“ treatment of pulpitis temporary and permanent teeth in children. ” lecturer: dr. katrin duda
TRANSCRIPT
PEDIATRIC DENTISTRY
“Treatment of pulpitis temporary and
permanent teeth in children.”
Lecturer: Dr. Katrin Duda
Pulp
From many perspectives, dental health is directly related to
the health of a unique tissue-that is, dental pulp.
However, the study of dental pulp is not restricted to
this tissue alone, but extends to its interactions with
many other tissues in health and disease. For example,
since dentin and pulp are anatomically and functionally
integrated, they are often referred to as the pulpodentin
complex.
Pulp
The pulp also interacts with other tissues
such as the periodontium and even the
central nervous system. Indeed, the
interrelationship between
dental pulp and other tissues is a major
theme in
the field of dentistry, in pulp biology
research,
and of course, in this textbook. It also
serves as a
rationale for the specialty of endodontics.
Pulp
According to one recent endodontics text, the purpose of
endodontic treatment is not to pre-serve the pulp but to
eliminate it, so as to remove those factors found in necrotic
and infected pulp that stimulate apical periodon-titis. 2 Thus,
the biologic rationale for nonsurgical endodontic treatment is
to manage the apical periodontitis that results from the
functional relationship between infected dental pulp and
apical tissue.
Pulp
Pulp
The dental pulp is the part in the center of a tooth
made up of living connective tissue and cells called
odontoblast. The dental pulp is a part of the dentin–
pulp complex (endodontium). The vitality of the
dentin-pulp complex, both during health and after
injury, depends on pulp cell activity and the
signaling processes that regulate the cell’s behavior.
Anatomy Pulp
Each person can have a total of up to 52 pulp
organs, 32 in the permanent and 20 in the primary
teeth. The total volumes of all the permanent teeth
organs is 0.38cc and the mean volume of a single
adult human pulp is 0.02cc. Maxillary central incisor
has shovel shaped coronal pulp with three short
horns on the coronal roof and triangular in cross
section. Canine has the longest pulp with elliptical
cross section.
Anatomy PulpThe large mass of pulp is contained within the pulp chamber of
the tooth. The shape of each pulp chamber corresponds
directly to the overall shape of the tooth, and thus is
individualized for every tooth; the pulp tissue in the pulp
chamber has two main divisions: coronal pulp and radicular
pulp. Crowns of the teeth contain coronal pulp. The coronal
pulp has six surfaces: the occlusal, the mesial, the
distel distal, the buccal, the lingual and the floor. Because
of continuous deposition of dentin, the pulp becomes
smaller with age. This is not uniform throughout the coronal
pulp but progresses faster on the floor than on the roof or
side walls.
Anatomy Pulp
Radicular pulp is that pulp extending
from the cervical region of the crown to
the root apex. They are not always
straight but vary in shape, size and
number. The radicular portion is
continuous with the periapical tissues
through.
Anatomy Pulp
Apical foraen is the opening of the radicular pulp
into the periapical connective tissue. The average
size is 0.3 to 0.4 mm in diameter. There can be
two or more foramina separated by a portion of
dentin and cementum by cementum only. If more
than one foramen is present on each root, the
largest one is designated as the apical foramen
and the rest are considered accessory
foramina. Most infections spread through the
apical foramen from the pulp to periapical tissue.
Anatomy Pulp
Accessory canals are
pathways from the
radicular pulp, extending
laterally through the
dentin to the periodontal
tissue seen especially in
the apical third of the
root. Accessory canals
are also called lateral
canals, because they are
usually located on the
lateral surface of the
roots of the teeth.
Anatomy Pulp
Development
The pulp has a background
similar to that of dentin,
because both are derived
from the dental papilla of
the tooth germ. During
odontogenesis, when the
dentin forms around the
dental papilla, the
innermost tissue is
considered pulp.
Structure of pulp
The central region of the coronal and radicular pulp contains
large nerve trunks and blood vessels. Has four layers :
Pulpal core, which is in the center of the pulp chamber with
many cells and an extensive vascular supply; except for its
location, it is very similar to the cell-rich zone.
Cell rich zone; which contains fibroblasts and undifferentiated
mesenchymal cells.
Cell free zone which is rich in both capillaries and nerve
networks.
Odontoblastic layer; outermost layer which contains
odontoblasts and lies next to the predentin and mature dentin.
Functions
The primary function of the dental pulp is to form dentin.
Other functions include:
Nutritive: the pulp keeps the organic components of the surrounding
mineralized tissue supplied with moisture and nutrients;
Sensory: extremes in temperature, pressure, or trauma to the dentin or
pulp are perceived as pain;
Protective: the formation of reparative or secondary dentin;
Formative: cells of the pulp produce dentin which surrounds and protects
the pulpal tissue.
Complications
Pulp acts as a security and alarm system for a tooth.
Slight decay in tooth structure not extending to the
dentin may not alarm the pulp but as the dentin gets
exposed, either due to dental caries or trauma,
sensitivity starts. The dentinal tubules pass the
stimulus to odontoblastic layer of the pulp which in
turns triggers the response. This mainly responds to
cold. At this stage simple restorations can be
performed for treatment.
Complications
As the decay progresses near the pulp the response also
magnifies and sensation to a hot diet as well as cold gets
louder. At this stage indirect pulp capping might work for
treatment but at times it is impossible to clinically diagnose
the extent of decay, pulpitis may elicit at this stage. Carious
dentin by dental decay progressing to pulp may get fractured
during mastication (chewing food) causing direct trauma to
the pulp hence eliciting pulpitis.
Complications
The inflammation of the pulp is known as pulpitis.
Pulpitis can be extremely painful and in serious cases
calls for root canal therapy or endodontic therapy.
Traumatized pulp starts an inflammatory response
but due to the hard and closed surroundings of the
pulp pressure builds inside the pulp chamber
compressing the nerve fibres and eliciting extreme
pain (acute pulpitis). At this stage the death of the
pulp starts which eventually progresses to periapical
abscess formation (chronic pulpitis).
Complications
The pulp horns recede with age. Also with increased
age, the pulp undergoes a decrease in intercellular
substance, water, and cells as it fills with an
increased amount of collagen fibers.This decrease in
cells is especially evident in the reduced number of
undifferentiated mesenchymal cells. Thus, the pulp
becomes more fibrotic with increased age, leading to
a reduction in the regenerative capacity of the pulp
due its loss of these cells.
Complications
Also, the overall pulp cavity may be smaller by
the addition of secondary or tertiary dentin, thus
causing pulp recession. The lack of sensitivity
associated with older teeth is due to receded
pulp horns, pulp fibrosis, addition of dentin, or
possibly all these age-related changes; many
times restorative treatment can be performed
without local anesthesia on older dentitions.
Pulpitis
Pulpitis is inflammation of dental pulp tissue. The
pulp contains the blood vessels the nerves and
connective tissue inside a tooth and provides the
tooth’s blood and nutrients. Pulpitis is mainly caused
by bacteria infection which itself is a secondary
development of caries (tooth decay). It manifests itself
in the form of a thoothach.
Causes
Pulpitis may be caused by a dental caries that penetrate
through the enamel and dentin to reach the pulp, or it may be
a result of trauma, such as thermal insult from repeated
dental procedures. Inflammation is commonly associated
with a bacterial infection but can also be due to other insults
such as repetitive trauma or in rare cases periodontitis. In the
case of penetrating decay, the pulp chamber is no longer
sealed off from the environment of the oral cavity.
Causes
When the pulp becomes inflamed, pressure begins to build up
in the pulp cavity, exerting pressure on the nerve of the tooth
and the surrounding tissues. Pressure from inflammation can
cause mild to extreme pain, depending upon the severity of
the inflammation and the body's response. Unlike other parts
of the body where pressure can dissipate through the
surrounding soft tissues, the pulp cavity is very different. It is
surrounded by dentin, a hard tissue that does not allow for
pressure dissipation, so increased blood flow, a hallmark of
inflammation, will cause pain.
Causes
When the pulp becomes inflamed, pressure begins to
build up in the pulp cavity, exerting pressure on the nerve
of the tooth and the surrounding tissues. Pressure from
inflammation can cause mild to extreme pain, depending
upon the severity of the inflammation and the body's
response. Unlike other parts of the body where pressure
can dissipate through the surrounding soft tissues, the
pulp cavity is very different. It is surrounded by dentin, a
hard tissue that does not allow for pressure dissipation, so
increased blood flow, a hallmark of inflammation, will
cause pain.
Causes Pulpitis
Pulpitis can often create so much pressure
on the tooth nerve that the individual will
have trouble locating the source of the pain,
confusing it with neighboring teeth, called
referred pain. The pulp cavity inherently
provides the body with an immune system
response challenge, which makes it very
difficult for a bacterial infection to be
eliminated.
Causes Pulpitis
If the teeth are denervated, this can lead to irreversible
pulpitis, depending on the area, rate of infection, and
length of injury. This is why people who have lost their
dental innervation have a reduced healing ability and
increased rate of tooth injury. Thus, as people age, their
gradual loss of innervation leads to pulpitis.
Diagnosis and classification of pulpal diseases
As in all infections, the body answers with increased
circulation (hyperaemia): the supplying blood vessels
expand. Hyperaemia can transform into an acute or
chronic pulpitis. A tooth with acute pulpitis is
extremely sensitive to temperature. Cool air is
sufficient to trigger the pain. In pulpitis acuta
serosa, extended capillary vessels cause the
excretion of granulocytes and serum. Activated
enzymes, causing the breakdown of proteins, create
pus, leading to severe pain in pulpitis acuta
purulenta.
Chronic pulpitis
Chronic pulpitis on the other hand is often
completely without symptoms. It is usually caused
by caries. White blood cells (leucocytes) accumulate
in the pulpa to combat inflammation. The bacteria
cause the blood vessels of the pulpa to become
permeable to serum (pulpitis serosa) and the
number of infection combating cells increases (e.g.,
lymphocytes). Bacteria aggravate the infection. Pus-
forming granulocytes supervene and the pain
intensifies.
Acute pulpitis
In reversible, acute pulpitis, the tooth
reacts to sweetness, cold and heat. The
pain lasts for a short while only. The
sensitivity test is positive. If caries can be
removed without opening the pulpa, the
tooth loses its symptoms. The pulpa can
be kept vital. This acute form of pulpitis is
therefore reversible.
Acute pulpitis
In irreversible pulpitis, which may be acute or
chronic, the tooth is permanently painful. The
dentin is frequently destroyed up to the pulpal
cavity and cariously altered. Pain continues even
after caries removal and medicamentous filling. The
tooth's sensitivity to touch and biting is joined by
decreasing or lacking reaction to a sensitivity test.
The damaged pulpa cannot be reversed to its
original healthy state, it is irreversible.
Diagnosis and classification of pulpal diseases
Vitality loss of the tooth marrow leads to pulpal
necrosis which initially shows no symptoms. This
may occur through a bacterial infection such as
gangrene or after trauma without the participation
of bacteria. If infection occurs in the jaw bone via
the foramen apicale, it results in acute or chronic
apical parodontitis. Diagnosis is confirmed with a
negative sensitivity test. Therapy consists of
trepanation with subsequent root canal preparation
and filling.
Root canal treatment
Root canal treatment can be divided into:
Removal of pulpal tissue
Determination of root canal length
Preparation of root canals
Filling of root canals
Root canal treatment
The determination of the root canal length specifies the
operational length of the root canal instruments by
displaying the length to the foramen apicale. A decisive
factor for the correct filling of the canals is its length,
previously determined by X-ray. The X-ray displays how
far the instrument is away from the root tip and which
length the instruments in the canal may have.
Determination of canal length can also be performed
electrically, whereby a probe is inserted into the canal
and the end of the root canals is indicated by a
measurement device.
Root canal treatment
Root canal preparation serves to prepare the
root canal for root filling. The canals are
extended and planed with flexible, mechanically
or manually driven drills and files, which adjust
even to arched or bent roots. Canal preparation
is also possible with ultrasound.
Canal preparation should be performed up to
the foramen apicale.
Root canal treatment
Root canal treatment
Root canal treatment
Unintended lateral penetration of the root is called
“via falsa” (the “wrong way” in Latin). The objective
of root canal filling is to fill the prepared root canal
with special, bacteria-proof paste and matching
gutta-percha tips and thus ensure sustainable
treatment success. Root canal filling is performed
with endogenous substances, which should be
tissue-compatible, hardening, fluid, dimensionally
stable, parietal, bacteria-proof, non-resorbable and
visible on X-ray.
Root canal treatment
In thermoplastic root canal filling, heated and
formable gutta-percha is injected into the
prepared root canal or inserted as gutta-percha
pins. The insertion of several gutta-percha pins
with hardening pastes is preferred. While the
orthograde root canal filling is normally
positioned from the crown, the retrograde root
canal filling is performed at the tip of the root
(e.g., in root tip resection).
Thank you for attention