Endodontics


Chairperson

• Jeffrey W. Hutter, DMD, M.Ed. Chair, Department of Endodontics; Director, Postdoctoral program in Endodontics

Faculty

• Yanling Jiang, DMD, D.Sc. Director of Predoctoral Program in Endodontics, Department of Endodontics, Department of General Dentistry
• William Walker, DDS, Associate Professor, Department of Endodontics
• Louay Abrass, DMD, Clinical Assistant Professor, Department of Endodontics

Clinic Coordinator

• Ms. Edlira Kerthi

Office Location

• 100 East Newton Street , 1st Floor, Room G-118

Clinic Hours

• Monday - Friday 8:15 a.m. - 4:30 p.m.

Learning Resource Texts (for Reference Only)

• Predoctoral Endodontic Laboratory and Clinic Manuals
• Pathways of the Pulp(8th Edition); Cohen & Burns-Mosby
• Review of Diagnosis, Oral Medicine, Radiology and Treatment Planning; 4th Edition Norman K.Wood-Mosby

Purpose and Rationale

Endodontics is that branch of dentistry that deals with the diagnosis and treatment of oral conditions which arise as a result of pathosis of the dental pulp. Its study encompasses related basic and clinical sciences, including the biology of the normal pulp and the attachment apparatus, etiology, diagnosis, and treatment of disease and injuries to the pulp and peri-radicular tissues. 

The Endodontic Patient Treatment Center provides the student with the opportunity to render care appropriate to diseases of the pulp and periapical tissues.

Inflammatory and degenerative pulp diseases are treated by non-surgical root canal therapy (NSRCT).

Students should be able to demonstrate competency as defined:

Course Description

The endodontic knowledge learned in the DMD II/AS I didactic and preclinical course (EN 521 and EN 522) provides instruction on case selection, treatment planning, non-surgical root canal therapy and interrelations with other dental disciplines. Clinical aspects of endodontics such as applied pharmacology, management of endodontic emergencies, and success and failure of endodontic cases are also stressed.

Course Goals

The course will provide students with the opportunity to enhance and increase their knowledge of endodontics. Once gained, this knowledge will be an important component of the knowledge base required to manage endodontic problems for patients in the clinic and to help the students achieve competency rendering nonsurgical root canal therapy. 

Competency: As defined by the Clinical and Behavioral Competencies BUSDM. Competency for Endodontic Therapy:

11. GRADUATES MUST BE COMPETENT IN THE PREVENTION, DIAGNOSIS, AND MANAGEMENT OF PULPAL AND PERIARADICULAR DISEASE FOR PATIENTS THROUGHOUT THEIR LIFECYCLE.

• Prevent pulpal disease through pulpal protection techniques.
• Perform non-surgical endodontic therapy in simple cases and recognize and refer complicated endodontics.
• Diagnose and manage pulpal and periradicular diseases.
• Recognize success and failure of endodontic treatment and indications for re-treatment or surgical intervention.
• Diagnose and manage dental emergencies of odontogenic and nonodontogenic origin.

Students will be expected to obtain pertinent history, perform a visual examination, make and interpret appropriate radiographs, perform and interpret pulp vitality, percussion and mobility tests and to apply data and knowledge of pulpal and periradicular disease gained in didactic courses and demonstrated on written examinations in arriving at a pulpal and periradicular diagnosis. Knowledge and skills in endodontic diagnosis will be expanded and reinforced in the clinical management of endodontic cases during the junior and senior years. Students will receive a performance rating on diagnosis for each case. Students will be required to demonstrate competency in endodontic diagnosis during the senior year (OD rotation, OD 640) 

Students will perform non-surgical root canal therapy on single rooted and multi-rooted teeth in the DMD III / IV and AS II clinical courses. Following diagnosis, they will be expected to perform coronal access, cleaning and shaping and obturation of the root canal system. They will receive a performance rating for each of these and an overall grade for each case completed. Necessary knowledge and skills learned in didactic and preclinical courses and tested through written and practical examinations on extracted teeth will be utilized.  

Students will be expected to apply appropriate values presented and tested in didactic courses in the management of endodontic problems for their patients. These include presentation of treatment options, appropriate sequencing in the overall treatment plan, timely delivery of care, sensitivity to patient needs and concerns, seeking assistance when indicated, and strict adherence to infection control protocols in all endodontic cases.

Course Objectives

At the end of the course the student should, independently and unsupervised, be able to demonstrate:

1. Knowledge

a. Ability to diagnose pulpal and periradicular disease.
b. Ability to treatment plan for non-surgical root canal therapy, including case selection criteria (indications, contraindications, prognosis).
c. Ability to treat endodontic emergencies including trauma, pain, and infection.
d. Ability to treatment plan for apexification and apexogenesis, including case selection crieteria (indications, contraindications, prognosis).
e. Ability to treatment plan for non-vital bleaching, including case selection criteria (indications, contraindications, prognosis).
f. Ability to evaluate clinical findings for assessing endodontic outcome.

2. Skills

a. Ability to collect appropriate clinical findings (e.g., signs, symptoms, test results) necessary for diagnosis of pulpal and periradicular disease.
b. Ability to properly isolate, anesthetize, access, clean and shape, obturate, temporize and interpret radiographs of teeth with relatively uncomplicated root canal systems.
c. Ability to collect appropriate clinical findings (e.g., signs, symptoms, test results) to evaluate outcome of endodontic treatment.

3. Attitude

a. Appropriate patient management skills.
b. Adherence to infection control techniques.
c. Timely delivery of care.
d. Sensitivity to patients’ needs and concerns.
e. Ability to seek assistance when needed or to refer case for specialist treatment when indicated.

Entry Level Skills or Prerequisites

Satisfactory completion of the pre-clinical didactic course, and the preclinical laboratory course (EN 521, EN 522)

Clinical Procedures: Approval

For case approval, submit the pre-operative radiograph* and the department approval form to the Predoctoral Endodontic Clinic Coordinator. Within three working days you will be notified of approval decision and cases may be picked up at that time from the Clinic Coordinator. At the time of notification of approval (and not before that) the patient can be scheduled for NSRCT. The patient will prepay at the time of the first appointment.

*The preoperative radiograph must not be pulled out of the full-mouth series, but a regular size copy made of optimal quality must be used. This will serve as the primary basis for rapid case approval. No bite-wings are allowed to be submitted.

Clinic Appointments

Patients can be seen from 8:15 a.m. to 4:30 p.m. depending on the clinical sessions scheduled on the fifth floor or first floor. Cases should begin to be closed 30 minutes before the end of the session.

The endodontic operatories are to be considered surgical suites, the following infection control protocol is mandatory:

1. Room must be prepared in accordance with CDC guidelines in order to comply with the universal precautions policy that exist at the school.
2. Before seating the patient, the operatory must be thoroughly clean, spray and wipe down work surfaces, unit etc. and disinfect sink area.
3. Make sure the proper and complete set-up of instruments for the procedure is available, with materials and sterilized instruments.
4. Disposable overgowns (supplied) must be worn by students in the clinical area
5. All previous radiographs including pre-operative film must be mounted and displayed appropriately.
6. A signed copy of the contract must be in the chart before treatment is started.
7. The patient’s chart must be available with an updated Medical History form (MHA)
8. Make sure you have a clear knowledge of the procedure to be followed.
9. Rubber dam is mandatory for all endodontic procedures performed in the clinic. Mechanism for Endodontic Consults on Predoctoral Patients
10. If a pulp exposure occurs during patient treatment in the general clinics, partial or complete pulp extirpation is necessary, and an endodontic faculty member or the postdoctoral endodontic resident on emergency must be called. One of these individuals must perform and/or help perform the procedure.
11. For non-emergency endo consults, the same procedure applies as in #1. If a patient under the care of a predoctoral student for endodontics experiences an endodontic problem between appointments and the problem requires emergency treatment, the predoctoral student will introduce the patient and the problem to the postgraduate student on emergency rotation. The predoctoral student will assist the postdoctoral endodontic resident in the treatment of the emergency and the management of the patient. There should be few problems of this nature, but it is the responsibility of the predoctoral student, to have problems of that nature taken care of at once.

Endodontic Emergencies on Nights Weekends and School Vacations (Pager Protocol)

If your patient should contact you at these times with endodontic emergencies, please direct your patient to call 617/638-8450. They should leave a voice message automatically activating the endo pager and a postdoctoral endodontic resident will return their call.

Endodontic Problems Experienced in Other Clinics

During cavity preparation, when caries is found to involve the pulp, or when a mechanical exposure occurs, the postdoctoral endodontic resident on emergency rotation, or an endodontic faculty, must be called to perform or supervise a pulpectomy or pulpotomy. This should be done in the clinic where the problem occurs. The predoctoral student should feel confident, after completing preclinical courses, to perform this procedure, and can do so as long as it is performed in the presence of the endodontic faculty member or the postdoctoral endodontic resident on emergency rotation.

Specific Clinical Objectives of the Predoctoral Endodontic Clinic

The general objectives are defined as follows: The ability to

1. Diagnose diseases of the pulp and peri-radicular tissues.
2. Identify and determine the etiological factors responsible for pulp
3. Diagnose and treat endodontic emergencies 
4. Manage pulp and peri-radicular disorders of traumatic origin
5. Manage pulpal disorders through transdentinal therapy either by pulp 
   extirpation, or a pulpotomy procedure.
6. Competently perform endodontic therapy on relatively uncomplicated 
   permanent teeth
7. Obturation of root canal systems with provisions for subsequent restoration
8. Management of infections of pulpal origin
9. Management of dental pain of pulp-periapical origin
10. Treatment of discolored pulpless teeth  Clinical Evaluation

Evaluation of performance in all clinical disciplines is based on the attainment of competency as defined by the statements of General Dentistry Practice Competencies.

In the competency-based learning and evaluation system, students formulate and express their thoughts at the beginning of each patient appointment about what the patient needs, what students intend to do to meet this need, and what students expect to occur during the process of meeting the need. The system leads students to evaluate their performance during and at the completion of each appointment. The competency-based learning and evaluation system increases the focus of the student-patient-faculty interaction. In addition to focusing on the completion of clinical procedures, the system encourages critical thinking, communication, self evaluation, and quality assurance.

Formative Evaluation Using Clinical Feedback

Formative evaluation is developed by the clinical faculty for each student at each clinic session. These reports describe the quality of the student’s performance and the extent to which the student needed assistance and direction. The program directors summarize these daily clinical reports and make judgments about the progress of each toward the achievement of competence (i.e., whether the student’s performance consistently meets the standards of care, whether the student shows independence in making appropriate decisions). Students having consistent problems in clinical performance receive feedback and corrective directions from the program directors. All students receive feedback related to their progress. Information is provided to the promotions committee.

The student will be asked to self -evaluate his/her performance at the end of every clinical session. Using such questions as “How did you do today?” and “What would you have you done different looking back now?”. Based on these and other answers and the instructors own observation as to how the case was managed . Also “How much assistance was needed ?” and was the amount provided appropriate for the students level of expertise?

The feedback will essentially be categorized under the following broad headings of: Knowledge, Skills, and Attitude.

The student should be able to demonstrate:

1. Knowledge

1. Ability to diagnose pulpal and periradicular disease.
2. Ability to treatment plan for non-surgical root canal therapy, including case selection criteria (indications, contraindications, prognosis).
3. Ability to treat endodontic emergencies including trauma, pain, and infection.
4. Ability to treatment plan for apexification and apexogenesis, including case selection criteria (indications, contraindications, prognosis).
5. Ability to treatment plan for non-vital bleaching, including case selection criteria (indications, contraindications, prognosis).
6. Ability to evaluate clinical findings for assessing endodontic outcome.

2. Skills

1. Ability to collect appropriate clinical findings (e.g., signs, symptoms, test results) necessary for diagnosis of pulpal and periradicular disease.
2. Ability to properly isolate, anesthetize, access, clean and shape, obturate, temporize and interpret radiographs of single rooted and multirooted teeth.
3. Ability to collect appropriate clinical findings (e.g., signs, symptoms, test results) to evaluate outcome of endodontic treatment.

3. Attitude

1. Appropriate patient management skills.
2. Adherence to infection control techniques.
3. Timely delivery of care.
4. Sensitivity to patients’ needs and concerns.
5. Ability to seek assistance when needed or to refer case for specialist treatment when indicated.

Case Submission for Summative Evaluation

The white endodontic sheet, X-ray mount with the mounted x-rays have to be handed in. Remember for a case to be evaluated, two pre-operative and two post-operative radiographs (use a double film) are required; one for the endodontic record and one for a permanent record for the chart. 

Evaluation Criteria:

1. Appropriate case management (diagnosis, patient care, antibiotics, etc.)
2. Appropriate pre-treatment (isolation with rubber dam).
3. Appropriate access cavity for the case.
4. Efficacy of cleaning and shaping (as evidenced by instrument placement and visualization of packing material)
5. Obturation of root canal system; (density of down pack and back pack)
6. . Absence of iatrogenic problems (perforation, permanent blockage)
7. Quality of radiographs
8. Neatness of case presentation Evaluation of Critical Thinking: Checklist:

Before starting each patient, the student should ask him/herself these questions:

Before bringing the patient in:

1. Is the area immaculately clean, and does it comply with universal precautions?
2. Are the relevant radiographs appropriately mounted and displayed?
3. Is the instrument set up in accordance with diagrams in the clinical manual?
4. After a review of the case, decide on type and amount of anesthetic or if its really necessary on a pulpless tooth? 
5. Is antibiotic coverage indicated, pre-med. or post-op?
6. Decide what you can realistically hope to accomplish in the time allotted
7. Are the instruments you’ve chosen, appropriate for the case? From the pre-op. radiograph, measure and check to see if 25 mm files will be the right length--(if not, 21mm or 30mm are available from the Clinic Coordinator) Plan ahead!

Before the patient leaves:

1. Is the tooth out of occlusion; a double thickness of articulating paper should be able to be drawn over the surface when all posterior only are in occlusion.
2. Is it necessary to obtain a prescription for antibiotics or analgesics from the faculty
3. Post-operative instructions (rinsing, sensitivity, eating, etc.)

Promotion Policies

A. Promotion from DMD III to DMD IV or AS I to AS II

The student must establish satisfactory progress in endodontics during the DMD III or AS I academic years to justify promotion into the DMD IV or AS II academic years. The student can accomplish this by demonstrating satisfactory performance, with faculty guidance and evaluation, in the following:

1. Diagnosis of pulpal and periradicular diseases.
2. Development of treatment plans for the management of teeth with pulpal and periradicular diseases.
3. Completed mandatory endodontic assisting; performed on one or two of the following endodontic procedures, including pulpotomy, pulpectomy or root-canal therapy.
4. Postdoctoral Endodontic Experience. As part of their DMD III or AS I endodontic education, students will be required to observe/assist postdoctoral endodontic residents in the performance of two non-surgical endodontic procedures. The experience should include observation /assisting cleaning,shaping and obturation in the postdoctoral clinic. Attendance will be monitored and is mandatory. Attendance of the two sessions will be part of the requirement for promotion to the DMD IV and AS II academic years.

B. DMD IV / AS II Academic Years

In order to demonstrate competency a student should complete the following, independently and unsupervised:

1. Successfully pass the DMD III / AS I academic years.
2. Complete his/her emergency rotation (OD 640) 
3. Demonstrated technical skills consistent with those of a general dentist, in performing endodontic procedures independently on teeth with relatively uncomplicated root canal systems.

*Externship: Students will receive credit for work done on externship. (Provided the grading at the externship site is calibrated in a similar fashion to BUSDM.)

To be eligible for graduation a DMD IV / AS II student must:

1. Receive passing grades in all didactic, pre-clinical and clinical courses.
2. Demonstrate competency in the aspects of the basic and clinical science of Endodontics as previously described.

top