Pulp therapy Flashcards
What are the features of the primary tooth crowns?
Shorter relative to their root length
Occlusal table is constricted buccolingually and narrower mesiodistally.
Thinner enamel and dentin (Half the thickness of of permanent teeth)
Direction of the enamel rods in the cervical area is angled towards the occlusal surface
Significant cervical constriction
Pronounced buccal cervical bulge
Contact areas are flat and very broad buccolingually
Whiter and a lighter shade
What are the features of the primary anterior tooth roots?
Mesio-distal width is much narrower than the crown when compared to the permanent teeth
What are the features of the roots of primary molars?
Primary molars exhibit a greater flare to accomodate developing successor teeth
Roots are relatively longer and more slender
What are the features of the pulp and root canal system of primary teeth?
Size of pulp relative to the crown is larger
Pulp horns are higher and closer to the DEJ and to the outer surface of the crown.
Mesial pulp horns are higher than distal pulp horns.
Pulp horns are present under each cusp of the primary molars
Large pulp chambers (mandibular molars are larger than maxillary molars)
RCS of primary molars are extremely tortuous and complex
Root canal system has many accessory canals
What are the goals of pulp therapy?
Retain tooth in non-pathologicla state
Maintain original arch length (Tooth is a great space maintainer)
Prevent malocclusion, aesthetic, phonetic and functional problems
What are the treatment options based on?
Patient’s medical history
Value of each involved tooth in relation to the child’s overall development
Alternatives to pulp treatment
Restorability of the tooth
What is examined in a patient before pulp therapy is decided?
Patient’s history related to discomfort
Thermal, chemical, or pressure stimuli (ask simple questions)
Carious destruction of marginal ridge
Soft tissue swelling or sinus tract
Mobility (Normal exfoliation vs abnormal root resorption)
What should be considered when making a diagnosis that leads to pulp therapy?
Pain
Pulp testing (questionable value in primary teeth)
Percussion (Pain on percussion indicates inflammation in supportive periodontal structures)
Soft tissue examination
Mobility
Radiographs
Patient/parent cooperation
Stages of dental development
Degree of difficulty in performing this treatment
Location of tooth
Ability to restore tooth
How can pain be understood better in children?
Question parents (Children can be unreliable)
Persistent pain = advanced inflammation
Spontaneous pain = advanced inflammation
Absence of pain = inconclusive
What should be examined in soft tissue?
Swelling (Non-vital tooth)
Exudate usually tracks buccally resulting in intra-oral or extra-oral swelling.
Intra-oral swelling more common in primary teeth because furcations are usually occlusal to the muscle attachments.
What does mobility mean?
Pathological mobility is due to resorption of bone, root, or both
Occurs with long term inflammation
Associated with non-vital primary tooth
What should be examined with radiographs?
Furcation area using a periapical or bitewing film
Depth of caries
Presence of calcified body in the pulp
Furcation involvement
Bone resorption
Internal and External root resorption
What are the contra-indications to pulp therapy?
Medical disorder (heart disease such as bacterial endocarditis)
Immuno-compromised children
Caries in root canal/root surface
Un-restorable tooth
Less than 2/3 of root remained
What are the levels of pulp therapy?
Indirect pulp capping
Direct pulp capping
Pulpotomy
Partial pulpectomy
Pulpectomy
What is indirect pulp capping?
Caries closest to the pulp is left in place and covered with a biocompatible material.
Can indirect pulp capping be used on primary teeth?
Yes it is an acceptable procedure for primary teeth with reversible pulp inflammation. (Provided diagnosis was with good history and proper clinical and radiographic examination and tooth is restored with a leakage free restoration)
Why should indirect pulp capping be done?
Maintains pulp vitality in a deep carious lesion.
Success rates at 3, 6 and 12 months are 100%, 98%, and 97% respectively
How should indirect pulp capping be done?
Using calcium hydroxide, zinc eugenol, GIC, etc
Should involve complete removal of all carious tissues from the lateral walls of the cavity preparation.
Restore with a material that seals the tooth from microleakage
What are the indications of indirect pulp capping?
No evidence of pulpitis
Reversible pulpitis when the deepest carious dentin is not removed to avoid pulp exposure
What is direct pulp capping?
Producing a seal in the primary tooth at the opening of the dental pulp.
Is direct pulp capping recommended for primary teeth? Why?
No it is not recommended for primary teeth due to high failure rate. (Internal resorption and acute dentoalveolar abscess)
High cellular content of primary pulp tissue may be responsible for failure
Undifferentiated mesenchymal cells may differentiate into osteoclasts
What is the difference between a pulpotomy and a pulpectomy?
Pulpotomy: Remove only coronal pulp tissue
Pulpectomy: Remove the coronal and radicular pulp tissue
What are the indications for a pulpotomy?
Marginal ridge caries
Reversible pulpitis
At least 2/3rds of root still present
Absence of abscess or fistula
No inter-radicular bone loss
No evidence of internal resorption
When extraction is contraindicated
When extraction is contra-indicated
What are the contraindications to a pulpotomy?
Spontaneous pain
Tenderness to percussion
Swelling or fistula
Pathological mobility
Internal or external resorption
Sign of acute dental infection
Periapical and inter-radicular radiolucency
Pulp calcification
Serous exudate at the exposure site
Uncontrollable haemorrhage from the amputated pulp stumps
What equipment are needed for a pulpotomy?
330 high speed bur
Topical and local anaesthesia
Rubber dam kit
Slow speed round burs
Excavators
Irrigation syringe
Spatula
Flat plastic instrument
Medicament (formocresol, ferric sulfate, etc)
Temporary filling material (cavit)
GIC (Fuji ii LC)
What are the steps to doing a pulpotomy?
Administer LA (with help from topical anaesthetic)
Isolate teeth with rubber dam
Remove caries and determine site of pulp exposure
Remove roof of the pulp chamber (If there is no apparent exposure, the cavity is made deeper until a ‘dip’ is felt)
Once the pulp chamber is entered move the bur sideways
Check the colour of the haemorrhage (Light red = less inflammation deep red = increased inflammation)
Amputate coronal pulp using a sterile low speed round bur and control bleeding using moistened cotton pellets
Apply medicament after haemostasis
Place cavit
Place Fuji II LC (GIC)
Prepare the tooth for a stainless steel crown restoration
What treatments can be used for devitalization during pulpotomy?
Formocresol
Gluteraldehyde
Electrocoagulation
What medicaments can be used for remineralization during pulpotomy?
Indirect pulp therapy
Bone Morphogenic Proteins
Collagen
What treatments can be used for preservation during pulpotomy?
Ferric sulphate
Calcium hydroxide
MTA
Lasers
What does electrocoagulation do?
Carbonizes and denatures the pulp tissue producing a layer of coagulative necrosis acting as a barrier between lining material and radicular pulp
How does ferric sulphate work?
On contact with blood a ferric ion-protein complex is formed.
The membrane of this complex seals the cut vessels mechanically producing haemostasis.
The agglutination protein complex forms plugs which occlude the capillary orifices preventing blood clot formation.
What are the features of MTA?
Introduced in dentistry to seal communication between root and external surfaces of a tooth.
Composition similar to portland cement with a setting time of 3 to 4 hours
Very high success rate.
What are the limitations of using MTA?
Difficult handling characteristics
Long setting time
Discolouration
Difficulty in removal after setting
High cost
What are the features of laser preservation?
Laser beam doesn’t contact the tissues
Incision can be made without inflicting mechanical trauma to the pulpal tissues
Procedure performed under aseptic conditions
High success rate shown
What are the issues with laser preservation?
Evidence is little and highly heterogenous
No real recommendations formulated
What replacement has been though of to replace formocresol?
Sodium hypocholorite (NaOCl)
What is the purpose of a pulpectomy?
Aim is to retain a tooth that would otherwise be extracted
To prevent space loss
Tooth with irreversible pulpitis
Is a pulpectomy recommended?
No, evidence of internal or external root resorption
More than 1/3 of the root length has been lost
What medicaments are used in pulpectomies?
zinc oxide eugenol
calcium hydroxide
KRI paste: iodoform + camphor + parachlorophenol + menthol
Maisto’s paste: KRI + zinc oxide + thymol + lanolin
Vitapex: Calcium hydroxide and iodoform
