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Endodontics material and bleaching system (1) Dental Material II lecture # 15

Today we will talk about material which is used in root canal treatment of teeth and the material which is used to Whitening shade of the teeth ..

Slide 2 :
Now endodontics is concerned with everything that has to do with root canal system whether it physiology, pathology. Treatment and tissues around the root .. so (Root canal system and periradicular tissue, tissue in the peri-apical area around root). Now these dental material used in this source of treatment can be used for removing pulpual tissue, cleaning canal, shaping them and then filling them .. Like when we drill a cavity in the crown you want to restore it by placing a restoration to seal it .. so the same does in the root canal system u clean it then remove infected tissue and then you shape it properly to resive a filling at the end . So you want to maintain a seal at the apical area at the apex of the root and seal coronaly to prevent bacteria from going inside again and causing recurrent infection .. same principle you want to prevent micro-leakage, recurrent caries, sensivity ,,,, bla bla bla ,,, :P Same goes for the root canal system you want to clean it and obdurate it or fill it prevent bacteria to income again and causing infection all over again.

Slide 3 :
This picture represent the tissue inside the pulp .. This is a lower molar there are lateral spaces into which pulpal tissue may go, so you dont just have one single pulpal tissue inside the canal there are lateral canals irregularities into which the pulpal tissue can go.

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So we need to clean the entire area and fill it to prevent the formation of the remainder of any space into which bacteria can come in and colonies .. cleaning w elshaping infection ..

Slide 4 & 5 :
Before we start RCT If you remember when we talk about cement we talk about something called direct and indirect pulp capping. We talked about calcium hydroxide that used for this purpose. Now the pulp might be exposed and need of treatment for many reasons. Maybe expose by caries, it can be exposed due to trauma (fracture on the tooth) or it can be exposed during cavity preparation. There are two procedures to treat the pulp or heal it before going into root canal treatment (Direct and Indirect pulp capping) ** So in cases of indirect pulp capping: we are leaving a very thin layer of dentine because you know that if you want to remove it because it is stained you will expose the pulp, so you want to avoid these exposure by leave a layer of disscolored dentine.

Slide 6 :
This is the 1st picture the dentist is trying to excavate the caries, then he leave this layer of stained dentine (it is hard but it is stained). So we dont 100% sure that there is no bacteria inside them. So in order to prevent pulp exposure we place a dressing on top of this layer, this dressing will be followed by restoration. The aim is to seal the cavity prevent any nutrients or new bacteria from going in, so even if there is still bacteria inside

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this stained layer. If there is no nutrients coming in these bacteria will be die. And will be a rest of carious process. So a layer of this discoloured dentine left a dressing is placed on the top which is mainly carbon hydroxide, its alkaline or it has a high PH (antibacterial). So it will kill any bacteria there, and will a rest a carious process and on the top we dont replace a tempering filling we place a Permanent filling, why ? because it is provide a better seal. Prevent any micro-leakage prevent any more bacteria to go in and causing caries all over again. So this is INDIRECT pulp capping. The pulp is not expose (Mainly the material which is used the carbon hydroxide, ZOE maybe used). Due to sedative effect some time we use bonding agent but you have to remember that when you want to use bonding agent you need to etch 1st. And you are etching or using acid very close to the pulp, so this may cause many problems. So your best choice is Calcium hydroxide. Sometimes mtra bond maybe use or resin modified glass inomer cement. Now the idea is to seal off any bacteria or nutrients and stop them from coming again. So you want to maintain a good seal (calcium hydroxide is good) because it has anti bacterial activity that is why it is the 1st choice. If by any chance the pulp is exposed. We need to do ** direct pulp capping. If you want to do direct pulp capping your exposer need to be very small and tiny, no bleeding outside of the pulp. So the pulp should not be inflamed, this is not be any symptom of severe pain. So pulp was exposed, all around is clean it is not carious exposer (the exposer did by the dentist during cavity preparation). So you have cleaned the wall of the cavity and you want to drill a little bit farther on the floor and a very small area of the pulp was exposure. You dont want go ahead to do root canal treatment you want to try save the pulp. So you do direct pulp capping now this area need to be clean. Or less infected so sometimes we use a

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solution called (sodium hypochlorite) like hapex to clean the exposure area. If there is no blood coming out no previous symptom with severe pain, so you will dress the pulp, you want try to heal it close this exposed area. Best material is Calcium hydroxide. :P

Slide 9 :
So this is an example, this is a fracture tooth due to trauma, so the incisor was fractured and this fractured involve the pulp (can you see the pink tissue). This is exposed pulp so you dont want to open it up and do RCT. It is an aggressive treatment. You want to try save it and heal and close this exposed area. So you applied calcium hydroxide (a thick layer followed by a permanent restoration) to provide good seal and to prevent any contamination. Another material we will learn about it later on. Its called MTA . Similar material it has high PH, it is Anti bacterial and it stimulates dentine formation, so when it stimulates the dentine formation a barrier or a bridge of calcified tissue will form and close up this expose area. So a dressing is place and then we review a patient after sometime maybe we can take X-ray, we will see there is a bridge of calcified.

Slide 11 :
If there is any chance with a patient come back with severe pain or swelling that means the inflammation is spread and the treatment was failed. You have to go on RCT. Pulp capping may fail because there is a chronic inflammation in the pulp, because the restoration fail and was associated with microleakage so there is no good seal around. Sometimes there is a blood clot formation at the exposed area, so there is no contact between the calcium hydroxide and the pulpal tissue. So because there is no contact there is no stimulation for dentine formation. So the medication doesnt reach the wall, so the treatment fail. So failure direct pulp capping maybe cased By : Restoration failure and micro-leakage.
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Because there is already chronic inflammation inside the pulp. And there was a clot formation at the exposure area. It will prevented calcium hydroxide from, making contact in the pulpal tissue and inducing dentine formation. So
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Already inflammation in the tissue. The restoration is fractured or failed casing micro-leakage. Large exposure associated with large bleeding with clot formation All of these lead to failed of pulp capping so we need to do RCT.

Slide 12 :
The 1st step of RCT is we want to gain access to the whole part entire pulpal tissue in the crown. You want to remove the pulpal tissue in the crown and then you want to go ahead and remove the pulpal tissue in the root canal. Now once you do that you need to wash that area and clean it. For that reason we need to use irrigants (certain solution). These solutions the purpose of them is to disinfection and remove the debris. Now when you drill the cavity in the crown we use the syringe air and water to clean it and remove the debris. We use phosphoric acid to etch and remove the smear layer. Same things in the root you want to irrigate to insert fluid under pressure to remove any debris and disinfect (remove bacteria or kill it). Now this irrigants needs to be non-toxic, non irritants, it should be able to remove debris, smear layer, it should be able to flow all over the surface. So it should have low surface tension, so it should be able to wet the surface properly and able to sterilize or disinfect. These are ideal properties that we want to be available in our irrigants. Now the irrigants that are available some of these properties are available but not all of them.
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Slide 13 :
The most commonly use irrigants are sodium hypochlorite. Some dentist use normal saline. You want something to disinfect, so sodium hypochlorite (2 _10 %). It is usually placed into syringe and then you insert the tip of the syringe inside the orifices of the canal and irrigate. But this technique is irritants due to hapex. So you should be careful when you use it not to allow it to contact with gingival or the tongue or the oral cavity. So that is why we need a good isolation, how ?? By using a rubber dam (green rubber sheet), we place it around the tooth that we are treating. It will isolate it from the rest of the oral cavity. There are alternatives materials that can be used but they are not as good sodium hypochlorite. One of them chlorohexidine like the mouth wash. Another material that can be used as a lubricant not irrigant is called EDTA. What does lubrication means? When you cleaned the canal or instruminting inside the canal you are using a file (you remember the odontodotics file in the metal lecture). Now to ease the use of these file when they go in and out we need something to lubricate like Vaseline lubricate. One of these lubricants is EDTA. Another uses of these material is when you have a canal that is calcified very narrow space left). EDTA is able to remove calcium from these calcified canal open them up a little bit, so you can instrument them easy. So EDTA is a lubricant, we can use it to move the file easily in and out the canal during instrumentation. And it can also be used to open the calcified or narrow canals because it can extract the calcium (remove it and open up the canal a little bit to get access to the whole surface of the canal). So EDTA it is a lubricant or a decalcifying agent or a cleathing agent

Slide 14 and 15 :
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Now when we do irrigation we remove the pulp to irrigated the canals we clean it but we cant fill the canals in the same day. You want to send the patient home and then call him back again to continue treatment. We cant finish the RCT only in one session we need two or three. So when we sent patient to the home we should not leave the canals empty and only put the temporary restoration above it. We should not remove any space inside the tooth. It should be filled. Any leave space it will be a big chance for bacteria to get inside it to colonize inside it. So you never leave a space inside the patient tooth !! When you send him home you need to place something temporary inside the canals, such as the temporary filling in the crown. Now this is temporary material needs to be able to fight bacteria to prevent re-infection of the canal. Now the best material is again Calcium hydroxide, this calcium hydroxide is non sitting material (it will not set). Why it is important the material not to set? Because you can easily remove it when the patient come back again. So it is a temporary material so I can place it inside the canals it can supply it by a syringe with a disposable tip. So we use one tip for each patient. So place the tip of the syringe inside the canal and inject it, sometime I can use acryl file. So this material will act as the temporary material and it will help to fight infection if there is any remaining tissue which is not able to remove it this material will kill it. Now after it is placed we can call the patient again after days or weeks, we remove it by using irrigants material which is sodium hydroxide and clean the canals again and go on with a permanent filling. Some time we use other type of material pasts that contains steroids or antibiotics in them but this material is more useful. Sometimes if you got young patient where his teeth are still immature (means that the Apex of the root is not closed yet like primary teeth, but this is a permanent teeth but still developing). The root does not closed yet.
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So it is not easy to obdurate or filled these root canal .. so what do we do ? We can place calcium hydroxide Again to form a barrier a calcified bridge that will close the apex of the root. And then we can go on our treatment. So calcium hydroxide can be used in immature teeth with open apex when it place inside it can induce the hard tissue formation to close the apex so we can after that do the obturation. When we obturation or filling of the canal your doing condensation we want something hard to condense against. If the apex is open your material will go out into the peri-apical tissue, so we want to close up the apex in immature teeth or induce root formation make it faster so that the apex can close and you can condense your filling material inside the canal. So this is another use of non sitting carbon hydroxide ..

Slide 16 :
Now we want to fill the canal. Previously they used to use pasts (medicated pasts ). That contain formaldehyde or iodoform. But formaldehyde is a very toxic material so may case many problems like inflammation, resorbtion ... ect A iodoform pasts it is a restorable which means it is high solubility it will not stay there. They used to use silver cones, the problem is this material is very hard if there is any chance you want to do retreatment. It is very hard to remove it outside of the canal and the problem of silver is corrosion. It can also cause staining. So the more current material which is use nowadays are Gutta percha or Gutta pur(ch)a from American, which is more commonly. And polyester resin.

Slide 17 :
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Both of them are basically made of rubber, so they are made of gutta percha rubber, zinc oxide filler to make them stronger, metallic salt to make them radio opaque so we can see them on radiograph. Why do you want to see them? We want to asses if it is good or not (for review later on). Plasticizers to add slight flexibility so we can manipulate them easily. And anti-oxidant to prevent oxidation of the material. If the material become oxidise it will be brittle.

Slide 18 :
So this material which is called thermoplastic material like impression compound (thermoplastic) when you heat it, it will become soft and it will cools down it set and hard. Same thing here .. So it either can be use it when it is cold in the form of cones (slide 19). It will be in different sizes according to root canal or we can use them after heating them and making them soft it become soft at (60 to 65). And become melted at 100. Now if they subjected to light for a long period of time it will become oxidise and hard and brittle and break easily which is not good. If you want to dissolve them to do retreatment we want to remove it from the canal by using (chloroform). It is an organic solvent like Egunol >> oil of orange is a solvent. For Gutta percha >> chloroform is a solvent. Now if they come in contact with certain material like acetone they will absorbed the liquid and swell, then when acetone evaporate, they shrink. The idea here is not to expose them to any liquid, they should be kept dry and in a seal container. They dont chemically bound to dentine. What is the significant of this? When we place them inside the canals you want to fill the canals completely. No if they dont bound chemically to dentine

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it means they might be small spaces or voids left .. What will these void seal with ? What can we use ? We use cement, we use sealers like a pasts. So inside the canals you will have Gutta percha and a sealer together. So the major space will be filled with Gutta percha and the very small spaces or voids will be filled with cement or with sealer. So we will have complete seal (no bacteria, no space)

slide 20 :
So this is Gutta percha use for core condensation so it is used when it is cold, for thermal packing they called (alpha phase Gutta percha). Alpha phase just refer to its structure. So beta phase gutta percha is the cold one. Slightly different structure from the alpha phase Gutta percha which was heated. So Gutta percha maybe softened or heated and then placed inside the canals. Now if you softening it they called thermafil system. If you making it melted and inject it inside the canal that called the system obtura.

slide 21 :
So when they melt the gutta percha they load it inside this gun and then inject it with this tip inside the canal or they melt it soft (this is the Gutta parcha around the file) they place it in this machine it is a small oven). This oven will heat it to 60 65 degree until it will soft. So you take it out and then place it in the canal. So you either soften the Gutta percha in this oven (thermafil system). Or they melt it away (pieces of gutta percha place it in this gun melt it and then inject it like a paste inside the canal). After that it will cool and become set. So thermafill system, soften gutta percha, obtura, melted gutta percha.

Slide 22 :
Another filling material it is similar it is called polyester resin. It is thermoplastic it contains polyester resin; it is contain barium
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sulphate, bioactive glass. This material is able to release calcium and phosphate which will promote bone formation. It is available as cold and thermoplastic material. So similar availability but the composition is slightly different.

Slide 23
Now sealers that are use to conduct very small spaces lead to have certain properties: 1-they need to be easy to use. 2-they need to proper's good seal. 3-they need to have low solubility. 4-Radiopaque. 5-Biocompatible. 6-long working time to takes time to fill root canal system not like when you use amalgam and you condense it.

In case in root canal treatment it will take some time especially if you working in molar tooth because it have multiple root you need some time so you need material has long working time and low setting time relatively. So these sealers will fill the spaces between the GP and it will also act as lubricant so that obturation technique or when obturating the method easy it easy to depth the GP inside the canal and condense it. 6b3n 2ltechneq of condensing GP will learn about it next semester. :P

Slide (24)
Now this the representation or this is the picture of what happened if you use GP with no sealers can you see the space so there is the gap there will be a gap. In this gap in the in left this space is available for bacterial to come in and colonize now if the space it close up it will be close up with sealers so prevent any infection from occurring again that's why it important to use the sealers.
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How it is use usually you mix it like the base and then the GP is depth in the sealers and then place in the canal. elsealers hada mtl 2lm3jonh btn5l6 ob3den bnmsk kol GP coin obn3'6ha bhl sealers obn76ha bl8nah 2ltaneh b6re8h mo3enh so GP will be surrounding with sealers and the sealers will help to contact with surface of dentine inside the canal and it will also attach the GP coins together so will have good seal all over.

Slide (25)
The material that used as a sealers depended in the basic compound some of them they based in calcium hydroxide and some of them based on zinc oxide eugenol or on glass ionomer or on resin. So same material can be used in different application each one has advantage and disadvantage for example: calcium hydroxide sealers they have high ph, antibacterial, easy to use and long working time but the problem is there have high solubility this is a major problem. Resin cements it has low solubility which is good and if you use a primer with them to etch the surface it will help to bond them to the dentine. Glass ionomer sealers their able to chemically bond to dentine, which is good but the problem is when they set they become very hard and retreatment very hard it they have to remove it completely when you want to do retreatment again and again the problem with solubility.

Slide 26 :
So zinc oxide eugenol base cement they are many formulations available or product available usually available as paste, paste you contaminate the two paste together to get one homogenous color. Now examples are: 1- Grossman 2- Rickets 3- Tubliseal

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Each one has different properties usually Grossman has good flow, low film thickness, use as enough working time 20 min working time, the solubility is low . Rickets for example has short working time and thin film thickness and you once thin film between the dentine and GP when you got thin film will get better bond ok. So it good to have slow or low film thickness of the sealers which means that it will flow even better a cement or sealers that have low film thickness it mean that will flowing very will covering the inside perper (I think I couldnt hear).

Slide (27)
So this is how it's supply as two paste (base and catalyst) mix together.

Slide (28)
Calcium hydroxide again is long working time, antibacterial, biocompatible, the disadvantage is high solubility. So the advantage and disadvantage are similar everywhere.

Slide (29)
This is seal apex.

Slide (30)
Resin sealers which are more commonly used now because their low solubility and long working time one of the famous ones are (AH plus) now before AH plus they used product AH26 the problem with AH26 it contain formaldehyde which is atocxic material so they made anewer material with no formaldehyde they call it AH plus so it has low solubility, good flow, long working time, low film thickness. Another material it called ADSEAL again by biocomability, low solubility. So in general resin sealers has low solubility. previous product used to have as I said formaldehyde some of them used to have silver silver it is the problem because of corrosion and shrinkage. So we can replace it by another
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material like barium for example to make it radiopaque so newer material are always used or developed to prevent or eliminate the disadvantage from previous material so AH plus it is commonly used. Another material it also used it is ADSEAL sealers. ADSEAL it is a newly develop present sealers.

Slide (31)
Again ADSEAL sealers it is a new material that is commonly used now.

Slide (32)
Glass ionomar sealers they can bond to enamel and dentine and they have low shrinkage but the working time is short and the retreatment it's difficult because when they set it become very hard so buy any chance if the treatment fail and want to do retreatment again it's difficult to remove it from root canal system is it's not commonly used.

Slide (33)
Polymer base material it's based in siloxane on rubber material now there are insoluble they have low solubility ,they have no dimension change they are dimension stable ,they are biocompatible but the problem is the y can't bond to dentine and they have no antibacterial activity. F2za btla7zo 2nh kl sealers 2lh sh3'lat koesh osh3'lat msh koesh f27na bn5tar 2lsealers 2le 59a29h koesh. That's why we use sealers are more advantage like resin sealers for example. So in general root canal material biocompatible, low toxicity, low irritation, easy to use, able to seal and flow so each material has different advantage and disadvantage and we select them according that. I will stop here we continue next time .. Finish..

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GooD LUCK ALL Done by : Sara Alomari & Dalia Shunnaq Special thanxxx for lovely friends: ruba,waad,arwa.amoon.alaa ..

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