1. Pulpitis of children temporal teeth. Conformities to law of clinical motion for children different age. Diagnostics, differential diagnostics.
2.Treatment of pulpitis of children temporal teeth. Choice of method of treatment depending on the form of pulpitis and state of root of tooth.
3. Unvital methods of treatment of pulpitis of children temporal teeth. Testimony. Method of treatment. Prognosis.
Etiology and pathogeny of children pulpitis
By the basic etiologic factor of pulpit for children, as well as for adults, there are microorganisms which get to mash from a carious cavity. It is mainly aerobic microorganisms or anaerobic microorganisms with aerobic. Except for it, a pulpit can develop under the action of traumatic, chemical and temperature factors.
The feature of inflammation which developed under the action of infectious factor is that toxins and products of metabolism of microorganisms operate on fabric of mash. The enzymes of microorganisms draw death of fabric of mash, which is accompanied formation of products of its disintegration, which influence on other, yet healthy areas of mash. Histaminum and gystaminliked matters assist development of inflammation, leucokotoxin and other bioactive connections. More frequent all a pulpit develops as a result of cariosity.
Sharp inflammation in the pulp starts from deceleration of blood stream in the area of irritation, there is agglutination of red corpuscles in the middle of vessels and marginate of polymorfnucleus leucocytes. Under act of hemotoxic neurohumors leucocytes move to the area of defeat.
At disintegration leucocytes select proteolitic enzymes in great numbers, as a result the areas of the festering melting appear in mash. Under the action of gystaminliked and other bioactive matters (neurohumors of inflammation) permeability of vessels, which is instrumental in the exit of cages of blood and plasma from a bloody river-bed in fabric of mash, rises. It conduces to the increase of osmolality, development of hypoxia and atsydoz, in it. All of it predetermines development of inflammation, irritation of nervous endings, and draws involuntary pain.
The first stage of sharp inflammation of mash is hyperemia. It is characterized expansion of arteriols and capillaries in mash. This state — reverse, if to liquidate reason of inflammation till it attained intensity, able to entail альтерацію of fabric of mash.
The protracted action of irritating factor conduces to growth of hyperemia and formation of exsudate. Hyperemia passes to serosal inflammation — also reverse process due to the function of the lymphatic system which provides the outflow of exsudate from filling out fabric. If the action of injury factors lasts, the walls of vessels are struck, the exit of leucocytes increases from them, the microfire of the festering melting appear mashes which meet then — festering inflammation develops.
A chronic fibrotic pulpit develops as a result of sharp serosal or festering inflammation of mash. In temporal teeth his development is possible as initially chronic to the process. A chronic fibrotic pulpit is characterized proliferation of fibred structures, which conduces to the compression and sclerosis of mash.
A chronic hypertrophic pulpitis— it also the display of proliferative processes in mash, with overwhelming excrescence of granulation and young connecting fabric.
A chronic gangrenous pulpit more frequent all develops as a result of festering inflammation of mash with participation of anaerobic microflora.
Classification of children pulpitis
For classification of pulpitis for children classification of pulpits of the Kiev medical institute is used (O. S. Yavorska, L. I. Urbanovich, 1961):
I. Sharp pulpitis (pulpitis acuta).
1) hyperemia of pulp (hyperaemia pulpae);
2) sharp limited pulpitis (pulpitis acuta serosa circumscripta);
3) sharp diffuse pulpitis (pulpitis acuta serosa diffusa);
4) sharp festering pulpitis (pulpitis acuta purulenta);
5) sharp traumatic pulpitis (pulpitis acuta traumatica);
а) the area of pulp damaged by chance is during treatment of caries;
b) opening of pulp is as a result of break of crown of the tooth;
II. Chronic pulpit (pulpitis chronica).
1) chronic fibrotic pulpitis (pulpitis chronica simplex, seu fibrosa);
2) chronic hypertrophic pulpitis (pulpitis chronica hypertrophica);
3) chronic gangrenous pulpitis (pulpitis chronica gangraenosa);
4) конкрементозний pulpitis (pulpitis concrementosa);
III. Pulpitis, complicated periodontitis (sharp, chronic or
sharped).
Clinical symptomatic of pulpitis of temporal teeth
The leading clinical sign of sharp inflammation of mash, regardless of his localization, is:
1) Sharp attackliked pain which arises up in a tooth without any external influence. External irritants (thermal, chemical, mechanical) always strengthen a pain attack or cause it.
2) A pain attack can be greater or more small duration and depends on prevalence of inflammatory process, virulence of microflora and reactive properties of pulp. Intervals without pain can be protracted at the insignificant defeat of mash and short at its intensive inflammation.
3) It is common the sign of sharp inflammation is strengthening of pain in a night-time.
In temporal teeth a sharp pulpitis is observed considerably rarer than chronic.
4) For the clinic of sharp pulpits of temporal teeth characteristic very rapid motion and intensive development of sharp inflammation is with rapid distribution on periapical fabrics. For this reason his initial forms, such however diagnosed hyperemia of pulp and sharp limited pulpitis is in a clinic.
To put duration and frequency of pain attacks preschool age, as a rule, caot define. At the same time it is very important to know for correct diagnostics, what interval of time passed from the first display of pain in a tooth. In such cases information of parents have an important value about time of origin of pain first, intervals which pain repeated oneself through, and also about reasons, that he was entailed or strengthened.
During diagnostics of pulpitis in a temporal tooth it follows in the first turn to take into account information of objective inspection. To them belong being of dentine in the day of carious cavity, sizes of cavity, its depth and localization, and also character of exsudate, got during opening of horn of mash (festering, bloodly). The pain reaction of pulp is on possibility estimated on the action of thermal irritants. Irritants cause pain a cold at serosal inflammation, however stop something him at festering. An auxiliary differential diagnostic sign is a reaction of causal tooth on percussion.
A sharp diffuse pulpitis can be diagnosed in temporal teeth with the fully formed root. He shows up sharp pain, without clear localization which first arises up without visible reasons. The attacks of pain are protracted, he sharply increases under the action of cold. The feature of clinical symptomatic of sharp diffuse pulpitis is distribution of pain, as a result a child is helpless to pin-point on a causal tooth. A child is capricious, is not half asleep.
Objectively. The carious cavity of different depth (more frequent deep ), filled the light softened dentine, appears during the inspection of tooth. Attempt to delete the softened dentine, and also sounding of bottom of carious cavity draws sharp pain. From the action of cold water there is great pain in a tooth. Percussion of tooth can be sickly.
Pathoanatomy. In pulp of temporal tooth there is a picture of sharp serosal inflammation with predominance of exsudate component: sharp expansion of capillaries and fulled by their blood, margination and output of them outside vessels, roundcells diffuse infiltration, diapedesis of red corpuscles, punctulate hemorrhages. Strom of connective tissue of pulp was swollen, loose. Noticeable vakuolisation of cytoplasm of cellular elements, cariopicnosis, cariolisys. There are degenerative changes of odontoblasts.
A sharp festering pulpit is the most widespread form of sharp inflammation of pulp in temporal teeth. He develops as a result of sharp serosal diffuse pulpit. Children have wilful, unbearable pain of pulsliked character, without clear localization. Very characteristic is an origin of pain in a night-time. Pain gradually grows and becomes permanent. Intensity of pain sharply grows as a result of reception of hot meal and some goes down from a calaboose. A festering pulpit develops in a temporal tooth mainly in the end 2-ї days from the beginning of disease.
Objectively. A deep carious cavity which does not have connection with the cavity of tooth appears during a review. The attempt of delete of the softened dentine a power-shovel from the bottom of carious cavity is accompanied sharp pain. Sounding of bottom quite often is accompanied opening of cavity of tooth with the selection of drop of pus, which appeared as a result of the festering melting of crown pulp. Pain weakens considerably after it. During opening the cavities of tooth find out sickly, sanguifluous mash in openings of the root ductings. There always are the phenomena of sharp periodontitis at festering inflammation of mash of temporal teeth. A tooth reacts on percussion, can have insignificant mobility. At that rate speech goes about a sharp pulpitis, complicated perifocal periodontitis. Such reaction of fabrics of periodont is explained entering of products of inflammation of mash his fabrics with next intoxication.
In the case of complication periodontitis next to sharp, attackliked, involuntary pain characteristic for sharp periodontitis pain appears at biting on a tooth, the edema of soft fabrics which surround a tooth develops. There is lymfadenitis of the proper group of lymphonoduss. The general state of child gets worse considerably, the temperature of body rises, sleep is violated, a child renounces a meal.
Pathoanatomy. Next to changes, characteristic for sharp serosal inflammation, there are destructive changes in pulp — leucocytic infiltration of fireliked or diffuse character is expressed. Collogen fibres fillings out, loose, some are in the state of homogenization, large accumulations of glycosaminoglycans (GAG). Most nervous fibres are stored. There are areas of the festering melting of fabric of different size in mash.
Chronic fibrotic pulpitis — is the most widespread form of chronic inflammation of pulp in temporal teeth. The feature of this disease is that it can develop as initially chronic process, without the clinically expressed stage of sharp inflammation of pulp. To put can grumble about aching pain, which arises up in a tooth during a meal, breathing in cold air, use of cold drinks. Sometimes, especially for the children of early age, a chronic fibrotic pulpit runs across unsymptomatic and shows up only during an inspection a doctor.
pic.1
Objectively. A deep carious cavity which can be reported with the cavity of tooth is determined (pic.1). Sometimes a chronic fibrotic pulpitis develops at the closed cavity of tooth, which clinically is not reported with a carious cavity.
If connection with the cavity of tooth is, sounding of him draws pain and insignificant sanguifluousness as a result of mechanical irritation of pulp.
If connection of carious cavity is not with the cavity of tooth, ran across chronic fibrotic pulpit very similar to the sharp deep caries. For differential diagnostics it follows carefully to probe being of dentine in the day of carious cavity, on possibility to estimate the action of thermal irritants and find out anamnesis in relation to character of pain in a tooth.
During roentgenologic research of temporal tooth with a chronic fibrotic pulpit sometimes find out the hearths of chronic granulating periodontitis, that more frequent meet in temporal teeth on the stage of resorbtion of root. At that rate speech goes about a chronic fibrotic pulpiis, complicated focal periodontitis. From data of S. V. Siobu (1967) in 57 % cases the chronic pulpitis of temporal teeth is accompanied the destructive changes of aroundteeth fabrics, especially on the stage of resorbtion of root.
Pathoanatomy. Chronic inflammation in pulp unlike sharp runs across with predominance of proliferative processes, vascular-exsudate processes are expressed considerably more poorly.
At a chronic fibrotic pulpit in temporal teeth there is excrescence of fibred connecting fabric, infiltration macrofags, lymfocyts, leucocytes, plasmatic cages. The walls of blood vessels sclerosed partly. The layer of odontoblasts is added atrophy, vacuolization and degeneration.
A chronic hypertrophic pulpit develops as a result of the protracted mechanical irritation of fabric of the opened pulp, which results in excrescence of granulation and young connecting fabric in pulp, which fills all of carious cavity gradually.
A tooth disturbs a child relatively little. To put can grumble about sanguifluousness from a tooth under time go. Most children avoid to chew the proper side jaws, what considerable stratifications of soft dental raid on teeth and phenomenon of catarrhal gingivitis testify to.
Objectively. The polypus of pulp of red color can fill all of carious cavity, sounding of him is poorly sickly, always accompanied bleeding. A reaction on percussion is painless. The chronic hypertrophic pulpitis of temporal teeth is diagnosed rarely, mainly in the stage of the formed root.
Pathoanatomy. At a hypertrophic pulpitis crown pulp is presented granulation and young connecting fabric with the microfires of festering infiltration. Root pulp fibrotic densed and infiltrated leucocytes.
Granulation fabric is outwardly covered a multi-layered flat epithelium.
A chronic gangrenous pulpitis is investigation of sharp festering or chronic fibrotic pulpitis of temporal tooth and develops in the case of joining of anaerobic microflora which conduces mashes to gradual necrosis.
A child can grumble about the unpleasant feelings in a tooth, especially during the reception of hot meal, however often complaints absent.
Objectively. A deep carious cavity appears in a temporal tooth, the cavity of tooth is opened, pulp partly or almost fully necrotic, grey color. Its superficial sounding is painless, pain arises up only during the deep sounding of openings of the root ductings. At this form of pulpitis often there are changes of periapical fabrics which appear roentgenologic.
Pathoanatomy. At a chronic gangrenous pulpitis the structure of crown pulp is broken, it is added necrosis, in the root ductings tailings of mash appear with the high degree of degenerative changes. The structure of cellular elements and fibres of pulp is saved only in apical part.
Ran across a pulpitis in temporal teeth closely related to the stage of development of tooth which represents the morfofunctional features of pulp and its ability to resist injury factors. On motion of pulpitis the state of general somatic health of child which determines the level of it immunological reactivity influences also. As marks T. F. Vinogradova (1987), a sharp pulpitis is diagnosed mainly for somatically healthy children which are rarely ill.
On the stage of the unformed root of temporal tooth which answers the period of morphological immaturity of pulp, a pulpitis is diagnosed not often. Prevailing forms is a chronic fibrotic pulpitis which develops as initially chronic process and runs across almost unsymptomaticaly, and sharpening of this pulpitis. Sharpening can be accompanied the expressed reaction from the side of periodont — perifocal periodontitis. First temporal molars are more frequent strucked, a carious cavity here is located on a masticatory surface.
In a period the fully formed root of temporal tooth which answers the period of functional maturity of pulp, prevalence of pulpitis considerably grows and, from data of M. A. Kodoly (1980), is 86,5 %. Diagnosed, both sharp and chronic, forms of inflammation of pulp, by the however prevailing form of pulpitis and there is a chronic fibrotic pulpitis in this period.
In a period sucked of roots of temporal teeth, which answers the period of fading of functional activity of pulp, prevalence of pulpitis goes down and is about 12% (M. A. Kodola and others, 1980). The chronic forms of pulpitis are diagnosed in this period only, quite often complicated focal periodontitis. Ran across a pulpitis almost unsymptomatical, that is explained the involutical changes of structure of pulp. A prevailing form is a chronic fibrotic pulpitis. More frequent than in other periods, a chronic gangrenous pulpitis is diagnosed.
Sharpening of chronic pulpitis can develop at any his form. It is arisen up for children after the carried viral or infectious diseases which are accompanied weakening of protective forces of organism. Complaints are similar to such at a sharp pulpitis: attackliked pain which can arise up at night, pain from temperature irritants.
Possible pain at biting on a tooth, reaction is from the side of soft fabrics which surround a tooth, and regional lymphonoduss. The general state of child can get worse: the temperature of body rises, a sickliness, head pain, appear. It is possible to find out from anamnesis, that similar pain even one time took place and before. A carious cavity, more frequent deep, appears during a review, that is reported with the cavity of tooth. Sounding of mash draws pain.
To differentiate track from a sharp serosal diffuse pulpit, sharp festering pulpit, sharpening of chronic periodontitis .
Treatment of pulpitis of temporal teeth
ENDODONTIC TREATMENT OF BABY TEETH
In spite of decline of prevalence of caries for children, yet there are children, feel like intensive carious destruction of teeth (pic. 2).
Pic. 2. Plural carious cavities are in baby teeth. Such clinical picture is observed for many children which act on treatment
Therefore all of practicing stomatologies must know the methods of prophylaxis and treatment of baby teeth. The maintainance of baby teeth in a dental row is important both for development of jaws and for forming for the children of the personal interest in the maintainance of healthy teeth. Early loss of baby teeth simply because they are a «child», or «first», without every idea about subsequent development of dental row for a child, no longer is justified.
Coming from it, the rational use of technologies of treatment of pulpitis and periodontitis of baby teeth is important, which will help:
· To save suckling molars with the defeat of pulp and periodont until eruption of the second teeth will not begin.
To prevent forming of harmful habits, such as introduction of proglossis to space in place of remote tooth.
· To save the function of mastication.
· To save an aesthetically beautiful kind.
That is most essential, keeping teeth, stomatology gives to understand both parents and child, that teeth are important organs and must be stored. Without an attempt to save an exodontia them is investigation of wrong point of view and can form the same attitude toward the second teeth both for parents and for a child in the future.
Presently stomatology have in an order methods of maintainance of teeth with the defeat of mash and periodont. Most suckling molars can be stored in case that they have an enough enamel and dentine for fixing of stoppings and metallic crowns.
Electing the method of treatment of pulpitis, it follows to take into account a form and remoteness of inflammation, group belonging and period of development of tooth, localization of carious cavity, state of immunological reactivity of organism (the carried and concomitant illnesses are in anamnesis).
Children have liquidation of inflammation of pulp and prophylaxis of diseases of periodont, jaw bones and soft fabrics, the primary objective of treatment of pulpitis maxillufacial areas. For children it is necessary to provide terms for subsequent formation of roots of the unformed teeth and physiology resorbtion of roots of temporal teeth.
Five methods of treatment of pulpitis are used in children stomatology:
1) conservative, or biological is a method, directed on the maintainance of viability and functional activity of all of mash;
2) congratulatory amputation of pulp is a method which foresees a delete under anaesthetizing of crown part of pulp and maintainance of viability and functional activity of root pulp;
3) congratulatory exterpation is the method of complete delete of pulp from a tooth under anaesthetizing;
4) unvital amputation is a delete of crown part of pulp after the previous devitalization of pulp;
5) unvital exterpation is the delete of all of pulp after its previous devitalization.
During treatment of pulpitis of temporal teeth for children more frequent than other apply the methods of unvital amputation and unvital exterpation .
The choice of method of treatment depends above all things on the form of pulpitis, stage of development of temporal tooth, presence of changes in periodont, which are determined clinically or roentgenologic.
A. Method of vital amputation pulptomia
Congratulatory amputation of mash is procedure of delete of the inflamed and infected crown pulp as a result of deep caries calculating on a maintainance in the congratulatory state of root pulp.
On root pulp which remained, medication is imposed with the purpose of removal of inflammation in it. Presently most widely common preparation efficiency of which is well-proven plenty of research works is formocresol, offered Bakli (Buckley) in a proportion 1:5.
Diagnosis
Many clinisists experience difficulty at the decision of question about that, whether congratulatory amputation of pulp must be conducted in a baby tooth with a carious cavity, in default of pulpitic was ill. The practical wideuse of glassionomer cements suggests an idea about their possible use for stopping of deep cavity since from it the changed fabrics and bottom are remote it is smoothed out by the round coniferous forest and low-speed tip of drill. It is considered that glassionomers own ability, freeing a fluorine to prevent a cariosity even in case that the several of the staggered fabrics is leave.
Experience proved that this incorrect conception resulted in the unsuccessful result of treatment, as greater part of such stoppings appears helpless (pic. 3).
Pic. 3. Stopping from glassionomer cement, put in a cavity without the complete delete of fabrics, staggered a caries
That just and for stoppings from an amalgam, fabrics staggered a caries put without a complete delete (pic. 4 and 5).
Pic. 4. Example of the off-grade amalgam stoppings imposition of which is conducted without application of toponarcosis
Pic. 5. On the sciagram of patient the snapshot of which is presented on a picture
Pic. 6. (a) On a sciagram dilution of bone fabric is determined in the area of branching of a 85 tooth restoration of which appeared склоіномерним cement to uneffective. (b) Periodontal abscess from 74 teeth, which stopping from glassionomer cement, put without a toponarcosis and at the incomplete delete of fabrics, staggered a caries stood on
In most teeth which treat oneself thus, mash perishes, periodontal abscesses develop (pic. 6). Reason of it is that in the baby teeth of inflammation of pulp develops till the symptoms of pulpitis are clinically determined. Endodontic treatment of baby molars must be conducted in all of cases, when proxymal is carious defect to the marginal comb. It also underlines importance of early diagnostics of proxymal caries with the use of bitted sciagrams. From such early beginning of inflammation of mash of baby molars of application of method of maintainance of crown pulp contra-indicated. The described conception of early development of inflammation of mash in reply to a cariosity is illustrated on pictures 7-11
Pic. 7. (a, b) A caries is on the aproxymal surfaces of baby molars. Crown pulp of these teeth, probably, inflamed, congratulatory amputation of pulp is rotined that is why
Pic. 8. (а) A picture illustrates early development of inflammation of mash under a carious defect at baby molars. Crown pulp usually appears attracted in an inflammatory process, yet to baring of pulp. (b) The histological picture of uncalcificated cut of carious defect of first baby molar, painted gematoxylini-eosini, demonstrates early inflammatory changes in the layer of odontoblasts. These changes were observed in reply to proxymal cariosity which engulfed the less than half of distance from a cheek to the tongue hump
Pic. 9. On a internalmouth sciagram deep carious cavities are rotined on aproxymal surfaces 74 and 75 teeth. Even in spite of the fact that baring of pulp, crown pulp is not determined roentgenologic, probably, inflamed that is why necessary leadthrough of congratulatory amputation of mash and these teeth
Pic.
Pic. 11. Example of clinical case which illustrates this conception also a) At a clinical inspection a marginal comb in the area of 84 teeth, clinical signs of caries, is not practically. b) On a bitted sciagram found out the caries of distal surface of 84 teeth which does not spread on pulp, (c, d) However actually in the moment of inspection pulp 84 teeth was already inflamed and needed pulpotomia with the subsequent making of steel crown
Pic. 12. Cheek abscess, related to large medio, – by occlusal amalgam restoration on baby molar. During restoration of tooth of clinical signs of openning of pulp chamber it was not.
Thus, restoration of large carious cavities of baby molars without the account of the state of mash consciously will not make good (pic. 12). It explains also, why many doctors consider that restoration of baby molars without pulpotomia only leads to forming of abscesses in the area of these teeth.
A testimony is to congratulatory amputation of pulp
A deep carious cavity is with considerable destruction (more for an one-third) of aproxymal surface of crown of the tooth.
Absence of inflammation is in root pulp. It is set subsequent signs.
(а) Anamnesis is absence of spontaneous or permanent pain. Pain would mean to irreversible pulpitis which spreads on root pulp.
(b) Bleeding after the delete of crown pulp is quickly stopped. The abundant and protracted bleeding testifies to inflammation of root pulp.
On a sciagram scolded baby tooth of resorbed no more than on an one-third. Absence of fistula motion. There is not destruction of bone fabric in the area of division of roots. Destruction of bone fabric in this area would testify to the necessity of endodontic treatment of pulpectomia .
There are not signs of internal resorbtion in a pulp chamber and in a root-canal.
Cases, when the delete of baby tooth is contra-indicated as a result of generalsomatic diseases, such as a disease of blood (for example, haemophilia).
Contra-indication is to congratulatory amputation of pulp
Tooth which is not subject restoration.
Destruction of bone fabric in the area of double- or third bifurcation roots.
Expressed resorbtion of roots.
Second teeth, near to eruption
Disease of heart: congratulatory amputation of pulp must not be executed for a child with a heart-disease, with rheumatism and other diseases of heart. To put such behave to the group of high risk of development of bacterial endocarditis from any invasion procedures
Pic. 13. For congratulatory amputation the followings instruments are needed: anestetics for applique and local anaesthesia, coniferous forests for the high speed tip of N of 330FG and for the low-speed tip of N of 8RA, plastic capacity for a premix, syringe, oxide of zinc with an eugenol (Kalzinol), set of thin rubberdams, stomatological mirror, pulpextractor and pincers, waddings rollers (small), power-shovels of different sizes, metallic spatula, glass for the premix of stopping material, formokresol in a proportion 1:5
Stages of congratulatory amputation (step by step)
Before the beginning of treatment complete anamnesis must be carefully collected and a clinicoradiological inspection is conducted
Stage 1: Applique anaesthesia proper anestetic
Pic. 14. The adequate anaesthetizing is needed. and) on attention mandibular anaesthesia is for lower teeth and infiltration — for overhead. For lower baby molars, except for mandibular anaesthesia a) infiltration anaesthesia of mucous membrane of cheek always must be conducted b) for the exception of cheek nerve at imposition of clamp during setting of rubberdam
Stage 2: An isolation of tooth is by rubberdam
Pic. 15. 75 tooth, isolated by rubberdam. It is necessary for prevention of infecting of pulp, hit of formokresol, on soft fabrics and for creation the patient of comfort terms
Stage 3: Delete pathologically of changed by the cariosity of fabrics and location baring of pulp
Pic. 16. Before to expose a pulp chamber, it is important to prepare a carious cavity — differently bleeding from mash will complicate the review of walls of carious cavity. It is also necessary to define the place of baring of pulp
( it is rotined a pointer), that it is simpler to get access to pulp
Stage 4: Delete of vault of pulp chamber
Pic. 17. Bor is entered in the exposed area of roof of chamber, all of vault is carefully taken off then. If an obvious openning chamber is not, a cavity is deepened. After it the coniferous forest does not move up depthfirst and moves so that to delete the vault of chamber (а). On this stage necessarily there will be bleeding from pulp
Stage 5: Delete of crown pulp by a large power-shovel or large round coniferous forest
Pic. 18. For the delete of fabric of crown pulp it is recommended to utillize a large power-shovel (а). At the use of the round coniferous forest it follows to observe a carefulness. Any surplus pressure can result in the perforation of bottom and complication of congratulatory amputation (b). After the delete of the inflamed crown pulp it is necessary to stop bleeding
Stage 6: Imposition of formokresol is on a wadding tampon on four minutes.
Pic.
Stage 7: Deleting of tampon from formokresol and verification of stop of bleeding.
Pic. 20. If after imposition of formokresol bleeding proceeds from the root ductings, it means that root pulp is inflamed. In this case mash must be remote fully, that pulpektomia is executed.
Stage 8: Filling of pulp chamber by cement
Pic. 21. After the stop of bleeding a pulp chamber is filled one of present kinds oxide of zinc with an eugenol, such as Kalzinol
Stage 9: Proceeding in a tooth is by a standard metallic crown
Pic. 22. Restoration of any tooth after treatment of pulpitis always must end with raising on him metallic crown (see a section 5). It is done for strengthening and defence of tooth, hyposthenic a delete plenty of hard fabrics, at treatment of pulpitis
Stage 10: After operation sciagram
Pic. 23. On a after operation internal mouth sciagram evidently, as filled the oxide of zinc with an eugenol pulp chamber of a 75 tooth, how fully bee-entrance of the root ductings is closed: preoperated sciagram (а), at once after an operation. Dilution of bone fabric in the area of branching of roots testifies that treatment is conducted abortively. In this case made decision or to delete a tooth, or conduct pulpectomia, and in the case of absence of destructive changes in periodont, quiet clinical picture it is recommended to watch on the state teeth during control reviews
Dynamic supervision
The state of teeth after congratulatory amputation of pulp must be controlled with the use of clinical and roentgenologic inspection during control visits, it is desirable each 6 months. Mouth sciagrams or clear pictures in a bite, which allow to consider consisting of bone fabric of area of divergence of roots, must be done inwardly.
Pic. 24. After congratulatory amputation there were the done series of control sciagrams in a 75 tooth: (а) before treatment, (b) at once after treatment, (с) through 3 misses, (d) after 12 months
From the side of bone fabric changes which are the sign of successful treatment of pic. 24 are not determined in the area of branching. A diagram shows efficiency of congratulatory amputation with application of formokresol from data of clinicoradiological inspection for 3—5 years.
Mechanism of action of formokresol
It is discovered that formokresol unactives oxidizing enzymes of fabric of pulp in the place of direct contact. He can have influence on the action of gyaluronidasa. Therefore to link ability squirrel and ingibs provides enzymes mummification. Formokrezol during congratulatory amputation of pulp in the whole world utillize beginning from 1930th, the small the amount of reports is marked about his side effects, we do not see reason for doubts in his safety.
There were the done attempts to find the alternative of formokresol, but with insignificant success. To that end next preparations were studied Sulfate of iron
This material lately caused large interest as an alternative of formokresol. The sulfate of iron was widely utillized for stopping of the gingival bleeding before the removal of molds and in endodontia. It is a wonderful hemostatic, at a contact with blood, creating a complex ions of ferum—protein, which stops up vessels, what bleeding is stopped due to. The remote results of treatment the method of pulptomia rotined that in a concentration a 15,5% sulfate of iron can be similarly effective, as well as formokresol. Preparation is produced under the name of Astringident (pic. 25).
Pic. 25. The sulfate of iron is produced a firm Ultradent (THE USA) under the name of Astringident. Usually he is inflicted by aplicator
Pic. 26. Clinical application of sulfate of iron. Bleeding is from a pulp chamber after amputation of crown pulp (а), which was shut-down (b) after the applique of sulfate of iron, by the basic alternative of formokresol.
However it should be remembered that the sulfate of iron has a «fixative» effect also. It is therefore necessary to conduct careful diagnostics of the state of mash in an area, where preparation will be inflicted. On a picture 26 shown gaemostas, got by the sulfate of iron after amputation of crown endodontium 55.
Glutaraldegid
Entered in practice of Gravenmade (1975), as a possible alternative of formokresol, glutaraldegid was widely tested in vivo. In theory he owns the prepotent mummifying operating on albuminous fabrics, conditioned two functional aldehydic groups. However most researchers, discovered that index of his efficiency not increase index of formokresol and, in spite of report about his advantage before formokresol, he never found wide practical application during congratulatory amputation of pulp of baby teeth. Such properties of glutaraldegid were recently marked, how to cause ability allergic reactions and irritations of eyes, probably, he will not make the competition of formokresol as preparation which is used for congratulatory amputation by pulp of baby molars.
Gydroxide of calcium
The hydroxide of calcium, widely in-use for the second teeth, was appraised, as a possible alternative of formokresol at treatment of pulpitis of baby teeth. From data of literature, the indexes of efficiency of this preparation during congratulatory amputation of pulp were considerably below (about 60%), than indexes of formokresol (to 98%). The most frequent complication at the use of hydroxide of calcium was a fulguration pulp, that proceeded, below than place of amputation. Therefore presently the use of hydroxide of calcium in treatment of pulp of baby teeth by the method of pulptomia contra-indicated.
V. Method of pulptomia
As it was already marked in a section And, in pulp of baby teeth irreversible changes can begin before time. If in a baby tooth crown pulp, rotined it congratulatory amputation which has a favourable prognosis usually, is attracted in an inflammatory process only. However often it appears that inflammation spreads on root fabric which becomes obvious on the uncontrolled bleeding even after imposition of formokresol. Yet worse, if mash perishes and a destructive process passes to periodont. If it happens, many practicing doctors delete a tooth or delete disintegration of pulp from crown part, and on maintenance in a root-canal impose formokresol. Efficiency of the last procedure is so low, that, to our opinion, it became antiquated and must not be used.
Pulpektomia, possibly, is one of methods, that is more correct in all understood, in a pedodontia. A lot of textbooks described difficult morphology of pulp of temporary molars, with many thin additional root ductings, that resulted in a confidence in that endodontic manipulations in them are heavy for implementation. This point of view is distant from truth. True, some baby teeth have difficult morphology of roots, but it is not contra-indication to endodontic interferences. Endodontic methods are utillized during more than 20 years in the USA for the maintainance of baby teeth even in the case of development of periodont.
Expedience of pulpektomia
Sense of this method is creation of access to the root ductings, delete of maximally possible amount of detritus, cleaning, disinfection and filling of the root ductings, by the proper material for support of baby tooth in the germ-free state.
A testimony is to pulpektomia
Irreversible of inflammation which spreads on root pulp
Pic. 27. If after the delete of crown pulp abundant and protracted bleeding even after 4-minute saved the applique of formokresol, it testifies to irreversible inflammation of root pulp and is a testimony to pulpektomia, to the delete of root pulp. Baby teeth are with necrotic pulp
Pic. 28. There are patients, in what unsymptoms in baby teeth pulp perishes at oppened of pulp chamber the diminished appears in a volume necrotic pulp of baby tooth with the phenomena of pathology of bone fabric in the area of divergence of roots
Pic. 29. Destruction of periodont in baby teeth usually appears in the area of double or thirdfurcation unlike periapical pathology, in examined permanent molars. It takes place because there is a great number of tubulis which provide connection of pulp chamber by a bone-in in the area of division of roots (b). On a picture it is rotined on remote baby molars. Pay attention in the presence of granulation fabric of the germinating in an area branching of pic. 29. Presence of fistula with festering separation (а) of sharp periodontal abscess, complicated or not inflammatory infiltrate of aroundjaws of soft fabrics (b), also there are shows to pulpektomia (before endodontic treatment)
Contra-indication
Medical untestimony for pulpektomia those, that and during congratulatory amputation (see a section A), but, in addition, there are other.
Crown of the tooth which is not subject restoration
Pic.
Pathological resorbtion of root
Pic. 31. Internalmouth sciagram on which evidently pathological resorbtion of root due to a chronic process in the area of 74 teeth with bringing in to the pathological process of follicle and rudiment of permanent premolar, an odontectomy is rotined in this case
Material for stopping of root-canal at pulpektomia in baby teeth
Any material, in-use for stopping of root-canal of baby teeth, must own property of resolved with that speed, that and at resorbtion of root before the fall of tooth. The most well-known and effective material for stopping of root-canal, in-use at pulpektomias in baby teeth, is a clean oxide of zinc, mixed with an eugenol. If several to pasture shown out for an apex, it will be fully resorbted by periapical fabrics (pic. 32). Recent researches confirm this point of view. To pasture (for example, Kalzinol) some brands of zinc eugenol can contain other ingredients, which are not such which resolve. In this case the particles of stopping paste can remain into the bone of alveolar sprout of jaw and influence on eruption of the second teeth.
In literature there are reports about the use of other stoppings materials, such as paste of Maisto (Maisto) and iodoform paste. However considered zinc eugenol paste still is the best stopping material for baby teeth
Pic. 32. Zinc eugenol paste was shown out for the apex of a 85 tooth. Through 3 months there is complete resolve of material from periapical fabrics
Types of pulpektomia
Pulpektomia can be conducted both for one and for two visits depending on a clinical picture. Therefore two methods will be described here:
– pulpektomia in one visit;
– pulpektomia in two visits.
A testimony is to pulpektomia in one visit:
Presence of the viable inflamed root pulp (see a pic. 27).
A baby tooth is with necrotic pulp (see a pic.28) without any concomitant symptoms of sharp inflammation (such, as inflammatory infiltrate).
Presence of fistula’s motion in the area of mucous membrane of alveolar sprout from the side of start mouth without the actively separated or sharp symptoms of inflammation (see the pic. of 29 а)
Pulpektomia in one visit: stage-by-stage description of method. A method foresees the leadthrough of pulpektomia and complete restoration of tooth, which carried out at a heat. At it the root ductings clean out and stop zinc eugenol paste, and then close a tooth a standard metallic crown.
Stage 1: A toponarcosis and isolation of tooth is by rubberdam
Pic. 33 (а) 85 tooth is isolated by rubberdam. In anamnesis involuntary pains which began after restoration of tooth the silver stopping of Ketac. On a sciagram dilution of bone fabric is determined in the areas of branching, which are a testimony to pulpektomia (b). Always to beginning treatment must be conducted roentgenologic research. Usually do a mouth sciagram inwardly
Stage 2: Delete of old restoration and opening of pulp chamber
Pic. 34. After the delete of the old helpless stopping evidently point of baring of pulp
Stage 3: Delete of vault of pulp chamber, as during congratulatory amputation, and determination of bee-entrance of the root ductings
Pic. 35. Usually three has roots of baby molars or four root-canals in lower molars and three — in overhead.
Included in mesiobuccal, medial-tongue and distal ductings of a 85 tooth.
This lower baby molar have four root-canals, that two distal channels. In most cases the root ductings discover without special difficults.
Stage 4: A diagnostic sciagram is from pulpextractorgramm in the root ductings
Pic.
Stage 5: Delete of content of the root ductings, cleaning, disinfection
Pic. 37. The root instruments of Khedstrema are entered in the root ductings, on 1—2 mm, not coming to the apex (а). In order to avoid the damage of rudiment of the second teeth which develops, it follows to observe a carefulness. The root ductings are processed the saw of Khendstrema a not more than 30 number (с) with a carefulness, as a root of baby teeth is fragile and it is usually distorted. Expansion of the root ductings by drylbor is not recommended on that reason. It follows to stop bleeding (А) within the limits of root-canal, keeping indoors for an apex. (Cit. for: Dental Update; with permission George Warman UK Ltd.)
Stage 6: Drying of the root ductings by waddings turundas. Imposition of tampon from formokresol in a pulp chamber on 4 min.
Pic.
Stage 7: Choice of canalfilling, proper size of root-canal
Pic. 39. Canalfilling for stopping of root-canal must be on one size less than, than the last cored instrument, utillized for treatment of the root ductings. It is done in an order to prevent his oppression and break in a root-canal. By sharp scissors canalfillings is cut on the half of his length which simplifies the leadthrough of manipulations in a company child, and also prevents the leadingout of stopping material for an apex.
Stage 9: Filling of pulp chamber by cement
Pic. 40. Pulp chamber is filled cement of one of the patented brands on the basis of oxide of zinc with an eugenol, such as Kalzino
Stage 10: Restoration of tooth by a standard metallic crown
Pic. 41.Treatment of a 85 tooth is conducted with the use of technology of pulpektomia, restoration — by a standard metallic crown
Stage 11: A sciagram is after treatment for control of stopping of the root ductings
Pic. 42. Sciagrams to to and after treatment of a 85 tooth. Pay attention, that root ropes are sealed within the limits of apex. It desired, but not always such, that a result is arrived at
Dynamic supervision
Teeth treatment of which was conducted the method of pulpektomia are under the supervision of clinisist. It follows to conduct a roentgenologic inspection during the planned visits. pulpektomia is considered as effective, if pains absent, there is not mobility of tooth, fistulas with a festering selection closed. The plan of leadthrough of roentgenologic inspection is made to order by us plugs one internalmouth sciagram in treatment and one — at once after treatment, and then through 6 months and after a year. Sciagrams must be estimated on the state bone fabric in the area of roots of tooth. The improvement of the state of bone in this area (pic. 43) or absence of worsening means that pulpektomia is conducted successfully. Any increase of hearth of destruction of bone fabric in the area of root is a testimony to the odontectomy. Pic. 43. Sciagrams to to and after treatment 74 teeth, and also control sciagram which testifies to successful treatment by the method of pulpektomia:
on a sciagram, done to treatment 74 teeth, destruction of bone fabric is determined in the area of divergence of roots;
a sciagram, done after treatment 74 teeth, demonstrates stopping of root-canal on the proper depth; (с) a sciagram, done after 6 months, testifies to successful treatment. (Cit. for: Dental Update; with permission George Warman UK Ltd.)
Other examples of stopping of the root ductings of baby molars
Case 1
Pic. 44. Series of sciagrams which demonstrate the gradual regeneration of bone fabric in the area of branching after pulpectomia, executed on a 75 tooth: (а) before treatment; (b) at once after treatment; (с) after 6 months; (d) in a year.
Case 2
Pic. 45. Series of sciagrams which testify to the positive results of pulpektomia, conducted in 74 teeth, continuous renewal of bone in the area of branching during 6-monthly to the period: (а) before treatment; (b) through 6 months
Case 3
Pic. 46. Example of pulpektomia, in overhead molar (54): (а) before treatment; (b) after treatment. Pay regard to quality of stopping of the mesiobuccal, cheek and palatal ductings
Is there canalfilling by the best instrument for stopping of root-canal?
The recently conducted research rotined that canalfilling was the best instrument for this method. Yet one his advantage is that he can enter zinc eugenol paste in the additional ductings which meet in baby molars, that well evidently on sciagrams, done after treatment (pic. 47). Canalfilling is a fragile instrument and at the careless use can break in a root-canal (pic. 48)
Pic. 47. Internalmouth sciagram 74 teeth with the sealed root ductings, on which evidently, that stopping material went out in an additional channel (pointers)
Pic. 48. Canalfilling which broke in the distal channel of a 75 tooth
Pic. 49. Sucklings chisels, sharpening of periodontal inflammation, which appeared reason, and treated by the described method of pulpektomia: (а) before treatment — sharpening of periodontal process is rotined; (b) a internalmouth sciagram shows dilution of bone fabric in the area of apexes of roots of central chisels; (с) the root ductings are sealed properly.
Pulpectomia in two stages and in two visits
A testimony to pulpectomia in two visits is:
Sharpening of chronic periodontal process with inflammatory infiltrate of soft fabrics maxillufacial areas (or without him), as rotined on a picture 49.
Continuous excretions an exsudate are from the root ductings.
The stages of pulpectomia are in two visits
Stage 1. First visits: urgent treatment is with the purpose of removal of sharp inflammation in periodont
That it is quick all needed to provide the outflow of exsudate from the hearth of inflammation. It is arrived at or through a carious cavity, or, if there is fistula, by his section (usually it is painless procedure). At a necessity necessary to conduct a toponarcosis. At opening of pulp chamber fabric which bleeds appears quite often (see the pic. of 37 b). Under anaesthesia the root ductings are carefully processed in an order maximally to give the outflow of exsudate from the hearth of inflammation and wash a channel. Then in a cavity pulps abandon a tampon from formokresol and close the temporal stopping. At presence of inflammatory infiltrate of fabrics or at other general symptoms of intoxication of organism it follows to appoint antibiotics. Our own research rotined that introduction of ammoxycylin in the mode of two doses allowed to prolong treatment through 48 hours after the primary draining of hearth of inflammation. If pain and inflammation calms down, the visit of patient is appointed in 7-10 days
Stage 2. Second visit: final stopping of root-canal
In 7-10 days it must not be complaints on pain in a tooth, and a clinical picture must show calming down of symptoms of inflammation. Pulp chamber and root ductings is processed with the use of rubberdam, and procedure of pulpectomia is conducted how it is described before, with the use of zinc eugenol to pasture for stopping of the root ductings.
Treatment of sucklings chisels which appeared reason of sharpening of inflammatory process in periodont.
With nonviable pulp at presence of destructive processes in periodont also can be brought through sucklings chisels by the method of pulpectomia, by a that method which was described before for temporary molars (pic. 49).
Indexes of efficiency of method of pulpectomia are in baby teeth
Most researchers report about high efficiency of method of pulpectomia. The number of positive results exceeds 80 % from the incurrence of baby teeth which responded to treatment this method.
Unvital amputation — used during treatment of pulpit of temporal teeth the roots of which are unformed fully or are resorting, that then, when endodontic interferences are undesirable. Testimonies to the leadthrough of method of unvital amputation at that rate is a sharp traumatic pulpitis (the casual opening of mash is during pre–fallowing of carious cavity), chronic fibrotic or hypertrophic pulpitis, chronic fibrotic pulpitis in the stage of sharpening.
It should be remembered that the method of unvital amputation in the considerable percent of cases gives complication as chronic granulating periodontitis in 2—3 years after his leadthrough.
Therefore if this method was utillized during treatment of pulpitis on the stage of the unformed root of temporal tooth, a child must be under surveillance of stomatology to the final forming of root. After completion of forming of root it follows endodontic to process the root ductings of temporal tooth and seal them the proper stoppings materials.
Unvital amputation is executed in 2—3 visits. During the first visit conduct the partial preparing of carious cavity, which foresees opening of it, partial necrotomy and opening of horn of pulp, and also conditioning, for fixing of bandage.
For the devitalization of pulp on the stage of the unformed root or resorbtion of root of temporal tooth, when the apical openings of the root ductings are wide and pulp is in a close touch with fabrics of periodont, it follows to apply pastes only on the basis of paraformaldegid. They to a great extent less toxic for periodont, than arsenic anhydride.
Paraformaldegid does a mummifying action on pulp, he joins water which is contained in pulp gradually, as a result pulp perishes and grows into dried up тяж of greyish color, saturated with formaldehyde. Paraformaldegid paste can be prepared eh tempore, mixing up taken equally powder of paraformaldegid and Anaesthesinum (to Trimecainum) with clove butter (by an eugenol). It is possible to utillize brandname preparations which contain paraformaldegid, such as “Parapasta” (Chema,Polfa), “Depulpin” (VOKO), “Devipulp” but other paraformaldegid paste is imposed in a temporal tooth on 10-14 days (table. 1).
During the second visit of child conduct a final necrotomy and forming of carious cavity, amputation of crown pulp, with deleting of it ( on possibility) from openings the root of canals. After amputation of crown pulp it follows to estimate the state of root pulp. It must be insensitive during sounding and not to bleed.
If the devitalization of pulp took place not fully, it follows repeatedly to impose paraformaldegid paste on 4—5 days.
Table 1. Composition and term of action of unvital pastes
|
Name |
Composition |
Terms of devitalization of teeth, days |
|
|
temporal |
permanent |
||
|
“Devipulp“ |
Paraformaldegid, unpain mean, phenol |
7– 10 |
8-14 |
|
“Depulpin“ |
|||
|
“Parapasta“ |
|||
|
“Necronerv“ |
|||
|
“Nervpasta“ |
|||
|
“Toxovit“ |
|||
|
“Pulparsen“ |
Arsenic anhydride, kobalt |
3-5 |
6-8 |
|
“Causticin“ |
Unpain mean, phenol. Arsenic anhydride |
Not used |
1-2 |
After amputation on root pulp it follows to impose a medical gasket which will provide the antiseptic state of the mummified root pulp on a necessary period. With this purpose it is possible to utillize pastes on the basis of cavity formalin ( cavity-formalin, “Paracin”, “Foredeit”, “Rezopast”, “Rezoform” but other); to pasture, that contain strong antiseptic in the composition (“Tepasta” (Chema, Polfa);
“Mummifying Paste” (PD, Switzerland) or zinc-eugenol paste.
Complete treatment imposition of the permanent stopping from the proper stopping material.
Unvital extyrpation is a method which foresees the complete delete of pulp after its previous devitalization.
By testimonies to the leadthrough of method of unvital extyrpation in temporal teeth there are practically all of forms of pulpitis on the stage of the formed root of temporal tooth, especially at presence of clinical or roentgenological signs of defeat of periodont and also sharp festering, chronic gangrenous and pulpitis, complicated periodontitis of temporal teeth which are on the stage of the unformed root. On the stage of resorbtion of root there is the rotined delete of temporal tooth at such forms of pulpitis.
In the case of sharp festering pulpit in the first visit expose the cavity of tooth, utillizing a high-circulating drill, and provide the outflow of festering exsudate. Pulp of root is usually sickly, that is why for its devitalization impose unvital paste.
During the second visit take off a bandage, delete root pulp, conduct antiseptic treatment of the root ductings. Some authors recommend to conduct the impregnation of the root ductings solution of silver of nitrate.
The root ductings stop to opening of apex of root pastes which do not render an irritate influence on periodont. To pasture, that used for stopping of the root ductings of temporal teeth, must answer certain requirements, namely:
to resolve to the extent of resorbtion of root of temporal tooth;
— easily to be entered in a root-canal;
— to be safe for periapical fabrics and rudiment of the second teeth;
— quickly to resolve in the case of leadingout of them for opening of apex of root;
— to have an antiseptic action;
— to have adgesia to the walls of root-canal;
— not to give sit in a root-canal;
— easily to retire from a root-canal in the case of necessity;
— to be roentgencontrastic;
— not to dye a tooth.
It should be noted that for today there is not material which would answer all of these requirements to a full degree. For stopping of the root ductings in temporal teeth more frequent all utillize zinc-eugenol paste, iodoform or timol to pasture, in separate causes— cavity-formalin paste with addition Iodoformium.
During treatment of chronic gangrenous pulpitis by the method of unvital extyrpation it is possible to make attempt delete pulp from the root ductings in the first visit after its previous coagulation by mixture of phenol (carbolic acid) with Anaesthesinum. If it does not succeed to be done, impose unvital paste.
After pulp extyrpation at a chronic gangrenous pulpitis for antiseptic treatment of the root ductings it is expedient to utillize preparations of antianaerobic action (perekys hydrogen, gypohlorid of sodium, metrodzhyl, metronidasol). It is related to that gangrenous detritus in the root ductings, except for a various aerobic microflora, contains anaerobes. Preparations from the group of nitroimidasol are specific antianaerobic characteristics. Before stopping it is possible to conduct the impregnation of the root ductings solution of silver of nitrate. For stopping of the root ductings after treatment of chronic gangrenous pulpitis it is possible to apply cavity-formalin paste with addition Iodoformium.
The biological (conservative) method of treatment of pulpitis of temporal teeth is used rarely, because has the limited testimonies and technical difficulties during implementation. He can be applied only in the case of the casual baring of mash, which happened within the limits of clinically healthy dentine during preparing of carious cavity. A temporal tooth must be fully formed, that testifies that his pulp is morphologically and functionally mature.
By the obligatory condition of effective treatment a biological method is an observance of rules of asepsis and antiseptics, that most problematic in the case of treatment of temporal teeth. On this reason children have conservative treatment of pulpitis preschool eye-lash is difficult and not always effective.
Congratulatory methods of treatment of pulpitis of temporal teeth, namely congratulatory amputation and congratulatory extyrpation is utillized extremely rarely. They can be applied in those cases, when sanation of oral cavity of child is conducted in the conditions of the general anaesthetizing. In other cases the use of this method is related to the necessity to conduct the injection anaesthetizing which is badly perceived the children of preschool age. Except for it, it is almost impossible to provide the observance of rules of asepsis and antiseptics which limits the use of these methods of treatment of pulpitis of temporal teeth also.
Thus, treatment of pulpitis of temporal teeth is difficult in implementation and not always effective. For this reason efforts of pedodontist must be directed on the prophylaxis of this complication of caries. It foresees the systematic planned reviews of children of preschool age with the purpose of early exposure and treatment of decay of temporal teeth. Wide sanitary educational work, studies of children, skills of hygiene of oral cavity, timely and high-quality treatment of caries, – it to save the unique possible and real way temporal teeth to their physiology change.
Treatment of pulpitis of temporal teeth
ENDODONTIC TREATMENT OF BABY TEETH
In spite of decline of prevalence of caries for children, yet there are children, feel like intensive carious destruction of teeth.
Therefore all of practicing stomatologies must know the methods of prophylaxis and treatment of baby teeth. The maintainance of baby teeth in a dental row is important both for development of jaws and for forming for the children of the personal interest in the maintainance of healthy teeth. Early loss of baby teeth simplybecause they are a «child», or «first», without every idea about subsequent development of dental row for a child, no longer is justified.
Coming from it, the rational use of technologies of treatment of pulpitis and periodontitis of baby teeth is important, which will help:
· To save suckling molars with the defeat of pulp and periodont until eruption of the second teeth will not begin.
To prevent forming of harmful habits, such as introduction of proglossis to space in place of remote tooth.
· To save the function of mastication.
· To save an aesthetically beautiful kind.
That is most essential, keeping teeth, stomatology gives to understand both parents and child, that teeth are important organs and must be stored. Without an attempt to save an exodontia them is investigation of wrong point of view and can form the same attitude toward the second teeth both for parents and for a child in the future.
Presently stomatology have in an order methods of maintainance of teeth with the defeat of mash and periodont. Most suckling molars can be stored in case that they have an enough enamel and dentine for fixing of stoppings and metallic crowns.
Electing the method of treatment of pulpitis, it follows to take into account a form and remoteness of inflammation, group belonging and period of development of tooth, localization of carious cavity, state of immunological reactivity of organism (the carried and concomitant illnesses are in anamnesis).
Children have liquidation of inflammation of pulp and prophylaxis of diseases of periodont, jaw bones and soft fabrics, the primary objective of treatment of pulpitismaxillufacial areas. For children it is necessary to provide terms for subsequent formation of roots of the unformed teeth and physiology resorbtion of roots of temporal teeth.
Five methods of treatment of pulpitis are used in children stomatology:
1) conservative, or biological is a method, directed on the maintainance of viability and functional activity of all of mash;
2) congratulatory amputation of pulp is a method which foresees a delete under anaesthetizing of crown part of pulp and maintainance of viability and functional activity of root pulp;
3) congratulatory exterpation is the method of complete delete of pulp from a tooth under anaesthetizing;
4) unvital amputation is a delete of crown part of pulp after the previous devitalization of pulp;
5) unvital exterpation is the delete of all of pulp after its previous devitalization.
During treatment of pulpitis of temporal teeth for children more frequent than other apply the methods of unvital amputation and unvital exterpation .
The choice of method of treatment depends above all things on the form of pulpitis, stage of development of temporal tooth, presence of changes in periodont, which are determined clinically or roentgenologic.
A. Method of vital amputation pulptomia
Congratulatory amputation of mash is procedure of delete of the inflamed and infected crown pulp as a result of deep caries calculating on a maintainance in the congratulatory state of root pulp.
On root pulp which remained, medication is imposed with the purpose of removal of inflammation in it. Presently most widely common preparation efficiency of which is well-proven plenty of research works is formocresol, offered Bakli (Buckley) in a proportion 1:5.
Diagnosis
Many clinisists experience difficulty at the decision of question about that, whether congratulatory amputation of pulp must be conducted in a baby tooth with acarious cavity, in default of pulpitic was ill. The practical wideuse of glassionomer cements suggests an idea about their possible use for stopping of deep cavity since from it the changed fabrics and bottom are remote it is smoothed out by the round coniferous forest and low-speed tip of drill. It is considered that glassionomers ownability, freeing a fluorine to prevent a cariosity even in case that the several of the staggered fabrics is leave.
Experience proved that this incorrect conception resulted in the unsuccessful result of treatment, as greater part of such stoppings appears helpless.
Pic. 3. Female patient – age: 10
Tooth 4.6 with three canals
Acute periapical abscess
Deep caries required prostodontic and ortodontic evaluation
That just and for stoppings from an amalgam, fabrics staggered a caries put without a complete delete.
Delivery of Irrigants
Syringe
Commercial endodontic syringes have a fine bore to allow delivery of irrigant into the apical part of the root canal system. Gauge 27 needles are manufactured with a cut away tip to allow irrigant to pass out sideways and reduce the risk of apical extrusion.
In most teeth which treat oneself thus, mash perishes, periodontal abscesses develop. Reason of it is that in the baby teeth of inflammation of pulp develops till the symptoms of pulpitis are clinically determined. Endodontic treatment of baby molars must be conducted in all of cases, when proxymal is carious defect to the marginal comb. It also underlines importance of early diagnostics of proxymal caries with the use of bitted sciagrams. From such early beginning of inflammation of mash of baby molars of application of method of maintainance of crown pulp contra-indicated. The described conception of early development of inflammation of mash in reply to a curiosity.
Thus, restoration of large carious cavities of baby molars without the account of the state of mash consciously will not make good (pic. 12). It explains also, why many doctors consider that restoration of baby molars without pulpotomia only leads to forming of abscesses in the area of these teeth.
A testimony is to congratulatory amputation of pulp
A deep carious cavity is with considerable destruction (more for an one-third) of aproxymal surface of crown of the tooth.
Absence of inflammation is in root pulp. It is set subsequent signs.
(а) Anamnesis is absence of spontaneous or permanent pain. Pain would mean to irreversible pulpitis which spreads on root pulp.
(b) Bleeding after the delete of crown pulp is quickly stopped. The abundant and protracted bleeding testifies to inflammation of root pulp.
On a sciagram scolded baby tooth of resorbed no more than on an one-third. Absence of fistula motion. There is not destruction of bone fabric in the area of division of roots. Destruction of bone fabric in this area would testify to the necessity of endodontic treatment of pulpectomia .
There are not signs of internal resorbtion in a pulp chamber and in a root-canal.
Cases, when the delete of baby tooth is contra-indicated as a result of generalsomatic diseases, such as a disease of blood (for example, haemophilia).
Contra-indication is to congratulatory amputation of pulp
Tooth which is not subject restoration.
Destruction of bone fabric in the area of double- or third bifurcation roots.
Expressed resorbtion of roots.
Second teeth, near to eruption
Disease of heart: congratulatory amputation of pulp must not be executed for a child with a heart-disease, with rheumatism and other diseases of heart. To put such behave to the group of high risk of development of bacterial endocarditis from any invasion procedures
Stages of congratulatory amputation (step by step)
Before the beginning of treatment complete anamnesis must be carefully collected and a clinicoradiological inspection is conducted
Stage 1: Applique anaesthesia proper anesthetic
The adequate anaesthetizing is needed and on attention mandibular anesthesia is for lower teeth and infiltration — for overhead. For lower baby molars, except for mandibular anaesthesia a) infiltration anaesthesia of mucous membrane of cheek always must be conducted b) for the exception of cheek nerve at imposition of clamp during setting of rubberdam
Stage 2: An isolation of tooth is by rubberdam
Stage 3: Delete pathologically of changed by the cariosity of fabrics and location baring of pulp
Before to expose a pulp chamber, it is important to prepare a carious cavity — differently bleeding from mash will complicate the review of walls of cariouscavity. It is also necessary to define the place of baring of pulp
( it is rotined a pointer), that it is simpler to get access to pulp
Stage 4: Delete of vault of pulp chamber
Bor is entered in the exposed area of roof of chamber, all of vault is carefully taken off then. If an obvious openning chamber is not, a cavity is deepened. After it the coniferous forest does not move up depthfirst and moves so that to delete the vault of chamber. On this stage necessarily there will be bleeding from pulp
Stage 5: Delete of crown pulp by a large power-shovel or large round coniferous forest
For the delete of fabric of crown pulp it is recommended to utillize a large power-shovel. At the use of the round coniferous forest it follows to observea carefulness. Any surplus pressure can result in the perforation of bottom and complication of congratulatoryamputation . After the delete of the inflamed crown pulp it is necessary to stop bleeding
Stage 6: Imposition of formokresol is on a wadding tampon on four minutes.
A little wadding tampon is dipped in formokresol and wring out in a gauze serviette, to delete surplus of solution before to place him in a pulp chamber on 4 min.
Stage 7: Deleting of tampon from formokresol and verification of stop of bleeding.
If after imposition of formokresol bleeding proceeds from the root ductings, it means that root pulp is inflamed. In this case mash must be remote fully, thatpulpektomia is executed.
Stage 8: Filling of pulp chamber by cement
After the stop of bleeding a pulp chamber is filled one of present kinds oxide of zinc with an eugenol, such as Kalzinol
Stage 9: Proceeding in a tooth is by a standard metallic crown
Restoration of any tooth after treatment of pulpitis always must end with raising on him metallic crown. It is done for strengthening anddefence of tooth, hyposthenic a delete plenty of hard fabrics, at treatment of pulpitis
Stage 10: After operation sciagram
Dynamic supervision
The state of teeth after congratulatory amputation of pulp must be controlled with the use of clinical and roentgenologic inspection during control visits, it is desirable each 6 months. Mouth sciagrams or clear pictures in a bite, which allow to consider consisting of bone fabric of area of divergence of roots, must be done inwardly.
From the side of bone fabric changes which are the sign of successful treatment of pic. 24 are not determined in the area of branching. A diagram shows efficiency of congratulatory amputation with application of formokresol from data of clinicoradiological inspection for 3—5 years.
Mechanism of action of formokresol
It is discovered that formokresol unactives oxidizing enzymes of fabric of pulp in the place of direct contact. He can have influence on the action of gyaluronidasa. Therefore to link ability squirrel and ingibs provides enzymes mummification. Formokrezol during congratulatory amputation of pulp in the whole world utillizebeginning from 1930th, the small the amount of reports is marked about his side effects, we do not see reason for doubts in his safety.
There were the done attempts to find the alternative of formokresol, but with insignificant success. To that end next preparations were studied Sulfate of iron
This material lately caused large interest as an alternative of formokresol. The sulfate of iron was widely utillized for stopping of the gingival bleeding before the removal of molds and in endodontia. It is a wonderful hemostatic, at a contact with blood, creating a complex ions of ferum—protein, which stops up vessels, what bleeding is stopped due to. The remote results of treatment the method of pulptomia rotined that in a concentration a 15,5% sulfate of iron can be similarly effective, as well as formokresol. Preparation is produced under the name of Astringident.
However it should be remembered that the sulfate of iron has a «fixative» effect also. It is therefore necessary to conduct careful diagnostics of the state of mash in an area, where preparation will be inflicted. On a picture 26 shown gaemostas, got by the sulfate of iron after amputation of crown endodontium 55.
Glutaraldegid
Entered in practice of Gravenmade (1975), as a possible alternative of formokresol, glutaraldegid was widely tested in vivo. In theory he owns the prepotentmummifying operating on albuminous fabrics, conditioned two functional aldehydic groups. However most researchers, discovered that index of his efficiency not increase index of formokresol and, in spite of report about his advantage before formokresol, he never found wide practical application during congratulatory amputation of pulp of baby teeth. Such properties of glutaraldegid were recently marked, how to cause ability allergic reactions and irritations of eyes, probably, he will not make the competition of formokresol as preparation which is used for congratulatory amputation by pulp of baby molars.
Gydroxide of calcium
The hydroxide of calcium, widely in-use for the second teeth, was appraised, as a possible alternative of formokresol at treatment of pulpitis of baby teeth. From data of literature, the indexes of efficiency of this preparation during congratulatory amputation of pulp were considerably below (about 60%), than indexes offormokresol (to 98%). The most frequent complication at the use of hydroxide of calcium was a fulguration pulp, that proceeded, below than place of amputation.Therefore presently the use of hydroxide of calcium in treatment of pulp of baby teeth by the method of pulptomia contra-indicated.
V. Method of pulptomia
As it was already marked in a section And, in pulp of baby teeth irreversible changes can begin before time. If in a baby tooth crown pulp, rotined it congratulatory amputation which has a favourable prognosis usually, is attracted in an inflammatory process only. However often it appears that inflammation spreads on root fabric which becomes obvious on the uncontrolled bleeding even after imposition of formokresol. Yet worse, if mash perishes and a destructive process passes to periodont.If it happens, many practicing doctors delete a tooth or delete disintegration of pulp from crown part, and on maintenance in a root-canal impose formokresol. Efficiency of the last procedure is so low, that, to our opinion, it became antiquated and must not be used.
Pulpektomia, possibly, is one of methods, that is more correct in all understood, in a pedodontia. A lot of textbooks described difficult morphology of pulp of temporary molars, with many thin additional root ductings, that resulted in a confidence in that endodontic manipulations in them are heavy for implementation. This point of view is distant from truth. True, some baby teeth have difficult morphology of roots, but it is not contra-indication to endodontic interferences. Endodonticmethods are utillized during more than 20 years in the USA for the maintainance of baby teeth even in the case of development of periodont.
Expedience of pulpektomia
Sense of this method is creation of access to the root ductings, delete of maximally possible amount of detritus, cleaning, disinfection and filling of the rootductings, by the proper material for support of baby tooth in the germ-free
Contra-indication
Medical untestimony for pulpektomia those, that and during congratulatory amputation, but in addition, there are other.
Pathological resorbtion of root
Material for stopping of root-canal at pulpektomia in baby teeth
Any material, in-use for stopping of root-canal of baby teeth, must own property of resolved with that speed, that and at resorbtion of root before the fall of tooth. The most well-known and effective material for stopping of root-canal, in-use at pulpektomias in baby teeth, is a clean oxide of zinc, mixed with an eugenol. If several to pasture shown out for an apex, it will be fully resorbted by periapical fabrics. Recent researches confirm this point of view. To pasture (for example, Kalzinol) some brands of zinc eugenol can contain other ingredients, which are not such which resolve. In this case the particles of stopping paste can remain into the bone of alveolar sprout of jaw and influence on eruption of the second teeth.
In literature there are reports about the use of other stoppings materials, such as paste of Maisto (Maisto) and iodoform paste. However considered zinc eugenolpaste still is the best stopping material for baby teeth
Types of pulpektomia
Pulpektomia can be conducted both for one and for two visits depending on a clinical picture. Therefore two methods will be described here:
– pulpektomia in one visit;
– pulpektomia in two visits.
A testimony is to pulpektomia in one visit:
Presence of the viable inflamed root pulp.
A baby tooth is with necrotic pulp without any concomitant symptoms of sharp inflammation (such, as inflammatory infiltrate).
Presence of fistula’s motion in the area of mucous membrane of alveolar sprout from the side of start mouth without the actively separated or sharp symptoms of inflammation.
Pulpektomia in one visit: stage-by-stage description of method. A method foresees the leadthrough of pulpektomia and complete restoration of tooth, which carried out at a heat. At it the root ductings clean out and stop zinc eugenol paste, and then close a tooth a standard metallic crown.
Stage 1: A toponarcosis and isolation of tooth is by rubberdam
Stage 2: Delete of old restoration and opening of pulp chamber
Stage 3: Delete of vault of pulp chamber, as during congratulatory amputation, and determination of bee-entrance of the root ductings
Stage 4: A diagnostic sciagram is from pulpextractorgramm in the root ductings
Stage 5: Delete of content of the root ductings, cleaning, disinfection
Stage 6: Drying of the root ductings by waddings turundas. Imposition of tampon from formokresol in a pulp chamber on 4 min.
Stage 7: Choice of canalfilling, proper size of root-canal
Stage 9: Filling of pulp chamber by cement
Stage 10: Restoration of tooth by a standard metallic crown
Stage 11: A sciagram is after treatment for control of stopping of the root ductings
Dynamic supervision
Teeth treatment of which was conducted the method of pulpektomia are under the supervision of clinisist. It follows to conduct a roentgenologic inspection during the planned visits. pulpektomia is considered as effective, if pains absent, there is not mobility of tooth, fistulas with a festering selection closed. The plan ofleadthrough of roentgenologic inspection is made to order by us plugs one internalmouth sciagram in treatment and one — at once after treatment, and then through 6 months and after a year. Sciagrams must be estimated on the state bone fabric in the area of roots of tooth. The improvement of the state of bone in this area or absence of worsening means that pulpektomia is conducted successfully. Any increase of hearth of destruction of bone fabric in the area of root is a testimony to the odontectomy. Other examples of stopping of the root ductings of baby molars
Is there canalfilling by the best instrument for stopping of root-canal.
The recently conducted research rotined that canalfilling was the best instrument for this method. Yet one his advantage is that he can enter zinc eugenol paste in the additional ductings which meet in baby molars, that well evidently on sciagrams, done after treatment . Canalfilling is a fragile instrument and at the careless use can break in a root-canal.
Pulpectomia in two stages and in two visits
A testimony to pulpectomia in two visits is:
Sharpening of chronic periodontal process with inflammatory infiltrate of soft fabrics maxillufacial areas (or without him).
Continuous excretions an exsudate are from the root ductings.
The stages of pulpectomia are in two visits
Stage 1. First visits: urgent treatment is with the purpose of removal of sharp inflammation in periodont
That it is quick all needed to provide the outflow of exsudate from the hearth of inflammation. It is arrived at or through a carious cavity, or, if there is fistula, by his section (usually it is painless procedure). At a necessity necessary to conduct a toponarcosis. At opening of pulp chamber fabric which bleeds appears quite often. Under anaesthesia the root ductings are carefully processed in an order maximally to give the outflow of exsudate from the hearth of inflammation and wash a channel. Then in a cavity pulps abandon a tampon from formokresol and close the temporal stopping. At presence of inflammatory infiltrate of fabrics or at other general symptoms of intoxication of organism it follows to appoint antibiotics. Our own research rotined that introduction of ammoxycylin in the mode of two doses allowed to prolong treatment through 48 hours after the primary draining of hearth of inflammation. If pain and inflammation calms down, the visit of patient is appointed in 7-10 days
Stage 2. Second visit: final stopping of root-canal
In 7-10 days it must not be complaints on pain in a tooth, and a clinical picture must show calming down of symptoms of inflammation. Pulp chamber and rootductings is processed with the use of rubberdam, and procedure of pulpectomia is conducted how it is described before, with the use of zinc eugenol to pasture for stopping of the root ductings.
Treatment of sucklings chisels which appeared reason of sharpening of inflammatory process in periodont.
With nonviable pulp at presence of destructive processes in periodont also can be brought through sucklings chisels by the method of pulpectomia, by a thatmethod which was described before for temporary molars.
Indexes of efficiency of method of pulpectomia are in baby teeth
Most researchers report about high efficiency of method of pulpectomia. The number of positive results exceeds 80 % from the incurrence of baby teeth which responded to treatment this method.
Unvital amputation — used during treatment of pulpit of temporal teeth the roots of which are unformed fully or are resorting, that then, when endodontic interferences are undesirable. Testimonies to the leadthrough of method of unvital amputation at that rate is a sharp traumatic pulpitis (the casual opening of mash is during pre–fallowing of carious cavity), chronic fibrotic or hypertrophic pulpitis, chronic fibrotic pulpitis in the stage of sharpening.
It should be remembered that the method of unvital amputation in the considerable percent of cases gives complication as chronic granulating periodontitis in 2—3 years after his leadthrough.
Therefore if this method was utillized during treatment of pulpitis on the stage of the unformed root of temporal tooth, a child must be under surveillance ofstomatology to the final forming of root. After completion of forming of root it follows endodontic to process the root ductings of temporal tooth and seal them the proper stoppings materials.
Unvital amputation is executed in 2—3 visits. During the first visit conduct the partial preparing of carious cavity, which foresees opening of it, partial necrotomyand opening of horn of pulp, and also conditioning, for fixing of bandage.
For the devitalization of pulp on the stage of the unformed root or resorbtion of root of temporal tooth, when the apical openings of the root ductings are wide and pulp is in a close touch with fabrics of periodont, it follows to apply pastes only on the basis of paraformaldegid. They to a great extent less toxic for periodont, than arsenic anhydride.
Paraformaldegid does a mummifying action on pulp, he joins water which is contained in pulp gradually, as a result pulp perishes and grows into dried up тяж ofgreyish color, saturated with formaldehyde. Paraformaldegid paste can be prepared eh tempore, mixing up taken equally powder of paraformaldegid and Anaesthesinum (to Trimecainum) with clove butter (by an eugenol). It is possible to utillize brandname preparations which contain paraformaldegid, such as “Parapasta” (Chema,Polfa), “Depulpin” (VOKO), “Devipulp” but other paraformaldegid paste is imposed in a temporal tooth on 10-14 days (table. 1).
During the second visit of child conduct a final necrotomy and forming of carious cavity, amputation of crown pulp, with deleting of it ( on possibility) from openings the root of canals. After amputation of crown pulp it follows to estimate the state of root pulp. It must be insensitive during sounding and not to bleed.
If the devitalization of pulp took place not fully, it follows repeatedly to impose paraformaldegid paste on 4—5 days.
Table 1. Composition and term of action of unvital pastes
|
Name |
Composition |
Terms of devitalization of teeth, days |
|
|
temporal |
permanent |
||
|
“Devipulp“ |
Paraformaldegid, unpain mean, phenol |
7– 10 |
8-14 |
|
“Depulpin“ |
|||
|
“Parapasta“ |
|||
|
“Necronerv“ |
|||
|
“Nervpasta“ |
|||
|
“Toxovit“ |
|||
|
“Pulparsen“ |
Arsenic anhydride, kobalt |
3-5 |
6-8 |
|
“Causticin“ |
Unpain mean, phenol. Arsenic anhydride |
Not used |
1-2 |
After amputation on root pulp it follows to impose a medical gasket which will provide the antiseptic state of the mummified root pulp on a necessary period. With this purpose it is possible to utillize pastes on the basis of cavity formalin ( cavity-formalin, “Paracin”, “Foredeit”, “Rezopast”, “Rezoform” but other); to pasture, that contain strong antiseptic in the composition (“Tepasta” (Chema, Polfa);
The first endotreatment was done more than 5 years before. Patient said he had some pain in region. Actually symptoms could come from second molar with deep mesial decay, which was referred to RD to treat. Parallel technique X-ray shows deep mesial caries on second molar
Discoloration of crown can hint on resorcinol formaldehyde content paste usage. After restoration removal typical view of Red Russian cement is seen
Road map of pulp chamber floor. Isthmusi between MB’s and MB – DB orifices are seen under high magnification. Irrigation and ultrasonic help to discover true orifices anatomy.
“Mummifying Paste” (PD, Switzerland) or zinc-eugenol paste.
Complete treatment imposition of the permanent stopping from the proper stopping material.
Unvital extyrpation is a method which foresees the complete delete of pulp after its previous devitalization.
By testimonies to the leadthrough of method of unvital extyrpation in temporal teeth there are practically all of forms of pulpitis on the stage of the formed root of temporal tooth, especially at presence of clinical or roentgenological signs of defeat of periodont and also sharp festering, chronic gangrenous and pulpitis, complicated periodontitis of temporal teeth which are on the stage of the unformed root. On the stage of resorbtion of root there is the rotined delete of temporal tooth at such forms of pulpitis.
In the case of sharp festering pulpit in the first visit expose the cavity of tooth, utillizing a high-circulating drill, and provide the outflow of festering exsudate. Pulp of root is usually sickly, that is why for its devitalization impose unvital paste.
During the second visit take off a bandage, delete root pulp, conduct antiseptic treatment of the root ductings. Some authors recommend to conduct the impregnation of the root ductings solution of silver of nitrate.
The root ductings stop to opening of apex of root pastes which do not render an irritate influence on periodont. To pasture, that used for stopping of the rootductings of temporal teeth, must answer certain requirements, namely:
to resolve to the extent of resorbtion of root of temporal tooth;
— easily to be entered in a root-canal;
— to be safe for periapical fabrics and rudiment of the second teeth;
— quickly to resolve in the case of leadingout of them for opening of apex of root;
— to have an antiseptic action;
— to have adgesia to the walls of root-canal;
— not to give sit in a root-canal;
— easily to retire from a root-canal in the case of necessity;
— to be roentgencontrastic;
— not to dye a tooth.
It should be noted that for today there is not material which would answer all of these requirements to a full degree. For stopping of the root ductings in temporal teeth more frequent all utillize zinc-eugenol paste, iodoform or timol to pasture, in separate causes— cavity-formalin paste with addition Iodoformium.
During treatment of chronic gangrenous pulpitis by the method of unvital extyrpation it is possible to make attempt delete pulp from the root ductings in the first visit after its previous coagulation by mixture of phenol (carbolic acid) with Anaesthesinum. If it does not succeed to be done, impose unvital paste.
After pulp extyrpation at a chronic gangrenous pulpitis for antiseptic treatment of the root ductings it is expedient to utillize preparations of antianaerobic action (perekys hydrogen, gypohlorid of sodium, metrodzhyl, metronidasol). It is related to that gangrenous detritus in the root ductings, except for a various aerobicmicroflora, contains anaerobes. Preparations from the group of nitroimidasol are specific antianaerobic characteristics. Before stopping it is possible to conduct the impregnation of the root ductings solution of silver of nitrate. For stopping of the root ductings after treatment of chronic gangrenous pulpitis it is possible to apply cavity-formalin paste with addition Iodoformium.
