Endodontics Pulp and periodontal diseases -diagnosis, therapy, prevention 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 Endodontics - terms • Endodont (dentin + pulp) • Pulp chamber • Root canal • Apical constriction • Apical foramen • Ramifications • Radiographic apex • Periodontal space Morphology >The root canal is not round it is usually oval (long axis mesiodistal direction) >The root canal is not straight - it deflects distal > Apical foramen is not on the top of the root but under it (distal or distooral side) Morphology > Between apical constriction and apical foramen the wall of root canal are divergent towards periodontal space > The root canal system has usually more foramina (ramifications) > The ramifications are situated mostly in apical area (first apical mm) > All apical foramina are situated in cementum Morphology 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 apical foramen is not on the top of the root but below (distal or distooral) Meyer's conclusions > The walls of the root canal between apical constriction to apical foramen are divergent > The root canal system has usually more apical foramina (side branches - ramifications) > The ramifications are situated mostly in apical area (first apical mm) > All foramina are situated in cementum Basic forms of the root canal systém (Weine) ill. A Vertucci Gulabivala Kartal a Yanikoglu.. lenka.roubalikova@tiscali. cz 12 Apical morphology 1. X - ray apex 2. Foramen apicale 3. Apical constrictionA 4. Periodontal ligament 5. Root cementum 6. Dentin Acc. to Guidener a Langel and Odontoblasts Predentin Dentin Dental pulp is in close connexion with dentin pulp - dentinal complex - endodont Dental pulp is a tissue of mesenchymal origin Compositin of the dental pulp connective tissue collagen fibres ground substance interfibrillar substance connective tissue cells (other celle- histiocytes, macrophages, dendritic celle, stem cells) blood vessels nerve fibres odontoblasts - dentine forming cells Fig. 3.1 Soft tissue of the pulp surrounded by dentine and enamel and cementum. Inset depicts the interface between dentine and pulp. 4 zones 1. central zone - larger nerves and blood vessels 2. cell rich zone - reserve cells (undifferentiated mesenchymal cells), fibroblasts 3. cell free zone (zone of Weil) - terminals of naked nerve fibres 4. odontoblastic zone ^ Dentine w Predentin^ w w nHnntnhl^K y TpII frpp 7nnp ^ TpII rirh 7nnp Fig. 3.4 Tissue section stained with hematoxylin and eosin showing dentine, predentine and pulp tissue proper with odontoblasts lining the periphery. Sensory nerves Blood vessel Dentine Odontoblasts Dendritic ce Stem cell Lymph vessel Pulp Macrophage Macrophage Memory T-cell Class II Non-class II Fig. 3.11 Constituents of primary significance in the defense of the pulp against foreign substances, including bacterial elements, make up the innate 'first line of defense'. Dentine Predentine Pulp Odontoblasts Nerves Dentinal tubule Dendritic eel Fig. 3.3 Cellular extensions of odontoblasts, nerves and cells of the immune system (dendritic cells) that occupy the pulpal ends of the dentinal tubules. Function of the dental pulp • Formative - dentine formation through the life • Nutritive - dental pulp maintains the vitality of dentine • Nervous function - afferent - efferent • Defensive function Formative function Formation of dentine through the life • primary dentine • secondary dentine • tertiary dentine Fig. 3.5 Microphotograph shows hard tissue repair following a cavity preparation (arrow). The circle indicates the bulk of new dentine being formed. Tubules near the enamel Tubules near the pulp Fig. 3.2 Density of dentinal tubules in various portions of the crown region in teeth. It has been estimated that the surface area taken by cross-cut tubules is ca. 2-3% in the periphery but near the pulp the dentinal tubules assume ca. 25% of the surface area (67)._ Nutritive function arterioles branching into terminal arterioles terminal capillary network - peripherally post capillary venules collective venules main venules anastomoses lymphatic vessels Fig 1-2-4 Vascularity of the pulp. A monomer is injected into the apical blood vessels and polymerized. The tooth is then demineralized.and the organic components arc digested away, allowing examination of the vascular tree." (O) Odontoblastic region: (V) venule: (A) arteriole. (Original magnification X900. Courtes) ofDrK.Taka-hashi.) Nervous function • Dental pulp - both vasomotor and sensory nerves (vasomotoric and defense functions) • vasomotor nerves - sympathetic division of the autonomic system (postganglion) • accompany arterioles Theories of pain transmission • dentin innervation Nerve fibrs in dentine tubules) • hydrodynamic mechanism • odontoblasic deformation Defense function • dentinal pain • smear layer • tubular sclerosis • irritation (tertiary) dentine formation • inflammation of the connective tissue Smear layer - scaling, abrasion, attrition, caries, cavity preparation microcrystalline debris (smear layer) extends into the dentinal tubules - covers dentinal surface (several u.m thick) reduction od dentine sensitivity and permeability (plugging of the tubules). • Tubular sclerosis - by milder or moderately irritating agents (slowly progressing caries, cavity preparation, abrasion, attrition, age changes) • peritubular dentine formation and • intratubular calcification • the tubules become narrower and are closed • Tertiary (irritative, irregular) dentine formation • defensive barrier against caries progression Fig 6-7 Tertiary dentin (TD) formed as a response to the healing of a lesion similar to that shown in Fig 6-5. Note the lightly stained, atubular interface dentin (I) and the dentinal tubules in the tertiary dentin. The odontoblasts lining the pulpal aspect of the tertiary dentin are short, and the cell-free zone is lacking in this area. (Hematoxylin-eosin stain; original magnification X65.) Pulp exposure due to crack caries Dentinal tubules exposed due to fracture caries From periodontal pockets via marginal leakage around fillings Transient bacteremia by anachoresis with A cavity or crown preparation root planing root resorption exposed dentinal tubules exposed accessory canals blood vessels in case of trauma oral bacteria \ \\ other bacteria Fig. 8.1 Drawing illustrating the pathways of entry for micro-organisms into the root canal. Obvious ways of entry are pulp exposures due to caries or trauma. Potential pathways are cracks in enamel and dentine due to trauma, and dentinal tubules exposed by caries, fracture, cavity or crown preparation, marginal leakage around fillings, root resorption or root planing. From periodontal pockets, potential pathways are via exposed accessory canals, via exposed dentinal tubules or via blood vessels in the case of trauma. During bacteremia, blood-borne bacteria may colonize an inflamed or necrotic pulp (anachoresis). (See text for details.)_ Most common factors leading to pulpal diseases • Infection (caries, periodontal pocket, traumatic injury, cracs, abrasion,blood circulation) • Trauma (interruption of blood vessels) • Traumatization (ruxismus, badly made fillings) • Chemical factors (filling materials, disinfectants • Physical factors - increasing of temperature (preparation withour water cooling) Ramification Two ways of endodontic teratment • Vital pulp therapy Dental pulp remain in the pulp chambre and root canals completely or partly • Root canal treatment Dental pulp is removed from the root canal completely, root canal is shaped, cleaned, filled Vital pulp therapy • Indirect pulp capping • Intermittent excavation • Direct pulp capping • Pulpotomy - Coronal: partly or completely - Deep pulpotomy 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. Consideration • If the disease of dental pulp is reversible: Vital pulp therapy • If the disease of dental pulp is ireversible Root canal treatment in DROXID p.a. C«tOH); Mf/4.10 Ca (OH)2 pH 12,5 See text medicaments in endodontics Indirect pulp capping Indirect pulp capping Only small amount of carious dentine left Calciumhydroxide cement Permanent filling Intermittent excavation Larger amount of carious dentine left Calcium hydroxide suspension Temporary filling 6 weeks Final excavation afterwards Permanent filling We expect improvement of tertiary dentin formation, dessication of carious dentine Direct pulp capping Directly on dental pulp Very small perforation surrounded with non carious dentine Calcium hydroxide Base filling Dentim brosge is formed Dentin bridge Rests of calcium hydroxide Connective tissue Calcified connective tissuá Dentin Predentin Odontoblasts Pulpotomy -Coronal - partial - Total Deep - inside root canal Calcium hydroxide, Base, Permanent filling Dentin bridge is formed Phases of the endodontic treatment * Investigation, diagnostic radiogram, consideration (local, regional, systemic factors) * Preendo: Removal of old fillings, carious dentin, temporary restoration - sontour of the tooth. * Dry operating field * Preparation of the access (endodontic cavity) Phases of the endodontic treatment • Opening of root canals • Initial flaring and removal of content of root ca • WL (working length) • Root canal shaping and cleaning (irrigation) • Recapitulation, final irrigation • Drying • Filling • Radiogram • Postendodontic treatment Access opening Shapes of endo cavities Number of root canals FIG. 7-5 Indispensable in endodontic treatment, the endodontic pathfinder serves as an explorer to locate orifices, as an indicator of canal angulation, and often as a chipping tool to remove calcification. Correct Incorrect FIG. 7-6 A, Sweeping motion in a slightly downward lingual-to-labial direetion (arrows), until the chamber is engaged, to obtain the best access to the lingual canal. B, Incorrect approach: directing the end-cutting bur in a straight lingual-to-labial direction. Mutilation of tooth structure and perforation will be the result in this small and narrow incisor. FIG. 7-30 Difficulties created by poor access preparation. A, Inadequate opening, which compromises instrumentation, invites coronal discoloration, and prevents good obturation. B, Overzealous tooth removal, resulting in mutilation of coronal tooth structure and weakening leading to coronal fracture. C, Inadequate caries removal, resulting in future carious destruction and discoloration. D, Labial perforation (lingual perforation with intact crowns is all but impossible in incisors). Surgica repair is possible, but permanent disfigurement and periodontal destruction will result. E, Furcal perforation of any magnitude, which (1) is difficult to repair, (2) causes periodontal destruction, and (3) weakens tooth structure, invites fracture. F, Misinterpretation ol angulation (particularly common with full crowns) and subsequent root perforation. This is extremely difficult to repair: and even when it is repaired correctly, because it occurred in a difficult maintenance area the result is a permanent periodontal problem. FIG. 7-31 Common errors in access preparation. A, Poor access placement and inadequate extension, leaving orifices unexposed. B, Better extension but not including the fourth canal orifice. C, Overextension, which weakens coronal tooth structure and compromises final restoration. D, Failure to reach the main pulp chamber is a serious error unless the space is heavily calcified. Bitewing radiographs are excellent aids in determining vertical depth. E, An iatrogenic problem is allowing debris to fall into the orifices. Amalgam filings and dentin debris can block access and result in endodontic failure. F, The most embarrassing error, and the one with the most damaging medical-legal potential, is entering the wrong tooth. A common site of this mishap is teeth that appear identical coronally. and the simple mistake is placing the rubber dam on the wrong tooth. Beginning the access cavity before placement of the rubber dam helps avoid this problem. Lingual Mesiolingual Distal Access Instruments Dia trepan Dia balls Preparation of the endodontic cavity Dia trepan Safe ended tips Batt's instruments Fissur bur lenka.roubalikova@tiscali.cz 77 Endodontic probes t Endodontic probes, microopeners 1IIII n I CANAL BLUE Hot o'sa « Root Canal ixaun ' VOW GmbH PO Bo< WWW • »1 ™ MuncfwvGwtruny Ultrasound tips Dye Opening of root canals Peeso - Largo burs Opening of the root cana Insertion of root canal instrument after opening the pulp chamber and root canal orifice Access cavity lenka.roubalikova@tiscali.cz 83 Pulpextractor Soft wire Prickles like harpune Insertion Contact with root canal wall - pull 1 mm Rotation Exstirpation during pull motion Canalshap > Reamers (penetration) > Files (shaping) lenka.roubalikova@tiscali.cz 85 Reamer K -reamer Triangl or square wire spun Symbol lenka.roubalikova@tiscali.cz 86 lenka.roubalikova@tiscali.cz 87 lenka.roubalikova@tiscali.cz 88 Reamer Rotation (clockwise) - penetration Application of plastic material (contraclockwise) lenka.roubalikova@tiscali.cz 89 Files 1. K-file 2. K-flexofile, flexicut, flex-R file 3. K-flex 4. H-file, S-file lenka.roubalikova@tiscali.cz 90 Kfile Wire triangl or square Symbol is always square lenka.roubalikova@tiscali.cz 91 Filing Also rotation 45°-90° lenka.roubalikova@tiscali.cz K-flexofile, flexicut, flex-R Triangle wire always Flexibility K- flexofile a flex - R file: non cutting tip and first blades are blunt Like K-file lenka.roubalikova@tiscali.cz 93 K-file and reamer lenka.roubalikova@tiscali.cz = Hedstroem file Ring lenka.roubalikova@tiscali.cz H-fil No rotation!! Pull motion only!! Risk of breakage in small sizes lenka.roubalikova@tiscali.cz 96 ISO > Diameter of the tip > Length of the cutting part >Taper lenka.roubalikova@tiscali.cz 97 lenka.roubalikova@tiscali.cz 98 d2= d1 + 0,32 The diameter increases for 0,02 mm On 100 length lenka.roubalikova@tiscali.cz 99 Apical morphology 1. X - ray apex 2. Foramen apicale 3. Apical constrictionA 4. Periodontal ligament 5. Root cementum 6. Dentin Acc. to Guidener a Langel and Working length • Distance between the referential point and apical constriction Estimation • Distance between apical constriction and apical foramen is appr. 0,5-0,75 mm • Distance between apical foramen and x-ray apex is appr. 0,5 - 0,75 mm. • Distance between apical constriction and x-apex is appr. 1,5 - 2mm Why apical constriction Small apical communication Minimal risk of damage of periodontium Prevention of overfilling (extrusion of filling material) Prevention of extrusion of infection Good decontamination Godd condition for root canal filling Radiogram X-ray with inserted root canal instrument Safe length: average length of teeth reduced for 2 - 3mm Tooth with clinical crown Procedure • Instrument ISO 15 introduced into the root canal, stop at the referential point • Estimation of location of apical constriction (1 - 1,5 mm distance from x-ray apex. If there is diference in the radiogram more than 2 mm - repeat If 2 mm or less - add to the safe length = working length Safe length • Maxilla: 11 20 12 18 C22-24 P20 M 18 mkk,20 P Safe length • Mandible 118 C20 -22 P18 M18 Remember- the length is for teeth with complete crown !!! Endometry, odontometry • Endometry devices based on measurement of electrical resistance Apexlocator Irrigation Irrigants • Sodium hypochlorite (1,5 - 5,5%) • Chlorhexidin (0,12% - 0,2%) • EDTA - etylendiaminotetraacetic acid 17% Irriga Sodiumhypochlorite 2-6% Oxidation a chloration Dissolving efect Bad smell, irritant. Syringe and cannula Activation of irrigation • Increased effectivity Vibration Increasing of temperature Decomposition of irrigants - dissociation Syringe and cannula Activation of irrigation • Increased effectivity Vibration Increasing of temperature Decomposition of irrigants - dissociation