Management of pulpal

1
Management of pulpal periradicular disease

• GDC
• ???

2

1. Introduction
2. Pulpal periradicular pathology
3. Pulp disease
4. Classification of periapical disease
5. Radiographic lesions of non-endodontic origin
6. Management of pulpal periradicular disease
7. Chemomechanical debridement
8. Root canal preparation
9. One-visit root canal treatment
10. Root canal obstruction
11. Assessment of root canal treatment

3
1.Introduction
4
Pulpal Periradicular Ds.
Bacteria
origin
aim of Tx.
5
2.Pulpal periradicular pathology
6
Sources

• Bacterial
• Mechanical Injury/Irritation
• Chemical

7
Modes of entry for bacteria into the root canal
system

• Caries
• Periodontal disease(dentine tubules, furcal
  canals, lateral canals)
• Erosion, attrition abrasion(dentinal tubules)
• Trauma with or without pulpal exposure
• Developmental anomalies
• Anachoresis(the passage of microorganisms into
  the root canal system from the bloodstream)

8
3.Pulp disease

• 3-1.Soft tissue change
• 3-2.Hard tissue change

9
3-1.Soft tissue change

• Reversible pulpitis
• Irreversible pulpitis
• Hyperplastic pulpitis
• Pulp necrosis

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3-1-1.Reversible pulpitis

• Sx.
• Pain
• ?? ?? ? ??(?)
• ?? ?? ???
• XR ??
• P/R(-)

• Tx.
• ??? D ??
• ??? ??

11
3-1-2.Irreversible pulpitis

• Sx.
• Pain
• ?? ?? ? or ???
• ?? ?? ? ??(?)
• ???? ??
• ?? ?? ??(if PDL involved)
• XR PDL widening

• Tx.
• RCT
• Ext.

12
3-1-3.Hyperplastic pulpitis

• Pulp polyp
• a form of irrv. pulpitis
• ?? ??? young pulp? ??

• Tx.
• RCT
• Ext.

13
3-1-4.Pulp necrosis

• end result of irrv. pulpitis

• Tx.
• RCT
• Ext.

14
3-2.Hard tissue change

• Pulp calcification
• Internal resorption

15
Pulp calcification

• 2D
• physiologic
• ?? ?/?? ?? ?
• ???? floor / ceiling
• 3D
• ?? ?? ?
• reactionary D mild stimuli
• reparative D strong stimuli

• Tx.
• ??? ??

16
Internal resorption

• dentinoclastic activity
• pink spot
• ???
• ??
• punched-out outline
• XR
• pulp cavity? ??

• Tx.
• RCT ?? ??
• Ext. ?? ?? ?

17
4.Classification of periapical disease

• 4-1.Acute apical periodontitis
• 4-2.Chronic apical periodontitis
• 4-3.Condensing osteitis
• 4-4.Acute apical abscess
• 4-5.Chronic apical abscess

18
4-1.Acute apical periodontitis

• Sx.
• P/R()
• PDL widening

• Tx.
• occl. adjustment
• RCT
• Ext.

19
4-2.Chronic apical periodontitis

• Sx.
• V/S(-)
• P/R() mild
• Td() apex
• XR ??(PDL wideningperiapical destruction)

• Tx.
• RCT
• Ext.

20
4-3.Conensing osteitis

• Chr. apical periodontitis? ??
• diffuse increase in trabecular b.
• XR concentric radio-opacity

• Tx.
• ?? ??? ??

21
4-4.Acute apical abscess

• Sx.
• moderate discomfort swelling/systemic
  involvement(?? ??, ???)
• P/R(), Td()
• XR well defined radiolucency
• Phoenix abscess
• acute exacerbation of a chr. situation during tx.

• Tx.
• 1
• ??? ?? ??
• Drainage
• Ax.
• 2
• RCT
• Ext

22
4-5.Chronic apical abscess

• Discharge
• intraoral sinus
• extraoral sinus
• PDL(perio. pocket? ??)

• Tx.
• RCT
• Ext.
• ?? ? ?? ?? ??(???)

23
5.Radiographic lesions of non-endodontic origin
24
Radiograghic lesions of non-endodontic origin

• Normal anatomical structures
• Maxillary sinus
• Mental foramen
• Nasopalatine foramen
• Benign lesions
• Cementoma
• Fibrous dysplasia
• Ossifying fibroma
• Primordial cysts
• Lateral periodontal cyst
• Dentigerous cyst

• Traumatic bone cyst
• Central giant cell granuloma
• Central haemangioma
• Ameloblastoma
• Malignant lesions
• Squamous cell carcinoma
• Osteosarcoma
• Chondrosarcoma
• Multiple myeloa

25
DDx.

• pulp vitality test
• XR (?? ???? ??)
• Bx.

26
6.Management of pulpal periradicular disease
27
Tx. sequence

• 1. pulpal perio. pain ?? ??
• 2. hopless teeth ??
• 3. ? ?? ?? ???
• 4. ?? ?? ? ?? ??

28
Endo. Tx.

• part of an overall plan of care? ??
• antiseptic principles ??
• chemomechanical debridement of the pulp cavity
• removal of infected dentine
• use of antimicrobial agents
• R/D ?? ??

29
Rubber dam ??

• Improved visibility
• Soft tissue protection
• Confinement of excess irrigant
• Prevention of saliva contamination
• Reduced liability in the medicolegal sense

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7.Chemomechanical debridement

• 7-1.Hand instruments
• 7-2.Automated instrumentation
• 7-3.Irrigation
• 7-4.Summery

31
Irrigating soln(chemo)hand auto.
Instruments(mechanical)

• Chemomechanical

32
7-1.Hand instruments

• Barbed broach
• Hedstrom file
• k type file

33
Barbed broach
7-1.Hand instruments

• ?? ? ???? ???? 90??
• ?? ??
• vital pulp ??
• soft foreign object ??

34
Hedstrom file
7-1.Hand instruments

• sharp cutting edge
• ???
• linear manner(?)
• rotation(?)
• ??
• flaring canals
• re-tx.

35
K type file
7-1.Hand instruments

• most commonly used
• standard taper 0.02mm/mm
• tip size
• ??(0.061.40mm)
• ??? ??(?)

36
Filing motion
7-1.Hand instruments

• Watchwinding
• gentle side-to-side rotation
• ?? 30??

• Balanced force
• efficient cutting
• 60CW 120 CCW
• C/E C/S? ??

37
NiTi files
7-1.Hand instruments

• hyperelasticity
• greater taper (0.020.12mm/mm)
• 360 rotation ??
• shape memory

38
Grater taper files
7-1.Hand instruments

• increased taper hand file
• tip size 20
• taper
• 0.06, 0.08, 0.10, 0.12
• Balanced force movement ??
• step back ???

39
7-2.Automated instrumentation

• easier quicker
• ex)
• GG bur
• Reciprocating handpieces
• Ultrasonic sonic units
• Rotary NiTi instrumentation

40
Reciprocating handpieces

• watchwinding type motion(60/90)
• light touch
• fine calcified canal?? ??

M4 reciprocating handpiece
41
Ultrasonic sonic units

• vibratory system
• C/I (?)
• C/S (?)
• ??
• post, ??? ?? ??
• ?? ?? ??
• apical sx.

Piezon ultrasonic unit
42
Spartan ultrasonic unit
43
Rotary NiTi instrumentation

• ??
• debris removal(?)
• canal transportation(?)
• smoother, faster canal prep.
• operator fatigue(?)

• ??
• ?? file? ?? ???? taper??? ?
• Orifice shapers
• ProFiles/ProTaper
• rotary GTs
• GG bur? ??? cutting bud? thin shaft? ?? ?
• Lightspeed

44
Rotaty nickel titanium files

• Orifice shapers
• ProFile
• Rotary GT
• Pro Taper

45

• Lightspeed(NiTi)
• GG bur(stainless steel)

46
7-3.Irrigation

• NaOCl accident
• Needle binding ??
• ?? ?
• ?? ?????
• 30?? ?? ??
• ??? ?? ? 24?? ?? ??
• ???/??? ??

• ?? ??
• ?? ??? ???
• ?? 23? filing ? ?? ??
• EDTA ??
• Smear layer?? ???

47
Acoustic microstreaming (ultrasonic irrigation)

• Ultrasonic handpiece
• ?? ? ?? ???debris??? ??
• NaOCl ??? ?? ?? ??

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7-4.Summery

• RTC? ??
• bacteria-free!!!

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8.Root canal preparation

• 8-1.Access
• 8-2.Canal identification
• 8-3.Straight-line radicular access preparation
  of coronal 2/3
• 8-4.Length determination
• 8-5.Apical preparation
• 8-6.Rotaty nickel titanium instrumentation
  techniques

50
Root canal prep.

• Biological objectives
• ??, ??, ??? ??

• Mechanical objectives
• continuous tapering
• original anatomy??
• foramen?? ??
• foramen? ??? ?? ??

51
Sequence

• 8-1.Access
• 8-2.Canal identification
• 8-3.Straight-line radicular access preparation
  of coronal 2/3
• 8-4.Length determination
• 8-5.Apical preparation

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8-1.Access
53
8-1.Access

• Coronal access
• unimpeded path
• pulp chamber roof ??
• ?? ??? floor?? ????? ??
• divergent wall
• straight-line path
• Radicular access

54
8-1.Access

• ?? ??? ??? ??
• But!! root prep.? ????? ??? ??
• esp. curved root in coronal 1/3

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8-1.Access

• A/O? ?? ??
• ?? ??
• ?? ?? ? ???
• ?? ??
• ?? ??? ??(?? ???? ??)
• ??? ??, ??? ??
• ?????? ??(Max. safe depth??)
• ?? ??? ??? ??
• ?? ?, ?? ???, ?? ??? ??

56
A/O
8-1.Access

• Mx. Incisor
• triangular
• Mx. Mn. Canine
• more ovoid triangular
• Mn. Incisor
• triangular
• 2nd canal 40

57
A/O
8-1.Access

• Premolar
• Mx. 1st PM
• ??? ? ovoid
• 2 canals
• 3rd canal 5(??)-tirangular
• Mx.2nd PM Mn. Premolar
• narrow oval shape
• 1 canal

?? ??
??
58
A/O
8-1.Access

• Mx. Molar
• triangular
• 4th canal 70
• Mn. Molar
• trapezoidal
• D root 2nd canal 33

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Access technique
8-1.Access

• A/O ?
• ?? ???
• ?? ???
• Crown
• ??

??
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Access technique
8-1.Access

• A/O ?
• R/D??
• Broken wall B/U
• (Am., copper band, temporary Cr. )
• Crown lenthening
• Occlusal reduction
• ??? ??? ?? ????
• canal ?? / ?? ?? ??
• ??? reference point

61
Access technique
8-1.Access

• ??
• round(?)/flat(?) ended bur
• excavator (coronal pulp ??)
• barbed broach (radicular pulp ??)
• low speed round bur (roof ??)
• tapered bur

62
8-2.Canal identification

• ?? ??, ??? ????? undulation (?, dentinal map)
• ???, ??(coaxial)
• NaOCl ??
• straight probe/DG16 endodontic explorer
• color
• dentine yellow/brown
• pulpal floor grey

63
8-2.Canal identification

• ??? ???.
• STOP TAKE XRAY!!!!

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Straight line access
8-2.Canal identification

• Refinement

• Troughing
• LN(long neck)bur
• Ultrasonic tip
• 4th canal

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8-3.Straight-line radicular access preparation
of coronal 2/3

• Pre-enlargment
• gradual opening up narrow canal orifices
• 1035 filies / watchwinding
• GG bur / Orifice shaper?? ?? ?? ??

66
8-3.Straight-line radicular access preparation
of coronal 2/3

• ??
• debris ?? ??, ??? ??
• file needle ?? ??(passive fit binding ??)
• precurved file ?? ??
• irrigant ?? ??(??? space)
• WLD? ? file?? ??

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Danger zone

• curved canal? furcation ??
• over-enlargement ??
• Limit the size of enlargement!!!!!
• if notstrip perforation!!!!!

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GG bur

• ??? ?? ??
• 5,6
• cavity wall??? ??
• 4
• orifice??? ??
• 3
• mid-canal ?? ?? ??
• 2
• curvature?? ???? ?? ??
• 1
• fragile
• ultra-slow speed?? ??

69
Crown-down technique

• ?? ??
• blocking with dentine debris??
• apical patency ?? ??
• small file with/without chelating agents??

70
8-4.Length determination

• Pre-op radiograph(????)
• ?? ?? ??(???, ?? ?? ??)
• Tactile feel (pre-enlargement?)
• Electronic apex locator

71
Radiograph

• ?? ??
• elongation/foreshortening ??
• ??? 2mm?? ?? ?? ??

72
Electronic apex locator

• AFA (left)
• Root ZX

• ????
• ??? ???? ?? ??? file??
• ??? ??, ???? minimal fluid
• ?? ??(?? ???, ??? ??)

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8-5.Apical preparation

• Vital case
• radiographic apex?? 2mm??? ??
• Non-vital case
• radiographic apex?? 2mm???? ??

• MAF
• curved canal 30
• very curved canal 25
• Flaring
• step-back
• greater taper hand file
• final apical prep? 0.02 taper? ???!!!

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8-5.Apical preparation

• Recapitulation
• 15 file
• Apical patency
• must be maintained at all times.
• 8,10 file (without binding or enlarging)
• re-tx., necrotic case?? ??
• ??
• apical blockage ???ledge, transportation ?? ??
• pulpal remnant ??
• intentional cleaning of full canal length

75
Ledge

• ??
• too large file
• canal blockage

76
Apical stop vs Apical seat

• overfilling ?? ???? resistance form ??

77
Zip Elbow

• ?? ???? ???? ? file?? ?

78
8-6.Rotary NiTi

• for enlargement!!!
• not for canal negotiation!!!

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8-6.Rotary NiTi

• effective in
• pre-enlargement
• coronal flaring
• crowndown manner
• file separation??
• Discard damaged files!!!

80
Instrumentation sequence

• large ? small
• larger taper ? smaller taper

81
Orifice shaper 0.06 ProFiles

• Orifice shaper 60/0.08
• Orifice shaper 50/0.07
• Orifice shaper 40/0.06

• ProFile 35/0.06
• ProFile 30/0.06
• ProFile 25/0.06
• ProFile 20/0.06

82
Rotary GT

• all size 20 at tip
• Rotary GT 0.10
• Rotary GT 0.08
• Rotary GT 0.06

83
Guidelines for rotary NiTi

• 150300 rpm
• light touch
• touch/retract/touch/retract technique
• advance files no more than 1mm at a time
• 4 seconds for each file
• damaged file ? discard
• caution!!
• calcified canal
• apical 1/3? 20/0.02 taper file ?? ? rotary file
  ??
• sharp curvature
• 2 canal ? 1 canal ? join?? ??
• large canal? ??? narrow??? ??

84

• Rotary NiTi file ??? ??
• ??? ??? ?? ??? ?? ??? ?!!!!

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9.One-visit root canal treatment
86
9.One-visit root canal treatment

• Single-visit tx. is appropriate for vital
  non-infected cases
• Infected cases benefit from a dressing of Ca(OH)2
• Coronal seal must be maintained to prevent
  recontamination

87
10.Root canal obstruction

• 10-1.Reuqirements before root canal filling
• 10-2.Properties of root filling materials
• 10-3.Types of root filling materials
• 10-4.Gutta-percha filling techniques
• 10-5.Under- overfilling
• 10-6.Root fracture
• 10-7.The remainder of the seal

88
10-1.Reuqirements before root canal filling

• Requirements
• chemomechanical prep. ??
• canal dry
• asymptomatic
• no serous exudate

• Persistent seepage?
• ??
• over-instrumentation
• periapical tissue damage
• WL ???
• Ca(OH)2 ??

89
10-2.Properties of root filling materials

• root canal filling mat.
• easily introduced into the root canal
• not irritate periradicular tissue
• not shrink
• seal laterally, apically, coronally
• impervious to moisture
• easily sterilized
• bacteriostatic
• radio-opaque
• not stain
• easily removed if necessary

• sealer
• ?
• good adhesion
• fine powder / 2-paste system
• set slowly

90
10-3.Types of root filling materials

• solid semisolid ( GP cone, silver point)
• sealers cements (Tubliseal, AH Plus, Pulp Canal
  Sealer, Roths Sealer, AH 26)
• medicated paste not recommended

91
10-4.Gutta-percha filling techniques

• 1.Cold condensation
• 2.Warm condensation

92
Cold condensation

• Single cone(not recommended as it does not seal
  laterally and coronally)
• cold lateral condensation

93
Warm condensation

• Warm lateral condensation
• Thermomechanical compaction
• Vertical condensation
• Thermoplasticised gutta-percha
• Carrier-based techniques

94
Cold Lat. condensation
95
Lat. condensation

• tapered canal prep ??
• Master GP cone
• tug back
• full length?? 0.5mm trimming
• Sealer
• master cone? apical 1/3 coating
• ??? ??

96
Lat. condensation

• Spreader
• long handle/finger spreader
• 1mm ?? ? ??
• firm pressure in an apical direction for 20s
• lateral pressure
• bend or break the spreader/root fx.
• GP cutting
• CEJ 1mm ??
• gingival level

97
Warm lateral condensation

• denser root filling
• ??
• heated spreader (in a hot bead sterilizer)
• friction of ultrasonic vibration

98
Thermomechanical compaction

• compactor?? (inverted H file ??)
• low-speed handpiece
• frictional heat ??
• ??
• ?? ???
• ??? straight part? ??

99
Vertical condensation

• heat downpack backfill
• ??
• 1. classical interrupted tech.
• pointed heat carrier
• flat ended plugger
• 2. continuous-wave tech.
• TouchN Heat/System B
• Buchanan plugger
• Obtura II

100
Classical interrupted tech

1. Heat carrier coronal ?? GP cone ??
2. Plugger loosely fitting plugger? condensing
3. Sustained push GP cone??? ( second wave of
   condensation)
4. ? 1,2,3 ? until 5mm from the canal terminus

101
Continuous-wave tech

• one continous wave of condensation
• ??
• GP cone plugger ??(WL-57mm)
• 23?? activation ???? condensing (binding point
  ????)
• 10 ?? inactivation ???? vertical pressure
  (sustained push)
• 1.5?? activation ???? ???? binding?? ??

102
Obtura II

• Backfill
• Internal resorption ? ??
• Apical resistance form ?? ??

103
Carrier-based system

• Thermafil
• solid central core GP covering
• ??
• solid core post ??
• ??? ? ?? ??(?)
• ???

104
10-5.Under- overfilling

• Underfilling
• debridement???
• ????, ??? ?? failure??

• Overfilling
• ??? ???? ???? ???? ?? ?? ??

105
Excess obturation material
106
10-6.Root fracture

• ???? ?? ??, ?? ??, over-instrumented canal?? ??
• ??
• passively fitting plugger/spreader??
• excessive obturation force?? ??

107
10-7.The remainder of the seal

• core ASPS
• Rec) bonding resin, GI over floor orifice

108
Am core
109
11.Assessment of root canal treatment

• 11-1.Success failure of root canal therapy
• 11-2.Management of failed root canal treatment

110
11-1.Success failure of RCT

• 14??? F/U? ???
• Success
• no loss of Fø
• no pain swelling
• no sinus tract
• normal PDL

111
Indication of failure of root canal therapy

• A lesion occurring subsequent to root canal tx.
• A pre-existing lesion increases in size
• A lesion has remained the same or only decreased
  in size over the 4-year observation period
• There is pain, swelling or loss of function
• A sinus tract is present
• Signs of continuing root resorption or
  hypercementosis are present

112
Post perforation
113
11-2.Management of failed root canal treatment

• Re-endo
• Periradicular sx.
• Extraction
• root fx.(???)
• gross caries(?? ??)

114
Root canal re-tx.

• surgical intervention ??? ??
• Pre-op XR ?? ??
• post
• filling material
• curves, perforation, ledge

115
Root canal re-tx.

• Rec)
• Loupes
• Headlamp
• Microscope

116
Root canal re-tx.

• ?? ??? ??
• surgical bur(high speed), long neck bur(low
  speed) ??
• ??
• ?? ?? ??
• crack ?? ??
• missing canal ??? ?? ??? ??

117
Root canal re-tx.

• furcation/canal orifice ??
• ultrasonic tip
• ?? ??? ?? ? ? ??
• endodontic explorer
• ???/??? ??
• ???? rougher

118
Root canal re-tx.

• Post ??
• ?? ?? ??? ??? ? ?? ??
• ultrasonic vibration
• ?? cement seal ??
• too high power ? ??? microcrack
• post extractor

119
Root canal re-tx.

• post fx. within a root canal
• post ?? cement ??? troughing
• small long-neck bur / ultrasonic tip??
• Masserann post removal kit
• trepan
• 2mm troughing ? ?? ??

120
GP removal

• H file (poorly condensed GP )
• GG bur (10001500rpm)
• NiTi rotary instrument(700 rpm)
• GP solvent (curvature??)

121
Steiglitz forceps(silver point removal)

• silver point
• sealing
• not good
• cement? ??
• ?? ??
• Steiglitz forcep / pin plier??
• forcep holding ???? ultrasonic vibration??

122
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123
Instrument fx.

• file fx. ???
• maintaining a good quality control program
• discarding any damaged instruments
• not forcing instruments
• using instruments in the correct sequence
• not rotating ss instruments more than a ¼ turn CW.

124
Instrument fx.

• fx. file ???
• Masserann trapan ultrasonic vibration
• microscope
• magnification lighting
• Loupes headlamp

125
Fx. / Bypass

• ???? ?? ??? ?
• apical ?? ?? ???
• ? ??? rounder
• Bypass ??? ?
• ?? ????? obturation
• ???? ?? ??(?)

126
Root canal re-tx.

• ???, ?? ?? ?? ? ????
• Ledge
• sharply curved file? bypass
• linear filing motion?? smoothening
• Blocked canal
• sharply curved file? penetrate
• unblock ??? ? ??
• over-instrumentation / perfortation

127
Root canal re-tx.

• ???
• technical improvement? ?? re-endo
• 9498
• periapical lesion?? ?
• 6278

• Re - endo ??? ???
• perforation
• ?? ??
• compromised cleaning obturation

128
Apical Sx

• Alternative to RCT
• ??? ??? ???? conventional RCT? ????? ?
• ???
• extensive expensive restoration
• large post
• sclerosed canal
• broken instrument
• biopsy
• root crack/fracture??

129
Thank you!!!