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Pulp therapy in primary teeth Flashcards

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1
Q

Management of the grossly
carious primary molar - options

A

Options
– Retain or
– Extract

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2
Q

If the grossly carious primary molars are left untreated or treated inadequately

A

– Pain
– Infection
– Damage to permanent successor
– Decreased masticatory function

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3
Q

Treatment planning for the management of the grossly carious primary molar- history/ symptoms…

A

– History of spontaneous severe pain
– Reported pain on biting
– Analgesics required
– History of swelling

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4
Q

Examination/clinical findings- management of the grossly carious primary molar

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 do you carry out for grossly carious primary molar

A

– TTP
– Mobility
– Radiographs

NB Sensibility testing unreliable in primary teeth

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6
Q

What do you look for on the radiograph

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

additional factors to consider - grossly carious primary molar

A

– Co-operation
– Past Medical History
– Parental wishes

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8
Q

What are the indications for tooth retention
Dental factors

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

Indications for tooth retention social factors

A

– Good patient compliance
– Regular attender and positive parental attitude

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10
Q

Indications for tooth retention medical factors

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

Indications for extraction
Dental factors

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

Indications for extraction medical factors

A

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

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13
Q

Indications for extraction social factors

A

An irregular attender, with poor compliance and
unfavourable parental attitudes

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14
Q

Primary pulp therapy procedures for the 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

Primary pulp therapy procedures for the non vital pulp

A

– Pulpectomy
– Non-vital pulpotomy – NOT INDICATED

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16
Q

Hall crown (vital pulp)- hall technique

A

Cement PMC over carious primary molars
* No LA or tooth preparation

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17
Q

Requirements for hall technique

A
  • Requires careful case selection
  • Must be accompanied with an effective
    preventive regime
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18
Q

Indications for the hall technique

A
  • 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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19
Q

What do you need before hall technique

A
  • Full clinical exam, bitewings and parental
    consent
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20
Q

contra indications of hall technique

A
  • Not if IE risk
  • Unusual morphology (e.g. accessory cusp)
  • Poor cooperation
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21
Q

Aims of 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
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22
Q

Indications for indirect pulp treatment

A
  • Tooth with deep carious lesion
  • No signs/symptoms indicative of pulpal pathosis
  • <2/3 Marginal ridge breakdown
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23
Q

Indirect pulp treatment technique

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)
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24
Q

Direct pulp cap why is it not routinely indicated?

A
  • Poor success rate
  • High incidence of internal resorption
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25
Aims of direct pulp cap
To promote dentine bridge & maintain vitality
26
Indications of direct pulp cap
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
27
Technique of direct pulp capping
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
28
Remember what about direct pulp capping?
NOT ROUTINELY INDICATED
29
Indications of vital pulpotomy
* Transient pain or asymptomatic tooth * Pulp minimally inflamed / reversible pulpitis * 2/3 Marginal ridge destroyed * Any doubt that pulp exposed – caries – iatrogenic
30
Aim of vital pulpotomy
To remove the coronal pulp, which has been clinically diagnosed as inflamed, retain healthy or reversibly inflammed radicular pulp
31
Technique vital pulpotomy
1. Local anaesthetic 2. Place rubber dam (mandatory) 3. Gain access 4. Remove caries 5. Remove roof of pulp chamber (with a sterile round bur) 6. Amputation 7. Control haemorrhage 8. Evaluate pulp stumps 9. Medication 10. Evaluate pulp stump after application of medicament 11. Restore 12. Review
32
Adequete access for direct pulp capping is achieved by?
Having no ledges or coronal pulp remnants Radicular pulp intact
33
6. Amputation? Vital pulpotomy
– remove coronal pulp (sterile excavator or large round steel bur) – NB Risk of perforation of pulp floor
34
7. Control haemorrhage? Vital pulpotomy
– Cotton pledget soaked in saline – Haemostatsis 4 minutes
35
8. Evaluate pulp stumps in vital pulpotomy
– Normal bleeding = non-inflamed pulp bright red colour good haemostasis Proceed with pulpotomy Abnormal bleeding-= inflamed pulp deep crimson continued bleeding after pressure
36
9. Medication for vital pulpotomy
– 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.
37
10. Evaluate pulp stumps after application of medicament
dark brown/black with minimal oozing
38
11. Restore with... in vital pulpotomy
 cover root stumps with reinforced ZOE paste (Kalzinol)  GIC core  restore with stainless steel crown
39
12. Review how- in vital pulpotomy
* Monitor – Signs – Symptoms – Mobility/tenderness – Exfoliation – Radiographic followup(1yr)
40
Alternatives in vital pulpotomy- medicaments?
- Saline + MTA – Mineral trioxide aggregate – similar success rate to ferric sulphate, – Pure calcium hydroxide powder (limited data on success rates)
41
Vital pulpotomy - alternatives to Ferric sulphate
Electrocautery- similar success NB Formocresol is no longer used -TOXIC
42
Desensitising Pulp Therapy Aim
To reduce pulpal inflammation and/or symptoms in order to facilitate subsequent pulpotomy or pulpectomy procedure
43
Indications of desensitising pulp therapy
* 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)
44
Desensitising pulp therapy - technique
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.
45
Since 2006 guidelines : Ledermix paste
* Alternative to Caustinerf – avoided use of formaldehyde * Contains triamcinalone acetonide (steroid) and demeclocycline (antimicrobial) * Reduces pulpal inflammation and pain = Desensitising * Was the medicament of choice. Now CONTRAINDICATED in primary teeth and in the under 12’s * Odontopaste – limited evidence
46
Success rates – Pulp therapy on vital tooth for direct pulp capping?
Poor
47
Success rates for indirect pulp capping (with no exposure) (pulp therapy on vital tooth)
More than 90% -3 years
48
Success rates of pulp therapy on the vital tooth- Vital pulpotomy
92 -96.4% at 4 years
49
Success rates- pulp therapy on the vital tooth Devitalisation pulpotomy
77 % -3 years (Ledermix success rarte for desensitising treatment not well documented)
50
Options for the non vital pulp
* Pulpectomy * Extraction
51
Pulpectomy in the primary molar aims?
* 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.
52
Aims for pulpectomy
* 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.
53
Contra- indications for pulpectomy
* Tooth unrestorable * Caries through bifurcation * Extensive root resorption * Extensive periapical pathology
54
Difficulties with carrying out pulpectomies on non vital teeth?
* Requires good patient co-operation * Complex morphology of root canal * Thin walls may make instrumentation without perforation difficult
55
Complex morphology of the 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)
56
Procedure of pulpectomy?
* Can be carried out in 1 or 2 stages 1. Pre-operative radiograph 2. Local anaesthetic (rubber dam clamp) 3. Rubber dam 4. Access cavity 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 9.Estimate working lengths of root canals 10 .Insert small files 11. Dry canals with pre-measured paper points, keeping 2 mm from root apices 12. If infection present (canal exudate and/or associated sinus) dress root canals with non-setting calcium hydroxide and temporise (two-stage procedure). 13. Consider prescribing a systemic antimicrobial 14. If the canals can be dried with paper points.../ If the presence of an exudate prevents drying of the canal
57
Access cavity design for upper arch pulpectomy?
* Triangular access * Apex towards pal * Base towards buccal
58
Access cavity design for lower arch pulpectomy
Rectangular
59
8. Irrigate... in pulpectomy
– Leur lock syringe – Side venting needle – normal saline (0.9%), Chlorhexidine solution (0.4%) or sodium hypochlorite solution (0.1%)
60
9. Estimate the working lengths of the root canals
keeping 2 mm short of the radiographic apex
61
10. Insert small files vital pulpotomy
(no greater than size 30) into canals and file canal walls lightly and gently (Note ribbon shaped canals)
62
14. If canals can be dried with paper points: vital pulpotomy
– 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)
63
If the presence of an exudate prevents drying of the canal...
consider a 2 stage technique, where the root canals are dressed with an antimicrobial agent for 7-10 days
64
Ideal root canal filling material
– 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
65
Follow-up of pulpotomy and pulpectomy
Clinical R/V 6monthly * Radiograph 12-18 m
66
* Clinical failure of treatment is indicated by
– pathological mobility – fistula / chronic sinus – pain
67
* Radiographic failure
– increased radiolucency – external / internal resorption – furcation bone loss
68
* Radiographic failure
– increased radiolucency – external / internal resorption – furcation bone loss
69
Potential complications of primary molar pulp therapy
* Periapical / interradicular pathology * Enamel defects -permanent successor * Internal resorption * Over-preparation -furcation
70
Remember...pulp treatment of primary molars is
NOT THE SAME AS PERMENANT INCISORS!

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