Pulp Therapy in Primary and Young Permanent Teeth
| Steven Chussid DDS | ||
| Director, Division of Pediatric Dentistry | ||
| Columbia University School of Dental and Oral Surgery | ||
| Diagnosis and Treatment Planning |
| Smaller in all dimensions, but pulp relatively larger | |
| Enamel thinner | |
| Great variation in size and shape of pulp | |
| Pulp horns slender and closely follow external anatomy of tooth | |
| Pulp chambers shallow and easily perforated | |
| Apical foramina large and accessory canals may be large and numerous |
| History of pain | |
| Radiographic evaluation | |
| Clinical exam | |
| Evaluation of exposure site |
| Duration | ||
| Longer duration offers poorer prognosis | ||
| Frequency | ||
| Spontaneous pain is sign of poorer prognosis | ||
| Related frequency of pain to specific stimuli | ||
| Location | ||
| Localization often difficult in children | ||
| Spontaneous | |
| Nocturnal Irreversible Nonvital | |
| Constant | |
| Thermal | |
| Chemical Reversible Vital | |
| Intermittent | |
| Vital pulp therapy | ||
| Protective base | ||
| Indirect pulp therapy | ||
| Direct pulp cap | ||
| Pulpotomy | ||
| Non-vital pulp therapy | ||
| Pulpectomy | ||
| Extraction | ||
| Protective base | ||
| An appropriate material is placed to seal dentinal tubules and act as a protective barrier to minimize pulp injury and permit the pulp to heal | ||
| Objectives | ||
| Radiopaque base between restoration and dentin | ||
| Prevent adverse signs and symptoms | ||
| Preserve health and vitality of restored tooth | ||
| Indirect pulp therapy | ||
| In a tooth with a deep carious lesion, carious dentin is not completely removed. The decay process is sealed with glass ionomer. | ||
| Objectives | ||
| Place a radiopaque base over the remaining affected dentin, but not in contact with the pulp | ||
| Halt the carious process and allow pulp healing and reparative dentin formation | ||
| Avoid internal resorption or other pathologic changes as determined by periodic clinical and radiographic evaluation | ||
| The base that should be used for indirect pulp therapy in the primary dentition is glass ionomer. |
| Direct pulp capping | ||
| Direct pulp capping is not recommended for carious exposures in primary teeth | ||
| Can be considered for a small mechanical or traumatic exposure | ||
| Material of choice for pulp capping in primary teeth is light-cured CaOH | ||
| Objectives | ||
| Atraumatically place radiopaque base over exposed pulpal tissue | ||
| Permit pulp healing and reparative dentin formation | ||
| Prevent further pulpal damage and avoid clinical signs and symptoms | ||
| Avoid pathologic changes as determined by periodic radiographic evaluation | ||
| Objectives | ||
| To eliminate or neutralize the effect of pulp involvement by caries or trauma | ||
| To avoid future adverse clinical signs and symptoms | ||
| There should be no sign of internal resorption, periradicular breakdown, or other pathology | ||
| Pulpotomy | |||
| Administer local | |||
| Isolate | |||
| Excavate caries | |||
| Remove roof of pulp chamber to gain access | |||
| Inspect pulp chamber | |||
| Hemostasis | |||
| No evidence of coronal tissue tags | |||
| Treatment of remaining radicular pulp | |||
| Non-pharmacotherapeutic | ||
| Amputate infected or affected coronal pulp tissue | ||
| Treat remaining radicular pulp tissue with electrical or laser energy source in such a way as to reduce or eliminate the residual infectious process | ||
| Pharmacotherapeutic | |||
| Inductive | |||
| Treatment of exposed radicular tissue in such a way as to induce reparative dentin and maintain vitality and function of the majority of remaining pulp tissue | |||
| Non- inductive | |||
| Treatment of exposed radicular tissue with a medication or fixative aimed to eliminate or neutralize any infectious process | |||
| Pharmacotherapeutic | |||
| Inductive | |||
| Calcium hydroxide | |||
| Glass ionomer | |||
| Ferric sulfate | |||
| Non- inductive | |||
| Formocresol | |||
| Gluteraldehyde | |||
| Topical hemostatic solution | |
| Astringedent®- 15% |
| Powerful fixing agent | ||
| Antibacterial | ||
| Large molecules with less chance of systemic distribution | ||
| Concentration 2-5% | ||
| Most success with 4% | ||
| Binds to enzymes and proteins | |
| Suppresses cell activity | |
| Non diffusible and self limiting | |
| Non-immunologic, non-mutanogenic, non-carcinogenic | |
| Reported side effects include: radiographic changes, delayed tissue healing, enamel defects, tissue degeneration, autoantibody induction |
| Actions | ||
| Bactericidal | ||
| Fixation | ||
| Progressive fibrosis | ||
| Buckley’s formocresol usually used in 1:5 dilution | |
| Hemostasis of radicular pulp tissue should be obtained prior to applying formocresol | |
| Pellet should be blotted dry the placed in pulp chamber for 5 minutes | |
| A ZOE or glass ionomer base is then placed |
| Reported undesirable effects | |||
| Leakage into hard and soft tissue | |||
| Mutanogenic and carcinogenic potential has been shown in animal studies | |||
| Enamel hypoplasia | |||
| Over retention | |||
| Ectopic eruption of permanent teeth | |||
| Hypomineralization | |||
| Pulpectomy | |
| Extraction | |
| Objectives | ||
| Remove as much necrotic pulp as possible in context of succedaneous tooth and root architecture | ||
| Reverse infectious process allowing periradicular tissue to heal | ||
| No adverse signs or symptoms | ||
| No further breakdown of supporting structures | ||
| Demonstrate evidence of successful fill | ||
| Resorption of filling material and tooth structure should occur normally | ||
| Administer local | ||
| Isolate | ||
| Excavate caries | ||
| Remove as much caries as possible before entering pulp | ||
| Remove entire roof of chamber to gain access | ||
| Debride canals | ||
| Canals of primary teeth should not be enlarged | ||
| Irrigate canals-carefully | ||
| Sterile saline | ||
| Local anesthesia | ||
| Sodium hypochlorite | ||
| Obterate canals | ||
| ZOE or iodoform paste | ||
| Can be placed with hand condenser, syringe or lentulo spiral | ||
| Radiographic evaluation | ||
| Restore tooth | ||
| One step versus two step procedure | ||
| Should be strategic tooth | ||
| More signs and symptoms=less chance for success | ||
| Consider medical history | ||
| Immunocompromised? | ||
| Cardiac problems? | ||
| Bleeding problems? | ||
| Fistula is not a contraindication, but make prognosis poorer | ||
| Indirect pulp treatment | |
| Pulpotomy | |
| Pulpectomy | |
| Indications | ||
| Infectious process cannot be arrested | ||
| Bony support cannot be maintained | ||
| Inadequate tooth structure remaining for restoration | ||
| Remaining root structure will not support crown | ||
| Vital pulp therapy | ||
| Protective base | ||
| Indirect pulp therapy | ||
| Direct pulp capping | ||
| Pulpotomy | ||
| Apexogenesis | ||
| Non-vital pulp therapy | ||
| Apexification | ||
| Pulpectomy | ||
| Extraction | ||
| Protective base | ||
| An appropriate material is placed to seal dentinal tubules and act as a protective barrier to minimize pulp injury and permit the pulp to heal | ||
| Objectives | ||
| Radiopaque base between restoration and dentin | ||
| Prevent adverse signs and symptoms | ||
| Preserve health and vitality of restored tooth | ||
| Indirect pulp therapy | ||
| In a tooth with a deep carious lesion, carious dentin is not completely removed. The decay process is sealed with glass ionomer. | ||
| Objectives | ||
| Place a radiopaque base over the remaining affected dentin, but not in contact with the pulp | ||
| Halt the carious process and allow pulp healing and reparative dentin formation | ||
| Avoid internal resorption or other pathologic changes as determined by periodic clinical and radiographic evaluation | ||
| Restore tooth and observe, reentering only if symptoms arise | ||
| Objectives | ||
| Atraumatically place radiopaque base over exposed pulpal tissue | ||
| Permit pulp healing and reparative dentin formation | ||
| Prevent further pulpal damage and avoid clinical signs and symptoms | ||
| Avoid pathologic changes as determined by periodic radiographic evaluation | ||
| Indications | ||
| Small carious exposure | ||
| Short standing mechanical or traumatic exposure | ||
| Light cured calcium hydroxide | ||
| Preserves cell rich coronal pulp | |
| Increased healing potential | |
| Physiologic apposition of tertiary dentin | |
| Obviate need for RCT | |
| Natural color and translucency preserved | |
| Conservatively enlarge exposure site | |
| Remove 1-2 mm of pulp tissue | |
| Irrigate | |
| Evaluate health of pulp tissue | |
| Gently apply calcium hydroxide dressing |
| Inductive Pharmacotherapeutic | ||
| Treatment of exposed radicular tissue in such a way as to induce reparative dentin and maintain vitality and function of the majority of remaining pulp tissue | ||
| Objectives | ||
| To eliminate or neutralize the effect of pulp involvement by caries or trauma | ||
| To avoid future adverse clinical signs and symptoms | ||
| There should be no sign of internal resorption, periradicular breakdown, or other pathology | ||
| Goal-continued root development | |
| Remove coronal portion of pulp | |
| Place agent to preserve radicular vitality | |
| Monitor | |
| RCT? | |
| Goal-apical closure | |
| Remove necrotic tissue short of apexification site | |
| Irrigate | |
| Dry well | |
| Place thick paste of calcium hydroxide |
| Leave treatment paste for about 6 months | |
| Evaluate for “positive stop” in apical area | |
| RCT or retreat with CaOH | |
| Long term prognosis |
| Bactericidal | ||
| Low grade irritation inducing hard tissue barrier formation | ||
| Dissolve necrotic debris | ||