Download - Clinical Management of Endodontic Cases
-
8/18/2019 Clinical Management of Endodontic Cases
1/91
1
Clinical Management ofEndodontic Cases
Dr. Abhishek Parolia
International Medical University
-
8/18/2019 Clinical Management of Endodontic Cases
2/91
Learning Objectives
To be able to analyze the criteria for patient selection for root canal procedure
To be able to apply the objectives of access cavity preparation
To be able to understand the clinical importance of anatomy of root apex
To be able to understand the need of debridement of root canal
To be able to select a suitable irrigant and use them in various clinical scenario
outcome for the best
To be able to understand the role of biofilm
To be able to explain the need of intracanal medicament
To be able to correlate the importance of coronal seal with the endodontic success
To be able to understand the mechanism of tissue regeneration
-
8/18/2019 Clinical Management of Endodontic Cases
3/91
To follow the Hippocratic Oath whichsays ”First, do not harm” the vital
healthy surrounding tissues
-
8/18/2019 Clinical Management of Endodontic Cases
4/91
Healthy tooth
-
8/18/2019 Clinical Management of Endodontic Cases
5/91
Oh NO…..
Let me
read
first..
Shocked
This is my
first time,
GOD please
save me
-
8/18/2019 Clinical Management of Endodontic Cases
6/91
Root canal treatment usually fails when treatment
falls short of acceptable standards
PROCEDURAL
ERRORSMICROBES FOREIGN
BODY
REACTION
In most cases, procedural errors do not jeopardize theoutcome of endodontic treatment unless a concomitant
infection is present.
-
8/18/2019 Clinical Management of Endodontic Cases
7/91
Microbes-responsible for success and failure in Endodontics
Elimination= SuccessPersistence= Failure
-
8/18/2019 Clinical Management of Endodontic Cases
8/91
ROOT CANAL THERAPY
The complete removal of all vital, necrotic tissue
and micro-organisms from the complex root
canal system
What is it ?
-
8/18/2019 Clinical Management of Endodontic Cases
9/91
OBTURATION AND
POST ENDODONTIC
RESTORATION
SHAPING AND CLEANING
DISINFECTION
CORONAL CAVITY
PREPARATION1
3
2
-
8/18/2019 Clinical Management of Endodontic Cases
10/91
Ray HA, Trope M (1995). Periapical status of endodontically treated teeth in relation
to the technical quality of the root filling and the coronal restoration. Int Endod J28:12-18.
The technical
quality of the
coronal
restoration
The technical
quality of the
endodontic
treatment
Poor coronal restorations even in
combination with good endodonticfillings
Negative impact onoutcome
-
8/18/2019 Clinical Management of Endodontic Cases
11/91
What percentage of success
after root canal treatment ?
8.6%
Endodontic59.4%
Restorative
Reason for failures of endodontically
treated teeth ( Vire 1991)
32%
Periodontal
?
-
8/18/2019 Clinical Management of Endodontic Cases
12/91
Kirkevang LL, Ørstavik D, Hörsted-Bindslev P, Wenzel A (2000).
Periapical status and quality of root fillings and coronal restorations
in a Danish population. Int Endod J 33:509-515.
Both the quality of the endodontic treatmentand the coronal restoration affect the health
of the periradicular
tissues in a synergistic way
-
8/18/2019 Clinical Management of Endodontic Cases
13/91
Knowledge
• Basic knowledge of the tooth and root canal
morphology of all the teeth and anatomical
variations in the number and locations of root
canals is crucial in endodontic treatmentoutcome.
-
8/18/2019 Clinical Management of Endodontic Cases
14/91
Accurate Diagnosis;
the first stage of successful therapy
-
8/18/2019 Clinical Management of Endodontic Cases
15/91
ACCURATE DIAGNOSIS
Is a result of the synthesis of
Scientific knowledge-recognizeoutside/inside the scope of the dentist
Clinical experience- very important
Interest- attitude
Curiosity –to suspect the unusualIntuition
Patience- to know the details
-
8/18/2019 Clinical Management of Endodontic Cases
16/91
CBCT
PULSE OXIMETRY
DENTA SCAN
ULTRASOUND
-
8/18/2019 Clinical Management of Endodontic Cases
17/91
Chief complaint
Medical
history
Dental
history
Patient
interaction
Physical
inspection
Diagnostic
tests
Radiographic Interpretation
Data Evaluation
Consult Referral
Diagnosis
Treatment
-
8/18/2019 Clinical Management of Endodontic Cases
18/91
Factors to be considered before
initiating endodontic therapy
Infection control
-
8/18/2019 Clinical Management of Endodontic Cases
19/91
FEAR OF LAW
-
8/18/2019 Clinical Management of Endodontic Cases
20/91
Isolation (Rubber Dam)
-
8/18/2019 Clinical Management of Endodontic Cases
21/91
Anesthesia and Pre-operative radiographs
-
8/18/2019 Clinical Management of Endodontic Cases
22/91
Application of Radiography to Endodontics
Diagnosis of hard tissue alterations of the teeth and periradicularstructures
Determine the number, location, shape, size, and direction ofroots and root canals
Estimate and confirm the length of root canals before
instrumentation
Aid in locating a pulp that is markedly calcified and/or receded
Determine the relative position of vital structures in the facial –lingual dimension
During following periradicular surgery
Evaluate the outcome of endodontic treatment
-
8/18/2019 Clinical Management of Endodontic Cases
23/91
INTERNAL ANATOMY OF TOOTH
Complex root canal system
-
8/18/2019 Clinical Management of Endodontic Cases
24/91
-
8/18/2019 Clinical Management of Endodontic Cases
25/91
Major apical diameter
Minor apical diameter/
Apical constriction/
Histological foramen
Root apex
Cementodentinal junction
Apical foramen
Cementum
Dentin
(Morning glory appearance)
-
8/18/2019 Clinical Management of Endodontic Cases
26/91
CORONAL CAVITY PREPARATION
Factors to be considered
Assessment of tooth restorability Presence of caries/ old restorative material
Removal of the Remaining Carious Dentin and Defective
Restorations
1. To mechanically eliminate as many bacteria as possible2. To eliminate the discoloured tooth structure that may
ultimately lead to staining of the crown
3. To reduce the risk of bacterial contamination and
blocking of the root canal space
-
8/18/2019 Clinical Management of Endodontic Cases
27/91
Radiographic measurement of the depth of the pulpchamber from the occlusal table
Position of teeth in jaws
Number, position and curvature of entire root canal
Use of magnifying loupes/ microscope
-
8/18/2019 Clinical Management of Endodontic Cases
28/91
-
8/18/2019 Clinical Management of Endodontic Cases
29/91
50% of all molars (maxillary and mandibular) have a
fourth canal, more than 30% of all premolars have a
third canal, and close to 25% of all anterior teethhave two canals.
S. Kim, S. Baek / Dent Clin N Am 2004 ;48 :11– 18
Exploration of
hidden canals at
high magnification
MICRO-OPENER
-
8/18/2019 Clinical Management of Endodontic Cases
30/91
Diagnosis
Detection of microfractures
Locating hidden canals Management of calcified canals
Perforation repair
-
8/18/2019 Clinical Management of Endodontic Cases
31/91
Achieve straight-line access to the apical foramen
locate all root canal orifices
Conserve sound tooth structure
Optimal access results in straight entry into the
canal orifice, with the line angles forming a funnel
that drops smoothly into the canal(s).
-
8/18/2019 Clinical Management of Endodontic Cases
32/91
The cementoenamel junction (CEJ) is the most important
anatomic landmark for determining the location of pulp
chambers and root canal orifices.
Krasner P, Rankow HJ. Anatomy of the pulp chamber floor. J Endod
2004;30(1):5.
Ceiling of the pulp chamber
At the level of the cementoenamel junction in 97 percent
to 98 percent of the maxillary and mandibular molars
Deutsch AS, Musikant BL. Morphological measurements of anatomic
landmarks in human maxillary and mandibular molar pulp
chambers. J Endod 2004;30:388 – 90.
-
8/18/2019 Clinical Management of Endodontic Cases
33/91
oLaw of orifice location 1
The orifices of the root canals are always located atthe junction of the walls and the floor
oLaw of orifice location 2oThe orifices of the root canals are located at the
angles in the floor wall junction
Law of orifice location 3The orifices of the root canals are located at the
terminus of the root development fusion lines
-
8/18/2019 Clinical Management of Endodontic Cases
34/91
ARMAMENTARIUM
LONG SHANK
ROUND BUR
LONG SHANK
SPOON
EXCAVATOR
DG 16 PROBE/
ENDODONTIC
EXPLORER
GATES GLIDDEN
ENDO
ACCESS
SAFE ENDED
DIAMOND
ABRASIVE
-
8/18/2019 Clinical Management of Endodontic Cases
35/91
-
8/18/2019 Clinical Management of Endodontic Cases
36/91
-
8/18/2019 Clinical Management of Endodontic Cases
37/91
Access cavity
The occlusal projection of the access cavity must be larger
than the base, to allow better visualization of the floor.
OCCLUSAL LOADOCCLUSAL LOAD
-
8/18/2019 Clinical Management of Endodontic Cases
38/91
OCCLUSAL LOADOCCLUSAL LOAD
REMEMBER!!!
-
8/18/2019 Clinical Management of Endodontic Cases
39/91
REMEMBER!!!
• Pulp extirpation should be done completely.
• Tissues from the pulp horns should be carefully removed
• Always check the patency of canal
•Periapical instrumentation should be avoided-Post-op pain
Don’t use an air syringe - possibility of an air embolism
Use Sodium hypochlorite (NaOCl)
• Disinfection
• Removal of hemorrhagic or purulent fluids
• Flushing action of debris and dentin chips
-
8/18/2019 Clinical Management of Endodontic Cases
40/91
Patency is important
Significant debris toremain harbored in the
canal’s apical third
(predisposing the case to
failure) Blockage can be a major
factor in causing
iatrogenic events (most
commonly, ledging andseparated instruments)
-
8/18/2019 Clinical Management of Endodontic Cases
41/91
Determine Correct working length
-
8/18/2019 Clinical Management of Endodontic Cases
42/91
Shaping and Cleaning
-
8/18/2019 Clinical Management of Endodontic Cases
43/91
BIOLOGICALMECHANICAL
OBJECTIVES
-
8/18/2019 Clinical Management of Endodontic Cases
44/91
Shaping facilitates cleaning by removing restrictive
dentin which allows for a more effective reservoir of
irrigant.
Shaping is the development of a “logical” cavity
preparation that is specific for the anatomy of any
given root.
Shaped canals hold a larger volume of irrigant that can
potentially circulate, penetrate, and clean into all
aspects of the root canal system.
-
8/18/2019 Clinical Management of Endodontic Cases
45/91
PROFILE
RaCe
-
8/18/2019 Clinical Management of Endodontic Cases
46/91
Greater tactile awareness of the apical constriction Reduce coronal binding of instruments
Less risk of inoculation of endodontic pathogens into
the periradicular tissues
Enhance penetration of irrigant into the root canalsystem
Less likelihood for a change in the working length
measurement during preparation
More effective performance of electronic apex locators
Crown down technique is preferred
-
8/18/2019 Clinical Management of Endodontic Cases
47/91
Shortening of
the working
length
-
8/18/2019 Clinical Management of Endodontic Cases
48/91
Mechanical instrumentation of root
canals can reduce bacterial
population
Effective elimination of bacteria
cannot be achieved without the use of
antimicrobial root canal irrigationand medication
-
8/18/2019 Clinical Management of Endodontic Cases
49/91
DISINFECTION
Disruption and
removal of the
biofilm
Elimination of the
smear layer
Debridement of
pulp remnants and
irritants
-
8/18/2019 Clinical Management of Endodontic Cases
50/91
A biofilm is a structured community of bacteriaenclosed in a protective, sticky polysaccharide matrixthat can adhere to a root canal surface.
Further, planktonic, free floating organisms withinbiofilm fragments disrupt, drift, and reattach to anysurface within the root canal system, including within
dentinal tubules
Biofilm
-
8/18/2019 Clinical Management of Endodontic Cases
51/91
Deposition ofa conditioning
film,
adhesionplanktonicmicrobes
colonization ofplanktonic
microorganism
s in a
polymeric
matrix
co-adhesion ofother
organisms
detachment ofbiofilm
microorganisms into
surroundings Endodontic Infectionand
Biofilm
BIOFILM
-
8/18/2019 Clinical Management of Endodontic Cases
52/91
BIOFILM
R.C.S.-Microenvironment; dense biofilm adhere to dentin
-
8/18/2019 Clinical Management of Endodontic Cases
53/91
There is convincing evidence that
microorganisms organized in this manner are farless susceptible to antimicrobial agents than
their planktonic counterparts, which have
traditionally been used to test the antimicrobialefficacy of substances in vitro.
• Wilson M. Susceptibility of oral bacterial biofilms to antimicrobial
agents. J Med Microbiol 1996;44:79– 87.
• Matthias Zehnder. Root Canal Irrigants. J Endod 2006;32:]389– 398
-
8/18/2019 Clinical Management of Endodontic Cases
54/91
IRRIGATION
Irrigation
-
8/18/2019 Clinical Management of Endodontic Cases
55/91
Irrigation
• NaOCl-2.5%,1%,0.5%
• CHX gluconate-0.2%,2%
• Ozonated water
• Bio Pure MTAD
• EDTA-17%
• Ultrasonics
•
Photo-activated disinfection• ECA
• LASER
-
8/18/2019 Clinical Management of Endodontic Cases
56/91
Significant factors that influence cleaning
SEQUENCE
TIME
VOLUME
FREQUENCY
STRENGTH
-
8/18/2019 Clinical Management of Endodontic Cases
57/91
The potential to debride and disinfect is further
influenced by alternating between specific typesof intracanal solutions, or using them in
combination.
“Final Rinse Solutions”
Advocated to enhance root canal cleaning
MTAD (Dentsply Tulsa Dental Specialties) Smear Clear (SybronEndo Specialties)
Chlorhexidine (CHX)
-
8/18/2019 Clinical Management of Endodontic Cases
58/91
Vital pulp tissue can defend against microorganisms and isthus largely noninfected until it gradually becomes necroticLangeland K. Tissue response to dental caries. Endod Dent Traumatol
1987;3:149 – 71.
Treatment of vital cases should focus
on asepsis, i.e. the prevention ofinfection entering a primarily sterile
environment (apical portion of the root
canal)
-
8/18/2019 Clinical Management of Endodontic Cases
59/91
In contrast, the pulp space of nonvital teeth with
radiographic signs of periapical rarefaction always harbors
cultivable microorganisms Zehnder M. Root Canal Irrigants. J Endod 2006;32:389– 398
Antisepsis key issue in nonvital cases
NaOCl
-
8/18/2019 Clinical Management of Endodontic Cases
60/91
NaOCl
• Tissue solvent-Best property
• Effective on biofilm and against micro-organism
present in dentinal tubules
• Removes organic components of smear layer
• Tissue irritant-confine to root canal system .
• 2.5-3% Best concentration
• Combine with chelating agent for better action
• Heat it, combine with ultrasonics –better action
-
8/18/2019 Clinical Management of Endodontic Cases
61/91
ULTRASONICS
-
8/18/2019 Clinical Management of Endodontic Cases
62/91
ULTRASONICS• 25 gauge irrigating needle connected to ultrasonic
unit+ 6% NaOCl solution for 1 min.- Very cleancanals
GutartsR. Et al. In vivo debridement efficacy of ultrasonic irrigation
following hand – rotary instrumentation in human mandibular
molars J.Endod 2005;31;166
Device for
heating syringes
filled withirrigation
solution (e.g.,
NaOCl) before
use
-
8/18/2019 Clinical Management of Endodontic Cases
63/91
23.10.2012 63
CHX
-
8/18/2019 Clinical Management of Endodontic Cases
64/91
CHX• Antibacterial, Substantive properties
• Various forms- Acetate/Hydrochloride/Digluconate
(Prferred)• Effective against E faecalis, A israelli,
P intermedia, F nucleatum…
•
Ability to inhibit adherence of certain pathogens• Lacks tissue dissolving property
• Does not remove smear layer
• 2% concentration Best as a final irrigant
• Zamany A, Safavi K, Spångberg LS. The effect of chlorhexidine as an endodonticdisinfectant. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:578 – 81.
-
8/18/2019 Clinical Management of Endodontic Cases
65/91
EDTA
-
8/18/2019 Clinical Management of Endodontic Cases
66/91
EDTA
It removes inorganic component of the smear layer
It detaches biofilm adhering to the root canal
It reacts with calcium ions of dentin
and forms soluble calcium chelates.It decalcifies dentin upto the depth
of 20-30 micrometer in 5 minutes
A continuous irrigation of 5 ml of 17% EDTA for 1 minute
Erosive EDTA-Use it carefully
-
8/18/2019 Clinical Management of Endodontic Cases
67/91
Erosive EDTA-Use it carefully
Use 7% Maleic acid instead of 17% EDTA
N. Vasudev Ballal,, K. Sreenesh,, M. Kundabala,, K.S. Bhat,
Shashirashmi Acharya. Comparison of the Efficacy of Maleic Acid
and EDTA in Smear Layer Removal From Instrumented Human Root
Canal: A Scanning Electron Microscopy Study . J Endod. 2009
-
8/18/2019 Clinical Management of Endodontic Cases
68/91
Improves working
time of the irrigant
Improves cutting
efficacy of hand
instruments
Reduces torsional loadon rotary nickel-
titanium instruments
Sodium Hypochlorite
-
8/18/2019 Clinical Management of Endodontic Cases
69/91
17 % EDTA
After the smear
removingprocedure a finalrinse with an
antisepticsolution appears
beneficial
-
8/18/2019 Clinical Management of Endodontic Cases
70/91
-
8/18/2019 Clinical Management of Endodontic Cases
71/91
Antibiotics
The local application of antibiotics -more effectivemode for delivering drugs than systemic routes ofadministration.
BioPure (MTAD) is effective in removing the smearlayer.
Tetraclean, is a mixture of an antibiotic(doxycycline), an acid and a detergent (like MTAD),with a very low surface tension and high degree ofefficacy against bacterial biofilms.
MTAD
-
8/18/2019 Clinical Management of Endodontic Cases
72/91
A) Tetracycline:
i) Broad spectrum antibiotic
Bacteriostatic in nature.
ii) Low pH
iii) Calcium chelator
Surface demineralization similar to citric acid
iv) Substantive property
v) Promotes healing
vi) Removes smear layer
B) Citric Acid – also removes smear layer, Bactericidal
C) Detergent – Tween 80, decreases surface tension.
Electrochemically activated (ECA)
-
8/18/2019 Clinical Management of Endodontic Cases
73/91
Electrochemically activated (ECA)
solutions
• Produced from tap water and low concentration
salt solutions
•
ECA solution found to be similar to NaOCl in debrisremoval but was more effective than NaOCl in
smear layer removal.
• Solovyeva AM, Dummer PM. Cleaning effectiveness of root canal
irrigation with electrochemically activated anolyte and catholyte
solutions: a pilot study. Int Endod J 2000;33:494-504.
Lasers assisted canal preparation
-
8/18/2019 Clinical Management of Endodontic Cases
74/91
Lasers assisted canal preparation
• Nd:YAG,erbium:YAG laser, Diode laser
• induces lethal photosensitization on canal
microbiota
• Adjuant to chemomechanical preparation
• High cost of lasers
• No access into severely curved canals
•
Not cleaned where optic fiber has not been touched
Light activated disinfection
-
8/18/2019 Clinical Management of Endodontic Cases
75/91
g
or photodynamic therapy(PAD)
• In combination with chemomechanical preparation ,the
advanced non-invasive LAD significantly inactivated
bacteria in biofilms
Z.Lim et.al. Light activated disinfection: an alternative
endodontic disinfection strategy. Aust Dent J 2009;54;108-
114.
Recent techniques
-
8/18/2019 Clinical Management of Endodontic Cases
76/91
Recent techniques
• Ozonated water
• Ozone (Healzone)
• High frequency current (Endox)
Efficacy on endodontic microbiota in biofilms, there is
good evidence that none of these aproaches canmatch a simple sodium hypochlorite irrigation
Intracanal Medication
-
8/18/2019 Clinical Management of Endodontic Cases
77/91
Intracanal Medication• Ca(OH)2- Universal for chronic infections
• Triple antibiotic paste (ciprofloxacin, metronidazole,and
minocycline)-Acute as well as chronic infections
• Ledermix – for acute infections and to prevent resorptions
• Ledermix and Ca(OH)2-chronic infection & to prevent
resorption
• IKI- resistant infections
• Eugenol- as obtundent
• CMCP-tissue fixative
-
8/18/2019 Clinical Management of Endodontic Cases
78/91
Calcium Hydroxide
The lethal effects of calcium hydroxide are due to severalmechanisms
Chemical action Damage to the microbial cytoplasmic membrane by the
direct action of hydroxyl ions
Suppression of enzyme activity and disruption ofcellular metabolism
Inhibition of DNA replication by splitting DNA
Calcium hydroxide
-
8/18/2019 Clinical Management of Endodontic Cases
79/91
Calcium hydroxide
The biological properties
• Biocompatibility (due to its low solubility inwater and limited diffusion)
• The ability to encourage periapical hard tissuehealing around teeth with infected canals
Inhibition of root resorption and stimulation of periapical healing after trauma.
-
8/18/2019 Clinical Management of Endodontic Cases
80/91
Calcium Hydroxide
• The ability of E. faecalis to colonize within
dentinal tubules and thus evade the hydroxyl ions
• Promotes the adhesion of bacteria to collagen (the
main organic component of dentine) which
increases the extent of tubule invasion and therebyresistance to further disinfection.
-
8/18/2019 Clinical Management of Endodontic Cases
81/91
T i i
-
8/18/2019 Clinical Management of Endodontic Cases
82/91
Tri- mix
A triple antibiotic paste consisting ofmetronidazole, ciprofloxacin and minocycline, has
been reported to be very effective in the
disinfection of the root canal system.
Windley et.al.,2005,Disinfection of immature teeth with a triple
antibiotic paste. J. Endod,31,439-43
I i i l i
-
8/18/2019 Clinical Management of Endodontic Cases
83/91
Irrigating solutions
23.10.2012 83
-
8/18/2019 Clinical Management of Endodontic Cases
84/91
• To achieve success -follow sound biologic principles
-
8/18/2019 Clinical Management of Endodontic Cases
85/91
• To achieve success -follow sound biologic principles.
•
Gentle manipulations carried out locally would give better and faster results – Avoid systemic drugs such asantibiotics and analgesics.
• It is fallacy to think that use of newer endodonticequipment and instrument would give higher successrate, these should be taken only as adjuncts.
• The real factor being the sound knowledge and skill ofhandling the biologic tissues.
FUTURE
-
8/18/2019 Clinical Management of Endodontic Cases
86/91
FUTURE
Tissue engineering
• Enamel crystals
• Implanting -Pulp dentin complex
• Revascularization
-
8/18/2019 Clinical Management of Endodontic Cases
87/91
TOOTH
ENAMEL
PULP-DENTIN
PERIODONTALLIGAMENT
Scaffold
Morphogen
Stem cell
Tissue-Engineered
Tissues
F
-
-
8/18/2019 Clinical Management of Endodontic Cases
88/91
F Amelogenin
Fluorapatite Nanorods
-
8/18/2019 Clinical Management of Endodontic Cases
89/91
Pulp-Dentin
Complex3-D Tissue Culture
BMP’s
Stem Cells
Scaffold
TransplantationRegeneration of
Dentin
R E V A S C U L A R I Z A T I O N
-
8/18/2019 Clinical Management of Endodontic Cases
90/91
CLOT
FORMATION
APICAL
TERPHINATION ANGIOGENESIS
PULPAL
NECROSIS
R E V A S C U L A R I Z A T I O N
Success of revascularization depends on canal disinfection during
the process with triple antibiotic paste
THANK YOU
-
8/18/2019 Clinical Management of Endodontic Cases
91/91
THANK YOU