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Aetiology, classification and pathogenesis of pulp and periapical disease

Aetiology, classification and pathogenesis of pulp and periapical disease

Dental pulp is a richly vascularized and innervated tissue, enclosed by surrounding tissues that are incapable of expanding, such as dentin. It has terminal blood flow and small-gauge circulatory access the periapex. All of these characteristics severely constrain the defensive capacity of the pulp tissue when faced with the different aggressions it may be subjected to. Pulp tissue can also be affected by a retrograde infection, arising from the secondary canaliculi, from the periodontal ligament or from the apex during the course of periodontitis. Due to the fact that periapical disease is almost inevitably preceded by pulp disease, we shall begin by describing the causes of pulp disease and will then proceed to a discussion of the causes of periapical disease. The course of illness and classification of these pathological entities will depend on the aetiology involved. We will analyse pulp necrosis and pulp degeneration that are capable of triggering reversible apical periodontitis or irreversible apical periodontitis.

Dental pulp is a richly vascularized and innervated tissue, enclosed by surrounding tissues that are incapable of expanding, such as dentin. It has terminal blood flow and small-gauge circulatory access the periapex. All of these characteristics severely constrain the defensive capacity of the pulp tissue when faced with the different aggressions it may be subjected to. Pulp tissue can also be affected by a retrograde infection, arising from the secondary canaliculi, from the periodontal ligament or from the apex during the course of periodontitis. Due to the fact that periapical disease is almost inevitably preceded by pulp disease, we shall begin by describing the causes of pulp disease and will then proceed to a discussion of the causes of periapical disease. The course of illness and classification of these pathological entities will depend on the aetiology involved. We will analyse pulp necrosis and pulp degeneration that are capable of triggering reversible apical periodontitis or irreversible apical periodontitis.

Warm UpWarm Up

Chief complaint • intermittent pain, sense of pressure, pain

on biting, hard to localize, patients answers for the most part are vague, seems to be focused on distal proximal aspect of quadrant

• level of agitation is such that accuracy of responsiveness in question

• taking penicillin for two days (irregular dosing)

Chief complaint • intermittent pain, sense of pressure, pain

on biting, hard to localize, patients answers for the most part are vague, seems to be focused on distal proximal aspect of quadrant

• level of agitation is such that accuracy of responsiveness in question

• taking penicillin for two days (irregular dosing)

Case #1 FactoidsCase #1 Factoids

Chief complaint • positive response to thermal challenge• hyperaemic or engorged pulp • w/o periapical extension

• treated in a single visit• RCT or HealOzone?• post treatment medication recommendations?• restorative considerations?

Chief complaint • positive response to thermal challenge• hyperaemic or engorged pulp • w/o periapical extension

• treated in a single visit• RCT or HealOzone?• post treatment medication recommendations?• restorative considerations?

Case #2 FactoidsCase #2 Factoids

Chief complaint • generalized discomfort on chewing in maxillary right

quadrant • strong focus on 1.6

• degenerating pulp with periapical extension• one visit• expectation of mild post-tx pain• NSAIDS, analgesics prescribed?• system or method of instrumentation• apical terminus – Rosenberg Technique - Discuss• irrigation routine – discuss• Comprehensive Care Considerations - discuss

Chief complaint • generalized discomfort on chewing in maxillary right

quadrant • strong focus on 1.6

• degenerating pulp with periapical extension• one visit• expectation of mild post-tx pain• NSAIDS, analgesics prescribed?• system or method of instrumentation• apical terminus – Rosenberg Technique - Discuss• irrigation routine – discuss• Comprehensive Care Considerations - discuss

Based on selected follow-up studies that offer the best evidence, the chance of

teeth without apical periodontitis to remain free of disease

after initial treatment or orthograde retreatment is 92 percent to 98 percent. The chance of teeth with apical periodontitis to

completely heal after initial treatment or retreatment is 74 percent to 86 percent, and their chance to be functional over time is 91 percent to 97 percent. Thus there does not appear to be a systematic difference in outcome between initial treatment and orthograde retreatment.

The outcome of apical surgery is less consistent than that of the nonsurgical treatment. The chance of teeth with apical periodontitis to completely heal after apical surgery is 37 percent to 85 percent, with a weighted average of approximately 70 percent. However, even with the lower chance of complete healing, the chance for the teeth to be functional over time is 86 percent to 92 percent.

Based on selected follow-up studies that offer the best evidence, the chance of

teeth without apical periodontitis to remain free of disease

after initial treatment or orthograde retreatment is 92 percent to 98 percent. The chance of teeth with apical periodontitis to

completely heal after initial treatment or retreatment is 74 percent to 86 percent, and their chance to be functional over time is 91 percent to 97 percent. Thus there does not appear to be a systematic difference in outcome between initial treatment and orthograde retreatment.

The outcome of apical surgery is less consistent than that of the nonsurgical treatment. The chance of teeth with apical periodontitis to completely heal after apical surgery is 37 percent to 85 percent, with a weighted average of approximately 70 percent. However, even with the lower chance of complete healing, the chance for the teeth to be functional over time is 86 percent to 92 percent.

J Calif Dent Assoc. 2004 Jun;32(6):493-503The success of endodontic therapy:

healing and functionality.Friedman S, Mor C.

University of Toronto Faculty of Dentistry, Canada.

J Calif Dent Assoc. 2004 Jun;32(6):493-503The success of endodontic therapy:

healing and functionality.Friedman S, Mor C.

University of Toronto Faculty of Dentistry, Canada.

Case #3 FactoidsCase #3 Factoids

Chief complaint • masticatory sensitivity

• RCT done prior – time indeterminate• apical periodontitis in evidence• 2 visits – interim calcium hydroxide procedure• NSAIDS, analgesics NO antibiotics prescribed• irrigation routine – citric acid and CHX• CLP considerations

Chief complaint • masticatory sensitivity

• RCT done prior – time indeterminate• apical periodontitis in evidence• 2 visits – interim calcium hydroxide procedure• NSAIDS, analgesics NO antibiotics prescribed• irrigation routine – citric acid and CHX• CLP considerations

J Endod. 2004 Oct;30(10):689-94. An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. Law A, Messer H. Postgraduate Endodontics, School of Dental Science, University of Melbourne, Melbourne, Australia.

J Endod. 2004 Oct;30(10):689-94. An evidence-based analysis of the antibacterial effectiveness of intracanal medicaments. Law A, Messer H. Postgraduate Endodontics, School of Dental Science, University of Melbourne, Melbourne, Australia.

The authors reviewed the literature evaluating the antibacterial effectiveness of intracanal medicaments used in the management of apical periodontitis. A PICO (problem, intervention, comparison, outcome) strategy was developed to identify studies dealing with calcium hydroxide, phenolic derivatives, iodine-potassium iodide, chlorhexidine, and formocresol. The final inclusion/exclusion criteria eliminated all papers except five that evaluated calcium hydroxide. The total sample size in the included studies was 164 teeth. Microbiologic sampling was performed before endodontic treatment (S1), after instrumentation and irrigation (S2), and after intracanal medication (S3). At S2, 62% of canals were positive. After medication, 27% still showed detectable growth. Of cultures that were positive at S2, 45% were still positive at S3. Most studies did not address issues of culture reversals or false positive and false negative cultures. The main component of antibacterial action appears to be associated with instrumentation and irrigation, although canals cannot be reliably rendered bacteria free. Calcium hydroxide remains the best medicament available to reduce residual microbial flora further.

The authors reviewed the literature evaluating the antibacterial effectiveness of intracanal medicaments used in the management of apical periodontitis. A PICO (problem, intervention, comparison, outcome) strategy was developed to identify studies dealing with calcium hydroxide, phenolic derivatives, iodine-potassium iodide, chlorhexidine, and formocresol. The final inclusion/exclusion criteria eliminated all papers except five that evaluated calcium hydroxide. The total sample size in the included studies was 164 teeth. Microbiologic sampling was performed before endodontic treatment (S1), after instrumentation and irrigation (S2), and after intracanal medication (S3). At S2, 62% of canals were positive. After medication, 27% still showed detectable growth. Of cultures that were positive at S2, 45% were still positive at S3. Most studies did not address issues of culture reversals or false positive and false negative cultures. The main component of antibacterial action appears to be associated with instrumentation and irrigation, although canals cannot be reliably rendered bacteria free. Calcium hydroxide remains the best medicament available to reduce residual microbial flora further.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Nov;96(5):618-24. Efficacy of chlorhexidine- and calcium hydroxide-containing medicaments against Enterococcus faecalis in vitro. Basrani B, Tjaderhane L, Santos JM, Pascon E, Grad H, Lawrence HP, Friedman S. Dalhousie University, Endodonic Division, Department of Dental Clinical Sciences, Halifax, Nova Scotia, Canada.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Nov;96(5):618-24. Efficacy of chlorhexidine- and calcium hydroxide-containing medicaments against Enterococcus faecalis in vitro. Basrani B, Tjaderhane L, Santos JM, Pascon E, Grad H, Lawrence HP, Friedman S. Dalhousie University, Endodonic Division, Department of Dental Clinical Sciences, Halifax, Nova Scotia, Canada.

OBJECTIVE: We sought to assess the efficacy of chlorhexidine (CHX) and calcium hydroxide, Ca(OH)(2), against Enterococcus faecalis in vitro. STUDY DESIGN: The effect of CHX (0.2% and 2% in gel or solution) and Ca(OH)(2) (alone or with 0.2% CHX gel) was evaluated by using the agar diffusion test and an in vitro human root inoculation method, to measure zone of inhibition or bacterial growth with optical density analysis, respectively. For optical density analysis, samples from infected root canals were collected after 7 days of medication and were cultured for 24 hours in brain-heart infusion to detect viable bacteria. RESULTS: In the agar diffusion test, CHX was effective against E faecalis in a concentration-dependent fashion, but Ca(OH)(2) alone had no effect. In the root canal inoculation test, CHX was significantly more effective against E faecalis than Ca(OH)(2) was (P < .05), but there were no significant differences between the modes of medication or concentrations of CHX. CONCLUSIONS: CHX is effective against E faecalis in vitro. Further in vivo studies are needed to confirm the value of CHX in clinical treatment.

OBJECTIVE: We sought to assess the efficacy of chlorhexidine (CHX) and calcium hydroxide, Ca(OH)(2), against Enterococcus faecalis in vitro. STUDY DESIGN: The effect of CHX (0.2% and 2% in gel or solution) and Ca(OH)(2) (alone or with 0.2% CHX gel) was evaluated by using the agar diffusion test and an in vitro human root inoculation method, to measure zone of inhibition or bacterial growth with optical density analysis, respectively. For optical density analysis, samples from infected root canals were collected after 7 days of medication and were cultured for 24 hours in brain-heart infusion to detect viable bacteria. RESULTS: In the agar diffusion test, CHX was effective against E faecalis in a concentration-dependent fashion, but Ca(OH)(2) alone had no effect. In the root canal inoculation test, CHX was significantly more effective against E faecalis than Ca(OH)(2) was (P < .05), but there were no significant differences between the modes of medication or concentrations of CHX. CONCLUSIONS: CHX is effective against E faecalis in vitro. Further in vivo studies are needed to confirm the value of CHX in clinical treatment.

• Chief complaint • localized, nodular swelling over maxillary

first molar• history of RCT, CAP evident• retx chosen as tx option• CHX and Ca(OH)2 used as interim treatment

dressing• NSAIDS, analgesics prescribed• Primary focus of failure – undetected MBx canal

• Chief complaint • localized, nodular swelling over maxillary

first molar• history of RCT, CAP evident• retx chosen as tx option• CHX and Ca(OH)2 used as interim treatment

dressing• NSAIDS, analgesics prescribed• Primary focus of failure – undetected MBx canal

Oral microorganismsOral microorganisms

Pulp and Periapical DiseasePulp and Periapical DiseasePulp and Periapical DiseasePulp and Periapical Disease

Root Canal TherapyRoot Canal Therapy

MechanicalInstrumentation

MechanicalInstrumentation IrrigationIrrigation

Intra-canal medication

Intra-canal medication

R.C. FillingR.C. Filling

Microbial Control Phase

Microbial Control Phase

Effect of Ca(OH)Effect of Ca(OH)22 on on MicroorganismsMicroorganismsin Necrotic Pulpsin Necrotic Pulps

Control of Endodontic InfectionControl of Endodontic Infection

1. Mech. preparation1. Mech. preparation

Apical PreparationApical PreparationApical PreparationApical Preparation

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Card et al. JOE 2002Card et al. JOE 2002Sjøgren U et al. IEJ 1997 Sjøgren U et al. IEJ 1997 Ørstavik D et al. IEJ 1991Ørstavik D et al. IEJ 1991Bystrøm et al. EDT 1987Bystrøm et al. EDT 1987Kerekes et al. JOE 1979Kerekes et al. JOE 1979

Control of Endodontic InfectionControl of Endodontic Infection

1. Mech. preparation1. Mech. preparation1. Mech. preparation1. Mech. preparation

#10#10#10#10#25#25#25#25

#40#40#40#40

Courtesy Dr. Richard WaltonCourtesy Dr. Richard Walton

Control of Endodontic InfectionControl of Endodontic Infection

1. Mech. preparation1. Mech. preparation

#25#25

#25#25#25#25

#25#25

Courtesy Dr. Richard WaltonCourtesy Dr. Richard Walton

Apical PeriodontitisApical PeriodontitisApical PeriodontitisApical Periodontitis

PrevalencePrevalenceIncreases with ageIncreases with age

• Age 50: 50% experience the diseaseAge 50: 50% experience the disease• Age > 60: 62% exhibit the conditionAge > 60: 62% exhibit the condition• US Census data: US Census data: 420 million root filled420 million root filled

At 90% success: 42 million failingAt 90% success: 42 million failing At 80% success: 84 million failingAt 80% success: 84 million failing At 60% success: 168 million failingAt 60% success: 168 million failing

• Eriksen 1991, 1998; Figdor 2002Eriksen 1991, 1998; Figdor 2002

PrevalencePrevalenceIncreases with ageIncreases with age

• Age 50: 50% experience the diseaseAge 50: 50% experience the disease• Age > 60: 62% exhibit the conditionAge > 60: 62% exhibit the condition• US Census data: US Census data: 420 million root filled420 million root filled

At 90% success: 42 million failingAt 90% success: 42 million failing At 80% success: 84 million failingAt 80% success: 84 million failing At 60% success: 168 million failingAt 60% success: 168 million failing

• Eriksen 1991, 1998; Figdor 2002Eriksen 1991, 1998; Figdor 2002

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Treatment Treatment OutcomeSOutcomeS

VariabilityVariability

50% to 95%50% to 95%Status quo or change?Status quo or change?Status quo or change?Status quo or change?

Effects of four Ni-Ti preparation Effects of four Ni-Ti preparation techniques techniques

on root canal geometry on root canal geometry assessed by micro-computed assessed by micro-computed

tomographytomographyPeters OA, Schonenberger K, Laib A. Int Endod J. 2001Peters OA, Schonenberger K, Laib A. Int Endod J. 2001Peters OA, Schonenberger K, Laib A. Int Endod J. 2001Peters OA, Schonenberger K, Laib A. Int Endod J. 2001

Maxillary molarsMaxillary molars ....all ....all instrumentation techniques instrumentation techniques left 35% or more of the left 35% or more of the canals' surface area canals' surface area unchangedunchanged. ….a strong . ….a strong impact of variations of impact of variations of canal canal anatomyanatomy was demonstrated.. was demonstrated..

Entomb existing bacteria Entomb existing bacteria Prevent coronal and apical Prevent coronal and apical

leakageleakage Strengthen the rootStrengthen the root

Principles Functions of Principles Functions of The Root Canal FillingThe Root Canal Filling

#1. Entomb existing bacteria

Bacteria and PrognosisBacteria and PrognosisSuccess by culturing resultsSuccess by culturing results

+ve culture+ve culture -ve culture-ve culture

Engstrom et al (1964)Engstrom et al (1964) 76%76% 89%89%

Zeldkow & Ingle (1963)Zeldkow & Ingle (1963) 83%83% 93%93%

Oliet & Sorin (1969)Oliet & Sorin (1969) 80%80% 91%91%

Sjögren et al. (1997)Sjögren et al. (1997) 68%68% 94%94%

Bystrom et al (1987)Bystrom et al (1987) 95%95%

If bacteria were entombed,

there would be NO difference

in the healing of teeth with PA lesions

If bacteria were entombed,

there would be NO difference

in the healing of teeth with PA lesions

Entomb existing bacteria Entomb existing bacteria Prevent coronal and apical Prevent coronal and apical

leakageleakage Strengthen the rootStrengthen the root

““State of The Art”State of The Art”Gutta-Percha + SealerGutta-Percha + Sealer

Prevent coronal and apical leakage

Prevent coronal and apical leakage

..stopping influx of periapical tissue derived fluid from reaching residual bacteria in the root canal system acting as a barrier, preventing re-infection of the root canal (Sundqvist and Figdor, 1998)

..stopping influx of periapical tissue derived fluid from reaching residual bacteria in the root canal system acting as a barrier, preventing re-infection of the root canal (Sundqvist and Figdor, 1998)

BeforeBefore

Completed endodontic procedureCompleted endodontic procedure

Permaflo PurplePermaflo Purple

Final polished restorationFinal polished restoration

Endo/Coronal StatusEndo/Coronal Status NN % API (periapical % API (periapical inflaminflamnn))

GE & GE & GRGRGood root filling and Good root filling and coronal restorationcoronal restoration

330330 91.491.4

GE & GE & PRPR

164164 44.144.1

PE & PE & GRGR

302302 67.667.6

PE & PE & PRPR

OverallOverall

188188

10101010

18.118.1

61%61%

Swanson et al. 1987 - Dye leakage to apexSwanson et al. 1987 - Dye leakage to apex

3 days: dye leakage to apex

Khayat et al. 1993 - Bacteria to apexKhayat et al. 1993 - Bacteria to apex

30 days: bacteria to apex

Trope et al. 1994 – Endotoxins to apexTrope et al. 1994 – Endotoxins to apex

20 days: endotoxin to apex

Swanson et al. 1987 - Dye leakage to apexSwanson et al. 1987 - Dye leakage to apex

3 days: dye leakage to apex

Khayat et al. 1993 - Bacteria to apexKhayat et al. 1993 - Bacteria to apex

30 days: bacteria to apex

Trope et al. 1994 – Endotoxins to apexTrope et al. 1994 – Endotoxins to apex

20 days: endotoxin to apex

Coronal LeakageCoronal Leakage

1. Mech. preparation1. Mech. preparation

Control of Endodontic InfectionControl of Endodontic Infection

2. Canal disinfection2. Canal disinfection

3. Obturation3. Obturation

4. Top filling4. Top filling

Smear ClearSmear ClearCa(OH)Ca(OH)22

ZZY-VACZZY-VACCHXCHX

Heal OzoneHeal OzoneBioPure™MTAD™BioPure™MTAD™

Adhesion Endodontics

Case #3 FactoidsCase #3 Factoids

Chief complaint • pain in maxillary right quadrant

• pre-existing RCT and CAP• calcium hydroxide placed in #1.5• NSAIDS, analgesics, no antibiotics• patient had persistent pain…swelling appeared• sinus tract traced to mesial root of #1.6• #1.6 retreated with calcium hydroxide• case obturated and transitionalized for 90 days

Chief complaint • pain in maxillary right quadrant

• pre-existing RCT and CAP• calcium hydroxide placed in #1.5• NSAIDS, analgesics, no antibiotics• patient had persistent pain…swelling appeared• sinus tract traced to mesial root of #1.6• #1.6 retreated with calcium hydroxide• case obturated and transitionalized for 90 days

Maxillary Molar TeethMaxillary Molar Teeth

Relocation of the canal orifices

Relocation of the canal orifices

Maxillary Molar TeethMaxillary Molar Teeth

Courtesy of Dr. Cliff RuddleCourtesy of Dr. Cliff Ruddle

Relocation of the canal orifices

Relocation of the canal orifices

Composite finishing bursComposite

finishing burs

Brasseler H274-016Brasseler H274-016

Never be surprisedNever be surprised

Ancillary MB canalsAncillary MB canals

Gingival Sulcus .5-2.0mm

Gingival Sulcus .5-2.0mm

Epithelial Attachment .75mm

Epithelial Attachment .75mm

Conn Tiss. Attachment 1.25mm

Conn Tiss. Attachment 1.25mm

Case #4 FactoidsCase #4 FactoidsChief complaint

• pain on chewing • inadequate RCT #3.6• deficient margins• patient unable to identify source• always review occlusion / facial type• opposing restorations

Chief complaint • pain on chewing

• inadequate RCT #3.6• deficient margins• patient unable to identify source• always review occlusion / facial type• opposing restorations

Hiatt proposed the lever principle to account for the high incidence of

fractured mandibular molars: the second molar is nearer the fulcrum

of mandibular closure and thusreceives the greatest force.

Hiatt proposed the lever principle to account for the high incidence of

fractured mandibular molars: the second molar is nearer the fulcrum

of mandibular closure and thusreceives the greatest force.

If 4 canals in an upper molar panics you…………………If 4 canals in an upper molar panics you…………………If 4 canals in an upper molar panics you…………………If 4 canals in an upper molar panics you…………………