Pulp Therapy - OPTECH Flashcards
Disadvantages of early primary tooth loss
- loss of space - increased malocclusion risk
- Decreased masticatory function
- Impeded speech development
- Psychological disturbance
- Trauma for anaesthesia/surgery
Indications for pulp treatment
- Good cooperation
- Promote positive attitude to oral health care
- MH precludes XLA
- Missing permanent successor
- Maintain strategically important teeth eg second primary molars
- Developmental state of tooth eg usually <9 yrs
Contraindications for pulp treatment
- Poor cooperation
- Poor dental attendance
- Medical history eg cardiac defect
- Multiple grossly carious teeth
- Advanced root resorption
- Close to exfoliation (2/3 root resorption)
- Gross bone loss
Primary tooth endo - considerations
- Compliance
- Root number and morphology
- Root canal pattern
- Layer of secondary dentine
- Porous pulpal floor with accessory canals
- Physiological resorption
- Risk of damage to permanent successor
- Small mouths - restricted access
Pulp status - capable of healing signs
- asymptomatic
- reversible pulpitis (provoked pain of short duration removed on withdrawal of the stimulus)
Pulp status - inflamed or incapable of healing signs
- Irreversible pulpitis:
- provoked pain that persists on stimulus removal
- spontaneous unprovoked pain
(And also keeping pt up at night?) - Sinus tract
- Soft tissue inflammation not from perio
- Excessive mobility not associated with trauma or exfoliation
- Furcation or apical radiolucency
- Radiographic evidence of internal or external resorption
Why do pulpotomy (primary teeth)?
- Carious or traumatic exposure of bleeding vital pulp
- radicular pulp is preserved, bleeding controlled, maintain tooth until normal exfoliation
Technique for pulpotomy
- Consent
- LA
- Rubber dam
- Remove caries
- Remove pulp chamber roof
- Remove coronal pulp with sterile excavator/round steel bur
- Assess pulp status
Saline soaked cotton pellet to stop bleeding ng - Place ferric sulphate (haemostatic) for 15-30 seconds and check bleeding, can reapply 4x max, assess pulp stumps
- Place ZnOE base (IRM) in pulp chamber
- Place GIC core
- Restore with PMC (for coronal seal)
Medicaments for pulpotomy in primary teeth
- ferric sulphate = best, haemostatic
- calcium hydroxide - associated with internal resorption
- MTA = discolouration, expensive
- LEDERMIX or odontopaste = SOS only (contains clindamycin, calcium hydroxide)
PULPECTOMY: Non vital primary molar signs
SYMPTOMS:
- spontaneous pain
- pain on biting
- “gum boil”
- “bad taste”
- facial swelling
SIGNS:
- sinus
- discolouration
SPECIAL INVESTIGATIONS:
- mobility
- TTP
- furcation or apical radiolucency
- pathological root resorption
CLINICAL FINDINGS:
- hyperaemic pulp
- necrotic pulp
CONSIDER XLA WITH FACIAL SWELLING
PULPECTOMY STEPS for primary tooth
- Consent
- LA
- Rubber dam
- Access
- Coronal pulp extirpation
- Use files to remove pulpal tissue from canals (2mm short of apex)
- Canal irrigation: sterile saline, LA; CHX
- Obturation (vitapex slurry) = calcium hydroxide + iodoform
- IRM seal - thick mix
- GIC core
- Restore with PMC
FOLLOW UP OF PULP TREATMENT:
CLINICAL:
- 6 monthly
RADIOGRAPHS:
- 12-18 monthly
What counts as clinical failure of pulp tx
- Pathological mobility
- Fistula/chronic sinus
- Pain
Radiographic failure of pulp treatment
- Increased radiolucency
- External/internal resorption
- Furcation bone loss
Indications for conventional crown
- extensive caries
- developmental defects like AI DI
- after pulpotomy or Pulpectomy (within same appt, already numbed up)
- definitive restorative tx in high caries risk kids
- if you have contact closed area and you can’t put crown on, need to make space
- if doing multiple teeth and need space
DEPENDS ON COMPLIANCE AND TIME IN APPT!!
Conventional crown - measurements
- 1 mm interproximal slices
- 2-3mm occlusal reduction while keeping shape of tooth
How to select crown for preformed metal crown for conventional
- measure mesio distal width of crown or space with divider and select crown
- trial and error after crown prep
- impression and crown prep on model
CAN ADJUST CROWN TO FIT BETTER with crown crimping pliers and curved crown scissors
Conventional crown technique
- Occlusal reductions (2-3mm), keeping the occlusal shape
- Interproximal reductions (1mm)
- Axial reduction (smoothing off)
- all using short tapered diamond bur
- for multiple crowns may need to prep slightly more interproximally
- GIC luting cement used ?
PMC HALL CROWN TECHNIQUE (6)
- No LA, caries or tooth prep
MUST PROTECT AIRWAYS WITH GAUZE - Appropriately sized PMC selected (don’t seat through contacts before cementing) and filled with GI cement
- Seated over carious primary molar using either finger pressure, or child’s own occlusal force
- Excess cement is flossed away
- Occlusion will be high, advise parents this will settle within a week
- note:
Space formation: - ortho separators
- need two visits
- place for 3-5 days
- flossed between E and D (for eg) to create space for PMC
- top half of separator remains above marginal ridge
How does hall technique work? (3)
- biological approach
- manipulates plaque environment by sealing it, separating it from SUBSTRATES
- good evidence that if caries sealed off well, lesion doesn’t progress
ASSESSMENT BEFORE HALL CROWN
CLINICAL
extent of caries: any pulpal involvement
- signs of irreversible pulpitis or dental abscess
- non physiological mobility
RADIOGRAPHY
- band of sound dentine between lesion and pulp
- signs of intra radicular pathology
- signs of dental abscess
Indications for Hall technique (3)
- Proximal lesions (class 2), cavitated or non cavitated
- Occlusal, non cavitated if patient cannot accept fissure sealant or conventional restoration
- Occlusal, cavitated lesion if patient cannot accept partial caries removal or conventional restoration
Contraindications hall crown (5)
- Irreversible pulpal involvement
- Insufficient sound tissue left to retain crown
- Patient co operation (endangering patients airway)
- Patient at risk from bacterial endocarditis
- Parent or child unhappy with aesthetics
- also no sound band of dentine between pulp and caries
Issues with hall crowns
- may prevent adjacent tooth from erupting/impact against it
- fracturing off
When is direct pulp capping generally not recommended?
For primary molars
What materials can be used in indirect pulp therapy
RMGIC or calcium hydroxide
Indirect pulp therapy technique
LA, rubber dam
- remove all caries at EDJ
- removal of soft deep carious dentine lying directly over pulp region with care to avoid a pulpal exposure
- placement of appropriate lining material such as RMGIC or calcium hydroxide
- definitive restoration to achieve optimum coronal seal, ideally PMC
Clinical indicator for pulpotomy
- Reversible pulpitis
- Caries extending more than 2/3 into dentine on X ray
- Any doubt that pulp is exposed (caries/iatrogenic)
Acute management for symptomatic apical periodontitis in a primary tooth
if a tooth is abscessed, there is often significant coronal destruction. The pulp chamber of such teeth can often be accessed, and a dressing of Ledermix or Odontopaste on some cotton wool placed within the chamber and sealed with a GIC will often lead to temporary resolution of symptoms and swelling. Again, more definitive treatment (extraction or pulpectomy) will be required for this tooth when time permits and as part of a comprehensive treatment plan.
FROM THE BOOK: what are the advantages of dressing/stabilising open cavities
- Introduction to dental procedures and usually does not involve local analgesia or complete caries removal.
• Reduction of Streptococcus mutans count. The temporary restoration deprives the bacteria in the active lesion of sugar and oxygen.
• GIC acts as a fluoride reservoir.
• Eating and toothbrushing are more comfortable.
