Single visit Endodontics in Necrotic tooth with chronic apical Periodontitis

O.R.Ganesh 2 year M.Sc.D Endo

Introduction
1Debate

is ongoing about the merits of a single-visit or multivisit approach to endodontic treatment. An extensive body of research has sought to determine relative success rates, pain associated with each approach, and its relationship to pulp vitality and the presence of periapical oseitis.

Introduction
2Recently,

it has been recognised that root canal treatment can be successfully carried out within a single visit, especially for the primary treatment of vital pulp or asymptomatic necrotic pulp. A single-visit treatment is preferred because it reduces total time for the treatment and travel time for the patient, It has good patient acceptance and is good for practice management.

Introduction
single-visit root canal treatment has become a common practice and offers several advantages, including a reduced flare-up rate, decreased number of operative procedures, and no risk of inter-appointment leakage through temporary restorations. Single-visit root canal therapy is less time consuming and more economical and, as a consequence, more appropriate to the needs of itinerant and busy patients.
3Therefore,

Introduction
4Even

after the subgroup analysis was limited to the treatment of teeth with apical periodontitis, a single visit was more favorable than multiple visits, although the difference in radiographic healing rate between the two treatment regimens was not statistically significant.

Introduction
necrosis can be partial or total. The partial type may exhibit some of the symptoms of an irreversible pulpitis. Total necrosis, before it clinically affects the periodontal liga-ment, is usually asymptomatic. 5There is no response to ther-mal or electric tests. Occasionally the teeth will darken.
5Pulp

Introduction
6However,

if heat is applied for too long, the tooth may respond, possibly relating to remnants of pulpal fluid or gases expanding and extending into the periapical region. Sometimes a traumatic injury to a tooth may prevent the lack of a response to pulp tests and mimic that of pulpal necrosis. Necrotic teeth usually have a history of trauma, extensive tooth decay (caries), periodontal disease, or rapid orthodontic tooth movement. In this case the necrosis is due to caries.

Introduction
spread of this infection into the periapical region has caused the apical periodontitis, hence the treatment of choice would be root canal treatment to eliminate the infection. Bulk of the literature would show a case of necrotic pulp with chronic apical periodontitis as a questionable case to be handled in a single visit, but since the advent of new instrumentation techniques, material science and technology, it is no more the case.
7The

Introduction
8Recent

studies have advocated the treatment of teeth with apical periodontitis in a single visit. Kvist et al observed no statistically significant differences between the groups of teeth with apical periodontitis treated with either singlevisit or multi-visit treatment regimens.6

Case Report
A 18 year old Female Filipino patient came to our graduate clinic in University of East, Manila Philippines on 05 march 2010 with the chief complaint of discolouration in her maxillary Right central incisor(11).

Case Report
Two year prior to consultation the patient noticed a small blackish spot on the mesial surface of the tooth. He did not seek any dental consultation. One year prior to consultation the blackish spot has slowly progressed to the size of a small hole on the mesial aspect of the tooth. The patient did not seek any dental consultation.

Case Report
Six months prior to consultation there was a increase in the size of the lesion. It also started involving the lingual surface and weakening the tooth structure. The patient was sensitive to cold drinks. The pain subsided as soon as the cold stimulus was removed. The patient had a quick, sharp and hyper response. Patient did not seek any dental consultation. Two months prior to consultation, the patient had sudden onset of pain .The pain was aggravated on taking hot and cold drinks. Pain last for 1520min. She also had pain on mastication.

Case Report
The patient took Mefenamic acid 500mg thrice daily for a week. Patient did not seek any dental consultation She did not have any pain currently. She did not have any sensitivity to hot and cold liquids also. She did not have any pain on mastication also

Case Report
She did not have any significant medical history. She had visited university of the east for her scaling but she did not have any previous history of root canal treatment. Upon Clinical examination the caries has extended up to pulp chamber and the caries was involving the facial, mesial, and lingual surfaces.

Case Report
The diagnostic test of tooth 11 revealed that there is negative response to the thermal, cold, EPT tests but was tender on percussion. The mobility was within the physiological limit. The adjacent tooth(21) was also tested. It showed a negative response to cold, thermal, EPT tests but not tender on percussion. The periodontal probing depth was normal (2-3mm)

Case Report
Radiographic evaluation shows that carious lesion extending from mesial surface to the pulp chamber and the lingual surface of the tooth 11. There was widening of the periodontal ligament space. There is also a radiolucency of 6mm in height and width of 5mm involving the apical region of tooth root11.

Case Report
Intra oral examination reveals that the buccal mucosa ,tongue ,gingiva were normal. There is no evidence of sinus tract or fistula From the patient Case History, Diagnostic tests and Radiograph Examination, the tooth 11 was diagnosed as Necrotic pulp with chronic apical periodontitis

Treatment protocol
As the tooth was necrotic and the patient did not have any pain so we decide not to administer local anesthesia. Initially, caries removal was done by using a spoon excavator and high speed hand piece on the tooth 11. Access cavity was prepared using a diamond round bur No 2 size under rubber dam isolationand. The internal walls were flared and smoothened with a tapering non-end cutting bur.

The working length was determined by using the apex locater, (DENTSPLY) after that the working length was confirmed with the radiograph the length was 25mm. I.A.F. was estimated by using the no 0.2mm , size 15 k file (Mani file).

The canal was prepared using the ProTaper file system (Dentsply Maillefer; Switzerland) with copious irrigation of prepared solution of 0.5% sodium hypochlorite . The Canal was prepared up to size F3.

Since tug back was achieved using the 50 size gutta-percha point (Gapadent) a radiograph was taken to confirm length. The canal was finally rinsed with sodium hypochlorite and dried with sterile paper points.(Gapadent)

Spreader reach test has conformed by 1mm short of working length by 30 size Finger spreader. The canal was obturated by packing the F3 ProTaper Gutta Percha Point with a few 0.02 Taper Gutta Percha points (Diadent) by Gold lateral condensation and using zinc oxide-eugenol as the sealer.

Excess gutta-percha was cut, a layer of glass-ionomer (Fuji, Japan) cement was placed over the cut gutta-percha. A composite (Filtek Supreme; 3M ESPE) restoration was given to provide a complete coronal seal and for esthetics. Patient was asked to report if she had any pain or discomfort.

Discussion
In the present case, pulp necrosis occurred as a result of the microbial contamination of the canals having been left untended for three years. 9Asymptomatic teeth with pulp necrosis patient comfort usually is attained without difficulty, so in this case we decided not to give local anesthesia because there is no preoperative pain, discomfort even during the instrumentation process.

Discussion
Hence we can safely conclude that unless and otherwise the patient feels any discomfort, due to Instrumentation of tooth with some remaining vital sensitive tissue in a necrotic tooth and any movement of a tooth with inflamed periradicular tissue during instrumentation. It would be unnecessary to administer LA in necrotic tooth without any pain.
This is the conclusion of our group in EBD class in last semester about Anaesthesia for non vital teeth during RCT

Discussion
A recent study showed that Root ZX produced significantly more accurate results compared to the use of Radiographs but in this case we have used both because we want to confirm the apex locator working length with radiograph working length.

Discussion
there is no contraindication in doing single visit root canal treatment for teeth with chronic apical periodontitis, in this case we did single visit because the patients is a high school student and won¶t be able to come for multi visit, so we decided to do the single visit root canal treatment .
11Although

Discussion
appears to be no difference in postoperative pain after single-visit endodontic treatment of teeth exhibiting pulp necrosis, teeth exhibiting necrotic pulps as well as those exhibiting chronic apical periodontitis and chronic apical abscesses resulting from pulp necrosis.
13Teeth 12There

with apical periodontitis but no previous root canal treatment can be treated in a single visit, with a low probability of a flare-up occurring.

Discussion
on the current best available evidence, single-visit root canal treatment appeared to be slightly more effective than multiple visit. treatment of pulpal necrosis with periapical symptoms involve thorough removal of necrotic pulp tissue from the root canal system.
15The 14Based

Discussion
single visit endodontic therapy there is less number of appointments thus preventing the reinfection of the root canal . Its very hard to get a perfect temporary seal between the appointments. This makes it extremely difficult and time-consuming to secure well fitting temporary restorations on teeth.
17 16In

Discussion
Most studies show no difference in success rate between single visit and multiple visit. When indicated, single visit endodontic therapy has been shown to be a safe and effective alternative to multiple visit treatment. Hence, keeping in mind the various criteria, single visit therapy can be done with reliable results.
This is the conclusion of our group in EBD class in last semester about, IS SINGLE VISIT ROOT CANAL TREATMENT BETTER THAN MULTIPLE VISIT ROOT CANAL TREATMENT ?

Conclusion
As in the present case, peri-radicular pathosis has occurred as a result of the microbial contamination of the canal having been left untreated for many years. So the tooth with large periapical pathology can be treated in single visit root canal treatment.

Reference
1.Pathway of the pulp 9 edition page no 94 2.Figini L Single or multiple visits for endodontic treatment?. Evidence-Based Dentistry (2008) 9, 24. doi:10.1038/sj.ebd.6400570 4.Bayram Incea Incidence of Postoperative Pain after Singleand Multi-Visit Endodontic Treatment in Teeth with Vital and Non-Vital Pulp European Journal of DentistryOctober 2009 - Vol.3 5.Pathway of the pulp 9 edition page no 36 6. http://www.toothiq.com/dental-diagnoses/dental-diagnosisnecrotic-tooth-overview.html 7. de Blanco LP.Treatment of crown fractures with pulp exposure. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:564±568

8. Principles and Practice of Endodontics ,MAHMOUD TORABINEJAD, DMD, M5D, PhD 3rd edition page no-40 9. Endodontics - Principles and Practice, 4th edition, Mahmoud Torabinejad & Richard E.Walton Pg no 143 10.Neeraj Malhotra, Kundabala M. Contemporary endodontic approach: single-visit root canal treatment revisited. ENDO (Lond Engl) 2009;3(3):215±225 11. Neeraj Malhotra Contemporary endodontic approach: singlevisit root canal treatment revisited ENDO (Lond Engl) 2009;3(3):215±225 12. Color Atlas of Endodontics John T.Johnson DDS, MS Pg No. 113

13.Contemporary endodontic approach: single-visit root canal treatment revisitedENDO (Lond Engl) 2009;3(3):215±225 14. C. Sathorn Effectiveness of single- versus multiple-visit endodontic treatment of teeth with apical periodontitis: a systematic review and meta-analysisa International Endodontic Journal, 2005;38: 347±355 15. PATHWAYS OF PULP STEPHEN COHEN 9 EDITION PAGE NO:56 16. Clinical and radiographic evaluation of one and two-visit endodontic treatment of asymptomatic necrotic teeth with apical periodontitis: a randomized clinical trial Molander A, Warfvinge J et al. British dental journal volume 2008;208 17.Contemporary endodontic approach: single-visit root canal treatment revisited Neeraj Malhotra, Kundabala M, Shashirashmi Acharya ENDO (Lond Engl) 2009;3(3):215±225

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