Pulp therapy in primary teeth Flashcards
Management of the grossly
carious primary molar - options
Options
– Retain or
– Extract
If the grossly carious primary molars are left untreated or treated inadequately
– Pain
– Infection
– Damage to permanent successor
– Decreased masticatory function
Treatment planning for the management of the grossly carious primary molar- history/ symptoms…
– History of spontaneous severe pain
– Reported pain on biting
– Analgesics required
– History of swelling
Examination/clinical findings- management of the grossly carious primary molar
– Clinical extent and site of caries
* marginal ridge breakdown
– Intra-oral swelling or sinus
– Extra-oral or facial swelling
– Number of carious teeth
* previous caries experience
What special investigations do you carry out for grossly carious primary molar
– TTP
– Mobility
– Radiographs
NB Sensibility testing unreliable in primary teeth
What do you look for on the radiograph
- extent of caries
- proximity of large restorations to pulp horn
- Periradicular or intraradicular pathology
- degree of pathological or physiological root
resorption - presence of a successor
additional factors to consider - grossly carious primary molar
– Co-operation
– Past Medical History
– Parental wishes
What are the indications for tooth retention
Dental factors
– Minimal number of extensively carious
primary molars likely to require pulp therapy
(<3)
– No permanent successor
– Where prevention of mesial migration of 1st
permanent molars is desirable
– Early orthodontic intervention required e.g.
cleft lip and palate
Indications for tooth retention social factors
– Good patient compliance
– Regular attender and positive parental attitude
Indications for tooth retention medical factors
– Patients at risk from an extraction (e.g. bleeding disorders,
hereditary angio-oedema)
– Patients at risk if a general anaesthetic is required for tooth
removal (e.g. some cardiac conditions, cystic fibrosis, muscular
dystrophies)
Indications for extraction
Dental factors
– Tooth unrestorable after pulp therapy
– Extensive internal root resorption
– Large number of carious teeth with likely
pulpal involvement (>3)
– Tooth close to exfoliation (>2/3 root
resorption)
– Contralateral tooth already lost (in the case of
a 1st primary molar, and if indicated
orthodontically)
– Extensive pathology or acute facial swelling
necessitating emergency admission
Indications for extraction medical factors
Patients at risk from residual infection (e.g.
immunocompromised, susceptibility to infective
endocarditis)
Indications for extraction social factors
An irregular attender, with poor compliance and
unfavourable parental attitudes
Primary pulp therapy procedures for the vital pulp
– Hall crown
– Indirect pulp treatment
– Direct Pulp capping – poor success rate, high incidence of
internal resorption.
– Vital pulpotomy
– Desensitising pulpotomy
Primary pulp therapy procedures for the non vital pulp
– Pulpectomy
– Non-vital pulpotomy – NOT INDICATED
Hall crown (vital pulp)- hall technique
Cement PMC over carious primary molars
* No LA or tooth preparation
Requirements for hall technique
- Requires careful case selection
- Must be accompanied with an effective
preventive regime
Indications for the hall technique
- No clinical or radiographic signs of pulp
involvement - Sufficient remaining sound tooth tissue to
retain crown - Good coop (avoid airway risk)
- Cl 1/ Cl 2 cavities if unable to accept
restorations
What do you need before hall technique
- Full clinical exam, bitewings and parental
consent
contra indications of hall technique
- Not if IE risk
- Unusual morphology (e.g. accessory cusp)
- Poor cooperation
Aims of indirect pulp treatment
- To arrest the carious process and provide conditions
conducive to the formation of reactionary dentine - To promote pulpal healing and preserve/maintain
vitality of the pulp tissue
Indications for indirect pulp treatment
- Tooth with deep carious lesion
- No signs/symptoms indicative of pulpal pathosis
- <2/3 Marginal ridge breakdown
Indirect pulp treatment technique
- Local anaesthetic
- Rubber dam
- Removal of all caries at the EDJ
- Careful removal soft deep carious dentine using hand
excavators or slowly rotating large round bur (+/- caries
detector dye) - Take care to AVOID PULPAL EXPOSURE
- Reinforced GI cement or calcium hydroxide as lining
- Definitive restoration to achieve optimal coronal seal
(adhesive restoration or preformed crown)
Direct pulp cap why is it not routinely indicated?
- Poor success rate
- High incidence of internal resorption
Aims of direct pulp cap
To promote dentine bridge & maintain vitality
Indications of direct pulp cap
ONLY if asymtomatic tooth, small exposure & in older child
(tooth due to shed in 1-2 years maximum) or if an
iatrogenic exposure or trauma, <2/3 marginal ridge loss
Technique of direct pulp capping
- Local anaesthetic
- Rubber dam
- Apply cotton wool pledget soaked in saline to arrest
haemorrhage. - Apply hard setting Calcium hydroxide cement (mineral
trioxide aggregate an alternative) - Restore, optimal coronal seal
Remember what about direct pulp capping?
NOT ROUTINELY INDICATED
Indications of vital pulpotomy
- Transient pain or asymptomatic tooth
- Pulp minimally inflamed / reversible pulpitis
- 2/3 Marginal ridge destroyed
- Any doubt that pulp exposed
– caries
– iatrogenic
Aim of vital pulpotomy
To remove the coronal pulp, which has been
clinically diagnosed as inflamed, retain healthy or
reversibly inflammed radicular pulp
Technique vital pulpotomy
- Local anaesthetic
- Place rubber dam
(mandatory) - Gain access
- Remove caries
- Remove roof of pulp chamber (with a sterile round bur)
- Amputation
- Control haemorrhage
- Evaluate pulp stumps
- Medication
- Evaluate pulp stump after application of medicament
- Restore
- Review
Adequete access for direct pulp capping is achieved by?
Having no ledges or coronal pulp remnants
Radicular pulp intact
- Amputation? Vital pulpotomy
– remove coronal pulp (sterile
excavator or large round steel
bur)
– NB Risk of perforation of pulp
floor
- Control haemorrhage? Vital pulpotomy
– Cotton pledget soaked in saline
– Haemostatsis 4 minutes
- Evaluate pulp stumps in vital pulpotomy
– Normal bleeding
= non-inflamed pulp bright red colour good haemostasis
Proceed with pulpotomy
Abnormal bleeding-=
inflamed pulp deep crimson continued bleeding after pressure
- Medication for vital pulpotomy
– place 15.5% ferric sulphate (Astringedent)
solution with a cotton pledget/
microbrush over pulp stumps –15 secs
– rinse
– dry
– Ferric sulphate arrests haemorrhage, it is
not a fixative.
- Evaluate pulp stumps after application of medicament
dark brown/black with
minimal oozing
- Restore with… in vital pulpotomy
cover root stumps with reinforced ZOE paste
(Kalzinol)
GIC core
restore with stainless steel crown
- Review how- in vital pulpotomy
- Monitor
– Signs
– Symptoms
– Mobility/tenderness
– Exfoliation
– Radiographic followup(1yr)
Alternatives in vital pulpotomy- medicaments?
- Saline + MTA
– Mineral trioxide aggregate – similar success rate to ferric sulphate,
– Pure calcium hydroxide powder (limited data on success rates)
Vital pulpotomy - alternatives to Ferric sulphate
Electrocautery- similar success
NB
Formocresol is no longer used -TOXIC
Desensitising Pulp Therapy Aim
To reduce pulpal inflammation and/or symptoms in order to
facilitate subsequent pulpotomy or pulpectomy procedure
Indications of desensitising pulp therapy
- Failure of haemostasis of radicular pulp stump during
pulpotomy - Non-compliant child who may need inhalation sedation for
further treatment - Hyperalgesic pulp (adequate analgesia not achieved)
Desensitising pulp therapy
- technique
- LA
- Rubber dam
- Removal of caries
- Place small pledget of cotton wool loaded with Odontopaste over exposure site (may be too
sensitive to remove roof of pulp chamber)
Note: previously Ledermix used, now contraindicated in primary teeth - Place a well sealed temporary dressing over the
pledget - Recall after 7-14 days and proceed with a pulpotomy
/ pulpectomy technique depending on findings.
Since 2006 guidelines :
Ledermix paste
- Alternative to Caustinerf – avoided use of formaldehyde
- Contains triamcinalone acetonide (steroid) and
demeclocycline (antimicrobial) - Reduces pulpal inflammation and pain = Desensitising
- Was the medicament of choice. Now CONTRAINDICATED in primary teeth and in the under 12’s
- Odontopaste – limited evidence
Success rates –
Pulp therapy on vital tooth for direct pulp capping?
Poor
Success rates for indirect pulp capping (with no exposure)
(pulp therapy on vital tooth)
More than 90% -3 years
Success rates of pulp therapy on the vital tooth-
Vital pulpotomy
92 -96.4% at 4 years
Success rates- pulp therapy on the vital tooth
Devitalisation pulpotomy
77 % -3 years
(Ledermix success rarte for desensitising treatment not well documented)
Options for the non vital pulp
- Pulpectomy
- Extraction
Pulpectomy in the primary molar aims?
- To remove irreversibly inflammed or necrotic radicular pulp
and clean root canal system. - To obturate root canals with a material that resorbs at same
rate as tooth.
Aims for pulpectomy
- To remove irreversibly inflammed or necrotic radicular pulp
and clean root canal system. - To obturate root canals with a material that resorbs at same
rate as tooth.
Contra- indications for pulpectomy
- Tooth unrestorable
- Caries through bifurcation
- Extensive root resorption
- Extensive periapical pathology
Difficulties with carrying out pulpectomies on non vital teeth?
- Requires good patient co-operation
- Complex morphology of root canal
- Thin walls may make instrumentation without perforation difficult
Complex morphology of the root canal…
– Mandibular 1st molars 3 (79.2%) or 4 (20.8%) canals, 2nd molars 3-4 canals,
– Maxillary 1st molars 3 canals,
– 2nd molars 3 (70.9%) or 4 (29.1%) canals and may exhibit connections involving furcation and horizontal anastomoses (Naser et al. 2008)
– Difficult to achieve proper cleansing by mechanical instrumentation and irrigation(Carotte 2005)
Procedure of pulpectomy?
- Can be carried out in 1 or 2 stages
1. Pre-operative radiograph
2. Local anaesthetic (rubber dam clamp)
3. Rubber dam
4. Access cavity
5. Removal of:
– caries
– roof of pulp chamber (non-end cutting bur)
– remnants of coronal pulp tissue (sharp sterile
excavator or large bur in SHP)
- Note whether radicular pulp is bleeding (one-stage
procedure) or necrotic (usually requiring two-stage
procedure) - Identify root canals
- Irrigate
9.Estimate working lengths of root canals
10 .Insert small files - Dry canals with pre-measured paper points, keeping 2 mm from root apices
- If infection present (canal exudate and/or associated
sinus) dress root canals with non-setting calcium
hydroxide and temporise (two-stage procedure). - Consider prescribing a systemic antimicrobial
- If the canals can be dried with paper points…/ If the presence of an exudate prevents drying of the canal
Access cavity design for upper arch pulpectomy?
- Triangular access
- Apex towards pal
- Base towards buccal
Access cavity design for lower arch pulpectomy
Rectangular
- Irrigate… in pulpectomy
– Leur lock syringe
– Side venting needle
– normal saline (0.9%), Chlorhexidine solution
(0.4%) or sodium hypochlorite solution (0.1%)
- Estimate the working lengths of the root canals
keeping 2 mm short of the radiographic
apex
- Insert small files vital pulpotomy
(no greater than size 30)
into canals and file canal walls lightly and
gently (Note ribbon shaped canals)
- If canals can be dried with paper points: vital pulpotomy
– obturate root canals by injecting or packing a
resorbable paste
* slow-setting pure zinc oxide eugenol
* non-setting calcium hydroxide paste
* calcium hydroxide and iodoform paste (VitapexTM or
EndoflasTM)
If the presence of an exudate prevents drying of the canal…
consider a 2 stage technique, where the root canals are
dressed with an antimicrobial agent for 7-10 days
Ideal root canal filling material
– Resorb at same rate as primary tooth
– Be harmless to the periapical tissue and permanent successor
– Resorb easily if extruded beyond the apex
– Antibacterial
– Ease of insertion
– Ease of removal
– Radiopaque
Follow-up of pulpotomy and pulpectomy
Clinical R/V 6monthly
* Radiograph 12-18 m
- Clinical failure of treatment is indicated by
– pathological mobility
– fistula / chronic sinus
– pain
- Radiographic failure
– increased radiolucency
– external / internal resorption
– furcation bone loss
- Radiographic failure
– increased radiolucency
– external / internal resorption
– furcation bone loss
Potential complications of primary molar pulp therapy
- Periapical / interradicular pathology
- Enamel defects -permanent successor
- Internal resorption
- Over-preparation -furcation
Remember…pulp treatment of primary molars is
NOT THE SAME AS PERMENANT INCISORS!
