13 Aetiology, classification and pathogenesis of pulp and periapical disease Dental pulp is a richly vascularized and innervated tissue, enclosed by surrounding tissues that are incapable of expanding, such as dentin. It has terminal blood flow and small-gauge circulatory access the periapex. All of these characteristics severely constrain the defensive capacity of the pulp tissue when faced with the different aggressions it may be subjected to. Pulp tissue can also be affected by a retrograde infection, arising from the secondary canaliculi, from the periodontal ligament or from the apex during the course of periodontitis. Due to the fact that periapical disease is almost inevitably preceded by pulp disease, we shall begin by describing the causes of pulp disease and will then proceed to a discussion of the causes of periapical disease. The course of illness and classification of these pathological entities will depend on the aetiology involved. We will analyse pulp necrosis and pulp degeneration that are capable of triggering reversible apical periodontitis or irreversible apical periodontitis.
14 Warm Up Chief complaint intermittent pain, sense of pressure, pain on biting, hard to localize, patients answers for the most part are vague, seems to be focused on distal proximal aspect of quadrantlevel of agitation is such that accuracy of responsiveness in questiontaking penicillin for two days (irregular dosing)
19 Case #1 Factoids Chief complaint positive response to thermal challengehyperaemic or engorged pulpw/o periapical extensiontreated in a single visitRCT or HealOzone?post treatment medication recommendations?restorative considerations?
21 Case #2 Factoids Chief complaint generalized discomfort on chewing in maxillary right quadrantstrong focus on 1.6degenerating pulp with periapical extensionone visitexpectation of mild post-tx painNSAIDS, analgesics prescribed?system or method of instrumentationapical terminus – Rosenberg Technique - Discussirrigation routine – discussComprehensive Care Considerations - discuss
24 J Calif Dent Assoc. 2004 Jun;32(6):493-503 The success of endodontic therapy: healing and functionality. Friedman S, Mor C. University of Toronto Faculty of Dentistry, Canada.Based on selected follow-up studies that offer the best evidence, the chance of teeth without apical periodontitis to remain free of disease after initial treatment or orthograde retreatment is 92 percent to 98 percent. The chance of teeth with apical periodontitis to completely heal after initial treatment or retreatment is 74 percent to 86 percent, and their chance to be functional over time is 91 percent to 97 percent. Thus there does not appear to be a systematic difference in outcome between initial treatment and orthograde retreatment. The outcome of apical surgery is less consistent than that of the nonsurgical treatment. The chance of teeth with apical periodontitis to completely heal after apical surgery is 37 percent to 85 percent, with a weighted average of approximately 70 percent. However, even with the lower chance of complete healing, the chance for the teeth to be functional over time is 86 percent to 92 percent.
25 Case #3 Factoids Chief complaint masticatory sensitivity RCT done prior – time indeterminateapical periodontitis in evidence2 visits – interim calcium hydroxide procedureNSAIDS, analgesics NO antibiotics prescribedirrigation routine – citric acid and CHXCLP considerations
27 J Endod Oct;30(10): An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. Law A, Messer H. Postgraduate Endodontics, School of Dental Science, University of Melbourne, Melbourne, Australia.The authors reviewed the literature evaluating the antibacterial effectiveness of intracanal medicaments used in the management of apical periodontitis. A PICO (problem, intervention, comparison, outcome) strategy was developed to identify studies dealing with calcium hydroxide, phenolic derivatives, iodine-potassium iodide, chlorhexidine, and formocresol. The final inclusion/exclusion criteria eliminated all papers except five that evaluated calcium hydroxide. The total sample size in the included studies was 164 teeth. Microbiologic sampling was performed before endodontic treatment (S1), after instrumentation and irrigation (S2), and after intracanal medication (S3). At S2, 62% of canals were positive. After medication, 27% still showed detectable growth. Of cultures that were positive at S2, 45% were still positive at S3. Most studies did not address issues of culture reversals or false positive and false negative cultures. The main component of antibacterial action appears to be associated with instrumentation and irrigation, although canals cannot be reliably rendered bacteria free. Calcium hydroxide remains the best medicament available to reduce residual microbial flora further.
28 Oral Surg Oral Med Oral Pathol Oral Radiol Endod Nov;96(5): Efficacy of chlorhexidine- and calcium hydroxide-containing medicaments against Enterococcus faecalis in vitro. Basrani B, Tjaderhane L, Santos JM, Pascon E, Grad H, Lawrence HP, Friedman S. Dalhousie University, Endodonic Division, Department of Dental Clinical Sciences, Halifax, Nova Scotia, Canada.OBJECTIVE: We sought to assess the efficacy of chlorhexidine (CHX) and calcium hydroxide, Ca(OH)(2), against Enterococcus faecalis in vitro. STUDY DESIGN: The effect of CHX (0.2% and 2% in gel or solution) and Ca(OH)(2) (alone or with 0.2% CHX gel) was evaluated by using the agar diffusion test and an in vitro human root inoculation method, to measure zone of inhibition or bacterial growth with optical density analysis, respectively. For optical density analysis, samples from infected root canals were collected after 7 days of medication and were cultured for 24 hours in brain-heart infusion to detect viable bacteria. RESULTS: In the agar diffusion test, CHX was effective against E faecalis in a concentration-dependent fashion, but Ca(OH)(2) alone had no effect. In the root canal inoculation test, CHX was significantly more effective against E faecalis than Ca(OH)(2) was (P < .05), but there were no significant differences between the modes of medication or concentrations of CHX. CONCLUSIONS: CHX is effective against E faecalis in vitro. Further in vivo studies are needed to confirm the value of CHX in clinical treatment.
29 Chief complaintlocalized, nodular swelling over maxillary first molarhistory of RCT, CAP evidentretx chosen as tx optionCHX and Ca(OH)2 used as interim treatment dressingNSAIDS, analgesics prescribedPrimary focus of failure – undetected MBx canal
32 Pulp and Periapical Disease Oral microorganisms
33 Microbial Control Phase Root Canal TherapyMechanicalInstrumentationIrrigationIntra-canalmedicationMicrobial Control PhaseR.C. FillingYou should not go to the fylling part before you have done eveerytjing in reason to decrease the bacterial count as low as possible. You should not fill it if you could not done
34 Effect of Ca(OH)2 on Microorganisms in Necrotic Pulps11661
35 Control of Endodontic Infection 1. Mech. preparationApical PreparationMicrobial ContentsVolume of#25#30#35#40Card et al. JOE 2002Sjøgren U et al. IEJ 1997Ørstavik D et al. IEJ 1991Bystrøm et al. EDT 1987Kerekes et al. JOE 1979
36 Control of Endodontic Infection 1. Mech. preparation#40#25#10Courtesy Dr. Richard Walton
37 Control of Endodontic Infection 1. Mech. preparation#25#25#25Courtesy Dr. Richard Walton
38 Apical Periodontitis Prevalence Increases with age Age 50: 50% experience the diseaseAge > 60: 62% exhibit the conditionUS Census data: 420 million root filledAt 90% success: 42 million failingAt 80% success: 84 million failingAt 60% success: 168 million failingEriksen 1991, 1998; Figdor 2002
39 General Population Cross-sectional studies No lesion (%) 100 80 60 40 20406080100No lesion (%)Lupi-Pegurier et al. 2002Buckley & Spangberg 1995Sidaravicius et al. 1999De Cleen et al. 1993Eriksen et al. 1995Marques et al. 1998De Moor et al. 2000Tronstad et al. 2000Hommez et al. 2002Ray & Trope 1995Dugas et al. 2002Petersson 1993Saunders 1997Kirkevang 2000Weiger 1997Cross-sectional studies
40 Treatment OutcomeSVariability50% to 95%Status quo or change?
41 Peters OA, Schonenberger K, Laib A. Int Endod J. 2001 Effects of four Ni-Ti preparation techniqueson root canal geometryassessed by micro-computed tomographyPeters OA, Schonenberger K, Laib A. Int Endod J. 2001Maxillary molars ....all instrumentation techniques left 35% or more of the canals' surface area unchanged. ….a strong impact of variations of canal anatomy was demonstrated..
42 Principles Functions of The Root Canal FillingEntomb existing bacteriaPrevent coronal and apical leakageStrengthen the root#1. Entomb existing bacteria
43 Bacteria and Prognosis Success by culturing results+ve culture-ve cultureIf bacteria were entombed,there would be NO differencein the healing of teeth with PA lesionsEngstrom et al (1964)76%89%Zeldkow & Ingle (1963)83%93%Oliet & Sorin (1969)80%91%Negative cultureBystrom et al (1987)95%Sjögren et al. (1997)68%94%
44 “State of The Art” Gutta-Percha + Sealer Entomb existing bacteria ..stopping influx of periapical tissue derived fluid from reaching residual bacteria in the root canal system acting as a barrier, preventing re-infection of the root canal (Sundqvist and Figdor, 1998)Entomb existing bacteriaPrevent coronal and apical leakageStrengthen the rootPrevent coronal and apicalleakage
45 Final polished restoration BeforePermaflo PurpleCompleted endodontic procedureFinal polished restoration
46 Endo/Coronal Status N % API (periapical inflamn) GE & GRGood root filling and coronal restoration33091.4GE & PR16444.1PE & GR30267.6PE & PROverall188101018.161%
47 Coronal Leakage Swanson et al. 1987 - Dye leakage to apex 3 days: dye leakage to apexKhayat et al Bacteria to apex30 days: bacteria to apexTrope et al – Endotoxins to apex20 days: endotoxin to apexThis is patetic. Why we still used - retreat. The function is to seal and every study show that it leaks.
57 Case #3 Factoids Chief complaint pain in maxillary right quadrant pre-existing RCT and CAPcalcium hydroxide placed in #1.5NSAIDS, analgesics, no antibioticspatient had persistent pain…swelling appearedsinus tract traced to mesial root of #1.6#1.6 retreated with calcium hydroxidecase obturated and transitionalized for 90 days
83 Case #4 Factoids Hiatt proposed the lever principle Chief complaintpain on chewinginadequate RCT #3.6deficient marginspatient unable to identify sourcealways review occlusion / facial typeopposing restorationsHiatt proposed the lever principleto account for the high incidence offractured mandibular molars: thesecond molar is nearer the fulcrumof mandibular closure and thusreceives the greatest force.