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Diagnosis , LA and isolation in endodontics

Dr.MADHU M.D.S Assistant proffesor ,Yogita Dental College.


03/05/12

- DIAGNOSIS AND TREATMENT PLANNING - NEWER TRENDS IN ANESTHESIA - ODDITIES IN TOOTH MORPHOLOGY - ACCESS PREPARATION - INSTRUMENTATION - IRRIGATION - OBTURATION - CONCLUSION
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Diagnosis and Treatment Planning

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- Pulp tesing - post endodontic disease - vertical root fracture - non ododntogenic lesions - trauma
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PULP TESTING

THERMAL & ELECTRIC

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Thermal Tests

CO2 Snow

Ice stick

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Thermal Tests
Cold always used Heat rarely used Compare reaction with adjacent and contra lateral

teeth Refractory period of at least 10 minutes before pulp can be retested accurately

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Classic Responses to Thermal (cold) Testing:

Normal Pulp: Moderate transient pain Reversible Pulpitis: Sharp pain; subsides quickly Irreversible pulpitis: Pain lingers Necrosis: No response

(Note false positive and false negative responses common)

Electric Pulp Test

Vital or non-vital In multi-rooted teeth, where one canal is vital tooth usually tests vital False positives and false negatives may occur

Electric Pulp Test


False positive reading:

Electrode contact with metal restoration or gingiva Patient anxiety Liquefaction necrosis Failure to isolate and dry teeth prior to testing

Electric Pulp Test

Post Endodontic Treatment Disease


vs

Endodontic Failure
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Diagnosis
Patient

Complaint ( if any) Clinical Examination Radiographic Examination Elimination of Other Possible Etiologies

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Patient Complaint
Can

patient localize symptoms to a particular tooth Temperature sensitivity Previous swelling or drainage Sensitivity to pressure chewing

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Radiographic Examination
Evaluation

of previous endodontic

treatment Periapical radiolucent lesion Bone loss on lateral aspect of root root fracture Tracing of sinus tract

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Eliminate Other Etiologies


Pulpitis

from another tooth Healing in progress Sinusitis Perio TMJ Neuralgias


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Etiology
Inadequate Fractures Coronal

prior root canal therapy

leakage Complex root canal anatomy

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Inadequate Prior Treatment


Canal Poorly cleaned and shaped canal Poorly obturated canal Missed

treated short of apex

canal-MB root Max Molars most common - D roots Mand Molars, Mand Incisors, Max Premolars
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Thermal sensitivity on RC Treated tooth

Missed canals the culprit

Patient had thermal sensitivity


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Treatment Options

Retreatment with possible disassembly Periapical Surgical Treatment Extraction

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Apical surgery

VERTICAL ROOT FRACTURE

PAIN AFTER ENDODONTIC TREATMENT

PATIENT SAYS HISTORY OF BITING SOMETHING HARD AND FEELING OF SHARP PAIN IMMEDIATELY

NO CROWNS AFTER rct

(a) Mandibular right first molar which has been root filled and restored with a large amalgam restoration. Note the diffuse V-shaped bone loss (arrows) around the mesial root which is a classic sign that a root fracture is present. (b) Periapical radiograph taken four months later clearly shows a major fracture with wide separation of fragments

Double or multiple sinus tracts

PERIAPICAL RADIOLUCENY

MID ROOT RADIOLUCENY

broad-based swelling

PERIAPICAL LESION

VERTICAL ROOT FRACTURE

Transillumination

A crack will block and reflect the light when transilluminated

Mandibular incisor area

Multiple

EPT positive

History to be taken

TRAUMA

NO ENDODONTIC TERATMENT

Treatment Planning

Two major decisions:


Is

root canal therapy indicated? Should I carry out this treatment myself or should I refer the case?

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Factors that add risk to Endodontic Cases

Patient

considerations Objective clinical findings Additional conditions

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Patient Considerations

Medical

history Local anesthetic considerations

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Objective Clinical Findings

Diagnosis Radiographic

findings

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Additional Conditions
Restorability Existing restoration Fractured tooth Resorptions Endo-perio lesions Trauma Previous endodontic treatment Perforations
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Do all crowns and bridges need to be RC treated ????

FOLLOW AN ENDODONTIST OR A PROSTHODONTIST

Facts says 50 70 % of crowns without RCT had to be RC treated in a span of 5 years

Local Anaesthesia in Endodontics

Maxillary teeth infiltration (85-100%)

Mandibular teeth Inferior alveolar nerve block (IANB) ????????

Effectiveness of Conventional IANB as measured by EPT


Childers et al. 1997 lido 2% 1:100K Clark et al. 1999 Dunbar et al. 1996 Guglielmo et al. 1999 Reitz et al. 1998 lido 2% 1:100K lido 2% 1:100K mepiv 2% 1:20K lido 2% 1:100K 63% 73% 43% 80%

71%

Always

use a long 25 gauge needle

2 reasons: 1. Less deflection 2. Less false negative aspiration

Reported Reasons for IAN Anaesthesia Failure


1. 2. 3.
1. 2. 3. 4. 5.

Operator Inexperience Armamentarium: Deflection of the needle tip Patient factors:


Variations in anatomy Accessory innervation Unpredictable spread of LA Local infection Pulpal inflammation

Pulpal Inflammation

Worsens

the scenario

Effectiveness of Conventional IANB: Irreversible Pulpitis


100% lip anaesthesia
Reisman et al. 1.8 mL lido 2% 1:100K epi 1997 Nusstein et al. 1.8 mL lido 2% 1998 1:100K epi Cohen et al. 2000 Claffey et al. 2004 1.8 mL lido 2% 1:100K epi 1.8 mL lido 2% 1:100K epi 25% 19% 50%

23%

Adjunctive Strategies
PDL Injection Intraosseous Buccal

Injection

block Intrapulpal Injection Different anaesthetic

Pregnant Patients
Which

Local Anaesthetic to use?

Articaine

4% 1:200 000 FDA category C Lidocaine 2% 1:100 000 FDA category B Mepivacaine 2% 1:20 000 FDA category C Mepivacaine 3% plain FDA category C

PDL Injection
Technique:
needle inserted into the gingival sulcus at a 30 degree

angle towards the tooth bevel placed towards bone advanced until resistance felt anaesthetic injected with continuous force for about 15 seconds. approx. 0.2 mL of solution 25 vs. 30 gauge needle

Adjunctive Strategies
Additional Anaesthetic PDL Injection Intraosseous

Injection Intrapulpal Injection Different anaesthetic

Intraosseous Injection
Technique

for mandibular infiltration Perforate the cortical plate to introduce LA in medullary bone Bathes the periradicular region in LA 2 commercial systems available:
Stabident (Patterson) X-Tip (Tulsa Dentsply)

Stabident

Stabident

Stabident

Stabident

X-Tip

Success of Conventional IANB + IO as Measured by EPT


Dunbar et al. Gallatin et al. Guglielmo et al. Reitz et al. 2% lido 1:100K 3% mepivacaine plain 2% lido 1:100K 2% lido 1:100K 90% 100% 100% 94%

IANB + IO in Cases of Irreversible Pulpitis


Nusstein et al. 1998 Lido 2% 1:100K 91% 79%/ 91% 80%/ 98% 82% (X-Tip) Parente et al. Lido 2% 1998 1:100K Reisman et al. 1997 Nusstein et al. 2003 Bigby et al. 2006 Mepivacaine 3% plain Lido 2% 1:100K Articaine 4% 1:100K

86%

Intrapulpal Anaesthesia

back-pressure

is the key to intrapulpal anaesthetic success

Topical Anaesthetic
Benzocaine

or Lidocaine Effectiveness?
Gill and Orr 1979: 15

second application no more effective than placebo Stern and Giddon 1975: 2-3 minutes=profound soft tissue anaesthesia

Conclusions:
If patient says it hurts, it hurts

Rubber Dam

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Why Should you use rubber dam?

Infection control not proven better than sterile cotton rolls

Protection of patient's soft tissue Huge time saver Improved access and visibility Very high patient acceptance
??????

Why Should you use rubber dam?

Protection of the patient's airway

Disadvantages of using Rubber Dam


Lack of axial orientation of the teeth Possible damage to the papillas More difficulties in taking Rx Allergic reactions are possible (alternative: rubber dam
composed of silicone)

Fast and easy placement by one person Very high level of patient comfort as no metal clamps are required Both arches are fully exposed and a completely dry field is achieved simultaneously

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