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Endodontics

Authors: Dr. Mandar Pimprikar
 

We clinicians deal with three different situations:

  1. Infected root canals (with vital pulp or Irreversible pulpitis)
  2. Infected root canals (with necrotic pulp) usually associated with apical periodontitis
  3. Revised treatment where there is persistent infection post treatment, associated with apical periodontitis and huge peri-apical lesions.
  1. For teeth with irreversible pulpitis, a clinician may finish the root canal treatment in one visit depending on the ability of the clinician to take care of the inflamed pulp tissue.
  2. In infected or necrotic cases and revised treatments, it is completely different set of problems; as intra radicular infection is the primary cause of periapical lesion. The endodontic procedure need to focus on asepsis and also on eliminating bacteria from the canal system. An optimal outcome will depend on effective irrigation and disinfection protocol. Substantial amount of bacterial load is reduced after instrumentation. 20% of root canal still show presence of bacteria and they escape in ‘hard to reach’ areas.

Q.1 - When to use intracanal medication?

Clinicians should decide to place the intracanal medication only when

  1. The canals are weeping in the second visit
  2. Canals do not get dry after using 3 to 4 paper points in succession
  3. Frank exudate from the canal

A common mistake by all the clinicians is- when they see a periapical lesion, they have decided to place intracanal medication.

It is advisable to follow irrigation protocol with shaping and review at the second visit.

If the canals are dry, there is no need to place the intracanal medication.

Calcium hydroxide is most commonly used intracanal medication apart from triple antibiotic paste.

  1. Calcium hydroxide has a PH of approximately 12.4 and
  2. It is soluble in water
  3. Commercially available as powder and paste

It is difficult to use only powder; so a vehicle is used with calcium hydroxide powder.

  1. Based on its consistency; vehicles are aqueous, viscous and oil base.Viscous and oil base does not allow dissociation of hydroxyl ions, so there role is questionable.
  2. Depending on antimicrobial activity; the vehicles are named as inert and biologically active.

Inert vehicles: distilled water, saline, glycerin, propylene glycol Biologically active:

  1. camphorated PARAMONOCHLOROPHENOL (CMCP)
  2. chlorhexidine
Clinical significance:

It is advised to use aqueous base calcium hydroxide.

It is even better if it is freshly mixed chair-side using calcium hydroxide and normal saline.

Chlorhexidine can be incorporated in the calcium hydroxide powder to make a paste for intracanal medication

OR

Use calcium hydroxide ready use paste in aqueous base which are commercially available.

Q.2- How to place calcium hydroxide?

If you are using freshly mixed paste then one can use

  1. A k-file in Counter clockwise direction by carrying the paste in the canal
  2. Shaping rotary file in Counter clockwise direction to quote the canal walls
  3. Sonic device to carry the paste in the canal

Never push the (ready to use) paste with the needle locked in the canal. This can push the paste in the peri-apex and cause discomfort to the patient.

Once the intracanal medication is placed, wait at least for 7 days to 2 weeks.

Remove all the calcium hydroxide by flushing out with the irrigant in the canals.

If the canals are dry and the tooth is a symptomatic; proceed for obturation. If the canals are still weeping; place another increment of medication and wait

Conclusion:

We as clinicians should have a clear understanding of root canal infection and use intra-canal medication as an additional method of disinfection.

Using calcium hydroxide will never be a substitute to efficient irrigation.

Primary focus should be to have shaping and cleaning protocol and not to compromise on principles of debridement.

If You Have any Question Regarding Endodontics Please feel free to send at: This email address is being protected from spambots. You need JavaScript enabled to view it. or This email address is being protected from spambots. You need JavaScript enabled to view it. . We will give you the answers in any of the upcoming issues of Guident.