1 Endodontics I. Case selection and treatment planning Common medical findings that may influence endodontic treatment planning 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 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 4 ◼ Pregnancy is not a contraindication to endodontics but it does modify treatment planning. Consult a physician if 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 trimester if possible no in emergency with caution yes, second trimesters YES, third trimester with caution – a risk of contractions). 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 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. 7 ◼ 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. 8 ◼ 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 9 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 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 ◼ 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 12 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. 13 ◼ 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 14 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). 15 ◼ 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 16 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) 17 ◼ 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 18 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 patientś normal meal and insulin schedule. Especially when surgical endodontics is indicated – consultation with specialist is useful. 19 ◼ 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 20 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. 21 ◼ 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 22 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. 23 ◼ 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 24 Behavioral and psychiatric disorders ◼ Patient´s ability of cooperation and drug interaction (local anaesthetics) Consultation of physician usefull and sometimes necessary. 25 Regional factors that influence endodontic case selection 26 ◼ Position of the tooth and its importance for function - The tooth must be valuable for the function (dystopic teeth,third molars etc..) 27 Local factors that may influence endodontic case selection 28 ◼ 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.) 29 30 31 Dentogingival complex DGC = biological width 2-4mm + sulcular depth 1-3mm = 3-7 mm Biological width Epithelium junction 1-2 mm+ Connective tissue junction - supraalveolar fibers 1 -2 mm = 2 - 4 mm Gargiulo AW, Wentz FM, Orban B (J Perio 1961) Vacek JS, Gher ME, Assad DA, Richardson AC, Gambaressi LI (Int J Perio & Rest Dent 1994) 1 - 2 mm 1- 2 mm 32 1,5 – 2 mm 1,5 mm 1 mm Ferrule effect 35 Non restorable teeth Elongation of clinical crown surgically Orthodontic extrusion Extraction 36 Diagnosis in endodontics - Chief complaint - Medical history - Dental history - History of present dental problem - Dental history interview Questionnaire 38 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 39 Examination and testing ◼ Pulp test - Thermal - Electric Radiographic examination 40 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 Velikost obrázku odpovídá skutečnosti – Snímek je ISOMETRICKÝ In vertical plane Parallel technique Film or sensor in a special holder Parallel to long axis of teeth If parallel technique is not possible The technique of isometric radiogram Apical position - projection Technique of bissecting angle In horizontal plane Orthoradial and excentric projection ◼ Orthoradial – the central beam goes parallel to interdental septa ◼ Excentric– the central beam goes from distal or mesial side. LR LR CBCT – cone beam computer tomography 52 CBCT Source and detector are rotating CBCT – cone beam computer tomography Definujte zápatí – název prezentace nebo pracoviště53 ◼ High diagnostic effect for details, possibility of 3D reconstruction ◼ Endodontics, implantoplogy,surgery, orthodontics other branches.Connections with i.o. scanners ◼ Irradiation lower in comparison to CT, but not insignificant ◼ Consider indications with regard to irradiation and price Definujte zápatí – název prezentace nebo pracoviště54 CBCT risks lenka.roubalikova@tiscali.cz 55 56 lenka.roubalikova@tiscali.cz 57 Lze generovat různé řezy High importanc by pathological processes concerning AH Definujte zápatí – název prezentace nebo pracoviště58 ◼ Endodontics ◼ Specification of diagnosis ◼ Resorption, complications ◼ Cysts, pathological changes in bone lenka.roubalikova@tiscali.cz 59 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 60 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. 61 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) 62 Pulpal disease ◼ Irreversible pulpitis Asymptomatic Can become symptomatic or necrotic 63 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. 64 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. 65 Periapical diseases ◼ Can propagate intraorally or/and extraorally - Subperiostal abscess - Submucous abscess - Abscess in surrounding tissues - Non limited inflammation - cellulitis 66 Two main approaches in endodontic therapeutical procedures ◼ Vital pulp therapy ◼ Root canal treatment 67 Clasification and guidelines for the therapy ◼ Initial pulpitis Increased but not prolongated pain on cold, absence of spontaneous pain. Histologically: hyperaemia Therapy: Indirect pulp therapy –IPT. Mostly Indirect pulp capping Clasification and guidelines for the therapy ◼ Mild pulpitis - Increased reaction on cold, hor and sweet stimuli, prolongated max 20s, spontaneous regression. - Histologically: inflammation of the coronal part of dental pulp. Terapy: IPT – indirect pulp therapy. Mostly intermittent excavation Clasification and guidelines for the therapy ◼ Moderate pulpitis Clear symptoms, strong pain, very prolongated reaction on cold, hot (minutes), possible pain on percussion, spontaneous pain, analgetics have only partiqal effect. Histologically: Extensive inflammation affecting the coronal pulp completely Thrapie: Coronal pulpotomy –partial/complete New clasification and guidelines for the therapy ◼ Severe pulpitis Haevy spontaneous pain, very strong pain on stimuli, sharp, throbbing, strong pain after lying down, pain on percussion and Histologically: Extensive inflammation in dental pulp, spreading probably into root canal . Terapie: Deep pulpotomy or pulpectomy Therapy - procedures ◼ Indirect pulp capping Caries next to dental pulp (caries pulpae proxima). Carious dentin is possible to remove almost completely. Decay is deep in small region. Appr 1 mm2 carious dentin can be left. Kalciumhydroxide cement,permanent filling Alternativs: MTA, Biodentine Formation of tertiary dentine. Therapy - procedures ◼ Intermitent excavation Large dental caries spreading towards dental pulp. Big amount of carious dentine. Hogh risk of perforation Suspension of calcium hydroxide, temporary filling for 6 weeks. Dessication of soft dentine, formation of tertiary dentine. 74 Intermitent excavation Pulpotomy 75 Nepřímé překrytí materiálem Biodentine Therapy - procedures ◼ Direct pulp capping ◼ Treatment of small perforation after preparation or traumatic dental injury in non carious dentine. Immediately ( 2 – 3hours). Suspension of calcium hydroxide hydroxidu vápenatého, calcium hydroxide cement, permanent filling. Alternatives: MTA, Biodentine aj. Dentin bridge formation Therapy - procedures Pulpotomy - Coronal ✓ Partial ( removal cca 2 mm of dental pulp) ✓ Total (removal dental pulp from the pulp chamber completely) ✓ Deep (removal of dental pulp to the root canal cca 4 mm of dental pulp apically can be left) Pulpotomy ◼ Aseptic approach ◼ Excavation of soft dentine ◼ Opening of the pulp chamber with sterile bur or diamond) Stopping bleeding (2,5% sodium hypochlorite) Capping using calcium hydroxide or bioactive cement, permanent filling. Dentine bridge Pulpotomy - indication ◼ Traumatic dental injury – opening of the pulp chamber - bigger perforation or longer time after the injury(more than 2 -3 hours) ◼ Perforation in carious dentine ◼ Reversible pulpitis It is necessary to consider - Age of the patient - Aseptic approach Dentin bridge ◼ Formation of dentin bridge ◼ Calcium hydroxide on dental pulp causes– necrosis – this necrosis is limited - it does not go deep into dental pulp (CO2 from dental pulp reacts with calcium hydroxide – a barrier of calcium carbonate occurs – do necrosis can not go deeper). This necrosis is resorbed during the reactive inflammation connective tissue – (fibrotic tissue) is formed, calcium salts can be deponed here, due to high alcality new odontoblasts are differenciated and they form new dentin – predentin and mineralized dentin. This is dentin bridge is formed when the direct pulp capping or pulpotomy is performed. 80 Root canal treatment ◼ Irreversible pulpitis ◼ Necrosis, gangreana ◼ Apical periodontitis Conservative, conservative/surgical approach, surgical approach. 81 82 Acces ◼ Access to 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 83 Access 84 Access 85 The wall is weakend 86 Dia trepan Dia round burs – balls Opening of the pulp chamber Steel round burs 87 Dia trepan Fissur bur Safe ended tips Batt´s instruments Removal of the roof of the pulp chamber 88 Finding of the root canal orifice 89 Finding and opening of rot canal orifices Endodontic probes Microopeners Ultrasound tips Dye 91 Finding and opening of root canal orifices Rounded burs - balls Miller´s burs Gates Glidden´s burs Peeso – Largo 92 Gates - Glidden Peeso-Largo 93 Gates – Glidden: Blunt, non active tip Programm point of breakage X-GATES Tip size : Gates 1 Max Diameter : Gates 4 Shank : Gates 3 « Weakness » point 95 Opening of the root canal orifice Ni-Ti instruments E.g: Profile O.S., ProTaper SX, IntroFile etc. 96 ACCESS Kit LN BUR (Long Neck) Improves visibility Tungsten Carbide Burs