National Medical University A.A. BogomoletsLecturer: Dr. A.V. Barysenko student: Parisa Pour Khosrow
Plan Specialized endodontic instruments and equipment Pain control in endodontics Endodontic cavity preparation Pulp amputation (pulpotomy): indications, technique Pulpectomy (pulp extirpation): indications, technique Root canal preparation Obturation of root canal
ENDODONTIC PULPITIS TREATMENT SPECIALIZED ENDODONTIC INSTRUMENTS AND EQUIPMENT Endodontic Instrument Case The collection of tiny endodontic instruments must beKept in an organized arrangement yet lend itself readily tosterilization. The metal endodontic instrument case meetsthese requirements. Storage cases have long beenavailable but never as refined as the modern cases. All ofthe reamers, files, broaches, burs, and filling equipment, aswell as paper points and cotton pellets, are stored andsterilized in the case. The dentist or assistant removesthese with sterile pliersonly as needed.
PAIN CONTROL IN ENDODONTICS In no other area of dentistry is the management of pain of greater importance than inendodontics. All too often the patient in need of endodontic therapy has endured a prolonged period ofever-increasing discomfort before seeking dental care. The reasons for this discomfort are manifold;however, there is one simple explanation in the overwhelming majority of these patients. It is possibleto achieve clinically effective pulpal anesthesia on all teeth, infected or not, in any area of the oralcavity, with a very high degree of success and without inflicting any additional pain on the patient inthe process. Management problems occurring during local anesthetic administration can be almostentirely prevented. Dentist are recommended following a few simple steps to make all local anestheticinjections as comfortable (atraumatic) as is possible. Although all of the steps are important, threestand out: (1) placement of the patient who is to receive an intraoral local anesthetic into the supinepositionbefore the injection, (2) the slow administrationof the local anesthetic solution, and (3) the useof conscious sedationbefore the administration of the local anesthetic. Clinically effective pain control can be achieved in the vast majority of patients requiringendodontic therapy. When problems achieving pain control occur, it is usually at the initial visit, whena frightened patient, who has been hurting for some period of time, finally seeks relief from pain yetoftentimes is unable to manage the fears of dentistry. Through a combination of thoughtful caring forthe patient, the use of conscious sedation, when indicated, and the effective administration of localanesthesia, endodontic treatment can proceed in a more relaxed and pleasant environment for both thepatient and dental staff.
ENDODONTIC PRETREATMENT Root canal therapy does not necessarily beginwith the placement of the rubber dam but with therestorative or periodontic procedures necessary tosimplify its placement.
RUBBER DAM APPLICATION Rubber dam application is an essential prerequisite for providingnonsurgical endodontic treatment. For root canal treatment, rapid,simple, and effective methods of dam applications have beendeveloped. In all but the most unusual circumstances, the rubber damcan be placed in less than 1 minute. Although the modern endodontic approach to the use of the dam haschanged, the importance and purposes of the dam remain the same: 1. It provides a dry, clean, and disinfected field. 2. It protects the patient from the possible aspiration or swallowing of tooth and filling debris, bacteria, necrotic pulp remnants, and instruments or operating materials. 3. It protects the patient from rotary and hand instruments, drugs, irrigating solutions, and the trauma of repeated manual manipulation of the oral soft tissues. 4. It is faster, more convenient, and less frustrating than the repeated changing of cotton rolls and/or saliva ejectors.
TREATMENT ENDODONTIC CAVITY PREPARATION Endodontic cavity preparation may be separated into two anatomicdivisions: (a) coronal preparation and (b) radicular preparation.Actually,coronal preparation is merely a means to an end, but to accuratelyprepare and properly fill the radicular pulp space, intracoronalpreparation must be correct in size, shape, and inclination. Caries and defective restorations remaining in an endodontic cavitypreparation must be removed for three reasons: (1) to eliminatemechanically as many bacteria as possible from the interior of thetooth, (2) to eliminate the discolored tooth structure, that may ultimatelylead to staining of the crown, and (3) to eliminate the possibility of anybacteria-laden saliva leaking into the prepared cavity. The last point isespecially true of proximal or buccal caries that extend into theprepared cavity.
PULP AMPUTATION (PULPOTOMY) This method of pulpitis treatment consists of in removingpart of pulp mainly coronal pulp. The vital pulp amputationis the partial pulp removing under anesthesia. Indications. Pulpotomy is indicated in cases ofirreversible pulpitis, mainly pulp hyperemia (in case ofineffective biological treatment), acute traumatic pulpitis(accidentally pulp wounded) and acute circumscriptionpulpitis in young patients. Also this method may beeffective for treatment of chronic fibrous pulpitis, chronichypertrophic pulpitis in young patients with incomplete rootformation.
TECHNIQUE After careful antiseptic irrigation of oral cavity the dentist provide proper localanesthesia. The tooth isolate by cotton roll or rubber dam. The teeth surfaceswipe with 2% iodine solution, 1% chlorhexydine solution or another antiseptics.The thorough preparation of caries cavity carried out. During preparation theroof of the pulp chamber is best perforated with a round bur. This bur is used toremove the roof of the pulp chamber from underneath to establish outline form.The outlines of caries preparation must coincide with outlines of pulp chamber.The pulp chamber should be frequently flushed with a sodium hypochloritesolution to remove debris. All of the tissue in the pulp chamber should be removed by the round bur or asharp spoon excavator. The tissue is carefully curetted from the pulp horns andother ramifications of the chamber. Failure to remove all tissue fragments fromthe pulp chamber may result in later discoloration of the tooth. At this point, thechamber should be irrigated well to remove blood and debris. It is very importantthe carefully control bleeding because the blood clot hinder the dentin bridgeformation. For the control bleeding 3% hydrogen peroxide solution, 5% epsilonamino-caproic-acid (EACA) solution are used.
TECHNIQUE After control bleeding and thorough irrigation of the cavity on the pulpstump medicament paste are placed. As usual the pastes with calciumhydroxide are used (see the pastes for the biological treatment ofpulpitis).These pastes placed on the pulp stumps without any pressure andcaries cavity hermetically sealed with temporary dressing. After 10-14 dayswhen pain is absent the temporary dressing changed on final restoration fromcomposites or amalgam. Variant of vital pulpotomy in young patients with incompletelydeveloped roots is called apexification. This procedure requires complete canalcleaning, shaping, removal of smear layer and disinfection before the apicalplacement of this material is accomplished using calcium hydroxide. Thecalcium hydroxide kills bacteria and creates en environment conductive for hardtissue formation.The material is left in place or changed every 3 to 6 months inan attempt to enhance the tissue response. During this time period the roothard tissue developed and the root formation is ended.
PULPECTOMYThe main treatment of pulp inflammation consist of in removing avital pulp from pulp chamber (pulp amputation) and root canal. Thisis termed pulp extirpation or pulpectomy. Totalpulpectomy,extirpation of the pulp to or near the apical foramen, isindicated when the root apex is fully formed and the foramensufficiently closed to permit obturation with conventional fillingmaterials. If the pulp must be removed from a tooth with anincompletely formed root and an open apex, partialpulpectomy(pulp amputation) is preferred. This technique leavesthe apical portion of pulp intact with the hope that the remainingstump will encourage completion of the apex. The necrotic or“mummified” tissue remaining in the pulp cavity of a pulpless toothhas lost its identify as an organ; hence, its removal is called pulpcavity debridement.
INDICATIONSPulp “mummification”with arsenic trioxide, formaldehyde, orother destructive compounds was at one time preferable toextirpation. With the advent of effective local anesthetics,pulpectomy has become a relatively painless process andsuperseded “mummification,” with its attendant hazards ofbone necrosis and prolonged postoperative pain.Pulpectomy is indicated in all cases of irreversible pulpdisease. With pulpectomy, dramatic relief is obtained incases of acute pulpitis resulting from infection, injury, oroperative trauma. Pulpectomy is usually the treatment ofchoice when carious or mechanical exposure has occurred.In a number of instances, restorative and fixed prostheticprocedures require intentional extirpation.
Technique The following are the steps in the performance of a well-executedpulpectomy: Obtain regional anesthesia. Prepare a minimal coronal openingand, with a sharp explorer, test the pulp for depth of anesthesia. If necessary, inject anesthetic intrapulpally. Complete the access cavity. Excavate the coronal pulp (amputation). Extirpate the radicular pulp. Control bleeding and d?bride and shape the canal. Place medication or the final filling. Each of these steps must be completed carefully before the next is begun, and each requires some explanation.
Abjuration of root canal Nearly 60% of the failures in the endodontic treatment were apparentlycaused by incomplete obliteration of the radicular space. Periradicular inflammation is presumed to persist under the influenceof any noxious substance. Bacteria certainly play a major role in the productionof toxic products in the root canal. However, in the absence of bacteria,degraded serum per se may well assume the role of the primary tissue irritant.The persistence of periradicular inflammation, in the absence of bacterialinfection, might thus be attributed to the continuing apical percolation of serumand its breakdown products. It is apparent that the preliminary objectives of operative endodonticsare total d?bridement of the pulpal space, development of a fluid-tight seal atthe apical foramen, and total obliteration of the root canal. The anatomic limitsof the pulp space are the dentinocementaljunctionapically, and the pulp chamber coronally. The root canal is ready to be filled when the canal is cleaned andshaped to an optimum size and dryness. Dry canals may be obtained withabsorbent points except in cases of apical periodontitis or apical cyst, in which“weeping” into the canal persists.
Abjuration of root canal The materials used to fill root canals have been legion, running thegamut from gold to feathers. Grossman grouped acceptable fillingmaterials into plastics, solids, cements, and pastes. He also delineated10 requirements for an ideal root canal filling material that apply equallyto metals, plastics, and cements: It should be easily introduced into a root canal. It should seal the canal laterally as well as apically. It should not shrink after being inserted. It should be impervious to moisture. It should be bacteriostatic or at least not encourage bacterial growth. It should be radiopaque. It should not stain tooth structure. It should not irritate periradicular tissue. It should be sterile or easily and quickly sterilized immediately before insertion. It should be removed easily from the root canal if necessary.
Sealers In addition to the basic requirements for a solid filling material, Grossman listed 11requirements and characteristics of a good root canal sealer: It should be tacky when mixed to provide good adhesion between it and the canal wall when set. It should make a hermetic [sic] seal. It should be radiopaque so that it can be visualized in the radiograph. The particles of powder should be very fine so that they can mix easily with the liquid. It should not shrink upon setting. It should not stain tooth structure. It should be bacteriostatic or at least not encourage bacterial growth. It should set slowly. It should be insoluble in tissue fluids. It should be tissue tolerant, that is, nonirritating to periradicular tissue. It should be soluble in a common solvent if it is necessary to remove the root canal filling. One might add the following to Grossman’s 11 basic requirements: It should not provoke an immune response in periradicular tissue. It should be neither mutagenic nor carcinogenic. In choosing a sealer, factors other than adhesion must be considered: setting time,ease of manipulation, antimicrobial effect, particle size, radiopacity, proclivity to staining,dissolvability, chemical contaminants (hydrogen peroxide, sodium hypochlorite),cytotoxicity, cementogenesis, and osteogenesis.
Cements, Plastics, and PastesThe cements, which have wide dentists acceptance, are primarily zincoxide-eugenol (ZOE) cements, the polyketones, and epoxy.Thepastescurrently in worldwide vogue are chlorapercha andeucapercha, as well as the iodoform pastes, which include both therapidly absorbable and the slowly absorbable types. Despite theirdisadvantages, pastes are applicable in certain cases. The plasticsshow promise, as do the calcium phosphate products. At present themethods most frequently used in filling root canals involve the use ofsolid-core points, that are inserted in conjunction with cementingmaterials. Gutta-percha and silver per se are not considered adequatefilling material unlessthey are cemented in place in the canal. Thesealers are to form a fluid-tight seal at the apex by filling the minorinterstices between the solid material and the wall of the canal, and alsoby filling patent accessory canals and multiple foramina. Dye-immersionstudies have shown the necessity of cementation, without which dyepenetrates back into the canal after compaction; this occurs with allknown solid-core root canal–filling techniques.
Gutta-percha Gutta-percha is by far the most universally used solid-core root canalfilling material and may be classified as a plastic. To date, modern plastics havebeen disappointing as solid-core endodontic filling materials. Chemically puregutta-percha (or balata) exists in two distinctly different crystalline forms (alpha andbeta) that can be converted into each other. The alpha form comes directly fromthe tree. Most commercial gutta-percha, however, is the beta crystalline form.There are few differences in physical properties between the two forms, merely adifference in the crystalline lattice depending on the annealing and/or drawingprocess used when manufacturing the final product. Traditionally, the beta form ofgutta-percha was used to manufacture endodontic gutta-percha points to achievean improved stability and hardness and reduce stickiness. Although techniques ofgutta-percha placement involving heating in the root canal caused reversiblephysical changes, no apparent changes in chemical composition take place. For endodontical usage the gutta-percha supplied by manufacturers inform of gutta-percha filling points which contain about 20% of its chemicalcomposition of gutta-percha, whereas the 60 to 75% of the composition is zincoxide filler. The remaining constituents are wax or resin to make the point morepliable and/or compactible and metal salts to lend radiopacity.
Methods of obturating the root canal space Today, most root canals are being filled with gutta-percha andsealers. The methods vary by the direction of the compaction (lateral orvertical) and/or the temperature of the gutta-percha, either cold or warm(plasticized). These are the two basic procedures: lateral compaction of cold guttapercha or vertical compaction of warmed gutta-percha. Other methodsare variations of warmed gutta-percha. The main methods are listed asfollows:Solid Core Gutta-Percha with Sealants A. Cold gutta-percha points 1. Lateral compaction 2. Variations of lateral compaction B. Canal-warmed gutta-percha 1. Vertical compaction C. Thermoplasticized gutta-percha 1. Solid-core carrier insertion
The Devitalize method of pulpitis treatment This method of pulpitis treatment consists of in removing part of pulp(amputation) or all coronal and radicular pulp (pulpectomy) after it previousdevitalization. It used in case of organism sensibility to anesthetics,ineffectiveness of vital treatment methods, some systemic diseases. Most often for pulp devitalization arsenic and paraformaldehydepreparations are used. These preparations act as protoplasmatic poison onoxidizing enzymes of pulp cells which leads to disturbance of metabolism,hypoxia with result of cell necrosis. The necrosis depth depends of durationand concentration of preparation. These preparations used in form of pastes,which consist of devitalization agents, anesthetics, antiseptics and oil(eugenol for example). For pulp devitalization is sufficient (0,0002÷0,0004) gof arsenic anhydride with act duration in one-rooted teeth 24 hours and inmulti-rooted – 48 hours. The paraformaldehyde paste cause pulpdevitalization during 10-14 days. The devitalize pulpitis treatment method divided on pulp amputation(pulpotomy) and pulpectomy. Indications for treatment methods are the sameas at vital methods usage.
The Devitalize method of pulpitis treatment The pulpotomy carried out at two appointments. At first appointmentthe treatment method is equal for pulpotomy and pulpectomy. After carefulantiseptic irrigation of oral cavity the dentist provide proper local anesthesia.The tooth isolate by cotton roll or rubber dam. The teeth surfaces wipe with2% iodine solution, 1% chlorhexydine solution or another antiseptics. Thethorough preparation of caries cavity carried out. In case of acute cariescourse very carefully removed the demineralized (leathery) dentin from thecaries cavity floor, when pulp perforation occurred it is not a big mistake. Incase of chronic caries course the pulp perforation made especially for betterpenetration of devitalize paste into the pulp. When hemorrhage developedmade the carefully control bleeding. Than on the caries cavity floor near thepulp horn or the perforation placed the small amount (the pellet with diameterabout 1 mm) of devitalize paste and little cotton pellet over it. Very carefullywithout pressure the caries cavity sealed with temporary dressing.
The Devitalize method of pulpitis treatmentAt the second appointment performed the following the steps of a pulpectomy: 1. Removing temporary dressing. 2. Caries cavity preparation. 3. Complete the access cavity. 4. Excavate the coronal pulp (amputation). 5. Extirpate the radicular pulp. 6. Control bleeding and d?bride and shape the root canal. 7. Place medication or the final root canal filling. 8. Obturation of the root canal. 9. Temporary dressing or final restoration with composites or amalgam.In case of pulpotomy at the second appointment performed the following steps: 1. Removing temporary dressing. 2. Caries cavity preparation. 3. Complete the access cavity. 4. Excavate the coronal pulp (amputation). After control bleeding and thorough irrigation of the cavity on the pulp stump medicament pasteare placed. As usual the pastes which contained resorzin formaldehyde, creosote, cresols(paramonochlorphenol), iodophorm, threeoxymethylenum are used. These pastes performedmummification action at the pulp stump. The pastes placed on the pulp stumps without anypressure and caries cavity hermetically sealed with temporary dressing. After 10 14 days when painis absent the temporary dressing changed on final restoration from composites or amalgam.