6. Pulp treatment lecture

Question 1

What are the 3 types of pulp treatment we can do?

Answer 1

1. Indirect pulp treatment
2. Vital pulpotomy
3. Desensitising procedure

Question 2

What are reasons for pulpal involvement in children?

Answer 2

• small size of teeth
• large pulp chambers
• failure to diagnose
• failure to treat caries early due to broad flat contacts between teeth
• rapid caries progression due to thinner enamel and dentine

Question 3

What was the initial treatment for when a marginal ridge breach occurs?

Answer 3

• when a marginal ridge breach greater than 3mm was observed over 90% of pulps were histologically inflamed
• complete caries removal would result to a pulp exposure
• therefore an elective vital pulpotomy was recommended followed by a crown

Question 4

What is the new treatment for when marginal ridge breach greater than 3mm is observed?

Answer 4

• in MRB, more than 50% of the inflammation seems to be restricted to the pulp horn
• Sealing infected carious dentine under a restoration decreases the numbers of viable organisms and shifts away from cariogenic species
• In permanent teeth the pulp has excellent repair capacity when there is no pulp exposure, the predictability decreases after a carious exposure
• Carious primary & permanent teeth show similar neural changes when pulp responds to deep caries, suggesting potential for repair in primary teeth
• indirect pulp cap is therefore an option

Question 5

What indications are there for pulp treatment?

Answer 5

• relieve symptoms
• remove infection
• avoid GA
• medical reasons if you need to avoid XLA
• space maintenance
• missing permanent successor
• compliant patient

Question 6

What are contraindications of doing pulp treatment?

Answer 6

• unrestorable tooth
• if there is severe pain or infection
• if there is advanced root resorption- primary roots are thin so RCT is not feasable and if you go through the apex you may damage the permanent successor
• medical reasons- if the pt is susceptible to infections, eg at risk of bacterial endocarditis
• poor pt compliance

Question 7

What are techniques for when you have a vital pulp?

Answer 7

• pulp capping- direct/indirect
• desensitisation
• vital pulpotomy- if the pulp is exposed

Question 8

What are the techniques for when you have a non-vital pulp?

Answer 8

• pulpectomy

Question 9

What is indirect pulp capping ?

Answer 9

• caries is partially removed, small amount left to cover pulp tissue
• no pulp exposure
• medicament placed
• aim is to allow reparative (tertiary dentine) to form to protect pulp

Question 10

When do you use indirect pulp capping?

Answer 10

• asymptomatic primary tooth with deep caries
• needs to be good history, examination, radiographs and leakage free restoration

Question 11

What is direct pulp capping?

Answer 11

• medicament placed on the exposed pulp to stimulate dentine formation
• eg. calcium hydroxide

Question 12

When do you use direct pulp capping?

Answer 12

• in asymptomatic teeth 1-2 years prior to normal exfoliation
• use when there has been iatrogenic/traumatic pinpoint pulpal exposure

Question 13

What is preferred over direct pulp capping?

Answer 13

• direct pulp capping is no longer recommended by the BSPD or APPD because the prognosis is quite poor.
• there is an increased risk of internal resorption
• instead do a vital pulpotomy

Question 14

What is a vital pulpotomy?

Answer 14

• removing the infected coronal pulp and leaving the radicular pulp behind if it is vital

Question 15

What medicaments do you use in vital pulpotomy?

Answer 15

• ferric sulphate
• MTA

Question 16

What are the indications for a vital pulpotomy?

Answer 16

• large carious/traumatic exposure
• irreversible pulpitis (vital pulp)
• no clinical or radiographic signs of infection

Question 17

What are the basic rules of vital pulpotomy?

Answer 17

• remove coronal pulp
• vital radicular pulp
• bleeding arrested with ferric sulphate
• apical part of pulp remains vital
• if when you remove the coronal pulp you find the pulp chambers are necrotic or there is too much bleeding, the tooth may need pulpectomy or extraction.

Question 18

What percentage is ferric sulphate and explain what it does?

Answer 18

• 15.5%
• haemostatic agent
• used to control gingival bleeding
• no fixative effect

Question 19

What can you place in the pulp chamber in vital pulpotomy?

Answer 19

MTA or ZOE

Question 20

What do you place in the cavity in pulpotomy?

Answer 20

• ZOE

Question 21

What do you place over a tooth which has undergone a pulpotomy?

Answer 21

• place PMC

Question 22

What are the 7 stages of doing a pulpotomy?

Answer 22

1. Remove contents of pulp chamber with excavator or slow speed handpiece
2. Irrigate with 3 in 1
3. Arrest bleeding with cotton pledget soaked in ferric sulphate
4. Remove cotton wool
5. Place MTA or ZOE in pulp chamber
6. Fill cavity with ZOE
7. Place PMC

Question 23

When is a desensitising procedure used?

Answer 23

• hyperalgesic pulp
• non-compliant child requiring inhalation sedation for further tx
• cannot numb tooth/cannot get bleeding to stop

Question 24

What is the aim of desensitising procedure?

Answer 24

• reduce pulpal inflammation and/or symptoms to facilitate subsequent pulpotomy/pulpectomy procedure

Question 25

What is the 3 stages in a desensitising procedure?

Answer 25

1. Place cotton wool pledget loaded with ledermix/odontopaste over the pulp
2. Place well sealed temporary dressing
3. Recall after 7-14 days to proceed with further tx

Question 26

What is the tx of choice if the pulp is non-vital?

Answer 26

• pulpectomy- but excellent cooperation is needed, case selection, highly skilled procedure
• extraction