Dr Sunny PurohitDepartment of Pedodontia

SDCH,SGDHE

Treatment of DeepCaries, Vital Pulp

Exposure, andPulpless Teeth

1 Hour Lecture in 1 Slide !

1. HISTORY OF PAIN

2.CLINICAL SIGNS AND SYMPTOMS

3. RADIOGRAPHIC INTERPRETATION

DIAGNOSTIC AIDS IN TH ESELECTION OF TEETH FORVITAL PULP THERAPY

The history of either presence or absence of pain may not be as reliable in the differential diagnosis of the condition of the exposed primary pulp as it is in permanent teeth.

Degeneration of primary pulp even to the point of abscess formation without the child's recalling pain or

discomfort is not uncommon

1. HISTORY OF PAIN

The history of a toothache should be the first consideration in the selection of teeth for vital pulp therapy

A toothache coincident with or immediately after a meal may notindicate extensive pulpal inflammation. The pain may be caused by an accumulation of food within a carious lesion, by pressure, or by a chemical irritation to vital pulp protected by only a thin layer of intact dentin.

A severe toothache at night

Spontaneous Pain

A gingival abscess or a draining fistula associated with atooth with a deep carious lesion is an obvious clinical sign of an irreversibly

diseased pulp

Abnormal tooth mobility

If pain is absent or minimal manipulation may during manipulation of

the diseased mobile tooth, the pulp is probably in a more

advanced and chronic degenerative condition

elicit localized pain in the area.

2.CLINICAL SIGNS AND SYMPTOMS

Pathologic mobility must be distinguished from normal mobility in primary teeth near exfoliation

Thickening of the periodontal ligament or rarefaction of the supporting bone. These conditions almost always rule out treatment other than an endodontic procedure or extraction of the tooth

Radiographic interpretation is more difficult in children than in adults??

3.RADIOGRAPHIC INTERPRETATION

The permanent teeth may have incompletely formed root ends, giving an impression of periapical radiolucency, and the roots of the primary teeth undergoing even normal physio-logic resorption often present a misleading picture or one suggestive of pathologic change.

The proximity of carious lesions to the pulp cannot

always be determined accurately in the x-ray film.

Radiographic interpretation is more difficult in children than in adults??

Radiographic evidence of calcified masses within the pulp chamber is diagnostically important. If the irritation to the pulp is relatively mild and chronic, the pulp will respond with inflammation and will attempt to eliminate the irritation by blocking with irregular dentin the tubules through which the irritating factors are transmitted. If the irritation is intense and acute and if the carious lesion is developing rapidly, the defense mechanism may not have a chance to lay down the

reparative dentin barrier, and the disease process may reach the pulp. In this instance the pulp may attempt to form a barrier at some distance from the exposure site.These calcified masses are sometimes evident in the pulp horn or even in the region of the pulp canal entrance.

The value of the electric pulp test in determining thecondition of the pulp of primary teeth is questionable,although it will give an indication of whether the pulp isVital

A complicating factor is the occasional positive response to the test in a tooth with a necrotic pulp if the content of the canals is liquid.

The reliability of the pulp test for the young child canalso be questioned sometimes because of the child'sapprehension associated with the test itself.

PULP TESTING

Thermal tests have reliability problems in the primary dentition, too. The lack of reliability is possibly related to the young child's inability to understand the test.

laser Doppler flowmeter and transmitted-lightphotoplethysmography

PHYSICAL CONDITION OF THE PATIENT

EVALUATION OF TREATMENT PROGNOSIS

Criteria For Selecting Patient For Pulp Therapy

Children with conditions that render them susceptible to subacute bacterial endocarditis

or those with nephritis, leukemia, solid tumors,

idiopathic cyclic neutropenia, or any condition that causes cyclic

or chronic depression of granulocyte and

polymorphonuclear leukocyte counts should not be subjected to the possibility of an acute infection resulting from failed pulp therapy

PHYSICAL CONDITION OF THE PATIENT

1. The level of patient and parent cooperation and motivation in receiving the treatment

2. The level of patient and parent desire and motivation in maintaining oral health and hygiene 3. The caries activity of the patient and the overall prognosis of

oral rehabilitation 4. The stage of dental development of the patient 5. The degree of difficulty anticipated in adequately performing

the pulp therapy (instrumentation) in the particular case 6. Space management issues resulting from previous extractions,

preexisting malocclusion, ankylosis, congenitally missing teeth, and space loss causedby the extensive carious destruction of teeth and subsequent drifting

7. Excessive extrusion of the pulpally involved tooth resulting from the absence of opposing teeth

EVALUATION OF TREATMENT PROGNOSIS

Approximately 75% of the teeth with deep caries have been found from clinical observations to have pulpal exposures

over 90% of the asymptomatic teeth with deep carious lesions could be successfully treated without pulp exposure using indirect pulp therapy techniques

Treatment of vital exposures, especially in primary teeth, has not been entirely successful. For this reason, clinicians prefer to avoid pulp exposure during the removal of deep caries

whenever possible.

TREATMENT OF THE DEEPCARIOUS LESION

The procedure in which only the gross caries is removed from the lesion and the cavity is sealed for a time with a biocompatible material is referred to as indirect pulp treatment

INDIRECT PULP TREATMENT (GROSS CARIESREMOVAL OR INDIRECT PULP THERAPY)

The clinical procedure involves removing the gross

caries but allowing sufficient caries to remain over the

pulp horn to avoid exposure of the pulp.

The walls of the cavity are extended to sound tooth structure because the presence of carious enamel and dentin at the

margins of the cavity will prevent the establishment of

an adequate seal (extremely important) during theperiod of repair. The remaining thin layer of caries in the base of

the cavity is covered with a radiopaque biocompatible base material and sealed with a durable interim restoration

However, the treated teeth should not be reentered to complete the removal of caries for at least 6 to 8 weeks. During this time the caries process in the deeper layer is arrested.

Rate of regular dentin formation during the indirectpulp treatment was highest during the first month, butdentin formation continued during the year ofexperimental observation. At the end of the 1-yearobservation period, some teeth had formed as much as390 μm of new dentin on the pulpal floor.

This observation provides justification for leaving the sealed interim restoration in place for longer than the minimal 6 weeks

Indirect pulp therapy has been proved to be a valuable therapeutic procedure in treating asymptomatic teeth with deep carious lesions

procedure reduces the risk of direct pulp exposure and preserves pulp vitality. One may question the need to reenter the tooth if it has been properly selected and monitored, if a durable restoration is placed initially, and if no adverse signs or symptoms develop. Most clinicians are successfully practicing indirect pulp treatment without reentry

The appropriate procedure should be selected onlyafter a careful evaluation of the patient's symptoms,results of diagnostic tests, and conditions at the

exposuresite.

The health of the exposed dental pulp is sometimesdifficult to determine, especially in children, andthere is often lack of conformity between clinicalsymptoms and histopathologic condition

VITAL PULP EXPOSURE

The size of the exposure, the appearance of the pulp, and the amount of bleeding are valuable observations in diagnosing the condition of the primary pulp.

For this reason the use of a rubber dam to isolate the tooth is extremely important; in addition, with the rubber dam the area can be kept clean and the work can be done more efficiently

SIZE OF THE EXPOSURE AND PULPALHEMORRHAGE

The most favorable condition for vital pulp therapy is the small pinpoint exposure surrounded by sound dentin.

However, a true carious exposure, even of pinpoint size, will be accompanied by inflammation of the pulp, the degree of which is usually directly related to the size of the exposure

A large exposure—the type that is encountered when a mass of leathery dentin is removed—is often

associated with a watery exudate or pus at the exposure site.

These conditions are indicative of advanced pulp degeneration and often of internal resorption in the pulp canal.

In addition, excessive hemorrhage at the point of carious exposure or during pulp amputation is invariably associated with hyperemia and generalized inflammation of the pulp. When a generalized inflammation of the pulp is observed, endodontic therapy or extraction of the tooth is the treatment of choice.

Waste basket diagnosis?

Pulp-capping procedures should be limited to small exposures that have been produced accidentally by trauma or during cavity preparation or to true pinpoint carious exposures that are surrounded by sound dentin

Pulp capping should be considered only for teeth in which there is an absence of pain, with the possible exception of discomfort caused by the intake of food. In addition, there should be either no bleeding at the exposure site, as is often the case in a mechanical exposure, or bleeding in an amount that would be considered normal in the absence of a hyperemic or inflamed pulp

DIRECT PULP CAPPING

All peripheral carious tissue should be excavated before excavation is begun on the portion of the carious dentin most likely to result in pulp exposure.

Thus most of the bacterially infected tissue will have been removed before actual pulp exposure occurs

Calcium hydroxide?? remains the standard material for

pulp capping normal vital pulp tissue. The possibility of

its stimulating the repair reaction is good. A hard-setting calcium hydroxide capping material

should be used.

PULPOTOMY

The calcium hydroxide pulpotomy technique is recommended in the treatment of permanent teeth with carious pulp exposures when there is a pathologic change in the pulp at the exposure site.

This procedure is particularly indicated for permanent teeth with immature root development but with healthy pulp tissue in the root canals. It is also indicated for a permanent tooth with a pulp exposure resulting from crown fracture when the trauma has also produced a root fracture of the same tooth.

The procedure is completed during a single appointment.

Pulpotomy Technique for Permanent Teeth.

Only teeth free of symptoms of painful pulpitis are considered for treatment.

The procedure involves the amputation of the coronal portion of the pulp as described, the control of hemorrhage, and the placement of a calcium hydroxide capping material over the pulp tissue remaining in the canals

After 1 year, a tooth that has been treated successfullywith a pulpotomy should have a normal periodontalligament and lamina dura, radiographic evidence of acalcified bridge if calcium hydroxide was used as thecapping material, and no radiographic evidence ofinternal resorption or pathologic resorption

The pulp chamber is dried with sterile cotton pellets. Next, a pellet of cotton moistened with a 1:5 concentration

of Buckley's formocresol and blotted on sterilegauze to remove the excess is placed in contact withthe pulp stumps and is allowed to remain for 5 minutes.Because formocresol is caustic, care must be taken toavoid contact with the gingival tissues. The pellets arethen removed, and the pulp chamber is dried with newpellets. A thick paste of hard-setting zinc oxide—eugenolis prepared and placed over the pulp stumps. The toothis then restored with a stainless steel crown

Pulpotomy Technique for Primary Teeth

A partial pulpectomy may be performed on primary teeth

when coronal pulp tissue and the tissue entering the pulp canals are vital but show clinical evidence of hyperemia. The tooth may or may not have a history of painful

pulpitis, but the contents of the root canals should not show evidence of necrosis (suppuration).

In addition, there should be no radiographic evidence of a thickened periodontal ligament or of radicular disease

PARTIAL PULPECTOMY

Removal of the coronal pulp as described for the pulpotomy

Procedure

The pulp filaments from the root canals are removed with a fine barbed broach

A Hedstrom file will be helpful in the removal of remnants of the pulp tissue.The file removes tissue only as it is withdrawn and penetrates readily with a minimum of resistance

The canals should then be dried with sterile paper points

The canals should then be dried with sterile paper points.When hemorrhaging is controlled and the canals remaindry, a thin mix of unreinforced zinc oxide--eugenol pastemay be prepared (without setting accelerators), and paper

points covered with the material are used to coatthe root canal walls. Small Kerr files may be used to file the paste into the

walls. The excess thin paste may be removed with paper points and Hedstrom files.

A thick mix of the treatment paste should then be prepared,rolled into a point, and carried into the canal. Root canalpluggers may be used to condense the filling material intothe canals

The primary components of KRI paste are zinc oxide and iodoform.

The main advantages of KRI paste compared with zinc oxide—eugenol paste are that KRI paste resorbs in synchrony with primary roots and is less irritating to surrounding tissues if a root is inadvertently overfilled.

ZOE or KRI Paste?

The complete removal of the necrotic pulp from the root canals of primary teeth and filling them with an inert resorbable material so as to maintain the tooth in the dental arch.

Pulpectomy

Tooth planned for pulpotomy –uncontrolled pulpal haemorrhage

Any primary teeth in absence of its successor permanent tooth

Any deciduous teeth with severe pulpal necrosis

ContraindicationsCommunication between pulp chamber and

furcationInsufficient tooth structure

Indications

Single Visit

Multiple Visit

Types of Pulpectomy

Indication1.Planned Pulpotomy –Bleeding not controlled2.Large carious exposure with involvement of

radicular pulp but no periapical changes

Single Visit

1 • Anaesthetized and isolated with rubber dam

2 • Access Cavity prepared (Bur Drop)

3 • Deroofing of pulp chamber

4• All coronal and Radicular

pulp to be removed With broaches

Procedure

Access Cavity & Deroofing

5 •Irrigate with saline •Diagnostic File radiograph

6 •Enlargement of Canal to make space for obturating material •Irrigation to flush dentinal shaving and pulp remnants

7 •Dry canal with adsorbant papers •Obturate followed by restoration and SS Crown

Procedure(Contd.)

Single Visit Pulpectomy

??

Indications Infection/Abscess/SinusNon vital Primary Teeth Teeth with necrotic Pulp

Multiple Visit Pulpectomy

Procedure

Radiograph

Given by Castagnola1.Similar pattern of resorbtion as primary

teethShould not irritate periapical tissues Disinfecting PropertiesAny part of material crossing apex should get

resorbed easilyShould not discolour the toothRadioopaqueHarmless to permanent tooth germ

Ideal Requirement of Root Canal Filling Material

Incremental Pressure Syringe

Obturation

1.ZOE2.Iodoform3.Vitapex/Metapex-Ca(OH)2 + Iodoform+ Oil Additive4.Walkoff Paste-Parachlorophenol

+camphor+Menthol(PCM)5.KRI Paste-PCM+Iodoform6.Maisto Paste-

ZO+Iodoform+Thymol+chlorchlorophenol +Lanolin7.MTA8.Endoflas-Barium Sulfate + Ca(OH)2+Iodoform+ Zoe

Obturating Material

1. INTERNAL RESORPTION

FAILURES AFTER VITALPULP THERAPY

An alveolar abscess occasionally develops some months after pulp therapy has been completed. The tooth usually remains asymptomatic, and the child is unaware of the infection, which may be present in the bone surrounding the root apices or in the area of the root bifurcation. A fistulous opening may be present, which indicates the chronic condition of the infection

2.ALVEOLAR ABSCESS

3. EARLY EXFOLIATION OROVERRETENTION OF PRIMARYTEETH WITH PULP TREATMENTS