Pulp therapy for primary teeth

1Pulp Therapy forPrimary Teeth

University of MinnesotaDivision of Pediatric Dentistry Definition of Pulp Therapy

Any procedure whereby the pulp of a tooth is treated in an effort to maintain the tooth as a healthy component of the dentition

Over severa l decades , the emphas i s in dentistry has shifted from the concept of a doomed organ that must be removed, to one of organ recovery and health.

Pulp Therapy(Treatment Philosophy)

Advances in pulp therapy have played an important role in this transition

Goals of Pulp Therapy

Maintain a healthy tooth for: Occlusion Arch length/space maintenance Prevention of infection Comfort Mastication Esthetics

Primary vs. Permanent Teeth

Compared to permanent teeth, primary teeth exhibit smaller overall dimension , and:Crowns Less enamel and dentin coverage Relatively larger pulp chambers and pulp horns Narrower occlusal tablesRoots More divergent molar roots Ancillary root canals Resorbable roots

Anatomic Considerations

Average d is tance (mm) f rom the mesial side of pulpchamber to mesial contac t po in t on enamel sur face

First Permanent Second Primary First PrimaryArch Molar Molar Molar

Maxilla 3.0 2.4 2.1Mandible 3.9 2.3 1.8

2Anatomic Considerations Anatomic Considerations

Objective of Pulp Therapy

The aim of pulp therapy is to SEAL the tooth off

from the external environment

Pulp Therapy

SUCCESS = CORRECT DIAGNOSIS Clinical appearance - hard tissues Clinical appearance - soft tissues Pain - type and when Percussion Pulp testing Radiograph

Clinical Appearance - Hard Tissues

1. Type and amount of caries Gross breakdown Arrested decay

2. Color of the tooth

3Clinical Appearance - Soft Tissues

1. Inflammation2. Fistula

acute chronic

3. Cellulitis

4Pain - Type and When

P a i n Histologic S t a t u s

History of Pain Severe pulpitis and necrosisKind

Intensity No correlation with extent of cariesIntensity+duration Severe pulpitis and necrosis

Spontaneous Correlates highly with extent of cariesPain of Percussion Correlates highly with necrosisThermal Sensitivity

Transient Considered normalPersistent Indicates pulpitis and partial necrosisNo response Indicates necrosis

5Percussion - May Reveal

1. Periapical pathology2. Traumatic occlusion

Pulp Testing

1. Percussion (reliable in children)2. Thermal (reliable in children)

Hot Cold

3. Electrical (not reliable in children)

Radiographs

The single most important diagnostic aid in children is a radiograph

1. Bitewing - will show Surfaces involved Depth of the lesion in relation to pulp

2. Periapical - will show Furcation or apical involvement Presence of calcified tissues External root or bone resorbtion Internal resorbtion

Radiographs

6Pulp Therapies Available

1. Indirect pulp cap2. Direct pulp cap3. Pulpotomy4. Pulpectomy5. Apexogenesis6. Apexification

Indirect Pulp Capping

Indirect Pulp Capping - Indications

1. Deep carious lesions encroaching upon, but not actually into the pulp

2. No history of chronic pain3. No radiographic pathology4. Vital pulp5. Normal tooth mobility6. Normal tooth color

The intent of Indirect Pulp Capping is to stimulate a tooth to participate in its own recovery

Indirect Pulp CappingSteps in the Procedure

1. Remove infected dentin almost to the point of pulp exposure (some carious dentin may remain)

2. Place Calcium Hydroxide over the remaining dentin in the floor of the cavity preparation

3. Place an intermediate restoration (resin modified glass ionomer cement)

4. Observe the tooth closely for 6-8 weeks during formation of secondary dentin

5. Remove intermediate restoration, remove residual caries, place final restoration

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8To Re-enter or Not Re-enter?

Controversial Will the caries advance if the margins of

the restoration remain sealed? Will removal of the intermediate

restoration further insult the pulp? If the tooth is asymptomatic, will periodic

clinical and radiographic evaluation be sufficient?

Intermission

9Direct Pulp Capping

Direct Pulp Capping - Indications

1. Small mechanical exposure ( > 1.0 mm)2. Small traumatic exposure (immediate)3. Asymptomatic vital pulp4. No coronal or periapical pathology

Direct Pulp Capping(An Historical Note)

F. A. Hunter (1883) went so far as to present the following formula for pulp capping:

Furthermore, he claimed 98% success and was loudly applauded at the meeting of the Missouri Dental Association in 1883.

Rx:Sorghum Molasses - one pintDroppings of the English sparrow - one pound

Dir: Mix wellSig: For pulp capping

Direct Pulp CappingSteps in the Procedure

1. Remove caries and make a conventional cavity preparation (which has resulted in a pinpoint exposure)

2. Gently clean the preparation with H2O23. Evaluate quality of hemorrhage and make sure bleeding

stops quickly4. Place Calcium Hydroxide (Dycal) directly on exposure5. Place appropriate base and final restoration

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Pulpotomy

Calcium Hydroxide Pulpotomy Indications

1. Primary teeth - is not indicated2. Permanent teeth

Carious or traumatic exposure Young vital tooth with incomplete root

formation Asymptomatic pulp No periapical or furcation pathology

Formocresol PulpotomyIndications

1. Permanent teeth - is not indicated2. Primary teeth

Carious or traumatic exposure Young vital tooth Asymptomatic pulp No periapical or furcation pathology

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1. Correct diagnosis2. Isolated field of operation3. Opening the cavity sufficiently so that the entire

pulp chamber is clearly visible4. Using a medicament of sufficient strength to

destroy all forms of bacteria

Formocresol PulpotomyCriteria for Success

1. Remove gross decay2. Remove roof of pulp chamber3. Remove coronal pulp tissue4. Apply dry cotton pellet5. Apply formocresole impregnated cotton pellets for 1 - 2

minutes6. Place IRM and a final restoration

Formocresole PulpotomySteps in the Procedure

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Pulpotomy - Success Rates(Summary from several studies)

Ca(OH)2 FormocresolHistologic 50% 92%Radiographic 64% 93%Clinical 71% 97%

Formocresol is the standard from which other medicaments are rated.

Thank You

University of MinnesotaDivision of Pediatric DentistryUniversity of Minnesota

Division of Pediatric Dentistry