pulp therapy in pediatric dentistry


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    1. 1. Pulp Therapy in Pediatric Dentistry
    2. 2. Indroduction • Despite the modern advances in prevention of dental caries and an increased understanding of the importance of maintaining the natural dentition, many teeth are still lost prematurely. • The primary objective of pulp treatment of an affected tooth is to maintain the integrity and health of oral tissues
    3. 3. • Additional reasons to preserve the integrity of the primary dentition are to 1. Reduce the likelihood of mesial drift and the resultant malocclusion. 2.Aid in mastication. 3.Preserve a pulpally involved primary tooth in the absence of a succedaneous tooth. 4.Prevent possible speech problems. 5.Maintain esthetics. 6.Prevent aberrant tongue habits 7.Maintain normal eruption time of the succedaneous teeth. 8.Prevent the psychological effects associated with early tooth loss.
    4. 4. Major function of pulp • As a review, the pulp performs five major functions: – Induction • Pulp participates in the induction and development of odontoblasts and dentin, which, when formed, induce enamel formation. – Formation • Odontoblasts form dentin. Dentin is formed continuously throughout the life of the tooth. Odontoblasts can also form a unique type of dentin in response to injury, such as occurs with caries, trauma, and restorative procedures.
    5. 5. Nutrition Via dentinal tubules, pulp supplies nutrients that are .essential for dentin formation and hydration Defense Odontoblasts form dentin in response to injury, particularly when the original dentin thickness has been compromised by caries, wear, trauma, or restorative procedures. Pulp also has the ability to elicit an inflammatory and immunologic response in an attempt to neutralize or eliminate invasion of dentin by caries-causing microorganisms and their .byproducts Sensation Through the nervous system, pulp transmits sensations mediated through enamel or dentin to .the higher nerve centers
    6. 6. • • • • • DIAGNOSIS OF PULP PATHOLOGY 1. PAIN An accurate history must be obtained of the type of pain, duration, frequency, location, spread, aggregating and relieving factors. Mode: is the onset spontaneous or provoked? Periodicity: do symptoms have temporal pattern or are they sporadic or occasional? Early pulpitis- symptoms seen in evening or after meal. • Frequency: have the symptoms persisted since they began/ have they been intermittent? • Duration: how long do symptoms last when they occur? • • • Quality of pain: Dull, aching - pain of bony origin. Throbbing, pounding, pulsing - pain of vascular origin. Sharp, recurrant, stabbing - pathosis of nerve root complexes, irreversible pulpitis. • • Postural change: pain accentuates by bending over, Time of day: pain in the mastigatory muscles on working may indicate occlusal disharmony or TMJ dysfunction or possible acute pulpalgia.
    7. 7. •Hormonal: menstrual tooth ache due to increase in body fluid retention. Teeth may ache and may become tender on percussion, symptoms disappear when cycle ends :-TYPES OF PAIN Momentary pain: Immediate stresses to hot or cold that disappear on the removal of the stimulus indicate that the .pathosis is limited to the coronal pulp Persistent pain: pain from thermal stimuli would indicate wide spread inflammation of the pulp, extending into the radicular .filaments Spontaneous pain: throbbing, constant pain that may keep the patient awake at night. This type of pain indicates pulpal (damage-irreversible pulpitis. (Ref B, pg 175 It suggests that pulpal disease has progressed too far and treatment confined to pulp chamber would be inadequate. ((Ref F, pg 336
    8. 8. Provoked pain: stimulated by thermal, chemical or mechanical irritant, and is eliminated when stimulus is removed. This sign indicates dentin sensitivity due to deep carious lesion or faulty restoration. The pulp is in the transition state and the condition is (usually reversible. (Ref E, pg 344 VISUAL AND TACTILE EXAMINATION. 2 This is one of the simplest tests, but most often is done casually during examination and as a result valid information is lost. A thorough visual, tactile examination of hard and soft tissue relies on checking of 3 C’s that is color, contour, (consistency. (Ref B, pg 175 MOBILITY. 3 Mobility in the primary tooth may result from physiological or pathological cause. Tooth mobility is directly proportional to the integrity of the attachment apparatus. Clinician should use two mouth mirror handles to apply alternating lateral forces in the facial lingual direction to observe the . degree of mobility of the tooth :-A measure of mobility is
    9. 9. 0-Horizntal_less than 0.2mm 1-Horizntal_0.2-1mm 2-Horizntal_1-2mm 3-horizntal and vertical_ more than 2mm PERCUSSION. 4 Pain from pressure on a tooth indicates that periodontal ligament is inflamed. A useful clinical test is to apply finger pressure to the tooth and check the child’s response by watching the eyes. (Ref B, ( pg 174-175 PALPATION. 5 Simple test done with fingertips using light pressure to examine tissue consistency and pain response. It determines presence, intensity and location of pain and presence of bony crepitus. (Ref B, (pg 174 RESTORABILITY. 6 Only a tooth which can be restored after endodontic therapy should .be considered for pulp therapy
    10. 10. PRESENCE OF DISCHARGING SINUS. 7 Indicates a non vital pulp (or an irreversibly diseased pulp) and (should be considered for non vital pulp therapy. (Ref A, pg 3 CHANGES IN COLOR. 8 (Discolored teeth may indicate a necrotic pulp. (Ref A, pg 03 RADIOGRAPHS. 9 Recent pre- operative radiographs are requisites to pulp therapy in primary and young permanent teeth. It demonstrates pathological conditions, position of succedaneous permanent tooth. These will dictate the decision on performing pulp therapy (for primary tooth. (Ref B, pg 174 One factor that must be remembered is that the lesion must be of sufficient dimensions to appear radio graphically and must .involve cortical bone :- Pathological entities that are observed are a. Pulp calcification: represents the pulp response to long standing lesion and is associated with pulp degeneration. This .contraindicates single visit pulpotomy
    11. 11. b. Internal resorption: it is associated with spontaneous pain at night and inflammation extending into radicular pulp. This contraindicates .single visit pulpotomy c. External resorption: pathologic resorption is invariably associated with no vital pulp and extensive inflammation in the supporting .tissues. The only viable treatment is pulpectomy or extraction d. Bone resorption: if minimum, pulpectomy is the choice but when (the born loss is extensive, extraction is indicated. (Ref H, pg 223 Current radiographs are essential to examining for caries and periapical changes. Interpretation of radiographs is complicated in children by physiologic root resorption of primary teeth and by .incompletely formed roots of permanent teeth The radiograph does not always demonstrate periapical pathosis, nor can the proximity of caries to the pulp always be accurately determined. What may appear as the intact barrier of secondary dentin overlying the pulp may always be a perforated mass of irregularly calcified and carious dentin overlying a pulp with extensive inflammation? The presence of calcified masses with in the pulp is .important to making a diagnosis of pulpal status
    12. 12. Pathologic changes in the periapical tissues surrounding primary molars are most often apparent in the bifurcation or trifurcation areas, rather than at the apexes (such as in permanent teeth). (Ref C, pg 803) :-Several additional factors worthy of consideration are as follows a. More than one view of the area of interest, each taken at different angle, is helpful for locating subtle changes (e.g., root (.fractures b. Pathologic changes should not be confused with the normal anatomy (e.g., mandibular canal, mental foramen, incisive fossa, (.nasopalatine canal c. Internal resoption is possible in permanent teeth but does not occur as .often as in primary teeth d. Treatment- induced calcification (i.e., bridging or apical closure) may be too thin to visualize radio graphically. (pg Ref (E, 525
    13. 13. PULPAL EXPOSURES AND HEMORRHAGE. 10 The size of the exposure, the appearance of the pulp, and the amount of hemorrhage are important factors in diagnosing the extent of inflammation in a cariously exposed pulp. A true carious exposure is always accompanied by pulpal inflammation. The pin point carious exposure may have pulpal inflammation varying from minimal to extensive to complete necrosis. However the massive exposure always has wide spread inflammation or necrosis and is not the candidate for any form of vital pulp therapy except in young, permanent teeth with incomplete root development. Excessive hemorrhage at an exposure site or during pulp amputation is evidence of extensive inflammation. These teeth should be (considered candidates for pulpectomy or extraction. (Ref C, 804 pg
    14. 14. PULP TESTING. 11 Pulp testing is widely used to assess vitality of mature permanent teeth but these are not reliable in deciduous teeth as fear of unknown makes the child patient apprehensive of the electric vitalometer and may give inaccurate results. Another reason is that newly erupted teeth may have incomplete innervations and there fore .may not give correct results Thermal test: This was first reported by jack in 1899 and it(1 • involved application of cold or heat to determine sensitivity to .thermal changes Cold test: It can be applied in several different ways like stream of cold air, cold- water bath, ethyl chloride, dry ice, pencil of ice. Agent is kept on the middle third of the facial structure of crown for 5 .seconds and the response is determined Heat test: These include warm sticks of temporary stopping, rotating dry prophycup, heated water bath, hot burnisher, hot gutta - percha .and hot compound
    15. 15. :-RESPONSE TO THERMAL TEST .No response- non vital pulp. 1 .Mild-moderate pain subsides in 1-2sec - normal. 2 Strong-momentary pain subsides in 1-2sec revesible. 3 .pulpitis Moderate to strong painful response that lingers. 4 for several seconds or longer after the stimulus has .(been removed-irreversible pulpitis –2)Electrical Pulp Testing is NOT reliable in primary teeth (due to the false patient’s response). ANESTHETIC TESTING. 12 If the patient continues to have vague, diffuse, strong pain and prior testing has been inconclusive, intra ligamentary anesthetic may be used .to identify the source of pain TEST CAVITY. 13 This test is performed when other methods have failed. The test cavity is made by drilling the enamel dentin junction of an unanesthetized tooth using a slow speed hand piece without water .coolant. If patient feels sensitivity it is indication of pulp vitality
    16. 16. PHYSIOMETRIC TEST. 14 It describes such tests that assess the state of the pulpal circulation, rather than the integrity of the nervous tissue thus providing valuable .information PHOTOPLETHYSMOGRAPHY. 15 This method involves passing light on the tooth and measuring the existing wavelength using a photocell and galvanometer. If a tooth with an intact blood supply is warmed there should be vascular .dilatation, and this would register as a current from the photo cell THERMOGRAPHY. 16 A hot object emits infrared radiation in proportion to its temperature. Measurement of this radiation may provide information (on pulpal circulation. (Ref B, pg 175-176 PULP HAEMOGRAM. 17 It was suggested that taking the first drop of blood from an exposed pulp and subjecting it to differential white cell count might be useful .in diagnosis of pulpal conditions
    17. 17. DUAL WAVELENGTH SPECTROMETRY. 18 Measures blood oxygenation changes within the capillary bed of .dental tissue and thus is not dependent on a pulsatile blood flow HUGES PROBEYE CAMERA. 19 This is used in detecting temperature changes as small as 0.1◦c .hence can be used to measure pulp vitality experimentally LIQUID CRYSTAL TESTING. 20 Cholesteric fluid crystals have been used to show the difference in tooth temperature with vital pulp being hotter and necrotic pulp (being cooler. (Ref B, pg 176-177 LASER DOPPLER FLOWMETRY. 21 The laser doppler flowmeter, developed in 1970s to measure the velocity of red blood cells in capillaries, is a non invasive, objective, painless alternative to traditional neural- stimulation methods, and (therefore is a promising test for young children. (Ref I, pg 332
    18. 18. A near infrared with a wavelength of 632.8 nm is produced by 1mw helium neon laser with in the flowmeter and this is transmitted along a flexible fiber optical conductor inside a specially designed round dental probe with a diameter of 2 mm. Enamel prisms and dentinal tubules guide the light to the pulp, where it is scattered both by static tissues by moving RBC’s. A fraction of backscattered light from the tooth is returned to the flowmeter along the pair of afferent optical fibers within the probe. The scattered light beams from moving RBC’s will be frequently shifted, while those from static tissue are unshifted indicating non vital pulp.
    19. 19. PULSE OXIMETRY. 22 It is proven atraumatic method of measuring vascular health by evaluating oxygen saturation. Pulse oximetry is based on placing arterial blood between light source and detector. Light source diode emits both infrared and red light, which is received by a photo -detector diode. Blood pulsating through the vessel changes the light path, which modifies the amount of detected . light. This determines the pulse rate EVALUATION OF TREATMENT PROGNOSIS BEFORE PULP THERAPY The diagnostic process of selecting teeth that are good candidates :-for vital pulp therapy has at least two dimensions Dentist must decide that the tooth has a good chance of . 1 . responding favorably to the pulp therapy The advisability of performing the pulp therapy and restoring the . 2 .tooth must be weighed against extraction and space management
    20. 20. The level of patient and parent cooperation and motivation in . 3 .receiving the treatment The level of patients and parent desire and motivation in maintaining . 4 .oral health and hygiene The caries activity of the patient and overall prognosis of oral . 5 .rehabilitation The degree of difficulty anticipated in performing the pulp therapy . 6 .in particular case Space management issues resulting from previous extractions, . 7 preexisting malocclusion, ankylosis, congenitally missing teeth, and space loss caused by extensive carious destruction of teeth and .subsequent drifting Excessive extrusion of pulpally involved tooth resulting from the . 8 (absence of opposing teeth (Ref D, pg 392
    21. 21. Pulp therapy in pediatric dentistry can be divided into • Vital pulp therapy pulp capping pulpotomy Non-Vital pulp therapy pulpoctomy apexogenesis -Direct -indirect - Devetalization -Preservation -Regeneration -Complete -partial apexification pulpectomy Non-Vital pulpotomy -Beachcresal -Formacresol
    22. 22. INDIRECT PULP CAPPING • DEFINITION • The procedure involving a tooth with a deep carious lesion where carious dentin removal is left incomplete, and the decay process is treated with a biocompatible material for sometime in order to avoid pulp tissue exposure is termed indirect pulp capping •INDICATIONS The teeth when pulpaly inflammation has been judged to be . 1 minimal and complete removal of caries would cause pulp exposure. ((Ref I, pg336 .Mild pain associated with eating. 2 .Negative history of spontaneous, extreme pain. 3 .No mobility. 4 When pulp inflammation is seen as nominal and there is a definite . 5 .layer of affected dentin after removal of infected dentin .Normal lamina dura and PDL space. 6
    23. 23. No radiolucency in the bone around the apices of the roots or in . 7 .the furcation Deep carious lesion, which are close to, but not involving he pulp . 8 in vital primary or young permanent teeth CONTRAINDICATIONS .Any signs of pulpal or periapical pathology. 1 Soft leathery dentin covering a very large area of the cavity, in a . 2 (non restorable tooth. (Ref I, pg 336 .Sharp, penetrating pulpalgia indicating acute pulpal inflammation . 3 .Prolonged night pain. 4 .Mobility of the tooth. 5 . Discoloration of the tooth. 6 .Negative reaction of electric pulp testing. 7 .Definite pulp exposure. 8 . Interrupted or broken lamina dura. 9 .Radiolucency about the apices of the roots. 10
    24. 24. OBJECTIVES The restorative material should seal completely the involved . 1 .dentin from the oral environment .The vitality of the tooth should be preserved. 2 No prolonged post-treatment signs or symptoms of sensitivity, . 3 .pain or swelling should be evident The pulp should respond favourably and tertiary dentin or. 4 reparative dentin should be formed, as evidenced by radiographic .evaluation There should be no evidence of internal resorption or other. 5 (pathologic changes. (Ref I, pg 336 .Arresting of carious process. 6 .Promoting dentin sclerosis. 7 .Stimulating formation of tertiary dentin. 8 . Remineralization of carious dentin. 9
    25. 25. Theory of indirect pulp capping • Indirect pulp therapy is a technique for avoiding pulp exposure in the treatment of teeth with deep carious lesions in which there exists no clinical evidence of pulpal degeneration or periapical disease. • The procedure allows the tooth to use the natural protective mechanisms of the pulp against caries. It is based on the theory that a zone of affected, demineralized dentin exist between the outer infected layer of dentin and the pulp. When the infected dentin is removed, the affected dentin can remineralize and the odontoblasts form reparative dentin, thus avoiding pulp exposure • • Kopel has identified three distinct layers in active caries:1. Necrotic, soft dentin not painful to stimulation and grossly infected with bacteria. 2. Firm but softened dentin, painful to stimulation but containing few bacteria. 3. Slightly discolored, hard, sound dentin containing few bacteria and painful to stimulation. • •
    26. 26. In indirect pulp therapy the outer layer of carious dentin are removed. Thus most of the bacteria are eliminated from the lesion. When the lesion is sealed, the substrate on which the bacteria act to produce acid is also removed. Exposure of the pulp occurs when the carious process advances faster than the reparative mechanism of the pulp. Care must also be taken in removing the caries to avoid exposure of the pulp. With the arrest of caries process, the reparative mechanism is able to lay down additional dentin and avoid a pulp exposure. If the preliminary caries removal is successful, the inflammation will be resolved and deposition of reparative dentin beneath the caries will allow subsequent eradication of the remaining caries without pulpal exposure. The rate of reparative dentin deposition has been shown to average 1.4um/day after cavity preparation in dentin of human teeth. The rate of reparative dentin formation decreases markedly after 48days. Dentin is laid down fastest during the first month after IPC and the rate diminishes steadily with time.
    27. 27. If the initial treatment is successful, when the tooth reentered the caries appears to be arrested. The color changes from deep red rose to light grey to light brown. The texture changes from spongy and wet to hard, and the caries appears dehydrated. The goal is to promote pulpal healing by removing the majority of the infected bacteria and sealing the lesion, which stimulates sclerosis of dentin and reparative dentin formation. As the procedure was originally practiced, after a minimum of 6 weeks the zinc oxide and eugenol, calcium hydroxide, and remaining carious dentin are removed. It was intended that the second instrumentation of the tooth would confirm the intended goals and would be followed by placement of a permanent restoration. For the experienced clinician using good case selection, however it may be preferable to avoid second instrumentation (and the potential (.risk of pulpal exposure
    28. 28. Periodic follow up of the tooth’s history along with pulp vitality testing and radiographic assessment is necessary. Indirect pulp capping is the excellent and conservative treatment option for some deep carious lesions in permanent teeth (especially if it avoids complete root canal treatment). It should be emphasized that the indirect pulp cap procedure is intended to avoid direct caries exposure.
    29. 29. TECHNIQUE OF INDIRECT PULP CAPPING First appointment Use local anesthesia and isolation with rubber dam. ↓ Establish cavity outline with high speed hand piece. ↓ Remove the superficial debris and majority of the soft necrotic dentin with slow speed hand piece using large round bur. ↓ Stop the excavation as soon as the firm resistance of sound dentin is felt. ↓ Periapical carious dentin is removed with a sharp spoon excavator. ↓ Cavity flushed with saline and dried with cotton pellet. ↓ Site is covered with calcium hydroxide. ↓ Remainder cavity is filled with reinforced ZOE cement.
    30. 30. Second appointment (6-8 weeks later) Between the appointment history must be negative and temporary restoration should be intact. ↓ Take a bitewing radiograph and observe for sclerotic dentin. ↓ Carefully remove all temporary filling material. ↓ Previous remaining carious dentin will have become dried out, flaky and easily removed. ↓ The area around the potential exposure will appear whitish and may be soft; which is predentin. Do not disturb this area. ↓ The cavity preparation is washed out and dried gently. ↓ Cover the entire floor with calcium hydroxide. ↓ Base is built up with reinforced ZOE cement or GIC. ↓ Final restoration is then placed
    33. 33. INFECTED VS AFFECTED DENTIN Infected dentin ▪Highly demineralized ▪Unremineralizable ▪Superficial layer ▪Lacking sensation ▪Stained by 0.5% fuschin or i.e. 1.0% acid red solution ▪Ultrastructure- intertubular dentin greately demineralized, with irregular scattered crystals. Presence of deteriorated collagen fibers that have only distinct cross bands and no interbands. ▪Should be excavated Affected dentin ▪Intermediately demineralized ▪Remineralizable ▪Deeper layer ▪Sensitive ▪Does not stain ▪Ultrasyructure: intertubular dentin Partially demineralized, but apatitie crystals bound like fringes to the Sound collagen fibers with distinct Cross bands and interbands. ▪Should be left remineralize.
    34. 34. N.Bs 1)In its classical application, the indirect pulp cap was covered with zinc oxide-eugenol cement, and following several weeks' observation, the cavity was re-entered to remove all remaining softened dentine. More commonly, the calcium hydroxide pulp cap is simply covered with a layer of hard setting cement and the tooth permanently restored at the same visit. Periodic clinical and radiographic review is then undertaken to monitor the pulp respons. 2)the presence of carious enamel and dentin at the margins of the cavity will prevent the establishment of an adequate seal (extremely important) during the period of repair.
    35. 35. DIRECT PULP CAPPING DEFINITION: The procedure in which the small exposure of the pulp, encountered during cavity preparation or following a traumatic injury or due to caries, with a sound surrounding dentin, is dressed with an appropriate biocompatible radiopaque base in contact with the exposed pup tissue prior to placing a restoration is termed as direct pulp capping. INDICATIONS 1. Light red bleeding from the exposure site that can be controlled by cotton pellet. 2. Traumatic exposures in a dry, clean field, which report to the dental office within 24 hours. (Ref I, pg 336) 3. Mechanical exposures less than I sq mm, surrounded by clear dentin in an asymptomatic vital deciduous tooth. 4. Mechanical or carious exposures less than 1 sq mm in an asymptomatic vital young permanent tooth. (Ref H, pg 225)
    36. 36. 5. Small pulp exposures produced during cavity preparation i.e. pin point exposure surrounded by sound dentin. 6. When the tooth is not painful, with the exception of discomfort caused by food intake. 7. Minimal or no bleeding from the exposure site. CONTRAINDICATIONS 1. Large pulp exposures. 2. Presence of caries surrounding the exposure site. 3. Excessive bleeding indicates hyperemia or pulpal inflammation. 4. Pain at night. 5. Spontaneous pain. 6. Tooth mobility. 7. Thickening of periodontal membrane. 8. Intraradicular radiolucency. 9. Purulent or serous exudates. 10. Swelling. 11. Fistula. 12. Root resorption. 13. Pulpal calcification.
    37. 37. OBJECTIVES 1. The vitality of tooth should be maintained. 2. No prolonged post-treatment signs or symptoms of sensitivity, pain or swelling should be evident. 3. Pulp healing and tertiary dentin formation should result. 4. There should be no pathologic change. 5. To create new dentin in the area of the exposure and subsequent healing of pulp. TREATMENT CONSIDERATIONS :Debridement Necrotic and infected dentin chips have to be removed else they will invariably be pushed into the exposed pulp during last stages of caries removal and impede healing and increase pulpal inflammation. Therefore it is prudent to remove all peripheral caries. If exposure occurs, non irrigating solution of normal saline or anesthetic solution is used to cleanse the area and keep he pulp moist.
    38. 38. TECHNIQUES OF DIRECT PULP CAPPINGRubber dam provides only means of working in a sterile environment, so it has to be used. ↓ Once an exposure is encountered, further manipulation of pulp is avoided. ↓ Cavity should be irrigated with saline, chloramines T or distilled water. ↓ Hemorrhage is arrested with light pressure from sterile cotton pellets. ↓ Place the pulp capping material, on the exposed pulp with application of minimal pressure so as to avoid forcing the material into pulp chamber. ↓ Place temporary restoration. ↓ Final restoration is done after determining the success pulp of capping which is done by determination of dentinal bridge, maintenance of pulp vitality, lack of pain and minimal inflammatory response.
    39. 39. HISTOLOGICAL CHANGES AFTER PULP CAPPING • These were illustrated by Glass and Zander in 1949. • After 24 hours: Necrotic zone adjacent to ca (oh) 2 pastes 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
    40. 40. FEATURES OF SUCCESSFUL PULP CAPPING 1. Maintenance of pulp vitality. 2. Lack of undue sensitivity or pain 3. Minimal pulp inflammatory response. 4. Ability of the pulp to maintain itself without progressive degeneration. 5. Lack of internal resorption and intaradicular pathosis.
    41. 41. MEDICATIONS AND MATERIAL USED FOR PULP CAPPING -The greatest benefit of Ca(OH)2 is the stimulation of reparative dentin bridge, due to a high alkalinity, which leads to enzyme phosphatase being activated and thus releasing of inorganic phosphate from the blood (calcium phosphate) leading to formation or dentinal bridge. It also has an antibacterial action. -When calcium hydroxide is applied directly to pulp tissue, there is necrosis of the adjacent pulp tissue and inflammation of the contiguous tissue. Compounds of similar alkalinity cause liquefaction necrosis when applied to pulp tissue. -Internal resorption may occur after pulp exposure and capping with calcium hydroxide. -Calcium from Dentin Bridge comes from the blood stream. The action of calcium hydroxide to form Dentin Bridge appears to be a result of low grade irritation in the underlying pulpal tissue after application
    42. 42. Isobutyl cyanoacrylate: It is an excellent pulp capping agent because of its haemostatic and bacteriostatic properties; at the same time it causes less inflammation than calcium hydroxide. But it can not be regarded as an adequate therapeutic alternative to calcium hydroxide since it does not produce a continuous barrier of a reparative dentin following application of the exposed pulp tissue. Disadvantage is that it is cytotoxic when freshly polymerized. Denaturated albumin: This protein has calcium binding properties. If a pulp exposure is capped with a protein, the protein may become a matrix for calcifation, thereby increasing the chances of biologic obliteration. Laser: ANDREAS MERITZ 1n 1998 evaluated the effect of direct pulp capping. Bone morphogenic protein (BMP): The demineralized bone matrix could stimulate new bone formation when implanted to ectopic sites such as muscles. The implications for pulp therapy are immense as it is capable of inducing reparative dentin.
    43. 43. Mineral trioxide aggregate (MTA): -TORABINEJAB described the physical and chemical properties of MTA in 1995. it is ash colored powder made primarily of fine hydrophilic particles of tricalcium aluminates, tricalcium silicate, silicate oxide, tricalcium oxide and bismuth oxide is added for radio-opacity. -When compared with calcium hydroxide, MTA produced significantly more dentinal bridging in shorter period of time with significantly less inflammation. Dentin deposition has began earlier with MTA. -The disadvantage of this technique is that 3 to 4 hours is needed for setting of MTA after placement. -The procedure involves placing MTA directly over the exposure site and sealing the tooth temporarily to allow the cement to harden. The tooth is later reentered and permanently sealed over the set MTA with an etched, dentin bonding agent and composite resin to prevent future bacterial micro leakage. :Properties It is biocompatible material and its sealing ability is better than . 1 .that of amalgam or ZOE .Initial pH is 10.2and set pH is 12.5. 2 .The setting time of cement is 4 hours. 3
    44. 44. The compressive strength is 70 MPA, which is comparable to that of . 4 .IRM Low cytotoxity- it presents with minimal inflammation if extended . 5 .beyond the apex Action: It has ability to stimulate cytokine and interleukins release from blood cells, indicating that it actively promotes Advantages over Ca(oH)2 1. 2. 3. 4. 5. Thicker dentinal bridge Less inflammation Less hyperemia Less pulpal necrosis Dentin bridge formation at faster rate
    45. 45. APPLICATIONS 1. 2. 3. 4. 5. Root end fillings DPC Apexification pulpotomy perforation repairs
    46. 46. LIMITATION OF DIRECT PULP CAPPING IN PRIMARY TEETH Caries process or pulp capping material may stimulate the undifferentiated mesenchymal cells that differentiate into odontoblastic cells which lead to internal resorption. High cellular content, abundant blood supply and consequently faster inflammatory response and poor localization of infection are some of the reasons that direct pulp capping is contraindicated in .primary teeth Calcification, chronic inflammation, necrosis and intraradicular . involvement
    47. 47. POINTS TO BE KEPT IN MIND DURING PROCEDURE OF IPC AND DPC -Staining carious lesion was proposed many years ago by FUSAYAMA to allow differentiation of remineralizable and non remineralizable dentin. These harmless dyes demonstrate non remineralizable dentin. Parts of the tooth that remain stain should be removed. Any tooth structure that does not stain can remain, since this soft dentin will remineralize. Examples of some brands of caries dentin test; caries detector, caries funder and sable seek. This method will limit the removal of decay to non - remineralizable dentin during divert and indirect pulp capping . -Location of the pulp exposure is an important consideration in the prognosis. If the exposure occurs on the axial wall of the pulp, with the pulp tissue coronal to exposure site, this tissue may be deprived of its blood supply and undergo necrosis, causing a failure. Then a pulpotomy or pulpectomy should be performed rather than a pulp cap.
    48. 48. -When pulp capping is done, care must be exercised while removing the deep carious dentin over the exposure site to keep to a minimum the pushing of dentin chips into the remaining pulp chamber. Studies have shown decreased success when dentin fragments are forced into the underlying pulp tissue. Inflammatory reaction and formation of dentin matrix are stimulated around these dentin chips. In addition, microorganisms may be forced into the tissue. The resulting inflammatory reaction can be so severe as to cause a failure. -Marginal seal over the pulp capping procedure is of prime importance since it prevents the ingress of bacteria and reinfection. -After pulpal injury, reparative dentin is formed as part of repair process. Although formation of Dentin Bridge has been used as one of the criteria for judging successful pulp capping, bridge formation can occur in teeth with irreversible inflammation. Moreover, a successful pulp capping has been reported without the presence of reparative dentin bridge over the exposure site.
    49. 49. PULPOTOMY DEFINATION-: Finn (1995) defined it as the complete removal of the coronal portion of the dental pulp,followed by placement of a suitable dressing or medicament that will promote healing and .preserve vitality of the tooth INDICATION-: 1)Carious or mechanical exposure of vital primary teeth and young permanent teeth,where inflammation is restricted to coronal pulp only. 2) History of only spontaneous pain. 3) Hemorrhage from exposure sites bright red and be controlled.
    50. 50. 4) 5) 6) 7) Absence of abscess or fistula. No interradicular bone loss. No interradicular radiolucency. At least 2/3rd of root length still present to ensure reasonable functional life. 8) In young permanent tooth with vital exposed pulp and incompletely formed apices
    51. 51. -:CONTRAINDICATION 1. History of spontaneous pain 2. Swelling 3. Fistula 4. Tenderness to percussion 5. Pathological mobility 6. External/internal root resorption 7. Periapical or interradicular radiolucency 8. Pulp calcifications 9. Pus or exudate from exposures site 10. Uncontrolled bleeding from the amputated pulp stump 11. Root resorption more than 1/3rd of root length 12. Large carious lesion with non-restorable crown 13. Highly, viscous, sluggish hemorrhage from canal orifice, which is uncontrollable 14. Medical contraindications like heart disease, immunocompromised patient
    52. 52. Calssification Of Vital Pulpotomy techniques Types Other name Features Examples Devitalization Mummification , cauterization It is intended to destroy or mummify the vital tissue. Single sitting •Formocresol •Electrosurgery •Laser Two stage •Gysi triopaste •Easlick’s formaldehyde •Paraform devitalizing paste Preservation Minimal devitalization, noninductive This implies maintaining the maximum vital tissue,with no induction of reparative dentin. •ZnO Eugenol •Glutaraldehyde •Ferric sulphate Regeneration Inductive, reparative This has formation of dentin bridge. •Ca(OH)2 •Bone morphogenic protein •
    53. 53. NON-VITAL PULPOTOMY Mortal pulpotomy ------ It is done in •Beechwood cresol compromised •formocresol cases Depending upon the size of exposure 1. Partial pulpotomy (shallow, low level or Cvek’s pulpotomy) 2. Cervical pulpotomy (deep, high level total or conventional pulpotomy) Classified depending upon the number of visits 1. Single visit pulpotomy 2. Multiple visit pulpotomy TREATMENT OBJECTIVES-: 1. 2. 3. 4. 5. 6. Amputate the infected coronal pulp, Neutralize any residual infectious process, Preserve the vitality of the rdicular pulp. Avoid breakdown of periradicular area Treat remaining pulp with medicament Avoid dystrophic pulpal changes
    54. 54. Vital Pulpotomy (A.DEVITALIZATION (SINGLE SITTING FORMOCRESOL PULPOTOMY Formocresol was introduced by Buckley in 1904 and since then a lot of modifications have been tried and advocated regarding the techniques of formocresol pulpotomies •History •Sweet (1930)- formulated the technique and was a multivisit formocresol technique. •Doyle (1962)- advocated 2 sitting procedure •Spedding (1965)- Gave 5 minute protocol •(partial devitilization). •Venham (1967)- Proposed 15 seconds procedure. •Current concept uses 4 minutes of application time. Formocresol by its chemical nature is the combination of : -Formaldehyde – 19% -Cresol – 35% - Glycerin – 19% -Water
    55. 55. Success following formocresol pulpotomy:Clinical success = 90100%Histological success = 70-80%Success depends on accurate .selection of the case Mechanical of action : it prevents tissue autolysis by bonding to the proteins. This bonding is of peptide groups of side chain amino acids and is a reversible process accomplished without changing the basic .structure of protein molecules Histological changes : These were demonstrated by Mass and .Zilbermann in 1933 and also by Massler and Mansokhani in 1959 .Immediately : Pulp becomes fibrous and acidophilic :After some days : Three zones appear •A broad eosinophilic zone of fixation •A broad pale staining zone of atrophy with poor cellular definition •Broad zone of inflammatory cells extending cells extending apically from the border of the pale staining zone year : Progressive apical movement of these zones with 1 only acidophillic zone left at the end of 1 year
    56. 56. 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
    57. 57. Technique for Pulptomy of the Primary Teeth •Anesthetize the tooth and isolate with rubber dam. ↓ •Remove all caries using high-speed straight fissure bur without entering the pulp chamber. •Remove dentinal roof with a large diamond stone or slow speed round bur for minimal trauma. •Enlarge the exposed area and deroof the pulp chamber. • •Remove any ledges or overhanging enamel with slow speed round bur. •Sharp spoon excavators are used to scoop out coronal pulp and pulpal remnants. •Clean the pulp chamber with saline and remove all debris. •Place a cotton pellet over the pulp stumps to achieve hemostasis.
    58. 58. •Place a cotton pellet over the pulp stumps to achieve hemostasis. ↓ •Using a cotton pellet apply diluted formocresol to the pulp for 4 min. ↓ •Place a small dry pellet over this to avoid contact of tissues with formocresol. ↓ •Remove cotton pellets and check for fixation,brownish discoloration of the pellet as well as the pulp stump is an indicator of fixation. ↓ •Place ZOE cement in the pulp chamber ↓ •Recall after one week and restore with a permanent restoration if patient is asymptomatic ↓ •Place a stainless steel crown
    59. 59. (a) The figure shows a lower right second primary molar where after removing the roof of the pulp chamber the coronal pulp is being completely removed using excavators. (b) Cotton pledget with the medicament placed over the radicular pulp tissue to control the bleeding. (c) On removal of the cotton pledget bleeding from the amputation sites has stopped. (d) Kalzinol (or any other zinc oxide eugenol preparation) placed in the pulp chamber prior to placing the coronal restoration. (e) Periapical radiograph of right upper first primary molar showing a completed pulpotomy. Note excellent condensation of cement in the pulp chamber and coronal restoration with stainless-steel crown.
    60. 60. •DISADVANTAGES OF FORMOCRESOL •Local toxicity: There is no actual healing of the pulp and the tooth becomes devitalized. •Systemic toxicity: studies have shown that full strength formocresol, is absorbed in to the systemic circulation from the pulpotomy site. Excretion is via the kidney and lungs. Some amount of formocresol remains cell bound in the liver,kidney and lungs. Cytogenic and mutagenic effect is observed due to its ability to denature nucleic acids by forming methylol derivatives and methylene cross links. Formocresol is also said to produce irreversible damage to the protein portion of enzymes,genetic material,membranes, and connective tissue. It affects directly the protein biosynthesis and cell reproduction by interacting with DNA and RNA and destroys the lipid component of the cell membrane. •Damage to succedaneous: it is seen that 1ml of formocresol diffuses through the apical foramen in 3 min.Thus there is high risk for the formation of enamel defects in the permanent successor following the use of formocresol in a primary teeth.
    61. 61. •Mutagenicity and carcinogenicity •Occurrence of dermatitis and pharyngitis •Antigenicity
    62. 62. If bleeding cannot be connot be controlled the health of the pulp is questionable and extraction or intermediate .sedative dressing will be considered • • • 1. 2. 3. 4. 5. Application of an appropriate lining or base such zinc oxide eugenol cement (IRM). IRM is the same as ZOE but has a reinforcing material added to make it more resistant to wear. An intermediate dressing may be appropriate when the pulpectomy cannot be completed in the following reasons: Child compliance is a proplem. Uncontrolled bleeding of pulp stumps- as an altranative to extraction Inadequte anaesthesia. Unable to extract tooth. Non-vital that requrire further management
    63. 63. Uses 1. 2. 3. 4. 5. As an intermediate restorative material for both Class I and II restorations. As a base under non-resin restorations. Restoration of deciduous teeth (when permanent teeth are two years or less from eruption). Restorative emergencies. baby tooth root canals .                                                                Handling characteristics    IRM powder and liquid should be mixed in less than one minute. The resulting putty consistency is then inserted into the cavity. If indicated, conventional methods of matrix application are appropriate.    
    64. 64. Advantages 1.    High strength comparable to zinc phosphate 2. Excellent abrasion resistance 3. Good sealing properties 4. Low solubility                                 Contraindications 1.    Because of its zinc-oxide eugenol composition, IRM will interfere with subsequent placement of a resin filling 2. Use of cavity varnishes.       Procedure 1. Complete removal of all coronal pulp. 2. Place ledermix paste over exposed pulp. 3. Cover with sterile cotton pellets. 4. Restore with reinforced zinc oxide eugenol(IRM)or glass ionomer cement. 5. Plan follow up care.
    65. 65. :N.B If you have a rather large cavity, you can remove the bulk of the . decay and place an "IRM" filling, also known as a sedative filling This will often slow or stop the progression of decay and help the patient feel better. It also may allow the tooth time to recover and lay down secondary dentin (sort of a second layer of scar tissue), sometimes eliminating the need for pulpal treatment like a root canal. Once the tooth is recovered and less inflamed, any remaining decay is removed and the final restoration (filling or crown) is placed. You mix the powder and the liquid together to make a kind of play
    66. 66. ELECTROSURGICAL PULPOTOMY(MACK AND DEAN,1993) • • • It is a non-chemical devitalization,whereas mummification eliminates pulp infection and vitality with chemical crosslinking and denaturation. Electrocautery carbonizes and heat denatures the pulp and bacterial contamination. Electrosurgery does little to improve on the formocresol pulpotomy but does not use any chemicals. After amputation of the coronal pulp,the pulp stumps are cauterized through this method. After completion,the pulp chamber is filled with zinc oxide and eugenol paste. The tooth is restored with a stainless crown. PROCEDURE: • • • Rubber dam isolation and administration of local anesthesia ↓ Caries removal with large round slow speed bur ↓ Sterile cotton pellets are placed in contact with pulp and pressure is applied to obtain hemostasis
    67. 67. •The hyfrecator plus 7-797 is set at 40% power and the 705A dental electrode is used to deliever the electrical arc ↓ • Cotton pellet is quickly removed and the electrode is placed 1-2mm above the pulpal stump ↓ • Electrical arc is allowed to bridge the gap to the pulpal stump for 1 second,followed by a cool-down period of 5 seconds ↓ • When the procedure is properly performed,the pulpal stumps appear dry and completely blackened • Pulp chamber is filled with ZOE placed directly against the pulpal stumps • Final restoration is then placed
    68. 68. LASER PULPOTOMY Jeng-fen-liuet al in 1999 studied the effect on Nd:YAG laser pulpotomy in primary teeth and noted 100% success with no signs or symptoms,and only one tooth had internal root resorption at the sixmonth follow up visit
    69. 69. TWO-VISIT DEVITALIZATION PULPOTOMY This is two stage procedure involving the use of paraformaldehyde to .fix the entire coronal and radicular pulp tissue :INDICATIONS 1. There is evidence of sluggish bleeding at the amputation site that is difficult to control. 2. Pus in the chamber , but none at the amputation site. 3. There is thickening of pdl. 4. History of pain. Contraindication: 1. .Non restorable 2. .Necrotic 3. .Soon to be exfoliated
    70. 70. :Formula of each agent used are as follows :GYSI TRIOPASTE FORMULA.1 *tricresol 10 ml *cresol 20 ml *glyserine 4 ml *paraformaldehyde 20 ml *zinc oxide 60 gm :EASLICK’S PARAFORMALDEHYDE FORMULA.2 paraformaldehyde 1 gm* *procaine base 0.03 gm *powdered asbestos 0.05 gm *petroleum jelly 125 gm *carimine to colour
    71. 71. 3.PARAFORM DEVITALIZING PASTE: *paraformaldehyde 1gm *lignocaine 0.06 gm *propylene glycol 0.05 ml *carbowax 1500 1.30 gm *carmine to colour PROCEDURE :FIRST VISIT • Isolation with rubber dam ↓ • Preparation of the cavity ↓ • Deep caries excavated ↓ • Enlarge the exposure with round bur
    72. 72. ↓ • Incorporate paraformaldehyde paste into the pellet and Place over exposure. ↓ • Seal the tooth for 1-2 weeks so that formaldehyde gas liberated from paraformaldehyde enters coronal and radicular pulp, thereby fixing the tissue. SECOND VISIT: • Pulpotomy is carried out under local anesthesia ↓ • Remove the cotton pellet and deroof the pulp chamber ↓ • Clean the cavity with saline and dry with cotton pellet ↓ • Pulp chamber filled with antiseptic paste and tooth is Restored.
    73. 73. PRESERVATION GLUTARALDEHYDE PULPOTOMY It has been widely tested,to replace formocresol. Studies have shown that application of 2-4%produces rapid surface fixation of the .underlying pulp tissue :Mechanism of action • Glutaraldehyde produces rapid surface fixation of the underlying pulpal tissue. • A narrow zone of eosinophilic,stained and compressed fixed tissue is found directly beneath the of application,which blends into vital normal appearing tissue apically. • With time,glutaraldehyde fixed zone is replaced by macrophagic action with dense collagenous tissue,thus the entire root canal tissue is vital. :Procedure • local anesthesia and a rubber dam are applied. • The operative procedure is in principle the same as for FC pellets
    74. 74. •soaked in a 2% buffered freshly prepared glutaraldehyde solution are placed on the wound surfaces and left in place for 3-5 min. •The pellets are removed and a slow-setting zinc oxide-eugenol cement covered with a fast-setting cement is placed and the cavity restored. ADVANTAGES OF GLUTARALDEHYDE OVER FORMOCRESOL: 1. it is bifunctional reagent,which allows it to form strong intra and intermolecular protein bonds leading to superior fixation by cross linkage. 2. it is excellent antimicrobial. 3. causes less necrosis of the pulpal tissue. 4. 15-20 times less toxic than formacresol. 5. demonstrates less systemic distribution. 6. it is low tissue binding,readily metabolized,eliminated in urine and expired in gases-90% of the drug is gone in 3 days.
    75. 75. 7. mutagenicity-Glutaraldehyde does not reach the nucleus of the liver cell. .antigenicity-less as compared to formocresol. 8 .Less dystrophic calcification in pulp canals. 9 Diffusability is limited, thus reducing the apical extension of . 10 .the material DISADVANTAGES 1. Neither the optimal concentration,nor the amount of time period of application has been coclusively established. 2. Failure rate is more than formocresol
    76. 76. Ferric sulfate The ferric sulfate the most suitable alternative to formocresol in the next few years. • In light of recent evidence, ferric sulfate can be used as a suitable alternative for those concerned about the toxicity of formocresol or have difficulty obtaining it in the United Kingdom. However, it must be remembered that ferric sulfate has no "fixative" effect. • For this reason, an accurate diagnosis of the state of the pulp tissue being left behind and on which ferric sulfate is being applied will need to be made. It is a non aldehyde haemostatic compound • (1)astringent; (2)forms a ferric ion-protein complex that mechanically occludes capillaries; (3) less inflammation than formocresol (4) 92.7% radiographic success rate. (5)100% clinical success (6)root resorption is not accelerated (7)internal resorption similar to formocresol ,no systemic or local side effects
    77. 77. Regeneration An ideal pulpotomy treatment should leave the radicular pulp vital , healthy and completely enclosed within an odontoblast-lined dentin chamber. CVEK’S PULPOTOMY This is called as calcium hydroxide pulpotomy or young permanent . partial pulpotomy. This was proposed by Mejare Cvek in 1993 Indications •It is indicated in young permanent teeth with incomplete root information and the radicular pulp is judged vital by the clinical and radiographic criteria.
    78. 78. PROCEDURE: Application of rubber dam ↓ All carious material is removed with excavators or slow speed round bur. ↓ Coronal pulp removed,to perform a pulpotomy. ↓ After arrest of the hemorrhage,Ca(OH)2 is applied to the exposed pulp,ensuring that there is no blood clot. ↓ The cavity is then sealed with temporary restorative material. A tooth should remain symptom free at recall and radiograph should show formation of a secondary dentine bridge. ↓ Then permanent restoration with amalgam is done.
    79. 79. Calcium hydroxide:advantages and disadvantages Advantages Disadvantages 1. Initially bacteriocidal then bactstatic 1. 2. Promotes healing and repair 2. 3. High pH stimulates fibroblasts Does exclusively stimulate reparative dentine 3. Associated with primary tooth resorption 4. May dissolve after one year with cavosurface dissolution Particles may obturate open 5. 6. tubules 7. May degrade during acid etching 8. Does not adhere to the dentin or resin restoration 4. Neutralizes low pH of acids 5. Stops intrnal resorption 6. Inexpensive and easy to use 7. Does not exclusively stimulate dentinogenesis Degrades upon tooth flexure Marginal failure with amalgam condensation
    80. 80. BONE MORPHOGENIC PROTEINS(BMP) Bone morphogenic proteins initiate endochondral bone formation. The main action of BMP’s is to stimulate undifferentiated pluripotent cells to differentiate in to cartilage and bone forming cells. BMP’s are abundant in bone and dentin and promote .osteogenesis and reparative dentin formation MINERAL TRIOXIDE AGGREGATE(MTA) MTA is the new medicament with an alkaline pH. It has shown significant improvement over the materials in promoting the healing of pulp and periradicular tissue. It is biocompatible,prevents bacterial leakage and is effective even in moist environment. Composition Tricalcium silicate Dicalcium silicate Tricalcium aluminate Tetracalcium aluminoferrite
    81. 81. Calcium silicate Bismuth oxide :Other uses of MTA are •pulp capping •root end filling •perforation repair in furcation,coronal,mild or apical portion of the root •repair of resorptive perforation if not too extensive
    82. 82. Non vital pulpotomy MORTAL PULPOTOMY Non vital pulpotomy) Ideally,non-vital tooth should be treated by ) pulpectomy,but sometimes it is impracticable due to nonnegotiable root canals and limited patient cooperation Selection criteria: 1. History of spontaneous pain 2. Swelling,redness or soreness of mucosa 3. Tooth mobility 4. Tenderness to percussion 5. Radiographic evidence of pathological root resorption or periradicular bone destruction 6. Pulp at the exposed site does not bleed
    83. 83. PROCEDURE: FIRST APPOINTMENT: Necrotic coronal pulp is removed ↓ Pulp chamber is irrigated with saline and dried with cotton pellet ↓ Infected radicular pulp is treated with strong antiseptic solution like beechwood cresol ↓ Seal cavity with temporary cement for 1-2 weeks SECOND APPOINTMENT: If the tooth is asymptomatic the pulp chamber is filled with an antiseptic paste ↓ The tooth then restored with stainless steel crown
    84. 84. Pulpectomy Pulpectomy involves removal of the roof and contents of pulp chamber in order to gain access to the root canals which are .debrided,enlarged and disinfected .Canals are filled with RESORBABLE MATERIALS . OBJECTIVES 1. Infectious process should resolve 2. Radiographic evidence of successful filling 3. Treatment should allow reosrption of primary root structures and filling materials at appropriate time 4. No post treatment pain,swelling or sensitivity 5. No radiographic evidence of further break down of supporting tissue 6. No internal or external resorption.
    85. 85. :General indications 1. Cooperative patient. 2. Pt should be in good health with no serious disease. 3. Maximum cooperation of pt and parent :General indications Young pt with systemic illness such as congenital ischemic . 1 .heart disease, leukemia 2.Children on long term corticosteriods therapy. Clinical indication: 1. Atooth previously planned for apulpotomy that shows either a dry pulp champer or uncontrolled pulpal hemorrage. 2. Indicated for any primary tooth in absence of its permenant successor. 3. Any deciduous tooth with severe pulpal necrosis provided there is no radiographic contraindication. 4. traumatized primary incisors with pulp exposures or acute or chronic abscesses.
    86. 86. .Pulpless tooth with stomas. 4 5. Pulpless primary teeth in hemophiliacs. .Pulpless primary molars holding orthodontic appliance . 6 :Clinical contraidications 1. Excessive tooth mobility. 2. Communication between the oral cavity and area of furcation. 3. Communication between the roof of the pulp champer, and the region of furcation. 4. Insufficient tooth structure to allow isolation by ruubber dam and extra cronal restoration. Radiographic indication: 1. Adequate peridontal and bony support. 2. Incipient internal root resorpation in the occlusal portion of the occlusal portion of the root canal.
    87. 87. Radiographic contraindication: 1. External root resorption. 2. Internal root resorption in the apical 3rd of the root. 3. Rdicular cyst, dentigrous – follicular cyst in assocition with the primary tooth. 4. Interradicular radiolucency that communicatees with gingival sulcus. Pulpectomy Technique • • Achieve adequate anesthesia and rubber dam isolation. Two phases-CORONAL phase,RADICULAR phase. I. Coronal phase: 1. Remove all caries. 2.Remove the roof of the pulp chamber with a high-speed handpiece. 3.Amputate the coronal aspect of the pulp tissue with a large
    88. 88. II. RADICULAR phase 1. The remaining pulp tissue occupying the root canals is removed using endodontic files at a predetermined working length, approximately 1 to 2 mm short of the root apices. 2.The canals should be enlarged several sizes beyond the size of the first file that fits snugly into the canal to a minimum final size of 30 to 35. 3.Throughout root canal instrumentation, the canals should be irrigated with sodium hypochlorite to aid in debridement. 4.Dry the canals with sterile paper points. The canals are filled with a treatment paste (Zinc.5 .Oxide/Eugenol at UKCD) using a pressure syringe .The tooth is restored with a stainless steel crown.6
    89. 89. Non-vital pulp therapy⎯primary tooth. (a) A carious, but restorable, non-vital primary molar. (b) Caries is eliminated and access made to the pulp. Gentle canal debridement is undertaken with smal files and irrigation. (c) Disinfection of the canal system. A pledget of cotton wool barely moistened with ledermix is sealed into the pulp chamber for 7-10 days. (d) The tooth is reopened at a second visit, and after irrigation and drying, a soft mixture of slow-setting zinc oxideeugenol cement is gently packed into the canals with the cotton-wool pledget. (e) The pulp chamber is packed with accelerated zinc oxideeugenol cement before .definitive restoration of the tooth
    90. 90. a) Periapical radiograph) showing files placed in the root canals of left lower second primary molar b) Root canals have been filled ) with pure zinc oxide eugenol •Root canal filling in an upper primary central incisor
    91. 91. N.B: •If iflammation is beyond the coronal pulp with only interradicular but no periapical radiolucency-single visit pulpectomy is done. •If pulp is necrotic with periapical involvement,filling is done at subsequent appointement. :Follow-up and review Though the pulpectomy technique carries a good prognosis, the . outcome is not as good as a vital pulpotomy Clinical follow-up augmented by one periapical radiograph on a yearly basis is required (391HFig. 8.27 (a)-(b)). The following clinical and :radiographic parameters can be taken as indications of success Clinical ;alleviation of acute symptoms• .tooth free from pain and mobility• Radiographic improvement or no further deterioration of bone condition in the • .furcation area
    92. 92. Criteria for an ideal pulpectomy obturant (treatment paste) 1. Antiseptic 2. Resorbable 3. Harmless to the adjacent tooth germ 4. Radiopaque 5. Non-impinging on erupting permanent tooth 6. Easily inserted 7. Easily removed Should not shrink.8 Insoluble in water.9 10.not discolour teeth.
    93. 93. Obturating materials: I. • • • • • • ZNO PASTE Most commonly used. Camp in 1984 introduced endodontic pressure syringe. Disadvantages: Overfilling causes Foreign body reaction Difference in rate of resorption from that of tooth root. Success rate 65% II. IODOFORM PASTE :Compostion .Derivative of iodine :Advantages •Resorbs rapidly •Extruded paste in periapical tissue is replaced with normal tissue
    94. 94. •Bactericidal potential •Can be removed if retreatment is required •Success rate 84% III.KRI paste: :Composition Iodoform 80.8%,camphor 4.86%,parachlorophenol 2.025%,menthol 1.215% IV. CALCIUM HYDROXIDE
    95. 95. V. VITAPEX Composition: • Calcium hydroxide and iodoform mixture-Vitapex,Neo Dental Chemical Products Co;Tokyo,has been published by Fuchino and Nishino in 1980. Properties: • Non toxic • Easy to apply • Resorbs at slightly faster rate than root • Radio opaque • 100% success rate. VI. ENDOFLAS :Composition •Zno-56.5%,Barium sulphate 1.63%,Iodoform 40.6%,Calcium hydroxide 1.07%,Eugenol Pentachlorophenol. Properities: •Microleakage is prevented. •70% success rate. VII.MTA
    96. 96. OBTURATION TECHNIQUES: 1.Endodontic pressure syringe -These apparatus consist of syringe barrel, threaded needle. Needle is withdrawn 3 mm with each quarter turn of the screw until the canal is visibly filled at the orfice. -The endodotic pressure syringe is also effective for placing the ZEO into the canals. -The Vitapex system also uses a syringe with the material in it. -The syringe is introduced up to 1/5th the distance from the apex of the canal and the material is slowly injected as the syringe is withdrawn from the canal. 2. Mechanical syringe Cement is loaded into the syringe with 30 gauge needle as per per the manifactures is recommendation and expressed into the canal. Press using continous pressure while withdrawing the needle.
    97. 97. Lentulo spiral technique. 3 •Pastes can also be filled by means of a Lentulo spiral mounted on the micro motor hand piece. •The direction of rotation needs to be checked for the material to properly flow into the canal. Incremental filling technique.4 •Endodontic plugger corresponding to the size of the canal with rubber stopper is used to place thick mix of cement into the canal. •Thick mix was prepared into a flame shape corresponding to size and shape of the canal and then tapped genently into the apical area with the help of plugger. •The primary teeth with their larger canals may be filled with a thin mix coating on the walls of the root canal with the help of a reamer in a anti-clock wise direction while taking it out slowly followed by the placement of the thicker mix which is then pushed manually.
    98. 98. Other techniques.5 .a)Amulgum plugger .b)Paper point .c)Plugging action with wet cotton pellet
    99. 99. Apexogenesis & Apexification Open apex -At the time of tooth eruption root development is only 62-80% i.e., 2/3rd of the root is formed. -If due to trauma or caries exposure the pulp undergoes necrosis, dentin formation ceases and root growth is arrested. -The resultant immature root will have an open apex which is also called as blunder buss canal. Problems faced with open apex -Due to large apical diameter and smaller coronal canal diameter debridement is difficult. -Lack of apical stop makes obturation difficult. -The thin root canal walls become prone to fracture. -Earlier open apices have been treated by periapical surgery with a retrograde filling but surgery has its drawbacks.
    100. 100. •Relative to the already shortened root, further root reduction (apicectomy) could result in an inadequate crown root ratio. •The apical walls are thin and could shatter when touched with a rotating bur. •The thin walls would make condensation of a retrograde filling difficult. •The periapical tissue may not adapt to the wide and irregular surface of the amalgam. •Surgery would remove the root sheath and prevent for further root development. •Surgery would be both physically and psychologically traumatic to the patient. Thus It is best to treat immature teeth with a non surgical approach. Based on the vitality of the pulp if the immature tooth has vital pulp exhibiting reversible pulpitis physiological root end development or apexogenesis is attempted. If irreversible pulpitis is present there is when pulp is necrotic then apexification root end closure is done by
    101. 101. .Maturation of permanent incisors a) Immature incisors showing short ) roots with incomplete, wide-open apices. The lateral walls of the roots . are thin and structurally weak b) The same teeth 2 years later,) the roots are now almost complete following continued dentine .deposition by healthy pulp
    102. 102. Apexogenesis •. -:DEFINATION Apexogenesis involves removal of the inflamed pulp and the placement of calcium hydroxide on the remaining healthy pulp tissue. Traditionally this has implied removal of the coronal portion of the pulp to permit continued dentin formation and apical closure in an immature tooth . Materials Used • Ca(Oh)2 • MTA • Bone morphogenic protein Clinical Evaluation -No clinical symptoms -No radiogarphic changes in pulp or periapex -Continued root development -Radiographically observed hard tissue barrier at the site of procedure -Sensitivity to vitality testing
    103. 103. :Goals of apexogenesis 1 Sustaining a viable Hertwig’s sheath, thus allowing continued development of root length for a more favorable crown-to-root ratio. 2 Maintaining pulpal vitality, thus allowing the remaining odontoblasts to lay down dentine producing a thicker root and decreasing the chance of root fracture. Promoting root end closure, thus creating a natural apical constriction 3 for root canal filling Generating a dentinal bridge at the site of the pulpotomy. While the 4 bridging is not essential for the success of the procedure, it does .suggest that the pulp has maintained its vitality Failures of Apexogenesis -Cessation of root growth -Development of signs and symptoms or periapical lesions -Calcific metamorphosis Operative procedure Under local anaesthesia and rubber dam, pulp tissue is excised • with a diamond bur running at high speed under constant water cooling. This causes least injury to the underlying pulp and is .preferred to hand excavation or the use of slow-speed steel burs
    104. 104. Microbial invasion of an exposed, vital pulp is usually superficial and • generally only 2-3 mm of pulp tissue should be removed (partial [(.pulpotomy [Cvek Excessive bleeding from the residual pulp which cannot be • ,controlled with moist cotton wool, or indeed no bleeding at all indicates that further excision is required to reach healthy tissue (.(coronal pulpotomy Removal of tissue may occasionally extend more deeply into the • tooth (full coronal pulpotomy) in an effort to preserve the apical .portion of the pulp and safeguard apical Closure Gently rinse the wound with sterile saline or sodium hypochlorite (1- • 2%)and remove any shredded tissue. All remaining tags of tissue in the coronal portion must be removed as they may act as a nidus for re-infection, and a pathway for coronal leakage
    105. 105. Apply a calcium hydroxide dressing to the pulp to destroy any • remaining microorganism and to promote calcific repair. In superficial wounds, a setting calcium hydroxide cement may be gently flowed onto the pulp surface, but if the excision was deep, it is often easier to prepare a stiff mixture of calcium hydroxide powder (analytical grade) in sterile saline or local anaesthetic solution, which is carried to the .canal in an amalgam carrier and gently packed into place with pluggers Overlay the calcium hydroxide dressing with a hard cement to • prevent its forceful injection into the pulp by chewing forces and a final adhesive restoration which will seal the preparation against the .re-entry of micro-organisms
    106. 106. REVIEW The total time for achievement of the goals of the apexogenesis ranges between 1 and 2 years depending on the degree of tooth development at the time of the procedure ,after a month• ,months 3• ,monthly intervals for up to 4 years in order to assess pulp vitality 6• periodic radiographic review should also be arranged to monitor• dentine bridge formation, root growth, and to exclude the development of necrosis and resorption. If vitality is lost, non-vital pulp therapy should be undertaken whether or not there is a (,calcific bridge (see below success rates for partial (Cvek) pulpotomies are quoted at 97%. • .Those for coronal pulpotomies at 75% •Elective pulpectomy and root canal treatment of a vital pulp may be considered at a later date only if the root canal is required for restorative purposes.
    107. 107. Pulp amputation (apexogenesis procedure) .of a permanent incisor a)Complicated fracture of an immature ) incisor with microbial invasion of the coronal pulp. The pulp has been exposed to .the mouth for more than 24 h b) Access to the coronal pulp and ) amputation of coronal pulp tissue with a diamond bur running at high speed with .constant water cooling c) Dressing the pulpal wound to promote ) calcific repair. Non-setting calcium hydroxide cement is flowed on to the pulp, then overlaid with a hard cement, and the .tooth restored with composite resin d) The same tooth after 12 months ) showing calcific barrier formation. The calcific barrier was directly inspected in this case, (not always required), and a new layer of setting calcium hydroxide cement placed on the barrier before definitive restoration. The remaining pulp has stayed healthy and deposited dentine to complete .root formation
    108. 108. Apexification -:DEFINATION is a method of inducing apical closure through the Apexification formation mineralized tissue in apical pulp region of a non vital tooth with an incompletely formed root. The mineralized tissue can be osteodentin, osteocementum, or bone or .combination of all Indications -Restorable immature tooth with pulp necrosis Contraindications 1-All vertical and unfavourable horizontal root fractures, 2-Resorptions 3-Short roots 4-Periodontally broken down tooth 5-Vital pulp
    109. 109. Objective: The aim of apexification is to induce either closure of the open apical third of the root canal or the formation of an apical “calcific barrier” against which obturation can be achieved Rationale: The technique of treatment is the usual cleaning and irrigation of the root canal, followed by sealing with a paste composed of camphorated chlorophenol and calcium hydroxide. Radiographic examination is made 3 and 6 months after the procedure, and when evidence of a root apex cap or barrier appears, the root canals are obturated. Actual root growth does not occur as a result of apexification, but radiographic evidence of a calcified mass at the root apex gives that impression.
    110. 110. Factors Affecting Apexification 1-Age of the patient 2-Root development 3-Location of apex 4-Apical diameter 5-Thorough cleaning & debridement 6-Temporary restorations Materials used are : 1-Calcium hydroxide Tricaclium phosphate-2 3-Bone growth factors 4-MTA
    111. 111. :Operative procedure Access with a high-speed, medium tapered fissure bur. In the pulp • chamber use safe-ended burs to remove the entire roof without the .danger of overcutting or Perforation Remove loose debris from the pulp chamber with hand instruments, • accompanied by copious, gentle irrigation with sodium hypochlorite (.solution (1-2% Gates Glidden drills may be used to improve access to canals for • instruments and irrigant. They should not be used deep in the canals of .immature teeth where they may overcut and create a strip perforation Canal preparation involves two processes: cleaning with irrigants to• free the root canal system of organic debris, micro-organisms and their toxins; and shaping with enlarging instruments, to modify the form of the existing canal to allow the placement of a well-condensed root . filling In canals which are often as wide as this, little dentine removal and shaping is needed. Sodium hypochlorite solution (1-2%) as an irrigant will continue dissolving organic debris and killing micro-organisms deep
    112. 112. Working apically, files are directed around the canal walls with a light • rasping action to remove adherent debris. Instrumentation is frequently punctuated by highvolume, low-pressure irrigation to flush .out debris Irrigant is delivered either by pre-measured, 27 gauge needle and • syringe or with the aid of sonic/ultrasonic energy. The latter involves flooding the canal with irrigant before inserting a small (size 16-20) file attached to a sonic/ultrasonic unit to stir the irrigant in the canal. Wall contact with the file should be avoided, as the action is liable to .cause turbulence in the irrigant which scrubs the walls of debris Provisional working length should be 2-3 mm from the radiographic • apex, estimated from an undistorted pre-operative periapical film. A working length radiograph is then taken to establish a definitive working length 1 mm short of the radiographic root apex. Further gentle filing and irrigation is then continued to the definitive working .length Dry canal with pre-measured paper points to avoid inadvertent over- • extension and damage to the periapical tissues
    113. 113. Fill canal with a relatively fluid proprietary calcium hydroxide paste • such as Ultracal (Optident, UK. This may be syringed into the canal via a disposable flexible tip or alternatively spun into the canal with a spiral paste filler. The antimicrobial and mild tissue solvent activity of non-setting calcium hydroxide will continue to cleanse the canal, and .its high pH is believed to encourage calcific root end closure A radiograph may be taken to ensure a dense fill to each root • .terminus Seal access cavity tightly between appointments to prevent the • leaching of calcium hydroxide, and critically, to prevent the re-entry of micro-organisms from the mouth which would disturb the process of root end closure. A 3 mm thickness of glass ionomer cement or .composite resin is adequate to provide a bacteria-tight seal Cotton-wool fibres should not be allowed to remain at the cavo.surface of the cavity
    114. 114. REVIEW monthly to monitor root end closure. At each appointment the 3• calcium hydroxide dressing is carefully washed from the canal and the presence of a calcified barrier assessed by gently tapping a pre.measured paper point at the working length Radiographs should be taken to assess the progress of barrier• .formation If the canal is closed, obturation may proceed. If calcific barrier • formation is not complete, the canal should be redressed for a further 3 months. Calcific barrier formation is usually complete .within 9-18 months, but could take up to 2 years
    115. 115. (. Root-end closure (apexification (a) Immature, permanent central incisor devitalized by trauma. (b) The same tooth 18 months later. Canal debridement and calcium hydroxide therapy has allowed the development of an apical calcific barrier. The canal has been densely obturated with thermoplastic gutta percha .and sealer
    116. 116. Filling canal with calcium hydroxide paste such as Ultracal a) Following irrigation and gentle debridement in a crown-to-apex ) . direction, the working length is determined b) Non-setting calcium hydroxide paste is syringed into the canal via ) . a flexible tip c) The same tooth 18 months later. A calcific barrier is apparent, ) . and the tooth is ready for definitive obturation and restoration (.d) The flexible tip system (Ultracal)
    117. 117. Manual obturation in apically divergent canal Obturation following root-end closure in an apically diverging canal. (a)The widest gutta percha point that will reach the apical terminus of the canal is warmed by passage of its tip through a and may be inverted in the widest canals. (b) Without delay, the point is introduced to the canal (the canal is already lightly coated with sealer), and advanced to adapt against the apical barrier. (c) Additional points are now packed around the master point with cold or warm condensation until the canal is densely filled.
    118. 118. Alternatives to the root-end closure procedure Recently the potential has arisen to seal open apices with mineral • trioxide aggregate (MTA). Based on Portland building cement it is packed into the canal with premeasured pluggers and sets to form a .hard, sealing, biocompatible barrier within 4 h •Moist cotton wool is placed into the canal to promote setting and the material is checked after at least 24 h before filling the remainder of the canal with gutta percha and sealer, or with composite and a fibre post. Clinical studies are ongoing, but this material seems likely to allow root end closure in 1 or 2 visits which will demand less patient compliance When pulp vitality is lost in an almost fully formed tooth, it may be • possible to avoid lengthy root-end closure procedures by creating an apical stop against which a root filling may be packed. Following crown to apex preparation as described above, endodontic hand files may be used in gentle watch-winding or balanced-force motion at working length to shave an apical seat for canal obturation. Alternatively, MTA can be packed into the apical 1-2 mm of the canal with pluggers .to provide an immediate apical seal
    119. 119. (a) Immature apex tooth . (b) Apical 'plug' of MTA and backfill with thermoplastic GP
    120. 120. :has described four successful results of apexification treatment's continued closure of the canal and apex to a normal appearance, ( 1 ) (2) a domeshaped apical closure with the canal retaining a blunderbuss , appearance no apparent radiographic change but a positive stop in the apical ( 3) ,area A positive stop and radiographic evidence of a barrier coronal to ( 4) .the anatomic apex of the tooth