Endodontics
Endodontics: diagnosis drives the procedure
Endodontic success starts with the right diagnosis. Differentiate reversible pulpitis, irreversible pulpitis, necrotic pulp, and previously treated teeth using history, cold testing, electric pulp testing, percussion, palpation, and radiographs. Cold testing is the most reliable vitality test for most teeth; EPT can be misleading after trauma, and a negative response does not always mean necrosis. Percussion and palpation point to apical inflammation but do not measure vitality.
Access must be complete: remove the chamber roof, locate all canals, and confirm with magnification and apex locators. Establish working length with an electronic apex locator and confirm radiographically. Cleaning and shaping remove tissue and infected dentin while preserving canal anatomy. Irrigation matters: sodium hypochlorite dissolves tissue and disinfects, EDTA removes the smear layer, and chlorhexidine has a role when NaOCl cannot be used; never mix NaOCl and chlorhexidine directly because a precipitate forms. Avoid air pressure and extrusion of irrigant.
Obturation seals the canal, but the coronal restoration is equally important. Traps include treating a cracked tooth as routine endodontics, failing to find a missed canal, overinstrumenting curved canals, and prescribing antibiotics for irreversible pulpitis without systemic involvement.
Rule of thumb: if the tooth is restorable, the pulp diagnosis fits, and the canal anatomy is manageable, treat; if the tooth is cracked, perforated, or has an untreatable root, refer or extract. Example: a symptomatic tooth with deep caries, a lingering cold response, and no periapical radiolucency usually needs pulpectomy, not antibiotics.