Vital Pulp Therapy - PDWGpdwg-ng.org/materials/Vital Pulp Therapy.pdf•Before attempting pulp therapy in the primary dentition, the clinician should be familiar with the basic differences

Vital Pulp Therapy

Outline

• Introduction into the objectives of pulp therapy

• Morphology of the root canal

• Clinical Assessment of the pulp status

• Vital pulpotomy medicaments

• Vital pulpotomy procedure

• Conclusion

Introduction

• Despite advances in understanding about how to prevent dental caries and the importance of maintaining the natural dentition, many teeth are still lost prematurely.

• The primary objective of pulp treatment is to maintain the integrity and health of oral tissues.

Other reasons

• Reduce the likelihood of mesial drift, supra-eruption of opposing teeth and the resultant malocclusion.

• Aid mastication.

• Preserve a pulpally involved primary tooth especially in the absence of a succedaneous tooth.

• Prevent possible speech problems.

Introduction

• Maintain aesthetics.

• Prevent aberrant tongue habits

• Prevent the psychological effects associated with early tooth loss.

• Maintain normal eruption time of the succedaneous teeth.

Introduction

• Before attempting pulp therapy in the primary dentition, the clinician should be familiar with the basic differences between primary and permanent root canal anatomy.

• The pulp performs five major functions namely induction, formation of tissues, provide nutrition, ensure defense following injury and provide sensation.

Pulp Function

Induction

• Pulp participates in the induction and development of odontoblasts and dentine, which, when formed, induce enamel formation.

Pulp Function - 2

Formation

• Odontoblasts form dentine continuously throughout the life of the tooth.

• Odontoblasts can also form a unique type of dentine (secondary and tertiary dentine) in response to injury, such as occurs with caries, trauma, and restorative procedures.

Pulp Function - 3

Nutrition

• The pulp supplies nutrients that are essential for dentine formation and hydration.

Pulp Function - 4

Pulp Therapy in Pediatric DentistryIntroduction

• Pulp functions (continued)– Nutrition

• Via dentinal tubules, pulp supplies nutrients that are essential for dentin formation and hydration.

– Defense• Odontoblasts form dentin in response to injury,

particularly when the original dentin thickness has been compromised by caries, wear, trauma, or restorative procedures. Pulp also has the ability to elicit an inflammatory and immunologic response in an attempt to neutralize or eliminate invasion of dentin by caries-causing microorganisms and their byproducts.

Defense

• Odontoblasts form dentine in response to injury, particularly when the original dentine thickness has been compromised by caries, tooth wear, trauma, or restorative procedures.

• Pulp also has the ability to elicit an inflammatory and immunologic response in an attempt to neutralize or eliminate invasion of the pulp by caries-causing microorganisms and their by products.

Pulp Function - 5

Sensation

• Through the nervous system, pulp transmits sensations, also mediated through dentine, to the higher nerve centers.

Pulp Function - 6

Pulp Therapy in Pediatric DentistryIntroduction

• Characteristics of Pulp Tissue

– Most similar to connective tissue

– Tremendous healing potential

– Apical vascularity is important to healing potential

– Coronal tissue is more cellular

– Apical tissue is more fibrous

– Pulp becomes more fibrotic with age

• Lymph vessels

• Blood vessels

• Nerve tissue

• Undifferentiated mesenchymal cells

• Fibroblasts

• Defense cells (neutrophils, lymphocytes, and macrophages)

• Odontoblasts

• Osteoclasts/Odontoclasts

Pulp Content

The healing potential of healthy pulp tissue is a function of:

• The vascularity of the pulp.

• The absence of cariogenic and inflammatory bacteria.

• The cellular/structural integrity of the pulp/dentin/enamel complex.

• The absence of a chemical and/or thermal insult.

Pulp Content

Morphology of The Root Canal

• The root canals of anterior primary teeth are relatively simple, have few irregularities, and are easily treated endodontically.

• The root canal systems in the posterior primary teeth contain many ramifications and deltas between canals making thorough debridement quiet difficult.

Pulp Therapy in Pediatric DentistryMorphology of The Root Canal

• Simultaneously, secondary dentin is deposited within the root canal system.

• The deposition produces variations and alterations in the number and size of the root canals, as well a many small connecting branches between the facial and lingual aspects of the canals.

• Accessory canals, lateral canals, and apical ramifications of the pulp may be found in 10 to 20% of primary molars.

• Primary teeth have characteristic ribbon-like radicular pulp.

• Primary molar roots are widely divergent and curved to allow for the development of the succedaneous tooth.

• Generally, there is only one canal present in each root of the primary molars when the formation of the roots has been completed.

• The primary tooth root will begin to resorb as soon as the root length is completed.

• The resorption causes the position of the apical foramen to change continually.

Morphology of The Root Canal

• The maxillary primary molars may have two to five canals, with the palatal root usually rounder and longer than the two facial roots.

• In the mesio-facial root, two canals occur in approximately 75% of the primary maxillary first molars and 85 to 95% of primary maxillary second molars.

Morphology of The Root Canal

Pulp Therapy in Pediatric DentistryMorphology of The Root Canal

• The thickness of enamel and dentin coronal to the pulp chamber is also thinner in a primary tooth.

• Since the distance from the occlusal surface and the floor of the pulp chamber is much shorter than in a permanent tooth, care must be taken when making an access opening into the pulp chamber to prevent perforation into the furcation area.

• The primary mandibular first and second molars usually have three canals which generally correspond to the external root canal anatomy.

• Approximately 75% of the mesial roots in primary first molars contain two canals; whereas in primary second molars, 85% of the mesial roots contain two canals.

Morphology of The Root Canal

History of Pain

Three important factors to consider

• Duration (how long does it hurt?)

• Frequency (how often does it hurt?)

• Location (where does it hurt?)

Clinical Assessment of Pulp Status

Extent of Lesion

• Location

• Colour

Mobility

• Differentiate between physiologic root resorption and pathologic root/bone loss

Soft tissue swelling

Lymphadenopathy

Pulp exposure - Hemorrhagic versus Necrotic

Clinical Assessment of Pulp Status

Types of Pain and Pulp Status

• Irreversible (indicated for non-vital pulpotomy)

• Spontaneous/Non-stimulated

• Nocturnal

• Constant

Clinical Assessment of Pulp Status

Reversible (indicated for vital pulpotomy)

• Pain stimulus on thermal, chemical irritation

• Intermittent in nature

Clinical Assessment of Pulp Status

Pulp Testing

• Percussion is most reliable in primary teeth

• Thermal sensitivity testing is reliable in primary teeth.

• Electrical pulp testing is NOT reliable in primary teeth due to the non-reliability of patient’s response.

Clinical Assessment of Pulp Status

Radiographic Examination

• Pathologic bone resorption.

o In the presence of infection, bone is destroyed.

o The bone destruction is seen in the furcation area of the tooth.

o With chronic and long-standing infection, resorption can become extensive involving the apical areas as well.

o Bone resorption is indicative of pulpal necrosis and non-vitality of the associated tooth.

Clinical Assessment of Pulp Status

Other radiographic evidence of pulpal pathology:

• Internal/External resorption.• Calcific changes. • Widened periodontal membrane/ligament.

Clinical Assessment of Pulp Status

• Histological changesThere is a poor correlation between clinical symptoms and histologic pulp status.

Clinical Assessment of Pulp Status

• Painless technique is essential. Adequate anaesthesia is compulsory in order to gain the child’s cooperation.

• Use rubber dam to maintain dry sterile field, prevention of aspiration or swallowing of dental instruments, isolate tooth and prevent soft tissue injury.

• Infection control principles must always be applied.• Consider the restorability of affected tooth.

General Principles of Treatment

A procedure in which the non vital coronal pulp (or part of it) is amputated, and a medicament is placed over the radicular pulp to help maintain its vitality.

Vital Pulpotomy

Indications• Mechanical or carious exposure of pulp• Inflammation limited to coronal pulp• Absence of spontaneous pain• Absence of swelling or alveolar abscess formation

Vital Pulpotomy

Pharmacologic agents:• Formocresol• Calcium hydroxide (not used for primary teeth)• Glutaraldehyde• Ferric sulphate • Mineral trioxide aggregate (MTA)• Paraformaldehyde for devitalization pulpotomy

Vital Pulpotomy Medicaments

Non pharmacologic agents• Laser• Electrosurgery

Vital Pulpotomy Medicaments

Formocresol

• Formocresol has been the ‘gold standard' material for vital pulpotomy many decades

• Introduced by Buckley 1904.

• Clinically emphasized by Sweet in 1930

• Contains 19% formaldehyde, 35% cresol, 15% water and glycerin

• Buckley formocresol comes as a 20% concentrated solution.

• Should be diluted as a 1:5 dilution before use.

• This is done by adding 3 parts of glycerin to 1 part of distilled water; then 1 part of formocresol to 4 parts of diluent.

• Success rate ranges from 70-97%.

Formocresol - 2

• Despite its efficacy, there are doubts about its safety.

• Suspected to be mutagenic, cytotoxic, carcinogenic thus posing threat to humans.

• IACR 2004 classified formaldehyde as carcinogenic to humans.

• Strong but not sufficient evidence of formocresolcausing leukemia and cancer of the paranasal sinuses (Zarzar 2003).

Formocresol - 3

• Suitable material replacement for formocresolinclude MTA, glutaraldehyde, ferric sulfate, BMP, osteogenic protein, bioactive glass.

• Non-pharmacologic haemostatic techniques e.gLaser and electro surgery.

• These replacement are equally effective without the side effects of formocresol.

Formocresol - 4

• Give Local anaesthesia.

• Isolate tooth with rubber dam.

• Use No 330 bur to create your cavity outline.

• Remove all carious dentine and the roof of the pulp chamber with a slow speed round bur.

• Amputate the coronal pulp with a slow speed round bur or a spoon excavator.

• Irrigate coronal pulp chamber with normal saline.

Formocresol Pulpotomy Procedure

• Place a moisten cotton pellet on the orifice of the canals to achieve haemostasis for between 3-5 minutes.

• Place cotton pellet moistened with formocresol on pulp stump for 5 minutes.

• The pulp stump should appear blackish brown.

• If there is bleeding after use of formocresol, check for residual pulp tissue otherwise indicative of irreversible pulpitis.

Formocresol Pulpotomy Procedure

• Remove the formocresol moistened cotton pellet.

• Cover the radicular root stump with medicament containing a drop of formocresol, a drop of eugenolmixed with eugenol powder.

• Fill the pulp chamber with zinc oxide eugenol.

• Restore with stainless steel crown

• Recall patient for follow-up.

Formocresol Pulpotomy Procedure

•

• Indicated in a vital young permanent tooth with pulpal exposure whose root apex(apices) is (are) still open.

• Infection must be limited to the coronal pulp tissue.

• Ca(oH)2 pulpotomy is done to facilitate the completion of apex formation

Apexogenesis

Apexogenesis:• Preserves pulp vitality• Results in the formation of dentinal bridge where

Ca(oH)2 is placed on the radicular pulp.• Ensures vitality of the radicular pulp tissue is

maintained• Normal apical end of root formation continues

and its closure ensured.

Apexogenesis

Conclusion

• Pulp therapy in children is time consuming but rewarding.

• A good history, clinical and radiographic examinations are very important in diagnosis and treatment.

• Good understanding of material choices is also very important.

Indications for vital pulpotomy:• Mechanical or carious exposure of pulp• Inflammation limited to coronal pulp• Presence of spontaneous pain• Absence of swelling or alveolar abscess formation

Quiz 1

Pharamcological agents for vital pulpotomy:• Formocresol• Glutaraldehyde• Ferric sulphate• Laser • Electrosurgery

Quiz 2

Steps for formocresol pulpotomy include:

• Remove carious tissue before mechanical exposure of coronal pulp tissue

• Extirpate the coronal pulp tissue using a spoon escavator or slow round bur

• Remove the radicular pulp tissue also

• Ensure placement of stainless steel crown.

Quiz 3

THANK YOU

• Slides were developed by Olubukola Olatosi of the Department of Child Dental Health, University of Lagos with inputs from Morenike Ukpong of the Obafemi Awolowo University Ile-Ife.

• The slides were developed and updated from multiple materials over the years.

• We hereby acknowledge that many of the materials are not primary quotes of the group.

• We also acknowledge all those that were involved with the review of the slides.

Acknowledgement