Case presentation group 8 Oral biology department Oral biology III Case presentation group 8 Oral biology department

Case study ผู้ป่วยหญิงไทยโสด อายุ 22 ปี มาพบทันตแพทย์เนื่องจากรู้สึกว่าตนเองมีฟันหน้าซ้อนเก ไม่มีความมั่นใจเวลายิ้มและต้องการจัดฟัน ผู้ป่วยให้ประวัติเพิ่มเติมว่า เมื่อประมาณ 5-6 ปีก่อนผู้ป่วยเคยล้มและฟันหน้ากระแทก ในตอนนั้นมีความรู้สึกปวดฟันเล็กน้อย และได้นำน้ำแข็งประคบบริเวณฟันหน้าบนแล้วค่อยๆ ดีขึ้นจึงไม่ได้พบทันตแพทย์ ปัจจุบันผู้ป่วยไม่มีอาการใดๆ ผู้ป่วยตรวจสุขภาพฟันครั้งสุดท้ายเมื่อ 3 ปีก่อน ไม่โรคประจำตัว ไม่มีประวัติการแพ้ยาใดๆ

Case study จากการตรวจในช่องปากพบว่า ฟันซี่ 11 มีวัสดุอุด composite filling ด้าน MLi พบขอบวัสดุไม่เรียบ ฟันซี่ 44 มีวัสดุอุดอมัลกัมด้าน OD พบรอยผุโดยรอบวัสดุ ฟันซี่ 45 พบฟันผุด้าน OM

Case study สภาพเหงือก โดยทั่วไปมีสีชมพู ยกเว้นบริเวณฟันหน้าบนมีลักษณะสีคล้ำกว่าปกติและบริเวณฟันหน้าล่างด้านในพบเหงือกมีสีแดงและมีหินปูนสะสมเล็กน้อย ไม่พบการโยกของฟัน จากการตรวจภายในช่องปาก และการให้ประวิติเพิ่มเติมของผู้ป่วย ทันตแพทย์จึงได้ทำการถ่ายภาพรังสีที่บริเวณฟันหน้าบนแสดงดังรูปที่ 2

Case study รูป 1 แสดงลักษณะทางคลินิกของผู้ป่วย

Case study รูป 2 แสดงภาพถ่ายรังสีของฟันหน้าบนของผู้ป่วย

Questions จากโจทย์ให้นิสิต 1. อธิบายการตรวจทางคลินิกในผู้ป่วยรายนี้และนิสิตคาดว่าจะมีการตรวจ เพิ่มเติมใดๆ ด้วยหรือไม่ พร้อมอธิบายเหตุผลประกอบ 2. ให้การวินิจฉัยรอยโรคที่เกิดขึ้นเมื่อได้ทำการตรวจทางคลินิกและภาพถ่าย รังสีเรียบร้อยแล้วและอธิบายถึงกระบวนการดำเนินโรค (Pathogenesis) 3. ให้การวางแผนรักษา พร้อมทั้งอธิบายขั้นตอนการรักษา รวมทั้งกลไกที่เกี่ยวข้อง ทางชีววิทยาของการรักษาที่ให้

History taking CC : รู้สึกว่าตนเองมีฟันหน้าซ้อนเก และไม่มีความมั่นใจเวลายิ้ม PI : เมื่อประมาณ 5-6 ปีก่อนผู้ป่วยเคยล้มและฟันหน้ากระแทก ในตอนนั้น มีความรู้สึกปวดฟันเล็กน้อย และได้นำน้ำแข็งประคบบริเวณฟันหน้า บนแล้วค่อยๆ ดีขึ้นจึงไม่ได้พบทันตแพทย์ ปัจจุบันผู้ป่วยไม่มีอาการ ใดๆ Dental history : ผู้ป่วยตรวจสุขภาพฟันครั้งสุดท้ายเมื่อ 3 ปีก่อน Medical history : ไม่โรคประจำตัว ไม่มีประวัติการแพ้ยาใดๆ

Clinical finding tooth Anterior teeth crowding #11 (MLi) Composite filling with marginal ditching. #44 (OD) , #45 (OM) Mucosa Gingiva is pale pink in general except labial aspect of anterior teeth is hyperpigmentation and lingual aspect of lower teeth is red, mild calculus deposition on lingual aspect of lower teeth , without tooth mobility. #11 (MLi) Composite filling with marginal ditching. #44 (OD) Amalgam filling with secondary caries. #45 (OM) Dental caries.

Radiographic finding From periapical radiograph shows #11 crown having radiopaque of restoration with radiolucent underneath well define margin of radiolucent area at apical 1/3 of root between #11-#12 size 5 x 7 mm2. and radiolucent line at distal aspect of coronal 1/3 of root.

Additional examination

Additional examination Visual and Palpation examination (Extra- and Intraoral) Facial symmetry, Sinus tract, Swelling คลำ Upper lip and base of nose localized or diffuse Firm or fructuant Change in color soft tissue swelling or bony expansion compares with and relates to the adjacent and contralateral tissues question : feel unusually sensitive during palpation

Additional examination Intraoral examination Percussion & Mobility & periodontal examination Inflammation in the periodontal apparatus Gloved finger tapping Back end of a mirror handle Light pressure The teeth should first be percussed occlusally ,and if the patient discerns no difference, the test should be repeates,purcussing the buccal and lingual aspects of the tooth. บ่งบอกว่ามี inflammation ที่ periodontal ligament บอกการมีชีวิตของ pulp ไม่ได้

Additional examination Pulp test Thermal test : - Cold test : refrigerant spray (ENDO ice) - Heat test : heated stopping gutta percha Endo ice ง่ายต่อการใช้ สามารถทำซ้ำได้ น่าเชื่อถือ และให้ผลใกล้เคียงกับ co2 Cold test : refrigerant spray (ENDO ice) The spray cotton pellet should be applied to the midface area of the tooth or crown Heat test : heated gutta perch or compound stick - light layer of lubrucant should be placed onto the tooth suface prior to applying the heated material to prevent the hot gutta percha or compound from adhering to the dry tooth surface

Additional examination Pulp test Electric Pulp Test & Laser Doppler Flowmetry Pulp vitality The tip of an endodontic explorer is coated with toothpaste and placed in contact with natural tooth structure *Assessment of pulp vatality is most frequently accomplish by electric pulp testing and/or cold testing * - the Dopper principle states that the light beam will be frequency – shifted by moving red blood cells but will remain unshifted as it passes through static tissue - measure the velocity at which the red blood cells are moving www.jaypeejournals.com

Additional examination Special Tests Staining and Transillumination detection of cracks and fractures http://bitedental.com.au/fractured-teeth-and-transillumination1 http://www.dentist-elk-grove.com/what-we-offer/microdentistry/

Additional examination Radiographic examination Cone-beam computed tomography systems (CBCT) endodontic (root canal) diagnosis, diagnosis of dental trauma

Additional information Additional Information จากการ ตรวจเพิ่มเติม ได้ข้อมูล ผล EPT ดังนี้ แปลผลได้ว่า... ซี่ 12 +ve to EPT ซี่ 11 –ve to EPT ซี่ 21 +ve to EPT No tenderness to percussion or palpation. No swelling and sinus tract opening. # 12 #11 #21 19 negative 22

Differential diagnosis and clinical impression

Classification of pulpal disease American Association of Endodontists (2008) Normal Pulp Reversible Pulpitis Irreversible Pulpitis Symptomatic irreversible pulpitis Asymptomatic irreversible pulpitis Pulp necrosis Previously Treated Previously Initiated Therapy

Classification of pulpal disease Torabinejad, M., Walton, Richard E. : Endodontics Principles and Practice, ed 4, China, 2009 : Saunders. PP. 70

Classification of periapical disease American Association of Endodontists (2008) Normal Apical Tissues Symptomatic Apical Periodontitis Asymptomatic Apical Periodontitis Acute Apical Abscess Chronic Apical Abscess Condensing Osteitis

Classification of periapical disease Torabinejad, M., Walton, Richard E. : Endodontics Principles and Practice, ed 4, China, 2009 : Saunders. PP. 70

# 11 pulp necrosis; asymptomatic apical periodontitis www.jaypeejournals.com www.deardoctor.com #11 (MLi) Composite filling with marginal ditching. EPT No tenderness to percussion or palpation No swelling and sinus tract opening Intraoral radiographic

Asymptomatic Apical Periodontitis Histopathological features Periapical granuloma Radicular cyst

Periapical granuloma Histopathological features inflamed granulation tissue surrounded by fibrous connective tissue wall cholesterol clefts with associated multinucleated giant cells Russell bodies Consist of inflamed granulation tissue surrounded by fibrous connective tissue wall Collection of cholesterol clefts with associated multinucleated giant cells Area of red blood cell extravasation with hemosiderin pigmentation Russell bodies(eosinophillic globules of globulin) may seen with numerous plasma cells but not specific

Periapical granuloma

Periapical granuloma Russell bodies

Radicular cyst (apical periodontal cyst, periapical cyst, root end cyst) Histopatological features very similar to periapical granulomas except for the presence of a central epithelium-lined (stratified squamous epithelium) cavity filled with fluid and semisolid material which is separated from the fibrovascular connective tissue capsule by a basement membrane Histopatological features Lined by stratified squamous epithelium Lumen may fill with fluid and cellular debris The lining epithelium may demonstrate linear or arch-shape calcifications….Rushton bodies - Dystofic calccification, cholesterol clefts with multinucleated giant celll, red blood cell, hemosiderin pigmentation may be present in the lumen, wall, or both Ref : shafer’s textbook of oral pathology / neville damm

Pathogenesis of pulpal and periapical disease

Pathogenesis of pulp necrosis Irritation of pulpal or periradicular tisssue Microbial Irritants Mechanical Irritants Thermal Irritants Chemical Irritants Irritation of pulpal or periradicular tissues Torabinejad, M., Walton, Richard E. : Endodontics Princi ples and Practice, ed 4, China, 2009 : Saunders. PP. 49-52

Pathogenesis of pulp necrosis Routes of root canal infection Dentinal tubules Direct pulp exposure Periodontal diseases Anachoresis

Pathogenesis of pulpal disease

Non-specific inflammatory response Irritant Antigent Pulpal response Non-specific inflammatory response Immunologic response

Increase blood flow , Dilation of vessels Increase Permeability Chemical mediators Histamine Bradykinin Arachidonic acid metabolism Vascular response Increase blood flow , Dilation of vessels Increase Permeability Edema

Leukocytes then squeeze through the intracellular spaces DilatIion of vessels Slowing of erythrocytes and the margination of leukocytes along the walls Leukocytes then squeeze through the intracellular spaces http://www.google.co.th/imgres?imgurl=&imgrefurl=http%3A%2F%2Fjcs.biologists.org%2Fcontent%2F122%2F17%2F3025.figures-only&h=0&w=0&tbnid=rPrb9Ho2JsAq-M&zoom=1&tbnh=247&tbnw=204&docid=zUBUGS3tC8S-cM&tbm=isch&ei=kN1FVKi5IY6eugTW_oCABg&ved=0CAQQsCUoAA http://jcs.biologists.org/content/122/17/3025.figures-only

Neutrophilic Leukocytes Phagocyte Repair  Neutrophilic Leukocyte Proteolytic enzymes (acute) ทำลาย cell ,fiber ground substances Lymphocyte Macrophage Plasma cell (chronic) Pulp necrosis Direct cytotoxic activity Cytokine

Pathogenesis of pulpal disease

Pathogenesis of pulp necrosis Trauma Damage to vessels entering the apical root canal system Reduced or inadequate blood flow Pulp hypoxia Ischemia ,leading to an infarct of the pulp infarct of the pulp คือ การตายของเนื้อเยื่อเนื่อง ยังมีชีวิตอยู่เเม้จะขาด ออกซิเจน เนื่องมาจากผลของ ATP ตายจาก 1.ATP หมด 2.Damage cell membrane 3.influx calcium เข้าเซลล์

Pathogenesis of periapical lesion Apical periodontitis is inflammation and destruction of periradicular tissue caused by etiological agents of endodontic origin. The microbial factors and host defense forces encounter, clash with, and destroy much of the periapical tissue resulting in the formation of various categories of apical periodontitis lesion

Initial apical periodontitis Generally caused by micro-organism invading from apical root canal into the periapical tissue Neuro-vasucular respones of inflammation : hyperemia, vascular congestion, edema of PDL, extravasation of neuatrophils Attract more neutrophil and macrophage into the area Releasing of inflammatory mediator : inflammatory cell release mediators and several cytokines for defense to micro-organism Stimulating Osteoclast activity : inflammatory cytokines induce osteoclast activity caused of bone resorption Established chronic apical periodontitis A prolonged presence of microbial irritants leads to a shift in the neutrophil-dominated lesion to a macrophage-, lymphocyte-, plasma cell- rich one Activated T-cell produce a variety of cytokines that down-regulate the output of pro-inflammatory cytokines Leading to suppression of osteoclast activity and reduce bone resorption The T-cell derived cytokines may concomitantly up-regulate the production of connective tissue growth factors with stimulatory and proliferative effects on fibroblasts and microvasculature

Treatment planning บอก CC

#11 endodontic treatment Periodontal treatment Treatment planning #11 endodontic treatment #44(OD),#45(OM) filling Refer orthodontist Periodontal treatment

#11 endodontic treatment Anesthesia None Definitive treatment Root canal treatment bleaching Preoperative treatment Caries removal Old composite resin removal Temporary wall with composite resin Restorative treatment Resin composite post & core with crown บอก CC

Bleaching Bleaching material แบ่งได้ 2 แบบ Extracoronal bleaching Intracoronal bleaching *** Pulp necrosis  Internal bleaching

Intracoronal bleaching sodium perborate Material of choice most intracoronal bleaching procedure Stable when dry Material of choice most intracoronal bleaching procedure Available in powder form or as various commercial preparation Stable when dry In the presence of acid, warm air, or water, it decomposes to form sodium metaborate, hydrogen peroxide, and nascent oxygen

Causes of tooth discolouration Pulpal necrosis Degrading of necrotic pulp tissue Intrapulpal hemorrhage blood degenerates and breaks down

Mechanism of tooth bleaching Hydrogen peroxide break downs very rapidly to water The oxygen molecules then attached the double carbon bonds and break them down to the single carbon bonds

Mechanism of tooth bleaching Bleaching agent  active oxygen species Break/cleave pigment bonds diffuse to the tooth , become smaller and absorb less light and hence appear lighter diffuse to the tooth and/or become smaller and absorb less light and hence appear lighter The mechanism of tooth bleaching is unclear. It differs depending on reaction conditions, including temperature, pH, light and presence of transition metals Oxidizers in bleaching agents act on the organic structure of dental hard tissues, slowly degrading them into chemical by-products, such as carbon dioxides, that are lighter in colour. Kelleher,Martin,: Dental bleaching,ed 1,London:Quintessence Publishing,2008,p.5

http://www.dentaltown.com/dentaltown/article.aspx?i=314&aid=4277

Endodontically Treated tooth Intracoronal bleaching 1. Walking bleaching technique 2. Thermocatalytic technique http://cchungdentalis.wordpress.com/2013/02/02/walking-techniques-non-vital-intraoral-bleaching/ http://www.identalhub.com/dental-improve-your-quality-of-life-with-brighter-smile---587.aspx

Case report Pre-treatment photograph shows a yellow-brown discoloration of tooth #8 caused by endodontic treatment. (b) Clinical results after 3 applications of the walking bleach technique, resulting in a slightly overbleached tooth. (a, b) Pre-treatment photograph demonstrates dark discoloration of right upper canine (#6). Root canal treatment had been completed many years ago. (c, d) Post-bleaching photograph before replacement of the stained distal composite resin restoration. A thermocatalytic intracoronal bleaching technique was used. The distal composite resin was replaced 2 weeks after bleaching. (e, f) Two-year postoperative/bleaching results show very nice esthetic appearance. Nonvital Tooth Bleaching: A Review of the Literature and Clinical Procedures

Complication Intracoronal bleaching External root resorption “Proper intracoronal bleach barrier” Chemical burn “Soft tissues should be protected by Vaseline or orabase” Damage to restorations “Residual hydrogen peroxide be totally eliminated prior to composite placement”

Post bleaching restoration Guideline of Smith CT. and Schuman N.(1997) The pulp chamber and access should be restoed with composite resin ….Wait for few days (7-14 days) placing composite resin Restoration of endodontically treated teeth: a guide for the restorative dentist. Smith CT1, Schuman N. Abstract This article provides a decision flow chart that can serve as a guide to selecting the optimum restorations for endodontically treated teeth. The process begins with an assessment of the endodontically treated tooth to determine its restorability. The restorable tooth is then evaluated for the amount of remaining coronal tooth structure. Anterior teeth with minimal or moderate coronal damage do not require complete coverage or a post and core. However, anterior teeth with significant coronal damage will require complete coverage plus a post and core. Posterior teeth with minimal coronal damage may be treated conservatively with partial-coverage restorations. For posterior teeth with moderate damage and those with curved roots, amalgam or resin composite foundations are used to support complete-coverage restorations. Posterior teeth with significant coronal damage require a post and core and a complete-coverage restoration. Michael A. Baumann,and Rudolf Beer,: Endodontology,ed2, German work published,2008.p350

#11 endodontic treatment Periodontal treatment Treatment planning #11 endodontic treatment #44(OD),#45(OM) filling Refer orthodontist Periodontal treatment

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