Pulp Therapy

Question 1

Histologically pulp of primary teeth compared to young/permanent teeth

Answer 1

• Primary teeth are histologically similar to the pulp of young permanent teeth, cell rich and vascular; primary teeth exhibit a more typical inflammatory response than permanent teeth in adults

Question 2

Morphology of primary teeth compared to permanent teeth

Answer 2

• Increased number of accessory canals especially in the pulpal floor
• Greater curvature of molar roots
• Flat, ribbon shaped canals, apices more open
• Relatively longer, more slender roots in molars
• Pulp horns closer to outer surface of tooth
• apical resorption
• Proximity of premolars
• Larger pulp relative to crown size
• Mesial pulp horns closer to surface than distal; pulp horns longer than external anatomy suggests

Question 3

Symptoms suggestive of vital pulp therapy. Examples of vital pulp therapy

Answer 3

A normal pulp (no pain) or reversible pulpitis (thermal, chemical, intermittent pain)

1. Protective base/liner
2. Indirect Pulp tx
3. Direct pulp caping
4. Pulpotomy
5. Partial Pulpotomy (permanent teeth)

Question 4

Protective Base (Liner)

• What are the indications for this treatment?
• Objectives?
• *Differences between primary and permanent teeth?

Answer 4

1. Indications:
   - normal pulp
   - dentin tubules exposed by cavity preparation
   - Minimize injury to the pulp
   - Promote pulp healing
   - Minimize post operative sensitivity
2. Objective:
   - Preserve pulpal vitality
   - promote pulpal healing
   - promote tertiary (reparative) dentin formation–up to 3.5 microns/day; more extensive response in primary than permanent teeth
   - minimize microleakage/post treatment sensitivity
   * *Same for permanent and primary teeth

Question 5

Indirect Pulp Therapy

• What are the indications for this treatment?
• Objectives?
• *Differences between primary and permanent teeth?

Answer 5

1. Indications:
   - deep carious lesions
   - reversible pulpitis
   - incomplete caries removal
   - no pulp exposure
   - pulp vital
2. Objectives: Complete seal, preserve vitality, no post-treatment symptoms, no harm to succedaneous teeth, continued root development in permanent teeth
   - Technique: apply Ca(OH)s, if planning to re-enter, wait 6-8 weeks to restore, most practitioners do not re-enter
   - Success rate : ~90%

Question 6

Indirect pulp therapy w/GI vs FMC pulpotomies in primary teeth?

Answer 6

IPT w/GI showed a higher overall success rate (93%) than FMC pulpotomies (75%) in tx deep caries in primary teeth (Farooq 2000)

• IPT success rates higher than FMC pulpotomies over 4 yr period; treatment of deep dentinal lesions w/caries control procedures prior to IPT or pulpotomy improved the success both txs
• IPT success rate in primary molars was 95% in a retrospective study (al-zayer 2003)
• Carious lesion undergoes mineral gain when sealed in indirect pulp tx (oliveira)

Question 7

Direct Pulp cap:

• What are the indications for this treatment?
• Objectives?
• *Differences between primary and permanent teeth?

Answer 7

1. Indications:
   - Small mechanical or traumatic exposure in primary teeth w/normal pulp
   - Small carious or mechanical exposure in permanent teeth w/normal pulp
   - Contraindicated for carious exposure in primary teeth
2. Objectives:
   - preserve vitality, no post tx sign/symptoms, pulp healing, tertiary dentin, no pathologic changes (in/external root resorption), for primary teeth: no harm to succedaneous teeth; for permanent teeth: continued apexogenesis for immature teeth

Question 8

Direct pulp capping and bleeding–important to keep in mind/ increase success?

Answer 8

• Success inversely related to bleeding at DPC
• Remove debris, irrigate w/saline or LA, keep pulp moist
• Do not allow clot to form; prevents contact of DPC material w/healthy pulp; may release products that attract bacteria
• Success rate up to 80-90% but 50% if pulp is inflamed

Question 9

Partial Pulpotomy

• What are the indications for this treatment?
• Objectives?
• *Differences between primary and permanent teeth?

Answer 9

1. Indications :
   - no pain or recent pain of short duration that subsided w/analgesics, no rxn to percussion, no swelling, no mobility
   - no in/external root resorption, no pathologic changes in PDL or surrounding bone
   - Pulp exposure during caries removal not exceeding 1-2 mm in diameter, with bleeding that stopped within 1-2 mins
   - inflammation and penetration of microorgs limited to superficial site, only superficial tissue removed at exposure site
2. Objective: vitality, continued apexogenesis in immature teeth
   * ** If carious exposure in primary teeth, full pulputomy

Question 10

Technique for Partial pulpotomy

Answer 10

A Cvek:
Enlarge exposure
partial extirpation (1-3 mm or deeper) or coronal pulp w/sterile round diamond bur
- place pulp capping material (CaOHs currently material of choice w/GIC or CaOH2 if composite restoration to be placed
- Total etch technique w/dentin bonding agents is gaining in popularity

Question 11

Advantages of a partial pulpotomy over a full cervical pulpotomy?

Answer 11

• Removes inflamed, infected pulp, but preserves cell-rich coronal pulp
• Facilitates washing away carious debris
• Allows better contact w/more material; increases healing potential
• Physiologic apposition of cervical dentin
• obviates need for RCT
• natural color and translucency preserved
• maintains vitalometer response

Question 12

Pulpotomy in primary teeth

• What are the indications for this treatment?
• Objectives?
• *Differences between primary and permanent teeth?

Answer 12

1. Indications:
   - deep lesion adjacent to pulp that is normal or reversibly inflamed or
   - pulp exposed by trauma
   - coronal tissue can be amputated
   - remaining radicular tissue vital (clinically and radiographically)
   - absence of spontaneous pain, swelling
2. Objectives:
   - Preserve vitality of radicular pulp
   - no adverse signs or symptoms
   - no radiographic pathology
   - -Technique: prep for SSC, excavate caries, unroof pulp chamber, amputate coronal pulp, hemostasis, treat remaining pulp w/medicament/pressure, neutralize, seal/restore

Question 13

What are the clinical and radiographic contraindications to pulpotomy in primary teeth?

Answer 13

• Hx of unprovoked pain
• Presence of fistula or swelling
• Uncontrolled pulpal hemorrhage
• Periapical or bifurcation radiolucency
• Pathologic resorption of pulp
• Dystrophic calcification
• more than 1/3 external root resorption; internal resorption

Question 14

What are each of these made of?

• Vitapex
• Maisto’s paste
• Ledermix

Answer 14

1. Vitapex: iodoform, CaOH2
2. Maisto’s Paste: iodoform, parachlorophenol, camphor-menthol
3. Ledermix used to be popular (now its not): dimethylchlorotetracycline, triamcinolone

Question 15

Formocresol:

• composition? dilution? method of action? caveats?
• success?

Answer 15

• Composition: 20% formaldehyde, 35% cresol 15% glycerin. Dilution: 1-5% is sufficient, there is no significant different between 100%.
• Fixation w/progressive fibrosis: acidophilic zone (fixation), pale staining zone (atrophy), broad zone of inflammatory cells, linear calcifications seen in longer term studies
• Bactericidal–~most important mech of axn
• No dentinal bridge, but calcific changes occur
• Fixation: preserves cells, inhibits autolytic changes and bacterial growth, coagulates protoplasm rendering it insoluble
• -Success 60-100% depending

Question 16

Glutaraldehyde: what is it? method of axn?

Answer 16

Also a powerful fixing agent

• antibacterial
• large molecule
• minimal systemic distribution
• tx conc 2-5%

Question 17

Ferric Sulfate: what is it, mech of axn? compared to FMC?

Answer 17

1. Forms protein complex, occludes capillaries, no antibacterial action
2. Similar radiographic/clinical success to FMC (Loh, 2004)
   - Meta-analysis: overall clinical success of FS: 78-100% similar to that of FMC (Peng 2007)

Question 18

MTA: what is it? benefcits? compared to FMC?

Answer 18

1. Tricalcium silicate, dicalcium silicate, tricalcium aluminate, calcium sulfate dehydrate, bismuth oxide, etc
2. hydrophilic particles set in the presence of moisture w/in 3-4 hours; working time is 5 minutes
3. Compressive strength equal to that of IRM
4. Sealing ability greater than amalgam
   - -Significantly more teeth w/root resorption FMC non in MTA (Aeinehchi 2007), No significant diff in radiographic success (Noorollahian 2008), meta analysis (Peng 2007) states higher clinical and radiographic success, MTA significantly superior to FMC

Question 19

Sodium Hypochlorite: compared to Ferric sulfate?

Answer 19

Compared to ferric sulfate:

• 12 months
• NaOCl: 100% clinical success (80% radiographic success; FS a little lower but not significantly significant difference

Question 20

Electrosugery : advantages? disadvantages?

Answer 20

1. Advantages: quick, self limiting, hemostasis
2. Disadvantages: heat tissue destruction, persistent inflammation, coagulation current can result in superficial zone of coagulation necrosis, energy cannot be isolated to surface, incites pathologic root resorption and periapical/furcal pathology and acute/chronic inflammation, edema, fibrosis, diffuse necrosis
   - -results in reparative dentin formation
   - -high success rates (80-95%

Question 21

Huth et al 2005 RCT of primary tooth pulpotmy techniques

Answer 21

Prospective randomized control teeth of 175 teeth (impressive):

• FMC, Er:Yag laser, 50 CaOH2, 50 ferric sulfate
• Everything was successful at 12 months
• at 24 months: FMC, Laser, Ferric Sulfate 80% or greater survival. CaOH2 at 50% significantly worse

Question 22

Pulpotomy in permanent teeth:

• What are the indications for this treatment?
• Objectives?
• *Differences between primary and permanent teeth?

Answer 22

1. Indications: pulp exposure, but all infected/affected coronal tissue can be removed
   - Undertaken when time/money prevent immediate conventional RTC (closed apex)

Question 23

Apexogenesis:

- objectives, indications

Answer 23

• encourage continued root formation
• promote tertiary dentin formation
• no evidence of inflammatory resorption
• no evidence of root resorption and periradicular pathosis

Question 24

Indications for non-vital pulp therapy in primary teeth

Answer 24

• Irreversible pulpitis, necrosis; tooth planned for pulpotomy with excessive hemorrhage from radicular pulp

Question 25

Nonvital pulp therapy for primary teeth: treatment options? indications

Answer 25

Pulpectomy - necrotic pulp, irreversible inflammation - Abscessed-in very limited instances--strategic importance of tooth is major consideration - adequate root remaining - cooperative patient - limit to incisors and second molars

Question 26

ZOE vs Vitapex: (Mortazavi 2004) Describe the study: overall success?

Answer 26

More short fills for ZOE, overfills w/Vitapex - Overall success 10-16 mo: Vitapex 100%, ZOE 78% statistically significant - Pulpectomy success rates in molars and incisors - likely not just due to material (ZOE consistently had more short fills)