Management of Deep Caries and Pulpally Involved Primary Teeth Flashcards
Objectives for conserving primary teeth?
- Maintain arch length
- Prevent and relieve pain/infection
- Restore aesthetics and function
- Prevent speech problems
- Prevent aberrant tongue habits
- Prevent adverse effects on underlying permanent teeth (Turner’s tooth)
- Avoid negative impact on child’s psychological and social functioning
What are some indications, in terms of medical history, for conserving primary teeth?
- Bleeding disorders and coagulopathies
- Oligodontia
What are some contraindications, in terms of medical history, for conserving primary teeth?
- Congenital heart conditions at risk of subacute endocarditis
- Immunocompromised children
- Poor healing ability
What are some dental factors for conserving primary teeth?
- General dental condition
- Restorability
- Life span of tooth
- Amount of bone support
- Significance of tooth to dental arch
- Pulp calcification, pathological root resorption
- Absence of permanent successor
What are the types of treatment approaches?
- Preventive
- Biological
- Conventional
What is the Preventive only Approach?
Slow down and arrest caries by using F varnish or SDF
What is the biological approach?
Incomplete caries removal + Restoration with good seal
E.g. Hall technique, Interim therapeutic restoration, IPC
How to diagnose pulp status in primary teeth?
- Pain history and characteristics
- Discolouration, mobility of tooth
- Surrounding soft tissues (redness, swelling, sinus tract)
- Percussion and thermal tests
- Radiographs
- Colour and nature of bleeding from exposed pulp during procedure
General considerations for vital pulp treatment?
- Absence of spontaneous pain
- Non-lingering pain during thermal testing
- NTTP, NTTPp, mobility within normal limits
- No soft tissue lesions e.g. swelling, sinus
- No perifurcation/periapical lesion on radiograph
What are the types of VPT?
- Hall technique
- Protective liner
- Indirect pulp cap
- Direct pulp cap
- Pulpotomy
What is the Hall Technique?
Cementation of preformed stainless steel crown with GIC to seal in decay
NO LA, caries removal or tooth preparation
What is a protective liner?
All caries removed, a thin layer of material is placed on pulpal surface of a deep cavity preparation
When is Hall Technique indicated?
Too young, too scared, special needs
Function of protective liner
- Cover exposed dentin tubules to act as protective barrier between restorative material and pulp
- Preserve tooth vitality, promote pulp healing and tertiary dentin formation and minimize microleakage and post-op sensitivity
Examples of Protective Liner
Calcium hydroxide, dentin bonding agent, GIC cement
What is an Indirect Pulp Cap?
Placement of biocompatible material over thin residual layer of affected dentin to stimulate healing and repair
What are the materials used for Indirect Pulp Cap?
Dentin bonding agent, calcium hydroxide, ZOE, RMGIC, MTA
What is the success rate of IPC?
> 90% success rate at 3 years follow up
Indications of Interim Therapeutic Restoration
- Excessive restorations to be done under GA
- Uncooperative child
- Special needs
- Partially erupted teeth
What is Interim Therapeutic Restoration?
- Caries removal except deepest part
- Restore with GIC
- Monitor for s/s and decide if need to re-excavate caries and replace with conventional restoration later on
Indication for Direct Pulp Cap?
Pin point mechanical exposure during cavity preparation or following traumatic injury
NOT for carious exposure
What is a Direct Pulp Cap?
Biocompatible radiopaque base e.g. calcium hydroxide or MTA placed over exposed pulp tissue
Restore with material that seals it from microleakage
What is indicated for primary teeth with carious exposures?
Vital pulpotomy (>90% success rate) > DPC (<75% success rate)
What is pulpotomy?
Removal of coronal pulp followed by placement of a medicament over radicular pulp stumps
3 main outcomes in pulpotomy?
- Preserve radicular pulp in healthy state
- Render radicular pulp inert
- Encourage tissue regeneration and healing at site of radicular pulp amputation
Indications for Pulpotomy?
- Carious or traumatic pulp exposure in a primary tooth with normal pulp or reversible pulpitis
- Inflammation/infection is deemed to be confined to coronal pulp and radicular pulp is vital
What is the procedure of a Vital Pulpotomy?
- LA
- Isolation with rubber dam
- Caries removal
- Remove roof of pulp chamber
- Amputate coronal pulp with spoon excavator or slow speed round bur
- Flush with saline, dry with cotton pellet
- Achieve hemostasis
- Place medicated cotton pellet over amputated pulp stumps
- Line pulpal floor with ZOE
- Restore tooth (Preferably SS crown)
What is the follow-up of pulpotomy?
6 monthly with annual radiograph
What is the success rate of formocresol/MTA pulpotomy?
90-95%
Possible complications following pulpotomy
- Premature exfoliation
- Pulpal calcification
- Internal resorption
- Enamel defects in succedaneous teeth
Medications for pulpotomy of primary teeth?
- 1/5 dilution Buckley’s formocresol
- Mineral Trioxide Aggregate
What does Formocresol consist of?
Formaldehyde 19%, Cresol 35% in distilled water and glycerine
What are the concerns of Formocresol?
Toxicity, mutagenicity and carcinogenicity, diffusion into systemic system
What are the benefits of 1/5 dilution of formocresol?
- Equally effective
- Less periapical and furcation radiolucencies
- Less tissue irritation
- Less cytotoxic
What are the benefits of MTA?
- Biocompatible
- Prevents microleakage and promotes tissue healing
What are the cons of MTA?
- Expensive
- May discolour teeth
What is the purpose of Ferric Sulphate?
Seals cut blood vessels mechanically to produce hemostasis
General Considerations for Pulpectomy?
- Variable and complex root morphology
- Thin canal walls and pulpal floor
- Ongoing physiological root resorption
- Proximity of underlying developing permanent teeth
What is the procedure of Pulpectomy?
- Remove radicular pulp
- Flush with sodium hypochlorite/chlorhexidine/sterile water or saline
- Establish working length with radiograph
- Use files to debride canals 2mm short of radiographic apex gently
- Irrigate and dry canals with paper points
- Fill canals with resorbable cements
- Radiographs to assess density and level of root fill
- Place cement base into pulp chamber followed by permanent restoration
What is the recall for Pulpectomy?
- 1 week
- 3 months
- 6 months
- Annually
Criteria for root canal filling material for primary teeth?
- Antiseptic
- Adhere to canal walls
- Does not shrink and discolor teeth
- Harmless to periapical tissues and tooth germs
- Resorb with root of primary tooth
What are the root canal filling material for primary teeth?
- ZOE
- Iodoform
- Calcium hydroxide with iodoform
What is the success rate for pulpectomy?
69%
Possible complications following pulpectomy of primary teeth?
- Premature exfoliation
- Over-retention
- Enamel defects in permanent teeth
What is Lesion Sterilization/Tissue repair (LSTR)?
Similar to pulpectomy but with no instrumentation of root canals
Indication for Lesion Sterilization/Tissue repair (LSTR)?
Primary tooth to be maintained < 12 months
What is the procedure for Lesion Sterilization/Tissue repair (LSTR)?
- Canal orifices enlarged slightly using large round bur
- Walls of pulp chamber cleaned with phosphoric acid, rinsed and dried
- A/B paste (clindamycin, metronidazole, ciprofloxacin) applied onto enlarged canal orifices and pulpal floor
- Cover with GIC and restore with SCC
