The clinic, diagnosis and differential diagnosis of pulpitis temporary and permanent teeth in children

The clinic, diagnosis and differential diagnosis of pulpitis temporary and permanent teeth in children. Choice of treatment depending on the stage of development of the tooth and forms of pulpitis. Conservative, vital and devitaltherapies: indications, methods of execution, possible complications and their prevention.

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 andmarginate 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 ofgystaminliked 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.

Symptoms of tooth pulp damage or disease

A diseased tooth pulp may cause inflammation or infection. The symptoms of a damaged or diseased tooth pulp may include:

·                  Unprovoked or spontaneous pain

·                  Sensitivity to hot and cold drinks and foods

·                  Pain when biting or chewing

·                  Loosening of the tooth

·                  Swelling of the gum near the affected tooth

·                  Oozing of pus surrounding the affected tooth

·                  Facial swelling.

Sometimes, tooth pulp may become damaged or diseased without presenting any symptoms. In these cases, the problem is usually diagnosed by special tests or x-rays during a dental check-up or treatment for other dental concerns.
Causes of tooth pulp damage or disease

There are many events that can lead to disease or damage to dental pulp. Some of these include:

·                  Deep-seated and untreated dental decay

·                  Decay beneath a deep filling

·                  Trauma that damages a tooth

·                  Habitual tooth grinding (bruxism)

·                  Advanced gum disease.

Complications of tooth pulp infection

If tooth pulp infection is left untreated, complications could include:

·                  Spreading infection – once the pulp becomes infected, it loses its ability to fight the spread of the infection. If bacteria find their way into the pulp chamber, the bacteria will multiply unchecked. This can cause a severe infection or an endodontic abscess when it spreads into the surrounding bone (a pocket or ‘blister’ of pus).

·                  Localised bone loss – the infection may spread around the ends of the infected root canal and cause bone loss in the jaw.

·                  Loss of tooth – the tooth may have to be removed, which interferes with the person’s ability to bite and chew. Tooth replacements such as dentures, bridges and dental implants may not be possible or may not be tolerated. They may be more costly and involve other issues that also need to be considered.

Diagnosis of tooth pulp problems

The dentist will listen to your symptoms, examine your teeth and perform other special investigations including taking x-rays. These x-rays also help the dentist to plan for the root canal treatment by revealing the number, size and curvature and depth of the roots, and showing how complicated the procedure may be. 

Root canal procedure

You may need one or more visits to complete the endodontic treatment, depending on root canals in your tooth. The exact procedure chosen by your dentist may differ from the procedure outlined here. Ask your dentist for further information. 
Generally, the typical root canal treatment includes:

·                  The procedure is usually performed using local anaesthetic. If the pulp is infected, anaesthesia may not always be necessary because the tooth no longer has any feeling.

·                  The affected tooth is wrapped in thin rubber (called a ‘rubber dam’) to prevent contamination of the root canals.

·                  The decayed portions of the tooth and any affected filling are removed.

·                  The pulp or pulp remnants are extracted.

·                  The dentist uses a special drill and small instruments to thoroughly clean and shape the root canals and to remove bacteria, pus and debris. The root canals may need to be shaped or hollowed out to ensure a smooth interior surface.

·                  The interior of the tooth is flushed with disinfectants and then dried.

·                  If the root canal is not infection free, it may be medicated and the tooth sealed with a temporary filling material. You may have to wait a few weeks, or even months, before the pulp canal is filled. If the dentist feels bacteria are still present at your next appointment, the cleaning procedure may be repeated and the tooth once again packed with medication. This stage will continue until the dentist feels the tooth is free from bacteria.

·                  The infection-free root canal is then sealed with long-lasting barrier materials (the root filling), usually a rubber-based material called ‘gutta-percha’.

·                  The tooth then undergoes restoration and the biting surfaces need protection – an artificial biting surface for the tooth is fashioned out of regular filling material.

·                  In many cases, where there is considerable loss of the tooth structure, there may be a need for an artificial crown made from porcelain or gold alloy or other materials.

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 onperiapical 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 nervousfibres 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 unsymptomaticand shows up only during an inspection a doctor.

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 ofresorbtion 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 anaerobicmicroflora 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.

 

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 congratulatory amputation . 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.

 

 

Materials for endodontical treatment

 

Ideal stopping material for root channels must answer the followings parameters:

1. To provide the reliable pressurizing of all of the system of root channel on all of its draught.

2. To be untoxic.

3. Not to irritate pericementum.

4. Not to give in a channel. It is desirable, that he was some increased in a volume at introduction to the channel or in the process of consolidation.

5. To own a bacteriostatic effect or eveot to support growth of bacteria.

6. Easily to be sterilized before the use.

7. To be X-ray contrast.

8. Not to change the color of tooth.

9. If necessary easily removed from a channel.

10. To have a sufficient for comfort work time of consolidation.

11. Not to dissolve in a tissue liquid.

12. To be good adhesive to the dentine and stopping material.

Such ideal material does not exist for today. However in a most degree these requirements are answered by the methods of stopping of root channels by a gutta-percha from siller. Majority of root channels in the whole world for today stopped with the use of gutta-percha.

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.

A biological method is directed on treatment of all of pulp. He has for a purpose if not to bring through pulp, then save its main functions: protective, plastic, and nourishing. The special value has saving of protective properties of pulp relatively to pericementum as a prophylaxis of apex periodontitis.

Testimony. The initial stages of sharp pulpitis are subject treatment a conservative method:

– hyperemia of pulp

– sharp limited pulpitis

– traumatic pulpitis

– chronic fibrose pulpitis is without the clinical and roentgenological displays of periodontitis.

A method is shown at presence of such terms:

– central localization of carious cavity

– absence of internal diseases and pathological changes is in pericementum

– insignificant duration of inflammatory process

Contra-indication: sharply positive reaction from the side of pericementum, signs of general periodontitis, decline of threshold of electro-excitability of pulp of over 40 mkA, rentgenological changes in apex tissues. In addition, teeth, which will be used as base under prosthesis constructions, inflammations of pulp for patients with the clinical displays of chronic dental intoxication, pulpitis for persons by age over 45 – 50 years, and also teeth, are not subject treatment this method with a carious cavity in the area of neck or root. At a safety method treatment of pulpitis use different medications: antibiotics and their combinations, combination ofsulfamid preparations with antibiotics, corticosteroids, calcareous facilities, enzymic, nitrofuranovy preparations, glucosaminglucane and other

 Corticosteroids preparations correct a contra inflammation action, take off pain, but reduce the reactive state of pulp and hinder forming of granulation fabric which is instrumental in the regeneration of pulp. Of short duration operating of corticosteroids on pulp (4 – 6 days) does not cause side changes in it. However expediently as a bandage, to limit to application of corticosteroids the term 3 – 5 days, with subsequent replacement their facilities which stimulate creating of dentin. Forming of dentin bridge in pulp make faster combination of corticosteroids with the calciumhydroxid.

 In the different samples of writing operates the calciumhydroxid on pulp more better than other facilities. Normalizing acid-basic balance of the inflamed pulp, these preparations correct contra inflammatory and exsiccation operate, stimulate formation of the second dentine and mineralization of the light, softened dentine. Pastes which contain the calciumhydroxid, antibiotics, sulfanilamid preparations, corticosteroids, are presently widespread That is why, and also preparations are ready on the basis of calciumhydroxid: Cavital, Calcipulpa, Actical, Dycal, Hydrex.

Promote efficiency of treatment of pulpitis also glucosaminoglucal (luronit, khoksurid, geparin) and nitrofuran. These preparations make faster repair processes in pulp due to the biological properties. Yes, luronit is preparation, which contains gualuron acid which plays an important role in the protect processes of pulp of tooth. Geparin in the case of sharp inflammation of pulp represses, diminishes vascular permeability, reduces pressure in pulp. In addition, glucosaminoglucan is instrumental in the compression of fibred formations of pulp, and to the end of 6 -8 week – calcinosis them. Medicines of nitrofurans have a wide spectrum of antimicrobial action, repress activity of antibiotic resistant cultures of microorganisms.

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.

ENDASEPT – dental material for treating infected tooth canals

Gel «EndAsept» is used for temporary infilling the infected canals at treatment of gangrenous pulpitis and chronic forms of a periodontitis, and also at a sharp periodontitis with necrotizing pulp. Gel «EndAsept» is applied in cases of unsuccessful treatment by nonspecific antiseptics or pastes on the basis of antibiotics and of corticosteroids.

Gel «EndAsept» contains antiseptics: metronidazole (10 %), begluconate of chlorine-hexidine (2 %), – actively overwhelming anaerobic flora of root canals. Metronidazole possesses a wide spectrum of action concerning the elementary, obligate anaerobic bacteria (spore – and non-sporeformative), is active concerning bacteroides, phuso-bacteria, clostridia. The mechanism antimicrobial actions consists in connectioitrogroup metronidazole with microbic DNA and the termination in this connection synthesis of nucleinic acids. In the mixed anaerobic-aerobic environment metronidazole has overwhelming effect on aerobic bacteria as a result of decomposition of metronidazole bacteroides appear metabolites, overwhelming growth of aerobic bacteria. Begluconate of chlorine-hexidine is one of the most active local antiseptic, and has fast and strong bactericidal effect on gram-positive and gram-negative bacteria. The mechanism of action of begluconate of chlorine-hexidine is connected with its surface-active properties – there is an infringement of permeability cytoplasmic membranes of microbes. Owing to hydrophil basis gel is easily entered into canals, deeply impregnating dentinal canaliculus, and washed well away from canals by water.