Figure 3: If the fracture is fresh, bleeding from the pulp will be present.
Fractured teeth with pulpal exposure: If it is fresh, bleeding from the pulp will be present. The fracture site is probed with an explorer. If the tip of the explorer
can enter the pulp chamber, endodontic involvement is certain (Figure 3). If the pulp is not exposed, the tooth still can
be non-vital due to bacterial invasion through the dentinal tubules.
Figure 4: Look for a draining tract apical to the mucogingival junction.
Oral pain: During the acute phase, or later on with the development of a periapical abscess, the patient might exhibit oral pain. In
some cases, the patient can show an excessive buildup of calculus on the effected side compared to the contralateral side.
Sinus tract formation: After the periapical infection develops, a draining tract can develop apical to the mucogingival junction (Figure 4). The
maxillary carnassial teeth, third premolars and first molars can develop the classic draining tract on the ventral aspect
of the associated orbit.
It is very important to realize that in many cases, the patient might not display any obvious clinical signs. Careful evaluation
of the oral cavity is an important part of the patient's physical examination. It is not uncommon for the diagnosis of endodontic
disease to be made during the time of the routine health examination. A lack of obvious pain does not rule out endodontic
disease. Another misconception is that if the tooth is solid in the alveolar bone, it is permissible to leave the tooth in
place without any treatment. The fallacy with this decision is that tooth mobility is a function of the periodontal structures
and has nothing to do with the state of the pulp. With endodontic disease, the periodontal structures are not affected significantly
unless the periapical pathology extends coronally up the periodontal ligament space and can result in tooth mobility. This
event is seen rarely.
•Treatment of endodontic disease
Endodontic disease can be compared to a bony sequestrum or a foreign body infection. In both of these cases, the body cannot
clear up the infection as long as the sequestrum or foreign body is present. With removal of the sequestrum or foreign body,
the body then can resolve the infection. With endodontic disease, the necrotic pulp is the foreign body or sequestrum. Without
any blood supply to this source of infection, the root-canal contents, the bacteria continue to percolate out through the
apical delta perpetuating the infection. Treatment of endodontic disease is based on removing the source of the infection,
the necrotic pulp chamber contents.
Root-canal therapy removes the infected pulp tissue and refills the pulp cavity with a material to prevent re-establishment
of bacteria in the root canal. Initially, the root canal is shaped by filing and disinfected by irrigation with a bactericidal
solution. The filing removes the contaminated surface of the dentinal walls and also shapes the canal for filling. The bactericidal
solution, sodium hypochlorite, chlorhexidine or EDTA aids in dissolution of the necrotic contents and provides chemical disinfection.
After the canal has been cleaned and dried, a dentinal sealant is placed in the canal to seal the dentinal tubules. The canal
is obturated (filled) with a material that prevents bacterial growth and conforms to the root-canal shape. The most commonly
used product is gutta percha. Although the entire pulp cavity should be filled with the obturation material, the most critical
part of the root-canal filling is the apical one-third. Communication of the pulp cavity to the periapical space is through
the apical delta and through accessory canals, when present. In most cases, these openings are limited to the apical one-third
of the root canal cavity.
Figure 5: If evidence of periapical infection is present, then antibiotics are indicated.