Discussion :
A comparative study carried out in 2016 ”KARIMI.Z” attempted to
investigate the prevalence of pulpal calcifications and study their
impact on the quality of endodontic treatment [1]. It was shown that
calcific degeneration appears to be a source of difficulty that needs to
be taken into consideration to improve the quality of endodontic
treatment. This can be achieved by adopting an appropriate clinical
procedure for each type of calcification.
Preoperative X-rays can be used to determine the location of pulp
calculi:
- pulp chamber
- root canal
- chamber and root canal,
and their relationship to the dentinal walls:
*Free: not attached to the dentinal walls and completely surrounded by
pulp tissue. Radiographically, it appears as a radiopacity surrounded by
a radiolucent halo.
*Adherent: attached to the root or cameral dentinal walls. On
radiography, the radiolucent halo separating the dentinal walls from the
calcified mass is absent.
*Root canal obliteration: complete disappearance of the root canal
passage in a portion or all of the canal.
Depending on the radiological type of pulp calculus, we can orientate
our therapeutic strategy:
- VIS-A-VIS of free coronal pulpolites (clinical case N°1); the success
of endodontic treatment depends on the correct design of the access
cavity. This involves establishing a contour shape linking the
projections of the pulp horns at occlusal level. An ordinary cavity is
then created and deepened using long-neck tungsten carbide burs. The
sensation of emptiness, long associated with entering the pulp
chamber, does not occur in the presence of calcified hard tissue. The
extent of the pulpolite is delimited by a colorimetric demarcation
between the dentin of the canal walls and the central calcified
tissue. This demarcation may be manifested by a hemorrhagic line of
underlying pulp tissue when the tooth in question is vital, otherwise
it is manifested by a line of necrotic pulp tissue debris. This line
of separation is then extended using ultrasonic diamond inserts, under
direct visual control (operating microscope / dental magnifying glass)
to better distinguish dentin tissue from calcified tissue. Once the
calcification has been completely circumscribed, the aim is to remove
it in a single block, simply mobilize it with an endodontic excavator
to detach it in a single block from the access cavity. The removal of
this calcified mass reveals an intact, clean pulp floor and clearly
distinguished canal entrances [4,5]
- VIS-A-VIS of adherent coronal pulpolite; the problem is that this type
cannot be mobilized despite circumferential clearance. So, once the
access cavity has been deepened, the first step is to liberate the
canal orifices. Then, slowly abrade the central calcified tissue. The
challenge is to know exactly how thick the pulp-stone can be abraded
without damaging the floor. Care should be taken with a long-necked
ball bur on a low-speed counter-angle or with an ultrasonic diamond
insert [4].
- VIS-A-VIS root canal calcifications; the idea in this situation is not
to negotiate all the way to the apical construction. This is an
iatrogenic error and can lead to the formation of dentinal plugs and
abutments, further complicating the management of this type of canal.
Once the root canal entrances have been located, root canal
penetration can begin. It is always important to remember that
instrument fractures are more difficult to treat on mineralized teeth.
Full canal catheterization should not be performed from the beginning,
preferring instead a crown-down approach [6]. Manual K8 or K10
files, and sometimes even K6 files, are used to progress through the
canal, but these instruments are very fragile and should be replaced
regularly. After initial penetration, rotary pre-enlargement
instruments can be used. It is important not to forget to pre-curve
manual instruments over the last few millimetres, to enable them to
bypass any mineralization present in the canal [7]. Advancing into
the canal can sometimes become easier as the instrument progresses,
since secondary dentinogenesis is more marked coronally than apically.
However, if the instrument no longer seems to be advancing correctly,
you should stop and try to feel how the instrument is engaged in the
canal. If there is a sensation of resistance to withdrawal, then the
canal is narrowed and you can continue as normal, opening the canal
progressively. If, on the other hand, the instrument appears to be
free in the canal, we are faced either with total apical
calcification, which is very rare, or with an abutment, in which case
we need to pre-curve the instrument further to find a zone where we
can obtain this sensation of resistance to withdrawal [8].
Abundant irrigation with sodium hypochlorite should always be
maintained, as the solvent action of NaOCl enables digestion of the
organic substances involved in pulpolite adhesion. Manual filing helps
to mobilize the pulpolite in a coronal direction, by establishing
low-amplitude back-and-forth movements. The use of chelating agents
facilitates progression within the canal by demineralizing the canal
walls and eliminating the mineral phase of calcification adhesions
[9]. It should also be remembered that, in the long-term, cement
deposits form at the apex, altering the position of the radiological
apex in relation to the anatomical apex. Root canal preparation must
therefore sometimes be carried out away from this radiological apex
[4].
- In the case of voluminous root canal calcification and if the clinical
situation allows (visibility, accessibility) ultrasonic inserts (ET20,
ETD25 Satelec®) are used to destroy this calcific obstruction, always
under direct visual microscopic control [4,10,11].
Conclusion
Pulpal calcifications are frequently encountered in the during dental
practice, and can take a variety of clinical forms, posing problems of
diagnosis and management. The indication for endodontic treatment cannot
be based on the presence of pulpolite alone, but rather on a diagnosis
supported by a clinical and radiological examination of the pulp status
of the tooth. NAOCLA thorough understanding of these particularities,
the choice of appropriate therapies and the use of optical aids are the
keys to successful treatment of mineralized teeth.
Acknowledgements
there are no acknowledgements.
Conflict of interest
Any financial interest or any conflict of interest exists.
Consent
Written informed consent was obtained from the patient to publish this
report in accordance with the journal’s patient consent policy
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