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TREATMENT OF

PULPAL & PERIAPICAL DISEASES

Pathway of the pulp,8th edition

By: karlina yusac 1


DENTAL EVALUATION

ØPeriodontal
considerations
ØRestorative
considerations
ØEndodontic
considerations
ØSurgical considerations
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ERIODONTAL CONSIDERATIONS

•Periodontal probing
•Mobility assessment
•Radiographic assessment
•Endodontic treatment should
not be planned for teeth with
poor periodontal prognosis
( e . g . mobility III )

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ESTORATIVE CONSIDERATIONS
RESTORATIVE

qRestorative treatment planning before


starting endodontic treatment in a
nonemergency situation
•Extensive loss of tooth structure
•Subosseous root caries (crown
lengthening may be needed)
•Poor crown-root ratio
•Lack of ferrule effect
•Misaligned tooth
qConsultation with a prosthodontist
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ENDODONTIC CONSIDERATIONS

vAnatomy of roots and canals


vProcedural errors
vSmall mouth
vInstruments
vOperator skill
vTime
qTo determine the level of anticipated
difficulty
qTo identify cases that should be
referred
q 5
SURGICAL CONSIDERATIONS

•Of particular value in the diagnosis of


nonodontogenic lesions
•Biopsy prior to definitive endodontic
treatment

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TREATMENT PLANNING

Scope of endodontics
§Vital pulp therapy
§Pulpectomy or RCT
§Endodontic surgery
§Retreatment
§Hemisection or root
amputation
§Bleaching
§Apexification or
apexogenesis 7
TREATMENT PLANNING

vTreatment or extraction?
vWhat kind of treatment ?
§Endodontic
§Periodontal
§Restorative
vWho will be the operator?
vSingle-visit or multi-visit?
vCost
vPrognosis

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EPARATION FOR TREATMENT

ØInfection control
§Universal precautions(operatory
preparation)
§Instrument sterilization
§Tooth isolation
ØPatient preparation
§Informed consent
§Pain control
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ECTION CONTROL GUIDE LINES

qDental personnel vaccinated against


hepatitis B
qThorough and updated patient medical
history
qProper barrier techniques for dental personnel
•Masks, protective eyewear, disposable
latex gloves
•Hands, wrists and lower forearms washed
with soap
•Use of vacuum suction (high-volume
evacuation) 10
for high-speed handpiece, water spray or
Reason for use of
Rubber dam
qProtection
§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
qReduced risk of cross -
contamination 11
qLegal considerations
INFORMED CONSENT

qContinuous rise in dental litigation


qFor consent to be informed
§The procedure and prognosis must
be described
§Alternatives to the recommended
treatment must
be presented along with their respective
prognoses
§Foreseeable risks must be described
§Patients must have the opportunity
to have 12
questions answered
PAIN CONTROL

oLocal anesthesia
oDivitalization

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Local Anesthesia (LA)
•When to anesthetize
ØLA 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 TREATMENT

Pretreatment emergency
•Irreversible pulpitis without acute apical
periodontitis
•Irreversible pulpitis with acute apical
periodontitis
•Pulp necrosis with acute apical periodontitis

Pathways of the pulp, 8th edition


Principles and practice of endodontics, 215th
edition
eversible pulpitis without AAP

Principles:
•Complete pulp removal
•Total cleaning and shaping (C/S) of
the
root canal system
•Pulpectomy is the best to achieve
pain
relief
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Irreversible pulpitis without AAP

•Multirooted teeth at the emergency


visit
Pulpotomy (removal of the
coronal pulp) or partial
pulpotomy (removal of the pulp
from the widest canal) acceptable
but less predictable in pain
relief
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Irreversible pulpitis with AAP

Combination of pulpal and periapical


symptoms
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 when
necessary 18
Pulp necrosis with AAP

•Without swelling
•With localized swelling
•With diffuse swelling

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Without Swelling

•Thorough removal of necrotic pulp


•Complete C/S of the root canal
ØIntroducing a small file (#10/15)
slightly beyond the apex to
establish drainage from the
periapical tissues
•Ca(OH)2dressing between visits to help
eliminate remaining bacteria
•Oral analgesics
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With Swelling

Principle :
debridement and drainage
Three ways to resolve swelling and
infection
§Drainage through the root canal
§Drainage by incising a fluctuant
swelling (incision and drainage,
I &D )
§Antibiotic treatment
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Localized Swelling

Firstly try to establish drainage from


root 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 whenever
possible
§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 systemic
signs
§Penicillin (1st choice) or
clindamycin or
erythromycin + Metronidazole

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Endo-Perio Interrelationship

•Clinical signs and symptoms



qPeriodontal abscess
Ømarginal / diffused
•dull-even pain, fullness
“high”

qPupal abscess
•radicular
•rapid onset
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•acute pain, severe discomfort
Endo-Perio Interrelationship
Clinical Signs and
Symptoms :

Pain 27
Endo-Perio Interrelationship

X-ray taken with GP in sinus tract

Radiolucenc 28
Endo-Perio Interrelationship

Probing-search motion & light force

Pocket 29
Treatment Sequence

Based on the condition of


the pulp :
VITALITY TREATMENT
qVITAL PERIO
q
qNON VITAL ENDO
ENDO + PERIO

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Treatment Sequence

Based on the COMPLEXITY :


LESSION
TREATMENT
§Combined Endo first
§Doubt Endo first

Why endo first ???

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Treatment Sequence

Why endo first ???


1.Significantly better
prognosis
2.Dramatically osseus fill-in
3.Minimal post treatment
sequelae

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SUMMARY
qPulpal status always dictates treatment of
periapical disease .
qDrainage of abscess should be performed before
endodontic
treatment .
qEndodontic treatment should be done first
prior to
periodontic treatment .
qApical healing regardless of marginal
periodontitis .
Ma rginal healing influenced by pulpal
infections .
qThe objectives of treatment are : 33
THANK
YOU 34

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