because of our occupational
exposure to droplets in saliva we must maintain strict precautions as we treat our patients due
to Coronavirus. Many providers are afraid to perform one visit Endodontics in the presence of
an abscess tooth in fear of a flare up, inadequate healing, or increased pain.
Here are some MYTHS associated with single visit vs multiple visit endodontics:
MYTH #1: Postoperative pain is greater when endodontic therapy is completed in a single visit,
especially in nonvital teeth.
FALSE…
Overwhelming evidence shows that postoperative pain resulting from treatment of vital or
nonvital teeth does not differ among patients treated in a single visit or in multiple visits. Many
studies like the study done by (Wang C et al. Clin Cosmet Investig Dent 2014) showed no
significant differences in pain after single-visit and multiple-visit treatment. A study done by
(Bhagwat et al. Contemp Clin Dent 2013 ) surprisingly described more postoperative pain
developing with conventional multiple-visit treatment versus single visit treatment.
MYTH #2: There is less healing when endodontic therapy is completed in a single visit,
especially in non-vital tooth.
FALSE…
A 3 to 6 month recall is a good time to monitor radiographic healing. However, a one-year

follow-up time is considered to be the golden standard to determine whether or not the lesion
has healed (Ørstavik 1996).
No studies demonstrated a statistically significant difference in healing rate (therapeutic
efficacy) between single- and multiple-visit treatment.
In a systematic review done by (C. Sathorn et al. IEJ 2008) found that single-visit root canal
treatment appeared to be slightly more effective than multiple visit with a 6.3% higher healing
rate.
No significant difference in radiographic evidence of healing between single visit and multiple
visit treatment was seen by study done by (Paredes-Vieyra J et al Endodontic Practice Volume
8).
MYTH #3 : Post- operative flare up is greater when endodontic therapy is completed in a single
visit.
FALSE…
Postoperative pain or swelling are collectively described as flare-up, which is probably one of
the most concerning issues that dentists practicing single-visit treatment. (Akbar et al J Clin Diag
Res 2015) in his study found that there was no significant difference in the flare-up rate
between single and multiple visit groups. He also showed prophylactic Amoxicillin had no
effect on inter-appointment flare up. However, in my over 20 years of clinical practice, I
noticed when I use calcium hydroxide on a highly infected necrotic pulp I get a high incidence of
flare-ups vs one visit endodontic therapy.
My go to drugs for a flare-up is Amoxicillin 500mg and a Medrol Dose Pack.
MYTH #4: Canals are cleansed if an antibacterial medicament such as Ca(OH)2 is left in the
tooth.
PARTLY TRUE…
Efficacy of calcium hydroxide in controlling intracanal bacterial population has been proven
true. However, despite the high alkalinity antibacterial properties of calcium hydroxide, some
bacteria species, such as E. faecalis and Candida albicans, have been found to be resistant to it.
Complete elimination of bacteria is not strictly necessary for a favorable outcome. A maximum
reduction of bacteria and effective canal sealing is usually sufficient in terms of healing, rather
than complete eradication (Seltzer & Bender OOO 1966)
Tooth #6 - One Or Two Visit Therapy For Abscessed Tooth?
Patient came in with pain and swelling on tooth #6. The diagnosis was a necrotic pulp with
acute apical abscess. Recommended endodontic treatment on tooth #6 immediately. Root
canal was performed in one visit using full strength 6% NaOCl, 17% EDTA, 99% Ethyl Alcohol,
Bioceramic Sealer (Brasseler USA) and regular Gutta Percha on this case. Patient returned in 1.5
years for a recall. Nice healing and osseous repair evident.
Key: I was able to properly, clean, shape, irrigate and adequately dry the canal, and used a
biocompatible and osteoconductive sealer with Calcium Hydroxide and MTA like properties.
A pre-op radiograph on tooth #6 with a large periapical lesion.
Endodontic cleaning and shaping was performed and a conefit was made in tooth #6.
A post-op radiograph was performed on tooth #6 with bioceramic sealer (BC) and gutta percha
(GP). Notice there is some overfill of the sealer. This is no problem with the BC sealer because
it is really a bone cement. It will eventually get incorporated in the bone.
A 1.5 year recall shows textbook osseous repair on tooth #6.
CASE 5
Toothache And Pregnant – Tooth #13

Patient came in with pain on tooth #13. The diagnosis was a necrotic pulp with acute apical
periodontitis. She was 5 months pregnant (2nd Trimester). She was afraid of dental x-rays and
dental work because it was her first pregnancy in which she had miscarriages before. However,
she was in excruciating pain. I assured her everything was going to be fine and it's perfectly safe
to get a root canal while pregnant if proper precautions are taken. We used a double lead
apron to take the digital radiographs to make her feel more comfortable. Local anesthesia
without epinephrine was used with buccal infiltration because that was her OBGYN
recommendation.
Endodontic treatment was performed very smoothly. The canals were long (29mm), narrow,
and dilacerated towards the distal. Full strength NaOCl was used with Glide Path Rotary files to
help get to working length. Edge Endo X7/.04 files were used to clean and shape the canals on
this case. Bioceramic Sealer by Brasseler USA was used to obturate the canals due to the long
and narrow nature. I called the patient the next day and she was completely asymptomatic. She
was happy she had the root canal performed pain free, safely, while pregnant.
Pre-op radiograph on tooth 13 with very deep restoration.
Endodontic treatment completed in one visit on tooth #13
Inverted post-op radiograph after endodontic completion. Notice the long length of the canals.
PREGNANCY AND ENDODONTIC THERAPY UPDATE

Analgesics, Antibiotics, Anesthetics, Antimicrobials, & Local Anesthesia
An expert workgroup, convened by the U.S. Health Resources and Services Administration in
collaboration with the American College of Obstetricians and Gynecologists and the American
Dental Association, developed a consensus statement regarding oral health care during
pregnancy.
Oral health care, including radiographs, pain medication and local anesthesia is safe throughout
pregnancy. An excellent table listing various pharmaceutical agents typically prescribed by
dentists is available within the consensus statement and indicates which ones may be used and
ones that should be avoided.
Most pharmacological agents that dentists commonly prescribe are safe for use in pregnancy,
but there are some antibiotics, including tetracycline, which should be avoided, and a few
analgesics that need to be used with caution.
Analgesics
Tylenol or Acetaminophen (ok to take more than 3 days if necessary)
*Less than 3 days:
Tylenol 3
Codeine
Aspirin
Ibuprofen
Naproxen
Antibiotics
Amoxicillin
Cephalosporins
Clindamycin
Metronidazole
PenVK
Local Anesthesia
Lidocaine with or without epi ***(according to new guidelines)
Bupivicaine
Mepivicaine
Antimicrobials
Use Alcohol Free Products
Peridex
Xylitol
American College of Obstetricians and Gynecologists Committee on Health Care for
Underserved Women. Oral Health Care During Pregnancy and Through the Lifespan (Number
569). 2013; Reaffirmed 2017. Accessed May 4, 2021.
Reviewed by: ADA Council on Advocacy for Access and Prevention and the ADA Center for
Dental Practice
Last Updated: May 4, 2021
GOT A HOT TOOTH? HERE ARE SOME HOT KEYS!
• Sometimes it is difficult to obtain appropriate anesthesia in mandibular molars with

symptomatic irreversible pulpitis. Studies show that the success rate of IANBs increased
with intraligamentary injections and buccal infiltrations with Articaine or Septocaine
that were performed before initiating treatment. They key is getting positive pressure
down the PDL for the intraligamentary injections (Shahi JOE 2018).
• Some studies conclude intraosseous injections such as Xtip and Stabident shows very
low- to moderate-quality to achieve high pulpal anesthesia during endodontic treatment
of mandibular molars with symptomatic irreversible pulpitis compared to IANB. The
reason is an increased acidity in the inflamed pulp reduces the amount of basic
anesthetic that penetrates the nerve’s membrane, thus delaying or preventing pulpal
anesthesia. Additionally, increased expression of tetrodotoxin-resistant sodium channels
occurs because of the increase of prostaglandins and the overexpression of sodium
channels (Zanjir JOE 2019).
• Studies show preoperative NSAIDs or opioids with or without acetaminophen may

increase the efficacy of local anesthesia injections. I sometimes would put the patient
on a Medrol Dose Pack for 1 week and performed the endodontic therapy using Nitrous
Oxide.
Carbocaine vs Xylocaine For IANB
Did you know plain 3% mepivacaine (Carbocaine) solutions are just as effective as 2% xylocaine
for an inferior alveolar nerve block?
A cartridge of either mepivacaine or prilocaine will work the same as 2% lidocaine with
epinephrine for pulpal anesthesia of at least 50-55 minutes. Clinically, this is an important
finding because when medical conditions or drug therapies suggest caution in administering
epinephrine-containing solutions, plain solutions can be used as an alternative for the inferior
alveolar nerve block. This is important for patients who are pregnant and afraid to use local
anesthetic with epinephrine. In addition for patients who have had serious heart issues such as
a recent heart attack. The maximum dose for an adult over 150 lbs. is 7 carpules and for
children around 66 lbs. is 3 1/2 carpules (Viera IEJ 2018).
Local Anesthesia Paralysis
Nerve injury can occur during block injections due to needle trauma, hematoma, or injected
anesthesia. However, it is still not very clear how the needle or injection ingredients cause
nerve damage. The incidences with block injections is between 0.15% to 0.54% whereas
permanent damage is rare at 0.0001% to 0.01% (Hillerup S. International Journal of Oral and
Maxillofacial Surgery 2006).
When performing a mandibular block injection, a patient may feel an electric shock around 3%
to 7% of the time. They usually jump while the injection is taking place. This usually resolves
quickly but if the patient winces while injecting, slightly withdraw and re-position the needle.
Some studies show using Articaine or Septocaine as a block can increase neuropathies 3.6%
more than lidocaine. However, Malamed said that this information lacked supporting data and
they were anecdotal reports. I personally would recommend to still stay away from using
Articaine or Septocaine in mandibular blocks for litigious reasons.
Profound anesthesia is key when performing dental procedures especially root canals.
When to refer to a dental microsurgeon if nerve damage is suspected:

Do a few clinical tests first.
1. Try a light touch test (use a soft brush or Q-tip to the lip and ask the patient in which
direction the stroke was in and make sure your record this data).
2. Pain test (use an explorer and access if they feel a pin like stick on the gingiva).
3. Temperature test (place and ice cube or warm gutta percha on the gingiva to see if
patient can feel the difference between the 2 stimuli).
Bagheri and Meyer suggest waiting 3 to 4 months to see if altered sensations improve. They
advised anti-inflammatories (Ibuprofen) or a tapered dose of steroids for 5 to 7 days soon after
injury or when patients complain of paresthesia.
TOPIC 4 – APEX LOCATORS
The invention of the apex locator started in 1942 by Suzuki and developed into a product by
Sunada in 1962. Electronic apex locators are devices that use an electrical circuit through the
patient's root canal and oral tissues to determine the location of the apical foramen. The apex
locator helps to reduce the treatment time and the radiation dose because of less amounts of
x-rays needed to confirm working length. There are many types of apex locators on the market.
Most studies show they are approximately 95% accurate.
CASE 1
Patient came in my office with pain on teeth #2 and #3. The teeth had a history of deep
restorations and were crown prepped with temporary restorations. Patient had sensitivity to
cold and biting for over 2 weeks. The pain was increasing every day. Endodontic treatment
was performed on both teeth due to acute irreversible pulpitis with acute apical periodontitis.
The palatal canal was very unusual on both teeth and in particular on tooth #2. The apex locater
kept reading out short and I trust it 95% of the time. I decided to obturate the canal where the
apex locator "said" zero – zero. The palatal canal came up about 3mm short of the radiographic
apex on tooth #2. On this one, I'd admit it didn't look pretty...so I retreated the palatal canal on
tooth #2. The final result was acceptable radiographically.
Pre-op radiograph of teeth #2 and #3. Both had deep restorations with temp crowns.
Post-op of tooth #2 showing the palatal canal is short.
Post-op radiograph show the missed portion of the apical 1/3 of the palatal canal on tooth #2.
Post-Op radiograph showing the apical 1/3 of the palatal canal properly cleaned and shaped
and obturated.
Here are some issues that can cause the apex locator to "misread"...
* Canal too large for the file

* Canal too dry
* Canal too wet
* Perforations
* Teeth with open apicies
* Coronal aspect not shaped before apex locator use
* Large lateral canal
* Root Resorption
* Metal of the crown
* Lip clip unstable
* Shortage in the cord
* Batteries worn out
* Corrosion of battery connectors
* "Cheap" Apex Locator from e-Bay
CASE 2
Patient presented with a necrotic pulp with chronic apical abscess on tooth #30. Endodontic
therapy was performed in 2 visits with calcium hydroxide. Respect the apical constriction by
using the apex locator. Notice I'm not at the radiographic apex on this case. The case appears to
be filled short. However, I'm at the physiological apex confirmed by the apex locator. I trust my
apex locator 99% of the time over the radiograph.
A 7 year recall shows nice osseous repair.
Pre-op radiograph of tooth #30 with periapical pathology associated with both roots
Post-op radiograph showing completion of endodontic therapy on tooth #30. Notice the gutta
percha is not to the radiographic apex.
A 7 year recall shows beautiful osseous healing.
CASE 3
Patient came in with pain and swelling on tooth #31. The dx was chronic apical abscess. It had a
previous root canal that appeared acceptable radiographically. However tooth #31 had a large
lesion wrapped around the apex. Patient did not want an extraction/implant and decided to
have the tooth retreated instead. Retreatment was performed in 2 visits with calcium
hydroxide. Patient returned asymptomatic with no swelling 3 weeks later for completion. The
apex locator kept reading "short". I had a decision to make...will I fill to the radiographic apex
to make my referring dentist happy because it will look prettier or fill to the anatomical apex? I
decided to trust my apex locator and filled "short".
The patient recently came back for another tooth 7 years later. I was able to get a 7 year recall
on tooth #31. It had "textbook" healing even though it was filled "short".
Pre-op on tooth #31 with previous root canal and large periapical pathology.
Endodontic retreatment was initiated on tooth #31 and calcium hydroxide was placed for 2
weeks.
Post-op radiograph of completion of case and the appearance of a short fill. The apex locator
read out at these lengths. I trusted the apex locator over the radiographic lengths.
A 7 year recall shows nice osseous repair with the case appearing to be “short”.
CASE 4
This was a very interesting case. Patient came in with a history of trauma on her anterior teeth
years ago. Tooth #25 has now become necrotic with a periapical lesion. She was in mild
discomfort. I decided to treat this tooth in one visit without using calcium hydroxide. I took
several measurements with the apex locator and it consistently read short compared to the
radiograph. Do you know why? Well due to the trauma and the lesion, there was apical
resorption so the apex locator read the mc (minor constriction) as the rd (resorptive defect).
Warm vertical condensation with Kerr EWT sealer (ZOE based) was used. I brought the patient
back for a 6 month recall and it showed very nice healing even though it does not appear to be
filled to the radiographic apex. Beauty does not necessarily translate to healing in endodontics.
Follow the biologic principles of endodontics and you'll get it right most of the time.
Pre-op radiograph of tooth #25. It had a previous history of a trauma and a large periapical
lesion.
A pre-op radiograph showing the apical resorption and the periapical pathology.
A post-op radiograph of the endodontic treatment completed to the minor constrictor.
A 6 month recall shows nice healing even though it appears to be radiographically short.
CASE 5
Patient came in pain and swelling on tooth #18. The diagnosis was a necrotic pulp with acute
apical abscess. Notice the large pathology present on the mesial and distal roots. Endodontic
treatment was performed in 2 visits using calcium hydroxide as an intracanal medicament. The
apex locator read short on the mesial and distal roots. It read short on the mesial root because
the canals had a mesial exit 3mm from the apex and the distal read short because of a
resorption defect due to the long standing pathology. Patient returned asymptomatic with no
swelling after 2 weeks. The case was obturated with warm vertical condensation and ZOE based
sealer. She returned in 6 months showing very nice healing and osseous repair.
Pre-op radiograph of tooth #18 with a large periapical pathology on the mesial and distal roots.
Calcium hydroxide was placed for 2 weeks on tooth #18. Some of the calcium hydroxide went
out of the foramen. This is usually not an issue.
Post-op radiograph of the completion on tooth #18 showing an early exit on the mesial root
and the distal root appears to be obturated short.
A 6 month recall shows nice healing and osseous repair on both roots.
CASE 6
Tooth #19 ~ Apex Locator Malfunctions

This young child came in pain on tooth #19. He was 10 years old. The diagnosis was acute
irreversible pulpitis. This case was vital, had a large pulp chamber, very large curved canals due
to his young age. These cases have to be managed very carefully to prevent overextension. In
addition, the apex locator will usually give false readings as you can see from the conefit
radiograph due to the large size of canals. The length was adjusted to the proper measurement
using paper points as a guide.
THE PAPER POINT TEST:

The paper point is inserted inside the canal once it’s cleaned, shaped, and dried. Measure and
not where the blood is located on the paper point at the tip. Cut off the tip where the blood is
located. Measure the paper point. This is where the working length should be.
This case was cleaned and shaped mostly by handfiles and full strength NaOCl. Bioceramic
sealer and gutta percha was used for obturation. Immature or young root canal systems can
present problems using the apex locator. When the apex is open or canal space is very large,
the apex locator measurements are inconsistent (Hulsmann Dental Traumatology 1989).
A pre-op of tooth #19 with a deep restoration and open apex.
The working length was established using the apex locator only. Notice how short the conefits
were. It was readjusted with the paper point test to the proper lengths.
A post-op completion of tooth #19.
TOPIC 5 – APEXIFICATION
The apexification procedure was described in 1966 by Al Frank in the JADA. It is used when the
pulp is necrotic and the apex is open or immature. Tradition endodontic treatment will be a
challenge because there is no apical stop for the obturation material. In order for the apex to
close, the pulp chamber has to be disease free and sealed. An apical barrier forms between 6
months and 3 years. When the apical barrier is formed then the obturation material can be
placed. The drawback is there is no continued root length or thickened dentin. These teeth are
subject to fracture in the future.
CASE 1
Patient was a 35 year old female that had a trauma when she was 7 years old on tooth #8. The
trauma caused the pulp to die before the apex could mature making management difficult
(tooth #8 erupts at age 6 and the apex matures at age 9). She recently experienced percussion
and palpation tenderness. Clinically the tooth was dark (over time the tooth turns darker as the
pulp dies leaving a blood clot/bacteria behind in the pulp chamber). The diagnosis was a
necrotic pulp with an open apex and chronic apical periodontitis. Apexification was the
procedure of choice for this case.
Tooth #8 was accessed and there was severe drainage. It was carefully and copiously irrigated
with 6% NaOCl. A size 140 was used to gauge the open apex. Calcium Hydroxide USP powder
was packed in for 1 month. Patient returned and the CaOH2 was "washed out". It was repacked
for 3 months. The tooth was reopened and now no drainage. A collocoate matrix was placed at
the apex then ProRoot MTA by Dentsply on top. Patient was told to get a core build up and
crown as soon as possible. She returned 2 years later to look at another tooth. She said she
forgot about tooth #8 and her dentist said just take it out and do an implant. She asked can I do
anything else. I said we can do "hero-dontics" and try.
She returned 2 months later. The Cavit was gone and there was recurrent decay inside the root.
I cleaned it all out. She wanted me to internally bleach the tooth as well. Sodium perborate and
superoxol was placed for 1 week as the bleaching agents. I placed a bonded restoration inside
the root and composite core. Patient was very satisfied with her final result. She was in her 3rd
trimester. She did not want an implant or extraction. This tooth has lasted 10 years so far.
Clinical view of tooth #8 with dark colored crown and incisal edge fracture from a trauma
several years ago.
Pre-op radiograph of tooth #8 with large periapical pathology with an open and immature apex.
Apexification procedure was initiated on tooth #8. Calcium hydroxide was placed and temp
restoration.
Patient returned in one month and the tooth was still draining. Apical gauging was performed
with a size 140 headstrom file.
Tooth #8 was re-cleaned and shaped. Calcium hydroxide USP powder was placed for 1 month
and Cavit.
Patient returned and the CaOH2 was washed out.
The CaOh2 was repacked again for 3 months with Cavit in place.
After 3 months there was still no bridge in place.
A collocoate matrix was placed at the apex to form a barrier. MTA was packed against the
barrier. The case was temporized with Cavit.
Patient did not get the tooth restored and returned after 2 years. The Cavit was now leaking
but an apical barrier did form and now the apex was closed.
Patient returned 2 months later with no Cavit and recurrent decay.
The decay was removed and internal bleaching was performed.
Patient returned in one week and the internal bleaching was successful. A composite core was
placed.
Patient was very satisfied with the result. The tooth has been stable for 10 years.
CASE 2
IMMEDIATE APEXIFICATION
One visit apexification was described by D.E Witherspoon in 2001. His study showed MTA as a
valuable material for use in one-visit apexification treatment, primarily for treating immature
teeth with necrotic pulps.
A 43 year old male came in the discomfort on tooth #8. The diagnosis was a necrotic pulp with
chronic apical periodontitis. He had a history of trauma and orthodontics. There is a periapical
lesion with root resorption at the apex. I decided to perform immediate apexification with a
ProRoot MTA plug.
The apex locator was very inaccurate due to the resorption so a traditional working length file
radiograph was done with a size 120 hand file. The canal was hand instrumented and carefully
irrigated with full strength 6% NaOCl and 17% EDTA. The canal was dried with large paper
points. MTA (ProRoot Dentsply Sirona Endodontics) was placed using the MAP device. It allows
you to pre-measure the amount of MTA and carry it precisely to the apex. Gutta percha was
placed on top of the MTA using the Obtura Spartan gun.
*Traditionally with long term calcium hydroxide you would have to wait 4-6 months for a
calcific bridge to form in order to get an apical stop.
**Now other Bioceramic Material can be used such as BC putty by Avalon Biomed, EdgeEndo,
and Brasseler USA.
Pre-op radiograph showing the resorptive defect at the apex on tooth #8, the periapical lesion,
and the open apex.
Endodontic treatment initiated and the apex is gauged with a size 120 file.
The MAP System (Micro Apical Placement) device used to place the MTA very precisely at the
apex.
MTA is being placed in the MAP carrier.
MTA is being placed inside the tooth with the MAP carrier with a rubber stopper at the
reference point.
Radiograph of the MTA plug placed at the apex on tooth #8.
Post-op radiograph of the MTA plug and gutta percha on top with Cavit. This is the Immediate
Apexification Technique.
A 6 month recall showing the tooth restored and healing at the apex.
TOPIC 6 – APEXOGENESIS & PULP CAPPING
Traumatic injuries to an immature permanent tooth may result in stop of dentin deposition and
root maturation. Most dental traumas occur in the 7 - 10 year-old age group with incomplete
apical root development (Andreason IJOS 1972). If the pulp vitality of a traumatized immature
tooth is lost, the treatment will be a challenge in endodontics.
Apexogenesis is a procedure that encourages the root to continue development as the pulp is
healed. Some also call it vital pulp capping. The tooth must be vital and the apex is open. Soft
tissue or the pulp is covered with a bioceramic material to encourage growth. The tip of the
root (apex) will continue to close as the child gets older. In turn, the walls of the root canal will
thicken. If the pulp heals, no additional treatment will be necessary. The more mature the root
becomes, the better the chance to save the tooth long term.
CASE 1
This case was a 6 year old who had a large cavity into the pulp on tooth #19. Apexoegensis was
performed with white MTA. The issue with white MTA is that it is known to stain the tooth.
Since this case was a molar with a stainless steel crown to be placed the staining was not an
issue.
The technique on Apexogenesis is as follows:

1. The tooth was anesthetized with 1 carp 2% Xylo 1/100ep and rubber dam was place.
2. The decay was carefully removed with a slow speed round bur.
3. “Healthy Pulp” was achieved where there was minimal bleeding.
4. Half strength NaOCl (2.5%) was used to irrigate the pulp, followed by saline, then 2%
Chlorohexidine.
5. MTA was placed on the pulpal floor directly on top of the pulp (3mm or more MTA
placed).
6. A moist cotton pellet placed on top of the MTA and Cavit.
7. Patient returned to his dentist for the final restoration.
A 6 month, 1.5 year, and 2.5 year recall was performed. The last recall showed complete
closure of the apex, increased root length, and increased root thickening.
The only difference now is that I would use Bioceramic Putty from (EdgeEndo or Avalon Biomed
Inc. or Brasseler USA) on anterior and bicuspid teeth due to staining from ProRoot MTA
(Dentsply Sirona Endodontics).
Pre-Op radiograph showing deep decay on tooth #19 with an open apex.
Post-Op radiograph of Apexogenesis completed with MTA and Cavit placed as the temporary
restoration.
A 6 month recall showing progress of root closure.
A 1.5 year recall showing the apex is continuing to close.
A 2.5 year recall showing the apex is closed.
CASE 2
Th patient had a trauma on tooth #9 due to an accident. It created a complicated crown

fracture involving the pulp on tooth #9. Tooth had a class III mobility. He was in pain. The apex
was still open. Apexogenesis was performed with Bioceramic Putty by Brasseler USA. The splint
was removed in 2 weeks and patient reported to be asymptomatic. Patient returned for an
evaluation for another tooth 3 years later. A LFOV CBCT was performed on tooth #9. The apex
has completely closed and there is a nice calcific barrier under the BC putty.
Pre-Op radiograph showing the complicated crown fracture on tooth #9
Apexogenesis procedure done and bioceramic putty by Brasseler USA was placed directly on
top of the pulp.
A 3 year recall showing the apex closed and a calcific barrier formed.
A LFOV 3D CBCT sagittal image showing the apex has closed and no resorption has taken place.
"SHORT" Trauma Keys On Anterior Teeth With An Open Apex:
1. A complicated crown fracture involving the pulp must be dressed with some kind of
calcium silicate cement or bioceramic material.
2. Don't use ProRoot MTA even the white type because it will cause staining due to the
heavy metal bismuth oxide present.
3. Only splint for 2 weeks if tooth was subluxated and use a non-rigid splint unless the
tooth is avulsed then splint for 4 weeks.
The apex can take up to 3 years to completely close after apexogenesis procedure.
CASE 3
This was a 6 year old referred to my office with pain on tooth #3. The diagnosis was acute
irreversible pulpitis and an incomplete or immature apex. What do you do? How you manage
the patient? How do you manage the tooth? I recommend Apexogenesis on cases like these
using nitrous oxide to relax the child and local anesthesia. Apexogenesis was performed using
ProRoot MTA Dentsply Sirona Endodontics on this case. I would not use MTA on a front tooth
due to staining from the bismuth oxide. I recommend Biodentine by Septodont North America,
Bioceramic Putty by Brasseler USA, Biocermic Putty by Edge Endo, or Bioceramic Putty by
Avalon Biomed.
Patient returned for a 6 month follow up and was asymptomatic. It's been 3 years now and the
roots have closed and matured. This is the typical time frame.
Don’t perform full endodontic therapy on these cases unless patient becomes symptomatic
or there is an obvious PA lesion.
Pre-Op radiograph on tooth #3 showing immature roots with deep decay.
Post-Op radiograph of Apexogenesis procedure performed on tooth #3 with ProRoot MTA.
A 6 month recall showing roots are maturing and patient is still asymptomatic.
A 3 year recall showing the roots are mature and the apex are now closed.
TOPIC 7 – APICAL SURGERY
ROOT END SURGERY OR RETREATMENT? IS THERE A MAJOR DIFFERENCE IN OUTCOMES?

A study in the Journal of Endodontics points out there is no statistically significant difference in
the survival of non-surgical retreatment vs apical surgery (Haxhia JOE 2021).
Surgical Advances in the Last Decade In Endodontics
1. A smaller osteotomy, approximately 3-4mm in diameter due to utilization of the surgical

microscope.
2. Root-tip resection of 3mm to eliminate lateral canals and apical ramifications.
3. A decreased or no root resection bevel angle.
4. Newer root end filling material such as Bioceramic Putty vs MTA.
Studies by Rubenstein and Kim shows the ability to work within a smaller osteotomy involving
reduced bone removal permits quicker healing and results in less eventful postoperative
healing (JOE 1999).
A main cause of nonsurgical endodontic failure is from the inability to clean and sterilize the
apical canal space, which is a complex anatomical entity. A study shows that the resection of
3mm of apex eliminates 98 percent of apical ramifications and 93 percent of lateral canals (Kim
and Kratchman JOE 2006).
When Should Endodontic Microsurgery Be Performed?
1. Properly performed endodontics was performed but failed with a persistent periapical
radiolucent lesion.
2. Adequately performed endodontics but patient has constant pain with or without
swelling.
3. Canal transportation, ledges and other iatrogenic problems with persistent pathology
and symptoms
4. Tooth with a large post and crown restoration completed and will damage the tooth
more by retreatment.
5. Calcified canals with symptoms and/or periapical radiolucency.
6. Broken instrument in apical half of the root that can’t be removed or bypassed.
7. Failed previous endodontic surgery.
8. Overfilled canal with periapical pathology.
9. Complex apical curvatures that are inaccessible from an orthograde approach.
(Kim JOE 2008)
CASE 1
A previous dentist performed root canal therapy on teeth #8 and #9. The apex was not gauged
properly and resulted in a significant overfill of the gutta percha. Apical surgery was performed
on both teeth in one visit after the retreatment.
Pre-Op radiograph showing previous root canal performed with an overextension of gutta
percha on teeth #8 and #9.
Endodontic retreatment was performed on teeth #8 and #9 prior to apical surgery.
The overextended gutta percha was removed (red arrow).
Post-op radiograph of the apical surgery completed on both teeth. No retrofill was needed.
The gutta percha was cold burnished according to Tanzilli et al. OOO 1980.
CASE 2
Patient came in 2015 with discomfort and localized swelling on tooth #19 with a buccal sinus
tract. It had a previous root canal that appear to be well done radiographically however there
was pathology evident on both the mesial and distal roots. I recommended a retreatment due
to chronic apical abscess. A retreatment was performed in 2 visits using calcium hydroxide.
Patient returned asymptomatic and the sinus tract had resolved. The case was completed using
warm vertical condensation with Kerr EWT sealer.
Three years later (2018) the patient returned with discomfort again with tooth #19. I
recommended an apicoectomy or extraction/implant. She decided to have the apicoectomy
instead. The surgery was performed on the mesial root only because the distal root healed well
from previous treatment. Under the microscope, there was an isthmus present that I could not
clean with irrigants nor calcium hydroxide. The isthmus was retroprepped with ultrasonics and
bioceramic putty was used for the retroseal (Brasseler USA).
A root canal isthmus is a narrow ribbon-shaped communication between two root canals. It
may contain pulp remnants, necrotic tissues, and micro-organisms and their byproducts. This
can lead to the failure of an acceptable root canal treatment. (Weller et al JOE 1995).
In endodontic surgery, guided tissue regeneration has been applied using different bone
substitute materials and/or different barrier membranes. This concept was first introduced in
1992 by Lindhe (Naymen et al. 1982). The concept was designed to facilitate tissue
regeneration by creating a stable environment and protected wound site. In addition, to
exclude non-desired fast proliferating cells from interfering with tissue regeneration so good
solid bone can regenerate in the surgical site. On the basis of currently available literature,
there is a low scientific evidence of a benefit related to the use of guided bone regeneration
procedure in endodontic surgery. (Corbella et al. Swiss Dental Journal 2016)
This is why I don't believe in placing DFDB (bone graft material) or membranes into the crypts
or a membrane on most cases after surgery. Many studies show they don’t have to be placed
for osseous healing. On this case, the patient returned in 6 months completely asymptomatic
with nice bone regeneration.
Pre-Op radiograph of tooth #19 with periapical pathology on both roots. It had a previous root
canal.
A retreatment was initiated on tooth #19 and calcium hydroxide was placed.
Post-op radiograph of the retreatment completed.
Patient returned in 6 months for a follow up. The distal root healed but the mesial root did not.
Patient returned for a 3 year recall and reported tenderness associated with tooth #19.
A pre-op radiograph of tooth #19 prior to apical surgery. The distal root has healed well.
An apical surgery was completed on the mesial root of tooth #19. It was retro-prepped with
ultrasonics and bioceramic putty was placed.
Post-op radiograph of patient returned in 6 months completely asymptomatic with nice

osseous healing.
TOPIC 8 – ANTIBIOTICS
MYTH #1 – Antibiotics Cure Endo Infections. No they don’t. Patient’s cure themselves once the
source of the infection is removed from the tooth.
MYTH #2 – Antibiotics Are Substitutes For Endo Surgery. Very seldom this solves the issue. In
many instances there are isthmuses that contain bacteria that antibiotics can’t reach. Apical
surgery is the best option.
MYTH #3 – The Most Important Decision Is Finding The “Right” Antibiotic. This is false. The
most important decision to make is do the patient even needs an antibiotic. If so choose the
one with the least side effects and most appropriate for the patient. PenVK is still the first
antibiotic of choice for endodontic infections.
Classic endodontic literature illustrates that systemic oral antibiotics is not indicated for a small
localized swelling in the absence of systemic signs and symptoms of infection or spread of
infection. A recent Cochrane Database Systematic review showed that antibiotics were of no
additional therapeutic benefit for healing of a localized periapical abscess. The routine
administration of antibiotics just because there is a periapical lesion can lead to resistant
infections and lowering the patient’s immune system.
Outcomes of pain and infection were dependent upon drainage being relieved through access
or incision and drainage. In most case when a patient is swollen and in pain, I recommend
performing an incision and drainage procedure. Evidence shows that antibiotics are an adjunct
in the management of periapical infections in these situations. In an effort to save the natural
dentition, effective treatment of odontogenic infections must include removal of the source of
infection through endodontic treatment.
In 2016, nearly 26 million oral systemic antibiotic prescriptions were written by dentists alone.
The bacterial microflora of the root canal is initially dominated by aerobes and facultative
anaerobes. As disease progresses, the ecosystem within the root canal system changes and is
largely characterized by anaerobic bacteria in primary infections. The most common species of
bacteria isolated in odontogenic infections are the anaerobic gram-positive cocci Streptococcus
milleri group and Peptostreptococcus. Anaerobic gram negative rods, such as Bacteroides
(Prevotella) also play an important role (Baumgartner et al Micro Bio Endo Disease 2008).
Whether primary or secondary involvement, infection will spread and the inflammatory
response will progress until the source of the irritation is managed or eliminated. Once an
endodontic infection is diagnosed, treatment is recommended the same day. This is what I do
routinely in my practice. Placing a patient on antibiotics and rescheduling to have the source
dealt with at a later time is not sound practice and may allow the infection to worsen.
If the infection is actively draining, the endodontic access may be left open until the next day or
a drain placed in the incision and left in place for 24-48 hours. I try to close all teeth if possible
with calcium hydroxide paste or powder mixture in place.
Which Antibiotics To Choose For An Endodontic Infection?
*Amoxicillin and Penicillin VK should be the first line of therapeutic antibiotics dentists
prescribe to patients without a penicillin allergy.
**Amoxicillin in combination with clavulanic acid (Augmentin) is effective for patients who
continue to have an unresolved or recalcitrant infection.
***Dentists should use metronidazole only to treat odontogenic infections when in

combination with a penicillin because this combination provides excellent gram-positive and
gram-negative coverage.
****For patients with an allergy to penicillin, clindamycin should be the antibiotic of choice;
however, because of the risk of colitis and the accompanying black box warning for clostridium
difficile associated diarrhea which can be fatal, the dentist should first consider Azithromycin or
Z-pack.
This is me in the hospital after being diagnosed with C.Diff. It was almost fatal.
Make sure the diagnosis is properly made before prescribing antibiotics. Unreasonable
prescriptions can cause resistant strands. According to the CDC antibiotic resistant infections
account for 23,000 deaths and billions of dollars in excess spending in the United States
annually.
The Most Common Antibiotics Rx For Endo Infections and Price I found on Good Rx
(No insurance required just tell your patients to download the app):
1. Penicillin - PenVK 500mg - $10/28tbs:

Treatment for odontogenic infections emphasizes penicillin as a first line of defense when
managing dental infections. Penicillin VK has good effectiveness, low toxicity, as well as low
cost. A loading dose of 1,000 mg of penicillin VK should be orally administered, followed by 500
mg every four to six hours for three to seven days. (Segura et al. IEJ 2016)
2. Amoxicillin - Amox 500mg - $10/30tbs:

Amoxicillin has a broader spectrum of activity than penicillin V. It does not provide any better
coverage in treating odontogenic infections, yet tends to be more effective against various
gram-negative anaerobes. It has an oral dosage of 1,000 mg loading dose with 500 mg
recommended dosing every eight hours for 3 to seven days.
Amoxicillin is also the antibiotic of choice for antibiotic prophylaxis of patients that are
medically compromised. It has an extended spectrum which lends to resistant strains of
microbes. (Little et al. Gen Dent. 2008)
3. Cephalosporins - Cephalexin - Keflex 500mg -$15/40tbs

The mechanism of action of cephalosporins is similar to that of penicillins. Cephalosporins are
not a first-line treatment in the management of odontogenic infections; however, they should
be considered when there is not a true allergy to penicillin. *Cephalexin is more commonly
used for sinus communications and for antibiotic prophylaxis in patients with prosthetic joints.
(Macy et al. Curr Allerg Asthma 2014)
4. Metronidazole - Flagyl 500mg - $10/14 tbs

Metronidazole is a synthetic antibiotic that is effective against anaerobic bacteria. It disrupts
bacterial DNA, thus inhibiting nucleic acid synthesis. It provides excellent anaerobic coverage
and should be used in conjunction with penicillin. If after the initial treatment symptoms do not
improve over a two- to three-day period then metronidazole may be added to the original
prescription of penicillin or clindamycin, with continuation of both antibiotics until completion.
Usual dosage follows a 1,000 mg loading dose and 500 mg every six hours for five to seven
days. (Durkin et al. JADA 2018)
5. Clindamycin - Cleocin 300mg - $15/30 caps
Clindamycin inhibits bacterial protein synthesis, making it bacteriostatic and bactericidal at high
dosages. Its use has increased in recent years due to increasing concern over penicillin
resistance, and as a viable option was the primary antibiotic of choice for patients with
antibiotic allergy to penicillin. *Clindamycin substantially increases the risk of developing C.
difficile infection even after a single dose, carrying a black box warning for C. difficile infection,
which can be fatal. Clindamycin should be prescribed with a 600 mg loading dose followed by
300 mg dosing every six hours for five to seven days. (Leffler et al N Engl J Med 2015).
6. Macrolides - Erythromycin (Don’t recommend Rx anymore for endo infections)

In dentistry, erythromycin is a macrolide with infrequent use in dentistry. Once prescribed as an
alternative to patients with a penicillin allergy due to its spectrum of activity similar to that of
penicillin V. Kuriyama and colleagues found that erythromycin was ineffective against
Streptococcus viridians and most Fusobacterium species and essentially not effective against
anaerobic bacteria. (Kuriyama et al. OOO 2000).
7. Azithromycin - Zpak - Zithromax 250mg (1pack - 6 tabs) $10/pack

Azithromycin is effective against a variety of aerobic and anaerobic gram-positive and gram-
negative bacteria with improved pharmacokinetics.
****For patients with a true allergy to penicillin, the primary alternative antibiotic
recommendation has changed...NOT CLINDAMYCIN! It is now azithromycin with a loading dose
of 500 mg, and then 250 mg for four additional days. (Moore et al JADA 130).
8. Flouroquinolones - Cipro 500mg - $10/14 tbs

Fluoroquinolones include the antibiotic ciprofloxacin which interferes with bacterial DNA
metabolism by inhibiting the enzyme topoisomerase which promotes replication. *It is not
effective against anaerobic bacteria usually found in endodontic infections.
**It should be considered as a second line therapy to penicillin V, metronidazole and
clindamycin if an infection is persistent and bacterial culture shows bacterial susceptibility.
(Sato et al IEJ 29).
CASE 1 – ENDO MISDIAGNOSIS BY HOSPITAL PHYSCIANS
PATIENT TESTIMONIAL
“Dr. Rico Short you did my root canal after I was in the hospital for 4 days with severe facial
swelling and many rounds of IV antibiotics. After getting discharged with no relief, I came to see
you and you performed a painless procedure and my facial swelling subsided after 1 day. It was
one of the best dental experiences I've ever had. You are a true artist and you're extremely
good at what you do!! Thank you for reaching out to me to advise me on my situation. I
consulted with many infectious disease doctors, a hospitalist, and an ER doctor and they all mis-
diagnosed me with facial cellulitis. You got it right and saved my tooth and relieved my awful
facial swelling. I recommend you to anyone who needs a root canal done the right way the very
first time!!!” – P.D
Patient was treated for a facial cellulitis. He actually had an abscess on tooth #19. Endodontic
therapy was completed and the swelling subsided. Antibiotics alone will not completely resolve
an endodontic infection.
CASE 2
Buccal space infections are primarily from mandibular or maxillary bicuspid or molar teeth, the
apices of which lie outside of the buccinator muscle attachments. They are readily diagnosed
because of marked cheek swelling but with minimal trismus or systemic symptoms. If these are
not taken care of soon it could lead to Ludwig's Angina which is a life threatening issue.
This patient presented with severe pain and swelling. An incision and drainage was performed
due to swelling. Patent was placed on PenVK 500mg every 6 hrs for 1 week and Motrin 800mg.
She returned with very little swelling and discomfort. The 2D PAX did not show a significant
periapical pathology associated with tooth #19. A LFOV CBCT was performed. There was a
notable lesion associated with tooth #19.
*This is a case where significant swelling and infection can be present but nothing significant
shows up on the radiograph* Endodontic treatment was performed tooth #19 due to a necrotic
pulp with acute apical periodontitis. Upon access the tooth was necrotic with pus discharge.
The canals were carefully and copiously irrigated, cleaned, shaped, and obturated with
Bioceramic Sealer and gutta percha in one visit.
Clinical photo of buccal swelling on the lower left.
A pre-op radiograph does not show any significant pathology.
A LFOV CBCT sagittal view shows periapical pathology associated with the distal root of tooth
#19. There is also a large lateral canal present.
A post-op radiograph of the completed endodontic therapy with bioceramic sealer and gutta
percha in one visit.
CASE 3
An 18 year came in with severe pain on tooth #30. He said the root canal was performed when
he was 10 years old and had been hurting for a year. He said it has gotten severe recently. The
pre-op shows a previous root canal with periapical pathology on the mesial and distal roots. A
LFOV 3D CBCT revealed pathology on both roots. There appears to be a vertical root fracture
(VRF) at the apex of the mesial root and a missed DL canal.
A retreatment was performed on tooth #18 in 2 visits using calcium hydroxide for 3 weeks. He
flared up with pain and severe swelling after 3 days. He was brought back in for an incision and
drainage. He was placed on Amox 500mg, 600mg Ibuprofen, and told to alternate with Tylenol
#3 as needed for severe pain. He did not respond to the Amox 500mg after 1 week. The patient
was switched to Clindamycin 300mg. He returned after 2 weeks asymptomatic with no swelling.
The case was competed with EdgeEndo Bioceramic Sealer technology and gutta percha. He
returned for a 6 months evaluation still asymptomatic with nice osseous healing.
A pre-op radiograph on tooth #30 with periapical pathology on both mesial and distal roots.
A sagittal view of the 3D CBCT shows the pathology and what appears to be a vertical root
fracture on the mesial root at the apex.
A coronal view of the 3D CBCT shows the large lesion on the mesial root on tooth #30.
Patient had a flare-up after 1 week and face was swollen on the lower right.
An incision and drainage procedure was performed and the swelling started to decrease.
Patient returned asymptomatic with no swelling or pain. Endodontic retreatment continued

with conefit.
A post-op radiograph with completion of endodontic retreatment using Edge Endo bioceramic
sealer and single cone gutta percha.
A 6 month recall shows very nice healing.
TOPIC 9 – BIOCERAMIC TECHNOLOGY
Bioceramic Technology are materials have been introduced as root repair cements such as MTA
and now root canal sealers. Bioceramics usually includes alumina and zirconia particles,
bioactive glass, calcium silicates, hydroxyapatite, and resorbable calcium phosphates (Kock et al
Endo Practice 2009). These materials are biocompatible, nontoxic, non-shrinking, and
chemically stable within the biological environment than other sealers such as Silicone or Resin
Based Sealers, Calcium Hydroxide based sealers, and ZOE based sealers (Zhou et al. JOE 2013).
Bioceramic Sealer Technology also has the ability to form hydroxyapatite during the setting
process and ultimately create a bond between dentin and the filling material (Loushine et al.
JOE 2011).
Weakened roots after root canal preparation can be a challenge especially in retreatment
cases. In my practice I use various sealers based on the case situation. However, I’m using more
Bioceramic Sealer Technology lately. It can be a bit more expensive but well worth it in some
cases. It does not resorb nor shrink like most other sealers. It speeds up treatment time and
many times there is no need to backfill the case. In addition, it is also retreatable as long as
gutta percha is in place.
Some cases I use it for are large canals, young patients (they don’t like the discomfort of heat
from warm vertical condensation), “Hot Teeth” towards the end when anesthesia is wearing
off, and long curved roots when I can’t get the heat down within 5 -7mm. In addition, it’s great
for retreatment cases because more dentin is always removed and you don’t want a vertical
root fracture, and others such as trauma, apical resorption, internal resorption, external
resorption, etc. Another unique advantage is it can be used with a cold single cone technique.
No firm hard condensation is need like that of warm vertical. This can also decrease the
fractures that may be caused by condensation of Gutta Percha with pluggers.
Studies are consistently reporting that calcium silicate Based sealers such as Bioceramic Sealer
can reinforce root strength and increase fracture resistance. However, if the canal preps are
conservative or a calcified case, I really don’t think it makes a significant difference. The
reinforcement effect is derived from the ability of sealer to bond to root dentin with good
sealer penetration into dentinal tubules.
A study published in the Dec 2018 JOE by Osiri et al. showed Bioceramic Coated Gutta Percha
Cones combined with Bioceramic Sealer provided a higher bond strength, maximum depth, and
circumferential penetration at the apical root level as well as a greater sealer penetration area
at all levels compared with Gutta Percha combined with AHplus Sealer.
In addition, a study by Gomes in June 2021 JOE shows Bioceramic Sealers perform better
histologically than resin based sealers such as AHplus.
CASE 1
Patient had pain on tooth #31 and required endodontic therapy. This was a pretty challenging
case. I used many small handfiles just to get a glide path. I then used heat treated NiTi files.04
taper which are very strong and flexible. Bioceramic Sealer with gutta percha was used.
Here are three types I use and like:
1. Edge Endo Bioceramic Sealer

2. Brasseler USA Bioceramic Sealer
3. Avalon Biomed NeoSealer Flo Bioceramic Sealer
Why Bioceramic Sealer?

Resin-based sealer will shrink upon setting while calcium hydroxide and zinc oxide eugenol-
based sealer can resorb over time. The Bioceramic sealers expand while setting, the expansion
is slight, less than 0.2% of total volume and once set will not resorb as easily.
*The purpose of the gutta-percha cone is to drive the sealer into cleaned isthmuses and
irregular gaps.
**It also serves as a soft core that will allow for retreatment as set bioceramic cement is a
challenge to go through with hand or rotary files.
***The hydrophilic nature, sealability, biocompatibility, antibacterial property, bioactivity, and

ease of delivery has made it a promising material to be used in endodontics.
>Warm vertical condensation would be impossible to get heat within 5 mm of the apex on this
case.
Pre-Op radiograph on tooth #31 with very long curved roots. Notice the roots are going under
tooth #32.
Post-Op radiograph on tooth #31 with bioceramic sealer technology.
CASE 2
Tooth #4 - Retreatment With Bioceramic Technology

Patient came in with pain on tooth #4. The tooth had a previous root canal with a post and a
buccal sinus tract. It also had an apicoectomy. The diagnosis was previous treatment with
chronic apical abscess. The gutta percha appears to have disappeared. But what probably
happened was the dentist tried to prepare a post space and pulled out the gutta percha then
cemented the post.
Patient wanted to save her tooth. A retreatment was performed in one visit. The post was
removed using ultrasonic tips. The canal was obturated using Bioceramic Gutta Percha and
Bioceramic Sealer. Some studies shows Bioceramic coated and non-coated gutta percha works
the same with Bioceramic sealer (Topcuoglu JOE 2013). In addition, there are studies that states
Bioceramic sealer + gutta percha strengthens the root and its more resistant to fracture. (Osiri
JOE 2018)
A 6 month recall shows nice healing and resolution of the sinus tract. This tooth had a previous
root canal and apicoectomy yet was still able to be saved by retreatment using Bioceramic
Technology.
This collage shows the pre-op radiograph with tooth #4 has a previous endodontic treatment.
A leaky crown, a screw post, and very little gutta percha present. The retreatment was
performed in one visit using a bioceramic cone and bioceramic sealer. A six month recall shows
very nice healing.
CASE 3
Patient came in with pain on tooth #18. A previous dentist recommended an extraction and
implant. His current dentist sent him to me for a second opinion. A LFOV 3D CBCT was
performed on tooth #18 with my Carestream 8100 CBCT unit. It revealed pathology on the
mesial and distal roots. It also revealed a "J-shaped" lesion which in some instances a vertical
root fracture. There was no obvious fracture on the CBCT image. A retreatment was performed
in one visit.
My Technique:
1. The gutta percha was removed with gates glidden drills, chloroform, and EdgeEndo
retreatment files.
2. Working length was established with my apex locator.
3. Canals were cleaned and shaped with EdgeEndo X7 files.
4. Irrigation of the canals were with Chlor-Xtra and the dripless syringe by Vista Apex Dental
Products.
5. 17% EDTA was used in each canal (4 total)
6. Final rinse and activation of Chlor-Xtra with the EndoUltra device.
7. Canals dried with paper points
8. Insertion of bioceramic sealer NeoSealer Flo by Avalon Biomed and single cone gutta percha.
9. Notice no puffs or lateral canals popped.
10. Temp restoration.
*Total treatment time 1hr.*
Patient reported to be asymptomatic after a few days. He returned in 6 months with very nice
osseous healing.
Pre-op radiograph on tooth #19 with a large periapical pathology. Notice the “J-shape” lesion.
A 3D bone rendering with CBCT shows the periapical pathology.
A coronal slice CBCT on the mesial root shows the appearance of a “J-shaped” lesion. Notice it
is filled short.
The coronal slice CBCT shows periapical pathology on the distal root. Notice it is filled short.
A post-op radiograph of the retreatment on tooth #19 with bioceramic sealer.
A 6 month recall shows very nice healing taking place.
CASE 4
Tooth #8 - Large Lateral Canal With Bioceramic Puff

Patient came in pain on tooth #8. She was 17 years old with a history of trauma and ortho. The
diagnosis was a necrotic pulp with acute apical periodontitis on tooth #8. Endodontic treatment
was performed in one visit using bioceramic sealer and gutta percha for the obturation. A large
lateral canal was "popped". Patient returned 5 months later with a small raised non-inflamed
area on the buccal mucosa. I performed a LFOV 3D CBCT. It was the bioceramic sealer that had
set up between the buccal bone and the gingival mucosa. It was very hard like a pebble. The
patient did not want me to do a curettage and remove the excess bioceramic sealer that had
set up. It may resorb in time. She will be recalled on 6 months intervals for the next 3 years.
A pre-op radiograph on tooth #8.
A post-op radiograph of tooth #8 with a large lateral canal and bioceramic putty.
Patient returned 5 months later for a follow up and noticed the firm non-inflamed raised area
on the buccal mucosa.
A radiograph taken after 5 months showing the biocearmic sealer still in place in the lateral
canal.
A LFOV 3D CBCT taken showing the bioceramic sealer in the lateral canal and the excess sealer
on the buccal.
The LFOV 3D CBCT on tooth #8 showing the bioceramic sealer on the buccal surface.
Case 5
Tooth #8 ~ Very Large Lesion One Visit BC Sealer

Patient came to my office in discomfort on tooth #8. She recalled a trauma in her childhood.
The diagnosis was a necrotic pulp with chronic apical periodontitis. Tooth #7 pulp tested
normal. A LFOV 3D CBCT was taken. There was a very large thru and thru lesion. I decided to
perform a one visit treatment using bioceramic sealer and gutta percha. The type used on this
case was Bioceramic Sealer by Brasseler USA.
Patient returned in one year with very nice healing taking place. This was possibly a bay or
pocket cyst / or a large granuloma. A biopsy would have been needed to confirm the diagnosis
of the lesion. I would not have tried this with a ZOE based Sealer (Kerr EWT) , CaOH based
Sealer (Sealapex), or Resin Based Sealer (AHplus). Bioceramic Sealers have MTA and Calcium
Hydroxide properties - it's very stable, non-staining, non-cytotoxic, makes hydroxyapatite, easy
to use, have a high pH to promote healing and osteoconductive.
A pre-op radiograph showing very a very large periapical lesion associated with teeth #8 and #9.
A LFOV 3D CBCT rendering showing the lesion from the buccal perspective.
A LFOV 3D CBCT bone rendering view from the palatal aspect showing the large lesion.
A conefit radiograph on tooth #8.
A post op radiograph of the completion on tooth #8. Bioceramic sealer was placed inside the
canal and a single cone gutta percha was used. It was expressed outside the apex on accident.
A 1 year recall shows very nice healing even with the bioceramic sealer outside the apex.
The 1 year 3D CBCT shows very nice osseous healing from the buccal.
The 1 year 3D CBCT shows very nice osseous healing from the palatal.
TOPIC 10 – CALCIUM HYDROXIDE
Calcium hydroxide is the most commonly used intracanal medication in endodontics (Haapasalo
IEJ 2000). The antimicrobial effect of Ca(OH)2 results from the release of hydroxyl ions when it
comes into contact with aqueous fluids (Farhad IEJ 2005). Ca(OH)2 has a wide range of
antimicrobial effects against common endodontic pathogens, but is less effective
against Enterococcus faecalis and Candida albicans (Xavier JOE 2013). Hermann introduced it in
1920 as a pulp-capping agent.
Various biological properties of Ca(OH) 2, such as antimicrobial activity, tissue-dissolving ability,

inhibition of tooth resorption, and hard tissue formation have been established by years of
research (Sousa JOE 2014). Its wide use in root canal treatment has been associated with
periapical healing and only a few adverse reactions. It is also very helpful in canals that can’t be
dried due to drainage of infections. It comes in a powder form (Calcium Hydroxide USP) and a
paste form ready to inject.
CASE 1
Patient came in severe pain on tooth #30. It had a very large periapical lesion. The diagnosis
was previous treatment with acute apical periodontitis. The dentist thought it had a vertical
root fracture on the distal because of “J-shaped” lesion and large screw post. The patient did
not want the tooth extracted and implant. I retreated the tooth in 2 visits using calcium
hydroxide. I located a 2nd distal canal. The case was obturated with gutta percha and Kerr EWT
sealer (ZOE based sealer) with warm vertical condensation. A 6 month recall showing nice
osseous repair and she is asymptomatic.
Pre-op radiograph showing very large lesion on tooth #30.
A retreatment was initiated on tooth #30. It was disassembled and calcium hydroxide
medication was placed. Notice it is not necessary to get the calcium hydroxide out of the apex.
Patient returned asymptomatic for completion. There were 2 roots in the distal located and
treated.
A 6 month recall shows very nice healing. The white radiopaque material outside of the apex is
not calcium hydroxide. It’s the radiopacifier called barium sulfate. This will take many years for
the macrophages to resolve.
• Sometimes it can be difficult to remove the calcium hydroxide efficiently from inside the
canals before obturation. A study by Carlos de Lima Diez in Jan 2021 JOE shows 70%
ethanol enhanced calcium hydroxide removal from the apical root third compared with
2.5% sodium hypochlorite or 17% EDTA.
CASE 2
A patient had root canals performed by her dentist 6 months prior. She said the teeth still didn't
feel right. She did not want her teeth to be extracted and implants placed. She flared up with
pain and her dentist referred her to me. Previous root canals were performed on teeth #30 and
#31. Many would think tooth #31 has a vertical root fracture due to the breakdown in the
furcation. The diagnosis was previous treatment with acute apical periodontitis.
A retreatment was performed on both teeth and calcium hydroxide was placed for 2 weeks.
Patient returned and both teeth were obturated with Bioceramic Sealer by Brasseler USA and
standard gutta percha. This is considered a "single cone" technique. Patient returned in 6
months with remarkable healing.
Pre-op radiograph of teeth #30 and #31. Both had previous endodontic therapy and large
periapical pathology. Tooth #31 (red arrows) appears to have a vertical crack due to J shaped
lesion and pathology into the furcation.
A retreatment was initiated on both teeth #30 and #31. Calcium hydroxide was placed in both
teeth.
Patient returned asymptomatic and both cases was completed with bioceramic sealer and gutta
percha in a single cone technique. Notice the overfill of bioceramic sealer. This usually will not
cause an issue because it is a bone cement. However it is advisable to keep the material inside
the root canal system.
A 6 month recall shows very nice healing on both teeth #30 and #31.
CASE 3
Patient presented with pain on teeth #12 and #13. The diagnosis was a necrotic pulp with acute
apical periodontitis on both teeth. There was also gross recurrent decay. He said a dentist
recommended to have these teeth extracted and implants placed. However, he wanted to try
to save the teeth. Endodontic treatment was performed at the same time in two visits on both
teeth using calcium hydroxide as the intracanal medicament. Patient reported to be
asymptomatic a few days later. He returned in 2 weeks for completion on both teeth. A 4 year
recall shows both teeth restored and periapical area on both teeth has healed well.
A pre-op radiograph on teeth #12 and #13 with gross recurrent decay and periapical pathology.
Endodontic treatment was initiated and calcium hydroxide was placed for 2 weeks in both teeth
#12 and #13.
A post-treatment radiograph of completion of endodontic therapy on teeth #12 and #13.
A 4 year recall shows very nice healing on both teeth #12 and #13.
TOPIC 11 – CARRIER BASED OBTURATION
Carrier-based obturation is a filling technique that can simultaneously deliver and compact
warm gutta-percha to the terminus of canals that have coronal or mid-root curvatures. The
gutta percha is usually heated in an oven before placed inside the canals. Thermafil is one of
the most common carrier based obturation techniques. Originally it was manufactured with a
metal core and coating of gutta percha. These are very difficult to retreat (Zogheib et al. Clin
Oral Invest 2013).
The Top 3 Endodontic Obturation Techniques Are:
1. Warm Vertical Condensation. This is the most commonly used technique in North
American
2. Carrier-based techniques such as Thermafil or GuttaCore.
3. Lateral condensation.
Carrier-based obturation was first described in 1978 and involved the coating of endodontic
files with thermoplasticized gutta percha.
The advantages of the carrier-based obturation (CBO) are related to the flow of the gutta-
percha inside the root canal space, which is achieved by the combination of the heating process
and the fact that the carrier facilitates the insertion of filling material and also slightly pressure
it alongside the canal walls (Hale IEJ 2012). Moreover, the simplicity of the CBO prevents the
risks and problems related to the use of spreaders, pluggers, heaters and compactors inside
complex root canal (Gutmann IEJ 1993).
The disadvantages of CBO techniques include the possible risk of overfilling (apical extrusion) or
underfilling if the obturators do not reach the full working length due to the complex canal
curvatures or less tapered preparation (Levitan et al. JOE 2013). Another potential disadvantage
of CBO, especially in severely curved canals, is the gutta-percha separating from the carrier,
thus leading to the formation of gaps (voids) between the root canal filling and the canal walls
reducing the sealing ability (Juhlin JOE 1993).
However, most studies show that CBO techniques are acceptable when compared to warm
vertical condensation, and lateral condensation (Wolcott et al JOE 1997).
CASE 1
Patient was referred from his dentist a few months after a root canal was performed on tooth
#14. Patient was still in pain and had swelling. Radiographically the root canal looked pretty
good but a little short of the apex. This canal system was very complicated. It had very long
curved roots up into the sinus area. Recommended a retreatment on this tooth.
Upon access, the case was previously obturated with Thermafil (carrier based obturation
system) by Dentsply. The Thermafils were removed using electric heat carriers and solvents.
The correct working lengths were established verified by an apex locator and an MB2 was
located. The canals were cleaned and shaped with heat treated NiTi files. Calcium hydroxide
was placed for 2 weeks and patient returned asymptomatic.
The canals were obturated with Biocermic Sealer and gutta percha.
***The use of Thermafil did not cause this case to fail. ***
It was inadequate cleaning and shaping and locating all the canals. Thermafil is an acceptable
obturation technique. The success rate of endodontic treatment using core-carrier obturation is
83% according to research (Wong et al BMC Oral Health). A survey in the USA reported that
core-carrier obturation was the second most frequently used obturation method among
general dentists. However, studies show there are very few Endodontist in the US that use
carrier based obturation.
A pre-op on tooth #14. It has a Thermafil treatment. Notice the canals were filled short and
periapical pathology is present.
Two of the plastic Thermafils removed.
Calcium hydroxide placed after the canals were thoroughly cleaned and shaped.
A post-op radiograph of the retreatment. Notice an MB2 was located and treated.
CASE 2
Thermafil or Carrier Based Obturation is one of the most used obturation methods of root canal
treatment by general dentists. However, most endodontists DON'T use Carrier Based
Obturation. One reason it can be very difficult to retreat especially around curves. Many
general dentist use it because it's "easy" and "fast". The problem lies when the canal is under
prepared. What this means is when a thermosoftened alpha gutta percha slides through
curvatures, oftentimes gutta percha gets wiped off the carrier and the carrier arrived naked in
its terminal extent. It's like having a "plastic" silver point...however the obturation looks good
on the x-ray. This gives a false sense of security. Why? Because it’s very radiopaque, dense, and
stiff. There can actually be pulp tissue left inside the canal but a Thermafil obturater still can be
"crammed" inside. Take the x-ray...and walah!...It's beautiful. However, if you used warm
vertical condensation, if the canals are under prepared, the gutta percha will bend, fold, or
won't go to the apex. So this acts as kind of a "safety net" built in. If the canals are not properly
cleaned and shaped a problem will happen no matter what your obturation technique choice.
Patients will get symptomatic and they will need a retreatment.
This is a retreatment case on this lower molar with Thermafil. How does the pre-op x-ray fill
look to you?
1) It has large lesions on the mesial and distal roots and patient is in pain.
2) Two visits using calcium hydroxide.
3) Completion with warm vertical.
4) 1 year recall showing nice healing.
A pre-op radiograph of a Thermafil case. Can you tell it’s a Thermafil case from this radiograph?
Most can’t tell. Tooth #19 had periapical pathology on the mesial and distal root.
A retreatment was performed in 2 visits using calcium hydroxide as an intracanal medicament
for 2 weeks.
A post-op radiograph of the case completed using warm vertical condensation and ZOE based
sealer (Kerr EWT).
A 1 year recall shows very nice healing.
CASE 3
I am not a proponent for carrier based obturation even though it is an acceptable technique.
They can be very difficult to retreat especially around a curve. The metal Thermafils are even
more difficult to remove than the plastic Thermafils.
This was a retreatment case on tooth #19 with metal Thermafils. The diagnosis was acute apical
periodontitis with a very large periapical lesion associated with the mesial root. I had to use
solvents and ultrasonics to remove the 2 metal carriers with microforceps. There was a missed
ML canal noted as well. This case was performed in 2 visits using calcium hydroxide and
obturated with warm vertical condensation. Patient returned in 6 months showing positive
signs of healing and osseous repair.
A pre-op radiograph with a metal Thermafil treated case. This case also had a very large
periapical pathology.
A retreatment was initiated which included removing the metal thermals with micro forceps
and chloroform. A missed ML canal was located. Calcium hydroxide was placed for 2 weeks.
The patient returned asymptomatic and the case was completed with warm vertical
condensation and Kerr EWT sealer. The mesial canals joined.
A 6 month recall shows very nice osseous healing.
TOPIC 12 – CLEANING AND SHAPING
One of the main goals of proper endodontics is adequate cleaning and shaping the canal space.
Endodontic canals are not circular in nature. They are usually ovoid shaped or odd shaped.
This is why irrigation is just as important as choosing the proper file for canal preparation. It is
important not to make iatrogenic errors such as canal perforations, canal transportations, or
instrument fractures inside the canals. If these errors are make, they usually can be repaired
with modern endodontic therapy.
Nickel-titanium files were introduced to endodontics almost 20 years ago (Walia JOE 1988). It
has resulted in dramatic improvements for successful canal preparation. Today there are more
than 60 canal preparation systems and file types. However, every instrument system is not
suitable for every clinician or all cases. There are also new orifice shapers and glide path files to
facilitate achieving the working length faster and more predictable than hand files alone.
Another game changer is the application of heat treatment to nickel titanium alloy, both before
and after the file is manufactured (Shen JOE 2013). This allows for more flexibility and efficient
cleaning and shaping of canal systems.
Is there a difference between handfiles and Ni-Ti files?

A study by (Pettiette et al. JOE 1990) found less canal transportation and fewer gross
preparation errors such as strip perforations. In addition studies demonstrated better healing in
the NiTi group than handfile stainless steel.
Cleaning And Shaping Canal Systems are best prepared in the following sequence:
1. Evaluate specific anatomy of the case – Is it calcified? Is it curved?

2. Scout the canal – Look for the canals under high power magnification and lighting.
3. Modify the coronal aspect – Remove any impedances to the canal system such as old
amalgam.
4. Negotiation to patency – Use small handfiles such as size 6 or 8 to get close to length
first.
5. Determination of working length – Use and apex locator or good radiograph.
6. Glide path preparation – Heat treated glide path files will help.
7. Shape canal to desired size – I prefer the crown down method (larger file to smaller then
repeat)
8. Gauge the foramen – Check the final file to length to help prevent overfill.
CASE 1
Patient came in pain on tooth #15. The roots on this tooth were very complex. Endodontic
treatment was performed in one visit. Irrigation performed with Chlor-Xtra by Vista Apex with
ultrasonic activation and 17% EDTA. The tools of choice was many small handfiles to open up
(6, 8, 10), DC Taper 17/04 by SS White for glide path, Edge Endo X7 for cleaning and shaping,
and NeoSealer Flo bioceramic sealer by Avalon Biomed.
Pre-Op radiograph of tooth #15 with deep restoration. The diagnosis was symptomatic
irreversible pulpitis.
A post op radiograph of tooth #15 with very divergent root canal anatomy.
CASE 2
Patient came in pain on tooth #18. There was a large decay on the distal close to pulp.
Endodontic treatment was complete in one visit on this case. The mesial canals were very
difficult to navigate due to the narrowness in the middle and apical 1/3. These cases take time
to instrument properly.
TIP: I used many 6, 8, and 10 handfiles with RCPrep and NaOCl, then I used a heat treated glide
path file to get to length, and finally heat treated NiTi files for the final cleaning and shaping.
This case was obturated with bioceramic sealer and gutta percha.
A pre-op radiograph of tooth #18 with deep recurrent decay on the distal.
A post-op radiograph of the completion of the case in one visit.
CASE 3
Patient came in pain on tooth #18. The dx was acute irreversible pulpitis. Notice the pre-op
radiograph and see the canals seems to disappear in two areas. It's not calcified...the canals are
very thin and curved. Endodontic treatment was performed in one visit using heat treated NiTi
files and Bioceramic Sealer. Notice the very complex anatomy in the mesial root. It's important
to recognize the complexity of these case to reduce file separation.
A pre-op radiograph of tooth #18. The mesial roots have canals that appear to disappear.
A post-op radiograph shows the diverse anatomy of the mesial root.
5 Ways To Minimize File Separation
1) Provide Adequate Access and/or Use Heat Treated Files To Be More Conservative
2) A Good Glide Path ~ Recommend a hand file at the apex to at least a size #10 prior to
rotary use. Also heat treated Glide Path NiTi rotary files are helpful.
3) Use Light Pressure ~ Use light touch and torque control motor. The pressure I
recommend is to hold the rotary hand piece like you would hold a very sharp #2 pencil.
4) Don’t Start Then Stop ~ Sudden changes in the motion of the file while inside the canal
can create unwanted forces on the file. A smooth gentle motion should be used.
5) Lubricate Well ~ The canals should be lubricated at all times while cleaning and shaping.
Recommend use of sodium hypochlorite in addition to RCPrep.
CASE 3
Patient came in pain due to a very large cavity on tooth #19. The canals on this case are very
narrow. These cases can easily cause an instrument to separate if not very careful. Endodontic
therapy was performed in one visit.
“SHORT” TIPS On Narrow Canal Cases:
1. For narrow canals stay away from any .06 taper Ni-Ti files! They will create a strip
perforation or separation.
2. Use small hand files first (6,8,10) with RCPREP then a heat treated glide path file. Then
get working lengths.
3. Once you get a size 25 at the apex using copious full strength NaOCl as your main
irrigation and if it's tight put the files down!
4. Chow et al. JOE 1983 showed irrigation can reach the apex once you get to a size 25/.04.
5. I recommend using .04 taper heat treated Ni-Ti file in crown down method for safer
cleaning and efficient shaping.
A pre-op radiograph of tooth #19. There is deep decay on the distal. The diagnosis was chronic
irreversible pulpitis.
A post-op of endodontic therapy on tooth #19. Notice how skinny the canals.
An off angle radiograph of tooth #19 showing the mesial canals merging in the apical 1/3 and
the distal canals are diverging in the apical 1/3.
Variable Taper Rotary Files vs Constant Taper
People ask me how I feel about variable taper in endodontics. It's an old concept that
resurfaces that tries to prevent "taper lock". The Vtaper 2H by SSWhite is a variable taper file
(1st case on tooth #2) .
*The concept of variable tapers is to minimize the engagement of the file against the canal wall
(Buchanan IEJ 200).
** An example is to think of one plastic cup placed into another (constant taper) vs a plastic cup
stacked on a styrofoam cup(variable taper).
***However if you use crown down as your method of cleaning and shaping with new file
technology, the variable taper concept is a moot point.
The metallurgy of heat treated files are "softer" but stronger and therefore more flexible.
Also crown down allows your irrigation agent (I like full-strength sodium hypochlorite) to work
in a more efficient manner.
As a result of better manufacturing and technology, we now have the ability — with constant
taper files — to create predictable, reproducible shapes around curves and calcified canals.
Heat treated files such as Edge Endo X7 ( 2nd case on tooth #15) works very safe and efficiently
around tough curves.
So I always teach dentists and other endodontists to pick the appropriate file for the case
because there is no one file fits all in endodontic therapy.
A pre-op of tooth #2 with deep mesial decay. The diagnosis was chronic irreversible pulpitis.
A post-op radiograph of the completion of endodontic therapy on tooth #2 (an inverted image).
This case was performed with the variable taper Vtaper 2H file by SS White.
A pre-op radiograph of tooth #15 with deep recurrent decay.
A post-op radiograph of tooth #15 using Edge Endo X7 files. These files have a constant taper.
Pain Control Studies In Cleaning And Shaping
Pain Control For SonEndo GentleWave vs Traditional Endodontic Therapy
New Study By Grigsby et al in August JOE 2020 discusses this topic.

“Post-Operative Pain After Treatment Using The GentleWave System: A Randomized Control
Trial.”
Conclusion:
Treatment using the GentleWave vs Traditional Cleaning and shaping shows there was NO
significant difference in the incidence or intensity of postoperative pain compared with a
standard endodontic treatment using a conventional side-vented needle and ultrasonic
activation.
Pain Control In Rotary vs Reciprocation
• Most studies show no difference in pain after endodontic therapy using rotary vs
reciprocation file systems.
Mollashahi et al. Comparison of Postoperative Pain after Root Canal Preparation with Two
Reciprocating and Rotary Single-File Systems: A Randomized Clinical Trial. (Iran Endo Journal
2017)
• However, there are a few studies that show rotary instrumentation has less post-op
pain than reciprocation.
Hou et al. Post endodontic pain following single-visit root canal preparation with rotary vs
reciprocating instruments: a meta-analysis of randomized clinical trials. (BMC Oral Health
2017)
TOPIC 13 – CONE BEAM TECHNOLOGY
CBCT Use in Endodontics: Is It The Standard of Care?

CBCT is not currently the standard of care in endodontics. Remember when more than 20 years
ago the surgical microscope was the “next big thing” in endodontics? Some say the microscope
would be the standard of care. Even with the advancement of the surgical microscope in
helping endodontists locate calcified canals, remove separated instruments, repair
perforations, and aid in microsurgical procedures to save teeth, it is still not the standard of
care. Sodium hypochlorite is the most widely used irrigation in endodontics and yet it is still not
considered the standard of care.
Interpreting the CBCT Scan

CBCT has some powerful uses in dentistry, such as diagnosis, surgical planning, implant
treatment planning but it can also be quite limited for use in some areas in dentistry. In
particular, the image resolution still can’t pick up micro-cracks or small vertical root fractures
that are the Achilles’ heel in root canal therapy when deciding between trying to save a tooth
with a root canal or do an extraction. Getting the proper training is critical to determine the
difference between artifacts and a crack for instance (Azevedo et al. CBCT Interp. 2017).
Advantages in Appropriate Use of CBCT Scans

It is advantageous to take a CBCT scan before dental surgery in many cases. This can help avoid
iatrogenic injuries involving anatomical structures, such as the maxillary sinus cavities, inferior
alveolar nerve, and so on. CBCT scans can help reveal extra root canal anatomy, traumatic
fractures, missed canals, resorptions, and perforations and help the clinician get properly
oriented during treatment complications. CBCT scans have been shown to locate significantly
more canals in root-filled teeth than periapical films alone. However, scans should not be used
as a screening tool to look for canals or to compensate for subpar diagnostic or clinical skills
(Davies et al IEJ 2015).
Limitations of CBCT Scans

CBCT scans can give us volumes of information preoperatively and during treatment. However,
a significant problem is that the images produced do not have high resolution, especially
around root-filled teeth or teeth with metal posts and crowns. Scatter and beam hardening
continue to be a challenge compared to 2-D radiographs even with more advanced image
filters. If this scattering and beam hardening is within, or close to, the tooth being assessed, the
resulting CBCT images will be of minimal diagnostic use (Mora et al. OOOORE 2017).
Diagnosis of Vertical Root Fractures

One study showed that CBCT scans cannot reliably detect small cracks (micro-cracks) or
incomplete vertical root fractures. They would have to be surgically flapped and viewed under
the surgical microscope for confirmation (Patel et al. IEJ 2013).
Detection of Canal Calcification
Canal sclerosis, or calcification, is a common challenge in adequately disinfecting canals. Studies
show that a CBCT scan may be of minimal benefit in assisting with the location of the canal as
the resolution is significantly worse than that of a periapical radiograph (Chang et al. JOE 2016).
CASE 1
DIAGNOSIS - Spontaneous Pain In Upper Left

Patient came in with generalized pain on the upper left. A 2D PAX was taken and did not reveal
anything significant. Pulp testing was inclusive as well. A LFOV 3D CBCT was taken. It revealed
periapical pathology on the DB root of tooth #14. The diagnosis was a necrotic pulp with
chronic apical periodontitis. She rescheduled for endodontic treatment on tooth #14. The 3D
CBCT aids in a more accurate diagnosis.
A pre-op radiograph of the upper left side. No apparent pathology was noted.
A 3D CBCT bone rendering shows the periapical pathology on the DB root of tooth #14.
The sagittal view of tooth #14 with CBCT shows pathology on the DB root.
The coronal view of the CBCT on tooth #14 shows the periapical pathology.
CASE 2
Tooth #19 - A CBCT Assisted Diagnosis & Bioceramic Case

Patient came in pain on tooth #19. It had a previous root canal. No obvious pathology on the 2D
PAX. A LFOV 3D CBCT was performed with my Carestream Dental 8100 CBCT unit. There was a
missed middle mesial canal and a perforation midroot in the distal. There was periapical
pathology in the mesial root at the apex and midroot on the distal root. A retreatment was
performed in one visit. The mesial root was retreated and the missed mesial canal located and
treated using NeoSealer Flo Bioceramic Sealer by Avalon Biomed and gutta percha. The distal
root perforation was repaired using bioceramic putty by Avalon Biomed. Patient reported to be
asymptomatic the next few days.
A pre-op radiograph of tooth #19. No apparent pathology.
A LFOV 3D CBCT from an axial view shows a missed mid-mesial root and a perforation on the
mesial aspect of the distal root on tooth #19.
A 3D CBCT LFOV showing periapical pathology on the mesial aspect of tooth #19
A post-op radiograph showing the completion of the retreatment on tooth #19 with the missed
middle mesial root treated and the perforation repair completed.
An inverted post-op radiograph showing all three mesial roots with separate apicies and the
perforation repair on the distal root.
CASE 3
Tooth #30 - What's Going On Inside?

periodontitis. The 2D PAX did not give me a lot of information on this case and it looked
strange. I decided to perform a 3D CBCT to get more details.
The 3D bone rendering showed periapical pathology associated with the mesial and distal root.
There were 2 distal roots and had pathology on the DL and DB root. The axial view showed 4
distinct canals. The coronal view showed the mesial roots merged at the apex and 2 distal
roots. The sagittal view show periapical pathology associated with both roots but did not show
the pathology with the 2D PAX on the mesial root.
Endodontic treatment was performed in 2 visits using calcium hydroxide as an intracanal

medicament. The patient came back in 2 weeks to complete and was asymptomatic. The
outcome was just like what I saw preoperative from the 3D CBCT. No guess work. The mesial
roots merged and there were 2 separate distal roots.
A pre-op radiograph on tooth #30. No obvious pathology noted.
A pre-op 3D CBCT bone rendering showing pathology on the mesial and distal root on tooth
#30.
A 3D CBCT bone rendering showing the DL root with periapical pathology.
An axial view of tooth #30 showing four canals (MB, ML, DB, and DL).
A coronal view 3D CBCT image showing merging mesial canals and periapical pathology.
A coronal view from the distal showing two distinct distal roots.
A sagittal view showing mesial root pathology.
A sagittal view showing pathology on the distal root.
A post-op radiograph showing completion of the case. The mesial roots merging and the distal
roots have independent exits.
CASE 4
Tooth #31 - Large Periapical Pathology Close To Inferior Alveolar Nerve Bundle
periodontitis. A LFOV CBCT was take to observe the size and location of the pathology and the
root canal anatomy. The pathology was very extensive sitting very close to the IANB on the
CBCT.
Endodontic treatment was performed in one visit. Notice the severe curvature of the canals. It’s
very important on these case not to over-instrument or overfill these case to prevent
paresthesia.
A pre-op radiograph of tooth #31 showing very curved roots, periapical pathology, and the
inferior alveolar nerve bundle.
A coronal view 3D CBCT image showing the close proximity of the inferior alveolar nerve (IAN)
and the periapical pathology (PAP).
A sagittal 3D CBCT view showing the large periapical pathology on tooth #31.
A periapical view of the endodontic treatment showing the conefit.
A post-op view showing the completion of the case on tooth #31.
A post-op inverted view of the completion on tooth #31.
TOPIC 14 – CRACKS AND FRACTURES
Crack detection is a very important diagnostic skill to develop in diagnosis. Some cracks are not
visible on the radiograph nor on the CBCT scan. The proper use of patient’s history, occlusion,
observation of wear patterns, bruxism, etc. are important information to gather prior to
endodontic therapy.
The presence of a crack alone does not provide information on the status of the pulp or
periapical tissues; other diagnostic tests must be performed to determine a diagnosis. A tooth
sloth is very important to isolate and identify a pathological crack. If the patient bites down and
feel discomfort and has more discomfort upon release this is pathological crack that will usually
necessitate endodontic therapy. Clinicians must be aware that the major problem with having
a crack in a tooth is the potential for bacterial penetration, which could lead to inflammation
and disease.
The long-term prognosis for a cracked tooth is better when the crack does not extend to the
root canal system. Patients should be advised, however, that cracks may continue to progress.
This may lead to a split tooth that will require an extraction. (Rivera and Walton et al.
Endodontic Principles 2009).
Cracks & Crowns
A study by Soares de Toubes et al in Nov 2021 Journal of Endodontics demonstrated that

providing full-coverage crowns led to a higher survival rate of cracked teeth than when onlays
were used. The overall success rate was 93.0%, and the overall survival estimates of CT
restored early were 98.6%, 94.9% and 55.9% at the 1-, 5-, and 11-year follow-ups, respectively.
CASE 1
Tooth #13 - Treat or Extract?

Patient came in with tooth pain on tooth 13 and required a root canal. I suspected a crack
because there was no signs of a restoration. The diagnosis was a necrotic pulp with acute apical
periodontitis and possible crack. There was also a periapical pathology but no significant
probing.
I decided to do a LFOV CBCT before treatment. And Viola! I was able to see buccal bone loss via
the 3D rendering and a vertical root fracture in multiple angles. So I didn't even have to open
the tooth. It will need an extraction, bone grafting, and implant.
A pre-op radiograph on tooth #13 with periapical pathology.
A pre-op LFOV 3D CBCT bone rendering showing periapical pathology associated with tooth
#13.
A coronal slice of the 3D CBCT shows a vertical root fracture or split tooth on tooth #13.
A coronal view of the 3D CBT shows the vertical root fracture from mesial to distal.
A sagittal view 3D CBCT shows the bone loss on the distal due to the root fracture.
CASE 2
Patient came in pain on tooth #5. He had an old amalgam present. Pulp testing revealed a
necrotic pulp with acute apical periodontitis. Upon access there was a crack noted under the
microscope.
Endodontic treatment was performed in one visit using Bioceramic Sealer and gutta percha.
There are some studies that show this combination can strengthen the integrity of the roots.
This tooth had 3 roots and 3 canals with separate portals of exits. Patient was told to have a full
coverage restoration as soon as possible.
CRACKED TOOTH KEYS:

A cracked tooth is defined as an incomplete fracture initiated from the crown and extending
subgingivally, usually directed mesiodistally. The fracture may extend through either or both of
the marginal ridges and through the proximal surfaces. Keep in mind if the fracture is small and
invisible at its furthest extent (even after staining), it likely continues deeper into the dentin
and long term prognosis becomes unfavorable.
In cases of cracked teeth, the patient should be fully informed that the long term prognosis is
questionable. Patients should be advised, that cracks may continue to progress and separate
causing a split tooth leading to extraction. One 2007 study by Tan, Chen and Wong (IEJ) out of
Singapore evaluated root-filled cracked teeth with a diagnosis of irreversible pulpitis and
determined a two-year survival rate of 85.5 percent.
A pre-op radiograph on tooth #5 with a large amalgam. You can see 3 roots on this pre-molar.
A clinical view shows the crack by the red arrows down the mesial aspect of tooth #5.
A post-op view shows root canal completion of tooth #5 and three separate canals.
CASE 3
Patient came in with sporadic pain on the lower left side. Pulp testing was within normal limits.
A bite test was performed on teeth #18 and #19 with a tooth slooth. The patient had some pain
on biting but more pain on releasing on tooth #18 but not on tooth #19. This is indicative of
cracked tooth syndrome. These micro-cracks will not show up on a LFOV 3D-CBCT. They are too
small. Endodontic treatment was performed in one visit tooth #18. The diagnosis was chronic
irreversible pulpitis with acute apical periodontitis.
I usually recommend performing endodontic treatment on these teeth even before trying to do
a crown to see if it would stop the pain or prevent the crack from going deeper into the pulp.
These become those dreaded "Hot Teeth" that become very difficult to anesthetize and
perform endodontic therapy down the road. Your patient will thank you when you just "endo
it".
A pre-op radiograph on teeth #18 and #19.
A post-op completion on tooth #18.
An inverted post-op radiograph on tooth #18.
PROGNOSIS OF CRACKED TEETH
1. FAVORABLE – Fracture in enamel only or enamel and dentin but does not extend to the
CEJ. No periodontal probing
2. QUESTIONABLE – Fracture in enamel and dentin extended to the CEJ and there is an
osseous lesion of endodontic origin
3. UNFAVORABLE – Fracture extends apical to the CEJ onto the root and associated with
probing and/or mobility.
TOPIC 15 – CYSTS AND GRANULOMAS
Necrosis of the dental pulp causes apical periodontitis which can eventually manifest as an
apical granuloma or radicular cyst (Lin et al JOE 2007). Both periapical lesions have an
inflammatory origin but show a different clinical course. Dentigerous cysts have no
inflammatory cause and are classified as developmental odontogenic cysts (Rodini et al OOO
2001). In most cases, apical periodontitis is initially treated by orthograde endodontic
treatment. If an apical lesion develops into a cyst, endodontic therapy alone is sometimes not
sufficient, and apicectomy or even extraction of the affected teeth is required. Nair et al.
demonstrated that up to 85% of all periapical lesions are granulomas.
There are two types of periapical cysts: the periapical true cyst and the periapical pocket cyst.
True cysts have a contained cavity or lumen within a continuous epithelial lining. The periapical
pocket cyst heals with endodontic therapy. The periapical true cyst usually requires endodontic
surgery (Nair et al. IEJ 1993).
CASE 1
Patient presented in extreme frustration. He had severe pain on the upper right side for over a
year. He then went to see an ENT doctor for a possible sinus infection however, the ENT did not
find anything. Patient reported the pain to go away then he developed a "cyst" growing out of
the side of his face. He went to a dermatologist. She decided to cut the "cyst" out externally but
it later came back with draining pus. He thought it could be cancer. The patient was then sent
to me from a friend who was a dentist. I took an x-ray that showed tooth #4 had a previous root
canal with missed canals which was causing the infection and draining "cyst".
I retreated tooth #4 in 2 visits using calcium hydroxide after locating the missed MB and DB
canals. Patient came back with no external draining sinus tract or "cyst" some thought it was.
This case was not a cyst. It was an extra oral sinus tract from an infected tooth #4. The case
was completed and the patient was so happy in the end. Unfortunately, he was left with a scar
from misdiagnosis from the dermatologist who thought it was a cyst.
A clinical view of the extra-oral draining sinus tract.
A close-up clinical view show the pus drainage.
A pre-op radiograph of tooth #4 which revealed periapical pathology and missed canals.
A retreatment was initiated on tooth #4. The MB, DB, and P canals were all located and
treated. Calcium hydroxide was placed inside the tooth.
Patient returned and calcium hydroxide was removed. A cone-fit radiograph was taken
showing all three roots.
A post-op of the treatment completed.
An inverted post-op view of the case completed on tooth #4.
A 6 month recall showing the extra-oral sinus tract stopped draining. He was left with a scar
from the misdiagnosis of a cutaneous cyst.
CASE 2
A 20 year old came in with sensitivity to cold on tooth #30. The periapical radiograph shows
decay under the restoration close to the pulp and a large periapical lesion close to the mesial
root. Pulp testing confirmed vitality and sensitivity to cold on tooth #30. Do you think the decay
was causing the lesion? Well the answer is no. The tooth was vital so you can't really have a
lesion form with a vital tooth unless it's a partially necrotic pulp. I set the patient to an oral
surgeon for a CBCT and biopsy because I was concerned about the lesion. Please understand,
CBCT can't diagnose a Cyst, Granuloma, or Cancer! It will only show you the size, location, and
anatomical structures surrounding the lesion. A biopsy will still be required.
After CBCT and Biopsy it was confirmed to be a traumatic bone cyst. A traumatic bone cyst
(TBC) is an uncommon nonepithelial lined cavity of the jaws not necessarily due to a trauma. It
was first described by Lucas in 1929. The lesion is mainly diagnosed in young patients most
frequently during the second decade of life. Radiographically there is no resorption of the roots
of the teeth. Traumatic bone cysts have been reported in the literature under a variety of
names: Solitary bone cyst, hemorrhagic bone cyst, extravasation cyst, progressive bone cavity,
simple bone cyst and unicameral bone cyst. Their etiology and pathogenesis have not yet been
clearly understood.
The oral surgeon treated the area with surgery and a bone graft. He returned 3 months later for
the root canal on tooth #30 due to the increased sensitivity to cold (Dx acute irreversible
pulpits). Endodontic treatment was performed in one visit. Notice the complexed anatomical
root canal systems including webbing in the distal root in the middle third.
A pre-op radiograph on toot #30. There is recurrent decay under the distal restoration.
However, note how large the periapical lesion is on the mesial aspect of tooth #30.
A post-op radiograph after the surgery from the oral surgeon and the bone and grafting had
healed. Patient returned with pain to hot and cold due to the deep recurrent decay on the
distal.
A post-op radiograph of the endodontic therapy on tooth #30.
CASE 3
Patient presented with pain on tooth #13. It had a previous root canal years ago and was
asymptomatic until recently. Upon radiographic interpretation there was a previous root canal
filled short of the apex and a lateral pathology. Could this be a lateral periodontal cyst or a
lesion from incomplete cleaning and shaping of the root canal system?
Lateral periodontal cysts are defined as nonkeratinized and noninflammatory developmental

cysts located adjacent or lateral to the root of a vital tooth. Also they will not heal after
endodontic therapy (Shear et al. JOPM 1994).
A retreatment was performed in one visit. Note the small lateral canal adjacent to the
pathology in which I was able to get sealer into. No special sealer just Kerr EWT which is a zinc
oxide eugenol sealer using warm vertical condensation. Patient returned in 6 months with nice
osseous repair without any surgical intervention.
A pre-op radiograph of tooth #13 with a previous root canal. There is periapical pathology on
the lateral aspect and the gutta percha (GP) is fill short of the apex.
A post-op radiograph of the retreatment completed in one visit. I was able to get sealer into
the lateral canal (LC).
An inversion of the image show the sealer in the later canal on tooth #13.
A 6 month post-op radiograph on tooth #13 showing nice healing.
CASE 4
Patient came in with pain on tooth #30. It had a previous root canal performed. The pre-op
radiograph shows inadequate cleaning/shaping/obturation. In addition, there is a large lesion
on the distal root and a smaller one on the mesial root.
Q: Is this cyst or granuloma?

A: The only way to really find out is to do a biopsy pre-operatively.
Q: Can cysts heal after root canal therapy?

A: Yes and No. Pocket or Bay Cysts will heal after root canal therapy but not True Cysts. True
Cysts have to be surgically removed.
Q: If the lesion is large is it a cyst?

A: No. The size of the lesion can't specify it's etiology.
Q: How often are cysts found in previously treated teeth?

A: Only about 20% of the time.
Endodontic retreatment was performed in 2 visits using calcium hydroxide for 2 weeks. Canals
were obturated using warm vertical condensation with ZOE based sealer. A 6 month recall
shows very nice healing on both roots. The lesion on the distal will take a little longer due to the
large size. Studies show it can take up to 8 years before the bone completely repairs. This was
not a cyst. This was a granuloma.
*The periapical granuloma is an accumulation of chronically inflamed granulation tissue seen at

the apex of a nonvital tooth.
*The radicular cyst is a lesion that develops over a prolonged period of time within an existing
periapical granuloma. A cyst, by definition, has an epithelial lining.
A pre-op radiograph on tooth #30. It had a previous root canal and lesions on the mesial and
distal root. The lesion on the distal root is significantly larger.
Endodontic treatment was initiated. Calcium hydroxide was placed for two weeks. Patient
returned and a cone-fit radiograph was taken.
A post-op radiograph of tooth #30 showing completion of the case.
A 6 month recall radiograph showing very nice healing on tooth #30.
CASE 5
Teeth #12 & #13 - Large Periapical Pathology and Swelling

A 58 year old female was referred from her dentist as an emergency to my office. She had
severe swelling and pain all the way up the nasolabial fold into her eye. The swelling was
coming from 2 teeth (#12 and #13). The diagnosis was a necrotic pulp with acute apical abscess.
There was a very large lesion present @14mm in diameter.
Is this a #cyst?
Does it need an #extraction?
Does it need #decompression?
Does it need a #biopsy?
An incision and drainage procedure was performed and patient was placed on antibiotics
(Amox 500mg) and steroids (Medrol Dose Pack) for 1 week. She returned feeling better and
most of the swelling subsided. Endodontic treatment was initiated on teeth #12 and #13
simultaneously. Calcium hydroxide was placed and patient returned in 2 weeks to complete. All
the swelling/pain had subsided and canals were obturated with warm vertical condensation
with Kerr EWT sealer. Patient returned in 6 months with signs of radiographic healing. She
returned in one year with significant healing and osseous regeneration.
SHORT KEYS:
*Correct Diagnosis is critical.
*No need to jump into an extraction/surgery or biopsy due to the large size of the lesion.
*This could have been large granuloma from the necrotic pulps or a pocket or bay cyst.
*True cysts will usually not heal with endodontic treatment.
A pre-op radiograph on teeth #12 and #13. Notice the very large periapical lesion.
A completion radiograph on teeth #12 and #13.
A 6 month recall on tooth #13 showing reduction in lesion size.
A 1 year recall on teeth #12 and #13 showing full osseous repair.
TOPIC 16 – DIAGNOSIS
Endodontic diagnosis is similar to being a private investigator, a lawyer, or good detective —

diagnosis cannot be made from a single isolated piece of information. The clinician must
systematically gather all of the necessary information to make an accurate diagnosis. When
taking the medical and dental history, the clinician should first understand the patient’s chief
complaint. This should be documents word for word in the patient’s chart. The clinical tests
and radiographic examination in combination with a thorough periodontal evaluation are then
used to confirm the diagnosis (Schweitzer et al. Gen Dent 2009).
Some valuable tools in diagnostic testing are: endo ice, tooth slooth, perio probe, and electric
pulp tester.
Sometimes it can be challenging to differentiate between radiopaque lesions and

understanding which ones require endodontic therapy. Below is a very nice tip chart courtesy
of Dr. Barett Andreason / Radiodontics.com.
CASE 1
Taurodontism – Mesotaurodont (Shaw et al. Journal of Anatomy 1928)

Patient came in with pain on tooth # 30. The diagnosis was acute irreversible pulpitis. Treating
these teeth can be fairly difficult. There's a lot of tissue to be removed and canals tortuous. I
used many handfiles and high volumes of 6%NaOCl with ultrasonic irrigation. Locating the
canals were very difficult because the orifice was very deep into to the root. The canals on this
case were cleaned and shaped with Edge Endo X7/.04 taper files also performed in 2 visits. It
was obturated with warm vertical condensation with Kerr EWT sealer.
Taurodontism is a condition found in the molar teeth of humans whereby the body of the tooth
and pulp chamber is enlarged vertically at the expense of the roots. As a result, the floor of the
pulp and the furcation of the tooth is moved apically down the root. It is estimated to be found
in about 2.5% of adult Caucasians. In a recent study, the prevalence of taurodontism in
premolars among Trinidadian patients was 4.79%.
A pre-op radiograph on tooth #30 with taurodontism.
A cone-fit showing 3 portals of exits on tooth #30.
A post-op radiograph of tooth #30 showing the 3 roots in this case.
CASE 2
Which Tooth? Where's The Issue? – Using Gutta Percha To Trace The Sinus Tract
Patient came in with pain on the upper right side. There was a lingual sinus tract.
Key: All sinus tracts should be traced if possible.
The sinus tract was traced with gutta percha. It went to tooth #2. The 2D does not show any
definitive pathology. However, there is a periodontal concern. A defect was on the distal of
tooth #2.
Would you treat perio or endo first? Is this perio or endo?
Pulp testing was non-vital on tooth #2. A LFOV 3D CBCT was taken to view the pathology. There
was periapical pathology on all 3 roots. Endodontic treatment was performed in 2 visits.
Calcium hydroxide was used as an intracanal medicament for 2 weeks. Patient returned with no
pain and sinus tract resolved. The case was obturated with warm vertical condensation.
This was a primary endo issue. This case showed no 2D radiographic pathology but it was
clearly seen on the 3D CBCT. When in doubt and can't see with the 2D image, I recommend
taking a LFOV 3D CBCT to get the diagnosis and treatment plan accurately.
A pre-op radiograph on tooth #2 with a crown in place.
A photo of the palatal sinus tract that opens and closes.
The sinus tract was place with gutta percha. The patient does not have to be anesthetized for
this. I usually place some topical gel on the sinus tract prior to tracing with the gutta percha.
The radiograph shows the gutta percha is tracing to the palatal root on tooth #2.
A 3D LFOV CBCT showing the pathology on the MB and DB root.
A LFOV 3D CBCT showing the pathology on the palatal root.
A cone-fit radiograph on tooth #2.
A post-op radiograph showing completion on tooth #2 and a defect repaired on the distal root
with MTA.
CASE 3
COMPLEX ODONTOMA AND OSTEOMA

Patient came with pain on tooth #31. It was an abutment for a 3 unit bridge. The dx was a
necrotic pulp with acute apical periodontitis. The 2D PAX showed a periapical radiolucency and
a radiopaque area. A LFOV 3D CBCT was taken to get more information. There was a lingual
lesion noted. The radiopacity have nothing to do with the tooth and was located on the buccal
aspect of the mandible. *This is more than likely a complex odontoma or an osteoma.
1. Complex odontomas are usually asymptomatic and are associated with changes such as
malformation, impaction, delayed eruption, malposition, cyst formation, displacement,
resorption, or devitalization of the adjacent teeth, causing expansion of the cortical
plate (Gedik et al. West Indian Med Journal 2014).
2. Osteoid osteoma is a benign skeletal neoplasm most frequently observed in young

individuals. The tumor most commonly occurs in the femur, the tibia, and the
phalanges; however, jaw lesions are very rare (Schafer et al. Oral Path 1974).
Both are benign lesions. However, I did refer the patient to see an oral surgeon for a biopsy.
Endodontic treatment was performed in one visit using bioceramics sealer. The patient
returned in 6 months and shows nice osseous repair.
A pre-op radiograph shows a radiolucent lesion associated with tooth #31. There is a
radiopaque area just mesial to tooth #31.
A LFOV 3D CBCT bone rendering shows the radiopaque area on the buccal aspect of the
mandible.
The LFOV 3D CBCT bone rendering shows pathology on the lingual aspect due to pathology
from tooth #31.
A LFOV 3D CBCT shows the large pathology associated with tooth #31.
The coronal view of the LFOV 3D CBCT shows the periapical pathology on the lingual aspect.
A post-op radiograph of tooth #31 showing completion of endodontic treatment.
A 6 month recall shows nice osseous healing taking place on tooth #31. Patient was referred to
an oral surgery for the radiopaque mass.
CASE 4
Large Cyst or Large Granuloma or Cancer?

Patient came in with pain on tooth #15. The diagnosis was a necrotic pulp with chronic apical
periodontitis with a large periapical radiolucency.
KEY: The size of the lesion has nothing to do with the healing potential. Some providers may
assume it's a cyst and will jump into surgery or an extraction/implant.
This case was treated with root canal therapy in 2 visits using calcium hydroxide. She returned
asymptomatic and the case was completed with Bioceramic Sealer by Brasseler USA and gutta
percha. Patient was recalled in 9 months to evaluate the area. The area revealed very nice
osseous repair due to the large size of the lesion.
A pre-op radiograph of tooth #15 with a large periapical lesion.
Endodontic treatment was initiated and calcium hydroxide was placed on tooth #15.
A post-op radiograph of tooth #15 with completion of endodontic therapy using bioceramic
sealer and gutta percha.
A 9 month recall showing nice healing of the lesion on tooth #15 and a retreatment was
performed on tooth #14.
***10 TIPS TO HELP DIAGNOSE CYST VS GRANULOMA VS ORAL CANCER***
1. You can't diagnose a cyst on a radiograph. It needs a biopsy with histology (White et al
1994 OOO)
2. There are statistically significant higher proportion of cysts found in the premolar than
in the molar region. (Mortensen et. al EJOS)
3. Fistulas occur more often in connection with granulomas than with cysts. (Mortensen
et. al EJOS)
4. 85% of all periapical lesions are granulomas the other less than 15% are cysts or other
non-odontogenic pathology. (Nair 2004 000)
5. Radicular cysts are considerably less frequent and occur in two distinct histological
categories: (I) apical true cysts and (II) apical pocket cysts. (Nair 1996 OOO)
6. Radicular true cysts are entirely enclosed by epithelium.
7. Granulomas and pocket cysts may heal after non-surgical root canal therapy, whereas
true cysts are self-sustaining and usually require apical surgery. (Simon JOE 1990)
8. Metastases of cancer in the mouth are extremely rare, comprising 1% of all malignant
mouth neoplasms. Because of its rarity, the diagnosis of metastatic lesions in the oral
cavity is very often missed.
9. Metastatic cancers are located in the mandible in 80 to 90% of cases. (Sanchez MOPO
2005).
10. Very rare, but sometimes metastatic lesions to jaws may show vague pain and
misdiagnosed as pathologic entities of dental origin such as pulpal/periapical disease.
(Khalili JOE 2010)
TOPIC 17 – ENDODONTIC FILES
Nickel-titanium was developed in the 1960’s. They were primarily for military use. Then later
they were developed for other applications in dentistry such as orthodontic wires. Eventually
endodontic handfiles were made of NiTi and tested by Walia et al in the 1980’s and later by
Serene. By weight NiTi files are 55% nickel and 45% titanium.
Some studies show NiTi instruments have imperfections such as milling marks, metal flash, or
rollover. These can lead to fractures in NiTi instruments due to surface imperfections (Alapati et
al. JOE 2003).
NiTi Reusage, Sterilization, and Cleaning
1. Thermal Sterilization does not affect fatigue life. (Mize et al. JOE 1998)
2. Thermal Sterilization does not affect the torsional resistance. (Silvaggia et al. JOE 1997)
3. Reuse must be closely monitored to avoid build- up or cyclic fatigue. (Berutti et al. IEJ
2006)
4. Reuse must be closely monitored to avoid NaOCl related corrosion (Sonntag et al. JOE
2007)
GLIDE PATH FILES - THE SECRET TO ROTARY SAFETY AND EFFICIENCY
What Are Glide Path Files?

NiTi glide path files are used for establishing a smooth path in rotary endodontics to the apex.
They have enhanced flexibility and small taper size of 2% or less.
When Are Glide Path Files Used In Endodontic Therapy?

After working length determination.
How Are Glide Path Files Used Clinically?

In clinical practice, this is usually achieved when a stainless steel size 10 K-file fits loosely in the
canal. Then use the Glide Path File.
What’s The Purpose Of A Glide Path File?

Together, they increase life of the mechanical rotary instruments that will be used for further
canal enlargement by controlling the torsional stress over them and decreasing the incidence of
fracture or other iatrogenic mishaps.
What Are Some Types Of Glide Path Files On The Market?
ProGlider - Dentsply
One G - MicroMega
EdgeGlidePath - EdgeEndo
Rpilot - VDW
DCTaperH - SSWhite
CASE 1
XP-3D Shaper File by Brasseler USA

Patient came in with discomfort on tooth #29. The diagnosis was chronic irreversible pulpitis.
Endodontic treatment was performed on tooth #29. The cleaning and shaping was mainly done
using the XP-3D Shaper File by Brasseler USA. It's a very uniquely designed file that responds by
expanding to body temperature inside the canal. It does not remove much dentin at all which
makes it minimally invasive. You can really feel it cleaning the walls of ovoid canals especially
figure 8 shaped canals.
Technique:
*Access
*Glide Path to Size 15
*Place XP Shaper inside canal for 5 strokes for a size 30/.02 taper. Taper can increase to a
30/.04 with 10 strokes.
*Run at 800-1000 RPM's
A pre-op radiograph on tooth #29 showing large decay.
A post-op radiograph of tooth #29 after using the XP3-Shaper file and obturation with warm
vertical condensation.
CASE 2
ENDOSEQUENCE SCOUT FILE SYSTEM BY BRASSELER USA

Patient came in pain on tooth #31. The diagnosis was acute irreversible pulpitis. Endodontic
treatment was performed on tooth #31. This tooth had very long roots and interesting anatomy
in the apical 1/3. The ML joined the Distal in the apical 1/3. I decided to use a system by
Brasseler USA called the EndoSequence Scout File System. I was very impressed at the strength
and elasticity of this heat treated file. Using it was very smooth and it didn't "pull me into the
canal".
My Technique:
I used small handfiles (6, 8, and 10) and a glide path file with RCPrep until I reached a size 15 at
the working length. Then I used the EndoSequence Scout Files with crown down at 500 RPM
with a torque setting of 2Ncm. The case finished with a 30/.04 at the apex. I obturated this case
with the Bioceramic Sealer by Brasseler USA and standard gutta percha via a single cone
technique.
A pre-op radiograph of tooth #31 with very long conical roots.
A post-op radiograph of tooth #30 showing the ML canal joining the Distal canal on tooth #31.
A post-op inversion radiograph of the completion on tooth #31.
CASE 3
EDGEENDO X7 FILE SYSTEM

Patient came in with pain to flossing and biting. Nothing obvious on the X-ray. Pulp testing
revealed extreme sensitivity to cold and some biting on tooth #2. Recommended root canal
therapy. Once accessed there was a small micro crack under the palatal cusp into the pulp horn
only visible with the surgical microscope. A CBCT would usually not pick this up because the
crack was so small.
The canals were very narrow and curved. Many handfiles and glide path files with plenty
RCPrep was used to get to the apex. I was able to get size 10 file to the apex on all 3 roots
verified with an apex locator. The canals were cleaned and shaped with EdgeEndo X7/.04 taper
universal heat treated rotary files. They were able to be precurved due to limited opening and
location of the tooth. Bioceramic Sealer was used by EdgeEndo. I didn’t want to burn the
patient’s lip & would not be able to get heat within 5-7mm of the apex if I used warm vertical
condensation. Notice the twisted canal anatomy on the DB root and Palatal root and the
curvature on the Mesial root.
A pre-op radiograph of tooth #2. Notice the restoration is shallow.
A post-op radiograph of the endodontic treatment on tooth #2 using EdgeEndo X7 files.
A post-op radiograph of tooth #2 with an inverted image.
“The 8 Golden Keys” To Minimize File Separation
1) Assess Case Complexity

If a case has severe root curvatures or if you see a canal then it disappears in the middle or
apical 1/3 then it will be a challenge. There is probably a bifurcation. Pick the best rotary file for
the job after using handfiles to the working length.
2) Provide Adequate Access

Straight line access and coronal flaring is very important. It take unnecessary stress off the file.
In addition, the “crown down” method is more efficient than the “step back” . In other words,
the rotaries are used from larger to smaller sizes in the “crown down” method. This allows for
better irrigation and less binding of the files.
3) Glide Path
Adequate glide path to the apex is critical before even picking up a nickel titanium rotary file.
Recommend a hand file at the apex to at least a size #15 prior to rotary use.
4) Light Pressure
Use light touch and torque control motor. Various files cause for different speeds and torque
settings. Refer to the manufacturer’s instructions. The pressure I recommend is to hold the
rotary hand piece like you would hold a very sharp #2 pencil trying not to break the lead tip
while writing.
5) Don’t Start Then Stop
Sudden changes in the motion of the file while inside the canal can create unwanted forces on
the file. A smooth gentle motion should be used while inserting and withdrawing the file inside
the canals. I like to use the 5 second rule. I work a canal with a NiTi file for five seconds or
strokes then change to a different file.
6) Lubricate Well
The canals should be lubricated at all times while cleaning and shaping. Recommend use of
sodium hypochlorite in addition to RCPrep (Premier) or Gylde (Dentsply Tulsa). These agents
will create less friction on the files while cleaning and shaping the canals.
7) Check Rotary Files

It is important to evaluate each rotary file before placing it into the canals. Look for shiny spots
or flattened areas. If you see any of these replace immediately. Thermal sterilization does not
affect fatigue life of the files.
8) Replace Rotary Files

Most manufactures recommend rotary files to be single use. However, there are some cases in
which the file may not contact any dentin or very little. In these cases, it should be ok to re-use
the file. My golden rule regardless is “Three Strikes” and you are “Out”!
WHAT IS THE PERFECT ROTARY FILE?
I get asked this question very often from clinicians around the world. Dr. Short, What is the
perfect rotary file for every single case? Well the answer is there is no perfect rotary file but
there are some better than others. Many lecturers and manufacturers are always trying to work
on and sell the “one file that fits all”. This is really impossible. Why?
* It’s because ALL canals are different!

** The file should not dictate the canal shape.
*** It’s the canal shape that should dictate the file type and the taper.
For instance check out tooth #18. The canals look "funky" on the pre-op. It has long, skinny, and
curved roots. You don't need a .06 taper on cases like this! The canal system used was a heat
treated NiTi file system and obturated with warm vertical condensation using ZOE based sealer.
The mesial roots merge and this is a danger zone for file separation.
A pre-op radiograph on tooth #18 that had cracked tooth syndrome cause pain.
A post-op radiograph on tooth #18 after endodontic therapy.
CASE 4
A SEPARATED FILE – IS IT A SIGNIFICANT PROBLEM?

Are You Still Worried About That Separated File In The Canal? What About One Outside?
periodontitis. Endodontic treatment was completed in one visit.
KEY...I noticed a separated file in the periapical film. I asked the patient how long ago was that
tooth #19 was extracted. She said 20 years. That separated NiTi rotary file has been in place for
20 years causing no pain or pathology in the bone. How many times as dentists and endodontist
we freak out over a separated file inside the tooth? If this happens, we must inform the patient
and document it in the chart.
A pre-op radiograph of a separated from a previous root canal from an extracted tooth #30. It
was probably filled outside the apex. Patient did not report any complications after the
extraction.
Endodontic treatment was completed on tooth #20. There are no plans to remove this file
from the bone. Notice there is no pathology around it.
The 4 SHORT Keys Regarding Separated Files:
1. The most common causes for file separation are root canal anatomy, improper use,
inadequate access, manufacturing defects, limitations in physical properties, and
insufficient knowledge about the root canal morphology and its variations. (Al-Quedah
IEJ 2006)
2. According to clinical studies, the overall endodontic instrument separation frequency

(either rotary or hand files) is between 1.83% and 8.2%. (Suter IEJ 2005)
3. The highest frequency of instrument separation is presented during the treatment of

molars especially lower molars (77% - 89% of all cases). (Tzanetakis JOE 2008)
4. Regardless of lesions, teeth with a separated instrument healed in 91% essentially no

change in success rate if it's cleaned properly prior to separation. (Spili, Crump JOE
2005).
CASE 5
CYCLIC FATIGUE AND TORSIONAL STRESS – CAUSES OF FILE SEPARATION

Previous dentist performed a pulpotomy on tooth #18 to get them out of pain but they still had
percussion and biting sensitivity. The canals were very calcified and curved. I performed
endodontic treatment on this case and then checked my file and it came up "short"....literally!
The severity of the canal created a file separation with a size 30/.04.
*The odds for rotary separation is 7x more than for handfiles.
**The probability of separating a file in apical third is 6x more likely when compared to coronal
and middle thirds of the canals.
Cyclic fatigue—along with torsional stress—are two main causes of breakage of NiTi endodontic
files. Sometimes it can be a manufacturer defect or operator error as well.
Cyclic Fatigue is when a material has repeated stress placed on it over a period of time and,
ultimately, this repetition breaks the material. It is similar to taking a piece of wire and bending
it back and forth until it separates (Ullmann et al. JOE 2005).
Torsional Stress is when an object is twisted with an applied force; when a portion of material
is locked into place and the rest continues to rotate, a breaking point is reached and breaking or
snapping occurs (Sattapan JOE 2000). (
The patient was told about the file separation and it was documented in the chart (THE
STANDARD OF CARE). I did not want to try to remove the file to make the x-ray look good. This
would have removed more precious dentin and actually made the x-ray look worse. This was a
vital case with no lesion and I was already at the apex with a size 15 handfile and a previous size
25/.04 so I know based on the studies the outcome would be favorable (Crump and Natkin). If it
had a lesion the success may be reduced only 5-7% (Fox and Spili).
A pre-op radiograph of tooth #18 after a previous pulpotomy. The mesial canals were calcified
and curves in the apical 1/3.
A post-op radiograph of the completion on tooth #18. A separated file occurred in the mesial
lingual canal in the apical 1/3.
A 1 year recall shows the area has healed very well even with the separated file in place.
TOPIC 18 – ENDO/PERIO RELATIONSHIPS
The relationship between periodontal and pulpal disease was first described by Simring and
Goldberg in 1964. Since then, the term “endo-perio” has been used to describe lesions due to
inflammatory products found in varying degrees in both the periodontium and the pulpal
tissues. The endo-perio lesion is a condition characterized by the association of periodontal and
pulpal disease in the same dental element.
Classification Endo-Perio Lesions (Glick and Frank et al. JPerio 1972)

There are four types of endo-perio lesions and they are classified due to their pathogenesis.
Proper diagnosis is critical to understand the particular category.
1. Endodontic lesions: an inflammatory process in the periodontal tissues resulting from

bacteria byproducts present in the root canal system of the tooth.
2. Periodontal lesions: an inflammatory process in the pulpal tissues resulting from

accumulation of dental plaque on the external root surfaces. Large lateral canals can
cause pulpal inflammation if patient has severe periodontal disease.
3. True-combined lesions: both an endodontic and periodontal lesion developing

independently and progressing concurrently which meet and merge at a point along the
root surface.
4. Iatrogenic lesions: usually endodontic lesions produced as a result of treatment

modalities such as a perforation.
CASE 1
Patient came in with pain on tooth #30. The diagnosis was a necrotic pulp with chronic apical
periodontitis. There is a furcation defect present. Is this a perio issue or endo issue? The
endodontic treatment was performed in 2 visits using calcium hydroxide and completed 2
weeks later (2nd xray) Patient returned in 6 months (3rd xray) and 2 year recall (4th xray)
intervals. The 2 year recall shows nice bony healing around the apex and in the furcation. This
was strictly and endo issue. If the etiology is the pulp the seemingly "perio-issue" will resolve
on its own. This is the key....these cases are usually necrotic and there are furcation or lateral
canals causing bone breakdown mimicking periodontal issues.
A pre-op radiograph of tooth #30. It has a furcation and periapical lesion.
A post-op radiograph showing completion of endodontic therapy. Notice there are no lateral
canals popped or significant puffs.
A 6 month recall showing healing taking place.
A 2 year recall showing very nice osseous healing.
CASE 2
TOOTH # 19 - Furcation Defect Perio? Endo?

Patient came in with pain associated with tooth #19. His dentist thought the tooth had a
vertical root fracture and/or had perio issues due to the furcation breakdown. There was a pre-
existing defect in the furcation radiographically. He had a sinus tract present on the buccal. The
dx was a necrotic pulp with chronic apical abscess. The sinus tract was traced into the furcation.
Endodontic treatment was initiated using calcium hydroxide medication.
Patient returned in 2 weeks to complete. The mesial canals were completed with gutta percha
using warm vertical condensation. The distal was obturated with Pro-Root MTA (Dentsply). A
one year recall shows nice healing of bone in the furcation. This was an endo issue not a perio
problem.
A pre-op radiograph showing a large amalgam on tooth #19 with a furcal defect.
A periapical film showing the sinus tract traced with gutta percha.
Endodontic treatment initiated and calcium hydroxide was placed for 2 weeks.
Patient returned asymptomatic. The mesial root was obturated with warm vertical
condensation and ZOE based sealer. The distal was gauged with a size 120 file.
A post-op radiograph shows the distal was obturated with ProRoot MTA (Dentsply) and also the
defect.
A 1 year recall shows very nice healing of the defect. This was an endo issue not a perio issue.
CASE 3
Patient came to my office in severe pain and swelling on tooth #19. The diagnosis was a
necrotic pulp with acute apical abscess. Notice there is no deep restoration or large decay. The
radiograph shows severe bony destruction. There was class II mobility and depressiblility. In
addition, there was deep probing in the furcation. This tooth appears to have a vertical root
fracture or a periodontal abscess. Some dentists would tell the patient to have this tooth
extracted and get an implant. Based on the preoperative status, I can understand why.
Endodontic treatment was performed in 2 visits using calcium hydroxide.
My only 3 irritants for this case:

1. Full Strength NaOCl
2. 17% EDTA final rinse for 1 minute
3. 99% Ethyl Alcohol
(No CHX, or Irritrol, MTAD, ChlorXtra, GentleWave, EndoVac, I can keep going...nothing wrong
with these things if you like them and understand how they work but you don’t need all that
stuff to do great endo with predictability). I’ve been doing this for over 20 years now. It was
completed after 3 weeks using warm vertical condensation with Kerr EWT sealer. Patient
returned for a 4 year recall. The osseous healing was remarkable! No mobility, no probing, and
the furcation filled in with bone.
A pre-op radiograph of tooth #19 that shows a large furcation lesion.
Radiograph shows calcium hydroxide placed inside the canals.
A post-op radiograph showing completion of the endodontic therapy. Notice there are no
lateral canals popped or “puffs”.
A 4 year post-op radiograph that shows textbook osseous healing.
TOPIC 19 – ENDODONTIC EMERGENCIES
Studies report a 60-82% incidence of endodontic emergencies among all dental emergencies
(Estrela et al. Braz Dent Jour 2011). Within this group, 20-42% of patients seek care for teeth
with symptomatic irreversible pulpitis (SIP). Additionally, about 60% of SIP patients also
complain of symptomatic apical periodontitis (SAP). The remaining 40% can present to your
office or in the emergency room with an acute apical abscess (Owatz JOE 2011). While pain due
to a severely inflamed pulp is characterized by dull, throbbing and lingering pain sensations, it
can be spontaneous or in response to an external stimulus, such as hot, cold or chewing. This
makes SIP the bulk of the emergency cases seen in dental clinics.
• Emergency cases with a diagnosis of SIP with vital pulps due to caries, large restorations,
cracked tooth syndrome or trauma are potential candidates for pulpotomies. The
primary reason for electing to do a pulpotomy over complete instrumentation is the lack
of sufficient time.
• Emergency cases with necrotic pulps will benefit from full pulpectomy procedures.
Avoid a partial pulpectomy because it can be problematic and create more pain for the
patient. It is important to spend quality time to get to the working length on these
cases.
LATEX ALLERGY
How To Handle A Latex Allergy Emergency In Your Office While Performing Endodontics
If you are a dentist performing a root canal, the rubber dam is critical. It is the standard of care
in dentistry in the United States. Unfortunately less than 44% of general dentist use a rubber
dam 100% of the time while performing root canal therapy. If not used, this could result in the
patient aspirating a file (going into the lungs), swallowing a file (stuck in the digestive track),
and/or recontaminating the surgical site due to poor isolation. This could also resort in a law
suit. In addition, it is critical to know the type of rubber dam you are using as a provider and if
the patient has a latex allergy. There is on occasion, a patient may not know if they have a latex
allergy.
This happened to me as an endodontic resident in 2000. I anesthetized the patient, placed the
rubber dam, then she started itching. I saw her tongue and lips starting to swell under the
rubber dam. I quickly removed the rubber dam. She then started having trouble breathing. She
was going into anaphylactic shock due to an unknown allergy to latex. I called 911. I gave her
Benadryl Elixir (the liquid works faster) that we had in the treatment room. Then immediately I
went to the "crash cart" and gave her an injection of Epinephrine with an Epi-Pen. She started
to get more stable. The EMS came and took her to the hospital for more testing and follow up.
This scenario could happen to any of us in the dental field while performing endodontic therapy
not knowing the patient is allergic to latex.
Here are some tips:
* Mild Reaction
Watch for these uncomfortable -- but not dangerous -- symptoms: Red, itchy rash where your
skin touched latex
Swelling around the skin where it touched you
Sneezing, runny nose, or teary eyes.
~ Give over the counter Benadryl
** Severe Reaction
These symptoms can be life-threatening:
Trouble breathing or swallowing
Stomach pain
Chest pain
Drop in blood pressure
Wheezing
Tightness in your chest
~ Call 911, Give over the counter Benadryl, Then Give Epi-Pen in the thigh area, Continue to
monitor patient until EMS arrives
Make sure all your drugs are ready and up to date in your crash cart and know where the cart is
located and how to use them
CASE 1
Buccal Space Infection
Buccal space infections are primarily from mandibular or maxillary bicuspid or molar teeth, the
apices of which lie outside of the buccinator muscle attachments. They are readily diagnosed
because of marked cheek swelling but with minimal trismus or systemic symptoms. If these are
not taken care of soon it could lead to Ludwig's Angina which is a life threatening issue.
An incision and drainage was performed due to swelling. Patent was placed on antibiotics and
steroids for 1 week. She returned with very little swelling and discomfort. The 2D PAX did not
show a significant PAP associated with tooth 19. A LFOV CBCT was performed. There was no
notable large lesion in the bone either.
This is a case where significant swelling and infection can be present but nothing significant
shows up on the radiograph. Endodontic treatment was performed. Upon access the tooth was
necrotic with pus discharge. The canals were carefully and copiously irrigated, cleaned, shaped,
and obturated with Bioceramic Sealer and gutta percha in one visit. A cool puff was noted on
the distal...I'm not a fan of puffs. Patient reported to be asymptomatic the next day.
A clinical photo of swelling on the lower left side.
A periapical x-ray showing tooth #19 with a crown.
A LFOV 3D CBCT showing pathology on the distal of tooth #19.
A post-op radiograph of the completion of tooth #19.
CASE 2
TOOTH #30 - Acute Apical Abscess Treatment

Patient came in with severe pain and swelling on the lower right side of her cheek. She had
been up for over 24 hrs in pain. She said she had a root canal done almost 2 years ago. Upon
radiographic examination, there was pathology associated with tooth #30. One could suspect a
cracked root on the mesial due to a "J-shape" or halo lesion. Also the canals were not cleaned
and shaped adequately and filled significantly short of the apex. I did not have a CBCT machine
at this time. I decided to perform an incision and drainage in order to get her relief very fast
and put her on a steroid (Medrol Dose Pack) and antibiotic (Amoxicillin 500mg).
The patient returned in 1 week to initiate root canal retreatment. She felt better even though
the source of the problem was not yet fixed. A retreatment was started and calcium hydroxide
medication was placed for 2 weeks then the patient came back to complete case. A 6 month
recall shows very nice healing. There was no crack in the mesial root.
A clinical view of the swelling on the lower right side.
Top left – A clinical view of the intraoral swelling on the buccal of teeth #29 and #30.
Top right – A pre-op radiograph of tooth #30 with a previous root canal and periapical
pathology
Lower left – A post-op radiograph of tooth #30 after completion and 6 month recall showing
nice healing
Lower right – A clinical view of the tissues returning back to normal.
CASE 3
Barodontalgia
Patient reported he had a slight toothache prior to boarding a flight. When he got in the air
there was intense pain and when he landed his face had swollen up.
AN INFECTED TOOTH CAN CREATE A CONDITION CALLED BARODONTALGIA.
WHEN THERE IS A SUDDEN CHANGE IN PRESSURE FROM FLYING OR DIVING AN INFECTED
TOOTH CAN CREATE SWELLING IN THE FACE.
THIS IS A SERIOUS CONDITION AND CAN BE FATAL.
THIS IS MOSTLY FROM A NECROTIC TOOTH.
He came to my office immediately off the plane. Tooth #13 diagnosis was a necrotic pulp with
acute apical abscess. This was the source of the swelling. Endodontic treatment was
performed and the swelling dissipated.
A clinical view of the swelling exacerbated by the flight causing barodontalgia.
A pre-op of tooth #13 with periapical pathology.
A post-op radiograph after the completion of tooth #13.
Patient follow up with no swelling or pain.
MANAGING SODIUM HYPOCLORITE ACCIDENT
1. Inform the patient about the cause and reassure them they are going to be fine.
2. Immediately irrigate with normal saline
3. Let the bleeding response continue
4. Leave the tooth open until all drainage has stopped
5. “Milk” the area to get more solution to come out
6. Prescribe NSAID’s, Antibiotics, and Steroid Pack (Medrol Dose Pack)
7. Call the patient the same night to check on them
8. Reappoint them in 2 weeks for an evaluation.
HOW TO MINIMIZE SODIUM HYPOCHLORITE ACCIDENTS
1. Place the irrigation need short of working length

2. Use a side-vented needle
3. Fit the irrigating needle loosely in the canal
4. Move the needle in an up and down motion
5. Don’t push on the head of the need full blast…go slow
TOPIC 20 – HEAT CARRIERS
Heat carriers are devices used to carry heat to the treatment of a root canal or retreatment of a
root canal. There are several heat carriers on the market such as TouchNHeat, System B, B&L
Heat Carriers. Some are corded and some are cordless.
Heat carriers are used during the warm vertical condensation technique in endodontics. They
also can be used to sear off the gutta percha using a single cone bioceramic technique. In
retreatments heat carriers can be used to retrieve plastic Thermofils and other carrier based
obturators.
CASE 1
Patient was referred from his dentist a few months after a root canal performed on tooth #14.
Patient was still in pain and had swelling. Radiographically the root canal looked pretty good
but a little short of the apex. This canal system was very complicated. It had very long curved
roots up into the sinus area. Recommended a retreatment on this tooth. Upon access, the case
was previously obturated with Thermafil (carrier based obturation system) by Dentsply. The
Thermafils were removed using electric heat carriers and solvents.
The technique is to use the heat carrier and place it directly in the center of the plastic core for
about 5 seconds and push down. Let the plastic core cool around the heat carrier tip for 20
seconds. Then pull the heat carrier tip out of the tooth. Most of the time the Thermofil core
will come out on the heat tip making the remaining gutta percha simple to remove.
The correct working lengths were established verified by an apex locator and an MB2 was
located. The canals were cleaned and shaped with heat treated NiTi files. Calcium hydroxide
was placed for 2 weeks and patient returned asymptomatic. The canals were obturated with
Biocermic Sealer and gutta percha. ***The use of Thermafil did not cause this case to fail. ***
It was inadequate cleaning and shaping and locating all the canals.
Thermafil is an acceptable obturation technique. The success rate of endodontic treatment

using core-carrier obturation is 83% according to research (Wong et al BMC Oral Health). A
survey in the USA reported that core-carrier obturation was the second most frequently used
obturation method among general dentists. However, studies show there are very few
Endodontist in the US that use carrier based obturation.
A pre-op radiograph of tooth #14 with previous Thermofil treatment. There is periapical
pathology present.
Heat carrier assisted the removal of the plastic Thermofils.
Tooth #14 was disassembled and calcium hydroxide was placed.
A post-op radiograph of the completion of tooth #14 with an MB2 located.
CASE 2
Tooth #19 With Thermofil Treatment
This was a previous root canal performed about five years ago on tooth #19. Patient all of a
sudden patient was in extreme pain and swelling. Looking at the root canal on the x-ray it looks
good but he was hurting. I recommended a retreatment. The canals were previously filled with
Thermofil. The Thermofil carriers were removed using a heat carrier. Chloroform and
headstroms files were used to remove the remaining gutta percha. CaOH2 was placed was
placed for 2 weeks. Patient returned in 2 weeks asymptomatic. I finished the case with gutta
percha using warm vertical condensation & ZOE based sealer. A 6 month recall showing very
nice healing.
A pre-op radiograph of tooth #19 with a large periapical lesion. The case was previously
performed with Thermofil. It’s difficult to tell the difference radiographically between this
material and normal gutta percha.
The retreatment on tooth #19 was initiated with calcium hydroxide placed for 2 weeks.
A post-op radiograph showing completion of tooth #19 with warm vertical condensation and
ZOE based sealer.
A 6 month recall shows very nice healing.
CASE 3
Tooth #30 - Massive Lesion (A Metal Thermofil Case)

Patient came on tooth #30. It had a previous root canal, post, vertical bone loss in mesial, metal
Thermofil and a large lesion. The Touch-N-Heat carrier was used to heat up the metal portion of
the Thermofil. This helped loosen it up. I then used chloroform to dissolve the gutta percha
around the metal Thermofil. Small diamond Stieglitz pliers were used to pull out the metal
carriers. The retreatment was done in 2 visits using calcium hydroxide. I could not remove the
metal Thermofil in the distal so it was bypassed. Case was obturated with ZOE based sealer and
warm vertical condensation. Patient returned in one year with beautiful healing.
A pre-op radiograph on tooth #30 with metal Thermofils.
The periapical lesion on tooth #30 is very large and there is an angular defect on the mesial
root.
The metal Thermofils were removed except for one in the distal root. I had to bypass it.
A post-op radiograph showing completion of the case.
A one year recall showing very nice radiographic healing on tooth #30.
TOPIC 21 – IATROGENIC MISHAPS AND PERFORATION MANAGAGEMENT
CASE 1
OVEREXTENSION
Endodontic mishaps happens to all clinicians including myself. However what’s the proper
approach to repair them? This patient came to my office in pain. He said a dentist performed a
root canal about 5 years ago on tooth #31. All of a sudden he stated that the tooth started
hurting like something...was in his jaw bone. Well actually it was...overextended filling material
(Thermofil). Some endodontists would jump right to surgery. My philosophy is different. I'd
rather "take the trash out" vs "sealing it in". If the patient does not respond favorably, an
apicoectomy could be performed later. Many of these cases are typically under-instrumented
therefore it's bacteria or remaining tissue causing the pain vs the material...unless it is
impinging on the inferior alveolar nerve.
I decided to retreat this tooth instead of apical surgery. I was able to retreat this case in 2 visits
using calcium hydroxide as an intracanal medicament and remove the overextended Thermofils
non-surgically.
My trick to remove Thermofil (Heat the plastic carrier with an electric heat tip and hold in the
center for 5 seconds, let it cool for 20 seconds, pull out and it usually comes out in one piece!)
He came back asymptomatic. The canals were obturated with warm vertical condensation using
Kerr EWT sealer.
A pre-op of tooth #31 with an overfill of Thermofill carriers.
The Thermofil carriers were removed and calcium hydroxide was placed on tooth #31.
A post-op of the completed case on tooth #31.
CASE 2
TOOTH #14 - OVERFILL

This patient came to see me with pain associated with tooth #14. It had a previous root canal
with a large post, draining sinus tract, and a lot of bone destruction. The diagnosis was previous
treatment with chronic apical abscess. This tooth appeared to be vertically cracked according to
the radiograph. Patient did not want to lose the tooth and get an implant right away. She
decided to have it retreated instead. I performed the retreatment in 2 visits using calcium
hydroxide and was able to remove the post with ultrasonics.
Upon obturation, I felt the gutta percha slide through the DB root out the apex. I told the
patient what happened and we will monitor the case for a while. Thankfully I sterilize my gutta
percha with a 1 min immersion in full strength NaOCl according to studies by Senia. In addition,
there are studies by Lin and Scribner that as long as the root canal is well done, an overfill will
usually not affect the success rate. I didn't want to do an apical surgery right away so I decided
to follow this patient up yearly for 6 years. Her 6 year recall has the tooth in place with the
same crown and area has healed well. In addition, it appears as if the "drifted" piece of gutta
percha went back into the DB root.
A pre-op radiograph with sinus tract traced with gutta percha and large periapical pathology.
Disassembly / post removal/ with calcium hydroxide in place on tooth #14.
Obturation with Warm Vertical and overfill on DB root on tooth #14.
A 6 year recall showing nice healing on tooth #14.
CASE 3
Tooth #25 had a previous root canal. The fill was "short" and there was swelling and an area of
infection. I retreated the case using calcium hydroxide for 2 weeks. My lengths were spot on
but there was an overextension of material. This used to really bother me. But now I relax! I
brought the patient back 6 months later and area is healing well and the crown is still intact!
Studies by Pascon et al OOO 1991 and several others shows overfill of gutta percha usually does
not affect periapical healing.
As an Endodontist, we are trained that every root canal case must look beautiful on the final x-
ray or our referring dentist may get upset. This may result in them not sending patients. Well
the reality is it's impossible for every case to come out perfect but that doesn't mean it won't
heal! I have been in practice over 22 years and seen a lot. Some beautiful cases fail and some
jacked up cases heal! I'm always humbled and amazed. As Endodontists, we have to stop trying
to treat the x-ray and treat the patient and the tooth with the best effort! Outcomes are not
necessarily equal to x-ray esthetics.
A retreatment was initiated with calcium hydroxide placed on tooth #25.
A final radiograph of the overextension of the gutta percha on tooth #25.
A 6 month recall of the area healing really well in the presence of the overfill.
TOPIC 22 – IMPLANTS VS ROOT CANAL SUCCESS
Single Tooth Implants & Restored Endodontically Treated Teeth have basically the same
"success" rate. Implants use survival rates and Endodontic (Root Canal) Treatment use success
rates. Both look at very different issues in regards to healing. Roughly both averaging about
95% of success depending on who's quoted but implants are usually at least double the cost of
a root canal and crown.
Furthermore, there are more long term post-operative complications with implants between 5
& 10 years such as smoking, implant screw abutment loosening, occlusal trauma causing failure,
patients taking antidepressants causing 4x implant failure. In addition, implants can’t move if
you want braces because there is no ligament.
In a study which many folks quote recommending implants vs root canal therapy, they say
implants had a 5-year implant survival rate of 99%, however all patients treated with dental
implants were healthy and nonsmokers. It’s about that 10 year mark where about 50% of
implants have problems including peri-implantitis which is difficult to treat. However, A well
done and well restored endodontically treated tooth can last a lifetime.
• S. L. Doyle, J. S. Hodges, I. J. Pesun, A. S. Law, and W. R. Bowles, “Retrospective cross

sectional comparison of initial nonsurgical endodontic treatment and single-tooth
implants,” Journal of Endodontics, vol. 32, no. 9, pp. 822–827, 2006.
• M. M. Bornstein, B. Schmid, U. C. Belser, A. Lussi, and D. Buser, “Early loading of non-

submerged titanium implants with a sandblasted and acid-etched surface: 5-year results
of a prospective study in partially edentulous patients,” Clinical Oral Implants Research,
vol. 16, no. 6, pp. 631–638, 2005.
Studies show that the root canal success and implant success is the same. However, studies
show more complications with implants long term vs root canal therapy.
CASE 1
Tooth #6 or Failing Implant #5 – Where Is The Source Of Pain?

Patient came in severe pain. She had an implant placed 5 months ago on tooth #5. Tooth #6
diagnosis was a necrotic pulp with acute apical periodontitis and the implant on tooth #5 was
failing. Endodontic treatment was performed on tooth #6. The implant on tooth #5 never
osseointegrated, was infected, and will need to be removed and possibly redone. Implants are
not the "silver bullet" and can fail. The implant on tooth #4 looks nice however.
A pre-op radiograph showing failing implant on tooth #5 and tooth #6 had a necrotic pulp with
acute apical periodontitis.
A post-op radiograph of endodontic treatment completed on tooth #6. The implant will be
removed on tooth #5.
Dental Implants And Peri-Implantitis
The research out of the University of Gothenburg aimed to evaluate the correlation between
dental implants, implant loss and peri-implantitis in 2015. The study consisted of 4,716
randomly selected participants that had all had dental implants in 2003-2004. Altogether, 7.6
percent of patients had lost at least one implant and 14.5 percent had developed peri-
implantitis with pronounced bone loss,” reported Dr. Jan Derks, a researcher at Sahlgrenska
Academy. Fifty percent of patients presented with some signs of peri-implantitis, but only
14.5% were considered to have moderate to severe implications (equating to a crestal bone
loss exceeding 2 mm). The 7.6 percent that had lost an implant showed an average loss of 29
percent of bone support. Interestingly, the rate of implant failure did not differ between the
general practice and specialty practices.
CASE 2
Patient came in with extreme pain on tooth #4. I took a 2D PAX and did not see anything
unusual. No probing or mobility. I took a 3D CBCT on tooth #4. There was a split tooth on tooth
#4. The tooth was deemed unsalvageable and recommended an extraction and implant.
Cracked Tooth vs Split Tooth vs Vertical Root Fracture:
1. A Cracked Tooth can be successfully root canal treated as long as the crack does not go
into the root canal system and the patient gets a full coverage restoration as soon as
possible.
2. A Split Tooth occurs when a crack goes into the root canal system and an extraction is
required. These are usually non-endodontically treated teeth.
3. A Vertical Root Fracture is usually from the apex up towards the coronal aspect of the
root. These teeth usually will have endodontic treatment already.
Tooth #4 appears to be normal on the 2D PAX. Upon LFOV 3D CBCT there is a fracture. This
was a split tooth that will require an extraction and implant.
Anti-Depressants & Implant Failure
We know that depression is real and is on the incline. According to the Centers for Disease
Control and Prevention (CDC), more than one in 10 Americans older than 12 use
antidepressants, making it the second most prescribed type of drug in the United States.
Studies show the use of antidepressants quadruples the risk of implant failure, with those odds
doubling again for each year of antidepressant use, according to research at the University of
Buffalo (UB). Implants require new bone to form around them to heal properly, but
antidepressants decrease the regulation of bone metabolism increasing the chance for implant
failure.
TOPIC 23 – INTERNAL BLEACHING
Tooth bleaching involves the alteration of light-absorbing or light-reflecting properties of

enamel and dentin stains, resulting in apparent whitening (Black et al Dental Cosmos 1916). In-
office bleaching, internally and externally, has been practiced since the early 20th century
employing peroxide compounds (Goldstein et al. JADA 1997). There are various techniques.
One is called the “walking bleach” technique by Spasser and Salva et al. JADA 1938. The
solution is placed inside the patient’s tooth with a temporary restoration for one week. The
patient returns and evaluate effectiveness of the internal bleaching.
Most teeth turn dark over a period of time after a trauma. There are some occasions
endodontic therapy was performed and there were remnant of tissue tags in the coronal
portion. This tissue left behind causes the dark tooth after endodontic therapy. My favorite
solutions used for internal bleaching is sodium perborate and superoxol.
Technique:
After endodontic therapy I place a small layer of Cavit on top of the gutta percha. I mix sodium
perborate and superoxol in a medicine cup. A tamp it dry to a mud like consistency. Then I use
an amalgam carrier to place it inside of the tooth and close with Cavit. I allow the agent to
remain for one week and then bring the patient back. If the patient is satisfied, I remove the
agent with a simple rinse with water then place a cotton pellet and Cavit or restore.
CASE 1
A clinical photo on tooth #9 which is dark from trauma.
A post op photo after internal bleaching on tooth #9
CASE 2
Internal bleaching on tooth #9
CASE 3
A 21 year old female was referred to our office because of a dark tooth. She had a history of a
trauma at age 9 on tooth #9. The tooth gradually turned darker over a period of time because
the nerve died out. Recommended endodontic treatment due to a necrotic pulp with internal
bleaching. Endodontic treatment was performed and internal bleaching.
A pre-op clinical photo on tooth #9 showing a dark colored crown.
A pre-op radiograph of tooth #9.
A post-op radiograph after endodontic therapy on tooth #9.
A post-op clinical photo after internal bleaching on tooth #9.
TOPIC 24 - IRRIGATION
Irrigation is a key part of successful endodontic treatment. It has several important functions: it
reduces friction between the instrument and dentinal wall, improves the cutting effectiveness
of the files and reduce the heat on the files, dissolves pulp tissue, cools the tooth, and it has a
washing effect of the microbes and biofilms inside the canal. Irrigation is also the only way to
impact those areas of the root canal wall not touched by mechanical instrumentation
(Haapasalo et al. BDJ 2014).
Sodium hypochlorite is the main irrigating solution used to dissolve organic matter and kill
microbes effectively. High concentration sodium hypochlorite such as 6% has a better effect
than 1 and 2% solutions (Baumgartner JOE 1984). Ethylenediaminetetraacetic acid (EDTA) is
needed as a final rinse to remove the smear layer.
Once again irrigation is a critical step in the endodontic process. It enhances the debridement
and disinfection of areas in the canal system insufficiently cleaned by hand and rotary
instruments. Irrigation is mainly performed with positive pressure by a syringe and a needle.
However, there are other devices that assist in irrigation such as EndoVac (negative pressure)
and GentleWave by SonEndo (non-instrumentation technology).
CASE 1
This patient came in with pain on tooth 18. The diagnosis was a necrotic pulp with acute apical
periodontitis. You can see from the pre-op that the inferior alveolar nerve is laying very close to
the apex of the distal root. Apical control of instrumentation, irrigation, medication, and
obturation is critical. Patient can get paresthesia in this area if it's violated.
Here are some SHORT tips that can help with apical control.
*Apex locators
*Side vented needle
*A good conefit with tugback
*Cone fit radiograph
*Place calcium hydroxide loosely (Don't bind the tip then push!)
*Use sealers that can resorb like ZOE based sealer
(Resin sealers like AHplus and Bioceramics will not resorb and can cause problems if extruded in
the inferior alveolar nerve)
*Don't go for "puffs"
*Don't "over pump" the gutta percha with sealer
Pre-op radiograph on tooth #18.
Notice how close the inferior alveolar nerve is to the apex. In these cases control of irrigation is
critical to not damage this vital structure.
A post-op radiograph of tooth #18 showing good apical control.
CASE 2
What Irrigation Is Best? Chlorohexidine or Sodium Hypochlorite

Tooth #29 – Diagnosis: A Necrotic Pulp With Apical Pathology.
Endodontic treatment was performed in one visit. There were 3 canals in this lower premolar.
I used full strength sodium hypochlorite in this case. Many dentists around the world ask me
why I don’t use 2% Chlorohexidine routinely in conventional treatment and/or retreatment.
Here’s Why! Studies by Siqueira et al.and Ayhan et al. in JOE 2017 found that higher
concentrations of NaOCl (4-5.25%) were more effective than 1-2% CHX in eradicating virulent
bacteria and E. faecalis. E. faecalis is one on the most resistant bacteria found in refractory
cases. Calcium hydroxide isn’t really effective against E. faecalis.
TIP: Sometimes I’ll let a little full strength NaOCl soak in the tooth and close it for 2 weeks
instead of calcium hydroxide.
Tooth #29 diagnosis was a necrotic pulp with a periapical lesion. Endodontic treatment was
completed in one visit using full strength NaOCl.
CASE 3
Triton – A New Irrigation Solution

Patient came in with pain on tooth #4. The diagnosis was a necrotic pulp with acute apical
periodontitis. Endodontic treatment was performed today. Upon access, I kept bumping into
what I thought was a ledge in the buccal root. It turned out to be another canal in the buccal
root (DB canal). The canals were cleaned and shaped using EdgeEndo X7 files. The canals were
irrigated with a new irrigation called Triton by Brasseler USA. This is a powerful irrigating
solution that dissolves organic and inorganic tissue. No need for any chelating agents such as
EDTA. Surfactants, Modifiers, and Chelators are all built in Triton. It's really convenient and
leaves the canal system very clean. There were a total of 3 canals. The canals were obturated
with NeoSealer Flo bioceramic sealer by Avalon Biomed and single cone gutta percha.
A pre-op radiograph on tooth #4.
A post-op radiograph of tooth #4 after using Trident.
ULTRASONIC IRRIGATION
Ultrasonic irrigation is the most widely used adjunct method of irrigating the root canal system.
Ultrasonic activation can remove pulp tissue remnants and hard tissue debris. However, there
are conflicting results regarding its antimicrobial efficacy. A review article in JOE 2019 by
Caputa et al stated the healing rate of apical periodontitis (area with periapical pathology) using
ultrasonic activation vs syringe activation was not improved in single rooted teeth. There were
13 studies where ultrasonic activation was favored overed syringe irrigation versus only 3
studies that favored syringe irrigation only.
Why I Choose A 30 Gauge Irrigation Needle - Minimum Invasive Endodontics

A Study In JOE Shows Apical Size Must Be A 30 With Curved Anatomy - ***This Compromises
Minimum Shaped Canals***
Studies show shaping must be at least a size 30 at the apex with curved canals to get the
irrigation to the apex while using a 30 gauge open sided irrigation syringe tip.
(Boutsioukis et al. JOE June 2021)
I use the dripless syringe by Vista Apex Dental Products.
GENTLEWAVE VS PASSIVE ULTRASONIC IRRIGATION
A study by Croteza et al in Sept 2020 JOE compared Gentlewave vs Passive Ultrasonic Irrigation
in retreatment cases.
The result was Passive Ultrasonic Irrigation performed better than Gentlewave in retreatment.
The GentleWave system was able to remove approximately 10% of the remaining filling
material from the entire canal, whereas PUI showed a better performance by removing 18%.
Some studies have even shown Continuous Ultrasonic Irrigation to be the most effective
technique in dentin debris removal from apical irregularities. It also prevents vapor lock which
allows the irrigation to go further into the dentinal tubules.
I like using the Endo Ultra from Vista Apex.
Why EDTA, RCprep, and NaOCl during Root Canal Therapy?
Sodium hypochlorite (NaOCl) is the most commonly used solution in endodontics, partly
because of its activity against endodontic bacteria. However, the presence of the smear layer
weakens the antibacterial activity of NaOCl in dentin. NaOCl dissolves organic tissue effectively,
but it has no effect on the inorganic portion of the smear layer. The smear layer consists of
organic and inorganic composition including bacteria and their byproducts trapped in dentinal
tubules. A decalcifying agent, such as EDTA and/or RCprep, is needed for file lubricant to
minimize instrument separation, chelation of the inorganic components and to complete the
removal of the smear layer from the root canal surface which will help prevent microleakage
and give better adaptation of the obturation material due to cleaner and smoother walls.
Unfortunately, EDTA lacks antimicrobial activity and can’t be used exclusively; therefore, most
Endodontist use NaOCl again as a final rinse after EDTA.
Recent studies by Calt and Serper recommended that root canals should be rinsed with 17%
EDTA for no longer than 1 minute to avoid dentin erosion. Then a final flush with NaOCl for no
longer than a minute to avoid dentinal tubular alterations. I prefer full strength NaOCl to make
sure the canal system is a clean as possible. In addition, I use 99% Ethyl Alcohol to remove any
chloride crystals that form during the irrigation procedure that could potentially block the
tubules causing microleakage or jeopardize the seal of obturation material. This study about
sodium chloride crystals forming was discussed by Short et al. in the Journal Of Endodontics.
TOPIC 25 – LATERAL CANALS
There are some studies that found lateral canals in 45% of most teeth (Rubach et al. J Perio
1965). Lateral canals are difficult to instrument and to irrigate during endodontic therapy and
may allow bacterial growth (De Deus JOE 1975). Although some authors found no correlation
between unfilled lateral canals and inflammation of the periodontal ligament, other studies
demonstrated their potential pathogenicity after healing of periradicular lesions in relation with
filling the lateral canals (Barthel et al JOE 2004).
The Lateral Canal ~ Does It Have To Be "Popped" For Healing?

Studies by Riccucci & Siqueira shows popping lateral canals does not enhance treatment
outcome and causes more inflammation histologically.
Conclusions From Their Review Study Of Lateral Canals....
(1) tissue within ramifications remain relatively unaffected by instruments and irrigants
after chemomechanical preparation, regardless of the preoperative pulp conditions;
(2) in cases with vital pulp, forcing obturation materials into lateral canals caused
unnecessary damage to the tissue, with consequent inflammation;
(3) material that radiographically appears in the lateral canals and apical ramifications was
forced into these areas, but this by no means indicates that the ramification is sealed or
disinfected.
(Riccucci et al JOE 2010)
Here are just a few cases out of the thousands I have performed in over 20 years where
popping a lateral canal doesn't matter in healing.
CASE 1
Tooth #30 diagnosis was a necrotic pulp with acute apical periodontitis. Notice the furcal
pathology. Endodontic treatment was completed in one visit. No lateral canal was popped. A
4 year recall shows perfect healing in the furcation.
CASE 2
Tooth #18 had a previous root canal with chronic apical periodontitis. There was periapical
pathology in the furcation. A retreatment was performed. No lateral canal was popped or
“puff”. Notice very nice healing.
CASE 3
Patient came in pain on teeth 2, 3, and 4. A retreatment was performed on tooth 2 in one visit
due to chronic apical periodontitis. A 4 year recall shows nice healing with no lateral canals or
puffs. Patient returned a few weeks later for a retreatment on tooth 4. The retreatment was
performed in one visit due to a large lesion present. No lateral canal or puff. A 4 year recall
shows very nice osseous healing. He came today for a root canal on tooth 3 due to a necrotic
pulp with acute apical periodontitis. No lateral canal or puff but guess what...it will still heal.
A pre-op radiograph of teeth #2 and #4. Both had previous root canal therapy with periapical
pathology. Notice the lateral lesion on tooth #4.
Endodontic retreatment was completed on both teeth. Notice no lateral canal was popped on
tooth #4.
A 4 year recall shows nice healing on teeth #2 and #4. Endodontic treatment was completed on
tooth #3 as well.
CASE 4
Endodontic treatment was performed on tooth #18 using warm vertical condensation and ZOE
based sealer on this case. Proper irrigation is key to clean & obturate only a fraction of these
lateral and accessory canals.
A pre-op radiograph on tooth #18. The diagnosis was chronic irreversible pulpitis.
Endodontic treatment was completed on tooth #18. Notice the lateral canals.
A post-op radiograph of tooth #18 inverted to show the lateral canal anatomy.
*Root canal therapy still works over 95% of the time whether you "pop" lateral canals or
not.*
Most of it depends on the type of sealer you use and how long you irrigate. For example AHplus
is a resin based sealer, very radiopaque and flows well but does not resorb which could be a
problem in certain areas such as the inferior alveolar nerve. In addition, AH plus due to the
resin component is known to create chronic inflammation. So does ZOE based sealers.
Research (Ricucci & Langland IEJ Vol 31) shows sealer in the ligament and bone with a "pop" or
"puff" creates a chronic immune response. However, Bioceramic Sealers are known to create
significantly less inflammation due to its biocompatibility. I almost exclusively use Bioceramic
Technology for Endodontic Therapy.
I appreciate Dr. Domenico Ricucci for all his work about the fate of lateral canals and they don't
always determine if a lesion heals or not. In fact lateral canals and puffs creates chronic
inflammation and slows healing histologically. Bender and Seltzer histological studies showed
the same thing.
TOPIC 26 – MAXILLARY SINISITUS OF ENDODONTIC ORIGIN
Endodontic infections that develop in the maxillary posterior teeth can easily spread into the
maxillary sinuses causing pathological effects (Tian et al JOE 2016). Patients with MSEO
experience common sinonasal symptoms, which include congestion, rhinorrhea,
retrorhinorrhea, facial pain, and foul odor, yet they rarely experience typical endodontic
symptoms (Williams et al AIM 1992). Thermal pain is normally absent because source teeth for
MSEO are either necrotic or have failing endodontic therapy. Percussion tenderness is typically
absent in MSEO because periapical infection is essentially draining into the sinus, eliminating
pressure. For this same reason, swelling or intraoral sinus tracts rarely form.
Maxillary Sinusitis Of Endodontic Origin (MSEO)
Your patient may be taking antibiotics for nothing.

Your patient may be seeing an ENT for nothing.
Your patient may not have seasonal allergies.
Your patient may have MSEO!
Headache, facial pain, unilateral nasal obstruction, postnasal drip, and nasal discharge are clues
to the presence of MSEO, especially when these symptoms are concurrent with a bacterial
etiology of endodontic origin.
CASE 1
Patient came in complaining of vague pain in her sinus area and giving her a headache. She was
heading to her physician and an ENT. She saw some of my posts regarding these cases and
came to see me first. Nothing obvious radiographically. Tooth #3 was calcified, did not respond
to pulp testing and was sensitive to the bite stick. I could not perform an EPT because it had a
crown on it. I recommended endodontic treatment on tooth 3 due to a necrotic pulp with acute
apical periodontitis. Upon access the tooth had a severely calcified pulp chamber with pulp
stones. Once I accessed the tooth, the canals were super tight and there was pus in the palatal
canal. This case was done in 2 visits. I did not place her on antibiotics. I didn't even use calcium
hydroxide. She returned in 2 weeks asymptomatic and I located an MB2. I thought maybe it
joined the MB but it had a separate portal of exit. All her pain in her sinus and headache was
completely resolved. In addition, her crown was saved.
A pre-op radiograph of tooth #3. It had a crown and the canals were calcified.
A post-op completion of tooth #3. Patient symptoms of MSEO were now gone.
CASE 2
Patient came in with very vague symptoms on the upper right quadrant. He had been treated
with antibiotics for a sinus infection and the symptoms went away for a while. But they recently
returned. Teeth 14, 15, and 16 were pulp and periapical tested. A previous root canal was
present on tooth 15. Teeth 14 and 16 tested vital and asymptomatic. The 2D PAX did not show
obvious pathology associated with this area. I performed a LFOV 3D CBCT in this area using a
Carestream 8100 unit. It revealed a large lesion associated with tooth 15. I recommended a
retreatment on tooth 15. A retreatment was performed in one visit. The patient was called a
few days later and reported to be asymptomatic with a reduced pressure in the area. These
symptoms of the sinus infection resolved without any antibiotics after the retreatment. This
was a MSEO case (Maxillary Sinusitis of Endodontic Origin).
A pre-op radiograph of tooth #15 with a previous root canal. It’s very difficult to see the
periapical lesion present.
A LFOV 3D CBCT bone rendering shows the periapical lesion associated with tooth #15.
A sagittal view 3D CBCT shows the MSEO creating the sinusitis associated with the pathology on
tooth #15.
A coronal view showing the pathology associated with the MB root.
Endodontic treatment was initiated and the conefit was performed on tooth #15.
A post-op radiograph on tooth #15.
CASE 3
Patient came with discomfort in the upper right area. She thought it could be sinus related.
Pulp testing revealed a necrotic pulp. The PAX showed periapical pathology but not the full
extent. A LFOV CBCT was taken with my Carestream 8100 in association with tooth #2. It
revealed a large radiolucent lesion encroaching the sinus area of approximately 13mm x 13mm.
This patient had symptoms of Maxillary Sinusitis of Endodontic Origin (MSEO).
Endodontic treatment was performed on tooth #2 and patient's symptoms of tooth pain and
sinusitis went away almost immediately. A follow up in 6 months is important to make sure the
lesion is reducing in size.
A pre-op radiograph on tooth #2. The diagnosis was a necrotic pulp with chronic apical
periodontitis.
A LFOV 3D CBCT on tooth #2. Notice the size of the lesion.
A sagittal view of tooth #2. Notice the mucosal thickening in the sinus (yellow arrows) and the
periapical pathology on the distal (red arrow).
A post-op on the completion of tooth #2.
CASE 4
Patient was referred to me from her dentist. She was complaining about pain in her upper left
side. She had a history of chronic sinus issues. The 2D PAX did not show any apparent
pathology. Pulp testing to cold and percussion was inconclusive. A LFOV 3D CBCT was taken in
the area. There was apical pathology associated with tooth 15. In addition, the maxillary sinus
was inflamed as a result of the long standing tooth asymptomatic tooth infection. Endodontic
treatment was performed in one visit. Tooth 15 had a necrotic pulp. The next day the patient
noticed relief in her sinus area. This was a case of maxillary sinusitis of endodontic origin
(MSEO). Sometimes patient have these issues in teeth and think it's a sinus issue and vice versa.
The CBCT was critical in order to diagnose this issue.
A pre-op radiograph on tooth #15. No evident of periapical pathology on tooth #15.
A LFOV 3D CBCT was taken. Notice the thickened mucosal lining of the sinus (red arrows) in
response to the periapical pathology on tooth #15 (yellow arrow). This is called (PAM)
Periapical Mucositis.
The LFOV 3D CBCT shows periapical pathology associated with the palatal root.
A post-op of the completion of tooth #15. Notice the MB and MB2 join.
Limited field CBCT imaging has been shown to significantly improve the ability to detect
odontogenic sources for sinusitis. In a study by Low, CBCT revealed 34% more lesions than
periapical radiography, as well as significantly more expansion of lesions into the maxillary
sinus, sinus membrane thickening, and untreated canals.
Inflammatory responses of the maxillary sinus to dental infection can present with varied
symptoms, clinical progression, and radiographic presentations. Periapical mucositis (PAM),
which appears on CT imaging as a mucosal thickening or dome-shaped soft tissue expansion in
the floor of the sinus directly adjacent to the infected root apex (see yellow arrows). A healthy
vital pulp will not contribute to any periradicular or odontogenic sinus inflammation. Only those
teeth with an infected necrotic pulp or failing endodontic treatment will generate MSEO. The
increased availability of in-office CBCT has increased clinicians’ recognition and ability to
diagnose MSEO.
Maxillary Sinusitis of Endodontic Origin (MSEO) - Inflammatory response of the maxillary sinus
to dental infection presenting with varied symptoms and often pain. Odontogenic sinus
infections may produce only a minimal, often asymptomatic local reaction in the antral floor
periosteum and/or mucosa for months or even years. Endodontic therapy will usually clear up
MSEO infections.
TOPIC 27 – OBTURATION TECHNIQUES
A well-shaped and cleaned canal system should create the conditions for just about any
obturation technique such as warm vertical condensation, lateral condensation, carrier based
obturation, and single cone technique. Best practices dictate that root canals should be filled as
completely as possible in order to prevent oral microorganism (Li et al. Active Biomater 2014).
Ideally, root canal obturations should seal all foramina leading to the periodontium, be without
voids, adapt to the instrumented canal walls, and end at working length (Ng et al IEJ 2011).
There are various acceptable materials and techniques to obturate root canal systems
including:
• sealer (cement/paste/resin) only

• sealer and a single cone of a stiff or flexible core material
• sealer coating combined with cold compaction of core materials
• sealer coating combined with warm compaction of core materials
• sealer coating combined with carrier-based core materials
(Endodontics Colleagues Of Excellence 2014)
CASE 1
Patient came in with pain on teeth 8 and 9. The dx was previously treated with SAP. She had
previous root canals done overseas. The teeth were left open or she didn't return for
permanent restoration. (Don’t ever leave teeth open if at all possible) Both had previous root
canals, leakage, single cone obturation, and PAP lesions. This case was contaminated with
various microorganisms including our arch enemy E. Faecalis! Tooth 9 appeared to have had an
apicoectomy as well. I performed a retreatment in 2 visits using 6% NaOCl (that's it...no special
Irritrol or CHX or MTAD...no studies show they increase the success rates or healing clinically.
Just invitro or extracted teeth) and calcium hydroxide paste (Ultracal).
Patient returned asymptomatic after 2 weeks. I used 17% EDTA as a final rinse (in which I
always do). The canals were dried with 99% Ethanol (Short et al JOE) to remove any chloride
crystals. The cases were obturated with gutta percha and Bioceramic Sealer by Brasseler USA.
Patient return in 6 months with teeth restored, completely asymptomatic, and with remarkable
healing!
A pre-op on teeth #8 and #9. Both teeth had previous root canal therapy and an apicoectomy.
Both teeth were left open and had periapical pathology.
Endodontic treatment was initiated on both teeth and calcium hydroxide was placed.
A post op radiograph after retreatment was completed using gutta percha and bioceramic
sealer.
A 6 month recall showing very nice healing.
CASE 2
Patient came in pain with tooth #12. The dx was a necrotic pulp with acute apical periodontitis.
There was a lesion present as well. Endodontic treatment was completed in one visit. HiFlow
Bioceramic Sealer by Brasseler USA was used to obturate this case with warm vertical
condensation. BC Sealer HiFlow exhibits a lower viscosity when heated and is more radiopaque,
making it optimized for warm obturation techniques. There was cool lateral canal with a buccal
puff (coming out at you) on the palatal root. I'm not a fan of puffs but this one was kinda cool.
A pre-op radiograph of tooth #12 with a large carious lesion.
A post-op radiograph of tooth #12 showing the lateral canals.
CASE 3
Tooth #19 ~ Large Periapical Lesion Retreatment One Visit

Patient came in pain on tooth #19. It had a previous root canal performed. The filling was short
of the apex. There were lesions on both roots. A LFOV 3D CBCT was taken. It confirmed the
filling material short on the mesial and distal roots with no crack noted. A retreatment was
performed in one visit using Chlor-Xtra by Vista Apex as the main irrigant and NeoSealer Flo by
Avalon Biomed as the sealer with gutta percha. Patient returned for a 1 year recall with nice
osseous repair evident.
A pre-op on tooth #19 with periapical pathology on the mesial and distal root. The obturation
was filled short.
A 3D CBCT bone rendering showing the pathology on tooth #19.
A 3D CBCT coronal view showing the mesial roots filled short on tooth #19.
A 3D CBCT coronal view showing the distal root filled short on tooth #19.
Radiograph showing conefit after disassembly on tooth #19.
A post-op radiograph on tooth #19 with obturation to length.
A 1 year recall showing very nice osseous healing on tooth #19 after a one visit retreatment.
TOPIC 28 – PAIN CONTROL IN ENDODONTICS
A systematic review in 2002 compared all endodontic pain studies evaluating oral NSAIDs
(Holstein et al. Endo Topics 2002). The authors concluded that NSAIDs combined with other
drugs such as acetaminophen provides effective pain control pretreatment or posttreatment in
endodontics. Although opioids are effective analgesics for moderate to severe pain, they have
no anti-inflammatory effects and as such will have no effect on the inflamed periapical tissues.
In my almost 20 years of practice I've found most post-operative dental pain can be controlled
with Ibuprofen 600mg (3 Motrin or Advil) alone or add 500mg of Acetaminophen (1 Extra
Strength Tylenol) over the counter for a greater synergistic pain relief effect. It's pretty rare
they need strong narcotics like Vicodin and Percocet. This over the counter combination of
Ibuprofen and Acetaminophen can be taken every 6 hours as needed for pain.
What about flare-ups? Flare-Ups can happen especially in necrotic cases when calcium
hydroxide is used. A number of investigations have evaluated the positive efficacy of
corticosteroids such as prednisone (or a Medrol Dose Pack) in the control of postoperative
endodontic pain or flare-ups (Marshal et al. Endo Topics 2002).
Believe it or not, most patients don't want to take narcotics. They don't like the way it makes
them feel and impairs their ability to work. The over the counter combination in which I give
after my procedures BUT before the anesthetic wears off is usually all they need to take for
pain control. This helps to keep narcotics out of the hands of children and teenagers. In
addition, it limits the potential narcotic abuse/dependence from patients.
CASE 1
Patient came in with pain on tooth #18. The diagnosis was acute irreversible pulpitis.
Endodontic treatment was performed in one visit. An intrapulpal injection was given because
the tooth was very difficult to anesthetize.
Intrapulpal Injection
A major drawback of the IP injection is that the needle and injection are made directly into the
pulp tissue or canal space; this injection is quite often painful. It’s important to prepare the
patient prior to giving this injection. The onset is immediate and the duration of the intrapulpal
injection is 15 to 20 minutes. In addition, strong back pressure is important while giving this
anesthesia. Simply dropping it on the pulp will not work (Birchfield et al JOE 1975).
A pre-op on tooth #18 with a crown. There was recurrent decay.

*Length control is very critical on these cases to avoid paresthesia.*
The inferior alveolar nerve appears to be going through the apical root area.
A post-op on tooth #18. Patient lost the crown. Notice the location of the inferior alveolar
nerve. It is important to not overfill these cases.
A “HOT MOLAR”
Got a patient with that "HOT" lower molar and you need to do a root canal? Have them to take
600mg of Ibuprofen one hour before endodontic therapy. Studies show it will significantly
increase the success rates of anesthesia.
Tupyota P, Chailertvanitkul P, Laopaiboon M, Ngamjarus C, Abbott PV, Krisanaprakornit S.

Supplementary techniques for pain control during root canal treatment of lower posterior teeth
with irreversible pulpitis: a systematic review and meta-analysis Aust Endod J JULY 2017
CASE 2
Patient came in severe pain on the lower right side. He went to a TMJ specialist and they saw
nothing. He heard about me from a friend. Pulp testing was inconclusive and a 3D CBCT was
taken. There was a small crack in the distal on tooth #31 that created a partially necrotic pulp
causing referred pain down the neck and migraines. Patient decided to have endodontic
treatment vs an extraction. The canal anatomy was a doozy...very tortuous. Endodontic
treatment was initiated but I could not get to working length on the first visit. I closed it and he
flared up with pain and swelling. I put him on an antibiotic (Amoxicillin 500mg and steroids – A
Medrol Dose Pack). The pain and swelling was relieved. The patient returned 3 weeks later for a
completion. Upon completion a periapical lesion had developed. He returned in 6 months for
an evaluation. He was asymptomatic, a crown was placed, and periapical lesion healed.
A pre-op on tooth #31. Notice the challenging root canal anatomy
A LFOV 3D CBCT was taken on tooth #31 and there was a crack in the distal (yellow arrow).
A post-op of the endodontic therapy on tooth #18 and notice a lesion developed in the apical
area.
A 6 month recall on tooth #18 shows the lesion has healed and the patient was still
asymptomatic. Tooth #19 pulp tested vital and normal. This is probable periapical cemental
dysplasia.
The Secret Sauce Of Pain Control After Dental Procedures:
Combining Ibuprofen with Acetaminophen for a synergistic effect of pain control. Studies show
that this combination resulted in more pain control after dental procedures than just ibuprofen
or Tylenol alone. Also studies showed that this combination was superior in pain control
compared to opioids/narcotics. (Moore and Hersh JADA 2013) In addition, another study
showed adding a narcotic did not increase the effectiveness of pain relief. (Best JOMFS 2017)
Narcotics are not the best first line response for pain control after a dental procedure.
Pain Control & Low Dose Aspirin Facts:
Did you know the cardioprotective effect of low-dose aspirin is preserved by giving the aspirin
first then waiting 2 hrs before giving the NSAIDs for pain relief in dental procedures?
(Brennan et al. OOO Endod 2007)
SUSPECTED OVERDOSE ~ WHAT DO YOU DO?
If you have a patient with a suspected drug overdose...what do you do? Call 911 then
administer Narcan. This drug should be in every dentist "crash cart". Narcan (naloxone) is an
opiate antidote. Opioids include heroin and prescription pain pills like morphine, codeine,
oxycodone, methadone and Vicodin.
When a person is overdosing on an opioid, breathing can slow down or stop and it can very
hard to wake them from this state. Narcan (naloxone) is a prescription medicine that blocks the
effects of opioids and reverses an overdose. It cannot be used to get a person high. If given to a
person who has not taken opioids, it will not have any effect on him or her, since there is no
opioid overdose to reverse. Narcan (naloxone) can be given by intramuscular (IM) injection -
into the muscle of the arm, thigh or buttocks - or with a nasal spray device which is the most
common for us as dentists (Kim et al. Am J Pub Health 2009).
Drugs and Root Canal Pain Management
The economic costs of drug use are enormous: In 2007 alone, illicit drug use cost our Nation
more than $193 billion in lost productivity, healthcare, and criminal justice costs. But the
human costs are worse. Nationwide, drug-induced overdose deaths now surpass homicides and
car crash deaths in America. Now doctors must be more responsible for prescribing narcotics
for acute and chronic pain unless absolutely necessary.
There was a systematic review study recently in the JADA in May about pain control and
endodontics. With the push to get away from narcotics unless absolutely necessary this article
was very insightful.
Evidence-based recommendations for analgesic efficacy to treat pain of endodontic origin.
Authors:Anita Aminoshariae, James C. Kulild, Mark Donaldson, Elliot V. Hersh
Results:
The authors analyzed 27 randomized, placebo-controlled trials. The authors divided the studies
into 2 groups: preoperative and postoperative analgesic treatments. There was moderate
evidence to support the use of steroids for patients with symptomatic irreversible pulpitis. Also,
there was moderate evidence to support nonsteroidal anti-inflammatory drugs (NSAIDs)
preoperatively or postoperatively to control pain of endodontic origin. When NSAIDs were not
effective, a combination of NSAIDs with acetaminophen, tramadol, or an opioid appeared
beneficial.
Conclusions and Practical Implications

NSAIDs should be considered as the drugs of choice to alleviate or minimize pain of endodontic
origin if there are no contraindications for the patient to ingest an NSAID. In situations in which
NSAIDs alone are not effective, the combination of an NSAID with acetaminophen or a centrally
acting drug is recommended. Steroids appear effective in irreversible pulpitis.
What I do in my practice:
* After a proper diagnosis I tell a patient they can take 600mg of Ibuprofen 1 hour prior to
treatment. This will help with post-op pain and can sometimes assist with anesthetizing hot
tooth.
* Post-Operatively I usually give my patients 600mg of Ibuprofen (3 Motrin or Advil) and 500mg
of Acetaminophen (1 Extra Strength Tylenol). This aids in pain control post operatively so as the
anesthetic is wearing off the analgesics are kicking in. Most patients say they never need
anything else and rarely do they have to take the narcotic like tramadol or Vicodin.
* Flare-Up Post-Op issues. There are on occasion the analgesic combo (Ibuprofen + Ex Tylenol)
or the narcotics are not working. I usually see this in retreatment cases a lot using calcium
hydroxide. I would prescribe a Medrol Dose Pack with a loading dose of 6 pills at one time (24
mg). This creates a loading or burst dose effect giving pain relief in usually a few hours without
the side effects of narcotics. Patients can still work and drive usually on this medication.
As a board certified endodontist, I am aware that patients sometimes request whatever drug
they desire and there are some dentists that comply. We must not fall victim to this cycle.
"Don't prescribe a water hose to put out a simple match." We should practice at the highest
level possible with evidence based care for our patients.
TOPIC 29 – REGENERATIVE ENDODONTICS
Regeneration is the process of renewal, restoration, and growth that makes genomes, cells, or
organisms resilient to natural fluctuations or events that cause disturbance or damage (Carlson
et al Princ Of Regen Bio 2007). Regeneration can either be complete where the new tissue is
the same as the lost tissue or incomplete where fibrosis occurs after the necrotic tissue is
removed (Min et al. Pathology 2006). In Regenerative Endodontics our goal is for the pulp to
“revitalize” or “regenerate” new pulp-like tissue so that that root maturation can occur in
absence of disease and patient can return to function, form, and esthetics.
The three most important treatment factors in regenerative endodontics are: Disinfection of
the root canal canal, Establish Bleeding (blood clot) to create a blood clot to carry the stem cells
inside the canal, and a bacteria tight Seal of the access opening.
The success rate of regenerative endodontics is relatively high if the procedure is done properly
and the patient is compliant. Some studies show a success rate of up to 90% (Murray et al. JOE
2007). The rate of root maturation is variable because of unique individual immune systems.
The majority of human case studies have shown good clinical outcomes for immature
permanent teeth with pulpal necrosis following regenerative endodontic procedures. The
complete process usually takes between 1 to 5 years (Hargreaves et al. JOE 2013). In addition,
a positive response to cold and/or electric pulp tests have occurred in some cases (Law et al.
JOE 2013).
The Regenerative Endodontic Procedure:
First Appointment
• Case must be necrotic and have an open apex
• Local anesthesia, dental dam isolation and access.
• Copious, gentle irrigation with 2.5% NaOCl using an irrigation needle with closed end
and side-vents. Then irrigation with saline or EDTA with irrigating needle positioned
about 1 mm from root end, to minimize cytotoxicity to stem cells in the apical tissues.
• Dry canals with paper points.
• Place calcium hydroxide inside canal and place an interim restoration for 4 weeks. A
triple antibiotic paste can be used instead of calcium hydroxide (ciprofloxacin,
metronidazole, and minocycline) as an alternative as root canal disinfectant.
Second Appointment
• Assess response to initial treatment. Make sure patient is asymptomatic. If there are
signs/symptoms of persistent infection redo the first appointment.
• Anesthetize with 3% mepivacaine or carbocaine without vasoconstrictor, dental dam
isolation.
• Copious and gentle irrigation with 17% EDTA and dry with paper points.
• Create bleeding into canal system by over-instrumenting with an endo file. The goal of
having the entire canal filled with blood to the level of the cemento–enamel junction.
• Place a resorbable matrix such as CollaPlug, Collacote, CollaTape, over the blood clot if
necessary and bioceramic putty on top. I don’t recommend white MTA due to the
staining.
• A 3–4 mm layer of glass ionomer or composite is flowed gently over the capping
material and light-cured. MTA has been associated with discoloration. Alternatives to
MTA such as bioceramics or tricalcium silicate cements like Biodentine, Bioceramic
Putty, etc. should be considered in teeth where there is an esthetic concern.
Follow-up (6 months, 1 year, 2 years, and 3 years)

• No pain, soft tissue swelling or sinus tract.
• Resolution of apical radiolucency (often observed 6-12 months after treatment)
• Increased width of root walls (this is generally observed before apparent increase
in root length and often occurs 12-24 months after treatment)
CASE 1
Tooth #24 ~ Dens Evaginatus With Large PAP

A 10 year old African American male was referred to my office. He had pain and swelling in the
lower anterior area. The diagnosis was a necrotic pulp with chronic apical abscess with a wide
open apex. Note the size of the lesion pre-operatively (1st xray). I treated tooth #24 with
Regenerative Endodontics using Pro-Root MTA (white) with a specialized technique that was
published in Dentistry Today. However, now I would use Bioceramic Putty or BioDentine now as
you will see why. You can see the extra cusp that was broken on the 1st photo. The completion
of the case (2nd Xray) with the MTA. The lesion size started getting smaller and note the
staining after 6 months (3rd X-ray). A 2 year recall (4th Xray) shows dramatic healing with the
apex continuing to form. However look at the staining! This is from the heavy metal bismuth
oxide found in the ProRoot MTA.
Dens evaginatus is a condition found in teeth where the outer surface appears to form an extra
bump or cusp. Premolars are more likely to be affected than any other tooth. This may be seen
more frequently in Asians. The pulp of the tooth may extend into the dens evaginatus. There is
a risk of the cusp like protrusions of the dens evaginatus tooth chipping off in normal function.
Hence this condition requires monitoring as the tooth can lose its blood and nerve supply as a
result and may need root canal treatment (Levitan et al. JOE 2006).
Clinical view of tooth #24 with Dens Evaginitus.
A pre-op radiograph of tooth #24 with dens evaginatus showing large periapical pathology and
open apex.
A post-op completion of the regeneration case on tooth #24.
A 6 month recall on tooth #24. Notice the apex is starting to mature or close.
A 2 year recall on tooth #24 showing healing taking place.
A 6 month recall showing the clinical view of the staining using white Pro-Root MTA.
Regenerative Endodontics - SHORT TIPS
Did you know it's the heavy metal content (bismuth oxide) in the MTA responsible for the dark
pigmentation of the tooth? Zirconium oxide is often used instead of bismuth oxide, as a
radiopacifying agent to reduce staining.
Here are some calcium silicate products that has little to no staining:
1. Biodentine (Septodont)
2. EndoSequence Root Repair Material & Bioceramic Sealer (Brasseler USA)
3. Odontocem (Australian Dental Manufacturing, Brisbane, Australia)
4. NeoFlo Sealer & Putty (Avalon Biomed)
5. Edge Bioceramic Sealer & Putty (EdgeEndo)
CASE 2
A 14 yr. old came in pain on tooth #29. It had an incompletely formed apex and periapical
pathology with buccal swelling. I decided to perform regenerative endodontics on this case.
After 1yr the apex closed and the PAP healed.
A pre-op radiograph on tooth #29 with an open apex and under-developed root. It also had
periapical pathology.
Regenerative Endodontics initiated on tooth #29. The tooth was anesthetized, access was
made, irrigation with ½ strength NaOCl, 17% EDTA, canal dried with large paper points, and
calcium hydroxide USP (powder mix with local anesthetic) placed inside the canal.
After 1 month tooth #29 was anesthetized with Carbocaine (no epi), accessed, irrigated with
17% EDTA, bleeding provoked with file, bioceramic putty placed, and Cavit placed or restore
with permanent restoration.
A post-op 1 year recall showing healing and closure of the root.
CASE 3
Tooth #20 had a necrotic pulp and immature apex. The regeneration procedure was performed
on this tooth. A 1.5 year recall shows the apex is closed. I don't believe in using triple antibiotic
paste. I use Calcium Hydroxide and also use a matrix of Collocate and Bioceramic Root Repair
Putty Material because it does not stain. Patient is now doing orthodontics.
A pre-op radiograph on tooth #20 with an open and immature apex.
A clinical photo of tooth #20.
Irrigation solutions used (saline, ½ strength NaOCl, 2% Chlorhexidine)
A radiograph of calcium hydroxide placed on tooth #20 after the first visit.
A post-op radiograph on tooth #20 with bioceramic putty and Collocoate matrix in place.
A 1.5 year recall showing the apex is now closed and patient in orthodontic therapy.
A clinical view showing no staining with the bioceramic putty material.
TOPIC 30 – RETREATMENT
Endodontic treatment can fail. If endodontic therapy fails the best choices are a retreatment or
apical surgery. Nonsurgical retreatment is usually less invasive than apical surgery and has a
less traumatic postoperative course. Studies show healing rates of retreatment can be up to
98% (Friedman et al. JCDA 2004).
The flow for retreatment are as follows: disassembly, repair of iatrogenic errors, location of
missed canals, shaping and disinfection of the canal system, and obturation. These procedures
can be very complex and will require specialized armamentarium and high skill level. The
surgical microscope allows the clinician to visualize the contents of canals better than loupes or
the naked eye. The microscope, specialized tools, and the assistance of the 3D CBCT
technology allows retreatment success at the highest level.
CASE 1
Tooth #23 – Vertical Root Fracture?

Patient came in with a buccal sinus tract associated with tooth #23. It had a previous root canal
(short fill), large screw post, large PAP, and what appears to be a crack or vertical root fracture.
Patient was given options to have tooth extracted and implant or retreatment or surgery. He
decided to have a retreatment instead.
The tooth was accessed with a diamond bur, the post was removed with ultrasonics, the gutta
percha was removed with Gates Glidden Drills and headstrom files. There was a lingual canal
missed from previous treatment. No crack or vertical root fracture was found. Calcium
hydroxide was placed for 2 weeks. The patient returned asymptomatic and sinus tract had
resolved. The case was completed. There was a little gutta percha extruded from the previous
treatment into the periapical lesion. This will usually NOT cause the area to heal.
Studies by (Sjogren et al. EJOS 1995) show large pieces of gutta percha were well encapsulated
and the surrounding tissue was free of inflammation. A 6 month recall shows nice osseous
repair. In a few years the macrophages will phagocytize that small piece of gutta percha
(Hatsuya et al. Japan Journal Med 1978).
A pre-op on tooth #23. Could it be a fracture or a crack?
A retreatment was initiated with calcium hydroxide placed for 2 weeks. Notice the piece of
gutta percha (GP) that got accidentally pushed out the apex. The macrophages will phagocytize
this in a few years.
A post-op radiograph on tooth #23. There were 2 canals.
A 6 month recall showing very nice healing.
CASE 2
Tooth #19 ~ Previous Treatment With Pathology

Patient came in with pain to biting on tooth #19. It had a previous root canal with a large core
build-up with 2 posts. Notice the gutta percha is crinkled in the mesial root. This is due to
inadequate cleaning and shaping. Radiographically there was pathology on both roots.
Retreatment was done in 2 visits using CaOH2 as an intracanal medicament for 2 weeks.
Main Irrigants: Full Strength NaOCl, 17%EDTA, Alcohol.
Chloroform and headstrom files were used to remove the gutta percha.
I did not have to take out the pins. Patient returned asymptomatic and case was completed
with warm vertical condensation with ZOE based sealer.
A 4 year recall shows nice osseous repair.
A pre-op radiograph on tooth #19 with 2 pins (yellow) and periapical pathology (red arrows).
A retreatment was initiated with calcium hydroxide in place.
A post-op radiograph of tooth #19.
A 4 year recall on tooth #19 with nice healing.
CASE 3
Tooth #10 ~ Large Post and Periapical Pathology

Patient came in with discomfort on tooth #10. A LFOV 3D CBCT was taken. The fill was short.
She chose to have a retreatment vs apical surgery. A retreatment was performed in one visit. I
used the SP-19 tip with the Enac Ultrasonic unit to remove the large post. The canal was
obturated with bioceramic sealer and gutta percha. Patient returned in 6 months with very nice
osseous repair.
A pre-op radiograph on tooth #9 with a large post and periapical pathology.
A 3D bone rendering of tooth #9 from the palatal aspect showing apical pathology.
The post was removed with ultrasonics. Notice the bacterial corrosion around the post.
The post was removed and the apex was gauged with a size 130 file.
A post-op of the completion of the retreatment on tooth #9.
A 6 month recall shows very nice healing on tooth #9.
CASE 4
Patient was referred to my office from his general dentist with pain and swelling associated
with tooth #31. It had a previous root canal from India over 5 years ago and the crown kept
falling off. In addition, it had a very large PAP and possible crack. He did not want to have the
tooth extracted and implant placed. I performed a retreatment in 2 visits using calcium
hydroxide as the intracanal medication. There was no crack noted. Patient returned for a 5 year
recall still asymptomatic and very nice bone healing.
Retreatment was initiated and calcium hydroxide was placed.
A post-op radiograph on tooth #31.
A 5 year recall shows very nice healing.
TOPIC 31 – ROOT RESORPTION
Resorption occurs when developmental precementum or predentin are lost or

damaged and inflammation of the adjacent soft tissues allows for clastic cell invasion (Tronstad
et al. EDT 1988). The location of this damage usually determines the type of resorption that
occurs. Resorption can’t be simply defined as internal or external. Internal root resorption
(IRR) is its own unique entity, whereas external resorption (ER) can take many forms.
Internal Root Resorptions (IRR)

IRR involves loss or damage to the predentin lining the pulp chamber or root canal spaces
combined with inflammation activating odontoclasts. When visible radiographically, IRR is
continuous with the pulp chamber or root canal space. It looks like a localized “ballooning” of
the canal space.
External Inflammatory Root Resorption (EIRR)

External resorptive diseases take several forms depending on their etiology, but share the
pathogenesis of loss or damage to the precementum lining the root surface combined with
inflammation of the adjacent periodontal ligament, activating odontoclasts. (Tronstad et al. EDT
1988). External inflammatory root resorption (EIRR) relates to endodontic pathosis and usually
it’s a necrotic pulp. Apical EIRR is often present in cases of apical periodontitis secondary to
pulp necrosis (Vier & Figuieredo IEJ 2010).
External Cervical Resorption (ECR)

External cervical resorption (ECR) is the form of resorption most often seen in clinical dental
practice. Sometimes on routine exams. Patients are usually in no pain. ECR occurs at the
cementoenamel junction due to developmentally missing, lost or damaged precementum in the
gap junction (this gap is present 10% of the time), combined with inflammatory tissues in the
junctional epithelium of the periodontal attachment apparatus, at the base of the gingival
sulcus. (Heithersay et al. Quint Int. 1999 and Patel et al. IEJ 2018) Proposed etiologies include a
history of orthodontics, trauma, periodontal therapy or internal bleaching. However, it often
presents idiopathically. Radiographically, lesions present as mixed radiolucencies, with a ground
glass appearance as the lesions extend inward. The dental pulp has its own protective
predentin therefore pulpal involvement is rare unless secondary caries or infection develops
within the resorptive cavity.
CASE 1
Extensive Cervical & External Resorption Case

Patient came in without any pain for an evaluation. He had a history of a trauma playing sports
when he was younger. He was 17 years old at this time. We evaluated teeth 8, 9, 10, 24, 25,
and 26. All had signs of resorption replacement resorption, cervical resorption, and external
resorption. Some more severe than others. The mom did not want to attempt to save any of
these teeth. She said when they start to hurt she will get them extracted.
Resorption occurs when developmental precementum or predentin are lost or damaged and
inflammation of the adjacent soft tissues allows for clastic cell invasion. (Tronstad) The location
of this damage, and therefore the associated tissues, determines the type of resorption that
occurs.
**It is very important to have teeth evaluated soon after a trauma. Sometimes we can save
them before it gets this bad. Especially in young children.
Anterior resorption on teeth 8, 9, and 10.
Anterior external resorption on teeth 10 and 11.
Anterior external resorption on the lower anterior teeth.
Anterior external cervical resorption and apical resorption.
CASE 2
Tooth #25 ~ External Cervical Resorption With CBCT Interpretation

Patient was referred by his general dentist for an evaluation on tooth 25. Patient had a history
of orthodontic treatment but no trauma. The 2D PAX shows resorption on the distal aspect of
tooth 25 in the coronal area. Pulp testing were within normal limits. The diagnosis was class III
external cervical resorption described by Hithersay. It is defined as a localized resorptive
process that involves the surface of root below epithelial attachment and coronal aspect of the
supporting alveolar process, namely the zone of connective tissue attachment. These case are
not pulpal diseases. The etiology is usually trauma or ortho due to the cementum being
stripped away, bacteria invading the area, which turns on the osteoclasts creating resorption.
The resorption does not enter into the pulp on these cases.
***A root canal will not fix this problem***
Essentially, treatment involves complete surgical removal of the resorptive tissue, placing a
bioceramic material such as MTA or BC putty and restoring the resulting defect Geristore or
other composite like restoration. However, I have had 10 year success treating some of these
non-surgically. Endodontic treatment might also be required in cases in which the ECR lesion
has perforated the root canal.
CBCT is a promising diagnostic tool for confirming the presence, appreciating the true nature,
and managing ECR. This patient decided to have an extraction and implant instead.
A pre-op of tooth #25 with external cervical resorption.
A 3D bone rendering of the cervical resorption on tooth #25. Notice the spot by the yellow
arrow.
A LFOV 3D CBCT of the external cervical resorption defect on tooth #25.
A sagittal view of the external resorptive defect on tooth #25.
An axial view 3D CBCT on tooth #25 with external cervical resorption.
CASE 3
Tooth #19...Unusual Anatomy – Idiopathic Resorption On The Distal Root

periodontitis. She had a history of orthodontics as a child which probably led to the resorption
on the distal root. Endodontic treatment was performed in 2 visits using calcium hydroxide. This
was a rare case that had 3 mesial canals with separate portals of exits and 2 distal canals. A
total of 5 canals. Vertucci type VIII in the mesial root and type IV in the distal root.
A pre-op radiograph of tooth #19. Notice the resorption on the distal root.
A post-op radiograph showing the 3 mesial root canals all with a separate portal of exit.
A post-op radiograph showing the 2 distal canals with a separate portal of exit.
CASE 4
External Cervical Resorption Vs Decay

An 11 year old female presented to my office due to her pediatric dentist seeing a radiolucency
on the distal crown portion of tooth #19. She had no pain. She had a history of stage 1 ortho in
which they banded this tooth. Radiographically you can see there is a "honeycomb" mixed
radiolucent/radiopaque appearance on the distal. This is a classic case of externa cervical
resorption. It's due to osteod bone-like repair after continuous breakdown. This is not decay
and can't simply be restored. You won't get a "stick" with your explorer like decay...the explorer
will usually go "straight through" and bleed.
The 2 most common causes of ECR are trauma and orthodontics. It is caused by small gaps in
the cementum being exposed (10% on all teeth) and recognized as antigenic by the immune
system causing the clastic cells to activate creating an auto-immune resorptive response. The
pulp is usually normal until the resorption gets larger creating a chronic environment in the
pulp. This is actually more of a periodontal issue that endodontic issue initially. Make sure you
get a good bitewing as well to see the extent of the defect as it relates to where the crestal
bone is located. This will help you determine the restorability and plan it properly.
In this case, the ortho treatment and band could have contributed to this issue. The mom did
not want to orthodontically super erupt the tooth, expose the area, clean it out and treat with
Tricyclic Acid, restore with Geristore, then wait to see if it becomes symptomatic. She was
concerned that the tooth would eventually break off and give her pain. She opted for the root
canal immediately with MTA internal repair. She was told this tooth will probably not make it
long term. She said as long as it gives her enough time to get an implant that's fine. Endodontic
treatment was performed in one visit using MTA (Dentsply) and Bioceramic Sealer (Brassler
USA). We hope that since MTA has a high pH @12.5 it can slow down the resorption.
A pre-op radiograph of tooth #18 with external cervical resorption (ECR).
A bitewing radiograph of the ECR (not decay). Notice the moth eaten appearance.
A conefit radiograph of tooth #18.
A post-op radiograph of tooth #18 after endodontic therapy and ProRoot MTA repair. Patient
reported back to his restorative dentist. A 6 month follow will take place.
CASE 5
Tooth #19 ~ Internal Resorptive Defect With Periapical Pathology

Patient came in pain on tooth #19. The dx was necrotic pulp with acute apical periodontitis. It
had and internal resorptive defect in the distal root and a PAP on the mesial root. Endodontic
treatment was performed in one visit and the defect was repaired with bioceramic putty. A 1
year recall shows nice healing.
Lit Review:
Internal root resorption is the progressive destruction of intraradicular dentin and dentinal
tubules along the canal walls as a result of clastic activities. It can be a contained IR or
perforating IR. LFOV 3D CBCT can help determine which one it is. It is seen as a radiolucent area
around the pulpal cavity, usually of incisors and mandibular molars and takes a "ballooning"
shape of the canal. It is usually "active" and endodontic treatment is warranted even in the
presence of no symptoms. The various etiological factors suggested for internal root resorption
include traumatic injury, decay, infection, and orthodontic treatment (Patel JOE 2010)
A pre-op of tooth #30 with Internal Resorption (IR) and periapical pathology (red arrow).
A post-op radiograph of completed treatment using bioceramic putty (BC putty) to seal the
internal resorptive defect in the distal root.
A 1 year post op radiograph showing very nice healing.
CASE 6
Tooth #14 - ECR Non-Surgical Management

Patient came in pain on tooth #14. The diagnosis was acute irreversible pulpitis with acute
apical periodontitis with an external cervical defect on the disto-palatal aspect. I did not have a
CBCT machine at this time or I would have taken a 3D image. Endodontic treatment was
performed in 2 phases.
The initial phase was a pulpectomy with non-surgical internal repair of the external resorptive
defect with ProRoot MTA (Dentsply USA). Lesions treated with MTA may eventually form a
noninflammatory layer, thereby hindering the ingrowth of resorption tissues. Furthermore,
studies have suggested the potential of MTA to promote the formation of reparative dentin and
cementum, which facilitates the forming of periodontal reattachment as well as functional
reconstruction.
The vascular tissue was removed using a slow speed round bur, sodium hypochlorite, and a
spoon explorer. Sodium hypochlorite help dissolve the granulomatous tissue and arrest
bleeding within the resorptive lesion, as well as disinfecting the root canal system.
The class II Hithersay ECR defect was repaired internally with ProRoot MTA. The high alkaline
pH of MTA will downregulate osteoclastic function and upregulate osteoblastic activity thus
arresting the resorptive process (Arnett 2008, Gandolfi et al 2007).
Patient returned in 2 weeks asymptomatic and the case was completed with warm vertical
condensation with ZOE based sealer.
Patient returned to see me 11 years later for a root canal on tooth #15. Tooth #14 was still
doing well, patient was asymptomatic, no inflammation or probing depths.
A pre-op radiograph of tooth #14 with external cervical resorption on the distal aspect.
Endodontic treatment was initiated and the defect was repaired with ProRoot MTA.
A post-op radiograph of endodontic therapy completion.
An 11 year recall showing the tooth and bone still intact with no advancement of the external
cervical resorption.
TOPIC 32 – SEALERS
Choosing an endodontic sealer for clinical use is an important decision that contributes to the
long-term success of non-surgical root canal therapy. Sealers can fill voids, canal spaces, lateral
canals, and accessory canals where core obturation materials cannot infiltrate. If the sealer
does not perform its function, microleakage may cause failure (Kim et al. Scanning 2015).
Zinc Oxide Eugenol Sealer (ZOE)

The zinc oxide-eugenol (ZOE) sealer formula was developed by Rickert and Dixon. In 1931 it
became Kerr sealer. The ZOE sealers have been a standard in endodontics since their
development, based on their long-term success. ZOE sealers contain zinc oxide powder and
eugenol liquid, an essential oil derived from cloves (Araki et al JOE 1994). ZOE sealers remain
popular because they set slow, low cost, good antibacterial properties, and very easy to use.
However the biocompatibility is poor (Leonardo et al. JOE 1997).
Salicylate Sealer
Salicylate-based sealers are referred to by their marketed therapeutic additives such as
Sealapex (Kerr) and Apexit / Apexit Plus (Ivoclar). Both are examples of a calcium-hydroxide-
containing salicylate sealers. Calcium hydroxide [Ca(OH)2] is both alkaline and antimicrobial. It
has desirable qualities for a therapeutic sealer. Unfortunately, Sealapex and Apexit/Apexit Plus
have not demonstrated the clinical effects desired. The solvation of calcium hydroxide is
required if therapeutic effects are to be achieved (Holland et al. JOE 1985).
Epoxy Resin Sealer

Epoxy resin was invented in 1938 by P. Castan, a Swiss chemist of de Trey (Zurich, Switzerland),
and AH 26 was developed by the same company during 1940s. In 1993, Spångberg et al.
reported that AH 26 releases formaldehyde, which recommended transition from AH 26 to AH
Plus, which does not release formaldehyde. AH Plus sealer is safe. Epoxy resin-based sealers
are very radiopaque, flows very well, and does not dissolve if overfilled in the periapical tissues
(Spangberg et al JOE 1993).
Calcium Silicate Sealer

Recently, sealers based on calcium silicates were developed as a new class of endodontic
sealers. Inspired by the excellent sealing these sealers establish a biological point of view on the
obturation of root canals. They create a bacteria-tight seal against reinfection of the root canal
system. Antibacterial properties as well as bioactive inducement of periapical healing and hard
tissue formation are added to the portfolio of sealers. They are ready-to-use sealers and sets in
the presence of moisture; usually in the dentinal tubules. Calcium silicate sealers such as
EndoSequence BC Sealer have higher antimicrobial activity for Enterococcus faecalis than both
epoxy resin (AH Plus) and ZOE sealers (Wainstein et al. Braz Oral Res 2016).
Summary of Sealers
Compared to AH Plus, calcium silicate sealers show the lowest relative microleakage among the
sealers. Calcium silicate sealers also exhibit the most favorable antimicrobial effect and
excellent biocompatibility compared to other sealers (Komabayashi et al. Dent Mat Jour 2020).
Top 4 Sealer Types Used
1. Calcium Hydroxide Based - Sealapex (Sybron)

2. Resin Based - AHplus (Maillefer)
3. Zinc Oxide Based - KerrEWT (Kerr)
4. Calcium Silicate Based - Bioceramic Sealer (Brasseler/Edge Endo/ Avalon Biomed)
Weakened Roots
Weakened roots after root canal preparation can be a challenge. Retreatment cases especially.
In my practice I use various sealers based on the case situation. However, I’m using more
Bioceramic Sealer Technology lately. It does not resorb nor shrink like most other sealers. And
believe it or not it’s retreatable. Some cases I use it for are large canals, young patients (they
don’t like the heat from warm vertical condensation), “Hot Teeth”, towards the end when
anesthesia is wearing off, and long curved roots when I can’t get the heat down within 5 -7mm.
In addition, it’s great for retreatment cases because more dentin is always removed and you
don’t want a vertical root fracture, and others such as trauma, apical resorption, internal
resorption, external resorption, etc. The unique thing is that it’s a cold single cone technique.
No real hard condensation is need like that of warm vertical. This can also decrease the
fractures that may be caused by condensation of Gutta Percha with pluggers.
Studies are consistently reporting that calcium silicate Based sealers such as Bioceramic Sealer
can reinforce root strength and increase fracture resistance. However, if the canal preps are
conservative or a calcified case, I really don’t think it makes a significant difference. The
reinforcement effect is derived from the ability of sealer to bond to root dentin with good
sealer penetration into dentinal tubules.
A study by Osiri et al JOE 2018 show Bioceramic Coated Gutta Percha Cones combined with
Bioceramic Sealer provided a higher bond strength, maximum depth, and circumferential
penetration at the apical root level as well as a greater sealer penetration area at all levels
compared with Gutta Percha combined with AHplus.
CASE 1
Patient came in pain on tooth #14. It had a previous root canal that appeared to be well done. A
LFOV 3D CBCT was performed. There was no obvious missed canal or pathology. A retreatment
was performed due to acute apical periodontitis. The tooth was disassembled and the gutta
percha was removed. I like using Gates Glidden (size 3 and 2 passively with crown down) to
remove the bulk of the coronal gutta percha safe and efficiently. Gates Gliddens are side cutting
instruments so they won’t create an additional canal or transportation. I then like to use
chloroform and a retreatment file. I like the one from EdgeTaper Retreatment File by
EdgeEndo. It's sturdy yet semi-flexible. The remaining 1/3 of the canal space I like to use small
headstrom files size 15.
I was able to locate under the microscope a missed MB2 and another palatal canal. All canals
were re-cleaned and shaped with EdgeEndo X7/.04 taper files. Irrigation was performed with
ChlorXtra by Vista Apex Dental Products and obturation with NeoSealer Flo bioceramic sealer
by Avalon Biomed.
A pre-op on tooth #14 with a previous root canal.
A retreatment was initiated and 5 canals were located on tooth #14.
A post-op radiograph of the case completed using NeoSealer Flo bioceramic sealer by Avalon
Biomed. Notice the MB and MB2.
A post-op radiograph showing the 2 palatal canals.
CASE 2
Patient had root canals performed by her dentist 6 months ago. She said the teeth still didn't
feel right. She did not want her teeth to be extracted and implants placed. She flared up with
pain and her dentist referred her to me. Previous root canals were performed on teeth 30 and
31. Many would think tooth 31 has a vertical root fracture due to the breakdown in the
furcation. The diagnosis was previous treated with acute apical periodontitis. A retreatment
was performed on both teeth and calcium hydroxide was placed for 2 weeks. Patient returned
and both teeth were obturated with Bioceramic Sealer by Brasseler USA and standard gutta
percha. This is considered a "single cone" technique. Patient returned in 6 months with
remarkable healing.
A pre-op on teeth #30 and #31 both had endodontic therapy but now it is failing.
A retreatment was initiated on both teeth and calcium hydroxide was placed.
Patient returned asymptomatic and the cases were obturated with Brasseler Bioceramic Sealer
and gutta percha in the single cone technique.
A 6 month recall shows very nice healing on both teeth.
CASE 3
Wishbone Anatomy...Kerr EWT Sealer (Zinc Oxide Sealer)

Patient came in with pain with a large cavity on tooth #18. The diagnosis was acute irreversible
pulpitis. Endodontic treatment was performed using EdgeEndo X7 / .04 taper files and warm
vertical condensation with Kerr EWT sealer. According to Vertucci's classification, the mesial
root presents with two separate canals at the apex in 59% of teeth, two canals joining with a
single apical foramen in 28% of teeth. This case was a Vertucci Type II aka The "Wishbone".
A pre-op radiograph on tooth #18 with large decay.
A post-op radiograph on tooth #18 using warm vertical condensation with Kerr EWT sealer.
CASE 4
Tooth #31 - Severely Curved Canals

Patient had pain on tooth #31 and required endodontic therapy. This was a pretty challenging
case. I used many small handfiles just to get a glide path. I then used heat treated NiTi files.04
taper which are very strong and flexible. Bioceramic Sealer by EdgeEndo with gutta percha was
used in this case.
Here are three bioceramic sealer types I use and like:

1. EdgeEndo Bioceramic Sealer
2. Brasseler USA Bioceramic Sealer
3. Avalon Biomed Bioceramic Sealer
Why Use Bioceramic Sealer?

Resin-based sealer will shrink upon setting while calcium hydroxide and zinc oxide eugenol-
based sealer can resorb over time. The Bioceramic sealers expand while setting, the expansion
is slight, less than 0.2% of total volume and once set will not resorb as easily.
Why Use A Gutta Percha Cone With Bioceramic Sealer?

1. The purpose of the gutta-percha cone is to drive the sealer into cleaned isthmuses and
irregular gaps.
2. It also serves as a soft core that will allow for retreatment. Set bioceramic sealer is a
challenge to remove with hand or rotary files. Ultrasonics would have to be used to
remove the set bioceramic sealer. It gets very hard like MTA.
3. The hydrophilic nature, sealability, biocompatibility, antibacterial property, bioactivity,
and ease of delivery has made it a promising material to be used in endodontics.
A pre-op radiograph on tooth #31 with severe curves. The diagnosis was chronic irreversible
pulpitis.
A post-op radiograph on tooth #31 using Bioceramic Sealer by Edge Endo and gutta percha.
TOPIC 33 – SEPARATED INSTRUMENTS
Separated files and instruments will happen to all of us as clinicians. However most can be
remove or bypassed safely with the proper tools and techniques. If the file can’t be remove or
bypassed apical surgery may be the next option. Most of the instruments we use will usually
not give the patient a foreign body reaction whether it separates inside the canal or outside the
canal. The issue is the bacteria, tissue, or byproducts beyond the separated instrument that’s
not removed.
The most common causes for separated instruments are root canal anatomy, improper use,
inadequate access, manufacturing defects, limitations in physical properties, and insufficient
knowledge about the root canal morphology and its variations (Al-Qudah et al IEJ 2006).
Stainless steel instruments commonly fail by excessive torque while Ni-Ti rotary files usually
fracture by torsional stress and cyclic fatigue (Grossman OOO 1969).
Recent advancements in devices such as ultrasonics and micro tube methods allow easier
removal of separated instruments. The dental operating microscope allows clinicians to
visualize and remove most broken instruments (Plotino et al JOE 2007). If you can’t see the
separated file in the microscope then it will be very difficult to remove. In addition, if the file
separates at the apex and there is no lesion studies show it’s ok to just leave it.
CASE 1 – SILVER POINT REMOVAL
Patient came in discomfort on tooth #8. He had a draining sinus tract with slight swelling. He
did not want to have an apical surgery. I performed a LFOV 3D image of the area. I decided to
retreat this case. I accessed it on the lingual through the porcelain crown. I could not get any
micro forceps on the silver point to pull it out. I irrigated with NaOCl and used many small files
to loosen it up. I then used the braided file technique. I placed a size 15, 20, and 25 file around
the silver point and braided or twisted it tightly. Then I used a pair of hemostats to pull up on
the files as they engaged the silver point. Then the silver point popped out. Notice the corrosion
at the tip. The canal was cleaned and shaped. A sandwich technique of Bioceramic Putty and
Bioceramic sealer was used at the apex because it was perforated due to the overextension of
the large silver point. The rest of the canal was obturated with gutta percha and Bioceramic
Sealer.
A pre-op on the silver point with broken handle on tooth #8.
The 3D CBCT bone rendering on tooth #8.
A sagittal view CBCT showing the overextension on tooth #8.
Access made and could not grab the silver point with microforceps.
I braided a size 10, 20, and 25 headstrom file into the access to engage the silver point. Then
used hemostats to grab the top of the files together.
A post op of the silver point removed on tooth #8.
Bioceramic Putty “Sandwich” Technique Used. Bioceramic Sealer at the apex, Bioceramic Putty
at the apex, then Bioceramic Sealer then gutta percha cone.
A post op of the obturation on tooth #8.
CASE 2
You Still Worried About That Separated File In The Canal? What About One Outside?
periodontitis. Endodontic treatment was completed in one visit.
KEY...I noticed a separated file in the PAX. I asked the patient how long ago was that tooth #19
was extracted. She said 20 years. That separated NiTi rotary file has been in place for 20 years
causing no pain or pathology in the bone. How many times as dentists and endodontist we
freak out over a separated file inside the tooth? If this happens, we must inform the patient and
document it in the chart.
A pre-op on tooth #20. Notice the separated file in the bone.
A post-op radiograph on tooth #20 and the separated file (red) will remain.
Four SHORT Keys Regarding Separated Files:
1. The most common causes for file separation are root canal anatomy, improper use,
inadequate access, manufacturing defects, limitations in physical properties, and
insufficient knowledge about the root canal morphology and its variations. (Al-Quedah
IEJ 2006)
2. According to clinical studies, the overall endodontic instrument separation frequency

(either rotary or hand files) is between 1.83% and 8.2%. (Suter IEJ 2005)
3. The highest frequency of instrument separation is presented during the treatment of

molars especially lower molars (77% - 89% of all cases). (Tzanetakis JOE 2008)
4. Regardless of lesions, teeth with a separated instrument healed in 91% essentially no

change in success rate if it's cleaned properly prior to separation. (Spili, Crump JOE
2005).
CASE 3
Patient presented with pain on tooth #30. It had a previous root canal with some very seriously
curved anatomy and a periapical lesion. The previous treatment was performed with Thermofil
and there was a separated file at the apex of the distal root. I decided to retreat this tooth
versus performing apical surgery. I opened the tooth up and located another distal canal using
the microscope. The Thermofils were removed by heating up the plastic core with a Touch N
Heat or System B.
***KEY: Activate the heat, place in center of plastic core, count 5 seconds, let cool 10 seconds,
then pull ~ 90% of the time the carrier will come out completely).
I tried to bypass the file in the distal root at the apex but could not (Remember the file will not
cause a failure as long as it’s sterile - Crump and Natkin also Kakahashi Stanley and Fitzgerald
studies!).
***It’s bacteria beyond the file that can cause failure***.
Calcium Hydroxide was placed in all 4 canals. Patient returned in 2 weeks asymptomatic and
case was completed. I obturated with warm vertical gutta percha and ZOE based sealer. Patient
returned in 6 months and healing is evident in both the mesial and distal roots in the presence
of the separated file.
A pre-op on tooth #30 with a separated instrument (S.I) in the apical 1/3 of the distal root.
A post-op retreatment on tooth #30 and could not remove the separated file from the distal
root at the apex.
A 6 month recall shows very nice healing even in the presence of the separated file.
TOPIC 34 – TRAUMA
Most traumatic dental injuries occur in children and teenagers but people of all ages can be
affected. Such injuries can be the result of sports mishaps, automobile accidents or bad falls.
Management of Traumatic Dental Injuries
1. Enamel Fracture (Uncomplicated Crown Fracture)
Enamel fractures usually require minimal treatment. The chipped enamel can either be
smoothed or repaired with composite or the tooth fragment can be bonded back in place.
2. Crown Fracture with Pulp Exposure (Complicated Crown Fracture)
For Immature Tooth: Pulp capping or shallow pulpotomy procedures are indicated. A
biologically acceptable material such as MTA or bioceramic putty is placed directly in
contact with the pulp to maintain the vitality. A final bonded restoration is placed or the
tooth fragment can be bonded back with composite.
For Permanent Tooth: Use vital pulp therapy with MTA or bioceramic putty followed by
bonded composite resin or bonded fractured crown segment restorations. If patient has
pain and pulp is very hyperemic it may need full endodontic therapy. If the tooth requires a
crown to restore function or esthetics, nonsurgical root canal treatment is indicated.
3. Luxation (Tooth gets jammed in the alveolar socket)
Emergent care. Reposition the tooth and apply a nonrigid splint. Allow healing of the
periodontal ligament and supporting bone. Then bring patient back to pulp test in 4 to 6
weeks.
Definitive care. Endodontic therapy is performed in teeth with pulpal necrosis or

irreversible pulpitis with a closed apex. The treatment for immature teeth varies from
pulp capping in vital cases or revascularization or regeneration in non-vital cases.
4. Avulsion (Tooth gets completely knocked out of socket)
If the apex is open and the tooth is reimplanted within 30 minutes there is a possibility
the tooth will survive but may need endodontic therapy in the future. If the apex is
closed the tooth should be reimplanted immediately. Tooth should be stabilized with a
non-rigid splint. Endodontic therapy can be performed at this time or patient can be re-
appointed in 2 -3 weeks. Patient should be placed on an antibiotic and an anti-
inflammatory. The patient should be referred to his or her physician to evaluate the
need for a tetanus booster if the avulsed tooth has come into contact with soil or if
tetanus coverage is uncertain. (Andreason et al. Endod Dent Trauma 1988)
The complete clinical trauma guideline by the AAE can be downloaded free at
www.aae.org/clinical-resources/trauma-resources.aspx.
CASE 1
A 10 year old patient came in pain on tooth #8. He was pushed into a pole at school. There was
a complicated vertical crown fracture with pulpal involvement on tooth #8. The crack did not go
into the root or it would be a vertical root fracture which usually requires an extraction.
Endodontic treatment was performed in one visit. A six month recall shows the case still doing
well and the patient is still asymptomatic. If we can get him old enough for an implant it's still a
success!
The case was obturated using new technology Bioceramic Gutta Percha and Bioceramic Sealer
by Brasseler USA. Some studies (Nagas and Ghoneim JOE 2011) show that these materials used
together may increase the fracture resistance. It also acts as a medicament (to possibly help
reduce resorption & increase healing time) and creates an "MTA" like seal (Zhang H JOE 2009)
due to the composition: Zirconium oxide, calcium silicates, calcium phosphate monobasic,
calcium hydroxide, filler and thickening agents. Setting time is 4 hours. However, in very dry
root canals, the setting time can be more than 10 hours. In addition, heat causes the material to
desiccate reducing its effectiveness. However, there are newer bioceramic sealers in which heat
does not significantly disturb the properties like Bioceramic High Flow Brasseler USA and
NeoSealer Flo by Avalon Biomed.
A pre-op radiograph with a vertical crack into the pulp on tooth #8.
Endodontic treatment was initiated and the conefit was determined.
A post-op radiograph of the completion on tooth #8 with gutta percha and bioceramic sealer.
A 6 month recall showing nice healing and stability.
CASE 2
An 11 year old had a trauma in the anterior region one month ago. She came in for an
evaluation. Tooth #9 did not respond to pulp testing. She was asymptomatic however. Patient's
mom decided not to have the root canal performed yet because she was not in pain. One
month later the tooth started to turn dark. But no severe symptoms. The mom decided to have
her daughter have the endodontic treatment because of the dark color. The diagnosis was a
necrotic pulp. The root canal was performed in one visit and the tooth was internally bleached.
TIP: I like to use a combo of sodium perborate + superoxol for one week.
She did not want a crown at her young age. The final result was very satisfying to the patient
and her mother. Ultimately it was restored with a composite core.
A clinical photo of the dark colored tooth #9.
A pre-op radiograph of tooth #9 with no apparent pathology.
A post-op radiograph of endodontic therapy completed on tooth #9.
A clinical photo of tooth #9 after internal bleaching.
So why does the tooth turn dark?
The tooth turns dark because of the blood clot that forms inside of the tooth after the trauma
or the red blood cells are dying. This is a very similar effect to bruising. A person may notice a
yellow, gray, or black discoloration. Many cases can be fixed with internal bleaching after the
root canal or placing a crown.
CASE 3
This case was a trauma case on a beautiful 7 year old girl in 2004. She got tooth #8 knocked out
and her dentist put it back with a splint. Which was part of the correct plan of treatment. She
went to another dentist 1 year later and he noticed the resorption all over the tooth and
mobility. (TIP) ~ Once a tooth is avulsed and the apex is closed or closed less than 1mm,
endodontic treatment is recommended to reduce external resorption.
Many dentist, periodontists, and even some endodontist would look at this tooth and say
extract because it looks pretty bad. I agree it looks pretty hopeless. However, I believe in the
healing power of the body and I understand the biology behind the etiology. I wanted to give it
a shot and so did the patient and her mom! I treated this case with 1 month of calcium
hydroxide. Then I used white MTA to obturate the entire root. Relax...I know the fill does not
look great but it was the best I could do at the time.
The last x-ray is a 4 year recall showing remarkable healing! She is now 18 years old, in college,
and still has her tooth. She loves me...lol.
"When put in the proper situation, the body has amazing healing potential."
A pre-op radiograph on tooth #8 with external resorption.
A post-op radiograph of white Pro-Root MTA to obturate the entire canal on tooth #8.
Endodontic therapy was performed on tooth #9 as well.
A 4 year recall shows very nice healing and reversed the external resorption.
CASE 4
Tooth #9 - Horizontal Root Fracture

An 11yr old came in pain on tooth #9 after a skate board accident causing a horizontal root
fracture. He was placed on antibiotics and NSAID's by his dentist. Fortunately, he was already in
ortho or the tooth would have probably been avulsed and been lost. It had a class III mobility. A
LFOV CBCT was taken and it showed the fracture very clearly. Patient returned in 2 weeks for a
follow up and tooth pulp tested vital. He returned in 6 months, 1 year, then 2 years and tooth
was still vital with only a class I mobility. No endodontic treatment was recommended at this
time. No resorption was taking place either. A 3 year recall with another LFOV CBCT shows the
fracture is healing very nice with callous repair. Sometimes we need to just wait and watch!
A pre-op radiograph of tooth #9 with a horizontal fracture.
A LFOV 3D CBCT bone rendering of the horizontal fracture on tooth #9 (red arrow).
A sagittal 3D view of the fracture on tooth #9.
A 3 year recall showing callous repair on tooth #9.
A 3D LFOV bone rendering showing repair of the fracture after 3 years.
A sagittal 3D view showing repair of the fracture after 3 years.
• A recent study by Keinan et al JOE Jan 2021 shows orthodontic movement of immature
traumatized teeth after apexification is safe. Only minor root resorption was shown.
• A study in JOE May 2021 by Pradeep Kumar et al on CBCT & Detecting Fractures
concluded fracture width >120 μm has been reported to be better visualized by CBCT
imaging which is approximately the size of a 15 handfile. From this systematic review
and meta-analysis, it can be concluded that the available evidence is weak with regard
to the diagnostic ability of CBCT imaging to identify VRFs in root-filled teeth compared
with direct visualization.
CASE 5
Patient had a trauma involving teeth 8 and 9 and was sent to me from a periodontist to try to
save. He was only 12 years old. The teeth were splinted by an oral surgeon. Patient also had
buccal swelling due to the pulps being necrotic. A LFOV 3D CBCT was taken showing the
pathology. Endodontic treatment was initiated on both teeth. CaOH powder USP was placed in
both teeth for one month. Patient returned asymptomatic. Both teeth were instrumented to
the fracture. Bioceramic Sealer was placed then Bioceramic Putty (Brasseler USA ) was used to
fill the canal to the fracture line. BC liner (Brasseler USA) was used to restore both teeth.
Patient returned with a 1 year recall showing remarkable healing and callous repair.
REFERENCES & REVIEW ARTICLES:
1. ACCESS
Access Cavity Preparations: Classification and Literature Review of Traditional and
Minimally Invasive Endodontic Access Cavity Designs
Shabbir, Juzer et al. Journal of Endodontics, Volume 47, Issue 8, 1229 – 1244.
2. ANATOMY
Current Challenges and Concepts in the Preparation of Root Canal Systems: A Review
Peters, Ove A. Journal of Endodontics, Volume 30, Issue 8, 559 – 567.
3. ANESTHESIA & PREGNANCY UPDATE

Anesthetic Efficacy of Gow-Gates, Vazirani-Akinosi, and Mental Incisive Nerve Blocks for
Treatment of Symptomatic Irreversible Pulpitis: A Systematic Review and Meta-analysis
with Trial Sequential Analysis Nagendrababu, Venkateshbabu et al. Journal of
Endodontics, Volume 45, Issue 10, 1175 - 1183.e3.
Pharmacotherapy during Pregnancy: An Endodontic Perspective

Ather, Amber et al. Journal of Endodontics, Volume 46, Issue 9, 1185 – 1194.
4. APEX LOCATORS
Clinical Efficacy of Electronic Apex Locators: Systematic Review Martins, Jorge N.R. et al.
Journal of Endodontics, Volume 40, Issue 6, 759 – 777.
5. APEXIFICATION
Treatment Options: Apexogenesis and Apexification Shabahang, Shahrokh Journal of
Endodontics, Volume 39, Issue 3, S26 - S29.
6. APEXOGENESIS AND PULP CAPPING

Vital Pulp Therapy with New Materials: New Directions and Treatment Perspectives—
Permanent Teeth Witherspoon, David E. Journal of Endodontics, Volume 34, Issue 7, S25
- S28.
7. APICAL SURGERY
Prognostic Factors in Apical Surgery with Root-end Filling: A Meta-analysis von Arx,
Thomas et al. Journal of Endodontics, Volume 36, Issue 6, 957 – 973.
8. ANTIBIOTICS
Antibiotic Use in 2016 by Members of the American Association of Endodontists: Report
of a National Survey Germack, Mark et al. Journal of Endodontics, Volume 43, Issue 10,
1615 – 1622.
9. BIOCERAMIC TECHNOLOGY
Are Premixed Calcium Silicate–based Endodontic Sealers Comparable to Conventional
Materials? A Systematic Review of In Vitro Studies Silva Almeida, Luiza Helena et al.
10. CALCIUM HYDROXIDE

Does Calcium Hydroxide Reduce Endotoxins in Infected Root Canals? Systematic Review
and Meta-analysis Bedran, Natália Rocha et al. Journal of Endodontics, Volume 46, Issue
11, 1545 – 1558.
11. CARRIER BASED OBTURATION

Time Required to Remove GuttaCore, Thermafil Plus, and Thermoplasticized Gutta-
percha from Moderately Curved Root Canals with ProTaper Files Beasley, Robert T. et al.
12. CLEANING AND SHAPING

Current Challenges and Concepts of the Thermomechanical Treatment of Nickel-
Titanium Instruments Shen, Ya et al. Journal of Endodontics, Volume 39, Issue 2, 163 –
172.
13. CONE BEAM TECHNOLOGY

Endodontic Applications of Cone-Beam Volumetric Tomography Cotton, Taylor P. et al.
14. CRACKS AND FRACTURES

Outcome and Survival of Endodontically Treated Cracked Posterior Permanent Teeth: A
Systematic Review and Meta-analysis Olivieri, Juan Gonzalo et al. Journal of
Endodontics, Volume 46, Issue 4, 455 – 463.
15. CYSTS AND GRANULOMAS

Nonsurgical Root Canal Therapy of Large Cyst-like Inflammatory Periapical Lesions and
Inflammatory Apical Cysts Lin, Louis M. et al. Journal of Endodontics, Volume 35, Issue 5,
607 – 615.
16. DIAGNOSIS
Pulp Inflammation Diagnosis from Clinical to Inflammatory Mediators: A Systematic
Review Zanini, Marjorie et al. Journal of Endodontics, Volume 43, Issue 7, 1033 – 1051.
17. ENDODONTIC FILES

Kinematic Effects of Nickel-Titanium Instruments with Reciprocating or Continuous
Rotation Motion: A Systematic Review of In Vitro Studies Ahn, So-Yeon et al. Journal of
18. ENDO/PERIO RELTATIONSHIPS
The Relationship of Endodontic–Periodontic Lesions Simon, James H.S. et al. Journal of
Endodontics, Volume 39, Issue 5, e41 - e46.
19. ENDODONTIC EMERGENCIES

Management of endodontic emergencies: Facts and fallacies Ricks, Linda Journal of
Endodontics, Volume 18, Issue 8, 417
20. HEAT CARRIERS

Warm vertical gutta-percha obturation: A technique update Jerome, Charles E. Journal of
21. IATROGENIC MISHAPS AND PERFORATION MANAGEMENT

Treatment Outcome of Repaired Root Perforation: A Systematic Review and Meta-analysis
Siew, Kailing et al. Journal of Endodontics, Volume 41, Issue 11, 1795 – 1804.
22. IMPLANTS VS ROOT CANAL SUCCESS

Retrospective Cross Sectional Comparison of Initial Nonsurgical Endodontic Treatment and
Single-Tooth Implants Doyle, Scott L. et al. Journal of Endodontics, Volume 32, Issue 9, 822 –
827.
23. INTERNAL BLEACHING

Comparison of the Bleaching Efficacy of Different Agents Used for Internal Bleaching:
A Systematic Review and Meta-Analysis Frank, Ariadne Charis et al. Journal of Endodontics,
Volume 48, Issue 2, 171 – 178.
24. IRRIGATION
Review of Contemporary Irrigant Agitation Techniques and Devices Gu, Li-sha et al. Journal
of Endodontics, Volume 35, Issue 6, 791 – 804.
25. LATERAL CANALS

Fate of the Tissue in Lateral Canals and Apical Ramifications in Response to Pathologic
Conditions and Treatment Procedures Ricucci, Domenico et al. Journal of Endodontics,
Volume 36, Issue 1, 1 – 15.
26. MAXILLARY SINUSITIS OF ENDODONTIC ORIGIN (MSEO)

Effects of Endodontic Infections on the Maxillary Sinus: A Case Series of Treatment
Outcome Siqueira, Jose F. et al. Journal of Endodontics, Volume 47, Issue 7, 1166 – 1176.
27. OBTURATION
Healing Rate and Post-obturation Pain of Single- versus Multiple-visit Endodontic Treatment
for Infected Root Canals: A Systematic Review Su, Yingying et al. Journal of Endodontics,
Volume 37, Issue 2, 125 – 132.
28. PAIN CONTROL IN ENDODONTICS
Pain Prevalence and Severity before, during, and after Root Canal Treatment: A Systematic
Review Pak, Jaclyn G. et al. Journal of Endodontics, Volume 37, Issue 4, 429 – 438.
29. REGENERATIVE ENDODONTICS

Considerations for Regeneration Procedures Law, Alan S. Journal of Endodontics, Volume
39, Issue 3, S44 - S56.
30. RETREAMTENT
Outcomes of Nonsurgical Retreatment and Endodontic Surgery: A Systematic Review
Torabinejad, Mahmoud et al. Journal of Endodontics, Volume 35, Issue 7, 930 – 937.
31. ROOT RESORPTION

Internal Root Resorption: A Review Patel, Shanon et al. Journal of Endodontics, Volume 36,
Issue 7, 1107 – 1121.
A Review of External Cervical Resorption Chen, Yiming et al. Journal of Endodontics, Volume
47, Issue 6, 883 – 894.
32. SEALERS
Are Premixed Calcium Silicate–based Endodontic Sealers Comparable to Conventional
Materials? A Systematic Review of In Vitro Studies Silva Almeida, Luiza Helena et al. Journal
of Endodontics, Volume 43, Issue 4, 527 – 535.
33. SEPARATED INSTRUMENTS

Management of Intracanal Separated Instruments Madarati, Ahmad A. et al. Journal of
34. TRAUMA
Epidemiology of Traumatic Dental Injuries Andersson, Lars Journal of Endodontics, Volume
39, Issue 3, S2 - S5.
ABOUT DR. RICO D. SHORT
Dr. Rico D. Short is a board-certified endodontist, author,

and speaker. In addition, he is an expert spokesperson
on Endodontics for the American Dental Association
(ADA), a professional organization representing
approximately 161,000 U.S. dentists.
Dr. Short attended the Medical College of Georgia School
of Dentistry to attain a Doctor of Dental Medicine
Degree in 1999. In 2002 he earned his post doctorate
degree in Endodontics from Nova Southeastern
University. Dr. Short added the final notch to his belt and
became a Diplomate of the American Board of
Endodontics in 2009. His private practice, Apex Endodontics P.C, was opened in 2004 and is
located in Smyrna Georgia just outside Atlanta.
Dr. Short has over 20 years of experience in dentistry and over 17 years in endodontics. He is a
member of the Fellow International College of Dentist, a graduate of the ADA Institute of
Diversity In Leadership Program, and an ADA Success Speaker. He is also an expert consultant in
endodontics to the Georgia Board of Dentistry and an assistant clinical professor at The Dental
College of Georgia in Augusta. Dr. Short is an independent national lecturer and is endorsed by
the American Association of Endodontists speaker’s bureau. Furthermore, he is an opinion
leader on various dental products before and after they hit the market.
Dr. Short has written numerous articles, appeared in many podcasts, and published in several
journals including Dentistry Today (He made the exclusive cover April 2013), Inside Dentistry,
UpScale Magazine, Rolling Out Magazine, and the Journal of Endodontics. He has authored two
books “Getting To The Root Of Your Problem” and “In The Eye Of A Storm.” In addition, he has
published over 1,000 articles on social media involving case studies in endodontics. They are
called “The SHORT Case Of The Day” in which he has a robust worldwide following of over
100,000 dentists. Dr. Short has lectured at the American Dental Association several times and
the National Dental Association annual meetings. He has lectured at local and large state
meetings including the California Dental Association, North Carolina Dental Association, Georgia
Dental Association, and many others throughout the United States and the Caribbean.
Dr. Short’s work has been published in dental journals around the world with opportunities to
speak in China, India, and the Philippines. Dr. Short was named one of the Top 40 Dentist under
40 in America by Incisal Edge Magazine in 2013, Top 20 Alumni Under 40 by Augusta University,
and has been named in Dentistry Today consistently as one of the top leaders in continuing
education.
Dr. Short has received several prestigious awards and accolades throughout his career. He is
very philanthropic in his community. Dr. Short has established an annual scholarship at The
Dental College of Georgia in Augusta, formally known as The Medical College of Georgia School
of Dentistry. He is an American Dental Association Success Speaker and a graduate of the
Institute of Diversity and Leadership Program. With this knowledge, Dr. Short travels around
the country speaking to dental students about the future of dentistry, student loan repayment,
and finding a job. In addition, he volunteers at various non-profit organizations and charity
dental clinics. In October 2012, Dr. Short was selected as a panelist for the Affordable Care Act.
He was invited to The White House to give his personal opinion about how The Affordable Care
Act would affect both businesses and citizens of our country from a healthcare provider
perspective.

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Endodontic Keys and Cases - Compressed

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A CLINICAL GUIDE TO MODERN ROOT CANAL THERAPY

Dr. Rico D. Short

Rico D. Short DMD, FICD

Board Certified Endodontist

This edition first published in 2022.

All rights reserved.

References & Review Articles

About Dr. Rico Short

Topic 1. Access (Conservative, Traditional, Minimum Invasive)

Topic 3. Anesthesia & Pregnancy Update

Topic 4. Apex Locators

Topic 6. Apexogenesis & Pulp Capping

Topic 7. Apical Surgery

Topic 9. Bioceramic Technology

Topic 10. Calcium Hydroxide

Topic 11. Carrier Based Obturation

Topic 12. Cleaning And Shaping

Topic 13. Cone Beam Technology

Topic 14. Cracks and Fractures

Topic 15. Cysts vs Granuloma

Topic 16. Diagnosis

Topic 17. Endodontic Files

Topic 18. Endo/Perio Relationships

Topic 19. Endodontic Emergencies

Topic 20. Heat Carriers

Topic 21. Iatrogenic Mishaps And Perforation Management

Topic 23. Internal Bleaching

Topic 24. Irrigation

Topic 25. Lateral Canals

Topic 26. Maxillary Sinusitis Of Endodontic Origin (MSEO)

Topic 27. Obturation Techniques

Topic 28. Pain Control In Endodontics

Topic 29. Regenerative Endodontics

Topic 30. Retreatment

Topic 31. Root Resorption

Topic 32. Sealers

Topic 33. Separated Instruments

Topic 34. Trauma

*Irrigation was performed with full strength sodium hypochlorite.

*Then the working length was established with an apex locator.

In the end I have a conservative access and a conservative shape.

Conservative access prepared with Z bur by SS White.

MINIMUM ACCESS CAVITY PREPARATIONS STUDIES

• Ultra-conservative (Ninja or Truss) did appear to negatively impact some treatment

3. “Current strategies for conservative endodontic access cavity preparation techniques

5. Access Size - Does It Matter?

***Also if a crown is placed access size may be a moot point.

Maxillary Central Incisors –

Maxillary Lateral Incisors –

Maxillary 1st Pre-Molars –

Maxillary 2nd Pre-Molars –

Maxillary 1st Molars –

Mandibular Central and Lateral Incisors –

Mandibular 1st Pre-Molars –

Mandibular 2nd Pre-Molars –

Mandibular 1st Molars –

Mandibular 2nd Molars –

1. PROBLEM: Unable To Find Canals Due To Excessive Bleeding