Treatment of acute and chronic periodontitis.

Basic principles and medication

Therapeutic dentistry department Sukhovolets I.O.

Periodontitis
Can be acute and chronic. Acute forms: 1. Serous 2. Purulent Chronic forms: 1. Fibrous 2. Granulating 3. Granulematouz

How to choose the treatment tactics?

It depends on: - General condition of the patient - Etiology and pathogenesis of pathological process - Type of periodontitis (acute or chronic)

Acute periodontitis treatment.

The main aim is:

To keep anatomical and functional completeness of tooth we are going to treat To remove the inflammation and infected tissues with accurate instrumental, medicamental root canal treatment

Acute periodontitis treatment. We have to:

Remove the pain Make conditions for exudation leakage!!! Antibacterial and anti inflammation treatment Stop the inflammation expansion in surrounding tissues Renew the anatomical form and function of the tooth

Treatment steps:
First visit: 1. Anaesthetization (if patient need it) 2. Mouse washing with antiseptics solution 3. Opening the carious cavity and tooth cavity (pulp chamber) 4. Orifice opening and widening 5. Length determination 6. Removing purulent exudation from the root canals 7. Medicamental cleaning of the root canal

First visit: recommendations

Mouse washing with antiseptic solutions 46 times for a day Anti inflammation drugs Antibacterial therapy (in some cases) Analgetics (in some cases)

Second visit:
1. X-ray for root canals visualization 2. Antiseptic oral washing 3. Removing of the temporary filling 4. Careful carious cavity preparation 5. Root canal cleaning (irritation) with solutions of antiseptics 6. Root canal widening with endodontic instruments 7. Root canal filling 8. X-ray after root canal filling

Third visit

Removing of the temporary filling Permanent filling

Access cavity preparation

1. 2. 3. 4.

Preoperative carious exposure Dome-ended fissure bur is used to penetrate pulp chamber Roof of pulp chamber removed with round bur Non end-cutting bur is used to 'lift lid' of pulp chamber and refine cavity

The depth of the pulp chamber can be estimated from a preoperative radiograph.

Search the access to pulp chamber and root canals: incisors and canines

Premolars:

Upper molars:

First upper premolar can have two connected canals with one or two apices or just two different canals In 42% medial buccal root of first upper molar has two canals and two apices Lower incisors can have two canals

Lower molars

The completed access cavity gives straight-line access to all the canals.

Root apex.
The average distance between the apical foramen and the most apical part of the root is 0.2-2.0 mm. The constriction can be 0.5-1.0 mm from the apical foramen.

Endodontic instruments:
There are two groups of instruments for root canal cleaning: 1. For coronal preparation 2. For apical preparation Hand instruments Rotary instruments

Instruments for Coronal Flaring

The following rotary instruments are used to prepare the coronal part of the root canal before the main part is prepared by hand instruments. Orifice openers are usually relatively thick in diameter and are consequently not very flexible. They are designed for coronal flaring, and should only be used in the 'straight' part of a root canal. The most common: Gates-Glidden Burs, NickelTitanium Orifice Openers

Left: Gates- Glidden burs Right: The Profile orifice openers

Hand instrument for apical preparation

K-files K-Flex files Flexofiles Hedstroem files Protapers

Colors and Sizes of Endodontic Files

Endodontic instruments

Rotary endodontic instruments

Rotary endodontic instruments manufactured from nickel-titanium are 3-4 times more flexible than equivalent flexible stainless steel instruments. The instruments have a greater taper than standard instruments (0.02 mm per mm), while retaining flexibility. They are designed for use in a continuous rotary action at a slow speed (150-350 rpm). There are now many different systems available, but the basic principles for their use are similar.

The most common rotary systems:

Tapered rotary files are available in tapers of 0.04, 0.06, 0.08, 0.10 and 0.12. Instruments are used in a crown-down manner Profiles and protapers (Dentsply), Quantec (Analytic Endodontics, Glendora, CA, USA), Hero (Micro-mega, Geneva, Switzerland), K3 (Kerr, Bretton, Peterborough, UK) and Greater Taper files, which are essentially used to flare rapidly a pre-prepared pilot channel in the apical part of the root canal.

A range of Profile 0.06 taper instruments

Irrigation

Irrigating solutions are usually delivered using a syringe with a 27 or 28 gauge needle. Care should be taken to ensure that the needle does not bind in the canal and that irrigating solution does not pass into periapical tissues. The role of the irrigant is to remove debris and provide lubrication for instruments. Specifically, an irrigant such as sodium hypochlorite will dissolve organic remnants and, most importantly, also has an antibacterial action.

Irrigation

Ideally irrigation should be performed between each file, at least every two to three files being the minimum. A most effective way of delivering irrigating solutions is through an ultrasonic handpiece. Ultrasonic agitation (acoustic microstreaming) has been shown to be effective at removing debris from canals.

Irrigants should:

Be antimicrobial Have a low surface tension Not be mutagenic, carcinogenic or overtly cytotoxic Possess tissue-dissolving properties Remain active following storage Be inexpensive

Antiseptic solutions for root canal treatment:

Sodium hypochlorite solution 3% or 5-8% Hydrogen peroxide 3-6% Parachlorophenol, or PCP Chlorhexidinum bigluconate 1-2% Furatsilini (Nitrofural) 0,5% Iodine solution EDTA 17% + hydrogen peroxide (1:1) Citric acid 40%

Left: ready to use iodine solution Right: EDTA solution

Monoject syringe, which has a safeended tip

Hand irrigation in a mandibular molar.

1.

Bevelled needle: irrigant forced apically; there is a risk of extrusion if the needle becomes lodged in the canal 2. Monoject tip: irrigant can pass sideways 3. Safe-ended tip: irrigant passes sideways

Root canal cleaning can be finished when:

Root canal is free from infected dentine The form of root canal is conical from the opening to the apex Root canal is clean Root canal is sterile Root canal is dry

Only after all that we can fill the root canal

Obturation has three aims:

to prevent reinfection of the cleaned canal system from the coronal end to prevent percolation of periradicular exudate into the root canal space to seal remaining bacteria within the root canal system.

Requirements before root canal filling

The tooth must be assymptomatic, chemomechanical preparation complete and the root canal dry before a root filling is inserted. Any serous exudate from the periapical tissues indicates the presence of inflammation. If there is persistent seepage, calcium hydroxide may be used as a root canal dressing until the next visit. It is advisable to recheck the canal length in situations of persistent seepage as this may frequently result from overinstrumentation and damage to the periapical tissues.

Filling materials for the root canal:

Fillers -

Metallic (silver, titanium) Non metalic (gutta-percha points, plastic points)

Ideally, a root canal filling material should:

be easily introduced into the root canal not irritate periradicular tissues not shrink after insertion seal the root canal laterally and apically be impervious to moisture be sterile or easily sterilised before insertion be bacteriostatic or at least not encourage bacterial growth be radio-opaque not stain tooth structure or gingival tissues be easily removed from the canal as necessary.

Gutta percha points

Filling materials for the root canal:

Sealers: - With calcium hydroxide (Sealapex (Kerr)) - With zinc and eugenol (Grossmans, Tubliseal (Kerr)) - With synthetic resin (AH Plus (Dentsply)) - With glass-ionomer cement (Ketac Endo (ESPE, Germany))

Zinc oxide eugenol sealer

Kerr's Pulp Canal Sealer is a zinc oxide and eugenol-based sealer with extra working time. It should be mixed carefully to a relatively thick consistency.

Resin sealer

The sealer AH Plus. Equal quantities from each tube are mixed on a paper pad before use.

Ideally, a sealer should:

satisfy the above requirements of a root filling material provide good adhesion to the canal wall have fine powder particles to allow easy mixing or be a two paste system set slowly

Root canal treatment:

Few words about modern concepts of root canal treatment: 1. Silver points are not recommended (especially for frontal teeth) as they do not seal the canal laterally or coronally and may cause tooth or gingival staining. 2. Medicated pastes include N2, Endomethosone, Spad, Kri and are not recommended as they may contain paraformaldehyde, which is cytotoxic.

OBTURATION TECHNIQUES

Cold lateral condensation Warm lateral condensation Warm vertical condensation Thermocompaction (ultrasonic and mechanical) Injection of thermoplasticized gutta percha

Treatment of chronic periodontitis

Chronic periodontitis widened periodontal ligament on the lateral incisor

Chronic periodontitis granulations near lover right incisor

Chronic periodontitis granuloma on the premolar tooth

Treatment of chronic periodontitis:

First visit 1. X-ray for root canals visualization 2. Carious cavity preparation 3. Pulp cavity opening 4. Orifice opening and widening 5. Removing the infected tissues from the root canals 6. Medicamental cleaning of the root canal 7. Root canal widening 8. Root canal filling 9. Temporary filling 10. X-ray after treatment is must have

Treatment of chronic periodontitis:

Second visit: 1. Removing of temporary filling 2. Permanent filling

Endodontic surgery may be needed when:

Canals are not accessible A previous treatment didnt heal A proper diagnosis cannot be made nonsurgically

The most common endodontic surgical procedure is called root-end resection.

Root end resection

Root-end resection involves opening the gum tissue near the tooth, removing the inflamed or infected tissue

Root end resection

and the possible placement of a filling in the root end.

Root end resection

A few stitches are placed in the gum to help the tissue heal.

Root end resection

Over a period of months, the bone heals around the end of the root.

Treatment of chronic periodontitis

Root amputation

This surgery is performed to remove one or more roots of a multirooted tooth without removing the crown. The root and the crown are sectioned lengthwise and removed.

Hemisection

Advance protaper technology in modern root canal treatment

Periodontitis treatment with using profiles

Modern root canal treatment with using protaper technology

Thank you for your attention!