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paeds 4th year > pulp therapy for primary molars > Flashcards

pulp therapy for primary molars Flashcards

1
Q

what are the two options when a patient comes in with a grossly carious primary molar?

A

> retain (do nothing or restorative)

> or extract

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2
Q

if a grossly carious tooth is left untreated or treated inadequately what may result?

A

> pain

> infection

> damage to permanent successor

> decreased masticatory function

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3
Q

when treatment planning for a grossly carious tooth, what symptoms from the history are important to find out?

A

> History of spontaneous severe pain

> Reported pain on biting

> Analgesics required

> History of swelling

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4
Q

on examination of a grossly carious tooth during treatment planning what are you looking for?

A

> 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

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5
Q

what special investigations are important for a grossly carious tooth?

A

> TTP

> Mobility

> Radiographs

NB Sensibility testing unreliable in primary teeth

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6
Q

what does radiographs allow us to see in grossly carious teeth?

A

> 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

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7
Q

what additional factors must you consider when treatment planning for grossly carious tooth?

A

> Co-operation

> Past Medical History

> Parental wishes

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8
Q

what dental factors are indications for tooth retention?

A

> 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

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9
Q

what social factors are indications for tooth retention?

A

> Good patient compliance

> Regular attender and positive parental attitude

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10
Q

what medical factors are indications for tooth retention?

A

> 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

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11
Q

what dental factors are indication for extraction?

A

> 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

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12
Q

what medical factors are indicators for extraction?

A

> Patients at risk from residual infection (e.g. immunocompromised, susceptibility to infective endocarditis

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13
Q

what social factors are indicators for extraction?

A

> An irregular attender, with poor compliance and unfavourable parental attitudes

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14
Q

what primary pulp therapy procedures do we do for a vital pulp?

A

> Hall crown

> Indirect pulp treatment

> Direct Pulp capping – poor success rate, high incidence of internal resorption.

> Vital pulpotomy

> Desensitising pulpotomy

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15
Q

what primary pulp therapy procedures do we do for a non vital pulp?

A

> Pulpectomy

> Non-vital pulpotomy – NOT INDICATED

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16
Q

what is the hall technique and what must it be accompanied by?

A

> Cement PMC over carious primary molars

> No LA or tooth preparation BUT

> Requires careful case selection

> Must be accompanied with an effective preventive regime

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17
Q

what are the indications for the hall technique?

A

> Full clinical exam, bitewings and parental consent

> 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

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18
Q

what are the contraindications for the hall technique?

A

> Not if IE risk

> Unusual morphology (e.g. accessory cusp)

> Poor cooperation

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19
Q

what are the aims of an indirect pulp treatment?

A

> 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

20
Q

what are the indications of an indirect pulp treatment?

A

> Tooth with deep carious lesion

> No signs/symptoms indicative of pulpal pathosis

> <2/3 Marginal ridge breakdown

21
Q

what is the technique of an indirect pulp treatment?

A
  1. Local anaesthetic
  2. Rubber dam
  3. Removal of all caries at the EDJ
  4. Careful removal soft deep carious dentine using hand excavators or slowly rotating large round bur (+/- caries detector dye)
  5. Take care to AVOID PULPAL EXPOSURE
  6. Reinforced GI cement or calcium hydroxide as lining
  7. Definitive restoration to achieve optimal coronal seal (adhesive restoration or preformed crown)
22
Q

what is the aim of direct pulp capping?

A

> aim is to promote dentine bridge and maintain vitality

23
Q

what is the success rate of direct pulp capping?

A

> poor success rate

> high incidence of internal resorption

24
Q

what are the indications for direct pulp capping ?

A

> 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

25
Q

what is the technique for direct pulp capping?

A
  1. Local anaesthetic
  2. Rubber dam
  3. Apply cotton wool pledget soaked in saline to arrest haemorrhage.
  4. Apply hard setting Calcium hydroxide cement (mineral trioxide aggregate an alternative)
  5. Restore, optimal coronal seal
26
Q

what is the aim of a vital pulpotomy?

A

> To remove the coronal pulp, which has been clinically diagnosed as inflamed, retain healthy or reversibly inflammed radicular pulp.

27
Q

what are the indications for a vital pulpotomy?

A

> Transient pain or asymptomatic tooth

> Pulp minimally inflamed / reversible pulpitis

> 2/3 Marginal ridge destroyed

> Any doubt that pulp exposed
- caries
- iatrogenic

28
Q

what is the technique for a vital pulpotomy?

A
  1. Local anaesthetic
  2. Place rubber dam (mandatory)
  3. Gain access (no ledges or remnants, plus radicular pulp intact)
  4. Remove caries
  5. Remove roof of pulp chamber - sterile round bur
  6. Amputation
    - remove coronal pulp (sterile excavator or large round steel bur)
    - NB Risk of perforation of pulp floor
  7. Control haemorrhage
    • Cotton pledget soaked in saline
      - Haemostatsis 4 minutes
  8. Evaluate Pulp Stumps
    - Normal bleeding
    = non-inflamed pulp bright red colour good haemostasis
    Proceed with pulpotomy
    - Abnormal bleeding
    = inflamed pulp deep crimson continued bleeding after pressure
  9. Medication
    - 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.
  10. Evaluate pulp stump after application of medicament
    - dark brown/black with minimal oozing
  11. Restore
    - cover root stumps with reinforced ZOE paste (Kalzinol)
    - GIC core
    - restore with stainless steel crown
  12. Review/ Monitor
    - Signs
    - Symptoms
    - Mobility/tenderness
    - Exfoliation
    - Radiographic followup(1yr)
29
Q

what are vital pulpotomys alternatives?

A

> Alternative medicaments include
- Saline + MTA
- Mineral trioxide aggregate – similar success rate to ferric sulphate,
- Pure calcium hydroxide powder, limited data on success rates.

> Electrocautery, similar success to Ferric sulphate

> NB Formocresol no longer used - TOXIC

30
Q

what is the aim of desensitising pulp therapy?

A

> To reduce pulpal inflammation and/or symptoms in order to facilitate subsequent pulpotomy or pulpectomy procedure

31
Q

what are the indications for a desensitising pulp therapy?

A

> 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)

32
Q

what is the technique for a desensitising pulp therapy?

A
  1. LA
  2. Rubber dam
  3. Removal of caries
  4. 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
  5. Place a well sealed temporary dressing over the pledget
  6. Recall after 7-14 days and proceed with a pulpotomy / pulpectomy technique depending on findings.
33
Q

since 2006 the guidelines for using ledermix paste has been contraindicated in primary teeth, what did it do, what did it contain and what was it used an alternative to?

A

> Alternative to Caustinerf – avoided use of formaldehyde

> Contains triamcinalone acetonide (steroid) and demeclocycline (antimicrobial)

> Reduces pulpal inflammation and pain = Desensitising

34
Q

what is the success rates for pulp therapy on a vital tooth?

A

> Direct pulp capping = poor

> Indirect pulp capping (no exposure) = >90% -3 years

> Vital pulpotomy = 92 -96.4% at 4 years

> Devitalisation pulpotomy = 77 % -3 years

35
Q

what are the aims of a pulpectomy in a non vital primary molar?

A

> 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

36
Q

what are the indications of a pulpectomy?

A

> Irreversible pulpitis involving both the coronal and radicular pulp

> Non vital radicular pulp with/without infection

> Primary molars with radiographic evidence of furcation pathology

> Non vital primary molars or incisors that need to be maintained in the arch

> 2/3 root

> Good patient compliance

> Ortho retention indicated

> PMH extn C/I

> Parent refusal to accept extn

37
Q

what are the contra indications for a pulpectomy?

A

> Tooth unrestorable

> Caries through bifurcation

> Extensive root resorption

> Extensive periapical pathology

38
Q

what are the difficulties revolving a pulpectomy?

A

> Requires good patient co-operation

> Complex morphology of 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)

> Thin walls may make instrumentation without perforation difficult

39
Q

what is the procedure for a pulpectomy?

A
  1. Pre-operative radiograph
  2. Local anaesthetic (rubber dam clamp)
  3. Rubber dam
  4. access cavity design
    - upper arch = triangular access, apex towards the pal
    - lower arch rectangular design
  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)
  6. Note whether radicular pulp is bleeding (one-stage procedure) or necrotic (usually requiring two-stage procedure)
  7. Identify root canals
  8. Irrigate
    - Leur lock syringe
    - Side venting needle
    - normal saline (0.9%), Chlorhexidine solution (0.4%) or sodium hypochlorite solution (0.1%)
  9. Estimate working lengths of root canals keeping 2 mm short of the radiographic apex
  10. Insert small files (no greater than size 30) into canals and file canal walls lightly and gently (Note ribbon shaped canals)
  11. Irrigate the root canals
  12. Dry canals with pre-measured paper points, keeping 2 mm from root apices
  13. If infection present (canal exudate and/or associated sinus) dress root canals with non-setting calcium hydroxide and temporise (two-stage procedure).
  14. Consider prescribing a systemic antimicrobial
  15. If canals can be dried with paper points:
    - 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)
40
Q

what If there is presence of an exudate and it prevents drying of the canal during a pulpectomy?

A

> consider a 2 stage technique

> where the root canals are dressed with an antimicrobial agent for 7-10 days

41
Q

what is an ideal root canal filling material to use in a pulpectomy?

A

> 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

42
Q

what is the follow up for a pulpotomy and a pulpectomy?

A

> clinical review 6 monthly

> radiograph in 12-18 months post op

43
Q

what are clinical signs of failure of a pulpectomy and pulpotomy?

A

> pathological mobility

> fistula / chronic sinus

> pain

44
Q

what are radiographic signs of failure of a pulpectomy and pulpotomy?

A

> increased radiolucency

> external / internal resorption

> furcation bone loss

45
Q

what are the potential complications of primary molar pulp therapy?

A

> Periapical / interradicular pathology

> Enamel defects -permanent successor

> Internal resorption

> Over-preparation -furcation

paeds 4th year (12 decks)

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