Pulpotomy Flashcards
What should be used to remove deeper coronal pulp tissue?
-STERILE burs and spoon excavator
What are the medicaments for treating pulp stumps after coronal pulp has been removed? How long should they be applied?
- Ferric sulphate: 20 seconds then fill with IRM
- Formocresol: dilution 1:5 apply with minimally dampened cotton pellet for 5 mins then fill with IRM
- MTA
What are the steps for a pulpotomy?
- Reduce entire occlusal by 1-1.5mm (as in stainless steel crown prep)
- Round edge between occlusal and lingual/buccal
- Remove remaining caries
- Assess the tooth for pulp treatment options
- Remove roof of pulp chamber (using fissure bur) in rectangular outline
- Remove coronal tissue (round 4-6), flush copiously with water, remove undercuts and any pulpal tissue they may be barring access to under cuts (round 2-4 or sharp spoon excavator)
- Control the bleeding by packing chamber with cotton pellets and applying pressure, if bleeding continues after 5 minutes pulpectomy or extraction may be indicated
- Apply medicament then rinse with copious amounts of water and air dry (ensure haemostatic, medicament free pulp)
- Fill coronal pulp chamber with IRM by packing down with amalgam plugger
- Complete stainless steel crown prep and cement crown with GIC
What is the difference in reaction between primary and permanent teeth re. pulpal reaction to insult?
-A lot less tertiary dentine in primary as caries progresses too fast for it to form
What questions should you ask for pain diagnosis? What are the clinical/radiographic signs of reversible pulpitis?
Pain diagnosis: C: don't ask O: Do ask L: Do ask D: Ask whether spontaneous S: Kept awake at night? Getting better/worse? P: Ask hot? cold? biting? A: Don't ask
Reversible pulpitis: -Sensitive pulp C: ?? (children) O: L: D: only to stimuli, stops straight away S: ? P: stimulus (hot/cold); beware of pain on biting A: ?
What are the clinical signs of irreversible pulpitis and necrotic pulp?
- Unable to achieve haemostasis in pulpotomy after 5minutes (as inflamed tissue further down in pulp)
- If necrotic pulp chamber will be empty, with possible brown remnants
When should/shouldn’t pulp therapy be done?
Should be done in reversible case: rest of pulp tissue in radicular pulp is healthy, done as deciduous pulp less likely to spontaneously resolve, removinf affected coronal will allow remaining radicular to heal
Irreversible onwards extract, radicular pulp probably affected and not gonna heal
What are the indications/contraindications for pulpotomy?
Think MHx, signs of irreversible onwards, tooth factors
Indications
-Bleeding disorders
(Haemophilia, Von Willebrands, Platelet disorders)–>avoids extractions
-Inflammation limited to coronal pulp
Reversible pulpitis: No spontaneous pain, abscence of abscess/swelling, mechanical or carious exposure
Contraindications:
- Congenital heart disease (risk of infective endocarditis)
- Immunocompromised
- Poor healing
- Special needs
Irreversible pulpitis and beyond:
- Spontaneous pain
- Uncontrolled haemorrhage in pulp
- Radiolucency/caries in furcation
- Internal/external root resorption
- Furcation/periapical bone lesions
- Fistula or swelling
- Unrestorable tooth
- child unable to cope with long procedure: refer for GA instead
- Tooth will exfoliate soon: consider XO
Where do abscesses usually present in kids and why?
- Furcation region due to accessory canals
- If single root then more likely to see at root apex
What should you determine if you detect mobility and deciduous tooth?
- Whether due to being near exfoliation or due to disease process causing attachment loss
- Compare with expected exfoliation time (age + x-rays)
T/F pulp test is reliable in children
F
If pain is keeping child awake at night, what should your preliminary thoughts be?
-Extraction, it is uncommon that this much pain occurs in deciduous teeth
What are the histological and clinical signs of healthy pulp?
HIst:
- Normal blood vasculature
- No inflammatory cells or changes
- No reparative dentine
- Normal odontoblast layer/cell free zone
Clin:
- Asymptomatic
- Caries free or minimal cavitation
What are the histological/clincal signs of reversible pulpitis?
Hist:
- Inflammatory cells/infiltrates limited to odontoblastic layer subadjacent to lesion
- reparative dentine
- Absent or necrotic odontoblast layer
- Poorly defined cell free zone
Clinical features:
- Pain in response to trigger
- Disappears when trigger removed
What are the histological/clinical signs of irreversible pulpitis?
- Inflammatory chagnes and cell infiltrate extending from coronal to radicular pulp
- Loss of coronal pulp vasculature and nervous system architecture
- reparative dentine
- absent or necrotic odontoblast layer
- Spontaneous, unprovoked pain
- Persistant/constant pain
