Pulp Therapy for Primary Molars

Question 1

if grossly carious molars are left untreated, what are the consequences?

Answer 1

pain
infection
damage to permanent successor
decreased masticatory function

Question 2

tooth retention indications

Answer 2

dental factors:
minimal number of extensively carious primary molars
no permanent successor
prevention of mesial migration of 1st permanent molars
early ortho intervention
social factors:
pt compliant
regular attender
medical factors:
pt at risk from an extraction eg bleeding disorder
pt at risk if a GA is required for tooth removal eg cystic fibrosis, muscular dystrophies

Question 3

Extractions indications

Answer 3

dental factors:
tooth unrestorable after pulp therapy
extensive internal root resorption
large number of carious teeth with likely pulp involvement
tooth close to exfoliation (2/3 root resorption)
contralateral tooth already lost
extensive pathology or acute facial swelling

social factors:
irregular attender
poor compliance
unfavourable parental attitude

medical factors:
risk of residual infection

Question 4

Pulp therapy techniques for vital pulp

Answer 4

Hall crown
indirect pulp tx
direct pulp capping (high incidence of internal root resorption)
vital pulpotomy
densitising pulpotomy

Question 5

Pulp therapy techniques for non-vital pulp

Answer 5

Pulpectomy
Non-vital pulpotomy

Question 6

Hall technique

Answer 6

Cement PMC over carious primary molar
no LA or tooth prep

indications:
full clinical exam
no clinical or radiographic indication of pulp involvement
good co-op

contra-indications
not if IE risk
unusual morphology eg accessory cusp
poor co-op

Question 7

Indirect pulp tx

Answer 7

Aims:
- arrest carious process and provide conditions conducive to the formation of reactionary dentine
- promote pulpal healing and preserve vitality of the pulp tissue

indications:
- tooth with deep carious lesions
- no signs/symptoms indicative of pulpal necrosis
- <2/3 marginal ridge breakdown

Question 8

Indirect pulp tx technique

Answer 8

LA
RD
removal of all caries at EDJ
careful removal of soft deep dentine using hand excavator
no pulp exposure
RMGI or CaOH
definitive restoration to achieve optimal coronal seal

Question 9

Direct pulp capping

Answer 9

poor success rate
high incidence of internal resorption
promotes dentine bridge and maintain vitality

Question 10

Indications for direct pulp capping

Answer 10

Asymptomatic tooth
small exposure
older children
iatrogenic exposure, <2/3 marginal ridge loss

Question 11

technique for direct pulp capping

Answer 11

LA
RB
cotton wool pledget soaked in saline to arrest haemorrhage
Hard setting CaOH cement
restore, optimal seal

Question 12

Vital pulpotomy

Answer 12

to remove coronal pulp, which has been clinically diagnosed as inflamed, retain healthy or reversibly inflamed radicular pulp

Question 13

indications of vital pulpotomy

Answer 13

transient pain
asymptomatic tooth
pulp minimally inflamed, reversible pulpitis
2/3 marginal ridge destroyed
any doubt that pulp exposed to caries/iatrogenic damage

Question 14

techniques for vital pulpotomy

Answer 14

LA
RD
Gain access
remove caries
remove roof of pulp chamber
amputation: remove coronal pulp/risk of perforation of pulp floor
control of haemorrhage : cotton pledget soaked in saline
evaluate pulp stones : normal bleeding, non-inflamed pulp bright red means good haemostasis, proceed with pulpotomy, abnormal bleeding seen inflamed pulp deep crimson continued bleeding after pressure
medication: 15.5% ferric sulphate (astringedent) solution with cotton pledget
evaluate pulp stump after
restore: roots covered with reinforced ZOE paste (kalzinol), GIC core, restore SS crown
review: 1yr follow up

Question 15

Desensitising pulpotomy

Answer 15

reduce pulpal inflammation and/or symptoms in order to facilitate subsequent pulpotomy or pulpectomy procedure

Question 16

indications for densitising pulpotomy

Answer 16

failure of haemostasis of radicular pulp stump during pulpotomy
non-compliant child who may need inhalation sedation for further tx

Question 17

techniques for densitising pulpotomy

Answer 17

LA
RD
removal of caries
place a small wedget of cotton wool loaded with odontopaste over exposure site
place a well sealed temporary dressing
recall after 1-2 weeks and proceed with pulpotomy

Question 18

Aims of pulpectomy

Answer 18

removal. of irreversibly inflamed or necrotic radicular pulp and clean root canal system
obturate root canal with a material that resorbs at the same rate as tooth

Question 19

indications of pulpectomy

Answer 19

irreversible pulpitis involving both the coronal and radicular pulp
non vital pulp radicular pulp with/without infection
primary molars with radiographic evidence of furcation pathology
non-vital primary molars
>2/3 root
good patient compliance
ortho retention indicated

Question 20

contra-indications of pulpectomy

Answer 20

tooth unrestorable
caries through bifurcation
extensive root resorption
extensive peri-apical pathology

Question 21

difficulties of pulpectomy

Answer 21

requires good pt co-op
complex root morphology eg mandibular 1st molars 79.2% 3 canals or 20.8% 4 cases. 2nd molars 71% 3 canals or 29% 4 canals.

Question 22

procedure of pulpectomy

Answer 22

pre op x rays
LA
RD
triangular access (apex towards palatal, base towards buccal)
removal of caries/roof of pulp chamber and remnants of coronal pulp
record whether radicular pulp is bleeding (one stage procedure) or necrotic (two stage procedure)
identify root canals
irrigate with Leur Lock syringe and side venting needle (use normal saline (0.9%), chlorhexidine sol (0.4%) or sodium hypochlorite (0.1%)
estimate WL of root canals by keeping 2mm short of the radiographic apex
insert small files into canals and file canal walls lightly and gently
irrigate the root canals
dry the canals with pre-measured paper points
if infection present, dress root canal with non-setting CaOH and temporise
consider prescribing systemic antimicrobial
if canals dried with paper points, obturate root canals by injecting a resorbable paste eg non setting CaOH

Question 23

Ideal root canal filling material

Answer 23

resorb at same rate as primary tooth
harmless to periapical tissue and permanent successor
resorb easily if extruded beyond apex
antibacterial
ease of insertion