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, 8th edition

Chapter Outline

• Common medical findings that may influence endodontics

• Dental evaluation

• Treatment planning

1.1 Common medical findings that may influence endodo

ntics

1.1.1 Pregnancy

• Not a contradiction to endodontics

• Modified treatment plan– Defer elective dental treatment during the firs

t trimester except emergency treatment– Provide routine dental care during the second tr

imester – Consult physician if necessary

1.1.2 Cardiovascular disease

• Medically compromised patientsMedically compromised patients

• Consult with physicians before initiation of Consult with physicians before initiation of treatmenttreatment

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 graftCoronary artery bypass graft

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

• Consultation is advisedConsultation 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 endod

ontic 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 牙髓外科• Retreatment 再处理• Hemisection or root amputation 牙半切或截根术• Bleaching 牙漂白• Apexification or apexogenesis

根尖发育成形术或根尖诱导术

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 BDental personnel vaccinated against hepatitis B• Thorough and updated patient medical historyThorough and updated patient medical history • Proper barrier techniques for dental personnel Proper barrier techniques for dental personnel

– Masks, protective eyewear, Masks, protective eyewear, disposable latex gldisposable latex glovesoves

– Hands, wrists and lower forearms washed with Hands, wrists and lower forearms washed with soapsoap

– Use of vacuum suctionUse of vacuum suction (high-volume evacuati (high-volume evacuation) for high-speed handpiece, water spray or ulton) for high-speed handpiece, water spray or ultrasonicsrasonics

– Use of rubber damUse 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 DamRubber Dam橡皮障橡皮障

Rubber DamRubber Dam橡皮障橡皮障

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 foggi

ng)– 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 (vita

l tissue may exists periapically)– Patient’s sense aids the clinician to determine workin

g length 根管工作长度– LA is unnecessary during obturation phase (obturatio

n 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 mola

rs– Buccal infiltration for premolars– Palatal infiltration for rubber dam retainer (optio

nal)

• Maxillary anterior teeth– Labial infiltration– Palatal anesthsia for rubber dam retainer (optiona

l)

• 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（ As2O3 ）– 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、按时复诊告知患者：选择失活剂、按时复诊• 暴露牙髓：不强调彻底去腐暴露牙髓：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：小球钻大小放置失活剂：小球钻大小 ++ 丁香油棉球丁香油棉球• ZOEZOE 暂封窝洞暂封窝洞

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 间接盖髓术• Direct pulp capping 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 le

sions is still controversial

Procedures1. 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. Base4. 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 o

r impossible

• Internal resorption

Conclusions

• The vital pulp therapies are predictable in teeth with tra

umatic or mechanical pulp exposure.• Direct pulp capping is contraindicated for teeth wit

h carious pulp exposure. Pulpotomy might be the ch

oice but is considered unproven.• When – for financial or other reasons – extraction is th

e only alternative, pulpotomy certainly should be consi

dered 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, 8th edition

Principles and practice of endodontics, 2th 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 th

e 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 a

nd 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 rin

ses 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 d

rainage– Spreading infections or systemic signs

• Penicillin (1st choice) or clindamycin or erythromycin + Metronidazole

Endodontic Emergency TreatmentDiagnosis and Symptoms Treatment Postop MedIrreversible pulpitis

Without AAP Complete C/S NSAIDscorticosteroids

With AAP Complete C/SCa(OH)2 dressing

NSAIDscorticosteroids

Pulpal necrosis

without swelling Complete C/SCa(OH)2 dressing

NSAIDs

With localized swelling Complete C/S

Ca(OH)2 dressingI&D

NSAIDs

With diffuse swelling Complete C/S

Ca(OH)2 dressingI&D

NSAIDsantibiotics