1. Root canal treatment is needed when the pulp becomes inflamed or infected due to deep dental caries, leaky fillings, trauma, or excessive orthodontic forces. 2. The pulp can progress from a reversible inflammation to an irreversible one where recovery is not expected, and eventually become necrotic with complete breakdown of cellular organization and no reparative potential. 3. Treatment depends on the pulpal status and ranges from removal of irritants for reversible pulpitis to complete root canal instrumentation and filling for irreversible pulpitis or necrotic pulp to relieve symptoms and prevent or treat apical periodontitis.

1. Why we need
Root Canal
Treatment ?

2. Aetiologyofthepulpandperiapical
pathosis
Microbial: dentalcaries
Mechanical: operative procedure(iatrogenic),trauma
Chemical: pulpal(acidetching,bond),periapical (irrigation)

3. 1- Due to deep Caries

5. 2- Due to Leaked Restoration

6. 3- Due to Trauma

7. 4- Excessive force during ortho.
treatment

8. EFFECT OF DENTAL MATERIALS ON
PULP
GIC – Well tolerated by pulp
• Calcium hydroxide – includes dentin bridge
formation.
• Zine oxide – eugenol- has an anti-bacterial
effect.
• Formocresol – Cause chronic inflammation of
the pulp.
• Dentin bonding agent – can irritate the pulp
causing inflammation
www.rxdentistry.blogspot.com

9. PhysiologyofPulpal
Pain
Odontogenicpain
sensibilityofthedentalpulp
2typesofsensorynervefibresinthe
1. myelinated Afibres(A-delta
andA-betafibres)
2.Unmyelinated Cfibres
coronalportionofthepulpandconcentratedinthepulp
horns
coreofthepulp extendinto the cell-freezone underneaththe
odontoblastic layer

12. Dentintubulefluidmovement
Dehydration Heat Cold
Dentinal
tubule
and fluid
Dentin
Odontoblast
movement
Sensory nerves
A-delta
fibers
Hyper-
osmoticsolutions

14. • Location
• Onset
• Timing(frequency,duration)
• Quality(sharp,dull,throbbing
• Intensity (0-10)
• Relieves/Aggravates
• Associatedsymptoms
14
Pain

16. REFERREDPAIN
Theperception ofpain inone partofthe bodythat is
distant fromtheactualsource ofthe pain is known as
referred pain.

17. Pulpal Status
Vital Nonvital
Normal Inflamed
Reversibly
Inflamed
Irreversibly
Inflamed
Necrotic

18. Pulpal Pain
•
Deep, dull, aching pain of a threshold nature
•
Often difficult to localize
•
Occurs irrelevant to biomechanical(masticatory)
functions

19. Common Characteristics of Pulpal Pain
1. Quality of pain is dull, aching, throbbing and
occasionally sharp
2. An identifiable condition that reasonably explains the
symptoms
3. Response to local noxious stimulation is
proportionate and predictable
4. Pulpal pain tends to get better or worse, but rarely
stays the same over time
5. Local anesthesia of the suspected tooth eliminates
the pain

20. Site of Pain vs. Source of
Pain
Site of Pain
• The location where the patient feels the pain
• Easily located by asking the patient to point out the
region of the body that is painful
Source of Pain
• That area of the body from which the pain actually
originates

21. Primary Pain
Site (where it hurts) = Source (where it
originates)
Eg./ cut finger
Heterotopic Pain
Site ≠ Source
Eg./ cardiac pain

23. Heterotopic Pain
Pain felt in an area other than its true site of
origin (associated with deep, somatic pain).
–Projected pain: perceived in the anatomic
distribution of the same nerve that
mediates the primary pain (painful
adjacent teeth).
–Referred pain: felt in an area innervated
by a different nerve from the one that
mediates the primary pain (teeth in
opposing arch, face, head, neck).
Does not cross the midline.
Convergence of afferent neurons.

24. TERMINOLOGY
Dental pulp – Tissue within each
tooth that contains the nerves, blood
vessels, and cells that make the tooth
a living organ
Pulpitis – A range of conditions from
inflammation all the way to pulpal
necrosis

25. TERMINOLOGY CON’T
Vitality – response of the pulpal tissue
to a stimulus(healthy to
nonresponsive)
Reversible/irreversible pulpitis –
Reactions of a vital pulp to stimuli
Necrotic – death of the pulp
Periapical Tissue
• chronic periodontitis
• acute periodontitis

26. WHY PULPAL
TESTING?
Pulp testing is done to
determine the treatment
need of the tooth

27. PAIN
An unpleasant sensory and
emotional experience
associated with actual or
potential tissue damage or
described in terms of such
damage.

28. Acute
v
Chronic

29. Acute Pain
Associated with tissue damage or injury.
Recent onset.
Limited duration.
Stimulation of peripheral and central
nociceptors by algogenic substances
(bradykinin, prostoglandin, leukotrienes,
histamines, substance P, excitatory AAs).

30. Chronic Pain
Prolonged persistence of pain beyond
the healing of tissue.
Frequently experienced in the absence
of peripheral stimulation or lesions.
Result from changes in the dorsal horn
and brain.

31. TOOTHACHE PAIN
Toothache of odontogentic origin can be
visceral (pupal) or musculoskeletal
(periapical or periodontal).
– When the pulp is exposed to a noxious
stimulus, there is a reactive inflammatory
response.
– The resulting edema is unable to expand
because of the surrounding inflexible cementum
→ ↑ tissue pressure and ↓ blood flow that
causes damaging effects to the pulp.

32. Considerations:
Healthy pulp (cellular) v Aged pulp (fibrous)
As an increasing amount of pulp tissue is involved,
the inflammatory process progresses apically, until
it extends out into the periapical tissue → apex
becomes sensitive to palpation and percussion.
Periapical inflammation from non-pulpal causes
can exhibit similar symptoms:
– Hyperocclusion
– Bruxism

33. Pulpal Status
Vital Nonvital
Normal Inflamed
Reversibly
Inflamed
Irreversibly
Inflamed
Necrotic

34. CLINICALCLASSIFICATIONOFPULPAL
ANDPERIAPICALDISEASES
PulpalDisease
•NormalPulp
•Reversible Pulpitis
•Irreversible Pulpitis
•Necrosis

35. PAIN
•Location
•Onset
•Timing (frequency, duration)
•Quality (sharp, dull, throbbing, aching,burning, etc.)
•Intensity (0-10)
•Relieves / Aggravates
•Associated symptoms

38. ReversiblePulpitis
Common causes:
Caries, recent restorative procedures, faulty
restorations, trauma, exposed dentinal tubules,
periodontalscaling.

39. Condition should return to normal with removal of the
cause.
Pulpal recovery will occur if reparative cells in the pulp are
adequate.

40. Treatmentof
ReversiblePulpitis

41. Removeirritant ifpresent(caries;fracture; exposeddentinaltubules).
– If nopulpexposure:CaOH,restore,monitor
– If pulpexposure:
Carious: initiateRCT
Mechanical: >1mm:initiateRCT
<1mm crownplanned:initiateRCT
<1mm: directcaporRCT
If recent operative or trauma – postpone additional treatment and
monitor.

42. IrreversiblePulpitis

43. Pulpalinflamationanddegenerationnotexpectedtoimprove.
A physiologically older pulp has less ability to recover due to decrease in
vascularity andreparative cells.
As inflammation spreads apically, cellular organization begins to break
down.
Localized pressure slows venous return, resulting in buildup of toxins and
lowerpH thatcauseswidespreadcellulardestruction.

44. Treatment ofIrreversible Pulpitis
Idealimmediate treatment
• (complete removal of pulpal tissue)completely relieve
occlusionifhaveacute periapicalperidontitis.

45. PulpalDisease
Necrotic
Pulp

46. NecroticPulp
Resultsfromcontinueddegenerationofanacutelyinflamedpulp.
Involvesaprogressedbreakdownofcellularorganizationandnoreparative
potential.
Commonly have apical radiolucent lesion. (always conduct proper pulp
testingtoruleoutanon-pulpal origin).
With multi-rooted teeth, one root may containpartially vitalpulp, whereas
otherrootsmay benonvital(necrotic).

47. TreatmentofNecroticPulp
Minimum immediatetreatment (if notextraction)
Partialinstrumentationofcanals:
– PlaceCa(OH)² intoallcanals
– completelyrelieveocclusionifhaveacuteapicalperiodontitis.
Idealimmediatetreatment
• Complete instrumentationofcanals:
– completelyrelieveocclusionifhaveacuteapicalperiodontitis.