Introduction Portals of entry to the pulp Concepts of infection Focus of infection Zones of Fish Kronfeld’s mountain pass theory Older v/s Newer Concepts in endodontics Endodontics: When to do and When not to do? Vital pulp therapy Rationale of Pulpotomy Vital pulp therapy over root canal therapy Root canal therapy over vital pulp therapy Rationale of Apexification Conclusion References

1. RATIONALE
OF ENDODONTICS
Dr. Urvashi Sodvadiya

2.  Introduction
 Portals of entry to the pulp
 Concepts of infection
 Focus of infection
 Zones of Fish
 Kronfeld’s mountain pass theory
 Older v/s Newer Concepts in endodontics
 Endodontics: When to do and When not to do?
 Vital pulp therapy
 Rationale of Pulpotomy
 Vital pulp therapy over root canal therapy
 Root canal therapy over vital pulp therapy
 Rationale of Apexification
 Conclusion
 References
FLOWCHART

4. Portals of entry to the pulp
Integrity of enamel
Accessary canals
Anachoresis
Integrity of cementum

5. Contains
pathogenic
microorganisms
Can occur
anywhere in the
body
Causes no
clinical
manifestations
Focus of infection
Francke OC. William Hunter’s ‘‘oral sepsis’’ and American odontology. Bull Hist Dent 1973: 21: 73–79.
Hippocrates first ‘report’ of focal infection
WD Miller (1890) The Micro-Organisms of the
Human Mouth: The Local and
General Diseases Which are
Caused By Them

6. The theory of focal infection had not been proved
Its infectious agents were unknown
Patients whose teeth and tonsils are removed often continue to suffer
from the original disease for which they were removed
Beneficial effects that occasionally occur after surgical measures are often
outweighed by harmful effects or no effects at all
Many suggested foci of infection heal after recovery from systemic
disease or when general health is improved with hygiene and dietary
measures
1940, Reimann and Havens
Reimann HA, Havens WP. Focal infection and systemic disease: a critical appraisal. J Am Med Assoc 1940: 114: 1–6.

7. Zones of FISH (1939)
Simon JHS et al. Role of virulence in periapical lesions. Endodontology, Vol 11,
1999.
“Based on study of bone infection”

8. Kronfeld’s mountain pass theory (1939)

9. OLDER v/s NEWER
CONCEPTS Of Root
Canal Therapy

10. OLDER NEWERV/S
From cleaning and shaping to shaping and cleaning
From Hollow tube theory to Seal-bio concept
Rickert U G, Dixon C M. The controlling of root surgery. In Transactions of the Eighth International Dental
Congress. Section 111a p15. Paris, 1931.
Klevant F J, Eggink C O. The effect of canal preparation on periapical disease. Int Endod J 1983; 16:
68.75.s
Rickert and
Dixon;1931
• Dubrow,
1976
• Nassem
Shah, 2012

11. From traditional sized access to the Cala Lilly
enamel preparation
OLDER NEWERV/S
From traditional endodontic therapy to minimal
invasive
endodontics (MIE)
Rickert U G, Dixon C M. The controlling of root surgery. In Transactions of the Eighth International Dental
Congress. Section 111a p15. Paris, 1931.
Klevant F J, Eggink C O. The effect of canal preparation on periapical disease. Int Endod J 1983; 16:
68.75.sClark D. Introducing the Clark Class I and II restoration. Oral Health. 2009;99(2):82.

12. Incipient acute inflammation Established chronic inflammation
Eurotium C. Biological and clinical rationale for root-canal treatment and. Endodontics E-Book. 2014 Jan 26:43.
Cells Condition
T cell predominant Periapical granuloma, Refractory
apical granuloma
B cell and plasma cell predominant Advanced periapical lesions
T/B ratio Higher: in radicular cyst than
granulomas and apical scar lesions

13. Bacteria
PMNs
LT
Attracts
more
macrophages
PG
Bone
resorption
Macrophages
CHRONIC
CONDITION
LP
Cell rest
of
Malassez
Sinus
tract
Acute
Exacerbation Of
Chronic Condition

14. Epithelial
proliferation
and Cyst

15. ENDODONTICS:
When to do and
When not to do??

16. Extra-oral swelling
with usual symptoms
of acute infection
Swelling near the
gingival margin
 Loss of crestal bone
interproximally
 No radiolucency at
the apices
Endodontic
treatment
“ACUTE
PERIODONTAL
ABSCESS”

17. Endodontic
treatment
ACUTE PERIAPICAL
ABSCESS
“Difference between Acute Periapical and Periodontal abscesses”

18. Sinus tract Note the absence of
periapical
involvement
Endodontic
treatment
LESION OF
CHRONIC
PERIODONTITIS

19. Local swelling on mesial
palatal surface of maxillary
left first molar
Sinus tracing
Endodontic
treatment
Chronic Sinus Tracts of
Pulpal Origin With
Drainage Through the
Gingival Sulcus
Surgical exposure confirms
diagnosis of a sinus tract
of pulpal origin.

20. Endodontic
treatment
Furcation or Lateral lesions
Without Loss of Attachment

21. Furcation bone loss Horizontal bone loss
Endodontic
treatment
Chronic Sinus Tracts of
Pulpal Origin With
Permanent Periodontal
Attachment Loss
24 year old male..
Chief complaint:
local swelling on
vestibular side of
46

22. Endodontic
treatment
- Endodontic
treatment

23. Endodontic
treatment
Endodontic
Surgery
Recurrent Acute Abscesses
in the buccal vestibule
“Classic” periapical lesion;
extends coronally 38 year old male..
Chief complaint:
Recurrent acute
abscesses in bucca
vestibule of 16

24. Endodontic
treatment
- 12 year old
- Referred for RCT of maxillary right first molar
Lesions Associated With
Aggressive
Forms of Periodontitis

25. Root canal completed: 18 months before
Periodontal probing: 7- mm localized
periodontal defect
Cemental tears
Endodontic
treatment

26. Coronal Fracture

27. Vertical Fracture

28. Vital Pulp therapy
Normal tubular dentin Gnarled dentin
Bjørndal L: Indirect pulp therapy and stepwise excavation, J Endod 34:S29-S33, 2008.
Mjör IA: Pulp-dentin biology in restorative dentistry, Chicago, 2002, Quintessence Publishing Co. Inc.

29. RATIONALE OF
PULPOTOMY

30. Pameijer CH, Norval G: Pulpal responses to restorative treatment. In Duke ES, editor: The changing practice of restorative dentistry,
Indianapolis, 2002, Indiana University Press.
Stanley HR: Pulp capping: conserving the dental pulp—can it be done? Is it worth it? Oral Surg Oral Med Oral Pathol
Visual appearance of exposure
and Amount of haemorrhage

31. Vital pulp therapy over Root canal treatment
Pulpal exposure of teeth with open apices
- A more generous blood supply
Bogen G, Kim JS, Bakland LK: Direct pulp capping with mineral trioxide aggregate: an observational study, J Am Dent
Assoc 139:305-315, 2008.

32. Root canal treatment over Vital pulp therapy
• Uncontrollable haemorrhage from the exposure site
• Purulent exudates from the exposure site, and
• Complete lack of bleeding
Matsuo T, Nakanishi T, Shimizu H, et al: A clinical study of direct pulp capping applied to carious-exposed pulps, J Endod 22:551-

33. MEDICAMENTS USED FOR PULP PROTECTION
Calcium Hydroxide pulpotomy/ mineral trioxide aggregate pulpotomy
Formocresol pulpotomy / Glutaraldehyde pulpotomy
Hess W: The treatment of teeth with exposed healthy pulps, Int Dent J 1:10-35, 1950.
Min KS, Park HJ, Le SK, et al: Effect of mineral trioxide aggregate on dentin bridge formation and expression of dentin sialoprotein and
heme oxygenase-1 in human dent pulp, J Endod 34:666-670, 2008.
Osseo-inductive medicaments
Non-pharmacotherapeutic procedure

34. Pulpotomy procedures
Pulp
exposure
from
Caries
Bahrololoomi Z, Moeintaghavi A, Emtaizi M, et al: Clinical and radiographic comparison of primary molars after formocresol
and electrosurgical pulpotomy: a randomized clinical trial, Indian J Dent Res 19:219-223, 2008.
Age: 9 years old
Tooth no: 36
Age: 41 years
Tooth no: 37

35. Pulpotomy procedures
Pulp exposure
from traumatic
fracture
Two significant differences
- Bacterial involvement
- Location of exposure
# Health of the pulp prior to trauma
# Diameter of the exposure
# No Concomitant luxation injury
# Stage of root development
28. Cvek M: Prognosis of luxated non-vital maxillary central incisors treated with calcium hydroxide and filled with gutta-
percha. A retrospective clinical study, Endod Dent Traumatol 8:45-55, 1992.
58. Olsburgh S, Krejci I: Pulp response to traumatic crown fractures, Endod Topics 5:26-40, 2003.

36. Direct Pulp Capping
Partial Pulpotomy
Cervical Pulpotomy

37. CASE
SELECTION

38. APEXIFICATION
RATIONALE

39. “ You may learn how to do
endodontic therapy in 3 years, but it
takes a whole lifetime to know when
exactly to do it!”

40. • Francke OC. William Hunter’s ‘‘oral sepsis’’ and American odontology. Bull Hist Dent
1973: 21: 73–79.
• Klevant F J, Eggink C O. The effect of canal preparation on periapical disease.
Int Endod J 1983; 16: 68.75.s
• Rickert U G, Dixon C M. The controlling of root surgery. In Transactions of the
Eighth International Dental Congress. Section 111a p15. Paris, 1931.
• Clark D. Introducing the Clark Class I and II restoration. Oral Health.
2009;99(2):82.
• Eurotium C. Biological and clinical rationale for root-canal treatment and.
Endodontics E-Book. 2014 Jan 26:43.
• Rickert U G, Dixon C M. The controlling of root surgery. In Transactions of the
Eighth International Dental Congress. Section 111a p15. Paris, 1931.
• Reimann HA, Havens WP. Focal infection and systemic disease: a critical appraisal. J Am
Med Assoc 1940: 114: 1–6.
• Simon JHS et al. Role of virulence in periapical lesions. Endodontology, Vol 11, 1999.
References

41. • Olsburgh S, Krejci I: Pulp response to traumatic crown fractures, Endod Topics 5:26-40,
2003.
• Bahrololoomi Z, Moeintaghavi A, Emtaizi M, et al: Clinical and radiographic
comparison of primary molars after formocresol and electrosurgical pulpotomy:
a randomized clinical trial, Indian J Dent Res 19:219-223, 2008.
• Matsuo T, Nakanishi T, Shimizu H, et al: A clinical study of direct pulp capping
applied to carious-exposed pulps, J Endod 22:551- 556, 1996.
• Pameijer CH, Norval G: Pulpal responses to restorative treatment. In Duke ES, editor:
The changing practice of restorative dentistry, Indianapolis, 2002, Indiana University
Press.
• Stanley HR: Pulp capping: conserving the dental pulp—can it be done? Is it
worth it? Oral Surg Oral Med Oral Pathol 68:628-639, 1989.
• Bjørndal L: Indirect pulp therapy and stepwise excavation, J Endod 34:S29-S33, 2008.
• Mjör IA: Pulp-dentin biology in restorative dentistry, Chicago, 2002,
Quintessence Publishing Co. Inc.
• Cvek M: Prognosis of luxated non-vital maxillary central incisors treated with
calcium hydroxide and filled with gutta-percha. A retrospective clinical study,
Endod Dent Traumatol 8:45-55, 1992.
• Meinig GE. Root Canal Cover-Up, 2nd edn. Bion Publishing, Ojai, CA, 1994