ALTERNATIVE ROOT CANAL THERAPY - Dr. Arjun A R

1. ALTERNATIVE ROOT CANAL THERAPY
ARJUN AR
2ND YEAR PG

2. CONTENTS
 INTRODUCTION
 VITAL PULP THERAPY TREATMENT MODALITIES
 PULPOTOMY
 PULP CAPPING
 GENTLE WAVE PROCEDURE
 LASERS
 REGENERATIVE ENDODONTICS
 NANOMATRIX GEL.
 OZONE GAS
 SURGICAL ALTERNATIVES TO A ROOT CANAL
 EXTRACTION
 NATURAL REMEDIES.
 CONCLUSION
 REFERENCES

3. INTRODUCTION
• The maintenance of pulpal health should be a primary
goal in treating deep carious lesions.
• Pulp exposure should be avoided whenever possible by
adopting the less invasive approach of incomplete or
selective caries removal. However, even using a more
conservative approach, pulp exposure is sometimes
inevitable.
• In cases in which pulp exposure is inevitable, root canal
treatment (RCT) is considered as the treatment of choice
because it has a considerably high success and survival
rate.

4. • It has been stated that the effectiveness of healing or biological
regeneration depends on the degree of inflammation of the pulp
tissue. In deep carious lesions, inflammation in the superficial
layers of the pulp is more pronounced compared with that in
the deeper layers.
• Nevertheless, a more conservative approach should be
considered for the management of pulp exposures in vital teeth.
Vital pulp therapy treatment modalities have been introduced as an
alternative to RCT. They include indirect and direct pulp capping,
partial pulpotomy, and complete pulpotomy.
• Main Vital Pulp Therapy Treatment Modalities are

5. techniques
Pulp capping
Pulpotomy
Direct Indirect
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6. CONSERVATIVE
1. Protective base
2. Indirect pulp therapy
3. Direct pulp therapy
4. Pulpotomy
RADICAL
1. Pulpectomy
2. Root filling
TREATMENT MODALITIES

7. Definition
 PULPOTOMY CAN BE DEFINED AS THE COMPLETE REMOVAL OF CORONAL
PORTION OF THE DENTAL PULP , FOLLOWED BY PLACEMENT OF SUITABLE
DRESSING OR MEDICAMENT THAT WILL PROMOTE HEALING & PRESERVE
VITALITY OF THE TOOTH
(Finn,1985 )
1. PULPOTOMY

8. INDICATION-:
• Cariously exposed primary teeth, when their retention is more advantageous than
extraction.
• Vital tooth with healthy periodontium
• Pain, if present not spontaneous nor persists after removal of the stimulus
• Tooth which is restorable
• Tooth with-2/3rd root length
• Hemorrhage from the amputation site is pale red & easy to control
• In mixed dentition stage primary tooth is preferable to a space maintainer

9. CONTRAINDICATION -:
• Evidence of internal resorption
• Presence of inter radicular bone loss
• Abscess , fistula in relation to teeth
• Radiographic sign of calcific globules in pulp chamber
• Caries penetrating the floor of pulp chamber
• Tooth close to natural exfoliation

10. TREATMENT OBJECTIVES-:
 Amputate the infected coronal pulp,
 Neutralize any residual infectious process,
 Preserve the vitality of the radicular pulp.
 Avoid breakdown of periradicular area
 Treat remaining pulp with medicament
Avoid dystrophic pulpal changes

11. A.DEVITALIZATION (SINGLE SITTING)
FORMOCRESOLPULPOTOMYTECHNIQUE
First advocated by SWEET(1930)
 FORMOCRESOL SOLUTION:
*19% formaldehyde
*35% cresol
*15% glycerine (veichle)
Buckley’s solution: 1:5 conc. Of formocresol solution

12. Mechanism Of Action:
Formocresol prevents tissue autolysis by bonding to protein. This is reversible
process and is accomplished without changing the basic overall structure of the
protein molecules.
Techniquefor Pulptomyof thePrimaryTeeth
 1. Profound anaesthesia for tooth and tissue.
 2. Isolate the tooth to be treated with a rubber dam.
 3. Excavate all caries.
 4. Remove the dentin roof of the pulp chamber.
• 5. Remove all coronal pulp tissue with a slow-speed No. 6 or 8 round bur or sharp spoon
excavator

13. 6. Achieve heamostasis with moist cotton pellets under pressure.
7. Apply diluted formocresol to pulp on cotton pellet for 3- 5 minutes. Pressure on pellet.
9. Pulp chamber is dried with new cotton pellets .
10. Place a thick paste of ZOE in contact with pulp stumps.
11. Place stainless steel crown (or bonded composite)

15. CVEK’S PULPOTOMY
• Its also called as calcium hydroxide pulpotomy or young permanent
partial pulpotomy.
• Its proposed by Mejare and Cvek in 1978 .
• It’s a procedure in which the inflamed pulp tissue beneath an exposure is
removed to a depth of 1-3mm .
• Indicated for a vital , traumatically exposed, young permanent tooth,
especially one with an incompletely formed apex.

18. ELECTROSURGICAL PULPOYOMY
 Mack & Dean,1993
 Non-pharmacological technique
 Non-chemical devitalisation , hear electrocautery carbonized & heat denatures the
pulp & bacterial contamination

19.  After amputation of the coronal pulp , the pulp stumps are cauterized
through this method. After completion ,the pulp chamber is filled with
ZnOE.
 The tooth is then restored with stainless steel crown
Disadvantage: contaminated pulp tissue does not promote adequate
current penetration . It cannot eliminate radicular pulp inflammation

20. FIG: Exposed or
nearly exposed pulp
1) Crown
2) Root
3) Restoration
4) PULP CAPPING
5) Pulp chamber
2.

21. PULP CAPPING TECHNIQUES
INDIRECT PULP
CAPPING
DIRECT PULP
CAPPING

22. Indirect pulp capping
A procedure where the deepest layer of the
remaining affected carious dentin is covered with a
layer of biocompatible material in order to prevent
pulpal exposure and further trauma to pulp .
-Grossman

24. Two Appointment
Technique

25. First appointment
• Tooth is isolated with a rubber dam
• The gross caries is removed with a large round bur (6 or
8) or sharp spoon exclavator .Care must be taken
removing the caries to prevent exposure of pulp .Care
must be taken to eliminate all the caries at the DEJ .
Because of its closeness to the surface caries left in the
areas will likely cause failure .
• The remaining thin layer of caries is covered
with a radiopaque biocompatible base
material and sealed with a durable interim
restoration
• Wait for 6-8 weeks.
• During this time the caries process
in the deeper layer is arrested.

26. .
• If the tooth is asymptomatic, the surrounding
soft tissues are free from swelling and the
temporary filling is intact , the bitewing
radiograph at the treated tooth should be taken
for the presence of reparative dentin .
• Carefully remove all the temporary filling material ,
especially base over the deep portion of the cavity
floor.The remaining affected carious dentin should
appear dehydrated and flaky and should be easily
removed
•The cavity preparation should be irrigated and gently dried.
•Cover entire floor with Hard setting Ca(OH)2 dressing
• Base should be placed with reinforced GIC or ZOE
• Final restoration with composite or Amalgam

27. Indirect Pulp capping Procedure

28. Materials used :
‘Calcium Hydroxide’ Zinc Oxide Eugenol
Glass Ionomer
Cement
28
Bio Dentine

29. direct pulp capping
definition:
• Procedure in which the exposed vital pulp is covered with a
protective dressing or base placed directly over the site of
exposure in an attempt to preserve pulpal vitality.
-
Grossman

30. Treatment procedure
Rubber dam provides only means of working in a sterile
environment, so proper isolation is done.
Once an exposure is encountered , further manipulation of
pulp is avoided.
Cavity should be irrigated with saline or distilled
water.
Haemorrhage is arrested with light pressure from
sterile cotton pellets.
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31. Place the pulp capping material on the exposed
pulp with application of minimal pressure so as
to avoid forcing the material into pulp chamber .
Place the temporary restoration.
Final restoration is done after determining the
success of pulp capping.
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32. Materials used :
Calcium
hydroxide
Mineral trioxide
aggregate
Zinc oxide
eugenol
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33. 3. Gentle Wave Procedure
• GentleWave® Procedure is a minimally invasive alternative to standard root canal
treatment.
• The innovative procedure utilizes Multisonic Ultracleaning® technology, which enables
procedure fluids to reach through the entire root canal system, providing efficient
cleaning of the complex root canal anatomies.

34. Powered by Multisonic Ultracleaning
• Unlike ultrasonic wavelength technology, which is widely used in dentistry, the
GentleWave Procedure uses multisonic technology.
• This means that multiple acoustic frequencies are generated at the same time, and
when this technology is paired with optimized procedure fluids, the GentleWave
System cleans even the deepest, most complex portions of the root canal system.
Mechanism of action
• To visualize how Multisonic Ultracleaning works, envision a vortex of cleaning fluids
traveling into the roots of your tooth.
• Even though the root canal system can be very complex, with several twists and turns,
this vortex of fluids is able to reach the deepest portions that the files used in standard
RCT simply cannot.

35. • The GentleWave System’s closed-loop Multisonic Ultracleaning technology can help to preserve
more of your natural tooth, while also eliminating the need for a majority of the instrumentation
used during standard RCT.
• Described as more comfortable than standard RCT,4 the GentleWave Procedure is a sought-after
root canal alternative, especially when patients learn it can typically be completed in just one visit

36. WhatsApp Video 2021-05-23 at 9.46.39 PM

37. 4. LASERS
Endodontics Using the Waterlase
• Dentistry has now been introduced to a new root canal treatment using the Er,Cr:YSGG
(erbium, chromium: yttrium scandium gallium garnet) laser to provide additional
important benefits to the patients.
• This new system should help reduce patient fear and improve their general attitude
towards dentistry.

38. • The device that provides such a treatment is the Waterlase Hydrokinetic Hard and Soft tissue
laser (Biolase Technology, Inc), the only laser system to receive FDA clearance for complete
endodontic therapy involving enamel, dentin, pulp, and other root canal procedures.
• This laser uses specialized fibers of various diameters and lengths that provide access to
effectively remove pulpal tissues and tooth structure from the root canal walls, and prepared
the canal for obturation.
• By utilizing the hydrokinetic process, in which water is energized by the YSGG laser
photons to cause molecular excitation and localized microexpansions, hard tissues are
removed cleanly and precisely with no thermal side effects.
• The energized particles are able to provide gentle environment for removing tissue at
the target point

39. • High temperature which is a general concern with most laser systems, is not an issue with the
Waterlase Hydrokinetic system.
• Studies have shown that the temperature of the pulpal tissue remains stable or drops
approximately 2 degree below the normal temperature when the laser and spray reach the
pulpal tissue
• The Waterlase Hydrokinetic system is already very versatile for both hard and soft tissue
applications, and the YSGG laser endodontic application is yet another remarkable
innovative discovery for dentistry.

40. Case Study
The following steps outline the process to complete an
EndoLase therapy using the Waterlase.
Endodontics Using the Waterlase
BY JAMES JESSE, DDS DentalTown Magazine

41. I. The steps, as outlined, demonstrate a basic method for the removal of
necrotic and infected tissue from root canals an enlarging and tapering
the canal a preparation for obturation.

42. Preparing Access to the Pulp Chamber for Pulpotomy
and Pulp Removal
Initially, use the Waterlase with very little laser energy to
desensitize the tooth.
Use the 600μm endo laser tip to complete this first step, and also
to condition the enamel for removal.
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43. Next, increase the laser energy slightly, together with the air and
water spray, to start to ablate the enamel and dentin until the
pulp of the infected tooth is exposed (Fig. 3).
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Once the pulp is exposed, perform a traditional pulpotomy using the Waterlase.

44. • Typically, this is a good point to check with the patient to see if they have felt any pain or
discomfort.
• Usually, the patient is very comfortable and has no complaints about pain. (If they feel
anything at this point, you may need to inject anesthetic directly into the pulp, which
takes the pain away).
• Continue with the procedure using the thinnest Waterlase endodontic fiber tip by
gradually adding laser energy.
• Desensitize and ablate the infected pulpal tissue and dentin until there is clear access
to the canal.

45. Cleaning and Shaping the Canal with the Waterlase
1. Once access to the canal is gained, continue with the thinnest
Waterlase endodontic fiber tip and work to about two-thirds of
the length of the diseased canal.
2. At this point, determine the working length of the root with a
#15 K file and either a digital or an apex locator (Fig. 5).
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46. 3. Usually, the patient has still not expressed any discomfort or pain. Continue the
EndoLase procedure by cleaning and enlarging the middle-third and apical end of the
canal.
4. Using a sequence of highly flexible Waterlase endodontic fiber tips (from thinnest to
thickest), gradually increase the laser energy and continue to clean and shape the canal to
achieve final preparation.
5. Use a series of measurements, starting with the #30 K file; determine if the canal is ready
for obturation.
6. If the #30 K file can easily reach the working length of the canal, and no debris or material
impedes the insertion of the file, the canal is ready for obturation.

47. Canal Obturation
1. At this point, the gutta percha master cone should fit into the entire working
length of the canal.
If so, the canal is ready for sealing.
2. Use paper absorbing points to thoroughly swab the canal of any moisture, as
a precautionary step.
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3. Use EndoRez (or a comparable sealant material) to seal the canal, also insert
one gutta percha cone, which allows for a pathway for a post or re-treatment.

48. • Remarkably, patients who received the EndoLase treatment had little or no discomfort
during the entire procedure. Instead, they express satisfaction that they are leaving the
office without any numbness.
• Generally, using the Waterlase to complete an EndoLase procedure allows to be very
conservative in the treatment of the anatomy of the inside of the tooth.
• It can easily follow the anatomy that is already there and do not have to enlarge the canal
any more than necessary.
• It has always been conservative during treatment of a tooth; now and can be similarly
conservative during endodontic treatments.
• The Waterlase allows for precise and clean removal of necrotic tissue, and has been fully
integrated into the primary method of endodontic treatment.

49. 5. Regenerative endodontics
• Regenerative endodontics: is a biologically based procedure designed to replace
damaged structures, Dentin and root structures Cells of the pulp-dentin
complex.
• Vital pulp therapy with pulp stem/progenitor cells might regenerate dentin-
pulp complex without the removal of the whole pulp.
• Regeneration of parts of the tooth structure can prevent or delay the loss of the
whole tooth.

50. The key ingredients for tissue engineering
Proteins that bind on receptors
on the cell and induce cellular
proliferation & differentiation.

51. Stem cell: ability to; Continuously divide to either replicate itself(self-renewing),
or
Produce specialized cells than can differentiate into various other types of cells or tissues
(multilineage differentiation)
Embryonic stem cells derive from the early mammalian embryo at the blastocyst stage
and have the capability to give rise to all kinds of cells.(Pluripotent)
Adult /Postnatal stem cells are just multipotent because their differentiation
potential is restricted to certain cell lineages

52. DPSCs: multipotency, high proliferation rates and accessibility

53. Growth factors
The key elements of tissue engineering and dentin regeneration

54. Developmental approaches for regenerative endodontic techniques
(J Endod 2007;33:377-90)

58. 6. Student Develops One-Shot Root Canal Alternative
• The treatment comprises 2 antibiotics, ciprofloxacin and metronidazole, along with nitric oxide all
encapsulated in an injectable, self-assembled biomimetic nanomatrix gel.
• Nanogels can be injected directly into a target and formulated to release medications throughout
a specific timeframe.
• Additionally, the gel mimics the natural extracellular matrix to
encourage the formation of new blood vessels in formerly
infected pulp tissue.
• Instead of performing a root canal, imagine bringing a dying tooth back to life. It
may be possible,

59. • The treatment was inspired by Ho-Wook Jun, PhD, an associate professor at the
school’s department of biomedical engineering who developed nanogels that can
regrow bone tissue after fractures and recruit blood vessels to damaged areas of
the heart.
• Current formulations have been limited to 4 to 6 weeks, but the researchers
are working to extend that the 5 or 6 months necessary for human studies.

60. • Another alternative is the use of ozone gas to irrigate the root cavity.
• According to a study in Interventional Neuroradiology, the ozone penetrates into the tubules of
the tooth beyond the drilled area. This kills bacteria and enables the dentist to save more of the
tooth, possibly averting the need for a root canal.
• Despite evidence that the ozone disinfects the tooth beneath the enamel, the possibility remains
that the infection can return at a later stage and a root canal treatment would then be necessary.
This is by no means a guaranteed option, but if your need for treatment is based on infection it
could buy you some extra time.
7. Ozone gas

61. It acts as a strong oxidizer for cell wall and cytoplasmic membrane of bacteria, leads to
oxidative decarboxylation of plaque pyruvate generating acetate and carbon di oxide as
byproducts. It oxidizes volatile sulphur compound precursor methionine to its
corresponding sulphoxide and thus prevents malodour associoated with root caries.
Effect of ozone

62. 8. SURGICAL ALTERNATIVES TO A ROOT CANAL
• In some cases, a root canal isn’t enough to save the tooth. Sometimes Endodontic surgery is the
best option. The surgery can work better in cases where the patient’s canal anatomy is
complicated, and there are tiny canals that don’t clearly show in X-rays. Surgery offers the
opportunity to treat damaged bone and root surfaces.
• An Apicoectomy is a specific procedure most likely seen as a more invasive alternative to a
root canal. During this operation, the provider makes an incision in the gum tissue exposing
the bone and surrounding tissue. They remove damaged tissue and refill the area using root-
end filling then reseal. The special root-end filling helps prevent reinfection. The bone
naturally heals around the root.

63. • While an Apicoectomy makes the list for alternatives to a root canal, it is important to
note that this procedure is really an alternative to extraction when the root canal needs
additional treatment.
• Finally, the ultimate alternative is tooth extraction. We want to note that as
endodontists, we strive to preserve natural teeth whenever possible. A root canal is
often the best alternative to extraction, and patients are typically happy they opted for a
root canal after a short healing period. They enjoy their natural bite without the pain
and infection they previously endured.

65. •One of the most popular alternatives to root canals is extraction of the offending tooth
and the replacement with a bridge, implant or partial denture. According to the American
Association of Endodontists (AAE), this doesn't compare with the advantages of
saving the natural tooth if possible.
9. Extraction
• Exodontia is defined as The painless removal of the whole tooth, or root, with minimal
trauma to the investing tissues, so that the wound heals uneventfully & no post-operative
prosthetic problem is created.
(Geoffray L Howe)

66. 1. Allen 1994 – caries in 48.8% cases – abscess.
2. Periodontal diseases – in 40.7% cases – to prevent alveolar ridge resorption.
3. Tooth with necrosed pulp & periapical lesion – not responding to endodontic treatment.
4. Grossly decayed 1M / 2M and 3rd molar.
INDICATIONS

67. It's well-known that food choices can affect oral health, and proponents of
natural remedies suggest that there are ways to heal dental infections through
diet. These typically include eliminating all processed sugars from the diet, eating
high-quality protein and avoiding grain products, among others. It's never a bad
idea to embrace a healthier lifestyle, but eating fruits and vegetables won't
restore a cracked tooth or fill a deep dental cavity
9. Natural remedies.

68. While these alternatives to root canals sound promising, none of them has the
potential to be the long-term solution a professional root canal procedure offers.
Contrary to expectations, the actual procedure isn't the primary cause of pain; the
damaged or infected tooth tissue is. Root canals enable patients to retain their natural
teeth, smile with confidence, chew effectively and enjoy life.
CONCLUSION

69. • Elmsmari F, Ruiz XF, Miró Q, Feijoo-Pato N, Durán-Sindreu F, Olivieri JG.
Outcome of partial pulpotomy in cariously exposed posterior permanent
teeth: a systematic review and meta-analysis. Journal of endodontics. 2019
Nov 1;45(11):1296-306.
REFERENCES
• Grossman's Endodontic Practice - 13th edition
• Laser and light amplification in dentistry; Dental Clinic of North America; Saunders
publication; October 2000; Vol 44; No.4
• No Drill Dentistry: A Review of Advances in Non-Rotary Methods of CariesRemoval
Dr Pradnya V. Bansode1, Dr Seema D. Pathak2, Dr M.B.Wavdhane3 Dr Vidya M. Patil4
• Developmental approaches for regenerative endodontic techniques (J Endod 2007;33:377-90)