Endodontics I. Case selection and treatment planning lenka.roubalikova@tiscali.cz Common medical findings that may influence endodontic treatment planning lenka.roubalikova@tiscali.cz 2 ■ Pregnancy ■ Cardiovaslular disease ■ Cancer ■ 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 3 ■ 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 4 ■ 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 - Druas 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 5 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. - Consultation 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 conaestive 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 10 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 11 Cancer ■ Risk of metastasis in jaws. Careful examination, OPG. ■ Cancer in orofacial region - all potential focuses must be removed, no endodontic treatment during and after radiotherapy. Risk of radionecrosis - radioosteomyelitis. Radiotherapy - decreasing number of osteoblasts, osteocyts, endothelial cells and blood flow. Routine dental procedures can be done if granulocyts counts is grater than 2000/mm3 platelet count grater than 50.000/mm3. Consultation with responsible specialist. lenka.roubalikova@tiscali.cz 12 HIV and aquired immunodeficiency syndrome I HIV patients do not have an increased risk of postoperative pain or inflammation. Precautions of infection of dentsiJ toarrL Generally - number of CD4 lymphocyts is important (less than 200/mm3 hihger risk of opportunistic infections). lenka.roubalikova@tiscali.cz Renal disease and dialysis ■ End stage renal disease - best way hospital setting. ■ Dialysis - consultation wsith the specialist ■ (some drugs are eliminated by dialysis, the treatment is best scheduled a day after dialysis since on the day of dialysis patients are generally fatiogued and have a bleeding tendency) lenka.roubalikova@tiscali.cz 14 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. Endodontic is an unlikely cause the bacteremia in comparison with extractions, scaling, periodontal sutgery. lenka.roubalikova@tiscali.cz 16 Patients with anticoagulation therapy ■ 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 17 Behavioral and psychiatric disorders Patient's ability of cooperation and drug interaction (local anaesthetics) Consultation of physician useful! and sometimes necessary. lenka.roubalikova@tiscali.cz 18 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 selection lenka.roubalikova@tiscali.cz 21 ■ 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 Biological width Distance between free gingiva ancK alveolar bone/ * >► cca 2 mm GargiuloAW, Wentz FM, Orban B (JPerio 1961) VacekJS, GherME, Assad DA, Richardson AC, Gambaressi LI (IntJ Perio& Rest Dent 1994) 24 lroubalikova@gmail.com Score 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 lenka.roubalikovatiscali.cz 27 Posouzení zbývajících zubních tkání - TRI Minimální skóre 0 Maximální skóre 18 Band I is h DB, Mc Donald AV, 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 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 Questionnaire lenka.roubalikova@tiscali.cz 32 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 33 Examination and testing Pulp test Thermal Electric Radiographic examination lenka.roubalikova@tiscali.cz 34 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 plane Parallel technique Modified parallel technique Technique of bissecting angle In vertical plane If parallel technique is not ossible In horizontal 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 46 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 47 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 causative. 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) lenka.roubalikova@tiscali.cz Pulpal disease ■ Irreversible pulpitis Asymptomatic Can become symptomatic or necrotic lenka.roubalikova@tiscali.cz 50 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 periodontal ligament space. lenka.roubalikova@tiscali.cz 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 52 Periapical diseases Can propagate intraorally or/and extraorally Subperiostal abscess Submucous abscess Abscess in surrounding tissues Non limited inflammation - cellulitis lenka.roubalikova@tiscali.cz 53 Endodontic treatment Irreversible pulpitis Necrosis, gangreana Apical periodontitis Conservative, conservative approach. I surgical approach, 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 Dia trepan Opening of the pulp chamber Dia round burs balls Steel round burs lenka.roubalikova@tiscali.cz 59 Removal of the roof of the pulp chamber Safe ended tips Batťs instruments Fissur bur lenka.roubalikova@tiscali.cz 60 Finding of the root canal orifice lenka.roubalikova@tiscali.cz 61 Finding and opeing of rot canal orifices i Endodontic probes Microopeners CANAL BLUE CorrmmaCotoranUr propylene 0CH Ml mm sokioon VDW GmOH _ Finding and opening of root canal orifices lenka.roubalikova@tiscali.cz Peeso - Largo 64 lenka.roubalikova@tiscali.cz 65 Gates - Glidden: Blunt, non active tip Programm point of breakage lenka.roubalikova@tiscali.cz 66 X-GATES Tip size : Gates 1 eakness » point Max Diameter: Gates 4 Shank : Gates 3 T\ingsten Carbide Burs LN BUR (Long Neck Improves visibility Removal of contents of root canal Pulpextractor Emoval of soft content - pulp, cotton,paper point Wider canals only!!! 1' 1 E' 1 1 i 1 Risks: breakage of the instrument Breaking of spurs and their pushing out lenka.roubalikova@tiscali.cz 79 Canal shaping > Reamers (penetration) > Files (shaping) lenka.roubalikova@tiscali.cz 81 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 ProFinder File Regresivní kónus Silikonové držátko Overení 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 Reamer Rotation (clockwise) — penetration Application of plastic material (contraclockwise) lenka.roubalikova@tiscali.cz 91 Files 1. K-file 2. K-flexofile, flexicut, flex-R 3. K-flex 4. H-file, S-file lenka.roubalikova@tiscali.cz 92 Kfile Wire triangl or square Symbol is always square 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 95 K-flex Rhombus Two blades in action Enough space for dentin chips Flexibility, effifacy lenka.roubalikova@tiscali.cz 96 1 K-file and reamer: difference lenka.roubalikova@tiscali.cz H- file ra No rotation!! Pull motion only!! Risk of breakage in small sizes • II lenka.roubalikova@tiscali.cz 99 ISO > Diameter of the tip > Length of the cutting part > Taper lenka.roubalikova@tiscali.cz 0,02 mm na 1mm 102 Canal shaping and cleaning ■ Basic rules > Elimination of infection > Enlargement till the apical constriction — simplify the shape 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 104 Canal shaping Coronal flaring (Weine 1982, Peřinka 2003) lenka.roubalikova@tiscali.cz 105 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 111 Shaping technique Rotation — 45° clockwise and contraclockwise K - reamer K- file lenka.roubalikova@tiscali.cz Shaping technique Rotation 45° slight pressure and pull motion K - reamer K- file Risk of ledging Zip, elbow effect Via falsa lenka.roubalikova@tiscali.cz 113 Shaping technique Filing H- file K - file Risk of periapical infection infection Risk of plug lenka.roubalikova@tiscali.cz 114 Shaping technique 90-180' K- flexofile K - file (?) 180-270c lenka.roubalikova@tiscali.cz 115 ■ Balanced force- 1. Introduce instrument 1 size bigger than apical size, 2. Rotation clockwise with very slight pressure, 90 -180° 3. Rotation contraclockwise, pressure forward, 4. Pull motion and clockwise rotation lenka.roubalikova@tiscali.cz 116 Methods of shaping Rotation and filing combined K - reamer H- file lenka.roubalikova@tiscali.cz Methods of shaping lenka.roubalikova@tiscali.cz 118 lenka.roubalikova@tiscali.cz Methods of shaping ■ Step back Reduction of working length 1 mm after 3 sizes of root canal instrument. lenka.roubalikova@tiscali.cz 120 Methods of shaping Modified double flared with balanced force Coronalflaring) Apicalpreparation balancedforce Step back Finalflaring lenka.roubalikova@tiscali.cz 121 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 only lenka.roubalikova@tiscali.cz 123 Working length Distance between referential point and apical constriction lenka.roubalikova@tiscali.cz Apical morphology EH 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 ■ Apexlocators ■ Combination lenka.roubalikova@tiscali.cz 126 X-ray Safe length I20C22-24.P20.M18. 20 ■ 118, C 20, P 18, M 18 lenka.roubalikova@tiscali.cz 127 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 Apexlocators ■ Rinciple is based on measurement of electric resistance in root canal. ■ Fast ■ No irradiation ■ Not always correct lenka.roubalikova@tiscali.cz 132 lenka.roubalikova@tiscali.cz 136 lenka.roubalikova@tiscali.cz 139 lenka.roubalikova@tiscali.cz 140