General pediatric dentistry for undergraduate

1. CLINICALS IN PEDIATRIC DENTISTRY

2. CONTENTS
• INDIRECT PULP CAPPING
• DIRECT PULP CAPPING
• PULPOTOMY
• APEXOGENESIS
• PULPECTOMY
• APEXIFICATION

3. INDIRECT PULP CAPPING

4. • Indirect pulp capping is defined as
a procedure where in small
amount of carious dentin is
retained in deep areas of cavity to
avoid exposure of pulp, followed
by placement of a suitable
medicament and restorative
material that seals off the carious
dentin and encourages pulp
recovery.(Ingle).

5. • Rationale
• Its rationale is that carious dentin consists of two distinct layers.
– An outer layer that is irreversibly denatured, infected, not
remineralizable and should be removed
– an inner layer that is reversibly denatured, not infected,
remineralizable and should be preserved.
• Removing the outer layers of the carious dentin, that contain the
majority of the microorganisms thus reducing the continued
demoralization of the deeper dentin layers from bacterial toxins,
and sealing the lesion to allow the pulp to regenerate reparative
dentin.

6. • Indications of IPC

7. • Contraindications of IPC

8. • Treatment Procedure

11. DIRECT PULP CAPPING

12. • It is defined by Kopel (1992)
as the placement of a
medicament or
nonmedicated material on a
pulp that has been exposed
in course of excavating the
last portions of deep
dentinal caries or as a result
of trauma.

13. • Objective
• To create new dentin in the area of the exposure
and subsequent healing of the pulp.
• Rationale
• To achieve a biologic closure of the exposure site
by deposition of hard tissue barrier (dentin
bridge) between pulp tissue and capping material
thus walling off the exposure site.

14. • Indications
• Small mechanical exposure
surrounded by sound dentin in
asymptomatic vital primary teeth
or young permanent teeth.
• Exposure should have bright red
hemorrhage that is easily
controlled by dry cotton pellet
with minimal pressure.
• True pin point exposure.

15. • Contraindications
• Severe toothache at night
• Spontaneous pain
• Tooth mobility
• Radiographic appearance of pulp,
periradicular degeneration.
• Excess of hemorrhage at the time of
exposure
• Serous exudate from the exposure
• External/internal root resorption
• Swelling/fistula.

16. • Treatment Procedure

18. • Histological Changes after Pulp
Capping
• After 24 hours: Necrotic zone
adjacent to calcium hydroxide paste
is separated from healthy pulp
tissue by a deep staining basophilic
layer.
• After 7 days: Increase in cellular and
fibroblastic activity.
• After 14 days: Partly calcified
fibrous tissue lined by odontoblastic
cells is seen below the calcium
protienate zone; disappearance of
necrotic zone.
• After 28 days: Zone of new dentin.

19. PULPOTOMY

20. • DEFINITION-:
• Pulpotomy can be defined as the complete
removal of coronal portion of the dental pulp ,
followed by placement of suitable dressing or
medicament that will promote healing &
preserve vitality of the tooth (Finn,1985 )

21. INDICATION-:
• Cariously exposed primary teeth, when their retention is more
advantageous than extraction.
• Vital tooth with healthy periodontium
• Pain, if present not spontaneous nor persists after removal of the
stimulus
• Tooth which is restorable
• Tooth with-2/3rd root length
• Hemorrhage from the amputation site is pale red & easy to control
• In mixed dentition stage primary tooth is preferable to a space

23. CONTRAINDICATION -:
• Evidence of internal resorption
• Presence of inter radicular bone loss
• Abscess , fistula in relation to teeth
• Radiographic sign of calcific globules in pulp chamber
• Caries penetrating the floor of pulp chamber
• Tooth close to natural exfoliation

24. CLASSIFICATION
I.Vital Pulpotomy techniques
1. DEVITALIZATION: (mummification & cauterization)
• Single Sitting:
1. Formocresol
2. Electrosurgery
3. Laser
• Two sittting:
1. Gysi triopaste
2. Easlick’s formaldehyde
3. Paraform devitalising paste

25. 2.PRESERVATION:
1.Glutaraldehyde
2.Ferric sulphate
3.MTA
3.REGENERATION: (inductive & reparative)
1.Bone morphogenic protein
II. Non-Vital pulpotomy techniques(mortal pulpotomy)
1.Beechwood cresol
2.formocresol

26. TREATMENT OBJECTIVES
• Amputate the infected coronal pulp
• Neutralize any residual infectious process
• Preserve the vitality of the radicular pulp.
• Avoid breakdown of periradicular area
• Treat remaining pulp with medicament
• Avoid dystrophic pulpal changes

27. A.DEVITALIZATION (SINGLE SITTING)
FORMOCRESOL PULPOTOMY TECHNIQUE
First advocated by SWEET(1930)
• FORMOCRESOL SOLUTION:
19% formaldehyde
35% cresol
15% glycerine (veichle)

28. Buckley’s solution: 1:5 conc. of formocresol
solution
• To prepare a 1:5 conc. of this formula-
• First thoroughly mix 3 part of glycerinre with
1 part of distilled water
• Then add 4 parts of this preparation to 1 part
Buckley’s formocresol & thoroughly mix again
• Mechanism Of Action: Formocresol prevents
tissue autolysis by bonding to protein. This is
reversible process and is accomplished
without changing the basic overall structure
of the protein molecules``

29. Single Visit Pulpotomy

31. • Step 1: Administration of local anesthesia
• Step 2: Apply a rubber dam
• Step 3: Use a sterile No.4 or 8 round bur (slow speed) to
remove all carious dentin, or a sharp spoon excavator
• Step 4: Place a No. 330' bur in the high-speed hand piece. Gain
occlusal access to the pulp chamber by preparing a Class 1
cavity preparation. It is better to make too large an opening
than one that is too small. Remove all overhanging enamel.
• Step 5: Excise the pulpal tissue to the orifices of the root canal.
Use a large spoon excavator to remove any remaining pulpal
tissue.The pulpal tissue should be amputated to the entrance
of the root canals.

32. • Step 6: After completing the amputation, evaluate the
hemorrhage. If the pulpal tissue has been removed
completely, hemorrhage should be minimal.A vital pulp with
minimal chronic inflammation should achieve hemostasis in
3 to 5 minutes.
• Step 7: Over the exposed pulp stump, place sterile cotton
pellet moistened (but not saturated) with formocresol, 20%
dilution.
• Step 8:Leave the formocresol in place for 1 minute, and then
remove the pellet. The pulp stump should appear blackish
brown .If there is bleeding, check for residual pulpal tissue.
Reapply formocresol for 2 minutes.
• Step 9: Fill the pulp chamber to about half its volume with a
thick mixture of zinc oxide-eugenol.
• Step 10:Prepare the tooth for a stainless steel crown

34. DEVITALIZATION PULPOTOMY(TWO
STAGE)
• Two stage procedure involves use of
paraformaldehyde to fix the entire coronal &
radicular pulp tissue.
• The medicaments used in this technique have
a devitalizing, mummifying and bactericidal
action.

35. • INDICATIONS
• .Profuse bleeding
• Difficulty in controlling bleeding
• Spontaneous pain
• Slight purulence discharge
• Thickened PDL

36. CONTRAINDICATION:
• Non restorable
• Necrotic
• Soon to be exfoliated

37. • Formula of each agent used are as follows:
1.GYSI TRIOPASTE FORMULA:
• tricresol 10 ml
• cresol 20 ml
• glyserine 4 ml
• paraformaldehyde 20 ml
• zinc oxide 60 gm

38. 2.EASLICK’S PARAFORMALDEHYDE FORMULA:
• paraformaldehyde 1 gm
• procaine base 0.03 gm
• powdered asbestos 0.05 gm
• petroleum jelly 125 gm
• carimine to colour

39. 3.PARAFORM DEVITALIZING PASTE:
• paraformaldehyde 1gm
• lignocaine 0.06 gm
• propylene glycol 0.05 ml
• carbowax 1500 1.30 gm
• carmine to colour

40. FIRST APPOINTMENT:
1. Isolation of the affected teeth with rubber dam
2. Preparation of the cavity , excavate the caries
3. On excavation of deep caries pulp exposure is encountered
, ensure that the exposed site is free of debris
4. Enlarge the cavity with round bur
5. Cotton pellet with paraformaldehyde is placed in the
exposure site ,seal it for 1 to 2 weeks

41. SECOND APPOINTMENT
1. In the second appointment pulpotomy is carried
with the help of L.A.
2. The roof of the pulp chamber is removed and
cleaned with saline and dried with cotton pellet
3. The pulp chamber is then filled with antiseptic
paste and the tooth is restored.

42. • Cvek’s Pulpotomy
• This is also called as calcium
hydroxide pulpotomy or young
permanent partial pulpotomy.
• Indicated in young permanent
teeth where the pulp is exposed
by mechanical or bacterial
means and the remaining
radicular tissue is judged vital by
clinical and radiographic criteria
whereas the root closure is not
complete.

44. Non Vital Pulpotomy (Mortal
Pulpotomy)
INDICATIONS
• When the inflammatory process affecting the
coronal pulp extends to the radicular pulp leading
to an irreversible change in the pulp tissue.
• When the pulp is completely non-vital, where
there may be an abscess present with or without
acute cellulites

45. I st visit:
• The necrotic coronal pulp is first removed, as recommended in the
vital pulpotomy technique.
• The necrotic debris in the pulp chamber is then cleared.
• If there is sufficient access to the radicular pulp canals then as much
as possible of the necrotic tissue is removed with a small excavator.
• A small pledget of cotton wool dipped in beechwood cresol is then
sealed into the cavity with temporary zinc oxide eugenol cement.

46. IInd visit:
• Usually 1-2 weeks later the dressing is removed, provided the signs and
symptoms of infection have cleared,
• The cavity is then restored in the same manner as used in the vital
pulpotomy technique.
• If it appears that there is no resolution of the symptoms then the
beechwood cresol should be replaced for a further 1-2 weeks,
• Other medcaments like formocresol and camphorated monochlorophenol
(Arnold and Rock, 1993) have been equally effective, at the second visit,
• after one to two weeks an antiseptic paste that is placed over the
radicular pulp remnants before restoring the tooth replaces the antiseptic
solution.

48. Apexogenesis

49. Apexogenesis
“Apexogenesis is defined as treatment of a vital pulp in
an immature tooth to permit continued root growth
and apical closure. A vital pulp of an immature tooth
may have a small exposure after trauma.” - Ingle

50. Apexogenesis
Vital pulp procedures which allow the continued
physiologic development and formation of the root
apex.
To bring about apical development and closure
Enhance continued root dentin formation

51. RATIONALE FOR APEXOGENESIS
 Root end development- normal pulp and minimal
inflammation.
 Pulp of immature teeth has significant reparative
potential.
 Pulp revascularisation and repair occurs more efficiently
tooth with an open apex.

52. GOALS OF APEXOGENESIS
• Sustaining a viable Hertwigs Sheath, thus allowing continued
development of root length for a more favorable crown to
root ratio.
• Maintaining pulpal vitality, thus allowing the remaining
odontoblasts to lay down dentin, producing a thicker root and
decreasing the chance of root fracture.
• Promoting root end closure, thus allowing a natural apical
constriction for root canal filling.
• Generating a dentinal bridge at the site of pulpotomy

53. INDICATIONS
• Immature tooth with incomplete root formation and
damage to the coronal pulp but with a presumed healthy
radicular pulp.
• Lack of abscess formation, excessive haemorrhage, no foul
odour
• Normal radiographic appearance
• Absence of sensitivity to percussion
• No abnormal responses to thermal stimuli

54. CONTRAINDICATIONS
• Avulsed and replanted or severely luxated tooth
• Severe crown root fracture that requires intraradicular retention
for
• restoration
• Tooth with an unfavorable horizontal root fracture (i.e. close to
the
• gingival margin)
• Carious tooth that is unrestorable

55. Procedure
• Anesthetize and isolate.
• After local anesthesia, rubber dam isolation, a conventional access cavity was
made with a high-speed bur using copious water spray.
• Strands of pulp and debris were removed coronal to the amputation site.
• Amputation of the coronal pulp at the cervical level was performed with a
sharp spoon excavator or a large sterile round bur.

56. • Bleeding of the pulp stump was controlled with saline on a cotton
pellet applied with gentle pressure.
• Calcium hydroxide powder was mixed with saline to a thick
consistency. The paste was carefully placed on the pulp stump
surface 1 to 2 mm thick.

57. Removal of coronal pulp
Haemostasis

58. Calcium hydroxide placement

59. Follow up
Time required
• 1 and 2 years depending on the degree of tooth
development at the time of the procedure.
• Recall every 3 months
• Clinically, the treatment was considered successful if
there were no signs or symptoms of pulp or periapical
disease (no history of pain and no clinical evidence of
swelling or sinus tract).

60. • Radiographically, the treatment was considered successful if there was
continued growth of the root and canal narrowing, and no widened
periodontal ligament, no periapical radiolucency and no internal or external
root resorption.

61. PULPECTOMY

62. • Pulpectomy is the total removal of pulp tissue
from the root canal
• Defined as complete removal of necrotic pulp
from the root canal of the primary tooth and
filling with an inert resorbable material so as
to maintain the tooth in the dental arch
• -by Mathewson (1995)

64. • Objectives of Pulpectomy
• Maintain the tooth free of infection
• Biomechanically cleanse and obturate the root
canals
• Promote physiologic root resorption
• Hold the space for the erupting permanent tooth.

65. • Indications of Pulpectomy
• A tooth previously planned for a pulpotomy that shows
• uncontrolled pulpal hemorrhage.
• Indicated for any primary tooth in absence of its
• permanent successor.
• Any deciduous tooth with severe pulpal necrosis provided
• there is no radiographic contraindication.
• Primary teeth with necrotic pulps and minimum of root
• resorption.
• Pulpless primary teeth with stomas.
• Pulpless primary teeth in hemophiliacs.
• Pulpless primary anterior teeth when speech, esthetics
• are a factor.
• Pulpless primary molars holding orthodontic appliance.

66. • Contraindications of Pulpectomy
• Communication between the roof of the pulp chamber
and the region of furcation.
• Insufficient tooth structure to allow isolation by
rubber dam and extra coronal restoration.
• Young patient with systemic illness such as congenital
ischemic heart disease, leukemia.
• Children on long-term corticosteroids therapy.
Excessive tooth mobility.

67. • Radiographic Contraindications
• • External root resorption.
• • Internal root resorption in the apical 3rd of the root.
• • Radicular cyst, dentigerous/follicular cyst in association
• with the primary tooth.
• • Inter-radicular radiolucency that communicates with the
• gingival sulcus.

69. • Single Visit Pulpectomy
Indication
• Large carious exposure with frank involvement of
radicular pulp but without any periapical changes.
• Primary teeth with inflammation extending beyond
coronal pulp, indicated by hemorrhage from the
amputated radicular stumps that is dark red, a slowly
oozing and uncontrollable

73. • Multiple Visit Pulpectomy
• Indications
• Indicated where infection, an abscess or chronic
sinus exists
• Nonvital primary teeth
• Teeth with necrotic pulp and periapical
involvement.

77. • Materials used for Obturation
• Zinc oxide eugenol
• Calcium hydroxide
• Iodoform
• Vitapex
• MTA
• Walkhoff paste
• KRI paste
• Maisto paste
• Endoflas

78. Zinc Oxide Eugenol
• Zinc oxide eugenol is said to have anti-inflammatory and
analgesic properties.
• Its limitations are slow resorption, irritation to the
periapical tissues, necrosis of bone and cementum and
alters the path of erupting teeth.
Iodoform Paste
• Iodoform has been added to various obturating material to
improve the properties as these pastes are bactericidal.

79. • Calcium Hydroxide
• In present generation calcium hydroxide has been used
as a prime root filling material for primary teeth. It is
commerciall available as Vitapex® and Metapex®.
• The rate of resorption of the material from within the
canals is faster than the rate of physiologic root
resorption.
• Studies have reported a success rate of 80 to 90
percent.

80. Vitapex
• favorable results with Vitapex® for root canal filling of primary teeth with a
success rate ranging from 96 to 100 percent.
Endofloss
• The advantages are that they are hydrophilic, so used n humid canals;
provide a good seal;
• has the ability to disinfect dentinal tubules due to its broad spectrum of
antibacterial activity, and is biocompatible.
• Ramar K et al. (2010) showed 100 percent clinical success
• and 81.1 percent radiographic success.

81. APEXIFICATION

82. • It is a method of inducing apical closure by
formation of a mineralized tissue in the apical
region of a nonvital permanent tooth with an
incompletely formed root apex

83. • Definition
• Apexification is a method of
inducing apical closure through
the formation of mineralized
tissue in the apical pulp region
of a nonvital tooth with an
incompletely formed root and an
open apex (Morse et al. 1990).

84. • Indication
• For nonvital permanent teeth with open apex
• Objective
• To induce either closure of open apical third of
root canal or the formation of an apical calcific
barrier against which obturation can be achieved.

85. • Materials Used
• Zinc oxide eugenol
• Metacresylacetate – compahorated parachlorophenol
• Tricalcium phosphate + β-tricalcium phosphate
• Resorbable tricalcium phosphate
• Collagen – calcium phosphate gel
• Calcium hydroxide
• Mineral trioxide aggregate.