Академический Документы
Профессиональный Документы
Культура Документы
INTRODUCTION
CHAPTER II
LITERATURE REVIEW
The pain is of very short duration and does not linger after the stimulus has
been removed.
In irreversible pulpitis:
There is often a history of spontaneous bouts of pain which may last from a
few seconds up to several hours.
When hot or cold fluids are applied, the pain elicited will be prolonged. In the
later stages, heat will be more significant; cold may relieve the pain.
Pain may radiate initially, but once the periodontal ligament has become
involved, the patient will be able to locate the tooth.
The tooth becomes tender to percussion once inflammation has spread to the
periodontal ligament.
has to achieve a hermetic filling which is the crucial stage to obtain a successful
endodontic treatment. (Ray A, 2009)
Root canal treatment consists, in major part, of cleaning and shaping the root
canal with files and reamers, either hand driven or motor driven, disinfecting the
canal, and then obturating the canal space. On occasion endodontists also prepare
post space and place posts for the referring dentist. Generally a root canal treatment
consists of pulp capping, pulpotomy, and pulpectomy. (Ray A, 2009)
completion. In addition, during the root canal preparation and obturation phases of
treatment, clinical criteria are essential to identify the achievement of an adequate
root canal obturation (Ray A, 2009).
It should be radiopaque.
It should not stain tooth structure.
It should not irritate periapical tissue.
The purpose of a sealant is to fill the spaces between increments of the bulk
fill material and to improve the quality of adaptation of the composite of sealant and
bulk fill to the walls of the root canal by filling the irregularities and minor
discrepancies between gutta percha and canal wall to help to maintain the seal around
the root filling (McCabe and Walls, 2008).
Functions of root canal sealers are as antimicrobial agent, helps in filling the
discrepancies between the filling material and the dentin walls, as a binding agent
between the filling material and the dentin walls, and as a lubricant and gives
radioopacity (Henston, et al., 2012).
The sealers are responsible for the principal functions of the final root filling,
sealing off of the root canal system, entombment of remaining bacteria and the filling
of irregularities in the prepared canal. Several, quite different chemical formulations
have served as bases for root canal sealers. They are essentially thin pastes that can be
both introduced into the canal system and used to coat the bulk fill material. The
setting time should extend over hours rather than minutes to allow for exacting
clinical technique (McCabe and Walls, 2008)
Root canal sealers can be classified according to the chemical composition
(Ingle): Zinc oxide-eugenol based cements, Calcium hydroxide containing cements,
Resin based cements, Glass Ionomer based cements, and experimental sealers. It can
also be classified according to Clark into absorbable and non-absorbable (Henston, et
al., 2012).
Grossmans ideal requirements of root canal sealer are:
1. Tacky which helps for good adhesion between it and the canal wall when
set.
2. Provide a hermetic seal.
3. Radiopaque to be seen in the radiograph.
4. easy to manipulate.
5. No shrinkage on setting.
6. No staining to tooth structure.
7. Bacteriostatic.
8. Set slowly.
9. Insoluble in tissue fluids.
10.Biocompatible.
11.Soluble in a common solvent.
12.Neither mutagenic nor carcinogenic.
13.Not provoke an immune response in periradicular tissue (Henston, et al.,
2012).
Adhesion of a root canal sealer means its capacity to attach to the dentinal
walls of the root canal provide bonding between it gutta percha. Bonding of root
canal sealer is carried out through 2 mechanisms. One of it is mechanical
interlocking. Sealer penetration (resin based) into the dentinal tubules resin tags. The
other is chemical reaction between sealer and dentin. The polyacrylic acid matrix of
GIC contains multiple ionized carboxylate groups than can chelate with calcium in
the mineral phase of dentin (Henston, et al., 2012).
their longer term solubility in sustaining this seal. These sealers are claimed to have
antimicrobical effects and biologic properties that stimulate a calcific barrier at the
apex, although these characteristics have not been conclusively and completely
demonstrated (Dagorstavik, 2005; McCabe and Walls, 2008). CaOH based cements
displayed no bonding on both dentin and gutta percha (Henston, et al., 2012).
One of the Glass Ionomer based cements, Ketac Endo is a GIC modified in its
properties by a group at Temple University to be used as cement into the canal. It was
introduced in Dentistry by Wilson and Kent in 1971 as a restorative material. In 1991,
it was introduced as root canal sealer. It provides favorable biological, chemical &
physical properties. It is very biocompatible. The glass ionomer sealer is known to
bond to dentin but may also bond to gutta-percha, because the polycarboxylic acid of
the glass ionomer may react with the zinc component of gutta-percha in a manner
similar to the polycarboxylate cements that have already been used as endodontic
sealers (Henston, et al., 2012).
In choosing a sealer, find a sealer that can seal the canal totally, well tolerated
by periradicular tissue, and inhibit microbial growth (Henston, et al., 2012).
much as it is needed. Morerover, the applicated sealer must have a minimal toxicity
level to prevent more damage when an overfilling occurs. (Banu K, 2006)
The use of a filling substance containing formaldehyde or paraformaldehyde
should be avoided because this substance can produce damaging effects to the patient.
Endodontic treatment of the first molar distal dental root, and on both mandibles, as
well as the dental root of premolar both mandibles should be carefully done because
the anatomical form of those roots are close to mandibular canal. The operator should
be careful to choose a filling substance from paste texture, because it is really difficult
to control while pouring it to the root canal (Banu K, 2006).
2.8.1 Gutta-Percha
The most widely used bulk fill material is gutta-percha. In its pure form gutta
percha is derived from latex as an isomer of rubber known as transpolyisoprene. It
can be produced in two crystalline forms and . It is less elastic and harder than
natural rubber. The form is the natural state and is mainly used in thermoplastic
manipulation techniques whilst the form is produced by cooling material slowly
(at a rate of about 0.5C per hour). The form is more commonly used with cold
packing techniques. (McCabe and Walls, 2008) Gutta-percha as used in dentistry
comprises between 19 and 22% transpolyisoprene, zinc oxide (between 60 and 75%)
and a variety of other components including colouring agents, resins, waxes,
antioxidants and metallic salts; the latter are incorporated to improve the visibility of
the material on radiographs. It is presented to the dentist in either tapered cones which
may or may not be matched to the sizes of the instruments used to prepare the canal
mechanically or as pellets of material to be loaded into a gun-type delivery system.
(McCabe and Walls, 2008)
CHAPTER III
CASE REPORT
3.2 Anamnesis
A male patient aged 22 years came to RSGM with a chief complaint of his anterior
tooth which has a deep dull throbbing pain; it is also very sensitive to cold and hot
liquids. He also complain that the teeth affect his social appearience and it is difficult
to clean his teeth. The patient is healthy in general and without any history of
systemic disease. The patient was not on any medication throughout the dental
treatment.
3.3 Medical Data
Blood group : O
Blood pressure : 110/70 mmHg
Heart disease : No
Diabetes mellitus : No
Haemophilia : No
Hepatitis : No
Others : No
Allergic to medicine : No
Allergic to specific food : No
Diagnosis
Per
-
Pres
-
M
-
Pal
-
Irreversible pulpitis
3.7 Diagnosis
Irreversible pulpitis due to caries profunda on tooth 11
3.9 Treatment
First visit (28 May 2015)
Upon the routine subjective, objective, and radiographic examinations, informed
consent was achieved, and patient was willing to give his consent. Diagnosis was
made based on radiograph and clinical examination which includes vitality tests
(Cold-test), sondasi test (direct stimulation to exposed dentin), percussion and
pressure test, test on mobility and palpation, and on the authors dental knowledge of
patients medical and dental history, the author have taken into consideration any
information the patient have given. In addition, this treatment modality was chosen
because the patient was young and willing to give his compliances throughout the
procedure.
Informed consent was made after discussing all available treatment options
and outcomes. Patient has agreed to continue his treatment after knowing all the
possible dental complication during and after the procedures, which include damage
or loss of tooth structure in gaining access to the canal, fracture of tooth structure, and
change in tooth color (becoming darker than adjacent teeth). During treatment,
complications may be discovered which make endodontic treatment impossible, or
which may require microsurgery or extraction. These complications may include
blocked canals due to fillings or prior treatment, natural calcifications, curved roots,
periodontal disease, and split or fractures of the tooth. Patient was informed that the
treatment may make take several visits over a few weeks to complete. Treatment will
be performed in accordance with accepted methods of clinical practice. He is also
well informed that he will undergo taking of a minimal number of radiograph photos
as dictated by the requirements of the case. Patient also understand that the use of
anesthetic can cause numbness and tingling of the lip, chin and/or tongue which may
be temporary or permanent. He must know the nature of the problem causing the need
for treatment: that is the nerve tissue within the tooth is dying and causing potential
risk of infection in the bone surrounding the tooth. He also understands the reasons
for treatment: the removal of the nerve tissue is to relieve or prevent infection.
Upon application of local anesthetic, patient was evaluated with blood
pressure (110/70mmHg), pulse rate (87/min) and respiration rate (18/min), which
appeared to be in normal range. Procedure was began with a buccal infiltration at
region 11, and followed by proper isolation of the working site with cotton roll at the
labial aspect to the aid of saliva suction, and patient was asked to bite on a biteblock
to ensure minimal saliva contamination. Access cavity to the pulp was made using a
high speed endodontic access bur and removal of the pulp chamber roof done at a
slow speed, and the orifice can be seen at the palatal site of tooth 11. Coronal pulp
was removed, the canal is easily located as this is an incisor, and then the pulp and its
inflamed tissue was extirpated from the canal with barbed broach file under constant
irrigation. Copious irrigation was carried out using sodium hypochlorite solution
(NaOCl) which helps to remove remaining organic tissues. The barbed broach was
inserted into the root canal as far as possible without forcing it and then turn it a full
360, later was pulled upwards removing the pulpal tissues. The broach was inserted a
few times and winds it around in order to remove all the pulpal tissues completely.
After finishing the mechanical preparation and rinsing, the root canal was dried with
sterile paper points. The cavity was covered with paper point dipped with eugenol,
temporary filling was used to cover the cavity, and patient was sent back.
Isolation of the working site with cotton roll at the labial aspect was done before the
temporary filling was removed. Working length was determined by using apex
locator, which is 25mm. Copious irrigation was carried out using sodium
hypochlorite solution.
The coronal two-thirds of the canal was explore with No. 10 and 15 k-files,
using a reciprocating back and forth motion. The instruments were worked passively
and progressively until they were loose. Then, cleaning and shaping of the root canal
were continued with a crown-down technique using protaper .When a smooth glide
path to the terminus is verified, sequentially carry first SX then S1, S2, F1, and F2 to
the full working length. The operator irrigates, recapitulate and re-irrigate after each
protaper instrument. After finishing the mechanical preparation and rinsing, the root
canal was dried with paper points. The cavity was covered with cotton pellet with
calcium hydroxide and temporary filling, and patient was sent back.
Figure 3.1 (Left) Clinical findings of the patient. (Right) Radiograph photo of tooth
11.
Figure 3.5 Radiograph photo after obturation with gutta-percha and endomethasone,
and covered with glass ionomer layer.
CHAPTER IV
DISCUSSION
The diagnosis of a tooth is most important in deciding the treatment plan of a
tooth. In this case, a vital pulpectomy was decided in the initial stage in order to
preserve the tooth. The cavity of the tooth was sufficiently deep from mesial and
distal sides. The patient did not have much complaint except that food sometimes got
stuck in the cavity of the tooth and there was spontaneous throbbing pain. All
symptoms like spontaneous throbbing pain as if tooth is under constant pressure and
patient is often awake at night due to pain indicated the late stage of irreversible
pulpitis. In cases, of irreversible pulpitis, it is impossible to maintain the vitality of
the pulpal tissues. At this stage of the inflammatory process, vital extirpation of the
pulp is the treatment of choice. The proper diagnosis is most important in this case so
that there would be no delay in the treatment of vital pulpectomy.
The proper diagnosis is most important in this case so that there would be no
delay in the treatment of vital pulpectomy. Episodes of short duration pain may be felt
occasionally during earlier stages of dentin caries. These pains are due to stimulation
of pulp tissue by movement of fluid through dentinal tubules that have been opened
to the oral environment by cavitation. Once bacterial invasion of the dentin is close to
the pulp, toxins and possibly even a few bacteria enter the pulp, resulting in
inflammation of the pulpal tissues. Initial pulpal inflammation is thought to be
evident clinically by production of sharp pains, with each pain lingering only a few
seconds (10 or less) in response to a thermal stimulus. A short, painful response to
cold suggests reversible pulpitis or pulpal hyperemia. Reversible pulpitis, as the name
implies, is a limited inflammation of the pulp from which the tooth can recover if the
caries producing the irritation is eliminated by timely operative treatment. When the
pulp becomes more severely inflamed, a thermal stimulus will produce pain that
continues after termination of the stimulus, typically longer than 10 seconds. This
clinical pattern suggests irreversible pulpitis, when the pulp is unlikely to recover
after removing the caries. Throbbing, continuous pain suggests partial or total pulp
necrosis that is treated only by root canal therapy or extraction (Roberson et al.,
2002).
In this case, the patient present with multiple class III caries. This is due to
malallignment of tooth that favors the accumulation of plaque. Furthermore the
patient has a bad oral habit and does not use the aid of dental floss or interdental
brush. Tooth 12, 21 and 22 are pulpitis reversible that will be treated with class III
composite filling. Tooth 11 is diagnosed with irreversible pulpitis. The transition from
reversible into irreversible pulpitis is indistinct and the definitive diagnosis is often
very difficult. With reversible pulpitis, the caries has not yet opened into the pulp.
The dentists reaction to the definitive diagnosis must be to pursue a goal of
maintaining the tooths vitality while simultaneously eliminating the patients pain
(Beer, 2008).
Vital pulpectomy is the removal or extirpation of the vital pulp to or near the
apical foramen (Ingle and Bakland, 2002). According to Ingle and Bakland (2002),
and Salman and Ahmed (2006), a vital pulpectomy is indicated in cases with
strategically located tooth with accessible canals and essentially normal supporting
bone. However, it is contra-indicated in cases with non-restorable tooth, internal /
external resorption, teeth without accessible canals, and significant bone loss. In this
case, vital pulpectomy is considered the choice of treatment because there are clinical
signs indicating irreversible inflammatory changes in the pulp, and also radiograph
that shows no internal / external root resorption and a strategically located tooth with
an accessible canal and sufficient supporting bone.
According to Edionwe, et al. (2014), it was observed that teeth with single
canal showed the least tendency for post-operative pain followed by teeth with two
canals and then three canals. Teeth with four canals had the highest tendency to
develop postoperative pain. Anterior teeth had the highest success rate at 6 months
review of 100%, while that of premolars and molars were 85.7 and 91.7%,
respectively. This may due to the predictable canal anatomy in incisors.
Furthermore, single canal being larger in size, in location easier to access and
clean. In this case, the author assume the prognosis is excellent due to studies which
show the success rate for teeth with pre-operative diagnosis of irreversible pulpitis
was found to be 100%. (Edionwe, et al., 2014) From a biological point of view, the
treatment of a tooth by pulpectomy is simple. It is the technique to gain access to the
root canals. The pulp tissue is removed and the root canal is filled with a material or
materials that are biocompatible and provide a long-lasting, bacteria-tight seal of the
canal. If this is achieved, the tooth will remain healthy and functional. Thus, a
pulpectomy may be carried out in all teeth with vital pulps, and the only limitations of
the method would be possible practical ones like an unusually complicated
morphology of a tooth. Considering the complexity of the root canal system,
pulpectomy treatment is amazingly successful, and a success rate of 9095 % is
within reach when optimal methods are used. (Tronstad, 2003)
denature proteins found in the root canal, thereby making them less toxic. Because of
the high pH of the material, up to 12.5, a superficial layer of necrosis occurs in the
pulp to a depth of up to 2 mm. Finally, calcium ions are an integral part of the
immunological reaction and may activate the calcium-dependent adenosine
triphosphatase reaction associated with hard tissue formation (Carrotte, 2004).
The irrigant in this case was the golden standard irrigant, sodium
hypochlorite (NaOCl), which is still the most popular intracanal irrigating solution
currently in use. It is both antimicrobial and able to break down tissue, which is
useful in vital cases. Unlike sodium hypochlorite, the extrusion of iodine and
chlorhexidine is thought to be more forgiving to the soft tissues as they do not
dissolve organic tissues. When hypochlorous acid, a substance present in NaOCl
solution, comes in contact with organic tissue it acts as a solvent and releases
chlorine, which combines with the protein amino group to form chloramines. The
chloramination reaction between chlorine and the amino group (NH) forms
chloramines that interfere in cell metabolism. Chlorine (a strong oxidant) has an
antimicrobial action, inhibiting bacterial enzymes and leading to an irreversible
oxidation of SH groups (sulphydryl group) of essential bacterial enzymes. Thus, the
saponification, amino acid neutralization, and chloramination reactions that occur in
the presence of microorganisms and organic tissue lead to the antimicrobial effect and
tissue dissolution process. (McCabe and Walls, 2008)
Based on this theory, the author used sodium hypochloride as the irrigant
medium in this case. Canal was cleaned to at least to the estimated working length
obtained from apex locator. The root canal was then prepared employing the crown
down technique using protaper to create a funnel shape. At the post-obturation review
appointment, patient was reviewed for pain, swelling, mobility, tenderness to
percussion, and periapical radiolucency. No complaint was reviewed, and patient was
satisfied with the treatment outcome. The tooth was followed with pro-post and core
treatment in prosthodontics department.
CHAPTER V
CONCLUSION
In this case, the patient present with multiple class III caries. The patient was
given oral health education and oral hygiene instruction to brush the teeth with a
rolling method to prevent interdental plaque accumulation. He is also advice to use
the aid of dental floss or interproximal brush to maintain clean interproximal areas
and to prevent further caries. Tooth 11 is diagnosed with irreversible pulpitis and was
successfully treated with vital pulpectomy.
REFERENCES
American Academy of Pediatric Dentistry. 2014. Guideline on Pulp Therapy for Primary and
Immature Permanent Teeth. Volume 36. No.6. pp 14-15.
Banu, K., et al. 2006. Anesthesia following overfilling of a root canal sealer into the
mandibular canal: A case report. Istanbul University. Turkey. Available online at :
http://www.orocentro.com.br/files/file-250416492.pdf
Beer, R. 2008. Pocket Atlas of Endodontics. Thieme
Bergenholtz, G.; Horsted-Bindslev, P.; Reit, C. 2003. Textbook ofendodontology. Blackwell
Publishing.
Carrotte, P. 2004. Endodontics: Part 9 Calcium Hydroxide, Root Resorption, Endo-perio
Lesions. England. British Dental Journal 2004. Vol. 197. pp 735 743.
Carrote, P. 2004. Endodontics: Part 3 Treatment of Endodontic Emergencies. England. British
Dental Journal 2004. Vol. 197. pp 299 305.
Dagrstavik. 2005. Materials used for root canal obturation: technical, biological and clinical
testing.
Endodontic
Topics
1601-1538.
Available
online
at
:
http://www.rpcendo.com/45va9r1lkl7/Modulo3/PDF12.pdf
Edionwe, J.I.; Shaba, O.P.; Umesi, D.C. 2013. Single visit root canal treatment: A prospective
study. Nigerian Journal of Clinical Practice. May-June 2014. Vol. 17. Issue 3.
Gunnar, B.; Bindslev, P.H.; Reit, C. 2010. Textbook of Endodontology 2nd ed. John Wiley &
Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United
Kingdom.
Henston, J.D.L.; Nitin, S.; Subhash, C.; Shamsher, S.; Raina, D.S. 2012. Root Canal Sealers &
its Role in Successful Endodontics A Review. Mind Reader Publications. Annals of
Dental Research. Volume 2 (2). Pp 68-78.
Ingle, J.I.; Bakland, L.K. 2002. Endodontics 5th ed. BC Decker Inc.
Martin, T.; Debelian, G. 2005. Endodontics manual for the general dentist. Quintessence.
McCabe, J.F.; Walls, A.W.G. 2008. Applied dental materisls. 9th ed. Blackwell Publishing.
Rahman, H.; Chandra, A.; Tikku, A.P.; Konwar, R.; Verma, P.; Yadav, R.K. 2012. Comparative
evaluation of cytotoxicity profile of different root canal sealers in vitro. Indian
Endodontics Society. Vol. June 2012.
Ray, A., et al. 2009. Endodontics: Colleagues for Excellence. Published for the Dental
Professional Community by the American Association of Endodontists. Available
onlineat:http://www.aae.org/uploadedfiles/publications_and_research/endodontics_co
lleagues_for_excellence_newsletter/fall09ecfe.pdf
Roberson, T. H. Heymann. E.J Swift Jr. 2002. Studervants Art and Science of Operative
Dentistry. 4th Edition. Mosby Inc.
Salman, A.M.; Ahmed, Y. 2006. Guideline on pulp therapy for primary teeth. Bahrain Dental
Society Newsletter. March 2006. Vol. 1, Issue 4.
Tronstad, L. 2003. Clinical endodontics: A textbook. 2nd ed. Thieme.