Endodontics I. Healing potential of dental pulp. Pulp capping. Pathology and pathophysiology of dental pulp Pulpal reactions Classification of pulpal and periodontal diseases Aim of endodontic treatment Healing of pulp diseases or removal bacteria from the root canal system and regeneration of damaged periodontal tissues. (Canal shaping, cleaning and filling) „ Endodontist helps nature only “ W.D.Miller Endodont Morphology Enamel Dentin Cementum Periodontium Pulp Odontoblasts Predentin Dentin Dental pulp Does the river freeze over? Endodont: dentin and pulp (morphological and functional unit) Vertucci Gulabivala Kartal a Yanikoglu…. Anatomie isthmu Apikální oblast Meyer 1962 3D Meyers conclusions The root canal is not round but oval (long axis mesiodistal) The root canal does not go straight but it deflects distal The outfall is not on the top of the root but below (distal or distooral) Meyer´s conclusions  The form of the outfall is funnel - shaped  The root canal system has usually more outfalls (ramifications)  The ramifications are situated mostly in apical area (first apical mm)  All outfalls are situated in cementum Basic forms of the root canal systém (Weine) Apical morphology 1. X – ray apex 2. Foramen apicale 3. Apical constrictionA 4. Periodontal ligament 5. Root cementum 6. Dentin Configuration of apical constriction Canal shaping terminates in apical constriction Small communication Less risk of periodontal damage Prevention of overfilling Prevention of apical transport of infectious material Possibility of good bacterial decontamination Possibility of good condensation of the root filling X- ray apex Real situation Macrocanal systém Microcanal system Healing potential of dental pulp Odontoblasts - Secondary dentin - Tertiary (reparative) dentin - Intratubular dentin (sclerosis) - -dentin bridge Hyperaemia - active - passive } infiltration, inflammation - stasis Pulp diseases Inflammation - pulpitis Consequences - Necrosis - Gangraena - Apical periodontitis Healing? Apical periodontitis acute chronic enosaeal, subperiostal, submucous phase Acute Chronic GangreanaNecrosis irritants Dental pulp Cummulative trauma of dental pulp Reasons Bacteria Mechanical irritants (overinstrumentation, trauma) Chemical (esp. phenolic based inracanal medicaments, overfilling,irrigants) Classification of pulp diseases Histopatological Hyperaemia Acute pulpitis serose partial total Acute pulpitis purulent partial total Classification of pulp diseases Histopatological Chronic pulpitis closed open ulcerous polypous Classification of pulp diseases Clinical Reversible pulpitis Pain does not persist after stimulus is removed Pain is difficult to localize Normal periradicular appearance Teeth are not tender to percussion Classification of pulp diseases Clinical Irreversible pulpitis Pain may develop spontaneously or from stimuli In later stages heat is more significant Response lasts from minutes to hours When the periodontal ligament is involved, the pain is localized A widened periodontal ligament may be seen in later stages Diagnosis History Presenting complaint Medical history Dental history Pain history Location Type and intensity of pain Duration Stimulus Relief (analgetics, antibiotics, sipping cold drinks) Diagnosis Clinical examination Extraoral (swelling, redness, extraoral sinuses, lymph nodes, degree of mouth opening) Intraoral examination Swelling, redness,palpation, percussion, sinus tract examination, teeth mobility,pockets Diagnosis Clinical examination Pulp sensitivity tests, radiographic examination, transillumination. Ca (OH)2 Disociation – strong alkalinity Low solubility Suspension Treatment of pulpal and periodontal diseases Vital methods Dental pulp remains vital. Pulp capping, pulpotomy. Non vital methods Dental pulp does not remain vital. Root canal treatment Pulp capping Indirect Direct Calcium hydroxide – influences the dental pulp indirectly – through dentin or directly on dental pulp Suspension (mixed with water Or ready made) Cement Temporary rooot canal filling - short term - middle term - long term Antiphlogistic Antimicrobial Improves dentinogenesis Indirect pulp capping Caries close to dental pulp, No pain Subbase, base filling Intermittent excavation Large caries, Slight pain Calcium hydroxide Base, temporary filling for 6 months Excavation Expectation: formation of reparative dentin Glassionomer – its rule in the treatment of deep caries No pain Clean border – 1 mm around the cavity Direct pulp capping Open pulp chamber -preparation, trauma Small perforation Surrounded by healthy dentin Done immediately Dentin bridge Rests od calcium hydroxide Calcified connective tissue Dentin Predentin Odontoblasts Pulpotomy Partial Injury of permanent teeth where apex is not completed. Small perforation, as soon as possible Pulpotomy Total Injury of permanent teeth where apex is not completed. Larger perforation, later than 2 hours Suspension Cementy Pro root MTA Dicalcium silicate Tricalcium silicate Tricalcium aluminate Tetracalcium aluminate Copper sulphate Bismuth trioxidate = portland cement Active biosilicate technology tm Septodont Active Biosilicate Technology™ is a proprietary technology developed according to state-of-theart pharmaceutical background applied to the high temperate ceramic mineral chemistry. lroubalikova@gmail.com 48 Biodentine - composition Powder Ca3SiO5 (tricalcium silicate C3S) Main core material Ca2SiO5 (dicalcium silicate C2S) Second core material CaCO3 (calcium carbonate) Filler CaO (calcium oxide) Filler Fe2O3 (iron dioxide) Shade ZrO2 (zirconium dioxide) Radiopacifier Liquid CaCl2 . 2 H2O Accelerator Hydrosoluble polymer Water reducing agent Water lroubalikova@gmail.com 49 Biodentine – setting reaction 2(3CaO.SiO2) + 6H2O 3CaO.2SiO2.3H2O + 3Ca(OH)2 C3S CSH CSH C3S C3S CSH CSHCa(OH )2 C3SC3S Ca(OH)2 Ca(OH)2 Ca(OH)2 C3S C3S H2O H2O H2O H2O H2O H2O lroubalikova@gmail.com 50 The hardening process results from of the formation of crystals that are deposited in a supersaturated solution. Setting time: 9 -12 min. lroubalikova@gmail.com 51 Bioactive technology – bioactive materials Indication a contraindiction of the endodontic treatment View - point Local Regional Systemic Indication a contraindiction of the endodontic treatment View - point Local Root canal morphology Severity of pulpal or periodontal disease Periodontal status lenka.roubalikova@tiscali.cz 56 Indication a contraindiction of the endodontic treatment View - point Regional Indikation a contraindiction of the endodontic treatment Poin of view Regional The value of the endodontic teeth Indikation a contraindiction of the endodontic treatment Poin of view  Systemic General health. Taking decision Vital methods? Root canal treatment? Extraction? Other surgery? Endodontic treatment Root canal shaping Root canal cleaning Root canal filing Phases of endodontic treatment Diagnosis X –ray Indicated? Restoration of the tooth Phases of RCT Accesss to the pulp chamber Cathetrization Negotiation of the WL Root canal shaping Recapitulation Irrigation Drying Filing X-ray Resistance and retention – postedndodontic treatment.