Pulp Therapy for vital teeth

Question 1

An immature permanent tooth is defined by the British Society of Paediatric Dentistry as

Answer 1

A tooth which is not fully formed, particularly the root apex

What happens if tooth vitality is lost
- Maturation process will cease leaving the tooth with a wide root canal, thin canal walls and an open apex.
- Lack of apical constriction to condense and contain a root filling makes RCT impossible in teeth with an open apex

Question 2

APEXOGENESIS

Answer 2

Apexogenesis is a process of maintaining radicular pulp vitality when the pulp is injured but not necrotic, which leaves the apical one-third of the dental pulp in the tooth, allowing the root to complete formation allowing continuation of root formation and thickening of dentinal walls which improves the tooth’s long-term prognosis

A portion of inflamed pulp is removed and filled with a bioceramic material that maintains vitality in the roots

Question 3

Apexogenesis techniques

Answer 3

Following an insult due to caries or trauma

1. Direct pulp capping
2. Indirect pulp capping
3. Partial pulpotomy
4. Coronal pulpotomy

Question 4

Apexogenesis techniques depend on

Answer 4

1. Pulpal status of the tooth
2. Presence/absence and size of pulpal exposure
3. Radicular pulpal health
4. Tooth restorability
5. Patient’s oral health, caries risk and motivation
6. Patient’s orthodontic needs
7. Whether the treatment should be performed under local analgesia or general anesthesia
8. Patient’s medical history.

Question 5

Techniques for the management of immature teeth with a normal pulp or reversible pulpitis include

Answer 5

1. Stepwise excavation
2. Indirect pulp capping
3. Direct pulp capping
4. Partial Pulpotomy
5. Coronal Pulpotomy

Question 6

Stepwise technique

Answer 6

Removal of deep caries without pulp exposure. A thin layer of caries is left, CaOH placed to activate formation of secondary dentine. After 6 weeks carious lesions are excavated and a well sealed restoration is placed

Disadvantage
Carries the risk of developing irreversible pulpitis
Re-opening of the pulp
Multi-sessions

Question 7

Indirect pulp capping

Answer 7

Excavation of all dental caries as close as possible to the pulp, and placement of a protective liner followed by a long-term restoration providing good coronal seal

Advantages
Does not carry the risk of an unintentional pulp exposure or irreversible pulpitis
the single session indirect pulp capping compared with the multi-session stepwise technique

Question 8

DIRECT PULP CAPPING

Answer 8

Promotes pulpal healing and reparative dentin formation following small pulp exposures during cavity preparation

Controls hemorrhage by capping the pulp with CaOH or mineral trioxide aggregate (MTA)

Closed apex during exposure and caries went into the pulp (RCT)

Open apex during exposure (pulpotomy or partial pulpotomy)

Indications of direct pulp capping
-Pulp exposed as a result of trauma
-Pulp is deemed to be only superficially contaminated
-Inflammation is reversible

Question 9

PARTIAL PULPOTOMY

Answer 9

A high-speed diamond bur is used to remove 2 mm of pulp tissue at a time until healthy pulp tissue is reached (bright red bleeding)

Bactericidal irrigant such as sodium hypochlorite or chlorhexidine is used and covered with CaOH or MTA then followed by a layer of light-cured resin-modified glass ionomer liner

Advantage -Partial coronal pulpotomy allows narrowing of lumen (more formation of dentine on lumen making tooth more stronger than coronal pulpotomy), complete coronal pulpotomy has high risk of fracture due to less coronal lumen narrowing (less dentine)

Question 10

Disadvantage of MTA

Answer 10

Extensive discolouration of pulp due to the presence of BIS-MAS oxide (not recommended to use in the pulp chamber of incisor teeth as it tends to cause extensive discoloration of the crown)

Portland cement could also be used as it is not usually associated with this discoloration problem