Pulp therapy in primary molars

Question 1

4 stages in diseases of pulp

Answer 1

normal –> inflamed –> necrosis –> infection

reversible pulpititis –> irreversible pulpitis –> pulp necrosis

Question 2

what is the defence response to pulpal pathology

Answer 2

tertiary/ reactionary dentine

Question 3

what differs in pulpal problems between primary and adult teeth

Answer 3

primary pulp horns are bigger–> sooner pulpal involvement, esp from interproximal caries
no difference in pulpal regeneration

Question 4

why is diagnosis of primary pulp status difficult

Answer 4

• unreliable tests
• kids unable to accurately describe symptoms
• precise diagnosis only possible with histological examination

Question 5

describe symptoms of reversible pulpitis

Answer 5

• provoked
• disappears on removal of stimulus
• shorter duration
• relieved with analgesia
• sharp pain

Question 6

describe symptoms of irreversible pulpitis

Answer 6

• spontaneous
• constant
• long duration
• not always relieved with analgesics
• dull throbbing ache
• sleep disruption
• swelling

Question 7

clinical findings of irreversible pulpitis 6

Answer 7

• sinus (discharge)
• swelling (intra oral and extra oral)
• clinical extent of caries
• discolouration
• TTT
• mobility

Question 8

what to look for on radiographs of pulpal problems in PRIMARY teeth 3

Answer 8

• caries extent
• interradicular radiolucency (due to accessory interradicular foramini in primary molars)
• resorption (external/ internal, physiological/ pathoogical)

Question 9

function of primary molar

a. mobility testing
b. TTP
c. vitality testing

Answer 9

a. mobility testing: physiological (near exfoliation) v pathological
b. TTP: distinguish food impaction from peri-radicular pathology
c. vitality testing: not accurate in primary teeth

Question 10

what medical factors would lead you to

a. restore/ retain
b. extract

Answer 10

a. restore/ retain: bleeding disorders, patients at risk of GA if required for extraction
b. extract: immune disorders, cardiac disorders (endocarditis risk)

Question 11

4 factor groups on decision to restore / extract

Answer 11

• medical factors
• social factors
• dental factors
• pulp status

Question 12

5 behavioural/ social factors on decision to restore or extract

Answer 12

• dental awareness
• motivation and compliance
• pattern of attendance (if poor attender, cannot monitor pulp therapy –> extract)
• co-operation and compliance
• age of the child (how long does tooth need to last?)

Question 13

8 dental factors on decision to restore or extract

Answer 13

• gross dental neglect
• restorability
• acute infection/ pathology
• number of teeth affected (don’t do pulp therapy on more than 3 teeth)
• time to exfoliation (if 1yr, minimal root resorption, retain with definitive restoration)
• strategic value of tooth
• hypodontia
• effect on developing dentition eg future crowding

Question 14

3 pulp status factors on decision to restore or extract

Answer 14

vital/ reversibly inflamed
irreversibly inflamed
non-vital

Question 15

pulp therapy for vital primary molars 2

Answer 15

indirect pulp capping

pulpotomy

Question 16

pulp therapy for non-vital primary molars 2

Answer 16

pulpectomy (RCT- rare for kids due to low compliance)

extraction

Question 17

3 aims of indirect pulp capping

Answer 17

-arrest caries
-allows formation of reactionary dentine and remineralisation of dentine
-promote pulp healing and preserve vitality
+maintain functional tooth

Question 18

what is indirect pulp cap

Answer 18

place protective covering over pulp leaving a layer of caries over pulp (normally stainless steel crown in primary molars)

Question 19

2 indications of indirect pulp cap

Answer 19

• deep carious lesion (large occlusal, moderate inter-proximal)
• no signs/symptoms of pulpal pathology (no exposure of pulp)

Question 20

3 provisions of indirect pulp cap

Answer 20

• good history and examination
• absence of radiographic pathology
• sound coronal seal is essential

Question 21

what is a pulpotomy

Answer 21

removal of coronal part of pulp tissue only to maintain vitality of radicular pulp

Question 22

what teeth are suitable for pulpotomy

Answer 22

vital, asymptomatic or transient pain

no radiographic pathology

Question 23

8 steps of pulpotomy

Answer 23

• LA and rubber dam isolation
• caries removal
• endodontic access cavity
• removal of coronal pulp tissue
• control of bleeding
• application of medicament
• sub base
• definitive restoration

Question 24

what is used as pulpotomy

a. medicament
b. sub base

Answer 24

a. medicament: ferric sulphate

b. sub base: zinc oxide eugenol

Question 25

how does ferric sulphate work

Answer 25

agglutination of blood proteins

reaction of blood and ferric sulphate ions to form a barrier (clot)

Question 26

3 alternative pulpotomy medicaments, why they are not widely used

Answer 26

• formocresol: formaldehyde associated with cancer
• calcium hydroxide: internal resorption–> high failure rate (primary pulp only)
• MTA: expensive and currently not readily available

Question 27

*label pulpotomy diagram *

when is desensitising pulpotomy used?

Answer 27

temporary measure in dying tooth to buy time before RCT/ extraction

Question 28

indications for desensitising pulpotomy 2

Answer 28

• hyperalgesic pulp (anaesthesia not achieved)

- poor compliance

Question 29

stages of desensitising pulpotomy

Answer 29

LA (maybe)
-odontopaste (ledermix)
-GIC temp 1-2/52
(followed by definitive tx/ extraction)

Question 30

2 ingredients of odontopaste (ledermix)

Answer 30

triamcinolone (anti-inflammatory) TRY I AM SITTING ALONE

demeclocycline (antibiotic)

Question 31

describe what an RCT involves

Answer 31

removal of soft tissue content from the coronal pulp chamber and root canals

Question 32

indications for RCT 3

Answer 32

• evidence of irreversible pulpitis
• evidence of pulpal necrosis
• hyperaemic pulp

Question 33

success % of

a. indirect pulp cap
b. ferric sulphate pulpotomy
c. pulpectomy (RCT)

Answer 33

a. indirect pulp cap: GIC & Calc hyd= 94%, formecrosol= 74%
b. ferric sulphate pulpotomy: 70-95%
c. pulpectomy (RCT): 86%

Question 34

6 ways to tell if pulp therapy has failed

Answer 34

• pain
• swelling
• sinus
• mobility
• TTP
• radiolucency in bone (pathologic resorption)

Question 35

most important factors in successful pulp therapy

Answer 35

case selection

coronal seal

Question 36

3 requirements for vital pulp therapy

Answer 36

restorable crown
vital pulp
no radiographic pathology