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

Treatment of pulpitis with biological, vital amputational and extirpation methods. Testimony, sequence and features of the stages.
Efficiency of methods, complication and methods of its prevention.

Therapeutic dentistry department Lecturer: as. Yavorska-Skrabut I.M.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Introduction
Endodontics is the specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the periradicular tissues that surround the root of the tooth.
Physical irritation Most generally brought on by extensive decay. Trauma Blow to a tooth or the jaw.
Causes of Pulpal Nerve Damage
Signs and Symptoms of Pulpal Nerve Damage

Pain when biting down. Pain when chewing. Sensitivity with hot or cold beverages. Facial swelling.
Endodontic Diagnosis
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
Diagnostic Testing
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 the mouth mirror handle held parallel to the long axis of the tooth.
Diagnostic Testing- contd

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.

Thermal sensitivity Necrotic pulp will not respond to cold or hot. Cold test Ice, dry ice, or ethyl chloride used to determine the response of a tooth to cold. 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.
Radiographs in Endodontics
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.
Show 4-5 mm beyond the apex of the tooth and the surrounding bone or pathologic condition. Present an accurate image of the tooth without elongation or fore-shortening. Exhibit good contrast so all pertinent structures are readily identifiable.
Requirements of Endodontic Films
Fig. 54-5 Quality radiograph in endodontics.
Diagnostic Conclusions
Normal pulp There are no subjective symptoms or objective signs. The tooth responds normally to sensory stimuli, and a healthy layer of dentin surrounds the pulp.
Pulpitis The pulp tissues have become inflamed. Reversible pulpitis The pulp is irritated, and the patient is experiencing pain to thermal stimuli. Irreversible pulpitis The tooth will display symptoms of lingering pain.
Periradicular abscess An inflammatory reaction to pulpal infection that can be chronic or have rapid onset with pain, tenderness of the tooth to pressure, pus formation, and swelling of the tissues.
Diagnostic Conclusions Periodontal abscess An inflammatory reaction frequently caused by bacteria entrapped in the periodontal sulcus. A patient will experience rapid onset, pain, tenderness of the tooth to pressure, pus formation, and swelling.
Periradicular cyst A cyst that develops at or near the root of a necrotic tooth. These types of cysts develop as an inflammatory response to pulpal infection and necrosis of the pulp.
Pulp fibrosis The decrease of living cells within the pulp causing fibrous tissue to take over the pulpal canal.
Necrotic tooth Also referred to as nonvital. Used to describe a tooth that does not respond to sensory stimulus.
Endodontic Procedures
Pulp capping A covering of calcium hydroxide is placed over an exposed or nearly exposed pulp to 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.
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 the root of the tooth. This procedure is commonly indicated for vital 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 complete removal of the dental pulp.
Fig. 54-14 A diagram of a pulpectomy.
Instruments and Accessories for Endodontic Procedures

Endodontic explorer Endodontic spoon excavator Broaches Endodontic files K-type Hedstrom
Table 54-1 Colors and Sizes of Endodontic Files

Rubber stops Paper points Spreaders Pluggers Glick No. 1 Millimeter ruler

Rotary instruments Gates-Glidden bur Pesso reamer Lentulo spiral
Medicaments and Dental Materials in Endodontics

Irrigation solution Sodium hypochlorite Hydrogen peroxide Parachlorophenol (PCP)
Medicaments and Dental Materials in Endodontics

Gutta-percha points Formocresol Root canal sealer
Anesthesia and pain control
Overview of Root Canal Therapy
Isolation and disinfection of the site Access preparation Debridement and shaping the canal Obturation
Surgical Endodontics
Indications for surgical intervention Endodontic failure caused by persistent infection, severely curved roots, perforation of the canal, fractured roots, extensive root resorption, pulp stones, or accessory canals that cannot be treated. Exploratory surgery to determine why healing has not occurred. Biopsy
To surgically remove the apical portion of the root with the use of a high-speed handpiece and bur. To evaluate: Inadequate sealing of the canal. Accessory canals. Fractures of the root. Pathological tissue around the root apex.
Apicoectomy and Apical Curettage
Retrograde Restoration
Completed when an apical seal is not adequate. A small class I preparation is made at the apex and sealed with filling materials such as gutta-percha, amalgam, or composite.
Root amputation A surgery performed to remove one or more roots of a multirooted tooth without removing the crown. Hemisection A procedure in which the root and the crown are cut lengthwise and removed.
Root Amputation and Hemisection
Treatment of Reversible Pulpitis

Remove irritant if present (caries; fracture; exposed dentinal 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 additional treatment and monitor.
Pulpal inflamation and degeneration not expected to improve. A physiologically older pulp has less ability to recover due to decrease in vascularity and reparative cells. As inflammation spreads apically, organization begins to break down. cellular
Localized pressure slows venous return, resulting in buildup of toxins and lower pH that causes widespread cellular destruction.
Endodontic Materials
The main objectives of root canal therapy are:
1. Removal of the pathologic pulp. 2. Cleaning and shaping of the root canal system. 3. Three dimensional obturation to prevent reinfection.
Irrigants are used to clean the root canal and are used in association with the shaping instruments.
Functions of irrigants
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.
Functions of irrigants include:
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 Hydrogen peroxide (H2O2) Chelating agents as EDTA.
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
Hydrogen peroxide
3% +/- NaOCl Production of O2 eliminate anaerobes Bubbles may prevent adequate contact of irrigant with debris Limited shelf life
Chlorhexidine
Hibisrcub(HIBISCRUB
is an antimicrobial preparation for pre-operative surgical hand disinfection, antiseptic handwashing
Usually used in 0.2% concentration Antibacterial, Substantivity. Flushing Lubricant

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 RC Prep which contains carbowax and is difficult to remove
Irrigants
Sterile water Local anaesthetic Saline (0.9%)

They only provide lubrication and gross debris removal functions.
Intracanal medicamanets
If root canal treatment cant 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 the pathogenic organisms which may cause infection ) Secondary functions Hard-tissue formation Pain control Exudation control Resorption control
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 and barium 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 required to be effective Resistant strains becoming more difficult to treat Allergies
Steroids
Triamicinolone, prednisolone Pain relief but no evidence of more effective than Ca(OH)2 ?use in root resorption by inhibiting odontoclasts ?depresses the host inflammatory response Not antibacterial but can be mixed with Ca(OH)2 Ledermix= triamicinolone+ tetracycline
Phenol based agents,

Aldehydes and Halidyes
Phenol, parachlorophenol(PCP), camphorated mono PCP, cresol, creosote, formacresol and chlorine. Antibacterial agents. Highly toxic agents. Possible mutagenic and carcinogenic effect.
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 the oldest and most common root filling material in use today. A natural latex produced from a genus of tropical trees 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.

Gutta percha taken from trees is in Alpha phase. Gutta percha in points used in the clinic is in Beta phase. Both phases differ in Melting temperature, volumetric changes and flow characteristics when molten.
Gutta percha
Advantages of gutta percha: Biocompatible Dimensionally stable Compactable Easily removed Cheap Disadvantages of gutta percha: Does not adhere to dentine Lacks rigidity
Metal points

Silver (gold, tin, lead and titanium have been used) Introduced in 1930s 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 Gutta percha.
Functions of sealer
Cementing (luting, binding) the core material (gutta percha) into the canal. Filling the discrepancies between the canal walls and core material Acting as a lubricant to enhance the positioning of the core filling material Acting as a bactericidal agent
Root canal sealers

Most sealers are toxic when freshly mixed Toxicity substantially reduced when set Most sealers are absorbable to some extent when exposed to tissue fluid Ideally sealer should flow backwards out of the canal However, no evidence that apical extrusion reduces success rate providing preparation and obturation are meticulous
Zinc-oxide eugenol
Grossmans, Tubliseal Antibacterial Radio-opaque Slightly toxic when freshly mixed. Good flow and working time Does not adhere soluble
Calcium hydroxide based sealers

Sealapex, Apexit Radio-opaque Soluble Biocompatible Preserve vitality of pulp stump and promote healing Does not adhere
Resin based sealers

AH26, AH Plus, Endorez, Epiphany, RealSeal. Adhesive Antibacterial Toxic when freshly mixed Show setting shrinkage when set
Glass-ionomer based sealers

Ketac Endo and ActiV GP. Mildly antibacterial Adheres to dentine Slightly soluble Unset GIC is cytotoxic but when set this reduces with time Very difficult to be removed
Silicone based sealers

Roekoseal sealer. Slightly expands when set. Addition type silicone. GuttaFlow is Roekoseal sealer with added gutta percha particles. Does not adhere to root canal.
New root canal filling materials

Resilon: resin-based cones. Similar in appearance and handling to gutta percha cones. Used with any resinbased sealer. Endorez cones: resin-coated gutta percha. Used with endorez sealer or any other resin-based sealer. ActiV GP: glass ionomer coated gutta percha. Used with glass ionomer based sealers.
Retrograde root filling materials

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 liquid ratio to decrease toxicity and solubility Short working time
Super EBA
Modified zinc oxide-eugenol High compressive and tensile strength Neutral pH Low solubilty Not affected by blood Good tissue response
Composite
Problems with moisture control Some good results in sealing ability but further work required
Glass Ionomer Cements

Bonds to tooth substance Biocompatibilty (Toxicity reduces when set) Some antibacterial properties Seal superior to amalgam
New materials
Diaket (Tricalcium phosphate paste)
Polyvinyl resin Good tissue response ?cementum forming
Mineral Trioxide aggregates (MTA)
Laser Hydroxyapatite
Seals better than amalgam or super EPA Not adversly affected by blood Marginal adaptation better than amalgam, IRM or super EBA ?cytotoxicity
MTA
Mineral trioxide aggregate: Pulp capping Nonsurgical apical closure Perforation repair Surgical root end filling
ACCESS CAVITIES
Despite advances there is always a chance of error in endodontic therapy, and diligence in the involved procedures is necessary.
it is important that the access preparation be precise Entering a tooth without an adequate radiograph is a fools errand.
Preoperative radiographs are essential because they tell us where pulp chambers are located in relationship to coronal surfaces, and at what angles canals enter pulp chambers
Gaining access to root canals, wherein the root canal instruments can be slipped easily into the canals to reach the apical portion, is the most important starting point of the root canal treatment. Before you lift that hand piece to start access cavity preparation, stop and think about the following three points:
Have you refreshed the knowledge of the morphology and anatomy of the tooth you are going to treat? Have you taken a good look at the tooth in the oral cavity? Its shape, size, tilt and morphology need careful consideration.
Have you spent sufficient time studying the radiograph?
When the access preparation is cut too small, it is often impossible to find all the canals in the tooth. Even if all the canals are located, it sets the stage for negotiation difficulties, file breakage, and unnecessary frustration during obturation procedures.
Conversely, access cavities that are cut too big are a betrayal of the clinicians first admonishment to do no harm, increasing the short-term possibility of perforation and the long-term probability of tooth and root fracture.
CHOOSE SAFE, EFFECTIVE BURS

choosing the wrong bur can presage a poor access result burs that are too large will inevitably increase the size of the final cavity preparation as well as significantly increase the potential for tooth perforation
#2 round is ideal for anterior and premolar access a #4 is optimal for molar access
As soon as the author drops into the chamber, the round bur has accomplished its purpose and is replaced with a tapered diamond bur.
In anterior and premolar teeth, the convenience form is afforded by extending the preparation from buccal to lingual; the conservation form is accomplished by preserving tooth structure in the mesial to distal dimension
Anterior - Triangular
Canines - ovoid
Premolar - Round
In posterior teeth, the line-angle extensions are cut to the working cusps and stop 1 mm to 2 mm short of the idling cusps.
In maxillary premolars and molars, the line angle extensions are taken to the palatal cusps (working) and are short of the buccal cusps (idling)
Molar - Rhomboid
Conversely, in mandibular premolars and molars the line angle extensions are taken to the buccal and are short of the lingual cusps
Straight-line access
Success in modern endodontic treatment may be dependent upon a well-designed access cavity to permit straight-line access to all the main root canals
instrument must negotiate past an overhang; arrow A indicates overhang preventing continuous straight line access; arrow B indicates point of greatest curvature on outside wall of
canal.
Showing a canal opened to the apex to a No. 20 reamer or file; arrow indicates the thickest, most engaged part of NiTi, most prone to fracture

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Treatment of pulpitis with biological, vital amputational and extirpation methods. Testimony, sequence and features of the stages.

Efficiency of methods, complication and methods of its prevention.

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

Causes of Pulpal Nerve Damage

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

Signs and Symptoms of Pulpal Nerve Damage

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

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

Diagnostic Testing- contd

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

Diagnostic Testing- contd

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

Diagnostic Testing- contd

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

Fig. 54-4 Placement of a pulp tester.

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

Requirements of Endodontic Films

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

Fig. 54-5 Quality radiograph in endodontics.

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

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

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

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

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

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

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

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

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

Fig. 54-11 Spreader and plugger.

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

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

Fig. 54-13 Example of a pulpotomy.

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

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

Fig. 54-14 A diagram of a pulpectomy.

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

Instruments and Accessories for Endodontic Procedures

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

Table 54-1 Colors and Sizes of Endodontic Files

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

Instruments and Accessories for Endodontic Procedures

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

Instruments and Accessories for Endodontic Procedures

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

Medicaments and Dental Materials in Endodontics

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

Medicaments and Dental Materials in Endodontics

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

Anesthesia and pain control

Overview of Root Canal Therapy

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

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

Apicoectomy and Apical Curettage

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

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

Root Amputation and Hemisection

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

Treatment of Reversible Pulpitis

The main objectives of root canal therapy are:

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

Functions of irrigants include:

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

Chemically active irrigants