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 0,0006-0,0008 g, more frequent in all on 24 hours in the same 1 roots on 36-48 hours in the teeth of multi roots.

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 S.A. (Switzerland);

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, Largo and other. Remember, that in access is success of endodontics treatment;

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 1,5 mm, to do impossible watched over periodontium.

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.