Pulp Therapy - OPTECH Flashcards
(30 cards)
Disadvantages of early primary tooth loss
- loss of space - increased malocclusion risk
- Decreased masticatory function
- Impeded speech development
- Psychological disturbance
- Trauma for anaesthesia/surgery
Indications for pulp treatment
- Good cooperation
- Promote positive attitude to oral health care
- MH precludes XLA
- Missing permanent successor
- Maintain strategically important teeth eg second primary molars
- Developmental state of tooth eg usually <9 yrs
Contraindications for pulp treatment
- Poor cooperation
- Poor dental attendance
- Medical history eg cardiac defect
- Multiple grossly carious teeth
- Advanced root resorption
- Close to exfoliation (2/3 root resorption)
- Gross bone loss
Primary tooth endo - considerations
- Compliance
- Root number and morphology
- Root canal pattern
- Layer of secondary dentine
- Porous pulpal floor with accessory canals
- Physiological resorption
- Risk of damage to permanent successor
- Small mouths - restricted access
Pulp status - capable of healing signs
- asymptomatic
- reversible pulpitis (provoked pain of short duration removed on withdrawal of the stimulus)
Pulp status - inflamed or incapable of healing signs
- Irreversible pulpitis:
- provoked pain that persists on stimulus removal
- spontaneous unprovoked pain
(And also keeping pt up at night?) - Sinus tract
- Soft tissue inflammation not from perio
- Excessive mobility not associated with trauma or exfoliation
- Furcation or apical radiolucency
- Radiographic evidence of internal or external resorption
Why do pulpotomy (primary teeth)?
- Carious or traumatic exposure of bleeding vital pulp
- radicular pulp is preserved, bleeding controlled, maintain tooth until normal exfoliation
Technique for pulpotomy
- Consent
- LA
- Rubber dam
- Remove caries
- Remove pulp chamber roof
- Remove coronal pulp with sterile excavator/round steel bur
- Assess pulp status
Saline soaked cotton pellet to stop bleeding ng - Place ferric sulphate (haemostatic) for 15-30 seconds and check bleeding, can reapply 4x max, assess pulp stumps
- Place ZnOE base (IRM) in pulp chamber
- Place GIC core
- Restore with PMC (for coronal seal)
Medicaments for pulpotomy in primary teeth
- ferric sulphate = best, haemostatic
- calcium hydroxide - associated with internal resorption
- MTA = discolouration, expensive
- LEDERMIX or odontopaste = SOS only (contains clindamycin, calcium hydroxide)
PULPECTOMY: Non vital primary molar signs
SYMPTOMS:
- spontaneous pain
- pain on biting
- “gum boil”
- “bad taste”
- facial swelling
SIGNS:
- sinus
- discolouration
SPECIAL INVESTIGATIONS:
- mobility
- TTP
- furcation or apical radiolucency
- pathological root resorption
CLINICAL FINDINGS:
- hyperaemic pulp
- necrotic pulp
CONSIDER XLA WITH FACIAL SWELLING
PULPECTOMY STEPS for primary tooth
- Consent
- LA
- Rubber dam
- Access
- Coronal pulp extirpation
- Use files to remove pulpal tissue from canals (2mm short of apex)
- Canal irrigation: sterile saline, LA; CHX
- Obturation (vitapex slurry) = calcium hydroxide + iodoform
- IRM seal - thick mix
- GIC core
- Restore with PMC
FOLLOW UP OF PULP TREATMENT:
CLINICAL:
- 6 monthly
RADIOGRAPHS:
- 12-18 monthly
What counts as clinical failure of pulp tx
- Pathological mobility
- Fistula/chronic sinus
- Pain
Radiographic failure of pulp treatment
- Increased radiolucency
- External/internal resorption
- Furcation bone loss
Indications for conventional crown
- extensive caries
- developmental defects like AI DI
- after pulpotomy or Pulpectomy (within same appt, already numbed up)
- definitive restorative tx in high caries risk kids
- if you have contact closed area and you can’t put crown on, need to make space
- if doing multiple teeth and need space
DEPENDS ON COMPLIANCE AND TIME IN APPT!!
Conventional crown - measurements
- 1 mm interproximal slices
- 2-3mm occlusal reduction while keeping shape of tooth
How to select crown for preformed metal crown for conventional
- measure mesio distal width of crown or space with divider and select crown
- trial and error after crown prep
- impression and crown prep on model
CAN ADJUST CROWN TO FIT BETTER with crown crimping pliers and curved crown scissors
Conventional crown technique
- Occlusal reductions (2-3mm), keeping the occlusal shape
- Interproximal reductions (1mm)
- Axial reduction (smoothing off)
- all using short tapered diamond bur
- for multiple crowns may need to prep slightly more interproximally
- GIC luting cement used ?
PMC HALL CROWN TECHNIQUE (6)
- No LA, caries or tooth prep
MUST PROTECT AIRWAYS WITH GAUZE - Appropriately sized PMC selected (don’t seat through contacts before cementing) and filled with GI cement
- Seated over carious primary molar using either finger pressure, or child’s own occlusal force
- Excess cement is flossed away
- Occlusion will be high, advise parents this will settle within a week
- note:
Space formation: - ortho separators
- need two visits
- place for 3-5 days
- flossed between E and D (for eg) to create space for PMC
- top half of separator remains above marginal ridge
How does hall technique work? (3)
- biological approach
- manipulates plaque environment by sealing it, separating it from SUBSTRATES
- good evidence that if caries sealed off well, lesion doesn’t progress
ASSESSMENT BEFORE HALL CROWN
CLINICAL
extent of caries: any pulpal involvement
- signs of irreversible pulpitis or dental abscess
- non physiological mobility
RADIOGRAPHY
- band of sound dentine between lesion and pulp
- signs of intra radicular pathology
- signs of dental abscess
Indications for Hall technique (3)
- Proximal lesions (class 2), cavitated or non cavitated
- Occlusal, non cavitated if patient cannot accept fissure sealant or conventional restoration
- Occlusal, cavitated lesion if patient cannot accept partial caries removal or conventional restoration
Contraindications hall crown (5)
- Irreversible pulpal involvement
- Insufficient sound tissue left to retain crown
- Patient co operation (endangering patients airway)
- Patient at risk from bacterial endocarditis
- Parent or child unhappy with aesthetics
- also no sound band of dentine between pulp and caries
Issues with hall crowns
- may prevent adjacent tooth from erupting/impact against it
- fracturing off
