Pulp Therapy in the Primary Dentition

Question 1

Why do you want to avoid extraction of primary teeth?

Answer 1

malocclusion
mastication
speech
aesthetics
avoidance of GA

Question 2

when a child presents with irreversible pulpitis there are 2 options, what are they?

Answer 2

extract
pulp therapy

Question 3

how is malocclusion caused if a tooth too is extracted too early?

Answer 3

for example:
extracting the E too early will cause the 6 to erupt into that space and preventing the underlying 5 going into that space - creating malocclusion

Question 4

what are the differences in pulp morphology of primary teeth compared to permanent?

Answer 4

-an increased number of accessory canals, especially in furcation area
- primary root canals are flat and ribbon like, unlike the conical or cylindrical shape of permanent root canals
- much more fine and filamentous - harder to navigate, harder to get debridement down the root canals
-primary root canals are more ribbon like- more difficult to access root canals as they arent as straight
- much more likely to perferate lateral sides of the root as dentine is much softer
-complete extirpation of pulp remnants almost impossible.
- the root canal opening is several mm coronal to the radiographic apex
- primary roots exfoliate/resorb

Question 5

what are the causes of irreversible pulpitis?

Answer 5

caries (most common)
trauma
wear

Question 6

what can be seen clinically or on a radiograph that indicates irreversible pulpitis?

Answer 6

where a third of the marginal ridge has broken down, even if pulp looks relatively unaffected on radiograph

Question 7

what procedure can be carried out if irreversible pulpitis is determined?

Answer 7

pulpotomy

Question 8

what is the definition of a carious exposure

Answer 8

when there is communication between the pulp chamber and oral cavity

Question 9

what is more commonly used now a days over a pulpotomy?

Answer 9

hall crown technique

Question 10

what is a pulp polyp?

Answer 10

a type of inflammatory hyperplasia. it occurs when the pulp has been exposed to caries or trauma.
pulp tissue reacts violently to contamination of pulp and overextends - necrotic pulp tissue

Question 11

what are the contraindications of pulp therapy in primary teeth?

Answer 11

if not enough tooth tissue, you should extract
pt is uncooperative
medically compromised - pulp therapy is invasive, may need antibiotics
orthodontist may have the decision to extract rather than carrying out pulp therapy - contributing to tx later on

Question 12

what are the 3 methods used to treat a vital primary tooth?

Answer 12

pulp capping
pulpotomy (pulp amputation)
densensitising pulp therapy

Question 13

when would a pulpotomy be carried out?

Answer 13

if there is irreversible pulpitis

Question 14

how would you know the difference between a vital and non vital tooth pulp when it is exposed?

Answer 14

vital - pulp will bleed
non vital - pulp will not bleed

Question 15

what are the 2 types of pulp capping and why use it?

Answer 15

way of protecting the pulp if you come close or expose the pulp
direct
indirect

Question 16

what is indirect pulp capping?

Answer 16

0.5mm from the pulp
no exposure
suitable for primary and permanent teeth
place a layer of hard setting calcium hydroxide to encourage new dentine growth

Question 17

what is direct pulp capping?

Answer 17

exposure of pulp
tooth is caries free
layer of hard setting calcium hydroxide
unsuitable for primary teeth with very rare exceptions

Question 18

what is a pulpotomy?

Answer 18

(pulp amputation)
involves removing the diseased portion of the coronal pulp only, or as much as we can, never go into radicular pulp
applying medicament to stop bleeding and sooth tooth, allowing tooth to continue functioning (keep it vital)

Question 19

what has a greater success in primary molars, pulp capping or pulpotomy?

Answer 19

pulpotomy

Question 20

what is the coronal pulp?

Answer 20

portion of pulp that is in the crown of tooth (pulp chamber) - large part of pulp that we access from the occlusal surface

Question 21

what is the radicular pulp?

Answer 21

pulp that is present in root canals

Question 22

when would you not carry out a pulpotomy?

Answer 22

abscess (infected or inflamed radicular pulp)
excessive bleeding upon access to pulp chamber (indicates inflamed radicular pulp)
no bleeding upon access to pulp chamber

Question 23

why dont you want to access the radicular pulp in a pulpotomy?

Answer 23

as we carry out a pulpotomy under the assumption that the radicular pulp is healthy

Question 24

what medicaments are used in pulp therapy in primary teeth and why are they placed?

Answer 24

formocresol
ferric sulphate
gluteraldehyde
calcium hydroxide
to try and keep the radicular pulp as healthy as we can

Question 25

which medicament do we use in DDH?

Answer 25

ferric sulphate

Question 26

what are the properties of formocresol?

Answer 26

powerful tissue fixative - material that renders the body cells in ert, keep them in the state they are and resistant to break down
tissue preservative
active ingredients include formalin which preserves human tissue and a powerful antiseptic called trisecol

Question 27

what are the side effects of formocresol?

Answer 27

-material is believed to be hazardous due to mutagenic and carcinogenic properties
-IARC in 2004 stated formocresol may play a role in cancer development - research done in animals
-local tissue damage as if leaks through apex of tooth - resulting in damage to tooth germ
-due to its quick absorption animal studies also showed a wide distribution of the material in organs such as the liver, kidneys etc
-many believe formocresol not only initiates superficial tissue damage but that about 80-90% of healthy pulp tissue becomes non-vital (devitalises radicular pulp)
- if too much placed can damage permanent tooth germ

Question 28

when using formocresol what are the most important things to ensure?

Answer 28

-always use as small an amount as possible - make sure cotton pledget or paper point has been well blotted
-isolation of the tooth involved is important (rubber dam?)
-well sealed restoration margins to prevent leakage of material into the mouth

Question 29

Who determined the guidenlines to advise that formocresol is no longer used in conjunction with pulp therapy?

Answer 29

IARC (international agency for research on cancer 2004)

Question 30

what are the properties of ferric sulphate?

Answer 30

haemostatic agent only
can be used to stop bleeding when doing a composite
not a fixative agent
may have antimicrobial qualities but not evidence to support
applied to the pulp stumps to stop bleeding,15% for 15 seconds

Question 31

what are the properties of gluteraldehyde?

Answer 31

aqueous solution (2-4%)
like formocresol, powerful fixative agent - but unlikely to replace it as not as effective
recently some toxic effects discovered
lack of research on material, what concentrations to use etc

Question 32

what are the properties of calcium hydroxide?

Answer 32

previously ruled out as a medicament for pulp therapy of primary teeth due to effect of internal resorption
encourages new dentine formation from pulp
often “dentine bridge” is formed
creates more dentine between the pul and oral environment - barrier
remaining pulp tissue now has an effective barrier against bacterial invasion
calcium hydroxide works by allowing healing within the pulp, rather than ‘fixing’ the tissue

Question 33

what is the stages of carrying out a pulpotomy?

Answer 33

1. LA (always necessary), isolate (ideally with dam)
2. Outline form to access caries - remove all caries to accessing the pulp chamber
3. large access cavity - need to be able to access all pulp horns. remove entire roof of pulp chamber, with a round stainless steel bur, taking care not to damage the floor of the pulp chamber - move slow speed laterally
4. remove contents with an excavator (only 4-5mm between roof and floor of pulp chamber), or a large round stainless steel bur. Once pulpal tissue is exposed - do not air dry with 3 in 1 syringe - risk of emphysema
5. irrigation with saline then light pressure from cotton wool pledget - aim to try to control bleeding
6. apply medicament of choice to pulp stumps, using cotton pledgets or applicators, for the correct time, e.g foromocresol 4-5 mins, ferric sulphate 15 seconds etc, repeat this step as necessary
7. assess amount of bleeding at this stage, if well controlled carry on, if uncontrolled may need to proceed with desensitising pulpotomy, pulpectomy or extraction
8. restore tooth, usually with layer of hard setting calcium hyroxide on base, then backfill with zinc oxide and eugenol. Then place permanent restoration (stainless steel crown in a posterior tooth ) (composite in anterior)

Question 34

what is densentising pulp therapy?

Answer 34

kills of the pulp
used in order to reduce pulpal inflammation and/or symptoms in order to facilitate subsequent extraction or pulpectomy

Question 35

what are the indications to follow through with desensitising pulp therapy?

Answer 35

carious pulp exposure but no signs or symptoms or loss of vitality
hyperaemic pulp during attempted pulpotomy
hyperalgesic pulp (adequate analgesia not obtained)

Question 36

what is the technique of desensitising pulp therapy?

Answer 36

1. open and gain access to pulp chamber (same as for pulpotomy)
2. place a cotton pledget with ledermix (steroidal antibiotic paste) directly over the exposure site
3. place a well sealed temp dressing
4. review 2 wks, proceed with extraction or pulpectomy

Question 37

what is the pulp therapy for non vital primary teeth?

Answer 37

pulpectomy
differs to pulp amputation because the aim is not to preserve the viable tissue, but to remove necrotic tissue and obturate canals
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