Why we need

Root Canal

Treatment ?

Aetiology of the Aetiology of the pulp and periapical pulp and periapical pathosispathosisMicrobialMicrobial: : dental cariesdental caries

MechanicalMechanical: : operative procedure (iatrogenic), operative procedure (iatrogenic),

traumatrauma

ChemicalChemical: : pulpal (acid etching, bond), pulpal (acid etching, bond),

periapical (irrigation) periapical (irrigation)

2- Due to Leaked Restoration

3- Due to Trauma

4- Excessive force during ortho. treatment

EFFECT OF DENTAL MATERIALS ON EFFECT OF DENTAL MATERIALS ON PULPPULP

GIC – GIC – Well tolerated by pulpWell tolerated by pulp• Calcium hydroxide – Calcium hydroxide – includes dentin includes dentin

bridge formation.bridge formation.• Zine oxide – Zine oxide – eugenol- has an anti-eugenol- has an anti-

bacterial effectbacterial effect..• Formocresol – Formocresol – Cause chronic Cause chronic

inflammation of the inflammation of the pulp.pulp.• Dentin bonding agent – Dentin bonding agent – can irritate the can irritate the

pulp causing inflammationpulp causing inflammation

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Physiology Physiology of Pulpal of Pulpal

PainPainOdontogenOdontogen

ic painic pain

sensibility of the sensibility of the dental pulpdental pulp

22 types of sensory types of sensory nerve fibres in thenerve fibres in the

1.1.myelinated A myelinated A fibres (A-delta fibres (A-delta and A-beta and A-beta fibres)fibres)

22.Unmyelinated C .Unmyelinated C fibresfibres

coronal portion of the pulp and coronal portion of the pulp and concentratedconcentrated in the pulp hornsin the pulp horns

core of the pulpcore of the pulp extend into the extend into the cell-free zone underneath the cell-free zone underneath the odontoblastic layerodontoblastic layer

Dentin tubule fluid Dentin tubule fluid movementmovement

Dehydration Heat Dehydration Heat Cold Cold

Dentinaltubuleand fluid

Dentin

Odontoblastmovement

Sensory nervesSensory nerves

A-deltafibers

HyperHyper - -osmoticsolutionsosmoticsolutions

• LLocationocation• OOnsetnset • TTimingiming (frequency, (frequency,

duration)duration)• QQualityuality (sharp, dull, (sharp, dull,

throbbingthrobbing• IIntensityntensity (0-10) (0-10)• RRelieveselieves // AAggravatesggravates• AAssociated symptomsssociated symptoms

1414

PaiPainn

REFERRED REFERRED PAINPAIN

TThe perception of pain in one he perception of pain in one part of the body that ispart of the body that is

distant from the actual source distant from the actual source of the pain is known asof the pain is known as

referred pain.referred pain.

Pulpal StatusPulpal Status

Vital Nonvital

Normal Inflamed

ReversiblyInflamed

IrreversiblyInflamed

Necrotic

Pulpal PainPulpal Pain

Common Characteristics of Pulpal Pain

1. Quality of pain is dull, aching, throbbing and occasionally sharp

2. An identifiable condition that reasonably explains the symptoms

3. Response to local noxious stimulation is proportionate and predictable

4. Pulpal pain tends to get better or worse, but rarely stays the same over time

5. Local anesthesia of the suspected tooth eliminates the pain

Site of Pain vs. Source of Site of Pain vs. Source of PainPain

Site of Pain• The location where the patient feels the pain

• Easily located by asking the patient to point out the region of the body that is painful

Source of Pain • That area of the body from which the pain actually

originates

Primary Pain Site (where it hurts) = Source (where it

originates)

Eg./ cut finger

Heterotopic Pain Site ≠ Source

Eg./ cardiac pain

Heterotopic PainHeterotopic PainPain felt in an area other than its true site of Pain felt in an area other than its true site of origin (associated with deep, somatic pain).origin (associated with deep, somatic pain).– Projected pain: Projected pain: perceived in the anatomic perceived in the anatomic

distribution of the same nerve that distribution of the same nerve that mediates the primary pain (painful mediates the primary pain (painful

adjacent teeth).adjacent teeth).– Referred pain: Referred pain: felt in an area innervated felt in an area innervated

by a different nerve from the one that by a different nerve from the one that mediates the primary pain (teeth in mediates the primary pain (teeth in

opposing arch, face, head, neck).opposing arch, face, head, neck).Does not cross the midline.Does not cross the midline.

Convergence of afferent neurons.Convergence of afferent neurons.

TERMINOLOGYTERMINOLOGY

Dental pulp Dental pulp – – Tissue within each Tissue within each tooth that contains the nerves, tooth that contains the nerves,

blood vessels, and cells that blood vessels, and cells that make the tooth a living organmake the tooth a living organ

PulpitisPulpitis – – A range of conditions A range of conditions from inflammation all the way to from inflammation all the way to

pulpal necrosispulpal necrosis

TERMINOLOGY CON’TTERMINOLOGY CON’T

VitalityVitality – response of the pulpal tissue to – response of the pulpal tissue to a stimulus(healthy to nonresponsive)a stimulus(healthy to nonresponsive)

Reversible/irreversible pulpitis Reversible/irreversible pulpitis – – Reactions of a vital pulp to stimuliReactions of a vital pulp to stimuli

Necrotic Necrotic – – death of the pulpdeath of the pulpPeriapical TissuePeriapical Tissue

• chronic periodontitischronic periodontitis• acute periodontitis acute periodontitis

WHY PULPAL WHY PULPAL TESTINGTESTING??

Pulp testing is done to Pulp testing is done to determine the treatment determine the treatment

need of the toothneed of the tooth

PAINPAINAn unpleasant sensory and An unpleasant sensory and

emotional experience emotional experience associated with actual or associated with actual or

potential tissue damage or potential tissue damage or described in terms of such described in terms of such

damage.damage.

AcuteAcutevv

ChronicChronic

Acute PainAcute PainAssociated with tissue damage or Associated with tissue damage or

injury.injury.

Recent onset. Recent onset.

Limited duration.Limited duration.

Stimulation of peripheral and central Stimulation of peripheral and central nociceptors by algogenic substances nociceptors by algogenic substances

(bradykinin, prostoglandin, (bradykinin, prostoglandin, leukotrienes, histamines, substance P, leukotrienes, histamines, substance P,

excitatory AAs).excitatory AAs).

Chronic PainChronic PainProlonged persistence of pain Prolonged persistence of pain beyond the healing of tissue.beyond the healing of tissue.

Frequently experienced in the Frequently experienced in the absence of peripheral stimulation absence of peripheral stimulation

or lesions.or lesions.

Result from changes in the dorsal Result from changes in the dorsal horn and brain.horn and brain.

TOOTHACHE PAINTOOTHACHE PAINToothache of odontogentic origin can be Toothache of odontogentic origin can be

visceral (pupal) or musculoskeletal visceral (pupal) or musculoskeletal (periapical or periodontal).(periapical or periodontal).

– When the pulp is exposed to a noxious When the pulp is exposed to a noxious stimulus, there is a reactive inflammatory stimulus, there is a reactive inflammatory response.response.

– The resulting edema is unable to expand The resulting edema is unable to expand because of the surrounding inflexible because of the surrounding inflexible cementum cementum → ↑ tissue pressure and ↓ blood ↑ tissue pressure and ↓ blood flow that causes damaging effects to the flow that causes damaging effects to the pulp.pulp.

ConsiderationsConsiderations::

Healthy pulp (cellular) v Aged pulp (fibrous)Healthy pulp (cellular) v Aged pulp (fibrous)

As an increasing amount of pulp tissue is involved, As an increasing amount of pulp tissue is involved, the inflammatory process progresses apically, until the inflammatory process progresses apically, until it extends out into the periapical tissue it extends out into the periapical tissue → apex becomes sensitive to palpation and percussion.

Periapical inflammation from non-pulpal causes can exhibit similar symptoms:– Hyperocclusion– Bruxism

Pulpal StatusPulpal Status

Vital Nonvital

Normal Inflamed

ReversiblyInflamed

IrreversiblyInflamed

Necrotic

CLINICAL CLASSIFICATION OF CLINICAL CLASSIFICATION OF PULPALPULPAL

AND PERIAPICAL DISEASESAND PERIAPICAL DISEASES

Pulpal Pulpal DiseaseDisease

•Normal PulpNormal Pulp

•Reversible Reversible

PulpitisPulpitis

•Irreversible Irreversible

PulpitisPulpitis

•NecrosisNecrosis

PAINPAIN•Location

•Onset

•Timing (frequency, duration)

•Quality (sharp, dull, throbbing, aching,burning, etc.)

•Intensity (0-10)

•Relieves / Aggravates

•Associated symptoms

Reversible Reversible PulpitisPulpitis

Common Common causes:causes:

Caries, recent restorative Caries, recent restorative procedures, faulty procedures, faulty

restorations, trauma, restorations, trauma, exposed dentinal tubules, exposed dentinal tubules,

periodontal scaling.periodontal scaling.

Condition should return to normal with Condition should return to normal with

removal of the cause.removal of the cause.

Pulpal recovery will occur if reparative Pulpal recovery will occur if reparative

cells in the pulp are adequate.cells in the pulp are adequate.

Treatment Treatment of of

Reversible Reversible PulpitisPulpitis

Remove irritant if present (caries; Remove irritant if present (caries; fracture; exposed dentinal tubules).fracture; exposed dentinal tubules).

– If no pulp exposure: CaOH, restore, If no pulp exposure: CaOH, restore, monitormonitor

– If pulp exposure:If pulp exposure:

Carious: initiate RCTCarious: initiate RCT

Mechanical: >1 mm: initiate RCTMechanical: >1 mm: initiate RCT

<1 mm crown planned: <1 mm crown planned: initiate RCTinitiate RCT

<1 mm: direct cap or RCT<1 mm: direct cap or RCT

If recent operative or trauma – postpone If recent operative or trauma – postpone additional treatment and monitor.additional treatment and monitor.

Irreversible Irreversible PulpitisPulpitis

Pulpal inflamation and degeneration Pulpal inflamation and degeneration not not expected to improve.expected to improve.

A physiologically older pulp has less ability to A physiologically older pulp has less ability to recover due to decrease in vascularity and recover due to decrease in vascularity and

reparative cells.reparative cells.

As inflammation spreads apically, cellular As inflammation spreads apically, cellular organization begins to break down.organization begins to break down.

Localized pressure slows venous return, Localized pressure slows venous return, resulting in buildup of toxins and lower pH resulting in buildup of toxins and lower pH

that causes widespread cellular destruction.that causes widespread cellular destruction.

Treatment of Treatment of Irreversible PulpitisIrreversible Pulpitis

IIdeal immediate treatmentdeal immediate treatment

• (complete removal of pulpal (complete removal of pulpal tissue)tissue)completelycompletely relieve relieve

occlusion if have acute occlusion if have acute periapical peridontitisperiapical peridontitis..

Pulpal DiseasePulpal Disease

NecrotiNecroticc

PulpPulp

Necrotic PulpNecrotic PulpResults from Results from continued degenerationcontinued degeneration

of an acutely inflamed pulp.of an acutely inflamed pulp.Involves a progressed Involves a progressed breakdown of breakdown of

cellularcellular organization and no reparative organization and no reparative potential.potential.

Commonly have Commonly have apical radiolucent apical radiolucent lesion.lesion. ( (alwaysalways conduct proper pulp conduct proper pulp

testing to rule out a non-pulpal origin).testing to rule out a non-pulpal origin).With multi-rooted teeth, one root may With multi-rooted teeth, one root may

contain contain partially vital pulppartially vital pulp, whereas , whereas other roots may be nonvital (necrotic).other roots may be nonvital (necrotic).

Treatment of Treatment of Necrotic PulpNecrotic Pulp Minimum immediate treatment (if not Minimum immediate treatment (if not

extraction)extraction)Partial instrumentation of canalsPartial instrumentation of canals::

– Place Ca(OH)² into all canalsPlace Ca(OH)² into all canals– completelycompletely relieve occlusion if have relieve occlusion if have

acute apical periodontitis.acute apical periodontitis. Ideal immediate treatmentIdeal immediate treatment

• Complete instrumentation of canals:Complete instrumentation of canals:– completelycompletely relieve occlusion if have relieve occlusion if have

acute apical periodontitisacute apical periodontitis.