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Presentation on theme: "ROOTS CYBERCOMMUNITY - SUMMIT V"— Presentation transcript:











11 Gettin’ on the same page

12 Gettin’ on the same page

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 quadrant level of agitation is such that accuracy of responsiveness in question taking penicillin for two days (irregular dosing)





19 Case #1 Factoids Chief complaint
positive response to thermal challenge hyperaemic or engorged pulp w/o periapical extension treated in a single visit RCT or HealOzone? post treatment medication recommendations? restorative considerations?


21 Case #2 Factoids Chief complaint
generalized discomfort on chewing in maxillary right quadrant strong focus on 1.6 degenerating pulp with periapical extension one visit expectation of mild post-tx pain NSAIDS, analgesics prescribed? system or method of instrumentation apical terminus – Rosenberg Technique - Discuss irrigation routine – discuss Comprehensive 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 indeterminate apical periodontitis in evidence 2 visits – interim calcium hydroxide procedure NSAIDS, analgesics NO antibiotics prescribed irrigation routine – citric acid and CHX CLP 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 complaint localized, nodular swelling over maxillary first molar history of RCT, CAP evident retx chosen as tx option CHX and Ca(OH)2 used as interim treatment dressing NSAIDS, analgesics prescribed Primary focus of failure – undetected MBx canal


31 3 D

32 Pulp and Periapical Disease
Oral microorganisms

33 Microbial Control Phase
Root Canal Therapy Mechanical Instrumentation Irrigation Intra-canal medication Microbial Control Phase R.C. Filling You 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 Pulps 1 1 6 6 1

35 Control of Endodontic Infection
1. Mech. preparation Apical Preparation Microbial Contents Volume of #25 #30 #35 #40 Card et al. JOE 2002 Sjøgren U et al. IEJ 1997 Ørstavik D et al. IEJ 1991 Bystrøm et al. EDT 1987 Kerekes et al. JOE 1979

36 Control of Endodontic Infection
1. Mech. preparation #40 #25 #10 Courtesy Dr. Richard Walton

37 Control of Endodontic Infection
1. Mech. preparation #25 #25 #25 Courtesy Dr. Richard Walton

38 Apical Periodontitis Prevalence Increases with age
Age 50: 50% experience the disease Age > 60: 62% exhibit the condition US Census data: 420 million root filled At 90% success: 42 million failing At 80% success: 84 million failing At 60% success: 168 million failing Eriksen 1991, 1998; Figdor 2002

39 General Population Cross-sectional studies No lesion (%) 100 80 60 40
20 40 60 80 100 No lesion (%) Lupi-Pegurier et al. 2002 Buckley & Spangberg 1995 Sidaravicius et al. 1999 De Cleen et al. 1993 Eriksen et al. 1995 Marques et al. 1998 De Moor et al. 2000 Tronstad et al. 2000 Hommez et al. 2002 Ray & Trope 1995 Dugas et al. 2002 Petersson 1993 Saunders 1997 Kirkevang 2000 Weiger 1997 Cross-sectional studies

40 Treatment OutcomeS Variability 50% to 95% Status quo or change?

41 Peters OA, Schonenberger K, Laib A. Int Endod J. 2001
Effects of four Ni-Ti preparation techniques on root canal geometry assessed by micro-computed tomography Peters OA, Schonenberger K, Laib A. Int Endod J. 2001 Maxillary 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 Filling Entomb existing bacteria Prevent coronal and apical leakage Strengthen the root #1. Entomb existing bacteria

43 Bacteria and Prognosis
Success by culturing results +ve culture -ve culture If bacteria were entombed, there would be NO difference in the healing of teeth with PA lesions Engstrom et al (1964) 76% 89% Zeldkow & Ingle (1963) 83% 93% Oliet & Sorin (1969) 80% 91% Negative culture Bystrom 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 bacteria Prevent coronal and apical leakage Strengthen the root Prevent coronal and apical leakage

45 Final polished restoration
Before Permaflo Purple Completed endodontic procedure Final polished restoration

46 Endo/Coronal Status N % API (periapical inflamn)
GE & GR Good root filling and coronal restoration 330 91.4 GE & PR 164 44.1 PE & GR 302 67.6 PE & PR Overall 188 1010 18.1 61%

47 Coronal Leakage Swanson et al. 1987 - Dye leakage to apex
3 days: dye leakage to apex Khayat et al Bacteria to apex 30 days: bacteria to apex Trope et al – Endotoxins to apex 20 days: endotoxin to apex This is patetic. Why we still used - retreat. The function is to seal and every study show that it leaks.


49 Smear Clear Ca(OH)2 ZZY-VAC CHX Heal Ozone
Control of Endodontic Infection Smear Clear Ca(OH)2 ZZY-VAC CHX Heal Ozone BioPure™MTAD™ 1. Mech. preparation 2. Canal disinfection 3. Obturation 4. Top filling

50 Adhesion Endodontics






56 100%

57 Case #3 Factoids Chief complaint pain in maxillary right quadrant
pre-existing RCT and CAP calcium hydroxide placed in #1.5 NSAIDS, analgesics, no antibiotics patient had persistent pain…swelling appeared sinus tract traced to mesial root of #1.6 #1.6 retreated with calcium hydroxide case obturated and transitionalized for 90 days


59 Maxillary Molar Teeth Serial Cross Section

60 Relocation of the canal orifices

61 Maxillary Molar Teeth Courtesy of Dr. Cliff Ruddle MBx canal


63 Relocation of the canal orifices


65 Composite finishing burs
Brasseler H

66 Never be surprised

67 MBx canal DBx canal

68 Ancillary MB canals

69 15% of Mdlr Molars have three canals

70 CLP

71 CLP

72 CLP

73 CLP

74 CLP

75 CLP

76 CLP

77 CLP

78 CLP

79 CLP

80 CLP

81 Epithelial Attachment .75mm Conn Tiss. Attachment 1.25mm
Gingival Sulcus .5-2.0mm Epithelial Attachment .75mm Conn Tiss. Attachment 1.25mm


83 Case #4 Factoids Hiatt proposed the lever principle
Chief complaint pain on chewing inadequate RCT #3.6 deficient margins patient unable to identify source always review occlusion / facial type opposing restorations Hiatt proposed the lever principle to account for the high incidence of fractured mandibular molars: the second molar is nearer the fulcrum of mandibular closure and thus receives the greatest force.




87 If 4 canals in an upper molar panics you…………………







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