Pulp therapy in primary and young Permanent TeethDr. Masar Mohammed
Pulp Therapy for Primary and Young Permanent TeethIntroduction Diagnostic Vital pulp therapy. - Pulp Capping a. Indirect pulp capping b. Direct pulp capping
The primary objective of pulp therapy is to maintain the integrity and health of the teeth and their supporting tissues.
Pulp: is defined as a special organ with a unique environment of the unyielding dentin surrounding a resistant, resilient soft tissue of mesenchymal origin reinforced with a ground substance. Morphology of pulp basically deals with configuration or structure of dental pulp.
Pulp cavity: Deciduous: o Dentin is thinner o Enamel is thinner o Pulp cavity is larger o Pulp horns are high in cusp region Permanent: o Dentin is thick o Pulp cavity smaller o Pulp horns lower in cusp region
Assessment (Cost-Benefit ratio)Preoperative assessment is essential todetermine whether pulp therapy or extractionis indicated.We should consider the following:1. Medical conditions.2. Overall assessment of the mouth (spacemanagement) and parental attitudes towarddental health.3. Assessment of the individual tooth.
1- Medical conditions:• Every effort should be made to conserveteeth in hemophilia• Children with systemic condition such ascongenital &acquired heart disease• Trauma of operative dentistry results intransient bacteraemia from the gingiva.• Also nephritis, leukemia, solid tumors,idiopathic and cyclic neutropenia
2- Overall assessment of the mouth(space management) and parentalattitudes toward dental health:For example, the dentist may invest more timeand effort to save a pulplly involved 2nd 1ry molar(E) in 4-year old child with unerupted 1stpermanent molars than to save a pulplly involved1st 1ry molar (D) in 8-year.Oral hygiene should be modifiedManagement of space lossThe dentist must evaluate parent attitude &improve it by motivation & education
3- Assessment of the individual tooth:Three considerations must be kept in minds:Can the tooth be restored if the pulp therapycan be performed? -Nothing was gained, ifpulp therapy is successful, and the crown ofthe involved tooth is non-restorable or theperiodontal structures are irreversiblydiseased. Stainless steel crown increase thechance of crown restoration after pulptherapy.
Does the dental age of the child (warrant) need retention of that particular tooth?- Dental age judge by root development ( when roots of primary molars have been more than half resorbed by the eruption of succedaneous teeth, extraction should be made.
If the pulp status is amenable to pulp therapy? - It will be answered in the diagnostic aid in the selection of teeth for vital pulp therapy.
Diagnostic1. Physical condition of the patient Congenital cardiac disease Immunosuppressed patients Children with nephritis, leukemia, tumors, cyclic neutropenia, uncontrolled diabetes.
Diagnostic2. History of painThe history of either presence or absence ofpain is not reliable in the differential diagnosisof the condition of the exposed primary pulpas it is in permanent teeth.
DiagnosticProvoked pain: is stimulated by heat, cold, sweets, air and chewing When the stimulus is removed the pain is reduced or disappears.These signs often indicate that the pulp is vital
Spontaneous pain usually wakes a child at night and may not relieve by analgesics. These signs usually indicate advanced, irreversible pulp damage
3. Clinical Examination Abnormal tooth mobilityTenderness to percussion SwellingSize of exposure and amount of pulpalbleeding4. Radiographic interpretation
Different types of Pulp therapy:1- Deciduous teeth:•Indirect pulp capping.•Direct pulp capping.•Pulpotomy.•Pulpectomy.
2- Young permanent teeth:•Indirect pulp capping.•Direct pulp capping.•Pulpotomy/ apexogenesis.•Apexification.
Vital pulp therapy Pulp capping: to maintain pulp vitally by placing a suitable dressing either directly on the exposed pulp (direct pulp capping) or on a thin residual layer of slightly soft dentine (indirect pulp capping).
Indirect pulp capping Indirect pulp capping is used when the tooth has a deep carious lesion. It may be successful in the primary dentition provided that the seal of the restoration is intact.
Indication: History: Absence of spontaneous pain. Clinical examination: 1. Large carious lesion in close proximity to pulp. 2. absence of lymphadenopathy . 3. normal color of tooth .
Radiographs: 1. Normal periodontal ligament space and lamina Dura . 2. No interradicular or per apical radiolucency .
Contraindication: History: a. prolong spontaneous pain and nocturnal tooth aches. b. sharp pain that persist after remove the stimulus. Clinically : a. excessive tooth mobility. b. tooth discoloration . C. non responsiveness to pulp testing technique.
Radiographic : a. large carious lesion with apparent pulp exposure. b. interrupted or broken lamina Dura . c. widened periodontal ligament space. d. radiolucency at the root apices or interradicular area.
Technique: 1. Remove caries 2. Clean the area.
3. Place Calcium Hydroxide 4. Place Zinc Phosphate cement 5. Permanent restoration or steel crown.
Direct pulp cappingDirect pulp capping is the procedure of covering the exposed vital pulp by a material which promotes healing of the vital pulp tissues. Pulp capping is not recommended if the diameter of the exposure is greater than a pin-point.
Indications: They should be limited to traumatic exposure during cavity preparation (mechanical exposure). Small pin point exposure surrounded by sound dentine. Mechanical or carious exposures in asymptomatic vital young permanent teeth. Recent exposure. Vital pulp free from infections.
No bleeding at the exposure site or an amount that would be considered normal. Normal radiographic findings.
Contraindications: Cariously exposed deciduous teeth The diameter of the exposure is greater than a pin-point There is a history of spontaneous pain. There is more than gentle bleeding from the exposure site.
Pathologic mobility. Pus or exudate from the exposure site. Fistulaswelling.
- Technique Isolate the tooth Prepare cavity in normal way, remove deep caries, gently with excavator, and clean the area. First removing peripheral caries, then proceeding towards the pulp A non-irritating solution such as normal saline or chloramines should be used for irrigation of the exposure sites before placement the capping material
Calcium hydroxide is the material of choice of capping exposed vital pulp tissue. When placed, the material should not beforced into the exposure site Zinc oxide-eugenol is placed over the calcium hydroxide layer as sealant then zinc phosphate cement and the permanent restoration is inserted at the same appointment.
N.B: Direct pulp capping is generally contraindicated for 1ry teeth because: Pulpal inflammation usually persists, increased cellular content, & results in total pulp necrosis or internal resorption, this by transforming of these cells into odontoclast and stimulation of osteoclast. Rapid spared of inflammation throughout the primary coronal pulp , due to increased blood supply.
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