King Abdulaziz University Faculty of Dentistry Conservative Dental Science Dept Endodontic Division Course Portfolio Course Name: Clinical Course Number: CDS 522 Academic Year: 2007/2008

Prepared by Course Director Dr Laila Bahammam

1 Course Portfolio

Contents: Page

• Preface------3

• Title page------

• Course Syllabus------4

• Course related material------37

• Examples of the extent of student learning ------37

• Instructor reflection of the course------38

2 Preface

In accordance to self evaluation for the last two years and with advances in the field of endodontics, we have integrated six new practices into the teaching methodology of this course as follows:-

1- Modular system for distribution of related lectures among the stuff

2 – Module Exams at the end of each module lectures

3 - Rotary Ni-Ti systems incorporated into the course schedule

4 – Electronic working length determination using EAL`s in the clinical sessions

5 – Students start to use of Rotary Ni-Ti system for cleaning and shaping of system

5 – E- sheet marking for evaluation of the student

6 – E-teaching on tutorials by incorporating e-discussion board

Each item is detailed in this document as ordered.

3 Course Syllabus

Course Name: Clinical Endodontics Course Number: CDS 522 Academic Year: 2007/2008

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Course syllabus:

Contents:

Instructor information

Course information

Course objectives

Learning resources

Course requirements and grading

Detailed course schedule

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Instructor information

Course Director Dr Laila Bahammam Assistant Professor Office location: Building # 10 ext. # 23211 Office hours: Wednesday (8-12 am) & Wednesday (1-5 pm) E-mail address: [email protected]

Faculty members:

Prof: Madiha Mahmoud Gomaa Course director for 4th year Office location: Building # 10 ext. # 23254 Office hours: Monday (8-12 am) & Monday (1-5 pm) E-mail address: [email protected]

Prof.: Sawsan Taha Abuzeid Office location: Building # 10 ext. # 23291 Office hours: Monday (8-12 am) & (1-5 pm) E-mail address: [email protected]

Prof. Omar Faheem Office location: Building # 12 ext. # 21010 Office hours: Tuesday (1-5pm) & Wednesday (1-5 pm) E-mail address: [email protected]

Prof. Ragab Eid Saif Office location: Building # 12 ext. # 21010 Office hours: Tuesday (1-5pm) & Wednesday (1-5 pm) E-mail address: [email protected]

Dr. Khaled Balto Associate professor

Office location: Building # 12 ext. # 21011 Office hours: Wednesday (8-12 am) and (1-5 pm) E-mail address: [email protected]

Dr. Lubna Shafei Assistant Professor Office location: Building # 10 ext. # 23254

6 Course information

Course name: clinical endodontics

Course number: CDS522

Course meeting times: one hour lecture followed by three hours clinical session weekly.

Course meeting places: student lectures will be held at the 5th year lecture room building #10 for female students and building #14 for male students.

Clinical sessions : 3 hours / week will be taken at building # 10 for female students and building # 12 for male students.

Course website

COURSE DESCRIPTION

This course is the first clinical endodontic course, which the students take after didactic and preclinical training in endodontics. The scope of the course includes preparing the students to be able to understand, recognize, diagnose and successfully treat pulpally involved or potentially pulpally involved teeth. Important fundamentals are stressed with emphasis on the correlation between basic clinical and biological principles. The course includes:

a. Classroom lecture series, which correlate between clinical and biological principles of endodontics.

b. Clinical exercises to perform endodontic treatment for:

1. Three (3) single canaled anterior teeth (bicuspids or incisors) 2. Two (2) premolars teeth (at least one bicanaled premolar) 3. One (1) upper or lower molar.

c. Along the course, the lecture time will precede the clinical session.

COURSE OBJECTIVES

Based on the content of the lecture series, required test and the recommended reading material, this course is expected to:

1. Prepare the student to demonstrate a mastery of performing the basic and the fundamental procedures in the field of endodontics, regardless of his future professional plans or areas of clinical interest.

2. Prepare the student who can evaluate his own clinical competency and know the extent of his diagnosis and operative capabilities therefore, he will not be hesitant in seeking the counsel of specialist or a colleague.

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3. Prepare the student who must demonstrate the mastery of recognizing the different levels of sophistication and complexity of endodontic cases that his patients present.

4. Prepare the student who must demonstrate the ability to state the theoretical and biological principles of every endodontic clinical procedure.

5. Prepare the student who must demonstrate a mastery of the dental materials and instruments used in endodontics.

6. Prepare the student who must demonstrate a mastery of tooth morphology.

Learning Resources:

1 - Text books:

1 – Main reference

Reference # 1. Cohen S., Hargreaves K , Pathways of the pulp. Ed.9, Mosby, Inc., 2006

2 – Supplementary references:-

Reference #1. Ingle J., Bakland L: Endodontics. Ed.5 BC Decker Inc., 2002

References # 2. Walton R., Torabinejad M: Principles and Practice of Endodontics. Ed.3 W.B. Saunders Company, 2002

The above mentioned text books are available at the students' library.

3 – Electronic Resources

URL:www,endoarabia.net " developed and maintained by the division members"

Course Requirements and Grading:

The primary objective of the division of Endodontics is to contribute to the total college efforts in preparing the students to become excellent clinical practitioners. In order to carry out this goal, clinical (5th year) Endodontic students will be evaluated by his/her performance on: Student evaluation: Student performance in the course will be evaluated as follow:

8 Continuous Assessment Final Examination

Marks Marks 1. 2 module Exams 10 1. Written Exam 80 2. 2 module Exams 10 2. Oral Exam 20 3. Midyear Exam 20 3. Practical Exam. 20 4. Clinical Requirements 40 80 120 T O T A L T O T A L

Clinic Grading Cards

The endodontic sheet form will only be utilized to record the student’s activity in clinic. The student should make appropriate diagnosis, entries for tooth, working length determination, cleaning and shaping of root canal (s) using step back instrumentation technique, root canal obturation technique using lateral gutta-percha obturation technique. All procedure grades will be recorded on the “Endodontic Clinical Evaluation Card”. The evaluation letter (‘A*, A , B*, B, C*, C- ,D*,D and E which is unacceptable) will be marked by the faculty staff. Evaluation form for every student is available with instructor every clinical session. The endodontic sheet for the clinical finished cases of student will be collected by the instructor, submitted to course director and kept in the Endodontic office.

2 module exams: Written first quiz will performed at the end of each lectures module, covering all the teaching materials up to this time. The question will be in form of MCQ, definitions or complete.

Midyear Exam: Written midyear exam will performed at the end of the first term, covering all the teaching materials up to this time. The question will be in form of MCQ, definitions or complete, and assay. 2 module exams: Written second quiz will performed at the end of each lectures module of the second term covering all the teaching materials up to this time. The question will be in form of MCQ, definitions or complete.

Final Exam: o Final (Written) Exam The Final Exam will cover all materials in the course. Test questions on the first quiz, Midyear, second quiz and Final examination will come from information found in the Lecture Outlines, Supplemental Reading

9 List, Lecture Presentations, and any other handouts provided during the progression of the course. o Data show Exam After the written exam, the students will be examined orally in the covering material during course. The exam will be performed in form of station, managing problem or other material discussed in the previous course using slide data show to keep the standardization of evaluation between student (males and females). Evaluation of final The final course grade will be determined by sum of the numerical grades of clinical requirement, first quiz, midyear exam, second quiz and Final Examinations.

Grading Scale:

85 to 100 = A 65 to 74 = C 75 to 84 = B 64 to 60 = D Below 60 = F

Grading policy: Attendance: Attendance is mandatory for all lectures and clinical sessions. Exceeding the maximum permissible absences might lead to your deprivement from attending the final exams. Unexcused absences from written exams will result in marks being deducted from your final grade.

Deadline for requirements completion: The deadline for completing the clinical requirements is the last day of the course as published by the Office of the Associate Dean for Education. Failure to complete the class assignments by the specified deadlines will result in reduction in the clinical requirement's marks relative to the number of the deficient requirement, which will undoubtedly affects the final overall student score.

Expectations from the students

Behavior of a dental student reflects on a student’s qualification and potential to become a competent dentist. Attitudes and behaviors inconsistent with the above mentioned definition will be unaccepted. As the King Abdulaziz University certifies that the student is competent to undertake a career as a dentist. It also certifies that in addition to the competency in dental knowledge and skills, the graduate possesses those personal traits essential to the profession of dentistry. Professionalism encompasses altruism, accountability, compassion, duty, excellence and respect for others.

Student responsibilities to the course: The student should be able to:

1. Review all the technical phases of starting from access preparation to canal system obturation.

10 2. Demonstrate competence in the use of root canal instruments both in preparation and in obturation of the single and multirooted teeth. 3. Demonstrate how to prevent and solve errors and mishaps that occurred during various phases of treatment. 4. Show competency in treatment of single, double and multirooted teeth 5. Evaluate the cleaned and shaped root canal in accordance with the standard criteria of evaluation 6. Evaluate the radiograph after canal obturation in accordance with the written crite

Lecture Schedule for the First Half of the Academic Year 2007-2008

DATE Lecture Title Lecture M 8/9/2007 Introduction, Clinical requirements, Lecture Schedule Prof. R. Saif

F 11/9/2007 M 15/9/2007 Diagnosis ( 2 hours lecture ) Prof. S. Abouzaid Dr. L.Bahammam F 18/9/2007 M 22/9/2007 Case selection and treatment planning (one hour Prof. S. Abouzaid lecture). F 25/9/2007 + All faculty staff Demo for pulp testing procedure ( one hour practical )

11 M 29/9/2007 Preparation for treatment – Rubber Dam, Endodontic Dr. K. Balto Radiography – magnification in Endodontics (2 hours F 2/10/2007 lecture) ﺑﺪاﻳﺔ إﺟﺎزة ﻋﻴﺪاﻟﻔﻄﺮ اﻟﻤﺒﺎرك ﺑﻨﻬﺎﻳﺔ ﻳﻮم اﻷرﺑﻌﺎء ٢١/٩/١٤٢٨هـ اﻟﻤﻮاﻓﻖ ٣/١٠/٢٠٠٧م Eid Vacation M 20/10/2007 Review (Step by Step) RCT procedures (1 hours Prof. R. Saif lecture). F 23/10/2007 All faculty staff practical (3 hours) M 27/10/2007 Role of Endodontics after dental traumatic injuries Prof. R. Saif F 30/10/2007 Dr. L. Bahammam M 3/11/2007 Role of Endodontics after dental traumatic injuries Prof. R. Saif F 6/11/2007 Dr. L. bahammam M 10/11/2007 Role of Endodontic after dental traumatic injuries Prof. R. Saif F 13/11/2007 Dr. L. bahammam M 17/11/2007 Rotary Ni-Ti Systems Dr. K. Balto F 20/11/2007 M 24/11/2007 Rotary Ni-Ti Systems Dr. K. Balto F 27/11/2007 M 1/12/2007 Rotary Ni-Ti Systems Prof. S. Abouzaid F 4/12/2007 M 8/12/2007 Practical Faculty staff F 11/12/2007 M 29/12/2007 Practical Faculty staff F 1/1/2008 M 5/1/2008 Practical Faculty staff F 8/1/2008 M 12/1/2008 Mid year Exam Faculty staff F 15/1/2008

Lecture Schedule for the First Half of the Academic Year 2007-2008

DATE Lecture Title Lecture M Oro-facial pain Prof. S. Abouzaid

F M Emergency treatment of endodontic pain Prof. S. Abouzaid

F M Endodontic surgery Dr. K. Balto

12 F M Endodontic surgery Dr. K. Balto

F

M Endodontic surgery Dr. K. Balto

F M Evaluation of Success and Failure: Prof. M.Gomaa F M Nonsurgical surgical Endodontic Retreatment Prof. M.Gomaa F M Nonsurgical surgical Endodontic Retreatment Prof. M.Gomaa F M practical Faculty staff F M practical Faculty staff F M practical Faculty staff F M Endodontic and Periodontic interrelationships Prof. R. Saif F M Restoration of endodontically treated teeth Prof. R. Saif F Dr. L. Bahammam M Practical Faculty staff F M Final Exam F

Detailed course contents

Lectures' learning objectives and outlines

Module 1

Introduction, clinical requirements, and lecture schedule

Learning objectives: Each student should understand how to prepare and manage the patient inside the clinic.

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Main points: 1. Learn the student how to collect the patient's personal data , taking the chief complain ( CC ) and history of CC 2. Learn the student how to record these data in endodontic chart 3. Learn the student how to perform extra-oral and intra-oral examination 4. Learn the students how to use different sensitivity ( sensibility ) tests : a. Cold test b. Hot test c. EPT d. Anesthetic test e. Cavity test 5. Learn the students how to perform mechanical tests a. Palpation test b. Percussion test c. Mobility test 6. Learn the students how to interpret the radiographs 7. Learn the student the criteria for selection of suitable endodontic cases 8. Each student should understand the indications and contraindications of endodontic treatment 9. Practical demonstration for all previous pulpal and periodontal tests

References: 1. Cohen S. Diagnostic procedures. In Cohen S, Burns RC, Pathways of the pulp. 8th ed. St Louis: CV Mosby, 2002: Chapter (1), P.3-30.

Module 1 Endodontic diagnostic procedures Learning objectives: Each student should understand how to properly analyze the information obtained from medical and dental histories, clinical examinations and diagnostic tests in order to make an accurate endodontic diagnosis. Main points: At the conclusion of the lesson, each student should be able to:

1 - Understand the basic diagnostic procedures available for making an accurate endodontic diagnosis. 2 - Understand the importance and methods of obtaining complete medical and dental histories. 3 - Understand the procedures required for conducting a proper oral examination. 4 - Understand how to correlate other dental problems of the patient as they relate to the success or failure of the endodontically treated tooth. 5 - Understand the differential diagnosis of pulpal versus periodontal pain 6 - Understand the differential diagnosis of pulpal versus periodontal pathosis Outline of Lecture: Diagnostic procedures in Endodontics Steps of diagnostic process • Subjective finding ƒ the chief complaint, ƒ medical and dental histories, ƒ history of the present condition

14 o Inception: o Intensity o Quality o Location: o Provoking factors: o Duration o Spontaneity o Attenuating factors: o Frequency and course ƒ Type of pain according to the origin & site of pain-coming from o Primary pain: o Heterotopic pain ƒ Differential diagnosis of pulpal and periodontal pain • Objective examination • Visual Examination • Periodontal evaluation o Percussion test o Palpation test o Mobility test • Pulpal evaluation o Sensitivity tests ƒ Thermal stimuli o Cold Tests: o Heat tests ƒ Electric pulp testing ƒ Limitations of sensitivity tests –False negative response –False positive response. o Vitality test –Laser Doppler flowmetry –Pulse Oximetry o Cavity Test o Transillumination Test o Biting Test o Wedging & Staining o Radiographic examination –Gutta-Percha tracing

• Differential diagnosis of pulpal and periradicular pathosis o Clinical feature o Radiographic feature • References Cohen S. Diagnostic procedures. In Cohen S, Burns RC, Pathways of the pulp. 8th ed. St Louis: CV Mosby, 2002: Chapter (1), P.3-30. Module 1 Case selection and treatment plan

Learning objectives: Each student should understand how to properly analyze and evaluate the collected data obtained during clinical examinations and diagnostic tests. In addition,

15 each student should understand how to evaluate the restorability of the affected tooth in order to decide the appropriate treatment plan

Main points: At the conclusion of the lesson, each student should be able to: 1. Understand how to correlate other dental problems of the patient as they relate to the success or failure of the endodontically treated tooth. 2. understand how to manage the medical compromise patients during endodontic treatment 3. Understand how to establish dental evaluate and restorability of the affected teeth 4. Understand how to establish the proper endodontic treatment plan 5. Outline of Lecture: Process of case selection & treatment planning. Evaluation of the patient: • Physically evaluation ™ Management of medically compromised patients. o Cardiovascular patient o Rheumatic fever o Artificial valve or with heart murmmur o Pace maker o Hypertension o Coronary artery bypass: o Dialysis patients. o Hemophilic patient. o Diabetic patient o Steroid Therapy o Cancers Patient o Allergics o Pregnancy o Kidney Disorder o Infectious Diseases o Hepatitis. o tuberculosis. o AIDs (human immuno deficiency virus HIV) o Organ Transplants o Orthopedic Implants

• Evaluation of the tooth o Morphological and anatomical consideration. o Pathological condition o Previous treatment. o Location of the tooth. o Restorability. o Periodontal status. o Accessibility: o Availability: o Strategic value of the tooth.

• Psychological Evaluation

16 o Motivation. o Difficult Patient. • Economic evaluation

Types of Endodontic treatment • Emergency treatment. • Single appointment root canal therapy. o Guidelines for One appointment Root Canal Therapy o Indication contraindication advantages and disadvantages of single appointment root canal therapy • Multiple appointment root canal therapy.

References: 1. Rosenberg P: Case selection and treatment planning. In Cohen S, Burns RC, Pathways of the pulp. 8th ed. St Louis: CV Mosby, 2002: Chapter (4), P.91- 102. 2. Module 2

Magnification devices in endodontics: the era of micro-endodontics Lecture outline for the students of the 5th year 2007 By: Khaled A. Balto; Associate Professor

Learning objectives: 1. describe the operative advantages of using magnification devices in endodontics 2. enumerate and elaborate on the elements that constitute magnification devices 3. describe the requirements for ideal surgical loups for each students Lecture outline:

1. The era of micro-endodontics: a. The growing need for predictability and consistency b. If a task can be seen better, it will be done better.

2. Magnification achieved by: a. Microscopes b. Loupes

3. Historical account on the use of magnifications in medicine and dentistry: a. Otollgists b. Ophthalmologists c. Neuro surgeons d. Endodontists

4. Advantages of the use of MDs in endodontics: a. Visualization of the surgical field b. Evaluation of surgical techniques c. Use of fewer radiographs d. Less occupation stress

17 5. Elements affecting the choice of magnification devices: a. resolution b. field depth c. field width d. weight e. working angle f. magnifying power

6. Resolution Vs. magnification 7. classification of loupes based on lenses design: class I, II, III and IV 8. The triad of microscope uses in endodontics 9. Elements of magnification power in microscopic endodontics 10. Operational utilization of magnification powers in micro-endodontics 11. The ideal magnification device for you !!

Module 2

Problems encountered during root canal working length estimation

Learning objectives: 1. describe the difficulties encountered during root canal treatment radiography and the strategies used to overcome them 2. describe the reasons for long and short electronic readings and the methods to overcome them. 3. enumerate the factors that control the quality of endodontic radiographs .

Lecture outline:

1. Importance of radiographic images in endodontic treatment a. Information for diagnosis b. Information for treatment phases c. Evaluation of success and failures

2. Requirements for Ideal radiographic image in endodontics a. Tooth should be at the middle of the x-ray film b. 2-3 mm of bone must be visible at the end of the apex c. Parallel technique=film is parallel to the long access of the tooth + central beam at right angel

3. What are the difficulties a. The need for parallelety b. Rubber dam in situe c. Cone placement d. Superimposition e. We do not know where the canal exit f. Mal-development!!!

4. The search for parallelism a. Film placement b. Cone placement

18 5. Film holding devise and their utilization during operative endodontics a. Endo ray b. Xcp holders

6. Over coming the obstacles of the rubber dam during endodontic film taking 7. Troubleshooting with an Apex Locator a. Short reading b. No reading c. Long reading

8. Operational utilization of Electronic Apex Locators 9. Problems encountered with films processing a. Temperature of the solutions b. Freshness of the solutions c. Light exposure d. Over-developing e. Under-fixing

Module 2

Rubber dam isolation in endodontic therapy Learning objectives: 1. learn techniques for single tooth isolation during root canal preparation 2. learn the techniques for isolation of badly destructed teeth during root canal treatment

Lecture outline:

1. When, Why and how 2. Winged Vs. Wingless clamps 3. Isolation technique for endodontic treatment a. Wingless clamps b. Winged clamps 4. THE SPLIT-DAM TECHNIQUE a. Indications b. Technique

5. Techniques of isolation of badly destructed teeth

Module 3 Role of Endodontic after Dental Traumatic Injuries

Learning objectives: Each student should identify the World Health Organization’s Application of International Classification of dental traumatic injuries. Also he should understand the definition, clinical and radiographic appearance, general management ( including emergency and definitive treatment ) of each type of dental trauma,

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Main points: At the conclusion of the lesson, each student should be able to: 1. Understand why it is important to record the complete history of a traumatic injury. 2. Understand the diagnostic procedures of dental trauma to detect the problem of affected tooth and surrounding structures. 3. Know the importance of determination of pulp status stage of root development that affecting the treatment plan 4. Know and identify the definition, clinical and radiographic features, , emergency and definitive treatment of different uncomplicated and complicated coronal fractures. 5. Know and identify the definition, clinical and radiographic features, emergency and definitive treatment of uncomplicated and complicated coronal/ root fractures. 6. Understand the treatment objective of complicated coronal fracture of tooth with immature root canal is maintain vitality of root canal ( in vital tooth) to allow apexogensis process, or induce apical closure by technique ( in nonvital tooth) 7. Know and identify the definition, methods used to diagnosis, clinical and radiographic features, emergency and definitive treatment of root fractures at different levels. 8. Know the different healing pattern of root fracture 9. Know and identify the definition, clinical and radiographic features, emergency and definitive treatment of different types of luxative injuries (including concussion, subluxation, lateral luxation, extrusion, intrusion). 10. Understand the treatment objective of luxative tooth is reposition as soon as possible then to stabilize anatomically correct position and achieve optimize healing of the periodontal ligament and neurovascular supply, while maintaining esthetic and functional integrity 11. Know the definition, clinical and radiographic features, emergency and definitive treatment of avulsed tooth. 12. Know the important of fasting reposition of avulsed tooth as soon as possible in its anatomically correct position to optimize healing of the periodontal ligament and neurovascular supply, while maintaining esthetic and functional integrity. 13. Know the factors affecting the prognosis of replantation of avulsed tooth. 14. Know the different typed of storage media for avulsed tooth 15. Know the requirements of an acceptable splint (types & time of splinting) 16. Know the endodontic treatment needed for an avulsed tooth based on: • Extra-oral period • Stage of root formation 17. Know the three types of periodontal healing observed by Andreasen following replantation of an avulsed tooth. 18. . Explain the role of calcium hydroxide in the replantation of an avulsed tooth. 19. Understand the sequelae of dental trauma on neurovascular structure and periodontal attachment

Outline of Lecture: • Diagnosis of traumatized tooth; • History of dental trauma

20 • Classification of dental traumatic injuries (WHO) • Enamel infraction : o Definition o Diagnosis o Emergency treatment o Definitive treatment • Complete Enamel fracture o Definition o Diagnosis o Emergency treatment o Definitive treatment • Enamel–dentin fracture (Uncomplicated crown fracture o Definition o Diagnosis o Emergency treatment o Definitive treatment

• Complicated crown fracture o Definition o Diagnosis o Factors affecting treatment plan o Emergency treatment o Definitive treatment • Vital pulp therapy : Management of vital immature traumatized tooth o o Partial o Cervical pulpotomy o Definition of apexogenesis

• Management of nonvital immature traumatized tooth o Apexification technique • Crown root fracture (uncomplicated and complicated ) o Definition o Diagnosis o Emergency treatment o Definitive treatment

• Root fracture o Definition o Types o Diagnosis o Emergency treatment o Definitive treatment o Time and type of splinting o Sequale of root fracture o Healing pattern of root fracture

• Luxation injuries o Definition of different types:

21 o Concussion. o Subluxation o Lateral luxation o Extrusive luxation o Intrusive luxation o Diagnosis o Emergency treatment o Definitive treatment

• Avulsion (exarticulation). o Definition o Diagnosis o Storage media o Factors affecting treatment plan o Emergency treatment o Splinting o Definitive treatmen-The effect of trauma on neurovascular structure Pulpal responses to traumatic injuries ƒ Pulpal necrosis, ƒ pulp canal obliteration ƒ Internal root resorption

The effect on the periodontal attachment 1. surface resorption 2. Inflammatory resorption 3. Dento-alveolar ankylosis and replacement resorption,

References: 1. Trope M, Chivian N, Sigurdsson A, Vann WF: Traumatic injuries. In Cohen S, Burns RC, Pathways of the pulp. 8th ed. St Louis: CV Mosby, 2002: Chapter (16), P: 603-645.

Module4

Emergencies in Endodontics

Learning objectives: After attending and reading this lecture, the student will be able to: 1. Define endodontic emergencies. 2. Identify causes of endodontic emergencies as they occur before treatment (pretreatment), between appointments (interappointments), or after obturation (post obturation), as well as emergencies resulting from traumatic injuries. 3. Differentiate between what constitutes a true emergency as opposed to urgency.

22 4. Understand and describe the emotional status of the emergency patient and explain how this complicates diagnosis and treatment. 5. Describe and outline a system of subjective and objective examinations and radiographic findings to identify the source of pain (pulpal or periradicular): a. Determine the source of pain. b. Establish a pulpal and periradicular diagnosis. c. Identify the etiologic factor of the pathosis. d. Design an emergency (short term) treatment plan. 6. Describe how to manage pretreatment emergencies. 7. Describe how to gain a profound anesthesia 8. Describe the emergency steps for treatment of painful irreversible pulpitis. 9. Outline the emergency steps involved in the treatment of necrotic pulp with acute apical periodontitis. 10. Describe the treatment of acute apical abscess. 11. Outline the indications and procedure for incision and drainage. 12. List the factors that relates to greater frequency of interappointment flare- ups and how to minimize their occurrence. 13. Describe treatment of acute apical periodontitis secondary to treatment. 14. List the causes of postendodontic emergency conditions. 15. Describe the emergency treatment required according to each condition. 16. Classify dental traumatic injuries that need emergency intervention. 17. Describe the emergency treatment plan required according to each type. 18. Detail the pharmacologic supportive therapy (analgesics, antibiotics, and anti- inflammatory agents) used in emergency situations. Outline of Lecture: Endodontic emergencies: Definitions. Differentiation of Emergency and Urgency Emergency categories: I. Pretreatment emergencies. II. Interappointment emergencies. Postobturation emergencies. Psychological and emotional management of the emergency patient. - System of diagnosis: Medical and dental histories. Subjective examination. Objective examination. Periodontal examination. Radiographic examination. Diagnostic outcome.

I. Pretreatment emergencies: 1. Acute Pulpitis. 2. Acute Pulpitis with Acute Apical Periodontitis. 3. Pulp Necrosis with periapical pathosis. 1. Acute Pulpitis: Clue for diagnosis Emergency treatment plan

2. Acute Pulpitis with Acute Apical Periodontitis: Clue for diagnosis Emergency treatment plan

23 -The problem of inadequate pain control during endodontic emergencies -Anesthetic considerations for pulpally and or periapically affected teeth: . -Local anesthetic techniques: Local infiltration. Regional nerve block. Supplementary injections: Intraligamental Intraseptal Intrapulpal Intraosseous

3. Pulp Necrosis with periapical pathosis: a. Acute apical periodontitis with no swelling: Clue for diagnosis Emergency treatment aim b. Acute apical abscess with localized swelling. Clue for diagnosis Emergency treatment aim c. Acute apical abscess with diffuse, extensive swelling: Clue for diagnosis Emergency treatment aim -Incision and drainage: Basic incision and drainage tray setup Steps for incision and drainage

II. Inter Appointment Emergencies "Flare-up": Definitions Inter appointment emergency conditions: - Incomplete removal of pulp tissue. - Apical periodontitis secondary to treatment. - Recrudescence of a chronic apical periodontitis. - Incomplete removal of pulp tissue: Possible causes. Management. - Apical periodontitis secondary to treatment: Probable causes: "separate or in conjunction" Microbial factors influencing the development of painful flare-up How can microorganisms cause flare-up? Mechanical injuries Chemical injuries Type of pain Emergency treatment -Recrudescence of a chronic apical periodontitis. Emergency treatment Preventive measures to infectious flare ups

III. Post-obturation emergencies Causes Emergency treatment

Emergency treatment for traumatized teeth. Classification Key points for diagnosis

24 Emergency treatment

References: 1. Weine F S : Endodontic Therapy, Ed 6, Mosby, Inc, 2004, Chapter 3, P 72. 2. Cohen S & burn R: Pathways of the pulp Ed 8, Mosby, Inc, 2002, Chapter 2, P 31

Module 4 Endodontic and Periodontic Interrelationships Tackling the vicious circle: Endo Perio Lesions Learning objectives: 1. Delineate the anatomic pathways of communication between the dental pulp and periodontal ligament. 2. Describe the effects of pulpal disease and endodontic procedures on the periodontium. 3. Describe the effects of periodontal disease and procedures on the pulp. 4. Identify which clinical diagnostic tests and finding are important in the differential diagnosis of periodontal- endodontic problem. 5. Understand treatment requirement and sequencing according to diagnostic findings. 6. Recognize when treatment has been successful or has failed and develop alternative treatment plan 7. Identify which complex cases should be considered for referral Outline of Lecture: 1. Intercommunication between pulpal and periodontal tissues: a. Embryonic origin b. Influence of pulpal pathologic conditions on the periodontal tissues c. Influence of periodontal inflammation on the pulp 2. Definitions: a. Vital pulp b. Healthy pulp c. Pulp and periodontal lesions d. Pulpal lesions e. Periodontal lesions f. Combined lesions 3. Pathways of intercommunication between pulp and periodontal tissues: a. Apical foramen b. Lateral canals c. Exposed dentinal tubules d. Palato-gingival grooves e. Vascular systems f. Neural pathways g. Common vascular lymphatic drainage h. Root fracture 4. Natural history of endodontic infections 5. Theoretic pathways of osseous lesions: a. Primary endodontic lesions b. Primary endodontic lesions with secondary periodontal involvement c. Primary periodontal lesions

25 d. Primary periodontal lesions with secondary endodontic involvement e. True combined lesions f. Concomitant pulpal and periodontal lesions 6. Differential diagnosis a. Tactic’s of assessment b. Parameters: i. Clinical ii. Radiographic iii. Histopathology 7. Clinical cases References: 1- Wang HL, Glickman GN: Endodontic and periodontal interrelationship. In Cohen S, Burns RC, Pathways of the pulp. 8th ed. St Louis: CV Mosby, 2002: Chapter (17), P: 651-664.

Module 5 Endodontic Surgery

Learning objectives: At the conclusion of the lesson, each student should be able: 1. Understand the potential false and true indications , and contraindications of endodontic surgery 2. Understand the importance of starting with conventional endodontic treatment before deciding the endodontic surgical approach. 3. Know the definition, objectives and indications of different periapical surgical procedures. a. Incision and drainage b. Trephination c. Apical curretage d. . e. Retrofilling (retroseal) 4. Know the indications and contraindications of different flap design 5. Understand how to locate the apex of the affected root 6. Understand how control the bleeding during surgical procedures to improve the vision 7. Understand how to perform the apical end preparation. 8. Understand the advantages of using ultrasonic system during retro- preparation. 9. know the properties of different retrofilling materials to be able to choice the suitable one 10. Know the postoperative instructions and care to improve the prognosis of the case 11. Understand the importance of using endodontic microscope 12. Understand the characters and clinical significance of isthmus 13. Identify the differences between, the indications and contraindications of corrective surgery including (hemisection, bicuspdization and root amputations) to preserve the endodontic- periodontal involved multirooted teeth 14. Understand the indications and contraindications of intentional reimplantation 15. Understands the indications and contraindications of endodontic endosseous implant

26 Outline of Lecture:

Endodontic Surgery Definition • Traditional Endo-surgery • Microsurgery Indication of endodontic surgery • False indication • True indication • Indication of microsurgery Contraindication of Endodontic Surgery Objectives of endodontic surgery procedures of periapical surgery 1- Incision & drainage 2- Cortical osteotomy (Trephination). 3- Periradicular curettage. 4- Apical resection . 5- Retrofilling (Retroseal). Incision & drainage: • Definition. • Objectives • Indications Cortical osteotomy • Definition. • Objectives of cortical trephination • Indications Periradicular curettage • Definition. • Objectives • Indications Apical resection • Definition. • Objectives • Indication Retrofilling • Definition. • Objectives • Indication

Steps of apical surgery • Flap design. • Localization of the apex. • Hemostasis • Root-end preparation. • Root end resection • Indication • Root beveling

27 • Objectives of root beveling • Indication of root end resection • Drawbacks • Root-end cavity preparation • Ultrasonic systems • Retroseal. • Properties of ideal retrofilling material • Types of retrofilling materials • Advantages and disadvantages • Postoperative care and instruction • Suture removal and evaluation

Microsurgery • Magnification • Instruments • Endodontic Microscope • Ultrasonic • Micro contra • Micro mirror • Illumination • Advantages of microsurgical approach •Classification of endodontic microsurgical case •Isthmus characteristics

Corrective Surgery 1- (root amputation). 2- Tooth hemisection. 3- Bicuspdization. 4- Intentional replantation. 5- Endodontic endosseous implant. •Definition •Indication and contraindication •Factors affecting prognosis of intentional reimplantation

References: Kim S: Endodontic Microsurgery. In Cohen S, Burns RC, Pathways of the pulp. 8th ed. St Louis: CV Mosby, 2002: Chapter (19), P: 683-725.

Module 6 Evaluation of Success and Failure:

Learning objectives: After attending this lecture, the student should be able to: - Define success - Recorganize signs of successful root canal treatment - Describe unsuccessful root canal treatment - Describe the most common modalities used to determine success or failure

28 - Describe how to explain the prognosis to the patient - Evaluate and estimate prognosis before, during, and after treatment - Describe the importance of recall appointments

Lecture outline: - What is success? - Prognosis: * Success rates * When to prognosticate * How to prognosticate - Variability of treatment results - Factors influencing success and failure - When to evaluate - Methods of evaluation - Causes of endodontic failures, recognition, prevention, and retreatment

References: * Pathways of the Pulp "Cohen and Hargreaves" (2006) * Principles and Practics of Endodontics "Walton and Torabinjad" (2002)

Module 6

Nonsurgical Endodontic Retreatment (I):

Learning objectives: After attending this lecture, the student should be able to: - Recorganize signs of successful root canal treatment - Identify causes of persistent apical periodontitis - Describe differences from intial treatment - State rational and indications for nonsurgical retreatment - State rational and indications for surgical retreatment - Discuss considerations for case selection for nonsurgical retreatment - Discribe the basic armamentarium and techniques for nonsurgical retreatment - Outline methods of detecting hidden and missed canals - Describe how to regain access to the apical foramen - Describe methods and techniques for removal of gutta-percha

Lecture outline: - Etiology of persistent apical periodontitis - Diagnosis of postreatment disease - Treatment planning * Nonsurgical versus surgical retreatment - Nonsurgical endodontic retreatment * Coronal Access Cavity Preparation * Post Removal Post Removal techniques Potential complications of post removal * Regaining Access to the Apical Area Misses canals Calcified canals Gutta-percha removal:

29 ¾ Using rotary systems to remove gutta-percha (R-endo) ¾ Conventional method of gutta-percha removal (heat and solvents) Managing solid core obturators Paste retreatment Silver point removal

References: * Pathways of the Pulp "Cohen and Hargreaves" (2006)

Nonsurgical Endodontic Retreatment (II):

Learning objectives: After attending this lecture the student should be able to: - Recognize the causes of instrument separation and its prevention - Evaluate and estimate the prognosis of instrument separation - Be familiar with the different methods for management of separated instruments - Identify and define canal impediments - Outline techniques for management of canal impedinebts - List the causes of root perforations - Describe techniques of perforation repair

Lecture outline: * Removal of Separated Instruments Causes of Instrument Separation Key consideration in assessing separated instrument Prognosis Removal Techniques * Management of Canal Impediments * Finishing the Retreatment - Repair of perforations * Factors affecting the prognosis * Pro-Root MTA * Steps of perforation repair - References: * Pathways of the Pulp "Cohen and Hargreaves" (2006)

Module 7 Restoration of endodontically treated teeth

Learning objectives: After attending this lecture the student should be able to: 1. State the effect of restorative procedures and materials on the pulp. 2. Describe the effect of restorative procedure on the pulp. 3. Describe the effect of restorative materials on the pulp. 4. Identify the risk of possible post restorative endodontic complication.

30 5. List and describe the indications for pre-restorative "prophylactic" endodontics. 6. Describe how to make a pre-restorative evaluation. 7. Discuss the effect of endodontics on the tooth. 8. Describe post endodontic treatment planning. 9. Identify guidelines for posts use. 10. Identify guidelines for post selection. 11. Recognize canal selection for post foundation. 12. Describe the different modalities of molars restoration after root amputation.

Outline of Lecture: I. Restorative dentistry and the vital pulp: Effect of restorative procedures and materials on the pulp. Risk of post-restorative endodontic complications. Indications of pre-restorative endo-therapy "prophylactic endodontics" Pre-restorative evaluation: A) Endodontic evaluation. B) Periodontal evaluation. C) Restorative evaluation. D) Esthetic evaluation. II. Restorative dentistry and the pulpless tooth: Effect of endodontics on the tooth. Changes in endodontically treated teeth. Treatment planning: Important considerations in treatment planning. Basic components used in restoration of pulpless teeth: Need for posts. Guidelines for posts use. Possible overuse of posts. III. Restoration of teeth after root amputation

References: 1. Wagnild GW, Mueller KI: Restoration of the endodontically treated tooth. In Cohen S, Burns RC, Pathways of the pulp. 8th ed. St Louis: CV Mosby, 2002: Chapter (22), P: 765..

Module 7 Bleaching Of Discolored Teeth

Learning objectives: After attending theses lectures, the student should be able to:- 1- Identify the causes of teeth discolorations. 2- Describe and differentiate between enamel and dentin discolorations. 3- Describe the internal bleaching techniques. 4- Describe the external bleaching techniques.

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Outline of Lecture:

- Causes of Discolorations. - Natural. - Iatrogenic. - Endodontically related discolorations - Obturating materials. - Remnants of pulpal tissue. - Intracanal medications. - Bleaching materials. - Hydrogen peroxide. - Sodium perborate. - Internal bleaching techniques - Thermocatalytic technique. - Walking Bleach technique. - Complications of bleaching. - External bleaching techniques.

References: 1. Walton RE, Rotstein I: Bleaching of discolored teeth: Internal and external. In Walton R, Torabinjad M: Principles and practical of endodontics. 3rd Ed. W.B: Saunders Company, 2002:Chapter (19), P: 331-345

2 - CLINICAL PROTOCOL

1. The clinic timings will be 3 hours only. 2. The student should attempt to treat single canaled teeth first then move on two or three canaled teeth. 3. If a single canaled tooth is not available, the student can initiate a two canaled bicuspid or molar.

32 4. The molar tooth should be initiated when the student has at least performed root canal therapy on two root canals. 5. If a two canaled bicuspids is not available the student can replace it with two single canaled bicuspids or anterior teeth. 6. The cases selected for treatment should be of routine nature and the students should discuss the case with instructors prior to initiating endodontic therapy. 7. It is the responsibility of the student to coordinate with the booking area regarding appointments for patients. 8. Case started with one instructor should be preferably completed under the supervision of same instructor. 9. The student start his/her treatment with taking chief complains, performing subjective and objective examination of the case. 10. The supervisor should discus and accepts the diagnosis of the case. 11. Strict aseptic technique will be followed in clinic and use of rubber dam will be mandatory. 12. It is important to have the endodontic therapy records properly filled out, signed and evaluated by the instructors in the endodontic sheet. 13. The radiographs belonging to each case should be properly arranged on mounts available at radiology. The radiographs and patient records should be handed over to instructors at the earliest opportunity. Each student must fulfill all endodontic steps of assigned teeth to the satisfaction of the instructor. • It is required that each student submits the finished endodontically treated teeth with the radiographs including five radiographs as follows: 1. Pre-operative radiograph 2. Working length determination radiograph 3. Master apical file radiograph 4. Intermediate radiograph (i.e.) a radiograph after cementation of the master cone and two accessory cones. o Or radiograph of properly selected master cone 5. Post operative radiograph (i.e.) a radiograph after cutting the excess gutta percha, cleaning the access, removal of the clamp, the rubber dam and placement of temporary filling. • Each step should be evaluated and signed by supervisor in the endodontic sheet. • All the radiographs and the signed sheet of the test case should be submitted to the division at the end of the clinical session. • Satisfactory completion of the clinical course is based on the following criteria: 1. Each student must follow accepted endodontic principles in treating the case from pre-operative examination selection of the case until filling of the root canal. 2. Each student is required to follow radiographic method in length determination. 3. Each student is required to follow the step-back technique in preparing the root canal system except in some cases step-down technique will be used. 4. Each student is required to follow cold compaction technique to obturate of root canal system. 5. In addition, each student must demonstrate his/her knowledge of the principles of radiography as applied to endodontic therapy by obtaining adequate radiographs at various stages during the endodontic procedures.

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Quick Guidelines for Treatment of an Endodontic Case

1. First appointment:

a. Review and update medical history – take medical history if not previously taken.

b. Question patient as to area of problem (chief complaint) and what type of symptoms patient is having. All has to be documented on the Endo therapy record.

c. Take preoperative film of suspected area if you don’t have a recent film. Review preoperative film for periapical changes, tooth morphology, pulpal morphology, caries or restorations impinging on pulp, etc.

d. Perform necessary diagnostic tests:

i. Sensitivity tests both electric pulp tester (EPT) and thermal “ICE” whenever are applicable to determine the condition of the pulp. ii. Percussion and palpation to check the periapical. iii. Test cavity in case of full coverage. iv. Anesthesia test in case of diffuse pain. v. Fistulous tracking test in case of sinus tract opening.

If information is sufficient, arrive at a diagnosis as to which pulp is involved and what treatment is necessary.

e. If endodontic treatment is required, explain to the patient what you are going to do and why it is necessary.

f. Anesthetize the tooth. After you disinfect the tooth and the area.

g. Isolate involved tooth with rubber dam (only tooth being treated needs to be isolated). Check with your instructor in case rubber dam cannot be placed.

h. Prepare access opening and refine it so each canal be entered. Debride pulp chamber. Irrigate with sodium hypochlorite. Use other solution if rubber dam is leaking.

i. Determine the working length of the canal.

j. Instrument the canal to the working length at least to the size that removes most of the pulpal tissues. During instrumentation, irrigate frequently with hypochlorite if the canal is difficult to negotiate, discuss with your instructor. After instrumentation, irrigate and dry canal.

k. Place a cotton pellet in chamber and close access opening with cavit (cotton pellet should be blotted almost dry before placement). Consult with your instructor the best type of medication in your case if its indicated.

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2. Second appointment:

a. Anesthetize the tooth b. Isolate the tooth with rubber dam c. Remove the temporary and the cotton pellet d. If the tooth is asymptomatic and no drainage present in the canal do the following:

i. Complete instrumentation ii. Irrigate with NaOCl iii. Dry canal with paper point iv. Fit the master cone and two accessory cones using cold compaction technique and radiograph the tooth. v. Complete canal filling procedure vi. Remove excess filling material vii. Place permanent or temporary filling material viii. Remove the rubber dam, the clamp, put temporary filling and take final radiograph

e. If the tooth is symptomatic and / or drainage is present in the canal(s), do the following:

i. Irrigate the canal ii. Re-debride the canal and complete instrumentation iii. Dry the canal iv. Place Ca(OH)2 , cotton pellet and temporary filling.

NOTE: These four steps may have to be done for several appointments until tooth is asymptomatic and no definite drainage is occurring into the canal(s), or Ca (OH)2 can be used in such cases.

3. Third appointment:

a. Anesthetize the tooth b. Isolate the tooth with rubber dam c. Remove the cavity and the cotton pellet d. If the tooth is asymptomatic and no drainage is present in the canal, fill it as outlined in the second appointment step (d).

Always consult with your instructor before dismissing the patient.

Assessment Guidelines Prior to taking the approval of competency examination: 1. The student must attain of an at least 80% in attendance sheet of both lectures and clinical session. 2. The student must fulfill of at least 60% of clinical requirements with satisfactory evaluated score

35 3. If the student has no completed cases at the scheduled end of the fifth year, he/she may receive failing grade

Marks of the clinical requirements

Tooth 3 Ant.× 5 Single RC PM Double RC PM Molar 3 or 4 RC

Marks 15 5 8 12

Course Related Materials Contents

36 1- Examples of Clinical requirments

2- Sample of: a- Module Exams b- Mid-year Exam c- Final Exam

Instructor Reflection Instructor Reflection on the course: The current course fulfills what the student need to know at this stage of education. The course enables the student to acquire recognition skill to diagnose and treat the pulpally and periradicularaly involved teeth with the least iatrogenic errors.

Strength Points: 1. It is fully applied course 2. Experienced teachers 3. Adequate teaching facilities 4. The clinical explanation and demonstration is performed by professors and lecturers of department even the clinical demonstration (highly qualified staff) not by genior members (demonstrators). This will allow the student at the end

37 of course , be able to manage and treat every simple and complicated endodontic involved cases either with single rooted or multirooted teeth with satisfactory result 5. The student is allowed to treat sufficient number of clinical cases so that he/she will get sufficient experience to manage the CC cases in the next year.. 6. Every two year, the course subjects redistributed over the staff allow the enhancement and development of the teaching 7. The student start to use the rotary systems for cleaning and shaping of the root canal system of some clinical cases 8. The student start to use the portable X-ray machine which facilitate radiography in the clinical sessions Weak Points: 1. Insufficient number of demonstrators comparable with increasing the number of the students every year. 2. Shortage of x-ray devices inside the clinical section lead to waste time during clinical procedures 3. Lack of qualified radiographer technician lead to several remake of x-ray film by student, increasing the waste time and the hazard of radiation 4. shortage of EAL`s in the clinical area 5. portable X-ray units are not enough compared with large number of students

Innovation and plan for future: 1. Each student successfully use the rotary root canal files for treatment of all clinical cases 2. Each student learn to use the digital radiographs 3. Up to date course every year 4. e-teaching 5. E- sheet marking for evaluation of the studen

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