Pulp therapies on deciduous teeth Flashcards
When may a carious deciduous tooth be saved instead of extracted?
Medical contraindications to extraction - excessive bleeding patient
Co-operative patient
Sufficient tooth structure remaining to allow tooth to be saved: after the pulpotomy it will support the filling
No bifurcation involvement (radiolucency in bifurcation area is indication for extraction as this is very hard to treat) , periapical lesion?
Psychologically advantageous - prevents child feeling upset by having tooth removed
Age of patient - will the tooth even last (maybe if child is 5 years old the primary tooth will last)
Indications for extraction over vital/non vital pulp therapy
Infection cannot be arrested - unsuccessful pulp therapy
Abscess or cellulitis
Bifurcation involvement/PA lesion
Poor periodontal/bony support
Inadequate tooth structure remaining for restoration (unrestorable)
Excessive pathologic root resorption
Types of pulp therapy for deciduous teeth
(vital and non vital)
indirect pulp capping
direct pulp capping (not for carious exposure of pulp)
pulpotomy
desensitising pulp therapy
pulpectomy
What pulpal conditions do the indications, objectives and type of pulp therapy depend on?
Pulp status -
Vital vs non-vital based on clinical diagnosis of:
-Normal pulp - symptom free and normal response to vitality testing
-Reversible pulpitis (vital inflamed pulp capable of healing - test with dressing)
-Symptomatic or asymptomatic irreversible pulpitis (vital inflamed pulp incapable of healing)
-Pulp necrosis
Clinical assessment of deciduous teeth (pulpal diagnosis)
- P/C and review of past and present dental history and treatment
- History of P/C - location, intensity, duration, stimulus, relief, spontaneity (SOCRATES)
- Medical History
- E/O and I/O examination including soft tissues
- Clinical test: TTP, TTPalp, mobility, sinus, discolouration, percussion sound for ankylosis
(Electric pulp and thermal tests usually help in permanent teeth) - Radiographic exam: periapical to diagnose pulpitis or necrosis (showing furcation, periapical tissues and surrounding bone)
Considerations before vital/non vital pulp therapy
Pts medical history (bleeding disorders, medically compromised, congenital heart defects is a contraindication)
Value of each tooth involved in relation to childs development
Alternatives to pulp therapies
Restorability of tooth
(Pulp status, root resorption, radicular bifurcation infection, periodontal support, child cooperativity, how many required)
Radiographic assessment of deciduous teeth
Infection and resorption:
extent of decay
bifurcation radiolucency - this is where resorption often occurs in primary teeth
stage or root development and resorption
periapical changes
Indirect pulp capping indications
deep carious lesion
signs of normal pulp/reversible pulpitis but no pulp exposure/signs of pulp degenration
Rationale behind indirect pulp capping
arrest caries progression
CaOH placement will enhance the formation of tertiary dentine
prevent pulp exposure
promote pulpal healing
Indirect pulp capping procedure
LA rubber dam
remove caries from EDJ
remove soft caries with slow HP or excavator
Place CaOH, DBA, GIC/ZOE (inhibit cariogenic bacteria)
Restore the tooth
Indications and contraindications for direct pulp capping
Primary tooth with normal pulp
Pulp exposure due to pinpoint mechanical exposure during cavity prep or trauma
ONLY when conditions for a favourable response are optimal (no bacteria in pulp)
Contraindications:-
-carious exposure of pulp
-radiographic signs of pathologic root resorption/furcation or apical infection (radiolucencies)
Direct pulp capping procedure
When pinpoint mechanical or traumatic exposure to pulp (during cavity prep or injury):
-MTA or CaOH liner/base placed on pulp tissue
-Restore tooth
Rationale behind direct pulp capping
Maintain tooth vitality
Promote pulpal healing
Prevent post op pain, sensitivity or swelling
Pulpotomy definition
removal of coronal pulp
we assume that the inflammation is reversible and doesn’t involve the radicular pulp
Indications for pulpotomy
cooperative child
Tooth is vital and restorable
Extensive caries - broken marginal ridge
Carious or mechanical exposure (trauma) of the normal/reversible pulp
no periapical or bifurcation involvement
normal pulp or reversible pulpitis signs - no signs of irreversible pulpitis
extraction is contraindicated
Medical condition that contraindicates pulp therapy
congenital heart defects
Contraindications of pulpotomy
uncooperative
non restorable
irreversible pulpitis
non vital tooth
pathology in
periapical and bifurcation regions
congiental heart defets - MH
Signs of irreversibly inflamed/infected pulp or radicular tissue
(pulpotomy may turn into pulpectomy or extraction)
Vital radicular tissue:-
-Suppuration
-Purulence
-Necrosis
-XS bleeding/haemhorrage (uncontrollable w damp cotton pellet after 10 mins)
-signs of radiographic radicular resorption or infection
NOTE: internal root resorption can be self limiting and stable - monitor
(extract if perforation leads to loss of surround bone or signs of XS infection/inflammation - PRESERVE SUCCESSOR)
Why is ferric sulphate used?
ASTRINGENT
forms ferric ion complex when in contact with blood and helps achieve haemostasis
minimises extravascular bleeding and prevents initiation of inflammatory process
conserves the radicular pulp
reparative dentine can be made
no systemic effects- unlike formocresol
Pulpotomy technique
LA Rubber dam
Access - remove caries
Remove roof of pulp chamber
Remove coronal pulp with excavator and amputate stumps with slow HP larger round bur
Irrigate PC
Control the haemorrhage with cotton pledget
Bleeding should stop within 4 mins !!
If the radicular pulp clots and is healthy - continue with pulpotomy
If there is uncontrolled bleeding or necrotic pulp - pulpectomy or extraction required.
15.5% ferric sulphate on microbrush to burnish the pulp stumps for 15 secs - rinse and dry
GIC or ZOE cement lining if necessary, adhesive restoration (lifespan of 2 or less years) or preformed metal crown.
Desensitising pulp therapy Technique
Inadequate analgesia
Odontopaste® (steroidal antibiotic paste) on a small pledget of cotton wool placed on pulp
temp rest gic
- review in 1-2 weeks
- continue pulpotomy
What is Ledermix?
A corticosteroid (triamcinolone acetonide) and tetracycline antibiotic
Pulpectomy
non vital pulp therapy
to remove irreversibly inflammed or necrotic radicular pulp tissue and gently clean the RC system
Tooth is obturated with a material that will resorb ay the same rate as primary tooth and will be eliminated rapidly if it extrudes through the apex
pupectomy indications
compliant child
irreversible pulpitis/ bleeds profusely during pulpotomy procedure
Non vital tooth with or without infection - suppuration or purulence
Should be no or minimal root resorption
What are teeth obturated with in a pulpectomy?
Slow setting pure ZOE
Non setting CaOH
CaOH and iodoform paste (VitapexTM or EndoflasTM)
(NOTE caoh not always used in primary teeth as causes chronic pulp inflammation and internal root resportion)
Pulpectomy procedure
Begins the same as pulpotomy
Root canal procedure:
-debride and shape canals with hand or rotary files
estimate WL to be 2mm short of apex
Use small files - no larger than size 30 to file walls gently
irrigate with Saline, CHX, or NaOCl (0.1%)
If symptoms or infection present - (exudate or associated sinus) dress with non setting CaOH and temporise
dry canals and obturate with Slow setting ZOE, Non setting CaOH* or CaOH and iodoform paste (vitapex)
definitive restoration to provide good seal - PFM
*consider MTA
Radiographic recall intervals for pulp therapy on deciduous teeth
Post-operative clinical assessment - at least every 6 months
Pulpotomies - at least every year
Must include furcation/periapical area (radiographs) - BW may suffice but if not visible then take PA
