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1. Pediatric endodontics DR. SWAPNIL PAKHALE
2. Introduction Definition: Pediatric endodontic is relatively
new terminology, which deals with the management of pulpally
involved teeth in children. Goals of Pulp Therapy: To allow a tooth
to remain in the Oral cavity in a non pathological state. To
maintain the arch length and tooth space. To restore a tooth to its
functional form. To prevent speech abnormality. To maintain
esthetic of child.
3. Reversible Pulpitis Pulp with reversible pulpits has mind
inflammation and it is capable of healing once the irritating
stimulus has been removed. Pain is only felt when a stimulus is
applied to the tooth and the pain ceases within a few seconds or
immediately upon removal of the stimulus. The pain is short and
sharp in nature but it is never spontaneous. There are no
radiographic changes evident in the periapical region.
4. Reversible Pulpitis Treatment: As Grossman has stated, The
best treatment for reversible pulpits is its prevention. Removal of
noxious stimulus generally is sufficient to allow the pulp to
return back to its healthy state.
5. Irreversible Pulpitis In case of irreversible pulpitis, the
pulp has been damaged beyond repair, and even the removal of the
noxious stimulus will not allow its proper healing. Once the
classic symptoms of irreversible pulpitis is lingering pain induced
by thermal stimuli. The initial reaction is a very sharp pain to
hot or cold stimuli followed by dull ache or throbbing pain for
minutes to hours after the stimulus is removed. Pain increases on
bending or lying down.
6. Irreversible Pulpitis Spontaneous pain is another hallmark
feature of irreversible pulpitis. If the periapical tissues are
involved, the tooth is tender to percussion. In the most cases,
radiographs are not useful in diagnosis but they can be helpful in
identifying the possible cause of the disease, e.g. Associated
caries, or fracture of tooth, etc. Treatment: The treatment
comprises of pulp extirpation and endodontic therapy if the tooth
is salvageable and extraction otherwise.
7. Hyperplastic Pulpitis Hyperplastic pulpitis is a productive
inflammatory response of pulp. It usually involves chronically
inflamed young pulp, widely exposed by caries on its occlusal
aspect. It is characterized by proliferative growth of inflamed
connective tissue rising out of the carious crown. The tissue is
mostly firm, insensitive to the touch and occasionally may cause
mild discomfort during mastication. No significant radiographic
changes are evident unless there is also periapical
involvement.
8. Hyperplastic Pulpitis Treatment: Extraction is usually
indicated. On the other hand, if the tooth can be restored,
pulpectomy and endodontic therapy are recommended prior to
restoration.
9. Necrosis There are no true symptoms of complete pulp
necrosis with its sensory nerves, is totally destroyed. Treatment:
If the both is salvageable endodontic therapy is indicated, else
extraction is the only solution.
10. Internal Resorption The term internal Resorption is applied
to the destruction of predentin and dentin. Treatment: Since the
pulp tissue cells are responsible for the destructive process, its
removal by endodontic therapy arrests any further Resorption.
11. PERIAPICAL LESIONS Teeth with normal periradicular tissues
are nonsensitive to percussion and palpation testing.
Radiographically, periradicular tissues are normal with an impact
lamina dura and a uniform periodontal ligament space.
12. PERIAPICAL LESIONS Acute Apical Periodontitis: It is
painful inflammation of the periodontal tissues. The patient will
generally complain of discomfort to biting or chewing. Sensitivity
to percussion is a hallmark diagnostic test result of acute
periradicular periodontics. Tooth is usually not sensitive to hot
or cold.
13. PERIAPICAL LESIONS Acute Apical Periodontitis: Depending on
the cause of inflammation, it may or may not respond to vitality
tests. Palpation testing may or may not produce a sensitive
response. Radiographically, the PDL space may appear normal,
widened, or there may be a distinct radiolucency. Treatment:
Determination of cause and relieving the symptoms. In case it is
because of pulpal involvement, endodontic therapy is
indicated.
14. PERIAPICAL LESIONS Acute Perirapical abscess It refers to
painful localized collection of plus in the periapical connective
tissue. It is characterized by rapid onset, spontaneous pain, pus
formation, and often swelling of the associated tissues. Percussion
testing produces a response that is usually exquisitely sensitive.
The tooth gives negative response to vitality tests.
Radiographically, the PDL space may be normal, slightly widened, or
demonstrate a distinct radiolucency.
15. PERIAPICAL LESIONS Acute Perirapical Abscess: Treatment:
Endodontic treatment concomitant with the drainage of abscess.
Suitable measures must also be taken to control any systematic
manifestations.
16. PERIAPICAL LESIONS Chronic Periradicular Abscess: An
inflammatory reaction to pulpal infection and necrosis
characterized by gradual onset, little or no discomfort and
intermittent discharge of pus through an associated sinus tract.
Treatment: Endodontic therapy if the tooth can be restored
otherwise extraction is the solution.
17. PERIAPICAL LESIONS Recrudescent Abscess: It refers to an
acute exacerbation arising from a pre- existing chronic lesion.
Tooth feels elevated in its socket. The tooth is severely tender.
The radiograph shows a well defined radiolucency. Treatment:
Endodontic treatment concomitant with the drainage of abscess.
18. PERIAPICAL LESIONS Focal Sclerosing Osteomyelitis:The
involved tooth will have an etiologic factor for low grade, chronic
inflammation such as a necrotic pulp, extensive restorative history
or a crack. Radiographically, the involved tooth will present with
increased radiodensity and opacity around one or more of the roots.
Treatment: These periradicular radiodensities resolve after
endodontic therapy if they have pulpal diagnosis of irreversible
pulpitis.
19. PERIAPICAL LESIONS Periapical Granuloma: This disease
entity is characterized by growth of granulation tissue in relation
to the periodontium at the apex in response continued bacterial
irritation. Treatment: Root canal therapy of the concerned
tooth.
20. PERIAPICAL LESIONS Periapical Cyst: The radicular cyst is a
chronic inflammatory lesion with a closed pathologic cavity, lined
either partially or completely by epithelium Radiograph shows a
distinct rarefaction at the apex with a thin radiopaque border.
Treatment: Treatment of periapical cyst is conservative initially
by root canal treatment. Surgical intervention is advisable only if
the conservative means fail.
21. OBJECTIVES of pulp therapy 1. Preservation of the arch
space. 2. Enhances aesthetics, mastication, prevent aberrant tongue
habits, aid in speech and prevent psychologic effects associated
with tooth loss. 3. Helps in maintenance of a healthy oral
environment, relief of pain. 4. Prevention of deleterious effects
on the succedaneous tooth, and the periapical tissue and on the
systematic condition of the child.
22. Indirect pulp capping It is defined by INGLE as procedure
involving a tooth with a deep carious lesion where carious dentin
removal is left incomplete, and the decay process is treated with a
biocompatible material for some time in order to avoid pulp tissue
exposure is termed as indirect pulp capping.
23. Indirect pulp capping Objective of Indirect Pulp Capping:
These were given by Eidelman in 1965: 1. Arresting the carious
process. 2. Promoting dentin sclerosis. 3. Simulating formation of
tertiary dentin. 4. Remineralization of carious dentin.
24. Indirect pulp capping Indications: Ideally, used when
pulpal inflammation has been judged to be minimal and complete
removal of caries would cause a pulp exposure. Contraindications:
Any signs of pulpal or periapical pathology. Soft leathery dentin
covering a very large area of the cavity, in a non restorable
tooth.
25. Indirect pulp capping
26. Indirect pulp capping Treatment Procedure: First
Appointment: Use local anesthesia and isolation with rubber dam.
Establish cavity outline with high speed handpiece. Removal all
caries using caries detector dye, i.e. infected dentin has to be
removed. Stop the excavation as soon as the firm resistance of
sound dentin is felt If there is a probability of exposure while
removing further caries, then a conservative approach is chosen by
placing a hard set calcium hydroxide and temporizing the
tooth.
27. Indirect pulp capping First Appointment: Site is covered
with Calcium Hydroxide. Remainder cavity is filled with reinforced
Zinc Oxide Eugenol cement. Cavity flushed with saline and dried
with cotton pellet.
28. Indirect pulp capping Second Appointment: If a reparative
dentin bridge is formed a permanent restoration followed by full
coverage restoration is chosen. But if there is some amount of
caries remaining on re-entry, carefully removal of caries, now
somewhat sclerotic may reveal a sound base of dentin without pulp
exposure. Between the appointment history must be negative and
temporary restoration should be intact
29. Indirect pulp capping Second Appointment: Previous
remaining carious dentin will have become dried out, flaky and
easily removed The area around the potential exposure will appear
whitish and may be soft; which is predentin. Do not disturb this
area. The cavity preparation is washed out and dried gently. Cover
the entire floor with Ca(OH)2 Base is built up with reinforced ZOE
cement or GIC Final restoration is then placed.
30. direct pulp capping It is defined by KOPEL (1992) as the
placement of a medicament or non-medicated material on a pulp that
has been exposed in course of excavating the last portions of deep
dentinal caries or as a result of trauma. Objective: To create new
dentin in the area of the exposure and subsequent healing of the
pulp.
31. direct pulp capping Rationale: To achieve a biologic
closure of the exposure site by deposition of hard tissue barrier
between pulp tissue and capping materials thus walling off the
exposure site. Indications: Small mechanical exposure surrounded by
sound dentin in asymptomatic vital primary teeth or young permanent
teeth. Exposure should have bright red hemorrhage that is easily
controlled by dry cotton pellet with minimal pressure.
32. direct pulp capping Contraindications: Serve toothache at
night Spontaneous pain. Tooth mobility Radiographic appearance of
pulp, Peri-radicular degeneration. Excess of hemorrhage at the time
of exposure. External/ Internal root resorption.
Swelling/Fistula.
33. direct pulp capping Treatment Considerations: Debribement:
Necrotic and infected dentin chips have be removed. Hemorrhage and
clothing: A blood clot should not be allowed to form at the
exposure site because it may impede pulpal healing. Exposure
Enlargement: The exposure site must be enlarged because : 1. It
removes inflammation and infected tissue in the exposed area. 2. It
facilitate washing away, Carious and non-carious debris.
34. direct pulp capping Treatment Considerations: 3. It allows
a closer contact of more capping medicament material to the actual
pulp tissue.
35. Direct pulp capping Technique of Direct Pulp Capping:
Rubber dam provides only means of working in a sterile environment,
so it has to be used. Once an exposure is encountered, further
manipulation of pulp is avoided. Cavity should be irrigated with
saline, chloramine T or distilled water. Hemorrhage is arrested
with light pressure from sterile cotton pellets
36. Direct pulp capping Technique of Direct Pulp Capping: Place
temporary restoration Final restoration is done after determining
the success of pulp capping which is done by determination of
dentinal bridge, maintenance of pulp vitality, lack of pain and
minimal inflammatory response Place the pulp capping material, on
the exposed pulp with application of minimal Pressure so as to
avoid forcing the material into pulp chamber.
37. pulp capping agents Materials, medicaments, antiseptics,
anti- inflammatory agents, antibiotics and enzymes have been
utilized as pulp-capping agents. Calcium hydroxide is generally
accepted as the material of choice for pulp capping. Calcium
Hydroxide: Herman (1930) introduced Calcium Hydroxide for Pulp
Capping. When calcium hydroxide is applied directly to pulp tissue,
there is necrosis of the adjacent pulp tissue and an inflammation
of the contiguous tissue.
38. pulp capping agents Calcium Hydroxide: Dentin bridge
formation occurs at the junction of the necrotic tissue and the
vital inflamed tissue. The three main calcium hydroxide products
are Pulpdent , Dycal and Hydrex (MPC). Advantages Disadvantages
Initially bacterial then bacteriostatic Does not exclusively
stimulate dentinogenesis Promotes healing and repair Does
exclusively stimulate reparative dentin High pH stimulates
fibroblasts Associated with primary tooth resorption.
39. pulp capping agents Calcium Hydroxide: Advantages
Disadvantages Neutralizes low pH of acids May dissolve after one
year with cavosurface dissolution. Stops internal resorption May
degrade during acid etching Inexpensive and easy to use Degrades
upon tooth flexure. Particles may obturate open tubules Marginal
failure with amalgam condensation. Does not adhere to the dentin or
resin restoration.
40. pulp capping agents Isobutyl Cyanoacrylate: Berkman in 1971
used it as capping agent and proved it to be an excellent
hemostatic agent as well as a reparative dentin bridge stimulator.
The disadvantage of this material is that it is cytotoxic when
freshly polymerized. Mineral Trioxide Aggregate (MTA) : Properties:
It is biocompatible material and its sealing ability is better than
that of amalgam or ZOE.
41. pulp capping agents Mineral Trioxide Aggregate (MTA) :
Properties: Initial pH is 10.2 and set pH is 12.5. The setting time
of cement is 4 hours. The compressive strength is 70 MPA, which is
comparable with that of IRM. Low cytotoxicity- It presents with
minimal inflammation if extended beyond the apex. Action: It has
ability to stimulate cytokine and interleukins release from bone
cells, indicating that it actively promotes hard tissue
information.
42. pulp capping agents Other Materials: Corticosteroid and
antibiotics, Inert materials (Isobutyl Cyanoacrylate and tricalcium
phosphate ceramic ), Collagen fibers (Influence mineralization),
4-META Adhesive, Denatured albumin, Laser, Bone morphogenic protein
(BMP).
43. pulpotomy Finn (1995) defined it as the complete removal of
the coronal portion of the dental pulp, followed by placement of a
suitable dressing or medicament that will promote healing and
preserve vitality of the tooth.
44. pulpotomy Classification of pulpotomy: Vital Pulpotomy:
Types Other Name Features Examples Devitaliza- tion Mummification ,
Cauterization It is intended to destroy or mummify the vital tissue
Single sitting Formocresol Electrosurgery Laser Two stage Gysi
Triopaste Easlicks formaldehyde Paraform devitalizing paste.
45. pulpotomy Classification of pulpotomy: Vital Pulpotomy:
Types Other Name Features Examples Preserva- tion Minimal
Devitalization, noninductive This implies maintaining the maximum
vital tissue, with no induction of reparative dentin. ZnO Eugenol
Glutaraldehyde Ferric Sulphate Regenra- tion Inductive, Reparative
This has formation of dentin bridge Ca(OH)2 Bone Morphogenic
Protein Mineral Trioxide Aggregate Enriched Collagen Freezed dried
bone Osteogenic Protein.
46. pulpotomy Classification of pulpotomy: Non-Vital Pulpotomy:
Types Other Name Features Examples Mortal pulpotomy It is done in
comprised cases Beechwood cresol Formcresol.
47. pulpotomy Objectives: Removal of inflamed and infected pulp
at the site of exposure thus preserving the vitality of the
radicular pulp and allowing it to heal. Rationale: Radicular pulp
is healthy and capable of healing after surgical amputation of the
infected pulp. Preserves vitality of the radicular pulp. Removal of
infected or inflamed pulp. Maintains tooth in a physiologic
condition.
48. pulpotomy Indications of Pulpotomy: 1. Pulp exposure in
primary teeth. 2. Teeth showing a large carious lesion but free of
radicular pulpitis. 3. History of only spontaneous pain. 4.
Hemorrhage from exposure site bright red and controlled. 5. Absence
of abscess or fistula. 6. No interradicular bone loss. 7. No
interradicular radiolucency. 8. At least 2/3rd of root length still
present to ensure reasonable functional life. 9. In young permanent
tooth with vital exposed pulp and incompletely formed apices.
49. pulpotomy Contraindications of Pulpotomy: 1. Persistent
toothache. 2. Tenderness on percussion. 3. Root resorption more
than 1/3rd of root length. 4. Large carious lesion with
non-restorable crown. 5. Highly viscous, sluggish hemorrhage from
canal orifice, which is uncontrollable. 6. Medical contradictions
like heart disease, immunocompromised patient. 7. Swelling or
fistula. 8. External or internal resorption. 9. Pathological
mobility. 10. Calcification of pulp.
50. Formocresol: Formocresol was introduced by Buckley in
1904.
51. Formocresol: Procedure: Anesthetize the tooth and isolate
with rubber dam Removal of all caries using high-speed straight
fissure bur without entering the pulp chamber Remove the dentinal
roof with large diamond stone or slow speed round bur for minimal
trauma Enlarge the exposed area and deroof the pulp chamber Remove
any ledges or overhanging enamel with slow speed round bur
52. Formocresol: Procedure: Sharp spoon excavators are used to
scoop out coronal pulp and pulpal remnants Clean the pulp chamber
with saline and removal all debris Place cotton pellet over the
pulp stumps to achieve hemostasis Using a cotton pellet apply
diluted Formocresol to the pulp for 4 mins
53. Formocresol: Procedure: Place a small dry pellet over this
to avoid contact of tissues with Formocresol Remove cotton pellets
and check for fixation, brownish discoloration of the pellet as
well as the pulp stump is an indicator of fixation Place ZOE cement
in the pulp chamber Recall after one week and restore with a
permanent restoration if patient is asymptomatic Place a stainless
steel crown
54. Two-visit Devitalization Pulpotomy: This is the two stage
procedure involving the use of paraformaldehyde to fix the entire
coronal and radicular pulp tissue. Indications: 1. There is
evidence of sluggish bleeding at the amputation site that is
difficult to control. 2. Pus in the chamber, but none at the
amputation site. 3. There is thickening of the pd1. 4. History of
pain.
56. Two-visit Devitalization Pulpotomy: Procedure: First Visit:
Anesthetize the tooth and isolate with rubber dam Preparation of
the cavity Deep caries excavated Enlarge the exposure with round
bur
57. Two-visit Devitalization Pulpotomy: Procedure: First Visit:
Incorporate paraformaldehyde paste into the pellet and place over
exposure Seal the tooth for 1-2 weeks so that formaldehyde gas
liberated from paraformaldehyde enters coronal and radicular pulp,
thereby fixing the tissue.
58. Two-visit Devitalization Pulpotomy: Second Visit: Pulpotomy
is carried out under local anesthesia. Remove the old cotton pellet
and deroof the pulp chamber Clean the cavity with saline and dry
with cotton pellet Pulp chamber filled with antiseptic paste and
tooth is restored.
59. Modified Formocresol pulpotomy This technique was used by
Trask (1972) in young permanent morals. In this technique
Formocresol pellet is sealed permanently in the tooth.
60. Cveks pulpotomy Indication: Indicated in young permanent
teeth where the pulp is exposed by mechanical or bacterial means.
Rationale: To preserve vitality of radicular pulp and allow for
normal root closure.
61. Cveks pulpotomy Procedure: Anesthetize the tooth and
isolate with rubber dam All carious material is removed with
excavators or slow speed round bur Coronal pulp removed, to perform
a pulpotomy After arrest of the hemorrhage, Ca(OH)2 is applied to
the exposed pulp, ensuring that there is no blood clot.
62. Cveks pulpotomy Procedure: The cavity is then sealed with
temporary restorative material A tooth should remain symptom free
at recall and radiograph should show information of a secondary
dentine bridge. Then permanent restoration with amalgam is
done.
63. Glutaraldehyde pulpotomy: It was first suggested by
S.Gravenmade . Mechanism of Action: Glutaraldehyde produces rapid
surface fixation of the underlying pulpal tissue. A narrow zone of
eosinophilic, stained, and compressed fixed tissue is found
directly beneath the area of application.
64. Advantages of Glutaraldehyde over Formocresol 1. It is
bifunctional reagent, which allows it to form strong intra and
intermolecular protein bonds leading to superior fixation by cross
linkage. 2. It is excellent antimicrobial. 3. Causes less necrosis
of the pulpal tissue. 4. Causes less dystrophic calcification in
pulp canals. 5. Less toxicity does not perfuse through the pulp
tissue to the apex. 6. Demonstrates less systematic distribution.
7. It is low tissue binding, readily metabolized, eliminated in
urine and expired in gases-90% of the drug is gone in 3 days. 8.
Antigenecity- Less as compared to Formocresol.
65. Laser Pulpotomy In 1985, Ebimara reported the effects of
Nd: YAG laser on the wound healing of amputed pulps. After complete
extirpation of pulp from pulp chamber exposure to Nd: YAG laser at
20 Hz was done. Then IRM paste was placed over the pulp stumps and
restoration was done. Electrosurgical Pulpotomy It is a non
chemical Devitalization, whereas mummification eliminates pulp
infection and vitality with chemical cross linking and
denaturation. The disadvantage of Electrosurgery is that the
contaminated pulp tissue does not promote adequate current
penetration.
66. Mortal Pulpotomy Non-vital pulpotomy. Ideally, non-vital
tooth should be treated by pulpectomy, but sometimes it is
impracticable due to non-negotiable root canals and limited patient
cooperation. Procedure: First Appointment: Necrotic coronal pulp is
removed. Pulp chamber irrigated with saline and dried with cotton
pellet.
67. Mortal Pulpotomy Procedure: First Appointment: Second
Appointment: Infected radicular pulp is treated with strong
antiseptic solution like beechwood cresol. Seal cavity with
temporary cement for 1-2 weeks. If the tooth is asymptomatic the
pulp chamber is filled with an antiseptic paste. The tooth then
restored with stainless steel crown.
68. Pulpectomy Mathewson(1995) defined it as the complete
removal of the necrotic pulp from the root canals of primary teeth
and filing them with an inert resorbable material so as to maintain
the tooth in the dental arch. Indications and Contraindications of
Pulpectomy: General Indications 1. Patient should be in good
general health with no serious disease. 2. Maximum cooperation of
patient and parents.
69. Pulpectomy Indications and Contraindications of Pulpectomy:
General Contraindications 1. Young patient with systemic illness
such as congenital ischemic heart disease, leukemia. 2. Children on
long term corticosteroids therapy. Clinical Indications 1. A tooth
previously planned for a pulpotomy that shows either a dry pulp
chamber or uncontrolled pulpal hemorrhage. 2. Indicated for any
primary tooth in absence of its permanent successor. 3. Any
deciduous tooth with severe pulpal necrosis provided there is no
radiographic contraindication.
70. Pulpectomy Indications and Contraindications of Pulpectomy:
Clinical Indications 4. Primary teeth with necrotic pulps and
minimum of root resorption. 5. Pulpless primary teeth with stomas
6. Pulpless primary teeth without permanent successors. 7. Pulpless
primary teeth in hemophiliacs. 8. Pulpless primary anterior teeth
when speech, aesthetics are a factor. 9. Pulpless primary molars
holding orthodontic appliance.
71. Pulpectomy Indications and Contraindications of Pulpectomy:
Clinical Contraindications 1. Excessive tooth mobility. 2.
Communication between the oral cavity and area of furcation. 3.
Communication between the roof of the pulp chamber, and the region
of furcation. 4. Insufficient tooth structure to allow isolation by
rubber dam and extra coronal restoration.
72. Pulpectomy Radiographic Indications: 1. Adequate
periodontal and bony support 2. Incipient internal root resorption
in the occlusal portion of the root canal. Radiographic
Contraindications: 1. External root resorption. 2. Internal root
resorption in the apical 3rd of the root. 3. Radicular cyst,
dentigerous/follicular cyst in association with the primary tooth.
4. Interradicular radiolucency that communicates with the gingival
sulcus.
73. Single visit pulpectomy Indication: Vital primary teeth but
with inflammation extending beyond coronal pulp, indicated by
hemorrhage from the amputated radicular stumps that is dark red, a
slowly oozing and uncontrollable.
74. Single visit pulpectomy Procedure: Tooth is anesthetized
and isolated Access cavity is prepared. Pulp chamber is deroofed
All accessible coronal and radicular pulp tissue is removed with
broaches. Irrigate with saline. A diagnostic file radiograph is
taken.
75. Single visit pulpectomy Procedure: The canals should be
filled with the aim of enlarging them to permit condensation of
root canal filling material Flush out all debris and dentin
shavings with the help of irrigating solutions Dry the canals with
adsorbent paper points Obturate the tooth completely sealing the
coronal and radicular pulp. Place the final restoration and
stainless steel crown.
76. Multi visit pulpectomy Indications: Given by Paterson and
Curzon in 1992 Indicated where infection, an abscess or chronic
sinus exists. Non-vital primary teeth. Teeth with necrotic pulp and
periapical involvement.
77. Multi visit pulpectomy Procedure: First Appointment(Access
Opening) Tooth is anesthetized and isolated. Access cavity is
prepared Pulp chamber is deroofed All accessible coronal and
radicular pulp tissue is removed with broaches. Formocresol cotton
pellet is placed in chamber and a temporary restoration is
done
78. Multi visit pulpectomy Procedure: Second
Appointment(Cleaning and Shaping) Appointment should be 5-7 days
apart Remove the temporary restoration Fill the canals,
progressively increasing the file diameter and complete the
biochemical (BMP) preparation Determine the working length
79. Multi visit pulpectomy Procedure: Second
Appointment(Cleaning and Shaping) Irrigate the canals Indication of
complete BMP is smooth canals that have the same shape as the
external walls Irrigate and debride Dry the canals and place
temporary restoration after placing a sterile cotton pellet in
chamber
80. Multi visit pulpectomy Procedure: Third
Appointment(Obturation) Remove the temporary restoration Irrigate
and dry the canals Start Obturating First coat the walls of canals
with thin watery mix of cement with the help of a reamer and then
use thick mix and fill the canals using lentulospirals
81. Multi visit pulpectomy Procedure: Third
Appointment(Obturation) Keep an adding fresh mix till no further
cement can be incorporated in canals Now seal the pulp chamber with
temporary restoration. Recall after 1 week and if the patient is
asymptomatic, do the final restoration and give a stainless steel
crown
82. Ideal requirements of root canal filling material 1. The
material should resorb as the primary tooth root resorbs. 2. It
should not irrigate the periapical tissues nor coagulate any
organic remnants in the canal. 3. It should have a stable
disinfecting power. 4. Any surplus material passed beyond the apex
should be resorbed easily. 5. It should be inserted easily into the
root canal and also removed easily if necessary. 6. It should not
be soluble in water. 7. It should not discolor the tooth. 8. It
should be harmless to the adjacent tooth germ.
85. Root canal materials Calcium Hydroxide: This material is
generally not used in pulp therapy for primary teeth. This material
was found to be easy to apply and resorbs at a slightly faster rate
than that of root. It has no toxic effects on permanent successor
and its radiopaque. For these reasons, Calcium hydroxide Iodoform
mixture can be considered to be nearly ideal primary tooth root
canal filling material. Gutta- Percha (Not indicated for primary
teeth): Since Gutta Percha is not a resorbable material, its use is
contraindicated in the primary teeth.
86. APExogenesis It is defined as the treatment of a vital pulp
by capping or pulpotomy in order to permit continued growth of the
root and closure of the open apex. Rationale: Maintenance of
integrity of the radicular pulp tissue to allow for continued root
growth. Indications: Indicated for traumatized or pulpally involved
vital permanent tooth when root apex is incompletely formed. No
history of spontaneous pain
87. APExogenesis No sensitivity on percussion. No hemorrhage.
Normal radiographic appearance. Contraindications: Evidence that
radicular pulp has undergone degenerative changes. Purulent
Drainage. History of prolonged pain. Necrotic debris in canal.
Periapical radiolucency.
88. APExogenesis Procedure: Application of rubber dam following
local anesthesia Remove all carious tooth structure and open up the
pulp chamber Remove cornal pulp tissue with excavators, care is
taken to prevent damage to radicular pulp. Rinse all the residual
debris and control hemorrhage by placement of a moist cotton pellet
over the amputed pulp
89. APExogenesis Procedure: Ca(OH)2 mixture is placed over the
pulp stumps, followed by temporary restoration. Follow-up
radiographs are taken periodically to check the root development.
Once root development is complete, the conventional root canal
treatment is done.
90. Apexification It is defined by Cohen as a method of induce
development of the root apex of an immature Pulpless tooth by
formation of osteocementum/bone like tissue. Indication: For
non-vital permanent teeth with open apex (Blunderbuss canals)
Objective: To induce either closure of open apical third of root
canal or the formation of an apical calcific barrier against which
Obturation can be achieved.
93. Apexification Procedure: First Visit: Preoperative
assessment includes clinical evaluation of color, mobility,
tenderness and swelling. Periapical radiograph should be evaluated
When acute signs and symptoms are absent, instrumentation is
recommended Application of rubber dam following local
anesthesia
94. Apexification Procedure: First Visit: Access is gained in
the pulp chamber Barbed broach used to remove debris and necrotic
pulp tissue from the canal Irrigation is performed with saline
Working length is determined
95. Apexification Procedure: First Visit: Circumferential
enlargement done by the file and irrigation is done with saline to
remove infected dentin from the canal walls Canal dried with paper
points Ca(OH)2 powder is used to fill 2 mm short of the
radiographic apex
96. Apexification Procedure: First Visit: Remaining of the
canal filled with Ca(OH)2 and Saline Barium sulphate added to radio
- opacity Dry pledget of Ca(OH)2 is then ejected into the pulp
chamber and forced against the paste ahead of it. Place temporary
restoration.
97. Apexification Procedure: Second Visit: This is after 6-24
months tooth is re-entered and Apexification is verified If it is
complete then RCT done.
98. Apexification Franks Criteria for Apexification: 1. Apex is
closed, through minimum recession of the canal. 2. Apex is closed
with no change in root space. 3. Radiographically apparent calcific
bridge at the apex 4. There is no radiographic evidence of apical
closure.
99. THANK YOU. SUBMITTED BY ,, MR. SWAPNIL.S.PAKHALE INTERN (
Batch -2008 )