1) Pulp Therapy for Primary Teeth

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Pulp therapy for primary teeth

There is two types of pulp therapy that we discuss in pediatric dentistry :

1- Pulp therapy for primary teeth.2- Pulp therapy for permanent teeth.(a- permanent teeth in young child .

B- permanent teeth in old pts )

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PULP THERAPY FOR PRIMARY TEETH **

There is two types of pulp therapy :

1- Vital pulp therapy : for teeth with a normal pulp or reversible pulpitis.2- Non-vital pulp therapy : for irreversible pulpitis or necrotic pulp.

** why do we perform the pulp therapy??

because there are a consequences of leaving an infected primary teethuntreated.

What is the consequences of leaving an infected primary teeth untreated?1- Abscess progresses , Facial swelling [ cellulitis ].2- Granulomatous rxn.3- Cystic development if there is a long periapical lesion,, especially the

dentigerous cyst.4- Interruption of normal development & eruption of permanent teeth .5- Systemic effects as result of chronic infection:

a- Immediate : Fever , malaise .b- Long term : poor nutrition Couse of pain .c- Growth & development .


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Indication & contraind for retaining the primary dentition :1- Where primary tooth to be conserved ( not extracted ) , pulp therapy

is indicated.2- Where pt exhibits signs & symptoms of pulpitis ( reversible or irrev )3- Where interproximal marginal ridge lost due to caries . most of time

if we have a class 2 lesion in primary molar most of the time we willneed pulp therapy but of course you have to assess the depth ofcarious lesion on the x-ray .

4- Where RG evidence of caries extending ( more than halfway fromADJ to pulp thats mean its a Big lesion )

5- Where there are clinical signs of pulpal necrosis.

Extraction of primary teeth should be avoided and pulp therapy advised :1- Medical history hemophilia , other bleeding diathesis , DM if its

uncontrolled we want to avoid extraction.2- Pt behavior bad experience with extraction , pulp tx may be less

stressful3- All primary molars present or where SM prevented loss of arch

dimension.

4- Crowding exo leads to further crowding of permanent teeth5- When there is Congenitally missing of successor like premolar so I

have to save E for example .6- Maintenance of masticatory function very important for growth &

development for the child7- Aesthetics.

Pic n slid 7 ;

If we look at x-ray here the premolar here is Congenitally missing

In the E very deep carious lesion if we see it in the x-ray in the Mesial pulphorn so if the premolar is missing we want to do ur best to save those tooth.


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We do pulpotomy and stainless steel crown . if we ignore the tooth and nottreat it we lose it and we will lose the space here !.

PTs FOR WHOM PULP THERAPY NOT ADVISED [ contraindicated ] :

1- Family attitude family background unfav towards dental tx.Some family think that the primary teeth should be remove becausethere is another teeth will replace it .

2- Medical problems pts whose general health at risk from transientbactermilas for example :a- CHD [congenital heart disease] risk of IE [infective endocarditis]b- Immunosuppression:

*primary disease [ genetically ] ex. Hypogamma.

*secondary disease [ medically ] ex. oncology pts and transplantrecipients.

3- BM pts with poor behavior to comply with dental tx.

4- dentition with multiple carious lesion ; multiple exo`s necessary

5-mixed dentition with crowded inc- balance loss of D justified. May

result in exo of PM at later stage. E retained if possible to preventmesial drift of 6 on eruption.

6- Grossly broken down primary molar with insufficient tooth structurefor coronal rest.

7- Tooth with caries penetrating floor of pulp chamber if the cariesreach the furcation area we should extract it.

8- Tooth close to exfoliation ex. More than 2/3 of root lengthremaining.

9- Tooth with advanced pathological root resorption.

Pic n slid 11 ;These is an exfoliate tooth wish has caries in it . we dont do pulp therapyfor it , we extract it .


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** INDIRECT PULP CAPPING ..

Definition :The procedures or steps taken to protect or maintain the vitality of the

carious tooth that if completely excavated all the caries the decay wouldresult in a pulp exposure.So u excavate the caries removing it with bur or excavator , then there isthe prime layer if u remove it > pulp exposure.

The term ( IPC ) was recently replaced by the term indirect pulp treatment(IPT)

Rational :1- In tooth with deep carious lesion.2- Carious dentine removal sometimes is left incomplete to avoid pulp

exp. ( we remove all the caries dentine on the wall and we left thecaries on the floor to prevent pulp exposure.)

3- A radiopaque Base placed over affected dentine to cover it andstimulate healing & repair.

4- then restored with dental material that seals dentine from oralenvironment.

Pic n slid 16 ;This is an ex of IPC . we remover the caries all the way until we reachsmear layer wish if we remove it > pulp exp.So u place a liner then GI . the coronal seal is incomplete in this case

th ats why there is a mistake ..

Benefits of IPT over pulpotomy include :1- Maintenance of physical integrity of pulp .


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2- Avoids use of pulpotomy agents wish is systemic toxicities.3- The Success rate of IPC is high in some case when we compare it with

pulpotomy .

Objectives of IPC :1- Pulpitis can be reversed , recovers from toxins of dental caries.2- Deposition of secondary dentine beneath the affected zone

Indications :1- Vital teeth with deep caries & reversible pulpitis where further

removal of dentine over pulp would result in exposure.2- (Beh ) lack of cooperative pulpotomy lengthy procedure .3- As an alternative Tx to pulpotomy .

What type of the medicaments that we use ?I told u we remove all the caries and we protect the last layer wish iscover the pulp so we put on the teeth the capping agent .The capping agent used is immaterial there are a list of material that we

can use it , it dose not matter wish one we use as long as seals cariousdentine from oral fluids .

Medicaments of IPC :1- Calcium hydroxide ( CH ) :

Consider the medicament of choice for pulp exposure .The Success rate up to 95 % .

2- Ledermix :

mix of antibiotics and cortisone to reduce pulp inflammation & reducepain & sensitivity.

3- GIC / RMGIC :Excellent material , Remineralization , the Success rate up to 93 % .


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Calcium hydroxide action :The Dr said we all know it .. Back to slid num 22 .

Success criteria of IPC :1- Vitality of tooth preserved2- No prolonged post-tx signs or symptoms of sensitivity , we dont want

pain or swelling or mobility .3- Pulp respond favorably by lying tertiary dentine formed upon RG

evaluation.4- No evidence of internal root resorption or other pathologic change .

Success depends on :1- Restorative material ;

if you compare amalgam and stain steel crown , we get 8 times failurein case of amalgam.

2- Careful dx , removal of caries from lateral walls leaving deep cariousdentine on floor to avoid a microscopic exposure .

3- Base that we used ;We have to fill cavity with GI to cover the remaining dentin , if we

dont fill it , it will be failure.The Success rate of CH+RMGI/ZOE > only CH liner , 9 times failure if weuse CH only .Benefit of use Base : thermal insulation , hardness , seal .Benefit of use RMGI base : Good sealing properties , antibacterial.

IPC Recommendation :IPC considered as alternative to FCP.

Success rate depend on placement of SSC immediately after theprocedure.


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** DIRECT PULP CAPPING ..

Rationale :When small exposure of pulp encountered during cavity preparation or

following trauma an placing appropriate biocompatible radiopaque baseor liner (calcium hydroxide and vitra bond ) may be placed in contact withexposed pulp tissue prior to placing a restoration .

Indication :Procedure is valid for normal pulp where- Small mechanical exposure in non carious tooth , when by mistake drill

a E instead of D we do DPC because vitality of the pulp ( noinflammation ).

- Small traumatic exposure in non carious tooth ( broken due trauma ).- DPC of a carious pulp exposure in primary tooth is not recommended.

Objectives :1- Vitality of the tooth should be maintained.2- No prolonged post-tx signs & symptoms of sensitivity , pain or swilling

should be evident.3- Pulp healing and tertiary dentin formation should result.4- There should be no pathological signs.

DPC material :1- Calcium hydroxide ;- promotes internal resorption of primary pulp.- Existing inflammation amplifies internal resorption with CH.- DPC of primary teeth with CH should be restricted to mechanical

exposure.2- Dentin Bonding Agent ;- Form an impermeable hybrid layer / seal , Not widely used .3- MTA.


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** PULPOTOMY ..

Definition :Amputation ( remove ) of coronal portion of affected or infected dentalpulp . Tx of remaining vital radicular pulp tissue surface should preservethe vitality & function of all or part of remaining radicular portion.Coronal pulp chamber filled with suitable base & tooth restored .

Indication :1- Primary teeth when infected coronal tissue reversibly inflamed &

radicular pulp vital we a asses that by clinical & RG if there is atenderness or mobility or abscess or radiolucent or internal resorptionor any things abnormal we dont do pulpotomy because this mean theradicular portion is also infected .

2- Carious pulp exposure .3- Traumatic pulp exposure .4- Primary molars with loss more than > 2/3 of marginal ridge usually

require a pulpotomy .

Contraindication :First of all when we remove the caries and pulp tissue u have to assesyour case clinically because sometimes clinical & RG examination will nottell you 100% every things , sometimes if we have irreversible pulpitis thiswill not show in x-ray , you will not see any things in x-ray.** x-ray cant show the disease in early stage and clinically the pt has notComplain of pain , sometimes the clinical & RG signs can be misleading ,

so we have to assess the bleeding " clinical assessment " the bleeding thatwe should see should be healthy bleeding , we place a cotton on the toothif the bleeding dose not stop that mean the pulp is inflamed , in thesecase the pulpotomy is not widely use , u should perform another form ofpulp therapy wish is called " pulpectomy in children " RCT-> adult .


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Pulpectomy mean total remove of pulp tissue .

** so what is the Contraindication :1- Inability to establish haemostasis after removal of coronal pulp

(irreversible pulpitis)2- Acute odontogenic infection ( abscess , pus , fever , facial swelling ,

cellulitis )3- Tooth unrestorable clinically .4- Tooth soon to exfoliate .5- Excessive tooth mobility.6- Internal or external root resorption + radiolucent.7- Medical history : cardiac and immunocompromised pt .

DR keep talking about the pictures in the slids ..

Objective :1- The vitality of radicular pulp maintained.2- No prolonged adverse clinical signs or symptoms such as prolonged

sensitivity, pain or swelling .

3- No evidence of internal root resorption or abnormal canal.4- No breakdown of periapical tissues , no harm to succedaneous tooth.

Slid 44 Dr ignore it :S .

Technique :Local anesthesia > Access : Remove all caries before reaching pulp if uleave any caries u fail we use High speed handpiece for access , and

pear shape bur or straight bur for caries remove > Amputation of pulp tolevel of cervical portion of the tooth ( arbitrary ) because themicroorganism cant reach more than cervix by using slow speedhandpiece or round bur -> medicament used to fix the pulp so u take acotton with normal saline on it and put it in the orifice and we wait 5 mins


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after u remove it the bleeding stop that mean ur treatment is OK and thenwe get a medicament ( liquid ) with a cotton we place it for minutes thenwe remove it -> IRM dressing condense it should be without any voidsand we dont want any space between the tooth and IRM > restoration :we put a layer with ZOE ( 2mm or 3mm ) it act like a bandage for wind andthen we fill a it with GI then we place a SSC.

Access for Pulpotomy & pulpectomy :- Anterior teeth : simple canal .- Upper molar : 2-5 canals , usually 4:2 MB , D&L roots usually fused .- Lower molar : 2-5 canals , usually 3:2 in Mesial root , 1 in Distal root.

Pulpotomy medicaments :- The ideal pulpotomy agent should meet the following criteria :

1- Non-toxic.2- Antimicrobial.3- Anti-inflammatory.4- Haemostatic to minimize clot.5- Promote true healing of pulp tissue (Regeneration )

6- Not to interfere with normal physiologic tooth development .

Pulpotomy medicaments ( agent ) :1- Reservation :- CH .- Ledermix.- Ferric sulfate.2- Devitalization :

- Formocresol.- Gluteraldehyde .- MTA.- Electrosurgery.- Lasers for amputation.


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3- Regeneration :- Bone morphogenetic proteins.- MTA.

Formocresol :

- Use for :Fixes affected & infected radicular tissue = replace a chronicinflammation to acute inflammation .

- Dr ignore slid num 52 .. :S.

- Effects of Formocresol on the pulp :Fixation , coagulation necrosis .

- Effects of Formocresol on the periapical tissues :Toxological , antigenticity , carcinogenicity, dentigerous cysts, enamelhypoplasia , accelerate tooth eruption .

**Carcinogenicity how ?!Because of high prev of accessory canals in furcation area of primarymolar , so when I remove Formocresol we cant remove it totally , itstill there and goes to under lying bone and Blood vessel through theaccessory canals .

- Effects of Formocresol systemically :Toxicity , carcinogenicity in animals causing failure & death , liver and

kidney morbidity .

- To minimize the toxicity of Formocresol :We do a dilution of this formulation 1 to 5 .


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- Buckley's Formocresol composed of :19% formaldehyde ( Fixative agent )35% tricresol ( anti-bact agent )15% glycerol31% water

- Some study said that the Formocresol is toxic so we replace it withFerric sulfate . and the other study said is not toxic we can use it !

Dr ignore slid num 60 , 61

Ferric sulfate ( FeSO4 ):- Comes as 15.5% concentration , aqueous.

- How it is work ?By causes agglutin of blood pressure due to chemical rxn of blood withFe & So4 ionsAgglutinated pressure form pulgs occlude capillary orifices, minimize

chances for inflammation & internal resorption .

- Benefits of Ferric sulfate :1- Non-toxic / non-carcinogenic.2- Readily available.3- Short application times 10-15 seconds ( Formocresol = 5 mins

sometimes only 3 mins )4- Success rates are comparable with Formocresol .

DR ignored slid num 64 .


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MTA ( Mineral Trioxide aggregate ):

- It is a substance like amalgam ..

Success rates :- Usually said the Success rate of E is higher than D (not general rule)- Type of immediate restoration influences the pulp therapy results.- The Success rates of immediate Stain steel crown (82%)>IRM(38%)

Success rate of formocresol pulpotomy :

- The reasons mentioned for failure were canal calcification .- How did we know if the therapy is successful ?The pt not complain of anything but when we take an x-ray we seechronic inflammation ( not painful ), so it dose not mean if the pt didnot complain > the treatment is successful .Maybe on the RG every thing is fine but when we do histology ofremaining pulp tissue we see a law grade inflammation or chronicinflammation ( not painful ) .

- The further we found failure and the longer we follow up the ptEx : if we saw the pt after 1 week without any symptoms -> mytreatment is okAfter one month i saw the pt again -> the pt is fineAfter 6 months I saw the pt again > the pt have an abscess.So the long we follow up the pt u find more failure .

** PULPECTOMY ..(RCT)

- Its the same criteria of RCT ..

- Indication:


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Tooth with irreversible pulpitis or necrosis.

- Contraindication :Dr said it previously .

- we determine the Working length and we remove all the pulp tissue .but the different between pulpectomy and RCT we dont do step backin pulpectomy and we dont use gates glidden to enlarge the orifice .

- we use NAOCL for irrigate but sometimes we dont like it because itaffect the permanent teeth so we can replace it with normal saline andwe dry .

- we use antibiotic if there was an abscess or systemic symptoms .

- goals :1- Elimination of infection.2- Prevention of further pathological tooth destruction.

3- Retaining tooth in function state awaiting normal exfoliation.

- The alternative of pulpectomy is extraction .Most of the cases in pediatric dentistry in general is extraction .

- We dont fill the canals with gutta percha , we fill it with Calciumhydroxide or ZOE or ledermix.

- Behavior management : should be a (+) kid or we have to workingunder GA .


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- The pulp canals in primary teeth is very complicated ,it have a lot ofaccessory canals , so we cant insure the cleaning of canal .

- Materials that we use it :** ZOE : Most commonly used filling for primary teeth .We use ZOE not reinforced type .** KRI paste : contain iodine thats why it has a very high success rate .(important note)benefit of iodine: act as bactericidal & the vapor of iodine inter theaccessory canal and sterilize it thats why it has a very high successrate & no effect on permanent tooth** CH ..** ledermix.** CH + iodine -> vitapex .

- You should to read the material from the slid ..

- Success rate :

*KRI paste is the highest cause of iodine 84-100%*ZOE 65-86%

- DR show an example about failed pulpectomy ; because of underfilledand radiolucent ..

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The best medicine in the world is a Mother's Hug .. MuM

1) Pulp Therapy for Primary Teeth

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