Pulp therapies on deciduous teeth

Question 1

When may a carious deciduous tooth be saved instead of extracted?

Answer 1

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)

Question 2

Indications for extraction over vital/non vital pulp therapy

Answer 2

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

Question 3

Types of pulp therapy for deciduous teeth
(vital and non vital)

Answer 3

indirect pulp capping
direct pulp capping (not for carious exposure of pulp)
pulpotomy
desensitising pulp therapy
pulpectomy

Question 4

What pulpal conditions do the indications, objectives and type of pulp therapy depend on?

Answer 4

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

Question 5

Clinical assessment of deciduous teeth (pulpal diagnosis)

Answer 5

1. P/C and review of past and present dental history and treatment
2. History of P/C - location, intensity, duration, stimulus, relief, spontaneity (SOCRATES)
3. Medical History
4. E/O and I/O examination including soft tissues
5. Clinical test: TTP, TTPalp, mobility, sinus, discolouration, percussion sound for ankylosis
   (Electric pulp and thermal tests usually help in permanent teeth)
6. Radiographic exam: periapical to diagnose pulpitis or necrosis (showing furcation, periapical tissues and surrounding bone)

Question 6

Considerations before vital/non vital pulp therapy

Answer 6

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)

Question 7

Radiographic assessment of deciduous teeth

Answer 7

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

Question 8

Indirect pulp capping indications

Answer 8

deep carious lesion

signs of normal pulp/reversible pulpitis but no pulp exposure/signs of pulp degenration

Question 9

Rationale behind indirect pulp capping

Answer 9

arrest caries progression

CaOH placement will enhance the formation of tertiary dentine

prevent pulp exposure

promote pulpal healing

Question 10

Indirect pulp capping procedure

Answer 10

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

Question 11

Indications and contraindications for direct pulp capping

Answer 11

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)

Question 12

Direct pulp capping procedure

Answer 12

When pinpoint mechanical or traumatic exposure to pulp (during cavity prep or injury):

-MTA or CaOH liner/base placed on pulp tissue

-Restore tooth

Question 13

Rationale behind direct pulp capping

Answer 13

Maintain tooth vitality

Promote pulpal healing

Prevent post op pain, sensitivity or swelling

Question 14

Pulpotomy definition

Answer 14

removal of coronal pulp

we assume that the inflammation is reversible and doesn’t involve the radicular pulp

Question 15

Indications for pulpotomy

Answer 15

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

Question 16

Medical condition that contraindicates pulp therapy

Answer 16

congenital heart defects

Question 17

Contraindications of pulpotomy

Answer 17

uncooperative

non restorable

irreversible pulpitis

non vital tooth

pathology in
periapical and bifurcation regions

congiental heart defets - MH

Question 18

Signs of irreversibly inflamed/infected pulp or radicular tissue

(pulpotomy may turn into pulpectomy or extraction)

Answer 18

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)

Question 19

Why is ferric sulphate used?

Answer 19

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

Question 20

Pulpotomy technique

Answer 20

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.

Question 21

Desensitising pulp therapy Technique

Answer 21

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

Question 22

What is Ledermix?

Answer 22

A corticosteroid (triamcinolone acetonide) and tetracycline antibiotic

Question 23

Pulpectomy

Answer 23

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

Question 24

pupectomy indications

Answer 24

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

Question 25

What are teeth obturated with in a pulpectomy?

Answer 25

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)

Question 26

Pulpectomy procedure

Answer 26

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

Question 27

Radiographic recall intervals for pulp therapy on deciduous teeth

Answer 27

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