PULP THERAPY IN PRIMARY DENTITION

Treatment Considerations for Pulp Therapy:

_______

The ______ of time the tooth to be _______

The _______ of the tooth

Patient/parent _______ for treatment and follow up

Patient's ______ status

Morphology

length - retained

restorability

cooperation

health

Patients health status? (5)

1. Immunologically compromised patients

2. Diabetes

3. Acquired or congential heart defects

4. Renal disorders

5. Bleeding disorders

Aim of Pulp Therapy in Children:

Preserve ________

Remove source of ______

Preserve the ______ tooth if no _____ is present

Maintain ______

Prevent ______ or _____ problems

arch length

infection

primary, successor

esthetics

habits or speech

Primary teeth vs. Perm Teeth: Primary have...

_____ and ______ roots

Molar roots are more ______ and ______

Molar roots ______ from the ______ area and more at the ______

Narrower and longer

slender and longer

flare out - cervical, apex

Primary teeth vs. Perm Teeth: Primary...

The thickness of dentin is _____.

The pulp chambers are comparatively ______ .

The pulp horns, especially the _____ horns, are _____ in primary _____

Less

larger

mesial - higher- molars

After primary root development, what continues in the root canal?

What does this affect?

Dentin deposition

Number, size, shape of root canals

T or F: Root canal variations are visible on X rays

F -> they are often not

How many canals:

Anterior?

Exception?

1

Mand incisors occasionally have two

What are the 4 steps of pulpal diagnosis in children?

1. History and characteristics of pain

2. Clinical examination

3. Radiographic examination

4. Operative diagnosis

Pulp diagnosis in children is as much an ____ as a ______

art as a science

Triggered by thermal or osmotic stimulus (e.g., cold drinks, eating candy)

Stops when stimulus is removed

Provoked pain

Not consistently associated with an external stimulus

May arise at any time of the day

Spontaneous pain

Indicative of minor, reversible pulp inflammation

Provoked pain

Provoked pain is often confused with what ???(3)

Interproximal impaction of food, soreness of exfoliation, eruption of permanent teeth

Pulpal Diagnosis of Children Steps (4)

History of characteristics of pain

Clinical exam

Radiographic Exam

Operative Dx

A clinical exam for pulpal dx consists of what 5 things?

Inspection of hard/soft tissues

Palpation

Percussion

Mobility

Pulp tests

May awake child from sleep (nocturnal pain)

Spontaneous pain

Spontaneous pain:

• Ask for any _______ or _______ used

• May be confused with _______ due to food impaction

swelling or anaglesics

papillitis

Children may not report any complaint, despite extensive _______ lesion and a draining ________ _______.

carious

sinus tracts

Children who have early childhood caries may have no experience of their teeth feeling any other way, and therffore what?

Have no special pain history to report

Varying degrees of pulp degeneration can be encountered with any what?

Report of pain

Inspection of hard/soft tissues? (6)

1. Tooth discoloration

2. Gross caries

3. Redness and swelling

4. Fistuale/ sinus tract

5. Fractured or missing restoration

6. Restorations with recurrent caries

Palpation may be useful for what?

May not be felt where?

May not be visualized __________

Acute and chronic dentoa lveolar abscesses

mucobuccal fold

externally

Chronic dentoalveolar abscess is associated ______- _____

bone destruction

Percussion may be useful for what?

What is an exception?

Using ______ may be more useful in younger children.

Acute periradicular periodontitis

recently traumatized teeth

fingertip

What is not a reliable and objective test?

Mobility

What testing mobility, what should you compare it to?

Contralateral

T or F:

1. Electrical methods for pulp testing have limited value in primary teeth?

2. They are reliable for the extent of pulpal inflammation?

T

F

What types of pulp tests may be more helpful in children?

__________ more effective than _________

What is unreliable?

Thermal

Carbon dioxide snow, ice/ethyl chloride

Heat

Limitations of radiographic exams:

Is periapical pathosis always demonstrated in radiographs?

Where should you check?

Can you determine the proximity of caries to the pulp?

______ dimension

Why can interpretation be difficult?

No

Furcal area (accessory under pulp chamber)

Not accurately

two

physiologic root resorption and poor quality of film/plate

Most variations within root canals of primary and permanent teeth are in what plane?

what does this mean?

May of the variatons that are already present may not be _______

Facioligual

Radiographs are not helpful (they show mesiodistal)

visible

Pulp exposure: size of the exposure

• Massive exposure?

• Poor canidate for any form of what?

Always associated with widespread inflammation or necrosis

vital pulp therapy

Pulp exposure: the color and amount of bleeding

• ______ ______ hemorrhage from an exposed pulp

• Evidende of extensive _______

dark/excessive

inflammation

For a pulpotomy, hemostasis should be obtained after ________ of light pressure with a moistened cotton pellet

Bleeding past this point indicates what??

2-3 mins

Inflammation of radicular pulp and a more radical treatment should be considered such as pulpectomy or extraction

What are the three vital pulp therapies???

Indirect Pulp Therapy

Direct Pulp Capping

Pulpotomy

What are the two non vital pulp therapies?

1. Pulpectomy

2. Lesion Sterilization/ tissue repair

Indirect Pulp Therapy Involves:

A detailed history of _____

Good knowledge of ______ and _____

No signs/symptoms of _________

Direct evaluation of the cavity duing _________

What kind of caries removal?

What needs to be obtained?

Pain

tooth anatomy and caries process

irreversible pulpitis

preperation

selective (leave affected dentin on floor) and no caries on cavity walls

Optimal coronal seal

Why do we not do complete caries removal in indirect pulp therapy?

May result in pulp exposure

What is used to remove carious dentin in indirect pulp therapy?

Where?

_______-______ walls

Large, round steel burs (#6 to #8).

Excavators only at the DEJ - angled outward

caries free walls at dentoenamel junction

What is placed before definitive restoration in indirect pulp therapy?

What are the definitive restorations?

Dycal/theracal/vitrebond/GIC

SCC Or resin (if 1 surface)

Success rate for IPT:

• 24 months?

• 48 months?

• Unable to determine its supreriority over ______ or _______

94.4% (moderate evidence)

83.4% (weak evidence)

DPC or pulpotomy

Hall technique: probability of surving without extraction

• 3 years?

• 5 years?

86%

80.5%

In what two ways is the Hall technique unique?

No local or tooth prep and SSC is cemented

Caries is not removed, but sealed into tooth by SSC, thus isolating it from rest of mouth

Indications for Direct Pulp Capping???

Pinpoint exposure (≤1 mm) of a healthy pulp

During cavity preparation

Following a traumatic injury

Objectives of Direct Pulp Capping:

Maintain ______

No post tx ______ or _____

Should result in ____ healing and ____ formation

No harm to _______

vitality

signs or symptoms (sensitivity, pain, swelling)

pulp - reparative dentin

permanent dentition

When Direct Pulp Capping, there should be no radiographic evidence of what three things??

pathologic external root resorption

progressive internal root resorption

furcation/apical radiolucency

What is a critical step of direct pulp capping?

hemorrhage control

Critical step:

• Without sufficent bleedig control what will happen?

• Compromise the contact between what?

any excessive serum or plasma occupy, fill, or create a space

contact between the dressing and the pulp

What two things are used for hemorrage control in direct pulp cappping?

Ferric Sulfate

Sodium Hypochlorite

Ferric sulfate:

• Acheives hemostatis by forming a ________ complex on the pulp surface after chemically reacting with _______ _______

• The complex mechanically seals the _______ ______

• May prevent problems encountered with _______ formation

ferric ion protein complex

severed blood vessels

clot

Sodium hypochlorite:

• A convenient hemostatic agent for vital pulp therapies when used at _________ concentrations.

• _____ free hemostasis

therapeutic

clot

Direct pulp capping materials ??(2)

Calcium Hydroxide

Mineral Trioxide Aggregate

Calcium Hydroxide: one of the dentist oldest friends

Poor ______ to _____ surfaces

Dissolves under _______

Unable to prevent _______

adhesion - dentin

Restorations

microleakage

Mineral trioxide aggregate (MTA)

_______ active substrate

Regulates _______ events in pulp cells

Superior to CH in terms of the absence of what?

More predictable ______ formation

Biologically

dentinogenic

an inflammatory response

hard dentin bridge

Evidence for DPC:

• 24 months?

• Comparing to CH, MTA, and DPC?

88.8%

No difference for primary teeth

Difficult to compare to to small number of good studies

DPC Evidence conclusions: DPC primary molars greater than 1mm exposure sites

• Hemorrhage control with SS, FS or SH solutions did what?

• MTA is a suitble alternative to ______ in terms of clinical and radiographic outcome.

• _____ should not be preffered for hemorrhage control if CH is chosenfor pulp capping in order to prevent ______ _______

Not affect the clinical and radiographic success.

CH

FS, internal resorption

Amputation of the affected /infected coronal portion of the pulp?

Why?

Pulpotomy - to preserve the vitality and function of the remaining (radicular) pulp

Indications of Pulpotomy: Pulp exposure on _____ tooth in which the inflammation/ infection is judged to be restricted to the ______ pulp

Primary

Coronal

If inflammation has spread into the tissues within the root canals, the tooth should be considered a candidate for what three thing?

Pulpectomy

Lesion Sterilization and Tissue Repair (LSTR)

Extraction

Contraindications for Pulpotomies:

History of __________

_____ tooth

Tooth near to ______

Evidence of ______ or ______ pathosis

Evidence of pathologic _______ ______

Pulp that does not ______

Inability to control _____ pulp hemorrhage after _____ pulp amputation

Pulp with ______ or ______ drainage

Presence of a _____- ______

Spontaneous pain

Nonrestorable

exfoliation

periapical or furcal

root resorption

bleed

radicular, coronal

serous or purulent

sinus tract

Inflamed vital (coronal) pulp tissue is amputated, leaving healthy radicular pulp tissue?

The remainging tissue has the capacity to do what?

Pulpotomy

Stay healthy if managed correctly

Pulpotomies require what three things???

Complete removal of inflamed/infected coronal pulp tissue

Appropriate wound dressing

Effective coronal seal

T or F: all caries is removed in pulpotomies

T

Bleeding from the expsoure sites is _______, should not be what?

normal, dark or excessive

Pulpotomy: remove the _______ pulp chamber roof using what bur on high speed?

Start from expsoure site, then go ________, do not touch what?

entire

non-end cutting bur

sideways, the floor

What is used to amputate all the coronal pulp in a pulpotomy?

6 or 8 round at slow speed

Pulpotomy:

• Wash the pulp chamber with what and dry with what?

• Control hemorrhage by doing what?

sterile saline and dry sterile cotton pellets

light pressure on the pulp stumps with slight moist pellets

During a pulpotomy, if hemostasis is not achieved within 2 to 3 minutes, the pulp tissue within the canals is probably _____ . The tooth may not be a ______ ______ .

• What should you precide with then?

Inflamed

Good candidate

pulpectomy or extraction

Wound Management for Pulpotomies??? (3)

- diluted formocresol solution (1/5 Buckley formula) for 5 minutes, ZOE cement

- 1.25-2.5% sodium hypochlorite and then MTA

- 15.5% ferric sulfate solution for 15 seconds, ZOE cement

What is used as base in pulpotomies?

Restorations?

GIC

SSC or resin

Evidence for pulptomy:

• Success rate at 24 months?

• hemorrhange control quality?

  • Formocresol?

  • Ferric sulfate?

  • NaOCL?

• pulpotoomy material quality?

  • MTA?

  • CH?

82.6%

strong/moderate

conditional low

contitional low

strong/moderate

recomendation against it use/low

Non Vital Pulp Therapies?? (2)

Pulpectomy

Lesion Sterilization/Tissue Repair

Indications for Pulpectomy:

_______ pulp is chronically inflamed/necrotic

History of _______ pain

_______/______ may be present

___________ hemorrhage from the pulpotomy site

Radicular

spontaneous/nocturnal/persistent

Abscess/fistula

Dark/excessive (uncontrollable)

Contraindications for Pulpectomy:

______ tooth

_______ _____

_______/______ perforation of pulp chamber floor

Excessive pathologic _______ ____

Excessive ______ loss

Presence of a _____ or _____

_______/______ lesion involving the crypt of the developing permanent successor

Unrestorable

Internal resorption

Mechanical/carious

root resorption (>1/3 of root)

bone

dentigerous or follicular cyst

Periapical/interradicular

What two things are used for every pulp therapy technique?

LA and rubber dam

What kind of caries removal in pulpectomy?

Complete

Extirpation, working length determination, shaping, irrigation and drying are all steps in what kind of pulp therapy?

Pulpectomy

What is the working length determination for pulpectomys?

Are apex locatars good to use?

2-3mm short of apex

Not reliable

Pulpectomy technique:

• Shaping?

• Irrigation and ______

• Filling with what?

• Restore with what?

NiTi and enlarge to 30-35

drying (naOcl should not extrude through the canals

Multiple things to rpevent extrusion through apex

GIC and SSC

A successful pulpectomy involves:

Healing of _____

Absence of (3)

Absence of resorption of _____ or ______

Absence of _____ or ______ resorption

fistulae

pain, mobility or abscess

periapical or intra-radicular bone

internal or external

Pulpectomized primary teeth may show delayed _________

why?

Exfoliation

Large amount of ZOE left in the chamber may impair the resorptive process

What is a common sequela of pulpectomy

Does this cause pathosis?

Retention of ZOE in the tissues

No

Lesion Sterilization/Tissue Repair is performed in primary teeth with what?

irreversible pulpitis/necrosis

Primary teeth that have a treatment plan for a pulpotomy but the radicular pulp exhibits clinical signs of irreversible pulpitis or pulp necrosis should get what?

Lesion sterilization / tissue repair

When a primary tooth is to be maintained for at least 12 months and exhibits root resorption, what should be done?

Lesion sterilization / tissue repair (this is preferred to pulpectomy)

T or F: LSTR has no instrumentation into the canals?

T

What is done in LSTR procedure?

Access the pulpal chamber, enlarge the canal orifices using a large round bur to create medication receptacles.

Etch (?), rinse and dry the chamber walls.

Place triple antibiotic paste.

Fill chamber with GIC

Restore with SSC

What is in triple antibiotic paste?

Mixture of clindamycin, metronidazole, and ciprofloxacin combined with propylene glycol.

Evidence for pulpecotomy:

• With Zo iodoform/CH and ZOE?

• With Iodoform?

• LSTR?

Conclusion?

90%

71%

75-80%

Endoflas = ZOE = Vitapex, Idoform has less success

LSTR are better than pulpectomeis in what teeth?

Pulpecomty is superior when?

Preoperative root resorption

Roots are intact

IPT?

DPC?

_____ = ______ low quality evidene

94.4% for 2 and 83.4% for 4

88.8% 2 years

CH = MTA

Pulpectomy:

• Hemorrhage control materials?

• Capping materials?

FC, FS, NaOCl

MTA, ZOE

Pulpectomy:

• Zo, idoform. CH and ZOE?

• Idodform?

90%

71%

LSTR Success rate?

75-80%