29. Primary Molar Pulp Therapy

Question 1

Aim of all paeds dentistry

Answer 1

• maintain a disease-free primary tooth until exfoliation

Question 2

Indications for pulp therapy in primary teeth

Answer 2

• to maintain an intact arch
• to avoid physiological and psychological trauma of extraction
• if extraction is medically contraindicated
• no permanent successor tooth
• space maintenance (mixed dent)
• cooperative child and carers

Question 3

Contraindications of pulp therapy in kids

Answer 3

• uncooperative child or carers
• child at risk of infection/immunosuppressed
• neglected dentition (more than 3 pulpotomies needed)
• severe acute infection
• unrestorable crown
• root caries
• more than 2/3 root resorption (near to exfoliation)

Question 4

What’s the ideal pulp therapy?

Answer 4

• harmless to pulp and surrounding structures
• no interferance with physiological root resorption
• promote healing of radicular pulp

Question 5

Aetiology of pulp disease

Answer 5

• microbial infection like in perm teeth
• rapid progression
• cruder diagnosis of pulp status (marginal ridge collapse? pain?)

Question 6

Types of vital pulp therapy

Answer 6

• indirect pulp therapy
• direct pulp cap
• single visit pulpotomy
• pulpectomy

Question 7

Example of non-vital pulp therapy

Answer 7

pulpectomy

Question 8

What is the line of amputation?

Answer 8

• the line through the point of the tooth where normal or reversible inflammation becomes irreversible inflammation towards the crown

Question 9

Bleeding carious exposure can lead to 2 situations?

Answer 9

• coronal amputation
• sensitive exposure

Question 10

What happens in a coronal amputation?

Answer 10

• if you can arrest the bleed, a ferric sulphate pulpotomy happens (one application)
• if there is copious blood, two applications of ferric sulphate or a pulpectomy

Question 11

What happens in sensitive exposure?

Answer 11

• use a temp dressing with Ledermix
• ferric sulphate pulpotomy

Question 12

Composition of Buckley’s formocresol

Answer 12

• 19% formaldehyde
• 35% tricresol
• 15% glycerin
• 31% water

Question 13

What dilution is used in Buckley’s formocresol?

Answer 13

• 1:5 dilution used
• 3 parts glycerol to 1 part water

Question 14

Properties of formaldehyde

Answer 14

• protein binding
• bacteriostatic
• can be bactericidal in the confines of the pulp system

Question 15

One-visit formocresol pulpotomy is gold-standard?
Clinical success?

Answer 15

• was until recently
• studies of full strength and 1/5th dilution show 55-98% clinical success
• 84% clinical and radiological success after a year at Newcastle too

Question 16

Issues with formaldehyde vapour in formocresol

Answer 16

• been classified as carcinogenic to humasn by IARC
• occupational/industrial studies
• nasopharyngeal/nasal/paranasal sinuses
• possible link to chronic myeloid leukaemia

Question 17

One-visit formocresol pulptomies is no longer advocated for by most UK paeds dentists. Why?

Answer 17

• no formaldehyde containing preps should be used in dentistry

Question 18

Alternatives to formacresol

Answer 18

• glutaraldehyde
• calcium hydroxide
• dentine chips
• modified collagen solutions
• electrocautery/lasers
• ferric sulphate
• bone morphogenic proteins (BMP)
• mineral trioxide aggregate (MTA)

Question 19

Ferric sulphate was derived from …
It’s … in nature

Answer 19

• calcium hydroxide pulpotomy for haemorrhage control
• styptic

Question 20

Ads and disads of ferric sulphate

Answer 20

• easily obtained
• expensive (80£ a bottle)

Question 21

Ferric sulphate is used how in restorative dentistry?

Answer 21

as a haemostatic agent

Question 22

Ferric sulphate is applied at …% for how long?

Answer 22

• 15.5
• 15 seconds

Question 23

How is a ferric sulphate pulpotomy done?

Answer 23

• analgesia
• caries is close to the pulp horn
• cavity prep (pulp exposure, vital and bleeding)
• remove roof of pulp chamber with a non-end cutting bur
• amputate coronal pulp tissue with sterile instruments
• arrest bleeding with cotton wool pressure
• try not to perforate floor of pulp chamber
• place a cotton wool pledget moist with 15% ferric sulphate for 15 seconds
• remove cotton wool and look for haemostasis (2nd application if still bleeding)
• place a layer of zinc oxide-eugenol cement over pulp stumps
• restore the crown
• GIC/composite and a preformed crown

Question 24

Why does ferric sulphate work as a pulpotomy material?

Answer 24

• ferric and sulphate ions cause agglutinations of blood proteins
• mechanically seals blood vessels

Question 25

Reasons for pulpotomy failure

Answer 25

• poor choice of teeth
• inadequate pulp amputation
• coronal leakage