Lecture 10
Theme. Devitalized extirpation, amputation and combined method of pulpitis
treatment. Mummification: stages, complication. Comparative characteristics
of different methods of
pulpitis treatment.
Treatment of pulpitis - one of major problems of
therapeutic dentistry, because prevalence of pulpits achieves 30-40% (on other
sources, - 20-25% for adults and 14% for children) and takes second seat after a caries among the diseases of teeth.
At treatment
of pulpitis a doctor decides such tasks:
1) removal of pain syndrome
2) liquidation of hearth of
inflammation;
3) stimulation of processes
of healing and dentinogenesis (at treatment of
pulpitis by a biological method);
4) saving of fabrics of periodontium is from
damages with the purpose of warning of development of periodontitis;
5) proceeding in integrity,
form and function of tooth as organ.
The methods of treatment of pulpitis schematically
can be represented so:
Methods of treatment of pulpitis
conservative
(saving
surgical (exception
of the vital functions of pulp) of pulp)
complete saving without devitalization devital
(biological method) (a complete
exception method
vital
extirpation)
the
partial saving complete
exception partial
exception
(vital amputation) (devital extirpation) (devital amputation)
mixed method mixed method
The method of extirpation (pulpectomy) foresees devitalized removal of all pulp after its necrotization (devitalization).
Mechanism of
action of arsenic paste.
Arsenic
anhydride or arsenic acid (As2O3) is one of strong poisons
- by protoplasm poison. Locking in pulp of SH-group in fabrics, poison
negatively influences on breathing. The processes of oxidization – restorations
processes are thus braked in connecting fabric, the amino acid, nucleic acids, RNA,
DNA are redistributed, that on a background common anoxaemia. Vessels are overwhelmed with the elements of
blood and torn, causing hemorrhages that draws necrotizat³on
of structures of tissues. An edema results in the compression of fabric of
pulp. Nervous fibres test a fatty regeneration.
Change in all groups of cellular elements of pulp result death of cages, in the
first turn of odontoblasts.
The
depth of defeat of pulp directly depends on an action and dose of arsenic acid.
All elements of crown pulp perish in the place of its appendix. The protracted
action can cause toxic changes in periodontitis
and necrosis of surrounding fabrics.
Arsenic
acid (anhydride) is used as paste. Such components enter in composition of
arsenic paste:
- antiseptics;
- anesthetic matters (cocaine and other);
- arsenic acid;
- astringent facilities (Y.M. Gofung suggested enter for deceleration of diffusion
of arsenic for an apex).
Arsenic
paste is imposed in an amount which answers the head of the drill on a size ¹
1, that is evened 0,0006-
When
it is necessary to prolong operate arsenic paste to 5-7 days, apply a wadding
marble with solution of formalin, which is imposed over arsenic paste or apply
pastes with a slow action.
Modern
arsenic paste is produced also dosed, as granules of different color depending
on necessary terms imposition to pasture (red, green, dark blue).
Good
devitalizing
action must pasture on the basis of paraformaldehyde.
Paraformaldehyde, paraform - is the hard
polymer of formaldehyde the fumes of which have a strong bactericidal,
dehydrating and mummifying action, and in high concentrations cause necrosis of
fabrics. At the temperature of body there is slow depolimerization
with a gradual selection to the monomer (to formaldehyde) which draws slow necrotization
of pulp.
The mechanism of action of paraformaldehyde consists in
influence on capillaries, expansion of vessels of bloods, to stasis
of blood in them and gradual mummification of fabrics of pulp. Preparation has
a less toxic action, than arsenic anhydride is on fabrics of periodontium.
In composition of paraformaldehyde paste
enter:
1) paraformaldehyde;
2) anesthetic
(the action of paraform is more
tender, slowly that is why for anaesthetizing it is necessary to add the far of
anesthetic);
3) eugenol.
Impose
paste in an amount, which on a size answers the head of the spherical drill ¹ 9
(it twice more than arsenic). More frequent in all devitalization
of pulp comes in 6-7 days in the teeth of the same 1 roots
and in 10-14 days - in multi roots. To pasture the term of imposition depends
also on character of inflammation of pulp of tooth and choice of method of treatment,
that partial or complete exception of inflammatory pulp.
Risk
of overdosing and toxic influencing of paraform on
surrounding fabrics is minimum, that is why he is
applied even in temporal teeth. Paraform paste
operates 7-14 days, but there are not complications even in 4 weeks. Widely use
these to pasture for children, and also in cases of unbearableness
of arsenic, anesthetics or at the necessity of
conducting of the deferred treatment (heart attack of myocardium, postoperation period).
Paraformaldehyde
enters also in the complement of mummifying pastes which apply after devital
amputation of pulp.
Paraformaldehyde pastes - „Depulpin" (Voco), „Devipulp", „Toxovit", „Necronerv" and others like that.
At treatment paraform paste the reaction of periodontium
is absent and results are remote the best. In two years clinical prosperity is
observed at the use of arsenic paste in 88,66% cases,
and roentgenologic - in 68%, and at the use of paraform
paste - accordingly in 96% and in 85% cases.
Devital extirpatiin has
wide distribution, but is not the modern method of treatment. She must be used
in those cases, when it is impossible to use the vital method of treatment.
Testimony:
1)
at unbearableness of anesthetics
as a result of sensib³l³zation of organism to them;
2)
at persons, more than 50 years;
3)
at heavy somatic pathology;
4)
at the expressed forms of diseases of cavity of mouth
are heavy degrees of general paradontitis,
inflammatory diseases of mucus shell of cavity of mouth;
5)
at the badly communicating channels of roots, their
large ramified;
6)
when a patient is afraid of various injections;
7)
at uneffectiveness of
methods of injections of anaesthetizing;
8)
at the failures of vital method.
Treatment
a devital method is carried out in two visits (now and then in
three).
A method of treatment is at the first visit:
1)
after a rest room the cavities of mouth prepare a
carious cavity so, a patient allows as far as (it is possible under anesthesia
to carry out the complete preparing);
2)
wash a carious cavity warm antiseptics;
3)
execute mostly directed necrectomy that choose an area, most close to the
sickly horn of pulp. By the spherical drill deepen in a dentine;
4)
taking away a dentine, grind off the bottom of carious
cavity easy, without pressure, motions;
5)
before opening of horn of pulp, if it was not
succeeded to do it a excavator, the drill is substituted by sterile. In the
case when this procedure is carried out without anesthesia, for anaesthetizing
it is possible to use "Liquid for treatment of pulp" (Omega-dent);
6)
perforation a
pulp chamber. Signs of opening of vault of pulp
chamber:
- point opening;
- point of liquid with blood;
7)
a carious cavity is carefully washed warm solution of antiseptic,
if necessary, for stopping of pain on a wadding marble bring in anesthetic.
The outflow of exudate through the perforation opening also diminishes pain;
8)
dry out a carious cavity a wadding marble and on the opened horn of mash impose
necrotizing paste by a probe or
flatter directly on the horn of pulp or at first lay on the bottom of
carious cavity, and then impose a paste by wadding marble on pulp;
9)
from above impose a dry sterile wadding marble (what
will take in exudate which is increased selected as a result of annoying pulp)
or marble with anesthetic.
It is possible to use Camphor phenol is antiseptic solution of firm Produits Dentaires
10)
easily, without pressure impose an air-tight bandage
from a water dentine, involved to sour similar consistency. A bandage
necessarily must be exactly from a water dentine, because he hardens at once
and it is possible to control investment impermeability. A dentine-paste
presses on pulp, creates a compression, causing a pain attack. In addition, she
overtakes a few hours (2-8), that can result in the impregnation of necrotizing
paste in surrounding fabrics and cause arsenic (whether paraformaldehyde) necrosis
of these fabrics and even bone of alveolar escape.
In
some cases, when a large carious cavity is IV and the V classes, which
interpenetrates under a gingival edge, it is heavy to attain the proper
pressurizing of dentine. Then it is recommended to close a carious cavity
rarely involved cement of phosphate or show out her on a masticatory surface,
and to close a cervical area a dentine from anesthetic.
Consequently, possibility of effluence or washing to pasture from the cavity of
tooth needs to be absolutely eliminated;
11)
explain a patient about importance of timely
continuation of treatment of this tooth, because at the stay of arsenic paste
in the tooth of more than 48 hours development of sharp apex periodontitis
is possible.
At
correct imposition to pasture pain in pulp halted almost at once, insignificant
pain is although admitted at the nearest two o'clock that is related to
operating of poison on nervous completions. It is necessary to explain it a
patient and for diminishing of pain to recommend adopting anesthetic.
A method of treatment is at the second visit:
1)
poll a patient and inspect a tooth and surrounding
fabrics (percussion necessarily);
2)
take off a bandage;
3)
carry out the final preparing of carious cavity; she
is extended, destroying to the middle of masticatory surface at the masticatory
group of teeth, and to the middle of palatal or tongue surface in frontal
teeth;
4)
expose the cavity of tooth (that take off the roof of pulp
chamber) and carry out trepanation by fissured
and the back cone drills. Manipulations in the cavity of tooth must be
conducted under visual control (through a mirror), in order to avoid the
perforation of bottom. The drill must be held strictly for the axes of tooth
(for warning of perforation of his walls);
5)
amputation of crown part of pulp (pulpotomy)
is here carried out at the same time, and if it did not happen, in the teeth of
multi roots amputate crown pulp by a sharp excavator, conduct medicinal
treatment;
6)
mouths of channels of roots extend funnel-shaped, to
facilitate their subsequent passing. For this purpose use the prolonged spherical
drills of small sizes, the special endodontics instruments
- Gates Glidden,
7)
by pulpextractor extirpation pulp. Under bath from antiseptic
(1 -2 drops bring in on mouth or moisten an instrument) of pulpextractor
of the proper size move cork-screw similar motion (to two turns) deep into
toward feeling of resistance (to the apex), and then for the axes of root draw
out a needle a, reverse (but to the lines) flounce together with twined about
round her root mash. If pulpextractor
enters tightly, it is necessary by preparations which contain EDTA
and drill – bor to extend a
channel, and then to carry out extirpation. It will warn his breaking
off in a channel;
8)
the channels of roots wash antisepts
and carry out instrumental treatment, using endodontics
instruments;
9)
channels dry out and deprive of fat and stop at the level of the apex opening
(under control a sciagram), a carious cavity is
purged from root stopping material, deprive of fat and dry out an alcohol,
ether or special facilities;
10)
if channels were stopped a not gutta-percha, impose
two insulating gaskets: from a water dentine and from phosphate or to glass
ionomer cement; at stopping of channels impose a detective only a cement
gasket;
11)
impose the permanent stopping.
The most frequent treatment is carried out in
two visits, but if very weighs the color
of tooth in the future, it is better in the second visit to impose the temporal
stopping from a water dentine or paste of dentine. In third times visit the
temporal stopping is partly taken off, to pasture tailings from the walls of
carious cavity washed well, an insulating gasket and permanent stopping is
imposed. A carious cavity is stopped in the third visit and then, when the root
stopping gives contraction at hardening (in the second visit impose the
temporal stopping, and in the third - substitute her by permanent).
If in the second visit a tooth
has a sensible reaction on percussion, (but
it is not considered as arsenic periodontitis),
better at once channels of roots not to stop, but it is good to wash and leave
in them tampon with eugenol,
Camphor phenol,
by rezortsin -
formalin mixture or creosofen
and pulpoperil (contains
phenol, creosote, eugenol,
chloroform) under a bandage from a water dentine on 2-3 days. In the cases when
the channels of roots are considerably ramified, for mummification of branches
of nervous fibres after devitalization
it is good arsenic paste to apply "Guayafen"
(Omega-dent), which contains: phenol, formaldehyde, and imposed
on 1-3 days under an air-tight bandage. Stopping of channels of roots carry out
during the third visit.
Method of devital amputation (devital pulpotomy)
This method of treatment of pulpitis is
forced and used
mainly at treatment of large teeth of roots.
Testimony:
1)
obliteration channels of roots;
2)
heavily clock-houses channels of roots because curvature of root.
Consciously
this method is applied only in the cases when:
3)
for a patient grave common condition of organism (after the heart attack of
myocardium, heavy operations);
4)
for mentally sick people;
5)
at impossibility of access to mouth of channels of roots through the difficult
opening of mouth;
6)
in third molars, when carious cavities are placed distal;
7)
at treatment of pulpitis of temporal teeth.
In
all other cases it is necessary to carry out extirpation
of pulp.
Contra-indications to
the method of devital amputation is: pulpitis are in the
second teeth of the same 1 roots at the good common state of organism.
Method of treatment at the first visit the
same, as a method of the first visit is described in this lecture at devital extirpation
and at the second
visited - at first the same, as at devital extirpation
(see the first 6 points of devital extirpation);
farther operate under circumstances. With age, under the action of different
pathological changes, on the walls of channel the second dentine which mineralization and obliteration road clearance of channel is
put aside. Deposits settle unevenly, that is why a channel acquires fanciful
outlines and difficult passing of endodontics
instruments. Curvatures of roots are instrumental in it also breakage of endodontics
instruments.
Necessarily
carry out an attempt „pass" all channels fully or even partly. If it is
not succeeded, then:
-
process cult of pulp solutions of antiseptics;
-
dry out the cavity of tooth;
-
for complete mummification of pulp in impassable channels use impregnation;
- close
a tooth the temporal stopping, then (sometimes on the third visit) - permanent
stopping.
Impregnation means
an impregnation and used in dentistry for the satiation of root part of pulp
mummify matters which deeply diffuse.
Matters for mummification quickly get to pulp, denaturation
the albumens of tissues, contraction necrotized fabric and warn its
disintegration, long keep an antiseptic action and mostly does not cause
destruction of fabrics of periodontium.
Mash is mummified is dried up with the fixed structure which is not laid out.
For
coverage of cult of pulp during devital
amputation of odontogenous paste, namely:
1)
zinc – eugenol;
2)
eugenol – timol;
Application
of biological pastes (with antibiotics and enzymes) at this method of treatment
of pulpitis is a flagrant error.
The
combined (mixed) devital method is
combination of pulpotmy and pulpectomy:
it is use in case when part of channels of roots clock-house, and part - no. One
or two communicating channels stop hardening paste, and from it is done unclock-houses the same as at treatment of devital
amputation a method (mummify).
It
is necessary to remember, that it is impossible to assume the origin of remaining pulpit. Reasons of his origin are
such: a doctor wanted to treat a tooth the method of vital extirpation,
but during work appeared, that one or two channels of roots are on some
reasons, unclock-houses or in general they did not
succeed to be found. Then on mouth of these channels in the first visit it
is necessary to impose arsenic paste for necrotization
of pulp in unclock-houses channels of roots and dentinal
bandage.
In the second visit, at
the repeated unsuccessful attempt to pass the channels of roots, a communicating
channel is stopped to the apex opening, and in impassable channels carry out impregnation
of the pulp left in them one of the adopted methods. Cult is covered mummifying
paste, and a tooth is closed the temporal stopping.
In
7-10 days in default of complaints and at the positive results of objective
inspection of tooth and surrounding fabrics the temporal stopping is
substituted by permanent.
If
a doctor did not impose arsenic paste, and at once began to impregnation
of channels of roots, it and will result in the origin of remaining pulpitis.
This method of treatment is combined, in fact begin from vital extirpation,
and conclude devital amputation. He is used more frequent
than method of devital amputation, because usually some of
channels however succeeded it is to pass: distal in molars
of lower jaw or palatal in molars of maxilla.
Combined (mixed) vital method. Under
anesthesia conduct extirpation
of pulp from a communicating channel and amputation from heavily clock-houses
of channels of roots. A channel is stopped paste which hardens, and above
retention points the other channels impose dentine – stimulant (odontogenous) paste, insulating a gasket
and permanent stopping. If a remaining pulpitis develops after such treatment,
it is necessary to impose arsenic paste and conduct impregnation
of impassable channels of roots one of methods.
An error will be imposition of arsenic paste in
a tooth with gangrenous pulp. It can result in arsenic periodontitis.
At the devital
methods of treatment, that at the use of
arsenic paste, possible also various errors and complications which arise up in
60% cases, namely:
1)
saving and often and strengthening of pain after imposition of arsenic paste.
It is related to that the melancholy of tamponade
is carried out or a pulp chamber was not preliminary opened,
inflammation proceeds in mash, but arsenic paste is sucked in slowly. Opening
of pulp chamber in one point not only approaches the action
of arsenic paste to pulp but also provides the outflow of products of
inflammation;
2)
overdosing of arsenic paste or its
display is prolonged cause intoxication of surrounding fabrics, because an
arsenic easily gets to fabrics of tooth (dentine, cement) and stays too long
there. A severe error, coming from aforesaid, the second or even multiple
application of arsenic paste is. If devitatzation did not
come from the first application, it is necessary extirpation of pulp under
anesthesia. Because at the repeated use to pasture complications are possible
as arsenic periodontitis, to necrosis of alveolar escape
and even body of jaw with next sequestration of bone and deformation of person.
Arsenic periodontitis treats
oneself by those rules, that and chronic apex periodontitis,
medicines - antidote of
arsenic are only used: 5% solution of unitiol;,
5-10% solution of iodide to potassium. Mechanism of action: active SH groups
enter into an action with tiol poisons of
As2O3, which are in fabric, and form untoxic
complexes with them. Fastening of poisons is instrumental in proceeding in the
functions of the enzymatic systems.
Application
of intracanal electrophoresis
of a 2% iodide to potassium or it is been a 5% iodine also effective.
In
transition sharp apex arsenic periodontitis in the
stage of intoxication in sharp apex periodontitis in the
stage of exudate a tooth is abandoned opened on 2-3 days.
3)
necrosis of gums, caused
the burn of arsenic paste, is a widespread enough error, especially for
doctors-beginners. Reasons:
-
the cavity of tooth and that is why imposition is not enough exposed to pasture
carried out blindly;
-
to pasture a floor a wadding tampon is not imposed;
-
diffuse of paste through badly hardening bandage.
In
relation to it cavities have most danger Black’s II and the V classes,
especially when the near gingival wall of the formed carious cavity takes place
alongside with gums or under them. It is necessary to follow a rule: not to conclude a reception
without a confidence in the good isolation of medicinal investment of bandage from a
water dentine, instead of paste of dentine!
If
already there was arsenic necrosis, it is necessary to treat him as the
infected wound. After tearing away of necrotic
masses the area of necrosis is sprinkled the singed magnesia or process
solutions of unitiol, to the iodide to potassium -
pinning a marble with medications.
Necrosis
is possible at
the use of paraform. C.Lust (1984) describes osteomyelitis which developed after the toxic operating of paraformaldehyde on intradental membrane between overhead 7 and by 6 teeth.
Necrosis of bone of alveolus.
Imposition of arsenic paste on the perforation of carious cavity in the area of
neck of tooth or bifurcation
draws development of osteomyelitis
with tearing away of sequester during great while after the delete of tooth.
Wrong use of diathermy
for devitalization of pulp
or for the stop of bleeding also causes heavy complications.
Breaking
basic technical rules (tension, strength of current and etc),
prolonged display can cause the heavy burns of fabrics of tooth and periodontium, to result
in necrosis of fabrics and loss of tooth. A defective vehicle can stagger a
current a doctor or patient. For warning of such complications a vehicle before
work must check experimental electrician. And before to begin to treat a
patient, operate a vehicle it is necessary to check on the bar of soap. For the
stop of bleeding of diathermy carry out 2-3
sec and an electrode is not taken to the apex on
Contra-indications to
diathermy are
cases, when treat a pulpitis in teeth, staggered parodontitis,
because electro- current negatively influences on sick periodontium.
Method of devital extirpation
Method of devital extirpation
is based on the delete of all pulp after its necrotization and conducted in two visits.
By shows to this method
there are pulpitis which it is impossible to bring through vital methods on objective reasons (absence of shows and presence of against shows, for
example, unbearableness of anesthetics, badly
communicating channels through their ramified, large curvature and etc).
For necrotization - use preparations of
arsenic anhydride and paraformaldehyde. In the first visits after necrectomy of carious cavity one of these preparations is
imposed on the exposed horn of pulp under a bandage.
Stages of conducting
of method of devital amputation (look lecture
material)
Combined method of treatment
Shows
to application of this method is:
· sharp
diffuse pulpitis
· chronic
forms of pulpitis of teeth of multiroots from heavily
by clock-houses by the channels of roots and one accessible for treatment and
stopping a channel.
At treatment
of pulpitis in such teeth at first conduct the partial delete of the softened
and pigmented fabrics of carious cavity, section of cavity of tooth, imposition
of devitalized pasts. In next visits expose the cavity of tooth, delete crown
pulp. After antiseptic treatment of cavity of tooth extend the mouths of
channels of roots the spherical drill. Then from the palatal channel of molars
of overhead jaw and distal channel of molars of lower jaw fully delete root
pulp, and a root channel after antiseptic treatment and drying is stopped some
hardening paste to the apex opening of root of tooth. Mash which was saved in
impassable channels, 2 — 3 times add impregnation, mummify resortsyn – formalin mixture
with subsequent abandonment above the mouths of channels of resortsyn – formalin
past or to paracyn-cement.