6. Pulp treatment lecture Flashcards
What are the 3 types of pulp treatment we can do?
- Indirect pulp treatment
- Vital pulpotomy
- Desensitising procedure
What are reasons for pulpal involvement in children?
- small size of teeth
- large pulp chambers
- failure to diagnose
- failure to treat caries early due to broad flat contacts between teeth
- rapid caries progression due to thinner enamel and dentine
What was the initial treatment for when a marginal ridge breach occurs?
- when a marginal ridge breach greater than 3mm was observed over 90% of pulps were histologically inflamed
- complete caries removal would result to a pulp exposure
- therefore an elective vital pulpotomy was recommended followed by a crown
What is the new treatment for when marginal ridge breach greater than 3mm is observed?
- in MRB, more than 50% of the inflammation seems to be restricted to the pulp horn
- Sealing infected carious dentine under a restoration decreases the numbers of viable organisms and shifts away from cariogenic species
- In permanent teeth the pulp has excellent repair capacity when there is no pulp exposure, the predictability decreases after a carious exposure
- Carious primary & permanent teeth show similar neural changes when pulp responds to deep caries, suggesting potential for repair in primary teeth
- indirect pulp cap is therefore an option
What indications are there for pulp treatment?
- relieve symptoms
- remove infection
- avoid GA
- medical reasons if you need to avoid XLA
- space maintenance
- missing permanent successor
- compliant patient
What are contraindications of doing pulp treatment?
- unrestorable tooth
- if there is severe pain or infection
- if there is advanced root resorption- primary roots are thin so RCT is not feasable and if you go through the apex you may damage the permanent successor
- medical reasons- if the pt is susceptible to infections, eg at risk of bacterial endocarditis
- poor pt compliance
What are techniques for when you have a vital pulp?
- pulp capping- direct/indirect
- desensitisation
- vital pulpotomy- if the pulp is exposed
What are the techniques for when you have a non-vital pulp?
- pulpectomy
What is indirect pulp capping ?
- caries is partially removed, small amount left to cover pulp tissue
- no pulp exposure
- medicament placed
- aim is to allow reparative (tertiary dentine) to form to protect pulp
When do you use indirect pulp capping?
- asymptomatic primary tooth with deep caries
- needs to be good history, examination, radiographs and leakage free restoration
What is direct pulp capping?
- medicament placed on the exposed pulp to stimulate dentine formation
- eg. calcium hydroxide
When do you use direct pulp capping?
- in asymptomatic teeth 1-2 years prior to normal exfoliation
- use when there has been iatrogenic/traumatic pinpoint pulpal exposure
What is preferred over direct pulp capping?
- direct pulp capping is no longer recommended by the BSPD or APPD because the prognosis is quite poor.
- there is an increased risk of internal resorption
- instead do a vital pulpotomy
What is a vital pulpotomy?
- removing the infected coronal pulp and leaving the radicular pulp behind if it is vital
What medicaments do you use in vital pulpotomy?
- ferric sulphate
- MTA
What are the indications for a vital pulpotomy?
- large carious/traumatic exposure
- irreversible pulpitis (vital pulp)
- no clinical or radiographic signs of infection
What are the basic rules of vital pulpotomy?
- remove coronal pulp
- vital radicular pulp
- bleeding arrested with ferric sulphate
- apical part of pulp remains vital
- if when you remove the coronal pulp you find the pulp chambers are necrotic or there is too much bleeding, the tooth may need pulpectomy or extraction.
What percentage is ferric sulphate and explain what it does?
- 15.5%
- haemostatic agent
- used to control gingival bleeding
- no fixative effect
What can you place in the pulp chamber in vital pulpotomy?
MTA or ZOE
What do you place in the cavity in pulpotomy?
- ZOE
What do you place over a tooth which has undergone a pulpotomy?
- place PMC
What are the 7 stages of doing a pulpotomy?
- Remove contents of pulp chamber with excavator or slow speed handpiece
- Irrigate with 3 in 1
- Arrest bleeding with cotton pledget soaked in ferric sulphate
- Remove cotton wool
- Place MTA or ZOE in pulp chamber
- Fill cavity with ZOE
- Place PMC
When is a desensitising procedure used?
- hyperalgesic pulp
- non-compliant child requiring inhalation sedation for further tx
- cannot numb tooth/cannot get bleeding to stop
What is the aim of desensitising procedure?
- reduce pulpal inflammation and/or symptoms to facilitate subsequent pulpotomy/pulpectomy procedure
What is the 3 stages in a desensitising procedure?
- Place cotton wool pledget loaded with ledermix/odontopaste over the pulp
- Place well sealed temporary dressing
- Recall after 7-14 days to proceed with further tx
What is the tx of choice if the pulp is non-vital?
- pulpectomy- but excellent cooperation is needed, case selection, highly skilled procedure
- extraction
