Deep Caries & Pulp Mx of Primary Teeth Flashcards
What are some dental factors to consider during pre-operative assessment?
- General dental condition (e.g few carious teeth needing pulp therapy)
- Restorability of tooth:
- Internal/external resorption
- Exposed root => resto process might damage successor
- Caries through pulpal floor
- Pulp calcification - Lifespan of tooth (e.g close to exfoliation)
- Amount of supporting bone
- Significance of tooth to dental arch (e.g loss of E => space loss)
- Absence of successor => might want to conserve primary tooth
What is the preventive only approach?
- Slow down & arrest caries using preventive measure (e.g topical fluoride)
- Caries initial/minimal or can be made self-cleansing (e.g disking)
- Require px & parental compliance => attend regular visits
What is the biological approach?
- Incomplete caries free, place resto w good seal => arrest remaining caries
- e.g Hall technique, ITR, IPC
How can we come to a diagnosis of pulp status in primary teeth?
- Pain history (SOCRATES)
- Clinical Examination
- discolouration
- redness, swelling, sinus tract
- mobility - Vitality tests
- percussion
- cold test
- EPT not valid, response inconsistent - Radiographs
- pathologic root resorption
- pathology at apical/furcal areas
- bone loss
- pulpal calcification - Bleeding from exposed pulp during procedure
- Pink/red & healthy => little bleeding
- Dark red/purple & necrotic => oozing
What are the types of pulp therapy?
Vital pulp therapy, for
- normal pulp
- reversible pulpitis
Non-vital pulp therapy, for
- irreversible pulpitis
- necrotic pulp
What are the clinical parameters that should be observed for teeth indicated for vital pulp therapy?
- No spontaneous pain
- Pain from thermal testing does not linger
- NTTP, NTTPp, mobility WNL
- No soft tissue lesions (e.g swelling, sinus)
- No PARL/perifurcation on radiograph
What are the indications for Hall Technique?
- Vital tooth
- If unable to do conventional resto for carious primary molars
Describe the Hall Technique
- Place separator at previous visit to make space for crown
- No LA, caries removal or tooth prep
- Cement preformed SSC with GIC – seal in decay
What is the rationale behind a protective base and what are some examples?
- Cover exposed dentinal tubules => Prevent microleakage & post-op sensitivity
- Protective barrier btw resto material/cement & pulp => Preserve tooth vitality, promote pulp healing & tertiary dentine formation
Examples of bases: Ca(OH)2, GIC
What is the indication for indirect pulp cap?
Vital asymptomatic tooth with deep caries adjacent to pulp
Describe the procedure for indirect pulp cap
- Place biocompatible material over thin residual layer of affected dentine – stimulate healing and repair (eg Ca(OH)2, ZOE, RMGIC, MTA)
- Restore tooth with material that seals against microleakage (eg CR)
>90% success rate at 3 years follow up
What are the indications (including pulpal status) for interim therapeutic restoration (ITR)?
- When conventional cavity prep & restorations not feasible (eg uncooperative child/special needs, partially erupted teeth)
- For caries control in child patients with multiple open carious lesions who would benefit from step-wise excavation or awaiting rehabilitation under GA
- Normal pulp/reversible pulpitis
Describe the procedure for ITR
- Caries removal, deepest carious dentine left so as to not expose pulp (different from IPC)
- Total/maximum caries removal at periphery of lesion
- Restore with GIC
- Monitor for s/s, decide if need to re-excavate caries & replace with conventional resto later on
What are the indications for direct pulp cap?
- Pin point mechanical exposure during cavity prep or following a traumatic injury
- NOT for carious pulp exposure
- Vital tooth
(rarely done for primary teeth)
What are clinical parameters to take note of that indicate success of vital pulp treatments (IPC, DPC)?
- Check that tooth remains vital
- No post tx s/s
- No radiographic evidence of pathologic changes
- No harm to succedaneous tooth
What are 3 possible ideal outcomes of pulpotomy?
- Preserve radicular pulp in healthy state
- Render radicular pulp inert
- Encourage tissue regeneration & healing at site of radicular pulp amputation (best!)
What are the indications for pulpotomy?
- Carious/mechanical/traumatic pulp exposure in primary tooth
- Inflammation/infection deemed to be confined to coronal pulp & radicular
pulp deemed to be vital => able to control bleeding
Describe the procedure for pulpotomy?
- Baseline x-ray & vitality tests
- Clean tooth, LA, RDI
- Caries free & remove pulp chamber roof
- Amputate coronal pulp (~2mm):
- Spoon excavator/high speed round bur (slow speed might catch pulp)
- Go down along the side until reach pulp chamber floor - Irrigate w saline & dry w cotton pellet
- Assess bleeding:
- Healthy red bleeding, can achieve haemostasis
- Dark red/purple, cannot achieve haemostasis => pulpectomy - Place medicated CP over amputated pulp stumps for 3-5min:
- Minimal amount of medicament (formocresol) => avoid cytotoxicity
- Soak CP in 1 drop of medicament & squeeze w gauze until damp - Place ZOE/GIC/IRM to fill pulp chamber
- Restore tooth (Ideally SSC)
What is the F/U Mx of pulpotomy of primary tooth?
F/U 6/12 with annual radiograph
Success rate of formocresol/MTA pulpotomy 90-95%
What are the possible complications following pulpotomy?
- Premature exfoliation
- Pulpal calcification
- Internal resorption
- Enamel defects in succedaneous teeth
(e.g Turner’s hypoplasia)
What are some medicaments used for pulpotomy?
- 1/5 dilution of formocresol (19% formaldehyde, 35% cresol)
- Ferric sulphate
- Mineral trioxide aggregate (MTA)
What are the effects of formocresol?
- Possible toxicity, diffusion into systemic system, potential mutagenicity & carcinogenicity => diluted for use
- 1/5 dilution vs non-diluted:↓ PA & furcation RL, ↓ tissue irritation, ↓ cytotoxicity
- Equally effective, high success rate
What is the mode of action of ferric sulphate?
- Ferric ion complex seals cut blood vessels => haemostasis
- Very acidic
- Success rate similar to formocresol
What are the features and effects of MTA?
- Biocompatible, prevent microleakage & promote tissue healing
- Expensive, may discolour teeth (not too bad cos will exfoliate)
- Success rate equal/higher than formocresol
What are difficulties faced when doing pulpectomy for primary teeth?
- Variable & complex root morphology
- Thin canal walls & pulpal floor
- Ongoing physiological root resorption
- Proximity of underlying developing permanent teeth
Describe the procedure for pulpectomy
- Baseline x-ray & vitality tests
- Clean tooth, LA, RDI
- Caries free & remove pulp chamber roof
- Remove radicular pulp (without enlarging canals)
- Flush with NaOCl/CHX/sterile water/saline
- Establish WL with radiograph
- Use files to gently debride canals 2mm short of radiographic apex
- Dry canals with paper points
- Fill canals with appropriate resorbable material
- Take radiograph to assess density & level of root fill
- Place cement base & permanent resto
- Recall 1 week, 3 months, 6 months, then annually until tooth exfoliates
What are the ideal properties for root canal filling material for primary teeth
- Antiseptic
- Adhere to canals
- Does not shrink
- Does not discolour teeth
- Harmless to periapical tissues and tooth germ
- Resorb with root of primary tooth
What are some root canal filling materials that can be used?
- ZOE (resorb slower than tooth but inconsequential)
- Iodoform
- Ca(OH)2 w Iodoform (Vitapex)
What are some complications after pulpectomy?
- Possible flare up => redo RCT if have s/s
- Premature exfoliation
- Over-retention
- Enamel defects in succedaneous teeth
What are the indications for lesion sterilisation / tissue repair (LSTR)
When the primary tooth is to be maintained for less than 12 months
Describe LSTR
Similar to pulpect but no instrumentation of root canals
1. Canal orifices enlarged slightly using large round bur
2. Walls of pulp chamber cleaned with phosphoric acid, rinsed and dried
3. A/B paste (clindamycin, metronidazole, ciprofloxacin) applied onto enlarged canal orifices & pulpal floor
4. Cover with GIC and restore with SSC
