Management of Deep Carious Lesions in Deciduous Dentition


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Class presentation on Management of Deep Carious Lesions in Deciduous Dentition
Created: 5th June 2013

Published in: Health & Medicine

Management of Deep Carious Lesions in Deciduous Dentition

  1. 1. Management of Deep Carious Lesions in Deciduous Dentition Fatima A. A. Sidra K.
  3. 3. Signs & Symptoms • History of pain • Visibly carious defect • Presence of • Irritable behavior provoked or • Difficulty chewing spontaneous pain • Tooth may be tender to percussion • Radiolucency
  4. 4. Anatomical Challenges • • • • • • • • • • Small teeth, large pulp chambers Thinner enamel and dentin Wider, shorter dentinal tubules Variations in pulp size and shape Slender pulp horns Shallow pulp chambers Large apical foramina Increased number of accessory canals and foramina Roots flare outwards Roots are narrower mesiodistally
  5. 5. Primary Tooth
  7. 7. Radiographs
  8. 8. Pulp Vitality Testing Electric Pulp Testing Thermal testing (hot: guttapercha; cold: cold drink or air blast) Pulp Oximetry
  9. 9. Percussion
  10. 10. Caution • Children tend to become anxious • Possibility of false positive or false negative • Recently traumatized tooth may not give a reliable response
  12. 12. Indirect Pulp Therapy • “A procedure in which material is placed over a thin layer of carious dentin that, if removed, might expose the pulp.” • Recommended for teeth with deep carious lesion but no pulpal degeneration.
  13. 13. Objectives • • • • Arrest carious process Promote dentin sclerosis Stimulate tertiary dentin formation Remineralize carious dentin
  14. 14. Indications • Mild discomfort from chemical or thermal stimuli • Absence of spontaneous or nocturnal pain • Absence of lymphadenopathy • Normal gingiva • Normal tooth color • Normal lamina dura and PDL space
  15. 15. Contraindications • • • • • • • • • • • Sharp, continuous pain Nocturnal pain Excessive tooth mobility Tenderness upon percussion Parulis Tooth discoloration Carious pulp exposure Abnormal lamina dura or PDL space Furcal radiolucency Pulpal calcification Non-restorable tooth
  16. 16. Periodontal Abscess
  17. 17. Technique • Provide local anesthesia and isolate the tooth • Assess the preoperative appearance of the lesion • Remove all infected tissue • Leave behind hard discolored dentin • Cover with calcium hydroxide liner • Re-enter after 6-8 weeks and place restoration
  18. 18. Factors affecting Success • Signs and symptoms consistent with reversible pulpitis • Absence of other clinical or radiographic lesions • Complete removal of caries except where exposure would occur • Excellent seal and prevention of bacterial contamination
  19. 19. IPT vs Direct Pulp Capping? • DPC is not recommended for carious pulp exposure • Higher risk of failure in primary dentition • Al-Zayer, Straffon, Feigal and Welch found 95% success rate with IPT • Nearly all teeth exfoliate at normal times following IPT
  20. 20. Pulpotomy • “Surgical removal of coronal pulp followed by placement of medicament under aseptic conditions.”
  21. 21. Indications • • • • • • Pulp exposure greater than suitable for IPT No radicular pulpitis Presence of pain (vital pulp) Tooth has two-thirds of its root length No evidence of internal resorption No bone loss, fistulas, or abscesses
  22. 22. Contraindications • Root resorption exceeds 1/3rd of root length • Non-restorable crown • Highly viscous, sluggish or absent hemorrhage at radicular orifices • Marked tenderness to percussion • Excessive mobility • Persistent tooth ache and coronal pus
  23. 23. Technique • • • • • • • • • • Anesthetize and isolate with a rubber dam Remove all superficial caries Enter the pulp chamber with a no.330 bur Amputate pulp with either a spoon excavator or round bur (leave radicular pulp intact) Achieve hemostasis with cotton pellets Dip cotton pellet in formocresol (1:5 dilution) Place over pulp stumps for 5 minutes Provide base of ZnOEugenol over amputation sites and condense over pulpal floor Use a second layer to fill the access opening Final restoration: preferably, stainless steel crown
  24. 24. No.330 bur
  25. 25. Enter the Pulp Chamber Here it is being entered with a fissure bur.
  26. 26. Amputate the Coronal Pulp
  27. 27. Achieve Hemostasis
  28. 28. Apply Formocresol
  29. 29. Final Restoration
  30. 30. Post-operative Evaluation
  31. 31. Success (and failure) • Clinical success rate of 80-95% • Drops to 74-88% if radiographic results included • Failure if: – – – – – Pain Swelling Fistula Periapical or inter-radicular radiolucency Internal or external resorption • 38% of pulpotomized teeth exfoliate prematurely
  32. 32. Alternative Materials • Preservation: corticosteroids, gluteraldehyde,, ferric sulphate, electrosurgery, lasers • Remineralization: TGF-b, freeze dried bone, mineral trioxide aggregate
  33. 33. Formocresol vs Ferric Sulphate? • Peng, Ye, et al found equivalent success rates • Ferric sulphate produces local, reversible inflammatory response • No toxic or harmful effects documented in literature since 1856 • Formocresol is cytotoxic, and systemically distributed; systemic distribution has been shown to cause immune sensitization, mutations and cancer in animal studies • Formocresol is a known human carcinogen
  34. 34. Non-vital Pulp: Pulpectomy • Removal of non-vital cariously exposed pulp chamber roof and contents • Often preferred for primary anteriors • Especially difficult for primary molars
  35. 35. Indications • • • • • Irreversible pulpitis Abscess or sinus opening Presence of pus Children with hemophilia No pathologic resorption of alveolar bone
  36. 36. Contraindications • • • • • Internal resorption Excessive mobility Non-restorable tooth Perforated floor of pulp chamber Underlying dentigerous or follicular cyst
  37. 37. Technique • • • • • • • • Treat pathologies such as abscess first Once resolved: provide anesthesia and isolate Remove all caries Access the pulp chamber carefully Remove pulp Irrigate with saline, fill canals with ZnO paste Fill pulp chamber with cement Restore
  38. 38. Some points about Obturation • Properties of ideal root filling material for primary teeth: – Resorbable, antiseptic, non-inflammatory, non-irritant, radiopaque, easy to use, does not discolor tooth • No such material exists; CaOH+iodoform comes closest • Gutta percha or silver points are contraindicated as they interfere with physiologic primary root resorption • ZnOEugenol and CaOH with iodoform are used
  39. 39. Obturation Techniques for ZnOEugenol • With a reamer: – A thin mix is made and carried into the root canals with a no.15 or no.20 reamer – The reamer is then: • Rotated clockwise and simultaneously tilted 10-15 times (facilitates entry) • Moved vertically and simultaneously tilted 10-15 times (facilitates lateral condensation and coating of canals) • Withdrawn anticlockwise 5 times (material stays inside the canal) • With wet cotton: similar to above but a squeezed wet cotton pellet is used to condense the material • With a lentule-spiral: material is taken inside the canal with a lentulo or lentulo spiral • Endodontic pressure syringes, jiffy tubes and tuberculin syringes may also be used
  40. 40. Obturation Techniques for CaOH with Iodoform • Canal is dried and an injectable syringe is loaded • The syringe is taken inside the canal; the material is extruded slowly while the syringe is withdrawn • This technique may also be used with Calcium preparations lacking iodoform
  41. 41. Final Restoration: Stainless Steel Crown • “Prefabricated semi-permanent restorations for both primary and permanent teeth.” • Available in a range of sizes from 2 to 7.
  42. 42. Indications • Extensive carious lesion • Developmental defects, to prevent loss of vertical dimension • Following pulpal therapy in primary teeth • Severe bruxism • As abutments • In fractured primary teeth • Correction of anterior single tooth crossbite
  43. 43. Contraindications • Imminent exfoliation of primary teeth • Nickel allergy • Anterior teeth due to esthetic concerns
  44. 44. Technique • Anesthetize the patient and isolate the tooth • Reduce the occlusal surface by 1.5-2.0 mm with a no.69 or 169 bur • Round all sharp angles by moving the bur at 45 degrees • Reduce the proximal surfaces • Select a crown, seat it and mark its extension • Trim the crown to below the mark • Contour and crimp it • Cementation is frequently done with glass ionomer • Check the margins
  45. 45. Benefits • Longer life than Class II amalgam restoration (withstand fracture, don’t need to be repeated) • More cost-effective • Ease of delivery • Less time-consuming than multi-surface amalgam restorations
  46. 46. Hall Technique • A unique and minimally invasive approach to managing deep carious lesions in deciduous dentition by cementing metal crowns over them • Pioneered by Dr.Norma Hall; published in 2006 as a retrospective study • Does not require local anesthesia, tooth preparation or even caries removal! • Requires careful case selection, a high level of clinical skills, and excellent patient management
  47. 47. A Radical New Way of Thinking • Instead of removing bacteria, it changes their cariogenic potential by cutting them off from substrates • What about soft dentin? Natural remineralization once the carious process arrests • The dentinal pulp complex has greater reparative potential when subject to caries than previously thought
  48. 48. Exclusion Criteria • • • • • • Irreversible pulpal involvement Insufficient tooth tissue left to support crown Lack of patient co-operation Patient at risk of bacterial endocarditis Aesthetic concerns When there is no need for a Hall crown: – Teeth close to shedding – Tooth more easily treated with partial caries removal – Several non-cavitated lesions better treated with a fissure sealant – Cleanable, arrested lesion
  49. 49. Procedure • • • • • • • Protect the child’s ariway Size the crown Fill it with cement Locate and seat fully Wipe away excess Seat further by asking the child to bite on it Check and clean
  50. 50. Extraction • Indications: – – – – Infectious process can’t be arrested Lack of bony support Lack of root support Inadequate tooth structure remaining for restoration – Patient has medical factors that contraindicate saving the primary tooth (for eg: congenital cardiac defects, immune suppression)
  51. 51. THANK YOU!
  52. 52. References • • • • • • • • • • • • “Pediatric Dentistry: Principles and Practice” by MS Muthu, 2nd edition Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB: Indirect pulp treatment of primary posterior teeth: a retrospective study (2003) Marchi JJ, de Araujo FB, Fröner AM, Straffon LH, Nör JE: Indirect pulp capping in the primary dentition: a 4 year follow-up study (2006) Ribeiro CC, de Oliveira Lula EC, da Costa RC, Nunes AM: Rationale for the partial removal of carious tissue in primary teeth (2012) ”New Options for Restoring a Deep Carious Lesion” by Dr. Robert Rada  ( Farooq NS, Coll JA, Kuwabara A, Shelton P: Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth (2000) Vij R, Coll JA, Shelton P, Farooq NS: Caries control and other variables associated with success of primary molar vital pulp therapy (2004) “Management of Deep Carious Lesions in Children” by Dr. Nevine Waly ( “Pulp Therapy in Primary and Young Permanent Teeth” by Dr. Steven Chussid ( Casas, Kenny, Judd and Johnston: Do we still need formocresol in pediatric dentistry? (2005) Peng L, Ye L, Guo X, Tan H, Zhou X, Wang C, Li R: Evaluation of formocresol versus ferric sulphate primary molar pulpotomy: a systematic review and meta-analysis (2007) The Hall Technique: A User’s Manual (University of Dundee; )