Preparation for treatment

1. Preparation for Treatment
Dr Raziye Salehi
Assistant professor of endodontics 14/4/2021 1

2. CHAPTER OUTLINE
 informed consent
 premedication with antibiotics
 anti-anxiety regimen
 pain medication
 tooth isolation
 dental dam components
 dental dam placement techniques
 Isolation of Teeth with Inadequate Coronal Structure
 disinfection of the operating field
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3. INFORMED CONSENT
o Endodontic treatment, like all dental treatment, must be preceded by informed consent. The dentist
must thoroughly explain the proposed treatment, the benefits, the risks, and alternative treatments,
including the option of no treatment at all.
o Informed consent is a legal concept developed via case law and is enforceable through judicial
actions.
o The prudent clinician will be careful to “inform before he or she performs.”
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4. PREMEDICATION WITH ANTIBIOTICS
 The AHA now recommends that prophylactic antibiotics be limited to only those patients with high
risk of developing IE, such as patients with the following conditions:
• Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
• A history of IE
• A cardiac transplant that develops cardiac valvulopathy
• Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
• A completely repaired congenital heart defect with prosthetic material or device, whether placed by
surgery or by catheter intervention, during the first 6 months after the procedure
• Any repaired congenital heart defect with residual defect at the site or adjacent to the site of a
prosthetic patch or a prosthetic device (that inhibits endothelialization)
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5.  The standard antibiotic regimen for all dental procedures is currently amoxicillin since it is better
absorbed by the gastrointestinal tract and maintains a higher serum level than penicillin.
 For patients at high risk of developing IE, it is recommended that the patient take prophylactic
antibiotics 1 h prior to dental treatment. This allows the antibiotics to reach adequate levels in the
blood stream.
 If the patient forgets to take the prophylactic dose, the recommended dosage may be administered
up to 2 h after the procedure.
PREMEDICATION WITH ANTIBIOTICS
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6. PREMEDICATION WITH ANTIBIOTICS
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7. ANTI-ANXIETY REGIMEN
 Patients presenting for endodontic treatment are often anxious about the procedure. There is often
an unrealistic assumption that the procedure will be painful.
 Such misinformation can result in making it difficult for the patient to be relaxed during treatment.
 Although a majority of patients are able to control their fear, some fail to do so.
 Clinicians should attempt to fully explain the dental procedures prior to treatment and discuss
possible minor discomforts during or after the treatment. Explanation of the treatment steps before
initiating the procedure has been shown to reduce the patient’s anxiety level.
 In cases where patient’s fear cannot be controlled, antianxiety protocol ranging from nitrous oxide
to conscious sedation can be administered.
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8. PAIN MEDICATION
 It can be challenging to completely anesthetize patients presenting for endodontic treatment with
inflamed pulp or periapical tissue.
 The low pH environment resulting from the inflamed pulp or periapical tissue may affect the
efficiency of local anesthetics and result in anesthetic failure.
 Prescribing low dose of oral ketamine (10 mg) before endodontic treatment has been shown to
enhance the effect of inferior alveolar nerve block in treatment of mandibular molars with
irreversible pulpitis.
 Other studies have shown that preoperative administration of ibuprofen or other non steroidal anti
inflammatory drugs (NSAID) 1 h prior to the local anesthesia injection is an effective method for
achieving a profound anesthesia during endodontic treatment in teeth with inflamed pulp tissue.
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9.  Postoperative pain may be anticipated following endodontic therapy.
 Irritation of the periapical area may be expected due to extrusion of debris, irrigation, and root
filling material during treatment.
 Studies have shown that prophylactic administration of pain medication may reduce postoperative
pain.
 Although postoperative pain may be mild or even absent following endodontic therapy, clinicians
often prescribe prophylactic pain medication to avoid possible moderate or severe pain after
endodontic treatment
PAIN MEDICATION
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10. TOOTH ISOLATION
 Dental dam isolation has been used for over 150 years, developed by Dr. Stanford C. Barnum in 1864.
 Dental dam isolation is the optimal method of endodontic isolation.
 Numerous advantages include:
• Protection of the patient from swallowing or aspiration of endodontic instruments, irrigants or medicaments.
• Creation of an aseptic operating field and elimination of salivary contamination of the root canal system and
instruments.
• Reduction in the microbial content of air turbine aerosols produced during dental procedures and thus a
reduction of cross-contamination risk in the dental practice.
• Creation of a more efficient and favorable working environment by minimizing rinsing and patient
conversations.
• Improved visibility by providing a dry field and minimizing mirror fogging.
• Retraction and protection of the tongue, lip and other soft tissues. 14/4/2021 10

11.  Although it may be inconvenient for a clinician to use with certain patients (mouth breathers,
patients with exaggerated gag reflex, severely anxious patients), inconvenience is not an
acceptable excuse for avoiding dental dam placement.
 Root canal treatment without dental dam isolation may place doctors under litigation risks if the
patient swallows or aspirates an endodontic instrument.
TOOTH ISOLATION
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12. A, Swallowed endodontic file ended up in the appendix resulting in acute appendicitis. B, Specimen
shows file in the appendix removed by appendectomy. Use of dental dam would have prevented this
complication. C, Dental burs can sometimes disengage from headpieces and be swallowed, as shown
here. This is also preventable with dental dam. 14/4/2021 12

13.  In some clinical situations (calcified pulp chambers, calcified canals, crowned teeth), locating the
canal(s) is challenging and may require orientation of the external root surface using a periodontal
probe.
 In such cases, and depending on the tooth location, placement of dental dam can be delayed
until canals are located to avoid excessive damage to the remaining tooth structure or possible root
perforation and its consequent complications. Once the canals are located, the dental dam should
be placed immediately.
 No endodontic file should be inserted into a canal without dental dam isolation
TOOTH ISOLATION
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14. Dental Dam Components
 The dental dam system consists of three main components:
• dental dam sheet
• dental dam Frame
• clamp
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15. Dental dam sheet
 The dental dam sheets are autoclavable and come in
• different thicknesses (thin,medium, heavy, extra heavy, and special heavy),
• colors (ranging from light yellow to gray),
• sizes (5 x 5 and 6 x 6 in) and
• materials (latex and nonlatex).
 The commonly used dental dam sheet in endodontics is the medium thickness due to its higher
resistance to tear compared to the thin sheets and its easier manipulation compared to the heavier
variants.
 The sheet also comes in a nonlatex form for patients with latex allergy.
• The nonlatex dental dam, however, comes in only one size- 6” × 6”, and one thickness—medium.
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16. Dental dam frame
 The function of the dental dam frame is to retract the sheet during
procedures and to allow visibility and access to the tooth.
 Frames are available in either metal or plastic.
 Although metal frames are more durable, they require removal before
taking radiographs.
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17. Clamp
 The function of the clamp is to retain the dental dam and frame on to the target tooth.
 In case of multiple tooth isolation, the clamp is always placed on the most posterior tooth to be
isolated.
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18. Image of a Hu-Friedy tiger clamp.
1. Central wing;
2. anterior wing;
3. bow;
4. beaks;
5.tines;
6. Forceps hole;
7. anterior notch;
8. posterior notch.
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19. types
 Different styles and shapes of rubber dam clamps are available for
specific situations. The following selection is recommended:
• anterior teeth: Ivory No. 9 or 212
• premolars: No. 0 and 2
• molars: No. 14, 14A, 56, and 205.
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20. Universal Clamp Designs
 Two designs, the “butterfly” Ivory No. 9 and the Ivory No. 56, are suitable for most isolations.
 The butterfly design (No. 9) has small beaks, is deep reaching, and can be applied to most
anterior and premolar teeth.
 The No. 56 clamp can isolate most molars.
 With teeth that are smaller, reduced by crown preparation, or abnormally shaped, a clamp with
smaller radius beaks (No. 0, 9,or 14) is necessary.
 Small-radius beaks can be positioned farther apically on the root, which stretches the dam
cervically in the interproximal space.
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21. Dental Dam Placement Techniques
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22. Single-Unit Method
 A hole is punched in the dam, and the sheet is then stretched
medium tight by attaching it at the four corners of the frame.
The central wings of the clamp are inserted, one at a time,
through the hole, and the entire system is carried as a unit
to the patient’s mouth using the forceps. The clamp is placed
on the target tooth, and the dam is released from the wings
of the clamp with a plastic instrument.
 This is a relatively safe method because the clamp is secured to the
dental dam.
 It is convenient in the case of anterior teeth and premolars,
and it is more challenging in the case of molars and
teeth with structural compromise due to reduced visibility.
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23. Clamp-First Insertion Method
 The clamp is first placed on the tooth. The punched dental dam, mounted loosely onto the four
corners of the frame, is then brought to the mouth, and the hole is stretched over the clamp. Floss
is used to carry the margins of the dam through the proximal contacts to completely cuff the tooth.
The dam is then stretched more fully onto the frame.
 This is one of the least complicated placement methods because the target tooth is
most easily visualized during clamp placement.
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24. Multiple Isolation of Proximate Teeth Method
 When root canal treatment is performed on multiple teeth that are proximate to each other, or when a tooth
cannot retain a clamp due to insufficient structure, multiple holes can be placed in the dental dam to allow
treatment of the
target tooth/teeth.
 In the case of a single target tooth unable to retain a clamp, the clamp is placed on a tooth distal to the target
tooth.
 In the case of multiple teeth to be treated, the clamp is placed on the most posterior target tooth if it canretain a
clamp.
 If this tooth is excessively compromised, the clamp should be placed on a more posterior tooth capable of
retaining a clamp. The most distal hole is then stretched over the clamp, and the remaining holes are drawn
over each additional tooth to be exposed for the procedure.
 It can be helpful in certain cases to place a second clamp on the most anterior tooth to be exposed with the
bow facing mesially.
 Ligation with dental floss may enhance isolation where necessary.
 In multiple tooth isolation of anterior teeth,clamps placed on teeth on opposite sides of the midline will
be oriented normally, with bows facing distally.
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25. 14/4/2021 25
Multiple tooth isolation for the treatment
of a maxillary first molar.
Multiple tooth isolation for treatment of a maxillary
second premolar using clamps on the maxillary first
and second molars and maxillary first premolar.
Multiple tooth isolation for treatment of maxillary
central incisors using clamps on canines.

26. Multiple Isolation of Distant Teeth Method
 When root canal treatment is performed on multiple
teeth that lie in different quadrants yet in the same arch
(maxillary or mandibular), a clamp may be placed on
each tooth to be treated, and two holes can be punched
on either side of the dam allowing simultaneous
treatment of both teeth.
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27. Split Dam Method
 The split dam method has many practical applications. It is
yet another useful isolation method when the target tooth
cannot accommodate a clamp due to insufficient structure.
 Two holes are punched in the dam separated by several
millimeters depending on the clinical circumstance. The material
between the holes is snipped with a pair of iris scissors
creating the split dam. The clamp is placed on a more distal
tooth and the sheet is then placed over the clamp and stretched
to include the target tooth and at least the next anterior tooth.
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28.  The split dam method is also effective when treating teeth
with calcified canals as it allows exposure of the external
contours of the target tooth, providing orientation during
deep exploration for the canal remnant.
 Additionally, the split dam can be a good choice when the
target tooth has been restored with a porcelain crown as
studies have shown that,even when properly stabilized,
clamps can damage porcelain fused to metal crowns.
 When root canal treatment is performed on two distant
teeth connected by a bridge, the split method can result
in a
large gap that may compromise isolation. In such cases,
the
margins of the split dam can be approximated from the
lingual/palatal to the buccal/labial using suture material,
piercing the sheet and passing under the bridge to be
tied off on the facial. Any remaining exposed tissue can
be blocked out using Oraseal or Liquiddam.
Split Dam Method
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29. Isolation of Teeth with Inadequate Coronal Structure
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30.  Ligation, the use of deep-reaching clamps, bonding, or building up before access are the major
methods of isolating teeth without adequate coronal tooth structure.
 Surgical management may also be required.
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31. Ligation
 Inadequate coronal structure is not always the cause of lack of retention.
 In young patients the tooth may not have erupted sufficiently to make the cervical area available for
clamp retention. In these cases, ligation with floss or the use of interproximal rubber Wedge is
indicated. Another approach is multiple tooth isolation.
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32. Deep-Reaching Clamps
 When the loss of tooth structure extends below the gingival tissues but there is adequate structure
above the crestal bone, a deep reaching clamp is indicated. It may be necessary to use a caulking
material or resin around the clamp to provide an adequate seal.
 Another option is the use of an anterior retainer regardless of the tooth type.
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33. Bonding
 When there is missing tooth structure, including the natural height of contour, retention can be
increased by bonding resin on the facial and lingual surfaces of the remaining tooth structure.
The clamp is placed apical to the resin undercut. After treatment the resin is easily removed.
 This technique is preferred over the more invasive technique of cutting horizontal grooves in the
facial and lingual surfaces for the prongs of the clamp.
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34. Tissue Management Procedures
 Large carious lesions or resorptive defects can lead to gingival tissue proliferation into the access
cavity, impeding dental dam isolation.
 Methods for removal of this tissue include resection via scalpel, rotary instruments, laser, or
electrosurgery if the remaining tooth structure lies above the bone.
 Electrosurgery allows clean removal of the gingival tissue combined with controlled hemostasis,
simplifying subsequent isolation. Caution should be exercised when using electrosurgery, as it can
lead to heat necrosis of the surrounding bone.
 Soft tissue laser is another method for removal of excessive gingival tissue with minimal resultant
hemorrhage.
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35. Crown Lengthening Procedures
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36.  rapid extrusion methods can facilitate clamp placement by repositioning structurally compromised
teeth more favorably,coronal to the alveolar crestal bone.
 The treatment concept requires moving the tooth rapidly to minimize concomitant coronal migration
of the supporting periodontium.
 Following the forced extrusion procedure, a stabilization period allows attachment fibers to
accommodate the new coronal location.
 Coronal repositioning can be achieved either orthodontically or surgically.
 unlike conventional orthodontic movement, rapid orthodontic extrusion involves forces greater than
50 grams.
Rapid Root Extrusion
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37.  Among factors critical to the treatment outcome are:
• crown to root ratio,
• Periodontal health,
• oral hygiene,
• esthetic appearance,
• Opposing occlusion,
• tissue biotype,
• root length
• root morphology
Rapid Root Extrusion
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38. Immediate Surgical Extrusion
 Endodontic treatment demands adequate isolation during treatment and prosthetic rehabilitation
demands adequate healthy tooth structure in harmony with the contiguous periodontal soft and
hard tissues.
 In order to reestablish biologic width and an adequate ferrule, various corrective procedures
utilized are clinical crown lengthening, orthodontic extrusion, or the forgotten modality of immediate
surgical extrusion.
 Clinical crown lengthening has the limitation of potentially causing collateral damage by removing
healthy bone support on adjacent teeth and its effect on esthetics in the anterior region can be
detrimental whereas orthodontic extrusion is time dependent, relying on patient compliance and
sometimes the need for additional remedial crown lengthening therapy consequent to mobilization
of the tooth.
 Immediate surgical extrusion is the intentional and controlled luxation of the root coronally with the
objective of stabilizing the root in a favorable restorative position.
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39. Surgical Crown Lengthening
 The crown length is defined as the distance between the gingival margin and the most
incisal/cuspal aspect of a tooth.
 Crown lengthening surgery is a procedure intended to increase this distance.
 1—2 mm of healthy tooth structure apical to a build-up is required for the ferrule effect. Additionally,
a dimension of about 2 mm of biologic width is necessary to accommodate the connective tissue
fibers and junctional epithelium.
 Adding both the ferrule effect dimension and the biologic width dimension, it can be concluded that
exposure of 3–4 mm of sound tooth structure coronally to bone is necessary for a successful crown
lengthening procedure.
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40.  The procedure entails tissue resection by design and therefore is contraindicated if the esthetics
will be compromised.
 An alternative to surgical crown lengthening in the esthetic zone is orthodontic extrusion that does
not The surgery reduces the bony support and should not be performed on mobile teeth.
Surgical Crown Lengthening
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41. Replacement of Coronal Structure
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42. Temporary Restorations
 When there is missing tooth structure but adequate retention, missing structure can be restored
with reinforced intermediate restorative material (IRM) containing zinc oxide–eugenol, glass
ionomers, or resins.
 These materials provide an adequate coronal seal and are stable until the definitive restoration is
placed.
 Bonded materials provide a better seal with improved strength and esthetics.
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43. Band Placement
 Placement of orthodontic bands may be indicated in cases of cracked or fractured teeth to provide
protection and support until a definitive restoration can be placed.
 The bands are available in various sizes and are appropriately contoured.
 A band can be cemented, and the missing tooth structure replaced with IRM.
 During the placement procedure, it is important to protect the canals and pulp chamber.
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44. Provisional Crowns
 Placement of temporary crowns is an option; however, they reduce visibility, result in the loss of
anatomic landmarks, and may change the orientation for access and canal location.
 Often temporary crowns are displaced during treatment by the rubber dam clamp. In general, when
provisional crowns are placed, they should be removed before endodontic treatment to provide the
correct orientation and maintain the remaining tooth structure.
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45. Rubber Dam Leakage
 Several proprietary products are available for placement around the rubber dam at the tooth–dam
interface should leakage occur.
 These are caulklike materials, putty, or light-cured resins; they are easily applied and removed after
treatment and are especially useful for isolation of an abutment for a fixed partial denture or for a
tooth that is undergoing active orthodontic treatment.
 The material can be placed on the gingival tissues at the dam–tooth interface after isolation.
 The caulking and putty materials adhere to wet surfaces, although the putty has a stiffer
consistency.
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46. Disinfection of the Operating Field
 Various methods and techniques are used to disinfect the tooth,clamp, and surrounding rubber
dam after placement.
 These disinfectants include alcohol, quaternary ammonium compounds,sodium hypochlorite,
organic iodine, mercuric salts, chlorhexidine, and hydrogen peroxide.
 An effective technique is as follows:
1. plaque is removed by rubber cup and pumice;
2. the rubber dam is placed;
3. the tooth surface, clamp, and surrounding rubber dam are scrubbed with 30% hydrogen peroxide;
and
4. the surfaces are swabbed with 5% tincture of iodine or with sodium hypochlorite
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47. Reference
 Ingle s endodontics- Ilan Rotstein, John I. Ingle. 7th Edition, Chapter 19.
 Endodontics principles and practice- M. Torabinejad, Ashraf F. Fouad. 6th Edition, Chaper 13.
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