treatment pulpal
TRANSCRIPT
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TREATMENT OFTREATMENT OF
PULPAL &PULPAL & PERIAPICAL DISEASESPERIAPICAL DISEASES
By: karlina yusac
Pathway of the pulp,8Pathway of the pulp,8thth editionedition
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DENTAL EVALUATIONDENTAL EVALUATION
Ø eriodontal
considerations
Ø estorativeconsiderations
Ø ndodontic onsiderations
Ø urgical considerations2
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RIODONTAL CONSIDERATIONSRIODONTAL CONSIDERATIONS
• Periodontal probing
• Mobility assessment•Radiographic assessment• ndodontic treatment should
ot be planned for teeth with
oor periodontal prognosis( . . )g mobility III
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ESTORATIVE CONSIDERATIONSESTORATIVE CONSIDERATIONS
q estorative treatment planning before tarting endodontic treatment in a
onemergency situation•Extensive loss of tooth structure• (Subosseous root caries crown
)lengthening may be needed• -Poor crown root ratio
•Lack of ferrule effect•Misaligned tooth
q onsultation with a prosthodontist
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NDODONTIC CONSIDERATIONSNDODONTIC CONSIDERATIONS
vAnatomy of roots and canals
vProcedural errorsvSmall mouthvInstrumentsvOperator skillvTime
q o determine the level of anticipateddifficultyq o identify cases that should bereferred
q 5
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SURGICAL CONSIDERATIONSSURGICAL CONSIDERATIONS
•Of particular value in the diagnosis of nonodontogenic lesions•Biopsy prior to definitive endodontic
treatment
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TREATMENT PLANNINGTREATMENT PLANNING
cope of endodontics§ Vital pulp therapy
§ Pulpectomy or RCT§ Endodontic surgery§Retreatment§ Hemisection or root
amputation§Bleaching§ Apexification or
apexogenesis 7
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TREATMENT PLANNINGTREATMENT PLANNING
vTreatment or extraction?v What kind of treatment ?
§Endodontic§Periodontal§Restorative
v Who will be the operator?
v - -Single visit or multi visit?vCostvPrognosis
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PARATION FOR TREATMENTPARATION FOR TREATMENT
Ø nfection control
§ (Universal precautions operatory)preparation
§Instrument sterilization
§Tooth isolation
Ø atient preparation§Informed consent§Pain control
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Reason for use of Reason for use of
Rubber damRubber damqProtection
§ aspiration or swallowing of instruments or irrigants
§ Soft tissue injury caused by instruments
qEfficiency§ (Improve visibility dry field and reduced
)mirror fogging
§ Minimize patient conversation§ Minimize the need for frequent rinsing
q -educed risk of cross ontamination
q egal considerations 11
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INFORMED CONSENTINFORMED CONSENT
q Continuous rise in dental litigationq For consent to be informed
§ he procedure and prognosis must be described
§ lternatives to the recommended reatment must
be presented along with their respectiveprognoses
§ oreseeable risks must be described§ Patients must have he opportunity
o have
uestions answered 12
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PAIN CONTROLPAIN CONTROL
o ocal anesthesiaoDivitalization
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Local Anesthesia (LA)Local Anesthesia (LA)
• When to anesthetizeØ 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§ LA is unnecessary during obturation phase(obturation
)pressure and extrusion of sealer may produce pain
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MERGENCY TREATMENTERGENCY TREATMENT
retreatment emergency
•Irreversible pulpitis without acute apicalperiodontitis• Irreversible pulpitis with acute apicalperiodontitis
• Pulp necrosis with acute apical periodontitis
,Pathways of the pulp 8th edition
,Principles and practice of endodontics 2th
edition15
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Irreversible pulpitis without AAP
•Multirooted teeth at the emergencyvisit
Pulpotomy (removal of the)coronal pulp or artial
ulpotomy (removal of the pulp)from the widest canal acceptable but less predictable in pain
relief17
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rreversible pulpitis with AAP
Combination of pulpal and periapicalsymptoms
.1 /Complete pulp removal and C S
.2 ( )Ca OH 2 medication in canals to prevent
bacterial regrowth
.3 Effective temporary coronal seal
.4 Occlusal reduction
.5 Oral analgesic medication whennecessary
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Pulp necrosis with AAP
• ithout swelling
• ith localized swelling• ith diffuse swelling
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Without Swelling
• Thorough removal of necrotic pulp• /Complete C S of the root canal
Ø (# / )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
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With Swelling
:rinciple ebridement and drainage
Three ways to resolve swelling andinfection
§Drainage through the root canal§ Drainage by incising a fluctuant
( ,swelling incision and drainage& )I D
§ Antibiotic treatment
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Localized Swelling
irstly try to establish drainage from oot 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
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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
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Diffuse Swelling
•Possible to turn into a medical emergency
-and life threatening condition
•Principles
§ /Thorough C S of the canals§Apical patency achieved wheneverpossible
§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
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Antibiotic Therapy
§ Indicated for patients with
•Diffuse swelling regardless of the establish of drainage
•Spreading infections or systemicsigns
§ ( )Penicillin 1st choice or clindamycin or
+erythromycin Metronidazole
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Endo-Perio Interrelationship
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•Clinical signs and symptoms
–
qPeriodontal abscess
Ømarginal / diffused
•dull-even pain, fullness“high”
–
qPupal abscess•radicular
•rapid onset
•acute pain, severe discomfort
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Endo-Perio Interrelationship
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X-ray taken with GP in sinus tract
Radiolucen
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Endo-Perio Interrelationship
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Probing-search motion & light force
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Treatment Sequence
Based on the COMPLEXITY :
ESSION
TREATMENT§Combined ndo first§ oubt ndo first
Why endo first ???
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Treatment Sequence
Why endo first ???
.1 Significantly betterprognosis.2 -Dramatically osseus fill in.3 Minimal post treatmentsequelae
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SUMMARY
q ulpal status always dictates treatment of.eriapical disease
q rainage of abscess should be performed efore ndodontic
.reatment
q ndodontic treatment should be done first rior to
.eriodontic treatment
q pical healing regardless of marginal.eriodontitis
Ma ginal healing influenced by pulpal.nfections
q :he objectives of treatment are 33