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Endo note 2 iintroduction

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  • 1. Biology And Clinical Rationale For Root Canal Therapy1/12/2009 Endo 2 1
  • 2. 1/12/2009 Endo 2 2
  • 3. Functions of the pulp1. Induction(Odonogenesis and Amelogenesis)2. Formation of dentine (Primary, Secondary-reactionary and Tertiary-reparative).3. Maintenance of dentine (fluid environment).4. Defence mechanism by inflammatory and immunological5. Sensation from dentine and enamel (pain, warning).6. Age changes (peritibular dentine, more solid tooth) (Walton and torabinjad – 1996). 1/12/2009 Endo 2 3
  • 4. Induction (Odonogenesis and Amelogenesis) Dental pulp 25mm31/12/2009 Endo 2 4
  • 5. Formation of dentine (coronal and radicular). Predentine thickness 15µ Primary dentine during development 4µ/day Regular Secondary dentine after develop 0.8µ/day Irregular Secondary dentine due to stimuli 3µ/day1/12/2009 Endo 2 5
  • 6. Formation of dentine (coronal and radicular).1/12/2009 Endo 2 6
  • 7. Formation of dentine (coronal and radicular).1/12/2009 Endo 2 7
  • 8. Maintenance of Dentine (fluid environment).1/12/2009 Endo 2 8
  • 9. Maintenance of Dentine (fluid environment). Pulpal end D-E Junction Tubules 65000 /mm2 15000/mm2 Diameter 3µ 1µ Surface area 45% 1%1/12/2009 Endo 2 9
  • 10. Maintenance Dentine (fluid environment).1/12/2009 Endo 2 10
  • 11. Defence mechanism (IIry dentine, reparative dentine, fluid flow).1/12/2009 Endo 2 11
  • 12. Sensation (pain, warning). 1 axon innervate 100 dentinal tubules and penetrate up to 100-200µ1/12/2009 Endo 2 12
  • 13. Age changes (peritibular dentine, more solid tooth).1/12/2009 Endo 2 13
  • 14. Theories of dentine hypersensitivity• Classic theory – (Direct innervations)A-δ fibres -sharp, localized pain (drilling, probing, air drying, application of hyper osmotic fluids heating and cooling the dentine electrical pulp testing)C- fibres -dull less localized pain (thermal, mechanical and chemical stimuli)A-β myelinated fibres-non-noxious mechanical stimulation (mastication and loading of teeth)• Odontoblast as receptors – (neural crest)• Hydrodynamic theory Rapid movement of fluid of in the dentinal tubules cause mechanical distortion of tissue 1/12/2009 Endo 2 14
  • 15. Sensation (pain, warning).1/12/2009 Endo 2 15
  • 16. Differential diagnosis of acute painsCondition Nature Triggers DurationOdontalgia Stabbing, throbbing, Hot, Tooth Hours-days cold and non-episodic. percussionTrigeminal Lancination, electrical, Light touch on Seconds neuralgia episodic trigger zoneCluster Severe ache, retro-obital Sleep, alcohol 30-45 min headache component, episodicAcute otitis Severe ache, throbbing,. Lowering head, Hours-days media deep to ear, nonepisodic barometric pressureBacterial Severe ache, throbbing. Lowering head, Hours-days sinusitis in maxillary posterior tooth percussion teeth, nonepisodicCardiogenic Short-lived ache left Exertion Minute posterior mandibleSialolithiasis Sharp, drawing, salivary Eating, induced Low ache sharp swelling, episodic salivation when triggered 1/12/2009 Endo 2 16
  • 17. Differential diagnosis of chronic painsCondition Nature Triggers DurationOdontalgia Dull ache, Hot, cold, tooth Days-weeks percussionTMJ pain Dull ache, sharp episodic Opening chewing Weeks-yearsMyalgia Dull ache, degree varies Stress, clenching Weeks-yearsAtypical facial P Dull ache severe episodes Spontaneous Weeks-yearsPhantom tooth P Dull ache severe episodes Spontaneous Weeks-yearsAllergic Dull ache in maxillary Lowering head Weeks-month sinusitis posterior teeth seasonalCausalgia Burning Post trauma, Weeks-years post surgicalPost herpitic Deep boring ache with Spontaneous Weeks-years neuralgia burning after shinglesCancer associated Variable,motor difficult, Spontaneous Days-months facial pain paresthesia 1/12/2009 Endo 2 17
  • 18. Aetiology of pulp & periapical diseaseBacteria 1-Coronal ingress(caries) 2-Radicular ingress (PDD)Trauma 1-Accident 2-PhysiologicalChemical 1-Filling material 2-ErosionIatrogenic 1-Cavity preparation (type of bur, speed, duration, nature of bur contact, cutting technique, amount vibration and cooling) 2-Restoration 3-Surgical trauma 4-Prosthetic treatment 5-Radiation 6-Orthodontic movement 7-Electric 8-Periodontal treatment 9-General AnaesthesiaOthers 1-Ageing 2-Internal resorption 3-External resorption 1/12/2009 Endo 2 18
  • 19. Bacteria1/12/2009 Endo 2 19
  • 20. Bacteria1/12/2009 Endo 2 20
  • 21. Chemical-Filling material1/12/2009 Endo 2 21
  • 22. Cavity Preparation1/12/2009 Endo 2 22
  • 23. RestorationPost operative complications of restorations are, Marginal staining, dentine hyperSensitivity,, corrosion and degradation, secondary caries, pulp inflammation and death (Gulabivala-2004). 1/12/2009 Endo 2 23
  • 24. Restoration If the thickness of dentine is <5mm Ca(OH)2 sub lining and ZnO/E dressing should be placed. Most effective material preventing microbial leakage LCC and GIC cause more damage to odontoblasts (Gulabivala-2004).1/12/2009 Endo 2 24
  • 25. Responses To InjuryDepend on,• The state of the pulp,• Previous history of irritants and repair,• The nature of the stimulus,• Duration of the irritation,• Any treatment provided.Mild injury –• Odontoblast die,• Acute inflammation in sub odontoblast layer,• Resolution 1/12/2009 Endo 2 25
  • 26. Major Acute Injury• Some pulp tissue die,• Acute inflammation in adjacent tissue,• Walling off affected area (fibrosis),• Pulpal abscess; pressure, pain,• Repair – depend on tissue capacity to repair and toxicity of necrosis (repair by fibrosis or reparative dentine),• If no repair, spread of necrosis to whole pulp. 1/12/2009 Endo 2 26
  • 27. Why Does The Pulp Die? A- No drainage within the pulp, (fluid can only move through rest of pulp), B- Limited access for repair (from apical direction only), C - Pulp is surrounded in three dimensions (by hard tissue), D - Stimulus is concentrated in the pulp (diffusion through tubules from large area and concentrated on small tissue), E- Limitations of dental materials available for treatment.1/12/2009 Endo 2 27
  • 28. Classification Of Pulp & Periapical Diseasea) Clinical normal pulp,b) Reversible pulpitis 1-Acute 2-Chronicc) ) Irreversible pulpitis 1-Acute 2-Chronic 3-Necrobiosisd) Pulp necrosis 1-With & 2-Without infectione) Degenerative changes 1-Atrophy 2-Hyperplasia (pulp polyp) 3-Calcification (partial, total) 4-Internal resorption.f) Previous RCT 1-Satisfactory (with & without infection) 2-Unsatisfactory (with &without infection)g) Perio-endo lesion 1-Endodontic origin 2-Periodontc origin 3-Combine P-E (do&not communicate) 1/12/2009 Endo 2 28
  • 29. Reversible Pulpitis• Short duration pain• After stimulation remove pain relieve• Tooth no tender to percussion• Difficult to localized the pain• Exaggerated respond to vitality test• Periapical area is normal in x-rays1/12/2009 Endo 2 29
  • 30. Recent Restoration• High filling or points• Micro leakage• Micro exposure• Thermal or mechanical injury to pulp• Inadequate lining under metalic restoration• Chemical irritation from lining or filling material• Galvanic current1/12/2009 Endo 2 30
  • 31. Irreversible Pulpitis• Early stages spontaneous pain last few second to hours, radiate and difficult locate the tooth• Latter stage hot thing pain, cold relieve the pain patent able to locate the tooth and tender to percussion 1/12/2009 Endo 2 31
  • 32. Dynamics of Pulpal Responses Reversible IrreversibleBacteria Low-grade Resistance Chronic inflammation Untreated pulpitis Virulence Treated AcuteResolution pulpitis mild Major Partial Total necrosis necrosisShort-term Acute insult inflammation 1/12/2009 Endo 2 32
  • 33. Indicators Of Pulpitis Indicator Irreversible Reversible pulpitis pulpitisSensitivity to thermal stimulation Yes YesRespond to thermal stimulation a) Lingering Yes No b) Short No YesPrevious history of pain Yes NoIntensity of pain a) Severe Yes No b) Mild No YesNature of pain – Spontaneous Yes NoTenderness to percussion Not always Rarely 1/12/2009 Endo 2 33
  • 34. Peri-apical Defence Mechanism1/12/2009 Endo 2 34
  • 35. Classification Of Periapical Periodontal Diseasea) Clinical normal periodontal tissue,b) Apical periodontitis 1-Acute 2-Chronic - Granuloma Radicular cyst - Apical true cyst - Apical pocket cys 3-Condensing osteitisa) Periapical abscess1- Acute 2-Chronicb) Facial cellulitisc) External root resorption 1- Surface 2- Inflammatory 3- Replacement 4- Invasive 5- Pressure 6- Orthodontic 7- Physiologic 1/12/2009 Endo 2 35
  • 36. Dynamics Of Periapical Inflammation Draining SinusBacterial Resistance ChronicInsult apical Cyst periodontitis Virulence SystemicShort-term Acute apical illnessinsult periodontitis Facial 1/12/2009 Endo 2 cellulitis 36
  • 37. General Order Of Treatment 1. Pain relief 2. Remove infection 3. Caries control 4. Periodontics 5. Endodontics 6. Orthodontics / Surgery 7. Prosthodontics1/12/2009 Endo 2 37
  • 38. Aims Of Endodontic Treatment• Biologic aims a) To remove all the debris support to bacterial growth b) To destroy all micro-organisms from the root canal• Mechanical aims c) Prepare root canal space for three dimensional filling d) To obturate prepared canal in order to completely seal from both apical (at the cemento-enamel junction) and coronal seal 1/12/2009 Endo 2 38
  • 39. • Root treated with a poor obturation but good coronal restoration had prognosis than good obturation and poor coronal restoration (Ray and Trope-1995).• Whatever the obturation system used if the canal system has not been adequately cleaned healing may not occur(Carrotte- 2004)1/12/2009 Endo 2 39