ENDODONTIC

EMERGENCIES
 Introduction
Definition
Difference between emergency and urgency
Diagnosis and management
Classification
Acute pulpitis
Acute alveolar abscess
Esthetic emergencies
Emergencies during the treatment
Post endodontic treatment emergencies
Conclusion
References

28-1-10 2
 INTRODUCTION
Emergency: Any urgent condition perceived by the
patient as requiring immediate medical or surgical
evaluation or treatment.

A sudden, urgent, usually unforeseen occurrence

requiring immediate attention.

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Dental emergency :
An acute condition affecting the teeth, such as
inflammation of the soft tissues surrounding teeth or
past treatment complications of dental surgery

Endodontic emergency:
Defined as an unscheduled visit associated with pain
or swelling from pulpoperiapical pathoses requiring
immediate diagnosis and treatment

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 1/3rd of all dental emergencies are from endodontic
origin

90% of emergencies with pain as symptom, the pain

is pulpal or periapical

In every year a number of on working days and

school days are lost due to dental pain in the world.

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 DIFFERENCE

Emergency Urgency

A condition requiring Indicates a less severe

an unscheduled office problem; a visit may be
visit with diagnosis and
treatment to be done scheduled for mutual
immediately , here the convenience of the
visit cannot be patient and the dentist
rescheduled because of
the severity of the
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problem. 6
 CLASSIFICATION
According to WALTON & TORABINEJAD

1.Pre treatment emergencies

2.Interappointment emergencies
3.Post treatment emergencies

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According to Grossman
1.Acute conditions
a. Reversible pulpitis
b. Irreversible pulpitis
c. Alveolar abscess
d. Periodontal abscess
2. Emergencies during treatment
3. Fractures
I. Crown
II. Root
4.Avulsed tooth
5.Reffered pain
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BDJ: Vol 197 no 6 sep 2004; 299-305

Before treatment
1. Pulpal pain
2.Acute periapical abscess
3.Cracked tooth syndrome
During treatment
1. Recent restorative treatment
2. Periodontal treatment
3. Exposure of pulp
4. Fracture of root or crown
5. Pain as a result of instrumentation
a. Acute apical periodontitis
b. Phoenix abscess
9
28-1-10
3 Ds of successful
management
Diagnosis
Definitive treatment
Drugs
 Diagnostic sequence
Obtain information about the patients medical and dental
histories.
Ask pointed subjective questions about the patients pain:
history, location, severity, duration, character, eliciting
stimuli.
Perform extraoral examination
Perform intraoral examination
Perform pulp testing procedures.
Use palpation and percussion sensitivity tests to determine
periapical status
Proper Interpretation of radiographs
Rapid and accurate diagnosis are important in the treatment of
endodontic emergencies

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 SIGN - An objective evidence of a disease, such
evidence as is perceptable to the examining
physycian.

SYMPTOM It is a subjective , not usually visible to

others, symptoms are the patients experiences about
the illness, disease, or injury.

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 Most of the times patient
comes with chief
Complaint of
Pain,
Swelling,
Transient loss of function.
Esthetic abnormalities.

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 ACUTE PULPITIS
Acute reversible pulpitis:
It is a mild to moderate inflammatory condition of the
pulp caused by noxious stimuli in which the pulp is
capable of returning to the uninflammed state
following removal of the stimuli

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SYMPTOMS

Short duration pain

Does not linger
Non tender to percussion
Might be difficult to localize
Might give an exaggerated response to vitality tests
No radiographic significance.

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CAUSES

Caries close to the pulp

Premature contact
Recurrent caries
Occlusal trauma
Thermal Shock
Microleakage
Galvanic shock
Chemical irritation - sweet or sour food
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 Choice of Treatment (Grossman)
The best treatment is prevention,

Protective base under restorations.

Avoid marginal leakage.
Occlusal reduction.
Avoid excessive heat during cavity preperation
Palliative treatment
Zinc oxide eugenol interim restoration
If pain disappears restoration
If not - Pulp extirpation.

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 ACUTE IRREVERSIBLE
PULPITIS
It is the persistent inflammatory condition of the
pulp, caused by a noxious stimuli

Abnormal sensation to cold

Abnormal sensation to hot

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SYMPTOMS

There is often a history of spontaneous bouts of pain which

may last from a few seconds up to several hours

When hot or cold fluids are applied, the pain elicited will be
more significant; cold may relieve the pain

Pain may radiate initially, but once the periodontal ligament has
become involved the patient will be able to locate the tooth

The tooth becomes tender to percussion once inflammation has

spread to the periodontal ligament

A widened periodontal ligament may be seen on the

radiographs in the later stages
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Causes

Bacterial involvement of pulp through caries.

Other factors-chemical, thermal, mechanical, or

galvanic irritation

Reversible pulpitis may deteriorate in to irreversible

pulptis
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Treatment

Anesthetize the affected tooth.

Apply rubber dam.
Prepare access cavity.
Remove the pulp from the chamber
Locate the root canal orifice.
Extirpate the pulp by sequentially. Instrumenting
with reamer or files or broaches to within 1mm
short of apex
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 Irrigate with sterile saline solution, NaOCl solution.
Dry the root canal with sterile absorbent points.
Insert a medicated cotton pellet moistened with an
obtudant.
Place a temp filling .
Relieve the occlusal trauma.
Analgesic if required

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 PULPOTOMY
Conditions where pulpectomy is not possible in
multirooted teeth
Anesthetize the affected tooth.
Apply rubber dam.
Prepare access cavity.
Remove the pulp from the pulp chamber with
spoon excavator or round bur
Cotton pellet moistened with formocresol is
placed in the cavity and it is sealed with
ZnOE
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 ACUTE ALVEOLOR ABSCESS
Localized collection of pus in the alveolar bone at the
root apex of the tooth following death of pulp with
extension of infection through the apical foramen into
the periapical tissue.

CAUSES

Bacterial involvement
H/0 of trauma
Mechanical or chemical irritation
Pulpitis or pulpal necrosis.
Exacerbation of chronic periapical lesion.
Endodontic-periodontic lesion ,deep pocket.
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 In severe conditions this odontogenic
infection can spread into the adjacent
soft tissues and leads to life threatening
complication called as cellulitis.
Bacteria mainly involving the acute cellulitis are
staphylococcus group
They produce hyluronidase, fibrolysin, collagenase
that breakdown the intercellular cementing substance.
This allows infection to spread rapidly
into the facial spaces and cause life
threatening situation

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 Simultanious bilateral spread of infection into
submandibular, sublingual and submental space s is
called as ludwigs angina.

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 PHLEGMON:

A massive cellulitis that does not go to suppuration

proceeds towards fast inflammatory infiltration of
subcutaneous tissue.

Skin is bluish in color because of

tissue cyanosis

Streptococcus haemolyticus

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 SYMPTOMS
Local reactions: SYSTEMIC REACTIONS:
Tenderness of tooth Elevated temperature
Severe throbbing pain GI disturbances
Swelling Malaise
Sinus tract nausea
Dizziness
Lack of sleep

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 DIAGONSIS
Pain and presence of swelling

Mobility of tooth

Non responsiveness to pulp testing

Sensitiveness to percussion

Small or large or diffuse radiolucency in radiographs

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 Apical trephination
TREATMENT

Local anesthesia
Isolation
Access cavity
If drainage does not occur, apical foramen is
enlarged to 25, 30 no size to obtain the drainage.
apical trephination .(weine)
If time permits, complete cleaning and shaping of
the canals .
Irrigation with NaOCl.
Closed dressing given with ZnOE/ Placement of
intracanal medication
Adjustment of occlusion
If systemic involvement is present prescribing the
antibiotics and analgesics.
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 BRITISH DENTAL JOURNAL VOL 198 NO. 12 JUNE 25 2005

Incisional drainage is the first principle in

management of acute dentoalveolar infection.
Penicillin-resistant bacteria are often present in acute
dental infection.
The presence of penicillin resistant bacteria does not
adversely affect the outcome of treatment even if
penicillin is prescribed.
It is likely that antibiotic therapy is often prescribed
unnecessarily in treatment of acute dental infection

28-1-10 31
 TRAUMATIC AND
EASTHETIC EMERGENCIES
Traumatic injury to a tooth can cause
1 cracked crown
2. fracture crown
3. fracture root

It can be broadly classified as

1. Crown fracture
2. Root fracture

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 CRACKED TOOTH
SYNDROME
Incomplete fracture of a vital posterior tooth that involves the
dentin and occasionally extends into the pulp

A fracture plane of unknown depth and direction passing

through tooth structure that if not already involving, may
progress to communicate with the pulp and
or periodontal ligament

30-50 years of age.

Mandibular 2nd molars > Mandibular 1st

molars > Maxillary premolars

Men = Women
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Two classic patterns of crack formation

1. Crack is centrally located and following the dentinal

tubules may extend to the pulp

2. Crack is more peripherally directed

and may result in cuspal fracture

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Symptoms:

Sensitive to hot and cold

Pain upon biting and rapidly ceases after
relieving the pressure

Diagnosis:

Thorough dental history.

History of trauma,
Clenching or bruxism and chewing habits.
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 Examine the teeth with an explorer

Check hot and cold sensitivity tests. If a sharp pain is

felt with temperature, and the pain rapidly diminishes
with removal of the stimulus, - fracture is more likely
present.

Probe the gum tissue for pockets

Check for a cracked filling, removal of filling help

to visualize the crack

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1. Transillumination method

2. Tooth Slooth technique

3. Use of dyes

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 Treatment

ASSESSMENT
OF TOOTH

LARGE SMALL
CRACK CRACK

WITHOUT PULP WITH PULP RESTORE WITH

INVOLVEMENT INVOLVEMENT COMPOSITE

STABILIZE THE TOOTH. STABILIZE THE TOOTH ,

OCCLUSAL ADJUSTMENTS, EXTIRPATE THE PULP,
PERMANENT STABILIZATION, ENDODONTIC THERAPY,
BONDED OR CAST CAST RESTORATION
RESTORATION

VERTICAL FRACTURES WITH HOPELESS

Dental traumatology 2006
PROGNOSIS SHOULD BE EXTRACTED
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 TOOTH FRACTURE
Most common cause is trauma,

More common in children

Fracture of tooth or teeth mainly depends on the

Energy of Impact
Mass and velocity of object
Resilience of the object
Shape of the object
Angle of direction

28-1-10 39
 CLASSIFICATION (Ellis)
Class I Only enamel fracture
Class II Enamel + Dentin
Class III Enamel + Dentin + pulp
Class IV Non vital with or with out
crown fracture
Class V Avulsion
Class VI Root fractures
Class VII Displacement
Class VIII Fracture of crown enmass
Class IX Deciduous tooth fractures
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 WHO CLASSIFICATION
873.60 enamel fracture
873.61 crown fracture involving enamel and dentin
with out pulp exposure
873.62 crown fracture with pulp exposure
873.63 root fractures
873.64 crown and root fractures
873.66 luxation
873.67 intrusion or extrusion
873.68 avulsion
873.69 other injuries

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Andreasens modification
873.64 unclomplicated crown and
root fractures
873.64 complicated crown
and root fractures.
873.66 concussion injury
873.66 subluxation
873.66 lateral luxation

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 HEITHERSAY AND MORILE
Class 1: fracture line does not extend below the level
of the attached gingiva

Class 2: fracture line extends below the level of the

attached gingiva, till level of alveolar crest.

Class 3:below the level of alveolar crest

Class 4: fracture line with in the coronal third of the

root, below the level of the alveolar crest

28-1-10 43
 In general tooth fractures can be grouped into 5
major categories

Fractures with out pulp

exposures
Fractures with pulp
exposures
Root fractures
Tooth avulsion
Luxation of tooth

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 TOOTH FRACTURE WITHOUT
PULP INVOLVEMENT
Ellis class I, II,
WHO classification 873.60, 61
They are ranging from chipping of
enamel to deep dentinal fractures

Treatment :
Only enamel fracture: Composite restoration
Dentin involvement :
Immediate : applying hard setting calcium hydroxide
bonded resin restoration.base
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 FRACTURE OF CROWN WITH
PULP EXPOSURE
Vital pulp exposures

Apex closed root canal treatment

Open apex pulpotomy, partial
pulpotomy, or apexogensis,

Necrotic pulp exposures

Open apex apexification

28-1-10Closed apex- root canal treatment 46
 TOOTH AVULSION
Avulsed tooth is a dental and
emotional problem

Main cause is trauma

Ellis class V

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 Reimplantation
Time Treatment Success rate

hr Immediate 80 %
reimplantation then
RCT
< 2 hrs Reimplantation 40 60 %
followed by
immediate RCT
> 2 hrs First endodontic 20 40 %
treatment later
reimplantation
> 12 hrs Better to discard the -
tooth.
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 MANAGEMENT (WEINE)
Part I (emergency treatment at the site of injury)
Cleaning the tooth under the running water

Reinsertion of tooth into the socket and

attain firm pressure .

If reinsertion not possible place the tooth

in the transport media

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Part II (emergency treatment at the dental office ):

Place the tooth in the saline

Health history, examination of area, radiographs
Wiping the gross debris from the root surface with
wet sponge
Irrigate the socket with saline
Reimplant the tooth
Check the position with radiographs
Splint with arch wire and composite

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 Part III (completion of endodontic treatment)

Closed apex - One week after replantation RCT is

adviced
Open apex watched with out pulp extirpation
Stabilization period 1 week
Post operative instructions
Soft diet
Antibiotics and analgesics for 1-4 days

Use of emdogain is controversial

JCDA January 2000, Vol. 66, No. 1
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TRANSPORT MEDIA

Saline

Distilled water

Milk

Oral vestibule, own saliva

HBSS (Save A Tooth Solution)

Coconut water

Viaspan
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28-1-10 53
Prognosis: Follow up

Time elapsed between 1w, 1m, 3m, 6m, 12m,

the injury and
reimplantation and annually for 5yrs

Fracture of alveolus

Blood clot in socket

Direct mud at site

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Fate of Reimplanted Tooth

Tooth may maintain vitality

Periodontally sound tooth may result

Possible external resorption

Ankylosis

If no endodontic treatment is done internal

resorption
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 ROOT FRACTURE
Ellis class VI
873.63

Can be divided into

Vertical &
Horizontal
1. Coronal
2. Middle
28-1-10 3. Apical third 56
 On the basis of level of root fracture in
relation to various horizontal plane of
periodontium
Class 1:fracture line nearing the
gingival attachment.

Class 2: fracture line extends below

the level of the attached gingiva but
not below the alveolar crest

Class 3: fracture line with in the

coronal one third of the root, but
below the level of alveolar crest

Class 4: when fracture line extends

below the level of the alveolar crest,
but with in middle third of the root

Class 5: when fracture line is in the

apical third of the root
28-1-10 57
 HORIZONTAL ROOT
FRACTURES
Diagnosis:
Patients history
Visual examination
Radiographs
Pulp vitality tests

Prognosis:
Location of the fracture
Root development
Direction of fracture
Displacement of fractured segment
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 Sequelae to root fractures (Andreasen)

Healing with calcified tissues.

Healing with interproximal connective tissue.

Healing with interproximal bone.

Healing with granulation tissue.

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 Treatment
Non surgical

No mobilty no treatment

Mobile coronal fragment repositioning

stabilization (4-6weeks)

Nonseparated segments: Root canal therapy for both the

segments and stabilization with interradicular splints

Separated segments: RCT for coronal segment only (apical

segment with vital tissue) . (cohen& burns)
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Surgical treatment (weine)
Apical 1/3rd fractures: rct of coronal segment only, apical
segment is left, it may heal, resorb in most instance does
not cause any problem.

Middle 1/3rd fractures: placement of cr-co pin joining

coronal and apical segment.

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VERTICAL ROOT FRACTURE
Etiology:

1. Physical traumatic injuries

2. Occlusal prematurities
3. Para functional habits
4. Resorption
5. Iatrogenic factors
Placement of posts
Forceful insertion of large sized files into
the canal, Vertical condensation

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 Vertical root fracture

28-1-10 63
Patients history Clinical examination
H/o of trauma, Crack probing

seizure disorders, Selective sensitivity by

bite tests
stroke,
Sinus tracts
Miocardial infarction,
Dental operating
Parafunctional habits microscope
Surgical exposure
28-1-10 Illumination and dyes 64
 Periodontal examination:
Narrow deep isolated pocket probe movement from
side to side is restricted

Radiographic examination:
1.Halo like bone loss (J shaped lesion )
2.Isolated bone loss
3.Radiolucent space between the long axis of the material
and canal wall
28-1-10 65
 TREATMENT
Extraction :

Single rooted teeth with vertical root fractures

Multirooted teeth with multiple root fractures

Hemisection:

Multirooted teeth with fracture confined to one root

only

Multirooted teeth with fracture confined to furcation

only
28-1-10 66
 LUXATION
Abnormal mobility of the tooth with in the socket
with or without displacement as a result of trauma or
injury

Five types of luxation injuries (Andreasen)

Concussion
Subluxation
Extrusive luxation
Lateral luxation
Intrusive luxation

28-1-10 67
 Concussion : injury to supporting structures without
abnormal loosing or displacement

Subluxation: injury with abnormal

loosing

Extrusive luxation: partial displacment

of the tooth out of its socket Intrusion

Lateral luxation: eccentric displacement

with fracture of alveolar socket

Intrusive luxation: displacement of

tooth deeper into the alveolar socket
28-1-10 68
 Subluxation

Extrusive luxation

Lateral luxation

Intrusive luxation

28-1-10 69
 TREATMENT
Concussion: requires only
relieving pressure by selective
grinding

Subluxation: occlusal relief

and splinting for 7-12 days

Extrusive luxation: reposition

and splinting it for 2-3 weeks

28-1-10 70
 Lateral luxation: reposition and splinting it for
15 days

Intrusive luxation:
1. repositioning immediately
2. wait and see with the hope that the tooth will re erupt
on its own

28-1-10 71
 EMERGENCIES WHEN THE
PATIENT IS UNDER
TREATMENT (FLARE UP)
Etiological factors
High filling
Micro leakage
Micro exposure of pulp
Thermal or mechanical injury during cavity
preparation or an inadequate lining under metallic
restorations
Chemical irritation from lining or filling materials
Electric effect of dissimilar metals

28-1-10 72
 Periodontal treatment
Exposure of pulp
Fracture of root or crown
FACTORS (WALTON):

Irritants with in the pulp

system

Iatrogenic factors

Host factors

28-1-10
General systemic factors 73
 EMERGENCIES
Acute apical periodontitis

Recrudescence of a chronic
apical abscess

Hypochlorite accident

Ingestion or Aspiration of
the instrument

28-1-10 74
 ACUTE APICAL
PERIODONTITS
Over instrumentation
Forcing the debris into the
periapical tissues

Symptoms :
Sensitive to percussion
Pain on biting
Throbbing and gnawing type of pain

Treatment :
NSAIDS, ketorolac, diclofenac , or Ketoprofen.
75
28-1-10
JCDA March 2003 vol 69 no 3. ( sackett)
1. Grade A NSAIDS preoperatively.

2. Grade B Antibiotics not recommended.

3. NSAIDS used as a solution.

4. Grade C - Corticosteroids have a weak

5. evidence in pain management.

28-1-10 76
 RECRUDESCENCE OF A
CHRONIC APICAL ABSCESS
Phoenix abscess
Chronic lesion become acute after
the first endodontic treatment.

Mechanism:
Recrudescence = breaking out
Facultative anaerobes multiply
rapidly after canal is opened by endodontic therapy
Canal instrumentation reduces some strains and some
virulant bacteria will grow rapidly

28-1-10 77
Symptoms:
Mobility, tenderness to percussion and swelling

Treatment :
Incision and drainage through the root canal
Initial exudation: irrigation with warm saline
If drainage shows resistance- leave the tooth open
Closed dressing 2-5 days later
If drainage is stopped closed dressing

28-1-10 78
 HYPOCLORITE ACCIDENT
Expelling of NaOCl beyond
the apex
This is due to locking the
needle of the irrigating
syringe in the canal and
forceful injecting the
irrigant
Symptoms :
Sudden extreme pain with
in mins after the irrigation
Swelling with in minutes
Profused prolonged
28-1-10
bleeding. 79
 1EJ Vol 39 2008

IEJ Vol 42 2009

28-1-10 80
 IEJ, vol 41, 2008

28-1-10 81
 TREATMENT
Allow the bleeding to
continue ,

Antibiotics, analgesics
for five and three days
respectively .

Prescribing anti
histamines (since it
should be considered as
hypersensitive reaction)

28-1-10 82
 ASPIRATION OR INGESTION
A serious problem, life threatening event.

Operator is responsible

Recognition:

Sudden disappearance of slipped instrument

Sudden violent gagging or spasmodic coughing ,

wheezing, decrease breathing sounds by the patient .

Radiographic evidence of presence of file in the

alimentary tract or airway
83
28-1-10
 TREATMENT
Radiographic examination
To know nature and size of the foreign body.

Antero-posterior chest radiograph.

Lateral chest radiograph.

Lateral neck radiograph

Supine abdominal radiograph.

28-1-10 84
 The draw back with these radiographs is limitation for
radio opaque objects, in this scenario the following
are considered.

Gastroscopy.
Bronchoscopy.
Computed tommography.
Monitoring of physical signs.
Test of stool for occult blood.
28-1-10 85
 If the instrument is in pharyngeal pouch and
oesophagus try to locate and remove with blunt long
tweezer
Instrument is in lungs surgical intervention.
Bronchus causing problem remove it surgically .
If it is in the alimentary tract monitor
radiographically and physical signs.
Advice the patient to take fibre diet so that it provides
better movement.
Usually it passes in faeces, if not remove surgically.

Prevention of these accidents is done by the universal

use of rubber dam and using a dental floss tied to the
instrument.
International Endodontic Journal, 41, 617622, 2008
28-1-10 86
At the time of ingestion 3 Hrs after , in small 2nd day, in the caecum 3rd day no evidence
Lower part of stomach. intestine of large intestine. of instrument.

28-1-10 International Endodontic Journal, 41, 617622, 2008 87

PREVENTION OF FLARE UPS
Proper diagnosis

Determination of correct working length

Radiographs

Apex locaters

Complete extirpation of pulp

Proper Irrigation

Aviod filling too close to radiographic apex

28-1-10 88
 Perform apical trephination only if necessary

Reduce the tooth from occlusion if apex is severely

violated by over instrumentation

Placement of intracanal medicament

Prescription of mild analgesics and antibiotics whenever

condition warrants it

28-1-10 89
 POST ENDODONTIC
TREATMENT
High restoration

Overfilling

Underfilling

Root fracture

28-1-10 90
 MANAGEMENT
Occlusal correction and removal of high points in
the restoration
Prescription of analgesics and, if the pain is more
severe and infection is present, antibiotics
An attempt at removal of the root filling and
repreparation of the root canal
Periradicular surgery

28-1-10 91
 REFERENCES

1. ENDODONTIC PRACTICE GROSSMAN

2. ENDODONTICS WEINE
3. PRINCIPLES AND PRACTICE OF ENDODONTICS WALTON
4. PATHWAYS OF PULP STEPHEN COHEN AND BURNS
5. ENDODONTICS- INGLE AND BACKLAND

JOURNALS
BDJ vol 197 No 6, Sept 2004 p 299 305
The crack tooth syndrome, JCDA Sept 2002, vol 168,No 8,
Preoperative pain and medications used in emergency patients with
irrevercible acute pulpitis and acute apical periodontitis a prospective
comparitive study. Journal of orofacial pain.Volume 21, Number 4, 2007
Emergency management of acute apical periodontitis, JCDA, Mar 2003
69, 169
28-1-10p 92
 Midtreatment flareups in endodontics, A dialemma. Dr Neeta shetty.
Journal of orofacial pain 2007 vol 21, nov 4
Pain associated with root canal treatment. 2009 feb 4 journal of orofacial
pain.
Microflora in teeth associated with apical periodontis, IEJ 2009
A double blind comparison of a supplimenal intraligamentary fantanyl
mepivacaine injection with 1;200000 epinephrine for irreversible pulpitis,
journal of pain and symptom management.
Clinical management of avulsed permanent incisor, JCDA Jan 200 vol 66
No 1
Analysis of 154 cases of teeth with cracks ,Dental traumatology 2006
An outcome audit of the treatment of acute dentoalveolar infection , impact
of penicillin resistance.BDJ vol 198 no 12 jun 25 2005.
A life threatening event from poorly managed dental pain. BDJ vol, 202 No
4Feb 24 2007
28-1-10 93
 Emergency management of acute apical periodontitis in permanent
dentition. review, March 2003 vol 69 no 3 JCDA
A systematic review of the diagnostic classification of traumatic dental
injuries , Dental traumatology, 2006
Gingival and bone necrosis caused by accidental NaOCl injection instead
of anaesthetic solution. IEJ Vol 41 2008
Accidental injection with NaOCl; A case report. IEJ Vol 42 2009
Palatal mucosal necrosis because of accidental NaOCl injection instead of
anaesthertic solution. IEJ Vol 39 2008
Accidental swallowing of an endodontic file.IEJ Vol 41 2008

28-1-10 94
THANK YOU

28-1-10
Have a nice day 95