ROOTS CYBERCOMMUNITY - SUMMIT V
Gettin’ on the same page
Gettin’ on the same page
Aetiology, classification and pathogenesis
of pulp and periapical disease
Dental pulp is a richly vascularized and innervated tissue, enclosed by
surrounding tissues that are incapable of expanding, such as dentin. It
has terminal blood flow and small-gauge circulatory access the periapex.
All of these characteristics severely constrain the defensive capacity of
the pulp tissue when faced with the different aggressions it may be
subjected to. Pulp tissue can also be affected by a retrograde infection,
arising from the secondary canaliculi, from the periodontal ligament or
from the apex during the course of periodontitis. Due to the fact that
periapical disease is almost inevitably preceded by pulp disease, we shall
begin by describing the causes of pulp disease and will then proceed to a
discussion of the causes of periapical disease. The course of illness and
classification of these pathological entities will depend on the aetiology
involved. We will analyse pulp necrosis and pulp degeneration that are
capable of triggering reversible apical periodontitis or irreversible apical
periodontitis.
Warm Up
Chief complaint
• intermittent pain, sense of pressure, pain
on biting, hard to localize, patients
answers for the most part are vague,
seems to be focused on distal proximal
aspect of quadrant
• level of agitation is such that accuracy of
responsiveness in question
• taking penicillin for two days (irregular
dosing)
Case #1 Factoids
Chief complaint
• positive response to thermal challenge
• hyperaemic or engorged pulp
• w/o periapical extension
• treated in a single visit
• RCT or HealOzone?
• post treatment medication recommendations?
• restorative considerations?
Case #2 Factoids
Chief complaint
• generalized discomfort on chewing in maxillary
right quadrant
• strong focus on 1.6
• degenerating pulp with periapical extension
• one visit
• expectation of mild post-tx pain
• NSAIDS, analgesics prescribed?
• system or method of instrumentation
• apical terminus – Rosenberg Technique - Discuss
• irrigation routine – discuss
• Comprehensive Care Considerations - discuss
J Calif Dent Assoc. 2004 Jun;32(6):493-503
The success of endodontic therapy:
healing and functionality.
Friedman S, Mor C.
University of Toronto Faculty of Dentistry, Canada.
Based on selected follow-up studies that offer the best evidence, the chance of
teeth
without apical periodontitis to remain free of disease
after initial treatment or orthograde retreatment is
92 percent to 98
percent. The chance of teeth with apical periodontitis to
completely heal after initial treatment or retreatment is 74 percent to
86 percent, and their chance to be functional over time is 91
percent to 97 percent. Thus there does not appear to be a systematic
difference in outcome between initial treatment and orthograde retreatment.
is less consistent
The outcome of apical surgery
than
that of the nonsurgical treatment. The chance of teeth with apical periodontitis
to completely heal after apical surgery is 37 percent
to 85 percent, with a weighted average of approximately 70 percent.
However, even with the lower chance of complete healing, the chance for the
teeth to be functional over time is 86 percent to 92 percent.
Case #3 Factoids
Chief complaint
• masticatory sensitivity
• RCT done prior – time indeterminate
• apical periodontitis in evidence
• 2 visits – interim calcium hydroxide procedure
• NSAIDS, analgesics NO antibiotics prescribed
• irrigation routine – citric acid and CHX
• CLP considerations
J Endod. 2004 Oct;30(10):689-94. An evidence-based analysis of the
antibacterial effectiveness of intracanal medicaments. Law A, Messer H.
Postgraduate Endodontics, School of Dental Science, University of Melbourne,
Melbourne, Australia.
The authors reviewed the literature evaluating the antibacterial effectiveness of
intracanal medicaments used in the management of apical periodontitis. A
PICO (problem, intervention, comparison, outcome) strategy was developed to
identify studies dealing with calcium hydroxide, phenolic derivatives, iodinepotassium iodide, chlorhexidine, and formocresol. The final
inclusion/exclusion criteria eliminated all papers except five that evaluated
calcium hydroxide. The total sample size in the included studies was 164 teeth.
Microbiologic sampling was performed before endodontic treatment (S1), after
instrumentation and irrigation (S2), and after intracanal medication (S3). At S2,
62% of canals were positive. After medication, 27% still showed detectable
growth. Of cultures that were positive at S2, 45% were still positive at S3. Most
studies did not address issues of culture reversals or false positive and false
negative cultures. The main component of antibacterial
action appears to be associated with instrumentation
and irrigation, although canals cannot be reliably
rendered bacteria free. Calcium hydroxide remains
the best medicament available to reduce residual
microbial flora further.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Nov;96(5):618-24. Efficacy of
chlorhexidine- and calcium hydroxide-containing medicaments against Enterococcus
faecalis in vitro. Basrani B, Tjaderhane L, Santos JM, Pascon E, Grad H, Lawrence HP,
Friedman S. Dalhousie University, Endodonic Division, Department of Dental Clinical
Sciences, Halifax, Nova Scotia, Canada.
OBJECTIVE: We sought to assess the efficacy of chlorhexidine (CHX) and calcium
hydroxide, Ca(OH)(2), against Enterococcus faecalis in vitro. STUDY DESIGN: The effect
of CHX (0.2% and 2% in gel or solution) and Ca(OH)(2) (alone or with 0.2% CHX gel) was
evaluated by using the agar diffusion test and an in vitro human root inoculation method,
to measure zone of inhibition or bacterial growth with optical density analysis,
respectively. For optical density analysis, samples from infected root canals were
collected after 7 days of medication and were cultured for 24 hours in brain-heart infusion
to detect viable bacteria. RESULTS: In the agar diffusion test, CHX was effective
against E faecalis in a concentration-dependent fashion, but
Ca(OH)(2) alone had no effect. In the root canal inoculation test,
CHX was significantly more effective against E faecalis than
Ca(OH)(2) was (P < .05), but there were no significant differences
between the modes of medication or concentrations of CHX.
CONCLUSIONS: CHX is effective against E faecalis in vitro. Further
in vivo studies are needed to confirm the value of CHX in clinical
treatment.
•
•
•
•
•
•
Chief complaint
• localized, nodular swelling over maxillary first
molar
history of RCT, CAP evident
retx chosen as tx option
CHX and Ca(OH)2 used as interim treatment
dressing
NSAIDS, analgesics prescribed
Primary focus of failure – undetected MBx canal
Pulp and Periapical Disease
Oral microorganisms
Root Canal Therapy
Mechanical
Instrumentation
Irrigation
Intra-canal
medication
Microbial Control Phase
R.C. Filling
Effect of Ca(OH)2 on Microorganisms
in Necrotic Pulps
Control of Endodontic Infection
Card et al. JOE 2002
Sjøgren U et al. IEJ 1997
Ørstavik D et al. IEJ 1991
Bystrøm et al. EDT 1987
Kerekes et al. JOE 1979
Volume of
Microbial Contents
1. Mech. preparation
#25
#30
#35
#40
Apical Preparation
Control of Endodontic Infection
1. Mech. preparation
#25
#10
#40
Courtesy Dr. Richard Walton
Control of Endodontic Infection
1. Mech. preparation
#25
#25
#25
Courtesy Dr. Richard Walton
Apical Periodontitis
Prevalence
Increases with age
• Age 50: 50% experience the disease
• Age > 60: 62% exhibit the condition
• US Census data: 420 million root filled
At 90% success: 42 million failing
At 80% success: 84 million failing
At 60% success: 168 million failing
• Eriksen 1991, 1998; Figdor 2002
No lesion (%)
40
20
0
60
Cross-sectional studies
Lupi-Pegurier et al. 2002
Hommez et al. 2002
Dugas et al. 2002
Tronstad et al. 2000
Kirkevang 2000
De Moor et al. 2000
Sidaravicius et al. 1999
Marques et al. 1998
Weiger 1997
Saunders 1997
Eriksen et al. 1995
Buckley & Spangberg 1995
Ray & Trope 1995
Petersson 1993
De Cleen et al. 1993
General Population
100
80
Treatment OutcomeS
Variability
50% to 95%
Status quo or change?
Effects of four Ni-Ti preparation techniques
on root canal geometry
assessed by micro-computed tomography
Peters OA, Schonenberger K, Laib A. Int Endod J. 2001
Maxillary molars ....all
instrumentation techniques
left 35% or more of the
canals' surface area
unchanged. ….a strong
impact of variations of canal
anatomy was demonstrated..
Principles Functions of
The Root Canal Filling
#1.Entomb
Entombexisting
existingbacteria
bacteria
Prevent coronal and apical
leakage
Strengthen the root
Bacteria and Prognosis
Success by culturing results
+ve culture
-ve culture
Engstrom
et al (1964)
89%
If bacteria
were76%
entombed,
Zeldkow & Ingle (1963)
83%
93%
Oliet & Sorin (1969)
80%
91%
Sjögren et al. (1997)
68%
94%
there would be NO difference
in
the
healing
of
teeth
with
PA
lesions
95%
Bystrom et al (1987)
“State of The Art”
Gutta-Percha + Sealer
..stopping influx of periapical tissue
Entomb
existing
bacteria
derived fluid from reaching residual
Prevent
coronal
andsystem
apical
bacteria
in the
root canal
acting
as a barrier, preventing
releakage
leakage
infection of the root canal
Strengthen
the root
(Sundqvist
and Figdor,
1998)
Before
Completed endodontic procedure
Permaflo Purple
Final polished restoration
Endo/Coronal Status
GE & GR
N
% API (periapical inflamn)
330
91.4
GE & PR
164
44.1
PE & GR
302
67.6
PE & PR
188
18.1
Overall
1010
61%
Good root filling and coronal
restoration
Coronal Leakage
Swanson et al. 1987 - Dye leakage to apex
3 days: dye leakage to apex
Khayat et al. 1993 - Bacteria to apex
30 days: bacteria to apex
Trope et al. 1994 – Endotoxins to apex
20 days: endotoxin to apex
Control of Endodontic Infection
Smear
Clear
1. Mech.
preparation
Ca(OH)
2
2. Canal disinfection
ZZY-VAC
3. Obturation
CHX
4. Top
filling
Heal
Ozone
BioPure™MTAD™
Adhesion Endodontics
Case #3 Factoids
Chief complaint
• pain in maxillary right quadrant
• pre-existing RCT and CAP
• calcium hydroxide placed in #1.5
• NSAIDS, analgesics, no antibiotics
• patient had persistent pain…swelling appeared
• sinus tract traced to mesial root of #1.6
• #1.6 retreated with calcium hydroxide
• case obturated and transitionalized for 90 days
Maxillary Molar Teeth
Relocation of the canal orifices
Maxillary Molar Teeth
Courtesy of Dr. Cliff Ruddle
Relocation of the canal orifices
Composite
finishing burs
Brasseler H274-016
Never be surprised
Ancillary MB canals
Gingival Sulcus
.5-2.0mm
Epithelial Attachment
.75mm
Conn Tiss.
Attachment 1.25mm
Case #4 Factoids
Chief complaint
• pain on chewing
• inadequate RCT #3.6
• deficient margins
• patient unable to identify source
account
for
• always to
review
occlusion / facial
typethe high incidence of
• opposing fractured
restorations
mandibular molars: the
Hiatt proposed the lever principle
second molar is nearer the fulcrum
of mandibular closure and thus
receives the greatest force.
If 4 canals in an upper molar panics you…………………