Moisture Control and Vitality TestingDr. Nessrin TahaClinical Doctorate in Endodontics (Melb), ADC (Sydney), FRACDS,MFDS (RCSI), Jordanian Board in Endodontics

Moisture ControlImportant during operative and endodontic procedures armamentarium includes:Suction( low and high volume)Cotton rollsRubber dam

Moisture ControlSaliva can block visibility, and interfere with the setting reaction of dental materials; therefore affecting their physical propertiesCotton rolls are placed in the buccal and lingual sulciIf you work on the lower teeth, you still need to place a roll on the epsilateral maxillary buccal sulcus to absorb parotid saliva

Rubber dam is an essential component of bacterial control

Rubber DamIts use is mandatory during root canal treatment even before accessAdvantages of rubber dam include:Biologic rational( most important)The dam reduces cross contamination of the root canal system with microorganisms from saliva

Rubber DamPatient and clinician protection (aspiration,litigation, aerosol)Soft tissues are retracted and protectedVisibility is improvedEfficiency is increased

An endodontic file has been inhaled due to no rubber dam barrierBDJ, 2004;197(9):527-534.

Rubber Dam Armamentarium:

1-The dam (thin, medium, heavy, extra heavy) Two different sizes 5*5, or 6*6 inchColor: yellow, green, blue, grayNon latex and latex dam* Always place the dull side of the dam toward the operator

Rubber Dam Armamentarium:

2- the rubber dam frame:Retracts and stabilize the damBoth metal and plastic frames are available*plastic frames are recommended as they appear radiolucent; don't mask areas on the film

Rubber dam

Rubber Dam Armamentarium:

3-clamps or retainersAnchor the dam to the tooth requiring treatment or to the most posterior tooth in case of multiple isolationAid in soft tissue retractionMade of stainless steel, consist of a bow and two jaws, wing or wingless

Rubber Dam3-clamps or retainersWings are extensions of the jaw provide additional retraction and facilitate placement of the dam as a single unitSpecific retainers for teeth with minimal tooth structure (apically inclined jaws)Serrated jaws( tiger clamps) increases stabilization of broken down teethUniversal clamps ( butterfly, 56 )

Fixation of Rubber Dam IClamps- winged or wingless

Rubber DamRubber dam punch, has a series of wholes on a rotating disk from which you can select according to the size of the toothForceps, holds and carries the retainer during placement and removalA template may be used to mark the position of the whole, or just place it in the center and trim excess over the nose

Rubber Dam Punch

Rubber Dam Placement1- Placement as a Unit: dam, frame and clamp all together2- Placement as a separate units: clamp then the dam ( tie the clamp with floss)3- Placement of clamp and dam, then frame4- Placement of dam and frame, then clamp (with butterfly clamps)

Wingless technique

Rubber Dam PlacementThe rubber dam is adjusted on the frame so that the mouth is completely coveredSlide the dam off the clamp wings using a plastic instrument, to cover the holes and constricts around the tooth neckFloss the dam through the contacts of the teeth

Winged techniqueBe sure to move the rubber down to the wing

Rubber Dam PlacementMultiple isolation: when several teeth require treatmentMultiple holes and the dam is flossed between the teeth, or single big hole include all six anteriors and clamp premolars or use a floss to ligate around the tooth

Difficult isolation casesLittle remaining tooth structure: use deep- reaching clamps, clamp adjacent teeth, clamp the gingivaExtensive caries in the tooth: build up with glass ionomer, use an orthodontic bandBridges: use a sealant in the seepage areasPorcelain restorations: risk of crazing the porcelain

Tooth is difficult to clamp onA slit has been cut in the rubber dam to enable this tooth to be isolated.*Have to consider the restorability of the tooth, crown lengthening procedure before RCT Or for posterior tooth, cement a mental band before RCT.BDJ, 2004;197(9):527-534.

For mouth breathing patient

Fixation the rubber dam II

System of DiagnosisMedical and Dental HistoryExamination: subjective & objective Intensity, spontaneity, duration, reproduce painPeriodontal examination (pulpal vs. periodontal)Radiographic examination

Diagnostic OutcomeReversible pulpitisIrreversible pulpitisAcute apical periodontitisAcute apical abscess

Dentinal sensitivity or Reversible pulpitisChief complaintsNo spontaneous painTransient pain onlyRecent history of restorative dental procedureExaminationsTooth is positive to vitality with no lingering painRadiograph no conclusive finding on periapical area

Apical Periodontitis

Draining sinus

Periodontal Examination

Pulp Vitality TestsThermal tests (cold and hot)Electrical test (EPT)Direct dentine stimulationLaser doppler flowmeterpulsoximeter

Principles of Pulp Vitality TestsTest the suspected toothSimilar tooth controls should be usedReplicate patients symptoms

Cold TestsMethods: Carbon dioxide (dry ice -78 degrees)Refrigerant (Endo ice -50 degrees)Ice (0 degree) Ice-cold water under rubber dam isolationDry the tooth and place cotton rollIn young teeth place the test close to the incisal one third

Refrigerant Spray

Cold TestIn middle aged and elderly move close to the cervical one thirdCold test should be applied until the patient responds: maximum 15 SecondsRecord the nature of responseNormal pulp- gives a brief sharp pain sensation or tingling from the tooth

Cold test Possible mechanism -causes contraction of the dentinal fluid within the dentinal tubules, results in rapid outflow of the fluid and then trigger the mechanoreceptors on the A delta fibre.An intense and prolonged response, lingered >30 seconds (irreversible pulpitis)- RCT No response (non-vital pulp)- RCTFalse response: False negative- Atrophic pulp (3%) False positive- contact gingiva or transfer to adjacent tooth, multi-rooted teeth

Heat TestsNot used routinely, only when the major symptom is heat sensitivityMight be injuriousHeated gutta percha applied on the labial surfaceHot instrumentIsolate with rubber dam and use hot water bathPossible false negative

Electric pulp testingInvolves a direct current of a high frequency electricity that can be variedDry and isolate the tooth (important)Apply flouride gel as a conductor on the electrodePatient should touch the electrode to complete the circuit- it gives a digital readingCompare the level of response with a control tooth

Electric Pulp Tester (EPT)Fluoride gel is applied on the tip of electrode

Electric Pulp Tester

Pulp TestingFalse negative with cold and EPT can occur in calcific metamorphesis (trauma cases)False positive in EPT occur through salivary contamination of the tested surfaceResults of one test are not conclusive for the presence or absence of diseaseSharp non lingering response indicates a vital pulp

Direct Dentin StimulationExposed dentine may be scratched with explorerAbsence of a response is not indicative as its presenceDrilling a test cavity without local anesthesia is the last resort

Pulp VitalityTestingAll the above tests could indicate the presence of intact nerve fibers carrying sensory impulsesHowever devices that detect pulp circulation are more indicative of pulp vitalityPulse oximeter and laser doppler flowmetry: expensive and for experimental work only

THANK YOU

References: Walton and Torabinejad :Chapter 4 and 8 Pathways of the pulp: Chapter 1 and 5

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