YEAR OF 2020-2021

TOTAL PAGES 110

Notes Endodontics
Abdallah IM Younis
Dental student level 3
1st edition
2020-2021

©2020, Abdallah Younis

Self publishing

No part of this book (Notes in Endodontics) may be reproduced or used in any manner
without written permission of the copy right owner.

Author’s Email: ayounis@hotmail.com

 Notes in Endodontics
1- Chapter One ( Introduction to Root Canal Treatment )
(a) Definitions

Root canal treatment: Is a dental procedure used to treat infection at the centre of a tooth.
Root canal treatment is not painful and can save a tooth that might otherwise have to be
removed completely

Pulpitis: A clinical and histologic term denoting inflammation of the dental pulp;
clinically described as reversible or irreversible and histologically described as
acute, chronic or hyperplastic.

(b) Root canal treatments

Classificatiom of root canal
treatments

Non-Surgical Root Surgical Root

Canal Treatments Canal treatments

indirect pulp Direct Pulp

Pulpectomy Apecioetomy
capping capping

Partial Complete
Apexofication
Pulpotomy Pulpotomy

Apexogenesis

(b.1) Non –surgical root canal treatments

pulpectomy (pulp extirpation): The complete Indications:

removal of the dental pulp. -Deep carious lesion extended to pulp portion in
permanent teeth with complete root formation.
- Large pulp exposure - Inflamed tooth –
Contraindications:
Tooth with a root fracture- highly resorbed root-
Pervious failures of pulpectomy-teeth with
incomplete root formation- Calcific pulp canal-
excessive present of pulp stones- Tooth with little
or no pulp exposure during caries removal.

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 Indications:
pulpotomy (pulp amputation): The removal -Exposed vital pulps in carious primary
of the coronal portion of a vital pulp as a means teeth
of preserving the vitality of the remaining - Exposed vital pulps in carious immature
radicular portion; may be performed as permanent teeth .
emergency procedure for temporary relief of emergency procedure for temporary relief of
symptoms or therapeutic measure. symptoms or therapeutic measure (Cvek
pulpotomy)
Contraindications:
Necrotic Pulp, Excessive and non-stoppable
bleeding even with use of vasoconstrictors,
chlorhexidine or sodium hypochlorite.
indirect Pulp Capping: It takes place within Indications: Thin layer remaining of dentin
the elimination of deep caries (reversible with or without caries
pulpitis) in which there is a final thin layer of Pinkish spot appears underlying the thin
dentin, if this layer had been removed the dentin.
pulp may expose.
A dental material is placed on thin layer to Contraindications: Microleakage, excessive or
protect the pulp and promotes reparative dentin large pulp exposure.
formation(e.g. Mineral Trioxide aggregate).

Direct Pulp Capping: It takes place within Indications: minimal pulp exposure size with
elimination of deep caries and the dental pulp minimal bleeding .
become exposed. A dental material is placed Contraindications: large pulp exposure with
directly over the exposed pulp to protect and excessive bleeding
promotes the formation of reparative dentin.
Apexofication : A method to induce a calcified Indications: immature permanent teeth that are
barrier in a root with an open apex or the non-vital with incompletely formed roots.
continued apical Contraindications: Mature permanent teeth,
development of an incompletely formed root in vital teeth.
teeth with necrotic pulps.

Apexogenesis: A vital pulp therapy procedure Indications: Immature vital permanent tooth
performed to encourage continued physiological Contraindications: Mature teeth, non vital
development and formation of the root end; immature teeth.
frequently used to describe vital pulp therapy
performed to encourage the continuation of this
process.

(b.2) Surgical Root Canal treatment

In this treatment we perform a minor surgical procedure called apicoectomy. apicoectomy is the
surgical removal of the apical portion of a root and adherent soft tissues; may be performed in
advance of root-end preparation for a root-end filling or as a definitive treatment.

Indications

1. When a non-surgical root canal treatment fails

2. When the infection threaten the bony structure after the non-surgical root canal treatment
3. When there are pulp stones in the canals and it is hard to perform the non surgical treatment.
4. Where there are procedural errors in non-surgical root canal treatment (e.g instrument
fragmentation).

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5. Anatomic variation (e.g root dilacerations).

2-Chapter Two (Biology, Pathology and Microbiology of Endodontium )

Endodontium (dentin-pulp complex): It comprises of dentin and pulp.

Dentin and pulp are related to each other:

 Both are derived from dental papilla.

 Dentinal tubules contain the odontoblastic process of the odontoblast and the cell
body is located at the pulp.
 Dentin provides protection for pulp, while pulp innervates dentin with nutrients.

Dentin: It is a calcified connective tissue composed of 70% inorganic material (hydroxyapatite),

20% organic (mainly collagen) and 10% water (by weight). Dentinal tubules are the major
channels for fluid diffusion across dentin.

Pulp: It is a mass of connective tissue that resides within the center of the
tooth, directly beneath the layer of dentin. Composed of blood and lymph
vessels nerves, and interstitial fluid.

Root canal system: The space containing the dental pulp inside the crown
and root of a tooth. [ Coronal( Chamber) + Radicular (Pulp canal)]

The dental pulp is divided into coronal and radicular(Root canal).

Figure 1.0 Dentin
(a) Coronal part- present in the crown
- The coronal part consist of pulp chamber and pulp horns. (Note: Coronal part = pulp
chamber).
- Each pulp chamber has a roof at its incisal or occlusal border often with projections
called pulp horns, and the pulp chambers of multi-rooted teeth have a floor at the cervical
portion with an opening (orifice) for each root canal
- Pulp horns: are protrusions of the dental pulp toward the dentin.
The number of pulp horns found within each cusped tooth (molars, premolars, and
canines) is normally one horn per sizeable cusp, and in young incisors, it is three (one
horn in each of the three facial lobes, which is the same as one lobe per mamelon). An
exception is one type of maxillary lateral incisor (called a peg lateral with an incisal edge
that somewhat resembles one cusp) that has only one pulp horn.

3
Figure 1.2 Parts of the pulp

4
Guide line of the number of
pulp horns in permanent
teeth
Teeth Number of cusps Number of horns
Maxillary Central Incisor - 3
Maxillary Lateral Incisor - 3 (only 1 in peg lateral)
Maxillary Canine 1 1
Maxillary First Premolar 2 2
Maxillary Second Premolar 4 4
Maxillary First Molar 3 or 4 3 or 4
Maxillary Second Molar - 3
Mandibular Central Incisor - 3
Mandibular Lateral Incisor - 3
Mandibular Canine 1 1
Mandibular First Premolar 2 2 or 1 (lingual cusp may be to
small)
Mandibular Second Premolar 2-3 2-3
Mandibular First Molar 5 5
Mandibular Second Molar 4 4

(b) Radicular Part (Root Canal Pulp)

The part of the dental pulp contained within the root portion of the tooth.
- Begins at root orifice and end at the apical portion of the root to be continuous with the
periapical tissues through the apical foramen or foramina.
Root Canal Orifice: the opening of the canal system at the base of the chamber where the
root canal begins.

Major apical foramen:

The exit of the root canal onto the external root surface, which is normally located within 3
mm of the root apex.
Minor apical foramen/apical constriction:
The apical part of the root canal with the narrowest diameter which is generally 0.5–1.5 mm
from the major apical foramen. It is the reference point often used as the apical termination of
canal instrumentation and filling procedures.
Accessory canal:
A small canal leaving the root canal that (usually) communicates with the external surface of
the root or furcation. Hence, it can be located anywhere along the length of the root (coronal,
middle, or apical third) and can be any type (patent, blind, loop). It also includes what have
been in the past termed lateral canals. Apical delta (or apical ramifications) is the region at or
near the root apex where the main canal divides into multiple accessory canals (more than
two).

5
 Root Canal System

Coronal (Pulp Chamber) Radicular (Root or Pulp Canal)

(a) Pulp Chamber Roof

(a) Accessory Canals
(b) Horns
(b) Apical Foramen
(c) Pulp floor

6
 Root Apex Anatomy

The apex of root can be closed or opened. It is closed when the root of the
tooth is completely formed (Mature root), and opened when the root of the
tooth is not completely formed (Immature). The Anatomy of the apical section
include:

 Anatomic Apex: The tip or end of the root determined morphologically on an

extracted natural teeth. This anatomical apex may or may not coincide with
the apical foramen.
 Apical Foramen: The main apical opening of the root canal. It is also known
as the major foramen.
 Apical Constriction or minor foramen (Minor apical diameter, minor
diameter): The apical portion of the root canal having the narrowest diameter;
position may vary but is usually 0.5-1.0mm from the anatomic apex.
 Cementodentinal junction (CDJ): The region at which the dentin and
cementum are united commonly. Its position can be in the range 0.5-3.0mm
from the anatomic apex.

Apical Foramen

Figure 1.3 Apical Anatomy

7
 Radiographic Apex

It is the tip of the root as determined

radiographically, and its location can
vary from the anatomical apex due to
root morphology and distortion of the
radiographic image.

Figure 1.5
Radiographic apex

Mature and Immature Root

Immature permanent root: Root of young

permanent teeth with incomplete apex
formation (open apex).

Characteristics: open apex, large canal, and a

short root.

Types: Blunderbuss and tubular

Figure 1.6 Blunderbuss and

Tubular
Figure 1.5 Immature
Root

Mature root: Root of permanent teeth with a complete apex (closed apex)

Types: - Type 1 (Straight)

- Type 2 (Curved)

(a) Slightly curved

(b) Severe

(c) Dilacerated

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Root Canal Classification Systems

Root Canal Classification systems

According to Clearing techniques and

According to 3D (Micro CT and CBCT)
2d (Cross sectioning)

weine's Classification Vertucci's

New Classification System
System Classification System

Weine’s Classification System

Type I: a single main canal from the pulp chamber to the apex of the root.

Type II: two separate canals starting from the pulp chamber and joining as one, just short of the root
apex.

Type III: two separate canals starting from the pulp chamber to the root apex.

Type IV: a single canal starting from the pulp chamber and dividing into two canals near the root
apex.

9
 Figure1.8 Weine’s
Classification

Vertucci’s Classification System

Type I: a single main canal is present starting from the pulp chamber to the root apex.

Type II: two separate canals leave the pulp chamber but join to form one canal to the apex.

Type III: one canal leaves the pulp chamber and divides into two smaller canals which later merge
again to exit through one canal.

Type IV: two separate as well as completely distinct canals run from the pulp chamber to the root
apex.

Type V: there is a single canal exiting the pulp chamber which divides into two canals with separate
apical foramina.

Type VI: two separate canals join at the middle of the root to form one canal which extends till the
apex, just short of the apex, and again divides into two.

Type VII: the canal starts as a single until the middle third of the root then divides into two separate
canals that re-join after some distance and then, near the apex, divides into two again.

Type VIII: the pulp chamber near the coronal portion divides into three separate canals extending till
the apex .

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Supplementary Configurations to Vertucci’s Classifications System by Sert and Bayirli

Type IX: a single canal starts from the pulp chamber and, during its course, divides into three.

Type X: a single canal starts from the pulp chamber and divides into two, out of which one canal further divides
into two with two foramina.

Type XI: a single canal starts from the pulp chamber and divides into two, out of which one further subdivides
into two and runs as three canals and ends with four foramina.

Type XII: two separate canals start from the pulp chamber, out of which one further subdivides into two and,
later, all three join to form one canal with one foramen.

Type XIII: a single canal starts from the pulp chamber and divides into two canal which rejoins as one and
further divides into three canals with three foramina.

Type XIV: four canals starts from the pulp chamber, and later, two of each will join and end with two foramina.

Type XV: three canals starts from the pulp chamber, out of which two join to form one canal and end with two
foramina.

Type XVI: two canals start from the pulp chamber, out of which one further subdivides into two and ends with
three foramina.

Type XVII: a single canal starts from the pulp chamber and divides into three canals which again rejoin to form
a single canal with a single foramen.

Type XVIII: three canals start from the pulp chamber and rejoin to form a single canal with a single foramen.

Type XIX: two canals start from the pulp chamber and join as a single canal, further again divide into two, and
rejoin as one canal with a single foramen.

Type XX: four canals start from the pulp chamber and end with four foramina.

Type XXI: four canals start from the pulp chamber and join as a single canal with a single foramen.

Type XXII: five canals start from the pulp chamber and one joins with another and ends as four canals with
four foramina.

Type XXIII: three canals start from the pulp chamber, out of which one further divides into two and ends with
four canals with four foramina.

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Figure1.9 Vertucci’s
Classification
12
New Classification System

The new classification can be adapted for root and root canal configurations, but it does not include
the following anatomical variations in root and root canal system:

- Root Canal Curvature

-Canal Bifurcation and Root Fusion

-Accessory Canals and Apical Ramification

-Dens Invaginatus

-Taurodontism

-Supernumerary Roots and others

It includes codes for three separate components: the tooth number, the number of roots, and the root
canal configuration. Root Canal
Configuration

Number of Roots
𝑹𝑻𝑵𝑶−𝑪−𝑭
_ Number of
foramina
Tooth Number. Number of
Orifices Number of pulp
canals
Any tooth numbering system can be used, but
FDI is commonly used in this classification

a. Example on single rooted tooth (Maxillary Left Central Incisor):

𝑅
_ 𝑇𝑁 𝑂−𝑪−𝑭

Since the example on a single root, so the R will be replaced by 1

1
_ 𝑇𝑁 𝑂−𝑪−𝑭, so this is the general code for single rooted teeth

Number of Roots (Single root): 1 [R = 1]

Tooth Number: 21 (FDI)
Root Canal Configuration: Figure 1.10
-Orifice(s): 1
-Canal(s): 1
-Foramen: 1
1 1−𝟏−𝟏
_21 ( If the number of orifice, canal and foramen is the same then a single code is
1 1−𝟏−𝟏
used, so _21 → 1_211

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 b. Example on a single root tooth ( Mandibular left First Premolar)

Number of Roots (Single root): 1 [R = 1]

Tooth Number: 34 (FDI)
Root Canal Configuration:
-Orifice(s): 1
-Canal(s): 2
-Foramen: 2
1 1−𝟐−𝟐
_34 , Number of canals and foramina are the same, so write only one “2”
for both → 1_341−𝟐
c. Example on tooth with two roots ( Maxillary Right First Premolar)
-In this case we have two roots and both of the must be identified: [ R1 stands for Figure 1.11
root no.1 which is the buccal root, and R2 stands for Palatal root ] Each root has its
own pulp configuration (O-C-F)
; The general code for double rooted teeth is:

𝑅
_ 𝑇𝑁𝑅1 𝑂−𝑪−𝑭 𝑅2 𝑂−𝐶−𝐹

The canal classification of maxillary right first premolar is:

Root(s): two roots
Tooth Number: 14 (FDI system)
𝑹𝟏 : is the buccal root (B) . O-C-F are: 1-1-1, so single 1 is enough
𝐑 𝟐 : is the Palatal root (P) . OCF are 1-1-1, so single 1 is enough
𝐬𝐨:
2
_ 15B1 P1

[Lateral Canal must be neglected in this system, only major pulp canals is
counted]

Figure 1.12
For multi-rooted teeth the general code is:

𝑅
𝑇𝑁𝑅1 𝑂−𝑪−𝑭 𝑅2 𝑂−𝐶−𝐹 𝑅𝑛 𝑂−𝐶−𝐹
_

Rn: includes Identification of more than 2 roots (R1,R2,R3 ,etc..)

14
Distribution of frequencies (%) of roots, root canals and apical foramina in human
permanent teeth

Frequencies may vary from a study to another.

Nerve fibers in Endodontium

The nerve supply of the dentin-pulp complex is mainly made up of A fibres (both delta and beta)
and C fibres. They are classified according to their diameter and their conduction velocity.

A fibres are mainly stimulated by an application of cold, producing sharp pain.

C fibres produces a dull aching pain, and responsible for referred pain.

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Age Changes to Dentin and Pulp

Age-related changes in dentine include the formation of secondary dentine and the reduction in
tubular lumen diameter (dentine sclerosis), which lead to a reduction in the volume of
the pulp chamber. In Pulp: calcification, fibrosis, compromised circulation and innervation.

Pathology of Endodontium ( Dentin-pulp complex)

Pathology of the dentin-pulp complex can occur due to various factors, including trauma, erosion,
attrition, abrasion, scaling, decay, infection, or age-related changes. Some common pathologies of the
dentin-pulp complex include:

1- Dental caries: This is the most common pathology of the dentin-pulp complex. Caries is a
bacterial infection that causes demineralization of the tooth enamel and dentin, leading to
cavities. If the caries progresses to the pulp, it can cause inflammation and infection of the
pulp tissue.

2- Pulpitis: Pulpitis is inflammation of the pulp tissue, which can be caused by dental caries,
trauma, or other factors. There are two types of pulpitis: reversible and irreversible.
Reversible pulpitis is characterized by mild to moderate inflammation, while irreversible
pulpitis is more severe and can lead to necrosis (death) of the pulp tissue.

3- Dental trauma: Trauma to the tooth can cause damage to the dentin-pulp complex.
Depending on the severity of the trauma, this can lead to pulpitis, necrosis of the pulp tissue
or even resorption

4- Pulp necrosis: It is the death of the pulp tissue. This can occur due to untreated caries,
trauma, or other factors. Pulp necrosis can lead to infection and inflammation in the
surrounding tissues and can ultimately result in the loss of the tooth.

5- Root resorption: A pathological process that results in the loss of root structure of a tooth.
It can affect both primary and permanent teeth and can occur due to a variety of factors,
including trauma, infection, orthodontic treatment, and genetics.

There are two types of root resorption: internal and external. Internal resorption occurs within
the pulp chamber or root canal space of the tooth, while external resorption occurs on the
outer surface of the root.

16
 (A) Internal resorption is typically caused by trauma or infection that results in inflammation
of the pulp tissue. The cells responsible for resorption, known as odontoclasts, begin to
break down the dentin and other structures within the pulp chamber, leading to the loss of
root structure. Internal resorption can be difficult to detect as it may not cause any
symptoms until it has progressed significantly.

(B) External resorption, on the other hand, is typically caused by pressure or trauma to the
outside of the tooth, such as from orthodontic treatment or injury. It can also be caused by
a dental cyst or tumor that develops adjacent to the tooth, which can put pressure on the
root and cause it to resorb. External resorption is usually easier to detect as it often causes
changes in the appearance of the affected tooth or the surrounding bone.

Classification of Pulpal diseases

Grossman’s Classification of pulpal diseases

1. Pulpitis
i-Reversible  Acute ( Symptomatic)
Chronic (Asymptomatic)
i-irreversible  Acute ( Symptomatic) Abnormally responsive to cold and heat.
Chronic (Asymptomatic) *Asymptomatic with pulp exposure
* Hyper plastic pulpitis
* Internal resorption

2. Pulp Degeneration
i- Calcific
ii- Atrophic
iii- Fibrous

2- Pulp Necrosis

Reversible pulpitis is a temporary condition that can be caused by various factors, including caries,
erosion, attrition, abrasion, operative procedures, scaling, or minor injuries. The symptoms typically
include (if it was symptomatic):

• Pain that ceases after the stimulus is removed

• Difficulty in pinpointing the pain, as the pulp lacks proprioceptive fibers

• Normal radiographic appearance in the periradicular area

• Lack of tenderness in the teeth during percussion, except when occlusal trauma is present

The treatment usually involves covering the exposed dentin, eliminating the causative factor, or
dressing the tooth as required. However, if not treated promptly, reversible pulpitis can progress to an
irreversible stage.

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Irreversible pulpitis occurs due to more severe insults from the same list of factors mentioned above,
and it may often develop from a reversible state. However, the symptoms of irreversible pulpitis differ
significantly, such as:

• Pain may arise spontaneously or from stimuli

• Heat sensitivity may be more pronounced in later stages

• Response duration may vary from minutes to hours

• Pain becomes localized when the periodontal ligament is affected

• Radiographic examination may reveal a widened periodontal ligament in advanced stages

To manage irreversible pulpitis, root canal therapy is necessary.

Hyperplastic Pulpitis

Hyperplastic pulpitis is a form of irreversible pulpitis and is also known as a pulp polyp. It occurs as a
result of proliferation of chronically inflamed young pulp tissue. Treatment involves root canal
therapy or extraction.

Pulp Necrosis

Pulp necrosis occurs as the end result of irreversible pulpitis; treatment involves root canal therapy or
extraction.

Pulp calcification:

• Physiological secondary dentine is formed after tooth eruption and the completion of root
development

• It is deposited on the floor and ceiling of the pulp chamber rather than the walls and with time can
result in occlusion of the pulp chamber

• Tertiary dentine is laid down in response to environmental stimuli as reactionary or reparative

dentine

• Reactionary dentine is a response to a mild noxious stimulus whereas reparative dentine is deposited
directly beneath the path of injured dentinal tubules as a response to strong noxious stimuli. Treatment
is dependent upon the pulpal symptoms.

Periradicular Pathology As a Result of Pulpal Diseases or Treatment

Acute apical periodontitis can be caused by occlusal trauma, bacteria escaping from infected pulps,
toxins from necrotic pulps, chemicals, irrigants, or overinstrumentation in root canal therapy. The
tooth is tender to biting, and a radiograph may show widening of the periodontal space. Treatment
depends on the pulpal diagnosis and can range from occlusal adjustment to root canal therapy or
extraction.

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Chronic apical periodontitis results from pulp necrosis, and affected teeth do not respond to pulp
sensitivity tests. Tenderness to biting is usually mild, but some tenderness may be present when
palpating over the root apex. Radiographic appearance can vary from minimal widening of the
periodontal ligament space to a large area of periapical tissue destruction. Treatment involves root
canal therapy or extraction.

Condensing osteitis is a subtype of chronic apical periodontitis and occurs due to a diffuse increase
in trabecular bone in response to irritation. Radiographically, a concentric radio-opaque area is seen
around the offending root. Treatment is only necessary if symptoms or pulpal diagnosis indicate a
need.

An acute apical abscess is a severe inflammatory response to microorganisms or their irritants that
have spread into the periradicular tissues.

Microbiology of Endodontium

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Gram-negative bacteria are consistently found in primary endodontic infections and appear
to be the most common microorganisms involved. Various species from multiple genera of
gram-negative bacteria have been identified in infections associated with apical periodontitis,
including abscesses. These genera include Dialister (such as D. invisus and D. pneumosintes),
Fusobacterium (such as F. nucleatum), Porphyromonas (such as P. endodontalis and P.
gingivalis), Prevotella (such as P. intermedia, P. nigrescens, P. baroniae, and P. tannerae),
Tannerella (such as T. forsythia), and Treponema (such as T. denticola and T. socranskii).

Gram-positive bacteria are also frequently detected in the endodontic mixed consortium.
Some of these gram-positive species have even been found in prevalence values as high as the
most commonly found gram-negative bacteria. The genera of gram-positive bacteria often
found in primary infections include Actinomyces (such as A. israelii), Filifactor (such as F.
alocis), Olsenella (such as O. uli), Parvimonas (such as P. micra), Peptostreptococcus (such
as P. anaerobius and P. stomatitis), Pseudoramibacter (such as P. alactolyticus),
Streptococcus (such as S. anginosus group), and Propionibacterium (such as P. propionicum
and P. acnes).

20
21
Chapter 3- Endodontic instruments and biomaterials

1- Instruments
There are several classifications of endodontic instruments, but in this book, the following
classification will be discussed: Grossman classification according to function, ISO- FDI
classification, non-official classification (book classification) and Isolating instruments
(Rubberdam)
- Grossman classification according to function
a. Exploring instruments: for locating the canal orifice and determination of patency of the
root canal (e.g. explorer)
b. Debriding instruments: for pulp extirpation and removing of foreign debris (e.g. barbed
broches)
c. Shaping instruments: for shaping the root canal apically and laterally (e.g. files)
d. Obturation Instruments: for filling of the cleaned and shaped space canal (e.g. gutta
percha)

According to ISO-FDI (bases on use )

Group I: Hand use only e,g manual files
Group II: Engine driven latch type e.g. Glidden Gates and Peso reamers.
Group III: Engine driven Ni-Ti rotary instruments
Group IV: Engine 3D adjusting instruments
Group V: Engine riven reciprocating instruments
Group VI: Sonic and ultrasonic instruments

Essential Instruments and materials for Endodontic Therapy ( Book Classification )

(A) Diagnostic Instrument

- Mirror
- Tweezer
- Probe
- Explorer
- Sensibility test instruments
- Methylene Blue
(B) Cavity Access and Caries removal
-Burs ( Round and Endo Z)
-Ultrasonic Scaler
-Contra ( high speed and Low speed)

(C) Cleaning and shaping instruments

- Manual Files
- Rotary Files
- Glidden Gates
- Irrigating Agents
- Chelating Agents
- Ultrasonic tip for irrigation
- Irrigation syringe with side vented

22
 (D) Isolating Instrument
-Rubber dam Kit
-Cotton Roll
-Gingival barrier
- Retraction cord
-Vasoconstrictors
-Medications to control saliva
(E) Anesthesia
- Dental Syringe
- Local Anesthesia
- Topical Anesthesia
(F) Restoration
- Composite ( packable and flowable)
-Etch and bond
-Matrix and wedge systems

23