AL-AZHAR UNIVERSITY- GAZA

FACULTY OF DENTISTRY

ENDODONTIC DEPARTMENT

PREPARED FOR :

DR. MOHAMMED ABU HASSIRA

SUBMITTED BY :

TASNEEM SAFI

2017
I. PATHWAYS OF PULP AND PERIRADICULAR INFECTION:

Micro-organisms in sa1iva, calculus or blood enter inside root canal through:

1. Exposed dentinal tubules due to caries, leaky restoration, fracture , crack ,

periodontal pocket, attrition , abrasion or naturally absent cement and enamel at
cemento-enamel junction.

2. Direct pulp exposure due to restorative procedure, fracture.

3. Laten canals due to periodontal disease with deep pockets.

4. Apical foramen due to periodontal disease with deep pockets.

5. Anachoresis due to micro-organisms circulating in blood or lymph leaching an area

of damaged tissues periapacaily.

II. ROLE OF BACTERIA IN PULP AND PERIRADICULAR INFECTION:

- Bacteria was found to be the main cause of pulp and periradicular infection.
Kakehashi et al 1965, made an experiment on 2 groups of rats; germ free and normal
microbial flora rats. Pulp exposures in rat teeth were left exposed to saliva. Pulp
necrosis and periapical pathosis.(abscesses) developed only in rats with normal oral
flora. So there is a direct role of bacteria in initiation of these pathosis.

- Patterns of microbial colonization:

Organisms that infect root canals enter as planktonjc form which is free floating
single micro-organism cells in an aqueous environment inside root canal which can
cause infection.

Then they form aggregates which are grouping of microorganisms of same species
and coaggregates which are grouping of microorganisms of different species.

Bacteria then, adhere to dentin surface, colonize and multiplay to form biofilms .
Sessile biofilms are aggregates of one or more species of bacteria in polysaccharide
matrix that synthesize and attach the microorganism to a solid surface (e.g tooth
surface).
-Infection in root canal:

Infection depends on :

Number of micro.organism X its virulence

Host resistance

-Selection of species inside root canal depends on oxygen tension, pH, nutrient
avaliable, virulence and microbial interaction (synergism / antagonism) and host
defence.

III. BACTRIAL PATHOGENICITY AND VIRULANCE FACTORS :

Bacterial virulence factors are:

1. Bacterial biofilm:

Microbial biofilms are resistant to antimicrobial agents and can not be removed by
mechanical preparation alone, inside bioflims micro-organisms have synergistic effect
or antagonistic effect on other microorganisms. So bioflims protect microorganisms
inside it. So it is one of the causes of endodontic failures. Therefore, it should be
eliminated to assure endodontic success.

2. Cellular components of micro-organisms:

a) Fimbrie (pilli) which allow adherence of bacteria to surfaces and allow aggregation
and conjugation.

b) Capsule of gram +/-ve bacteria that protects it from phagocytosis.

c) Extracellular vesicles in cytoplasm of gram -ye bacteria

- Some vesicles are secreted that have the same structure as parent micro-
organisms.They will bind to antibodies produced thus protecting their parent micro-
organsins.

- Some vesicles contain enzymes and toxins allow bacterial adhesion, and cause
heamagglutination, hemolysis proteolytic action.

3. Micro-organisms secreted byproducts:

Micro-organisms produce and secrete acids and enzymes as

a) Enzymes that neutralize immunoglobulins and complement systems as IgA

protease

b) Enzymes that aid in the spread of organisms in host tissue. They cause direct
damage by degrading components of the extracellular matrix of the connective tissue.

- Proteinases : breaks down proteins.

- Collagenase : breaks down collagen.

- Hyaluronidase : breaks down hyaluronic acid, a constituent of the ground substance

of the connective-tissue.

- Chondriotin sulftase and acid phosphatase

- Fibrinolysin: is produced by many hemolytic streptococci. It lysis fibrin clot and is

involved in the spread of the infection through tissues.

c) Endotoxins
Composed of Lipopolysaccharide (Lipid A portion) which is component of outer
membrane of Gram -ye bacteria only. It is released after micro-organisms death, It
activates complement system,cause fever, shock and bone resorption. It increases in
symptomatic cases.

d) Exotoxin
Composed of polypeptide which is produced in cytoplasm of Gram+ve bacteria
mainly,also gram-ve. It is secreted by living micro-organisms. One of exotoxins is
Leukotoxin which creates small holes on leukocyte membrane causing cell lysis.
IV. BACTRIAL IDENTIFICATION TECHNIQUE :

Microorganisms identification can be done with culturing technique or with the more
recent moleculer methods.

**Culturing is now not done routinely.

When to culture?

1. Persistent or Progressive signs and symptoms.

2. Medically compromised patients.

3. Sterility check test as teaching or research device.

Technique:

 Tooth is isolated by rubber darn.

 Tooth is disinfected to avoid contamination of oral flora.

 After access preparations samples are taken by sterile paper points and placed in
transport
media that support growth of both aerobic and anerobic microorganisms.

 Media used may be enriched blood agar or broth media (fluid thioglycolate or
chopped meat broth) for facultative and fastidious anerobic micro-organisms.

 If no growth occurs this indicates sterile field.

 Disadvantage of culturing long laboratory procedures, not all organisms could

be cultured and contamination of samples could occur.

** Molecular Methods:

Molecular techniques as Polyrnerase Chain Reaction (PCR) have been used to

detect bacteria in endodontic infections.
PCR technique has allowed detection of microbes by amplification of their
DNA .
V. TYPES OF FLORAOF PULP AND PERIRADICULAR LESIONS :

Types of endodontic infection

1. Intraradicular: infection inside root canal.

It can be divided into primary, secondary and persistent infection

2. Extraradicular: infection outside of of root canal

1.Intraradicular:

a) Primary infectjon: the first microorganisms which invade and Colonize necrotic
pulp. They are mixed polymicrobial infection mainly anerobic and Some facultative
microorganisms, with increase in obligate anerobes especially gm-ye bacteria Each
root canal contains about 5-8 different Species
By PCR, micro-organisms identified from infected canals were mainly:

* Firmcutes: streptococcus (mutans, sanginosus, intermedius) associated with smooth

and pit & fissure caries.
Peptostreptococcus (anaerobius)
Enterococcus fecalis

* Fusobacterja: Fusobacteriurn (nucleatum, peridonticum)

* Spirochetes: Treponema (socranskii, denticola)

* Actinobacteria: Actinomyces (Israelli, odontolyticus, naeslundii) associated with

root caries
Propinibactenum (propinicum, acnes)

* Proteobacteria: Campylobacter rectus

* Bacteroidetes:
Black Pigmented Bacteroids (BPB) increase in acute infection, symptomatic cases and
flare ups.

Recent classification of BPB:

I) Asaccharolytic Bacteroides:

Porphyrotnonas(EfldOd0fltaIis Gingivaiis)
II) Sacchirolytic Bacteroides:

Prevotella (Mel ani nogenica, Intermedia, Nigrescens)

b) Secondary infection: Microorganisms are introduced in root canals during

treatment, between appointments and after root, canal obturation. It consists of mixed
infection as Iry infection.

C) Persistent infection: It consists of resistant micro-organisms to irrigation and

medication. They can endure nutrition deprivation, SO they cause persistent or
recurrent infection leading to endodontic fauiler . It consist of microorganisms as
primery or secondery infection but fewer species, with increase in gm+ve facultative
anerobic especially Enterococcus feacails 77% and fungi (Candida Albicans) .

2.Extraradicular infection:
Infection in per radicular area may be caused by:
o Intrardicular infection that extends to periapical area. e.g. acute apical abscess
caused by necrotic pulp, which need endodontic treatment. It contains
microorganisms similar to their intraradicular source, but with increase in Gram
–ve anerobic bactereia of bacteroids as Prevotella (den icolla, intermedia,
nigrcscens) and Porphyromonas (endodontalis, gingivalis)

Or

o Apical actinomycosis which need endodontic surgery for its elimination.

VI. METHODS OF CONTROL AND ERADICATION OF ROOT CANAL
INFECTION :

 It has been well established that bacteria play a definite role in the development
of pulpitis

and subsequent per.radicular periodontitis

 Consequently, a major goal of endodontic therapy is the elimination of bacteria

and of tissue substrate that supports bacterial growth from the root canal system.
By :

1. Isolation and barrier techniques: gloves, glasses, masks, shields, hand washing,
rubber dam.

2. Sanitation of the field, instrument sterilization.

3. Endodonric procedures to remove bacteria and their byproducts (proper chemo-

mechanical preparation, irrigation with 2.5-5% sodium hypochlorite or 2%
chlorohexidine, in between visits intra-canal medicaments as calcium hydroxide).

4. Endodontic procedures to prevent recontamination (temporary restoration 3mm

thick Cavit or IRM , 3 dimensional obturation, permanent restoration within 30
days).

5. Sometimes systemic antibiotic is needed.

REFERENCES :

Ingle IL, Bakland LK,. Baumgartner JC. Ingle’s Endodontics 6.6 ed. BC Decker Inc., 2008.

Hargreaves KH , Cohen S. Cohen’s Pathways of the pulp. 10th ed. Mosby El Sevier, 2011.