Professional Documents
Culture Documents
Dr. Nidal
Dr. Nidal
The study of the form, function and health of, injuries to, and diseases of the dental pulp and periradicular region, their prevention and treatment.
Fiber
Proteoglycan
Decorin Versican
CELLS (odontoblast, fibroblast, undifferentiated cell, macrophage, dendritic cell) FIBERS AND GLYCOPROTEIN (collagen type I, III, no elastic fiber, fibronectin) GROUND SUBSTANCES (glycosaminoglycans, chondroitin sulfate proteoglycan) BLOOD VESSELS, NERVES, LYMPH VESSELS
C fibers
A-delta fibers
y y y y y y
Conduction velocity 30-70 m/s Very low threshold, nonnoxious sensation 50% of myelinated fibers in pulp Functions not fully known Conduction velocity 2-30 m/s Lower threshold Involved in fast, sharp pain Stimulated by hydrodynamic stimuli Sensitive to ischemia Sharp pain
Conduction velocity 0-2 m/s Higher threshold Involved in slow, dull pain Stimulated by direct pulp damage Sensitive to anesthetics Dull pain
Conduction velocity 0-2 m/s Post-ganglionic fibers of superior cervical ganglion Vasoconstriction
Diagnosis
Medical history Dental history Chief complaint Examination Clinical tests Radiographs
Medical history
Cardiovascular diseases : Recent MI Congenital HD Valve replacement Rheumatic HD Bleeding disorders : Dialysis patients Alcoholic abusers Patients taking Aspirin Diabetes : Uncontrolled DM (Insulin shock OR Diabetic coma )
Allergy : Latex rubber ( use Vinyl instead ) Sodium hypochlorite Physical disabilities Parkinsons disease Spinal cord injuries Stroke Steroid therapy Susceptibility to infection Cancer, AIDS & Pregnant patients
Dental history
Chief complaint As expressed in patients own words Location Pointing with one finger Chronology When symptoms were initially perceived Spontaneous OR provoked Immediate OR delayed Persistent OR intermittent Momentary OR lingering
Description Dull, drawing OR aching ~ pain of bony origin Throbbing OR pulsing ~ vascular response to inflam. Electric, recurrent OR stabbing ~ nerve pathosis Aching, pulsing, throbbing, dull, radiating, flashing OR stabbing ~ pulpal & periapical pathosis Intensity Mild, Moderate OR Severe Affecting factors Aggravating factors Relieving factors
Examination
Extraoral Facial asymmetry
Presence & extent of swelling in head & neck region Lymphadenopathy Presence of fistula Presence of TMJ dysfunction
Clinical tests
Palpation Mobility test Percussion Periodontal examination Pulp sensitivity tests Selective local anesthesia Sinus tract exploration
Palpation
Gently using the index finger Rolling motion Bidigital OR bimanual palpation
Mobility test
The blunt handle of two metal instruments Lateral force D Facial-lingual direction Vertical movement DDegree of depressibility
Percussion
Biting on a cotton roll OR a low speed suction tip
Periodontal examination
Recording the depth of all pockets Determination of any furcation involvement
Radiographs
Two dimensional Periapical lesions : Loss of lamina dura Radiolucency remains at root apex Hanging drop appearance Degenerative pulp changes : Pulp stones Extensive canal calcification Root resorption
Pulp status
1. 2. 3. 4. 5. 6. 7. Normal pulp Reversible pulpitis Irreversible pulpitis Necrosis Acute apical abscess Acute apical periodontitis Chronic apical periodontitis
Normal pulp
Asymptomatic with normal response to thermal and electrical stimuli Intact lamina dura with no resorption No painful response to palpation & percussion
Reversible pulpitis
Asymptomatic with quick, sharp response that subsides immediately after stimuli removal No spontaneous pain
Irreversible pulpitis
Sensitivity to thermal stimuli of long duration Previous history of pain severe spontaneous pain Tenderness to percussion ( Not always )
Necrosis
No response to thermal OR electric stimuli Tenderness to percussion ( Not always ) Crown darkening ( In anterior teeth )
Description
Symptoms
Treatment
Reversible Pulpitis
Tooth is sensitive to cold. Pain disappears when the triggering factor is removed.
Irreversible Pulpitis
Tooth sensitivity remains after the triggering factor is removed. Or pain could be spontaneous, happening without a triggering factor such as throbbing pain at night.
Root Canal Treatment. Sleeping on high pillows might temporarily work as a remedy to reduce toothache usually aggravated by increased blood flow from low head position.
Periapical Infection
Tooth becomes tender for bite pressure. At this stage the bacterial infection has traveled through the root canal and reached the jaw bone surrounding the tooth.
Abcess / Swelling
Bacterial infection spreads to the tissue around the jaw bone and causes a swelling, which will have general systemic reactions and implications.
3- Due to Trauma
Basic principles of Endodontic Treatment 1- Endodontic Diagnosis 2- Patient Education 3- Local Anesthesia 4- Rubber Dam Isolation (single isolation) 5- Access Cavity 6- Working length 7- Instrumentation 8- Obturation 9- Final restoration
Steps of RCT
1. 2. 3. 4. 5. 6. 7. 8. Local anesthesia Preparation of tooth Isolation of tooth Access cavity preparation Working length determination Preparation of root canal system Irrigation Obturation of root canal system
Local anesthesia
Infiltration Block Intraligamentous Intrapulpal
Preparation of tooth
All caries & defective restorations should be removed Tooth protected against fracture Tooth should be capable of being restored & isolated
Isolation of tooth
Using the rubber dam Gauze pack to protect the pharynx Safety chain or dental floss
Complete removal of the roof of pulp chamber Minimise binding of instruments (Straight line access ) Avoid damage to pulp chamber Introduce instruments into root canals with undue binding The occlusal projection should be larger than the base Access should be a two- stage procedure Conserve as much sound tooth structure as possible
Maxillary premolars
Through occlusal surface Ovoid in bucco-lingual direction
Maxillary molars
Triangle with the base towards the buccal, and the apex palatally Oblique ridge must be intact
Mandibular premolars
Through occlusal surface Ovoid in bucco-lingual direction
Mandibular molars
Rectangular outline Preserve the marginal ridge
1. Elimination of microorganisms. 2. Remove pulpal tissues and debris. 3. Allowing placement of a three dimensional root filling.
shaped canal preparation. 2. The original anatomy maintained. 3. Position of the apical foramen maintained. 4. Foramen as small as possible.
Patency :
Def. : Absence of soft or hard tissue blockage in the apical third of the canal. File used : A small flexible k-file ( not H file )which will passively move through the apical constriction without widening it ( Buchanan, 1989 ). Size of file : # 10 , # 15 and # 20 .
1. Always work in a wet canal. 2. Irrigation is done frequently and copiously. 3. Explore the canal with a small file. 4. Gradual enlargement of canal using successively larger files ( DO NOT SKIP !!). 5. Remove debris and dentine using a circumferential filing at or close to WL. 6. Avoid forcing or continuing to rotate the instrument that binds on insertion. 7. Keep away from the danger zone. 8. Do not perforate the apical foramen.
Limitations :
1. It has a tendency to straighten the severely curved canals. 2. Debris frequently collects at the apical region and either becomes extruded through the apex or blocks the canal. 3. Loss in WL is noticed because of the reduction of curvature of the canals during mid-root flaring.
WL determination
Apical preparation
1. Serially enlarge to MAF at WL. 2. Step-back for 4 instruments. 3. Circumferential & anticurvature filing. 4. Recapitulate.
Advantages
1. Removing most of infected materials and bacteria from coronal third of the canal. 2. Reduce the chance of extrusion of debris from the apical foramen. 3. Most of the resistance & obstacles encountered during preparation of curved canals originate from the coronal portion of the canal are removed.
Incremental removal of dentine from a coronal to apical direction. Straight k- type files are used in a large to small sequence with a clockwise rotation motion without apical pressure until the WL is reached.
Advantages
1. It produces less apical extrusion of debris. 2. It prevents excessive amount of bacteria and / or other debris coronally. 3. It allows irrigation to be effective to the complete depth that the cleaning & shaping instruments reach.
Flex-R file ( with a triangular CS and modified non-cutting tip ) is used in a reaming action. Clockwise rotation of file no more than 180 degrees. Anticlockwise rotation of file 120 degrees or greater with digital apical pressure until the desired WL is obtained.
Advantages :
1. Can be used in severe curved canals without transportation or ledge formation. 2. Can open calcified canals rapidly.
Concern :
1. Possibility of apical blockage. 2. Possibility of instrument fracture.
Profile series 29 % Quantic series 2000 Hero 642 Protaper Greater taper ( GT ) Light speed
1. Pulp tissues must be removed before any rotary shaping can be used. 2. Working time of each instrument in the canal should not be longer than 5 seconds. 3. Rotation should never be stopped in the canal. 4. Gentle apical pressure with a light in and out movement while working must be applied at all times. 5. Instrument should be cleaned and checked each time they are removed from the canal. 6. Copiously irrigated throughout the preparation. 7. Check files often for stress or deformation, and discard them frequently.
Piezoelectric
Low frequency ultrasonic vibrations ( 20 42 kHz ).
Generation of multiple low velocity currents of liquid ( 2.6 % NaOCl ) around the vibrating file. Violent agitation of irrigation solution allows cleaning of root canal walls. The file should be used in a gentle up and down motion. Useful in heavily infected canals.
Micro
Mega 1500
Serial preparation: Use of a series of progressively larger instruments which fit successively further away from the apical foramen A small file is reused at working length to ensure canal patency Master apical file is inserted to full working length
Points to remember
The canal should retain its preoperative shape Keep instruments & irrigants within the confines of root canal system Sequential usage of instruments Copious irrigation during preparation
Irrigation
Eliminate microorganisms Flush out debris lubricate root canal instruments Dissolve organic debris Sodium hypochlorite is the most commonly used Chlorhexidine, saline, water, anesthetic solution and EDTA
1. Dissolution of debris : Concentration of solution, volume, time of contact, temperature, mechanical action, surface area and the structural integrity of pulpal tissues can affect the dissolving ability of an endodontic irrigant. 2. Antibacterial activity. 3. Non toxicity to periapical tissues. 4. Flushing out organic and inorganic debris : volume of irrigant solution, size of canal, needle size and the depth of penetration into the root canal can affect the ability of any solution physically to flush out loose debris. 5. Low surface tension : ST : Forces between molecules that produces a tendency for the surface area of a liquid to decrease.
6. Removal of smear layer : SL : A layer of debris, composed of both organic and inorganic materials, remaining on canal walls after endodontic instrumentation. 7. Lubrication of endodontic instruments.
Chlorhexidine ( CHX )
1. Significant antibacterial activity. 2. Low toxicity to periapical tissues. 3. Can be used in teeth with patent apices. 4. No tissue dissolving ability. 5. Concentration ranges between 0.2% - 2.0% .
Hydrogen peroxide
1. Foaming action helps debris removal. 2. The nascent oxygen released can destroy some bacteria. 3. Bleaching action on discolored teeth. 4. Low ability to dissolve necrotic tissues. 5. Very limited antimicrobial activity. 6. Concentration : 3% .
Other types
1. Isotonic saline solution ( 0.9% NaCl ). 2. Sterile distilled water. 3. Glyoxide ( 10% carbamid peroxide in an anhydrous glycerine base. 4. Castor oil based irrigants. 5. Bis dequalinium acetate ( BDA ). 6. Electro chemically activated water ( ECA ).
1. Effective infection control procedures before RCT. 2. Flushing of pulpal chamber with NaOCl. 3. Irrigation should be performed slowly without undue pressure. 4. Needle is bent at angle that allows easy access. 5. Frequent exchange of irrigant & use of large quantities.
1. Eliminate any remaining bacteria after canal instrumentation. 2. Reduce inflammation of periapical tissues & pulpal remnants. 3. Render canal contents inert & neutralise tissue debris. 4. Act as a barrier against leakage from temporary filling. 5. Help to dry persistently wet canals.
1. CMCP, thymols, eugenol, creosate, cresol. 2. High toxicity to efficacy ratio. 3. Limited antibacterial effect.
1. NaOCl, iodine potassium iodide. 2. Potent oxidising agents with rapid bactericidal effects. 3. Dissolve necrotic tissue & debris. 4. Toxicity, staining, allergy.
1. Calasept, vitapex, hypocal, reogan. 2. Creation of an environment for healing of pulpal or periapical tissues. 3. Antimicrobial effect. 4. Elimination of apical seepage ( weeping ). 5. Induction of calcified tissue formation.
1. Penicillin, sulpha preparations, metronidazol, tetracycline clindamycin. 2. Sensitization, drug resistance & limited spectrum.
Obturation of RC system
Objectives: 1. To prevent the passage of microorganisms and fluid along the root canal 2. To fill the whole root canal to block the portals of exit to the periapex, dentinal tubules and the accessory canals When to fill ? 1. Asymptomatic tooth ( No pain, swelling OR tenderness ) 2. Dry canals 3. Intact temporary filling
Gutta percha
Is an unsaturated polymer of isoprene Rigid at ordinary temperature It becomes pliable at 25-30 C, soften at 60 C and melts at 100 C with partial decomposition Soluble in chloroform, eucalyptol, benzene & xylene When exposed to light and air, it undergoes degenerative oxidation and becomes brittle
Advantages of GP
1. It is compactable and has good adaptability to root canal walls 2. It can be softened by heat OR organic solvents 3. It is inert, non-allergic and bio-compatible 4. It is radio opaque 5. Doesnt discolor the tooth structure 6. It has dimensional stability 7. It can be easily removed from the canal
Disadvantages
1. It lacks rigidity 2. It lacks adhesiveness 3. It can be stretched
Hydron
Disadvantages of LC technique
1. Time consuming 2. Difficult in fine, curved canals 3. Pressure exerted can deform the root canal and create micro- fractures within dentin 4. Can cause vertical root fracture 5. It creates non- homogeneous mass with void formation