ROOTS CYBERCOMMUNITY - SUMMIT V

Gettin on the same page

Gettin on the same page

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.

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)

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?

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

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

to
completely heal after apical surgery is 37 percent to 85
percent, with a weighted average of approximately 70 percent. However, even
nonsurgical treatment. The chance of teeth with apical periodontitis

with the lower chance of complete healing, the chance for the teeth to be
functional over time is 86 percent to 92 percent.

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

J Endod. 2004 Oct;30(10):689-94. 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, iodinepotassium 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.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Nov;96(5):618-24. 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.

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

Pulp and Periapical Disease

Oral microorganisms

Root
Root Canal
Canal Therapy
Therapy
Mechanical
Mechanical
Instrumentation
Instrumentation

Irrigation
Irrigation

Intra-canal
Intra-canal
medication
medication

Microbial Control Phase

R.C.
R.C.Filling
Filling

Effect of Ca(OH)2 on Microorganisms

in Necrotic Pulps

Control of Endodontic Infection

Card et al. JOE 2002

Sjgren U et al. IEJ 1997
rstavik D et al. IEJ 1991
Bystrm et al. EDT 1987
Kerekes et al. JOE 1979

Volume of
Microbial Contents

1. Mech. preparation
#25
#30
#35
#40

Apical Preparation

Control of Endodontic Infection

1. Mech. preparation

#25
#10
#40
Courtesy Dr. Richard Walton

Control of Endodontic Infection

1. Mech. preparation

#25
#25
#25

Courtesy Dr. Richard Walton

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

No lesion (%)
40

20

60

Cross-sectional studies
Lupi-Pegurier et al. 2002

Hommez et al. 2002

Dugas et al. 2002

Tronstad et al. 2000

Kirkevang 2000

De Moor et al. 2000

Sidaravicius et al. 1999

Marques et al. 1998

Weiger 1997

Saunders 1997

Eriksen et al. 1995

Buckley & Spangberg 1995

Ray & Trope 1995

Petersson 1993

De Cleen et al. 1993

General Population

100

80

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

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..

Principles Functions of
The Root Canal Filling
#1.Entomb
Entombexisting
existingbacteria
bacteria
Prevent coronal and apical
leakage
Strengthen the root

Bacteria and Prognosis

Success by culturing results
+ve culture

-ve culture

Engstrom
et al (1964)
If bacteria
were76%
entombed,89%
Zeldkow & Ingle (1963)

83%

93%

Oliet & Sorin (1969)

80%

91%

Sjgren et al. (1997)

68%

94%

there would be NO difference

in
the
healing
of
teeth
with
PA
lesions
95%
Bystrom et al (1987)

State of The Art

Gutta-Percha + Sealer
..stopping influx of periapical tissue
Entomb
existing
bacteria
derived fluid from reaching residual
Prevent
coronal
andsystem
apical
bacteria
in the
root canal
acting
as a barrier, preventing
releakage
leakage
infection of the root canal
Strengthen
the root
(Sundqvist
and Figdor,
1998)

Before

Completed endodontic procedure

Permaflo Purple

Final polished restoration

Endo/Coronal Status
inflamn)

GE &
GR

% API (periapical

330

91.4

164

44.1

302

67.6

188

18.1

1010

61%

Good root filling and

coronal restoration

GE &
PR
PE &
GR
PE &
PR

Coronal Leakage
Swanson et al. 1987 - Dye leakage to apex
3 days: dye leakage to apex
Khayat et al. 1993 - Bacteria to apex
30 days: bacteria to apex
Trope et al. 1994 Endotoxins to apex
20 days: endotoxin to apex

Control of Endodontic Infection

Smear
Clear
1. Mech.
preparation

Ca(OH)
2
2. Canal disinfection
ZZY-VAC
3. Obturation
CHX
4. Top
filling
Heal
Ozone
BioPureMTAD

Adhesion Endodontics

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 painswelling appeared
sinus tract traced to mesial root of #1.6
#1.6 retreated with calcium hydroxide
case obturated and transitionalized for 90 days

Maxillary Molar Teeth

Relocation of the canal orifices

Maxillary Molar Teeth

Courtesy of Dr. Cliff Ruddle

Relocation of the canal orifices

Composite
finishing burs
Brasseler H274-016

Never be surprised

Ancillary MB canals

Gingival Sulcus
.5-2.0mm

Epithelial Attachment
.75mm

Conn Tiss.
Attachment 1.25mm

Case #4 Factoids
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.

If 4 canals in an upper molar panics you