Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Endodontic Cases
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
Healthy tooth
Let me
read
first..
Oh NO..
Shocked
This is my
first time,
GOD please
save me
MICROBES
FOREIGN
BODY
REACTION
Elimination= Success
Persistence= Failure
What is it ?
3
2
OBTURATION AND
POST ENDODONTIC
RESTORATION
CORONAL CAVITY
PREPARATION
The technical
quality of the
coronal
restoration
The technical
quality of the
endodontic
treatment
Negative impact on
outcome
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 J
28:12-18.
?
What percentage of success
after root canal treatment ?
Reason for failures of endodontically
treated teeth (Vire 1991)
59.4%
Restorative
8.6%
Endodontic
32%
Periodontal
Knowledge
Accurate Diagnosis;
the first stage of successful therapy
ACCURATE DIAGNOSIS
Is a result of the synthesis of
Scientific knowledge-recognize
outside/inside the scope of the dentist
Clinical experience- very important
Interest- attitude
ULTRASOUND
PULSE OXIMETRY
CBCT
DENTA SCAN
Treatment
Diagnosis
Consult Referral
Data Evaluation
Radiographic Interpretation
Diagnostic
tests
Medical
history
Physical
inspection
Dental
history
Chief complaint
Patient
interaction
FEAR OF LAW
Root apex
Apical foramen
(Morning glory appearance)
Cementodentinal junction
Cementum
Dentin
Exploration of
hidden canals at
high magnification
MICRO-OPENER
Diagnosis
Detection of microfractures
Locating hidden canals
Management of calcified canals
Perforation repair
ARMAMENTARIUM
LONG SHANK
ROUND BUR
DG 16 PROBE/
ENDODONTIC
EXPLORER
ENDO
ACCESS
LONG SHANK
SPOON
EXCAVATOR
SAFE ENDED
DIAMOND
ABRASIVE
GATES GLIDDEN
C Inci
Lat In
Canine
1st PM
2nd PM
1st Mo
2nd Mo
3rd Mo
C Inci
Canine
2nd PM
1st Mo
1st PM
2nd Mo
Access cavity
OCCLUSAL LOAD
OCCLUSAL LOAD
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
Dont 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
Patency is important
Significant debris to
remain harbored in the
canals apical third
(predisposing the case to
failure)
Blockage can be a major
factor in causing
iatrogenic events (most
commonly, ledging and
separated instruments)
OBJECTIVES
MECHANICAL
BIOLOGICAL
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.
PROFILE
RaCe
Shortening of
the working
length
DISINFECTION
Elimination of the
smear layer
Debridement of
pulp remnants and
irritants
Disruption and
removal of the
biofilm
Biofilm
A biofilm is a structured community of bacteria
enclosed in a protective, sticky polysaccharide matrix
that can adhere to a root canal surface.
Further, planktonic, free floating organisms within
biofilm fragments disrupt, drift, and reattach to any
surface within the root canal system, including within
dentinal tubules
Deposition of
a conditioning
film,
detachment of
biofilm
microorganism
s into
surroundings
Endodontic Infection
and
Biofilm
co-adhesion of
other
organisms
adhesion
planktonic
microbes
colonization of
planktonic
microorganism
s in a
polymeric
matrix
BIOFILM
IRRIGATION
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
VOLUME
STRENGTH
SEQUENCE
TIME
FREQUENCY
Antisepsis
key issue in nonvital cases
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
ULTRASONICS
25 gauge irrigating needle connected to ultrasonic
unit+ 6% NaOCl solution for 1 min.- Very clean
canals
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 with
irrigation
solution (e.g.,
NaOCl) before
use
23.10.2012
63
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
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
Sodium Hypochlorite
Improves working
time of the irrigant
Improves cutting
efficacy of hand
instruments
Reduces torsional load
on rotary nickeltitanium instruments
17 % EDTA
..
Antibiotics
The local application of antibiotics -more effective
mode for delivering drugs than systemic routes of
administration.
BioPure (MTAD) is effective in removing the smear
layer.
Tetraclean, is a mixture of an antibiotic
(doxycycline), an acid and a detergent (like MTAD),
with a very low surface tension and high degree of
efficacy against bacterial biofilms.
MTAD
A) Tetracycline:
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.
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 can
match a simple sodium hypochlorite irrigation
Intracanal Medication
Ca(OH)2- Universal for chronic infections
Triple antibiotic paste (ciprofloxacin, metronidazole,and
Calcium Hydroxide
The lethal effects of calcium hydroxide are due to several
mechanisms
Chemical action
Damage to the microbial cytoplasmic membrane by the
direct action of hydroxyl ions
Suppression of enzyme activity and disruption of
cellular metabolism
Inhibition of DNA replication by splitting DNA
Calcium hydroxide
The biological properties
Biocompatibility (due to its low solubility in
water and limited diffusion)
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 thereby
resistance to further disinfection.
Ledermix
A glucocorticosteroid-antibiotic compound, has
anti-inflammatory,
anti-bacterial
and
antiresorptive properties, all of which help to
reduce the periapical inflammatory reaction
including clastic-cell mediated resorption.
Prompts more favorable healing in replanted
teeth.
Z. Mohammadi, & P. V. Abbott. On the local applications of
antibiotics and antibiotic-based agents in endodontics and
dental traumatology International Endodontic Journal, 42, 555
567, 2009
Tri- mix
A triple antibiotic paste consisting of
metronidazole, 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
Irrigating solutions
23.10.2012
83
OBTURATION
Root canal obturation
should be done
completely seal (fluid
FUTURE
Tissue engineering
Enamel crystals
Implanting -Pulp dentin complex
Revascularization
Morphogen
TOOTH
Stem cell
Scaffold
ENAMEL
TissueEngineered
Tissues
PULPDENTIN
PERIODONTAL
LIGAMENT
Amelogenin
Fluorapatite Nanorods
Stem Cells
BMPs
Scaffold
Pulp-Dentin
Complex
Regeneration of
Dentin
Transplantation
R E VA S C U L A R I Z AT I O N
PULPAL
NECROSIS
APICAL
TERPHINATION
CLOT
FORMATION
ANGIOGENESIS
THANK YOU