Introduction to endodontics,Introduction to endodontics,pathohistological and clinical pathohistological and clinical classification of pulpal diseases, classification of pulpal diseases,

indication and contraindication of indication and contraindication of endodontic treatmentendodontic treatment

4.Year - Dental Medicine4.Year - Dental Medicine

Pulp normalityPulp normality

histologic normalityhistologic normality clinical normalityclinical normality

The The CLINICALLY NORMAL PULPCLINICALLY NORMAL PULP vital to testing proceduresvital to testing procedures responcive to a variety of excitationsresponcive to a variety of excitations free of spontaneous symptoms !!!free of spontaneous symptoms !!!

The The MICROSCOPICALLY NORMAL PULPMICROSCOPICALLY NORMAL PULP demonstrates only those histologic features that are demonstrates only those histologic features that are compatible with its age.compatible with its age.

It is free of inflammatory change of any type!!!It is free of inflammatory change of any type!!!

Dental pulp - healthyDental pulp - healthy

Dental pulp - inflamed, infectedDental pulp - inflamed, infected

Acute pulpitis

Dental pulpDental pulp

DPDP : dental pulp : dental pulpOBOB : odontoblast : odontoblast DD : dentin : dentinPDPD : predentin : predentinTFTF : Tom's fiber : Tom's fiber

The response of the pulpThe response of the pulp

The response of the pulp to injury or irritants occcur very The response of the pulp to injury or irritants occcur very soon, when the stimuly are mildsoon, when the stimuly are mild

Pulpodentonal reactions occurs when chemical, Pulpodentonal reactions occurs when chemical, mechanical, bacterial irritants attack the odontoblasts, mechanical, bacterial irritants attack the odontoblasts, namely Tome´s fibers, transmit a excitation to the pulp namely Tome´s fibers, transmit a excitation to the pulp

The response of the pulp depends on the character and The response of the pulp depends on the character and intensity of stimulyintensity of stimuly

Histopathologic Histopathologic classificationclassification of pulpal diseasesof pulpal diseases A. A. Regresive changesRegresive changes

B. B. Inflammatory Inflammatory changeschanges

1.1. Pulpal hyperemyPulpal hyperemy

2.2. Acute pulpitisAcute pulpitis

3.3. Chronic pulpitisChronic pulpitis

C. C. Necrosis of the Necrosis of the pulppulp

D. D. Gangraena of the Gangraena of the pulppulp

Acute pulpitisAcute pulpitis serose partial total purulent partial total

Chronic pulpitisChronic pulpitis1. clausa2. a tergo3. granulomatosa interna4. aperta ulcerosa5. aperta hypertrophica

A. Regresive changesA. Regresive changes

vacuolar degeneration of odontoblastsvacuolar degeneration of odontoblasts hyalinic degeneration of the pulphyalinic degeneration of the pulp lipidic degeneration of the pulplipidic degeneration of the pulp reticular atrophyreticular atrophy pathological calcificationpathological calcification

A.A. Regresive changes:Regresive changes:VVacuolar degeneration of acuolar degeneration of odontoblastsodontoblasts

Odontoblasts react very Odontoblasts react very quickly for many stimulies.quickly for many stimulies.

We can often find parts with We can often find parts with vacuolization of vacuolization of odontoblasts.odontoblasts.

This change can be result of This change can be result of pathologic damage of the pathologic damage of the pulppulp

It is the result of It is the result of intracellular or extracellular intracellular or extracellular break - down of cells break - down of cells metabolismmetabolism

A. Regresive changes:A. Regresive changes: Hyalinic degeneration of the Hyalinic degeneration of the pulppulp

In this regresiva change, we can find an albumenic In this regresiva change, we can find an albumenic substances in the pulpsubstances in the pulp

This type of degeneratin is typical in teeth:This type of degeneratin is typical in teeth: of old people of old people with chronic inflammationwith chronic inflammation

A.A. Regresive changes:Regresive changes:Lipidic degeneration of the pulpLipidic degeneration of the pulpReticular atrophyReticular atrophy

LIPIDIC DEGENERATIONLIPIDIC DEGENERATION::

We can find it in pulp with chronic inflammationWe can find it in pulp with chronic inflammation It is break - down of metabolism, and the result is It is break - down of metabolism, and the result is

the the lipids in cellslipids in cells

RETICULAR ATROPHYRETICULAR ATROPHY::

It is regresive change present in pulp of old peopleIt is regresive change present in pulp of old people Lost odontoblasts and pulpal cells are compensated by Lost odontoblasts and pulpal cells are compensated by

tissuetissue

A. Regresive changes:A. Regresive changes: Pathological calcificationPathological calcification

Normal pulp doesn´t contain hard calcified substancesNormal pulp doesn´t contain hard calcified substances PULPAL DENTICULPULPAL DENTICUL - is hard, mineralisated substance - is hard, mineralisated substance

located in the pulpal tissue located in the pulpal tissue Usually in pulp we can find 1 - 12 denticulsUsually in pulp we can find 1 - 12 denticuls Sometimes they are small microscopic, sometimes biggist Sometimes they are small microscopic, sometimes biggist

and they can fill pulp chamber or root canal, or obliterate it and they can fill pulp chamber or root canal, or obliterate it totally.totally.

Clinical classificationClinical classification of pulpal diseasesof pulpal diseases

1. HEALTHY PULP:1. HEALTHY PULP: without clinical symptomswithout clinical symptoms

2. REVERSIBLE FORM OF PULP INFLAMMATION:2. REVERSIBLE FORM OF PULP INFLAMMATION: pulp with clinical symptoms, in which we can preserve the vitalitypulp with clinical symptoms, in which we can preserve the vitality of the pulp by treatmentof the pulp by treatment

3. IRREVERSIBLE FORM OF PULP INFLAMMATION:3. IRREVERSIBLE FORM OF PULP INFLAMMATION: pulp with clinical symptoms, in which we cannot preserve the pulp with clinical symptoms, in which we cannot preserve the

vitalityvitality of the pulp by treatmentof the pulp by treatment

4. DEATH OF THE PULP:4. DEATH OF THE PULP: pulp with lost vitality, necrotic, gangrenouspulp with lost vitality, necrotic, gangrenous

Symptoms typical forSymptoms typical for reversible processreversible process

pain present only for impulse, never spontaneouspain present only for impulse, never spontaneous patient can localize the painpatient can localize the pain pain is of short duration, pain is of short duration, analgetics stop the painanalgetics stop the pain Vitality test: short sensation, it leaves immediatelyVitality test: short sensation, it leaves immediately pain for percussion is never presentpain for percussion is never present RTG: caries, filling next to the pulpRTG: caries, filling next to the pulp

tercial dentine is presenttercial dentine is present

periapical finding is negativeperiapical finding is negative

Symptoms typical forSymptoms typical for irreversible processirreversible process

spontaneous pain through day, intervals without pain are spontaneous pain through day, intervals without pain are shorter, shorter,

intervals with pain start to be longerintervals with pain start to be longer pain through night is presentpain through night is present pain is neuralgiformicpain is neuralgiformic analgetics do not stop the painanalgetics do not stop the pain Vitality test: attack of neuralgiformic painwhich leaves very Vitality test: attack of neuralgiformic painwhich leaves very

slowlyslowly

pulzating painpulzating pain patient cannot localize the tooth, sometimes even the jawpatient cannot localize the tooth, sometimes even the jaw pain for percussion is present, periapex is inflammedpain for percussion is present, periapex is inflammed RTG: caries, filling close to the pulp, or in pulpRTG: caries, filling close to the pulp, or in pulp

tercial dentine is not present tercial dentine is not present

Right diagnosisRight diagnosis

How do the right diagnosis?How do the right diagnosis?

anamnesisanamnesis symptomatologysymptomatology clinical examinationsclinical examinations knowlwdges of pathology of the pulpknowlwdges of pathology of the pulp clinical experiencesclinical experiences

From all this points we make the clinical dg.:From all this points we make the clinical dg.:

REVERSIBLE OR IRREVERSIBLE PULPAL DISEASEREVERSIBLE OR IRREVERSIBLE PULPAL DISEASE

Reversible or irreversible pulpal Reversible or irreversible pulpal disease?disease?

Reversible form of pulp inflammation Reversible form of pulp inflammation turns into irreversible form of pulp turns into irreversible form of pulp inflammation inflammation

- to pulpitis.- to pulpitis.

In clinical practice this moment play the key role in In clinical practice this moment play the key role in decision of the decision of the TREATMENT CHOICETREATMENT CHOICE - -

to treat hyperemia without pulpotomy or extirpation to treat hyperemia without pulpotomy or extirpation and preserve the pulp vitality or and preserve the pulp vitality or

to treat pulpitis as irreversible inflammation with to treat pulpitis as irreversible inflammation with endodontic treatment. endodontic treatment.

Reversible or irreversible pulpal Reversible or irreversible pulpal disease?disease?

The appropriate decision is not easy because the The appropriate decision is not easy because the histologic changes are frequently not in correlation histologic changes are frequently not in correlation with with

the clinical symptoms.the clinical symptoms.

for appropriate diagnosis we have clinical symptomsfor appropriate diagnosis we have clinical symptoms

Reversible or irreversibleReversible or irreversible pulpal disease? pulpal disease?

B. INFLAMMATORY CHANGES:B. INFLAMMATORY CHANGES:

HyperemyHyperemy Acute pulpitis - acute serous partial pulpitisAcute pulpitis - acute serous partial pulpitis –––––––––––––––––––––––––––––––––––––––––––––– ––––––––––––––––––––––––––––––––––––––––––––––

- acute serous total pulpitis- acute serous total pulpitis - acute purulent partial pulpitis- acute purulent partial pulpitis - acute purulent total pulpitis- acute purulent total pulpitis Chronic pulpitisChronic pulpitis

C. NECROSISC. NECROSIS D. GANGRAENAD. GANGRAENA

reversible

irreversible

Endodontic

Endodontic treatmentEndodontic treatment

What is endodontics?What is endodontics?

Endodontics is the area of Endodontics is the area of dentistry concerned with the dentistry concerned with the prevention, diagnosis and prevention, diagnosis and treatment of disorders of the treatment of disorders of the dental pulp dental pulp

Years ago, such teeth with Years ago, such teeth with diseased or injured pulps were diseased or injured pulps were extracted. Today endodontic extracted. Today endodontic treatment offers a way for a safe treatment offers a way for a safe and effective means of saving and effective means of saving the teeth. the teeth.

Considerations Considerations for endodontic therapyfor endodontic therapy

1. Is the tooth needed or important? Does it have an opponent? Could it some day serve as an abutment for prosthesis?

2. Is the tooth salvageable, or is it so badly destroyed that it cannot be restored?

3. Is the entire dentition so completely broken down that it would be virtually impossible to restore?

4. Is the tooth serving esthetically, or would the patient be better served by its extraction and a more cosmetic replacement?

5. Is the tooth so severely involved periodontally that it would be lost soon for this reason?

6. Is the practitioner capable of performing the needed endodontic procedures?

Indications Indications for endodontic therapyfor endodontic therapy

Presence of irreversible pulpal disease Presence of irreversible pulpal disease

Prophylactic pulpal therapy which may be Prophylactic pulpal therapy which may be needed prior to other treatment procedures needed prior to other treatment procedures (restorative dentistry, prosthodontics & (restorative dentistry, prosthodontics & periodontics)periodontics)

Contraindications Contraindications forfor endodontic therapyendodontic therapy

The objections are listed according to:The objections are listed according to:

status of the patientstatus of the patient dental reasonsdental reasons local reasonslocal reasons

Status of the patient:Status of the patient:

Age - past middle lifeAge - past middle life Health of the patient - DM, leukemia, terminal cancer, radiation Health of the patient - DM, leukemia, terminal cancer, radiation necrosis, tuberculosis, syphilis ...necrosis, tuberculosis, syphilis ... Too many treated pulpless teeth Too many treated pulpless teeth

Contraindications Contraindications for endodontic therapyfor endodontic therapy

Dental reasons:Dental reasons:

Pulpless teeth are not salvageable if there are associated periapical Pulpless teeth are not salvageable if there are associated periapical and periodontal lesionsand periodontal lesions

Local reasons:Local reasons:

the periapical lesion is an apical cystthe periapical lesion is an apical cyst the tooth is badly broken down by cariesthe tooth is badly broken down by caries the involved tooth is badly fracturedthe involved tooth is badly fractured the involved tooth has a mechanical root perforationthe involved tooth has a mechanical root perforation the involved tooth has perforating internal or external root resorptionthe involved tooth has perforating internal or external root resorption the involved tooth is wholly or partially luxatedthe involved tooth is wholly or partially luxated

Contraindications Contraindications forfor endodontic therapy endodontic therapy

Severe, untreatable periodontal disease Severe, untreatable periodontal disease Condition of remaining teeth Condition of remaining teeth Non-restorable teeth Non-restorable teeth Extensive resorption Extensive resorption Vertical root fractures Vertical root fractures Malpositioning of teeth Malpositioning of teeth Limited accessibility Limited accessibility Non-strategic tooth Non-strategic tooth Aberrant root morphology Aberrant root morphology Unfavorable crown:root ratio Unfavorable crown:root ratio Predicatable failures Predicatable failures Proximity to vital structures Proximity to vital structures

Thank youThank you

for for attention !attention !