2 Treatment of Pulpitis With Biological, Vital Amputational and Extirpation Methods-1

7/14/2019 2 Treatment of Pulpitis With Biological, Vital Amputational and Extirpation Methods-1

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Copyright 2003, Elsevier Science (USA). All rights reserved.

Treatment of pulpitis withbiological, vital amputationaland extirpation methods.

Testimony, sequence andfeatures of the stages.Efficiency of methods,

complication and methods of itsprevention.

Therapeutic dentistry department

Lecturer: as. Yavors’ka-Skrabut I.M.




Endodontics is the specialty of dentistrythat manages the prevention, diagnosis,and treatment of the dental pulp and the

periradicular tissues that surround theroot of the tooth.

Introduction




• Physical irritation • Most generally brought on by extensive

decay.

• Trauma

– Blow to a tooth or the jaw.

Causes of Pulpal NerveDamage




• Pain when biting down.• Pain when chewing.

• Sensitivity with hot or cold beverages.

• Facial swelling.

Signs and Symptoms of PulpalNerve Damage




• Subjective examination – Chief complaint

– Character and duration of pain

– Painful stimuli

– Sensitivity to biting and pressure

Endodontic Diagnosis




• Objective examination – Extent of decay

– Periodontal conditions surrounding

the tooth in question

– Presence of an extensive restoration

– Tooth mobility

– Swelling or discoloration

– Pulp exposure

Endodontic Diagnosis


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•

Percussion tests – Used to determine whether the

inflammatory process has extended

into the periapical tissues. – Completed by the dentist tapping on

the incisal or occlusal surface of the

tooth in question with the end of themouth mirror handle held parallel tothe long axis of the tooth.

Diagnostic Testing



• Palpation tests – Used to determine whether the

inflammatory process has extended

into the periapical tissues. – The dentist applies firm pressure to

the mucosa above the apex of the

root.

Diagnostic Testing- cont’d



•

Thermal sensitivity• Necrotic pulp will not respond to cold

or hot.

• Cold test

• Ice, dry ice, or ethyl chloride used todetermine the response of a tooth tocold.

• Heat test• Piece of gutta-percha or instrument

handle heated and applied to the

facial surface of the tooth.




• Electric pulp testing• Delivers a small electrical stimulus to the

pulp.

• Factors that may influence readings:

• Teeth with extensive restorations.

• Teeth with more than one canal.

• Failing pulp can produce a variety of

responses.• Control teeth may not respond as

anticipated.

• Moisture on the tooth during testing.

• Batteries in the tester may be weak.




Fig. 54-4 Placement of a pulp tester.



•

Initial radiograph – Diagnosis.

• Working length film

– Used to determine the length of the canal.

• Final instrumentation film – Taken with the final size files in all canals.

• Root canal completion film

–

Taken after the tooth as been temporized.• Recall films

– Taken at evaluations.

Radiographs in Endodontics



• Show 4-5 mm beyond the apex of the toothand the surrounding bone or pathologiccondition.

• Present an accurate image of the tooth withoutelongation or fore-shortening.

• Exhibit good contrast so all pertinent structuresare readily identifiable.

Requirements of EndodonticFilms




Fig. 54-5 Quality radiograph in endodontics.




• Normal pulp – There are no subjective symptoms or

objective signs. The tooth respondsnormally to sensory stimuli, and a healthylayer of dentin surrounds the pulp.

Diagnostic Conclusions




• Pulpitis – The pulp tissues have become inflamed.

• Reversible pulpitis

– The pulp is irritated, and the patient isexperiencing pain to thermal stimuli.

• Irreversible pulpitis

– The tooth will display symptoms of lingeringpain.





• Periradicular abscess – An inflammatory reaction to pulpal

infection that can be chronic or have rapidonset with pain, tenderness of the tooth topressure, pus formation, and swelling of the tissues.





•

Periodontal abscess – An inflammatory reaction frequently

caused by bacteria entrapped in theperiodontal sulcus. A patient will

experience rapid onset, pain, tenderness of the tooth to pressure, pus formation, andswelling.

Diagnostic Conclusions-




• Periradicular cyst – A cyst that develops at or near the root of

a necrotic tooth. These types of cystsdevelop as an inflammatory response topulpal infection and necrosis of the pulp.





• Pulp fibrosis – The decrease of living cells within the pulp

causing fibrous tissue to take over thepulpal canal.





• Necrotic tooth – Also referred to as nonvital. Used to

describe a tooth that does not respond to

sensory stimulus.





• Pulp capping – A covering of calcium hydroxide is placed

over an exposed or nearly exposed pulpto encourage the formation of irritated

dentin at the site of injury.• Indirect pulp cap is indicated when a thin

partition of dentin is still intact.

• Direct pulp cap is indicated when the pulp

has been slightly exposed.

Endodontic Procedures




Fig. 54-11 Spreader and plugger.




• Pulpotomy – Involves the removal of the coronal portion

of an exposed vital pulp.

– Completed to preserve the vitality of the

remaining portion of the pulp within theroot of the tooth.

– This procedure is commonly indicated forvital primary teeth, teeth with deep carious

lesions, and emergency situations.





Fig. 54-13 Example of a pulpotomy.




• Pulpectomy

– Also referred to as root canal therapy;

procedure involves the completeremoval of the dental pulp.





Fig. 54-14 A diagram of a pulpectomy.

Instruments and Accessories for




•

Endodontic explorer• Endodontic spoon excavator

• Broaches

•

Endodontic files – K-type

– Hedstrom

Instruments and Accessories forEndodontic Procedures




Table 54-1 Colors and Sizes of EndodonticFiles

I t t d A i




• Rubber stops• Paper points

• Spreaders

•

Pluggers• Glick No. 1

• Millimeter ruler

Instruments and Accessoriesfor Endodontic Procedures

I t t d A i




•

Rotary instruments – Gates-Glidden bur

– Pesso reamer

–

Lentulo spiral

Instruments and Accessoriesfor Endodontic Procedures

M di ts d D t l




•

Irrigation solution – Sodium hypochlorite

– Hydrogen peroxide

– Parachlorophenol (PCP)

Medicaments and DentalMaterials in Endodontics

M di m ts d D t l




• Gutta-percha points• Formocresol

• Root canal sealer

Medicaments and DentalMaterials in Endodontics

O i f R t C l




•

Anesthesia and pain control

• Isolation and disinfection of the site

• Access preparation

• Debridement and shaping the canal

• Obturation

Overview of Root CanalTherapy




• Indications for surgical intervention – Endodontic failure caused by persistent

infection, severely curved roots,perforation of the canal, fractured roots,

extensive root resorption, pulp stones, oraccessory canals that cannot be treated.

– Exploratory surgery to determine whyhealing has not occurred.

– Biopsy

Surgical Endodontics

Api t m nd Api l




• To surgically remove the apical portion of theroot with the use of a high-speed handpieceand bur.

• To evaluate:

– Inadequate sealing of the canal.

– Accessory canals.

– Fractures of the root.

– Pathological tissue around the root apex.

Apicoectomy and ApicalCurettage




• Completed when an apical seal is notadequate. A small class I preparation is madeat the apex and sealed with filling materialssuch as gutta-percha, amalgam, or

composite.

Retrograde Restoration

Root Amputation and




•

Root amputation – A surgery performed to remove one or more

roots of a multirooted tooth withoutremoving the crown.

• Hemisection

– A procedure in which the root and thecrown are cut lengthwise and removed.

Root Amputation andHemisection




Treatment of

Reversible

Pulpitis




• Remove irritant if present (caries; fracture; exposeddentinal tubules).

– If no pulp exposure: CaOH, restore, monitor – If pulp exposure:

• Carious: initiate RCT

• Mechanical: >1 mm: initiate RCT<1 mm crown planned: initiate RCT

<1 mm: direct cap or RCT

• If recent operative or trauma – postpone additionaltreatment and monitor.




• Pulpal inflamation and degeneration not expected toimprove.

• A physiologically older pulp has less ability to recoverdue to decrease in vascularity and reparative cells.

• As inflammation spreads apically, cellularorganization begins to break down.

• Localized pressure slows venous return, resulting inbuildup of toxins and lower pH that causeswidespread cellular destruction.




Endodontic

Materials




The main objectives of root canal therapyare:

1. Removal of the pathologic pulp.

2. Cleaning and shaping of the root canalsystem.

3. Three dimensional obturation to preventreinfection.

Functions of




Functions of

irrigants• Irrigants are used to clean the root canaland are used in association with theshaping instruments.

• Functions of irrigants include:1. Lubrication of instruments used to shape

the canal.

2. Flushing out of gross debris.3. Dissolution of organic and inorganic

tissue.

4. Antimicrobial effect.




Irrigants

• Ideal properties:

– Lubricant– Antimicrobial

– Dissolve organic debris

– Flushing– Biocompatible

– Cheap




Classification of irrigants

• Chemically inactive irrigants– Water

– Saline

– Local anaesthetic solution

• Chemically active irrigants

– Sodium hypochlorite (NaOCl).– Oxidizing agents as Hydrogenperoxide (H2O2)

– Chelating agents as EDTA.

http://images.google.com/imgres?imgurl=http://www.made-in-china.com/image/2f0j00HMVERpUgRDchM/Dental-Root-Canal-Irrigation-Needle.jpg&imgrefurl=http://www.made-in-china.com/showroom/shaadental/product-detailuMIEAptYTzcD/China-Dental-Root-Canal-Irrigation-Needle.html&usg=__wiYzrJ5ojiNdmqoCUqgpX-0KXHs=&h=249&w=457&sz=28&hl=en&start=2&tbnid=Lr_CuYQPUkI7SM:&tbnh=70&tbnw=128&prev=/images?q=root+canal+irrigation&gbv=2&hl=en&sa=G




Irrigants

• Use– Adequate volume required

– Stays within the confines of root canal– Never deliver with excessive force

• Apical extrusion results in pain and possible swelling.

– Use luer-lok 27 gauge endodontic needle– Efficiency enhanced with ultrasonic,

sonic and mechanical instruments





























Sodium hypochlorite

• 0.5-5.25 %

• Antibacterial

• Dissolve organic matter• Corrosive/caustic

• Low toxicity

• Apical reaction

• Rubber dam

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Hydrogen peroxide

• 3% +/- NaOCl

• Production of O2 eliminateanaerobes

• Bubbles may prevent adequatecontact of irrigant with debris

• Limited shelf life














http://images.google.com/imgres?imgurl=http://backoffice.p2ulive.co.uk/Uploads/Products/5ac294c3-8dd7-45ff-8aa3-d227ceb87d71/CareChlorhexidineAntisepticMouthwashMint.jpg&imgrefurl=http://www.pharmacy2u.co.uk/search.aspx?guid=88eaf3c6-1688-4020-9477-6bb5ce2f79a6&usg=__m3Rz5stowPDq9Bu5J64ONavh7vM=&h=300&w=300&sz=11&hl=en&start=4&tbnid=uMwiW3-IO2HffM:&tbnh=116&tbnw=116&prev=/images?q=chlorhexidine&gbv=2&hl=en&sa=G




Chlorhexidine

• Hibisrcub(HIBISCRUB is an antimicrobialpreparation for pre-operative surgical handdisinfection, antiseptic handwashing

• Usually used in 0.2%concentration

• Antibacterial, Substantivity.• Flushing

• Lubricant

•


















http://www.d2dendo.co.uk/bmz_cache/d/de19f3375a2dde483b00021e916bbfb0.image.110x110.gif




Chelating agent

• Ethylene Diamine Tetracetic Acid“EDTA” (File-eze, RC Prep)

• Remove smear layer allowing

cleaning of tubules• Soften dentine

• Not antibacterial

• File-eze is water soluble unlike RCPrep which contains carbowax andis difficult to remove






















Irrigants

• Sterile water

• Local anaesthetic

• Saline (0.9%)

They only provide lubrication andgross debris removal functions.




Intracanal medicamanets• If root canal treatment can’t be finished in a single visit,

root canals are dressed with medicaments.• Functions of intracanal medicaments:

– Primary function: antimicrobial activity

• Antisepsis(is the destruction or inhibition of (slowing

the growth of) microorganisms )• Disinfection(Cleaning an article of some or all of thepathogenic organisms which may cause infection )

– Secondary functions

• Hard-tissue formation

• Pain control• Exudation control

• Resorption control

https://media.supplychain.nhs.uk/media/images/ILD1103/thumb/3925_21329_ILD1103.jpg




Intracanal medicament

• Ideal properties– Antibacterial

– Penetrates dentinal tubules

– Control exudation or bleeding

– Biocompatibile.– Eliminates pain

– Induce calcific barrier

– No effect on temporary

– Radio-opaque

– Does not stain tooth



























Calcium hydroxide

• Hypocal(contains calcium hydroxide andbarium sulfate)

• Ca(OH)2, 34-50% Ba SO4,5-15%Methylcellulose.

• Antibacterial (pH>12)• Denatures protein• Synergestic with NaOCL

• Cytotoxic-local necrosis, calcific barrier• Cheap• Dries weeping canals




Antibiotics

• Combination of drugs requiredto be effective

• Resistant strains becomingmore difficult to treat

• Allergies




Steroids

• Triamicinolone, prednisolone• Pain relief but no evidence of more effective

than Ca(OH)2

• ?use in root resorption by inhibitingodontoclasts

• ?depresses the host inflammatory response

• Not antibacterial but can be mixed withCa(OH)2

• Ledermix= triamicinolone+ tetracycline

P eno ase agents,




eno ase agents,Aldehydes and Halidyes

• Phenol, parachlorophenol(PCP),camphorated mono PCP, cresol,

creosote, formacresol and chlorine.• Antibacterial agents.

• Highly toxic agents.

• Possible mutagenic and carcinogeniceffect.

http://www.medicdirect.co.uk/images/root_canal_treatment_2.jpg




Obturating materials

• Ideal properties of root canal filling materials:– Antimicrobial– Biocompatible.– Good flow

– Adhesive in nature– Dimensionally stable– Not affected by moisture– Radio-opaque

– Good handling– Easily removed, post prep or retreat– Does not stain dentine– Cheap































Gutta Percha

Gutta percha “ Isoprene” (C5H8) is one of theoldest and most common root filling material inuse today.

A natural latex produced from a genus of tropicaltrees

• Polymers of isoprene:

– Cis-natural rubber– Trans-gutta percha.




Gutta percha points used in

clinic consists of:

• Gutta percha 20%• Zinc oxide 60-75%

• Metal sulphides, waxes, resin,

opacifiers

Gutta percha is available in 2 phases;Alpha and Beta.

http://www.synca.com/images/gutta_cone.jpg




• Gutta percha taken from trees is inAlpha phase.

• Gutta percha in points used in theclinic is in Beta phase.

• Both phases differ in Meltingtemperature, volumetric changes andflow characteristics when molten.







Gutta percha

Advantages of gutta percha:• Biocompatible

• Dimensionally stable• Compactable• Easily removed

• CheapDisadvantages of gutta percha:• Does not adhere to dentine

• Lacks rigidity

M t l i t

http://www.synca.com/images/gutta_cone.jpg




Metal points Silver (gold, tin, lead and titanium have been used) Introduced in 1930’s Silver preferred due to antibacterial effect

Rigid, unyielding Impossible to adapt to canals Poor seal as canal not commonly circular in shape Corrosion

Difficult to remove for post Titanium- biocompatible and avoids corrosion




Sealers

• Sealers are used in association with Guttapercha.

• Functions of sealer

– Cementing (luting, binding) the corematerial (gutta percha) into the canal.

– Filling the discrepancies between thecanal walls and core material

– Acting as a lubricant to enhance thepositioning of the core filling material

– Acting as a bactericidal agent

http://images.google.com/imgres?imgurl=http://www.carsondental.com/admin/uploads/tubliseal_medium.jpg&imgrefurl=http://www.carsondental.com/manufacturers/m-kerr-dental-products-products.php&usg=__QlfdHRwVLHrKKEfZVY50HIT4evA=&h=300&w=300&sz=47&hl=en&start=1&tbnid=gSrlxEvSjK-ikM:&tbnh=116&tbnw=116&prev=/images?q=tubliseal&gbv=2&hl=en&sa=G




Root canal sealers

• Most sealers are toxic when freshlymixed

• Toxicity substantially reduced when set

• Most sealers are absorbable to someextent when exposed to tissue fluid• Ideally sealer should flow backwards out

of the canal

– However, no evidence that apicalextrusion reduces success rateproviding preparation and obturationare meticulous























Zinc-oxide eugenol

• Grossmans, Tubliseal

• Antibacterial

• Radio-opaque

• Slightly toxic whenfreshly mixed.

• Good flow and

working time• Does not adhere

• soluble

Calcium hydroxide


http://images.google.com/imgres?imgurl=http://www.sybronendo.com/pix/SybronEndo/Products/SealApex/Sealapex-1000x1000.jpg&imgrefurl=http://www.sybronendo.com/index/sybronendo-fill-sealapex-xpress-02&usg=__R0xd0AnHl0By_DIckQIs2qVuJ04=&h=1000&w=1000&sz=381&hl=en&start=2&tbnid=OFG_kw92Ak-L-M:&tbnh=149&tbnw=149&prev=/images?q=sealapex&gbv=2&hl=en&sa=G





Calcium hydroxide

based sealers• Sealapex, Apexit

• Radio-opaque

• Soluble• Biocompatible

• Preserve vitality of pulp stump and

promote healing• Does not adhere


















http://images.google.com/imgres?imgurl=http://www.dentsply-india.com/images/uk%20images/ahplus.jpg&imgrefurl=http://www.dentsply-india.com/product/endo3.htm&usg=__A_uFld-9EjIzLklilgwJJYtw8Jk=&h=203&w=181&sz=7&hl=en&start=1&tbnid=QjauoYdUSJIiUM:&tbnh=105&tbnw=94&prev=/images?q=ah+plus&gbv=2&hl=en&sa=G




Resin based sealers

• AH26, AH Plus, Endorez,Epiphany, RealSeal.

• Adhesive

• Antibacterial

• Toxic when freshly mixed• Show setting shrinkage when set

Gl i b d l















http://www.realworldendo.com/eng/images/activgp.jpg





Glass-ionomer based sealers

• Ketac Endo and ActiV GP.

• Mildly antibacterial

• Adheres to dentine

• Slightly soluble

• Unset GIC is cytotoxic butwhen set this reduces with time

• Very difficult to be removed

















http://images.google.com/imgres?imgurl=http://www.dentalproductshopper.com/files/product/images/guttaflow_src_1.jpg&imgrefurl=http://www.dentalproductshopper.com/guttaflow&usg=__wDuk5TQ9sbu8343-rD6_YBNVqco=&h=400&w=400&sz=95&hl=en&start=3&tbnid=ull6xdSwlqWDiM:&tbnh=124&tbnw=124&prev=/images?q=guttaflow&gbv=2&hl=en&sa=G




Silicone based sealers

• Roekoseal sealer.

• Slightly expands when set.

• Addition type silicone.

• GuttaFlow is Roekoseal sealer

with added gutta perchaparticles.

• Does not adhere to root canal.

New root canal filling



















New root canal fillingmaterials

• Resilon: resin-based cones. Similarin appearance and handling to gutta

percha cones. Used with any resin-based sealer.

• Endorez cones: resin-coated guttapercha. Used with endorez sealeror any other resin-based sealer.

• ActiV GP: glass ionomer coatedgutta percha. Used with glassiono er based sealers

Retrograde root filling




Retrograde root fillingmaterials

• Ideal properties– Seals apex– Biocompatible– Ease of handling– Moisture and blood tolerant– Low solubility

– Radio-opaque– Good tissue response– Bonds to dentine




Amalgam

• Corrosion

• Apical inflammation

• Poor sealing ability

• Mercury toxicity




IRM

• Modified zinc oxide-eugenol

• Seals better than amalgam

• Need high powder to liquidratio to decrease toxicity andsolubility

• Short working time

S EBA




Super EBA

• Modified zinc oxide-eugenol

• High compressive and tensile

strength• Neutral pH

• Low solubilty

• Not affected by blood

• Good tissue response

C it




Composite

• Problems with moisturecontrol

• Some good results in sealingability but further work

required




Glass Ionomer Cements

• Bonds to tooth substance

• Biocompatibilty (Toxicity reduces whenset)

• Some antibacterial properties

• Seal superior to amalgam




New materials

• Diaket (Tricalcium phosphate paste)– Polyvinyl resin– Good tissue response

– ?cementum forming• Mineral Trioxide aggregates (MTA)– Seals better than amalgam or super EPA– Not adversly affected by blood– Marginal adaptation better than amalgam, IRM

or super EBA– ?cytotoxicity

• Laser• Hydroxyapatite

MTA




MTA

• Mineral trioxide aggregate:

• Pulp capping

• Nonsurgical apical closure

• Perforation repair

• Surgical root end filling




ACCESS CAVITIES




• Despite advances there is always achance of error in endodontictherapy, and diligence in the involvedprocedures is necessary.




• it is important that the accesspreparation be precise

• Entering a tooth without an adequateradiograph is a “fool’s errand.”




• Preoperative radiographs areessential because they tell us wherepulp chambers are located inrelationship to coronal surfaces, andat what angles canals enter pulpchambers




• Gaining access to root canals,wherein the root canal instrumentscan be slipped easily into the canalsto reach the apical portion, is themost important starting point of theroot canal treatment. Before you lift

that hand piece to start accesscavity preparation, stop and thinkabout the following three points:




• Have you refreshed the knowledge of themorphology and anatomy of the tooth youare going to treat?

• Have you taken a good look at the tooth inthe oral cavity? Its shape, size, tilt andmorphology need careful consideration.

• Have you spent sufficient time studyingthe radiograph?




• When the access preparation is cuttoo small, it is often impossible tofind all the canals in the tooth.

• Even if all the canals are located, itsets the stage for negotiationdifficulties, file breakage, andunnecessary frustration duringobturation procedures.







• Conversely, access cavities that arecut too big are a betrayal of theclinician’s first admonishment to dono harm, increasing the short-termpossibility of perforation and thelong-term probability of tooth and

root fracture.

CHOOSE SAFE,




EFFECTIVE BURS

• choosing the wrong bur can presage apoor access result

• burs that are too large will inevitablyincrease the size of the final cavitypreparation as well as significantlyincrease the potential for toothperforation




• #2 round is ideal for anterior andpremolar access

• a #4 is optimal for molar access




• As soon as the author drops into thechamber, the round bur hasaccomplished its purpose and isreplaced with a tapered diamond bur.




• In anterior and premolar teeth, theconvenience form is afforded byextending the preparation frombuccal to lingual; the conservationform is accomplished by preservingtooth structure in the mesial to

distal dimension

A t i T i l




Anterior - Triangular

C i id




Canines - ovoid

P l R d




Premolar - Round




• In posterior teeth, the line-angleextensions are cut to the workingcusps and stop 1 mm to 2 mm shortof the idling cusps.




• In maxillary premolars and molars,the line angle extensions are taken tothe palatal cusps (working) and areshort of the buccal cusps (idling)

M l Rh mb id




Molar - Rhomboid




• Conversely, in mandibular premolarsand molars the line angle extensionsare taken to the buccal and are shortof the lingual cusps




Straight line access




Straight-line access

• Success in modern endodontictreatment may be dependent upon awell-designed access cavity to permitstraight-line access to all the mainroot canals







overhang; arrow A indicates overhangpreventing continuous straight line




preventing continuous straight lineaccess; arrow B indicates point of

greatest curvature on outside wall ofcanal.

Showing a canal opened to the apex to aNo. 20 reamer or file; arrow indicates

h h k d f



the thickest, most engaged part of

NiTi, most prone to fracture

Documents

2 Treatment of Pulpitis With Biological, Vital Amputational and Extirpation Methods-1