h apd

What management strategies can we do on vital primary teeth?

*Indirect pulp therapy

- Stepwise caries removal

- one stage PCR

Direct pulp capping

- Ca(OH)2

- MTA

- Biodentine

Pulpotomy

- MTA

- Ferric sulphate

- Ca(OH)2

etc

-Why do we not commonly use direct pulp caps?

*Poor outcomes

High risk of internal resorption and necrosis

-When would we consider a direct pulp cap?

*Small traumatic pulp exposures in asymptomatic teeth

Must ensure rubber dam used

-What treatment should we provide following indirect pulp therapy?

*PMC

RMGIC base and composite restoration

DO NOT use amalgam or GIC

-What diagnostic tests can be done?

*Sensibility testing is not used in children

Look at radiograph to see if the residual dentine thickness - layer of dentine between pulp and cavity?

If a child is in pain that has kept the awake at night or they have been sent home from school for example - we tx it as irreversible pulpitis

-How do we determine necrosis via activity of lesion?

*More active lesions will have much much more necrosis

If lesion has arrested, less necrosis

-3 types of pulpotomy treatment

*Fixation/denaturisation

- Formocresol (contains formaldehyde)

Arrest of bleeding

- ferric sulphate

- Electrosurgery

- laser

Regeneration of hard tissue

- MTA

- Ca(OH)2

- Biodentine

- Ca enriched cement

-How can we regenerate hard tissue

*Remove the coronal pulp - manipulate the remaining tissue to regenerate into hard tissue e.g. MTA/Biotdentine

-Why don't we use formocresol anymore? UK

*Contains formaldehyde which has carcinogenic properties

-What do we commonly use for pulpotomy?

*Remove coronal pulp

Add ferric sulphate to stop bleeding by forming a clot - place using a moist cotton wool pledget and gentle pressure - apply for 20 secs and then wash off with sterile water

ZoE placed directly over the pulp tissue

Optimal restorative seal for success

-How to use ferric sulphate

*Redistribute into smaller syringes to avoid mess and wastage

Arrest pulpal bleeding with moist cotton wool pledget and gentle pressure

Apply using microbrush for 20 secs

Wash off using sterile water

Repeat if bleeding persists

-Features of MTA

*Mineral trioxide aggregate

Expensive

Difficult to manipulate

Grey or white forms

Good biocompatibility

Induces hard tissue formation

-Cellular mechanisms of MTA

*Promotes revascularisation

Antibacterial

Stimulates collagen formation

Releases growth factors from dentine

Promotes dentine-like formation

-Features of Biodentine

*Cheaper than MTA

Easier to manipulate than MTA

Use in bigger volume to fill up canal

-Cellular mechanisms of Biodentine

*Biocompatible

Releases Ca(OH)2 on setting

Stimulates hard tissue formation

-How to manage irreversibly inflamed or non-vital primary teeth

*Pulpectomy:

1 stages OR

2 stages (purulent or excess bleeding)

Dependent on whether bleeding can be stopped, state of infection, presence of pus

-What can we use in pulpectomy

*ZOE

Ca(OH)2 +/- iodoform pastes

Antibiotic preps

-Clinical procedure for a pulpectomy

*Pre-op PA - root morphology, permanent successor

LA and rubber dam

Identify root canals

Irrigate with normal saline = CHX or Na hypochlorite

Estimate WL 2mm short of apex

Gentle filing with small files

Irrigate and dry canals

If infection present, obturate canals with ZOE, non-setting Ca(OH)2, or premixed Ca(OH)2 and iodoform paste

Success with under-filled rather than overfilled

Restore with good coronal seal

-How to approach infection and pulpectomy

*If infection present (sinus) dress root canals with Ca(OH)2 paste and temporise

Complete 2 weeks later

-If able to dry canals appropriately, what can you obturate with?

*If canals can be dried, obturate canals by injecting/packing with slow-setting pure zinc oxide eugenol, non-setting Ca(OH)2 paste or premixed Ca(OH)2 and iodoform paste

-What is lesion sterilisation and tissue repair therapy?

*Pulpectomy variation:

Placement of mixture of three antibiotics in infected root canals

Metronidazole, ciprofloxacin, minocycline

Antibiotics placed in pulp chamber for a short period OR sealed in tooth permanently

Want to avoid antibiotic resistance in the UK so we dont use it

-What is ledermix

*Desensitising paste

Contains steroid and antimicrobials

As a temp base under dressing

-When would we use ledermix

*As a temp base under dressing

Aim to suppress inflammatory response between visits

-What is odontopaste

*Zinc oxide based paste

Contains clindamycin hydrochloride and triamcinolone acetonide (steroid)

-Why would we use odontopaste

*Inadequate analgesia - helps to relive symptoms temporarily

Child cannot cope with long appts

Aims to suppress inflamatory response due to acting directly with inflamed tissue

-What is KEY to remember between pulpotomies in primary teeth and permanent incisors

*Pulpotomy technique/medicaments are very different to pulpotomy techniques for traumatically exposed vital permanent incisors (i.e Cvek technique)

-Primary Root Canal Infections are polymicrobial.

What microorganism dominate this

*Dominated by Obligate Anaerobic Bacteria

-List 4 Aims of Irrigation

*1) Killing and Removal of Microorganisms

2) Removal of Necrotic/Inflamed Tissue

3) Removal of Dentine Debris and Smear Layer

4) Provide Lubrication and reduce friction for instrumentation

-List 4 'obstacles' in Root Canal Disinfection

*1) Anatomical Complexities

2) Smear Layer

3) Fluid Dynamics

4) Biofilm & Resistant Microbiota

-Describe how Root Anatomy can cause Irrigation Difficulties

*Root Canals may have irregular and complex systems such as

- Webs, Loops, Cul De Sac, Fins, Lateral Canals and Apical Deltas. Irrigation is the only way of disinfecting the majority of the root canal system.

Only 61% of Canal Walls are instrumented

40% of Canal Walls remain infected after instrumentation

-What is the Smear Layer composed off (5)

*1) Inorganic Substances

2) Organic Substances

3) Fragments of Odontoblastic Processes

4) Microorganisms

5) Necrotic Debris

-List two problems associated with the smear layer

*1) Provides Protection for Bacteria

2) Inhibits/Delays penetration of irrigant into the dentinal tubules

-Why does the Irrigation Needle Tip need to be placed close to the apical region

*Irrigant only penetrates 1-2mm further than the end of the needle. This will cause Fluid Motion (Movement of the Irrigant Fluid within the canal)

-What happens if there is an Absence of Fluid Motion

*Stagnation Plane

- there will be no more flushing of debris or penetration of irrigant if a stagnation plane is created

-What are the Rules for Irrigation

*1) Use a side-venting needle with a Luer-Lok Syringe

2) Keep the Needle Tip moving to prevent it wedging and forcing irrigant through the apex

3) Use Gentle Pressure

4) Constant Agitation to improve fluid flow

5) If the Needle Binds then Stop

-How far away from the apex should the needle be

*In normal Endo Cases - 2mm

In cases where there is an Open Apex - 3-4mm

-What is Dynamic Pumping

*Using a Gutta Percha Point to stir up and move the irrigant inside the canal to improve Fluid Dynamics

-Define Biofilm

*any group of microorganisms in which cells stick to each other and often also to a surface.

These adherent cells are frequently embedded with a self produced matrix of Extracellular Polymeric Substance (EPS)

-What is Extracellular Polymeric Substance made up of

*A polymeric conglomeration generally composed of extracellular DNA, proteins and polysaccharides

-What are Planktonic Cells

*free flowing bacteria in suspension. Bacteria which are loose and easily flushed out of the root canal system

-The microbial cells growing in a biofilm are distinct from planktonic cells of the same organism. Explain Why

*Bacteria living in the Biofilm are much more difficult to remove as they adhere to dentinal walls compared to Bacteria of the same kind which are loose in suspension

-How do biofilms form?

*attachment, colonization, development into complex organisations, active dispersal along canal walls

-Explain why Bacteria is far less susceptible to Antimicrobial Killing when within the Biofilm than when in its Planktonic Phase

*Bacteria within the Biofilm is adhered to the canal walls, Bacteria in its planktonic phase is loose and easily removed.

-List Resistant Microbiota in Root Canal Systems

*1) E.Faecalis

- high level of resistance to wide range of antimicrobial agents

Cultures of Root Canals irrigated with NaOCl always yielded positive cultures of E.Faecalis.

-List the Ideal Characteristics of an Endodontic Irrigant (15)

*1) Effective Antimicrobial Action

2) Non Irritating to the Periapical Tissue

3) Stable in Solution

4) Prolonged Antimicrobial Effect

5) Active in the Presence of Blood, Serum, Protein Tissue

6) Low Surface Tension

7) Not Interfere with Repair of Periapical Tissue

8) Not Stain Tooth Structure

9) Does not Induce Cell Mediated Immune Response

10) Able to completely remove the smear layer

11) Non Toxic, Non Antigenic, Non Carcinogenic

12) No Adverse Effects on Properties of exposed dentine

13) No adverse effects on the sealing ability of the filling materials

14) Easy to Use

15) Cheap

-What concentration of NaOCl is used in Root Canals

*5.25%

UG's use 1-2%

-What are the Advantages of NaOCl (3)

*1) It is the only endodontic irrigant which dissolves organic matter

2) Antimicrobial

- Effective with Time and Good Preparations against all endodontic bacteria

3) Affordable

-How do we maintain the desired antimicrobial effect of NaOCl when Diluted

*- Use Larger Volumes of Irrigant

- Use Irrigant for Longer Time

A Higher Concentration of NaOCl will require Less Time to reach its desired antimicrobial effect

-What is the effect of Increasing the Temperature of NaOCl on its antimicrobial ability

*Increasing the Temperature can Improve Tissue Dissolution

at 60 Degrees it will Completely dissolve tissue but can destroy osteoblast and cause corrosion of metal instruments.

The antimicrobial effect increases by double for each 5 degree rise in temperature

-Why is a continuous replenishment of irrigant required to get optimal effects of NaOCl

*Chlorine Ions are responsible for tissue dissolving. The antibacterial capacity is rapidly consumed especially during the first phase of tissue dissolution

-What are the Disadvantages of using NaOCl (5)

*1) Minimally removes Dentine Debris & Smear Layers

2) Affects the Mechanical Dentine Properties

- Reduces Dentine Flexural Strength

3) Rare cases of Allergic-Like Reaction causing Dermatitis

4) Toxic to Vital Tissues causing Haemolysis, Epithelial Ulceration and Necrosis

5) Can cause corrosion of metal objects

- in UK endodontic files have been deemed single use

-How do you manage Severe Extrusion Injuries of NaOCl where it has extruded through the apex

*This is a Medical Emergency, Stop the Procedure Immediately.

Assess

If a small amount has extruded then it is not as emergent. If large amounts then the patient needs to be taken to hospital as you can get Haemolysis, Epithelial Ulceration and Necrosis around site of Extrusion

-Why does EDTA remove the Smear Layer

*It is a Chelating Agent therefore has the ability to scavenge up and form ring-shaped internal complexes with metallic ions including calcium

-List Properties of EDTA (4)

*1) Synthetic Amino Acid

2) Removes the Smear Layer

3) Not Bactericidal/Static

- But eventually kills bacteria by starvation as metallic ions needed for bacterial growth are chelated

4) Relatively Non Toxic

-What are the benefits of using EDTA penultimate followed by NaOCl

*EDTA then using NaOCl can allow NaOCl to penetrate a lot deeper into the dentinal tubules now that the smear layer will be removed.

-Describe the depth of penetration of EDTA

*The effects of EDTA are more coronally and less so apically

-What is the consequence if EDTA is used for too long

*Dissolution of Dentine. Therefore it is only used minimally during RCT

-Describe the concentrations of EDTA and when it should be used

*- Available as a solution of 15-17%

- Should be used as a penultimate rinse for approximately 1-2mins

-List Properties of Chlorhexidine

*- Cationic Bisbiguanide Antiseptic

- Broad Spectrum, making resistance less likely

- Bactericidal at High Concentrations and Bacteriostatic at Low Concentrations

- Demonstrates Substantively

- Less Toxic than NaOCl

- No Harmful Effects to Dentine or Corrosion of Instrument

-Chlorhexidine demonstrates substantivity. What does this mean

*It continues to act once its been removed

-What concentration is Chlorhexidine used in

*Used at 0.2-2%

-Chlorhexidine can be Bacteriostatic or Bactericidal at different concentrations. Describe How

*At high concentrations it is Bactericidal. At low concentrations it is Bacteriostatic.

-What are the disadvantages of Chlorhexidine (3)

*1) No Tissue Dissolving Effects

2) Cannot Remove the Smear Layer

3) Potential for Severe Allergic Reaction

-What percentage of Iodine is found in Iodine Potassium Iodide

*2% Iodine in 4% Potassium Iodide.

-What is the use of Iodine Potassium Iodide

*Acts as an oxidising agent that attacks key proteins, nucleotides and fatty acids. This leads to cell death.

-List 3 Advantages of Iodine Potassium Iodide

*1) Broad Antimicrobial Spectrum

2) Substantive Effects

3) Low Toxicity relative to NaOCl

-List 5 Disadvantages of Iodine Potassium Iodide

*1) Allergic Reaction to Iodine

2) Can Stain Dentine

3) Not Stable in presence of organic material

4) No Tissue Dissolving properties

5) Unable to Remove Smear Layer

-What do Hydrogen Peroxide do

*Hydroxy-Free Radicals destroy proteins and DNA.

Concentrations vary from 3% and 5%. It is no longer used as a routine irrigant

-List an Advantage of Hydrogen Peroxide

*Active Against Bacteria, Virus & Yeasts

-List 4 Disadvantages of Hydrogen Peroxide

*1) Antimicrobial Efficacy is poorer than NaOCl

2) Less Tissue Dissolving Capacity than NaOCl

3) Can Release O2 Gas

4) Potential Danger, seepage into the tissues may lead to air emphysema

-MTAD is an Irrigant used. What is it composed of

*It is a mixture of

- 3% Doxycycline

- 4.25% Citric Acid

- A Surface Detergent

-List 3 Advantages of MTAD

*1) Doxcycline provides broad-spectrum antibacterial effect

2) Citric Acid removes the smear layer

3) No Adverse Effects on the Physical Properties of the Tooth

-List 5 Disadvantages of MTAD

*1) Less Efficient on Biofilm

2) More Toxic than NaOCl

3) Expensive

4) Risk of Bacterial Resistance (Tetracycline)

5) Risk for Tetracycline Staining

-How does Photo-Activated Disinfection work

*A Dye (Toluidine Blue) is introduced to the root canal. A low power laser is then used to activate the dye.

The photosensitizer molecules attach to bacteria and following the introduction of the laser irradiation, singlet oxygen is produced which ruptures the cell wall.

-List 3 Advantages of Photo-Activated Disinfection

*- Broad Spectrum of Activity with Little Risk of Resistance

- May Destroy Some Bacteria left by some other irrigants

- No Risk of Toxicity

-List 3 Disadvantages of Photo-Activated Disinfection

*1) Efficacy depends on power, length of exposure, absorption of light into tissues and distance from tip to target.

2) No Evidence to suggest any benefit over other irrigants

3) Expensive.

-Electronically Activated Water is also known as Oxidative Potential Water. How does it work

*It essentially involves electrolysing saline solution. It is commonly used to disinfect dental piping and tubing by creating Hypochlorous Acid and Free Radicals which can remove biofilm and destroy bacteria.

-Irrigant can be activated Ultrasonically to improve the efficacy.

Describe How

*Ultrasonic Agitation causes Acoustic Micro-streaming, enhancing the antibacterial efficiency of the irrigants.

This disrupts the biofilm and can eliminate more bacteria from the canal than hand instrumentation alone.

-How can Endo-Perio Lesions be Classified according to the Simon Classification

*1) Primary Endodontic Lesion, Secondary Periodontal Lesion

2) Primary Periodontal Lesion, Secondary Endodontic Lesion

3) True, Combined Perio-Endo Lesion

-What is a True Perio-Endo Lesion

*A true combined lesion is where you have a separate periodontal lesion and a separate endodontic lesion which can coalesce

-What is a Primary Endo Secondary Perio Lesion

*Originally an Endo Lesion, the infection spreads from the Apex and along the root to the gingiva.

Pulpal infection can also spread from accessory canals to the gingiva or furcation

-What is a Primary Perio Secondary Endo Lesion

*A periodontal pocket which can deepen to the apex and secondarily involve the pulp.

Alternatively a Periodontal Pocket can infect the pulp through a Lateral Canal

-In Reality it can be difficult to determine which the original source of the infection was i.e. Was it from Periodontal Tissues or Was it from Periapical Tissues or Both.

Therefore Other Classifications other than Simon's have been Suggested.

Give an Example

*Abbot & Castro Salgado 2009

- Concurrent Endodontic & Periodontal Disease without Communication

- Concurrent Endodontic & Periodontic Disease with Communication

-Radiographically, how can you determine if the Periodontal and Endodontic Lesions communicate

*If the Radiograph shows Periapical Pathology and a Deep Pocket, with no bone in between the lesion then assume there is communication between the two lesions

-What do Non-Communicating Lesions suggest

*True Combined Lesions with Independent Aetiologies

-List Common Symptoms of Perio-Endo Lesions

*1) Swelling of Gingiva

2) Pus Discharge

3) Pocket Formation

4) Fistula Tract (sinus)

5) Tender to Percussion

6) Mobility

-What is Assessed in an Endodontic Examination (4)

*1) Restorative Status

2) TTP

3) Tenderness in Sulcus

4) Swelling/Sinus

-What is assessed in a Periodontal Examination (4)

*1) 6PPC including Bleeding Index

2) Pus Discharge from Pocket

3) Mobility

4) Furcation

-What 3 Signs on Radiographs indicate Perio-Endo Lesions

*1) A Vertical Periodontal Defect

2) A Radiolucency around the Apex

3) A J-Shaped Lesion

-When is a CBCT Scan indicated to Diagnose Perio Endo Lesions

*When conventional radiography does provide sufficient detail

Complex 3-D Anatomy or Suspicion of other causes such as resorption or perforation

-Explain the Rationale for Management of Primary Endo Secondary Perio Lesions

*These have an Endodontic Aetiology.

Endodontic Infection is draining via the PDL in this instance causing the Periodontal Lesion to present as a Narrow Defect.

The Endodontic Treatment Alone will eradicate the source of infection

-When do you Review Primary Endo Secondary Perio Lesions

*Review after 3 months and instigate Non Surgical Periodontal Therapy if pocketing is still present.

Review after another 3 months, if there is no resolution of Perio Lesion then consider Surgical Intervention

-Explain the Rationale for Management of Primary Perio Secondary Endo Lesions

*These Lesions have a Periodontal Aetiology, but the tooth has become Non-Vital so also Requires RCT.

This means Endodontic and Periodontal Therapy are both required. It is best to undertake these Simultaneously.

-Why is it best to Undertake Periodontal & Endodontic Therapy simultaneously

*There are Separate sources of bacteria in the Perio Pocket and in the Endo Lesion, therefore you do not want to treat one and leave the other as this is a potential for the other bacteria to contaminate the treated lesion

-Some People Advocate Placing CaOH inside the Prepared Canal rather than Obturating whilst assessing the response to Periodontal Therapy.

Why?

*Holding Obturation, maintains the ability to reclean the root canal if there is no resolution.

See if the Periodontal Lesion resolves before placing a definitive obturation in the prepared canal. CaOH allows the ability to re-enter if the canal if need be.

-How can you manage Molar Teeth where one root is considerably more affected than the other root

*Root Resection or Hemisection

Top = root resection

Bottom = hemisection

-Which Roots of Molar Teeth often undergo Root Resection

*Mesio-Buccal or Disto-Buccal Roots of Upper Molar Teeth

-Which Teeth is Hemisection of Roots commonly undertaken on

*Lower Molars

-What is the Prognosis of Primary Endo Secondary Perio Lesions

*Generally Good Prognosis

-What is the Prognosis of Primary Perio Secondary Endo Lesions

*Prognosis is dependent on extent of Periodontal Bone Loss