UNIVERSITATEA DE MEDICIN I FARMACIE IULIU HAIEGANU CLUJ NAPOCA

CONTRIBUII LA FARMACOTERAPIA GANGRENELOR PULPARE CU NOI DERIVAI APLICAI N STOMATOLOGIE

REZUMATUL TEZEI DE DOCTORAT

Conductor tiinific, Prof. Dr. LIVIU SAFTA Doctorand, BICHER MIHAELA

2006

CUPRINS

Introducere ... Capitolul 1 Gangrena pulpar . 1.1. Istoric 1.2. Definiie . 1.3. Etiologie. 1.3.1.Flora microbian.. 1.4. Morfopatologia .. 1.4.1. Microscopic 1.4.2. Histochimic 1.1. Simptomatologia gangrenei .. Capitolul 2 Tratamentul gangrenei pulpare simple .. 2.1. Instrumentarul tratamentului gangrenei pulpare .. 2.2. Instrumentarea canalelor radiculare . 2.2.1. Generaliti . 2.2.2. Scopul instrumentrii . 2.2.3. Principiile de instrumentare 2.2.4. Determinarea lungimii de lucru .. 2.2.5. Tipuri de micri n timpul instrumentrii .. 2.2.6. Instrumentarea canalelor curbe ... Capitolul 3 Soluiile de irigare utilizate pentru splturi endodontice . Capitolul 4 Tratamentul medicamentos al gangrenei pulpare simple ... 4.1. Antisepticele .. 4.1.1. Clasificarea antisepticelor .. 4.1.2. Indicaiile antisepticelor . Capitolul 5 Obturarea canalelor radiculare .. 5.1. Paste resorbabile .. 5.2. Cimenturi i materiale pentru obturaii radiculare de durat 5.2.1. Cimenturi pe baz de zinc-oxid-eugenat (ZOE) 5.2.2. Materiale pe baz de Gutaperc . 5.2.3. Cimenturi pe baz de rini 5.2.4. Materiale biologice 5.2.5. Alte materiale . 5.3. Conuri Capitolul 6 Contribuii personale . 6.1. Introducere i ipotez de lucru .. 6.2 Material i metod 6.2.1 Substana de cercetat.......................................................................... 6.2.2 Cercetri farmacologice preliminarii cu preparate din Calendula officinalis L................................................................................................. 6.2.2.1 Aciunea antimicrobian......................................................... 6.2.2.2. Aciunea cicatrizant.............................................................. 6.3. Studiul clinic asupra efectelor extractului de Calendula officinalis l. utilizat n tratamentul gangrenei pulpare.............................................................. 6.3.1. Obiectivele urmrite........................................................................ 6.4. Material i metod......................................................................................

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6.4.1. Criterii de alegere a pacienilor pentru tratament............................. 6.5. Stabilirea diagnosticului 6.6. Etapele generale de tratament ... 6.6.1. Crearea accesului la camera pulpar .. 6.6.2. Evidarea coninutului gangrenos 6.6.3. Rzuirea dentinei alterate .. 6.6.4. Trepanarea apexului .. 6.6.5. Dezinfecia canalelor radiculare . 6.6.6. Uscarea canalelor radiculare ... 6.6.7. Verificarea lungimii canalului radicular . 6.6.8. Obturaia canalului radicular .. 6.6.9. Obturaia definitiv . 6.7. Cazuri clinice studiate ... Obturaii radiculare cu Pasta nr. 1 Cazul 1 .. Cazul 2 .. Cazul 3 .. Cazul 4 .. Cazul 5 .. Cazul 6 .. Cazul 7 .. Cazul 8 .. Cazul 9 .. Obturaii radiculare cu Pasta nr. 2 Cazul 10 Cazul 11 .. Cazul 12 Obturaii radiculare cu cu Pasta nr. 3 ... Cazul 13 Cazul 14 Cazul 15 Obturaii radiculare cu Forfenan .. Cazul 16 .. Cazul 17 Cazul 18 Obturaii radiculare cu hidroxid de calciu Cazul 19 Cazul 20 Cazul 21 Cazul 22 Obturaii radiculare cu Endometazon . Cazul 23 Cazul 24 Cazul 25 Cazul 26 Capitolul 7 Rezultate i discuii Concluzii .. Contribuii personale Bibliografie .

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Rezumatul tezei de doctorat Contribuii la farmacoterapia gangrenelor pulpare cu noi derivai aplicai n stomatologie BICHER Mihaela Medic specialist stomatologie general Cuvinte cheie: gangren, paraformaldehid, extract fluid de Calendula Officinalis L. Partea I

GANGRENA PULPAR GENERALITI Definiie: Gangrena pulpar este o mortificare septic, caracterizat prin

descompunerea pulpei dentare sub influena germenilor anaerobi de putrefacie, care intereseaz strict teritoriul dintelui fr nici un rsunet asupra parodoniului apical.Este un proces septic localizat n esuturile cu vitalitate pierdut n care are loc descompunerea esuturilor sub aciunea germanilor bacterieni. Organul pulpar si poate pierde vitalitatea lent sau brusc. Etiologie: Originea acestei afeciuni este bacterian, avnd o flor microbian mixt, aerob i anaerob care provine n special din cavitatea bucal, din mediul salivar, avnd ca poart de intrare o leziune carioas penetrant. Flora microbian, dup cum se tie din literatur, este alctuit din: streptococi(grampozitivi, anaerobi), coci gram-pozitivi, anaerobi,; coci gram-negativi; bacili gram-negativifacultativ anaerobi; bacili gram-negativi strict anaerobi; ciuperci(Candida albicans, cea mai frecvent ntlnit). Aceste microorganisme sunt patogene deoarece au capacitatea de a alemina enzime capabile de distrucii tisulare.Cile de ptrundere a acestor microorganisme sunt diferite: avansarea unui proces carios care ajunge s deschid camera pulpar, canale aberante laterale care comunic cu eventualele pungi parodontale, fisuri ale smalului, calea retrograd prin orificiul apical, calea hematogen, prin fenomenul de anacorez. Morfopatologie: n gangrena pulpar are loc pierdera total a configuraiei

structurale a pulpei dentare. Astfel distingem trei tipuri de gangren: gangren umed (cnd aceasta a fost precedat de un proces inflamator pulpar seros sau purulent), gangrena uscat

(cnd aceasta succede unui proces necrotic de origine traumatic sau chimic), gangrena gazoas(germenii microbieni produc gaze care dilacereaz esuturile necrotice). Microscopic: Examenul microscopic ne indic prezena unui depozit eterogen de diferite substane proteice i minerale n care se gsesc celule alterate i resturi de fibre conjunctive n cantitate mic. Histochimic: este o mas semiputred, alctuit din materii grase, polipeptide alterate, hidrogen sulfurat, ap, acid acetic i dioxid de carbon. SIMPTOMATOLOGIA GANGRENEI Simptomatologia gangrenelor este srac, ele evolund n general fr o reacie din partea pacientului, acesta acuznd prezena unei carii cu pierde de substan, modificare de culoare a dintelui n cauz i persistena unui miros fetid. Clinic acest lucru se confirm. La examenul clinic se observ o leziune carioas, profund, cu o mare cantitate de dentin ramolit la acest nivel. Sondarea canalelor radiculare sunt nedureroase, nesngernde, cu prezena esutului pulpare dezagregate umede sau uscate, testele de vitalitate fiind

negative.Uneori, datorit expansiunii brute a gazelor din spaiul endodontic (amoniac, CO2) apare o sensibilitate la lichide fierbini. Diagnosticul pozitiv: Un rol important n diagnosticul gangrenei pulpare simple sau complicate, alturi de semnele clinice prezentate anterior l are radiografia dentar retroalveolar. Aceasta ne arat o transparen crescut a canalului radicular i stmtorarea lumenului radicular prin depozite de dentin. Diagnosticul diferenial: Diagnosticul diferenial se face cu: necroza pulpar, gangrena complicat cu parodontit apical acut, parodontita apical cronic, pulpita cronic. Evoluia: Evoluia gangrenelor este spre parodoniul apical cu complicaii la acest nivel: parodontita apical acut i purulent. TRATAMENTUL GANGRENEI PULPARE SIMPLE Atitudinea terapeutic la dinii cu gangren a fost concluzionat n funcie de natura germenilor patogeni de la nivelul canalelor radiculare. Este foarte important nlturarea germenilor microbieni prin ndeprtarea mediului de dezvoltare a acestora: dentina ramolit coronar i canalicular, printr-un tratament mecanic foarte riguros. Al doilea pas foarte important este inhibarea dezvoltrii ulterioare a germenilor microbieni printr-un tratament antiseptic, medicamentos, urmat de obturaia de canal radicular.

Tratamentul de ndeprtare a dentinei ramolite se numete tratament mecanic i se realizeaz cu ajutorul acelor de canal care sunt diferite n funcie de timpul de lucru. Astfel avem: instrumente cu care se cerceteaz sau se permeabilizeaz canalul radicular: acele extractoare de nerv; instrumente cu care se ndeprteaz coninutul canalului radicular: acele Kerr tip burghiu i cele tip pil; instrumente cu care se lrgesc canalele radiculare: acele Haedstrom; instrumente cu care se obtureaz canalele radiculare: acele Lentullo. SOLUII DE IRIGARE UTILIZATE PENTRU SPLTURI ENDODONTICE Rolul soluiilor de irigare este de eliminare a detritusurilor din canalele radiculare rezultate n urma tratamentului mecanic. Soluiile au rol de dezinfecie i de diminuare a numrului germenilor endocanaliculari. Soluiile utilizate conform literaturii de specialitate sunt: apa distilat steril i ser fiziologi(0,9%); soluiile antibiotice; hipocloritul de sodiu (2,5%-5%); cloramina; iod, iodura de potasiu; EDTA, chelatori; clorhexidina; compui cuaternari de amoniu. Cea mai utilizat soluie de irigare la ora actual este hipocloritul de sodiu 2,5% deoarece are avantajul c distruge germenii microbieni i detritusul organic. Este alcalin, are efect antimicrobian cert, iar n concentraii mai mari (5%) este iritant. n cazul utilizrii acestuia trebuie avut grij ca lichidul s nu fie mpins dincolo de apex. Poate fi utilizat n secven cu EDTA-ul deoarece se consider c aceste dou soluii, singure nu au o eficacitate maxim asupra detritusurilor.

TRATAMENTUL MEDICAMENTOS AL GANGRENEI PULPARE

Etapele tratamentului n gangrena pulpar sunt: tratament mecanic, tratamentul medicamentos i fizic, de sterilezare i dezinfecie a canalului radicular i obturaia radicular. Actual se urmrete dezinfecia i nu sterilizarea canalelor radiculare. Dup ndepartarea esutului necrozat prin tratamentul mecanic i ndeprtarea acestuia prin splturile cu soluiile dezifectante cunoscute se aplic ntotdeauna un pansament medicamentos dezinfectant. Acesta poate fi ocluziv sau semiocluziv n funcie de tipul gangrenei ntlnite, i se manine timp de 24-48 de ore. Antisepticele utilizate n stomatologie sunt pe baz de fenol, au un efect bacteriostatic de durat i reduc cantitatea de germeni microbieni. Ele se clasific dup starea lor fizic n

momentul introducerii lor n canal: soluii, paste, gazoaese, solide, sau dup modul de aciune: coagulante, oxidante, precipitante, astringente. Soluiile antiseptice utilizate sunt: Chlumsky, Walchoff, sol. Tricrezol, sol. Rockles 4 sau 8. Halogenii i iodul(n soluie: iod-iodurat) sunt soluii cu toxicitate minim i nu sunt toxice. Un antiseptic frecvent utilizat la ora actual este hidroxidul de calciu. Este considerat un antiseptic convenional dar poate distruge bacteriile din canalele radiculare. Are o aciune antimicrobian naspecific legat de un pH foarte ridicat, alcalinutatea sa avnd un efect distructiv asupra mambranei bacteriene, a sistemului membranelor celulare i al structurii proteice. Activitatea acestuia a fost demonstrat experimental. OBTURAREA CANALELOR RADICULARE Obturaia radicular este ultima etap a tratamentului endocanalicular i are ca scop izolarea ct mai bine endodoniul de esuturile nvecinate, pentru conservarea strii de echilibru indispensabil procesului de cicatrizare. Scopul obturrii canalului radicular este de eliminare a oricror ci de acces spre canalele radiculare dinspre cavitatea oral sau spaiul periodontal. Materialul de obturaie radicular trebuie s prezinte anumite proprieti. Aceste sunt cunoscute din literatur. Obturaia radicular cu paste este asociat cu conurile de gutaperc. Acestea asigur o etaneitate a obturaiei radiculare iar datorit coninutului de sulfat de bariu este radioopac ceea ce ofer obturaie posibilitatea de a putea fi controlat radiologic.

Partea a II-a CONTRIBUII PERSONALE Obiective i ipoteza de lucru Cunoscndu-se foarte bine compoziia microbian mixt din gangrenele pulpare, n lucrarea de fa, ne-am propus s realizm cteve paste de obturaie endocanaliculare, pe baz de extracte naturale din plante. Extractul nostru este de Calendula officinalis L.(Glbenele). Teza urmrete s demonstreze eficacitatea acestor paste noi utilizate n obturaia canalului radicular gangrenos, dorind s se adreseze ambelor regiuni afectate. Material i metod substana de cercetat
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Calendula officinalis L. este o plant indigen, de culoare portocalie sau galben. Datorit compoziiei ei are o serie de proprieti care au fost studiate cu mult timp n urm: actiunea cicatrizant, antiinflamatorie, antimicrobian. Datorit acestor proprieti aceast plant este utilizat pe scar larg n cosmetic (unguente)i n medicin (ceaiuri, infuzii). Pentru demonstrarea acestor aciuni s-a obinut un extract fluid de Calendula officinalis L., din flori uscate i alcool 50 60 %. Studiile experimentale(pe animale), au fost efectuate de noi n laboratoarele de microbiologie i fiziopatologie a USAMV- Cluj-Napoca i au demonstrat i susinut ce s-a studiat i cercetat cu ani n urm despre plant. Extractul obinut de noi a fost utilizat pentru a obine pastele de tratament endodontic. STUDIUL CLINIC ASUPRA EFECTELOR EXTRACTULUI DE CALENDULA OFFICINALIS L. UTILIZAT N TRATAMENTUL GANGRENEI PULPARE SIMPLE I COMPLICATE Obiectivele urmrite Preparatele obinute de noi au urmtoarea compoziie : Pasta nr.1 este alctuit din: oxid de zinc, calciu fosforic, hidroxid de calciu, xilin, NaHCO3, ser fiziologic, extract fluid de calendula. Are o consisten moale fiind uor de manipulat, este de culoare galben verzuie, cu miros aromat detorit extractului din compoziie. Pasta nr.2 conine: oxid de zinc, eugenol, formol, extract de calendula. Are o consisten mult mai moale ceea ce o face mai greu de manevrat. Are o culoare alb glbuie, i cu un miros aromat. Pasta nr. 3 conine: oxid de zinc, miniu (PbO2), iodoform, eugenol, extract de calendula. Material i metod S-au luat n studiu un numr de 124 de pacieni la care li s-au studiat 160 de dini cu diagnosticul de gangren pulpar. Pacienii au fost selectai n funcie de vrst, de starea de sntate, de topografia dinilor, de starea parodoniului etc. Stabilirea diagnosticului n scopul stabilirii diagnosticului s-au realizat examinri clinice i radiografii dentare retroalveolare. S-a ntocmit fia de tratament stomatologic, care este foarte complex.

Loturile de dini studiate au fost mprite astfel: lotul nr.1(30 de dini)a fost tratat cu Pasta nr.1; lotul nr.2(30 de dini) cu Pasta nr.2; lotul nr3(15 dini) a fost tratat cu Pasta nr.3; lotul nr. 4(30 de dini) cu Forfenan; lotul nr.(30 de dini) cu hidroxid de calciu; lotul nr.6(25 de dini) tratai cu Endomatazon.Repartiia dinilor s-a fcu n tabele i grafic. Etapele generale de tratament Etapele de tratament endodontic au fost : tratamentul mecanico antiseptic, splaturile endodontice cu hipoclorit de sodiu 2,5%, pansamentele dezinfectante i n final obturaia de canal radicular,definitiv, care s-a realizat cu pastele noi pe baz de extract fluid de Calendula officinalis L. asociate cu con de gutaperc. Rezultatele noastre au fost reprezentate n tabele i grafic. Aceste au fost interpretate statistic, prin calcularea diferenei ntre dou secvene. Rezultatele obinute au fost favorabile, cea mai eficient dintre pastele noastre fiind Pasta nr.1 care are un coninut crescut n hidroxid de calciu la care I-am adugat i extractul de Calendula officinalis L. ce are o serie de proprieti enumerate anterior. CONCLUZII 1. Gangrena pulpar se caracterizeaz prin mortificarea septic a pulpei dentare i descompunerea sa sub aciunea germenilor anaerobi de putrefacie, care intereseaz strict teritoriul dintelui (gangren pulpar simpl, sau i cu implicarea parodoniului apical (gangrena complicat). 2. Evoluia gangrenei pulpare simple este spre parodoniul apical. Dup cum se tie din literatur, descompunerea fermentativ a substanelor proteice din canaliculele dentinare i a substanei organice din structura smalului, determin scderea rezistenei dintelui favoriznd fracturarea coronar sau corono-radicular la presiuni masticatorii obinuite. Totodat gangrena dentar poate constitui un important focar de infecie pentru ntreg organismul, determinnd apariia mbolnvirilor la distan: glomerulo-nefrite, endocardite. 3. Prezena unui numr foarte mare i foarte complex de microorganisme la acest nivel, ne oblig la o atitudine terapeutic mai complex i mai special dect la tratamentul altor afeciuni ale pulpei dentare (ex. Pulpita acut). 4. ndeprtarea n ntregime a esutului gangrenos coronar i pulpar, a dentinei ramolite de la acest nivel, este primul pas n reuita tratamentului. Splturile cu soluii

antiseptice, de tipul hipocloritului de sodiu 2,5%, au un rol important prin distrugerea microorganismelor i a mediului de dezvoltare al acestora. 5. Un rol important n finalizarea tratamentului l are obturaia radicular de care am ncercat s ne ocupm n lucrarea de fa. Dei exist o multitudine de paste utilizate n tratamentele endocanaliculare, cu un pre destul de mare, ne-am gndit s aducem o modest contribuie n acest sens prin realizarea unor paste noi, mai ieftine pe baz de extract natural de Calendula officinalis L. 6. Prin experienele noastre am demonstrat o serie de aciuni ale extractului, susinnd ceea ce literatura de specialitate a specificat. 7. Datorit rezultatelor obinute i cunoscnd efectele benefice ale glbenelelor asupra organismului ne-am propus s introducem acest extract n compoziia unor paste de obturaie radicular. n compoziia pastelor intr o serie de substane, clesice, care se gsesc i n pastele deja existente. 8. Am ncercat obinerea unor paste noi de obturaie endodontic, care s nu inhibe desfurarea proceselor de aprare tisular la nivel periapical. 9. Datorit numeroaselor utilizri din domeniul medicinii, ne-am propus s introducem acest plant i n stomatologie, sub forma extractului lichid care n amestec cu o serie de substane cunoscute s creeze o past sau mai multe utilizate n obturaia radicular. 10. Sunt paste originale care pot fi realizate n cabinetul stomatologic fr s necesite importul de medicamente i materiale. Pastele noastre nu necesit importul de materiale deoarece acestea se gsesc la noi n ar. n cazul n care avem nevoie de alte substane putem s apelm la Institutul de chimie, la Facultatea de chimie, la farmacii sau la Facultatea de Fasmacologie pentru a procura ceea dorim pentru a obine o past de obturaie. 11. Tehnologia de obinere a pastelor nu este pretenioas i poate fi realizat n farmacii. 12. Preul pastelor propuse de noi este sczut n comparaie cu preul pastelor importate, existente pe pia. 13. Aceste paste noi au fost utilizate n tratamentul gangrenei pulpare simple i complicate ca i obturaie definitiv, n asociere cu con de gutaperc. 14. Din studiile efectuate s-a ajuns la concluzia c o singur past, Pasta nr.1, este o past uor de manipulat i de introdus n canalele radiculare. Este o past cu o consisten moale, aderent de acele Lentullo i de pereii canalului radicular. Este o past cu cele mai multe reuite n tratamentul cazurilor de gangren pulpar.
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15. Pasta nr. 2 are o consisten mai moale dect Pasta nr. 1 fiind mai greu de manipulat i de introdus n canalele radiculare. Introducerea acestei paste n canalele radiculare s-a fcut cu ajutorul conurilor de gutaperc pe care a fost aplicat. A fost utilizat n tratamentul cazurilor de gangren pulpar. 16. Pasta nr.3 pe baz de oxid de plumb (miniu) nu a ndeplinit cerinele noastre din nici un punct de vedere, fiind o past greu manevrabil, neaderent i care face priz ntr-un scurt timp de la contactul cu aerul. 17. n urma observaiilor clinice, n aceste cazuri, complicaiile acute au fost mai rare iar evoluia clinic a fost lipsit de durere sau alte efecte secundare. Este bine cunoscut faptul c dup trecerea unui timp evoluia procesului infecios endocanalicular ct i periapical depinde de obturaia radicular corespunztoare i de reactivitatea general a organismului. 18. n concluzie se poate afirma c pastele realizate de noi, n special Pasta nr.1 prezint o serie de avantaje care primeaz asupra procentajului mic de dezavantaje care au fost descrise n lucrare. CONTRIBUII PERSONALE 1.Obinerea extractului fluid de Calendula officinalis L. cu sprijinul catedrei de Botnic Farmaceutic Cluj-Napoca, n proporie de 1: 2, ceea ce nseamn c s-a utilizat un litru de alcool etilic(50-60%) i dou kg de flori uscate de Calendula officinalis L. Acestea au fost puse la macerat timp de dou sptmni iar produsul obinut a fost apoi filtrat obinnduse extractul.Acesta este de culoare brun-rocat, cu miros uor aromat. Poate fi pstrat mai mult timp n sticle de culoare nchis pentru a nu fi descompus i a nu i pierde proprietile sub aciunea luminii. 2.Verificarea aciunii microbiene a extractului asupra florei microbiene ntlnite n gangrena pulpar n special asupra stafilococului aureu. smnrile pe plci Petri i demonstrarea aciunii bactericide s-a realizat cu ajutorul catedrei de microbiologie a Universitii de tiine Agricole i Medicin Veterinar Cluj-Napoca. Efectul bactericid a fost demonstrat prin apariia zonei de inhibiie din jurul stafilococului aureu. 3.Verificarea aciunii cicatrizante, cunoscut din literatur, a extractului fluid de Calendula officinalis L. obinut de noi. Aciunea cicatrizant a fost urmrit pe flictene realizate experimental de noi pe iepuri albinoi. Acest lucru a fost posibil de realizat cu ajutorul catedrei de fiziopatologie a Universitii de tiine Agricole i Medicin Veterinar Cluj-Napoca. Procesul de vindecare-cicatrizare a plgilor s-a fcut zilnic prin observaii directe, din prima zi de tratament pn la vindecarea complet.Vindecarea s-a realizat n 15

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18 zile de la pipetarea cu extractul fluid realizat de noi, ceea ce ne-a confirmat aciunea cicatrizant a extractului nostru. 4. Am realizat cele trei paste de obturaie radicular pe baz de extract fluid de Calendula officinalis L.cu ajutorul farmaciei din comuna Cojocna. 5. Observaiile noastre au fost fcute pe un numr de 124 de pacieni cu vrste cuprinse ntre 13- 60 de ani, de ambele sexe, respectndu-se deontologia cercetrii medicale i cu consimmntul pacienilor. Pacienii alei au ndeplinit anumite condiii, nu neaprat de starea de sntate a cavitii bucale ci n special de starea de sntate. Numrul de dini studiai a fost de 160, diagnosticai cu gangren pulpar simpl i complicat cu parodontit apical cronic, att clinic ct i radiologic. Tratamentul a fost realizat indiferent de tipul de gangren ntlnit, fr a exista preferine de tratament. 6. La toate cazurile de gangren ntlnite s-a realizat un tratament mecanico-antiseptic riguros de ndeprtatre a dentinei ramolite coronare i mai ales radiculare, prin rzuirea ei pn la dentin sntoas, splturile endocanaliculare fiind realizate cu soluie de hipoclorit de sodiu 2,5%. Aceasta este o soluie dezinfectant foarte utilizat la ora actual n stomatologie i n industrie pe scar larg. 7. Pansamentele dezinfectante intermediare au jcat un rol foarte important deoarece nu am avut numai cazuri de gangren pulpar simpl, la care uneori nu este necesar acest pas. 8. O alt contribuie important a fost verificarea lungimii canalului radicular cu ajutorul radiografiilor retroalveolare, cu con de gutaperc pe canal. Acest lucru a fost realizat n cabinetele specializate de radiologie din Cluj-Napoca. 9. Dinii diagnosticai cu gangren pulpar simpl sau complicat cu parodontit apical cronic au fost mprii n mai multe loturi n funcie de pasta de obturaie cu care urma a fi tratat. Astfel avem: a. lotul nr. 1 n numr de 30 de dini a fost tratat cu Pasta nr. 1 b. lotul nr. 2 n numr de 30 de dini a fost tratat cu Pasta nr. 2 c. lotul nr. 3 n numr de 15 dini a fost tratat cu Pasta nr. 3 d. lotul nr. 4 n numr de 30 de dini a fost tratat cu Forfenan e. lotul nr. 5 n numr de 30 de dini a fost tratat cu hidroxi de calciu f. lotul nr. 6 n numr de 25 de dini a fost tratat cu Endometazon Repartiia dinilor tratai a fost reprezentat n tabele i grafic. Rezultatele favorabile i nefavorabile au fost calculate statistic i reprezentate n tabel i grafic n lucrare.

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10. Dup efectuarea tratamentul endodontic i realizarea obturaiei radiculare definitive corecte pacienii au fost dispensarizai.Astfel controlul tratamentului s-a fcut la un interval de 30 de zile, 60 de zile, 3 luni respectiv 6 luni. 11. S-au realizat radiografii retroalveolare pentru verificare tratamentului

endocanalicular la 30 de zile, 60 de zile, 3 luni respectiv 6 luni. 12. Pastele endocanaliculare realizate de noi (Pasta nr.1; Pasta nr.2; Pasta nr.3) pe baz de extract fluid de Calendula officinalis L. sunt paste de obturaie endocanaliculare definitive, ele nefiind folosite ca i paste provizorii, fiind asociate n tratament cu con de gutaperc. 13. Am realizat un studiu comparativ al efectelor favorabile i nefavorabile ntre dou paste pa baz de extract fluid de Calendula officinalis L., respectiv ntre Pasta nr. 1 i Pasta nr. 2.Cunoscnd compoziia celor dou paste am dorit s verificm care din cele dou sunt mai eficiente n tratamentul gangrenei pulpare. Rezultatele au fost reprezentate grafic.(Fig.1 a i b)
Tratament cu pasta nr. I
40 30 % 20 10 0 I C PM M1 M2 M3 % 25 20 15 10 5 0 I C PM M1 M2 M3 Tip dinte Rezultate favorabile Rezultate nefavorabile Rezultate favorabile

Tratament cu pasta nr. II

Tip dinte Rezultate nefavorabile

a Fig. 1

n figura 1 a. sunt reprezentate rezultatele favorabile i nefavorabile n tratamentul endodontic cu Pasta nr. 1 a lotului nr. 1 de 30 de dini. Rezultatele favorabile sunt n 90% din cazurile studiate. n figura 1 b. sunt reprezentate rezultatele favorabile i nefavorabile n tratamentul endodontic cu Pasta nr. 2 a lotului nr. 2 de 30 de dini. Rezultatele favorabile sunt n 73,34% din cazurile studiate. Rezultatele statistice i reprezentate grafic arat o eficien superioar n cazul tratamentului cu pasta nr. 1 care conine hidroxid de calciu i extract de calendula, comparativ cu Pasta nr. 2 n care se afl eugenol i formol alturi de extractul de calendula.

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i n acest caz s-a calculat semnificaia diferenei ntre dou frecvene (%) i s-a recurs la exprimarea procentual a rezultatelor obinute. [33] 14. Am realizat de asemenea un studiu comparativ al reuitelor i nereuitelor n tratamentul gangrenei pulpare ntre pasta de hidroxid de calciu i Forfenan. Rezultatele i n acest caz au fost reprezentate gafic i statistic.(Fig.2.)

Tratamentul cu hidroxid de calciu

40 30 % % 20 10 0 I C PM M1 M2 M3 25 20 15 10 5 0

Tratamentul cu Forfe nan

PM

M1

M2

M3

Tip dinte Rezultate favorabile Rezultate nefavorabile

Tip dinte Rezultate favorabile Rezultate nefavorabile

a Fig. 2

n figura 2 a. sunt reprezentate rezultatele favorabile i nefavorabile n tratamentul endodontic cu hidroxid de calciu a lotului nr. 5 de 30 de dini. Rezultatele favorabile sunt n 90% din cazurile studiate. n figura 2 b. sunt reprezentate rezultatele favorabile i nefavorabile n tratamentul endodontic cu Forfenan a lotului nr. 4 de 30 de dini. Rezultatele favorabile sunt n 73,34% din cazurile studiate. Rezultatele statistice i reprezentate grafic arat o eficien superioar n cazul tratamentului cu past de hidroxid de calciu, comparativ cu Forfenan care conine paraformaldehid. i n acest caz s-a calculat semnificaia diferenei ntre dou frecvene (%) i s-a recurs la exprimarea procentual a rezultatelor obinute. [33]

Bibliografie selectiv

1. ZEROSI C.- Terapeutica conservativ n odonto-stomatologie, ed. Medical Bucureti, 1965, 20-69; 327-366; 383-440. 2. Curs de terapie Buco-Dentar Institutul de medicin i farmacie, Facultatea de stomatologie, disciplina terapie buco-dentar, Bucureti, 1996, 251-258.
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3. GAFAR, M. Odontologie i parodontologie, Ed. Didactic i pedagogic, Bucureti, 1983, 165-200. 4. GAFAR, M, ILIESCU A. Odontologie II, Endodonie clinic i paraclinic, Ed.Medical, Bucureti, 1998, 59-62. 5. CHERLEA I., Tratamente endodontice, Ed. Timioara, 2000, 157-159, 160-187. 6. ROMAN A., POP A. Caria dentar de la teorie la practic, Ed. Dacia, ClujNapoca, 2000, 38-96. 7. ANDREESCU C., ILIESCU A.- Compoziia i structura esuturilor dure dentare, Ed. Cerna, Bucureti, 1995. 8. ILIESCU A., GAFAR M. Cariologie i odontologie restauratoare, Ed. Medical, Bucureti, 2000, 15-30; 31-50; 95-120. 9. BRIESENO B.M., WILLERHAUSEN B. Root canal sealer cytotoxicity on human gingival fibroblast II Silicone and resin based sealers, J.Endodon., 1991, 17; 137 10. ANDREESCU C. Bolile pulpei dentare, Ed. Cerna, Bucureti, 1996. 11. BUIUC D.,NEGRUT M.-Tratat de microbiologie clinica,Ed.Bucuresti,1999 12. GAFAR M.,ANDREESCU C.,DIMITRIU H.-Curs de patologie si terapie odontala,vol I si II,1990. 13. BERG I.O.,NORD C.E.-Method for anaerobic bacteria for endodontic specimens, SCAN D.,J.DENT.RES.,1993. 14. GAFAR M., ANDREESCU C., SITEA M. Metode i tehnici curente n stomatologie, Ed. Medical, Bucureti, 1980, 175-183. 15. TORNACK C.D. Therapeutic armentarium, cpt.14 in Clark J.W. editor, Clinical Dentistry, vol. 4, Harper et Row Publishers, Philadelphia, 1985. 16. AVERBACH R.E., KLEIER D. J.- Armantarium and sterilization,cpt.6, pg.117149, in: Cohen S., Burns R., (editors), Pathways of the pulp, 7th Edition, Mosby 1998. 17. ROMAN A. Instrumentarul endodontic i tehnici de obturare radicular, Ed.Presa Universitar, Cluj-Napoca, 2001, 4-96. 18. BRAT D. Materiale dentare utilizate n cabinetul stomatologic, Ed. Helion, Timioara, 1994, 164-176. 19. SHEELY E.C.,ROBERT G.J.-Use of Calcium hydroxide for apical format healing in non-vital imature permanent teeth,British Dental Journal,London,1997,183; 241. 20. FOREMAN P.C., BARNES I.E. A review of calcium hydroxide, Int.End.J., 1990, 23; 283-297 21. NICA I., NICA L., ANGHEL M.,-Aciunea hipocloritului de sodiu asupra floreibacteriene din canalele radiculare- Actualiti n stomatologie i chirurgie ORO-MAXFACIALA,TIMIOARA ,1993, 23. 22. PEYROUX J., ROSSIGNOL P., DELAVEAU P. Plantes madicinales et phytotherapie, 1981, 15; 210-216. 23. TMA M., ONIGA I. Produse fitoterapeutice romneti, UMF Cluj-Napoca, 2000, 5-90. 24. BEZANGER B.L., et al. - Plantes medicinales, Iienne Ed. Maloine Paris, 1990, 56-57. 25. PINTEA-BORZA A. Referat de doctorat: Biosinteza i dinamica acumulrii uleiurilor volatile i acizilor grai in Calendula officinalis L., Facultatea de Chimie i Chimie industrial, Cluj-Napoca, 1996. 26. PINTEA-BORZA A. Referat de doctorat: Compoziia chimic a speciei Calendula officinalis L., Influena factorilor interni asupra biosintezei pigmenilor carotenoidici, Facultatea de Chimie i Chimie industrial, Cluj-Napoca, 1995.

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27. PINTEA A. Carotenoide, lipide i ali compui activi n Calendula officinalis L., coord. Prof. Dr. Carmen Socaciu, Universitatea Babes-Balyai, Facultatea de Chimie i Inginarie chimic, Cluj-Napoca, 2001, 5-8; 42-48. 28. DELLA LOGGIA R., BECKER H., ISAAC O., TUBARO A. Topical antiinflammatory activity of Calendula officinalis L. extracts, Ed. Planta Medica, 1990, 56; 658. 29. DELLA LOGGIA R., SOSA S., LEITNER Zs., ISAAC O., TUBARO A. Antiinflammatory activity if Calendula Seed Oil in Fatty Acids, Ed. Planta Medica, 1991, 57, Suppliment Issue 2, A 49. 30. DELLA LOGGIA R., TUBARO A., SOSA S., ISAAC O., BECKER H., SAAR St. The role of triterpenoids in the topical anti-inflammatory activity of Calendula officinalis L. flowers, Ed. Planta Medica, 1994, 60; 516-520. 31. PEYROUX J., ROSSIGNOL P., DELAVEAU P. Plantes Med. Phytotherap., 1982, 15; 210 32. DUMENIL G., CHEMLI R., BALANSARD G., - Evaluation of antibacterial properties of Calendula officinalis flowers and mother homeopathic tinctures of Calendula officinalis, Annales Pharmaceutique Francaises, 1980, 38 ; 493-499. 33. SCHWARTZ D. Methodes statistiques a lusage des medicines et des biologistes Ed. Medicales Flamarion, Paris, 1980, 203.

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CURRICULUM VITAE

Numele i prenumele : BICHER MIHAELA Data i locul naterii : 11. 04. 1968, BRAOV, jud. BRAOV, ROMNIA. e-mail: mihaela_bicher@yahoo.com Studii i activitate profesional: n anul 1986 am absolvit Liceul de tiine ale Naturii din Cluj-Napoca, secia de chimie industrial, cu media general 8,69. ntre anii 1987-1989 am fost angajat la fabrica de medicamente Terapia din ClujNapoca n anul 1990 am devenit studenta la Facultatea de Medicin i Farmacie din ClujNapoca, secia medicin general, pn n anul 1991. ntre anii 1991-1995 am fost studenta Facultii de Stomatologie din Cluj-Napoca, pe care am absolvit-o n 1995 cu media general de licen 9,25, i cu numrul de nregistrare 196/02. 10. 1995. Ca student am participat la comunicri tiinifice din cadrul sesiunilor tiinifice Studeneti i la edinele U.S.S.M. din cadrul Facultii de Stomatologie. n data de 1. 01. 1996 am fost angajat la Uunitatea militar 01930 (aviaie) din Cluj-Napoca, ca medic stomatolog, unde am lucrat pn n anul 2000. n 1998 am fost admis la doctorat avnd ca i conductor tiinific pe dl. Prof. Univ. dr. LIVIU L. SAFTA, titlul tezei de doctorat fiind : Contribuii la farmacoterapia gangrenei pulpare cu noi derivai aplicai n stomatologie. n anul 2000 am fost preluat ca i medic stomatolog de ctre Unitatea militar 01943 (Escadrila de elicoptere Someeni, Cluj-Napoca), pn n anul 2001. n 30. 01. 2001 am deschis cabinetul de stomatologie proprietate personal, n satul Snnicor, jud. Cluj, care a funcionat pn n anul 2004. n mai 2003, am obinut titlul de Medic specialist stomatolog, stomatologie general, cu media general 8,60. Din anul 2004 lucrez la cabinetul paroprietate personal din Comuna Cojocna, jud. Cluj, fiind n relaii contractuale cu Casa de Asigurri de Sntate din ClujNapoca.

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n perioada 15 octombrie 2005 21 ianuarie 2006 am participat la cursul de perfecionare postuniversitar a pregtirii profesionale cu titlul : RADIODIAGNOSTIC MAXILO- DENTAR.

Experien profesional: medic specialist stomatolog, stomatologie general am o vechime n meseria de medic stomatolog, de 11 ani.

Publicaii : n anul 2004 am publicat n Revista Medical Ordean, lucrarea cu titlul : Studiu comparativ asupra eficienei hidroxidului de calciu i al paraformaldehidei n gangrena pulpar. n anul 2005 am publicat n revista trimestrial Transilvania stomatologic, lucrarea cu titlul Utilizarea extractului de Calendula officinalis L.n tratamentul gangrenei pulpare. Am participat la o serie de prezentri de aparatur, i medicamente stomatologice, precum i la congrese de stomatologie att n Cluj- Napoca ct i n alte localiti din ar. Am urmat o serie de cursuri postuniversitare de pregtire n domeniul stomatologiei. Locul actual de munc : Cabinetul stomatologic proprietate personal din Comuna Cojocna, jud. Cluj, fiind n relaii contractuale cu Casa de Asigurri de Sntate din Cluj- Napoca. Starea civil : necstorit. Limbi strine : englez i francez. Sunt membr a Colegiului Dentitilor din Romnia din anul 1996.

Cluj-Napoca, iunie, 2006

dr.BICHER MIHAELA Medic specialist stomatolog

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Abstract of PH Thesis Contributions to the Drug Therapy of Pulp Gangrene with New Derivatives used in Denistry BICHER Mihaela Medic specialist stomatologie generala Key words: gangrene, paraformaldehyde, fluid extract of Calendula Officinalis L I. Part Introduction

The main cause of root canal infection is dental caries that, by its evolution, results in the communication between the oral environment and the dental pulp. At the level of the gangrenous dental pulp, there is a number of microorganisms that find optimal developmental and multiplication conditions. These may maintain infectious, toxic or allergic phenomena at apical level, as well as at a distance. Pulp gangrene is characterized by decomposition processes at the level of the pulp, under the action of anaerobic putrefaction germs. In this thesis, we initiated the study of pulp gangrene starting from the treatment time and classical root canal filling materials, and trying to improve these materials by using plant extracts. Thus, we used in addition to classical root canal filling materials, materials combined with Calendula officinalis L. (marigold) extract. This extract is known to be used in cosmetics, for creams and ointments, in medicine, due to its cicatrizing, antimicrobial, antiinflammatory and antiviral actions. The literature shows that the Calendula officinalis L. extract is not toxic, nor irritating, nor does it cause allergic reactions. In order to bring a modest contribution to an increased efficacy in the endodontic treatment of pulp gangrene, I aimed to study this field on which I have focused my attention for 6 years. The study was initiated in the dental office of the Emergency Military Hospital of Cluj-Napoca, and was continued in my private dental office. I wish to sincerely thank my scientific coordinator, Prof. Dr. Liviu Safta, who kindly assisted me in this research. I also express my gratitude towards Prof. M. Tma, Prof. C. Socaciu, Prof. Dr. L. Mureanu for the suggestions they gave me on the occasion of the presentations based on this thesis. I also thank pharmacist M. Polinicencu for her help in the preparation of the pastes used in the present research.

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PULP GANGRENE General presentation Definition. Pulp gangrene is a septic mortification, characterized by the decomposition of the dental pulp under the influence of anaerobic putrefaction germs, which strictly involves the tooth territory, without any involvement of the apical periodontium. Etiology. The origin of this disorder is bacterial, having a mixed microbial, aerobic and anaerobic flora derived especially from the oral cavity, from the salivary environment, having a penetrating carious lesion as an entry site, consisting of: streptococci (gram-positive, anaerobic), gram-positive cocci, anaerobic; gram-negative cocci; gram-negative bacilli facultatively anaerobic; gram-negative bacilli, strictly anaerobic; fungi (Candida albicans, the most frequently encountered). Pathomorphology. Three types of gangrene are differentiated: wet gangrene (when this has been preceded by a serous or purulent pulp process), dry gangrene (when this follows a necrotic process of traumatic or chemical origin), gas gangrene (microbial germs cause gases that dilacerate necrotic tissues). Microscopy. Microscopic examination indicates the presence of a heterogeneous deposit of various protein and mineral substances that contain small amounts of altered cells and connective fiber remnants. Histochemistry. It is a semi-rotten mass, consisting of fat matter, altered polypeptides, sulfurated hydrogen, water, acetic acid, and carbon dioxide.

SYMPTOMATOLOGY OF PULP GANGRENE The symptomatology of pulp gangrene is poor, usually there is no reaction from the part of the patient, who complains of the presence of a caries with substance loss, changed tooth color, and persistence of a fetid odor. This is clinically confirmed. The clinical examination reveals a deep carious lesion, with a large amount of softened dentin at this level. The probing of root canals is painless, without bleeding, with the presence of wet or dry disaggregated pulp tissue, vitality tests being negative. Sometimes, due to the sudden expansion of gases in the endodontic space, (ammonium, CO2), sensitivity to hot liquids appears. Positive diagnosis. An important role in the diagnosis of simple or complicated pulp gangrene, along with the previously described clinical signs, is played by retroalveolar

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radiography, which shows an increased transparency of the root canal and the narrowing of the root lumen by dentin deposits. Differential diagnosis. Differential diagnosis includes: pulp necrosis, complicated gangrene with acute apical periodontitis, chronic apical periodontitis, chronic pulpitis. Evolution. The evolution of pulp gangrene is towards the apical periodontium with complications at this level: acute and purulent apical periodontitis.

TREATMENT OF SIMPLE PULP GANGRENE The therapeutic approach in the case of gangrenous teeth was decided depending on the nature of the pathogenic germs at the level of root canals. It is extremely important to remove the microbial germs by removing their developmental environment: the softened crown and root canal dentin, by an extremely rigorous mechanical treatment. The second important step is the inhibition of the subsequent development of microbial germs by antiseptic drug therapy, followed by root canal filling. The treatment for the removal of the softened dentin is called mechanical treatment and is performed with the root canal needles that differ depending on the working time.

ENDODONTIC IRRIGATION SOLUTIONS The role of irrigation solutions is to eliminate detritus from the root canals, which results following mechanical treatment. The solutions are intended for disinfection and the reduction of the number of root canal germs. The most currently used irrigation solution is 2.5% sodium hypochlorite because it has the advantage of destroying microbial germs and organic detritus. It is alkaline, it has a definite antimicrobial effect, and in high concentrations (5%) is irritating.

DRUG THERAPY OF PULP GANGRENE The therapeutic steps in pulp gangrene are: mechanical treatment, drug and physical treatment, sterilization and disinfection of the root canal, and root canal filling. The current aim is the disinfection, not the sterilization of the root canals. After the removal of the necrosed tissue by mechanical treatment and by irrigation using the known disinfecting

21

solutions, a disinfecting (occlusive or semi-occlusive) drug dressing is applied. The antiseptic solutions used are: Chlumsky, Walchoff, Tricrezol, Rockles 4 or 8. An antiseptic that is currently frequently used is calcium hydroxide. It is considered a conventional antiseptic, but it can destroy bacteria from the root canals. It has a non-specific antimicrobial action related to an extremely high pH, its alkalinity having a destructive effect on the bacterial membrane, the cell membrane system, and the protein structure.

ROOT CANAL FILLING Root canal filling is the last step of root canal treatment and is aimed at isolating the endodontium from the neighboring tissues, in order to maintain the equilibrium state that is essential for the cicatrizing process. The aim of root canal filling is to eliminate any way of access towards the root canals from the oral cavity or the periodontal space. Root filling materials must have certain properties. These are known from the literature. Root filling using pastes is associated with gutta percha cones. These ensure the seal of the root filling and, due to the barium sulfate content, are radiopaque, which allows the radiological control of the filling.

II. Part PERSONAL CONTRIBUTIONS Objectives and work hypothesis The mixed microbial composition in pulp gangrene being well known, the aim of this thesis was to obtain some root canal filling pastes based on natural plant extracts. Our extract is Calendula officinalis L. (marigold). The thesis aims to demonstrate the efficacy of these new pastes in the filling of the gangrenous root canal, addressing both affected areas. Material and method studied substance Calendula officinalis L. is an indigenous plant, of orange or yellow color. Due to its composition, it has a number of properties that were studied a long time ago: cicatrizing, antiinflammatory, antimicrobial effects. Due to these properties, this plant is used on a wide scale in cosmetics (ointments) and in medicine (tea, infusions). In order to demonstrate these actions, a fluid extract of dry Calendula officinalis L. flowers and 50-60% alcohol was obtained. Experimental studies (on animals) were performed by us in the laboratories of

22

microbiology and pathophysiology of USAMV Cluj-Napoca, which demonstrated and supported the previous studies on this plant. The extract obtained by us was used in order to obtain the pastes for endodontic treatment.

CLINICAL STUDY ON THE EFFECTS OF CALENDULA OFFICINALIS L. EXTRACT USED IN THE TREATMENT OF SIMPLE AND COMPLICATED PULP GANGRENE Aims The preparations obtained by us have the following composition: Paste no. 1 consists of zinc oxide, phosphoric calcium, calcium hydroxide, xiline, NaHCO3, physiological serum, calendula fluid extract. It has a soft consistency, being easy to handle, it has a yellow-greenish color, an aromatic odor due to the extract. Paste no. 2 contains zinc oxide, eugenol, formol, calendula extract. It has a much softer consistency, which makes it more difficult to handle. It has a white-yellowish color and an aromatic odor. Paste no. 3 contains zinc oxide, minium (PbO2), iodoform, eugenol, calendula extract. Material and method The study included 124 patients, in whom 160 teeth with the diagnosis of pulp gangrene were studied. The patients were selected depending on age, health status, tooth topography, periodontal status, etc. Making of diagnosis In order to make the diagnosis, clinical examinations and retroalveolar radiographs were performed. A dental treatment record was drawn up, which is extremely complex. The groups of studied teeth were divided as follows: group no. 1 (30 teeth) treated with Paste no. 1; group no. 2 (30 teeth) treated with Paste no. 2; group no. 3 (15 teeth) treated with Paste no. 3; group no. 4 (30 teeth) treated with Forfenan; group no. 5 (30 teeth) treated with calcium hydroxide; group no. 6 (25 teeth) treated with Endomethasone. The distribution of teeth is shown in the tables and diagram.

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General treatment steps The steps of the endodontic treatment were: mechanical aseptic treatment, endodontic irrigation with 2.5% sodium hypochlorite, disinfecting dressings and finally, definitive root canal filling, which was performed using the new pastes based on Calendula officinalis L. extract associated with a gutta percha cone. Our results were presented in the tables and diagram. These were statistically interpreted, by calculating the difference between two sequences. The results obtained were favorable, the most effective of our pastes being Paste no. 1, which has a high calcium hydroxide content, to which we added the Calendula officinalis L. extract, with the above mentioned properties. CONCLUSIONS 1. Pulp gangrene is characterized by the septic mortification of the dental pulp and its decomposition under the action of anaerobic putrefaction germs, which strictly involves the tooth territory (simple pulp gangrene) or may also involve the apical periodontium (complicated pulp gangrene). 2. The evolution of simple pulp gangrene is towards the apical periodontium. As the literature shows, the fermentative decomposition of protein substances from the dentinal canaliculi and of organic substances from the enamel structure causes a decrease in tooth resistance, favoring crown or crown-root fracture during normal masticatory pressure. At the same time, dental gangrene may represent an important infection factor for the whole organism, determining the appearance of distant disease: glomerulonephritis, endocarditis, etc. 3. The presence of an extremely high number of complex microorganisms at this level requires a more complex and special therapeutic approach than in the case of other dental pulp diseases (e.g. acute pulpitis). 4. The complete removal of the gangrenous crown and pulp tissue, of softened dentin at this level, is the first step of a successful treatment. Irrigation with antiseptic solutions, such as 2.5% sodium hypochlorite, plays an important role by the destruction of microorganisms and their developmental environment. 5. An important role in the finalization of treatment is played by root filling, with which we deal in this thesis. Although there is a multitude of pastes used in root filling treatment, which are quite expensive, we attempted to bring our modest contribution by obtaining new, cheaper pastes based on natural Calendula officinalis L. extract.

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6. By our experiments, we demonstrated a number of actions of this extract, which supports the literature data. 7. Due to the results obtained and knowing the beneficial effects of Calendula on the organism, we aimed to introduce this extract in the composition of some root filling pastes. The composition of these pastes includes a number of classical substances that are found in the already existing pastes. 8. We attempted to obtain some new endodontic filling pastes, which should not inhibit tissue defense processes at periapical level. 9. Due to its wide use in the field of medicine, we aimed to introduce this plant in dentistry under the form of a liquid extract mixed with a series of known substances, in order to obtain one or more pastes used in root filling. 10. These are original pastes that can be obtained in the dental office without requiring the import of drugs and materials. Our pastes do not require the import of materials because they are available in Romania. In case we need other substances, we may ask for the help of the Institute of Chemistry, the Faculty of Chemistry, the Faculty of Pharmacology or pharmacies in order to acquire the materials necessary for the obtaining of a tooth filling paste. 11. The technology of obtaining pastes is not sophisticated and can be performed in pharmacies. 12. The price of the pastes proposed by us is low compared to the price of the imported pastes available on the market. 13. These new pastes were used in the treatment of simple and complicated pulp gangrene as definitive filling, in association with a gutta percha cone. 14. The studies performed allow us to conclude that Paste no. 1 is the only paste that is easy to handle and introduce in root canals. It is a soft paste, adherent to lentulo spirals and root canal walls. It has the highest success rate in the treatment of pulp gangrene cases. 15. Paste no. 2 has a softer consistency than Paste no. 1, being more difficult to handle and introduce in root canals. This paste was introduced in root canals on gutta percha cones. It was used in the treatment of pulp gangrene cases. 16. Paste no.3 based on lead oxide (minium) did not meet our requirements from any point of view, being difficult to handle, non-adherent and setting rapidly in contact with air. 17. Following our clinical observations, in these cases acute complications were less frequent and clinical evolution was not accompanied by pain or other side effects. It is well

25

known that after a certain time, the evolution of the infectious root canal and periapical processes depends on the adequate root filling and the general reactivity of the organism. 18. We may conclude that the pastes obtained by us, in particular Paste no. 1, present a number of advantages that outweigh the few disadvantages described in this thesis.

PERSONAL CONTRIBUTIONS 1. Obtaining of the Calendula officinalis L. fluid extract, with the support of the Department of Pharmaceutical Botany Cluj-Napoca, in a proportion of 1:2, which means that one liter ethyl alcohol (50-60%) and two kg dry Calendula officinalis L. flowers were used. 2. Checking the microbial action of the extract on the microbial flora found in pulp gangrene, especially on Staphylococcus aureus. Petri plates were seeded and bactericidal action was demonstrated with the help of the Department of Microbiology of the University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca. The bactericidal effect was demonstrated by the appearance of the inhibition area around Staphylococcus aureus. 3. Checking the cicatrizing action, known in the literature, of the Calendula officinalis L. fluid extract obtained by us. The cicatrizing action was monitored on phlyctenae experimentally induced by us in albino rabbits. This was possible with the support of the Department of Pathophysiology of the University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca. Wound healing-cicatrizing was observed daily, since the first day of treatment until complete healing. Healing occurred within 15-18 days from the pipetting of the fluid extract obtained by us, which confirmed the cicatrizing action of our extract. 4. We prepared the three root filling pastes based on the Calendula officinalis L. fluid extract with the help of the Cojocna pharmacy. Their composition is presented in the thesis. 5. Our observations were performed on 124 patients aged between 13-60 years, of both sexes, with the respect of the ethical principles of medical research and the patients consent. The chosen patients met certain requirements, related to their general health status rather than the health of their oral cavity. The number of the studied teeth was 160, diagnosed with simple and complicated pulp gangrene with chronic apical periodontitis, both clinically and radiologically. Treatment was administered regardless of the type of gangrene, with no treatment preferences. 6. In all the gangrene cases found, a rigorous mechanical-aseptic treatment was performed for the removal of the softened dentin of the crown and especially of the root, by scraping it until healthy dentin was uncovered, root canal irrigation being performed using a
26

2.5% sodium hypochlorite solution. This is a disinfecting solution which is currently widely used in dentistry and industry. 7. Intermediate disinfecting dressings played an extremely important role, because we had not only simple pulp gangrene cases, which sometimes do not require this step. 8. Another important contribution consisted of checking the length of the root canal using retroalveolar radiographs, with a gutta percha cone in the canal. This was performed in the specialized radiological services of Cluj-Napoca. 9. The teeth diagnosed with simple or complicated pulp gangrene with chronic apical periodontitis were assigned to several groups depending on the filling paste that was to be used. These groups were as follows: g. group no. 1, including 30 teeth, treated with Paste no. 1 h. group no. 2, including 30 teeth, treated with Paste no. 2 i. group no. 3, including 15 teeth, treated with Paste no. 3 j. group no. 4, including 30 teeth, treated with Forfenan k. group no. 5, including 30 teeth, treated with calcium hydroxide l. group no. 6, including 25 teeth, treated with Endomethasone The distribution of the treated teeth is shown in the tables and diagram. Favorable and unfavorable results were statistically calculated and represented in the tables and diagram in the thesis. 10. After endodontic treatment and the performance of correct definitive root filling, the patients were followed up at 30 days, 60 days, 3 months, and 6 months, respectively. 11. Retroalveolar radiographs were performed in order to check root canal treatment at 30 days, 60 days, 3 months, and 6 months, respectively. 12. The root filling pastes prepared by us (Paste no. 1; Paste no. 2; Paste no. 3) based on Calendula officinalis L. fluid extract are definitive pastes; they are not used as temporary pastes, being associated with a gutta percha cone in treatment. 13. We performed a comparative study of the favorable and unfavorable effects of two pastes based on Calendula officinalis L. fluid extract, namely Paste no. 1 and Paste no. 2. Knowing the composition of these two pastes, we aimed to establish which of the two was more effective in the treatment of pulp gangrene. The results were graphically represented (Fig. 1 a and b).

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Treatment with paste no. 1

40 30 % 20 10 0 I C PM M1 M2 M3 Tooth type Favorable results Unfavorable results % 25 20 15 10 5 0 I

Treatment with paste no. 2

PM

M1

M2

M3

Tooth type Favorable results Unfavorable results

a Fig. 1

Figure 1 a shows the favorable and unfavorable results of endodontic treatment with Paste no. 1 in group no. 1, including 30 teeth. Favourable results represent 90% of the studied cases. Figure 1 b shows the favorable and unfavorable results of endodontic treatment with Paste no. 2 in group no. 2, including 30 teeth. Favorable results represent 73.34% of the studied cases. Statistical and graphically represented results indicate a higher efficacy in the case of treatment with Paste no. 1, which contains calcium hydroxide and calendula extract, compared to Paste no. 2, which contains eugenol and formol associated with calendula extract. The significance of the difference between the two frequencies (%) was also calculated in this case and the results obtained were expressed in percent [33]. 14. We also performed a comparative study of success and failure in the treatment of pulp gangrene between the calcium hydroxide and Forfenan pastes. The results were also graphically and statistically represented (Fig. 2).

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Treatment with calcium hydroxide

40 30 % 20 10 0 I C PM M1 M2 M3 Tooth type Favorable results Unfavorable results % 25 20 15 10 5 0 I

Treatment with Forfenan

PM

M1

M2

M3

Tooth type Favorable results Unfavorable results

a Fig. 2

Figure 2 a shows the favorable and unfavorable results of endodontic treatment with calcium hydroxide in group no. 5, including 30 teeth. Favorable results represent 90% of the studied cases. Figure 2 b shows the favorable and unfavorable results of endodontic treatment with Forfenan in group no. 4, including 30 teeth. Favorable results represent 73.34% of the studied cases. Statistical and graphically represented results indicate a higher efficacy in the case of treatment with the calcium hydroxide paste compared to the Forfenan paste, which contains paraformaldehyde. The significance of the difference between the two frequencies (%) was also calculated in this case and the results obtained were expressed in percent [33].

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CURRICULUM VITAE

Name: BICHER MIHAELA Date and place of birth: 11.04.1968, Braov, Romania e-mail: mihaela_bicher@yahoo.com Studies and professional activity: In 1986, I graduated from the Natural Science High School of Cluj-Napoca, section of industrial chemistry, with the general score 8.69. Between 1987-1989, I worked at the Terapia pharmaceutical factory of Cluj-Napoca Between 1990-1991, I was a student in general medicine at the Faculty of Medicine and Pharmacy of Cluj-Napoca. Between 1991-1995, I was a student of the Faculty of Dentistry of Cluj-Napoca, from which I graduated in 1995 with the general mean score 9.25, registration number 196/02.10.1995. As a student, I participated in the Students Scientific Sessions with scientific papers and in the USSM meetings of the Faculty of Dentistry. Between 1.01.1996 - 2000, I worked at the Military Unit 01930 (aviation) of ClujNapoca, as a dentist. In 1998, I became a PhD student, my scientific director being Prof. Dr. Liviu L. Safta. The title of my PhD thesis is Contributions to the pharmacotherapy of pulp gangrene by the use of new derivatives in dentistry Between 2000-2001, I worked as a dentist at the Military Unit 01943 (Helicopter Squadron of Someeni, Cluj-Napoca). -Between 30.01.2001-2004, I worked as a dentist in my own private dental office, in Snnicoar village, Cluj county. In May 2003, I became a specialist in general dentistry, with the general score 8.60. Since 2004, I have worked in my private dental office of Cojocna, Cluj county, on a contract basis with the Health Insurance House of Cluj-Napoca. Between 15 October 2005 - 21 January 2006, I participated in the postgraduate training course entitled MAXILLODENTAL RADIODIAGNOSIS. Professional experience: a specialist in general dentistry I have 11 years of experience as a dentist.

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Publications: In 2004, I published in Revista Medical Ordean the paper entitled: A comparative study on the efficacy of calcium hydroxide and paraformaldehyde in pulp gangrene. In 2005, I published in the Transilvania stomatologic journal the paper entitled: Use of Calendula officinalis L. extract in the treatment of pulp gangrene.

I participated in a number of dental equipment and pharmaceutical exhibitions, as well as in national congresses of dentistry. I attended a number of postgraduate training courses in dentistry.

Current workplace: Personal private dental office of Cojocna, Cluj county, on a contract basis with the Health Insurance House of Cluj-Napoca. Marital status: single Foreign languages: English and French I have been a member of the Romanian College of Dentists since 1996. Cluj-Napoca, June, 2006 Dr. BICHER MIHAELA Specialist in dentistry

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