Deep Caries And Pulp Treatment In Primary Teeth

Question 1

Objectives for maintaining primary teeth

Answer 1

1. Maintain arch length — 6 erupt forward, space not maintained for erupting teeth
2. Restore function — only have deciduous molars to chew on, function easily impeded. Soft foods often sweet
3. Relieve pain and infection
4. Psychological effects associated with tooth loss
5. Aberrant tongue habits
6. Prevent adverse effects on permanent teeth
7. Prevent speech problems
8. Avoid negative impact on child’s psychological and social functioning

Question 2

Indications for pulp therapy of primary teeth (want to avoid exo)

Answer 2

Bleeding disorders
Coagulopathies
Oligodontia

Question 3

Contraindications for pulp therapy in primary teeth

Answer 3

Congenital heart conditions —> at risk for subacute bacterial endocarditis

Immunocompromised

Poor healing ability

Question 4

Dental factors to consider in whether to do pulp therapy for primary tooth

Answer 4

General dental condition

Restorability of tooth

Pulpal calcification, pathologic root resorption

Lifespan of tooth

Significance of tooth to dental arch eg anterior vs molar space lost

Amount of supporting bone

Absence of permanent successor

Question 5

Differentiating mobility of tooth due to infection vs exfoliation

Answer 5

If infection, may have mobility of surrounding teeth as well

Question 6

How to diagnose pulpal status in primary tooth

Answer 6

History and characteristic of pain
Discolouration 
Mobility
Redness, swelling, sinus tract
Get child to bite down, if pain will stop biting or make eye movements 
Radiograph 
Nature of bleeding from exposed pulp 

EPT not valid
Percussion and thermal testing unreliable

Question 7

Primary molar radiolucency is usually at

Answer 7

Furcation area. Pulpal floor very thin, infection likely to go through pulpal floor into furcation area and cause mobility

Question 8

Options for vital pulp therapy in primary teeth

Answer 8

Hall technique
Protective liner
Pulp capping
Pulpotomy

Question 9

What is the Hall technique

Answer 9

For vital asymptomatic pulp, when you are unable to carry out conventional restorative treatment for carious primary molars

Cement preformed ssc with gic to seal in caries

Question 10

What is a protective base (vital pulp therapy)

Answer 10

Place caoh2/gic on exposed dentin tubules at pulpal surface of cavity prep —> act as protective barrier between restorative material and pulp —> promote pulpal healing and laying down of tertiary dentine

Question 11

What is interim therapeutic restoration

Answer 11

Conventional cavity prep and restoration not feasible because child uncooperative, moisture control etc. Or numerous open cavities, would benefit from step wise excavation

Maximum removal of PERIPHERAL caries, form good seal so that can lay down tertiary dentine, protecting pulp for you to continue with caries free next time (vs pulp cap where you remove everything)

Question 12

In order to do pulp cap, the pulp exposure must be

Answer 12

Pin point mechanical exposure, not carious pulp exposure

Pulp still vital and healthy

Question 13

Follow up to pulp capping

Answer 13

Tooth vitality
Radiographic changes of pathologic changes
Signs and symptoms post treatment
No harm to suceedaneous tooth

Question 14

The 3 main approaches in pulpotomy

Answer 14

Preserve radicular pulp in healthy state

Render radicular pulp inert so that it is fine until tooth exfoliates

Encourage tissue regeneration and healing at site of radicular pulp amputation

Question 15

Steps for vital pulpotomy of primary tooth

Answer 15

1. LA
2. Isolation
3. Caries removal, remove peripheral caries first so that carious material does not go into exposed pulp (make it more inflamed/infected, reducing chance of success)
4. Remove roof of pulp chamber
5. Amputate coronal pulp
6. Flush with saline, dry with cotton pellet
7. Hemostasis
8. Place medicated cotton pellet over amputated root stumps for 305 minutes
9. Line with soft mix of quick set ZOE cement
10. Place cement base, restore with SSC

Question 16

How to amputate coronal pulp in vital pulpotomy of primary tooth

Answer 16

Big spoon excavator or slow speed round bur

Question 17

How do you know if the infection has spread to the radicular pulp in vital pulpotomy

Answer 17

Put medicated cotton pellet over amputated pulp stump for 1-2 minutes. If stop bleeding after 1-2min, radicular pulp is healthy. If still bleeding after 1-2min, inflammation has spread to radicular pulp, need to pulpect or extract

Question 18

Complications following pulpotomy

Answer 18

Premature exfoliation
Pulpal calcification
Internal resorption
Enamel defects in succeedaneous permanent tooth

Question 19

Benefits of 1/5 dilution of Buckley’s formocresol

Answer 19

Medicament for pulpotomy of primary tooth

• reduced periapical and furcation radiolucencies
• less tissue irritation
• less cytotoxic

Question 20

Medicaments that you can use for pulpotomy of primary tooth

Answer 20

Formocresol, buffered glutaraldehyde, ferric sulphate, calcium hydroxide, MTA, NaOCl

Question 21

Pros and cons of ferric sulphate as medicament for pulpotomy of primary tooth

Answer 21

Seals cut blood vessels, hemostasis

Very caustic, can cause tissue burn if go through pulpal floor

Question 22

What is devitalising/desensitising pulpotomy

Answer 22

For primary teeth. Reduce pulpal inflammation/symptoms to allow pulpotomy/pulpectomy to be carried out subsequently

Question 23

Indications for devitalising pulpotomy

Answer 23

Pulp is hyperalgesic, cannot achieve adequate analgesia

Carious exposure with no signs and symptoms of loss of vitality

Non compliant child who refuses LA

Question 24

Problems with RCT in primary teeth

Answer 24

Variable and complex root morphology

Physiological root resorption so no apical stop

Thin canals and pulpal floor

Proximity of developing tooth underneath

Question 25

What is non vital pulpotomy

Answer 25

Remove necrotic coronal pulp

Seal medicated cotton pellet over infected radicular pulp for 1-2 weeks

Place antiseptic paste over radicular pulp remnants

Not treatment of choice, eg uncooperative child, canal unnegotiable, pulpectomy impossible

Question 26

What type of root canal fill is used in RCT of primary teeth

Answer 26

Resorbable cement eg ZOE, Vitapex (calcium hydroxide with iodoform), calcium hydroxide with olive oil

Question 27

Complications following pulpectomy of primary teeth

Answer 27

Premature exfoliation

Over retention

Enamel defects in succeedaneous permanent teeth