TREATMENT OF CHRONIC APICAL PERIODONTITIS. PRINCIPLES.

INDICATIONS AND CONTRAINDICATIONS

ENGL
Lecture 4,
Year 4 , Semester 7
© 2020 V.Nicolaiciuc
 Treatment of chronic apical periodontitis is one of the
most important problems in modern dentistry. A special
dental literature appears quite a lot of work with the
suggestions on the application of new methods and
conservative treatment of chronic apical periodontitis.
But these methods are not always effective because of
the apical periodontal disease over a long period may not
appear subjectively, at the time, as the pathological process
progresses. There is a need to use of conservative and
surgical treatment.
It should be used more often such conservative-
surgical methods, such as hemisection, amputation of roots
and root-resection. Only such an approach can guarantee a
positive result in the treatment of apical periodontitis.
In chronological aspect, chronic apical periodontitis
developed by 2 ways: conservative and surgical.
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 Conservative methods are based on the effects of
antibiotics and antiseptics on the contents of the root canal.
Despite the advances in dentistry, unfortunately,
conservative methods are not always completely eliminate
the pathological focus in the periodontium (Marchenko,
1967, states that a full recovery in chronic apical
periodontitis have been reported with conservative methods
of treatment, one third (1/3) of treated patients).
Important causes of failure of conservative treatment
are anatomical particularly of roots and poor root canal filling
because of imperfect technique of root canal (60-70% of the
apical periodontitis affects multi-rooted teeth).
Thus, we can say that the main achievement of the
conservative method is to keep the tooth and its functions. A
disadvantage is a small percentage of recover and
maintaining focus of inflammation.

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 The importance of the problem, and many methods of
treatment of apical periodontitis has led to the fact that for
the Unification of the European Society of Endodontics in
1986 adopted Decision protocol for practitioners doctors.
This protocol includes the following recommendations:
1. Data on the disease and tooth, as an important source in the
diagnosis;
2. Diagnosis and treatment plan with a particular emphasis of the
tooth;
3. Preparation of the caries cavity;
4. Isolate the tooth Rubber-Dum sheet to prevent ingestion and
aspiration of endodontic instruments;
5. Removing the roof of the pulp chamber and to create access to
the mouths of the root canal;
6. Measurement of the working length of root canal:
Instrumental treatment of root canal to the apical foramen on 1-1,5
mm from radiographic apex.
Identification
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of the working length of the root canal; 4
 7. Preparation of the root canal
• Removal remains of the pulp (necrotical masses);
• Medical treatment;
• Modelling of the root canal (shape);
8. Root canal irrigation solutions:
• Sodium hypochlorite (2.5-3%);
• Solutia chlorine bleach (physiologic);
• Distilled water;
9. Use of medications to maintain the root canal or
bactericidal or bacteriostatic environment;
10. The use of calcium hydroxide to form a calcified barrier in
immature roots and crown and root perforation part;
11. Selection of filling materials for Grossman;
12. Sealing of the root canal;
13. Determination of the effectiveness of endodontic
treatment. Criteria for successful treatment:
• No pain, swelling, fistula;
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• X-ray - periapical tissues
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were normal. 5
 Based on the proposals of the European Association of
Endodontics would like to note that all of these steps are
important to special attention should be paid to the tool and
drug treatment and root canal filling.

The treatment consists of three stages:

1. Liberation of the root canal using a mechanical
(instrumental) treatment of necrotic masses and infected
dentin from the walls of the root canal to the cement-
dentinal junction (apical foramen). Expansion of the
channel and its preparation for sealing.
2. Sterilization of the root canal and dentinal tubules, with
medication and physical therapies methods.
3. Hermetisation (sealing) of endodontic space by hermetic
filling.

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 Indications and contraindications:

A. General factors:
The treatment can be performed in clinically healthy patients with mild
form or focal disease. In severe systemic diseases carried immediate
removal of the tooth, under the cover of antibiotics. In older people, the
non-transportable patients with mental disorders, preferably a tooth
extraction.
B. Local factors:
Chewing value of the tooth and the need for replacement.
The topology of the tooth. Teeth located in the arch distally in patients with
obstructed opening of the mouth, wisdom teeth, ectopic teeth are treated, only in
exceptional cases.
The integrity of the coronal part of the tooth. Teeth, which destroyed part of the
coronal to the root, and the root is of no value, teeth with perforated walls of the
root canal, can not be treated.
The state of marginal periodontium. Teeth with bone pockets, mobility of II-III
degree are not subject to conservative treatment.
The status of the root. Measured by X-ray data. Conservative treatment is
indicated in the teeth with straight or curved roots, permeable roots, root
canals without broken endodontic tools.
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 Can not be treated (contraindications):

• Teeth with bell-shaped root canals in the form of the

bayonet;
• The teeth, root canals are broken endodontic tools, and can
not remove them (the remnants of endodontic instruments,
pins, remnants of filling materials);
• Multi-root (molars) teeth with false paths;
• Teeth with extensive destructive process.

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 Radiograph can identify:

The presence of foreign bodies (needles, broken drills,

poorly filled root canals, pins, dentikli, etc.);
The number and shape of the roots;
The length of the root canal compared to the adjacent
teeth;
The data on the width and shape of the cavity of the tooth,
secondary dentine deposition, of false way;
The ratio of the roots of the various anatomical structures
(mental foramen, sinus, nasal opening, mandibular canal,
Impacted teeth, etc.);
Possible responses of chronic apical periodontitis.
X-ray examinations are not absolute, since the data is much
dependent on the projections. Therefore, X-ray image must be
compared with the clinical data on the shape and size of the
teeth.
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 STAGES OF TREATMENT APICAL PERIODONTITIS

Treatment of acute and chronic apical periodontitis in the

acute stage is successful, if done it strictly in sequence.

1.Rentgenografiya of causal tooth

According to X-ray refine the clinical form of the
disease, determine the nature and location of the
pathological process, manifested changes near apical tissue,
find out the possibility of saving the tooth, outline a
treatment plan and monitor long-term after treatment.

2. Analgesia
Severe persistent pain, is dramatically enhanced by
mechanical stimulation, inhibit preparation of caries cavities.
Therefore shows conduction and infiltration anesthesia. The
treatment of periodontitis can do without using of analgesia
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 When preparing of causal tooth it is necessary to
capture it, when we prepare with mechanic handle piece.
When work with turbine installation, due to high speed (300
thousand revolutions per minute), as well as due to the fact
that the tip is driven by compressed air, and there is no
vibration - the pressure on the causative tooth is virtually
absent, therefore, there is no pain when we prepare caries
cavity.

3. Preparation of caries cavity

The goal of treatment - to create a good direct access
to the cavity of the tooth, to neutralize microflora.
Relevant existing burs prepare a cares cavity, take out existing
filling, produce excision abnormal areas of enamel and
dentin and the formation of caries cavities. In this and all
subsequent stages of treatment apical periodontitis
recommended use of antiseptic.
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 4. Opening tooth cavity
Fissure or round bur removed a roof, carefully remove
the edge of the dentin, creating good access to the pulp
chamber.

5. Removing necrotic tissue of coronal pulp

Tooth cavity is washed thoroughly with an antiseptic
solution with a syringe and cotton bolls impregnated with
antiseptics. The remains of the necrotic tissue of coronal pulp
is removed with excavator and a large round bur.
Tooth cavity washed again. Antiseptic treatment at all
stages of treatment apical periodontitis combined with
instrumental.

6. Extension mouths of root canals

By the method described in the section on the
treatment of pulpitis, the mouth of root canal extends
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 7. Evacuation of the necrotic tissue of the root canals
In periodontitis Pulp extractor can be used to remove
some large fragments of necrotic pulp or food debris that
filled the lumen of the root canal. Evacuation of necrotic
mass doing step by step, without pressure, under the guise
of an antiseptic.
Pulp extractor (broach, tirnerv) soaked in an
antiseptic solution is introduced at third (1/3) root canal. The
tool is removed and washed in an antiseptic solution is then
introduced to the 2/3 root canal procedure is repeated.
Finally, pulp extractor introduced to the whole length
of the channel, and retrieved the remains necrotic
masses. Each third of the root canal after the liberation of
the necrotic masses washed with cotton turundas to the root
needle, heavily impregnated with 3.5% sodium hypochlorite
solution and 3% hydrogen peroxide.
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 Pay particular attention to work in the apical third of the
canal, so as not to push the contents to the periapical tissue.

Fig. Evacuation of necrotic

tissue “step by step”
(1/3,1/2,2/3, etc.)

8. Excision of pathologic tissue from the walls of the root canal

and its medicamentous treatment
The purpose - to remove infected predentin from the walls of the
root canal, maximum dilated root channel for its high-quality filling
and create access to the apical tissues.
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 Special attention is paid to the root canal disinfection
protocol, i,e, eliminate microorganisms.
This is achieved by a combination of instrumental and
medicamentous treatment, irrigation with large spectrum of
antiseptic.

9. Expansion of apical foramen (top)

Expansion of apical foramen in the treatment of acute
and aggravated chronic periodontitis is important. This
creates access to the apical periodontium and the outflow of
exudates from the focal.
Methods expansion of the apical foramen. To expand
the apical foramen use triangular root needle, rimmer, or K
file. Selected endodontic instruments are inserted into the
root canal to stop and spend the rotational motion using the
fingertips (not a machine). At the same time produce a small
pressure.
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 At the opening of the apical foramen doctor feels the
instrument failure, and the patient have sensation a pain. To
reduce the effect of pain - tooth to be followed.
Confirmation of the opening of the apical foramen (apex) is
exudate in the root canal and a sense of relief to the patient.

10. Filling of the root canal

Filling the root canal can be at:
1. Elimination of pain (no complaints from the patient);
2. Discontinuation of elimination of exudate and odor of the root
canal. In acute and chronic exacerbate periodontitis it occurs 5-7
days after a outflow;
3. Painless percussion and palpation of the gums near the illness
tooth;
4. Trundle of the root canal must be dry (not wet);
5. Trundle of the root canal should be odorless;
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 6. Trundle of the root canal should be white. Filling of root
canal is done to block the opening of the tooth apex,
isolating near apical tissue from infected macro-and
micro-channels of the tooth. This is a crucial stage of
treatment. On the quality of his performance depends
largely on the fate of the tooth and the effectiveness of
the previously held hard work.

11. Permanent filling

Need to do X-ray control quality filling of root canal. Next, the
final cavity preparation, removal of excess filling paste root
canal, the tooth is isolated, dried, imposed isolation pads and
permanent filling. Restored anatomical form and function of
the tooth.
Treatment of acute and exacerbated chronic periodontitis is
making in two - three visits. Treatment of chronic
periodontitis in the case of a good permeability of root canals
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 Radiography is required prior to treatment. This is the
basis of the most appropriate method of treatment.
Depending on how the process takes place (chronic,
acute or exacerbation), the decision on the number of visits.
Acute and exacerbate process are treated in two visits.
Chronic processes - in one visit.
Exceptions are chronic periodontitis with poorly
permeable root canals. This increases the number of visits
and medications are used on the basis of EDTA to expand and
pass root canals and physiotherapy techniques. In addition to
these methods is necessary to remember the addition of
conservative – surgical methods: hemisection, amputation,
resection of the root apex.

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 Resection - removal of the apical part
of root with the adjacent
pathologically altered tissue.
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Fig. Radiography of teeth
34 and 35 in isometric retro
alveolar:
a) X-Ray made w ​ ith the
purpose of diagnosis.
Observe the shape
interdental radio
transparent net, bounded
by teeth 34 and 35, the
appearance of cystic form.
Channels 34 and 35 teeth
without fillings;
b) Radiography root canals
accuracy control at 34 and
35. 35 teeth filling canal to
the apex. Filling the over-
flow channel 34. Filling
material - intradont - inside
the cyst;
c) control X-Ray in the day
of surgery
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 Fig. X-Ray of patient K. 10 years after treatment
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 Hemisection - removal the root with adjacent part of the
crown of the tooth with pathological alteraited tissue on the
molars of the lower jaw.

Fig. Isometric retro alveolar radiographic incidence and ortoradial

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tooth 46 patient's N.
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 Fig. Same case (patient N) after 11 years.
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 Amputation - removal the root with pathologic process
without removing the crown of the tooth. Amputation
applied on the maxillary molars.

Fig. Radiography of teeth 17, 16, 15 the incidence retro alveolar

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isometric and ortoradial.
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