THERAPIES FOR PERIAPICAL LESIONS OF ENDODONTIC ORIGIN

THERAPIES FOR PERIAPICAL LESIONS OF ENDODONTIC ORIGIN

INTRODUCTION :

Conservative treatment of a tooth affected by apical periodontitis is an intervention which consists of the definitive surgical and medicinal removal of the infectious and necrotic focus; it allows the healing of the periodontal ligament and the alveolar bone as well as the cementum closure of the apex.

1. Principles of treatment:
   • Remove gangrenous (necrotic and infected) tissue;
   • Make impossible the life and development of germs which could persist;
   • Make the further development of any new microbial flora in this cavity impossible.

• On the apical side , any bacteremic state in the blood circulation of the deep periodontium can allow an anchoritic fixation of germs in the canal; to avoid this, a cemental closure is desirable, thanks to the canal obturation.
• On the coronary side , the same problem of hermeticity; a watertight coronary obturation is essential.

2. Therapeutic steps:
3. Root canal trimming:

The infected canal is “trimmed”. Surgically, using various instruments, all necrotic and infected soft tissue is removed until the dentin surface of the canal wall is completely exposed, making it hard and clean. This trimming is also associated with a gesture of penetrating the instruments along the entire length of the canal to reach its end, after widening it if necessary.

• Penetration of the canal : It must precede its trimming; This penetration must, among other things: avoid any backflow of gangrenous debris into the deep periodontium; and any injury to it.
• Becoming of dentin tubules: The germs infest the dentin, they invade the tubules which constitute closed systems conducive to their development: heat, humidity, existence of an organic substrate, scarcity of oxygen favorable to anaerobes.
  • Fully opening the canalicular orifices allows disinfectant, gaseous or detergent substances to penetrate them.
  • Currently, the EDTA – CIONa combination seems to provide satisfactory results.
• The fate of accessory pulpo-periodontal canals: When there is a latero-radicular granuloma, it is possible to see radiographically the accessory canal to which it is connected. Often, this canal is also obturated, acting by pressure on the obturating paste, using a well-adjusted gutta cone “lateral condensation technique”; or with hot gutta techniques where the paste flows into the canal; after this the granuloma disappears.

2.  Root canal disinfection:

Disinfectants are used at two points in the treatment:

• extemporaneously, as “irrigants”, associated with canal debridement;
• as “dressings” after debridement and before root canal filling. “Intermediate filling”

2-1) “Extemporaneous” disinfectants – Irrigants:

• Chlorhexidine : ( see 3rd Year Endodontic Pharmacology course)
• Sodium hypochlorite:

2NaOCl+H2O 2NaOH + Cl2 + 1/2O2

• It is a strongly alkaline product and decomposes on contact with organic matter, releasing nascent chlorine and oxygen.
  • This product has a low surface tension which allows its rapid diffusion into the canal and dentin.
    • It involves:

-Solubilization of albumins.

-Saponification of fats.

-Lubrication of the walls.

-Cl2 and O2 (very powerful antiseptics).

• EDTA:

Ethylenediaminetetraacetic acid in solution or gel is a chelator which is used to dissolve “endodontic smear layer”. “See Endodontic Pharmacology course”

2-2) Disinfectant dressings:

calcium hydroxide: “properties: See endodontic pharmacology course”

• “magisterial form in powder + physiological serum = creamy consistency, which is deposited in the canal using a Lentulo paste filler at the LT.
• In commercial syringes which also contain opacifiers.

3. Maintaining disinfection, root canal filling:

Root canal filling prevents the existence of a dead space where the development of germs is facilitated by a humid, warm, closed environment.

3.  LIPOE therapies themselves:
4. Treatment of acute apical periodontitis:

This is an emergency treatment, the aim being to relieve the patient because the pain can be very severe.

1-1) Simple acute apical porodontitis:

• The passage of bacteria or toxins from the root canal system into the periodontal space induces ligament inflammation and can also be associated with occlusal trauma or occur after intraligamentous anesthesia. This is a common complication of this type.

of anesthesia.

Emergency treatment:

• If acute apical periododontitis is a complication of endodontic infection ,
  • if it is initial the vitality tests are positive “especially on the multi-rooted” “persistence of vital pulp tissue” the treatment is pulpectomy.
  • When apical periodontitis is present:

The treatment consists of creating the access cavity on the affected tooth, debriding and disinfecting the canals as much as possible.

• Calcium hydroxide medication is put in place,
• the coronary cavity is closed with a non-compressive dressing.
• The tooth is then placed under occlusion.
• If the apical periodontitis is a post-operative consequence of conservative treatment or intraligamentary anesthesia : the tooth is placed in under-occlusion (static and dynamic) it is then important to check

the absence of contact during lateral movements (milling while holding the tooth between the thumb and index finger).

• Prescription : A prescription for Ibuprofen (400mg three times a day for at least 48 hours) is given to the patient.

Prescribing antibiotic therapy is not justified, except in patients presenting a particular medical risk.

2-1) Primary acute apical abscess :

• In the case of propulsion of irritant by over-instrumentation for example).
• Clinically the tooth is very painful to percussion, and simple contact with the opposing tooth is unbearable for the patient.

Emergency treatment:

• Debride the canals where possible to significantly reduce the bacterial load.
• Calcium hydroxide medication is placed in the canal, and the tooth is filled with a non-compressive temporary coronal filling: the tooth is placed under occlusion.
• Prescription: Ibuprofen (400 mg 3 times a day for at least 48 hours)
• Unjustified ATB (except for at-risk patients).

3-1) Secondary acute apical abscess or Phoenix abscess:

• The passage of bacteria from the endodontic system into the periapical granulomatous tissue causes infection of the chronic lesion and an intraosseous abscess forms.
• The intraosseous excess pressure linked to the presence of pus in the lesion is extremely painful.

Emergency treatment:

The only way to relieve the patient is therefore to allow the evacuation of this pus:

1.  by intracanal or transcanal route:

• After debridement of the canal, a fine file is placed in the canal and is used beyond the foramen after pre-disinfection and irrigation of the canal to avoid pushing back microorganisms.
• The pus can then gradually drain back up the canal; abundant irrigation is continued as long as a flow is perceptible; the tooth is left open for 15 minutes; if the flow has been satisfactory, close the tooth.

2.  by incision:

• If intracanal drainage cannot be obtained and a gingival abscess is present and collected (Godet sign); drainage is obtained by incision of the abscess; after anesthesia of the mucous membranes, a clean incision up to bone contact is made with a number 11 scalpel blade;

the incision allowing drainage, the tooth can be closed.

3. If no abscess is present (or not collected) and intracanal drainage cannot be obtained : the tooth is left open for 48 hours.

• In all cases the patient is seen again within 48 hours, when the lesion is

“cooled”. The endodontic system is cleaned and disinfected. Calcium hydroxide medication is placed in the canal to reduce the periapical inflammatory process; the tooth is sealed with a temporary waterproof dressing and placed in sub-occlusion;

• Endodontic treatment is considered during a third session;
• The root canal system is shaped, cleaned, disinfected and filled in the same session provided that the three required conditions are met , namely:
  • Adapting a gutta cone to the working length
  • Possible canal drying;
  • Total absence of symptoms.
• Prescription:

Antibiotic prescription in this situation is recommended (amoxicillin 2g per day for 7 days), painkillers (NSAID or Paracetamol) and mouthwashes are also prescribed.

2-) Treatment of chronic apical periodontitis:

1-2 ) Chronic apical periodontitis: “granuloma”:

• Inflammation is accompanied by destruction of the hard tissues of the tooth (apical or lateroradicular radiolucent zone) and the development of tissue

granulomatous or cystic. It is not painful as long as the lesion is not in the so-called acute phase; this lesion is an extra-radicular consequence of the pathology, which is intracanal.

Treatment:

It does not require emergency treatment; endo treatment is scheduled and can be performed in a single session.

• NO PRESCRIPTION.

2-2 ) Condensing osteitis;

• Endodontic treatment will reverse the process or the defense mechanism may give way to the classic mechanisms of decalcification.

3-2) Chronic apical fistulized periodontitis:

• The presence of a fistula should reassure the practitioner. Treatment of a fistulated tooth takes place in one session .
• The fistula acts as a safety valve.
• A few days after the canal filling, the fistula disappears . The removal of the cause leads to the removal of the effect.

3-3 Apical cyst :

This term is used to differentiate an apical cyst of endodontic origin from a latero-radicular cyst which is not necessarily associated with a devitalized tooth.

• Except for extremely large lesions, surgery is not justified,

endo treatment will be sufficient, if the image does not disappear surgery is necessary.

Apical Surgery: “5th Year Course”

• It is sometimes necessary if the lesion does not disappear following endocanal treatment.

4.  Causes of failure:

• Insufficient preparation;
• Incomplete occlusion;
• Non-hermetic sealing;
• The existence of a root fracture;
• The existence of dehiscence;
• The existence of fenestration;
• The existence of a combined endo-periodontal lesion.

Conclusion :

• The treatment of apical periodontitis is now a very common procedure . However, since it involves the body’s deep reactions, it must be carried out with great caution because it can lead to very serious infectious complications.
• Among all the therapeutic procedures currently proposed, it seems that the evolution is increasingly towards more biological than mechanical formulas, towards more specific than blind disinfection.

Summary:

Appendix:

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THERAPIES FOR PERIAPICAL LESIONS OF ENDODONTIC ORIGIN

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THERAPIES FOR PERIAPICAL LESIONS OF ENDODONTIC ORIGIN