Endodontics I. Case selection and treatment lanning lenka.roubalikova@tiscali.cz Common medical findings that may influence endodontic treatment planning lenka.roubalikova@tiscali.cz Pregnancy Cardiovaslular disease HIV and acuired immunodeficiency syndrome End stage renal disease Dialysis Diabetes Prosthetic implants Patients with anticoagulation therapy Behavioral and psychiatric disorders lenka.roubalikova@tiscali.cz ■ Pregnancy Cardiovaslular disease Cancer HIV and acuired immunodeficiency syndrome End stage renal disease Dialysis Diabetes Behavioral and psychiatric disorders Psychosocial evaluation Recent medical research: Dental implications lenka.roubalikova@tiscali.cz ■ Pregnancy is not a contraindication to endodontics but it does modify treatment planning. Consult a physician iif you are not sure. - Ragiography If possible NO!!! Lead apron and thyroid collar Drugs Antibiotics (penicilin, cephalosporin, clarithromycin - all with caution !) Analgetics (paracetamol - with caution!) Local anaestetics (first if possible no in emergency with caution yes, second trimesters YES, third trimester with caution - a risk of contractions). lenka.roubalikova@tiscali.cz Pregnancy Cardiovaslular disease Cancer HIV and acuired immunodeficiency syndrome End stage renal disease Dialysis Diabetes Prosthetic implantation Behavioral and psychiatric disorders Psychosocial evaluation Recent medical research: Dental implications lenka.roubalikova@tiscali.cz 6 Cardiovascular disease - Vulnerability to emotional and physical or stress during dental treatment including endodontics. onsultation with the patient's physician is mandatory before the initiation of endodontic treatment if within 6 month after the attack. lenka.roubalikova@tiscali.cz ■ Patients who have had heart attack (myocardial infarcation) within 6 month should not have elective dental care. Medication can potentially interact with vasoconstrictors in LA Increased susceptibility to repeat the heart attack. lenka.roubalikova@tiscali.cz ■ Risk of vasoconstrictors No administration: - Patients with non stable angina pectoris - Uncontrolled hypertension - Refractory arythmia - Recent myocardial infarction (less than 6 month - Recent stroke (less than 6 month) - Recent coronary bypass graft (less than 3 month) - Uncontrolled congestive heart failure - Uncontrolled hyperthyreoidism ■ lenka.roubalikova@tiscali.cz Risk of bacterial endocarditis Caused by a bacteremia - can be associated with endodontic treatment. It is potentially fatal. Patients who have a history of murmur or mitral valve prolapse with regurgitation Rheumatic fever Congenital heart defect Arteficial heart valves lenka.roubalikova@tiscali.cz Risk of bacterial endocarditis Must be minimized using ANTIBIOTIC PROPHYLAXIS Short term administration of antibiotic in high dosage - according to recent recommendation. lenka.roubalikova@tiscali.cz HIV and aquired immunodeficiency syndrome ■ HIV patients do not have an increased risk of postoperative pain or inflammation. Precautions of infection of dental team. Generally - number of CD4 lymphocyts is important (less than 200/mm3 hihger risk of opportunistic infections lenka.roubalikova@tiscali.cz lenka.roubalikova@tiscali.cz Diabetes ■ Patients with well medically controlled diabetes and free of serious complications (renal disease, hypertension, coronary atherosclerotic disease) is a candidate for endodontic treatment. - Non insulin patient may require insulin - Insulin patient may require hihger dosis of insulin - Source of glucosa should be available - Appointments should be scheduled with consideration given to the patients normal meal and insulin schedule. Especially when surgical endodontics is indicated - consultation with specialist is useful. lenka.roubalikova@tiscali.cz Prosthetic implant ■ Can require antibiotics prophylaxis depending on time after implantation and other patient's diseases. Consultation with patient's physician. Endodontic is an unlikely cause the bacteremia in comparison with extractions, scaling, periodontal sutgery. lenka.roubalikova@tiscali.cz Patients with anticoagulation therapy i Risk of bleeding from dental pulp and root canal Risk of haematoma when nerve blocking anaesthesia is used Treatment depending on laboratory tests, consultation with specialist. lenka.roubalikova@tiscali.cz Behavioral and psychiatric disorders Patient's ability of cooperation and drug interaction (local anaesthetics) Consultation of physician usefull and sometimes necessary. lenka.roubalikova@tiscali.cz Regional factors that influence endodontic case selection lenka.roubalikova@tiscali.cz Position of the tooth and its importance for function The tooth must be valuable for the function (dystopic teeth,third molars etc. lenka.roubalikova@tiscali.cz Local factors that may influence endodontic case selectio lenka.roubalikova@tiscali.cz Periodontal consideration (poor periodontal prognosis - no endodontic treatment) - Surgical consideration (some lesions are nonodontogenic) ■ Restorative consideration (root intraosseus caries, poor crown/root ratio, extensive periodontal defects) ■ Others (calcification, obliteration,root resorption, dilaceration etc.) lenka.roubalikova@tiscali.cz 23 lroubalikova@gmail.com Distance between free gingiva anc alveolar bone/ Biological width cca 2 mm GargiuloAW, Wentz \FM, Orban B (JPerio 1961) Vacek JS, Gher ME, Assad DA, Richardson AC, Gambaressi LI (Int J Perio & Rest I Dent 1994) lroubalikova@gmail.com Rest of hard dental tissues tooth restorable index So 6re Description 0 >_l/3 no supragingival dentin dentin 1 Width of remaining dentin is £.1,5 mm 2 Supragingival dentin width and height is app.l mm _>2/3 3 Sufficient amount od dentin — more than 1,5 x 1mm i Sextant: ML MB DB Minimal height 1 mm Minimal width before the treatment 1,5 mm Posouzení zbývajících zubních tkání - TRI Minimální skóre 0 Maximální skóre 18 Bandlish DB, Mc DonaldAV, Setchel DJ Assesment of the amount of remaining coronal dentine in root treated teeth Journal of Dentistry 2006;9:699 28 lroubalikova@gmail.com Non restorable teeth \7 Elongation of clinical crown surgically Orthodontic extrusion Extraktion lroubalikova@gmail.com 30 lroubalikova@gmail.com Diagnosis in endodontics Chief complaint Medical history Dental history History of present dental problem Dental history interview uestionnaire lenka.roubalikova@tiscali.cz Examination and testing ■ Extraoral examination (inspection - facial symetry, loss of definition of the nasolabial fold,palpation of the cervical and submandibular lymph nodes) Intraoral examination Soft tissue examination Intraoral swelling Intraoral sinus tract Palpation Percussion Mobility Periodontal examination lenka.roubalikova@tiscali.cz Examination and testing Pulp test Thermal Electric Radiographic examination lenka.roubalikova@tiscali.cz Intraoral radiography Film or sensor placed in oral cavity Special apparatus Teeth Alveolar bone Periodontal space Fillings Caries Impacted teeth Level of endodontic treatment Position of the tubus In vertical plane In horizontal ülane Parallel technique Modified parallel technique Technique of bissecting angle I n vertical plane If parallel technique is not ossible orizontal plane Orthoradial and excentric projektion Clinical classification od pulpal and periapical diseases Pulp diseases -Normal pulp - Reversible pulpitis - Irreversible pulpitis - Necrosis Periodontal diseases - Periradicular periodontitis (chronic apical periodontitis) - Periradicular abscess (acute apical periodontitis) lenka.roubalikova@tiscali.cz Pulpal disease ■ Normal pulp — no spontaneus symtoms, the pulp respond to pulp tests, symptoms are mild, do not cause patient's discomfort. Transient sensation reversing in seconds ■ Reversible pulpitis Stimulation is uncomfortable, sharp pain,revers quickly after irritation, (dental caries, recent dental treatment, exposed dentin, defective restoration) lenka.roubalikova@tiscali.cz Pulpal disease ■ Irreversible pulpitis Symptomatic - Intermittent spontaneus pain Pain on stimuli asp. cold — stimul can cause an attack of pain. Pain is sharp or dull, usually referred Patient can hardly recognise which tooth is lenka.roubalikova@tiscali.cz Pulpal disease ■ Irreversible pulpitis Symptomatic pain during the night during the time the attacks are longer the stimuli are less on cold but more on hot during time the patient can recognize the causative tooth - X ray negative or widened periodontal ligament space. (Thickening of periodontal membrane) I lenka.roubalikova@tiscali.cz Pulpal disease ■ Irreversible pulpitis Asymptomatic Can become symptomatic or necrotic lenka.roubalikova@tiscali.cz Necrosis and gangraena Necrotic pulp become very often gangrenous no symptoms no response on vitality tests pain on hot typical smell (gangraena can be open or closed) no radiographic finding or widened of Deriodontal ligament space. lenka.roubalikova@tiscali.cz 51 Periapical diseases ■ Apical periodontitis (periradicular periodontitis) - Chronic No symptoms, no response on vitality tests, periapical radiolucency. Can become acute (exacerbation) Acute Symptomatic, pain on percussion, bite, hot, palpation, mobility.No respons on vitality tests. X ray - periapical radiolucency, or widened periodontal ligament space. lenka.roubalikova@tiscali.cz Periapical diseases Can propagate intraorally or/and extraorally Subperiostal abscess Submucous abscess Abscess in surrounding tissues Non limited inflammation - cellulitis lenka.roubalikova@tiscali.cz Endodontic treatment Irreversible pulpitis ■ Necrosis, gangreana Apical periodontitis Conservative, conservative approach. I surgical approachy surgical lenka.roubalikova@tiscali.cz Acces ■ Accessto the pulp chamber Penetration to the pulp chamber and removal of its roof > Orifices of root canals must be seen clearly > The instrument goes through to the root canal without bending > Walls of the endodontic cavity are divergent lenka.roubalikova@tiscali.cz 55 Opening of the pulp chamber Dia trepan Dia round burs balls Steel round burs lenka.roubalikova@tiscali.cz Removal of the roof of the pulp chamber Dia trepan Safe ended tips Batťs instruments Fissur bur lenka.roubalikova@tiscali.cz 60 lenka.roubalikova@tiscali.cz 61 Finding and opeing of rot canal orifices lenka.roubalikova@tiscali.cz 62 Ultrasound tips can be covered with diamond or smooth or bladed Finding and opening of root canal orifices lenka.roubalikova@tiscali.cz Peeso - Largo 64 lenka.roubalikova@tiscali.cz 65 X-GATES eakness » point Max Diameter: Gates 4 Shank : Gates 3 Opening of the root canal orifice Ni-Ti instruments I., ProTaper SX, IntroFile etc. z 68 Tungsten Carbide Burs LN BUR (Long Neck Improves vi si bil i Removal of contents of root canal Pulpextractor Emoval of soft content - pulp, cotton,paper point Wider canals only!!! Risks: breakage of the instrument Breaking of spurs and their pushing out lenka.roubalikova@tiscali.cz >Access ! >Size ! >mode of use ! Canal shaping > Reamers (penetration > Files (shaping lenka.roubalikova@tiscali.cz Iniciální flaring — katetrizace Glide path Seznámit se s průchodností a anatomií kanálového systému Vytvořit cestu pro strojové opracování Snížit riziko zalomení kořenových nástrojů C+ file Ostrý hrot Čtvrecový průřez - stabilita Flkexibilita Vhodný pro kalcifikované kanálky ProFinder File Regresivní kónus Silikonové držátko Ověření průchodnosti První zprůchodnění Úhel vstupu do kanálku Místo pro strojové nástroje Reamer K -reamer = Kerruv pronikac Triangl or square wire spun Symbol lenka.roubalikova@tiscali.cz Blades Space for dentin chips Rotation - reaming achtion - panetration lenka.roubalikova@tiscali.cz Reamer Rotation (clockwise) - penetration Application of plastic material (contraclockwise) lenka.roubalikova@tiscali.cz Files — 1. K-file 2. K-flexofile, flexicut, flex-R 3. K-flex 4. H-file, S-file lenka.roubalikova@tiscali.cz 92 K file Wire triangl or square lenka.roubalikova@tiscali.cz 93 K-file Filing Also rotation 45° -90° lenka.roubalikova@tiscali.cz K-flexofile, flexicut, flex-R Triangle wire always V Flexibility K- flexofile a flex — R file: non cutting tip and first blades are blunt Like K-file lenka.roubalikova@tiscali.cz K-flex — Rhombus Two blades in action Enough space for dentin chips Flexibility, effifacy lenka.roubalikova@tiscali.cz lenka.roubalikova@tiscali.cz 99 ISO > Diameter of the tip > Length of the cutting part > Taper lenka.roubalikova@tiscali.cz Canal shaping and cleaning ■ Basic rules > Elimination of infection > Enlargement till the apical constriction — simplify the shap Final result: > 6% taper, 3 more in comparison to the apical size > Gangraena — clean dentin chips lenka.roubalikova@tiscali.cz Canal cleaning □ Elimination of infection Mechanically — instrumentation, irrigation Chemically — irrigiation, temporary root canal filling lenka.roubalikova@tiscali.cz Canal shaping Coronal flaring (Weine 1982, Peřinka 2003) 107 lenka.roubalikova@tiscali.cz 108 Importance Protection against fracture of root canal instrument Better cleaning of coronal part Effective irrigation Better conditions for establishment of working length Better conditions for apical preparation Less risk of complication lenka.roubalikova@tiscali.cz Shaping technique Rotation — 45° clockwise and conttraclockwise K - reamer lenka.roubalikova@tiscali.cz K- file Shaping technique Rotation 45° slight pressure and pull motion K - reamer K- file lenka.roubalikova@tiscali.cz Risk of ledging Zip, elbow effect Via falsa Shaping technique lenka.roubalikova@tiscali.cz 114 Shaping technique K- flexofile K - file (?) lenka.roubalikova@tiscali.cz ■ Balanced force 1. Introduce instrument 1 size bigger than apical size Rotation clockwise with very slight pressure, 90 180° Rotation contraclockwise, pressure forward, Pull motion and clockwise rotation lenka.roubalikova@tiscali.cz Methods of shaping Rotation and filing combined lenka.roubalikova@tiscali.cz Methods of shaping Circumferential filing lenka.roubalikova@tiscali.cz lenka.roubalikova@tiscali.cz Methods of shaping ■ Step back Reduction of working length 1 mm after 3 sizes of root canal instrument. H- file K-file K-flexofile lenka.roubalikova@tiscali.cz 120 Methods of shaping Modified double flared with balanced force Coronalflaring) Apicalpreparation balancedforce Step back Finalflaring lenka.roubalikova@tiscali.cz Methods of shaping ■ Step down H —file opening of root canal Gates Glidden Establishment of working length H-file GG- files H-file step back lenka.roubalikova@tiscali.cz Methods of shaping ■ Crown down presureless Coronal flaring K —file contraclockwise onl lenka.roubalikova@tiscali.cz Working length Distance between referential point and apical constriction lenka.roubalikova@tiscali.cz Apical morphology 1. X-ray apex 2. Foramen apicale 3. Apical constriction 4. Periodontal ligament 5. Root cement 6. Dentin Distance of apical constriction is 1 - 1,5mm from the apex. Establishment of working length X-ray Aoexlocators Combination lenka.roubalikova@tiscali.cz X-ray Safe length I20C22-24,P20,M18, 20 118, C 20, P 18, M 18 lenka.roubalikova@tiscali.cz X-ray method ■ Root canal instrument in root canal (ISO 15) Safe length X-ray Estimation — apical constriction lenka.roubalikova@tiscali.cz Why apical constriction Small comunication Less risk of damage of periodontal ligament Prevention of extrusion of root canal filling Good compaction of root canal filling (guttapercha) lenka.roubalikova@tiscali.cz 130 lenka.roubalikova@tiscali.cz 131 Apexlocators Rinciple is based on measurement of electric resistance in root canal. Fast No irradiation Not always correct lenka.roubalikova@tiscali.cz lenka.roubalikova@tiscali.cz 139 lenka.roubalikova@tiscali.cz 142