Treatment Pulpal

8/6/2019 Treatment Pulpal

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TREATMENT OFTREATMENT OF

PULPAL &PULPAL & PERIAPICAL DISEASESPERIAPICAL DISEASES

By: karlina yusac

Pathway of the pulp,8Pathway of the pulp,8thth editionedition

1



DENTAL EVALUATIONDENTAL EVALUATION

Ø eriodontal

considerations

Ø estorativeconsiderations

Ø ndodontic onsiderations

Ø urgical considerations2



RIODONTAL CONSIDERATIONSRIODONTAL CONSIDERATIONS

• Periodontal probing

• Mobility assessment•Radiographic assessment• ndodontic treatment should

ot be planned for teeth with

oor periodontal prognosis( . . )g mobility III

3



ESTORATIVE CONSIDERATIONSESTORATIVE CONSIDERATIONS

q estorative treatment planning before tarting endodontic treatment in a

onemergency situation•Extensive loss of tooth structure• (Subosseous root caries crown

)lengthening may be needed• -Poor crown root ratio

•Lack of ferrule effect•Misaligned tooth

q onsultation with a prosthodontist

4



NDODONTIC CONSIDERATIONSNDODONTIC CONSIDERATIONS

vAnatomy of roots and canals

vProcedural errorsvSmall mouthvInstrumentsvOperator skillvTime

q o determine the level of anticipateddifficultyq o identify cases that should bereferred

q 5



SURGICAL CONSIDERATIONSSURGICAL CONSIDERATIONS

•Of particular value in the diagnosis of nonodontogenic lesions•Biopsy prior to definitive endodontic

treatment

6



TREATMENT PLANNINGTREATMENT PLANNING

cope of endodontics§ Vital pulp therapy

§ Pulpectomy or RCT§ Endodontic surgery§Retreatment§ Hemisection or root

amputation§Bleaching§ Apexification or

apexogenesis 7



TREATMENT PLANNINGTREATMENT PLANNING

vTreatment or extraction?v What kind of treatment ?

§Endodontic§Periodontal§Restorative

v Who will be the operator?

v - -Single visit or multi visit?vCostvPrognosis

8



PARATION FOR TREATMENTPARATION FOR TREATMENT

Ø nfection control

§ (Universal precautions operatory)preparation

§Instrument sterilization

§Tooth isolation

Ø atient preparation§Informed consent§Pain control

9





Reason for use of Reason for use of

Rubber damRubber damqProtection

§ aspiration or swallowing of instruments or irrigants

§ Soft tissue injury caused by instruments

qEfficiency§ (Improve visibility dry field and reduced

)mirror fogging

§ Minimize patient conversation§ Minimize the need for frequent rinsing

q -educed risk of cross ontamination

q egal considerations 11



INFORMED CONSENTINFORMED CONSENT

q Continuous rise in dental litigationq For consent to be informed

§ he procedure and prognosis must be described

§ lternatives to the recommended reatment must

be presented along with their respectiveprognoses

§ oreseeable risks must be described§ Patients must have he opportunity

o have

uestions answered 12



PAIN CONTROLPAIN CONTROL

o ocal anesthesiaoDivitalization

13



Local Anesthesia (LA)Local Anesthesia (LA)

• When to anesthetizeØ LA should be given at each appointment

• Three misconceptions§ Necrotic teeth may be instrumented without LA(vital tissue

)may exists periapically

§ ’Patient s sense aids the clinician to determine

working length§ LA is unnecessary during obturation phase(obturation

)pressure and extrusion of sealer may produce pain

14



MERGENCY TREATMENTERGENCY TREATMENT

retreatment emergency

•Irreversible pulpitis without acute apicalperiodontitis• Irreversible pulpitis with acute apicalperiodontitis

• Pulp necrosis with acute apical periodontitis

,Pathways of the pulp 8th edition

,Principles and practice of endodontics 2th

edition15





Irreversible pulpitis without AAP

•Multirooted teeth at the emergencyvisit

Pulpotomy (removal of the)coronal pulp or artial

ulpotomy (removal of the pulp)from the widest canal acceptable but less predictable in pain

relief17



rreversible pulpitis with AAP

Combination of pulpal and periapicalsymptoms

.1 /Complete pulp removal and C S

.2 ( )Ca OH 2 medication in canals to prevent

bacterial regrowth

.3 Effective temporary coronal seal

.4 Occlusal reduction

.5 Oral analgesic medication whennecessary

18



Pulp necrosis with AAP

• ithout swelling

• ith localized swelling• ith diffuse swelling

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Without Swelling

• Thorough removal of necrotic pulp• /Complete C S of the root canal

Ø (# / )Introducing a small file 10 15 slightly beyond the apex to establish drainage from the

periapical tissues

• ( )Ca OH 2 dressing between visits to help

eliminate remaining bacteria•Oral analgesics

20



With Swelling

:rinciple ebridement and drainage

Three ways to resolve swelling andinfection

§Drainage through the root canal§ Drainage by incising a fluctuant

( ,swelling incision and drainage& )I D

§ Antibiotic treatment

21



Localized Swelling

irstly try to establish drainage from oot canals

• /C S of the root canal• ( / )Introducing a small file size 10 15 slightly

beyond the apex to establish drainage• &No I D in case of good drainage

• ( )Ca OH

2 medication

•Access seal•If pus continues to drain through the canal and

cannot be dried within a reasonable period of, <time the tooth may be left open for 24 hrs

22



Incision and Drainage

Indicated for localized fluctuant soft tissue

swelling•Principles§Incise at the site of the greatest

fluctuance§Dissect gently and extend to the roots

§Keep wound clean with hot saltwater mouth rinses or CHX mouth rinse

23



Diffuse Swelling

•Possible to turn into a medical emergency

-and life threatening condition

•Principles

§ /Thorough C S of the canals§Apical patency achieved wheneverpossible

§Tooth left open

§ &I D in the absence of drainage through the canals with a rubber dam drain

( ~ )inserted or sutured 2 3 days

§Referral to oral surgeons

24



Antibiotic Therapy

§ Indicated for patients with

•Diffuse swelling regardless of the establish of drainage

•Spreading infections or systemicsigns

§ ( )Penicillin 1st choice or clindamycin or

+erythromycin Metronidazole

25



Endo-Perio Interrelationship

26

•Clinical signs and symptoms

–

qPeriodontal abscess

Ømarginal / diffused

•dull-even pain, fullness“high”

–

qPupal abscess•radicular

•rapid onset

•acute pain, severe discomfort






28

X-ray taken with GP in sinus tract

Radiolucen




29

Pocket

Probing-search motion & light force





Treatment Sequence

Based on the COMPLEXITY :

ESSION

TREATMENT§Combined ndo first§ oubt ndo first

Why endo first ???

31



Treatment Sequence

Why endo first ???

.1 Significantly betterprognosis.2 -Dramatically osseus fill in.3 Minimal post treatmentsequelae

32



SUMMARY

q ulpal status always dictates treatment of.eriapical disease

q rainage of abscess should be performed efore ndodontic

.reatment

q ndodontic treatment should be done first rior to

.eriodontic treatment

q pical healing regardless of marginal.eriodontitis

Ma ginal healing influenced by pulpal.nfections

q :he objectives of treatment are 33



THANK

YOU

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Treatment Pulpal