CHAPTER IINTRODUCTION

Root canal treatment (RCT) is a standard component of dental therapy which is performed on most teeth. It has a success rate of 30 to 98% (Edionwe, et al., 2014). Pulpectomy is the complete surgical removal of the vital dental pulp (AAE, 2003). It is primarily carried out to prevent the development of a destructive course of pulpal inflammation, which may result in root canal infection and associated painful events (Bergenholtz, et al., 2003). A root canal is a complex three-dimensional space. The objective of contemporary canal preparation techniques is to clean and shape this space to remove bacteria and infected debris and then to prepare the space for easier obturation. There is no attempt to try to prepare the space to conform to a notional geometric form. As a consequence contemporary obturation materials need to be plastic during placement to allow them to be moulded to the canal form. It should also be possible to remove part or the entire root filling with ease after it is completed, to permit the use of a post to facilitate restoration of the tooth or repeat endodontics if that is ever required (McCabe and Walls, 2008).In this case report, we will discuss the ideal treatment that can be done for a patient who have a chief complain of deep dull throbbing pain on his anterior upper tooth.

CHAPTER IILITERATURE REVIEW

2.1 Pathogenesis of cariesDental caries is a process which may take place on any tooth surface in the oral cavity where a microbial biofilm (dental plaque) is allowed to develop for a period of time. The bacteria in the biofilm are always metabolically active, causing minute fluctuations in pH. These may cause a net loose of mineral from the tooth when the pH is dropping. This is called demineralization. Alternatively there may be a net gain of mineral when the pH is increasing. This is called remineralization. The cumulative result of these demineralization and remineralization processes may be a net loss of mineral and a carious lesion which can be seen. (Edwina A.M., et.al. 2003) The proximal enamel surfaces immediately gingival of the contact area are the second most susceptible areas to caries. These areas are protected physically and are relatively free from the effects of mastication, tongue movement, and salivary flow. Often the gingival aspect of the facial and lingual smooth enamel surface that is supragingival but gingival of the occlusogingival height of contour is neither rubbed by the bolus of food nor cleaned by the toothbrush. Therefore these surface areas are habitats for the caries-producing mature plaque (Roberson et al., 2002).Important ecologic determinants for the plaque community on the proximal surfaces are the topography of the tooth surface, the size and shape of the gingival papillae, and the oral hygiene of the patient. A rough surface (caused by caries, a poor quality restoration, or a structural defect) restricts adequate plaque removal. This results in retention of a more advanced successional plaque stage, favoring the occurrence of caries or periodontal disease at the site (Roberson et al., 2002).

Figure 2.1 Progression of caries on interproximal surfaces. A, Initial demineralization. B, When caries are detectable radiographically. C, Cavitation of the enamel surface. D, Advanced cavitated lesions (Roberson et al., 2002).

2.2 Diagnosis for PulpitisThe indications, objectives, and type of treatment depend on whether the pulp is vital or nonvital, based on the clinical diagnosis of normal pulp (symptom free and normally responsive to vitality testing), reversible pulpitis (pulp is capable of healing), symptomatic or asymptomatic irreversible pulpitis (vital inflamed pulp is incapable of healing), or necrotic pulp. The clinical diagnosis is derived from: 1. A comprehensive medical history. 2. A review of past and present dental history and treatment, including current symptoms and chief complaint. 3. A subjective evaluation of the area associated with the current symptoms/chief complaint by questions on the location, intensity, duration, stimulus, relief, and spontaneity. 1. Where is the pain?2. When was the pain first noticed?3. Description of the pain.4. Under what circumstances does the pain occur?5. Does anything relieve it?6. Any associated tenderness or swelling.7. Previous dental history: recent treatment; periodontal treatment; any history of trauma to the teeth4. An objective extraoral examination as well as examination of the intraoral soft and hard tissues. 5. If obtainable, radiograph(s) to diagnose pulpitis or necrosis showing the involved tooth, furcation, periapical area, and the surrounding bone. 6. Clinical tests such as palpation, percussion, and mobility.Diagnostic aids include periapical radiographs taken with a paralleling technique, electric pulp tester for testing pulpal responses, ice sticks, hot gutta-percha, cold spray and hot water for testing thermal responses, and periodontal probe. Teeth exhibiting signs and/or symptoms such as a history of spontaneous unprovoked toothache, a sinus tract, soft tissue inflammation not resulting from gingivitis or periodontitis, excessive mobility not associated with trauma or exfoliation, furcation/apical radiolucency, or radiographic evidence of internal/external resorption have a clinical diagnosis of irreversible pulpitis or necrosis. These teeth are candidates for non-vital pulp treatment. Teeth exhibiting provoked pain of short duration relieved with over-the-counter analgesics, by brushing, or upon the removal of the stimulus and without signs or symptoms of irreversible pulpitis, have a clinical diagnosis of reversible pulpitis and are candidates for vital pulp therapy. Teeth diagnosed with a normal pulp requiring pulp therapy or with reversible pulpitis should be treated with vital pulp procedures (AAPD, 2014).Caries advances more rapidly in dentin than in enamel because dentin provides much less resistance to acid attack because of less mineralized content. Often, pain is not reported even when caries invades dentin, except when deep lesions bring the bacterial infection close to the pulp. Episodes of short duration pain may be felt occasionally during earlier stages of dentin caries. These pains are due to stimulation of pulp tissue by movement of fluid through dentinal tubules that have been opened to the oral environment by cavitation. Once bacterial invasion of the dentin is close to the pulp, toxins and possibly even a few bacteria enter the pulp, resulting in inflammation of the pulpal tissues. Initial pulpal inflammation is thought to be evident clinically by production of sharp pains, with each pain lingering only a few seconds (10 or less) in response to a thermal stimulus (Roberson et al., 2002).A short, painful response to cold suggests reversible pulpitis or pulpal hyperemia. Reversible pulpitis, as the name implies, is a limited inflammation of the pulp from which the tooth can recover if the caries producing the irritation is eliminated by timely operative treatment. When the pulp becomes more severely inflamed, a thermal stimulus will produce pain that continues after termination of the stimulus, typically longer than 10 seconds. This clinical pattern suggests irreversible pulpitis, when the pulp is unlikely to recover after removing the caries. Throbbing, continuous pain suggests partial or total pulp necrosis that is treated only by root canal therapy or extraction (Roberson et al., 2002).In summary, in reversible pulpitis: The pain is of very short duration and does not linger after the stimulus has been removed. The tooth is not tender to percussion. The pain may be difficult to localize. The tooth may give an exaggerated response to vitality tests. The radiographs present with a normal appearance, and there is no apparent widening of the periodontal ligaments.In irreversible pulpitis: There is often a history of spontaneous bouts of pain which may last from a few seconds up to several hours. When hot or cold fluids are applied, the pain elicited will be prolonged. In the later stages, heat will be more significant; cold may relieve the pain. Pain may radiate initially, but once the periodontal ligament has become involved, the patient will be able to locate the tooth. The tooth becomes tender to percussion once inflammation has spread to the periodontal ligament. A widened periodontal ligament may be seen on the radiographs in the later stages (Carrotte, 2004).

2.3 Root Canal TherapyThe general purpose of endodontic treatment is to maintain teeth survival as long as possible in the mouth cavity. The treatment undergoes three stages: the pulp space biomechanic preparation, root canal sterilization, and root canal filling. The root canal filling cannot be hindered if the stage prior to filling is done correctly and adequately. The purpose of root canal filling is to fill up or block all root canal and to form a fluid-tight seal on the apical foramen of the tooth, so that any possibility of a secondary infection occurrence due to the mouth cavity or periradicular tissue leakage into the root canal system can be avoided. Clinically, the success of an endodontic treatment can be determined by an X-ray photo, clinical sign and/or symptom, histologic and immunopathologic examinations. Ideally, the root canal filling stage has to achieve a hermetic filling which is the crucial stage to obtain a successful endodontic treatment. (Ray A, 2009)Root canal treatment consists, in major part, of cleaning and shaping the root canal with files and reamers, either hand driven or motor driven, disinfecting the canal, and then obturating the canal space. On occasion endodontists also prepare post space and place posts for the referring dentist. Generally a root canal treatment consists of pulp capping, pulpotomy, and pulpectomy. (Ray A, 2009)

2.4 Vital PulpectomyVital pulpectomy is the removal of the vital pulp in fully formed roots, where the apical portal of exit is sufficiently closed to form an apical stop in obturation. Pulpectomy is indicated in all cases of irreversible pulp disease. In the event of acute pulpalgia, pulpectomy extends blessed relief to a suffering patient (Ray A, 2009). The stages are as following:1. Explain the treatment plan, risk and benefit to the patient and ask the patient to sign informed consent if he/she agrees to do so.a. Root canal treatment: Even though it is anticipated that this treatment may extend the time in which a tooth will remain uninfected until further necessary procedures may be successfully performed at a more appropriate time. Referral to an endodontic specialist may be necessary as determined by the attending dentist. b. Numbness: There is the possibility of injury to the nerves of the face or tissues of the oral cavity during the administration of anesthetics or during the treatment procedures which may cause a numbness of the lips, tongue, tissues of the mouth, and/or facial tissues. This numbness is usually temporary, but may be permanent.c. Fracture: As much as the crown portion of the tooth may have been weakened due to the extensive nature of the procedure and/or that the tooth injury or disease which necessitated this procedure, the tooth may be more susceptible to fracture or breakage. d. Temporary crown: Should the tooth structure which is remaining appear to be excessively fragile, it may be necessary to place a temporary crown on the tooth in order to preserve it. e. Extraction: Should the tooth not heal, fracture extensively, or be unacceptable for having a complete root canal treatment performed, extraction of the tooth may be necessary. f. Pain: In most cases, once the pulpectomy has been performed and the initial pain has subsided, the tooth is no longer painful. However, in some cases, severe pain or extreme sensitivity will persist. If so, it is the patient's responsibility to notify the dentist immediately.2. Evaluate the patients blood pressure and administer local anaesthesia if the blood pressure is normal (120/80).3. Disinfection of the operative field including rubber dam with an antiseptic.4. Removal of caries, old fillings, etc. and access opening. 5. Pulp extirpation aims at the removal of all necrotic pulp tissue. 6. Irrigation of the pulp chamber using a solution of sodium hypochlorite before carrying out any instrumentation is important. (Sodium hypochlorite is usually sold as a 5% solution. This may be diluted with purified water BP to the operator's preference.)7. Control the bleeding with sterile cotton pellet soaked with saline solution or sterile paperpoint soaked with eugenol, and cover with temporary filling.8. On second visit, measurement of working length, reaming and filling are carried out. The pulp wound should be placed just inside the apical foramen, ideally at the apical constriction. Statistically, in most instances one mm short of the apex is "just inside the foramen." In order to place the wound there and to avoid instrumentation through the apical foramen, a thin instrument is teased into the canal to a level that is estimated to be 1-2 mm shy of the radiographic apex. By means of a radiograph (working length x-ray) taken with this instrument in place, the pulpectomy level is decided, usually 1 mm short of the radiographic apex.9. Cleaning and shaping of the root canal using copious amounts of irrigation solution.10. When the cleaning and shaping is finished the canal is dried and filled with a paste of calcium hydroxide and sterile water (instead of sterile water an anesthetic solution, isotonic saline, or sodium hypochlorite solution can be used).11. The canal can be filled during the next visit if there are no symptoms and no exudation (Carrotte, 2004).

2.5 Obturation of Root CanalThe purpose of the obturation phase of endodontic treatment is to prevent the reinfection of root canals that have been biomechanically cleaned, shaped and disinfected by instrumentation, irrigation and medication procedures. Grossman has summarized the ideal properties of root canal obturation materials (Table 2.1) (Ray A, 2009).The contemporary approach to obturating the root canal space is to use a malleable bulk fill material in association with a thin sealant that is used to fill the space around the bulk fill material and to refine adaptation of the materials particularly to the walls of the prepared root canal. (McCabe and Walls, 2008)Successful obturation requires the use of materials and techniques capable of densely filling the entire root canal system and providing a fluid tight seal from the apical segment of the canal to the cavo-surface margin in order to prevent reinfection. This also implies that an adequate coronal fills or restoration be placed to prevent oral bacterial microleakage. It has been shown that endodontic treatment success is dependent both on the quality of the obturation and the final restoration. The quality of the endodontic obturation is usually evaluated using radiographic images upon completion. In addition, during the root canal preparation and obturation phases of treatment, clinical criteria are essential to identify the achievement of an adequate root canal obturation (Ray A, 2009).

It should be easily introduced into the root canal system.It should be radiopaque.

It should seal the canal laterally as well as apically.It should not stain tooth structure.

It should not shrink after being inserted.It should not irritate periapical tissue.

It should be impervious to moisture.It should be sterile or easily and quickly sterilized immediately before insertion.

It should be bacteriostatic or at least not encourage bacterial growth.It should be easily removed from the root canal if necessary.

Table 2.1 Grossmans Ideal Properties of Root Canal Obturation Materials.(Ray A, 2009)

2.6 Root canal sealersIn endodontic practice, the success of root canal therapy mainly depend on achieving a compact fluid tight seal of the apical end of the root canal, so as to prevent the ingress and accumulation of irritants causing biological breakdown of attachment apparatus leading to failure. Root canal sealers along with solid core material play a major role in achieving the fluid tight seal. Several types of root canal sealers are used in endodontic practice with each one having own merits and demerits. Sealers are basically selected based on their sealing ability, adhesive properties, biocompatibility & antimicrobial efficacy (Henston, et al., 2012).The purpose of a sealant is to fill the spaces between increments of the bulk fill material and to improve the quality of adaptation of the composite of sealant and bulk fill to the walls of the root canal by filling the irregularities and minor discrepancies between gutta percha and canal wall to help to maintain the seal around the root filling (McCabe and Walls, 2008). Functions of root canal sealers are as antimicrobial agent, helps in filling the discrepancies between the filling material and the dentin walls, as a binding agent between the filling material and the dentin walls, and as a lubricant and gives radioopacity (Henston, et al., 2012).The sealers are responsible for the principal functions of the final root filling, sealing off of the root canal system, entombment of remaining bacteria and the filling of irregularities in the prepared canal. Several, quite different chemical formulations have served as bases for root canal sealers. They are essentially thin pastes that can be both introduced into the canal system and used to coat the bulk fill material. The setting time should extend over hours rather than minutes to allow for exacting clinical technique (McCabe and Walls, 2008) Root canal sealers can be classified according to the chemical composition (Ingle): Zinc oxide-eugenol based cements, Calcium hydroxide containing cements, Resin based cements, Glass Ionomer based cements, and experimental sealers. It can also be classified according to Clark into absorbable and non-absorbable (Henston, et al., 2012).Grossmans ideal requirements of root canal sealer are:1. Tacky which helps for good adhesion between it and the canal wall when set. 2. Provide a hermetic seal. 3. Radiopaque to be seen in the radiograph. 4. easy to manipulate. 5. No shrinkage on setting. 6. No staining to tooth structure. 7. Bacteriostatic. 8. Set slowly. 9. Insoluble in tissue fluids. 10.Biocompatible. 11.Soluble in a common solvent. 12.Neither mutagenic nor carcinogenic. 13.Not provoke an immune response in periradicular tissue (Henston, et al., 2012).Adhesion of a root canal sealer means its capacity to attach to the dentinal walls of the root canal provide bonding between it gutta percha. Bonding of root canal sealer is carried out through 2 mechanisms. One of it is mechanical interlocking. Sealer penetration (resin based) into the dentinal tubules resin tags. The other is chemical reaction between sealer and dentin. The polyacrylic acid matrix of GIC contains multiple ionized carboxylate groups than can chelate with calcium in the mineral phase of dentin (Henston, et al., 2012).The ZnOE-based sealers represent the gold standard in endodontics because of their long history of successful usage, making their positive qualities outweight their negative aspects, like staining, irritating potential, slow setting time and solubility. Zinc oxide-eugenol sealer should firmly bond to dentin and gutta percha. The setting reaction of the zinc oxide-eugenol mixtures is a chelation reaction occurring with the zinc ion of the zinc oxide. In addition, eugenol is a solvent of gutta percha that may soften it during the setting reaction and increase bonding of sealer to gutta-percha (Henston, et al., 2012). Modified Zinc oxide-eugenol cements are widely used and are exemplified by Grossmans formulation:Powder: 42 parts zinc oxide, 27 parts stabellite resin, 15 parts bismuth subcarbonate, 15 parts barium sulphate and 1 part sodium borate.Liquid: eugenol. This does have an exceptionally long setting time (up to 2 months), but has been shown to give consistent results with a good peripheral seal and produces a filling that is retrievable. (McCabe and Walls, 2008)Resin-based sealers were introduced some years ago and today are accepted worldwide; epoxy-based cements are the primary ones, with many useful properties like antimicrobial action, adhesion to dentin walls, ease of using and mixing, good sealability and relative insolubility. (McCabe and Walls, 2008)Calcium hydroxide-containing sealers, in which the calcium hydroxide is incorporated in a ZnOE or is resin-based, have also been introduced. The calcium hydroxide products provide a good short-term seal but there are some concerns about their longer term solubility in sustaining this seal. These sealers are claimed to have antimicrobical effects and biologic properties that stimulate a calcific barrier at the apex, although these characteristics have not been conclusively and completely demonstrated (Dagorstavik, 2005; McCabe and Walls, 2008). CaOH based cements displayed no bonding on both dentin and gutta percha (Henston, et al., 2012).One of the Glass Ionomer based cements, Ketac Endo is a GIC modified in its properties by a group at Temple University to be used as cement into the canal. It was introduced in Dentistry by Wilson and Kent in 1971 as a restorative material. In 1991, it was introduced as root canal sealer. It provides favorable biological, chemical & physical properties. It is very biocompatible. The glass ionomer sealer is known to bond to dentin but may also bond to gutta-percha, because the polycarboxylic acid of the glass ionomer may react with the zinc component of gutta-percha in a manner similar to the polycarboxylate cements that have already been used as endodontic sealers (Henston, et al., 2012).In choosing a sealer, find a sealer that can seal the canal totally, well tolerated by periradicular tissue, and inhibit microbial growth (Henston, et al., 2012).

2.7 Overfilling During ObturationOver instrumentation of the root canal with hand or mechanically driven files can perforate the mandibular canal, allowing the extrusion of sealers, dressing agents, irrigation solutions, and the passage of microorganisms into the canal, during endodontic treatment. Experimental studies have shown that eugenol and paraformaldehyde are the main materials causing neurotoxic reactions. If overfilling occurs, two filling incidents may happen i.e. root canal solidly filled or unsolidly filled conditions by filling substance. According to Ingle et al., 60% of endodontic treatment failure is caused by the failure of root canal filling. Furthermore Grossman et al. state that endodontic treatment failure is due to nonhermetic filling up to 67% (Banu K, 2006). There are several alternatives to overcome overfilling during an endodontic treatment. They are by taking no treatment, conventional endodontic treatment, or performing an endodontic surgery. In specific overfilling cases, one can do no correction measure depending upon the used type of filling or sealing substance and how far the filling/ sealing substance overpasses the apical foramen. Should the substance be biocompatible, e.g. gutta percha or titanium cones and it does not pass the apical foramen more than 1 mm, no action or correction measures are needed. (Banu K, 2006)The same approach is applied if the substance can be re-absorbed by our body in the form of paste or cement form substance. If the substance which passes the apical foramen cannot be re-absorbed, or it is biocompatible but it passes the apical foramen not more than 1 mm, the conservative measure such as a conventional endodontic treatment is applicable. This treatment consists of X-ray photo of the overfilled tooth and expelling all substance from the root canal. For substance from paste or cement, one can use a reamer or K type file. (Banu K, 2006) Consecutively, a root canal re-preparation with precise and adequate procedures must be done. It is then followed by re-filling the root canal using a new substance, and the last measure is an X-ray photo to see the precision of the filling and sealing (Banu K, 2006).Endodontic surgery is the management or prevention of periradicular pathosis by surgical approach. The aim of surgical endodontics is to prevent noxious substances from within the root canal causing inflammation in the periodontal ligament and beyond. The objective of surgical endodontics is to achieve a satisfactory seal of the root canal and thus prevent noxious substances entering into the adjacent tissues. It can be curettage (apico curettage) or apicoectomy. Apico curettage is a measure to take out tissues at the apical area, and apicoectomy is a surgery measure to cut dental apex and take out some surrounding tissue (necroting cementum). The root canal filling can be done before or right after the dental apex is cut (Banu K, 2006).

2.7.1 Preventing OverfillingTo prevent an overfilling during endodontic treatment, operators should take cautious actions by emphasizing several matters, such as work with lege artis attitude during treatment process including calculating work length precisely, proper usage of intracanal apparatus, maintaining resistency form during the root canal preparation, no excessive pressure towards intracanal tool during the preparation process and towards filling substance during root canal filling, as well as utilizing sealer only as much as it is needed. Morerover, the applicated sealer must have a minimal toxicity level to prevent more damage when an overfilling occurs. (Banu K, 2006) The use of a filling substance containing formaldehyde or paraformaldehyde should be avoided because this substance can produce damaging effects to the patient. Endodontic treatment of the first molar distal dental root, and on both mandibles, as well as the dental root of premolar both mandibles should be carefully done because the anatomical form of those roots are close to mandibular canal. The operator should be careful to choose a filling substance from paste texture, because it is really difficult to control while pouring it to the root canal (Banu K, 2006).

2.8 Bulk Filling MaterialsThe purpose of the bulk filling material is to provide an inert mass that can be used to fill the large defect which comprises the prepared root canal. These materials have to be malleable during the insertion phase and must be dimensionally stable. The most commonly used products are based on a modified natural rubber gutta-percha. More recently a polyester resin-based material has been developed with similar handling characteristics to gutta-percha. (McCabe and Walls, 2008)

2.8.1 Gutta-PerchaThe most widely used bulk fill material is gutta-percha. In its pure form gutta percha is derived from latex as an isomer of rubber known as transpolyisoprene. It can be produced in two crystalline forms and . It is less elastic and harder than natural rubber. The form is the natural state and is mainly used in thermoplastic manipulation techniques whilst the form is produced by cooling material slowly (at a rate of about 0.5C per hour). The form is more commonly used with cold packing techniques. (McCabe and Walls, 2008) Gutta-percha as used in dentistry comprises between 19 and 22% transpolyisoprene, zinc oxide (between 60 and 75%) and a variety of other components including colouring agents, resins, waxes, antioxidants and metallic salts; the latter are incorporated to improve the visibility of the material on radiographs. It is presented to the dentist in either tapered cones which may or may not be matched to the sizes of the instruments used to prepare the canal mechanically or as pellets of material to be loaded into a gun-type delivery system. (McCabe and Walls, 2008)

2.8.2 Polyester ResinResilon is a commercially available material which is based on thermoplastic synthetic polyester, barium sulphate, bismuth chlorate and a bioactive glass. It is claimed that the bioactive glass releases calcium and phosphate ions from its surface on exposure to bodily fluids stimulating bone growth. This material is also available in both tapered and pelleted forms for use with either cold or thermoplastic filling techniques. (McCabe and Walls, 2008)

CHAPTER IIICASE REPORT

3.1 Patient IdentityExamination date : 28 May 2015Medical Record No. : 2015-0665*Full name : Mr. JName of parents : Mr. RSex : MalePlace / Date of birth : Bandung / 3 July 1993Age : 22 yearsMarital status : SingleReligion : ChristianOccupation : Private sectorHome address : Cimahi

3.2 AnamnesisA male patient aged 22 years came to RSGM with a chief complaint of his anterior tooth which has a deep dull throbbing pain; it is also very sensitive to cold and hot liquids. He also complain that the teeth affect his social appearience and it is difficult to clean his teeth. The patient is healthy in general and without any history of systemic disease. The patient was not on any medication throughout the dental treatment.3.3 Medical DataBlood group : OBlood pressure : 110/70 mmHgHeart disease : NoDiabetes mellitus : NoHaemophilia : NoHepatitis : NoOthers : NoAllergic to medicine : NoAllergic to specific food : No

3.4 Extraoral ExaminationLip : NormalTMJ : NormalLymph Nodes : Normal

3.5 Intraoral ExaminationIntraoral findingsDiagnosis

ToothCTSPerPresMPal

11++----Irreversible pulpitis

3.6 Radiograph findingsRadiograph finding shows that there was radiolucency at the mesial and distal sides of tooth 11, almost reaching the pulp.

3.7 DiagnosisIrreversible pulpitis due to caries profunda on tooth 11

3.8 Treatment OptionPro- Vital pulpectomy on tooth 11

3.9 TreatmentFirst visit (28 May 2015)Upon the routine subjective, objective, and radiographic examinations, informed consent was achieved, and patient was willing to give his consent. Diagnosis was made based on radiograph and clinical examination which includes vitality tests (Cold-test), sondasi test (direct stimulation to exposed dentin), percussion and pressure test, test on mobility and palpation, and on the authors dental knowledge of patients medical and dental history, the author have taken into consideration any information the patient have given. In addition, this treatment modality was chosen because the patient was young and willing to give his compliances throughout the procedure.Informed consent was made after discussing all available treatment options and outcomes. Patient has agreed to continue his treatment after knowing all the possible dental complication during and after the procedures, which include damage or loss of tooth structure in gaining access to the canal, fracture of tooth structure, and change in tooth color (becoming darker than adjacent teeth). During treatment, complications may be discovered which make endodontic treatment impossible, or which may require microsurgery or extraction. These complications may include blocked canals due to fillings or prior treatment, natural calcifications, curved roots, periodontal disease, and split or fractures of the tooth. Patient was informed that the treatment may make take several visits over a few weeks to complete. Treatment will be performed in accordance with accepted methods of clinical practice. He is also well informed that he will undergo taking of a minimal number of radiograph photos as dictated by the requirements of the case. Patient also understand that the use of anesthetic can cause numbness and tingling of the lip, chin and/or tongue which may be temporary or permanent. He must know the nature of the problem causing the need for treatment: that is the nerve tissue within the tooth is dying and causing potential risk of infection in the bone surrounding the tooth. He also understands the reasons for treatment: the removal of the nerve tissue is to relieve or prevent infection.Upon application of local anesthetic, patient was evaluated with blood pressure (110/70mmHg), pulse rate (87/min) and respiration rate (18/min), which appeared to be in normal range. Procedure was began with a buccal infiltration at region 11, and followed by proper isolation of the working site with cotton roll at the labial aspect to the aid of saliva suction, and patient was asked to bite on a biteblock to ensure minimal saliva contamination. Access cavity to the pulp was made using a high speed endodontic access bur and removal of the pulp chamber roof done at a slow speed, and the orifice can be seen at the palatal site of tooth 11. Coronal pulp was removed, the canal is easily located as this is an incisor, and then the pulp and its inflamed tissue was extirpated from the canal with barbed broach file under constant irrigation. Copious irrigation was carried out using sodium hypochlorite solution (NaOCl) which helps to remove remaining organic tissues. The barbed broach was inserted into the root canal as far as possible without forcing it and then turn it a full 360, later was pulled upwards removing the pulpal tissues. The broach was inserted a few times and winds it around in order to remove all the pulpal tissues completely. After finishing the mechanical preparation and rinsing, the root canal was dried with sterile paper points. The cavity was covered with paper point dipped with eugenol, temporary filling was used to cover the cavity, and patient was sent back.

Second visit (3 June 2015)Isolation of the working site with cotton roll at the labial aspect was done before the temporary filling was removed. Working length was determined by using apex locator, which is 25mm. Copious irrigation was carried out using sodium hypochlorite solution. The coronal two-thirds of the canal was explore with No. 10 and 15 k-files, using a reciprocating back and forth motion. The instruments were worked passively and progressively until they were loose. Then, cleaning and shaping of the root canal were continued with a crown-down technique using protaper .When a smooth glide path to the terminus is verified, sequentially carry first SX then S1, S2, F1, and F2 to the full working length. The operator irrigates, recapitulate and re-irrigate after each protaper instrument. After finishing the mechanical preparation and rinsing, the root canal was dried with paper points. The cavity was covered with cotton pellet with calcium hydroxide and temporary filling, and patient was sent back.

Third visit (12 June 2015)Objective test, including percussion and pressure test were found to be negative. Isolation of the working site with cotton roll at the labial aspect was done before the temporary filling was removed. Then, sterilization state was reconfirmed by evaluating the cotton pellet based on the states of smell and color; and dryness of calcium hydroxide. When the tooth was confirmed asymptomatic and before a final obturation was done, a trial obturation was done using the right sized of gutta percha cone in accordance to F2 then reconfirmation with periapical radiograph, which shown the gutta percha has reached the optimum working length. Proper isolation of the working site with cotton roll at the labial aspect in the aid of saliva suction, the root canal was profusely irrigated with sodium hypochlorite. Before the gutta percha cone was inserted, sterile paper points were used to dry the root canal. The obturation was done with single cone technique and sealer endomethasone. The gutta percha was cut at the orifice level with heated straight explorer before the glass ionomer layer were applied. Cavity was covered with temporary filling. A periapical radiograph was taken to evaluate the obturation is hermetic and has reached the full length of working length.Fourth visit (18 June 2015)A periapical radiograph was taken in order to confirm if there was no complication to the periodontal tissues. When the patient returned to the clinic after a week, he was asked if there was any complaint. Control of the obturation was done, subjective and objective test were done, according to the percussion and pressure test. All tests were negative upon, and the pericapical radiograph showed well adaptation of the gutta percha. The tooth was followed with pro-post and core treatment in prosthodontic department.

Figure 3.1 (Left) Clinical findings of the patient. (Right) Radiograph photo of tooth 11.

Figure 3.2 Extirpation of the pulp.

Figure 3.3 Trial photo.

Figure 3.4 Endomethasone powder and Eugenol liquid.

Figure 3.5 Radiograph photo after obturation with gutta-percha and endomethasone, and covered with glass ionomer layer.

Figure 3.6 Radiograph photo after 1 week control.

CHAPTER IVDISCUSSION

The diagnosis of a tooth is most important in deciding the treatment plan of a tooth. In this case, a vital pulpectomy was decided in the initial stage in order to preserve the tooth. The cavity of the tooth was sufficiently deep from mesial and distal sides. The patient did not have much complaint except that food sometimes got stuck in the cavity of the tooth and there was spontaneous throbbing pain. All symptoms like spontaneous throbbing pain as if tooth is under constant pressure and patient is often awake at night due to pain indicated the late stage of irreversible pulpitis. In cases, of irreversible pulpitis, it is impossible to maintain the vitality of the pulpal tissues. At this stage of the inflammatory process, vital extirpation of the pulp is the treatment of choice. The proper diagnosis is most important in this case so that there would be no delay in the treatment of vital pulpectomy.The proper diagnosis is most important in this case so that there would be no delay in the treatment of vital pulpectomy. Episodes of short duration pain may be felt occasionally during earlier stages of dentin caries. These pains are due to stimulation of pulp tissue by movement of fluid through dentinal tubules that have been opened to the oral environment by cavitation. Once bacterial invasion of the dentin is close to the pulp, toxins and possibly even a few bacteria enter the pulp, resulting in inflammation of the pulpal tissues. Initial pulpal inflammation is thought to be evident clinically by production of sharp pains, with each pain lingering only a few seconds (10 or less) in response to a thermal stimulus. A short, painful response to cold suggests reversible pulpitis or pulpal hyperemia. Reversible pulpitis, as the name implies, is a limited inflammation of the pulp from which the tooth can recover if the caries producing the irritation is eliminated by timely operative treatment. When the pulp becomes more severely inflamed, a thermal stimulus will produce pain that continues after termination of the stimulus, typically longer than 10 seconds. This clinical pattern suggests irreversible pulpitis, when the pulp is unlikely to recover after removing the caries. Throbbing, continuous pain suggests partial or total pulp necrosis that is treated only by root canal therapy or extraction (Roberson et al., 2002).In this case, the patient present with multiple class III caries. This is due to malallignment of tooth that favors the accumulation of plaque. Furthermore the patient has a bad oral habit and does not use the aid of dental floss or interdental brush. Tooth 12, 21 and 22 are pulpitis reversible that will be treated with class III composite filling. Tooth 11 is diagnosed with irreversible pulpitis. The transition from reversible into irreversible pulpitis is indistinct and the definitive diagnosis is often very difficult. With reversible pulpitis, the caries has not yet opened into the pulp. The dentists reaction to the definitive diagnosis must be to pursue a goal of maintaining the tooths vitality while simultaneously eliminating the patients pain (Beer, 2008). Vital pulpectomy is the removal or extirpation of the vital pulp to or near the apical foramen (Ingle and Bakland, 2002). According to Ingle and Bakland (2002), and Salman and Ahmed (2006), a vital pulpectomy is indicated in cases with strategically located tooth with accessible canals and essentially normal supporting bone. However, it is contra-indicated in cases with non-restorable tooth, internal / external resorption, teeth without accessible canals, and significant bone loss. In this case, vital pulpectomy is considered the choice of treatment because there are clinical signs indicating irreversible inflammatory changes in the pulp, and also radiograph that shows no internal / external root resorption and a strategically located tooth with an accessible canal and sufficient supporting bone.According to Edionwe, et al. (2014), it was observed that teeth with single canal showed the least tendency for post-operative pain followed by teeth with two canals and then three canals. Teeth with four canals had the highest tendency to develop postoperative pain. Anterior teeth had the highest success rate at 6 months review of 100%, while that of premolars and molars were 85.7 and 91.7%, respectively. This may due to the predictable canal anatomy in incisors.Furthermore, single canal being larger in size, in location easier to access and clean. In this case, the author assume the prognosis is excellent due to studies which show the success rate for teeth with pre-operative diagnosis of irreversible pulpitis was found to be 100%. (Edionwe, et al., 2014) From a biological point of view, the treatment of a tooth by pulpectomy is simple. It is the technique to gain access to the root canals. The pulp tissue is removed and the root canal is filled with a material or materials that are biocompatible and provide a long-lasting, bacteria-tight seal of the canal. If this is achieved, the tooth will remain healthy and functional. Thus, a pulpectomy may be carried out in all teeth with vital pulps, and the only limitations of the method would be possible practical ones like an unusually complicated morphology of a tooth. Considering the complexity of the root canal system, pulpectomy treatment is amazingly successful, and a success rate of 9095 % is within reach when optimal methods are used. (Tronstad, 2003)Pre-treatment factors presented in the literature that may influence the prognosis of endodontic therapy include: age, gender, general health, tooth location, pulp status, symptoms, size of the lesion, and periodontal conditions. However, only the presence of apical periodontitis has been demonstrated to influence the treatment outcome, leading to a 10 25% lower success rate than if it were not present pre-operatively. Despite the result of previous study, Edionwe, et al. (2014) reported that there was no statistical significance between the outcomes of treatment after review with age or sex or pre-operative symptoms. Therefore, it can be said to be a viable option for patients, irrespective of age, sex, or pre-operative symptoms (pain, tenderness to percussion, and periapical radiolucency). In this case, there was no periapical lesion upon the treatment. Taking account that patient is a general healthy with no medical compromise young 22-year-old man, and willing to give his compliances and cooperate throughout the procedure, vital pulpectomy was chosen as the treatment. In this case, several intracanal medicaments were used, including essential oil (eugenol) and calcium hydroxide. Eugenol was applied into the root canal using paper point after the extirpation of pulpal tissues due to its strong bactericidal, disinfecting and desensitizing effect (Gunnar, et al., 2010; Ray, et al., 2009). Calcium hydroxide was later applied after cleaning and shaping the root canal. Calcium hydroxide is used in both the preservation of the vital pulp and the disinfection of the prepared root canal system. It is suggested that calcium hydroxide arrests inflammatory root resorption and stimulation of healing.It also has a bactericidal effect and will denature proteins found in the root canal, thereby making them less toxic. Because of the high pH of the material, up to 12.5, a superficial layer of necrosis occurs in the pulp to a depth of up to 2 mm.Finally, calcium ions are an integral part of the immunological reaction and may activate the calcium-dependent adenosine triphosphatase reaction associated with hard tissue formation (Carrotte, 2004).The irrigant in this case was the golden standard irrigant, sodium hypochlorite (NaOCl), which is still the most popular intracanal irrigating solution currently in use. It is both antimicrobial and able to break down tissue, which is useful in vital cases. Unlike sodium hypochlorite, the extrusion of iodine and chlorhexidine is thought to be more forgiving to the soft tissues as they do not dissolve organic tissues. When hypochlorous acid, a substance present in NaOCl solution, comes in contact with organic tissue it acts as a solvent and releases chlorine, which combines with the protein amino group to form chloramines. The chloramination reaction between chlorine and the amino group (NH) forms chloramines that interfere in cell metabolism. Chlorine (a strong oxidant) has an antimicrobial action, inhibiting bacterial enzymes and leading to an irreversible oxidation of SH groups (sulphydryl group) of essential bacterial enzymes. Thus, the saponification, amino acid neutralization, and chloramination reactions that occur in the presence of microorganisms and organic tissue lead to the antimicrobial effect and tissue dissolution process. (McCabe and Walls, 2008)Based on this theory, the author used sodium hypochloride as the irrigant medium in this case. Canal was cleaned to at least to the estimated working length obtained from apex locator. The root canal was then prepared employing the crown down technique using protaper to create a funnel shape. At the post-obturation review appointment, patient was reviewed for pain, swelling, mobility, tenderness to percussion, and periapical radiolucency. No complaint was reviewed, and patient was satisfied with the treatment outcome. The tooth was followed with pro-post and core treatment in prosthodontics department.

CHAPTER VCONCLUSION

In this case, the patient present with multiple class III caries. The patient was given oral health education and oral hygiene instruction to brush the teeth with a rolling method to prevent interdental plaque accumulation. He is also advice to use the aid of dental floss or interproximal brush to maintain clean interproximal areas and to prevent further caries. Tooth 11 is diagnosed with irreversible pulpitis and was successfully treated with vital pulpectomy.

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