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

1. Management of
Deep Carious Lesions
in Deciduous Dentition
Fatima A. A.
Sidra K.

2. PATIENT PRESENTATION

3. Signs & Symptoms
• History of pain
• Visibly carious defect
• Presence of
• Irritable behavior
provoked or
• Difficulty chewing
spontaneous pain
• Tooth may be tender
to percussion
• Radiolucency

4. Anatomical Challenges
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Small teeth, large pulp chambers
Thinner enamel and dentin
Wider, shorter dentinal tubules
Variations in pulp size and shape
Slender pulp horns
Shallow pulp chambers
Large apical foramina
Increased number of accessory canals and foramina
Roots flare outwards
Roots are narrower mesiodistally

5. Primary Tooth

6. DIAGNOSTIC AIDS

7. Radiographs

8. Pulp Vitality Testing
Electric Pulp Testing
Thermal testing (hot: guttapercha; cold: cold drink or air blast)
Pulp Oximetry

9. Percussion

10. Caution
• Children tend to become anxious
• Possibility of false positive or false negative
• Recently traumatized tooth may not give a
reliable response

11. TREATMENT OPTIONS

12. Indirect Pulp Therapy
• “A procedure in which material is placed over
a thin layer of carious dentin that, if removed,
might expose the pulp.”
• Recommended for teeth with deep carious
lesion but no pulpal degeneration.

13. Objectives
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Arrest carious process
Promote dentin sclerosis
Stimulate tertiary dentin formation
Remineralize carious dentin

14. Indications
• Mild discomfort from chemical or thermal
stimuli
• Absence of spontaneous or nocturnal pain
• Absence of lymphadenopathy
• Normal gingiva
• Normal tooth color
• Normal lamina dura and PDL space

15. Contraindications
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Sharp, continuous pain
Nocturnal pain
Excessive tooth mobility
Tenderness upon percussion
Parulis
Tooth discoloration
Carious pulp exposure
Abnormal lamina dura or PDL space
Furcal radiolucency
Pulpal calcification
Non-restorable tooth

16. Periodontal Abscess

17. Technique
• Provide local anesthesia and isolate the tooth
• Assess the preoperative appearance of the
lesion
• Remove all infected tissue
• Leave behind hard discolored dentin
• Cover with calcium hydroxide liner
• Re-enter after 6-8 weeks and place
restoration

19. Factors affecting Success
• Signs and symptoms consistent with
reversible pulpitis
• Absence of other clinical or radiographic
lesions
• Complete removal of caries except where
exposure would occur
• Excellent seal and prevention of bacterial
contamination

20. IPT vs Direct Pulp Capping?
• DPC is not recommended for carious pulp
exposure
• Higher risk of failure in primary dentition
• Al-Zayer, Straffon, Feigal and Welch found
95% success rate with IPT
• Nearly all teeth exfoliate at normal times
following IPT

21. Pulpotomy
• “Surgical removal of coronal pulp followed by
placement of medicament under aseptic
conditions.”

22. Indications
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Pulp exposure greater than suitable for IPT
No radicular pulpitis
Presence of pain (vital pulp)
Tooth has two-thirds of its root length
No evidence of internal resorption
No bone loss, fistulas, or abscesses

23. Contraindications
• Root resorption exceeds 1/3rd of root length
• Non-restorable crown
• Highly viscous, sluggish or absent hemorrhage
at radicular orifices
• Marked tenderness to percussion
• Excessive mobility
• Persistent tooth ache and coronal pus

24. Technique
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Anesthetize and isolate with a rubber dam
Remove all superficial caries
Enter the pulp chamber with a no.330 bur
Amputate pulp with either a spoon excavator or round bur
(leave radicular pulp intact)
Achieve hemostasis with cotton pellets
Dip cotton pellet in formocresol (1:5 dilution)
Place over pulp stumps for 5 minutes
Provide base of ZnOEugenol over amputation sites and
condense over pulpal floor
Use a second layer to fill the access opening
Final restoration: preferably, stainless steel crown

25. No.330 bur

26. Enter the Pulp Chamber
Here it is being entered with a fissure bur.

27. Amputate the Coronal Pulp

28. Achieve Hemostasis

29. Apply Formocresol

30. Final Restoration

31. Post-operative Evaluation

32. Success (and failure)
• Clinical success rate of 80-95%
• Drops to 74-88% if radiographic results included
• Failure if:
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Pain
Swelling
Fistula
Periapical or inter-radicular radiolucency
Internal or external resorption
• 38% of pulpotomized teeth exfoliate prematurely

33. Alternative Materials
• Preservation: corticosteroids, gluteraldehyde,,
ferric sulphate, electrosurgery, lasers
• Remineralization: TGF-b, freeze dried bone,
mineral trioxide aggregate

34. Formocresol vs Ferric Sulphate?
• Peng, Ye, et al found equivalent success rates
• Ferric sulphate produces local, reversible
inflammatory response
• No toxic or harmful effects documented in
literature since 1856
• Formocresol is cytotoxic, and systemically
distributed; systemic distribution has been shown
to cause immune sensitization, mutations and
cancer in animal studies
• Formocresol is a known human carcinogen

35. Non-vital Pulp: Pulpectomy
• Removal of non-vital cariously exposed pulp
chamber roof and contents
• Often preferred for primary anteriors
• Especially difficult for primary molars

36. Indications
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Irreversible pulpitis
Abscess or sinus opening
Presence of pus
Children with hemophilia
No pathologic resorption of alveolar bone

37. Contraindications
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Internal resorption
Excessive mobility
Non-restorable tooth
Perforated floor of pulp chamber
Underlying dentigerous or follicular cyst

38. Technique
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Treat pathologies such as abscess first
Once resolved: provide anesthesia and isolate
Remove all caries
Access the pulp chamber carefully
Remove pulp
Irrigate with saline, fill canals with ZnO paste
Fill pulp chamber with cement
Restore

39. Some points about Obturation
• Properties of ideal root filling material for primary
teeth:
– Resorbable, antiseptic, non-inflammatory, non-irritant,
radiopaque, easy to use, does not discolor tooth
• No such material exists; CaOH+iodoform comes
closest
• Gutta percha or silver points are contraindicated
as they interfere with physiologic primary root
resorption
• ZnOEugenol and CaOH with iodoform are used

40. Obturation Techniques
for ZnOEugenol
• With a reamer:
– A thin mix is made and carried into the root canals with a no.15
or no.20 reamer
– The reamer is then:
• Rotated clockwise and simultaneously tilted 10-15 times (facilitates
entry)
• Moved vertically and simultaneously tilted 10-15 times (facilitates lateral
condensation and coating of canals)
• Withdrawn anticlockwise 5 times (material stays inside the canal)
• With wet cotton: similar to above but a squeezed wet
cotton pellet is used to condense the material
• With a lentule-spiral: material is taken inside the canal with
a lentulo or lentulo spiral
• Endodontic pressure syringes, jiffy tubes and tuberculin
syringes may also be used

41. Obturation Techniques
for CaOH with Iodoform
• Canal is dried and an injectable syringe is
loaded
• The syringe is taken inside the canal; the
material is extruded slowly while the syringe is
withdrawn
• This technique may also be used with Calcium
preparations lacking iodoform

42. Final Restoration: Stainless Steel
Crown
• “Prefabricated semi-permanent restorations
for both primary and permanent teeth.”
• Available in a range of sizes from 2 to 7.

43. Indications
• Extensive carious lesion
• Developmental defects, to prevent loss of
vertical dimension
• Following pulpal therapy in primary teeth
• Severe bruxism
• As abutments
• In fractured primary teeth
• Correction of anterior single tooth crossbite

44. Contraindications
• Imminent exfoliation of primary teeth
• Nickel allergy
• Anterior teeth due to esthetic concerns

45. Technique
• Anesthetize the patient and isolate the tooth
• Reduce the occlusal surface by 1.5-2.0 mm with a
no.69 or 169 bur
• Round all sharp angles by moving the bur at 45
degrees
• Reduce the proximal surfaces
• Select a crown, seat it and mark its extension
• Trim the crown to below the mark
• Contour and crimp it
• Cementation is frequently done with glass ionomer
• Check the margins

46. Benefits
• Longer life than Class II amalgam restoration
(withstand fracture, don’t need to be
repeated)
• More cost-effective
• Ease of delivery
• Less time-consuming than multi-surface
amalgam restorations

47. Hall Technique
• A unique and minimally invasive approach to
managing deep carious lesions in deciduous
dentition by cementing metal crowns over them
• Pioneered by Dr.Norma Hall; published in 2006 as
a retrospective study
• Does not require local anesthesia, tooth
preparation or even caries removal!
• Requires careful case selection, a high level of
clinical skills, and excellent patient management

48. A Radical New Way of Thinking
• Instead of removing bacteria, it changes their
cariogenic potential by cutting them off from
substrates
• What about soft dentin? Natural
remineralization once the carious process
arrests
• The dentinal pulp complex has greater
reparative potential when subject to caries
than previously thought

49. Exclusion Criteria
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Irreversible pulpal involvement
Insufficient tooth tissue left to support crown
Lack of patient co-operation
Patient at risk of bacterial endocarditis
Aesthetic concerns
When there is no need for a Hall crown:
– Teeth close to shedding
– Tooth more easily treated with partial caries removal
– Several non-cavitated lesions better treated with a
fissure sealant
– Cleanable, arrested lesion

50. Procedure
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Protect the child’s ariway
Size the crown
Fill it with cement
Locate and seat fully
Wipe away excess
Seat further by asking the child to bite on it
Check and clean

51. Extraction
• Indications:
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Infectious process can’t be arrested
Lack of bony support
Lack of root support
Inadequate tooth structure remaining for
restoration
– Patient has medical factors that contraindicate
saving the primary tooth (for eg: congenital
cardiac defects, immune suppression)

52. THANK YOU!

53. References
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“Pediatric Dentistry: Principles and Practice” by MS Muthu, 2nd edition
Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB: Indirect pulp treatment of primary posterior teeth: a
retrospective study (2003)
Marchi JJ, de Araujo FB, Fröner AM, Straffon LH, Nör JE: Indirect pulp capping in the primary
dentition: a 4 year follow-up study (2006)
Ribeiro CC, de Oliveira Lula EC, da Costa RC, Nunes AM: Rationale for the partial removal of carious
tissue in primary teeth (2012)
”New Options for Restoring a Deep Carious Lesion” by Dr. Robert Rada

(http://www.dentistrytoday.com/dental-materials/8820-new-options-for-restoring-a-deep-cariouslesion)
Farooq NS, Coll JA, Kuwabara A, Shelton P: Success rates of formocresol pulpotomy and indirect
pulp therapy in the treatment of deep dentinal caries in primary teeth (2000)
Vij R, Coll JA, Shelton P, Farooq NS: Caries control and other variables associated with success of
primary molar vital pulp therapy (2004)
“Management of Deep Carious Lesions in Children” by Dr. Nevine Waly
(http://www.scribd.com/doc/88316496/Management-of-Deep-Carious-Lesions-in-Children)
“Pulp Therapy in Primary and Young Permanent Teeth” by Dr. Steven Chussid
(http://www.columbia.edu/itc/hs/dental/d7710/client_edit/Pulp_Therapy.pdf)
Casas, Kenny, Judd and Johnston: Do we still need formocresol in pediatric dentistry? (2005)
Peng L, Ye L, Guo X, Tan H, Zhou X, Wang C, Li R: Evaluation of formocresol versus ferric sulphate
primary molar pulpotomy: a systematic review and meta-analysis (2007)
The Hall Technique: A User’s Manual (University of Dundee;
http://www.scottishdental.org/resources/HallTechnique.htm )