Treatment of Pulpal and Periapical Diseases

1
Treatment of Pulpal and Periapical Diseases
2
1. Case Selection and Treatment
Planning?????????

• Pathways of the pulp, 8th edition

3
Chapter Outline

• Common medical findings that may influence
  endodontics
• Dental evaluation
• Treatment planning

4
1.1 Common medical findings that may influence
endodontics
5
1.1.1 Pregnancy

• Not a contradiction to endodontics
• Modified treatment plan
• Defer elective dental treatment during the first
  trimester except emergency treatment
• Provide routine dental care during the second
  trimester
• Consult physician if necessary

6
1.1.2 Cardiovascular disease

• Medically compromised patients
• Consult with physicians before initiation of
  treatment

7

• Myocardial infarction ????
• (heart attack) within past 6 months
• Increased susceptibility to repeat infarctions
  and other cardiovascular complications
• Contraindication to any elective dental care

8

• Patients with a history of
• Heart murmur ????
• Mitral valve prolapse with regurgitation ?????
• Rheumatic fever ???
• Congenital heart defect ???
• Artificial heart valves ????
• Increased susceptibility to infective (bacterial)
  endocarditis ???????
• Potentially fatal complication
• Prophylactic antibiotic therapy
• ????????

9

• Coronary artery bypass graft
• Antibiotic prophylaxis is not needed after the
  first few months of recovery
• Consultation is advised

10
1.1.3 Cancer

• Patients undergoing chemotherapy and/or
• radiation to the head and neck
• Impaired healing responses
• Consult the patients physician before initiation
  of treatment

11
1.1.4 AIDS

• Infection control
• Asymptomatic patients are usually candidates for
  endodontic treatment
• Medical consultation before endodontic surgery
  for HIV-infected patients

12
1.1.5 Diabetes

• Well controlled patients are candidates for
  endodontic treatment
• Medical consultation for patients with serious
  complications or before endodontic surgery
• Renal disease
• Hypertension
• Coronary atherosclerotic disease
• ????????

13
1.1.6 Dialysis ? ?

• Bleeding tendency
• Elective endodontic treatment should be postponed

14
1.1.7 Prosthetic implants

• Heart valves
• Vascular grafts
• Pacemakers ???
• Cerebrospinal fluid shunts
• Prosthetic joints????
• Antibiotic prophylaxis to prevent infection at
  the site of the prosthesis
• Medical consultation highly recommended

15
1.1.8 Behavioral and psychiatric disorders

• Consultation before using
• Sedatives???
• Hypnotics???
• Antihistamines ????

16
1.2 Dental evaluation

• Periodontal considerations
• Restorative considerations
• Endodontic considerations
• Surgical considerations

17
1.2.1 Periodontal considerations

• Periodontal probing
• Mobility assessment
• Radiographic assessment
• Endodontic treatment should not be planned for
  teeth with poor periodontal prognosis (e.g.
  mobility III)

18
1.2.2 Restorative considerations

• Restorative treatment planning before starting
  endodontic treatment in a nonemergency situation
• Extensive loss of tooth structure
• Subosseous root caries (crown lengthening may be
  needed)
• Poor crown-root ratio
• Lack of ferrule effect
• Misaligned tooth
• Consultation with a prosthodontist

19
1.2.3 Endodontic considerations

• Anatomy of roots and canals
• Procedural errors
• Small mouth
• Instruments
• Operator skill
• Time
• To determine the level of anticipated difficulty
• To identify cases that should be referred

20
1.2.4 Surgical considerations

• Of particular value in the diagnosis of
  nonodontogenic lesions
• Biopsy prior to definitive endodontic treatment

21
(No Transcript)
22
1.3 Treatment planning

• Scope of endodontics
• Vital pulp therapy ????
• Pulpectomy or RCT ??????????
• Endodontic surgery ????
• Retreatment ???
• Hemisection or root amputation ???????
• Bleaching ???
• Apexification or apexogenesis
• ?????????????

23
Treatment planning

• Treatment or extraction?
• What kind of treatment ?
• Endodontic
• Periodontal
• Restorative
• Who will be the operator?
• Single-visit or multi-visit?
• Cost
• Prognosis

24
2. Preparation for treatment

• Infection control
• Universal precautions
• (operatory preparation)
• Instrument sterilization
• Tooth isolation ????
• Patient preparation
• Informed consent ????
• Pain control

25
2.1 Infection Control

• Dental personnel are at risk of exposure to a
  host of infectious organisms
• Risk of cross-contamination in the dental
  environment

26

• Effective infection control procedures
• Reduce the number of micro-organisms in the
  working environment
• Protect patients and the dental team
• Improve the outcome of endodontic treatment

27
Universal precautions

• American Dental Association (ADA) recommendation
• Each patient is considered potentially infectious
• The same strict infection control policies
  applied to all patients

28
Infection control guidelines

• Dental personnel vaccinated against hepatitis B
• Thorough and updated patient medical history
• Proper barrier techniques for dental personnel
• Masks, protective eyewear, disposable latex
  gloves
• Hands, wrists and lower forearms washed with soap
• Use of vacuum suction (high-volume evacuation)
  for high-speed handpiece, water spray or
  ultrasonics
• Use of rubber dam

29

• Cross-contamination related with handpieces
• Surface contamination ????
• Air contamination ????
• Suction contamination ????

30
Rubber Dam ???
Routine placement of the rubber dam is considered
the standard of care in USA
31
Reasons for use of rubber dam

• Protection
• aspiration or swallowing of instruments or
  irrigants
• Soft tissue injury caused by instruments
• Efficiency
• Improve visibility (dry field and reduced mirror
  fogging)
• Minimize patient conversation
• Minimize the need for frequent rinsing
• Reduced risk of cross-contamination
• Legal considerations

32
Components of rubber dam system

• Rubber dam (sheet) ???
• Frame ????
• Retainers (clamps) ????
• Punch ??????
• Forceps ????

33
2.2 Informed consent

• Continuous rise in dental litigation
• For consent to be informed
• The procedure and prognosis must be described
• Alternatives to the recommended treatment must be
  presented along with their respective prognoses
• Foreseeable risks must be described
• Patients must have the opportunity to have
  questions answered

34
?????????   ????????,????????,??????????
??????_____________, ????_________????________??
???(??????/????,?????/?????)?????????????(?)????
(??????????) ?????X??,?????????????????????
????????????????????????????????????????????,?????
?????,???????????????????????(??????),????????????
??????????????????????????,??????????????????????
???,?????????????????????????????????,????????????
????????????,?????????? ?????????????????????
?????????????????????,???????? ????????????,
??????????????(??????/????,?????/??????)??????????
???????????????????? ????????_________________
____________ _______????,???????________?? ????
____________ ??____________ ????(????
???????????) ____________ ??????____________
??____________
35
2.3 Pain control

• Local anesthesia
• Divitalization ???

36
2.3.1 Local anesthesia (LA)

• When to anesthetize
• LA should be given at each appointment
• Three misconceptions
• Necrotic teeth may be instrumented without LA
  (vital tissue may exists periapically)
• Patients sense aids the clinician to determine
  working length ??????
• LA is unnecessary during obturation phase
  (obturation pressure and extrusion of sealer may
  produce pain)

37
local anesthetics

• Lidocaine ????
• Articaine ????

38
???(????)
39
Techniques

• Conventional techniques
• Supraperiosteal injection (local infiltration)
• Regional nerve block
• Supplemental techniques
• Periodontal ligament (PDL) injection
• Intrapulpal injection
• Intraseptal injection
• Intraosseous (IO) injection

40

• Maxillary posterior teeth
• Posterior superior alveolar (PSA) block for
  molars
• Buccal infiltration for premolars
• Palatal infiltration for rubber dam retainer
  (optional)
• Maxillary anterior teeth
• Labial infiltration
• Palatal anesthsia for rubber dam retainer
  (optional)

41

• Mandibular teeth
• Inferior alveolar nerve (IAN) block for anterior
  and posterior teeth
• Incisive nerve block for premolars and anterior
  teeth
• Labial infiltration for anterior teeth

42
Periodontal ligment (PDL) injection

• 27-gauge/short or 30-gauge/ultrashort needle
• Placed into the periodontal space between the
  root and the interseptal bone
• Bevel facing the root
• 0.2mL of anesthetic slowly deposited on the
  distal of each root of the tooth

43

• Index of successful PDL injection
• Presence of resistance to anesthetic deposition
• Ischemia of the soft tissue at the site of
  injection
• Contraindications
• Presence of infection or inflammation in the area
  
• of needle insertion (e.g. acute apical abscess)

44
Intrapulpal injection

• 27-gauge/short needle
• Inserted into the pulp chamber or canal
• Resistance met and 0.20.3mL of the solution
  expressed
• In lack of a snug fit of the needle
• warm gutta percha?? inserted around the needle
• Injection under pressure after cooling

45
2.3.2 ??? Devitalization

• ????????????,????????????????????,???????
• ?????????????

46

• ?? ????????????,??????????????????????,??????????
  ????

47
?????

• ????
• (????,????)
• ?????????????
• ??????????
• ??????
• ???????14?
• ??7-10?

48
?????

• ???(As2O3)
• ??????????????
• ???????????
• ???????????
• ????????24-48??
• ????????????

49
????

• ??????????????
• ???????????
• ?????????????????
• ???????????????
• ZOE????

50

• ???
• ??????
• ????
• ?????
• ????

• ???
• ????
• ??????
• ??????

51
3. Vital Pulp Therapy??????

• Indirect pulp capping ?????
• Direct pulp capping ?????
• Pulpotomy ?????
• Principles and practice of endodontics
• 2th edition

52
3.1 Indirect pulp capping

• Indications
• deep carious lesions
• No history of pulpalgia
• No signs of irreversible pulpitis
• No pulp exposure
• after excavation of carious dentine

53
Pulp Capping Materials

• Calcium hydroxide ????
• The most commonly-used
• (direct) pulp-capping material
• Water-based calcium hydroxide
• Resin-based Calcium hydroxide
• e.g. Dycal, Timeline

54

• Zinc oxide-eugenol cement (ZnOE)
• Only for indirect pulp capping
• Bactericidal effect and hermetic marginal seal
• Cytotoxicity-use of ZnOE as a liner in deep
  carious lesions is still controversial

55
Procedures

• 1. Remove all softened, mushy or leathery dentine
• 2. Either ZOE or Ca(OH)2 placed on the remaining
  dentin to kill or suppress bacteria
• 3. Base
• 4. Temporary or permanent restoration

56
3.2 Direct pulp capping

• Indications
• Accidental or mechanical pulp exposure (normal
  pulp)
• Cavity preparation
• Placement of pins
• Trauma
• Mainly for immature permanent teeth with recent
  (lt24 hr) traumatic pulp exposure or mechanical
  exposure during cavity preparation

57

• Should mature teeth be pulp capped?
• Size of exposure limited to 1mm
• Contraindicated for carious tooth with
• pulp involvement

Enamel-dentin fracture with pulpal involvement
Direct pulp capping
58
Hemostatic reagents???

• Saline ??
• Hydrogen peroxide ???
• Diluted sodium hypochlorite ????
• Chlorhexidine ???

59
Pulp capping materials

• Calcium hydroxide
• Mineral trioxide aggregates (MTA)
• ????????

60
Procedures

• Ca(OH)2 applied to the exposure to stimulate
  differentiation of new odontoblast-like cells and
  formation of secondary dentin
• Temporary restoration placed over Ca(OH)2
• Follow-up
• Permanent restoration
• Pulpotomy or endodontic treatment for symptomatic
  tooth

61
3.3 pulpotomy

• Indication
• Immature permanent teeth

62
Procedures

• Removal of all carious dentin and pulp tissue to
  the level of the radicular pulp
• Vital pulp stump capped with Ca(OH)2
• Temporary restoration
• Follow-up
• Asymptomatic permanent restoration
• Symptomatic endodontic treatment

63
Potential problems with pulpotomy as a permanent
treatment

• Impossible to determine whether all disease
  tissue has been removed
• The remaining radicular pulp tissue may undergo
  mineralization
• Making further endodontic treatment difficult or
  impossible
• Internal resorption

64
Conclusions

• The vital pulp therapies are predictable in teeth
  with traumatic or mechanical pulp exposure.
• Direct pulp capping is contraindicated for teeth
  with carious pulp exposure. Pulpotomy might be
  the choice but is considered unproven.
• When for financial or other reasons
  extraction is the only alternative, pulpotomy
  certainly should be considered for the benefit of
  the patient.

65
4. Emergency Treatment

• Pretreatment emergency
• Irreversible pulpitis without acute apical
  periodontitis
• Irreversible pulpitis with acute apical
  periodontitis
• Pulp necrosis with acute apical periodontitis
• Pathways of the pulp, 8th edition
• Principles and practice of endodontics, 2th
  edition

66
4.1 Irreversible pulpitis without AAP

• Principles
• Complete pulp removal
• Total cleaning and shaping (C/S) of the root
  canal system ???????
• Pulpectomy is the best to achieve pain relief

67

• Pulpectomy
• Complete removal of the vital pulp tissue
  followed by cleaning , shaping and filling of
  the root canal(s).
• Indicated for tooth with pulpitis

68

• Multirooted teeth at the emergency visit
• Pulpotomy (removal of the coronal pulp) or patial
  pulpotomy (removal of the pulp from the widest
  canal) acceptable but less predictable in pain
  relief

69
Procedure

• C/S of the root canal system
• A dry cotton pellet placed in the pulp chamber
• Complete caries removal and effective temporary
  coronal seal to prevent contamination
• Occlusal reduction ????

70
4.2 Irreversible pulpitis with AAP

• Combination of pulpal and periapical symptoms
• Complete pulp removal and C/S
• Ca(OH)2 medication in canals to prevent bacterial
  regrowth
• Effective temporary coronal seal
• Occlusal reduction
• Oral analgesic medication when necessary

71
4.3 Pulp necrosis with AAP

• Without swelling
• With localized swelling
• With diffuse swelling

72
Without swelling

• Thorough removal of necrotic pulp
• Complete C/S of the root canal
• Introducing a small file (10/15) slightly beyond
  the apex to establish drainage from the
  periapical tissues
• Ca(OH)2 dressing between visits to help eliminate
  remaining bacteria
• Oral analgesics

73
With swelling

• Principle
• debridement?? and drainage
• Three ways to resolve swelling and infection
• Drainage through the root canal
• Drainage by incising a fluctuant swelling
  (incision and drainage, ID)
• Antibiotic treatment

74
Localized swelling

• Firstly try to establish drainage from root
  canals
• C/S of the root canal
• Introducing a small file (size 10/15) slightly
  beyond the apex to establish drainage
• No ID in case of good drainage
• Ca(OH)2 medication
• Access seal
• If pus continues to drain through the canal and
  cannot be dried within a reasonable period of
  time, the tooth may be left open for lt24 hrs

75

• Incision and drainage
• Indicated for localized fluctuant soft tissue
  swelling
• Principles
• Incise at the site of the greatest fluctuance
• Dissect gently and extend to the roots
• Keep wound clean with hot saltwater mouth rinses
  or CHX mouth rinse

76
Diffuse swelling

• Possible to turn into a medical emergency and
  life-threatening condition
• Principles
• Thorough C/S of the canals
• Apical patency achieved whenever possible
• Tooth left open
• ID in the absence of drainage through the canals
  with a rubber dam drain inserted or sutured (23
  days)
• Referral to oral surgeons

77
Antibiotic therapy

• Indicated for patients with
• Diffuse swelling regardless of the establish of
  drainage
• Spreading infections or systemic signs
• Penicillin (1st choice) or clindamycin or
  erythromycin Metronidazole

78
Endodontic Emergency Treatment