1

Non-

Pharmacological

Behaviour

Management

DR MITAKSHARA NIRWAN

ldquoAlthough the operative

dentistry may be perfect but

appointment is a failure if the

child departs in tearsrdquo

- Mc Elory (1895)

Behavior Behaviour is an Observable act which can be described in similar ways by more than one person It is defined as any change observed in the functioning of an organism

Behavior management The means by which the dental health team effectively amp efficiently performs dental treatment amp simultaneously instills a positive dental attitude in the child (Wright1975)

Behavior modification Defined as the attempt to alter human behavior amp emotion in beneficial way amp in accordance with laws of learning

Behavior shaping Is the procedure which slowly develops behavior by reinforcing a successive approximation of the desired behavior until the desired behavior comes in to being

BEHAVIORAL PATTERNS IN

CHILDREN

According to age

bull Pre-cooperative stage ndash less than 2 years bull Cooperative stage- above 2 years

Clinical classification of behaviour patterns

2

bull Cooperative bull Lacking cooperative ability bull Potentially cooperative

Lampshirersquos Classification

Pinkhamrsquos Classification

2

I Co-operative behavior (+ve)

1) Cooperative behaviour

2) Lacking co-operative

ability

3) Potentially cooperative

behavior

Wright Classification

II Uncooperative behaviour (-ve)

1Uncontrolled

behaviorhystericalincorrigible

2Defiant behaviorobstinate

3Timid behavior

4Tense cooperative

5Whining behavior

6Stoic behavior

Wilson classification

Normalbold

Tasteful timid

Hysterical rebellious

Nervous fearful

Factors affecting behavior of children

Wright summarized the following factors bull Medical history bull Maternal anxiety

bull Family and peer influence

bull Dental office environment

bull Growth and development

bull Personal factors

bull Environmental factors

bull Other variables

Role of Dentist in childrsquos behavior

Appearance of dental office Personality of dentist

Time and length of appointment

Maternal influence on Childrsquos Behaviour

Motherrsquos behavior Childrsquos behavior

1 Over protective

a Dominant

b Overindulgent

Submissive shy

anxious aggressive demanding

2 Overindulgent Aggressive spoiled demanding displays temper

3 Under affectionate Usually well behaved but may be unable to

cooperate shy may cry easily

4 Rejecting Aggressive overactive disobedient

5 Authoritarian

6 Identification

Evasive amp dawdling

Cries easily lacks confidence

Behaviour Mangement

Fundamentals of behaviour management

Positive approach

Team attitude

Truthfulness

Organization

Tolerance

Flexiblity

3

Classification of behavior management

Management

Psychological Pharmacological Psychological

Communication

Behavior shaping

Behavior Management

Behavior shaping

Desensitization

Modeling

Contingency management

Disruptive

Voice control

Aversive

HOME

Physical Restraints

Others

Distraction

Audio Analgesia

Bio feed back

Hypnosis

Humor

Coping

Relaxation

COMMUNICATION

communication

Verbal

speech

Non-verbal

Body language

smiling

Eye contact Showing concern

By Touching

Give him a pat

Giving him hug

Expression of feeling

Both

DENTAL TERMINOLOGY WORD SUBSTITUTE

Rubber dam Rain coat

Rubber dam clamp Tooth button

R D frame Coat rack

Sealant Tooth paint

Topical fluoride gel Cavity fighter

Air syringe Wind gun

Suction Vacuum cleaner

Study models Statues

Alginate Pudding

High speeds Whistle

Low speeds Motor cycle

Euphemism Tell Show Do Technique (TSD)

Cornerstone of behaviour management

Given by Addleston in 1959

Objectives

1 Teach the patient imp aspects of the

dental visit amp familiarize the patient with

the dental setting

2 Shape the patientrsquos response to

procedures

through desensitization amp well described

expectations

4

Alternatives to TSD

Tell Play Do

Tell Show Play Doh

Tell Play Do with

Smart Phone Dentist

Game Ask Tell Ask

DESENSITIZATION

Demonstrated by James popularized by Wolpe

Desensitization is a therapeutic technique that pairs an

anxiety- evoking stimulus with a response inhibitory to

anxiety In each situations the percieved link between the

stimulus and the anxiety response is weakened

Involves 3 Stages

1Training the patient to relax

2Constructing a hierarchy of fear

3Introducing each stimulus in the

hierarchy

Modeling

Giver by Bandura (1967) Allowing a pt to observe 1more individual

who demonstrate appropriate behavior in particular situation

Steps in modeling Pt attention obtained Desired behavior is modeled Physical guidance of desired behavior Reinforcement of the guided behavior may be provided Reinforcement of behavior that did not require guidance Reinforcement for appropriate behavior initiated without modeling

Types 1 Live model 2 Symbolic or vicarious model

CONTINGENCY MANAGEMENT

Is a method of modifying the behavior of children by

presentation or withdrawal of reinforcers

Positive reinforcer

Henry W Fields 1984

Contingent presentation

Increases frequency of

behavior

Negative reinforcer

Stokes amp Kennedy1980

Contingent withdrawal

Increases the frequency of

behavior

Material

bull Candies

bull Gums

bull Cookies

bull Toys

Social

bull Praise

bull Facial expressions

bull Nearness

bull Physical contact

Activity

bull TV

bull Camping outdoor

bull Music

Reinforcers

Coping

Defined as the cognitive amp behavioral efforts made by an individual to master tolerate or reduce stressful situations

2types

a) Behavioral physical amp verbal activities

b) Cognitive silent amp thinking in mind to keep calm

It enables

ndash reality-oriented working

- cognitive reappraisal

- emotion cognitions

5

Distraction

Distraction is a tactic designed to divert a patient attention away from their current behavior to focus their interest in something else Types Audio Distraction Audiovisual Distraction

Relaxation

Effective in reducing immediate anxiety and fear

Involves series of basic exercises which may take several months to learn amp practice

Voice control

Given by Pinkham in 1985

Modification of the timbre intensity and pitch of ones voice in an attempt

to dominate the interaction between dentist and child

Objectives

bull To gain the patient attention and

compliance

bull To avoid negative or avoidance

behavior

bull To establish authority

Indications bull Uncoperative and inattentive

patients

Contraindications bull Children who due to age

disability mental or emotional immaturity are unable to understand

Hypnosis

First suggested by Franz A Mesmer in

1773

Altered state of consciousness

characterized by heightened suggestibility

to produce desirable behavioral and

physiological changes

Most effective in the presence of anxiety

Not all patients can be hypnotized

Basic mechanism - relief of pain through

suggestions of relief given in a close

trusting interpersonal situation

Henon outlined following uses

bull To reduce nervousness and

apprehension

bull To eliminate defence mechanisms

that patient use to postpone dental

work

bull To control functional or

psychosomatic grapping

bull To prevent thumb sucking and

bruxism

bull To induce anesthesia

Hand over Mouth Exercise (HOME)

Given by DR EVANGELINE JORDAN (1920)

Evangeline Jordan - If a normal child will not listen but continues to cry

and strugglehellip Hold a folded napkin over the childrsquos mouthhellipand

gently but firmly hold his mouth shut

Other terminologies bull Aversive Conditioning by Lenchner and Wright bull Emotional surprise therapy by Lampshire bull HOM airway restricted (HOMAR) by Levitas (1947) bull Aversion by Crammer (1973)

Children who are

momentarily hysterical

belligerent or defiant

3-6 yrs old

Child who can understands

simple verbal commands

Indications

Contraindications

Very young immature frightened child with serious physical mental or emotional handicap

6

Variationshellip Hand over mouth with airway restricted Towel over mouth

Towel over mouth with airway restricted

Body

Papoose board

Triangular sheet

Pedi wrap

Bean Bag

Safety belt

Extremities

Posey straps

Velco straps

Towel amp Tape

Head

Forearm support

Plastic bowl

Head positioner

Mouth

Tongue blades

Mouth Prop

Bite blocks

Positive Stabilization Mouth

Tongue blade open mouth wide prop Molt mouth prop

Rubber bite blocks

Extremities

Posey Strap

Head

Body

Papoose board

Pedi-wrap

7

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

2

I Co-operative behavior (+ve)

1) Cooperative behaviour

2) Lacking co-operative

ability

3) Potentially cooperative

behavior

Wright Classification

II Uncooperative behaviour (-ve)

1Uncontrolled

behaviorhystericalincorrigible

2Defiant behaviorobstinate

3Timid behavior

4Tense cooperative

5Whining behavior

6Stoic behavior

Wilson classification

Normalbold

Tasteful timid

Hysterical rebellious

Nervous fearful

Factors affecting behavior of children

Wright summarized the following factors bull Medical history bull Maternal anxiety

bull Family and peer influence

bull Dental office environment

bull Growth and development

bull Personal factors

bull Environmental factors

bull Other variables

Role of Dentist in childrsquos behavior

Appearance of dental office Personality of dentist

Time and length of appointment

Maternal influence on Childrsquos Behaviour

Motherrsquos behavior Childrsquos behavior

1 Over protective

a Dominant

b Overindulgent

Submissive shy

anxious aggressive demanding

2 Overindulgent Aggressive spoiled demanding displays temper

3 Under affectionate Usually well behaved but may be unable to

cooperate shy may cry easily

4 Rejecting Aggressive overactive disobedient

5 Authoritarian

6 Identification

Evasive amp dawdling

Cries easily lacks confidence

Behaviour Mangement

Fundamentals of behaviour management

Positive approach

Team attitude

Truthfulness

Organization

Tolerance

Flexiblity

3

Classification of behavior management

Management

Psychological Pharmacological Psychological

Communication

Behavior shaping

Behavior Management

Behavior shaping

Desensitization

Modeling

Contingency management

Disruptive

Voice control

Aversive

HOME

Physical Restraints

Others

Distraction

Audio Analgesia

Bio feed back

Hypnosis

Humor

Coping

Relaxation

COMMUNICATION

communication

Verbal

speech

Non-verbal

Body language

smiling

Eye contact Showing concern

By Touching

Give him a pat

Giving him hug

Expression of feeling

Both

DENTAL TERMINOLOGY WORD SUBSTITUTE

Rubber dam Rain coat

Rubber dam clamp Tooth button

R D frame Coat rack

Sealant Tooth paint

Topical fluoride gel Cavity fighter

Air syringe Wind gun

Suction Vacuum cleaner

Study models Statues

Alginate Pudding

High speeds Whistle

Low speeds Motor cycle

Euphemism Tell Show Do Technique (TSD)

Cornerstone of behaviour management

Given by Addleston in 1959

Objectives

1 Teach the patient imp aspects of the

dental visit amp familiarize the patient with

the dental setting

2 Shape the patientrsquos response to

procedures

through desensitization amp well described

expectations

4

Alternatives to TSD

Tell Play Do

Tell Show Play Doh

Tell Play Do with

Smart Phone Dentist

Game Ask Tell Ask

DESENSITIZATION

Demonstrated by James popularized by Wolpe

Desensitization is a therapeutic technique that pairs an

anxiety- evoking stimulus with a response inhibitory to

anxiety In each situations the percieved link between the

stimulus and the anxiety response is weakened

Involves 3 Stages

1Training the patient to relax

2Constructing a hierarchy of fear

3Introducing each stimulus in the

hierarchy

Modeling

Giver by Bandura (1967) Allowing a pt to observe 1more individual

who demonstrate appropriate behavior in particular situation

Steps in modeling Pt attention obtained Desired behavior is modeled Physical guidance of desired behavior Reinforcement of the guided behavior may be provided Reinforcement of behavior that did not require guidance Reinforcement for appropriate behavior initiated without modeling

Types 1 Live model 2 Symbolic or vicarious model

CONTINGENCY MANAGEMENT

Is a method of modifying the behavior of children by

presentation or withdrawal of reinforcers

Positive reinforcer

Henry W Fields 1984

Contingent presentation

Increases frequency of

behavior

Negative reinforcer

Stokes amp Kennedy1980

Contingent withdrawal

Increases the frequency of

behavior

Material

bull Candies

bull Gums

bull Cookies

bull Toys

Social

bull Praise

bull Facial expressions

bull Nearness

bull Physical contact

Activity

bull TV

bull Camping outdoor

bull Music

Reinforcers

Coping

Defined as the cognitive amp behavioral efforts made by an individual to master tolerate or reduce stressful situations

2types

a) Behavioral physical amp verbal activities

b) Cognitive silent amp thinking in mind to keep calm

It enables

ndash reality-oriented working

- cognitive reappraisal

- emotion cognitions

5

Distraction

Distraction is a tactic designed to divert a patient attention away from their current behavior to focus their interest in something else Types Audio Distraction Audiovisual Distraction

Relaxation

Effective in reducing immediate anxiety and fear

Involves series of basic exercises which may take several months to learn amp practice

Voice control

Given by Pinkham in 1985

Modification of the timbre intensity and pitch of ones voice in an attempt

to dominate the interaction between dentist and child

Objectives

bull To gain the patient attention and

compliance

bull To avoid negative or avoidance

behavior

bull To establish authority

Indications bull Uncoperative and inattentive

patients

Contraindications bull Children who due to age

disability mental or emotional immaturity are unable to understand

Hypnosis

First suggested by Franz A Mesmer in

1773

Altered state of consciousness

characterized by heightened suggestibility

to produce desirable behavioral and

physiological changes

Most effective in the presence of anxiety

Not all patients can be hypnotized

Basic mechanism - relief of pain through

suggestions of relief given in a close

trusting interpersonal situation

Henon outlined following uses

bull To reduce nervousness and

apprehension

bull To eliminate defence mechanisms

that patient use to postpone dental

work

bull To control functional or

psychosomatic grapping

bull To prevent thumb sucking and

bruxism

bull To induce anesthesia

Hand over Mouth Exercise (HOME)

Given by DR EVANGELINE JORDAN (1920)

Evangeline Jordan - If a normal child will not listen but continues to cry

and strugglehellip Hold a folded napkin over the childrsquos mouthhellipand

gently but firmly hold his mouth shut

Other terminologies bull Aversive Conditioning by Lenchner and Wright bull Emotional surprise therapy by Lampshire bull HOM airway restricted (HOMAR) by Levitas (1947) bull Aversion by Crammer (1973)

Children who are

momentarily hysterical

belligerent or defiant

3-6 yrs old

Child who can understands

simple verbal commands

Indications

Contraindications

Very young immature frightened child with serious physical mental or emotional handicap

6

Variationshellip Hand over mouth with airway restricted Towel over mouth

Towel over mouth with airway restricted

Body

Papoose board

Triangular sheet

Pedi wrap

Bean Bag

Safety belt

Extremities

Posey straps

Velco straps

Towel amp Tape

Head

Forearm support

Plastic bowl

Head positioner

Mouth

Tongue blades

Mouth Prop

Bite blocks

Positive Stabilization Mouth

Tongue blade open mouth wide prop Molt mouth prop

Rubber bite blocks

Extremities

Posey Strap

Head

Body

Papoose board

Pedi-wrap

7

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

3

Classification of behavior management

Management

Psychological Pharmacological Psychological

Communication

Behavior shaping

Behavior Management

Behavior shaping

Desensitization

Modeling

Contingency management

Disruptive

Voice control

Aversive

HOME

Physical Restraints

Others

Distraction

Audio Analgesia

Bio feed back

Hypnosis

Humor

Coping

Relaxation

COMMUNICATION

communication

Verbal

speech

Non-verbal

Body language

smiling

Eye contact Showing concern

By Touching

Give him a pat

Giving him hug

Expression of feeling

Both

DENTAL TERMINOLOGY WORD SUBSTITUTE

Rubber dam Rain coat

Rubber dam clamp Tooth button

R D frame Coat rack

Sealant Tooth paint

Topical fluoride gel Cavity fighter

Air syringe Wind gun

Suction Vacuum cleaner

Study models Statues

Alginate Pudding

High speeds Whistle

Low speeds Motor cycle

Euphemism Tell Show Do Technique (TSD)

Cornerstone of behaviour management

Given by Addleston in 1959

Objectives

1 Teach the patient imp aspects of the

dental visit amp familiarize the patient with

the dental setting

2 Shape the patientrsquos response to

procedures

through desensitization amp well described

expectations

4

Alternatives to TSD

Tell Play Do

Tell Show Play Doh

Tell Play Do with

Smart Phone Dentist

Game Ask Tell Ask

DESENSITIZATION

Demonstrated by James popularized by Wolpe

Desensitization is a therapeutic technique that pairs an

anxiety- evoking stimulus with a response inhibitory to

anxiety In each situations the percieved link between the

stimulus and the anxiety response is weakened

Involves 3 Stages

1Training the patient to relax

2Constructing a hierarchy of fear

3Introducing each stimulus in the

hierarchy

Modeling

Giver by Bandura (1967) Allowing a pt to observe 1more individual

who demonstrate appropriate behavior in particular situation

Steps in modeling Pt attention obtained Desired behavior is modeled Physical guidance of desired behavior Reinforcement of the guided behavior may be provided Reinforcement of behavior that did not require guidance Reinforcement for appropriate behavior initiated without modeling

Types 1 Live model 2 Symbolic or vicarious model

CONTINGENCY MANAGEMENT

Is a method of modifying the behavior of children by

presentation or withdrawal of reinforcers

Positive reinforcer

Henry W Fields 1984

Contingent presentation

Increases frequency of

behavior

Negative reinforcer

Stokes amp Kennedy1980

Contingent withdrawal

Increases the frequency of

behavior

Material

bull Candies

bull Gums

bull Cookies

bull Toys

Social

bull Praise

bull Facial expressions

bull Nearness

bull Physical contact

Activity

bull TV

bull Camping outdoor

bull Music

Reinforcers

Coping

Defined as the cognitive amp behavioral efforts made by an individual to master tolerate or reduce stressful situations

2types

a) Behavioral physical amp verbal activities

b) Cognitive silent amp thinking in mind to keep calm

It enables

ndash reality-oriented working

- cognitive reappraisal

- emotion cognitions

5

Distraction

Distraction is a tactic designed to divert a patient attention away from their current behavior to focus their interest in something else Types Audio Distraction Audiovisual Distraction

Relaxation

Effective in reducing immediate anxiety and fear

Involves series of basic exercises which may take several months to learn amp practice

Voice control

Given by Pinkham in 1985

Modification of the timbre intensity and pitch of ones voice in an attempt

to dominate the interaction between dentist and child

Objectives

bull To gain the patient attention and

compliance

bull To avoid negative or avoidance

behavior

bull To establish authority

Indications bull Uncoperative and inattentive

patients

Contraindications bull Children who due to age

disability mental or emotional immaturity are unable to understand

Hypnosis

First suggested by Franz A Mesmer in

1773

Altered state of consciousness

characterized by heightened suggestibility

to produce desirable behavioral and

physiological changes

Most effective in the presence of anxiety

Not all patients can be hypnotized

Basic mechanism - relief of pain through

suggestions of relief given in a close

trusting interpersonal situation

Henon outlined following uses

bull To reduce nervousness and

apprehension

bull To eliminate defence mechanisms

that patient use to postpone dental

work

bull To control functional or

psychosomatic grapping

bull To prevent thumb sucking and

bruxism

bull To induce anesthesia

Hand over Mouth Exercise (HOME)

Given by DR EVANGELINE JORDAN (1920)

Evangeline Jordan - If a normal child will not listen but continues to cry

and strugglehellip Hold a folded napkin over the childrsquos mouthhellipand

gently but firmly hold his mouth shut

Other terminologies bull Aversive Conditioning by Lenchner and Wright bull Emotional surprise therapy by Lampshire bull HOM airway restricted (HOMAR) by Levitas (1947) bull Aversion by Crammer (1973)

Children who are

momentarily hysterical

belligerent or defiant

3-6 yrs old

Child who can understands

simple verbal commands

Indications

Contraindications

Very young immature frightened child with serious physical mental or emotional handicap

6

Variationshellip Hand over mouth with airway restricted Towel over mouth

Towel over mouth with airway restricted

Body

Papoose board

Triangular sheet

Pedi wrap

Bean Bag

Safety belt

Extremities

Posey straps

Velco straps

Towel amp Tape

Head

Forearm support

Plastic bowl

Head positioner

Mouth

Tongue blades

Mouth Prop

Bite blocks

Positive Stabilization Mouth

Tongue blade open mouth wide prop Molt mouth prop

Rubber bite blocks

Extremities

Posey Strap

Head

Body

Papoose board

Pedi-wrap

7

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

4

Alternatives to TSD

Tell Play Do

Tell Show Play Doh

Tell Play Do with

Smart Phone Dentist

Game Ask Tell Ask

DESENSITIZATION

Demonstrated by James popularized by Wolpe

Desensitization is a therapeutic technique that pairs an

anxiety- evoking stimulus with a response inhibitory to

anxiety In each situations the percieved link between the

stimulus and the anxiety response is weakened

Involves 3 Stages

1Training the patient to relax

2Constructing a hierarchy of fear

3Introducing each stimulus in the

hierarchy

Modeling

Giver by Bandura (1967) Allowing a pt to observe 1more individual

who demonstrate appropriate behavior in particular situation

Steps in modeling Pt attention obtained Desired behavior is modeled Physical guidance of desired behavior Reinforcement of the guided behavior may be provided Reinforcement of behavior that did not require guidance Reinforcement for appropriate behavior initiated without modeling

Types 1 Live model 2 Symbolic or vicarious model

CONTINGENCY MANAGEMENT

Is a method of modifying the behavior of children by

presentation or withdrawal of reinforcers

Positive reinforcer

Henry W Fields 1984

Contingent presentation

Increases frequency of

behavior

Negative reinforcer

Stokes amp Kennedy1980

Contingent withdrawal

Increases the frequency of

behavior

Material

bull Candies

bull Gums

bull Cookies

bull Toys

Social

bull Praise

bull Facial expressions

bull Nearness

bull Physical contact

Activity

bull TV

bull Camping outdoor

bull Music

Reinforcers

Coping

Defined as the cognitive amp behavioral efforts made by an individual to master tolerate or reduce stressful situations

2types

a) Behavioral physical amp verbal activities

b) Cognitive silent amp thinking in mind to keep calm

It enables

ndash reality-oriented working

- cognitive reappraisal

- emotion cognitions

5

Distraction

Distraction is a tactic designed to divert a patient attention away from their current behavior to focus their interest in something else Types Audio Distraction Audiovisual Distraction

Relaxation

Effective in reducing immediate anxiety and fear

Involves series of basic exercises which may take several months to learn amp practice

Voice control

Given by Pinkham in 1985

Modification of the timbre intensity and pitch of ones voice in an attempt

to dominate the interaction between dentist and child

Objectives

bull To gain the patient attention and

compliance

bull To avoid negative or avoidance

behavior

bull To establish authority

Indications bull Uncoperative and inattentive

patients

Contraindications bull Children who due to age

disability mental or emotional immaturity are unable to understand

Hypnosis

First suggested by Franz A Mesmer in

1773

Altered state of consciousness

characterized by heightened suggestibility

to produce desirable behavioral and

physiological changes

Most effective in the presence of anxiety

Not all patients can be hypnotized

Basic mechanism - relief of pain through

suggestions of relief given in a close

trusting interpersonal situation

Henon outlined following uses

bull To reduce nervousness and

apprehension

bull To eliminate defence mechanisms

that patient use to postpone dental

work

bull To control functional or

psychosomatic grapping

bull To prevent thumb sucking and

bruxism

bull To induce anesthesia

Hand over Mouth Exercise (HOME)

Given by DR EVANGELINE JORDAN (1920)

Evangeline Jordan - If a normal child will not listen but continues to cry

and strugglehellip Hold a folded napkin over the childrsquos mouthhellipand

gently but firmly hold his mouth shut

Other terminologies bull Aversive Conditioning by Lenchner and Wright bull Emotional surprise therapy by Lampshire bull HOM airway restricted (HOMAR) by Levitas (1947) bull Aversion by Crammer (1973)

Children who are

momentarily hysterical

belligerent or defiant

3-6 yrs old

Child who can understands

simple verbal commands

Indications

Contraindications

Very young immature frightened child with serious physical mental or emotional handicap

6

Variationshellip Hand over mouth with airway restricted Towel over mouth

Towel over mouth with airway restricted

Body

Papoose board

Triangular sheet

Pedi wrap

Bean Bag

Safety belt

Extremities

Posey straps

Velco straps

Towel amp Tape

Head

Forearm support

Plastic bowl

Head positioner

Mouth

Tongue blades

Mouth Prop

Bite blocks

Positive Stabilization Mouth

Tongue blade open mouth wide prop Molt mouth prop

Rubber bite blocks

Extremities

Posey Strap

Head

Body

Papoose board

Pedi-wrap

7

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

5

Distraction

Distraction is a tactic designed to divert a patient attention away from their current behavior to focus their interest in something else Types Audio Distraction Audiovisual Distraction

Relaxation

Effective in reducing immediate anxiety and fear

Involves series of basic exercises which may take several months to learn amp practice

Voice control

Given by Pinkham in 1985

Modification of the timbre intensity and pitch of ones voice in an attempt

to dominate the interaction between dentist and child

Objectives

bull To gain the patient attention and

compliance

bull To avoid negative or avoidance

behavior

bull To establish authority

Indications bull Uncoperative and inattentive

patients

Contraindications bull Children who due to age

disability mental or emotional immaturity are unable to understand

Hypnosis

First suggested by Franz A Mesmer in

1773

Altered state of consciousness

characterized by heightened suggestibility

to produce desirable behavioral and

physiological changes

Most effective in the presence of anxiety

Not all patients can be hypnotized

Basic mechanism - relief of pain through

suggestions of relief given in a close

trusting interpersonal situation

Henon outlined following uses

bull To reduce nervousness and

apprehension

bull To eliminate defence mechanisms

that patient use to postpone dental

work

bull To control functional or

psychosomatic grapping

bull To prevent thumb sucking and

bruxism

bull To induce anesthesia

Hand over Mouth Exercise (HOME)

Given by DR EVANGELINE JORDAN (1920)

Evangeline Jordan - If a normal child will not listen but continues to cry

and strugglehellip Hold a folded napkin over the childrsquos mouthhellipand

gently but firmly hold his mouth shut

Other terminologies bull Aversive Conditioning by Lenchner and Wright bull Emotional surprise therapy by Lampshire bull HOM airway restricted (HOMAR) by Levitas (1947) bull Aversion by Crammer (1973)

Children who are

momentarily hysterical

belligerent or defiant

3-6 yrs old

Child who can understands

simple verbal commands

Indications

Contraindications

Very young immature frightened child with serious physical mental or emotional handicap

6

Variationshellip Hand over mouth with airway restricted Towel over mouth

Towel over mouth with airway restricted

Body

Papoose board

Triangular sheet

Pedi wrap

Bean Bag

Safety belt

Extremities

Posey straps

Velco straps

Towel amp Tape

Head

Forearm support

Plastic bowl

Head positioner

Mouth

Tongue blades

Mouth Prop

Bite blocks

Positive Stabilization Mouth

Tongue blade open mouth wide prop Molt mouth prop

Rubber bite blocks

Extremities

Posey Strap

Head

Body

Papoose board

Pedi-wrap

7

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

6

Variationshellip Hand over mouth with airway restricted Towel over mouth

Towel over mouth with airway restricted

Body

Papoose board

Triangular sheet

Pedi wrap

Bean Bag

Safety belt

Extremities

Posey straps

Velco straps

Towel amp Tape

Head

Forearm support

Plastic bowl

Head positioner

Mouth

Tongue blades

Mouth Prop

Bite blocks

Positive Stabilization Mouth

Tongue blade open mouth wide prop Molt mouth prop

Rubber bite blocks

Extremities

Posey Strap

Head

Body

Papoose board

Pedi-wrap

7

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

7

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

1

Impact of Handheld Devices on

Children An Evaluation of Usage amp

Dependency Behaviour

0092

DR MITAKSHARA NIRWAN

Handheld devices

A handheld device is a pocket size

computing device with a display

screen and inputoutput interface like

an external or touchscreen keyboard

For example- smartphones tablet

computers handheld videogame

consoles

Haruki Murakami

ldquoCell Phones are so

convenient that they have

become an inconveniencerdquo

Introduction

The most famouscommonly used and easily accessible type of gadgets are

lsquoHandheld devicesrsquo They are as popular in children as they are in adults

The access and ownership of these devices amongst children has grown

substantially in the past decade Concerns exist regarding excessive usage

and the impact of frequent consumption of mobile media on their health and

behaviour

Aims and Objective

This objective of this study was to asses the level of use of handheld

devices among children aged 0-12 years and their positive and negative

impacts on them It further describes the dependency of these devices

and the behavioral problems associated with it

Materials and Methods An online survey was conducted and a self administered questionnaire

was prepared specially for the parents which included a total of 15

questions regarding the usage and dependency of the device

A total of 100 responses were collected from parents who had children

aged 0-12 years who used these devices on daily basis

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

2

Level of Usage (Q 123)

Results Purpose (Q7)

Improved

communication and

learning

Using more than

one type of

device

Helped in

Speech

Positive Impacts -

(Q58 amp 9)

P value 0003(s) P value-0007 P value-0006(s)

Reduced parent-

child interaction Disrupted sleep Lack of motivation for academics

Negative Impacts (Q81213)

P value-0001(s) P value-0002(s) P value-0006

Time when children use

the device the most

Isolation of the

child Behavioral impact when gadget is

taken back

Dependency

Behaviour (Q10111415)

P value-002(s) P value 002(s) P value-044

This study was done to evaluate the level of usage of handheld devices and their impact

on the children aged 0-12 years The questionnaire was made such that it asked both the

positive and negative impact and further included the questions regarding the

dependency

784 children had access to smartphone and 17 used tablets

The most common age group in which the devices was used the most was 5-8 years

followed by 9-12 followed by 0-4 (Arlinda et al 2019 )

Another study done by (Rachel Bedford et al 2016) concluded increase usage of mobile

phones 5122 in 6ndash11 monthshy olds through to 9205 by 25ndash36 months

745used these devices several times a day out of which 539 used it for more than

one hourday 255 used it for less than one hour and 206 for more than 2 hours

Various studies follow the same recommendation given by AAP to limit the duration of

gadget amongst children

Discussion

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

3

Improve of Cognitive Skills

Amongst the positive impacts most parents have answered that the usage of these

devices has helped their child communicate and learn better and it has showed significant

results According to (Sundus M 2018)These devices improve the cognitive skills and

develop their learning skills fasterThe competition skills also get better It gives time for brain to think and process information better Another study which supports this (LF

Jonathan et al 2016)

Motor Physical Exercise

This study has shown that children like to use more than one type of device

sometimesUsing these devices improve fine motor skillshand eye coordination and

hands and fingers become more efficient (Srinahyanti et al 2019) (Sundus M 2018)

Speech Improvement

392 Parents say that maybe usage of the devices has helped improve speech in their

children but Various studies show otherwise as most of them shows that usage of handheld

devices causes delay of speech (Srinahyanti et al 2019)

Reduced parent child interaction

The negative impacts are more when compared to the positive ones Usage of gadgets

has resulted in reduced parent child interaction Less face to face interaction can

cause detachment from family members and value which in turn also causes isolation

of the child as he is more comfortable with the gadget (M Suhana-2017)

Sleep Disorders

This study shows that most parents have agreed that usage of these devices does

cause disruption of sleep Various studies have shown that children get fewer hours of

sleepdrowsiness during the day and dramatic increase in day time sleep because of

the screen usage (Acc to National Sleep Foundation) ( Cain N et al 2010)

In this study most number of parents have

agreed that their children might be dependent on

these devices and also had showed restless and

violent behavior if the gadget is snatched from

them

Most number of kids (667) are heavily

dependent as they like to use the device during

their meal time

Various other studies have assessed the screen

time dependency and have concluded that

various kids suffer from SDD

Conclusion The study conclusively shows that the impact of handheld devices is akin to the

importance of table salt in our meals most significant for our growth and

development in moderate amounts and hazardous in excess The negatives clearly

outweigh the positives with the latter too few and far in between This study also

points towards further extensive research on the subject because we need to find ways and also educate parents to optimise the role of these devices in their

childrenrsquos life taking advantage of their positive attributes and minimising their

negative ones

References 1Wahyuni AS Siahaan FB Arfa M Alona I Nerdy N The Relationship between the Duration of Playing

Gadget and Mental Emotional State of Elementary School Students Open Access Maced J Med Sci

20197(1)148ndash151

2Sundus M Department of Computer Science Lahore-The Impacts of using Gadgets on ChildrenJournal of Depression and Anxiety 2018vol 7(1)296

3Amawi SO Subki AH Khatib HA et al Use of Electronic Entertainment and Communication Devices Among

a Saudi Pediatric Population Cross-Sectional Study Interact J Med Res 20187(2)e13

4Julia ldquoHandheld Screen Time Linked with Speech Delays in Young Childrenrdquo Present Pediatric Acad Soc

Meet 2017

5C Rowan ldquoThe Impact of Technology on Child Sensory Motor Developmentrdquo 2003

6Impact of media use on children and youth Paediatr Child Health 20038(5)301ndash317

7Naik SV Children and their gadgets A pedodontist perspective Int J Oral Health Sci 2018857-8

8Roberts DF Foehr UG Rideout V Generation M Media in the lives of 8‐18 year‐olds A Kaiser Family

Foundation Study 2005

9Arya K Time spent on television viewing and its effect on changing values of school going children Anthropologist 20046269‐71

10 Lerner C Barr R Screen Sense Setting the Record StraightResearch‐Based Guidelines for Screen

Use for Children Under 3 Years Old Early learning project at Georgetown university 2014 p 1‐10

11SrinahyantiYasaratodo Wau Imelda Free Unita Manurung Nur Arjani-Influence of gadget A positive

and Negative Impact of Smartphone Usage for Early Child2019

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

4

THANK YOU

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

1

Morankar Rahul Aditi Kapur Krishan Gauba Ashima Goyal

MANAGEMENT OF ENDODONTIC INSTRUMENT SEPARATION IN

PRIMARY TEETH

CASE REPORT

Journal of South Asian Association of Pediatric Dentistry 2020

DR MITAKSHARA NIRWAN

bull Introduction

bull Aims amp Objectives

bull Case report

bull Discussion

bull Conclusion

bull Pros amp Cons

bull References

CONTENTS

Separation of endodontic instrument is an unexpected complication and its prevalence is not known It is a common belief among the dental professionals that rotary nickelndashtitanium (NiTi) instruments separate more frequently than stainless steel hand instruments

However literature revealed that in permanent teeth the reported prevalence of separated endodontics manual instruments is in the range of 07-74 whereas for rotary NiTI instruments it is

approximately 04-5

Fractured root canal instruments may include endodontic files Gates Glidden burs finger spreaders

and paste fillers

INTRODUCTION

The aim of this study is to describe the management strategies for endodontic

instrument separation in a root canal of primary teeth with emphasis on factors

requiring consideration in different clinical situations

AIMS amp OBJECTIVES

CASE 1

A 6-year-old male child reported with the chief complaint of spontaneous toothache in mandibular left second primary molar since few days It has aggravated following dental treatment at a private dental clinic Clinical examination revealed an underprepared access cavity with 75 and incomplete caries removal

which was sealed with glass ionomer cement

An intraoral periapical radiograph revealed a separated instrument of about 6ndash7 mm size in the distal root

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

2

The separated instrument was lodged firmly in distobuccal root canal 2ndash3 mm below the cementoenamel junction The instrument was bypassed successfully with no 15 and no 20 H-files but attempts for its retrieval were not successful

GatesndashGlidden (GG) drills no 2 (07 mm) and no 3 (09 mm) were used to drill around the instrument after which it was retrieved successfully using no 25 H-file

All the canals were instrumented till size 30 k-file followed by obturation with metapex and restoration with glass ionomer cement amp followed by placement of a crown and loop space maintainer for missing 74 The instrument retrieved was a manual reamer measuring 6 mm in length

The patient was asymptomatic since then and is under regular follow-up

CASE 2

A 5-year-old female child reported with the chief complaint of spontaneous toothache in mandibular left second

primary molar Clinical examination revealed deep occlusal caries with fractured lingual wall and pain on

percussion An intraoral periapical radiograph revealed caries involving pulp without any furcation or periapical

area of rarefaction and pulpectomy was planned

All the canals were enlarged using NiTi rotary files with a 4 taper operating at 500 rpm with minimum torque

setting An orifice opener [(0825 19 mm) of 8 taper size 25 length 19 mm] and nos 0420 file was used for

instrumentation of root canal This was followed by file nos 0425 which got separated in the distobuccal root

canal The radiograph confirmed a separated instrument of length 3ndash4 mm in the middle third of the root canal

The instrument was bypassed with no 15 k-file but could not get retrieved As instrument separation had occurred with 0425 file the involved root canal was sufficiently debrided before separation and the level of instrument separation was at the mid-root region so it was decided to obturate and seal this tooth with

periodic follow-ups instead of immediate extraction All other canals were enlarged till size 0430 in the sequential manner followed by obturation using metapex and placement of stainless steel crown

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

3

CASE 3

A 5-year-old female child has complaint of mild intermittent pain with primary mandibular left first molar She

had undergone pulpectomy treatment for the same during which an instrument separation has occurred in

the mesiobuccal root canal by a resident doctor

A radiograph revealed a separated instrument of about 4 mm in size lodged in the apical third but within the

confines of the mesial root An attempt was made for its retrieval but was unsuccessful The extraction of the

involved tooth was carried out under local anesthesia followed by a band and loop space maintainer

CASE 4

A 7-year-old male child reported with a chief complaint of mild intermittent pain on food lodgment with the primary mandibular right first and second molars The patient had a history of dental treatment at a private

dental clinic few months back which he did not continue further

Clinical examination revealed glass ionomer restoration with 85 and proximal caries with 84 leading to food lodgment An intraoral periapical radiograph with 85 revealed empty root canals with a separated

instrument of about 3ndash4 mm size beyond the apex of mesial root close to the developing succedaneous premolar

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

4

DISCUSSION

Stainless steel files usually separate fracture due to the excessive amounts of torque and overuse or the

preexisting distortion of the instrument whereas in NiTi rotary files it is a combined result of torsional stress and cyclic fatigue

Therapeutic options for the management of separated endodontic instruments include no intervention nonsurgical (orthograde conservative) management surgical management and tooth extraction

Use of ultrasonic scaler Masserann technique Endo extractor and Cavi-Endo ultrasonic instruments are some of the methods popular for retrieval of a separated endodontic instrument in the permanent tooth

In case 1 a 6-mm-long manual reamer was retrieved successfully with the use of GG drill using a manual file and copious irrigation which is the most desired treatment outcome

In case 2 the retrieval of separated rotary file lodged in the middle third of the root canal was unsuccessful in spite of multiple attempts It was therefore managed with routine obturation followed by restoration to maintain the tooth in its physiological functional state It was kept under close periodic follow-up at least

every 3 months This treatment option should be encouraged where it is possible to follow up the patient clinically and radiographically at close periodic intervals as there is the possibility of instrument escaping

into bone due to physiological root resorption

In cases 3 and 4 an instrument has separated in the apical root portion

In case 3 it was within the root canal and thus an attempt was made for its retrieval which was

unsuccessful It was therefore extracted to prevent the fractured instrument from getting exposed in the bone following resorption as there is no accurate and consistent established age for initiation of resorption in primary teeth known per se

In case 4 an immediate extraction of involved tooth was carried out as the separated instrument was beyond the apex of the primary tooth root

Age of the child clinical signs and symptoms and amount of root resorption are the factors which can also influence the management of separated instrument in primary teeth

Moreover if an instrument has separated after initial cleaning and shaping of root canal maintaining a tooth is not a problem as clinical signs and symptoms are not anticipated and the good prognosis is expected

However if an instrument has separated early during the initial cleaning and shaping of the root canal clinical symptoms may compromise the prognosis

Therefore these factors should be kept in mind while planning a suitable management strategy to avoid or at least reduce the burden of extraction and wear of space maintainer for longer period

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

5

CONCLUSION

The management and prognosis of a primary tooth with a separated instrument is

dependent on the level of instrument fracture within the root age of the child root

resorption and clinical signs and symptoms of the involved tooth

Different management approaches can be tried depending on clinical situations keeping

in mind benefits vs risks in preserving the tooth

PROS amp CONS

PROS

The entire procedure is given

by step by step

Well descriptive xrays and

photographs

CONS

Medical history has not been

given

REFERENCES

1 TOMER ANIL K ET AL ldquoBROKEN FILE RETRIEVAL PUZZLE IN ENDODONTICSrdquo

(2016)

2 SHENOY A MANDAVA P BOLLA N ET AL A NOVEL TECHNIQUE FOR REMOVAL OF

BROKEN INSTRUMENT FROM ROOT CANAL IN MANDIBULAR SECOND MOLAR

INDIAN J DENT RES 201425(1)107ndash110

3 PATEL J MORAWALA A TALATHI R ET AL RETRIEVAL OF A BROKEN INSTRUMENT

FROM ROOT CANAL IN PRIMARY ANTERIOR TEETH UNIV RES J DENT 20155(3)203ndash

206

4 MORANKAR R GOYAL A GAUBA K ET AL MANUAL VERSUS ROTARY

INSTRUMENTATION FOR PRIMARY MOLAR PULPECTOMIES - A 24 MONTHS

RANDOMIZED CLINICAL TRIAL PEDIAT DENT J 201828(2)96ndash102

5 KASHYAP NILOTPOL (2018) RETAINING PRIMARY MOLARS WITH INSTRUMENT

SEPERATION A CASE REPORT AND CLINICAL GUIDE

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

6

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

1

IMPACT OF 6 CITRIC ACID AND ENDOACTIVATOR AS IRRIGATION ADJUNCTS ON OBTURATION QUALITY AND PULPECTOMY OUTCOME IN

PRIMARY TEETH

NEETU JAIN SHALINI GARG ABHISHEK DHINDSA SAKSHI JOSHI HARJOY

KHATRIA

PEDIATRIC DENTAL JOURNAL 2019 29

1

DR MITAKSHARA NIRWAN

CONTENTS

bull INTRODUCTION

bull AIMS amp OBJECTIVES

bull CASE REPORT

bull RESULTS

bull DISCUSSION

bull CONCLUSION

bull PROS AND CONS

bull REFERENCES

2

INTRODUCTION

bull ENDODONTIC THERAPY IN PRIMARY TEETH INVOLVES DISINFECTION OF THE ROOT CANAL

SYSTEM AND ITS OBTURATION WITH RESORBABLE PASTE

bull THE CONTENTS OF ROOT CANAL ALONG WITH SMEAR LAYER ARE EXPECTED TO BE REMOVED

DURING THE BIOMECHANICAL PREPARATION

bull IN VITRO AND CLINICAL DOCUMENTS HAVE INDICATED THAT MECHANICAL PREPARATION OF

THE CANAL LEAVES LARGE PORTIONS OF THE CANAL WALLS UNDEBRIDED AND COMPLETE

REMOVAL OF THE BACTERIA BY THIS MECHANICAL PROCEDURE ALONE IS UNLIKELY TO BE SEEN

THEREFORE SOME FORM OF DISINFECTIONIRRIGATION IS MANDATORY TO KILL THE

MICROORGANISMS AND TO REMOVE THE RESIDUAL TISSUES

3

bull THE IDEAL REQUISITES OF A ROOT CANAL IRRIGANT AS GIVEN BY ZEHNDER ARE

1 BROAD ANTIMICROBIAL SPECTRUM

2 HIGH EFFICACY AGAINST ANAEROBIC AND FACULTATIVE MICROORGANISMS ORGANIZED

IN BIOFILMS

3 ABILITY TO DISSOLVE NECROTIC PULP TISSUE REMNANTS

4 ABILITY TO INACTIVATE ENDOTOXIN

5 ABILITY TO PREVENT THE FORMATION OF A SMEAR LAYER DURING INSTRUMENTATION OR

TO DISSOLVE THE LATTER ONCE IT HAS FORMED

6 SYSTEMICALLY NONTOXIC WHEN THEY COME IN CONTACT WITH VITAL TISSUES

NONCAUSTIC TO PERIODONTAL TISSUES AND WITH LITTLE POTENTIAL TO CAUSE AN

ANAPHYLACTIC REACTION

SINCE NO SINGLE IRRIGANT HAS THESE OPTIMAL PROPERTIES STUDIES HAVE REPORTED THE USE

OF TWO OR MORE SOLUTIONS IN A SPECIFIC SEQUENCE OR IN COMBINATIONS FOR BETTER

RESULTS 4

bull SEVERAL IRRIGATING SOLUTIONS ALONG WITH CHELATING AGENTS HAVE BEEN USED

DURING BIOMECHANICAL PREPARATION OF ROOT CANAL BOTH IN PRIMARY AND

PERMANENT TEETH

bull HOWEVER NONE OF THE AVAILABLE IRRIGATING SOLUTIONS HAS BEEN REGARDED CLEARLY

AS OPTIMAL SOLUTION BECAUSE OF THEIR LIMITED EFFECTIVENESS ESPECIALLY IN APICAL

13RD OF THE ROOT CANAL SYSTEM

bull TO OVERCOME SUCH LIMITATIONS USE OF ENDOACTIVATOR HAS BEEN PROPOSED AS AN

IRRIGATION FACILITATOR THAT IS BASED ON SONIC VIBRATION (UP TO 10000 CPM) WHICH

FACILITATES THE IRRIGANT PENETRATION AND ITS RENEWAL WITHIN THE CANAL

bull ACTIVATION SYSTEMS RESULTED IN BETTER REMOVAL OF THE SMEAR LAYER IN THE APICAL

THIRD OF ROOT CANALS IN COMPARISON TO CONVENTIONAL IRRIGATION

5

CITRIC ACID

bull CITRIC ACID IS A WEAK ORGANIC ACID WITH THE APPEARANCE OF WHITE CRYSTALLINE

POWDER AT ROOM TEMPERATURE

bull IT CAN EXIST EITHER IN WATER-FREE FORM (ANHYDROUS) OR MONOHYDRATE FORM THE

WATER-FREE FORM CRYSTALLIZES FROM THE HOT WATER WHEREAS THE MONOHYDRATE

FORMS FROM THE COLD WATER THE LATTER MAY BE CONVERTED TO ANHYDROUS FORM BY

HEATING MORE THAN 78degC

bull CITRIC ACID OCCURS NATURALLY IN THE BODY IN MITOCHONDRIA AND IS USED BY BLOOD

BANKS TO PREVENT COAGULATION OF TRANSFUSED BLOOD CITRIC ACID IS ALSO ESSENTIAL

TO HUMAN METABOLISM AND IS FOUND IN MANY FOODS

6

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

2

bull THE BIOLOGICAL EFFECTS OF CITRIC ACID ON THE PERIODONTAL STRUCTURE HAS BEEN

EXTENSIVELY STUDIED IN PERIODONTICS

bull NEUMAN AND NEWMAN SHOWED THAT CITRIC ACID IS THE MOST EFFECTIVE ACID IN

ALTERING THE SOLUBILITY OF HYDROXYAPATITE

bull YAMAGUCHI ET AL SHOWED THAT CITRIC ACID SOLUTION HAD ANTIBACTERIAL EFFECTS ON

ALL 12 ROOT CANAL BACTERIA TESTED

bull ARIAS-MOLIZ ET AL SHOWED THAT ETHYLENEDIAMINETETRAACETIC ACID (EDTA) HAS NO

BACTERICIDAL ACTIVITY EVEN AFTER 1 HOUR CONTACT

bull THIS ACID HAS THE ABILITY OF ROOT CANAL IRRIGATION AND ALSO SMEAR LAYER REMOVAL

DIFFERENT CONCENTRATIONS (1ndash50) HAVE BEEN PROPOSED GUTMANN ET AL CONCLUDED

THAT 10 CITRIC ACID IS BETTER THAN ULTRASOUND FOR SMEAR LAYER REMOVAL FROM THE

ROOT END CAVITIES

7

bull STUDIES HAVE SHOWN IRRIGATION WITH 6 CA FOR 15 OR 30 SECONDS IS QUITE

EFFECTIVE IN REMOVING ALL THE COMPONENTS OF THE SMEAR LAYER OF THE PRIMARY

TEETH WHEREAS PERITUBULAR DENTIN DESTRUCTION WAS OBSERVED WHEN HIGHER

CONCENTRATION OF CITRIC ACID WAS USED AS AN IRRIGATING SOLUTION

8

AIMS amp OBJECTIVES

bull THIS STUDY WAS AIMED TO EVALUATE THE CLINICAL AND RADIOGRAPHIC OUTCOME OF

PULPECTOMY ALONG WITH QUALITY OF OBTURATION USING 6 CITRIC ACID AND

ENDOACTIVATOR

9

CASE REPORT

bull 350 CHILDREN (3-9 YEARS) WITH CLINICAL SIGNS AND SYMPTOMS OF CHRONIC IRREVERSIBLE

PULPITIS IN DEEPLY CARIOUS TEETH WERE SCREENED DURING SCHOOL DENTAL HEALTH

PROGRAM FROM MAY 2014-JULY 2014

bull 123 CHILDREN REPORTED TO THE DEPARTMENT AND 67 CHILDREN WERE SELECTED BASED ON

INCLUSION AND EXCLUSION CRITERIA

RECRUITMENT OF PATIENTS

10

INCLUSION CRITERIA

bull HISTORY OF SPONTANEOUS PAIN AND UNCONTROLLED BLEEDING AFTER PULP AMPUTATION

EXCLUSION CRITERIA

bull EVIDENCE OF INTERNAL OR EXTERNAL (PHYSIOLOGICPATHOLOGIC) ROOT RESORPTION OF MORE THAN A THIRD OF ITS LENGTH

bull ROOT CANAL OBLITERATION OR ANATOMIC ANOMALIES

bull INADEQUATE BONE SUPPORT OR NON RESTORABLE TOOTH

bull ONCE PATIENTS ELIGIBILITY WAS CONFIRMED THE TREATMENT PROCEDURE WAS

EXPLAINED TO THE PARENTGUARDIAN AND INFORMED WRITTEN CONSENT WAS

OBTAINED FROM PARENTSGUARDIANS SHOWING WILLINGNESS FOR THEIR

CHILDRENS TREATMENT 11

PROCEDURE

bull PULPECTOMY WAS PERFORMED BY ONE OPERATOR OF PEDIATRIC DENTISTRY DEPARTMENT

USING A STANDARDIZED TREATMENT PROTOCOL FOR ALL THE PATIENTS

bull AFTER ADMINISTRATION OF LOCAL ANESTHESIA RUBBER DAM WAS APPLIED FOR ISOLATION

bull ACCESS CAVITY WAS PREPARED USING AIR-ROTOR HAND PIECE WITH 8 ROUND BUR AND

PULP TISSUE WAS EXTIRPATED WITH THE HELP OF SPOON EXCAVATOR

bull FURTHER THE NEGOTIATION OF THE CANALS WAS DONE WITH 10 K-FILE

bull A DIAGNOSTIC RADIOGRAPH WAS TAKEN FOR ROOT LENGTH DETERMINATION AND

WORKING LENGTH WAS KEPT 1 MM SHORT OF THE RADIOGRAPHICAL APEX

bull ALL ROOT CANALS WERE INSTRUMENTED MANUALLY USING K-FILES AND WERE IRRIGATED

WITH 10 ML 09 NORMAL SALINE AND 1 SODIUM HYPOCHLORITE AS STANDARDIZING

PROTOCOL FOR ROOT CANAL PREPARATION AND DISINFECTION

12

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

3

GROUP 1 (CA + E) - IRRIGATION WAS DONE

WITH 10 ML OF 6 CITRIC ACID (CITOCID AMMDENT)

AND IRRIGANTS WERE SONICALLY AGITATED WITH

ENDOACTIVATOR (DENTSPLY) FOR 30 S PER CANAL USING REDBLUE

ENDOACTIVATOR TIP

GROUP 2 (CA) - 10 ML OF 6 CITRIC ACID FOR 1 MIN USING

27 GAUZE IRRIGATING NEEDLE

GROUP 3(SH + E) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION AND SONIC ACTIVATION WITH ENDOACTIVATOR

GROUP 4(SH) - 10 ML OF 1 SODIUM HYPOCHLORITE

SOLUTION USING IRRIGATING NEEDLE (CONTROL GROUP)

bull TEETH UNDERGOING PULPECTOMY WERE RANDOMLY ENROLLED BY CHIT METHOD INTO THREE

STUDY AND ONE CONTROL GROUP

13

bull IN CITRIC ACID GROUPS FINAL RINSE WITH NORMAL SALINE WAS DONE TO REMOVE THE

REMAINING CRYSTALS (CHELATES)

bull FOLLOWING BIOMECHANICAL PREPARATION THE ROOT CANALS WERE DRIED WITH STERILE

ABSORBENT PAPER POINTS AND OBTURATED WITH VITAPEX USING HAND HELD

LENTULOSPIRAL FINAL RESTORATIONS WERE DONE USING COMPOSITE RESIN

14

bull CLINICAL FOLLOW UP WAS DONE AT 24 H1 WEEK 1 MONTH 6 MONTH AND 12

MONTH TO CHECK PAIN PRESENCE AND PAIN FREQUENCY (ONCEMORE THAN ONCE)

SWELLING FISTULA SENSITIVITY TO PERCUSSION

bull RADIOGRAPHIC FOLLOW UP WAS DONE AT 6 MONTH AND 12 MONTH FOR ANY

DEVIATED ERUPTION OF SUCCEDANEOUS TEETH EXCESS FILING MATERIAL AND ITS

RESORPTION EXTERNALINTERNAL ROOT RESORBTION CALCIFIC METAMORPHOSIS

PRESENCE OF FURCATION RADIOLUCENCY

CLINICAL amp RADIOGRAPHIC FOLLOW UP

15

RADIOGRAPHIC ASSESSMENT OF OBTURATION QUALITY

bull POSTOPERATIVE RADIOGRAPHS WERE VISUALLY ASSESSED FOR QUALITY OF OBTURATION BY

TWO INDEPENDENT EXAMINERS (SG AD) WHO WERE BLINDED WITH REGARD TO

IRRIGATION PROTOCOL GROUP TO ENHANCE CALIBRATION EACH EXAMINER ASSESSED THE

RADIOGRAPH INDEPENDENTLY AND LATER REVIEWED TOGETHER FOR FINAL ASSESSMENT

INDIVIDUAL ROOT WAS TAKEN AS UNIT OF ANALYSIS FOR GRADE OF OBTU- RATION AND

SCORING CRITERIA WERE AS GIVEN BY COLL JA 1996

1 UNDER FILLED - FILLING MATERIAL ENDED 1 MM OR MORE SHORT OF THE APEX

2 OPTIMAL FILLING- FILLING MATERIAL APPEARED TO END AT THE RADIOGRAPHICAL APEX

3 OVERFILLED - FILLING MATERIAL EXTRUDED PAST THE RADIOGRAPHIC APEX

4 OPTIMALLY FILLED ROOTS WERE FURTHER ASSESSED FOR THE PRESENCE OF VOIDS AND VOID

AREA (ROOT CANAL SURFACE UNTOUCHED BY THE ROOT CANAL FILLING MATERIAL) IN THREE

VISUALLY DIVIDED SECTIONS OF THE ROOT IE CORONAL MIDDLE AND APICAL 13RD

16

RESULTS

bull OVERALL CLINICAL AND RADIOGRAPHIC SUCCESS RATE OVER A PERIOD OF ONE YEAR WAS

9886 amp 977 RESPECTIVELY

bull ALL GROUPS WERE SIGNIFICANTLY (P = 001) EFFECTIVE IN ALLEVIATING PAIN WITHIN 24 H

OF PULPECTOMY

17 18

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

4

19

bull IMMEDIATE POST OPERATIVE RADIOGRAPHIC ASSESSMENT REVEALED 68 (102150) ROOTS

WITH OPTIMAL OBTURATION AND 32 (48150) WITH OVERFILLINGUNDERFILLING MAXIMUM

NO OF OPTIMAL FILLINGS WERE OBSERVED IN GROUP1 (CA + E) (3333) FOLLOWED BY

GROUP 2 (CA) (2549) GROUP 3(SH + E) (2549) AND GROUP 4(SH) (1568)

bull CITRIC ACID GROUPS HAD MORE NUMBER OF OPTIMALLY FILLED ROOTS 588 (60102) THAN

NON CITRIC ACID GROUPS 412 (42102)

bull ENDOACTIVATOR CONTRIBUTED TO 18 OF OPTIMAL OBTURATION IRRESPECTIVE OF

CHELATING AGENT USED

20

21

bull MAXIMUM NO OF VOIDS AND VOID AREAS WERE IN NON CITRIC ACID GROUPS

(6419 amp 5384) COMPARED TO CITRIC ACID GROUPS (3580 amp 4615)

RESPECTIVELY

bull ANALYSIS OF ROOT 13RD REVEALED MAXIMUM NO OF VOID AREA IN APICAL

13RD (4755) FOLLOWED BY MIDDLE 13RD (3846) AND CORONAL 13RD

(1398)

bull LEAST NO OF VOIDS amp VOID AREA (1111 amp 1608) WERE OBSERVED WHEN

ENDOACTIVATOR ALONG WITH CHELATING AGENT WAS USED (GROUP 1)

HOWEVER THIS WAS STATISTICALLY INSIGNIFICANT

22

DISCUSSION

bull IN THE PRESENT STUDY 1 SODIUM HYPOCHLORITE WAS USED ALONG WITH 6 CITRIC ACID

(CHELATING AGENT) WHICH IS REPORTED TO BE AS EFFECTIVE AS 17 EDTA

bull CITRIC ACID (BIOLOGICAL ACID) IS FOUND TO BE BIOCOMPATIBLE AND LEAST IRRITATING TO

PERIAPICAL TISSUES THAN OTHER CHELATING AGENTS

bull USE OF SODIUM HYPOCHLORITE SOLUTION FOLLOWING CHELATING AGENT WAS AVOIDED AS IT

RAPIDLY PRODUCES SEVERE EROSION OF ROOT CANAL WALL DENTIN

bull TRADITIONAL APPROACH OF DELIVERING IRRIGANTS INTO THE ROOT CANAL SPACE USING

SYRINGES AND METAL NEEDLES HAS BEEN FOUND TO BE INEFFECTIVE ESPECIALLY IN THE AREAS OF

ANASTOMOSES BETWEEN CANALS AND APICAL 13RD OF ROOT CANAL

23

bull THEREFORE TO ACHIEVE BETTER CLEANING EFFICIENCY IRRIGANT ACTIVATION HAS BEEN

RECOMMENDED SONIC ACTIVATION HAS BEEN REPORTED TO RESULT IN BETTER ROOT CANAL

CLEANLINESS AS COMPARED TO NO ACTIVATION OF IRRIGANT

24

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

5

CONCLUSION

bull USE OF 6 CITRIC ACID DEFINITELY HELPED IN RAPID ELIMINATION OF PAIN RESOLUTION OF

PERI-RADICULAR RADIOLUCENCY BETTER OBTURATION QUALITY IN TERMS OF LESS VOIDS AND

VOID AREAS ALONG WITH MAXIMUM NO OF OPTIMAL OBTURATION UP TO APICAL AREA

bull 6 CITRIC ACID AND ENDOACTIVATOR IRRIGATION PROTOCOL PROVED TO BE THE BETTER

IRRIGATION PROTOCOL WHICH MAY CONTRIBUTE TO LONG TERM SUCCESS OF PRIMARY

TOOTH AND THE HEALTH OF UNDERLYING PERMANENT TOOTH

bull 6 CITRIC ACID ALONG WITH ENDOACTIVATOR MAY BE RECOMMENDED AS IRRIGATION

ADJUNCTS IN PULPECTOMY PROCEDURE OF PRIMARY TEETH

25

PROS AND CONS

PROS

bull PROPER EXPLANATION OF THE MATERIALS

USED

CONS

bull NO PREOPERATIVE AND POSTOPERATIVE

RADIOGRAPHS

26

REFERENCES

bull RAMACHANDRA JA NIHAL NK NAGARATHNA C VORA MS ROOT CANAL IRRIGANTS IN

PRIMARY TEETH WORLD J DENT 20156(3)229-234

bull MOHAMMADI Z JAFARZADEH H SHALAVI S KINOSHITA JI UNUSUAL ROOT CANAL

IRRIGATION SOLUTIONS J CONTEMP DENT PRACT 201718(5)415-420

bull ZEHNDER M ROOT CANAL IRRIGANTS J ENDOD 2006 32389- 98

bull SMITH JJ amp WAYMAN BE AN EVALUATION OF THE ANTIMICROBIAL EFFECTIVENESS OF

CITRIC ACID AS A ROOT CANAL IRRIGANT JOURNAL OF ENDODONTICS 1986 12(2) 54-58

bull TANNURE PN AZEVEDO CP BARCELOS R GLEISER R PRIMO LG LONG-TERM OUTCOMES OF

PRIMARY TOOTH PULPECTOMY WITH AND WITHOUT SMEAR LAYER REMOVAL A RANDOMIZED

SPLIT-MOUTH CLINICAL TRIAL PEDIATR DENT 201133316E20 27

bull CARON G NHAM K BRONNEC F MACHTOU P EFFECTIVENESS OF DIFFERENT FINAL IRRIGANT

ACTIVATION PROTOCOLS ON SMEAR LAYER REMOVAL IN CURVED CANALS J ENDOD

2010361361E6

bull COLL JA SADRIAN R PREDICTING PULPECTOMY SUCCESS AND ITS RELATIONSHIP TO

EXFOLIATION AND SUCCEDANEOUS DENTITION PEDIATR DENT 19961857E63

28

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

1

LOCAL

ANESTHESIA

DR MITAKSHARA NIRWAN

CONTENTS

Definition

Methods of inducing local anesthesia

Desirable properties

Electrophysiology of nerve conduction

Impulse propagation and spread

Mode and site of action of local anesthesia

Classification of local anesthetic according to biological site and mode of action

Dissociation of local anaesthetics

Mechanism of action of local anaethetics

Local anaesthetic agent

2

3

DEFINITION

Local anesthesia is defined as a loss of sensation in

a circumscribed area of the body caused by depression

of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves

An important feature of local anesthesia is that it produces

LOSS OF SENSATION WITHOUT INDUCING LOSS OF

CONSCIOUSNESS

4

METHODS OF INDUCING LOCAL

ANESTHESIA

Low temperature

Mechanical trauma

Anoxia

Neurolytic agents such as alcohol amp phenol

Chemical agents such as local anesthetics

PROPERTIES OF LOCAL

ANESTHESIA

It should not be irritating to tissue to which it is applied

It should not cause any permanent alteration of nerve structure

Its systemic toxicity should be low

Time of onset of anesthesia should be short

It should be effective regardless of whether it is injected into the tissue or applied locally to mucous membranes

The duration of action should be long enough to permit the completion of procedure

5 6

It should have the potency sufficient to give complete

anesthesia with out the use of harmful concentration solutions

It should be free from producing allergic reactions

It should be free in solution and relatively undergo

biotransformation in the body

It should be either sterile or be capable of being sterilized by

heat with out deterioration

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

2

ELETROPHYSIOLOGY OF

NERVE CONDUCTION

There is an electrical charge across the membrane

This is the membrane potential

The resting potential (when the cell is not firing) is a negative

electrical potential of -70mv that exists across the nerve

membrane produced by different concentrations of either side of

the membrane

The interior of nerve is NEGATIVE in relation to exterior

7 8

inside

outside

Resting potential of neuron = -70mV

+

-

+

-

+

-

+

-

+

-

SLOW DEPOLARIRIZATION

9

RAPID DEPOLARIZATION

The interior of nerve is POSITIVE in relation to exterior

REPOLARIZATION

10

bull Repolarization takes 07 msec

bull Depolarization takes 03 msec

SODIUM PUMP -

energy comes from the oxidative metabolism of ATP

bull The entire process require 1 msec

IMPULSE PROPOGATION

IMPULSE SPREAD

The propagated impulse travels along the nerve

membrane towards CNS The spread of impulse differs

in myelinated and unmyelinated nerve fibers

DEPOLARIZED SEGMENT ADJACENT RESTING AREA

MODE AND SITE OF ACTION OF LOCAL

ANESTHETICS

Local anesthetic agent interferes with excitation

process in a nerve membrane in one of the

following ways

Altering the basic resting potential of nerve

membrane

Altering the threshold potential

Decreasing the rate of depolarization

Prolonging the rate of repolarization

12

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

3

CLASSIFICATION OF LOCAL ANESTHETIC

SUBSTANCES ACCORDING TO

BIOLOGICAL SITE AND MODE OF ACTION

CLASS A

Agents acting at receptor site on external surface of nerve membrane

Chemical substance Biotoxins (eg tetrodotoxin and saxitoxin)

CLASS B

Agents acting on receptor sites on internal surface of nerve membrane

Chemical substance Quaternary ammonium analogues of lidocaine

scorpion venom 13

CLASS C Agents acting by receptor independent of

physiochemical mechanism

Chemical substance Benzocaine

CLASS D Agents acting by combination of receptors and

receptor independent mechanisms

Chemical substance most clinically useful anesthetic agents

(eg lidocaine mepivacaine prilocaine)

14

BASED ON THE SOURCE

NATUAL

SYNTHETIC

OTHERS

BASED ON MODE OF APPLICATION

bull INJECTABLE

bull TOPICAL

BASED ON DURATION OF ACTION

bull ULTRA SHORT

bull SHORT

bull MEDIEM

bull LONG

BASED ON ONSET OF ACTION SHORT

INTERMEDIATE

LONG

15

DISSOCIATION OF LOCAL

ANESTHETICS

Local anesthetics are available as salts (usually

hydrochlorides) for clinical use

The salts both water soluble and stable is dissolved in

either sterile water or saline

In this solution it exists simultaneously as unchanged

molecule (RN) also called base and positively charged

molecules (RNH+) called cations

RNH+ ==== RN+ H

+

16

The relative concentration of each ionic form in the solution varies

in the pH of the solution or surrounding tissue

In the presence of high concentration of hydrogen ion (low pH) the

equilibrium shifts to left and most of the anesthetic solution exists

in cationic form

RNH+ gt RN

+ + H

+

As hydrogen ion concentration decreases (higher pH) the

equilibrium shifts towards the free base form

RNH+ lt RN + H

+

17

The relative proportion of ionic form also depends on pKa or DISSOCIATION CONSTANT of the specific local anesthetic

The pKa is a measure of molecules affinity for H+

ions

When the pH of the solution has the same value as pKa of the local anesthetic exactly half the drug will exists in the RNH

+ form and

exactly half in RN form

The percentage of drug existing in either form can be determined by Henderson Hasselbalch equation

Log baseacid = pH - pKa

18

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

4

MECHANISM OF ACTION OF LOCAL

ANESTHETICS

The following sequence is proposed mechanism of action of LA

Displacement of calcium ions from the sodium channel receptor site

Binding of local anesthetic molecule to this receptor site

Blockade of sodium channel

19

Decrease in sodium conductance

Depression of rate of electrical depolarization

Failure to achieve the threshold potential level

Lack of development of propagated action potential

Conduction blockadehellip

20

21

Na + Na +

22

LOCAL ANESTHETIC AGENT

COMERCIALLY PREPARED LOCAL ANESTHESIA

CONSISTS OF

Local anesthetic agent (xylocaine lignocaine 2)

Vasoconstrictor (adrenaline 1 80000)

Reducing agent (sodium metabisulphite)

Preservative (methylparabencapryl

hydrocuprienotoxin)

Fungicide (thymol)

Vehicle (distillde waterNaCl)

LOCAL ANESTHETIC AGENT

The local anesthetics used in dentistry are divided

into two groups

ESTER GROUP

AMIDE GROUP

23 24

ESTER GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

an ester linkage

A hydrophilic secondary or tertiary

amino group

AMIDE GROUP It is composed of the following

An aromatic lipophilic group

An intermediate chain containing

amide linkage

A hydrophilic secondary or tertiary

amino group

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

5

25

CLASSIFICATION OF LOCAL ANESTHETICS

ESTERS

Esters of benzoic acid

Butacaine

Cocaine

Benzocaine

Hexylcaine

Piperocaine

Tetracaine

Esters of Para-amino

benzoic acid

Chloroprocain

Procaine

Propoxycaine

26

AMIDES Articaine

Bupivacaine

Dibucaine

Etidocaine

Lidocaine

Mepivacaine

Prilocaine

Ropivacaine

QUINOLINE

Centbucridine

PHARMACOKINETICS OF LOCAL

ANESTHETICS UPTAKE

When injected into soft tissue most local anesthetics produce

dilation of vascular bed

Cocaine is the only local anesthetic that produces

vasoconstriction initially it produces vasodilation which is

followed by prolonged vasoconstriction

Vasodilation is due to increase in the rate of absorption of the

local anesthetic into the blood thus decreasing the duration of

pain control while increasing the anesthetic blood level and

potential for over dose 27

AMIDE LOCAL ANESTHETICS

The metabolism of amide local anesthetics is more

complicated then esters The primary site of

biotransformation of amide drugs is liver

Entire metabolic process occurs in the liver for lidocaine

articaine etidocaine and bupivacaine

Prilocaine undergoes more rapid biotransformation then the

other amides

28

REFERENCES

Handbook of local anesthesia ndash Stanley F Malamed ndash 6th

edition

Essentials of Local Anesthetic Pharmacology Daniel E

Becker Anesth Prog 2006 Fall 53(3) 98ndash109

WIKIPEDIEA

29

THANK YOU

30

1

Pharmacological Methods of Behavior

Management

DR MITAKSHARA NIRWAN

DEFINITIONS

bull Conscious Sedation ndash A minimally depressed level of consciousness that retains

the patients ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command

(American Dental Association House Of Delegates 2000)

bull Deep Sedation ndash An induced state of depressed consciousness

accompanied by partial loss of protective reflexes including the inability to continuously maintain an airway independently and or to respond purposefully to physical stimulation or verbal command

bull General Anesthesia (G A) ndash An induced state of unconsciousness or complete loss of

protective reflexes including the inability to continually maintain an airway independently and respond purposefully to physical stimulation or verbal command

Conscious sedation

ADVANTAGES

Conscious

Protective reflexes active amp intact

Stable vital signs

Operating dentist may perform sedation

Minimum amount of equipment required

Prolong detainment in recovery room not required

Risk of complication very low

Excellent choice for poor ndash risk pt in dental office

Cost effective

General anesthesia

ADVANTAGES Not absolutely

essential May be the only

method Not necessary (no

pain reaction) Amnesia always

present

Conscious sedation

DISADVANTAGES

Pt cooperation is essential

Extremely difficult or mentally handicapped pt cannot always be managed

Use of local anesthesia is a must

Amnesia may or may not be present

General anesthesia DISADVANTAGES

Pt unconscious

Protective reflexes are depressed

Depressed

Advanced training required Dentist must not act also as anesthetist

Special equipment necessary

Detainment in recovery area necessary

High IOP amp postoperative complications

Not indicated in dental office

More expensive

Fundamental Concepts

bull Techniques that utilize drugs to induce co-operative yet conscious state in an otherwise uncooperative child ndash CONSCIOUS SEDATION

2

GOALS

1 To facilitate the provision of quality care

2 To minimize the extremes of disruptive behavior

3 To promote a positive psychologic response to treatment

4 To promote patient welfare amp safety

5 To return the patient to physiologic state

OBJECTIVES

1 The pt mood must be altered

2 The pt must remain conscious at all times

3 The pt must be cooperative

4 All protective reflexes must remain intact and active

5 Vital signs must remain stable and with in normal limits

6 The ptrsquos pain threshold should be elevated

7 Amnesia may be present

Indications

1 Preschool children

2 Lack of Psychological Emotional maturity

3 Lack of Cognitive Physical Medical disability

4 Fearful amp anxious pts

5 Pt who require extensive amp complicated dental care amp would require or benefit from prolonged visits

6 Acute pain

7 Traumatic injuries

Operating Facilities amp Equipment

A positive pressure O2 delivery system capable of administering gt than 90 O2 at 10L min flow for 60 min (650L ldquoErdquo cylinder)

OR

Self inflating bag valve mask device (15L min)

A functional suction apparatus with appropriate suction catheters

Monitoring equipment - PO BPC PC or Capno

Inhalation sedation unit

100 O2 amp never less than 25

A fail safe mechanism that is checked and calibrated annually

Must have appropriate scavenging system

Emergency drugs

Techniques of sedation

Routes for drug administration

bull Oral

bull Rectal

bull Inhalational

bull Transmucosal

ndash Sublingual

ndash Intranasal

bull Parenteral

ndash IM

ndash sub mucosal

ndash IV

3

Oral Sedation

Advantages

1 Almost universally accepted and the easiest method

2 Decreased incidence and severity of adverse reaction

3 Low cost

Disadvantages

1 Absorption is variable

2 Prolonged latent period(30 min)

3 Reversal of any unwanted effect is also difficult

4 Inability to readily lighten or deepen the level of sedation

5 Prolonged duration of action

Rectal Sedation

Advantages 1 Incidence and intensity of

drug related side effects is minimized

2 Drug absorption occurs from the large intestine directly into the circulation

3 The lack of a needle syringe or other equipment

4 The ease of administration

5 The low cost

Disadvantages

1 Inconvenience to the administrator amp pt

2 The variable absorption of drugs from the large intestine

3 The slow onset of action amp the relatively long duration of action

4 Inability to titrate the drug dosage

5 The inability to reverse the action of the drug the prolonged recovery

Intranasal sedation

Advantages

Rapid onset (10 ndash 15 min)

Simple amp relatively painless

Less pt cooperation is required

Absorbed directly into the C V S

Intranasal sedation

Disadvantages

1 Dependence on nasal mucous membrane

2 Shorter duration of action(40-60min)

3 Multiple dosage may be necessary

Drugs

Midazolam ndash 02mgkg

Sufentanil ndash 15 ndash 3 mcgkg

Ketamine ndash 3-6mg kg

Sublingual sedation

Advantages

1 Pt acceptance

2 Rapid onset

3 High bioavailability

Drugs

Oral Transmucosal Fentanyl Citrate (OTFC)

Intramuscular Sedation

Advantages

1 More rapid onset of action

2 Absorbed directly into the C V system

3 More reliable absorption of drug

4 Pt cooperation is not as essential

Disadvantages

1 Time factor ndash its 15 min latent period

2 Pt may not be willing to accept the injection

3 The prolonged duration of action(2-4 hrs more)

4 Possibility of injury to the tissues at the site of injection caused by either the drug or the needle

4

Sites of I M administration

1 Gluteal area

2 Vastus lateralis

3 Mid ndash deltoid area

Drugs

Diazepam

Midazolam

Hydroxyzine

Inhalation Sedation

Advantages

1 The onset of action is more rapid

2 Peak clinical level is achieved rapidly(3-5min) - permit titration

3 Administrator has complete control over the actions of the drug - safety feature

4 No significant over dosage

5 Flexible duration of action

6 Recovery time is rapid amp most complete

7 No injection is required

8 With N2O- O2 it is safe with very few side effects

Disadvantages

1 The initial cost of the equipment is high 2 The continuing cost of the gases is high 3 The equipment occupies considerable space 4 N2O is not a potent agent 5 A degree of cooperation is required from the pt 6 Chronic exposure to N2O is deleterious to the health of

dental personnel

Contraindications

1 Nasal obstruction 2 Cyanosis at rest 3 Poor cooperation 4 1st trimester of pregnancy 5 Fear of masks

I V Sedation

Advantages

1 The onset of action is the most rapid 2 The dosage may be titrated 3 Suitable level of sedation can be provided 4 The recovery period is shorter 5 Side effects are extremely uncommon 6 Control of salivary secretions is possible 7 The gag reflex is diminished 8 Effectively diminishes motor disturbances 9 Provides immediate access to CVS in emergency

Disadvantages

1 Venipuncture is necessary

2 Complication may rise at the site of the venipuncture

3 Monitoring must be more intensive

4 Recovery is not complete at the end of the procedure

5 Reversal of sedation is difficult

5

N2O-O2 (Relative Analgesia)

colorless sweet smelling gas

Pharmacokinetics

Absorption through pulmonary epithelium

It is approx 15 times as soluble as is nitrogen It replaces nitrogen in blood

It is carried in solution in plasma of the blood

It is not metabolized by the body

Elimination ndash majorndash lungs minor --- skin

perspiration urine and intestinal gas

Pharmacodynamics

Dose related

10 ndash 25 Lightheaded

Changes in visual amp auditory sensation

Tingling of hands amp feet

Suffusing warmth

Remote from the immediate environment

Reduced anxiety

25-50 max analgesic properties and aberration of vision hearing and proprioception mild drowsiness euphoria amnesia and increased sleepiness and dreams

35 conc will achieve maximum analgesia

bull CNS

ndash Cerebrum-primarily affected

ndash Safe but weak anesthetic agent

bull RESPIRATORY SYSTEM

ndash Increased Tidal and minute volumes

bull CARDIOVASCULAR SYSTEM

ndash 2 studies ndash decreased cardiac output

bull FETAL SYSTEMS

ndash Miscarriage in humans

bull OTHER SYSTEMS

ndash Depression of spinal reflexes increase muscle tone indicates stage of delirium

ndash Muscle rigidity-narcotics + nitrous oxide

ndash Nausea and vomitting - GIT

ndash HEMATOPOIESIS ----- prolonged exposure

Adverse reactions and toxicity

EMOTIONAL REACTIONS

DREAMS HALLUCINATIONS

No acute toxicity

Chronic toxicity ndash bone marrow

depression

PROCEDURE

Diffusion Hypoxia

Sevoflurane

A fluorinated derivative of isopropyl ether ndash synthesized in 1970

Potent anaesthetic agent with rapid uptake amp speedy recovery

Day-case surgery

Problem

Attaching vaporiser to any of the currently available machine

BENZODIAZEPINES

Diazepam 1961 lipid soluble

Uses-alcoholism epilepsy labor tetanus and cerebral palsy

- sedation and amnesia

- varieties of neurosis amp anxiety states

Pharmacokinetics

Orally Rectal IMIV or SC

Well absorbed through GIT

Excretion in urine

6

bull Pharmacodynamics

ndash Depress the brain stem reticular system and the limbic system thalamus and hypothalamus

ndash It is a centrally acting muscle relaxant Has anti-convulsant properties

Adverse reaction amp toxicity

ndash Confusion nausea headache increased appetite decreased salivation and jaundice Thrombophlebitis

ndash Rebound phenomenon

ndash Toxicity drowsiness confusion sleep and coma

Dosage Oral or Rectal ndash 02-05mgkg

Maximum single dose 10mg

IV- 025mgkg

Supplied Tablets 2 5 10 mg

Suspension ndash 5mg

Midazolam Water soluble ndash non-irritant

Oral IM IV

Metabolism- liver

Onset IV 3 -5mins

oral 20 ndash 30mins

Oral administration anxious patients requiring relatively short dental procedure

No rebound phenomenon

Better anxiolysis amp amnesia (retrograde amnesia)

Adverse effects Respiratory depression

dose dependant apnea

Dosage Oral ndash 025 to 1mgkg to maximum single dose 20mg

IM ndash 01 to 015mgkg to a maximum of 10mg

IV ndash slow IV

Supplied Syrup ndash 2mgml

Injectable ndash 1mgml amp 5mgml vials

Flumazenil specific benzodiazepines antagonist

selectively inhibits CNS effects

IV administration amp not recommended below 18yrs of age

02mg over 15 seconds after 45seconds 02mg then after 60seconds to maximum of 1mg

Sedative-Hypnotics

Barbiturates First truly effective drugs for the management of anxiety Generalized CNS depressants Produce dose dependent effects

Sedation ---- sleep ---- GA ---- coma

Suppress the CNS and result in sedation and amnesia Advantages

Rapid onset and short duration Disadvantages

no analgesic effect and possible hypotension Must be used with caution in trauma patients because they may cause

apnea and hypoventilation

DOSE Pentobarbital Sodium 100mg Secobarbital Sodium 100 to 200mg Children 30 to 100mg

bull Chloral Hydrates (Mickey Finn Knock out drops ) First synthesized in 1832 first member of the hypnotic group of drugs

Widely used as conscious sedation agent

Properties

Unpleasant taste

Nausea vomiting

Quite irritating to skin and to mucous membranes

GI irritation

Dosages Individualized for each patient 25 ndash 50mgkg

maximum of 1g

Supplied oral capsule ndash 500mg

oral solution ndash 250 amp 500mg5ml

Rectal suppositories ndash 324 amp 648mg

Narcotics

Do produce sedation amp euphoria greater in children

LA is required but dose should be decreased

Meperidine Synthetic opiate agonist

Very water soluble

Orally SC IM or IV

Peak effect by oral 1 hr amp lasts upto 4 hrs

Adverse reactions

-Seizures

-Extreme caution in hepatic or renal diseases or history of seizures

7

Dosage Oral SC or IM ndash 1to 22mgkg not to exceed 100 mg

Supplied Oral Tablets ndash 50 amp 100mg

Oral Syrup ndash 50mgml

Parental solution ndash 25 50 75 amp 100mgml

Fentanyl

Synthetic opiate narcotic analgesic

Very potent 01mg = 10mg Morophine75mg Meperidine

Pharmacokinetics

IV IM SM

Metabolized in liver Excreted in urine

Fentanyl Onset ndash 7 to 15mins

Duration ndash 1 to 2 hrs

Pharmacodynamics

Respiratory depression RR but returns to normal rapidly Tidal volume amp response to co2 depressed for extended period

Apnea

Less emetic than meperidine

NOT RECOMMENDED IN CHILDREN BELOW 2yrs

Dosage 0002 to 0004mgkg

Supplied 005mgml in 2 amp 5ml ampoules

Reversal drug Naloxone

Semisynthetic opiate antagonist

No agonist activity

Onset 2 to 5mins SC or IM amp 1 to 2mins IV

Reversal 45mins

Pt should be kept under continual surveillance

Adverse reaction nausea vomiting sweating hypotension hypertension ventricular tachycardia fibrillation

Dosage IV SC IM 001mgkg then 01mgkg every 2- 3mins maximum 2mg

Supplied 002 004 1mg solutions

Antihistamines

Hydroxyzine

Oral or IM

Effect ndash 15 ndash 30mins

Half-life ndash 3 hrs

Uses

To relieve anxiety

Used as an anti-histamine

Used to control nausea and vomiting including that associated with motion sickness and pregnancy

Adverse reaction dry mouth drowsiness hypersentivity

Dosage Oral ndash 1 to 2mgkg

IM ndash 11mgkg

Promethazine Oral or IM Onset 15 to 60mins Duration 4 to 6 hrs Uses

To prevent and treat nausea and vomiting associated with motion pregnancy or surgery

Produces sedation and reduce swelling pain and trismus

Lower seizure threshold Adverse reaction dry mouth blurred vision thickening of bronchial secretions Dosage OralIM ndash 05-11mgkg

maximum 25 mg

Diphenhydramine

Oral IM IV

Onset -1hr

Duration ndash 4 to 6 hr

Metabolized in liver

Adverse reaction disturbed coordination thickening of bronchial secretions

Dosage Oral IM IV ndash 1 to 15mgkg

maximum 50mg

Tranquilizers

Major tranquilizer antipsychotic produce calmness control symptoms of psychoses cause reversible extra pyramidal symptoms and do not tend to cause habituation

Minor tranquilizer antianxiety agents also cause calmness do not cause extrapyramidal symptoms Used in conditions like nervous tension and mild depression

8

Classification

Antipsychotics

Phenothiazine derivatives

Chlorpromazine promazine

Butryophenones

Haloperidol

Rauwolfia alkaloids

Reserpine

Antianxiety drugs

Propyl alcohol derivatives

Meprobamate

Benzodiazepine derivatives

Diazepam

Miscellaneous compounds

Hydroxyzine

Meprobamate

White crystalline powder slightly bitter in taste

Only administered orally

Peak blood concentration ----1 to 3hrs

10 ---------excreted unchanged Rest --- excreted as a oxidized derivative or as a glucoronide

Uses

To relieve day time anxiety

Induce sleep in insomniacs

To reduce anxiety associated with dental treatment

Anti-convulsant ndash petit mal epilepsy

Adverse reaction leucopenia acute non-thrombocytopenic purpura ecchymoses eosinophilia edema adenopathy

Dosage Childrengt 6yrs 100 to 200mg

Not recommended for children under 6yrs

Monitoring during sedation

1 Pulse

2 Blood pressure

3 ECG

4 Respiration

5 Temperature

Pulse

Manual Electronic

bull Radial Brachial

bull Facial labial

Blood pressure

ndash Stethoscope amp sphygmomanometer

ndash Automatic devices

ndash Direct cannulation of an artery ndash very accurate

Electrocardiograph

Heart rate rhythm myocardial function

9

Respiration

ndash Monitoring respiratory rate

ndash Observing the rise amp fall of the chest wall

ndash Observing the color of mucous membrane

ndash Observing the inflation amp deflation of the reservoir bag

Devices for monitoring respiration

1 The Precordial pretracheal stethoscope

2 The esophageal stethoscope

ndash Respiratory rate

ndash Heart rate

ndash Any abnormal sounds

Pulse Oximeter

ndash Oxygen saturation

ndash Heart rate

ndash Oxisensor site

ndash Fingers

ndash Toe

ndash Ear lobe

Mechanism

Oxygenated Hb ndash red light

Deoxygenated Hb- infrared light

Tissue pressure from arterial pulse (plethysmography)

Advantages

ndash Safe amp noninvasive

ndash Simple to use

ndash Information is rapidly available for clinical decision

ndash Indirectly indicates respiratory adequacy

Disadvantages

ndash Finger probes can get dislodged

ndash Emitted light source may cause burning

ndash Non reusable probes are expensive

ndash Does not directly determine airway patency

Capnography

1 The presence absence of air flow

2 Indicates depth amp adequacy of respiration

3 Continues analysis of the co2 content of the respired air ndash indicates respiratory adequacy

Temperature

ndash Disposable nondisposable thermometer

ndash Esophageal rectal temp probe

10

Discharge criteria

Cardiovascular function is satisfactory amp stable

Airway patency is uncompromised amp satisfactory

Pt is easily arousable amp protective reflexes intact

State of hydration is adequate

Pt can talk if applicable

Pt can sit unaided if applicable

Pt can ambulate with minimal assistance if applicable

Presedation level of responsiveness achieved

Responsible individual is available

1

PULP THERAPY OF VITAL TEETH

DR MITAKSHARA NIRWAN

Contents

Indirect pulp capping

Direct pulp capping

Medications amp materials used in pulp capping

Pulpotomy

MTA

Apexogenesis

INDIRECT PULP CAPPING

Pieter Van Forest - first to speak about root canal therapy

Glove designed instruments that could prepare a canal to a certain size and taper(1910)

Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in

deep areas of cavity to avoid exposure of pulp followed by placement of a suitable medicament and

restorative material that seals off the carious dentin and encourages pulp recovery (Ingle)

A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a

time with a biocompatible material (McDonald)

Objective of indirect pulp capping

These were given by Eidelman in 1965

bull Arresting the carious process

bull Promoting dentin sclerosis

bull Stimulating formation of tertiary dentin

bull Remineralization of carious dentin

Layers of Carious Dentin Indications of Indirect Pulp Capping

History

Mild pain associated with eating

Negative history of spontaneous extreme pain

Clinical Examination

Deep carious lesion which are close tobut not involving the pulp in vital primary or young

permanent teeth

No mobility

Nominal pulp inflammationdefinite layer of affected dentin after removal of infected dentin

Radiographic examination

Normal lamina dura amp PDL space

No radiolucency around the apices

2

Contraindications of Indirect Pulp Capping

History

Sharp penetrating pulpalgia

Prolonged spontaneous pain especially at night

Clinical examination

Mobility of tooth

Discoloration of tooth

Negative reaction of electric pulp testing

Radiographic examination

Definite pulp exposure

Break in the lamina dura

Radiolucency around the apices

Widened PDL space

Treatment procedure

Sequelae of Indirect Pulp Capping Three distinct types of new dentin formation take place

1 Cellular fibrillar dentinmdashfirst 2 months

2 Globular dentinmdash3 months

3 Tubular dentin (uniform mineralized dentin)

bull 15th of reparative dentin formation begins in less than 30 days

bull After 3 months 01 mm is formed

DIRECT PULP CAPPING Defined by Kopel (1992) as the placement of a medicament or non medicated material on a pulp that

has been exposed in course of excavating the last portions of deep dentinal caries or as a result of

trauma

Objective

To create new dentin in the area of the exposure and subsequent healing of the pulp

Rationale

achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge)

between pulp tissue and capping material thus walling off the

INDICATIONS

Small mechanical exposure

Easily controlled haemorrhage

Bright red haemorrhage

True pinpoint exposure

CONTRAINDICATIONS

Severe toothache at night

Spontaneous pain

Tooth mobility

Radiographic appearance of pulp periradicular de- generation

Excess of hemorrhage at the time of exposure Serous exudate from the exposure

Externalinternal root resorption

Swellingfistula

Histological Changes after Pulp Capping

These were illustrated be Glass and Zander in 1949

After 24 hours Necrotic zone adjacent to calcium

hydroxide paste is separated from healthy pulp

tissue by a deep staining basophilic layer

After 7 days Increase in cellular and fibroblastic

activity

After 14 days Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium

proteinate zone disappearance of necrotic zone

After 28 days Zone of new dentin

3

Medications and Materials Used for Pulp Capping Calcium hydroxide

Corticosteroids amp antibiotics

Inert materials

Collagen fibers

4-META adhesive

Direct bonding

Isobutyl cyanoacrylate

Denatured albumin

Mineral trioxide aggregate

Laser

Bone morphogenic protein

PULPOTOMY

Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp

followed by placement of a suitable dressing or medicament that will promote healing and

preserve vitality of the tooth

American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of

affected infected coronal portion of the dental pulp preserving the vitality and function of the

remaining part of radicular pulp

Objectives

bull Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the

radicular pulp and allowing it to heal

bull Maintain the tooth in the dental arch

Rationale

bull Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp

bull Preserves vitality of the radicular pulp

bull Maintains tooth in a physiologic condition

Indications of Pulpotomy bull Mechanical pulp exposure in primary teeth

bull Teeth showing a large carious lesion but free of radicular pulpitis

bull History of only spontaneous pain

bull Hemorrhage from exposure sites bright red and can be controlled

bull Absence of abscess or fistula

bull No interradicular bone loss

bull No interradicular radiolucency

Contraindications of Pulpotomy bull Persistent toothache

bull Tenderness on percussion

bull Root resorption more than 13rd of root length

bull Large carious lesion with nonrestorable crown

bull Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable

bull Medical contradictions like heart disease immuno compromised patient

bull Swelling or fistula

bull External or internal resorption

bull Pathological mobility

bull Calcification of pulp

Classification of pulpotomy

4

Formocresol Pulpotomy

Iby BUCKLEY in 1904

Sweet (1930) Formulated multi visit technique

Doyle (1962) Advocated 2 sitting procedure (complete devitalization)

Spedding (1965) Gave 5 minute protocol (partial devitali- zation)

Venham (1967) Proposed 15 seconds procedure

Current concept uses 4 minutes of application time

Composition of formocresol Buckleyrsquos Formula

bull Cresol ndash 35 percent

bull Glycerol ndash 15 percent

bull Formaldehyde ndash 19 percent

bull Water ndash 31 percent

Mechanism of Action

It prevents tissue autolysis by bonding to the proteins Bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without

changing the basic structure of protein molecules

Histological Changes

bull Demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959

bull Immediately the pulp becomes fibrous and acidophillic

bull Seven to fourteen days Three zones appear

a broad eosinophilic zone of fixation

b broad pale-staining zone of atrophy with poorcellular definition

c broad zone of inflammation extending apically into normal pulp tissue

bull One yearndash Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

Modified Formocresol Pulpotomy

Used by TRASK(1972)

The technique is identical to that described for primary teeth except that the formocresol pellet is

sealed permanently in the tooth

Two-visit Devitalization Pulpotomy

Indications

bull There is evidence of sluggish bleeding at the amputation site that is difficult to control

bull Pus in the chamber but none at the amputation site

bull There is thickening of the PDL

bull History of pain

Contraindications

bull Nonrestorable tooth

bull Tooth with necrotic pulp

5

Glutaraldehyde Pulpotomy

It was first suggested by S Gravenmade Introduced by Kopel in 1979

Mechanism of Action

bull Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue

bull A narrow zone of eosinophilic stained and compressed fixed tissue is found directly beneath the area of application which blends into vital normal appearing tissue apically

bull With time the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue thus the entire root canal tissue is vital

Cvekrsquos Pulpotomy

bull This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy

bull This was proposed by Mejare and Cvek16 in 1978

bull Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the

remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is

notcomplete

MINERAL TRIOXIDE AGGREGATE (MTA) Torabinejad described the physical and chemical properties of MTA in 1995

It is ash colored powder made primarily of fine hydrophilic particles of

1 tricalcium aluminate

2 tricalcium silicate

3 silicate oxide

4 tricalcium oxide

5 bismuth dioxide

Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous

structure This gel solidifies into a hard structure in less than three hours

PROPERTIES OF MTA

It is biocompatible material and its sealing ability is better than that of amalgam or ZOE

Initial pH is 102 and set pH is 125

The setting time of cement is 4 hours

The compressive strength is 70 MPA which is comparable with that of IRM

Low cytotoxicity ndash It presents with minimal inflammation if extended beyond the apex

Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in

pulpal tissues and it promotes rapid cell growth

APEXOGENESIS

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale

Maintenance of integrity of the radicular pulp tissue to allow for continued root growth

Indications

bull Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed

bull No history of spontaneous pain

bull No sensitivity on percussion

bull No hemorrhage

bull Normal radiographic appearance

Contraindications

bull Evidence that radicular pulp has undergone degenerative changes

bull Purulent drainage

bull History of prolonged pain bull Necrotic debris in canal

bull Periapical radiolucency

6

1

Gupta A Dhingra R Chaudhari P Gupta A

Department of Paedodontics and Preventive Dentistry Faculty of Dental Sciences SGT University Gurgaon Haryana India

Journal of Indian Society of Pedodontics and Preventive Dentistry

Volume 35 I Issue 3 I July-September 2017

A COMPARISION OF VARIOUS MINIMALLY

INVASIVE TECHNIQUES FOR THE REMOVAL

OF DENTAL FLUOROSIS STAINS IN

CHILDREN

DR MITAKSHARA NIRWAN

CONTENTS

bull Introduction

bull Aims

bull Materials and Methods

bull Results

bull Discussion

bull Conclusion

bull Critical analysis

bull References

INTRODUCTION

bull Dental fluorosis is a developmental disturbance of dental enamel caused by

successive exposure to high concentrations of fluoride during tooth

development

bull Various methods of therapy are advocated for the treatment of fluorosis -

stained teeth which range from invasive ceramic veneer bonding restorations

to abrasive chemical treatments

bull The combination of dental bleaching techniques and microabrasion appears

as an excellent conservative solution to reestablish health in fluorosis

affected teeth

AIMS

bull The aim of the study was to evaluate and compare the effectiveness of

minimally invasive techniques for the removal of dental fluorosis

stains in children in vivo

MATERIALS AND METHODS

Patients visiting the department of Pedodontics and Preventive dentistry

Faculty of Dental Sciences SGT University Gurgaon

bull Sample size 90 patients

bull Age group 10 -17 years

bull Caries cracks or periodontal

disease on anterior teeth

bull Abscess draining sinus

cellulitis

bull Non vital teeth

hypersensitive exposed

crevices

bull Orthodontic appliance

bull Past history of bleaching

bull At least two permanent

maxillary anterior teeth

bull TSIF of score 4

bull Free of systemic diseases

Inclusion criteria Exclusion criteria

2

Groups

Group A In office bleaching with 35 hydrogen peroxide( Pola Office

Bleaching kit) activated by light emitting diode (LED) bleaching unit

(35 HP)

Group B Enamel microabrasion (EM) (PREMA Enamel Microabrasion

System) followed by in-office bleaching with 44 carbamide peroxide

gel (EM)

Group C In-office bleaching with 5 sodium hypochlorite (5

NaOCl)

A baseline colour evaluation was done by taking digital photograph of

the maxillary anterior teeth

RESULTS

Group 1

Colour stability

Group 2 Group 3

Tooth sensitivity

Tooth sensitivity values were taken before the treatment

which was compared to immediate postoperative and follow

up visits It was checked using an electric pulp tester

maximum

moderate

least

immediately

group 2

group 1

group 3

1 month

group 2

group 1

group 3

3 month

group 2

group 1

group 3

Patient satisfaction score

Satisfaction was assessed on visual analog scale

Range 1 to 5

Groups percentage of patients

who were satisfied with

the treatment

Number of patients

who reported slight

reappearance of colour

Group 1

90

7

Group 2

83

8

Group 3

73

7

3

Number of Appointments

Groups One sitting Two sittings Three

sittings

Group 1

25

4

1

group 2

26

3

1

Group 3

30

0

0

DISCUSSION

bull Hydrogen peroxide is capable of penetrating the tooth osmosis and through porosities and cracks subsequently acting directly on the pigmented molecules

bull Gurgan et al investigated 3 different light systems and found out that diode laser system with gave best tooth whitening and least tooth sensitivity

bull In the EM group the surface reflects and refracts light from the surface in such way that mild imperfections in underlying enamel are camouflaged While the highly polished surface of enamel enhances the aesthetic appearance

bull Train et al and Loguercio et al also had the similar results in their studies with EM mild fluorosis showed best results moderate showed moderate results while it had little effect on severe fluorosis

bull NaOCl was only effective on mild stains while moderate and severe

stains could only be lightened to quite an extent but could not be

completely removed

bull When NaOCl comes in contact with hypomineralized and discoloured

enamel it degrades and removes the chromogenic organic material

located on the enamel surface

CONCLUSION

bull It was concluded that esthetic appearance of teeth mild fluorosis can

be achieved by bleaching and microabrasion But in cases of

moderate fluorosis a combination of any of theses modalities can be

used

bull As no special maintenance precautions are required these maybe be

considered as an interesting alternative to conventional operative

treatment

bull Focuses on only TSIF of 4

bull Electric pulp testing is not the

right method to check for

sensitivity

bull Tooth Sensitivity changes

from person to person

bull Food habits can cause

staining of the teeth

bull Minimally invasive

bull Cheaper to veneers

bull Minimal loss of tooth structure

bull 4 parameters checked for the success of treatment

bull Inclusion of specific score of fluorosis for comparing the results

bull Maximum 3 appointments needed

CRITICAL ANALYSIS

Pros Cons

REFERENCES

bull Gurgan S Cakir FY Yazici E Different light-activated in officebleaching

systems Lasers Med Sci 201025817-22

bull Train TE McWhorter AG Seale NSWilson CF Guo IY Examination of

esthetic improvement and surface alteration following microabrasion in

fluorotic human incisors in vivoPediatr dent 199618353-62

bull Loguercio AD Correia LD Zago C Tagliari D Neumann E Gomes OM et al

Clinical effectiveness of two microabrasion materials materials for the

removal of enamel flurosis stains Oper Dent 200732531-8

4

2

GOALS

1 To facilitate the provision of quality care

2 To minimize the extremes of disruptive behavior

3 To promote a positive psychologic response to treatment

4 To promote patient welfare amp safety

5 To return the patient to physiologic state

OBJECTIVES

1 The pt mood must be altered

2 The pt must remain conscious at all times

3 The pt must be cooperative

4 All protective reflexes must remain intact and active

5 Vital signs must remain stable and with in normal limits

6 The ptrsquos pain threshold should be elevated

7 Amnesia may be present

Indications

1 Preschool children

2 Lack of Psychological Emotional maturity

3 Lack of Cognitive Physical Medical disability

4 Fearful amp anxious pts

5 Pt who require extensive amp complicated dental care amp would require or benefit from prolonged visits

6 Acute pain

7 Traumatic injuries

Operating Facilities amp Equipment

A positive pressure O2 delivery system capable of administering gt than 90 O2 at 10L min flow for 60 min (650L ldquoErdquo cylinder)

OR

Self inflating bag valve mask device (15L min)

A functional suction apparatus with appropriate suction catheters

Monitoring equipment - PO BPC PC or Capno

Inhalation sedation unit

100 O2 amp never less than 25

A fail safe mechanism that is checked and calibrated annually

Must have appropriate scavenging system

Emergency drugs

Techniques of sedation

Routes for drug administration

bull Oral

bull Rectal

bull Inhalational

bull Transmucosal

ndash Sublingual

ndash Intranasal

bull Parenteral

ndash IM

ndash sub mucosal

ndash IV

3

Oral Sedation

Advantages

1 Almost universally accepted and the easiest method

2 Decreased incidence and severity of adverse reaction

3 Low cost

Disadvantages

1 Absorption is variable

2 Prolonged latent period(30 min)

3 Reversal of any unwanted effect is also difficult

4 Inability to readily lighten or deepen the level of sedation

5 Prolonged duration of action

Rectal Sedation

Advantages 1 Incidence and intensity of

drug related side effects is minimized

2 Drug absorption occurs from the large intestine directly into the circulation

3 The lack of a needle syringe or other equipment

4 The ease of administration

5 The low cost

Disadvantages

1 Inconvenience to the administrator amp pt

2 The variable absorption of drugs from the large intestine

3 The slow onset of action amp the relatively long duration of action

4 Inability to titrate the drug dosage

5 The inability to reverse the action of the drug the prolonged recovery

Intranasal sedation

Advantages

Rapid onset (10 ndash 15 min)

Simple amp relatively painless

Less pt cooperation is required

Absorbed directly into the C V S

Intranasal sedation

Disadvantages

1 Dependence on nasal mucous membrane

2 Shorter duration of action(40-60min)

3 Multiple dosage may be necessary

Drugs

Midazolam ndash 02mgkg

Sufentanil ndash 15 ndash 3 mcgkg

Ketamine ndash 3-6mg kg

Sublingual sedation

Advantages

1 Pt acceptance

2 Rapid onset

3 High bioavailability

Drugs

Oral Transmucosal Fentanyl Citrate (OTFC)

Intramuscular Sedation

Advantages

1 More rapid onset of action

2 Absorbed directly into the C V system

3 More reliable absorption of drug

4 Pt cooperation is not as essential

Disadvantages

1 Time factor ndash its 15 min latent period

2 Pt may not be willing to accept the injection

3 The prolonged duration of action(2-4 hrs more)

4 Possibility of injury to the tissues at the site of injection caused by either the drug or the needle

4

Sites of I M administration

1 Gluteal area

2 Vastus lateralis

3 Mid ndash deltoid area

Drugs

Diazepam

Midazolam

Hydroxyzine

Inhalation Sedation

Advantages

1 The onset of action is more rapid

2 Peak clinical level is achieved rapidly(3-5min) - permit titration

3 Administrator has complete control over the actions of the drug - safety feature

4 No significant over dosage

5 Flexible duration of action

6 Recovery time is rapid amp most complete

7 No injection is required

8 With N2O- O2 it is safe with very few side effects

Disadvantages

1 The initial cost of the equipment is high 2 The continuing cost of the gases is high 3 The equipment occupies considerable space 4 N2O is not a potent agent 5 A degree of cooperation is required from the pt 6 Chronic exposure to N2O is deleterious to the health of

dental personnel

Contraindications

1 Nasal obstruction 2 Cyanosis at rest 3 Poor cooperation 4 1st trimester of pregnancy 5 Fear of masks

I V Sedation

Advantages

1 The onset of action is the most rapid 2 The dosage may be titrated 3 Suitable level of sedation can be provided 4 The recovery period is shorter 5 Side effects are extremely uncommon 6 Control of salivary secretions is possible 7 The gag reflex is diminished 8 Effectively diminishes motor disturbances 9 Provides immediate access to CVS in emergency

Disadvantages

1 Venipuncture is necessary

2 Complication may rise at the site of the venipuncture

3 Monitoring must be more intensive

4 Recovery is not complete at the end of the procedure

5 Reversal of sedation is difficult

5

N2O-O2 (Relative Analgesia)

colorless sweet smelling gas

Pharmacokinetics

Absorption through pulmonary epithelium

It is approx 15 times as soluble as is nitrogen It replaces nitrogen in blood

It is carried in solution in plasma of the blood

It is not metabolized by the body

Elimination ndash majorndash lungs minor --- skin

perspiration urine and intestinal gas

Pharmacodynamics

Dose related

10 ndash 25 Lightheaded

Changes in visual amp auditory sensation

Tingling of hands amp feet

Suffusing warmth

Remote from the immediate environment

Reduced anxiety

25-50 max analgesic properties and aberration of vision hearing and proprioception mild drowsiness euphoria amnesia and increased sleepiness and dreams

35 conc will achieve maximum analgesia

bull CNS

ndash Cerebrum-primarily affected

ndash Safe but weak anesthetic agent

bull RESPIRATORY SYSTEM

ndash Increased Tidal and minute volumes

bull CARDIOVASCULAR SYSTEM

ndash 2 studies ndash decreased cardiac output

bull FETAL SYSTEMS

ndash Miscarriage in humans

bull OTHER SYSTEMS

ndash Depression of spinal reflexes increase muscle tone indicates stage of delirium

ndash Muscle rigidity-narcotics + nitrous oxide

ndash Nausea and vomitting - GIT

ndash HEMATOPOIESIS ----- prolonged exposure

Adverse reactions and toxicity

EMOTIONAL REACTIONS

DREAMS HALLUCINATIONS

No acute toxicity

Chronic toxicity ndash bone marrow

depression

PROCEDURE

Diffusion Hypoxia

Sevoflurane

A fluorinated derivative of isopropyl ether ndash synthesized in 1970

Potent anaesthetic agent with rapid uptake amp speedy recovery

Day-case surgery

Problem

Attaching vaporiser to any of the currently available machine

BENZODIAZEPINES

Diazepam 1961 lipid soluble

Uses-alcoholism epilepsy labor tetanus and cerebral palsy

- sedation and amnesia

- varieties of neurosis amp anxiety states

Pharmacokinetics

Orally Rectal IMIV or SC

Well absorbed through GIT

Excretion in urine

6

bull Pharmacodynamics

ndash Depress the brain stem reticular system and the limbic system thalamus and hypothalamus

ndash It is a centrally acting muscle relaxant Has anti-convulsant properties

Adverse reaction amp toxicity

ndash Confusion nausea headache increased appetite decreased salivation and jaundice Thrombophlebitis

ndash Rebound phenomenon

ndash Toxicity drowsiness confusion sleep and coma

Dosage Oral or Rectal ndash 02-05mgkg

Maximum single dose 10mg

IV- 025mgkg

Supplied Tablets 2 5 10 mg

Suspension ndash 5mg

Midazolam Water soluble ndash non-irritant

Oral IM IV

Metabolism- liver

Onset IV 3 -5mins

oral 20 ndash 30mins

Oral administration anxious patients requiring relatively short dental procedure

No rebound phenomenon

Better anxiolysis amp amnesia (retrograde amnesia)

Adverse effects Respiratory depression

dose dependant apnea

Dosage Oral ndash 025 to 1mgkg to maximum single dose 20mg

IM ndash 01 to 015mgkg to a maximum of 10mg

IV ndash slow IV

Supplied Syrup ndash 2mgml

Injectable ndash 1mgml amp 5mgml vials

Flumazenil specific benzodiazepines antagonist

selectively inhibits CNS effects

IV administration amp not recommended below 18yrs of age

02mg over 15 seconds after 45seconds 02mg then after 60seconds to maximum of 1mg

Sedative-Hypnotics

Barbiturates First truly effective drugs for the management of anxiety Generalized CNS depressants Produce dose dependent effects

Sedation ---- sleep ---- GA ---- coma

Suppress the CNS and result in sedation and amnesia Advantages

Rapid onset and short duration Disadvantages

no analgesic effect and possible hypotension Must be used with caution in trauma patients because they may cause

apnea and hypoventilation

DOSE Pentobarbital Sodium 100mg Secobarbital Sodium 100 to 200mg Children 30 to 100mg

bull Chloral Hydrates (Mickey Finn Knock out drops ) First synthesized in 1832 first member of the hypnotic group of drugs

Widely used as conscious sedation agent

Properties

Unpleasant taste

Nausea vomiting

Quite irritating to skin and to mucous membranes

GI irritation

Dosages Individualized for each patient 25 ndash 50mgkg

maximum of 1g

Supplied oral capsule ndash 500mg

oral solution ndash 250 amp 500mg5ml

Rectal suppositories ndash 324 amp 648mg

Narcotics

Do produce sedation amp euphoria greater in children

LA is required but dose should be decreased

Meperidine Synthetic opiate agonist

Very water soluble

Orally SC IM or IV

Peak effect by oral 1 hr amp lasts upto 4 hrs

Adverse reactions

-Seizures

-Extreme caution in hepatic or renal diseases or history of seizures

7

Dosage Oral SC or IM ndash 1to 22mgkg not to exceed 100 mg

Supplied Oral Tablets ndash 50 amp 100mg

Oral Syrup ndash 50mgml

Parental solution ndash 25 50 75 amp 100mgml

Fentanyl

Synthetic opiate narcotic analgesic

Very potent 01mg = 10mg Morophine75mg Meperidine

Pharmacokinetics

IV IM SM

Metabolized in liver Excreted in urine

Fentanyl Onset ndash 7 to 15mins

Duration ndash 1 to 2 hrs

Pharmacodynamics

Respiratory depression RR but returns to normal rapidly Tidal volume amp response to co2 depressed for extended period

Apnea

Less emetic than meperidine

NOT RECOMMENDED IN CHILDREN BELOW 2yrs

Dosage 0002 to 0004mgkg

Supplied 005mgml in 2 amp 5ml ampoules

Reversal drug Naloxone

Semisynthetic opiate antagonist

No agonist activity

Onset 2 to 5mins SC or IM amp 1 to 2mins IV

Reversal 45mins

Pt should be kept under continual surveillance

Adverse reaction nausea vomiting sweating hypotension hypertension ventricular tachycardia fibrillation

Dosage IV SC IM 001mgkg then 01mgkg every 2- 3mins maximum 2mg

Supplied 002 004 1mg solutions

Antihistamines

Hydroxyzine

Oral or IM

Effect ndash 15 ndash 30mins

Half-life ndash 3 hrs

Uses

To relieve anxiety

Used as an anti-histamine

Used to control nausea and vomiting including that associated with motion sickness and pregnancy

Adverse reaction dry mouth drowsiness hypersentivity

Dosage Oral ndash 1 to 2mgkg

IM ndash 11mgkg

Promethazine Oral or IM Onset 15 to 60mins Duration 4 to 6 hrs Uses

To prevent and treat nausea and vomiting associated with motion pregnancy or surgery

Produces sedation and reduce swelling pain and trismus

Lower seizure threshold Adverse reaction dry mouth blurred vision thickening of bronchial secretions Dosage OralIM ndash 05-11mgkg

maximum 25 mg

Diphenhydramine

Oral IM IV

Onset -1hr

Duration ndash 4 to 6 hr

Metabolized in liver

Adverse reaction disturbed coordination thickening of bronchial secretions

Dosage Oral IM IV ndash 1 to 15mgkg

maximum 50mg

Tranquilizers

Major tranquilizer antipsychotic produce calmness control symptoms of psychoses cause reversible extra pyramidal symptoms and do not tend to cause habituation

Minor tranquilizer antianxiety agents also cause calmness do not cause extrapyramidal symptoms Used in conditions like nervous tension and mild depression

8

Classification

Antipsychotics

Phenothiazine derivatives

Chlorpromazine promazine

Butryophenones

Haloperidol

Rauwolfia alkaloids

Reserpine

Antianxiety drugs

Propyl alcohol derivatives

Meprobamate

Benzodiazepine derivatives

Diazepam

Miscellaneous compounds

Hydroxyzine

Meprobamate

White crystalline powder slightly bitter in taste

Only administered orally

Peak blood concentration ----1 to 3hrs

10 ---------excreted unchanged Rest --- excreted as a oxidized derivative or as a glucoronide

Uses

To relieve day time anxiety

Induce sleep in insomniacs

To reduce anxiety associated with dental treatment

Anti-convulsant ndash petit mal epilepsy

Adverse reaction leucopenia acute non-thrombocytopenic purpura ecchymoses eosinophilia edema adenopathy

Dosage Childrengt 6yrs 100 to 200mg

Not recommended for children under 6yrs

Monitoring during sedation

1 Pulse

2 Blood pressure

3 ECG

4 Respiration

5 Temperature

Pulse

Manual Electronic

bull Radial Brachial

bull Facial labial

Blood pressure

ndash Stethoscope amp sphygmomanometer

ndash Automatic devices

ndash Direct cannulation of an artery ndash very accurate

Electrocardiograph

Heart rate rhythm myocardial function

9

Respiration

ndash Monitoring respiratory rate

ndash Observing the rise amp fall of the chest wall

ndash Observing the color of mucous membrane

ndash Observing the inflation amp deflation of the reservoir bag

Devices for monitoring respiration

1 The Precordial pretracheal stethoscope

2 The esophageal stethoscope

ndash Respiratory rate

ndash Heart rate

ndash Any abnormal sounds

Pulse Oximeter

ndash Oxygen saturation

ndash Heart rate

ndash Oxisensor site

ndash Fingers

ndash Toe

ndash Ear lobe

Mechanism

Oxygenated Hb ndash red light

Deoxygenated Hb- infrared light

Tissue pressure from arterial pulse (plethysmography)

Advantages

ndash Safe amp noninvasive

ndash Simple to use

ndash Information is rapidly available for clinical decision

ndash Indirectly indicates respiratory adequacy

Disadvantages

ndash Finger probes can get dislodged

ndash Emitted light source may cause burning

ndash Non reusable probes are expensive

ndash Does not directly determine airway patency

Capnography

1 The presence absence of air flow

2 Indicates depth amp adequacy of respiration

3 Continues analysis of the co2 content of the respired air ndash indicates respiratory adequacy

Temperature

ndash Disposable nondisposable thermometer

ndash Esophageal rectal temp probe

10

Discharge criteria

Cardiovascular function is satisfactory amp stable

Airway patency is uncompromised amp satisfactory

Pt is easily arousable amp protective reflexes intact

State of hydration is adequate

Pt can talk if applicable

Pt can sit unaided if applicable

Pt can ambulate with minimal assistance if applicable

Presedation level of responsiveness achieved

Responsible individual is available

1

PULP THERAPY OF VITAL TEETH

DR MITAKSHARA NIRWAN

Contents

Indirect pulp capping

Direct pulp capping

Medications amp materials used in pulp capping

Pulpotomy

MTA

Apexogenesis

INDIRECT PULP CAPPING

Pieter Van Forest - first to speak about root canal therapy

Glove designed instruments that could prepare a canal to a certain size and taper(1910)

Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in

deep areas of cavity to avoid exposure of pulp followed by placement of a suitable medicament and

restorative material that seals off the carious dentin and encourages pulp recovery (Ingle)

A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a

time with a biocompatible material (McDonald)

Objective of indirect pulp capping

These were given by Eidelman in 1965

bull Arresting the carious process

bull Promoting dentin sclerosis

bull Stimulating formation of tertiary dentin

bull Remineralization of carious dentin

Layers of Carious Dentin Indications of Indirect Pulp Capping

History

Mild pain associated with eating

Negative history of spontaneous extreme pain

Clinical Examination

Deep carious lesion which are close tobut not involving the pulp in vital primary or young

permanent teeth

No mobility

Nominal pulp inflammationdefinite layer of affected dentin after removal of infected dentin

Radiographic examination

Normal lamina dura amp PDL space

No radiolucency around the apices

2

Contraindications of Indirect Pulp Capping

History

Sharp penetrating pulpalgia

Prolonged spontaneous pain especially at night

Clinical examination

Mobility of tooth

Discoloration of tooth

Negative reaction of electric pulp testing

Radiographic examination

Definite pulp exposure

Break in the lamina dura

Radiolucency around the apices

Widened PDL space

Treatment procedure

Sequelae of Indirect Pulp Capping Three distinct types of new dentin formation take place

1 Cellular fibrillar dentinmdashfirst 2 months

2 Globular dentinmdash3 months

3 Tubular dentin (uniform mineralized dentin)

bull 15th of reparative dentin formation begins in less than 30 days

bull After 3 months 01 mm is formed

DIRECT PULP CAPPING Defined by Kopel (1992) as the placement of a medicament or non medicated material on a pulp that

has been exposed in course of excavating the last portions of deep dentinal caries or as a result of

trauma

Objective

To create new dentin in the area of the exposure and subsequent healing of the pulp

Rationale

achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge)

between pulp tissue and capping material thus walling off the

INDICATIONS

Small mechanical exposure

Easily controlled haemorrhage

Bright red haemorrhage

True pinpoint exposure

CONTRAINDICATIONS

Severe toothache at night

Spontaneous pain

Tooth mobility

Radiographic appearance of pulp periradicular de- generation

Excess of hemorrhage at the time of exposure Serous exudate from the exposure

Externalinternal root resorption

Swellingfistula

Histological Changes after Pulp Capping

These were illustrated be Glass and Zander in 1949

After 24 hours Necrotic zone adjacent to calcium

hydroxide paste is separated from healthy pulp

tissue by a deep staining basophilic layer

After 7 days Increase in cellular and fibroblastic

activity

After 14 days Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium

proteinate zone disappearance of necrotic zone

After 28 days Zone of new dentin

3

Medications and Materials Used for Pulp Capping Calcium hydroxide

Corticosteroids amp antibiotics

Inert materials

Collagen fibers

4-META adhesive

Direct bonding

Isobutyl cyanoacrylate

Denatured albumin

Mineral trioxide aggregate

Laser

Bone morphogenic protein

PULPOTOMY

Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp

followed by placement of a suitable dressing or medicament that will promote healing and

preserve vitality of the tooth

American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of

affected infected coronal portion of the dental pulp preserving the vitality and function of the

remaining part of radicular pulp

Objectives

bull Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the

radicular pulp and allowing it to heal

bull Maintain the tooth in the dental arch

Rationale

bull Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp

bull Preserves vitality of the radicular pulp

bull Maintains tooth in a physiologic condition

Indications of Pulpotomy bull Mechanical pulp exposure in primary teeth

bull Teeth showing a large carious lesion but free of radicular pulpitis

bull History of only spontaneous pain

bull Hemorrhage from exposure sites bright red and can be controlled

bull Absence of abscess or fistula

bull No interradicular bone loss

bull No interradicular radiolucency

Contraindications of Pulpotomy bull Persistent toothache

bull Tenderness on percussion

bull Root resorption more than 13rd of root length

bull Large carious lesion with nonrestorable crown

bull Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable

bull Medical contradictions like heart disease immuno compromised patient

bull Swelling or fistula

bull External or internal resorption

bull Pathological mobility

bull Calcification of pulp

Classification of pulpotomy

4

Formocresol Pulpotomy

Iby BUCKLEY in 1904

Sweet (1930) Formulated multi visit technique

Doyle (1962) Advocated 2 sitting procedure (complete devitalization)

Spedding (1965) Gave 5 minute protocol (partial devitali- zation)

Venham (1967) Proposed 15 seconds procedure

Current concept uses 4 minutes of application time

Composition of formocresol Buckleyrsquos Formula

bull Cresol ndash 35 percent

bull Glycerol ndash 15 percent

bull Formaldehyde ndash 19 percent

bull Water ndash 31 percent

Mechanism of Action

It prevents tissue autolysis by bonding to the proteins Bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without

changing the basic structure of protein molecules

Histological Changes

bull Demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959

bull Immediately the pulp becomes fibrous and acidophillic

bull Seven to fourteen days Three zones appear

a broad eosinophilic zone of fixation

b broad pale-staining zone of atrophy with poorcellular definition

c broad zone of inflammation extending apically into normal pulp tissue

bull One yearndash Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

Modified Formocresol Pulpotomy

Used by TRASK(1972)

The technique is identical to that described for primary teeth except that the formocresol pellet is

sealed permanently in the tooth

Two-visit Devitalization Pulpotomy

Indications

bull There is evidence of sluggish bleeding at the amputation site that is difficult to control

bull Pus in the chamber but none at the amputation site

bull There is thickening of the PDL

bull History of pain

Contraindications

bull Nonrestorable tooth

bull Tooth with necrotic pulp

5

Glutaraldehyde Pulpotomy

It was first suggested by S Gravenmade Introduced by Kopel in 1979

Mechanism of Action

bull Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue

bull A narrow zone of eosinophilic stained and compressed fixed tissue is found directly beneath the area of application which blends into vital normal appearing tissue apically

bull With time the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue thus the entire root canal tissue is vital

Cvekrsquos Pulpotomy

bull This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy

bull This was proposed by Mejare and Cvek16 in 1978

bull Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the

remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is

notcomplete

MINERAL TRIOXIDE AGGREGATE (MTA) Torabinejad described the physical and chemical properties of MTA in 1995

It is ash colored powder made primarily of fine hydrophilic particles of

1 tricalcium aluminate

2 tricalcium silicate

3 silicate oxide

4 tricalcium oxide

5 bismuth dioxide

Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous

structure This gel solidifies into a hard structure in less than three hours

PROPERTIES OF MTA

It is biocompatible material and its sealing ability is better than that of amalgam or ZOE

Initial pH is 102 and set pH is 125

The setting time of cement is 4 hours

The compressive strength is 70 MPA which is comparable with that of IRM

Low cytotoxicity ndash It presents with minimal inflammation if extended beyond the apex

Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in

pulpal tissues and it promotes rapid cell growth

APEXOGENESIS

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale

Maintenance of integrity of the radicular pulp tissue to allow for continued root growth

Indications

bull Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed

bull No history of spontaneous pain

bull No sensitivity on percussion

bull No hemorrhage

bull Normal radiographic appearance

Contraindications

bull Evidence that radicular pulp has undergone degenerative changes

bull Purulent drainage

bull History of prolonged pain bull Necrotic debris in canal

bull Periapical radiolucency

6

1

Gupta A Dhingra R Chaudhari P Gupta A

Department of Paedodontics and Preventive Dentistry Faculty of Dental Sciences SGT University Gurgaon Haryana India

Journal of Indian Society of Pedodontics and Preventive Dentistry

Volume 35 I Issue 3 I July-September 2017

A COMPARISION OF VARIOUS MINIMALLY

INVASIVE TECHNIQUES FOR THE REMOVAL

OF DENTAL FLUOROSIS STAINS IN

CHILDREN

DR MITAKSHARA NIRWAN

CONTENTS

bull Introduction

bull Aims

bull Materials and Methods

bull Results

bull Discussion

bull Conclusion

bull Critical analysis

bull References

INTRODUCTION

bull Dental fluorosis is a developmental disturbance of dental enamel caused by

successive exposure to high concentrations of fluoride during tooth

development

bull Various methods of therapy are advocated for the treatment of fluorosis -

stained teeth which range from invasive ceramic veneer bonding restorations

to abrasive chemical treatments

bull The combination of dental bleaching techniques and microabrasion appears

as an excellent conservative solution to reestablish health in fluorosis

affected teeth

AIMS

bull The aim of the study was to evaluate and compare the effectiveness of

minimally invasive techniques for the removal of dental fluorosis

stains in children in vivo

MATERIALS AND METHODS

Patients visiting the department of Pedodontics and Preventive dentistry

Faculty of Dental Sciences SGT University Gurgaon

bull Sample size 90 patients

bull Age group 10 -17 years

bull Caries cracks or periodontal

disease on anterior teeth

bull Abscess draining sinus

cellulitis

bull Non vital teeth

hypersensitive exposed

crevices

bull Orthodontic appliance

bull Past history of bleaching

bull At least two permanent

maxillary anterior teeth

bull TSIF of score 4

bull Free of systemic diseases

Inclusion criteria Exclusion criteria

2

Groups

Group A In office bleaching with 35 hydrogen peroxide( Pola Office

Bleaching kit) activated by light emitting diode (LED) bleaching unit

(35 HP)

Group B Enamel microabrasion (EM) (PREMA Enamel Microabrasion

System) followed by in-office bleaching with 44 carbamide peroxide

gel (EM)

Group C In-office bleaching with 5 sodium hypochlorite (5

NaOCl)

A baseline colour evaluation was done by taking digital photograph of

the maxillary anterior teeth

RESULTS

Group 1

Colour stability

Group 2 Group 3

Tooth sensitivity

Tooth sensitivity values were taken before the treatment

which was compared to immediate postoperative and follow

up visits It was checked using an electric pulp tester

maximum

moderate

least

immediately

group 2

group 1

group 3

1 month

group 2

group 1

group 3

3 month

group 2

group 1

group 3

Patient satisfaction score

Satisfaction was assessed on visual analog scale

Range 1 to 5

Groups percentage of patients

who were satisfied with

the treatment

Number of patients

who reported slight

reappearance of colour

Group 1

90

7

Group 2

83

8

Group 3

73

7

3

Number of Appointments

Groups One sitting Two sittings Three

sittings

Group 1

25

4

1

group 2

26

3

1

Group 3

30

0

0

DISCUSSION

bull Hydrogen peroxide is capable of penetrating the tooth osmosis and through porosities and cracks subsequently acting directly on the pigmented molecules

bull Gurgan et al investigated 3 different light systems and found out that diode laser system with gave best tooth whitening and least tooth sensitivity

bull In the EM group the surface reflects and refracts light from the surface in such way that mild imperfections in underlying enamel are camouflaged While the highly polished surface of enamel enhances the aesthetic appearance

bull Train et al and Loguercio et al also had the similar results in their studies with EM mild fluorosis showed best results moderate showed moderate results while it had little effect on severe fluorosis

bull NaOCl was only effective on mild stains while moderate and severe

stains could only be lightened to quite an extent but could not be

completely removed

bull When NaOCl comes in contact with hypomineralized and discoloured

enamel it degrades and removes the chromogenic organic material

located on the enamel surface

CONCLUSION

bull It was concluded that esthetic appearance of teeth mild fluorosis can

be achieved by bleaching and microabrasion But in cases of

moderate fluorosis a combination of any of theses modalities can be

used

bull As no special maintenance precautions are required these maybe be

considered as an interesting alternative to conventional operative

treatment

bull Focuses on only TSIF of 4

bull Electric pulp testing is not the

right method to check for

sensitivity

bull Tooth Sensitivity changes

from person to person

bull Food habits can cause

staining of the teeth

bull Minimally invasive

bull Cheaper to veneers

bull Minimal loss of tooth structure

bull 4 parameters checked for the success of treatment

bull Inclusion of specific score of fluorosis for comparing the results

bull Maximum 3 appointments needed

CRITICAL ANALYSIS

Pros Cons

REFERENCES

bull Gurgan S Cakir FY Yazici E Different light-activated in officebleaching

systems Lasers Med Sci 201025817-22

bull Train TE McWhorter AG Seale NSWilson CF Guo IY Examination of

esthetic improvement and surface alteration following microabrasion in

fluorotic human incisors in vivoPediatr dent 199618353-62

bull Loguercio AD Correia LD Zago C Tagliari D Neumann E Gomes OM et al

Clinical effectiveness of two microabrasion materials materials for the

removal of enamel flurosis stains Oper Dent 200732531-8

4

3

Oral Sedation

Advantages

1 Almost universally accepted and the easiest method

2 Decreased incidence and severity of adverse reaction

3 Low cost

Disadvantages

1 Absorption is variable

2 Prolonged latent period(30 min)

3 Reversal of any unwanted effect is also difficult

4 Inability to readily lighten or deepen the level of sedation

5 Prolonged duration of action

Rectal Sedation

Advantages 1 Incidence and intensity of

drug related side effects is minimized

2 Drug absorption occurs from the large intestine directly into the circulation

3 The lack of a needle syringe or other equipment

4 The ease of administration

5 The low cost

Disadvantages

1 Inconvenience to the administrator amp pt

2 The variable absorption of drugs from the large intestine

3 The slow onset of action amp the relatively long duration of action

4 Inability to titrate the drug dosage

5 The inability to reverse the action of the drug the prolonged recovery

Intranasal sedation

Advantages

Rapid onset (10 ndash 15 min)

Simple amp relatively painless

Less pt cooperation is required

Absorbed directly into the C V S

Intranasal sedation

Disadvantages

1 Dependence on nasal mucous membrane

2 Shorter duration of action(40-60min)

3 Multiple dosage may be necessary

Drugs

Midazolam ndash 02mgkg

Sufentanil ndash 15 ndash 3 mcgkg

Ketamine ndash 3-6mg kg

Sublingual sedation

Advantages

1 Pt acceptance

2 Rapid onset

3 High bioavailability

Drugs

Oral Transmucosal Fentanyl Citrate (OTFC)

Intramuscular Sedation

Advantages

1 More rapid onset of action

2 Absorbed directly into the C V system

3 More reliable absorption of drug

4 Pt cooperation is not as essential

Disadvantages

1 Time factor ndash its 15 min latent period

2 Pt may not be willing to accept the injection

3 The prolonged duration of action(2-4 hrs more)

4 Possibility of injury to the tissues at the site of injection caused by either the drug or the needle

4

Sites of I M administration

1 Gluteal area

2 Vastus lateralis

3 Mid ndash deltoid area

Drugs

Diazepam

Midazolam

Hydroxyzine

Inhalation Sedation

Advantages

1 The onset of action is more rapid

2 Peak clinical level is achieved rapidly(3-5min) - permit titration

3 Administrator has complete control over the actions of the drug - safety feature

4 No significant over dosage

5 Flexible duration of action

6 Recovery time is rapid amp most complete

7 No injection is required

8 With N2O- O2 it is safe with very few side effects

Disadvantages

1 The initial cost of the equipment is high 2 The continuing cost of the gases is high 3 The equipment occupies considerable space 4 N2O is not a potent agent 5 A degree of cooperation is required from the pt 6 Chronic exposure to N2O is deleterious to the health of

dental personnel

Contraindications

1 Nasal obstruction 2 Cyanosis at rest 3 Poor cooperation 4 1st trimester of pregnancy 5 Fear of masks

I V Sedation

Advantages

1 The onset of action is the most rapid 2 The dosage may be titrated 3 Suitable level of sedation can be provided 4 The recovery period is shorter 5 Side effects are extremely uncommon 6 Control of salivary secretions is possible 7 The gag reflex is diminished 8 Effectively diminishes motor disturbances 9 Provides immediate access to CVS in emergency

Disadvantages

1 Venipuncture is necessary

2 Complication may rise at the site of the venipuncture

3 Monitoring must be more intensive

4 Recovery is not complete at the end of the procedure

5 Reversal of sedation is difficult

5

N2O-O2 (Relative Analgesia)

colorless sweet smelling gas

Pharmacokinetics

Absorption through pulmonary epithelium

It is approx 15 times as soluble as is nitrogen It replaces nitrogen in blood

It is carried in solution in plasma of the blood

It is not metabolized by the body

Elimination ndash majorndash lungs minor --- skin

perspiration urine and intestinal gas

Pharmacodynamics

Dose related

10 ndash 25 Lightheaded

Changes in visual amp auditory sensation

Tingling of hands amp feet

Suffusing warmth

Remote from the immediate environment

Reduced anxiety

25-50 max analgesic properties and aberration of vision hearing and proprioception mild drowsiness euphoria amnesia and increased sleepiness and dreams

35 conc will achieve maximum analgesia

bull CNS

ndash Cerebrum-primarily affected

ndash Safe but weak anesthetic agent

bull RESPIRATORY SYSTEM

ndash Increased Tidal and minute volumes

bull CARDIOVASCULAR SYSTEM

ndash 2 studies ndash decreased cardiac output

bull FETAL SYSTEMS

ndash Miscarriage in humans

bull OTHER SYSTEMS

ndash Depression of spinal reflexes increase muscle tone indicates stage of delirium

ndash Muscle rigidity-narcotics + nitrous oxide

ndash Nausea and vomitting - GIT

ndash HEMATOPOIESIS ----- prolonged exposure

Adverse reactions and toxicity

EMOTIONAL REACTIONS

DREAMS HALLUCINATIONS

No acute toxicity

Chronic toxicity ndash bone marrow

depression

PROCEDURE

Diffusion Hypoxia

Sevoflurane

A fluorinated derivative of isopropyl ether ndash synthesized in 1970

Potent anaesthetic agent with rapid uptake amp speedy recovery

Day-case surgery

Problem

Attaching vaporiser to any of the currently available machine

BENZODIAZEPINES

Diazepam 1961 lipid soluble

Uses-alcoholism epilepsy labor tetanus and cerebral palsy

- sedation and amnesia

- varieties of neurosis amp anxiety states

Pharmacokinetics

Orally Rectal IMIV or SC

Well absorbed through GIT

Excretion in urine

6

bull Pharmacodynamics

ndash Depress the brain stem reticular system and the limbic system thalamus and hypothalamus

ndash It is a centrally acting muscle relaxant Has anti-convulsant properties

Adverse reaction amp toxicity

ndash Confusion nausea headache increased appetite decreased salivation and jaundice Thrombophlebitis

ndash Rebound phenomenon

ndash Toxicity drowsiness confusion sleep and coma

Dosage Oral or Rectal ndash 02-05mgkg

Maximum single dose 10mg

IV- 025mgkg

Supplied Tablets 2 5 10 mg

Suspension ndash 5mg

Midazolam Water soluble ndash non-irritant

Oral IM IV

Metabolism- liver

Onset IV 3 -5mins

oral 20 ndash 30mins

Oral administration anxious patients requiring relatively short dental procedure

No rebound phenomenon

Better anxiolysis amp amnesia (retrograde amnesia)

Adverse effects Respiratory depression

dose dependant apnea

Dosage Oral ndash 025 to 1mgkg to maximum single dose 20mg

IM ndash 01 to 015mgkg to a maximum of 10mg

IV ndash slow IV

Supplied Syrup ndash 2mgml

Injectable ndash 1mgml amp 5mgml vials

Flumazenil specific benzodiazepines antagonist

selectively inhibits CNS effects

IV administration amp not recommended below 18yrs of age

02mg over 15 seconds after 45seconds 02mg then after 60seconds to maximum of 1mg

Sedative-Hypnotics

Barbiturates First truly effective drugs for the management of anxiety Generalized CNS depressants Produce dose dependent effects

Sedation ---- sleep ---- GA ---- coma

Suppress the CNS and result in sedation and amnesia Advantages

Rapid onset and short duration Disadvantages

no analgesic effect and possible hypotension Must be used with caution in trauma patients because they may cause

apnea and hypoventilation

DOSE Pentobarbital Sodium 100mg Secobarbital Sodium 100 to 200mg Children 30 to 100mg

bull Chloral Hydrates (Mickey Finn Knock out drops ) First synthesized in 1832 first member of the hypnotic group of drugs

Widely used as conscious sedation agent

Properties

Unpleasant taste

Nausea vomiting

Quite irritating to skin and to mucous membranes

GI irritation

Dosages Individualized for each patient 25 ndash 50mgkg

maximum of 1g

Supplied oral capsule ndash 500mg

oral solution ndash 250 amp 500mg5ml

Rectal suppositories ndash 324 amp 648mg

Narcotics

Do produce sedation amp euphoria greater in children

LA is required but dose should be decreased

Meperidine Synthetic opiate agonist

Very water soluble

Orally SC IM or IV

Peak effect by oral 1 hr amp lasts upto 4 hrs

Adverse reactions

-Seizures

-Extreme caution in hepatic or renal diseases or history of seizures

7

Dosage Oral SC or IM ndash 1to 22mgkg not to exceed 100 mg

Supplied Oral Tablets ndash 50 amp 100mg

Oral Syrup ndash 50mgml

Parental solution ndash 25 50 75 amp 100mgml

Fentanyl

Synthetic opiate narcotic analgesic

Very potent 01mg = 10mg Morophine75mg Meperidine

Pharmacokinetics

IV IM SM

Metabolized in liver Excreted in urine

Fentanyl Onset ndash 7 to 15mins

Duration ndash 1 to 2 hrs

Pharmacodynamics

Respiratory depression RR but returns to normal rapidly Tidal volume amp response to co2 depressed for extended period

Apnea

Less emetic than meperidine

NOT RECOMMENDED IN CHILDREN BELOW 2yrs

Dosage 0002 to 0004mgkg

Supplied 005mgml in 2 amp 5ml ampoules

Reversal drug Naloxone

Semisynthetic opiate antagonist

No agonist activity

Onset 2 to 5mins SC or IM amp 1 to 2mins IV

Reversal 45mins

Pt should be kept under continual surveillance

Adverse reaction nausea vomiting sweating hypotension hypertension ventricular tachycardia fibrillation

Dosage IV SC IM 001mgkg then 01mgkg every 2- 3mins maximum 2mg

Supplied 002 004 1mg solutions

Antihistamines

Hydroxyzine

Oral or IM

Effect ndash 15 ndash 30mins

Half-life ndash 3 hrs

Uses

To relieve anxiety

Used as an anti-histamine

Used to control nausea and vomiting including that associated with motion sickness and pregnancy

Adverse reaction dry mouth drowsiness hypersentivity

Dosage Oral ndash 1 to 2mgkg

IM ndash 11mgkg

Promethazine Oral or IM Onset 15 to 60mins Duration 4 to 6 hrs Uses

To prevent and treat nausea and vomiting associated with motion pregnancy or surgery

Produces sedation and reduce swelling pain and trismus

Lower seizure threshold Adverse reaction dry mouth blurred vision thickening of bronchial secretions Dosage OralIM ndash 05-11mgkg

maximum 25 mg

Diphenhydramine

Oral IM IV

Onset -1hr

Duration ndash 4 to 6 hr

Metabolized in liver

Adverse reaction disturbed coordination thickening of bronchial secretions

Dosage Oral IM IV ndash 1 to 15mgkg

maximum 50mg

Tranquilizers

Major tranquilizer antipsychotic produce calmness control symptoms of psychoses cause reversible extra pyramidal symptoms and do not tend to cause habituation

Minor tranquilizer antianxiety agents also cause calmness do not cause extrapyramidal symptoms Used in conditions like nervous tension and mild depression

8

Classification

Antipsychotics

Phenothiazine derivatives

Chlorpromazine promazine

Butryophenones

Haloperidol

Rauwolfia alkaloids

Reserpine

Antianxiety drugs

Propyl alcohol derivatives

Meprobamate

Benzodiazepine derivatives

Diazepam

Miscellaneous compounds

Hydroxyzine

Meprobamate

White crystalline powder slightly bitter in taste

Only administered orally

Peak blood concentration ----1 to 3hrs

10 ---------excreted unchanged Rest --- excreted as a oxidized derivative or as a glucoronide

Uses

To relieve day time anxiety

Induce sleep in insomniacs

To reduce anxiety associated with dental treatment

Anti-convulsant ndash petit mal epilepsy

Adverse reaction leucopenia acute non-thrombocytopenic purpura ecchymoses eosinophilia edema adenopathy

Dosage Childrengt 6yrs 100 to 200mg

Not recommended for children under 6yrs

Monitoring during sedation

1 Pulse

2 Blood pressure

3 ECG

4 Respiration

5 Temperature

Pulse

Manual Electronic

bull Radial Brachial

bull Facial labial

Blood pressure

ndash Stethoscope amp sphygmomanometer

ndash Automatic devices

ndash Direct cannulation of an artery ndash very accurate

Electrocardiograph

Heart rate rhythm myocardial function

9

Respiration

ndash Monitoring respiratory rate

ndash Observing the rise amp fall of the chest wall

ndash Observing the color of mucous membrane

ndash Observing the inflation amp deflation of the reservoir bag

Devices for monitoring respiration

1 The Precordial pretracheal stethoscope

2 The esophageal stethoscope

ndash Respiratory rate

ndash Heart rate

ndash Any abnormal sounds

Pulse Oximeter

ndash Oxygen saturation

ndash Heart rate

ndash Oxisensor site

ndash Fingers

ndash Toe

ndash Ear lobe

Mechanism

Oxygenated Hb ndash red light

Deoxygenated Hb- infrared light

Tissue pressure from arterial pulse (plethysmography)

Advantages

ndash Safe amp noninvasive

ndash Simple to use

ndash Information is rapidly available for clinical decision

ndash Indirectly indicates respiratory adequacy

Disadvantages

ndash Finger probes can get dislodged

ndash Emitted light source may cause burning

ndash Non reusable probes are expensive

ndash Does not directly determine airway patency

Capnography

1 The presence absence of air flow

2 Indicates depth amp adequacy of respiration

3 Continues analysis of the co2 content of the respired air ndash indicates respiratory adequacy

Temperature

ndash Disposable nondisposable thermometer

ndash Esophageal rectal temp probe

10

Discharge criteria

Cardiovascular function is satisfactory amp stable

Airway patency is uncompromised amp satisfactory

Pt is easily arousable amp protective reflexes intact

State of hydration is adequate

Pt can talk if applicable

Pt can sit unaided if applicable

Pt can ambulate with minimal assistance if applicable

Presedation level of responsiveness achieved

Responsible individual is available

1

PULP THERAPY OF VITAL TEETH

DR MITAKSHARA NIRWAN

Contents

Indirect pulp capping

Direct pulp capping

Medications amp materials used in pulp capping

Pulpotomy

MTA

Apexogenesis

INDIRECT PULP CAPPING

Pieter Van Forest - first to speak about root canal therapy

Glove designed instruments that could prepare a canal to a certain size and taper(1910)

Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in

deep areas of cavity to avoid exposure of pulp followed by placement of a suitable medicament and

restorative material that seals off the carious dentin and encourages pulp recovery (Ingle)

A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a

time with a biocompatible material (McDonald)

Objective of indirect pulp capping

These were given by Eidelman in 1965

bull Arresting the carious process

bull Promoting dentin sclerosis

bull Stimulating formation of tertiary dentin

bull Remineralization of carious dentin

Layers of Carious Dentin Indications of Indirect Pulp Capping

History

Mild pain associated with eating

Negative history of spontaneous extreme pain

Clinical Examination

Deep carious lesion which are close tobut not involving the pulp in vital primary or young

permanent teeth

No mobility

Nominal pulp inflammationdefinite layer of affected dentin after removal of infected dentin

Radiographic examination

Normal lamina dura amp PDL space

No radiolucency around the apices

2

Contraindications of Indirect Pulp Capping

History

Sharp penetrating pulpalgia

Prolonged spontaneous pain especially at night

Clinical examination

Mobility of tooth

Discoloration of tooth

Negative reaction of electric pulp testing

Radiographic examination

Definite pulp exposure

Break in the lamina dura

Radiolucency around the apices

Widened PDL space

Treatment procedure

Sequelae of Indirect Pulp Capping Three distinct types of new dentin formation take place

1 Cellular fibrillar dentinmdashfirst 2 months

2 Globular dentinmdash3 months

3 Tubular dentin (uniform mineralized dentin)

bull 15th of reparative dentin formation begins in less than 30 days

bull After 3 months 01 mm is formed

DIRECT PULP CAPPING Defined by Kopel (1992) as the placement of a medicament or non medicated material on a pulp that

has been exposed in course of excavating the last portions of deep dentinal caries or as a result of

trauma

Objective

To create new dentin in the area of the exposure and subsequent healing of the pulp

Rationale

achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge)

between pulp tissue and capping material thus walling off the

INDICATIONS

Small mechanical exposure

Easily controlled haemorrhage

Bright red haemorrhage

True pinpoint exposure

CONTRAINDICATIONS

Severe toothache at night

Spontaneous pain

Tooth mobility

Radiographic appearance of pulp periradicular de- generation

Excess of hemorrhage at the time of exposure Serous exudate from the exposure

Externalinternal root resorption

Swellingfistula

Histological Changes after Pulp Capping

These were illustrated be Glass and Zander in 1949

After 24 hours Necrotic zone adjacent to calcium

hydroxide paste is separated from healthy pulp

tissue by a deep staining basophilic layer

After 7 days Increase in cellular and fibroblastic

activity

After 14 days Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium

proteinate zone disappearance of necrotic zone

After 28 days Zone of new dentin

3

Medications and Materials Used for Pulp Capping Calcium hydroxide

Corticosteroids amp antibiotics

Inert materials

Collagen fibers

4-META adhesive

Direct bonding

Isobutyl cyanoacrylate

Denatured albumin

Mineral trioxide aggregate

Laser

Bone morphogenic protein

PULPOTOMY

Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp

followed by placement of a suitable dressing or medicament that will promote healing and

preserve vitality of the tooth

American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of

affected infected coronal portion of the dental pulp preserving the vitality and function of the

remaining part of radicular pulp

Objectives

bull Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the

radicular pulp and allowing it to heal

bull Maintain the tooth in the dental arch

Rationale

bull Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp

bull Preserves vitality of the radicular pulp

bull Maintains tooth in a physiologic condition

Indications of Pulpotomy bull Mechanical pulp exposure in primary teeth

bull Teeth showing a large carious lesion but free of radicular pulpitis

bull History of only spontaneous pain

bull Hemorrhage from exposure sites bright red and can be controlled

bull Absence of abscess or fistula

bull No interradicular bone loss

bull No interradicular radiolucency

Contraindications of Pulpotomy bull Persistent toothache

bull Tenderness on percussion

bull Root resorption more than 13rd of root length

bull Large carious lesion with nonrestorable crown

bull Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable

bull Medical contradictions like heart disease immuno compromised patient

bull Swelling or fistula

bull External or internal resorption

bull Pathological mobility

bull Calcification of pulp

Classification of pulpotomy

4

Formocresol Pulpotomy

Iby BUCKLEY in 1904

Sweet (1930) Formulated multi visit technique

Doyle (1962) Advocated 2 sitting procedure (complete devitalization)

Spedding (1965) Gave 5 minute protocol (partial devitali- zation)

Venham (1967) Proposed 15 seconds procedure

Current concept uses 4 minutes of application time

Composition of formocresol Buckleyrsquos Formula

bull Cresol ndash 35 percent

bull Glycerol ndash 15 percent

bull Formaldehyde ndash 19 percent

bull Water ndash 31 percent

Mechanism of Action

It prevents tissue autolysis by bonding to the proteins Bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without

changing the basic structure of protein molecules

Histological Changes

bull Demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959

bull Immediately the pulp becomes fibrous and acidophillic

bull Seven to fourteen days Three zones appear

a broad eosinophilic zone of fixation

b broad pale-staining zone of atrophy with poorcellular definition

c broad zone of inflammation extending apically into normal pulp tissue

bull One yearndash Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

Modified Formocresol Pulpotomy

Used by TRASK(1972)

The technique is identical to that described for primary teeth except that the formocresol pellet is

sealed permanently in the tooth

Two-visit Devitalization Pulpotomy

Indications

bull There is evidence of sluggish bleeding at the amputation site that is difficult to control

bull Pus in the chamber but none at the amputation site

bull There is thickening of the PDL

bull History of pain

Contraindications

bull Nonrestorable tooth

bull Tooth with necrotic pulp

5

Glutaraldehyde Pulpotomy

It was first suggested by S Gravenmade Introduced by Kopel in 1979

Mechanism of Action

bull Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue

bull A narrow zone of eosinophilic stained and compressed fixed tissue is found directly beneath the area of application which blends into vital normal appearing tissue apically

bull With time the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue thus the entire root canal tissue is vital

Cvekrsquos Pulpotomy

bull This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy

bull This was proposed by Mejare and Cvek16 in 1978

bull Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the

remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is

notcomplete

MINERAL TRIOXIDE AGGREGATE (MTA) Torabinejad described the physical and chemical properties of MTA in 1995

It is ash colored powder made primarily of fine hydrophilic particles of

1 tricalcium aluminate

2 tricalcium silicate

3 silicate oxide

4 tricalcium oxide

5 bismuth dioxide

Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous

structure This gel solidifies into a hard structure in less than three hours

PROPERTIES OF MTA

It is biocompatible material and its sealing ability is better than that of amalgam or ZOE

Initial pH is 102 and set pH is 125

The setting time of cement is 4 hours

The compressive strength is 70 MPA which is comparable with that of IRM

Low cytotoxicity ndash It presents with minimal inflammation if extended beyond the apex

Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in

pulpal tissues and it promotes rapid cell growth

APEXOGENESIS

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale

Maintenance of integrity of the radicular pulp tissue to allow for continued root growth

Indications

bull Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed

bull No history of spontaneous pain

bull No sensitivity on percussion

bull No hemorrhage

bull Normal radiographic appearance

Contraindications

bull Evidence that radicular pulp has undergone degenerative changes

bull Purulent drainage

bull History of prolonged pain bull Necrotic debris in canal

bull Periapical radiolucency

6

1

Gupta A Dhingra R Chaudhari P Gupta A

Department of Paedodontics and Preventive Dentistry Faculty of Dental Sciences SGT University Gurgaon Haryana India

Journal of Indian Society of Pedodontics and Preventive Dentistry

Volume 35 I Issue 3 I July-September 2017

A COMPARISION OF VARIOUS MINIMALLY

INVASIVE TECHNIQUES FOR THE REMOVAL

OF DENTAL FLUOROSIS STAINS IN

CHILDREN

DR MITAKSHARA NIRWAN

CONTENTS

bull Introduction

bull Aims

bull Materials and Methods

bull Results

bull Discussion

bull Conclusion

bull Critical analysis

bull References

INTRODUCTION

bull Dental fluorosis is a developmental disturbance of dental enamel caused by

successive exposure to high concentrations of fluoride during tooth

development

bull Various methods of therapy are advocated for the treatment of fluorosis -

stained teeth which range from invasive ceramic veneer bonding restorations

to abrasive chemical treatments

bull The combination of dental bleaching techniques and microabrasion appears

as an excellent conservative solution to reestablish health in fluorosis

affected teeth

AIMS

bull The aim of the study was to evaluate and compare the effectiveness of

minimally invasive techniques for the removal of dental fluorosis

stains in children in vivo

MATERIALS AND METHODS

Patients visiting the department of Pedodontics and Preventive dentistry

Faculty of Dental Sciences SGT University Gurgaon

bull Sample size 90 patients

bull Age group 10 -17 years

bull Caries cracks or periodontal

disease on anterior teeth

bull Abscess draining sinus

cellulitis

bull Non vital teeth

hypersensitive exposed

crevices

bull Orthodontic appliance

bull Past history of bleaching

bull At least two permanent

maxillary anterior teeth

bull TSIF of score 4

bull Free of systemic diseases

Inclusion criteria Exclusion criteria

2

Groups

Group A In office bleaching with 35 hydrogen peroxide( Pola Office

Bleaching kit) activated by light emitting diode (LED) bleaching unit

(35 HP)

Group B Enamel microabrasion (EM) (PREMA Enamel Microabrasion

System) followed by in-office bleaching with 44 carbamide peroxide

gel (EM)

Group C In-office bleaching with 5 sodium hypochlorite (5

NaOCl)

A baseline colour evaluation was done by taking digital photograph of

the maxillary anterior teeth

RESULTS

Group 1

Colour stability

Group 2 Group 3

Tooth sensitivity

Tooth sensitivity values were taken before the treatment

which was compared to immediate postoperative and follow

up visits It was checked using an electric pulp tester

maximum

moderate

least

immediately

group 2

group 1

group 3

1 month

group 2

group 1

group 3

3 month

group 2

group 1

group 3

Patient satisfaction score

Satisfaction was assessed on visual analog scale

Range 1 to 5

Groups percentage of patients

who were satisfied with

the treatment

Number of patients

who reported slight

reappearance of colour

Group 1

90

7

Group 2

83

8

Group 3

73

7

3

Number of Appointments

Groups One sitting Two sittings Three

sittings

Group 1

25

4

1

group 2

26

3

1

Group 3

30

0

0

DISCUSSION

bull Hydrogen peroxide is capable of penetrating the tooth osmosis and through porosities and cracks subsequently acting directly on the pigmented molecules

bull Gurgan et al investigated 3 different light systems and found out that diode laser system with gave best tooth whitening and least tooth sensitivity

bull In the EM group the surface reflects and refracts light from the surface in such way that mild imperfections in underlying enamel are camouflaged While the highly polished surface of enamel enhances the aesthetic appearance

bull Train et al and Loguercio et al also had the similar results in their studies with EM mild fluorosis showed best results moderate showed moderate results while it had little effect on severe fluorosis

bull NaOCl was only effective on mild stains while moderate and severe

stains could only be lightened to quite an extent but could not be

completely removed

bull When NaOCl comes in contact with hypomineralized and discoloured

enamel it degrades and removes the chromogenic organic material

located on the enamel surface

CONCLUSION

bull It was concluded that esthetic appearance of teeth mild fluorosis can

be achieved by bleaching and microabrasion But in cases of

moderate fluorosis a combination of any of theses modalities can be

used

bull As no special maintenance precautions are required these maybe be

considered as an interesting alternative to conventional operative

treatment

bull Focuses on only TSIF of 4

bull Electric pulp testing is not the

right method to check for

sensitivity

bull Tooth Sensitivity changes

from person to person

bull Food habits can cause

staining of the teeth

bull Minimally invasive

bull Cheaper to veneers

bull Minimal loss of tooth structure

bull 4 parameters checked for the success of treatment

bull Inclusion of specific score of fluorosis for comparing the results

bull Maximum 3 appointments needed

CRITICAL ANALYSIS

Pros Cons

REFERENCES

bull Gurgan S Cakir FY Yazici E Different light-activated in officebleaching

systems Lasers Med Sci 201025817-22

bull Train TE McWhorter AG Seale NSWilson CF Guo IY Examination of

esthetic improvement and surface alteration following microabrasion in

fluorotic human incisors in vivoPediatr dent 199618353-62

bull Loguercio AD Correia LD Zago C Tagliari D Neumann E Gomes OM et al

Clinical effectiveness of two microabrasion materials materials for the

removal of enamel flurosis stains Oper Dent 200732531-8

4

4

Sites of I M administration

1 Gluteal area

2 Vastus lateralis

3 Mid ndash deltoid area

Drugs

Diazepam

Midazolam

Hydroxyzine

Inhalation Sedation

Advantages

1 The onset of action is more rapid

2 Peak clinical level is achieved rapidly(3-5min) - permit titration

3 Administrator has complete control over the actions of the drug - safety feature

4 No significant over dosage

5 Flexible duration of action

6 Recovery time is rapid amp most complete

7 No injection is required

8 With N2O- O2 it is safe with very few side effects

Disadvantages

1 The initial cost of the equipment is high 2 The continuing cost of the gases is high 3 The equipment occupies considerable space 4 N2O is not a potent agent 5 A degree of cooperation is required from the pt 6 Chronic exposure to N2O is deleterious to the health of

dental personnel

Contraindications

1 Nasal obstruction 2 Cyanosis at rest 3 Poor cooperation 4 1st trimester of pregnancy 5 Fear of masks

I V Sedation

Advantages

1 The onset of action is the most rapid 2 The dosage may be titrated 3 Suitable level of sedation can be provided 4 The recovery period is shorter 5 Side effects are extremely uncommon 6 Control of salivary secretions is possible 7 The gag reflex is diminished 8 Effectively diminishes motor disturbances 9 Provides immediate access to CVS in emergency

Disadvantages

1 Venipuncture is necessary

2 Complication may rise at the site of the venipuncture

3 Monitoring must be more intensive

4 Recovery is not complete at the end of the procedure

5 Reversal of sedation is difficult

5

N2O-O2 (Relative Analgesia)

colorless sweet smelling gas

Pharmacokinetics

Absorption through pulmonary epithelium

It is approx 15 times as soluble as is nitrogen It replaces nitrogen in blood

It is carried in solution in plasma of the blood

It is not metabolized by the body

Elimination ndash majorndash lungs minor --- skin

perspiration urine and intestinal gas

Pharmacodynamics

Dose related

10 ndash 25 Lightheaded

Changes in visual amp auditory sensation

Tingling of hands amp feet

Suffusing warmth

Remote from the immediate environment

Reduced anxiety

25-50 max analgesic properties and aberration of vision hearing and proprioception mild drowsiness euphoria amnesia and increased sleepiness and dreams

35 conc will achieve maximum analgesia

bull CNS

ndash Cerebrum-primarily affected

ndash Safe but weak anesthetic agent

bull RESPIRATORY SYSTEM

ndash Increased Tidal and minute volumes

bull CARDIOVASCULAR SYSTEM

ndash 2 studies ndash decreased cardiac output

bull FETAL SYSTEMS

ndash Miscarriage in humans

bull OTHER SYSTEMS

ndash Depression of spinal reflexes increase muscle tone indicates stage of delirium

ndash Muscle rigidity-narcotics + nitrous oxide

ndash Nausea and vomitting - GIT

ndash HEMATOPOIESIS ----- prolonged exposure

Adverse reactions and toxicity

EMOTIONAL REACTIONS

DREAMS HALLUCINATIONS

No acute toxicity

Chronic toxicity ndash bone marrow

depression

PROCEDURE

Diffusion Hypoxia

Sevoflurane

A fluorinated derivative of isopropyl ether ndash synthesized in 1970

Potent anaesthetic agent with rapid uptake amp speedy recovery

Day-case surgery

Problem

Attaching vaporiser to any of the currently available machine

BENZODIAZEPINES

Diazepam 1961 lipid soluble

Uses-alcoholism epilepsy labor tetanus and cerebral palsy

- sedation and amnesia

- varieties of neurosis amp anxiety states

Pharmacokinetics

Orally Rectal IMIV or SC

Well absorbed through GIT

Excretion in urine

6

bull Pharmacodynamics

ndash Depress the brain stem reticular system and the limbic system thalamus and hypothalamus

ndash It is a centrally acting muscle relaxant Has anti-convulsant properties

Adverse reaction amp toxicity

ndash Confusion nausea headache increased appetite decreased salivation and jaundice Thrombophlebitis

ndash Rebound phenomenon

ndash Toxicity drowsiness confusion sleep and coma

Dosage Oral or Rectal ndash 02-05mgkg

Maximum single dose 10mg

IV- 025mgkg

Supplied Tablets 2 5 10 mg

Suspension ndash 5mg

Midazolam Water soluble ndash non-irritant

Oral IM IV

Metabolism- liver

Onset IV 3 -5mins

oral 20 ndash 30mins

Oral administration anxious patients requiring relatively short dental procedure

No rebound phenomenon

Better anxiolysis amp amnesia (retrograde amnesia)

Adverse effects Respiratory depression

dose dependant apnea

Dosage Oral ndash 025 to 1mgkg to maximum single dose 20mg

IM ndash 01 to 015mgkg to a maximum of 10mg

IV ndash slow IV

Supplied Syrup ndash 2mgml

Injectable ndash 1mgml amp 5mgml vials

Flumazenil specific benzodiazepines antagonist

selectively inhibits CNS effects

IV administration amp not recommended below 18yrs of age

02mg over 15 seconds after 45seconds 02mg then after 60seconds to maximum of 1mg

Sedative-Hypnotics

Barbiturates First truly effective drugs for the management of anxiety Generalized CNS depressants Produce dose dependent effects

Sedation ---- sleep ---- GA ---- coma

Suppress the CNS and result in sedation and amnesia Advantages

Rapid onset and short duration Disadvantages

no analgesic effect and possible hypotension Must be used with caution in trauma patients because they may cause

apnea and hypoventilation

DOSE Pentobarbital Sodium 100mg Secobarbital Sodium 100 to 200mg Children 30 to 100mg

bull Chloral Hydrates (Mickey Finn Knock out drops ) First synthesized in 1832 first member of the hypnotic group of drugs

Widely used as conscious sedation agent

Properties

Unpleasant taste

Nausea vomiting

Quite irritating to skin and to mucous membranes

GI irritation

Dosages Individualized for each patient 25 ndash 50mgkg

maximum of 1g

Supplied oral capsule ndash 500mg

oral solution ndash 250 amp 500mg5ml

Rectal suppositories ndash 324 amp 648mg

Narcotics

Do produce sedation amp euphoria greater in children

LA is required but dose should be decreased

Meperidine Synthetic opiate agonist

Very water soluble

Orally SC IM or IV

Peak effect by oral 1 hr amp lasts upto 4 hrs

Adverse reactions

-Seizures

-Extreme caution in hepatic or renal diseases or history of seizures

7

Dosage Oral SC or IM ndash 1to 22mgkg not to exceed 100 mg

Supplied Oral Tablets ndash 50 amp 100mg

Oral Syrup ndash 50mgml

Parental solution ndash 25 50 75 amp 100mgml

Fentanyl

Synthetic opiate narcotic analgesic

Very potent 01mg = 10mg Morophine75mg Meperidine

Pharmacokinetics

IV IM SM

Metabolized in liver Excreted in urine

Fentanyl Onset ndash 7 to 15mins

Duration ndash 1 to 2 hrs

Pharmacodynamics

Respiratory depression RR but returns to normal rapidly Tidal volume amp response to co2 depressed for extended period

Apnea

Less emetic than meperidine

NOT RECOMMENDED IN CHILDREN BELOW 2yrs

Dosage 0002 to 0004mgkg

Supplied 005mgml in 2 amp 5ml ampoules

Reversal drug Naloxone

Semisynthetic opiate antagonist

No agonist activity

Onset 2 to 5mins SC or IM amp 1 to 2mins IV

Reversal 45mins

Pt should be kept under continual surveillance

Adverse reaction nausea vomiting sweating hypotension hypertension ventricular tachycardia fibrillation

Dosage IV SC IM 001mgkg then 01mgkg every 2- 3mins maximum 2mg

Supplied 002 004 1mg solutions

Antihistamines

Hydroxyzine

Oral or IM

Effect ndash 15 ndash 30mins

Half-life ndash 3 hrs

Uses

To relieve anxiety

Used as an anti-histamine

Used to control nausea and vomiting including that associated with motion sickness and pregnancy

Adverse reaction dry mouth drowsiness hypersentivity

Dosage Oral ndash 1 to 2mgkg

IM ndash 11mgkg

Promethazine Oral or IM Onset 15 to 60mins Duration 4 to 6 hrs Uses

To prevent and treat nausea and vomiting associated with motion pregnancy or surgery

Produces sedation and reduce swelling pain and trismus

Lower seizure threshold Adverse reaction dry mouth blurred vision thickening of bronchial secretions Dosage OralIM ndash 05-11mgkg

maximum 25 mg

Diphenhydramine

Oral IM IV

Onset -1hr

Duration ndash 4 to 6 hr

Metabolized in liver

Adverse reaction disturbed coordination thickening of bronchial secretions

Dosage Oral IM IV ndash 1 to 15mgkg

maximum 50mg

Tranquilizers

Major tranquilizer antipsychotic produce calmness control symptoms of psychoses cause reversible extra pyramidal symptoms and do not tend to cause habituation

Minor tranquilizer antianxiety agents also cause calmness do not cause extrapyramidal symptoms Used in conditions like nervous tension and mild depression

8

Classification

Antipsychotics

Phenothiazine derivatives

Chlorpromazine promazine

Butryophenones

Haloperidol

Rauwolfia alkaloids

Reserpine

Antianxiety drugs

Propyl alcohol derivatives

Meprobamate

Benzodiazepine derivatives

Diazepam

Miscellaneous compounds

Hydroxyzine

Meprobamate

White crystalline powder slightly bitter in taste

Only administered orally

Peak blood concentration ----1 to 3hrs

10 ---------excreted unchanged Rest --- excreted as a oxidized derivative or as a glucoronide

Uses

To relieve day time anxiety

Induce sleep in insomniacs

To reduce anxiety associated with dental treatment

Anti-convulsant ndash petit mal epilepsy

Adverse reaction leucopenia acute non-thrombocytopenic purpura ecchymoses eosinophilia edema adenopathy

Dosage Childrengt 6yrs 100 to 200mg

Not recommended for children under 6yrs

Monitoring during sedation

1 Pulse

2 Blood pressure

3 ECG

4 Respiration

5 Temperature

Pulse

Manual Electronic

bull Radial Brachial

bull Facial labial

Blood pressure

ndash Stethoscope amp sphygmomanometer

ndash Automatic devices

ndash Direct cannulation of an artery ndash very accurate

Electrocardiograph

Heart rate rhythm myocardial function

9

Respiration

ndash Monitoring respiratory rate

ndash Observing the rise amp fall of the chest wall

ndash Observing the color of mucous membrane

ndash Observing the inflation amp deflation of the reservoir bag

Devices for monitoring respiration

1 The Precordial pretracheal stethoscope

2 The esophageal stethoscope

ndash Respiratory rate

ndash Heart rate

ndash Any abnormal sounds

Pulse Oximeter

ndash Oxygen saturation

ndash Heart rate

ndash Oxisensor site

ndash Fingers

ndash Toe

ndash Ear lobe

Mechanism

Oxygenated Hb ndash red light

Deoxygenated Hb- infrared light

Tissue pressure from arterial pulse (plethysmography)

Advantages

ndash Safe amp noninvasive

ndash Simple to use

ndash Information is rapidly available for clinical decision

ndash Indirectly indicates respiratory adequacy

Disadvantages

ndash Finger probes can get dislodged

ndash Emitted light source may cause burning

ndash Non reusable probes are expensive

ndash Does not directly determine airway patency

Capnography

1 The presence absence of air flow

2 Indicates depth amp adequacy of respiration

3 Continues analysis of the co2 content of the respired air ndash indicates respiratory adequacy

Temperature

ndash Disposable nondisposable thermometer

ndash Esophageal rectal temp probe

10

Discharge criteria

Cardiovascular function is satisfactory amp stable

Airway patency is uncompromised amp satisfactory

Pt is easily arousable amp protective reflexes intact

State of hydration is adequate

Pt can talk if applicable

Pt can sit unaided if applicable

Pt can ambulate with minimal assistance if applicable

Presedation level of responsiveness achieved

Responsible individual is available

1

PULP THERAPY OF VITAL TEETH

DR MITAKSHARA NIRWAN

Contents

Indirect pulp capping

Direct pulp capping

Medications amp materials used in pulp capping

Pulpotomy

MTA

Apexogenesis

INDIRECT PULP CAPPING

Pieter Van Forest - first to speak about root canal therapy

Glove designed instruments that could prepare a canal to a certain size and taper(1910)

Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in

deep areas of cavity to avoid exposure of pulp followed by placement of a suitable medicament and

restorative material that seals off the carious dentin and encourages pulp recovery (Ingle)

A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a

time with a biocompatible material (McDonald)

Objective of indirect pulp capping

These were given by Eidelman in 1965

bull Arresting the carious process

bull Promoting dentin sclerosis

bull Stimulating formation of tertiary dentin

bull Remineralization of carious dentin

Layers of Carious Dentin Indications of Indirect Pulp Capping

History

Mild pain associated with eating

Negative history of spontaneous extreme pain

Clinical Examination

Deep carious lesion which are close tobut not involving the pulp in vital primary or young

permanent teeth

No mobility

Nominal pulp inflammationdefinite layer of affected dentin after removal of infected dentin

Radiographic examination

Normal lamina dura amp PDL space

No radiolucency around the apices

2

Contraindications of Indirect Pulp Capping

History

Sharp penetrating pulpalgia

Prolonged spontaneous pain especially at night

Clinical examination

Mobility of tooth

Discoloration of tooth

Negative reaction of electric pulp testing

Radiographic examination

Definite pulp exposure

Break in the lamina dura

Radiolucency around the apices

Widened PDL space

Treatment procedure

Sequelae of Indirect Pulp Capping Three distinct types of new dentin formation take place

1 Cellular fibrillar dentinmdashfirst 2 months

2 Globular dentinmdash3 months

3 Tubular dentin (uniform mineralized dentin)

bull 15th of reparative dentin formation begins in less than 30 days

bull After 3 months 01 mm is formed

DIRECT PULP CAPPING Defined by Kopel (1992) as the placement of a medicament or non medicated material on a pulp that

has been exposed in course of excavating the last portions of deep dentinal caries or as a result of

trauma

Objective

To create new dentin in the area of the exposure and subsequent healing of the pulp

Rationale

achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge)

between pulp tissue and capping material thus walling off the

INDICATIONS

Small mechanical exposure

Easily controlled haemorrhage

Bright red haemorrhage

True pinpoint exposure

CONTRAINDICATIONS

Severe toothache at night

Spontaneous pain

Tooth mobility

Radiographic appearance of pulp periradicular de- generation

Excess of hemorrhage at the time of exposure Serous exudate from the exposure

Externalinternal root resorption

Swellingfistula

Histological Changes after Pulp Capping

These were illustrated be Glass and Zander in 1949

After 24 hours Necrotic zone adjacent to calcium

hydroxide paste is separated from healthy pulp

tissue by a deep staining basophilic layer

After 7 days Increase in cellular and fibroblastic

activity

After 14 days Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium

proteinate zone disappearance of necrotic zone

After 28 days Zone of new dentin

3

Medications and Materials Used for Pulp Capping Calcium hydroxide

Corticosteroids amp antibiotics

Inert materials

Collagen fibers

4-META adhesive

Direct bonding

Isobutyl cyanoacrylate

Denatured albumin

Mineral trioxide aggregate

Laser

Bone morphogenic protein

PULPOTOMY

Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp

followed by placement of a suitable dressing or medicament that will promote healing and

preserve vitality of the tooth

American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of

affected infected coronal portion of the dental pulp preserving the vitality and function of the

remaining part of radicular pulp

Objectives

bull Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the

radicular pulp and allowing it to heal

bull Maintain the tooth in the dental arch

Rationale

bull Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp

bull Preserves vitality of the radicular pulp

bull Maintains tooth in a physiologic condition

Indications of Pulpotomy bull Mechanical pulp exposure in primary teeth

bull Teeth showing a large carious lesion but free of radicular pulpitis

bull History of only spontaneous pain

bull Hemorrhage from exposure sites bright red and can be controlled

bull Absence of abscess or fistula

bull No interradicular bone loss

bull No interradicular radiolucency

Contraindications of Pulpotomy bull Persistent toothache

bull Tenderness on percussion

bull Root resorption more than 13rd of root length

bull Large carious lesion with nonrestorable crown

bull Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable

bull Medical contradictions like heart disease immuno compromised patient

bull Swelling or fistula

bull External or internal resorption

bull Pathological mobility

bull Calcification of pulp

Classification of pulpotomy

4

Formocresol Pulpotomy

Iby BUCKLEY in 1904

Sweet (1930) Formulated multi visit technique

Doyle (1962) Advocated 2 sitting procedure (complete devitalization)

Spedding (1965) Gave 5 minute protocol (partial devitali- zation)

Venham (1967) Proposed 15 seconds procedure

Current concept uses 4 minutes of application time

Composition of formocresol Buckleyrsquos Formula

bull Cresol ndash 35 percent

bull Glycerol ndash 15 percent

bull Formaldehyde ndash 19 percent

bull Water ndash 31 percent

Mechanism of Action

It prevents tissue autolysis by bonding to the proteins Bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without

changing the basic structure of protein molecules

Histological Changes

bull Demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959

bull Immediately the pulp becomes fibrous and acidophillic

bull Seven to fourteen days Three zones appear

a broad eosinophilic zone of fixation

b broad pale-staining zone of atrophy with poorcellular definition

c broad zone of inflammation extending apically into normal pulp tissue

bull One yearndash Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

Modified Formocresol Pulpotomy

Used by TRASK(1972)

The technique is identical to that described for primary teeth except that the formocresol pellet is

sealed permanently in the tooth

Two-visit Devitalization Pulpotomy

Indications

bull There is evidence of sluggish bleeding at the amputation site that is difficult to control

bull Pus in the chamber but none at the amputation site

bull There is thickening of the PDL

bull History of pain

Contraindications

bull Nonrestorable tooth

bull Tooth with necrotic pulp

5

Glutaraldehyde Pulpotomy

It was first suggested by S Gravenmade Introduced by Kopel in 1979

Mechanism of Action

bull Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue

bull A narrow zone of eosinophilic stained and compressed fixed tissue is found directly beneath the area of application which blends into vital normal appearing tissue apically

bull With time the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue thus the entire root canal tissue is vital

Cvekrsquos Pulpotomy

bull This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy

bull This was proposed by Mejare and Cvek16 in 1978

bull Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the

remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is

notcomplete

MINERAL TRIOXIDE AGGREGATE (MTA) Torabinejad described the physical and chemical properties of MTA in 1995

It is ash colored powder made primarily of fine hydrophilic particles of

1 tricalcium aluminate

2 tricalcium silicate

3 silicate oxide

4 tricalcium oxide

5 bismuth dioxide

Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous

structure This gel solidifies into a hard structure in less than three hours

PROPERTIES OF MTA

It is biocompatible material and its sealing ability is better than that of amalgam or ZOE

Initial pH is 102 and set pH is 125

The setting time of cement is 4 hours

The compressive strength is 70 MPA which is comparable with that of IRM

Low cytotoxicity ndash It presents with minimal inflammation if extended beyond the apex

Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in

pulpal tissues and it promotes rapid cell growth

APEXOGENESIS

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale

Maintenance of integrity of the radicular pulp tissue to allow for continued root growth

Indications

bull Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed

bull No history of spontaneous pain

bull No sensitivity on percussion

bull No hemorrhage

bull Normal radiographic appearance

Contraindications

bull Evidence that radicular pulp has undergone degenerative changes

bull Purulent drainage

bull History of prolonged pain bull Necrotic debris in canal

bull Periapical radiolucency

6

1

Gupta A Dhingra R Chaudhari P Gupta A

Department of Paedodontics and Preventive Dentistry Faculty of Dental Sciences SGT University Gurgaon Haryana India

Journal of Indian Society of Pedodontics and Preventive Dentistry

Volume 35 I Issue 3 I July-September 2017

A COMPARISION OF VARIOUS MINIMALLY

INVASIVE TECHNIQUES FOR THE REMOVAL

OF DENTAL FLUOROSIS STAINS IN

CHILDREN

DR MITAKSHARA NIRWAN

CONTENTS

bull Introduction

bull Aims

bull Materials and Methods

bull Results

bull Discussion

bull Conclusion

bull Critical analysis

bull References

INTRODUCTION

bull Dental fluorosis is a developmental disturbance of dental enamel caused by

successive exposure to high concentrations of fluoride during tooth

development

bull Various methods of therapy are advocated for the treatment of fluorosis -

stained teeth which range from invasive ceramic veneer bonding restorations

to abrasive chemical treatments

bull The combination of dental bleaching techniques and microabrasion appears

as an excellent conservative solution to reestablish health in fluorosis

affected teeth

AIMS

bull The aim of the study was to evaluate and compare the effectiveness of

minimally invasive techniques for the removal of dental fluorosis

stains in children in vivo

MATERIALS AND METHODS

Patients visiting the department of Pedodontics and Preventive dentistry

Faculty of Dental Sciences SGT University Gurgaon

bull Sample size 90 patients

bull Age group 10 -17 years

bull Caries cracks or periodontal

disease on anterior teeth

bull Abscess draining sinus

cellulitis

bull Non vital teeth

hypersensitive exposed

crevices

bull Orthodontic appliance

bull Past history of bleaching

bull At least two permanent

maxillary anterior teeth

bull TSIF of score 4

bull Free of systemic diseases

Inclusion criteria Exclusion criteria

2

Groups

Group A In office bleaching with 35 hydrogen peroxide( Pola Office

Bleaching kit) activated by light emitting diode (LED) bleaching unit

(35 HP)

Group B Enamel microabrasion (EM) (PREMA Enamel Microabrasion

System) followed by in-office bleaching with 44 carbamide peroxide

gel (EM)

Group C In-office bleaching with 5 sodium hypochlorite (5

NaOCl)

A baseline colour evaluation was done by taking digital photograph of

the maxillary anterior teeth

RESULTS

Group 1

Colour stability

Group 2 Group 3

Tooth sensitivity

Tooth sensitivity values were taken before the treatment

which was compared to immediate postoperative and follow

up visits It was checked using an electric pulp tester

maximum

moderate

least

immediately

group 2

group 1

group 3

1 month

group 2

group 1

group 3

3 month

group 2

group 1

group 3

Patient satisfaction score

Satisfaction was assessed on visual analog scale

Range 1 to 5

Groups percentage of patients

who were satisfied with

the treatment

Number of patients

who reported slight

reappearance of colour

Group 1

90

7

Group 2

83

8

Group 3

73

7

3

Number of Appointments

Groups One sitting Two sittings Three

sittings

Group 1

25

4

1

group 2

26

3

1

Group 3

30

0

0

DISCUSSION

bull Hydrogen peroxide is capable of penetrating the tooth osmosis and through porosities and cracks subsequently acting directly on the pigmented molecules

bull Gurgan et al investigated 3 different light systems and found out that diode laser system with gave best tooth whitening and least tooth sensitivity

bull In the EM group the surface reflects and refracts light from the surface in such way that mild imperfections in underlying enamel are camouflaged While the highly polished surface of enamel enhances the aesthetic appearance

bull Train et al and Loguercio et al also had the similar results in their studies with EM mild fluorosis showed best results moderate showed moderate results while it had little effect on severe fluorosis

bull NaOCl was only effective on mild stains while moderate and severe

stains could only be lightened to quite an extent but could not be

completely removed

bull When NaOCl comes in contact with hypomineralized and discoloured

enamel it degrades and removes the chromogenic organic material

located on the enamel surface

CONCLUSION

bull It was concluded that esthetic appearance of teeth mild fluorosis can

be achieved by bleaching and microabrasion But in cases of

moderate fluorosis a combination of any of theses modalities can be

used

bull As no special maintenance precautions are required these maybe be

considered as an interesting alternative to conventional operative

treatment

bull Focuses on only TSIF of 4

bull Electric pulp testing is not the

right method to check for

sensitivity

bull Tooth Sensitivity changes

from person to person

bull Food habits can cause

staining of the teeth

bull Minimally invasive

bull Cheaper to veneers

bull Minimal loss of tooth structure

bull 4 parameters checked for the success of treatment

bull Inclusion of specific score of fluorosis for comparing the results

bull Maximum 3 appointments needed

CRITICAL ANALYSIS

Pros Cons

REFERENCES

bull Gurgan S Cakir FY Yazici E Different light-activated in officebleaching

systems Lasers Med Sci 201025817-22

bull Train TE McWhorter AG Seale NSWilson CF Guo IY Examination of

esthetic improvement and surface alteration following microabrasion in

fluorotic human incisors in vivoPediatr dent 199618353-62

bull Loguercio AD Correia LD Zago C Tagliari D Neumann E Gomes OM et al

Clinical effectiveness of two microabrasion materials materials for the

removal of enamel flurosis stains Oper Dent 200732531-8

4

5

N2O-O2 (Relative Analgesia)

colorless sweet smelling gas

Pharmacokinetics

Absorption through pulmonary epithelium

It is approx 15 times as soluble as is nitrogen It replaces nitrogen in blood

It is carried in solution in plasma of the blood

It is not metabolized by the body

Elimination ndash majorndash lungs minor --- skin

perspiration urine and intestinal gas

Pharmacodynamics

Dose related

10 ndash 25 Lightheaded

Changes in visual amp auditory sensation

Tingling of hands amp feet

Suffusing warmth

Remote from the immediate environment

Reduced anxiety

25-50 max analgesic properties and aberration of vision hearing and proprioception mild drowsiness euphoria amnesia and increased sleepiness and dreams

35 conc will achieve maximum analgesia

bull CNS

ndash Cerebrum-primarily affected

ndash Safe but weak anesthetic agent

bull RESPIRATORY SYSTEM

ndash Increased Tidal and minute volumes

bull CARDIOVASCULAR SYSTEM

ndash 2 studies ndash decreased cardiac output

bull FETAL SYSTEMS

ndash Miscarriage in humans

bull OTHER SYSTEMS

ndash Depression of spinal reflexes increase muscle tone indicates stage of delirium

ndash Muscle rigidity-narcotics + nitrous oxide

ndash Nausea and vomitting - GIT

ndash HEMATOPOIESIS ----- prolonged exposure

Adverse reactions and toxicity

EMOTIONAL REACTIONS

DREAMS HALLUCINATIONS

No acute toxicity

Chronic toxicity ndash bone marrow

depression

PROCEDURE

Diffusion Hypoxia

Sevoflurane

A fluorinated derivative of isopropyl ether ndash synthesized in 1970

Potent anaesthetic agent with rapid uptake amp speedy recovery

Day-case surgery

Problem

Attaching vaporiser to any of the currently available machine

BENZODIAZEPINES

Diazepam 1961 lipid soluble

Uses-alcoholism epilepsy labor tetanus and cerebral palsy

- sedation and amnesia

- varieties of neurosis amp anxiety states

Pharmacokinetics

Orally Rectal IMIV or SC

Well absorbed through GIT

Excretion in urine

6

bull Pharmacodynamics

ndash Depress the brain stem reticular system and the limbic system thalamus and hypothalamus

ndash It is a centrally acting muscle relaxant Has anti-convulsant properties

Adverse reaction amp toxicity

ndash Confusion nausea headache increased appetite decreased salivation and jaundice Thrombophlebitis

ndash Rebound phenomenon

ndash Toxicity drowsiness confusion sleep and coma

Dosage Oral or Rectal ndash 02-05mgkg

Maximum single dose 10mg

IV- 025mgkg

Supplied Tablets 2 5 10 mg

Suspension ndash 5mg

Midazolam Water soluble ndash non-irritant

Oral IM IV

Metabolism- liver

Onset IV 3 -5mins

oral 20 ndash 30mins

Oral administration anxious patients requiring relatively short dental procedure

No rebound phenomenon

Better anxiolysis amp amnesia (retrograde amnesia)

Adverse effects Respiratory depression

dose dependant apnea

Dosage Oral ndash 025 to 1mgkg to maximum single dose 20mg

IM ndash 01 to 015mgkg to a maximum of 10mg

IV ndash slow IV

Supplied Syrup ndash 2mgml

Injectable ndash 1mgml amp 5mgml vials

Flumazenil specific benzodiazepines antagonist

selectively inhibits CNS effects

IV administration amp not recommended below 18yrs of age

02mg over 15 seconds after 45seconds 02mg then after 60seconds to maximum of 1mg

Sedative-Hypnotics

Barbiturates First truly effective drugs for the management of anxiety Generalized CNS depressants Produce dose dependent effects

Sedation ---- sleep ---- GA ---- coma

Suppress the CNS and result in sedation and amnesia Advantages

Rapid onset and short duration Disadvantages

no analgesic effect and possible hypotension Must be used with caution in trauma patients because they may cause

apnea and hypoventilation

DOSE Pentobarbital Sodium 100mg Secobarbital Sodium 100 to 200mg Children 30 to 100mg

bull Chloral Hydrates (Mickey Finn Knock out drops ) First synthesized in 1832 first member of the hypnotic group of drugs

Widely used as conscious sedation agent

Properties

Unpleasant taste

Nausea vomiting

Quite irritating to skin and to mucous membranes

GI irritation

Dosages Individualized for each patient 25 ndash 50mgkg

maximum of 1g

Supplied oral capsule ndash 500mg

oral solution ndash 250 amp 500mg5ml

Rectal suppositories ndash 324 amp 648mg

Narcotics

Do produce sedation amp euphoria greater in children

LA is required but dose should be decreased

Meperidine Synthetic opiate agonist

Very water soluble

Orally SC IM or IV

Peak effect by oral 1 hr amp lasts upto 4 hrs

Adverse reactions

-Seizures

-Extreme caution in hepatic or renal diseases or history of seizures

7

Dosage Oral SC or IM ndash 1to 22mgkg not to exceed 100 mg

Supplied Oral Tablets ndash 50 amp 100mg

Oral Syrup ndash 50mgml

Parental solution ndash 25 50 75 amp 100mgml

Fentanyl

Synthetic opiate narcotic analgesic

Very potent 01mg = 10mg Morophine75mg Meperidine

Pharmacokinetics

IV IM SM

Metabolized in liver Excreted in urine

Fentanyl Onset ndash 7 to 15mins

Duration ndash 1 to 2 hrs

Pharmacodynamics

Respiratory depression RR but returns to normal rapidly Tidal volume amp response to co2 depressed for extended period

Apnea

Less emetic than meperidine

NOT RECOMMENDED IN CHILDREN BELOW 2yrs

Dosage 0002 to 0004mgkg

Supplied 005mgml in 2 amp 5ml ampoules

Reversal drug Naloxone

Semisynthetic opiate antagonist

No agonist activity

Onset 2 to 5mins SC or IM amp 1 to 2mins IV

Reversal 45mins

Pt should be kept under continual surveillance

Adverse reaction nausea vomiting sweating hypotension hypertension ventricular tachycardia fibrillation

Dosage IV SC IM 001mgkg then 01mgkg every 2- 3mins maximum 2mg

Supplied 002 004 1mg solutions

Antihistamines

Hydroxyzine

Oral or IM

Effect ndash 15 ndash 30mins

Half-life ndash 3 hrs

Uses

To relieve anxiety

Used as an anti-histamine

Used to control nausea and vomiting including that associated with motion sickness and pregnancy

Adverse reaction dry mouth drowsiness hypersentivity

Dosage Oral ndash 1 to 2mgkg

IM ndash 11mgkg

Promethazine Oral or IM Onset 15 to 60mins Duration 4 to 6 hrs Uses

To prevent and treat nausea and vomiting associated with motion pregnancy or surgery

Produces sedation and reduce swelling pain and trismus

Lower seizure threshold Adverse reaction dry mouth blurred vision thickening of bronchial secretions Dosage OralIM ndash 05-11mgkg

maximum 25 mg

Diphenhydramine

Oral IM IV

Onset -1hr

Duration ndash 4 to 6 hr

Metabolized in liver

Adverse reaction disturbed coordination thickening of bronchial secretions

Dosage Oral IM IV ndash 1 to 15mgkg

maximum 50mg

Tranquilizers

Major tranquilizer antipsychotic produce calmness control symptoms of psychoses cause reversible extra pyramidal symptoms and do not tend to cause habituation

Minor tranquilizer antianxiety agents also cause calmness do not cause extrapyramidal symptoms Used in conditions like nervous tension and mild depression

8

Classification

Antipsychotics

Phenothiazine derivatives

Chlorpromazine promazine

Butryophenones

Haloperidol

Rauwolfia alkaloids

Reserpine

Antianxiety drugs

Propyl alcohol derivatives

Meprobamate

Benzodiazepine derivatives

Diazepam

Miscellaneous compounds

Hydroxyzine

Meprobamate

White crystalline powder slightly bitter in taste

Only administered orally

Peak blood concentration ----1 to 3hrs

10 ---------excreted unchanged Rest --- excreted as a oxidized derivative or as a glucoronide

Uses

To relieve day time anxiety

Induce sleep in insomniacs

To reduce anxiety associated with dental treatment

Anti-convulsant ndash petit mal epilepsy

Adverse reaction leucopenia acute non-thrombocytopenic purpura ecchymoses eosinophilia edema adenopathy

Dosage Childrengt 6yrs 100 to 200mg

Not recommended for children under 6yrs

Monitoring during sedation

1 Pulse

2 Blood pressure

3 ECG

4 Respiration

5 Temperature

Pulse

Manual Electronic

bull Radial Brachial

bull Facial labial

Blood pressure

ndash Stethoscope amp sphygmomanometer

ndash Automatic devices

ndash Direct cannulation of an artery ndash very accurate

Electrocardiograph

Heart rate rhythm myocardial function

9

Respiration

ndash Monitoring respiratory rate

ndash Observing the rise amp fall of the chest wall

ndash Observing the color of mucous membrane

ndash Observing the inflation amp deflation of the reservoir bag

Devices for monitoring respiration

1 The Precordial pretracheal stethoscope

2 The esophageal stethoscope

ndash Respiratory rate

ndash Heart rate

ndash Any abnormal sounds

Pulse Oximeter

ndash Oxygen saturation

ndash Heart rate

ndash Oxisensor site

ndash Fingers

ndash Toe

ndash Ear lobe

Mechanism

Oxygenated Hb ndash red light

Deoxygenated Hb- infrared light

Tissue pressure from arterial pulse (plethysmography)

Advantages

ndash Safe amp noninvasive

ndash Simple to use

ndash Information is rapidly available for clinical decision

ndash Indirectly indicates respiratory adequacy

Disadvantages

ndash Finger probes can get dislodged

ndash Emitted light source may cause burning

ndash Non reusable probes are expensive

ndash Does not directly determine airway patency

Capnography

1 The presence absence of air flow

2 Indicates depth amp adequacy of respiration

3 Continues analysis of the co2 content of the respired air ndash indicates respiratory adequacy

Temperature

ndash Disposable nondisposable thermometer

ndash Esophageal rectal temp probe

10

Discharge criteria

Cardiovascular function is satisfactory amp stable

Airway patency is uncompromised amp satisfactory

Pt is easily arousable amp protective reflexes intact

State of hydration is adequate

Pt can talk if applicable

Pt can sit unaided if applicable

Pt can ambulate with minimal assistance if applicable

Presedation level of responsiveness achieved

Responsible individual is available

1

PULP THERAPY OF VITAL TEETH

DR MITAKSHARA NIRWAN

Contents

Indirect pulp capping

Direct pulp capping

Medications amp materials used in pulp capping

Pulpotomy

MTA

Apexogenesis

INDIRECT PULP CAPPING

Pieter Van Forest - first to speak about root canal therapy

Glove designed instruments that could prepare a canal to a certain size and taper(1910)

Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in

deep areas of cavity to avoid exposure of pulp followed by placement of a suitable medicament and

restorative material that seals off the carious dentin and encourages pulp recovery (Ingle)

A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a

time with a biocompatible material (McDonald)

Objective of indirect pulp capping

These were given by Eidelman in 1965

bull Arresting the carious process

bull Promoting dentin sclerosis

bull Stimulating formation of tertiary dentin

bull Remineralization of carious dentin

Layers of Carious Dentin Indications of Indirect Pulp Capping

History

Mild pain associated with eating

Negative history of spontaneous extreme pain

Clinical Examination

Deep carious lesion which are close tobut not involving the pulp in vital primary or young

permanent teeth

No mobility

Nominal pulp inflammationdefinite layer of affected dentin after removal of infected dentin

Radiographic examination

Normal lamina dura amp PDL space

No radiolucency around the apices

2

Contraindications of Indirect Pulp Capping

History

Sharp penetrating pulpalgia

Prolonged spontaneous pain especially at night

Clinical examination

Mobility of tooth

Discoloration of tooth

Negative reaction of electric pulp testing

Radiographic examination

Definite pulp exposure

Break in the lamina dura

Radiolucency around the apices

Widened PDL space

Treatment procedure

Sequelae of Indirect Pulp Capping Three distinct types of new dentin formation take place

1 Cellular fibrillar dentinmdashfirst 2 months

2 Globular dentinmdash3 months

3 Tubular dentin (uniform mineralized dentin)

bull 15th of reparative dentin formation begins in less than 30 days

bull After 3 months 01 mm is formed

DIRECT PULP CAPPING Defined by Kopel (1992) as the placement of a medicament or non medicated material on a pulp that

has been exposed in course of excavating the last portions of deep dentinal caries or as a result of

trauma

Objective

To create new dentin in the area of the exposure and subsequent healing of the pulp

Rationale

achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge)

between pulp tissue and capping material thus walling off the

INDICATIONS

Small mechanical exposure

Easily controlled haemorrhage

Bright red haemorrhage

True pinpoint exposure

CONTRAINDICATIONS

Severe toothache at night

Spontaneous pain

Tooth mobility

Radiographic appearance of pulp periradicular de- generation

Excess of hemorrhage at the time of exposure Serous exudate from the exposure

Externalinternal root resorption

Swellingfistula

Histological Changes after Pulp Capping

These were illustrated be Glass and Zander in 1949

After 24 hours Necrotic zone adjacent to calcium

hydroxide paste is separated from healthy pulp

tissue by a deep staining basophilic layer

After 7 days Increase in cellular and fibroblastic

activity

After 14 days Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium

proteinate zone disappearance of necrotic zone

After 28 days Zone of new dentin

3

Medications and Materials Used for Pulp Capping Calcium hydroxide

Corticosteroids amp antibiotics

Inert materials

Collagen fibers

4-META adhesive

Direct bonding

Isobutyl cyanoacrylate

Denatured albumin

Mineral trioxide aggregate

Laser

Bone morphogenic protein

PULPOTOMY

Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp

followed by placement of a suitable dressing or medicament that will promote healing and

preserve vitality of the tooth

American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of

affected infected coronal portion of the dental pulp preserving the vitality and function of the

remaining part of radicular pulp

Objectives

bull Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the

radicular pulp and allowing it to heal

bull Maintain the tooth in the dental arch

Rationale

bull Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp

bull Preserves vitality of the radicular pulp

bull Maintains tooth in a physiologic condition

Indications of Pulpotomy bull Mechanical pulp exposure in primary teeth

bull Teeth showing a large carious lesion but free of radicular pulpitis

bull History of only spontaneous pain

bull Hemorrhage from exposure sites bright red and can be controlled

bull Absence of abscess or fistula

bull No interradicular bone loss

bull No interradicular radiolucency

Contraindications of Pulpotomy bull Persistent toothache

bull Tenderness on percussion

bull Root resorption more than 13rd of root length

bull Large carious lesion with nonrestorable crown

bull Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable

bull Medical contradictions like heart disease immuno compromised patient

bull Swelling or fistula

bull External or internal resorption

bull Pathological mobility

bull Calcification of pulp

Classification of pulpotomy

4

Formocresol Pulpotomy

Iby BUCKLEY in 1904

Sweet (1930) Formulated multi visit technique

Doyle (1962) Advocated 2 sitting procedure (complete devitalization)

Spedding (1965) Gave 5 minute protocol (partial devitali- zation)

Venham (1967) Proposed 15 seconds procedure

Current concept uses 4 minutes of application time

Composition of formocresol Buckleyrsquos Formula

bull Cresol ndash 35 percent

bull Glycerol ndash 15 percent

bull Formaldehyde ndash 19 percent

bull Water ndash 31 percent

Mechanism of Action

It prevents tissue autolysis by bonding to the proteins Bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without

changing the basic structure of protein molecules

Histological Changes

bull Demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959

bull Immediately the pulp becomes fibrous and acidophillic

bull Seven to fourteen days Three zones appear

a broad eosinophilic zone of fixation

b broad pale-staining zone of atrophy with poorcellular definition

c broad zone of inflammation extending apically into normal pulp tissue

bull One yearndash Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

Modified Formocresol Pulpotomy

Used by TRASK(1972)

The technique is identical to that described for primary teeth except that the formocresol pellet is

sealed permanently in the tooth

Two-visit Devitalization Pulpotomy

Indications

bull There is evidence of sluggish bleeding at the amputation site that is difficult to control

bull Pus in the chamber but none at the amputation site

bull There is thickening of the PDL

bull History of pain

Contraindications

bull Nonrestorable tooth

bull Tooth with necrotic pulp

5

Glutaraldehyde Pulpotomy

It was first suggested by S Gravenmade Introduced by Kopel in 1979

Mechanism of Action

bull Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue

bull A narrow zone of eosinophilic stained and compressed fixed tissue is found directly beneath the area of application which blends into vital normal appearing tissue apically

bull With time the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue thus the entire root canal tissue is vital

Cvekrsquos Pulpotomy

bull This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy

bull This was proposed by Mejare and Cvek16 in 1978

bull Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the

remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is

notcomplete

MINERAL TRIOXIDE AGGREGATE (MTA) Torabinejad described the physical and chemical properties of MTA in 1995

It is ash colored powder made primarily of fine hydrophilic particles of

1 tricalcium aluminate

2 tricalcium silicate

3 silicate oxide

4 tricalcium oxide

5 bismuth dioxide

Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous

structure This gel solidifies into a hard structure in less than three hours

PROPERTIES OF MTA

It is biocompatible material and its sealing ability is better than that of amalgam or ZOE

Initial pH is 102 and set pH is 125

The setting time of cement is 4 hours

The compressive strength is 70 MPA which is comparable with that of IRM

Low cytotoxicity ndash It presents with minimal inflammation if extended beyond the apex

Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in

pulpal tissues and it promotes rapid cell growth

APEXOGENESIS

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale

Maintenance of integrity of the radicular pulp tissue to allow for continued root growth

Indications

bull Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed

bull No history of spontaneous pain

bull No sensitivity on percussion

bull No hemorrhage

bull Normal radiographic appearance

Contraindications

bull Evidence that radicular pulp has undergone degenerative changes

bull Purulent drainage

bull History of prolonged pain bull Necrotic debris in canal

bull Periapical radiolucency

6

1

Gupta A Dhingra R Chaudhari P Gupta A

Department of Paedodontics and Preventive Dentistry Faculty of Dental Sciences SGT University Gurgaon Haryana India

Journal of Indian Society of Pedodontics and Preventive Dentistry

Volume 35 I Issue 3 I July-September 2017

A COMPARISION OF VARIOUS MINIMALLY

INVASIVE TECHNIQUES FOR THE REMOVAL

OF DENTAL FLUOROSIS STAINS IN

CHILDREN

DR MITAKSHARA NIRWAN

CONTENTS

bull Introduction

bull Aims

bull Materials and Methods

bull Results

bull Discussion

bull Conclusion

bull Critical analysis

bull References

INTRODUCTION

bull Dental fluorosis is a developmental disturbance of dental enamel caused by

successive exposure to high concentrations of fluoride during tooth

development

bull Various methods of therapy are advocated for the treatment of fluorosis -

stained teeth which range from invasive ceramic veneer bonding restorations

to abrasive chemical treatments

bull The combination of dental bleaching techniques and microabrasion appears

as an excellent conservative solution to reestablish health in fluorosis

affected teeth

AIMS

bull The aim of the study was to evaluate and compare the effectiveness of

minimally invasive techniques for the removal of dental fluorosis

stains in children in vivo

MATERIALS AND METHODS

Patients visiting the department of Pedodontics and Preventive dentistry

Faculty of Dental Sciences SGT University Gurgaon

bull Sample size 90 patients

bull Age group 10 -17 years

bull Caries cracks or periodontal

disease on anterior teeth

bull Abscess draining sinus

cellulitis

bull Non vital teeth

hypersensitive exposed

crevices

bull Orthodontic appliance

bull Past history of bleaching

bull At least two permanent

maxillary anterior teeth

bull TSIF of score 4

bull Free of systemic diseases

Inclusion criteria Exclusion criteria

2

Groups

Group A In office bleaching with 35 hydrogen peroxide( Pola Office

Bleaching kit) activated by light emitting diode (LED) bleaching unit

(35 HP)

Group B Enamel microabrasion (EM) (PREMA Enamel Microabrasion

System) followed by in-office bleaching with 44 carbamide peroxide

gel (EM)

Group C In-office bleaching with 5 sodium hypochlorite (5

NaOCl)

A baseline colour evaluation was done by taking digital photograph of

the maxillary anterior teeth

RESULTS

Group 1

Colour stability

Group 2 Group 3

Tooth sensitivity

Tooth sensitivity values were taken before the treatment

which was compared to immediate postoperative and follow

up visits It was checked using an electric pulp tester

maximum

moderate

least

immediately

group 2

group 1

group 3

1 month

group 2

group 1

group 3

3 month

group 2

group 1

group 3

Patient satisfaction score

Satisfaction was assessed on visual analog scale

Range 1 to 5

Groups percentage of patients

who were satisfied with

the treatment

Number of patients

who reported slight

reappearance of colour

Group 1

90

7

Group 2

83

8

Group 3

73

7

3

Number of Appointments

Groups One sitting Two sittings Three

sittings

Group 1

25

4

1

group 2

26

3

1

Group 3

30

0

0

DISCUSSION

bull Hydrogen peroxide is capable of penetrating the tooth osmosis and through porosities and cracks subsequently acting directly on the pigmented molecules

bull Gurgan et al investigated 3 different light systems and found out that diode laser system with gave best tooth whitening and least tooth sensitivity

bull In the EM group the surface reflects and refracts light from the surface in such way that mild imperfections in underlying enamel are camouflaged While the highly polished surface of enamel enhances the aesthetic appearance

bull Train et al and Loguercio et al also had the similar results in their studies with EM mild fluorosis showed best results moderate showed moderate results while it had little effect on severe fluorosis

bull NaOCl was only effective on mild stains while moderate and severe

stains could only be lightened to quite an extent but could not be

completely removed

bull When NaOCl comes in contact with hypomineralized and discoloured

enamel it degrades and removes the chromogenic organic material

located on the enamel surface

CONCLUSION

bull It was concluded that esthetic appearance of teeth mild fluorosis can

be achieved by bleaching and microabrasion But in cases of

moderate fluorosis a combination of any of theses modalities can be

used

bull As no special maintenance precautions are required these maybe be

considered as an interesting alternative to conventional operative

treatment

bull Focuses on only TSIF of 4

bull Electric pulp testing is not the

right method to check for

sensitivity

bull Tooth Sensitivity changes

from person to person

bull Food habits can cause

staining of the teeth

bull Minimally invasive

bull Cheaper to veneers

bull Minimal loss of tooth structure

bull 4 parameters checked for the success of treatment

bull Inclusion of specific score of fluorosis for comparing the results

bull Maximum 3 appointments needed

CRITICAL ANALYSIS

Pros Cons

REFERENCES

bull Gurgan S Cakir FY Yazici E Different light-activated in officebleaching

systems Lasers Med Sci 201025817-22

bull Train TE McWhorter AG Seale NSWilson CF Guo IY Examination of

esthetic improvement and surface alteration following microabrasion in

fluorotic human incisors in vivoPediatr dent 199618353-62

bull Loguercio AD Correia LD Zago C Tagliari D Neumann E Gomes OM et al

Clinical effectiveness of two microabrasion materials materials for the

removal of enamel flurosis stains Oper Dent 200732531-8

4

6

bull Pharmacodynamics

ndash Depress the brain stem reticular system and the limbic system thalamus and hypothalamus

ndash It is a centrally acting muscle relaxant Has anti-convulsant properties

Adverse reaction amp toxicity

ndash Confusion nausea headache increased appetite decreased salivation and jaundice Thrombophlebitis

ndash Rebound phenomenon

ndash Toxicity drowsiness confusion sleep and coma

Dosage Oral or Rectal ndash 02-05mgkg

Maximum single dose 10mg

IV- 025mgkg

Supplied Tablets 2 5 10 mg

Suspension ndash 5mg

Midazolam Water soluble ndash non-irritant

Oral IM IV

Metabolism- liver

Onset IV 3 -5mins

oral 20 ndash 30mins

Oral administration anxious patients requiring relatively short dental procedure

No rebound phenomenon

Better anxiolysis amp amnesia (retrograde amnesia)

Adverse effects Respiratory depression

dose dependant apnea

Dosage Oral ndash 025 to 1mgkg to maximum single dose 20mg

IM ndash 01 to 015mgkg to a maximum of 10mg

IV ndash slow IV

Supplied Syrup ndash 2mgml

Injectable ndash 1mgml amp 5mgml vials

Flumazenil specific benzodiazepines antagonist

selectively inhibits CNS effects

IV administration amp not recommended below 18yrs of age

02mg over 15 seconds after 45seconds 02mg then after 60seconds to maximum of 1mg

Sedative-Hypnotics

Barbiturates First truly effective drugs for the management of anxiety Generalized CNS depressants Produce dose dependent effects

Sedation ---- sleep ---- GA ---- coma

Suppress the CNS and result in sedation and amnesia Advantages

Rapid onset and short duration Disadvantages

no analgesic effect and possible hypotension Must be used with caution in trauma patients because they may cause

apnea and hypoventilation

DOSE Pentobarbital Sodium 100mg Secobarbital Sodium 100 to 200mg Children 30 to 100mg

bull Chloral Hydrates (Mickey Finn Knock out drops ) First synthesized in 1832 first member of the hypnotic group of drugs

Widely used as conscious sedation agent

Properties

Unpleasant taste

Nausea vomiting

Quite irritating to skin and to mucous membranes

GI irritation

Dosages Individualized for each patient 25 ndash 50mgkg

maximum of 1g

Supplied oral capsule ndash 500mg

oral solution ndash 250 amp 500mg5ml

Rectal suppositories ndash 324 amp 648mg

Narcotics

Do produce sedation amp euphoria greater in children

LA is required but dose should be decreased

Meperidine Synthetic opiate agonist

Very water soluble

Orally SC IM or IV

Peak effect by oral 1 hr amp lasts upto 4 hrs

Adverse reactions

-Seizures

-Extreme caution in hepatic or renal diseases or history of seizures

7

Dosage Oral SC or IM ndash 1to 22mgkg not to exceed 100 mg

Supplied Oral Tablets ndash 50 amp 100mg

Oral Syrup ndash 50mgml

Parental solution ndash 25 50 75 amp 100mgml

Fentanyl

Synthetic opiate narcotic analgesic

Very potent 01mg = 10mg Morophine75mg Meperidine

Pharmacokinetics

IV IM SM

Metabolized in liver Excreted in urine

Fentanyl Onset ndash 7 to 15mins

Duration ndash 1 to 2 hrs

Pharmacodynamics

Respiratory depression RR but returns to normal rapidly Tidal volume amp response to co2 depressed for extended period

Apnea

Less emetic than meperidine

NOT RECOMMENDED IN CHILDREN BELOW 2yrs

Dosage 0002 to 0004mgkg

Supplied 005mgml in 2 amp 5ml ampoules

Reversal drug Naloxone

Semisynthetic opiate antagonist

No agonist activity

Onset 2 to 5mins SC or IM amp 1 to 2mins IV

Reversal 45mins

Pt should be kept under continual surveillance

Adverse reaction nausea vomiting sweating hypotension hypertension ventricular tachycardia fibrillation

Dosage IV SC IM 001mgkg then 01mgkg every 2- 3mins maximum 2mg

Supplied 002 004 1mg solutions

Antihistamines

Hydroxyzine

Oral or IM

Effect ndash 15 ndash 30mins

Half-life ndash 3 hrs

Uses

To relieve anxiety

Used as an anti-histamine

Used to control nausea and vomiting including that associated with motion sickness and pregnancy

Adverse reaction dry mouth drowsiness hypersentivity

Dosage Oral ndash 1 to 2mgkg

IM ndash 11mgkg

Promethazine Oral or IM Onset 15 to 60mins Duration 4 to 6 hrs Uses

To prevent and treat nausea and vomiting associated with motion pregnancy or surgery

Produces sedation and reduce swelling pain and trismus

Lower seizure threshold Adverse reaction dry mouth blurred vision thickening of bronchial secretions Dosage OralIM ndash 05-11mgkg

maximum 25 mg

Diphenhydramine

Oral IM IV

Onset -1hr

Duration ndash 4 to 6 hr

Metabolized in liver

Adverse reaction disturbed coordination thickening of bronchial secretions

Dosage Oral IM IV ndash 1 to 15mgkg

maximum 50mg

Tranquilizers

Major tranquilizer antipsychotic produce calmness control symptoms of psychoses cause reversible extra pyramidal symptoms and do not tend to cause habituation

Minor tranquilizer antianxiety agents also cause calmness do not cause extrapyramidal symptoms Used in conditions like nervous tension and mild depression

8

Classification

Antipsychotics

Phenothiazine derivatives

Chlorpromazine promazine

Butryophenones

Haloperidol

Rauwolfia alkaloids

Reserpine

Antianxiety drugs

Propyl alcohol derivatives

Meprobamate

Benzodiazepine derivatives

Diazepam

Miscellaneous compounds

Hydroxyzine

Meprobamate

White crystalline powder slightly bitter in taste

Only administered orally

Peak blood concentration ----1 to 3hrs

10 ---------excreted unchanged Rest --- excreted as a oxidized derivative or as a glucoronide

Uses

To relieve day time anxiety

Induce sleep in insomniacs

To reduce anxiety associated with dental treatment

Anti-convulsant ndash petit mal epilepsy

Adverse reaction leucopenia acute non-thrombocytopenic purpura ecchymoses eosinophilia edema adenopathy

Dosage Childrengt 6yrs 100 to 200mg

Not recommended for children under 6yrs

Monitoring during sedation

1 Pulse

2 Blood pressure

3 ECG

4 Respiration

5 Temperature

Pulse

Manual Electronic

bull Radial Brachial

bull Facial labial

Blood pressure

ndash Stethoscope amp sphygmomanometer

ndash Automatic devices

ndash Direct cannulation of an artery ndash very accurate

Electrocardiograph

Heart rate rhythm myocardial function

9

Respiration

ndash Monitoring respiratory rate

ndash Observing the rise amp fall of the chest wall

ndash Observing the color of mucous membrane

ndash Observing the inflation amp deflation of the reservoir bag

Devices for monitoring respiration

1 The Precordial pretracheal stethoscope

2 The esophageal stethoscope

ndash Respiratory rate

ndash Heart rate

ndash Any abnormal sounds

Pulse Oximeter

ndash Oxygen saturation

ndash Heart rate

ndash Oxisensor site

ndash Fingers

ndash Toe

ndash Ear lobe

Mechanism

Oxygenated Hb ndash red light

Deoxygenated Hb- infrared light

Tissue pressure from arterial pulse (plethysmography)

Advantages

ndash Safe amp noninvasive

ndash Simple to use

ndash Information is rapidly available for clinical decision

ndash Indirectly indicates respiratory adequacy

Disadvantages

ndash Finger probes can get dislodged

ndash Emitted light source may cause burning

ndash Non reusable probes are expensive

ndash Does not directly determine airway patency

Capnography

1 The presence absence of air flow

2 Indicates depth amp adequacy of respiration

3 Continues analysis of the co2 content of the respired air ndash indicates respiratory adequacy

Temperature

ndash Disposable nondisposable thermometer

ndash Esophageal rectal temp probe

10

Discharge criteria

Cardiovascular function is satisfactory amp stable

Airway patency is uncompromised amp satisfactory

Pt is easily arousable amp protective reflexes intact

State of hydration is adequate

Pt can talk if applicable

Pt can sit unaided if applicable

Pt can ambulate with minimal assistance if applicable

Presedation level of responsiveness achieved

Responsible individual is available

1

PULP THERAPY OF VITAL TEETH

DR MITAKSHARA NIRWAN

Contents

Indirect pulp capping

Direct pulp capping

Medications amp materials used in pulp capping

Pulpotomy

MTA

Apexogenesis

INDIRECT PULP CAPPING

Pieter Van Forest - first to speak about root canal therapy

Glove designed instruments that could prepare a canal to a certain size and taper(1910)

Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in

deep areas of cavity to avoid exposure of pulp followed by placement of a suitable medicament and

restorative material that seals off the carious dentin and encourages pulp recovery (Ingle)

A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a

time with a biocompatible material (McDonald)

Objective of indirect pulp capping

These were given by Eidelman in 1965

bull Arresting the carious process

bull Promoting dentin sclerosis

bull Stimulating formation of tertiary dentin

bull Remineralization of carious dentin

Layers of Carious Dentin Indications of Indirect Pulp Capping

History

Mild pain associated with eating

Negative history of spontaneous extreme pain

Clinical Examination

Deep carious lesion which are close tobut not involving the pulp in vital primary or young

permanent teeth

No mobility

Nominal pulp inflammationdefinite layer of affected dentin after removal of infected dentin

Radiographic examination

Normal lamina dura amp PDL space

No radiolucency around the apices

2

Contraindications of Indirect Pulp Capping

History

Sharp penetrating pulpalgia

Prolonged spontaneous pain especially at night

Clinical examination

Mobility of tooth

Discoloration of tooth

Negative reaction of electric pulp testing

Radiographic examination

Definite pulp exposure

Break in the lamina dura

Radiolucency around the apices

Widened PDL space

Treatment procedure

Sequelae of Indirect Pulp Capping Three distinct types of new dentin formation take place

1 Cellular fibrillar dentinmdashfirst 2 months

2 Globular dentinmdash3 months

3 Tubular dentin (uniform mineralized dentin)

bull 15th of reparative dentin formation begins in less than 30 days

bull After 3 months 01 mm is formed

DIRECT PULP CAPPING Defined by Kopel (1992) as the placement of a medicament or non medicated material on a pulp that

has been exposed in course of excavating the last portions of deep dentinal caries or as a result of

trauma

Objective

To create new dentin in the area of the exposure and subsequent healing of the pulp

Rationale

achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge)

between pulp tissue and capping material thus walling off the

INDICATIONS

Small mechanical exposure

Easily controlled haemorrhage

Bright red haemorrhage

True pinpoint exposure

CONTRAINDICATIONS

Severe toothache at night

Spontaneous pain

Tooth mobility

Radiographic appearance of pulp periradicular de- generation

Excess of hemorrhage at the time of exposure Serous exudate from the exposure

Externalinternal root resorption

Swellingfistula

Histological Changes after Pulp Capping

These were illustrated be Glass and Zander in 1949

After 24 hours Necrotic zone adjacent to calcium

hydroxide paste is separated from healthy pulp

tissue by a deep staining basophilic layer

After 7 days Increase in cellular and fibroblastic

activity

After 14 days Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium

proteinate zone disappearance of necrotic zone

After 28 days Zone of new dentin

3

Medications and Materials Used for Pulp Capping Calcium hydroxide

Corticosteroids amp antibiotics

Inert materials

Collagen fibers

4-META adhesive

Direct bonding

Isobutyl cyanoacrylate

Denatured albumin

Mineral trioxide aggregate

Laser

Bone morphogenic protein

PULPOTOMY

Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp

followed by placement of a suitable dressing or medicament that will promote healing and

preserve vitality of the tooth

American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of

affected infected coronal portion of the dental pulp preserving the vitality and function of the

remaining part of radicular pulp

Objectives

bull Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the

radicular pulp and allowing it to heal

bull Maintain the tooth in the dental arch

Rationale

bull Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp

bull Preserves vitality of the radicular pulp

bull Maintains tooth in a physiologic condition

Indications of Pulpotomy bull Mechanical pulp exposure in primary teeth

bull Teeth showing a large carious lesion but free of radicular pulpitis

bull History of only spontaneous pain

bull Hemorrhage from exposure sites bright red and can be controlled

bull Absence of abscess or fistula

bull No interradicular bone loss

bull No interradicular radiolucency

Contraindications of Pulpotomy bull Persistent toothache

bull Tenderness on percussion

bull Root resorption more than 13rd of root length

bull Large carious lesion with nonrestorable crown

bull Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable

bull Medical contradictions like heart disease immuno compromised patient

bull Swelling or fistula

bull External or internal resorption

bull Pathological mobility

bull Calcification of pulp

Classification of pulpotomy

4

Formocresol Pulpotomy

Iby BUCKLEY in 1904

Sweet (1930) Formulated multi visit technique

Doyle (1962) Advocated 2 sitting procedure (complete devitalization)

Spedding (1965) Gave 5 minute protocol (partial devitali- zation)

Venham (1967) Proposed 15 seconds procedure

Current concept uses 4 minutes of application time

Composition of formocresol Buckleyrsquos Formula

bull Cresol ndash 35 percent

bull Glycerol ndash 15 percent

bull Formaldehyde ndash 19 percent

bull Water ndash 31 percent

Mechanism of Action

It prevents tissue autolysis by bonding to the proteins Bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without

changing the basic structure of protein molecules

Histological Changes

bull Demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959

bull Immediately the pulp becomes fibrous and acidophillic

bull Seven to fourteen days Three zones appear

a broad eosinophilic zone of fixation

b broad pale-staining zone of atrophy with poorcellular definition

c broad zone of inflammation extending apically into normal pulp tissue

bull One yearndash Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

Modified Formocresol Pulpotomy

Used by TRASK(1972)

The technique is identical to that described for primary teeth except that the formocresol pellet is

sealed permanently in the tooth

Two-visit Devitalization Pulpotomy

Indications

bull There is evidence of sluggish bleeding at the amputation site that is difficult to control

bull Pus in the chamber but none at the amputation site

bull There is thickening of the PDL

bull History of pain

Contraindications

bull Nonrestorable tooth

bull Tooth with necrotic pulp

5

Glutaraldehyde Pulpotomy

It was first suggested by S Gravenmade Introduced by Kopel in 1979

Mechanism of Action

bull Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue

bull A narrow zone of eosinophilic stained and compressed fixed tissue is found directly beneath the area of application which blends into vital normal appearing tissue apically

bull With time the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue thus the entire root canal tissue is vital

Cvekrsquos Pulpotomy

bull This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy

bull This was proposed by Mejare and Cvek16 in 1978

bull Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the

remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is

notcomplete

MINERAL TRIOXIDE AGGREGATE (MTA) Torabinejad described the physical and chemical properties of MTA in 1995

It is ash colored powder made primarily of fine hydrophilic particles of

1 tricalcium aluminate

2 tricalcium silicate

3 silicate oxide

4 tricalcium oxide

5 bismuth dioxide

Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous

structure This gel solidifies into a hard structure in less than three hours

PROPERTIES OF MTA

It is biocompatible material and its sealing ability is better than that of amalgam or ZOE

Initial pH is 102 and set pH is 125

The setting time of cement is 4 hours

The compressive strength is 70 MPA which is comparable with that of IRM

Low cytotoxicity ndash It presents with minimal inflammation if extended beyond the apex

Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in

pulpal tissues and it promotes rapid cell growth

APEXOGENESIS

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale

Maintenance of integrity of the radicular pulp tissue to allow for continued root growth

Indications

bull Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed

bull No history of spontaneous pain

bull No sensitivity on percussion

bull No hemorrhage

bull Normal radiographic appearance

Contraindications

bull Evidence that radicular pulp has undergone degenerative changes

bull Purulent drainage

bull History of prolonged pain bull Necrotic debris in canal

bull Periapical radiolucency

6

1

Gupta A Dhingra R Chaudhari P Gupta A

Department of Paedodontics and Preventive Dentistry Faculty of Dental Sciences SGT University Gurgaon Haryana India

Journal of Indian Society of Pedodontics and Preventive Dentistry

Volume 35 I Issue 3 I July-September 2017

A COMPARISION OF VARIOUS MINIMALLY

INVASIVE TECHNIQUES FOR THE REMOVAL

OF DENTAL FLUOROSIS STAINS IN

CHILDREN

DR MITAKSHARA NIRWAN

CONTENTS

bull Introduction

bull Aims

bull Materials and Methods

bull Results

bull Discussion

bull Conclusion

bull Critical analysis

bull References

INTRODUCTION

bull Dental fluorosis is a developmental disturbance of dental enamel caused by

successive exposure to high concentrations of fluoride during tooth

development

bull Various methods of therapy are advocated for the treatment of fluorosis -

stained teeth which range from invasive ceramic veneer bonding restorations

to abrasive chemical treatments

bull The combination of dental bleaching techniques and microabrasion appears

as an excellent conservative solution to reestablish health in fluorosis

affected teeth

AIMS

bull The aim of the study was to evaluate and compare the effectiveness of

minimally invasive techniques for the removal of dental fluorosis

stains in children in vivo

MATERIALS AND METHODS

Patients visiting the department of Pedodontics and Preventive dentistry

Faculty of Dental Sciences SGT University Gurgaon

bull Sample size 90 patients

bull Age group 10 -17 years

bull Caries cracks or periodontal

disease on anterior teeth

bull Abscess draining sinus

cellulitis

bull Non vital teeth

hypersensitive exposed

crevices

bull Orthodontic appliance

bull Past history of bleaching

bull At least two permanent

maxillary anterior teeth

bull TSIF of score 4

bull Free of systemic diseases

Inclusion criteria Exclusion criteria

2

Groups

Group A In office bleaching with 35 hydrogen peroxide( Pola Office

Bleaching kit) activated by light emitting diode (LED) bleaching unit

(35 HP)

Group B Enamel microabrasion (EM) (PREMA Enamel Microabrasion

System) followed by in-office bleaching with 44 carbamide peroxide

gel (EM)

Group C In-office bleaching with 5 sodium hypochlorite (5

NaOCl)

A baseline colour evaluation was done by taking digital photograph of

the maxillary anterior teeth

RESULTS

Group 1

Colour stability

Group 2 Group 3

Tooth sensitivity

Tooth sensitivity values were taken before the treatment

which was compared to immediate postoperative and follow

up visits It was checked using an electric pulp tester

maximum

moderate

least

immediately

group 2

group 1

group 3

1 month

group 2

group 1

group 3

3 month

group 2

group 1

group 3

Patient satisfaction score

Satisfaction was assessed on visual analog scale

Range 1 to 5

Groups percentage of patients

who were satisfied with

the treatment

Number of patients

who reported slight

reappearance of colour

Group 1

90

7

Group 2

83

8

Group 3

73

7

3

Number of Appointments

Groups One sitting Two sittings Three

sittings

Group 1

25

4

1

group 2

26

3

1

Group 3

30

0

0

DISCUSSION

bull Hydrogen peroxide is capable of penetrating the tooth osmosis and through porosities and cracks subsequently acting directly on the pigmented molecules

bull Gurgan et al investigated 3 different light systems and found out that diode laser system with gave best tooth whitening and least tooth sensitivity

bull In the EM group the surface reflects and refracts light from the surface in such way that mild imperfections in underlying enamel are camouflaged While the highly polished surface of enamel enhances the aesthetic appearance

bull Train et al and Loguercio et al also had the similar results in their studies with EM mild fluorosis showed best results moderate showed moderate results while it had little effect on severe fluorosis

bull NaOCl was only effective on mild stains while moderate and severe

stains could only be lightened to quite an extent but could not be

completely removed

bull When NaOCl comes in contact with hypomineralized and discoloured

enamel it degrades and removes the chromogenic organic material

located on the enamel surface

CONCLUSION

bull It was concluded that esthetic appearance of teeth mild fluorosis can

be achieved by bleaching and microabrasion But in cases of

moderate fluorosis a combination of any of theses modalities can be

used

bull As no special maintenance precautions are required these maybe be

considered as an interesting alternative to conventional operative

treatment

bull Focuses on only TSIF of 4

bull Electric pulp testing is not the

right method to check for

sensitivity

bull Tooth Sensitivity changes

from person to person

bull Food habits can cause

staining of the teeth

bull Minimally invasive

bull Cheaper to veneers

bull Minimal loss of tooth structure

bull 4 parameters checked for the success of treatment

bull Inclusion of specific score of fluorosis for comparing the results

bull Maximum 3 appointments needed

CRITICAL ANALYSIS

Pros Cons

REFERENCES

bull Gurgan S Cakir FY Yazici E Different light-activated in officebleaching

systems Lasers Med Sci 201025817-22

bull Train TE McWhorter AG Seale NSWilson CF Guo IY Examination of

esthetic improvement and surface alteration following microabrasion in

fluorotic human incisors in vivoPediatr dent 199618353-62

bull Loguercio AD Correia LD Zago C Tagliari D Neumann E Gomes OM et al

Clinical effectiveness of two microabrasion materials materials for the

removal of enamel flurosis stains Oper Dent 200732531-8

4

7

Dosage Oral SC or IM ndash 1to 22mgkg not to exceed 100 mg

Supplied Oral Tablets ndash 50 amp 100mg

Oral Syrup ndash 50mgml

Parental solution ndash 25 50 75 amp 100mgml

Fentanyl

Synthetic opiate narcotic analgesic

Very potent 01mg = 10mg Morophine75mg Meperidine

Pharmacokinetics

IV IM SM

Metabolized in liver Excreted in urine

Fentanyl Onset ndash 7 to 15mins

Duration ndash 1 to 2 hrs

Pharmacodynamics

Respiratory depression RR but returns to normal rapidly Tidal volume amp response to co2 depressed for extended period

Apnea

Less emetic than meperidine

NOT RECOMMENDED IN CHILDREN BELOW 2yrs

Dosage 0002 to 0004mgkg

Supplied 005mgml in 2 amp 5ml ampoules

Reversal drug Naloxone

Semisynthetic opiate antagonist

No agonist activity

Onset 2 to 5mins SC or IM amp 1 to 2mins IV

Reversal 45mins

Pt should be kept under continual surveillance

Adverse reaction nausea vomiting sweating hypotension hypertension ventricular tachycardia fibrillation

Dosage IV SC IM 001mgkg then 01mgkg every 2- 3mins maximum 2mg

Supplied 002 004 1mg solutions

Antihistamines

Hydroxyzine

Oral or IM

Effect ndash 15 ndash 30mins

Half-life ndash 3 hrs

Uses

To relieve anxiety

Used as an anti-histamine

Used to control nausea and vomiting including that associated with motion sickness and pregnancy

Adverse reaction dry mouth drowsiness hypersentivity

Dosage Oral ndash 1 to 2mgkg

IM ndash 11mgkg

Promethazine Oral or IM Onset 15 to 60mins Duration 4 to 6 hrs Uses

To prevent and treat nausea and vomiting associated with motion pregnancy or surgery

Produces sedation and reduce swelling pain and trismus

Lower seizure threshold Adverse reaction dry mouth blurred vision thickening of bronchial secretions Dosage OralIM ndash 05-11mgkg

maximum 25 mg

Diphenhydramine

Oral IM IV

Onset -1hr

Duration ndash 4 to 6 hr

Metabolized in liver

Adverse reaction disturbed coordination thickening of bronchial secretions

Dosage Oral IM IV ndash 1 to 15mgkg

maximum 50mg

Tranquilizers

Major tranquilizer antipsychotic produce calmness control symptoms of psychoses cause reversible extra pyramidal symptoms and do not tend to cause habituation

Minor tranquilizer antianxiety agents also cause calmness do not cause extrapyramidal symptoms Used in conditions like nervous tension and mild depression

8

Classification

Antipsychotics

Phenothiazine derivatives

Chlorpromazine promazine

Butryophenones

Haloperidol

Rauwolfia alkaloids

Reserpine

Antianxiety drugs

Propyl alcohol derivatives

Meprobamate

Benzodiazepine derivatives

Diazepam

Miscellaneous compounds

Hydroxyzine

Meprobamate

White crystalline powder slightly bitter in taste

Only administered orally

Peak blood concentration ----1 to 3hrs

10 ---------excreted unchanged Rest --- excreted as a oxidized derivative or as a glucoronide

Uses

To relieve day time anxiety

Induce sleep in insomniacs

To reduce anxiety associated with dental treatment

Anti-convulsant ndash petit mal epilepsy

Adverse reaction leucopenia acute non-thrombocytopenic purpura ecchymoses eosinophilia edema adenopathy

Dosage Childrengt 6yrs 100 to 200mg

Not recommended for children under 6yrs

Monitoring during sedation

1 Pulse

2 Blood pressure

3 ECG

4 Respiration

5 Temperature

Pulse

Manual Electronic

bull Radial Brachial

bull Facial labial

Blood pressure

ndash Stethoscope amp sphygmomanometer

ndash Automatic devices

ndash Direct cannulation of an artery ndash very accurate

Electrocardiograph

Heart rate rhythm myocardial function

9

Respiration

ndash Monitoring respiratory rate

ndash Observing the rise amp fall of the chest wall

ndash Observing the color of mucous membrane

ndash Observing the inflation amp deflation of the reservoir bag

Devices for monitoring respiration

1 The Precordial pretracheal stethoscope

2 The esophageal stethoscope

ndash Respiratory rate

ndash Heart rate

ndash Any abnormal sounds

Pulse Oximeter

ndash Oxygen saturation

ndash Heart rate

ndash Oxisensor site

ndash Fingers

ndash Toe

ndash Ear lobe

Mechanism

Oxygenated Hb ndash red light

Deoxygenated Hb- infrared light

Tissue pressure from arterial pulse (plethysmography)

Advantages

ndash Safe amp noninvasive

ndash Simple to use

ndash Information is rapidly available for clinical decision

ndash Indirectly indicates respiratory adequacy

Disadvantages

ndash Finger probes can get dislodged

ndash Emitted light source may cause burning

ndash Non reusable probes are expensive

ndash Does not directly determine airway patency

Capnography

1 The presence absence of air flow

2 Indicates depth amp adequacy of respiration

3 Continues analysis of the co2 content of the respired air ndash indicates respiratory adequacy

Temperature

ndash Disposable nondisposable thermometer

ndash Esophageal rectal temp probe

10

Discharge criteria

Cardiovascular function is satisfactory amp stable

Airway patency is uncompromised amp satisfactory

Pt is easily arousable amp protective reflexes intact

State of hydration is adequate

Pt can talk if applicable

Pt can sit unaided if applicable

Pt can ambulate with minimal assistance if applicable

Presedation level of responsiveness achieved

Responsible individual is available

1

PULP THERAPY OF VITAL TEETH

DR MITAKSHARA NIRWAN

Contents

Indirect pulp capping

Direct pulp capping

Medications amp materials used in pulp capping

Pulpotomy

MTA

Apexogenesis

INDIRECT PULP CAPPING

Pieter Van Forest - first to speak about root canal therapy

Glove designed instruments that could prepare a canal to a certain size and taper(1910)

Indirect pulp capping is defined as a procedure where in small amount of carious dentin is retained in

deep areas of cavity to avoid exposure of pulp followed by placement of a suitable medicament and

restorative material that seals off the carious dentin and encourages pulp recovery (Ingle)

A procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a

time with a biocompatible material (McDonald)

Objective of indirect pulp capping

These were given by Eidelman in 1965

bull Arresting the carious process

bull Promoting dentin sclerosis

bull Stimulating formation of tertiary dentin

bull Remineralization of carious dentin

Layers of Carious Dentin Indications of Indirect Pulp Capping

History

Mild pain associated with eating

Negative history of spontaneous extreme pain

Clinical Examination

Deep carious lesion which are close tobut not involving the pulp in vital primary or young

permanent teeth

No mobility

Nominal pulp inflammationdefinite layer of affected dentin after removal of infected dentin

Radiographic examination

Normal lamina dura amp PDL space

No radiolucency around the apices

2

Contraindications of Indirect Pulp Capping

History

Sharp penetrating pulpalgia

Prolonged spontaneous pain especially at night

Clinical examination

Mobility of tooth

Discoloration of tooth

Negative reaction of electric pulp testing

Radiographic examination

Definite pulp exposure

Break in the lamina dura

Radiolucency around the apices

Widened PDL space

Treatment procedure

Sequelae of Indirect Pulp Capping Three distinct types of new dentin formation take place

1 Cellular fibrillar dentinmdashfirst 2 months

2 Globular dentinmdash3 months

3 Tubular dentin (uniform mineralized dentin)

bull 15th of reparative dentin formation begins in less than 30 days

bull After 3 months 01 mm is formed

DIRECT PULP CAPPING Defined by Kopel (1992) as the placement of a medicament or non medicated material on a pulp that

has been exposed in course of excavating the last portions of deep dentinal caries or as a result of

trauma

Objective

To create new dentin in the area of the exposure and subsequent healing of the pulp

Rationale

achieve a biologic closure of the exposure site by deposition of hard tissue barrier (dentin bridge)

between pulp tissue and capping material thus walling off the

INDICATIONS

Small mechanical exposure

Easily controlled haemorrhage

Bright red haemorrhage

True pinpoint exposure

CONTRAINDICATIONS

Severe toothache at night

Spontaneous pain

Tooth mobility

Radiographic appearance of pulp periradicular de- generation

Excess of hemorrhage at the time of exposure Serous exudate from the exposure

Externalinternal root resorption

Swellingfistula

Histological Changes after Pulp Capping

These were illustrated be Glass and Zander in 1949

After 24 hours Necrotic zone adjacent to calcium

hydroxide paste is separated from healthy pulp

tissue by a deep staining basophilic layer

After 7 days Increase in cellular and fibroblastic

activity

After 14 days Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium

proteinate zone disappearance of necrotic zone

After 28 days Zone of new dentin

3

Medications and Materials Used for Pulp Capping Calcium hydroxide

Corticosteroids amp antibiotics

Inert materials

Collagen fibers

4-META adhesive

Direct bonding

Isobutyl cyanoacrylate

Denatured albumin

Mineral trioxide aggregate

Laser

Bone morphogenic protein

PULPOTOMY

Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp

followed by placement of a suitable dressing or medicament that will promote healing and

preserve vitality of the tooth

American Academy of Pediatric Dentistry (1998) defined pulpotomy as the amputation of

affected infected coronal portion of the dental pulp preserving the vitality and function of the

remaining part of radicular pulp

Objectives

bull Removal of inflamed and infected coronal pulp at the site of exposure thus preserving the vitality of the

radicular pulp and allowing it to heal

bull Maintain the tooth in the dental arch

Rationale

bull Radicular pulp is healthy and capable of healing after surgical amputation of the infected coronal pulp

bull Preserves vitality of the radicular pulp

bull Maintains tooth in a physiologic condition

Indications of Pulpotomy bull Mechanical pulp exposure in primary teeth

bull Teeth showing a large carious lesion but free of radicular pulpitis

bull History of only spontaneous pain

bull Hemorrhage from exposure sites bright red and can be controlled

bull Absence of abscess or fistula

bull No interradicular bone loss

bull No interradicular radiolucency

Contraindications of Pulpotomy bull Persistent toothache

bull Tenderness on percussion

bull Root resorption more than 13rd of root length

bull Large carious lesion with nonrestorable crown

bull Highly viscous sluggish hemorrhage from canal orifice which is uncontrollable

bull Medical contradictions like heart disease immuno compromised patient

bull Swelling or fistula

bull External or internal resorption

bull Pathological mobility

bull Calcification of pulp

Classification of pulpotomy

4

Formocresol Pulpotomy

Iby BUCKLEY in 1904

Sweet (1930) Formulated multi visit technique

Doyle (1962) Advocated 2 sitting procedure (complete devitalization)

Spedding (1965) Gave 5 minute protocol (partial devitali- zation)

Venham (1967) Proposed 15 seconds procedure

Current concept uses 4 minutes of application time

Composition of formocresol Buckleyrsquos Formula

bull Cresol ndash 35 percent

bull Glycerol ndash 15 percent

bull Formaldehyde ndash 19 percent

bull Water ndash 31 percent

Mechanism of Action

It prevents tissue autolysis by bonding to the proteins Bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without

changing the basic structure of protein molecules

Histological Changes

bull Demonstrated by Mass and Zilbermann11 in 1933 and also by Massler and Mansokhani in 1959

bull Immediately the pulp becomes fibrous and acidophillic

bull Seven to fourteen days Three zones appear

a broad eosinophilic zone of fixation

b broad pale-staining zone of atrophy with poorcellular definition

c broad zone of inflammation extending apically into normal pulp tissue

bull One yearndash Progressive apical movement of these zones with only acidophillic zone left at the end of 1 year

Modified Formocresol Pulpotomy

Used by TRASK(1972)

The technique is identical to that described for primary teeth except that the formocresol pellet is

sealed permanently in the tooth

Two-visit Devitalization Pulpotomy

Indications

bull There is evidence of sluggish bleeding at the amputation site that is difficult to control

bull Pus in the chamber but none at the amputation site

bull There is thickening of the PDL

bull History of pain

Contraindications

bull Nonrestorable tooth

bull Tooth with necrotic pulp

5

Glutaraldehyde Pulpotomy

It was first suggested by S Gravenmade Introduced by Kopel in 1979

Mechanism of Action

bull Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue

bull A narrow zone of eosinophilic stained and compressed fixed tissue is found directly beneath the area of application which blends into vital normal appearing tissue apically

bull With time the glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue thus the entire root canal tissue is vital

Cvekrsquos Pulpotomy

bull This is also called as calcium hydroxide pulpotomy or young permanent partial pulpotomy

bull This was proposed by Mejare and Cvek16 in 1978

bull Indicated in young permanent teeth where the pulp is exposed by mechanical or bacterial means and the

remaining radicular tissue is judged vital by clinical and radiographic criteria whereas the root closure is

notcomplete

MINERAL TRIOXIDE AGGREGATE (MTA) Torabinejad described the physical and chemical properties of MTA in 1995

It is ash colored powder made primarily of fine hydrophilic particles of

1 tricalcium aluminate

2 tricalcium silicate

3 silicate oxide

4 tricalcium oxide

5 bismuth dioxide

Hydration of the powder results in a colloidal gel composed of calcium oxide crystals in an amorphous

structure This gel solidifies into a hard structure in less than three hours

PROPERTIES OF MTA

It is biocompatible material and its sealing ability is better than that of amalgam or ZOE

Initial pH is 102 and set pH is 125

The setting time of cement is 4 hours

The compressive strength is 70 MPA which is comparable with that of IRM

Low cytotoxicity ndash It presents with minimal inflammation if extended beyond the apex

Mineral trioxide aggregate (MTA) has demonstrated the ability to induce hard-tissue formation in

pulpal tissues and it promotes rapid cell growth

APEXOGENESIS

It is defined as the treatment of a vital pulp by capping or pulpotomy in order to permit continued

growth of the root and closure of the open apex

Rationale

Maintenance of integrity of the radicular pulp tissue to allow for continued root growth

Indications

bull Indicated for traumatized or pulpally involved vital permanent tooth when root apex is incompletely formed

bull No history of spontaneous pain

bull No sensitivity on percussion

bull No hemorrhage

bull Normal radiographic appearance

Contraindications

bull Evidence that radicular pulp has undergone degenerative changes

bull Purulent drainage

bull History of prolonged pain bull Necrotic debris in canal

bull Periapical radiolucency

6

1

Gupta A Dhingra R Chaudhari P Gupta A

Department of Paedodontics and Preventive Dentistry Faculty of Dental Sciences SGT University Gurgaon Haryana India

Journal of Indian Society of Pedodontics and Preventive Dentistry

Volume 35 I Issue 3 I July-September 2017

A COMPARISION OF VARIOUS MINIMALLY

INVASIVE TECHNIQUES FOR THE REMOVAL

OF DENTAL FLUOROSIS STAINS IN

CHILDREN

DR MITAKSHARA NIRWAN

CONTENTS

bull Introduction

bull Aims

bull Materials and Methods

bull Results

bull Discussion

bull Conclusion

bull Critical analysis

bull References

INTRODUCTION

bull Dental fluorosis is a developmental disturbance of dental enamel caused by

successive exposure to high concentrations of fluoride during tooth

development

bull Various methods of therapy are advocated for the treatment of fluorosis -

stained teeth which range from invasive ceramic veneer bonding restorations

to abrasive chemical treatments

bull The combination of dental bleaching techniques and microabrasion appears

as an excellent conservative solution to reestablish health in fluorosis

affected teeth

AIMS

bull The aim of the study was to evaluate and compare the effectiveness of

minimally invasive techniques for the removal of dental fluorosis

stains in children in vivo

MATERIALS AND METHODS

Patients visiting the department of Pedodontics and Preventive dentistry

Faculty of Dental Sciences SGT University Gurgaon

bull Sample size 90 patients

bull Age group 10 -17 years

bull Caries cracks or periodontal

disease on anterior teeth

bull Abscess draining sinus

cellulitis

bull Non vital teeth

hypersensitive exposed

crevices

bull Orthodontic appliance

bull Past history of bleaching

bull At least two permanent

maxillary anterior teeth

bull TSIF of score 4

bull Free of systemic diseases

Inclusion criteria Exclusion criteria

2

Groups

Group A In office bleaching with 35 hydrogen peroxide( Pola Office

Bleaching kit) activated by light emitting diode (LED) bleaching unit

(35 HP)

Group B Enamel microabrasion (EM) (PREMA Enamel Microabrasion

System) followed by in-office bleaching with 44 carbamide peroxide

gel (EM)

Group C In-office bleaching with 5 sodium hypochlorite (5

NaOCl)

A baseline colour evaluation was done by taking digital photograph of

the maxillary anterior teeth

RESULTS

Group 1

Colour stability

Group 2 Group 3

Tooth sensitivity

Tooth sensitivity values were taken before the treatment

which was compared to immediate postoperative and follow

up visits It was checked using an electric pulp tester

maximum

moderate

least

immediately

group 2

group 1

group 3

1 month

group 2

group 1

group 3

3 month

group 2

group 1

group 3

Patient satisfaction score

Satisfaction was assessed on visual analog scale

Range 1 to 5

Groups percentage of patients

who were satisfied with

the treatment

Number of patients

who reported slight

reappearance of colour

Group 1

90

7

Group 2

83

8

Group 3

73

7

3

Number of Appointments

Groups One sitting Two sittings Three

sittings

Group 1

25

4

1

group 2

26

3

1

Group 3

30

0

0

DISCUSSION

bull Hydrogen peroxide is capable of penetrating the tooth osmosis and through porosities and cracks subsequently acting directly on the pigmented molecules

bull Gurgan et al investigated 3 different light systems and found out that diode laser system with gave best tooth whitening and least tooth sensitivity

bull In the EM group the surface reflects and refracts light from the surface in such way that mild imperfections in underlying enamel are camouflaged While the highly polished surface of enamel enhances the aesthetic appearance

bull Train et al and Loguercio et al also had the similar results in their studies with EM mild fluorosis showed best results moderate showed moderate results while it had little effect on severe fluorosis

bull NaOCl was only effective on mild stains while moderate and severe

stains could only be lightened to quite an extent but could not be

completely removed

bull When NaOCl comes in contact with hypomineralized and discoloured

enamel it degrades and removes the chromogenic organic material

located on the enamel surface

CONCLUSION

bull It was concluded that esthetic appearance of teeth mild fluorosis can

be achieved by bleaching and microabrasion But in cases of

moderate fluorosis a combination of any of theses modalities can be

used

bull As no special maintenance precautions are required these maybe be

considered as an interesting alternative to conventional operative

treatment

bull Focuses on only TSIF of 4

bull Electric pulp testing is not the

right method to check for

sensitivity

bull Tooth Sensitivity changes

from person to person

bull Food habits can cause

staining of the teeth

bull Minimally invasive

bull Cheaper to veneers

bull Minimal loss of tooth structure

bull 4 parameters checked for the success of treatment

bull Inclusion of specific score of fluorosis for comparing the results

bull Maximum 3 appointments needed

CRITICAL ANALYSIS

Pros Cons

REFERENCES

bull Gurgan S Cakir FY Yazici E Different light-activated in officebleaching

systems Lasers Med Sci 201025817-22

bull Train TE McWhorter AG Seale NSWilson CF Guo IY Examination of

esthetic improvement and surface alteration following microabrasion in

fluorotic human incisors in vivoPediatr dent 199618353-62

bull Loguercio AD Correia LD Zago C Tagliari D Neumann E Gomes OM et al

Clinical effectiveness of two microabrasion materials materials for the

removal of enamel flurosis stains Oper Dent 200732531-8

4