endo fall 2013

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endo fall 2013
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2013-12-07 16:07:07
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endo fall 2013
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  1. APEXOGENESIS
    • Promotion of root growth to length and maturation of the apex
    • Pulp is VITAL
    • Vital pulp therapy
  2. Vital pulp therapy
    • Previously called Apexogenesis
    • – Defined as treatment of vital pulp in an immature tooth to permit continued dentin formation and apical closure
    • – The goal is maintenance of vitality to allow continued development of the entire root, not just the apex
    • Pulp Capping or Pulpotomy
    • Immature tooth with incomplete root formation and with damage to the coronal pulp
    • (radicular pulp is presumed to be healthy)
    • crown must be fairly intact and restorable
  3. APEXIFICATION
    • Induction of root end formation
    • (apical calcific barrier)
    • Pulp is NECROTIC
    • Root-End Closure or regenerative
  4. Vital pulp therapy techniques
    • • Pulp capping
    • • Shallow pulpotomy
    • • Deep pulpotomy with Ca(OH)2
    • • Deep pulpotomy with MTA
  5. Shallow Pulpotomy: Cvek Technique
    • • Local anesthesia
    • • Rubber dam isolation
    • • Exposed dentin is washed with normal saline or 3% NaOCl
    • • Exposed pulp tissue is removed with a spoon excavator from the pulp wound site
    • • Extruding granulation tissue that forms within 24 hours and may proliferate and protrude with time, is also removed
    • Pulpotomy is accomplished with a water cooled #4 round metal or diamond burr in a high speed handpiece
    • • The tissue is removed to a depth of 2mm below the exposure (shallow or partial pulpotomy)
    • • The wound is gently washed with normal saline, and hemostasis is attained
    • • The wound is washed again to remove the clot (important!), and dressed with a liner
    • • Materials used: Ca(OH)2 paste, hard-setting calcium hydroxide or MTA
    • • The reminder of the cavity is carefully sealed with a hard-setting cement, such as IRM, or
    • glass ionomer
    • • When the cement has set, the tooth may be restored with acid-etched composite
    • • This will prevent microleakage at the site and restore the tooth to its proper form
  6. Shallow pulpotomy success criteria
    • • Tooth is asymptomatic and functions properly
    • • No radiographic evidence of apical periodontitis
    • • No indication of root resorption
    • • The tooth responds to pulp testing
    • Treatment Evaluation
    • • Continued root development and dentin formation are evident radiographically, if the
    • tooth was immature at the time of treatment
    • • If the pulp becomes necrotic or formation is arrested, apexification is then necessary
  7. Deep pulpotomy Possible Outcomes
    • • Ideal result – continued apical growth of the root with a normal or nearly normal apex
    • • Treatment failure is cessation of growth and apical disease, requiring root-end closure of root canal system
    • (Apexification)
  8. Vital Pulp Therapy: Complications
    • leakage
    • pulp necrosis
    • PA pathology
    • • If it occurs before complete root development, root-end closure is necessary
    • • If contamination occurs after root formation, root canal treatment is required
  9. Contradictions
    • • Avulsed, replanted or severely luxated tooth
    • • Severe crown-root fracture that requires intraradicular retention for restoration
    • • Tooth with unfavorable horizontal root fracture (i.e., close to the gingival margin)
    • • Necrotic pulp
  10. Root-End Closure: Indications
    • • Restorable immature tooth with pulp necrosis
    • Previously called Apexification
    • – Defined as the process of creating an environment within the root canal and periapical tissues after pulpal death that allows a calcified barrier to form across the open apex
  11. Root-End Closure: Contraindications
    • • All vertical and most horizontal root fractures
    • • Replacement resorption (ankylosois)
    • • Very short roots
    • • Marginal periodontal breakdown
    • • Vital pulps
  12. Root-End Closure Technique with Ca(OH)2
    • • Access
    • • Instrumentation
    • • Placement of Ca(OH)2 or MTA
  13. Root-End Closure Technique with MTA
    • Description of Technique
    • • Local anesthesia
    • • Rubber dam isolation & surface disinfection
    • • Conventional access is made with a highspeed burr to allow debridement of the canal(s)
    • • Calcium hydroxide paste is placed for one week to disinfect the root canal system
    • • Mixture of MTA and sterile water is prepared, and carried into the canal with an amalgam carrier
    • • MTA mix is condensed to the apical extent using pluggers or paper points to create a 3-4 mm
    • apical plug
    • • MTA placement is verified radiographically. If unsatisfactory, rinse and repeat the procedure
    • • Moist cotton pellet is placed in the canal to ensure proper setting of MTA
  14. Patient Case considerations:
    •  Medical history
    •  Anesthesia
    •  Patient disposition
    •  Ability to open mouth
    •  Gag reflex
    •  Emergency condition
  15. Geriatric Considerations
    •  Changes in cellular, extracellular and supportive elements in the pulp
    •  More pulpal calcification
    •  Increased cervical caries
    •  Healing similar to younger patients if healthy
    •  Access and canal location more difficult
  16. RETREATMENT
    • • Eliminates bacteria
    • • Better outcome than Sx
    • • Preserves root length
    • • New restoration needed
    • • Surgery as a fall-back
  17. ENDO SURGERY
    • • Apicectomy
    • • Amputates infected part of root
    • • Retrofill attempts to confine bacteria
    • • Lesser long-term outcome
    • • Shorter root
    • • Restoration may be preserved?
    • • Limited fall-back options
  18. (T/F) endodontic surgery offers more favorable initial success, but nonsurgical retreatment offers a more favorable long-term outcome
    T
  19. TREATMENT SEQUENCE for DISEASE of PULPAL ORIGIN is to:
    • 1 TREAT with RCT
    • 2 RETREAT with RCT if not healing
    • 3 SURGERY after RE-Tx if still not healing
    • 4 EXTRACT
  20. RE-Tx INDICATIONS
    • • PERIAPICAL PATHOLOGY
    • • HIGH RISK OF FAILURE
    • Intracanal Bacteria
    • CONTRAINDICATIONS
    • • POOR PROGNOSIS
    • • POOR FEASIBILITY
    • • INADEQUATE TOOTH STRUCTURE
  21. POST REMOVAL
    • • POST TYPE:
    • Active Versus Passive
    • Serrated Versus Smooth
    • Tapered Versus Parallel
    • • CEMENT TYPE:
    • Zinc Phosphate - Glass-Ionomer - Resin
    • • ULTRASONIC VIBRATION: “Spartan” “Mini-Endo” “CPR”
    • • POST EXTRACTORS
  22. Ultrasonic post removal settings
    • low water
    • high intensity: post removal
    • low intensity: find canals
  23. GP REMOVAL
    • • HEATED PLUGGERS
    • • Flex-R- FILES
    • • HEDSTROM FILES – don’t unscrew
    • • SOLVENTS, chloroform - careful!
    • • ROTARY INSTRUMENTS, GPX
    • • VERIFY w. ADDITIONAL X-ray
  24. SEPARATED FILE REMOVAL
    • • VISUALIZE, microscope
    • • BYPASS, small ss files
    • • REMOVE
    • • NiTi or SS FRAGMENT ?
    • • ULTRASONIC VIBRATION
    • • TINY PLIERS
    • • SPECIAL TOOLS, tubes
  25. soft paste
    • ZOE based
    • could have toxins, steroids, iodine disinfectant
  26. hard paste
    ZnPO4 or black-copper
  27. TYPES OF ENDO SURGERY
    • • Incision & Drainage
    • • Periradicular Surgery
    • • Perforation Repair
    • • Tooth Resection
  28. INCISION & DRAINAGE
    • I: Fluctuant swelling from APA
    • CI: Nonfluctuant swelling
    • CI: Bleeding disorder
    • • Spreading infection  OMS
    • • Vertical incision
    • • Maintain Drainage
    • THE TOOTH MUST BE CLEANED OUT TOO
  29. PERIAPICAL SURGERY
    • I: Failure of Retreatment
    • I: Canal blocked (eg calcification, file, post)
    • I: Removal of apical fragment, horizontal fracture
    • I: Biopsy (cyst, granuloma, or other?)
    • CI: Tooth has not been treated or retreated first
    • CI: Anatomic factors
    • (thick bone, short root, IAC, perio, bvs, foramina)
    • CI: Medical reasons
    • • Decreased Crown to Root ratio
  30. APICAL SURGERY SEQUENCE
    • • Treatment Plan and Flap Design
    • • Incision and Reflection
    • • Apical Access
    • • Periradicular Curettage
    • • Root-end Resection
    • • Root-end Cavity Preparation & Filling is usual
    • • Flap Repositioning and Suturing
    • • Postoperative Care and Instructions
    • • Tissue specimen to Oral Path
    • • Suture Removal
    • • Follow-up
  31. FLAP DESIGNS FOR ACCESS
    • • Semi - Lunar or Curved Submarginal Flap
    • • Ochsenbein - Luebke or Scalloped Submarginal Triangular or Rectangular Flaps
    • • Full Mucoperiosteal Flap MORE ACCESS THAN FOR PERIO SURGERY
  32. RESECTION (APICECTOMY)
    • • Removal of root tip including:
    • lateral canals, apical delta, infected cementum
    • • Remove >= 3 mm
    • horizontal
    • pack with COLLAPLUG (CALCITEK): resorbable collagen
  33. ROOT-END FILLING MATERIALS
    • (also used for perforation repair)
    • • Amalgam
    • • Reinforced ZOE, e.g. Super EBA
    • • Resin-Composite + DBA
    • • MTA, Mineral Trioxide Aggregate
    • • Resin-Modified Glass-Ionomer, e.g. Geristore
  34. ROOT AMPUTATION
    • I: Localized bone loss
    • I: Localized endodontic failure
    • I: Localized root fracture
    • CI: Insufficient remaining support
    • CI: Insufficient remaining tooth structure
    • • Usually on MB root upper molars
    • • Angled cut, cleansable profile
    • • New restoration needed
    • • Sequellae include fracture and caries
  35. Localized bone loss
    • I: Localized endodontic failure
    • I: Localized root fracture
    • CI: Insufficient remaining support
    • CI: Insufficient remaining tooth structure
    • • Usually on lower molars
    • • Vertical cut at expense of unwanted part
    • • New restorations needed
    • • Sequellae include fracture and caries
  36. BICUSPIDIZATION
    • I: Localized furcal bone loss - perio
    • I: Localized furcal bone loss - endo
    • I: Localized furcal caries
    • CI: Remaining perio or endo disease
    • CI: Insufficient remaining tooth structure
    • CI: Anatomy (fused roots etc.)
    • • Vertical cut to create 2 premolars
    • • Usually on lower molars
    • • New restoration needed
  37. retrograde periodontitis
    Periodontal tissue destruction from apical foramen migrate from apex to CEJ
  38. Laterial canals are very frequently found:
    • Posterio > Anterior
    • Apical 1/3 > Coronal 1/3
    • Also located in furcation of molars (30%)
    • route for 1’ endo lesions to cause periodontal breakdown.
  39. Do teeth with severe periodontitis require root canal therapy?
    no clinical evidence that periodontal disease cause pulpal inflammation
  40. Recommend EXT for VRF if:
    • Narrow probing >5mm.
    • Mobile fragments.
    • Radiographic lesion.
    • Patient does not want any RISK.
  41. Recommend endodontic treatment for VRF if:
    • No/little probing defect.
    • Crack does not enter root canal.
    • No radiographic lesion
  42. HRF does not allow communication to periodontium.
    True
  43. endo-perio DDX Symptoms
    • Endo lesion
    • 1. Localized
    • 2. Often associated with severe pain
    • 3. May have temperature sensitivity
    • Perio lesion
    • 1. Generalized and diffuse discomfort
    • 2. Little or no pain
  44. endo-perio DDX Clinical appearance
    • Endo lesion
    • 1. Coronal defects - caries & failing large restoration
    • Perio lesion
    • 1. No coronal defect
    • 2. Inflamed gingiva, plaque, calculus
  45. endo-perio DDX Radiographic Appearance
    • Endo lesion
    • 1. Coronal Defect: Caries, failing restoration, fracture
    • 2. Bony lesion extends from apical to cervix (retrograde perio).
    • 3. Bony defect is localized
    • Perio lesion
    • 1. Generalized bone loss
    • 2. Multiple teeth involved
    • 3. No coronal defect
    • 4. Bony lesion extends from cervical to apex.
  46. endo-perio DDX VITALITY:
    • Endo lesion
    • 1. May or may not be vital, but
    • 2. For Endo-Perio cases, it is mostly non-vital.
    • Perio lesion
    • 1. Vital.. very vital.
  47. endo-perio DDX Palpation & Percussion
    • Endo lesion
    • 1. Depends on periradicular status.
    • Perio lesion
    • 1. Generally non-responsive
  48. endo-perio DDX Periodontal Probing
    • Endo lesion
    • 1. None.
    • 2. If sulcular drainage, narrow probing down to apex.
    • 3. If VC or VRF, narrow probing down to the level of crack.
    • Perio lesion
    • 1. Generally increased. Broad attachment loss.
    • 2. Multiple teeth involved.
    • 3. Usually does not extend to apex
  49. Presents both characteristics of Endo & Perio lesions
    • 1. Loss of vitality
    • 2. Generalized bone loss
    • 3. Mobility
    • 4. Failing restoration
    • 5. Gingival inflammation
    • 6. Caries
  50. Endo-perio combined lesions
    • Treatment:
    • 1. RCT first then Perio follow-up.
    • 2. Pulpal infection will continue to feed infection to
    • periodontium.
    • Prognosis:
    • 1. Bony defect from Endo lesion will regenerate.
    • 2. Periodontal defect is irreversible.
  51. most endo failure caused by:
    procedural, operative errors
  52. missed canals
    • MB2 or ML canals of Max. Molars
    • 2nd D canals of Mand. Molars
    • 2nd canals of Mand. cuspids, bicuspids, and anterior teeth
    • 2nd and 3rd canals of Max. bicuspids
  53. HOW MUCH REMAINING DENTIN THICKNESS IS NEEDED ?
    • • 0.5 mm (Stanley V Cox)
    • • SUBCLINICAL EXPOSURE
    • • CONTAMINATION
    • • PRIOR INSULT
  54. The diameter of the tooth bulk in the same direction as the applied force is most important for fracture resistance.
    • true
    • Posts tend to move the site of fracture _____
    • apically
    • Stress tends to be concentrated at the apical termination of the post
  55. HOW SHOULD THE POST SPACE BE MADE ?
    • 1 Heated instrument
    • 2 Gates Glidden
    • 3 Post drill / Peeso
  56. HOW LONG SHOULD THE POST SPACE BE ?
    • > Clinical Crown
    • • 4 - 6 mm GP remaining
    • • Compromise on length
    • • Parallel post design
    • • Resin post cement
    • • << 1/3 root width
  57. HOW MUCH TOOTH STRUCTURE IS NEEDED ?
    AT LEAST 2mm ABOVE THE CROWN MARGIN
  58. CAST TAPERED
    • + Strong + Non-corrosive
    • - Wedging effect
    • - Poor retention
    • - Dentin removal
    • - Extra appointment
    • - Expensive
  59. CAST (mostly) PARALLEL
    • + Strong + Non-corrosive + Good retention + No wedging effect + Conservative
    • - Extra appointment - Expensive
  60. PREFABRICATED
    • + Good retention + No wedging effect + Conservative + Fast + Inexpensive
    • - Weaker
    • - Less well adapted
    • - Shoulder ?
  61. Increased retention of prefab posts
    • serrated over smooth
    • long over short
    • wider posts NOT MORE RETENTIVE
  62. NON-VITAL BLEACHING STEPS
    • • Barrier to protect PDL & prevent resorption
    • • Glass-ionomer base over the RCT
    • • Sodium perborate with water / local
    • • Mix into a thick slurry, pack
    • • Temporize • Do not use superoxyl (resorption)
    • • Do not use heat ( resorption)
    • • Change weekly
    • • Effective on blood breakdown products
    • • Ineffective on tetracycline, metal oxides
  63. Conditions Demand Avoidance of Surgery:
    • ● Bleeding Disorders
    • ● Head & Neck Radiation
    • ● Bisphosphonate Therapy
  64. Maximizing Endodontic Prognosis Rests on:
    • elimination of microorganisms (bacteria) from infected root canals
    • GOAL of RCT: eliminate, SEAL
  65. ENDO Success
    • Clinical
    • • No symptoms
    • Radiographic
    • • Contours and width or PDL are normal
    • • PDL contours are widened mainly around excess root filling
    • • Lamina dura intact
  66. ENDO Failure
    • Clinical
    • • Symptoms present
    • Radiographic
    • • Little or no reduction in periradicular rarefaction
    • • Decrease in periradicular rarefaction, but no resolution
    • • Appearance of new rarefaction or an increase in the size of initial rarefaction
    • • Broken or poorly defined lamina dura
  67. ENDO UNCERTAIN OUTCOME
    • Uncertain
    • Radiographic
    • • Ambiguous or technically unsatisfactory radiograph which could not be interpreted with certainty
    • • Periradicular rarefaction less than 1 mm and broken lamina dura
    • • Tooth was extracted prior to recall due to reasons not related to endodontic outcome
  68. ‘Strict’ vs. ‘Functional’ Success
    • • Strict – no detectable disease
    • • Functional – tooth functions without clinical symptoms
  69. Healed-Functional*
    Asymptomatic teeth with no or minimal radiographic periradicular pathosis
  70. Functional
    treated tooth or root that is serving its intended purpose in the dentition
  71. Nonhealed- Nonfunctional
    Symptomatic teeth with or without radiographic periradicular pathosis
  72. Healing
    • Teeth with periradicular pathosis, which are asymptomatic and functional,
    • or
    • teeth with or without radiographic periradicular pathosis which are symptomatic but whose intended function is not altered.
  73. Factors Associated with the Outcome of Endodontic Treatment
    • • Patient associated factors
    • Motivation and compliance with care
    • Age - related conditions ?
    • Systemic diseases
    • • Diabetes
    • Other factors
    • • Smoking
    • • Xerostomia
    • Periapical OSteitis
    • NOT Relevant
    • HIV
  74. Surgical and Nonsurgical Procedures
    • NO systematic difference in outcome of surgical and non-surgical treatment.
    • • 12-month recall, a statistically significant (p<0.05) higher healing rate was observed for cases surgically retreated.
    • • At the final 48-month recall, no such difference was found.
    • • Slower healing dynamics of re-treatment group.
    • • Late failures in surgical group.
  75. SURGERY CONCLUSIONS
    • • Always retreat before surgery
    • • Extract instead of re-surgery
  76. post and core prostheses had a substantially lower rate of complications than either fixed partial dentures or implant prostheses
    True

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