Deep Caries & Pulp Mx of Young Permanent Teeth

Question 1

What are some features of young permanent teeth, in relation to pulp therapy?

Answer 1

• Large pulp – more prone to pulp exposure
• Incomplete dentine deposition – thin canal wall => more likely to fracture

Question 2

What are the aims of vital pulp therapy in young permanent teeth?

Answer 2

Maintain vitality => allow continued physiologic development including:
- Laying down of dentine
- Formation of apex (apexogenesis)

Question 3

What are some types of pulp treatment for vital and non-vital young permanent teeth?

Answer 3

Vital
- Protective base
- Indirect pulp cap
- Direct pulp cap
- Partial pulpotomy
- Pulpotomy

Non-Vital
- Revascularisation
- Apical plug

Question 4

What is the difference in success rate of pulp capping and pulpotomy in young permanent teeth, as compared to mature permanent teeth?

Answer 4

Higher success rate – good blood supply via open apices

Question 5

What is the difference in indications for DPC for young permanent teeth as compared to other types of teeth?

Answer 5

DPC can be indicated in young permanent teeth with small carious exposure – if successful, teeth with immature roots should show continued root development

Question 6

Describe the procedure for partial pulpotomy

Answer 6

1. Superficial inflamed pulp tissue at exposure site is removed to a depth of 1-3mm to reach healthy pulp tissue
2. Control pulpal bleeding by irrigation with bactericidal solution eg NaOCl, CHX
3. Place Ca(OH)2/MTA over site (at least 1.5mm thick)
4. Place cement base + resto w good seal to prevent microleakage

Question 7

What are the indications for partial pulpotomy?

Answer 7

• Young vital permanent teeth
• Small carious exposure (<2mm) in which pulp hemorrhage is controlled after removal of superficial inflamed pulp tissue
• Traumatic exposure (≤4mm) in which pulp haemorrhage controlled (known as Cvek pulpotomy when done in young permanent teeth in relation to trauma)

Question 8

What is the determining factor between doing a partial pulpotomy and doing a complete pulpotomy?

Answer 8

After removing 1-3mm depth of pulp:
- Bleeding can be controlled => partial pulpotomy
- Remaining pulp hyperemic, cannot achieve hemostasis => complete pulpotomy

Question 9

What is the F/U Mx of (partial) pulpotomy of young permanent tooth?

Answer 9

• 1 week: ensure no discomfort
• 1 month: x-ray to check for apical pathology & perform EPT
• 3 months: x-ray to compare root development (may see hard tissue barrier, lack of barrier does NOT indicate RCT)
• Review 6 monthly for at least 3 years

Question 10

For a young permanent tooth that had previously undergone pulpotomy, what are the Mx options after apex formation is complete?

Answer 10

1. Routine elective RCT OR
2. Observe & do RCT only when:
   - Signs of pathosis, radicular calcification
   - Post-core crown needed

Question 11

What are the associated problems of non-vital immature teeth, in relation to pulp therapy?

Answer 11

• Lack of apical stop to condense GP
• “Blunderbuss” (wider) apex => difficult to obturate
• Thin walls of immature root may fracture if apicectomy (remove tip) attempted

Question 12

What are the aims of non-vital pulp therapy for young permanent teeth?

Answer 12

Promote formation of a hard tissue barrier at apex to allow placement of root filing

Question 13

Describe the procedure for apical plug

Answer 13

Visit 1
1. Clean tooth, LA, RDI
2. Gain access into pulp chamber w/o weakening crown
3. Remove necrotic pulp
4. Establish WL w radiograph (1-2mm short of radiographic apex)
5. Canal debridement & irrigation w NaOCl
6. Dry canals w paper points
7. Fill canals to apex w non-setting Ca(OH)2 paste – to disinfect canal space
8. Place CP & seal cavity w TD
Visit 2
9. After 2-4 weeks, remove TD and wash out Ca(OH)2
10. If no exudate, place MTA plug (3-5mm thick) to form apical barrier
- If complete closure cannot be achieved with MTA, collagen plug can be placed at root end before packing of MTA
11. Place wet sponge/paper point & seal w TD for 1 week => let MTA set (MTA requires moisture to set)
Visit 3
12. f no s/s, fill root w thermoplastic GP & restore tooth
- if canal walls are very thin, canal space can be filled with MTA or CR

Question 14

What is the aim for revascularisation and what are its indications?

Answer 14

Aim: induce continued root development or thickening of canal walls

For teeth w poor prognosis where MTA plug or apexification may not work
- e,g very short root, large open apex, very thin walls

Question 15

What is used in revascularisation and what does it contain?

Answer 15

Triple Antibiotic Paste
- Metronidazole
- Ciprofloxacin
- Minocycline (causes yellow discolouration – no longer included)