Periodontitis: etiology, pathogenesis, classification

20. Treatment of acute apical periodontitis. First aid. Sequence and features of the stages of treatment. Modern technologies and instruments   for treatment of the root’s canals. Features of filling

 

TREATMENT OF  APICAL PERIODONTITIS

Choice of treatment tactics periodontitis depends on the etiology and course of the pathological process (acute, chronic, chronic relapses ¬ tion), anatomical and topographical features of roots, presence of periapical pathology centers, as well as general ¬ tion of the patient.

Existing treatments for periodontitis rather conventionally possible in ¬ divided into four groups (Table 20):

1) conservative – is aimed at preserving anatomich ¬ tion and functional values ​​of the patient tooth;

2) conservative-surgical – is aimed at preservation ¬ ing basic functions tooth. Provides for removal of roots ¬ tion or navkolokorenevyh tissue destroyed about pathological ¬ tsesom, which are not treated;

3) Surgery – removal of the patient’s tooth and pathologically altered alveolar bone;

4) physical.

Conservative treatment of periodontitis conducted to eliminate periodontal pockets of infection (abnormal ¬ these tissues pulp, dentin, and root canal microflora mikrokanaltsiv) by careful instrumental, drug

Tabl.20. Methods of treatment of periodontitis

 

Root canal treatment and obturation, which creates conditions for tissue regeneration and periodontal periapikal ¬ plot.

Indications for surgical and conservative and surgical techniques is ineffective or impossible by ¬ ing conservative treatment in full or the presence of contraindications to its holding as follows:

– The patient’s tooth is the cause of acute septic condition hronich ¬ tion of infection and intoxication;

– The complete destruction of the crown, if recovery is not possible ¬;

– Large perforated wall top or bottom of the cavity of the tooth.

CONSERVATIVE PERIODONTAL TREATMENT

Treatment of acute and exacerbation of chronic periodontitis. One of the main objectives of treatment of acute aggravation of chronic periodontitis ¬ renoho is fastest for the elimination of ¬ fuel process in periodontal tissues, eliminating pain and redress ¬ prevention of the spread of the inflammatory process.

Treatment of periodontitis involves the action of root canal and periapical mikrokanaltsi inflammatory focus.

Tactics doctor depends on the etiology of periodontitis, the stage of the inflammatory process and the overall condition of the patient.

Treatment of acute infectious periodontitis. Acute infectious periodontitis has a very short phase of intoxication, but strongly expressed exudation, which is developing very quickly. ¬ ality sudat formed in the periapical area may move into surrounding tissue in different ways: through root canal because of alveolar jaw bone under the periosteum with muscles or vestibular ¬ Covo (palate) side and then under the mucous membrane, a cleft in periodontalniy to broadcast ‘ yazky. The main problem we have ¬ in the treatment of acute infectious periodontitis (as ce ¬ port, and purulent) are: elimination of pain, creating conditions for the outflow of fluid, antimicrobial and anti-inflammatory for treatment cessation prevalence of periodontal tissue inflammation, restoration of anatomic form and function of the tooth.

Methods of treatment of acute periodontitis consists of several stages and carried out several visits. In the first visit to conduct the following stages of treatment:

1. Anesthesia. Given the inflammatory changes of soft tissues around the tooth of the patient, presence of abscess, and sometimes difficulty opening the mouth, to hold the anesthesia.

2. Antiseptic treatment of the oral cavity. Patients at th ¬ stry periodontitis, especially purulent, because serious condition caot follow the oral hygiene, take only softened food, so the teeth covered with plaque, ¬ vanym infected by various microorganisms. Prior to treatment is necessary to remove soft plaque by using hydrogen peroxide solution and irrigation furatsilinom, herb.

3. Dissection cavity including topographic and anatomical features of the patient tooth. The cavity of the tooth must be disclosed so that was free access to the root ¬ th channel. In 2-3-root teeth after opening and extended ¬ ing tooth cavity reveal mouth root canal for up to ¬ munication internally root hog type Gates Glidden.

4. Remove purydnyh mass of root canal. The quality of further treatment depends on the careful removal of infected ¬ vanoho collapse pulpovoyi tissue residues seal thick material infected softened dentin and other under ¬ raznykiv.

Putrydni mass removed from the channel by pulpoekstraktora gradually, layer by layer, carefully so as not to push ¬ infected periapical tissue in the hole, constantly processing channel antiseptic solutions.

After removing all the possible allocation of mass putrydnyh ce ¬ port or purulent fluid mixed with blood or without. Fluid pump in paper or cotton turundas.

5. Drug treatment of root canal. His oprovodyat one nepodrazlyvyh and fast likarskyh rozchyniv (1% solution of chlorhexidine, 1% solution yodyno ¬ Lu, 3% solution of hydrogen peroxide, etc.).. Handling mozhna zdiysnyuvaty using a syringe or cotton turundas dootrymannya turundas clean.

6. Disclosure of the apical aperture. If the fluid does not form ¬ lyayetsya the channel, ie, apical hole not disclosed, the pislyaretelnoho drug processing and drying roots ¬ nevoho feed him reveal. For the outflow of fluid through the root canal apical required drainage hole. Apical hole revealing the root tip, file or rymerom gently rotating motion around an axis, a tool for promoting zaverhivkovoyi area. This manipulation should be done very carefully so as not to injure and not secondarily infecting tissue Periodontal. Rugged channels, as well as in the case of obliteration of the apical opening of its opening and expansion ¬ ation channels conducted by hand and machine drill Extenders (rymeriv and files). After the fluid outflow channel was washed and left in it turundas abundantly moistened ¬ ments enzyme (trypsin, chymotrypsin) with antibiotics (strepto-mitsynom, lincomycin) for 1-2 days under loose or hermetych ¬ Noah bandage.

If subgingival or abscess to develop pidokisnoho and drain.

Type of bandages, and the nature of substance that is injected, ¬ zhat depends on the general condition of the patient, severity of inflammation, the number and nature of the fluid that is excreted through the root canal. Acute purulent periodontitis, commonly suprovodzhuyet ¬ Xia violation of the general condition of the patient expressed his collaterals ¬ edema, a large number of purulent fluid, treated by imposing a loose bandage. In root canal halls ¬ shayut enzyme solution with antibiotics to develop ¬ isotonic sodium chloride rank or 0.25% solution of novocaine, sorbents, antiseptics. The patient should be general ¬ tion treatment: detoxification therapy, a large number of warm ¬ Vitamin them drinks, analgesics, antipyretic, desensybilizyvni pre ¬ Paraty. In addition, the designated rinsing solution furatsilinom 0.02%, 1% sodium bicarbonate, decoction of herbs 6 – 8 times a day.

In case of acute serous periodontitis, characterized by little local pain, a small number of fluid, not expressed reaction of the oral mucosa, root ca ¬ NAL handle aqueous solutions of enzymes, antiseptics, etc., it leaves emulsion enzymes with nitrofurans or combined sorbentni preparations, tooth close tight bandage.

In the second visit to the choice of methods further ¬ tion treatment depends on patient complaints and objective results of the survey: percussion, palpation, the state removed from the root canal that Rundu, presence of exudate. Also taken into account, which was imposed band – tight or loose.

If after the close of the tooth tight bandage no complaints, well passed the seal tooth, reaction to percussion or negative slabkopozytyvna, turundas clean and dry, no fluid in the channel, conduct thorough preparation carious porozh ¬ nyny, drug and instrument processing channel, filling the channel and cavity.

These steps are carefully laid in the method of treatment of chronic periodontitis ¬ th.

Sometimes the patient does not have complaints, but during the test you ¬ defines a positive reaction to percussion, the root canal found a small amount of purulent or serous fluid. In such cases, after cavity preparation, tooth cavity and instrumental treatment of the channel last thoroughly treated with an antibiotic solution of enzyme or sorbent, leaving turundas the emulsion of the enzyme and antibiotic ¬ teak re-impose tight bandage for 2 days and end of treatment in follow-up visit.

Treatment of acute toxic periodontitis not fundamentally different from acute infectious periodon ¬ Titus. The success of treatment depends on the elimination of at ¬ sooner commit inflammation, removal of necrotic masses or toxic substances from the channel and the introduction of anti-inflammatory and antidote pre ¬ Paraty in periodontal tissue.

For the treatment of periodontal inflammation caused ¬ ses applications devitalizyvnyh paste (arsenious), perform the following steps:

1. Remove devitalizyvnoyi paste.

2. Devitalna extirpation of the pulp.

3. Treatment of root canal specific antidote containing sulfhydryl groups – 5% solution unitiolu, sodium thiosulfate. These solutions abundantly washed roots ¬ Neve channels and leave them on turundas 1 – 2 days in fact, enclosed protec ¬ bandage. In the multi-teeth, difficult passable channels necessary to electrophoresis iodine.

In the second visit after symptoms disappear eksu ¬

ing concrete and conduct further aggravation of drug at ¬

making channels 5% solution of iodine, 1% solution yodynolu

and instrument processing channel in full 5. Filling channels in the apical hole syleramy with prolonged antiseptic and anti-inflammatory diyeyu. Treatment traumatic periodontitis. Acute periodontitis arising from errors and complications of treatment e Pol ¬ pita, hematoma formation in the case of hysterectomy pulp output formalinumisnyh syleriv on top of the root, root perforations, etc., are treated mainly by physical methods: electrophoresis of 1% solution of potassium iodide, 10% solution of calcium male ¬ rydu, UHF, laser therapy. If after 5 – 6 sessions of treatment the pain does not decrease but even increases the need to develop plug-root canal treatment and to methods for tooth ¬ savage treatment of acute infectious periodontitis.

Treatment of chronic exacerbated periodontitis includes two basic methods – the treatment of acute periodontitis ¬ tion and treatment of chronic periodontitis.

In the 1st – 2nd visit to perform the stages of treatment GOST ¬ acute infectious periodontitis. Only after removal of inflamed ¬ tion and transfer it into a chronic condition treatment stages perform ¬ tion of a form of chronic periodontitis.

Treatment of chronic periodontitis – a heavy head ¬ data. Due to the complex and highly variable anatomical and topographic structure of teeth, presence of numerous dentinal ka-naltsiv containing plasma processes, ¬ ve almost is impossible to completely eliminate infected tissues. This focus contributes to the maintenance of stable and pathological changes in periodontal. The main objectives of treatment of chronic periodontitis – the elimination of periodontal pockets of infection and the subsequent effect on the microflora of root canals and their branches, liquidation affect ¬ ing toxins and biogenic amines – decay products of tissue proteins, the elimination or reduction in periodontal inflammation, pro ¬ guarantee of conditions for regeneration of all components Periodontal, where ¬ sensitization of the patient.

Chronic periodontitis treated as for one and a few visits, but regardless of the number of treatment skladayet ¬ Xia a number of stages. Only in case of conscientious performance of each stage can achieve success in the treatment of this complex patho ¬ nology teeth.

Step 1. Dissection of the empty cavity and tooth ¬ us.

 

Fig.6 Definition of the working length of the tooth root canal

electronic apex locator,:

A – diagram of the measurement, B – position of the tip

Diagnostic File: 1 – not brought to the apex, 2 – in the apical

hole, 3 – withdrawn by the crown

The purpose of the first stage – to provide free access to the root canal openings. For the successful preparation is necessary to clearly define the topographic and anatomical features of the patient the tooth, which should be aiming X-ray. As you know, in de pulpovanomu tooth replacement caot be formed dentin remineralization or place it, so particular care should be done nekrotomiyu cavity, in other areas of development-m’yakshenoho dentin will be the focus of infection that can result in ¬ stimulates the destruction of the remaining crown.

Step 2. Expansion ustiv root canal to free access to them and their further processing.

The mouths extend special vnutrishnokanalnymy for ¬ frames or nodular boramy small sizes.

Stage 3. Remove putrydnyh (positive) mass of the channel.

Under a layer of antiseptic solutions using pulpekst-raktora remove remnants of necrotic pulp tissue in order to prepare the channel to the processing tool.

To do this, using 0.5 – 1% solution of chlorine bleach, 0.02% chlorhexidine solution bihlyukonatu that produce atomic chlorine, which denaturuye cytoplasmic proteins of microorganisms, 1% solution yodynolu. Most infected root canal orifice, especially ¬ Quantity of apical third, because you want to delete putrydni fractional mass, changing the bath with an antiseptic during the removal of each new portion of decay. Very carefully to work in the apical third of the channel, not to push its content in the periapical tissue.

Step 4. Tool processing channel – it nayvid ¬ povidalnishyy stage endodontic treatment.

The purpose of this phase – removal of infected dentin from the canal walls, providing access to the apical hole and if not ¬ obhidnosti – opening it, and create conditions for further sealing the channel.

Treatment of root canal begins with determining its length. The length of the root can be defined in three different ways: radiologically, with clearing tables (see Fig. 104, Table. 16, 17) and by apekslokatora – elektronnometrychno (Figure 118).

Expansion and formation of root canal conducted by special sets of endodontic instruments of different methods. The most common is the standard method by which the channel extends K-rymeramy or K-files with sequence ¬ it increases their diameter at 3 -4 size, not reaching the radiological length of 1 mm. This technique should vyko ¬ rystovuvaty tool for processing lines, crowded channels, especially in front teeth.

Nowadays the most popular method of instrumentals ¬ tion treatment of narrow channels is preparation technique ka ¬ sions, including “step-back” (“step back” – the expansion of the channel from September hivkovoho ¬ hole to mouth, fig. 6). According to this method is applied ¬ ing endodontic instruments from smaller to larger. Detail this method, see “Pulpitis.”

Begin work in the channel K-file smallest size (010), which freely passes on marked depth of the channel, gradually apply the K-larger files, to the physiological narrowing of the root canal should be enlarged to the size of the file 025. Tools should only rotate clockwise and constantly return to the smaller instruments. After each replacement instrument channel was washed with an antiseptic, not to block the top of dentinal sawdust.

The next stage of this method – extension channel instru ¬ ments larger sizes (up to 040 – 045), but less length to ensure a uniform conical shape toward the channel mouth.

More wall channel alignment file (Hedstrema), promo ¬ vayut after each administration tool, then the first channel ¬ tovyy fillings.

Recently developed flexible endodontic instruments with rounded tip of the nickel-titanium alloy and offered ¬ novana method of such instruments, known as “Crown down” (“step-down”) – expansion of the channel from the mouth to the apex.

This technique is based on a consistent replacement endodontych-making tools from large to smaller. Channel pochy ¬ nayut expand with ustovoyi parts, gradually moving to the middle, and apical part. Stages of the coronal-apical canal enlargement technique is shown in Fig. 7.

Came the spread of root canal treatment by the method of balanced forces (Balanced forcse).

Methods: endodontic instruments impose a 1 / 3 len ¬ zhyny channel and manually rotate counterclockwise. During his rotation at the same time should do a little pressure in the apical direction. The balance of these two forces will take dentin

 

Fig.7 “Step-back” – appliances expansion co ¬ radicands channel (Shi ¬ Irina initial channel number 10 for ISO, working length 21 mm), continued:

and – processing of initial root canal file (№ 10);

b, c, d – treatment of root canal file, one number greater than the previous one, until the free passage of the root canal instrument of this size (master file number 25);

g-of – treatment of root canal files, on a number larger than the initialism and shorter by 1 mm apical to the formation of the stop, then go to a file, one number higher and therefore

1 mm shorter than the previous;

and th – additional processing, the expansion and shaping of the cone ustoviy root canal, and – restore patency of the channel master file; K – final mechanical treatment of root canal file Hedstrema in size, the corresponding master file

Fig.8.

 “Crown-down “- a root canal enlargement technique (working length, 21 mm) without zatyskuvannya file. To perform this technique it is desirable to use flexible instruments with nickel-titanium alloy with rounded tip.

Tool processing channel is considered complete if koreznevyy channel meets the following requirements:

– Fully released from infected dentin;

– Has a conical shape throughout from apex to mouth;

– Sufficiently advanced;

– Has formed apical stress;

– Dry, clean, sterile.

 

 

 

continued: and – input file number 35 in the root canal

to the point of first resistance, b-d – root canal preparation

drylboramy smaller, until at 16 mm will be possible to enter a file

Number 35, is – passing the apical part of root canal at 19 mm;

a – Root canal preparation drylborom, One Size

lower than the previous one, ie the number thirty, the same – the root preparation

channel file one size smaller than the previous one, ie the number 25;

of the district – Root canal preparation described by a sequence

to achieve the full working length of root canal

Drug treatment of root canals during treatment ¬ tion periodontitis. The main objectives of drug treatment are:

1. Exercise influence on etiological factor – infection, toxins, chemical and toxic substances and others. Contained in the root canal and its branches, and mikrokanaltsyah periapical area.

2. Anti-inflammatory effect on periodontal tissue damage.

3. Stimulate the process of periodontal tissue regeneration, and damaged the alveolar bone.

To solve these problems, drugs for medical treatment of root canals and zaapikalnoho space must meet the following requirements:

1. Levy antibacterial or bactericidal action on th ¬ lovni microorganisms – factors of periodontitis.

2. Have a high capacity for diffusion in and you mikrokanaltsi ¬ kryvleni branch root canals.

3. Be chemically stable and not inaktyvuvatysya in the root canal.

4. Levy-inflammatory action, not irritate periodontal tissues.

5. Do not be antigenic, sensybilizyvnoho effects on periodontal tissues and the organism as a whole.

Depending on the timing of action on microorganisms and damaged tissue Periodontal all medications can be divided into 2 groups:

1. Preparations immediate or short-term, action. their impact pochy ¬ nayetsya after 5 – 10 seconds and lasts 1-3 – 5 min. This is mainly drugs acting factor which gases and gases (chlorine, iodine, oxygen, etc.)..

2. Long-acting preparations (1-3 – 5 – 7 days). These drugs or their mixtures exert not only antiseptic or antimicrobial action but also exert both anti-inflammatory and regenerative action – affect the inflammatory process in the periapical tissues.

The success of treatment depends on correct choice of drug for medical treatment channels. Because a significant role in the etiology and pathogenesis of inflammatory processes in periodontal (acute and chronic) play as aerobes, anaerobes, and so, nesporotvorni micro ¬ organisms, the positive effect of treatment available, applied ¬ ing drugs that act on all types of flora. To do this you need to know the main clinical features of a particular type of microorganisms.

Thus, clinical signs of anaerobic infection is hnylisnyy sharp smell of the canal, thick yellowish-gray pus, moist hanhre ¬ noznyy gray-black decay, absence or very low treatment effect of the thick ¬ pre ¬ antybakterial use these drugs. Kokov microflora characterized by a large number of light nehustoho purulent exudate without noticeable odor.

In order to impact on anaerobes appropriate medical treatment for a tooth canal use nitrofurans, 1-0,5% dioksydynu solution, suspension baktrymu and metronidazole, fuzydyn-sodium, which in this case it is better to patients under the scheme. As in patients with chronic periodontitis or aggravation is a significant contamination of root canal pathogenic staphylococcus is resistant to other antiseptics, justified applications ¬ tion or ekterytsydu Khlorophilipt.

When choosing drugs for the drug treated ¬ tion channel must consider not only the duration of its bacteria ¬ tsydnoyi and bacteriostatic action, solubility in water and biological fluids, but also the nature and stage of periodontal tissue inflammation and the general condition of the patient.

All medical facilities for treatment of root ca ¬ left and periapical tissues rather can be divided into several groups, taking into account the main mechanism of action.

1. Antiseptics, halogens and okysnyuvachi. A large group of antiseptic methods of root canal treatment includes methods based on the use of therapeutic effect gases. Apply chlorine and kysenumisni compounds that are capable of enhancement ¬ schuvaty redoksypotentsial environment, and this shows their disinfection plant performance. Thus, the bactericidal action of chlorine is related to its Resolution ¬ nistyu hloruvaty okysnyuvaty and organic matter. Chlorine in con ¬ tact with the tissues and forms a chloride hlornuvatystu acid. The latter is a labile compound is decomposed into atomic oxygen and hydrochloric acid. Oxygen produces oxidative effect on bacteria, and acid chlorides and denaturuye proteins and destroys the fabric ¬ us dead, decomposing. Atomic oxygen as powerful oxidants and reductant causes hydrolysis of proteins and also denaturuye them. He makes a very strong bactericidal action. Methods of gas that ¬ rapiyi very diverse. For gas use different substances. Thus, N. Prinz still applied in 1917 dyhloramin, VA Dubrovin (1927) – aqua regia and bertoletovu salt. These methods are presently not used because these drugs podraz ¬ nyuyut periapical tissue and cause irreversible processes in the inflamed tissues.

However, the high bactericidal activity hlorumisnyh drugs can be achieved using modern halogen compounds, of which the form ¬ lyayetsya chlorine, which penetrates deep into mikrokanaltsiv and eliminates bacteria and their toxins. These drugs are 1 – 2% solution of chlorine bleach, 0.5% chlorhexidine solution. High clinical effect observed in the case of 3 – 5% develop ¬ ranks sodium hypochlorite, which is quite strong oxidants. This drug dissolves and infected predentyn putrydni mass of tis ¬ nyn pulp and simultaneously antiseptic effect on these tissues.

As oxidants are also used 3% solution of hydrogen peroxide. In root canal solution of hydrogen peroxide interact with organic matter and alkalis, resulting in the formation of atomic oxygen bubbles, which contribute to, firstly, mechanical clearing the channel, and secondly, have a weak bactericidal effect.

Among the halogens for root canal treatment is widely used iodine. Atomic iodine produces a high bactericidal effect on the microbial association of root canal and periapical space. To wash the root canal using 3 – 5% solution of iodine and 1% solution yodynolu. Yodynol – a compound of iodine with polyvinyl alcohol, which reduces the galling effect of iodine, but it slows down the selection of compounds and thus prolongs its action.

In yodynolu used yodonat – aqueous solution of iodine with a complex surface-active substances, which has a high germicidal and antifungal effect; yoddytseryn – iodine compounds with dimethyl sulfoxide and glycerin.

2. Quaternary ammonium compounds. This group antysep ¬ tics are 0.5 – 1% solution etoniyu, 1% solution of benzalkonium chloride, 0.15% solution decamethoxin. These drugs exert bactericidal and bacteriostatic effect on microbial associations and yeast fungi, almost not irritate periodontal tissues.

3. Phenol compounds. Preparations based on phenol caused ¬ nyuyut deep denaturation of the protein of the cytoplasm of microorganisms, which provides high undifferentiated bactericidal action. Use 3 – 5% solution of carbolic acid (phenol) or a compound of camphor, 5% solution of phenol not only affects all kinds of microorganisms, but also coagulating cells of granulation tissue in the compound of phenol camphor last softens this effect due to the gradual release of phenol.

Apply as 1% solution kamforoparamonohlor-phenol.

Krezofen (cresophene) – polyvalent germicide based hlorfenolu, thymol and dexamethasone, it is also you ¬ korystovuyut for antiseptic processing channels.

Similar properties have some complex preparations: krezodent (crezodent), mepatsyl (mepacil solution), endotyn (endotine), which are based on camphor, phenol, metakryzolu, they are also used for antiseptic processing channels for 2 – 5 days.

If you only use antiseptic methods processed ¬ tion channels to reach their sterility is very difficult, moreover, supported by a very limited time. Antiseptics coagulation proteins, and this, in turn, prevents the penetration deep into preparations for the destruction of microorganisms in dentinal tubules.

Imprehnatsiyni methods. To address the shortcomings of some anti ¬ septic drugs for treatment of root canals used with ¬ owl special medications that can penetrate to different depths in the dentinal tubules, compact remnants of necrotic tissue – imprehnuvaty them and prevent reinfiku tub channel. Because of these drugs stop the disintegration of tissues, and irritation of the periapical tissues, the conditions for regeneration. These properties of substances imprehnatsiynyh ¬ wines make these methods very valuable.

On these principles based method for silver co ¬ radicands channels, first proposed by I. Howe in 1916 he is entering into the tooth cavity of concentrated silver nitrate, which recovers 10% solution of formaldehyde. Unasli dock ¬ chemical reduction reaction of silver in the necrotic pulp and dentinal tubules in metallic silver precipitate falls. Urach ¬ vuyuchy that silver and formaldehyde have high diffuse properties ¬ Vost, dentinal tubules and thin branching root ca ¬ left filled with silver throughout, and coagulant protein silver covers them like a seal.

In practical clinical work using modifications of this method, aimed at preventing irritation periodon ¬. For example, Goldschmidt (1935) proposed the use of 2.5% alcoholic solution of silver nitrate, and for his recovery – 4% solution pirohalovoyi acid. YS Pekker (1950) proposed to apply thirty% aqueous solution of silver nitrate, as well as reductant –

4% hydroquinone solution.

Method of silver: cleaned root canal preferred to chew ¬ alcohol or isotonic sodium chloride solution and Exactly ¬ syat to tooth cavity with tweezers or pipette 2 – 3 drops of silver nitrate, pushing its root tip along the canal, the procedure is repeated to fill the channel, and then brought into in the tooth cavity (or mouth of the channel) 3 – 4 drops Recovery of silver (4% solution of hydroquinone or pirohalovoyi acid). After 3 -4 min ball of wool sucking the remains and, depending on the form of periodontal or plombuyut channel, or ¬ kryvayut tightly, leaving the ball over ustyam from renewable vachem silver for 2 – 3 days. The disadvantage of this method is zabarv ¬ ing tooth in the dark, which greatly limits its use, especially in front teeth. This disadvantage can be reduced if before plating grease wall cavity and on the tooth ¬ rozhnyny glycerine or petroleum jelly to prevent diffusion of silver. The method is very common in pediatric dentistry and periodontal treatment in the case of elderly patients with sclerotic altered and distorted channels.

For impregnation infectious-toxic Use ¬ ing as resorcinol-formalinovu liquid that is prepared ex tempore.

Impregnation technique: the glass plate consistently mix 2 parts 40% solution of formaldehyde (formalin), 2 parts of saturated solution of resorcinol and 1 part 10% develop ¬ sodium hydroxide rank.

The finished mixture is pinkish-red color make very obe ¬ Supervisory in the mouth prepared root canal small portion ¬ we gradually pushed along the channel. Above the channel for ¬ leave the ball out of cotton wool moistened with resorcinol-formalinovoyu ridy ¬ Noah, and then dry ball and a tooth covering the tight bandage on 2 -3 days. To prevent tooth coloring in pink, the liquid should not fall on the wall cavity or need time to rinse.

To enhance the diffusion of fluid in mikrokanaly S.Y. Weiss (1965) proposed the first to enter the channel resorcinol-formaldehyde ¬ new mixture, and catalyst (sodium hydroxide or antyformin).

Resorcinol-formalinova fluid (liquid Albrecht) dyfundu ¬ ing in the dentinal tubules and root canals branching, imprehnuye necrotic masses are not available for tool processing, produces a bactericidal effect on the microflora.

Antiseptics vegetable. For treatment of co ¬ radicands channels are used as finished dosage forms of herbal medicines and infusions, decoctions and extracts of plants, which has antiseptic action. Different types of plants operate on different types of micro ¬ root canal flora. Thus, drugs with celandine (Cheldonium majus) have a fungicide action, walnut Greek (yuhlon) – acting on coca and simpler Kalanchoe juice exerts anti-inflammatory effect through the influence of a mixed microflora, and others. Therefore, for root canal irrigation using a mixture of different likars ¬ hah plants or a combination of drugs. Here are the most in ¬ shyreni and effective herbal antiseptics.

Novoimanin – preparations of hypericum prodiryav ¬ lenoho, produced in a 1% alcohol solution, operating on anaerobic and aerobic strepto-and staphylococci.

Khlorophilipt – preparation of a mixture of eucalyptus leaf chlorophylls, produced in a 1% alcohol and 2% oil ¬ solution and has a high antistaphylococcal activity.

Salvin – preparation of the leaves salviyi, issued in the form of emission you ¬ 1% alcohol solution, produces high antiseptic, antifungal and disinfecting effect. To wash ¬ local root canals prepared solution diluted with isotonic solution of chloride triyu ¬ 1:10.

Antibacterial drugs. Nitrofuran drugs.

Purpose of root canal filling

1.                     To prevent bacteria and bacterial elements from spreading from (or through) the canal system to the periapical area.

2.                     The fully instrumented root canal has to be provided with a tight and long-lasting obturation.

3.                     A root canal filling material should, therefore, prevent infection/reinfection of treated root canals. Together with an acceptable level of biocompatibility (inert material) this will provide the basis for  promoting healing of the periodontal tissues and for maintaining healthy periapical conditions.

 

Instruments for root canal filling

 

OBTURATING MATERIALS

Historically, a variety of materials have been employed to obturate the root canal, falling into three broad categories:

1.                     Solids;

2.                     Semisolids (Fig. 1);

3.                     Pastes (sealers).

 

Fig. 1 Assorted gutta-percha points and absorbent paper points with 0,06 taper are shown here, with color coded ends for easy identification of the size of the point.

Gutta percha points Function and features ›     •Non-soluble, non-irritant points that are condensed into the pulp chamber during obturation ›     •Standardised type: follows same ISO classification as endodontic files ›     • Non-standardised: have a greater taper than the standard ISO type Varieties ›     • Can be packaged in single dose or bulk packages ›     • Different sizes with different tapers available

 

Sealers

Regardless of the obturation technique employed, sealers are an essential component of the process. Sealers fill the space between the canal wall and core obturation material and may fill lateral and accessory canals, isthmuses, and irregularities in the root canal system.

The ideal properties of endodontic sealer are as follows:

1.                     It should be viscous when mixed to provide good adhesion between it and the canal wall when set.

2.                     It should produce a watertight seal

3.                     It should be radiopaque so that it can be visualized on X-ray.

4.                     The particles of powder should be very fine so they can mix easily with the liquid.

5.                     It should not shrink on setting.

6.                     It should not stain tooth structure.

7.                     It should be bacteriostatic or at least not encourage bacterial growth.

8.                     It should set slowly.

9.                     It should be insoluble in tissue fluids.

10.                It should be tissue-tolerant, that is nonirritating to periradicular tissue.

11.                It should be soluble in a common solvent in case removal of the root canal filling becomes necessary.

The most popular sealers are grouped by type:

1.                     Zinc oxide-eugenol formulations(“Dexodent”,”Tubbli Seal”);

2.                     Calcium hydroxide sealers(“Calasept”, “Apexit”, “Sealapex”);

3.                     Glass- ionomers(“Ketac-Endo Aplicar” – ESPE);

4.                     Resins (AH – Plus, AH 26).

 

A wide variety are available. The calcium hydroxide materials (e.g. Sealapex) (Fig. 2) or the eugenol-based sealers (e.g. Tubliseal) are perhaps the safest choice. Some would advocate the routine use of non-setting calcium hydroxide paste (Hypocal) as an inter-appointment medicament.

 

 Calcium hydroxide This is considered separately, because it has a wide range of applications in endodontics due to its antibacterial properties and an ability to promote the formation of a calcific barrier. The former is thought to be due to a high pH and also to the absorption of carbon dioxide, upon which the metabolic activities of many root-canal pathogens depend. It is also proteolytic.

Non-setting calcium hydroxide paste

Non-setting calcium hydroxide has a very high pH (of the order of 11) and has a potent antimicrobial action as a consequence. It is also a mild tissue irritant and has been shown to promote closure of root apex (apexification) in teeth where loss of vitality has occurred before normal growth and development of the tooth is complete. The rationale for its routine use as a medicament between visits during endodontics is unclear but it can be left within the tooth for long periods of time when trying to induce apex closure or arrest root resorption.

 

Direct  pulp capping, partial  and  complete  pulpotomy  are  important  treatment  options  for  the immature  permanent  tooth.  Whether  the  coronal pulp  tissue  is  preserved  in  total,  partially  removed, or removed to the  base of the pulpal floor,  the  preservation of the radicular pulp tissue allows continuing  development and apical  maturation  (apexogenesis)  of teeth with open apices. Moreover, in cases of trauma,  in  which tooth development  may  be  interrupted,  induction  of  apexogenesis  should  be  the clinician’s  primary  goal,  with  the  pulp  protection and  encouragement of the remain vitality.

 

In  teeth  that  have  suffered trauma,  with  necrotic  pulps and  periapical  pathosis, teeth  are treated to stimulate apical  barrier formation (apexification).  The  time  required  to  barrier  formation  can  be  variable,  with  times  from  5  to  20 months. Materials based on Ca(OH)₂  is  suitable  in  pulpotomy  as direct  pulp  capping  treatment; they can  be expected  to provide apical  maturation at comparable time  periods. The  human  pulp  and  surrounding tissue  have  extraordinary regenerative  capacity when a  microbe-free  environment  is  provided.

Indications of calcium hydroxide usage include:

a)                     • To promote apical closure in immature teeth.

b)                    • In the management of perforations.

c)                     • In the treatment of resorption.

d)                    • As a temporary dressing for canals where filling has to be delayed. In the management of recurrent infections during RCT.

 

Regardless of the sealer selected, all are toxic until they set. For this reason, extrusion of sealers into the periradicular tissues should be avoided.

1.                     Zinc oxide-eugenol and resin sealers have a history of successful use over an extended period. Zinc oxide-eugenol sealers have the advantage of being resorbed if extruded into the periradicular tissues. Also this group of materials provides an anti-inflammatory action to the periradicular tissues, because they contain steroid anti-inflammatory medicine in their composition.

2.                      Calcium hydroxide sealers were recently introduced for their potential therapeutic benefits. In theory these sealers exhibit an antimicrobial effect and have osteogenic potential. Unfortunately these actions have not been demonstrated, and the solubility required for release of calcium hydroxide is a distinct disadvantage.

3.                      Glass ionomers have been advocated for use in sealing the radicular space because of their dentin bonding properties. A disadvantage is their difficult removal if retreatment is required.

4.                     Sealers containing paraformaldehyde (e.g. “FOREDENT”) are contraindicated in endodontic treatment. Although the lead and mercury components have been removed from the formulations over time, the paraformaldehyde content has remained constant and toxic. These sealers are not approved by the U. S. Food and Drug Administration. These materials can be used in the case of sclerosed and obliterated root canals, when instrumental treatment can’t be hold; as a result the paste on the basis of paraformaldehyde is applied only at the root canal orifices. In this case the mummifying of the pulp is conducted.

Controversy surrounds removal of the smear layer before obturation. The smear layer is created on the canal walls by manipulation of the files during cleaning and shaping procedures. It is composed of inorganic and organic components that may contain bacteria and their by-products. In theory remnants left on the canal wall may serve as irritants or substrates for bacterial growth or interfere with the development of a seal during obturation. Although fluid movement may occur in obturated canals, bacterial movement does not appear to take place. Recent evidence suggests that removal of the smear layer can enhance penetration of the sealer into the dentinal tubules.

Mummification method. In sclerosed, obliterated, curved root canals, when it is hard to do a proper instrumental endodontic treatment, it is allowed to use pastes that are based on paraformaldehyde for root canal sealing. Depending on clinical situation such pastes are applied either at root canal orifices (sclerosed canal), or the root canal is filled only in the straight part of its (in highly curved canals). Impregnation method envisages usage of AgNO₃ sol. in instrumental not available root canals, for antiseptic treatment (disadvantage- during non-careful handling, tooth crown can be stained in black color).

Removal of the smear layer can be accomplished after cleaning and shaping by irrigation with 17% ethylenediaminetetraacetic acid (EDTA) for 1 minute. Irrigation should be followed with a final rinse of sodium hypochlorite.

Acceptable methods of placing the sealer in the canal include the following:

1.                     • Placing the sealer on the master cone and pumping the cone up and down in the canal

2.                     • Placing the sealer on a file and spinning it counter clockwise

3.                     • Placing the sealer with a lentulo spiral

4.                     • Using a syringe

5.                     • Activating an ultrasonic instrument

The clinician should use care when placing sealer in a canal with an open apex to avoid extrusion.

Solid materials

Silver cones met many of the criteria for filling materials but suffered from several deficiencies. The rigidity that made them easy to introduce into the canal also made them impossible to adapt to the inevitably irregular canal preparation, encouraging leakage. When leakage occurred and the points contacted tissue fluids, they corroded, further increasing leakage.

Semisolid material

Gutta-percha, a semisolid material, is the most widely used and accepted obturating material. Gutta-percha is a natural product that consists of the purified coagulated exudate of mazer wood trees (Isonandra percha) from the Malay archipelago or from South America.

 

 

Gutta-percha does not adhere to the canal walls, regardless of the filling technique applied, resulting in the potential for marked leakage. Therefore, it is generally recommended that gutta-percha (used cold or heated) is used together with a sealer. For an optimal seal the sealer layer should generally be as thin as possible.

 

ROOT FILLING TECHNIQUES

 

 

Root canal filling techniques.

Solid core technique

Single cone The single-cone technique consists of matching a cone to the prepared canal. For this technique a type of canal preparation is advocated so that the size of the cone and the shape of the preparation are closely matched. When a gutta-percha cone fits the apical portion of the canal snugly, it is cemented in place with a root canal sealer.  Although the technique is simple, it has several disadvantages and cannot be considered as one that seals canals completely. After preparation, root canals are seldom round throughout their length, except possibly for the apical 2 or 3 mm. Therefore, the single-cone technique, at best, only seals this portion.

Cold lateral condensation  (Fig. 3)  This is a commonly taught method of obturation and is the gold standard by which others are judged. The technique involves placement of a master point chosen to fit the apical section of the canal. Obturation of the remainder is achieved by condensation of smaller  accessory points. The steps involved are:

 

 

 1.  Select a GP master point to correspond with the master apical file instrument. This should fit the  apical region snugly at the working length so that on removal a degree of resistance or ‘tug-back’ is  felt. If there is no tug-back select a larger point or cut 1 mm at a time off the tip of the point until a good fit is obtained. The point should be notched at the correct working length to guide its placement to the apical constriction.

 2 . Take a radiograph to confirm that the point is in correct position if you are in any doubt.

 3.  Coat walls of canal with sealer using a small file.

 4.  Insert the master point, covered in cement.

 5 . Condense the GP laterally with a finger spreader to provide space into which accessory points can be inserted until the canal is full.

 6.  Excess GP is cut off with a hot instrument and the remainder packed vertically into the canal with a cold plugger.

 

 

 

Softened core techniques

 

Warm lateral condensation As above, but uses a warm spreader after the initial cold lateral condensation. Finger spreaders can be heated in a flame or a special electronically heated device (Touch of heat) can be used (Fig. 5).

 

 

Vertical condensation

In this technique (Fig. 6) the GP is warmed using a heated instrument and then packed vertically. A good apical stop is necessary to prevent apical extrusion of the filling, but with practice a very dense root filling can result. Time consuming.

 

Fig. 6   Diagram of the warm vertical condensation technique.

 

 

Thermomechanical compaction This involves a reverse turning (e.g. McSpadden compactor or GP condenser) instrument which, like a reverse Hedstroem file, softens the GP, forcing it ahead of, and lateral to the compactor shaft. This is a very effective technique, particularly if used in conjunction with lateral condensation in the apical region, but requires much practice to perfect. 

Thermoplasticized injectable GP (e.g. Obtura, Ultrafil) These commercial machines (Fig. 7) extrude heated GP (70-160°C) into the canal. It is difficult to control the apical extent of the root filling, and some contraction of the GP occurs on cooling. Useful for irregular canal defects, e.g. following internal root resorption.

 

Coated carriers (e.g. Thermafil) These are cores of metal or plastic coated with GP. They are heated in an oven (Fig. 8) and then simply pushed into the root canal to the correct length. The core is then severed with a bur. A dense filling results, but again apical control is poor and extrusions common.  They are expensive and difficult to remove.

 Once the filling is in place the tooth will need to be permanently restored, provided the follow-up radiograph is satisfactory. Fillings that appear inadequate radiographically may be reviewed regularly, or replaced, depending upon the clinical circumstances.

THE CORONAL SEAL

Regardless of the technique used to obturate the canals, coronal microleakage can occur through seemingly well-obturated canals within a short time, potentially causing infection of the periapical area. A method to protect the canals in case of failure of the coronal restoration is to cover the floor of the pulp chamber with a lining of glass ionomer cement after the excess gutta-percha and sealer have been cleaned from the canal. Glass ionomers have the intrinsic ability to bond to the dentin, so they do not require a pretreatment step. The resin-modified glass ionomer cement is simply flowed approximately 1 mm thick over the floor of the pulp chamber and polymerized with a curing light for 30 seconds. Investigators found that this procedure resulted ione of the experimental canals showing leakage.