Lecture 9
Treatment of pulpitis with biological, vital amputation and extirpation methods. Testimony, sequence and features of the stages. Efficiency of methods, complication and methods of its prevention.
Treatment of pulpitis – one of major problems of therapeutic dentistry, because prevalence of pulpits achieves 30-40% (on other sources, – 20-25% for adults and 14% for children) and takes second seat after a caries among the diseases of teeth.
At treatment of pulpitis a doctor decides such tasks:
1) removal of pain syndrome
2) liquidation of hearth of inflammation;
3) stimulation of processes of healing and dentinogenesis (at treatment of pulpitis by a biological method);
4) saving of fabrics of periodontium is from damages with the purpose of warning of development of periodontitis;
5) proceeding in integrity, form and function of tooth as organ.
The methods of treatment of pulpitis schematically can be represented so:
Methods of treatment of pulpitis
conservative (saving surgical (exception
of the vital functions of pulp) of pulp)
complete saving without devitalization devital
(biological method) (a complete exception method
vital extirpation)
the partial saving complete exception partial exception
(vital amputation) (devital extirpation) (devital amputation)
mixed method mixed method
Consequently, basic are two directions, two approaches to treatment of pulpitis – biological and surgical. At biological approach efforts of doctor are directed on complete liquidation of inflammatory process in pulp and proceeding in their function. Surgical treatment is taken to its partial or complete exception. The methods of treatment of pulpitis with saving of viability of pulp divide into actually biological at which pulp is saved fully, and method of vital amputation, which viability of root pulp is saved at, and crown is withdrawn.
Biological methods of treatment of pulpitis are progressive. It is convincingly proved that to the initial inflammatory reactions in mash peculiar reverse. At the complex action of different medications in pulp property shows up not only to limit an inflammatory hearth but also to treat ability inflammatory process.
A biological method allows liquidate inflammation in pulp, to stimulate dentinogenesis, keeping the same a reliable biological barrier from penetration of microorganisms in fabrics of periodontium, due to what he remains intact.
Actually biological method of treatment of pulpitis (saving of viability of all pulp).
Testimony. Above all things pay attention to the diagnosis of pulpitis that vividly speaking, weigh, whether will «allow» us to apply a biological method diagnosis.
Such diagnosis can be:
1) hyperemia of pulp;
2) sharp limited pulpitis;
3) a sharp traumatic pulpitis is without the defeat of pulp;
4) a chronic fibrous pulpitis of early form (without opening of pulp or with opening of her during preparing) is without the clinical and roentgenologic signs of periodontitis;
5) on some sources is a sharp diffuse pulpit, when exudate serous only;
6) for children and teenagers at the unfinished forming of roots of teeth.
First three is adopted forms of pulpitis are absolute testimonies to application of biological method of treatment, fourth, the fifth and sixth is adopted forms – by relative testimonies. It is contra-indicated to treat other forms of pulpitis a biological method.
Contra-indications to the use of method is also:
1) above all things – age is senior after 30-35 years. (better to 30);
2) somatic diseases of commons, especially hypertensive illness, atherosclerosis, diabetes et al, at the reduced immunity;
3) presence of sharp diseases of respirators the day before or during treatment;
4) high intensity of caries (7 and anymore), localization of carious cavity in a cervical area or in the area of root, because inflammation of crown pulp can quickly pass to the root. In addition, herein
it is technically heavy to execute this method a case through the closeness of gingival
edge, relatively small depth of carious cavity for imposition of multi-layered gaskets. In general, advantage at treatment this method it is needed to give carious cavities Black’s I class;
5) chronic diseases of mucus shell of cavity of mouth;
6) chronic parodontitis or periodontosis;
7) pregnancy;
8) decline of electro-excitability of mash to 25-35 mcA and more;
9) roentgenologic changes are in periodontal fabrics of tooth;
10) necessity of coverage of tooth by an artificial crown in the nearest time or use of tooth for fixing prosthetic appliance;
11) if from the moment of origin of pain passed more than 48 hours;
12) the unfavorable operating is on pulp (self-treatment);
13) presence of allergic reactions on medications, which will be used;
14) bad state of hygiene of cavity of mouth.
To treat a pulpitis a conservative (biological) method it is possible in one or two stages, in one, two or three visits. It is thus necessary to adhere to such terms:
1) to carry out the rational anaesthetizing with the use of anesthetics without vasoconstrictors (adrenalin);
2) carefully to withdraw all necrotized dentine. Carving of necrotized, infected pulp of dentine must be full maximally. The least of the softened fabrics are left in a cavity even draw failures in treatment, because active proteolytic enzymes and numerous microorganisms are present in the softened dentine. They continue to annoy pulp and neutralize medications which are used;
3) correctly to form a cavity;
4) preparations and their mixtures need to be picked up taking into account compatibility in tolerant for an organism doses;
5) to adhere to the maximally possible in the cavity of mouth asepsis on all stages of treatment, at possibility to work with the use of rubber dam.
Stages of treatment of pulpitis:
1) anesthetizing;
2) mechanical treatment of carious cavity;
3) medicinal treatment of carious cavity;
4) depriving of fat and dehydration of carious cavity;
5) imposition of medical gasket;
6) raising of stopping.
After anaesthetizing carry out mechanical treatment of carious cavity.
Preparing of hard fabrics must not be traumatic for pulp, hat is why it is carried out layer, alternated with washing of antiseptic solutions. At approaching to pulp the drill changes on sterile, here use a not turbine, but electric drill, work on less turns.
For antiseptic treatment of carious cavity apply heat solutions of antiseptics and other medications in such concentrations, which will not annoy pulp:
– 0,5% solution of peroxide of hydrogen;
– 0,5% solution of novocaine;
– decoctions of medical plants.
An obligatory condition is warming up of liquid: entering is needed only stream of warm liquid, not to cause the additional irritation of the inflamed pulp. Working on the teeth of overhead jaw, it is given a patient in the arm-chair of horizontal position. Thus comfortably to use rubber dam. During treatment it is impossible to allow a patient spitting; it is necessary to delete saliva and washing liquid from a mouth by saliva ejector.
After preparing and washing of carious cavity it is necessary to deprive of fat and dehydrate her. Drying is carried out sterile wadding rolls, instead of air, because it is set that the stream of air, directed on a dentine during a 1 sec, results in displacement of kernels of odontoblasts. An alcohol and ether does not apply an action through their irritating.
Farther impose a medical gasket. Distinguish direct and indirect coverage of pulp. Medications can be included in a direct contact with pulp (direct coverage), or to operate on pulp mediated, here between mash and medications there is a thin layer of dentine.
When after the exception of all softened dentine abandon the thin layer of strong hard dentine, he can be not touched. From data of some authors, and through such layer of dentine medicines well diffuse in fabric of pulp (that the indirect method of coverage is used in this case). Other authors consider that leave effective direct coverage of pulp by medications (through opened in one point pulp chamber).
Testimonies to opening of pulp for its irrigation is:
1) initial forms of inflammation of pulp are in teeth with chronic motion of caries at which between the bottom of carious cavity and pulp there is a considerable layer of dentine (softened, transparent, primary or replaceable). On these areas of penetration of medicines from a carious cavity in the cavity of tooth it is labored through windings, chaotically placing dentinal tubules, but partial diffusion of medications is possible;
2) an origin of pulpitis is at a fleeting sharp cariosity and the same mushroom growth of pulpitis.
In other cases or in general does not open a pulpo chamber, or
The necessity of opening of pulpo chamber arises up more frequent in the teeth of overhead jaw. And in the teeth of lower jaw there are the best terms for diffusion of medications in pulp.
In the cases when a pulp chamber is not opened and used method of indirect coverage of pulp (and it, mainly, at a chronic pulpitis or at hyperemia of pulp), more frequent treat in one visit and biological pastes which contain a hydroxide of calcium apply, eugenol.
In cases of direct coverage of pulp treat in two visits. On the first stage apply antibiotics, vitamins and also combinations of medicinal matters, that use medications which have antimicrobial, and antiinflammation action, in a liquid form (enter on a marble) and as biological pastes. The term of coverage of pulp depend biological paste on chemical nature properties of preparations which are its member: for enzymes -1-2 days, antibiotics – 2-3 days.
At treatment of pulpitis it is possible biological methods application and procedures of physical therapies:
– a low frequency ultrasound. After preparing a cavity is processed an ultrasound through 0,02% solution of furatsilin.
– low – power helium – neon laser – 40-60 sec operate through a carious cavity or neck of tooth, on a course -1 -3 procedures.
Features of stopping of carious cavity. It is very important to provide the complete pressurizing of cavity after treatment and abandonment in her of medicinal preparations, that warns the repeated infecting In any case, whether at unanimous treatment, whether at in two visits, with the permanent stopping hurrying is not needed.
Treating in one visit, over medical paste impose the temporal stopping from an artificial dentine. The permanent stopping is imposed in 5-7 days, when satisfied of effectiveness of treatment. Absence of pain, proper indexes of EOD (halt of decline of threshold of excitability), is testimonies to the permanent stopping.
How is it carried out in practice? The temporal stopping is taken off then a gasket is imposed from phosphate or to glass ionomer cement and permanent stopping. Advantage gets composite stopping materials, because the eventual result of treatment depends on reliability of isolation of pulp from the irritation influencing from the cavity of mouth.
On the second stage (and at the second visit) all of it is neatly taken off, with the observance of sterility, medical paste is imposed, an insulating gasket and permanent stopping belongs. Raising of the permanent stopping can be carried on the third visit which is appointed in 7-5 days.
If in the second visit a patient complains in the presence of pain, the repeated imposition of medical bandage is carried out yet on 1-2 days. If pain does not disappear after double imposition a tampon with medications, it is recommended to apply one of surgical methods of treatment.
In connection with weight of in two visit treatment modern doctors are inclined to treat the biological method of in one visit and in one visit which eliminates the additional injuring of pulp in the second visit after the removal of bandage. The use of such high-quality medical gaskets is instrumental in success in this case, as Life, (firm Kerr), Ducal (firm Dentsply) and other, which at a small carious cavity do not only need additional insulating gaskets from a water dentine but also can be used simultaneously and as medical and as an insulating gasket, that gaskets do not need additional imposition of insulating. However in every concrete case a doctor must have individual approach to the choice of method of treatment and amount of visits.
In the process of treatment or in the nearest time after his completion complications can develop with such signs:
– relapse of feelings of pains;
– saving of sensitiveness of tooth is to the cold irritants;
– pain at bite on a tooth.
It is necessary in case of occurring of similar complications:
– to replace a medicinal gasket;
– to appoint electroforesis of a 2-5% solution of anestetic on the area of transitional fold near this tooth.
If measures are accepted not effective, it is necessary to apply the operative methods of treatment of pulpitis.
Special preparation, intended for biological treatment of pulpitis on the first stage, – Pulpal of analgesic (firm Produits Dentaires
The biological methods of treatment of pulpits continue to be perfected the workers of researches develop the new compounding of biological pastes.
All patients the biological method of treatment of pulpitis was applied in which undertake on a clinical account with the purpose of prophylaxis of without symptoms development of apex periodontitis. EOD is conducted through 1, 6, 12 months. For this term the indexes of EOD must recommence to 2-12 mcA. At suspicion on death of pulp a tooth is subject endodontics treatment.
Consequently, efficiency of treatment of pulpitis in remote terms (1-1,5) is estimated a biological method after such criteria:
– absence of pain;
– normalization of electro-excitability;
– quiet reaction of periodontium;
– absence is on the sciagram of changes in a periapical area;
– saving of quality of stopping.
Often there is a necessity in home or derivative terms to give first help at pulpitiss. In such cases inward appoint unnarcotic anesthetic (analgin, pentalgin and similar). Thus pain disappears on 3-5 hours.
To the surgical methods treatments of pulpitis belong: vital amputation and extirpation, devital amputation and extirpation and the combined methods.
Vital amputation or vital pulpotomy is a variety of biological method of treatment of pulpitis at which keep viability of root pulp for the prophylaxis of odontogenous hearths and sensibіlіzation of organism from a periapical area.
Testimony to application of vital amputation in comparing to the biological method something extended. This method can be applied at those forms of pulpitis and also at:
1) to any localization of carious cavity;
2) sharp diffuse pulpitis, if a reaction from the side of periodontium is poorly expressed;
3) chronic fіbrous pulpitis;
4) chronic hypertrophy pulpitis;
5) EOD to 40 mcA;
6) to the presence of chronic disease of mucus shell of cavity of mouth;
7) sharp and chronic pulpitis of temporal teeth in a period resorbtіon of roots and second teeth with the reformed roots;
8) to uneffectiveness of biological method of treatment of pulpitis.
Contra-indications also less, but, unlike a biological method, pulpotomy it is not recommended to carry out in the teeth of the same 1 roots, because they do not have the clear differentiating between crown and root pulp.
A method is based on the capacity of root mash for plastic and reparative processes. He foresees the exception of inflammatory crown and mouth pulp and saving of root pulp for which necessary terms are created for proceeding iormal vital functions.
At treatment of pulpitis by the method of vital amputation changes which take place in the wound of pulp can be divided into two phases:
I phase – hydratation; at which on a background sharp inflammation due to an edema:
– fabric of wound is enriched water and exudate;
– a sour environment is created in a wound;
– there are disorders of circulation of blood with the phenomena of stagnation, exudation;
– there is disintegration and necrosis of fabrics;
– there is swelling of colloids;
– ions are prevailed above the ions of calcium and H – potassium above OH – by ions.
The II phase is dehydratation, for her characteristic:
– a release of fabrics is from water;
– an alkaline environment becomes in a wound;
– under the action of enzymes there is tearing away of necrotized mass;
– disappearance of swelling of colloids;
– normalization of circulation of blood.
Negligible quantity of necrotized fabric, blood clots which are stays after pulpotomy, the healing wounds of pulp promote, because result in excrescence of granulation.
Due to the plastic function of pulp cult of pulp can keep vital functions, here on the surface of wound a connecting – tissue capsule (connecting – tissue scar) or root pulp replaced appears by dentine and dentin similar fabric. It depends on composition of biological paste which is imposed on cult of pulp.
At the casual opening of horn of pulp formation of transparent and reparative dentine is possible which closes the horn of pulp that it is necessary to consider as an original process of scarring, it does possible therapeutic action of medical pastes which are used at the biological methods of treatment. They are instrumental in the increase of function of odontoblasts that shows up the original process of regeneration, formation of reparative dentine.
The method of vital amputation requires the previous careful anaesthetizing. The effect of anaesthetizing is more expressed, if peremedication is preliminary conducted is medicinal preparation of patient, which has for an object by medications of calming action to stabilize the function of the central nervous system, remove condition of inadequate reaction of patient on manipulation of doctor.
In 30-45 minutes after peremedication conduct infiltration, conduction or other anesthesia.
The method of vital amputation consists of five successive actions.
The first action is preparation of carious cavity:
1) antiseptically processed cavities of mouth;
2) for help spherical and the fissured drills opens up widely
carious cavity or hatches on occlusal or other surface;
3) all is carefully withdrawn a dentine necrotized, here a carious cavity is repeatedly washed warm unirritating, sterile solutions antiseptiks.
The second action is a resection of vault of cavity of tooth:
1) by the spherical drill a above pulp vault is thinned;
2) the overhanging edges of enamel and dentine are taken off thus, that the walls of carious cavity were directly prolonged in the walls of cavity of tooth;
3) by the sterile spherical drill № 1 or № 3 perforation without pressure
a above pulp vault is in the area of the most salient horn of pulp (medial – cheeks – in molars, cheeks – in premolars);
4) the perforation opening broadens the greater on sizes spherical drill, then the fissured drill is carve all above pulp vault on a border with the edges of carious cavity.
The third action is an exception of crown pulp:
1) by a sharp excavator ladling motion with a turn on 90° is carve crown pulp (a wound must be cut, instead of lacerated);
2) broaden the spherical drill of small sizes of channels of roots; it is possible to use endodontics instruments as Gates Glidden, Peeso and other;
3) a little power-shovel is withdraw mouth pulp.
A fourth action is a stop of bleeding and antiseptic treatment:
1) now it is very important to stop bleeding. Used for this purpose: 0,5-1 % solution of peroxide of hydrogen, solution of adrenalin, any anesthetic. At the intensive bleeding use diathermy a spherical electrode by force to the current of 40-50 mcA during 2-3 sec;
2) a cavity is again irrigated anthiseptics and dry out a sterile wadding marble.
A fifth action is coverage of cult of pulp:
1) tactic of doctor is such farther, as well as at treatment a biological method, that it is possible at once on cult to impose odontogenous paste;
2) paste is covered a water dentine, insulating gasket and permanent stopping; other variants of isolation are possible.
Stage at treatment of vital amputation a method the same, as well as at treatment actually by a biological method: one or two stages, one, two or three visits.
Concluding treatment of pulpitis is expedient setting of procedures of physical therapies (microwave therapy and other).
A patient undertakes on a clinical account. In default of complaints through 1, 6, it is 12 months necessary it is needed to carry out EOD, argued that root pulp did not perish. If necessary sciagraphy is conducted in the area of this tooth for determination of the state of periodontium.
There is a method of deep amputation. He is carried out after the above-mentioned method, but withdrawot only crown and mouth pulp, but partly and root (at different level of length of channel). The purpose of this method is the partial saving of root pulp (for example, in pulp with the unformed roots).
The method of vital amputation is used in practice, unfortunately, not often, because requires the conscious choice of doctor, presence of sterile medicines and facilities which would be „by a hand”, ready to application in any instant.
Vital extirpation or vital pulpectomy (an exception of pulp is under anesthesia) among the methods of complete exception of pulp is most progressive. This method of treatment at correct implementation gives the least percent of complications.
Advantages of vital extirpation:
a) absence of the toxic operating is on fabrics of periodontium preparations of arsenic;
b) treatment is carried out in one session;
c) manipulations in a tooth are not sickly.
Disadvantages of method:
a) a risk of complications is during conducting of anesthesia (unbearableness of anesthetic and other);
b) bleeding from a channel, which can arise up at tearing away of vascular-nervous bunch from fabrics of periodontium;
c) absence of reactions of patient is during endodontics manipulations;
d) origin of pain at bitibg as a result of formation of hematoma in a periapical area or destroying of stopping material for the apex of root.
e) development of remaining root pulpitis, because pulp is deleted only from a macrocanal and in mіcrocanals she can remain living.
A testimony is to vital extirpation:
1) all total forms of pulpitis: sharp diffuse, sharp festering, sharp traumatic with the wound of pulp, chronic fibrous (late form), chronic gangrenous, chronic hypertrophy, chronic
calculus;
2) retrograde and initial pulpitis, pulpitis, complicated focal periodontitis, sharpening of chronic pulpitis;
3) pulpitis, complicated periodontitis, lymphadenitis;
4) pulpits which treated oneself biological methods, but there was complication;
5) in the cases when diagnosis „ allows” to apply the biological methods of treatment, but there are other contra-indications, that a pulpitis of any form is at presence of somatic diseases;
6) at localization of carious cavity in a vestibular area or in cement of root of tooth;
7) intact teeth which it is necessary depulpation after orthopaedic or by orthodontics testimonies;
8) at treatment of teeth under bridge prosthetic appliances;
9) general paradontitis II and the III degrees of weight, especially before surgical interference.
Contra-indication is to the method of vital extirpation.
1) unbearableness of anesthetics;
2) grave somatic condition of patient, declining years;
3) for patients with the broken psyche;
4) in the last and in the first (if there is a threat of abortion) weeks of pregnancy;
5) for patients with the viral and bacterial infections of oral mucous membrane (OMM) and nose;
6) children have the temporal and second teeth with the uncompleted forming of roots;
7) anatomic features of roots (curvature, bend) of some groups of teeth.
The method of vital extirpation requires valuable anaesthetizing and observance of rules of asepsis. The best anaesthetizing is achieved an injection method, especially explorer anesthesia. Intrapulp anesthesia and new methods is used also anesthesia – inwardly – nipple. For them the special needles and syringes, proper skills, are needed, however high an effect is.
Applique anesthesia can be used as auxiliary, because she is ineffective. Use the liquid forms of local anesthetics, which bring in a carious cavity on wadding marble. Depending on the mechanism of action of anesthetic he is abandoned on 15-30 min or on 1 -2 days.
The best effect can be attained uniting the explorer anaesthetizing with intrapulp anesthesia and premedication.
Stages of vital extirpation:
1) hygiene of cavity of mouth, antiseptic treatment of teeth in the area of localization of peccant tooth;
2) anaesthetizing which would allow lasted to work in the cavity of tooth: at treatment of the same 1 root tooth-1 -1,5 hours, multi root -1,5-2 hours ;
3) a carious cavity is prepared and wash, if anesthesia is valuable, preparing conclude in the same visit;
4) perforation the vault of cavity the sterile spherical drill and fissured extend him (by circular motions) gradually, carving a vault within the limits of cavity of tooth; expose and form her so that
the skins of carious cavity passed without appearances in the cavity of tooth, forming a sheer line;
5) if a pulp chamber is exposed on a sufficient width, amputation of pulp is the same carried out and when it did not happen, pulp is amputated a excavator;
6) by antiseptic solutions, by wadding tampons with the peroxide of hydrogen, wash blood, tailings of pulp an alcohol;
7) extend the spherical drill or special endodontics instruments (Gates Glidden, Largo, Peeso and other) mouth of channels of roots; remember thus, that the fields of endodonticso treatment – in access to the channel;
8) by pulpextractor extraction the pulp. Before it mouths of root channel inflict 1 -2 drops of antiseptic, pick up pulpextractor of the proper size. He is slowly entered the wall of root channel to the apex (before feeling of easy resistance), returning cork-screw similar motion on 1 -2 turns about axis, and take out together with the mash winded on him. If she was not taken out at once, procedure is repeated once or twice.
The index of complete exception of pulp is:
a) presence of whole pulp;
b) absence of pain is at the repeated introduction of pulpextractor (if anesthesia is un valuable);
c) absence of bleeding.
In the narrow channels of roots pulp can be pranged circulating motions of drill bore (K – reamer). This method of exception of pulp creates a sword-cut, and pulpextractor abandons the lacerated wound with the large area of damage (Krammer J., Schlepper N., 1996);
9) after extirpation of pulp from the channels of roots stop bleeding, using a 3% solution of peroxide of hydrogen and other.
In the last years foreign firms developed hemostatic:
on the basis of sulfate of aluminium:
– Alu-Jen Gel and Alu-Jen Liquid (firm of Jen Dentfl);
on the basis of chloride of aluminium:
– Racesteptine (firm of Septodont);
– Altrac;
– Alustin (firm of Cheme) – has рemostatics and disinfection action;
Endo J № 4 (firm of Vladmiva);
Kapramin (firm of Vladmiva), is a bactericidal characteristic;
on the basis of sulfate of iron:
– Hemostab (firm of Omega – dent),
on the basis of carbolic resin:
– Carbolized Resin (firm of Produits Dentaires
10) by endodontics instruments from walls take off predentin;
11) narrow channels extend on the width of 2-3 sizes of drill – bor align their walls, it is given channels cone form;
12) parallel process channels preparations which contain EDTA, which help to extend him and deprive of fat; use: Verifix (Spad), Largal ultra (Septodont), Canal Plus (Septodont), 20%
solution of EDTA and others like that;
13) channels wash by anthiseptis, in particular, 3-5%;
14) channels dry out dry papers pins, by Stuptic, Netispad and other;
15) channels stop to the physiology apex, which answers the level of cement – dentin – channel connection which is stirred in the distance 1-
For stopping of channels use plastic hardenings pastes (sealers), pins (detectives) and their combinations. At treatment of gangrenous pulpitis it follows to give advantage pastes which are antiseptic characteristics. At treatment of hypertrophy pulpitis of stopping of channels it is impossible to underlay on the second visit, because again the sickly will overgrow and bleeding granulation;
16) after stopping of channels it is necessary to do control sciagraphy, convinced in quality stopping;
17) an insulating gasket (to insulate root and stopping material from the permanent stopping) and permanent stopping is farther imposed. If root stopping material gives contraction at consolidation, in the first visit it is better to impose the temporal stopping, and in the second (after contraction of the root stopping) – to substitute her by permanent.
Bleeding at treatment of pulpitis – one of the most frequent complications.
Arises up through:
– tearing away of pulp from a vascular-nervous bunch at congratulatory extirpation;
– through the trauma of periodontium by an endodontics instrument;
– for patients with hypertensive illness;
– at the bad rolling up of blood.
Influencing of adrenalin is instrumental in bleeding in anesthetic mixtures, because vasoconstrictor causes the sharp narrowing of capillaries, and then their expansion at first.
In all cases before stopping it is necessary to enter in a root channel dry wadding tampon and convinced, whether there is not admixtures of blood. Bleeding is stopped by diathermy, by a 3% solution of peroxide hydrogen, by the melancholy of tamponade channel dry sterile tampon or paper pin and other
If a channel is stopped, carefully not stopping bleeding, formation of hematoma is possible in periodontium that causes the protracted poststopping pain. Paste not enough fill channel and resolves afterwards.
In the cases when reliably stopping bleeding was not succeeded, better on days to leave in a channel styptic solutions or eugenol on tampon and to stop them in a next visit.
The method of extirpation (pulpectomy) foresees devital exception of all pulp after its necrotization (devitalization).
Mechanism of action of arsenic paste.
Arsenic anhydride or arsenic acid (As2O3) is one of strong poisons – by protoplasm poison. Locking in pulp of SH-group in fabrics, poison negatively influences on breathing. The processes of oxidization – restorations processes are thus braked in connecting fabric, the amino acid, nucleic acids, RNA, DNA are redistributed, that on a background common anoxaemia. Vessels are overwhelmed with the elements of blood and torn, causing hemorrhages that draws necrotizatіon of structures of tissues. An edema results in the compression of fabric of pulp. Nervous fibres test a fatty regeneration. Change in all groups of cellular elements of pulp result death of cages, in the first turn of odontoblasts.
The depth of defeat of pulp directly depends on an action and dose of arsenic acid. All elements of crown pulp perish in the place of its appendix. The protracted action can cause toxic changes in periodontitis and necrosis of surrounding fabrics.
Arsenic acid (anhydride) is used as paste. Such components enter in composition of arsenic paste:
– antiseptics;
– anesthetic matters (cocaine and other);
– arsenic acid;
– astringent facilities (Y.M. Gofung suggested enter for deceleration of diffusion of arsenic for an apex).
Arsenic paste is imposed in an amount which answers the head of the drill on a size № 1, that is evened 0,0006-
When it is necessary to prolong operate arsenic paste to 5-7 days, apply a wadding marble with solution of formalin, which is imposed over arsenic paste or apply pastes with a slow action.
Modern arsenic paste is produced also dosed, as granules of different color depending oecessary terms imposition to pasture (red, green, dark blue).
Good devitalizing action must pasture on the basis of paraformaldehyde.
Paraformaldehyde, paraform – is the hard polymer of formaldehyde the fumes of which have a strong bactericidal, dehydrating and mummifying action, and in high concentrations cause necrosis of fabrics. At the temperature of body there is slow depolimerization with a gradual selection to the monomer (to formaldehyde) which draws slow necrotization of pulp.
The mechanism of action of paraformaldehyde consists in influence on capillaries, expansion of vessels of bloods, to stasis of blood in them and gradual mummification of fabrics of pulp. Preparation has a less toxic action, than arsenic anhydride is on fabrics of periodontium.
In composition of paraformaldehyde paste enter:
1) paraformaldehyde;
2) anesthetic (the action of paraform is more tender, slowly that is why for anaesthetizing it is necessary to add the far of anesthetic);
3) eugenol.
Impose paste in an amount, which on a size answers the head of the spherical drill № 9 (it twice more than arsenic). More frequent in all devitalization of pulp comes in 6-7 days in the teeth of the same 1 roots and in 10-14 days – in multi roots. To pasture the term of imposition depends also on character of inflammation of pulp of tooth and choice of method of treatment, that partial or complete exception of inflammatory pulp.
Risk of overdosing and toxic influencing of paraform on surrounding fabrics is minimum, that is why he is applied even in temporal teeth. Paraform paste operates 7-14 days, but there are not complications even in 4 weeks. Widely use these to pasture for children, and also in cases of unbearableness of arsenic, anesthetics or at the necessity of conducting of the deferred treatment (heart attack of myocardium, postoperation period).
Paraformaldehyde enters also in the complement of mummifying pastes which apply after devital amputation of pulp.
Paraformaldehyde pastes – „Depulpin” (Voco), „Devipulp“, „Toxovit“, „Necronerv” and others like that.
At treatment paraform paste the reaction of periodontium is absent and results are remote the best. In two years clinical prosperity is observed at the use of arsenic paste in 88,66% cases, and roentgenologic – in 68%, and at the use of paraform paste – accordingly in 96% and in 85% cases.
Devital extirpatiin has wide distribution, but is not the modern method of treatment. She must be used in those cases, when it is impossible to use the vital method of treatment.
Testimony:
1) at unbearableness of anesthetics as a result of sensibіlіzation of organism to them;
2) at persons, more than 50 years;
3) at heavy somatic pathology;
4) at the expressed forms of diseases of cavity of mouth are heavy degrees of general paradontitis, inflammatory diseases of mucus shell of cavity of mouth;
5) at the badly communicating channels of roots, their large ramified;
6) when a patient is afraid of various injections;
7) at uneffectiveness of methods of injections of anaesthetizing;
8) at the failures of vital method.
Treatment a devital method is carried out in two visits (now and then in three).
A method of treatment is at the first visit:
1) after a rest room the cavities of mouth prepare a carious cavity so, a patient allows as far as (it is possible under anesthesia to carry out the complete preparing);
2) wash a carious cavity warm antiseptics;
3) execute mostly directed necrectomy that choose an area, most close to the sickly horn of pulp. By the spherical drill deepen in a dentine;
4) taking away a dentine, grind off the bottom of carious cavity easy, without pressure, motions;
5) before opening of horn of pulp, if it was not succeeded to do it a excavator, the drill is substituted by sterile. In the case when this procedure is carried out without anesthesia, for anaesthetizing it is possible to use “Liquid for treatment of pulp” (Omega-dent);
6) perforation a pulp chamber. Signs of opening of vault of pulp chamber:
– point opening;
– point of liquid with blood;
7) a carious cavity is carefully washed warm solution of antiseptic, if necessary, for stopping of pain on a wadding marble bring in anesthetic. The outflow of exudate through the perforation opening also diminishes pain;
8) dry out a carious cavity a wadding marble and on the opened horn of mash impose necrotizing paste by a probe or flatter directly on the horn of pulp or at first lay on the bottom of carious cavity, and then impose a paste by wadding marble on pulp;
9) from above impose a dry sterile wadding marble (what will take in exudate which is increased selected as a result of annoying pulp) or marble with anesthetic. It is possible to use Camphor phenol is antiseptic solution of firm Produits Dentaires
10) easily, without pressure impose an air-tight bandage from a water dentine, involved to sour similar consistency. A bandage necessarily must be exactly from a water dentine, because he hardens at once and it is possible to control investment impermeability. A dentine-paste presses on pulp, creates a compression, causing a pain attack. In addition, she overtakes a few hours (2-8), that can result in the impregnation of necrotizing paste in surrounding fabrics and cause arsenic (whether paraformaldehyde) necrosis of these fabrics and even bone of alveolar escape.
In some cases, when a large carious cavity is IV and the V classes, which interpenetrates under a gingival edge, it is heavy to attain the proper pressurizing of dentine. Then it is recommended to close a carious cavity rarely involved cement of phosphate or show out her on a masticatory surface, and to close a cervical area a dentine from anesthetic. Consequently, possibility of effluence or washing to pasture from the cavity of tooth needs to be absolutely eliminated;
11) explain a patient about importance of timely continuation of treatment of this tooth, because at the stay of arsenic paste in the tooth of more than 48 hours development of sharp apex periodontitis is possible.
At correct imposition to pasture pain in pulp halted almost at once, insignificant pain is although admitted at the nearest two o’clock that is related to operating of poison oervous completions. It is necessary to explain it a patient and for diminishing of pain to recommend adopting anesthetic.
A method of treatment is at the second visit:
1) poll a patient and inspect a tooth and surrounding fabrics (percussion necessarily);
2) take off a bandage;
3) carry out the final preparing of carious cavity; she is extended, destroying to the middle of masticatory surface at the masticatory group of teeth, and to the middle of palatal or tongue surface in frontal teeth;
4) expose the cavity of tooth (that take off the roof of pulp chamber) and carry out trepanation by fissured and the back cone drills. Manipulations in the cavity of tooth must be conducted under visual control (through a mirror), in order to avoid the perforation of bottom. The drill must be held strictly for the axes of tooth (for warning of perforation of his walls);
5) amputation of crown part of pulp (pulpotomy) is here carried out at the same time, and if it did not happen, in the teeth of multi roots amputate crown pulp by a sharp excavator, conduct medicinal treatment;
6) mouths of channels of roots extend funnel-shaped, to facilitate their subsequent passing. For this purpose use the prolonged spherical drills of small sizes, the special endodontics instruments – Gates Glidden,
7) by pulpextractor extirpation pulp. Under bath from antiseptic (1 -2 drops bring in on mouth or moisten an instrument) of pulpextractor of the proper size move cork-screw similar motion (to two turns) deep into toward feeling of resistance (to the apex), and then for the axes of root draw out a needle a, reverse (but to the lines) flounce together with twined about round her root mash. If pulpextractor enters tightly, it is necessary by preparations which contain EDTA and drill – bor to extend a channel, and then to carry out extirpation. It will warn his breaking off in a channel;
8) the channels of roots wash antisepts and carry out instrumental treatment, using endodontics instruments;
9) channels dry out and deprive of fat and stop at the level of the apex opening (under control a sciagram), a carious cavity is purged from root stopping material, deprive of fat and dry out an alcohol, ether or special facilities;
10) if channels were stopped a not gutta-percha, impose two insulating gaskets: from a water dentine and from phosphate or to glass ionomer cement; at stopping of channels impose a detective only a cement gasket;
11) impose the permanent stopping.
The most frequent treatment is carried out in two visits, but if very weighs the color of tooth in the future, it is better in the second visit to impose the temporal stopping from a water dentine or paste of dentine. In third times visit the temporal stopping is partly taken off, to pasture tailings from the walls of carious cavity washed well, an insulating gasket and permanent stopping is imposed. A carious cavity is stopped in the third visit and then, when the root stopping gives contraction at hardening (in the second visit impose the temporal stopping, and in the third – substitute her by permanent).
If in the second visit a tooth has a sensible reaction on percussion, (but it is not considered as arsenic periodontitis), better at once channels of roots not to stop, but it is good to wash and leave in them tampon with eugenol, Camphor phenol, by rezortsin – formalin mixture or creosofen and pulpoperil (contains phenol, creosote, eugenol, chloroform) under a bandage from a water dentine on 2-3 days. In the cases when the channels of roots are considerably ramified, for mummification of branches of nervous fibres after devitalization it is good arsenic paste to apply “Guayafen” (Omega-dent), which contains: phenol, formaldehyde, and imposed on 1-3 days under an air-tight bandage. Stopping of channels of roots carry out during the third visit.
Method of devital amputation (devital pulpotomy)
This method of treatment of pulpitis is forced and used mainly at treatment of large teeth of roots.
Testimony:
1) obliteration channels of roots;
2) heavily clock-houses channels of roots because curvature of root.
Consciously this method is applied only in the cases when:
3) for a patient grave common condition of organism (after the heart attack of myocardium, heavy operations);
4) for mentally sick people;
5) at impossibility of access to mouth of channels of roots through the difficult opening of mouth;
6) in third molars, when carious cavities are placed distal;
7) at treatment of pulpitis of temporal teeth.
In all other cases it is necessary to carry out extirpation of pulp.
Contra-indications to the method of devital amputation is: pulpitis are in the second teeth of the same 1 roots at the good common state of organism.
Method of treatment at the first visit the same, as a method of the first visit is described in this lecture at devital extirpation and at the second visited – at first the same, as at devital extirpation (see the first 6 points of devital extirpation); farther operate under circumstances. With age, under the action of different pathological changes, on the walls of channel the second dentine which mineralization and obliteration road clearance of channel is put aside. Deposits settle unevenly, that is why a channel acquires fanciful outlines and difficult passing of endodontics instruments. Curvatures of roots are instrumental in it also breakage of endodontics instruments.
Necessarily carry out an attempt „pass” all channels fully or even partly. If it is not succeeded, then:
– process cult of pulp solutions of antiseptics;
– dry out the cavity of tooth;
– for complete mummification of pulp in impassable channels use impregnation;
– close a tooth the temporal stopping, then (sometimes on the third visit) – permanent stopping.
Impregnation means an impregnation and used in dentistry for the satiation of root part of pulp mummify matters which deeply diffuse. Matters for mummification quickly get to pulp, denaturation the albumens of tissues, contraction necrotized fabric and warn its disintegration, long keep an antiseptic action and mostly does not cause destruction of fabrics of periodontium. Mash is mummified is dried up with the fixed structure which is not laid out.
For coverage of cult of pulp during devital amputation of odontogenous paste, namely:
1) zinc – eugenol;
2) eugenol – timol;
Application of biological pastes (with antibiotics and enzymes) at this method of treatment of pulpitis is a flagrant error.
The combined (mixed) devital method is combination of pulpotmy and pulpectomy: it is use in case when part of channels of roots clock-house, and part – no. One or two communicating channels stop hardening paste, and from it is done unclock-houses the same as at treatment of devital amputation a method (mummify).
It is necessary to remember, that it is impossible to assume the origin of remaining pulpit. Reasons of his origin are such: a doctor wanted to treat a tooth the method of vital extirpation, but during work appeared, that one or two channels of roots are on some reasons, unclock-houses or in general they did not succeed to be found. Then on mouth of these channels in the first visit it is necessary to impose arsenic paste for necrotization of pulp in unclock-houses channels of roots and dentinal bandage.
In the second visit, at the repeated unsuccessful attempt to pass the channels of roots, a communicating channel is stopped to the apex opening, and in impassable channels carry out impregnation of the pulp left in them one of the adopted methods. Cult is covered mummifying paste, and a tooth is closed the temporal stopping.
In 7-10 days in default of complaints and at the positive results of objective inspection of tooth and surrounding fabrics the temporal stopping is substituted by permanent.
If a doctor did not impose arsenic paste, and at once began to impregnation of channels of roots, it and will result in the origin of remaining pulpitis. This method of treatment is combined, in fact begin from vital extirpation, and conclude devital amputation. He is used more frequent than method of devital amputation, because usually some of channels however succeeded it is to pass: distal in molars of lower jaw or palatal in molars of maxilla.
Combined (mixed) vital method. Under anesthesia conduct extirpation of pulp from a communicating channel and amputation from heavily clock-houses of channels of roots. A channel is stopped paste which hardens, and above retention points the other channels impose dentine – stimulant (odontogenous) paste, insulating a gasket and permanent stopping. If a remaining pulpitis develops after such treatment, it is necessary to impose arsenic paste and conduct impregnation of impassable channels of roots one of methods.
An error will be imposition of arsenic paste in a tooth with gangrenous pulp. It can result in arsenic periodontitis.
At the devital methods of treatment, that at the use of arsenic paste, possible also various errors and complications which arise up in 60% cases, namely:
1) saving and often and strengthening of pain after imposition of arsenic paste. It is related to that the melancholy of tamponade is carried out or a pulp chamber was not preliminary opened, inflammation proceeds in mash, but arsenic paste is sucked in slowly. Opening of pulp chamber in one point not only approaches the action of arsenic paste to pulp but also provides the outflow of products of inflammation;
2) overdosing of arsenic paste or its display is prolonged cause intoxication of surrounding fabrics, because an arsenic easily gets to fabrics of tooth (dentine, cement) and stays too long there. A severe error, coming from aforesaid, the second or even multiple application of arsenic paste is. If devitatzation did not come from the first application, it is necessary extirpation of pulp under anesthesia. Because at the repeated use to pasture complications are possible as arsenic periodontitis, to necrosis of alveolar escape and even body of jaw with next sequestration of bone and deformation of person.
Arsenic periodontitis treats oneself by those rules, that and chronic apex periodontitis, medicines – antidote of arsenic are only used: 5% solution of unitiol;, 5-10% solution of iodide to potassium. Mechanism of action: active SH groups enter into an action with tiol poisons of As2O3, which are in fabric, and form untoxic complexes with them. Fastening of poisons is instrumental in proceeding in the functions of the enzymatic systems.
Application of intracanal electrophoresis of a 2% iodide to potassium or it is been a 5% iodine also effective.
In transition sharp apex arsenic periodontitis in the stage of intoxication in sharp apex periodontitis in the stage of exudate a tooth is abandoned opened on 2-3 days.
3) necrosis of gums, caused the burn of arsenic paste, is a widespread enough error, especially for doctors-beginners. Reasons:
– the cavity of tooth and that is why imposition is not enough exposed to pasture carried out blindly;
– to pasture a floor a wadding tampon is not imposed;
– diffuse of paste through badly hardening bandage.
In relation to it cavities have most danger Black’s II and the V classes, especially when the near gingival wall of the formed carious cavity takes place alongside with gums or under them. It is necessary to follow a rule: not to conclude a reception without a confidence in the good isolation of medicinal investment of bandage from a water dentine, instead of paste of dentine!
If already there was arsenic necrosis, it is necessary to treat him as the infected wound. After tearing away of necrotic masses the area of necrosis is sprinkled the singed magnesia or process solutions of unitiol, to the iodide to potassium – pinning a marble with medications.
Necrosis is possible at the use of paraform. C.Lust (1984) describes osteomyelitis which developed after the toxic operating of paraformaldehyde on intradental membrane between overhead 7 and by 6 teeth.
Necrosis of bone of alveolus. Imposition of arsenic paste on the perforation of carious cavity in the area of neck of tooth or bifurcation draws development of osteomyelitis with tearing away of sequester during great while after the delete of tooth.
Wrong use of diathermy for devitalization of pulp or for the stop of bleeding also causes heavy complications.
Breaking basic technical rules (tension, strength of current and etc), prolonged display can cause the heavy burns of fabrics of tooth and periodontium, to result iecrosis of fabrics and loss of tooth. A defective vehicle can stagger a current a doctor or patient. For warning of such complications a vehicle before work must check experimental electrician. And before to begin to treat a patient, operate a vehicle it is necessary to check on the bar of soap. For the stop of bleeding of diathermy carry out 2-3 sec and an electrode is not taken to the apex on
Contra-indications to diathermy are cases, when treat a pulpitis in teeth, staggered parodontitis, because electro- current negatively influences on sick paradontium.
