Pulp therapy in primary molars Flashcards
4 stages in diseases of pulp
normal –> inflamed –> necrosis –> infection
reversible pulpititis –> irreversible pulpitis –> pulp necrosis
what is the defence response to pulpal pathology
tertiary/ reactionary dentine
what differs in pulpal problems between primary and adult teeth
primary pulp horns are bigger–> sooner pulpal involvement, esp from interproximal caries
no difference in pulpal regeneration
why is diagnosis of primary pulp status difficult
- unreliable tests
- kids unable to accurately describe symptoms
- precise diagnosis only possible with histological examination
describe symptoms of reversible pulpitis
- provoked
- disappears on removal of stimulus
- shorter duration
- relieved with analgesia
- sharp pain
describe symptoms of irreversible pulpitis
- spontaneous
- constant
- long duration
- not always relieved with analgesics
- dull throbbing ache
- sleep disruption
- swelling
clinical findings of irreversible pulpitis 6
- sinus (discharge)
- swelling (intra oral and extra oral)
- clinical extent of caries
- discolouration
- TTT
- mobility
what to look for on radiographs of pulpal problems in PRIMARY teeth 3
- caries extent
- interradicular radiolucency (due to accessory interradicular foramini in primary molars)
- resorption (external/ internal, physiological/ pathoogical)
function of primary molar
a. mobility testing
b. TTP
c. vitality testing
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
what medical factors would lead you to
a. restore/ retain
b. extract
a. restore/ retain: bleeding disorders, patients at risk of GA if required for extraction
b. extract: immune disorders, cardiac disorders (endocarditis risk)
4 factor groups on decision to restore / extract
- medical factors
- social factors
- dental factors
- pulp status
5 behavioural/ social factors on decision to restore or extract
- 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?)
8 dental factors on decision to restore or extract
- 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
3 pulp status factors on decision to restore or extract
vital/ reversibly inflamed
irreversibly inflamed
non-vital
pulp therapy for vital primary molars 2
indirect pulp capping
pulpotomy
pulp therapy for non-vital primary molars 2
pulpectomy (RCT- rare for kids due to low compliance)
extraction
3 aims of indirect pulp capping
-arrest caries
-allows formation of reactionary dentine and remineralisation of dentine
-promote pulp healing and preserve vitality
+maintain functional tooth
what is indirect pulp cap
place protective covering over pulp leaving a layer of caries over pulp (normally stainless steel crown in primary molars)
2 indications of indirect pulp cap
- deep carious lesion (large occlusal, moderate inter-proximal)
- no signs/symptoms of pulpal pathology (no exposure of pulp)
3 provisions of indirect pulp cap
- good history and examination
- absence of radiographic pathology
- sound coronal seal is essential
what is a pulpotomy
removal of coronal part of pulp tissue only to maintain vitality of radicular pulp
what teeth are suitable for pulpotomy
vital, asymptomatic or transient pain
no radiographic pathology
8 steps of pulpotomy
- 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
what is used as pulpotomy
a. medicament
b. sub base
a. medicament: ferric sulphate
b. sub base: zinc oxide eugenol
how does ferric sulphate work
agglutination of blood proteins
reaction of blood and ferric sulphate ions to form a barrier (clot)
3 alternative pulpotomy medicaments, why they are not widely used
- formocresol: formaldehyde associated with cancer
- calcium hydroxide: internal resorption–> high failure rate (primary pulp only)
- MTA: expensive and currently not readily available
*label pulpotomy diagram *
when is desensitising pulpotomy used?
temporary measure in dying tooth to buy time before RCT/ extraction
indications for desensitising pulpotomy 2
- hyperalgesic pulp (anaesthesia not achieved)
- poor compliance
stages of desensitising pulpotomy
LA (maybe)
-odontopaste (ledermix)
-GIC temp 1-2/52
(followed by definitive tx/ extraction)
2 ingredients of odontopaste (ledermix)
triamcinolone (anti-inflammatory) TRY I AM SITTING ALONE
demeclocycline (antibiotic)
describe what an RCT involves
removal of soft tissue content from the coronal pulp chamber and root canals
indications for RCT 3
- evidence of irreversible pulpitis
- evidence of pulpal necrosis
- hyperaemic pulp
success % of
a. indirect pulp cap
b. ferric sulphate pulpotomy
c. pulpectomy (RCT)
a. indirect pulp cap: GIC & Calc hyd= 94%, formecrosol= 74%
b. ferric sulphate pulpotomy: 70-95%
c. pulpectomy (RCT): 86%
6 ways to tell if pulp therapy has failed
- pain
- swelling
- sinus
- mobility
- TTP
- radiolucency in bone (pathologic resorption)
most important factors in successful pulp therapy
case selection
coronal seal
3 requirements for vital pulp therapy
restorable crown
vital pulp
no radiographic pathology
