Treatment of Pulpal and Periapical Diseases

1. Case Selection and Treatment Planning

病例选择与治疗计划

Pathways of the pulp, 8 th edition

Chapter Outline

• Common medical findings that may influence endodontics • Dental evaluation • Treatment planning

1.1 Common medical findings that may influence endodontics

1.1.1 Pregnancy

• Not a contradiction to endodontics • Modified treatment plan – Defer

elective dental treatment

during the first trimester except emergency treatment – Provide routine dental care during the second trimester – Consult physician if necessary

1.1.2 Cardiovascular disease

• Medically compromised patients • Consult with physicians before initiation of treatment

Myocardial infarction

心肌梗死 •

(heart attack) within past 6 months

• Increased susceptibility to repeat infarctions and other cardiovascular complications

Contraindication to any elective dental care

Patients with a history of – Heart murmur 心脏杂音 – Mitral valve prolapse with regurgitation 二尖瓣回流 – Rheumatic fever 风心病 – Congenital heart defect 先心病 • – Artificial heart valves 人工瓣膜 • • Increased susceptibility to infective (bacterial) endocarditis 细菌性心内膜炎

Potentially fatal complication Prophylactic antibiotic therapy

预防性使用抗生素

Coronary artery bypass graft

• Antibiotic prophylaxis is not needed after the first few months of recovery • Consultation is advised

1.1.3 Cancer

Patients undergoing chemotherapy and/or radiation to the head and neck

• Impaired healing responses • Consult the patient’s physician before initiation of treatment

1.1.4 AIDS

• •

Infection control

• Asymptomatic patients are usually candidates for endodontic treatment

Medical consultation before endodontic surgery for HIV-infected patients

1.1.5 Diabetes

• • Well controlled patients are candidates for endodontic treatment

Medical consultation for patients with serious complications or before endodontic surgery

– Renal disease – Hypertension – Coronary atherosclerotic disease 冠状动脉粥样硬化

1.1.6 Dialysis

透 析

• • Bleeding tendency

Elective endodontic treatment should be postponed

1.1.7 Prosthetic implants

– Heart valves – Vascular grafts – Pacemakers 起搏器 – Cerebrospinal fluid shunts – Prosthetic joints 人工关节 •

Antibiotic prophylaxis to prevent infection at the site of the prosthesis

•

Medical consultation highly recommended

1.1.8 Behavioral and psychiatric disorders

Consultation before using • Sedatives 镇静剂 • Hypnotics 催眠药 • Antihistamines 抗组胺药

1.2 Dental evaluation

• • • •

Periodontal considerations Restorative considerations Endodontic considerations Surgical considerations

1.2.1 Periodontal considerations

• Periodontal probing • • Mobility assessment • Radiographic assessment

Endodontic treatment should not be planned for teeth with poor periodontal prognosis (e.g. mobility III)

1.2.2 Restorative considerations

• •

Restorative treatment planning before starting endodontic treatment in a nonemergency situation

– Extensive loss of tooth structure – Subosseous root caries (crown lengthening may be needed) – Poor crown-root ratio – Lack of ferrule effect – Misaligned tooth

Consultation with a prosthodontist

1.2.3 Endodontic considerations

• • – Anatomy of roots and canals – Procedural errors – Small mouth – Instruments – Operator skill – Time

To determine the level of anticipated difficulty To identify cases that should be referred

1.2.4 Surgical considerations

• Of particular value in the diagnosis of nonodontogenic lesions • Biopsy prior to definitive endodontic treatment

1.3 Treatment planning

• • • • • • •

Scope of endodontics Vital pulp therapy

活髓保存

Pulpectomy or RCT

牙髓摘除术或根管治疗

Endodontic surgery Retreatment

再处理 牙髓外科

Hemisection or root amputation Bleaching

牙漂白

Apexification or apexogenesis

根尖发育成形术或根尖诱导术 牙半切或截根术

Treatment planning

• Treatment or extraction?

• What kind of treatment ?

– Endodontic – Periodontal – Restorative • Who will be the operator? • Single-visit or multi-visit?

• Cost • Prognosis

2. Preparation for treatment

• Infection control – Universal precautions (operatory preparation) – Instrument sterilization – Tooth isolation 患牙隔离 • Patient preparation – Informed consent 知情同意 – Pain control

2.1 Infection Control

• Dental personnel are at risk of exposure to a host of infectious organisms • Risk of cross-contamination in the dental environment

Effective infection control procedures

• Reduce the number of micro-organisms in the working environment • Protect patients and the dental team • Improve the outcome of endodontic treatment

Universal precautions

• • • American Dental Association (ADA) recommendation

Each patient is considered potentially infectious The same strict infection control policies applied to all patients

Infection control guidelines

• •

Dental personnel vaccinated against hepatitis B Thorough and updated patient medical history

• Proper barrier techniques for dental personnel – Masks, protective eyewear,

disposable latex gloves

– Hands, wrists and lower forearms washed with soap –

Use of vacuum suction

(high-volume evacuation) for high-speed handpiece, water spray or ultrasonics –

Use of rubber dam

Cross-contamination related with handpieces

• Surface contamination 表面污染 • Air contamination 空气污染 • Suction contamination 回吸污染

Rubber Dam

橡皮障

Routine placement of the rubber dam is considered the standard of care in USA

Reasons for use of rubber dam

• • • •

Protection

– aspiration or swallowing of instruments or irrigants – Soft tissue injury caused by instruments

Efficiency

– Improve visibility (dry field and reduced mirror fogging) – Minimize patient conversation – Minimize the need for frequent rinsing

Reduced risk of cross-contamination Legal considerations

Components of rubber dam system

• • • • •

Rubber dam (sheet)

橡皮障

Frame

橡皮障架

Retainers (clamps)

橡皮障夹

Punch

橡皮障打孔器

Forceps

橡皮障钳

2.2 Informed consent

• Continuous rise in dental litigation • For consent to be informed – The procedure and prognosis must be described – Alternatives to the recommended treatment must be presented along with their respective prognoses – Foreseeable risks must be described – Patients must have the opportunity to have questions answered

根管治疗知情同意书 请阅读以下同意书，若您同意下列内容，请在治疗开始前签字。 本人因诊断为_____________, 同意授权_________医生进行________的根 管治疗（镍钛机动预备/手动预备，热牙胶充填/冷侧压充填）。同时我也同意 上述医生在他(她)认为必要 (或按治疗计划认为必要) 的情况下照X线片，使 用药物治疗、麻醉以及相关设备或处理措施。 本人已充分理解根管治疗是保留患牙的最佳治疗方法。完善的根管治疗较 其它牙髓治疗难度大、费时，需要精良的器械和技术，费用也较高。根管治疗 需要去除牙内感染的牙髓组织（含血管、神经），然后用充填材料封闭根管。 根管治疗成功率较高。但少数患牙因牙齿本身的情况较复杂，也可能需要再处 理、根尖周手术甚至被拔除；在治疗过程中，可能出现器械折断于根管内、根 管壁侧穿或髓底穿以及牙体折裂。治疗之后，患牙通常需要以桩核或全冠修复 来保护和恢复患牙功能，否则易发生牙体折裂。 根管治疗与麻醉的常见并发症包括：疼痛、肿胀、牙关紧闭、感染、出血 以及唇、牙龈或舌的麻木，但麻木极少持续。 我已了解了根管治疗的情况, 就诊医生已向我介绍了根管治疗（镍钛机动 预备/手动预备，热牙胶充填/冷侧压充填等）具体步骤及相应特点。我的疑问 也已从就诊医生处得到满意的回答。 本人同意医生采用_____________________________ _______治疗方案， 具体治疗费用约________元。 患者姓名： ____________ 时间：____________ 患者签名（若患者为未成年人则由监护人代签）： ____________ 主诊医生签名：____________ 时间：____________

2.3 Pain control

• •

Local anesthesia Divitalization

失活法

2.3.1 Local anesthesia (LA)

• When to anesthetize –

LA should be given at each appointment

• Three misconceptions – Necrotic teeth may be instrumented without LA (vital tissue may exists periapically) – Patient’s sense aids the clinician to determine working length 根管工作长度 – LA is unnecessary during obturation phase (obturation pressure and extrusion of sealer may produce pain)

local anesthetics

Lidocaine

利多卡因

Articaine

阿替卡因

碧兰麻

(

阿替卡因

)

Techniques

• Conventional techniques –

Supraperiosteal injection (local infiltration)

–

Regional nerve block

• Supplemental techniques – Periodontal ligament (PDL) injection – Intrapulpal injection – Intraseptal injection – Intraosseous (IO) injection

• Maxillary posterior teeth – Posterior superior alveolar (PSA) block for molars – Buccal infiltration for premolars – Palatal infiltration for rubber dam retainer (optional) • Maxillary anterior teeth – Labial infiltration – Palatal anesthsia for rubber dam retainer (optional)

• Mandibular teeth – Inferior alveolar nerve (IAN) block for anterior and posterior teeth – Incisive nerve block for premolars and anterior teeth – Labial infiltration for anterior teeth

Periodontal ligment (PDL) injection

• 27-gauge/short or 30-gauge/ultrashort needle • Placed into the periodontal space between the root and the interseptal bone • Bevel facing the root • 0.2mL of anesthetic slowly deposited on the distal of each root of the tooth

• • Index of successful PDL injection – Presence of resistance to anesthetic deposition – Ischemia of the soft tissue at the site of injection

Contraindications

–

Presence of infection or inflammation in the area of needle insertion (e.g. acute apical abscess)

Intrapulpal injection

• 27-gauge/short needle • Inserted into the pulp chamber or canal • Resistance met and 0.2~0.3mL of the solution expressed • In lack of a snug fit of the needle – warm gutta percha 牙胶 inserted around the needle – Injection under pressure after cooling

2.3.2

失活法

Devitalization

– 用化学药物封于牙髓创面上，引起牙髓血运 障碍而使牙髓组织坏死失去活力，以达到无 痛操作 – 使牙髓失活的药物称为失活剂

失活 法可以有效地达到无痛操作，常规用于 干髓治疗。其他去髓治疗在麻醉效果不佳， 或对麻醉剂过敏时才采用失活法

常用失活剂

• 多聚甲醛 （三聚甲醛，简称“三甲”） – 引起牙髓血运障碍而发生坏死 – 毒性弱于亚砷酸较安全 – 作用相对缓慢 – 封药时间：全牙髓

14

天 根髓

7-10

天

常用失活剂

• 亚砷酸（

As 2 O 3

） – 毒性强：细胞原生质、神经、 血管 – 作用迅速：牙髓血运的影响 – 无自限性：化学性根尖周炎 – 严格控制封药时间：

24-48

小时 – 禁用于根尖孔未形成的患牙

操作步骤

• 告知患者：选择失活剂、按时复诊 • 暴露牙髓：不强调彻底去腐 • 减压引流、控制出血：酚、肾上腺素棉球 • 放置失活剂：小球钻大小

+

丁香油棉球 •

ZOE

暂封窝洞

失活法 – 增加就诊次数 – 牙体变色 适用于后牙 – 失活不全 麻醉法 – 缩短疗程 – 适用于全口牙 – 作用迅速完全

3. Vital Pulp Therapy

活髓保存治疗

• • •

Indirect pulp capping Direct pulp capping

间接盖髓术 直接盖髓术

Pulpotomy

牙髓切断术 “

Principles and practice of endodontics” 2th edition

3.1 Indirect pulp capping

Indications

– deep carious lesions – No history of pulpalgia – No signs of irreversible pulpitis – No pulp exposure after excavation of carious dentine

Pulp Capping Materials

Calcium hydroxide

氢氧化钙 • The most commonly-used (direct) pulp-capping material – Water-based calcium hydroxide – Resin-based Calcium hydroxide e.g. Dycal, Timeline

Zinc oxide-eugenol cement (ZnOE)

•Only for indirect pulp capping •Bactericidal effect and hermetic marginal seal •Cytotoxicity-use of ZnOE as a liner in deep carious lesions is still controversial

Procedures

1. Remove all softened, mushy or leathery dentine 2. Either ZOE or Ca(OH) 2 placed on the remaining dentin to kill or suppress bacteria 3. Base 4. Temporary or permanent restoration

3.2 Direct pulp capping

• •

Indications: Accidental or mechanical pulp exposure (normal pulp)

– Cavity preparation – Placement of pins – Trauma

Mainly for immature permanent teeth with recent (<24 hr) traumatic pulp exposure or mechanical exposure during cavity preparation

Should mature teeth be pulp capped?

•Size of exposure limited to 1mm •Contraindicated for carious tooth with pulp involvement

Enamel-dentin fracture with pulpal involvement Direct pulp capping

Hemostatic reagents

止血剂

• • • •

Saline

盐水

Hydrogen peroxide

双氧水

Diluted sodium hypochlorite

次氯酸钠

Chlorhexidine

洗必泰

Pulp capping materials

• •

Calcium hydroxide Mineral trioxide aggregates (MTA)

矿化三氧化聚合物

Procedures

1. Ca(OH) 2 applied to the exposure to stimulate differentiation of new odontoblast-like cells and formation of secondary dentin 2. Temporary restoration placed over Ca(OH) 2 3. Follow-up 4. Permanent restoration 5. Pulpotomy or endodontic treatment for symptomatic tooth

3.3 pulpotomy

Indication: Immature permanent teeth

Procedures

• Removal of all carious dentin and pulp tissue to the level of the radicular pulp • Vital pulp stump capped with Ca(OH) 2 • Temporary restoration • Follow-up • Asymptomatic: permanent restoration • Symptomatic: endodontic treatment

Potential problems with pulpotomy as a permanent treatment

• Impossible to determine whether all disease tissue has been removed • The remaining radicular pulp tissue may undergo mineralization – Making further endodontic treatment difficult or impossible • Internal resorption

Conclusions

• • The vital pulp therapies are predictable in teeth with traumatic or mechanical pulp exposure.

Direct pulp capping is contraindicated for teeth with carious pulp exposure. Pulpotomy might be the choice but is considered unproven.

• When – for financial or other reasons – extraction is the only alternative, pulpotomy certainly should be considered for the benefit of the patient.

4. Emergency Treatment

Pretreatment emergency • Irreversible pulpitis without acute apical periodontitis • Irreversible pulpitis with acute apical periodontitis • Pulp necrosis with acute apical periodontitis Pathways of the pulp, 8 th edition Principles and practice of endodontics, 2 th edition

4.1 Irreversible pulpitis without AAP

Principles: • Complete pulp removal • Total cleaning and shaping (C/S) of the root canal system 根管清理和成形 • Pulpectomy is the best to achieve pain relief

Pulpectomy

•Complete removal of the vital pulp tissue followed by cleaning , shaping and filling of the root canal(s).

•Indicated for tooth with pulpitis

• Multirooted teeth at the emergency visit – Pulpotomy (removal of the coronal pulp) or patial pulpotomy (removal of the pulp from the widest canal) acceptable but less predictable in pain relief

Procedure

• • C/S of the root canal system • A dry cotton pellet placed in the pulp chamber

Complete caries removal and effective temporary coronal seal to prevent contamination

• Occlusal reduction 咬合调整

4.2 Irreversible pulpitis with AAP

Combination of pulpal and periapical symptoms • Complete pulp removal and C/S • Ca(OH) 2 medication in canals to prevent bacterial regrowth • Effective temporary coronal seal • Occlusal reduction • Oral analgesic medication when necessary

4.3 Pulp necrosis with AAP

• • •

Without swelling With localized swelling With diffuse swelling

Without swelling

• Thorough removal of necrotic pulp • Complete C/S of the root canal – Introducing a small file (#10/15) slightly beyond the apex to establish drainage from the periapical tissues • Ca(OH) 2 dressing between visits to help eliminate remaining bacteria • Oral analgesics

With swelling

•

Principle: debridement

清理

and drainage

• Three ways to resolve swelling and infection – Drainage through the root canal – Drainage by incising a fluctuant swelling (incision and drainage, I&D) – Antibiotic treatment

Localized swelling

Firstly try to establish drainage from root canals

• C/S of the root canal – Introducing a small file (size 10/15) slightly beyond the apex to establish drainage – No I&D in case of good drainage • Ca(OH) 2 medication • Access seal – If pus continues to drain through the canal and cannot be dried within a reasonable period of time, the tooth may be left open for <24 hrs

•

Incision and drainage

• Indicated for localized fluctuant soft tissue swelling

Principles

– Incise at the site of the greatest fluctuance – Dissect gently and extend to the roots – Keep wound clean with hot saltwater mouth rinses or CHX mouth rinse

Diffuse swelling

• • Possible to turn into a medical emergency and life threatening condition

Principles

– Thorough C/S of the canals – Apical patency achieved whenever possible – Tooth left open – I&D in the absence of drainage through the canals with a rubber dam drain inserted or sutured (2~3 days) – Referral to oral surgeons

Antibiotic therapy

• Indicated for patients with – Diffuse swelling regardless of the establish of drainage – Spreading infections or systemic signs • Penicillin (1st choice) or clindamycin or erythromycin + Metronidazole

Endodontic Emergency Treatment Diagnosis and Symptoms Irreversible pulpitis Without AAP Treatment Complete C/S Postop Med With AAP Complete C/S Ca(OH) 2 dressing NSAIDs corticosteroids NSAIDs corticosteroids Pulpal necrosis without swelling NSAIDs With localized swelling With diffuse swelling Complete C/S Ca(OH) 2 dressing Complete C/S Ca(OH) 2 dressing I&D Complete C/S Ca(OH) 2 dressing I&D NSAIDs NSAIDs antibiotics